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1 | AN ACT concerning public aid.
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2 | Be it enacted by the People of the State of Illinois,
| ||||||||||||||||||||||||
3 | represented in the General Assembly:
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4 | Section 5. The Children's Health Insurance Program Act is | ||||||||||||||||||||||||
5 | amended by changing Sections 20 and 40 and adding Section 27 as | ||||||||||||||||||||||||
6 | follows:
| ||||||||||||||||||||||||
7 | (215 ILCS 106/20)
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8 | Sec. 20. Eligibility.
| ||||||||||||||||||||||||
9 | (a) To be eligible for this Program, a person must be a | ||||||||||||||||||||||||
10 | person who
has a child eligible under this Act and who is | ||||||||||||||||||||||||
11 | eligible under a waiver
of federal requirements pursuant to an | ||||||||||||||||||||||||
12 | application made pursuant to
subdivision (a)(1) of Section 40 | ||||||||||||||||||||||||
13 | of this Act or who is a child who:
| ||||||||||||||||||||||||
14 | (1) is a child who is not eligible for medical | ||||||||||||||||||||||||
15 | assistance;
| ||||||||||||||||||||||||
16 | (2) is a child whose annual household income, as | ||||||||||||||||||||||||
17 | determined by the
Department, is above 133% of the federal | ||||||||||||||||||||||||
18 | poverty level and at or below 300%
200%
of the federal | ||||||||||||||||||||||||
19 | poverty level;
| ||||||||||||||||||||||||
20 | (3) is a resident of the State of Illinois; and
| ||||||||||||||||||||||||
21 | (4) is a child who is either a United States citizen or | ||||||||||||||||||||||||
22 | included in one
of the following categories of | ||||||||||||||||||||||||
23 | non-citizens:
|
| |||||||
| |||||||
1 | (A) unmarried dependent children of either a | ||||||
2 | United States Veteran
honorably discharged or a person | ||||||
3 | on active military duty;
| ||||||
4 | (B) refugees under Section 207 of the Immigration | ||||||
5 | and
Nationality Act;
| ||||||
6 | (C) asylees under Section 208 of the Immigration | ||||||
7 | and
Nationality Act;
| ||||||
8 | (D) persons for whom deportation has been withheld | ||||||
9 | under
Section 243(h) of the Immigration and | ||||||
10 | Nationality Act;
| ||||||
11 | (E) persons granted conditional entry under | ||||||
12 | Section 203(a)(7) of the
Immigration and Nationality | ||||||
13 | Act as in effect prior to April 1, 1980;
| ||||||
14 | (F) persons lawfully admitted for permanent | ||||||
15 | residence under
the Immigration and Nationality Act; | ||||||
16 | and
| ||||||
17 | (G) parolees, for at least one year, under Section | ||||||
18 | 212(d)(5)
of the Immigration and Nationality Act.
| ||||||
19 | Those children who are in the categories set forth in | ||||||
20 | subdivisions
(4)(F) and (4)(G) of this subsection, who enter | ||||||
21 | the United States on or
after August 22, 1996, shall not be | ||||||
22 | eligible for 5 years beginning on the
date the child entered | ||||||
23 | the United States.
| ||||||
24 | (b) A child who is determined to be eligible for assistance | ||||||
25 | may remain
eligible for 12 months, provided the child maintains | ||||||
26 | his or
her residence in the State, has not yet attained 19 |
| |||||||
| |||||||
1 | years of age, and is not
excluded pursuant to subsection (c). A | ||||||
2 | child who has been determined to
be eligible for assistance | ||||||
3 | must reapply or otherwise establish eligibility
at least | ||||||
4 | annually.
An eligible child shall be required, as determined by | ||||||
5 | the
Department by rule, to report promptly those changes in | ||||||
6 | income and other
circumstances that affect eligibility. The | ||||||
7 | eligibility of a child may be
redetermined based on the | ||||||
8 | information reported or may be terminated based on
the failure | ||||||
9 | to report or failure to report accurately. A child's | ||||||
10 | responsible
relative or caretaker may also be held liable to | ||||||
11 | the Department for any
payments made by the Department on such | ||||||
12 | child's behalf that were inappropriate.
An applicant shall be | ||||||
13 | provided with notice of these obligations.
| ||||||
14 | (c) A child shall not be eligible for coverage under this | ||||||
15 | Program if:
| ||||||
16 | (1) the premium required pursuant to
Section 30 of this | ||||||
17 | Act has not been paid. If the
required premiums are not | ||||||
18 | paid the liability of the Program
shall be limited to | ||||||
19 | benefits incurred under the
Program for the time period for | ||||||
20 | which premiums had been paid. If
the required monthly | ||||||
21 | premium is not paid, the child shall be ineligible for
| ||||||
22 | re-enrollment for a minimum period of 3 months. | ||||||
23 | Re-enrollment shall be
completed prior to the next covered | ||||||
24 | medical visit and the first month's
required premium shall | ||||||
25 | be paid in advance of the next covered medical visit.
The | ||||||
26 | Department shall promulgate rules regarding grace periods, |
| |||||||
| |||||||
1 | notice
requirements, and hearing procedures pursuant to | ||||||
2 | this subsection;
| ||||||
3 | (2) the child is an inmate of a public institution or a | ||||||
4 | patient in an
institution for mental diseases; or
| ||||||
5 | (3) the child is a member of a family that is eligible | ||||||
6 | for health benefits
covered under the State of Illinois | ||||||
7 | health benefits plan on the basis of a
member's employment | ||||||
8 | with a public agency.
| ||||||
9 | (Source: P.A. 92-597, eff. 6-28-02; 93-63, eff. 6-30-03.)
| ||||||
10 | (215 ILCS 106/27 new) | ||||||
11 | Sec. 27. Transition to capitated managed care system. | ||||||
12 | (a) On and after July 1, 2008, the Department of Healthcare | ||||||
13 | and Family services shall implement a capitated managed care | ||||||
14 | system for selected populations of persons. Under the capitated | ||||||
15 | managed care system, the State shall pay a fixed amount per | ||||||
16 | individual per month to a third-party entity to manage the | ||||||
17 | program of health care benefits and assume the risk associated | ||||||
18 | with the payment of medical bills without regard to actual | ||||||
19 | medical claims incurred. | ||||||
20 | (b) The Department shall adopt rules establishing the | ||||||
21 | populations that must participate in the capitated managed care | ||||||
22 | system. At a minimum, those populations must include all | ||||||
23 | persons eligible for benefits under Sections 20 and 40. The | ||||||
24 | Department shall adopt rules providing for the implementation | ||||||
25 | and continued oversight of the capitated managed care system. |
| |||||||
| |||||||
1 | (c) The Department shall implement the capitated managed | ||||||
2 | care system in a manner that maximizes all available State and | ||||||
3 | federal funds, including those obtained through | ||||||
4 | intergovernmental transfers, supplemental Medicaid payments, | ||||||
5 | and the disproportionate share program. | ||||||
6 | (d) The Department shall implement actuarially sound, | ||||||
7 | risk-adjusted capitation rates for recipients in the capitated | ||||||
8 | managed care program which cover comprehensive care, | ||||||
9 | catastrophic care, and an Enhanced Benefits Account Program | ||||||
10 | that rewards recipients for taking part in activities that | ||||||
11 | improve their health. | ||||||
12 | (e) The Department shall promptly apply for all waivers of | ||||||
13 | federal law and regulations that are necessary to allow the | ||||||
14 | full implementation of this Section.
| ||||||
15 | (215 ILCS 106/40)
| ||||||
16 | Sec. 40. Waivers.
| ||||||
17 | (a) The Department shall request any necessary waivers of | ||||||
18 | federal
requirements in order to allow receipt of federal | ||||||
19 | funding for:
| ||||||
20 | (1) the coverage of families with eligible children | ||||||
21 | under this Act; and
| ||||||
22 | (2) for the coverage of
children who would otherwise be | ||||||
23 | eligible under this Act, but who have health
insurance.
| ||||||
24 | (b) The failure of the responsible federal agency to | ||||||
25 | approve a
waiver for children who would otherwise be eligible |
| |||||||
| |||||||
1 | under this Act but who have
health insurance shall not prevent | ||||||
2 | the implementation of any Section of this
Act provided that | ||||||
3 | there are sufficient appropriated funds.
| ||||||
4 | (c) Eligibility of a person under an approved waiver due to | ||||||
5 | the
relationship with a child pursuant to Article V of the | ||||||
6 | Illinois Public Aid
Code or this Act shall be limited to such a | ||||||
7 | person whose countable income is
determined by the Department | ||||||
8 | to be at or below such income eligibility
standard as the | ||||||
9 | Department by rule shall establish. The income level
| ||||||
10 | established by the Department shall not be below 200%
90% of | ||||||
11 | the federal
poverty
level. Such persons who are determined to | ||||||
12 | be eligible must reapply, or
otherwise establish eligibility, | ||||||
13 | at least annually. An eligible person shall
be required, as | ||||||
14 | determined by the Department by rule, to report promptly those
| ||||||
15 | changes in income and other circumstances that affect | ||||||
16 | eligibility. The
eligibility of a person may be
redetermined | ||||||
17 | based on the information reported or may be terminated based on
| ||||||
18 | the failure to report or failure to report accurately. A person | ||||||
19 | may also be
held liable to the Department for any payments made | ||||||
20 | by the Department on such
person's behalf that were | ||||||
21 | inappropriate. An applicant shall be provided with
notice of | ||||||
22 | these obligations.
| ||||||
23 | (Source: P.A. 92-597, eff. 6-28-02; 93-63, eff. 6-30-03.)
| ||||||
24 | Section 10. The Illinois Public Aid Code is amended by | ||||||
25 | changing Section 5-2 and by adding Sections 5-3.5 and 5-16.14 |
| |||||||
| |||||||
1 | as follows:
| ||||||
2 | (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
| ||||||
3 | Sec. 5-2. Classes of Persons Eligible. Medical assistance | ||||||
4 | under this
Article shall be available to any of the following | ||||||
5 | classes of persons in
respect to whom a plan for coverage has | ||||||
6 | been submitted to the Governor
by the Illinois Department and | ||||||
7 | approved by him:
| ||||||
8 | 1. Recipients of basic maintenance grants under | ||||||
9 | Articles III and IV.
| ||||||
10 | 2. Persons otherwise eligible for basic maintenance | ||||||
11 | under Articles
III and IV but who fail to qualify | ||||||
12 | thereunder on the basis of need, and
who have insufficient | ||||||
13 | income and resources to meet the costs of
necessary medical | ||||||
14 | care, including but not limited to the following:
| ||||||
15 | (a) All persons otherwise eligible for basic | ||||||
16 | maintenance under Article
III but who fail to qualify | ||||||
17 | under that Article on the basis of need and who
meet | ||||||
18 | either of the following requirements:
| ||||||
19 | (i) their income, as determined by the | ||||||
20 | Illinois Department in
accordance with any federal | ||||||
21 | requirements, is equal to or less than 70% in
| ||||||
22 | fiscal year 2001, equal to or less than 85% in | ||||||
23 | fiscal year 2002 and until
a date to be determined | ||||||
24 | by the Department by rule, and equal to or less
| ||||||
25 | than 100% beginning on the date determined by the |
| |||||||
| |||||||
1 | Department by rule, of the nonfarm income official | ||||||
2 | poverty
line, as defined by the federal Office of | ||||||
3 | Management and Budget and revised
annually in | ||||||
4 | accordance with Section 673(2) of the Omnibus | ||||||
5 | Budget Reconciliation
Act of 1981, applicable to | ||||||
6 | families of the same size; or
| ||||||
7 | (ii) their income, after the deduction of | ||||||
8 | costs incurred for medical
care and for other types | ||||||
9 | of remedial care, is equal to or less than 70% in
| ||||||
10 | fiscal year 2001, equal to or less than 85% in | ||||||
11 | fiscal year 2002 and until
a date to be determined | ||||||
12 | by the Department by rule, and equal to or less
| ||||||
13 | than 100% beginning on the date determined by the | ||||||
14 | Department by rule, of the nonfarm income official | ||||||
15 | poverty
line, as defined in item (i) of this | ||||||
16 | subparagraph (a).
| ||||||
17 | (b) All persons who would be determined eligible | ||||||
18 | for such basic
maintenance under Article IV by | ||||||
19 | disregarding the maximum earned income
permitted by | ||||||
20 | federal law.
| ||||||
21 | 3. Persons who would otherwise qualify for Aid to the | ||||||
22 | Medically
Indigent under Article VII.
| ||||||
23 | 4. Persons not eligible under any of the preceding | ||||||
24 | paragraphs who fall
sick, are injured, or die, not having | ||||||
25 | sufficient money, property or other
resources to meet the | ||||||
26 | costs of necessary medical care or funeral and burial
|
| |||||||
| |||||||
1 | expenses.
| ||||||
2 | 5.(a) Women during pregnancy, after the fact
of | ||||||
3 | pregnancy has been determined by medical diagnosis, and | ||||||
4 | during the
60-day period beginning on the last day of the | ||||||
5 | pregnancy, together with
their infants and children born | ||||||
6 | after September 30, 1983,
whose income and
resources are | ||||||
7 | insufficient to meet the costs of necessary medical care to
| ||||||
8 | the maximum extent possible under Title XIX of the
Federal | ||||||
9 | Social Security Act.
| ||||||
10 | (b) The Illinois Department and the Governor shall | ||||||
11 | provide a plan for
coverage of the persons eligible under | ||||||
12 | paragraph 5(a) by April 1, 1990. Such
plan shall provide | ||||||
13 | ambulatory prenatal care to pregnant women during a
| ||||||
14 | presumptive eligibility period and establish an income | ||||||
15 | eligibility standard
that is equal to 133%
of the nonfarm | ||||||
16 | income official poverty line, as defined by
the federal | ||||||
17 | Office of Management and Budget and revised annually in
| ||||||
18 | accordance with Section 673(2) of the Omnibus Budget | ||||||
19 | Reconciliation Act of
1981, applicable to families of the | ||||||
20 | same size, provided that costs incurred
for medical care | ||||||
21 | are not taken into account in determining such income
| ||||||
22 | eligibility.
| ||||||
23 | (c) The Illinois Department may conduct a | ||||||
24 | demonstration in at least one
county that will provide | ||||||
25 | medical assistance to pregnant women, together
with their | ||||||
26 | infants and children up to one year of age,
where the |
| |||||||
| |||||||
1 | income
eligibility standard is set up to 185% of the | ||||||
2 | nonfarm income official
poverty line, as defined by the | ||||||
3 | federal Office of Management and Budget.
The Illinois | ||||||
4 | Department shall seek and obtain necessary authorization
| ||||||
5 | provided under federal law to implement such a | ||||||
6 | demonstration. Such
demonstration may establish resource | ||||||
7 | standards that are not more
restrictive than those | ||||||
8 | established under Article IV of this Code.
| ||||||
9 | 6. Persons under the age of 18 who fail to qualify as | ||||||
10 | dependent under
Article IV and who have insufficient income | ||||||
11 | and resources to meet the costs
of necessary medical care | ||||||
12 | to the maximum extent permitted under Title XIX
of the | ||||||
13 | Federal Social Security Act.
| ||||||
14 | 7. Persons who are under 21 years of age and would
| ||||||
15 | qualify as
disabled as defined under the Federal | ||||||
16 | Supplemental Security Income Program,
provided medical | ||||||
17 | service for such persons would be eligible for Federal
| ||||||
18 | Financial Participation, and provided the Illinois | ||||||
19 | Department determines that:
| ||||||
20 | (a) the person requires a level of care provided by | ||||||
21 | a hospital, skilled
nursing facility, or intermediate | ||||||
22 | care facility, as determined by a physician
licensed to | ||||||
23 | practice medicine in all its branches;
| ||||||
24 | (b) it is appropriate to provide such care outside | ||||||
25 | of an institution, as
determined by a physician | ||||||
26 | licensed to practice medicine in all its branches;
|
| |||||||
| |||||||
1 | (c) the estimated amount which would be expended | ||||||
2 | for care outside the
institution is not greater than | ||||||
3 | the estimated amount which would be
expended in an | ||||||
4 | institution.
| ||||||
5 | 8. Persons who become ineligible for basic maintenance | ||||||
6 | assistance
under Article IV of this Code in programs | ||||||
7 | administered by the Illinois
Department due to employment | ||||||
8 | earnings and persons in
assistance units comprised of | ||||||
9 | adults and children who become ineligible for
basic | ||||||
10 | maintenance assistance under Article VI of this Code due to
| ||||||
11 | employment earnings. The plan for coverage for this class | ||||||
12 | of persons shall:
| ||||||
13 | (a) extend the medical assistance coverage for up | ||||||
14 | to 12 months following
termination of basic | ||||||
15 | maintenance assistance; and
| ||||||
16 | (b) offer persons who have initially received 6 | ||||||
17 | months of the
coverage provided in paragraph (a) above, | ||||||
18 | the option of receiving an
additional 6 months of | ||||||
19 | coverage, subject to the following:
| ||||||
20 | (i) such coverage shall be pursuant to | ||||||
21 | provisions of the federal
Social Security Act;
| ||||||
22 | (ii) such coverage shall include all services | ||||||
23 | covered while the person
was eligible for basic | ||||||
24 | maintenance assistance;
| ||||||
25 | (iii) no premium shall be charged for such | ||||||
26 | coverage; and
|
| |||||||
| |||||||
1 | (iv) such coverage shall be suspended in the | ||||||
2 | event of a person's
failure without good cause to | ||||||
3 | file in a timely fashion reports required for
this | ||||||
4 | coverage under the Social Security Act and | ||||||
5 | coverage shall be reinstated
upon the filing of | ||||||
6 | such reports if the person remains otherwise | ||||||
7 | eligible.
| ||||||
8 | 9. Persons with acquired immunodeficiency syndrome | ||||||
9 | (AIDS) or with
AIDS-related conditions with respect to whom | ||||||
10 | there has been a determination
that but for home or | ||||||
11 | community-based services such individuals would
require | ||||||
12 | the level of care provided in an inpatient hospital, | ||||||
13 | skilled
nursing facility or intermediate care facility the | ||||||
14 | cost of which is
reimbursed under this Article. Assistance | ||||||
15 | shall be provided to such
persons to the maximum extent | ||||||
16 | permitted under Title
XIX of the Federal Social Security | ||||||
17 | Act.
| ||||||
18 | 10. Participants in the long-term care insurance | ||||||
19 | partnership program
established under the Partnership for | ||||||
20 | Long-Term Care Act who meet the
qualifications for | ||||||
21 | protection of resources described in Section 25 of that
| ||||||
22 | Act.
| ||||||
23 | 11. Persons with disabilities who are employed and | ||||||
24 | eligible for Medicaid,
pursuant to Section | ||||||
25 | 1902(a)(10)(A)(ii)(xv) of the Social Security Act, as
| ||||||
26 | provided by the Illinois Department by rule.
|
| |||||||
| |||||||
1 | 12. Subject to federal approval, persons who are | ||||||
2 | eligible for medical
assistance coverage under applicable | ||||||
3 | provisions of the federal Social Security
Act and the | ||||||
4 | federal Breast and Cervical Cancer Prevention and | ||||||
5 | Treatment Act of
2000. Those eligible persons are defined | ||||||
6 | to include, but not be limited to,
the following persons:
| ||||||
7 | (1) persons who have been screened for breast or | ||||||
8 | cervical cancer under
the U.S. Centers for Disease | ||||||
9 | Control and Prevention Breast and Cervical Cancer
| ||||||
10 | Program established under Title XV of the federal | ||||||
11 | Public Health Services Act in
accordance with the | ||||||
12 | requirements of Section 1504 of that Act as | ||||||
13 | administered by
the Illinois Department of Public | ||||||
14 | Health; and
| ||||||
15 | (2) persons whose screenings under the above | ||||||
16 | program were funded in whole
or in part by funds | ||||||
17 | appropriated to the Illinois Department of Public | ||||||
18 | Health
for breast or cervical cancer screening.
| ||||||
19 | "Medical assistance" under this paragraph 12 shall be | ||||||
20 | identical to the benefits
provided under the State's | ||||||
21 | approved plan under Title XIX of the Social Security
Act. | ||||||
22 | The Department must request federal approval of the | ||||||
23 | coverage under this
paragraph 12 within 30 days after the | ||||||
24 | effective date of this amendatory Act of
the 92nd General | ||||||
25 | Assembly.
| ||||||
26 | 13. Subject to appropriation and to federal approval, |
| |||||||
| |||||||
1 | persons living with HIV/AIDS who are not otherwise eligible | ||||||
2 | under this Article and who qualify for services covered | ||||||
3 | under Section 5-5.04 as provided by the Illinois Department | ||||||
4 | by rule.
| ||||||
5 | 14. Subject to the availability of funds for this | ||||||
6 | purpose, the Department may provide coverage under this | ||||||
7 | Article to persons who reside in Illinois who are not | ||||||
8 | eligible under any of the preceding paragraphs and who meet | ||||||
9 | the income guidelines of paragraph 2(a) of this Section and | ||||||
10 | (i) have an application for asylum pending before the | ||||||
11 | federal Department of Homeland Security or on appeal before | ||||||
12 | a court of competent jurisdiction and are represented | ||||||
13 | either by counsel or by an advocate accredited by the | ||||||
14 | federal Department of Homeland Security and employed by a | ||||||
15 | not-for-profit organization in regard to that application | ||||||
16 | or appeal, or (ii) are receiving services through a | ||||||
17 | federally funded torture treatment center. Medical | ||||||
18 | coverage under this paragraph 14 may be provided for up to | ||||||
19 | 24 continuous months from the initial eligibility date so | ||||||
20 | long as an individual continues to satisfy the criteria of | ||||||
21 | this paragraph 14. If an individual has an appeal pending | ||||||
22 | regarding an application for asylum before the Department | ||||||
23 | of Homeland Security, eligibility under this paragraph 14 | ||||||
24 | may be extended until a final decision is rendered on the | ||||||
25 | appeal. The Department may adopt rules governing the | ||||||
26 | implementation of this paragraph 14.
|
| |||||||
| |||||||
1 | 15. Subject to appropriations and federal approval, | ||||||
2 | any individual who resides in Illinois and has an income | ||||||
3 | level, as determined by the Illinois Department in | ||||||
4 | accordance with any federal requirements, that is between | ||||||
5 | zero and 100% of the federal poverty guidelines as | ||||||
6 | published annually by the United States Department of | ||||||
7 | Health and Human Services. The Department shall promptly | ||||||
8 | apply for all waivers of federal law and regulations that | ||||||
9 | are necessary to allow the full implementation of this | ||||||
10 | paragraph 15.
| ||||||
11 | The Illinois Department and the Governor shall provide a | ||||||
12 | plan for
coverage of the persons eligible under paragraph 7 as | ||||||
13 | soon as possible after
July 1, 1984.
| ||||||
14 | The eligibility of any such person for medical assistance | ||||||
15 | under this
Article is not affected by the payment of any grant | ||||||
16 | under the Senior
Citizens and Disabled Persons Property Tax | ||||||
17 | Relief and Pharmaceutical
Assistance Act or any distributions | ||||||
18 | or items of income described under
subparagraph (X) of
| ||||||
19 | paragraph (2) of subsection (a) of Section 203 of the Illinois | ||||||
20 | Income Tax
Act. The Department shall by rule establish the | ||||||
21 | amounts of
assets to be disregarded in determining eligibility | ||||||
22 | for medical assistance,
which shall at a minimum equal the | ||||||
23 | amounts to be disregarded under the
Federal Supplemental | ||||||
24 | Security Income Program. The amount of assets of a
single | ||||||
25 | person to be disregarded
shall not be less than $2,000, and the | ||||||
26 | amount of assets of a married couple
to be disregarded shall |
| |||||||
| |||||||
1 | not be less than $3,000.
| ||||||
2 | To the extent permitted under federal law, any person found | ||||||
3 | guilty of a
second violation of Article VIIIA
shall be | ||||||
4 | ineligible for medical assistance under this Article, as | ||||||
5 | provided
in Section 8A-8.
| ||||||
6 | The eligibility of any person for medical assistance under | ||||||
7 | this Article
shall not be affected by the receipt by the person | ||||||
8 | of donations or benefits
from fundraisers held for the person | ||||||
9 | in cases of serious illness,
as long as neither the person nor | ||||||
10 | members of the person's family
have actual control over the | ||||||
11 | donations or benefits or the disbursement
of the donations or | ||||||
12 | benefits.
| ||||||
13 | (Source: P.A. 93-20, eff. 6-20-03; 94-629, eff. 1-1-06; | ||||||
14 | 94-1043, eff. 7-24-06.)
| ||||||
15 | (305 ILCS 5/5-3.5 new) | ||||||
16 | Sec. 5-3.5. Method of providing health benefits coverage. | ||||||
17 | (a) Subject to appropriation and federal approval, the | ||||||
18 | Department of Healthcare and Family Services shall provide | ||||||
19 | health benefits coverage to eligible individuals by: | ||||||
20 | (1) subsidizing the cost of privately sponsored health | ||||||
21 | insurance, including employer-based health insurance, to | ||||||
22 | assist individuals in taking advantage of available | ||||||
23 | privately sponsored health insurance; and | ||||||
24 | (2) purchasing or providing health care benefits for | ||||||
25 | eligible individuals. |
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1 | For individuals eligible for Medicaid under a mandatory | ||||||
2 | eligibility group who have access to privately sponsored health | ||||||
3 | insurance, the health benefits provided under subdivision | ||||||
4 | (a)(2) shall continue to be the benefit package specified in | ||||||
5 | the State Medicaid plan. In addition, such individuals shall be | ||||||
6 | subject to nominal cost-sharing only, in accordance with the | ||||||
7 | State Medicaid plan. | ||||||
8 | (b) The subsidization provided pursuant to subdivision | ||||||
9 | (a)(1) shall be credited to the eligible individual. | ||||||
10 | (c) For an eligible individual who is not included in a | ||||||
11 | mandatory Medicaid eligibility group, the Department is | ||||||
12 | prohibited from denying coverage to an individual who is | ||||||
13 | enrolled in a privately sponsored health insurance plan | ||||||
14 | pursuant to subdivision (a)(1) because the plan does not meet | ||||||
15 | federal benchmarking standards or cost-sharing and | ||||||
16 | contribution requirements. To be eligible for inclusion in the | ||||||
17 | Program, the plan shall contain comprehensive major medical | ||||||
18 | coverage which shall consist of physician and hospital | ||||||
19 | inpatient services. The Department is prohibited from denying | ||||||
20 | coverage to an individual who is enrolled in a privately | ||||||
21 | sponsored health insurance plan pursuant to subdivision (a)(1) | ||||||
22 | because the plan offers benefits in addition to physician and | ||||||
23 | hospital inpatient services. | ||||||
24 | (d) For all eligible individuals, provisions related to | ||||||
25 | benefits, cost-sharing, and premium assistance benefit costs | ||||||
26 | shall be consistent with federal law and regulations. |
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1 | (e) The Department shall promptly apply for all waivers of | ||||||
2 | federal law and regulations that are necessary to allow the | ||||||
3 | full implementation of this Section. | ||||||
4 | (305 ILCS 5/5-16.14 new) | ||||||
5 | Sec. 5-16.14. Transition to capitated managed care system. | ||||||
6 | (a) On and after July 1, 2008, the Department of Healthcare | ||||||
7 | and Family Services shall implement a capitated managed care | ||||||
8 | system for selected populations of persons. Under the capitated | ||||||
9 | managed care system, the State shall pay a fixed amount per | ||||||
10 | individual per month to a third-party entity to manage the | ||||||
11 | program of health care benefits and assume the risk associated | ||||||
12 | with the payment of medical bills without regard to actual | ||||||
13 | medical claims incurred.
The Department shall adopt rules | ||||||
14 | establishing the populations that must participate in the | ||||||
15 | capitated managed care system. | ||||||
16 | (b) A medical assistance recipient shall not be required to | ||||||
17 | participate in, and shall be permitted to withdraw from, the | ||||||
18 | managed care program under the following circumstances: | ||||||
19 | (1) A pregnant woman with an established relationship, | ||||||
20 | as defined by the Department, with a comprehensive prenatal | ||||||
21 | primary care provider that is not associated with the | ||||||
22 | managed care provider in the participant's service area may | ||||||
23 | defer participation in the managed care program while | ||||||
24 | pregnant and for 60 days post-partum. | ||||||
25 | (ii) An individual with a chronic medical condition |
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1 | being treated by a specialist physician who is not | ||||||
2 | associated with a managed care provider in the | ||||||
3 | participant's service area may defer participation in the | ||||||
4 | managed care program until the course of treatment is | ||||||
5 | complete. | ||||||
6 | (c) The following medical assistance recipients shall not | ||||||
7 | be required to participate in a managed care program | ||||||
8 | established pursuant to this Section, but may voluntarily opt | ||||||
9 | to do so: | ||||||
10 | (i) A person receiving services provided by a | ||||||
11 | residential alcohol or substance abuse program or facility | ||||||
12 | for the mentally retarded. | ||||||
13 | (ii) A person receiving services provided by an | ||||||
14 | intermediate care facility for the mentally retarded or who | ||||||
15 | has characteristics and needs similar to such persons. | ||||||
16 | (iii) A person with a developmental or physical | ||||||
17 | disability who receives home and community-based services | ||||||
18 | or care-at-home services through existing waivers under | ||||||
19 | section 1915(c) of the Social Security Act or who has | ||||||
20 | characteristics and needs similar to such persons. | ||||||
21 | (iv) Native Americans. | ||||||
22 | (v) Medicare/Medicaid dually eligible individuals not | ||||||
23 | enrolled in a Medicare TEFRA plan. | ||||||
24 | (d) The following medical assistance recipients shall not | ||||||
25 | be eligible to participate in a managed care program | ||||||
26 | established pursuant to this Section: |
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1 | (i) A person receiving services provided by a long term | ||||||
2 | home health care program, or a person receiving inpatient | ||||||
3 | services in a State-operated psychiatric facility or a | ||||||
4 | residential treatment facility for children and youth. | ||||||
5 | (ii) A person eligible for Medicare participating in a | ||||||
6 | capitated demonstration program for long-term care. | ||||||
7 | (iii) An infant living with an incarcerated mother in a | ||||||
8 | county jail or in a correctional facility as defined in | ||||||
9 | Section 3-1-2 of the Unified Code of Corrections. | ||||||
10 | (iv) A person who is expected to be eligible for | ||||||
11 | medical assistance for less than 6 months. | ||||||
12 | (v) A person who is eligible for medical assistance | ||||||
13 | benefits only with respect to tuberculosis-related | ||||||
14 | services. | ||||||
15 | (vi) A certified blind or disabled child living or | ||||||
16 | expected to be living separate and apart from his or her | ||||||
17 | parent for 30 days or more. | ||||||
18 | (vii) A resident of a nursing facility at the time of | ||||||
19 | enrollment. | ||||||
20 | (viii) An individual receiving hospice services at the | ||||||
21 | time of enrollment. | ||||||
22 | (ix) A person who has primary medical or health care | ||||||
23 | coverage available from or under a third-party payor which | ||||||
24 | may be maintained by payment, or part payment, of the | ||||||
25 | premium or cost-sharing amounts, when payment of such | ||||||
26 | premium or cost-sharing amounts would be cost-effective, |
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1 | as determined by the Department. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
2 | (x) A foster child in the placement of a voluntary | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
3 | agency. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
4 | (e) The Department shall adopt rules providing for the | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
5 | implementation and continued oversight of the capitated | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
6 | managed care system. The rules shall provide for the | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
7 | implementation of the system in a manner consistent with the | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
8 | Department's implementation of a capitated managed care system | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
9 | under subsection (a) of Section 27 of the Children's Health | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
10 | Insurance Program Act. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
11 | (f) The Department shall implement the capitated managed | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
12 | care system in a manner that maximizes all available State and | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
13 | federal funds, including those obtained through | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
14 | intergovernmental transfers, supplemental Medicaid payments, | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
15 | and the disproportionate share program. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
16 | (g) The Department shall implement actuarially sound, | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
17 | risk-adjusted capitation rates for recipients in the capitated | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
18 | managed care program which cover comprehensive care, | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
19 | catastrophic care, and an Enhanced Benefits Account Program | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
20 | that rewards recipients for taking part in activities that | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
21 | improve their health. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
22 | (h) The Department shall promptly apply for all waivers of | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
23 | federal law and regulations that are necessary to allow the | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
24 | full implementation of this Section.
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