Rep. Robyn Gabel

Filed: 5/25/2023

 

 


 

 


 
10300SB1298ham002LRB103 28018 KTG 62535 a

1
AMENDMENT TO SENATE BILL 1298

2    AMENDMENT NO. ______. Amend Senate Bill 1298 by replacing
3everything after the enacting clause with the following:
 
4
"ARTICLE 1.

 
5    Section 1-1. Short title. This Article may be cited as the
6Substance Use Disorder Residential and Detox Rate Equity Act.
7References in this Article to "this Act" mean this Article.
 
8    Section 1-5. Funding for licensed or certified
9community-based substance use disorder treatment providers.
10Subject to federal approval, beginning on January 1, 2024 for
11State Fiscal Year 2024, and for each State fiscal year
12thereafter, the General Assembly shall appropriate sufficient
13funds to the Department of Human Services to ensure
14reimbursement rates will be increased and subsequently
15adjusted upward by an amount equal to the Consumer Price

 

 

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1Index-U from the previous year, not to exceed 5% in any State
2fiscal year, for licensed or certified substance use disorder
3treatment providers of ASAM Level 3 residential/inpatient
4services under community service grant programs for persons
5with substance use disorders.
6    If there is a decrease in the Consumer Price Index-U,
7rates shall remain unchanged for that State fiscal year. The
8Department of Human Services shall increase the grant contract
9amount awarded to each eligible community-based substance use
10disorder treatment provider to ensure that the level and
11number of services provided under community service grant
12programs shall not be reduced by increasing the amount
13available to each provider under the community service grant
14programs to address the increased rate for each such service.
15    The Department shall adopt rules, including emergency
16rules in accordance with Section 5-45 of the Illinois
17Administrative Procedure Act, to implement the provisions of
18this Act.
19    As used in this Act, "Consumer Price Index-U" means the
20index published by the Bureau of Labor Statistics of the
21United States Department of Labor that measures the average
22change in prices of goods and services purchased by all urban
23consumers, United States city average, all items, 1982-84 =
24100.
 
25
ARTICLE 5.

 

 

 

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1    Section 5-10. The Illinois Administrative Procedure Act is
2amended by adding Section 5-45.35 as follows:
 
3    (5 ILCS 100/5-45.35 new)
4    Sec. 5-45.35. Emergency rulemaking; Substance Use Disorder
5Residential and Detox Rate Equity. To provide for the
6expeditious and timely implementation of the Substance Use
7Disorder Residential and Detox Rate Equity Act, emergency
8rules implementing the Substance Use Disorder Residential and
9Detox Rate Equity Act may be adopted in accordance with
10Section 5-45 by the Department of Human Services and the
11Department of Healthcare and Family Services. The adoption of
12emergency rules authorized by Section 5-45 and this Section is
13deemed to be necessary for the public interest, safety, and
14welfare.
15    This Section is repealed one year after the effective date
16of this amendatory Act of the 103rd General Assembly.
 
17    Section 5-15. The Substance Use Disorder Act is amended by
18changing Section 55-30 as follows:
 
19    (20 ILCS 301/55-30)
20    Sec. 55-30. Rate increase.
21    (a) The Department shall by rule develop the increased
22rate methodology and annualize the increased rate beginning

 

 

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1with State fiscal year 2018 contracts to licensed providers of
2community-based substance use disorder intervention or
3treatment, based on the additional amounts appropriated for
4the purpose of providing a rate increase to licensed
5providers. The Department shall adopt rules, including
6emergency rules under subsection (y) of Section 5-45 of the
7Illinois Administrative Procedure Act, to implement the
8provisions of this Section.
9    (b) (Blank).
10    (c) Beginning on July 1, 2022, the Division of Substance
11Use Prevention and Recovery shall increase reimbursement rates
12for all community-based substance use disorder treatment and
13intervention services by 47%, including, but not limited to,
14all of the following:
15        (1) Admission and Discharge Assessment.
16        (2) Level 1 (Individual).
17        (3) Level 1 (Group).
18        (4) Level 2 (Individual).
19        (5) Level 2 (Group).
20        (6) Case Management.
21        (7) Psychiatric Evaluation.
22        (8) Medication Assisted Recovery.
23        (9) Community Intervention.
24        (10) Early Intervention (Individual).
25        (11) Early Intervention (Group).
26    Beginning in State Fiscal Year 2023, and every State

 

 

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1fiscal year thereafter, reimbursement rates for those
2community-based substance use disorder treatment and
3intervention services shall be adjusted upward by an amount
4equal to the Consumer Price Index-U from the previous year,
5not to exceed 2% in any State fiscal year. If there is a
6decrease in the Consumer Price Index-U, rates shall remain
7unchanged for that State fiscal year. The Department shall
8adopt rules, including emergency rules in accordance with the
9Illinois Administrative Procedure Act, to implement the
10provisions of this Section.
11    As used in this subsection, "consumer price index-u" means
12the index published by the Bureau of Labor Statistics of the
13United States Department of Labor that measures the average
14change in prices of goods and services purchased by all urban
15consumers, United States city average, all items, 1982-84 =
16100.
17    (d) Beginning on January 1, 2024, subject to federal
18approval, the Division of Substance Use Prevention and
19Recovery shall increase reimbursement rates for all ASAM level
203 residential/inpatient substance use disorder treatment and
21intervention services by 30%, including, but not limited to,
22the following services:
23        (1) ASAM level 3.5 Clinically Managed High-Intensity
24    Residential Services for adults;
25        (2) ASAM level 3.5 Clinically Managed Medium-Intensity
26    Residential Services for adolescents;

 

 

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1        (3) ASAM level 3.2 Clinically Managed Residential
2    Withdrawal Management;
3        (4) ASAM level 3.7 Medically Monitored Intensive
4    Inpatient Services for adults and Medically Monitored
5    High-Intensity Inpatient Services for adolescents; and
6        (5) ASAM level 3.1 Clinically Managed Low-Intensity
7    Residential Services for adults and adolescents.
8(Source: P.A. 101-81, eff. 7-12-19; 102-699, eff. 4-19-22.)
 
9    Section 5-20. The Illinois Public Aid Code is amended by
10adding Section 5-47 as follows:
 
11    (305 ILCS 5/5-47 new)
12    Sec. 5-47. Medicaid reimbursement rates; substance use
13disorder treatment providers and facilities.
14    (a) Subject to federal approval, the Department of
15Healthcare and Family Services, in conjunction with the
16Department of Human Services' Division of Substance Use
17Prevention and Recovery, shall provide a 30% increase in
18reimbursement rates for all Medicaid-covered ASAM Level 3
19residential/inpatient substance use disorder treatment
20services.
21    No existing or future reimbursement rates or add-ons shall
22be reduced or changed to address this proposed rate increase.
23No later than 3 months after the effective date of this
24amendatory Act of the 103rd General Assembly, the Department

 

 

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1of Healthcare and Family Services shall submit any necessary
2application to the federal Centers for Medicare and Medicaid
3Services to implement the requirements of this Section.
4    (b) Parity in community-based behavioral health rates;
5implementation plan for cost reporting. For the purpose of
6understanding behavioral health services cost structures and
7their impact on the Medical Assistance Program, the Department
8of Healthcare and Family Services shall engage stakeholders to
9develop a plan for the regular collection of cost reporting
10for all entity-based substance use disorder providers. Data
11shall be used to inform on the effectiveness and efficiency of
12Illinois Medicaid rates. The Department and stakeholders shall
13develop a plan by April 1, 2024. The Department shall engage
14stakeholders on implementation of the plan. The plan, at
15minimum, shall consider all of the following:
16        (1) Alignment with certified community behavioral
17    health clinic requirements, standards, policies, and
18    procedures.
19        (2) Inclusion of prospective costs to measure what is
20    needed to increase services and capacity.
21        (3) Consideration of differences in collection and
22    policies based on the size of providers.
23        (4) Consideration of additional administrative time
24    and costs.
25        (5) Goals, purposes, and usage of data collected from
26    cost reports.

 

 

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1        (6) Inclusion of qualitative data in addition to
2    quantitative data.
3        (7) Technical assistance for providers for completing
4    cost reports including initial training by the Department
5    for providers.
6        (8) Implementation of a timeline which allows an
7    initial grace period for providers to adjust internal
8    procedures and data collection.
9    Details from collected cost reports shall be made publicly
10available on the Department's website and costs shall be used
11to ensure the effectiveness and efficiency of Illinois
12Medicaid rates.
13    (c) Reporting; access to substance use disorder treatment
14services and recovery supports. By no later than April 1,
152024, the Department of Healthcare and Family Services, with
16input from the Department of Human Services' Division of
17Substance Use Prevention and Recovery, shall submit a report
18to the General Assembly regarding access to treatment services
19and recovery supports for persons diagnosed with a substance
20use disorder. The report shall include, but is not limited to,
21the following information:
22        (1) The number of providers enrolled in the Illinois
23    Medical Assistance Program certified to provide substance
24    use disorder treatment services, aggregated by ASAM level
25    of care, and recovery supports.
26        (2) The number of Medicaid customers in Illinois with

 

 

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1    a diagnosed substance use disorder receiving substance use
2    disorder treatment, aggregated by provider type and ASAM
3    level of care.
4        (3) A comparison of Illinois' substance use disorder
5    licensure and certification requirements with those of
6    comparable state Medicaid programs.
7        (4) Recommendations for and an analysis of the impact
8    of aligning reimbursement rates for outpatient substance
9    use disorder treatment services with reimbursement rates
10    for community-based mental health treatment services.
11        (5) Recommendations for expanding substance use
12    disorder treatment to other qualified provider entities
13    and licensed professionals of the healing arts. The
14    recommendations shall include an analysis of the
15    opportunities to maximize the flexibilities permitted by
16    the federal Centers for Medicare and Medicaid Services for
17    expanding access to the number and types of qualified
18    substance use disorder providers.
 
19
ARTICLE 10.

 
20    Section 10-1. The Illinois Administrative Procedure Act is
21amended by adding Section 5-45.36 as follows:
 
22    (5 ILCS 100/5-45.36 new)
23    Sec. 5-45.36. Emergency rulemaking; Medicaid reimbursement

 

 

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1rates for hospital inpatient and outpatient services. To
2provide for the expeditious and timely implementation of the
3changes made by this amendatory Act of the 103rd General
4Assembly to Sections 5-5.05, 14-12, 14-12.5, and 14-12.7 of
5the Illinois Public Aid Code, emergency rules implementing the
6changes made by this amendatory Act of the 103rd General
7Assembly to Sections 5-5.05, 14-12, 14-12.5, and 14-12.7 of
8the Illinois Public Aid Code may be adopted in accordance with
9Section 5-45 by the Department of Healthcare and Family
10Services. The adoption of emergency rules authorized by
11Section 5-45 and this Section is deemed to be necessary for the
12public interest, safety, and welfare.
13    This Section is repealed one year after the effective date
14of this amendatory Act of the 103rd General Assembly.
 
15    Section 10-5. The Illinois Public Aid Code is amended by
16changing Sections 5-5.05, 5A-12.7, 12-4.105, and 14-12 and by
17adding Sections 14-12.5 and 14-12.7 as follows:
 
18    (305 ILCS 5/5-5.05)
19    Sec. 5-5.05. Hospitals; psychiatric services.
20    (a) On and after January 1, 2024 July 1, 2008, the
21inpatient, per diem rate to be paid to a hospital for inpatient
22psychiatric services shall be not less than 90% of the per diem
23rate established in accordance with paragraph (b-5) of this
24section, subject to the provisions of Section 14-12.5 $363.77.

 

 

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1    (b) For purposes of this Section, "hospital" means a the
2following:
3        (1) Advocate Christ Hospital, Oak Lawn, Illinois.
4        (2) Barnes-Jewish Hospital, St. Louis, Missouri.
5        (3) BroMenn Healthcare, Bloomington, Illinois.
6        (4) Jackson Park Hospital, Chicago, Illinois.
7        (5) Katherine Shaw Bethea Hospital, Dixon, Illinois.
8        (6) Lawrence County Memorial Hospital, Lawrenceville,
9    Illinois.
10        (7) Advocate Lutheran General Hospital, Park Ridge,
11    Illinois.
12        (8) Mercy Hospital and Medical Center, Chicago,
13    Illinois.
14        (9) Methodist Medical Center of Illinois, Peoria,
15    Illinois.
16        (10) Provena United Samaritans Medical Center,
17    Danville, Illinois.
18        (11) Rockford Memorial Hospital, Rockford, Illinois.
19        (12) Sarah Bush Lincoln Health Center, Mattoon,
20    Illinois.
21        (13) Provena Covenant Medical Center, Urbana,
22    Illinois.
23        (14) Rush-Presbyterian-St. Luke's Medical Center,
24    Chicago, Illinois.
25        (15) Mt. Sinai Hospital, Chicago, Illinois.
26        (16) Gateway Regional Medical Center, Granite City,

 

 

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1    Illinois.
2        (17) St. Mary of Nazareth Hospital, Chicago, Illinois.
3        (18) Provena St. Mary's Hospital, Kankakee, Illinois.
4        (19) St. Mary's Hospital, Decatur, Illinois.
5        (20) Memorial Hospital, Belleville, Illinois.
6        (21) Swedish Covenant Hospital, Chicago, Illinois.
7        (22) Trinity Medical Center, Rock Island, Illinois.
8        (23) St. Elizabeth Hospital, Chicago, Illinois.
9        (24) Richland Memorial Hospital, Olney, Illinois.
10        (25) St. Elizabeth's Hospital, Belleville, Illinois.
11        (26) Samaritan Health System, Clinton, Iowa.
12        (27) St. John's Hospital, Springfield, Illinois.
13        (28) St. Mary's Hospital, Centralia, Illinois.
14        (29) Loretto Hospital, Chicago, Illinois.
15        (30) Kenneth Hall Regional Hospital, East St. Louis,
16    Illinois.
17        (31) Hinsdale Hospital, Hinsdale, Illinois.
18        (32) Pekin Hospital, Pekin, Illinois.
19        (33) University of Chicago Medical Center, Chicago,
20    Illinois.
21        (34) St. Anthony's Health Center, Alton, Illinois.
22        (35) OSF St. Francis Medical Center, Peoria, Illinois.
23        (36) Memorial Medical Center, Springfield, Illinois.
24        (37) A hospital with a distinct part unit for
25    psychiatric services that begins operating on or after
26    July 1, 2008.

 

 

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1    For purposes of this Section, "inpatient psychiatric
2services" means those services provided to patients who are in
3need of short-term acute inpatient hospitalization for active
4treatment of an emotional or mental disorder.
5    (b-5) Notwithstanding any other provision of this Section,
6and subject to appropriation, the inpatient, per diem rate to
7be paid to all safety-net hospitals for inpatient psychiatric
8services on and after January 1, 2021 shall be at least $630,
9subject to the provisions of Section 14-12.5.
10    (b-10) Notwithstanding any other provision of this
11Section, effective with dates of service on and after January
121, 2022, any general acute care hospital with more than 9,500
13inpatient psychiatric Medicaid days in any calendar year shall
14be paid the inpatient per diem rate of no less than $630,
15subject to the provisions of Section 14-12.5.
16    (c) No rules shall be promulgated to implement this
17Section. For purposes of this Section, "rules" is given the
18meaning contained in Section 1-70 of the Illinois
19Administrative Procedure Act.
20    (d) (Blank). This Section shall not be in effect during
21any period of time that the State has in place a fully
22operational hospital assessment plan that has been approved by
23the Centers for Medicare and Medicaid Services of the U.S.
24Department of Health and Human Services.
25    (e) On and after July 1, 2012, the Department shall reduce
26any rate of reimbursement for services or other payments or

 

 

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1alter any methodologies authorized by this Code to reduce any
2rate of reimbursement for services or other payments in
3accordance with Section 5-5e.
4(Source: P.A. 102-4, eff. 4-27-21; 102-674, eff. 11-30-21.)
 
5    (305 ILCS 5/5A-12.7)
6    (Section scheduled to be repealed on December 31, 2026)
7    Sec. 5A-12.7. Continuation of hospital access payments on
8and after July 1, 2020.
9    (a) To preserve and improve access to hospital services,
10for hospital services rendered on and after July 1, 2020, the
11Department shall, except for hospitals described in subsection
12(b) of Section 5A-3, make payments to hospitals or require
13capitated managed care organizations to make payments as set
14forth in this Section. Payments under this Section are not due
15and payable, however, until: (i) the methodologies described
16in this Section are approved by the federal government in an
17appropriate State Plan amendment or directed payment preprint;
18and (ii) the assessment imposed under this Article is
19determined to be a permissible tax under Title XIX of the
20Social Security Act. In determining the hospital access
21payments authorized under subsection (g) of this Section, if a
22hospital ceases to qualify for payments from the pool, the
23payments for all hospitals continuing to qualify for payments
24from such pool shall be uniformly adjusted to fully expend the
25aggregate net amount of the pool, with such adjustment being

 

 

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1effective on the first day of the second month following the
2date the hospital ceases to receive payments from such pool.
3    (b) Amounts moved into claims-based rates and distributed
4in accordance with Section 14-12 shall remain in those
5claims-based rates.
6    (c) Graduate medical education.
7        (1) The calculation of graduate medical education
8    payments shall be based on the hospital's Medicare cost
9    report ending in Calendar Year 2018, as reported in the
10    Healthcare Cost Report Information System file, release
11    date September 30, 2019. An Illinois hospital reporting
12    intern and resident cost on its Medicare cost report shall
13    be eligible for graduate medical education payments.
14        (2) Each hospital's annualized Medicaid Intern
15    Resident Cost is calculated using annualized intern and
16    resident total costs obtained from Worksheet B Part I,
17    Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
18    96-98, and 105-112 multiplied by the percentage that the
19    hospital's Medicaid days (Worksheet S3 Part I, Column 7,
20    Lines 2, 3, 4, 14, 16-18, and 32) comprise of the
21    hospital's total days (Worksheet S3 Part I, Column 8,
22    Lines 14, 16-18, and 32).
23        (3) An annualized Medicaid indirect medical education
24    (IME) payment is calculated for each hospital using its
25    IME payments (Worksheet E Part A, Line 29, Column 1)
26    multiplied by the percentage that its Medicaid days

 

 

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1    (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18,
2    and 32) comprise of its Medicare days (Worksheet S3 Part
3    I, Column 6, Lines 2, 3, 4, 14, and 16-18).
4        (4) For each hospital, its annualized Medicaid Intern
5    Resident Cost and its annualized Medicaid IME payment are
6    summed, and, except as capped at 120% of the average cost
7    per intern and resident for all qualifying hospitals as
8    calculated under this paragraph, is multiplied by the
9    applicable reimbursement factor as described in this
10    paragraph, to determine the hospital's final graduate
11    medical education payment. Each hospital's average cost
12    per intern and resident shall be calculated by summing its
13    total annualized Medicaid Intern Resident Cost plus its
14    annualized Medicaid IME payment and dividing that amount
15    by the hospital's total Full Time Equivalent Residents and
16    Interns. If the hospital's average per intern and resident
17    cost is greater than 120% of the same calculation for all
18    qualifying hospitals, the hospital's per intern and
19    resident cost shall be capped at 120% of the average cost
20    for all qualifying hospitals.
21            (A) For the period of July 1, 2020 through
22        December 31, 2022, the applicable reimbursement factor
23        shall be 22.6%.
24            (B) For the period of January 1, 2023 through
25        December 31, 2026, the applicable reimbursement factor
26        shall be 35% for all qualified safety-net hospitals,

 

 

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1        as defined in Section 5-5e.1 of this Code, and all
2        hospitals with 100 or more Full Time Equivalent
3        Residents and Interns, as reported on the hospital's
4        Medicare cost report ending in Calendar Year 2018, and
5        for all other qualified hospitals the applicable
6        reimbursement factor shall be 30%.
7    (d) Fee-for-service supplemental payments. For the period
8of July 1, 2020 through December 31, 2022, each Illinois
9hospital shall receive an annual payment equal to the amounts
10below, to be paid in 12 equal installments on or before the
11seventh State business day of each month, except that no
12payment shall be due within 30 days after the later of the date
13of notification of federal approval of the payment
14methodologies required under this Section or any waiver
15required under 42 CFR 433.68, at which time the sum of amounts
16required under this Section prior to the date of notification
17is due and payable.
18        (1) For critical access hospitals, $385 per covered
19    inpatient day contained in paid fee-for-service claims and
20    $530 per paid fee-for-service outpatient claim for dates
21    of service in Calendar Year 2019 in the Department's
22    Enterprise Data Warehouse as of May 11, 2020.
23        (2) For safety-net hospitals, $960 per covered
24    inpatient day contained in paid fee-for-service claims and
25    $625 per paid fee-for-service outpatient claim for dates
26    of service in Calendar Year 2019 in the Department's

 

 

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1    Enterprise Data Warehouse as of May 11, 2020.
2        (3) For long term acute care hospitals, $295 per
3    covered inpatient day contained in paid fee-for-service
4    claims for dates of service in Calendar Year 2019 in the
5    Department's Enterprise Data Warehouse as of May 11, 2020.
6        (4) For freestanding psychiatric hospitals, $125 per
7    covered inpatient day contained in paid fee-for-service
8    claims and $130 per paid fee-for-service outpatient claim
9    for dates of service in Calendar Year 2019 in the
10    Department's Enterprise Data Warehouse as of May 11, 2020.
11        (5) For freestanding rehabilitation hospitals, $355
12    per covered inpatient day contained in paid
13    fee-for-service claims for dates of service in Calendar
14    Year 2019 in the Department's Enterprise Data Warehouse as
15    of May 11, 2020.
16        (6) For all general acute care hospitals and high
17    Medicaid hospitals as defined in subsection (f), $350 per
18    covered inpatient day for dates of service in Calendar
19    Year 2019 contained in paid fee-for-service claims and
20    $620 per paid fee-for-service outpatient claim in the
21    Department's Enterprise Data Warehouse as of May 11, 2020.
22        (7) Alzheimer's treatment access payment. Each
23    Illinois academic medical center or teaching hospital, as
24    defined in Section 5-5e.2 of this Code, that is identified
25    as the primary hospital affiliate of one of the Regional
26    Alzheimer's Disease Assistance Centers, as designated by

 

 

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1    the Alzheimer's Disease Assistance Act and identified in
2    the Department of Public Health's Alzheimer's Disease
3    State Plan dated December 2016, shall be paid an
4    Alzheimer's treatment access payment equal to the product
5    of the qualifying hospital's State Fiscal Year 2018 total
6    inpatient fee-for-service days multiplied by the
7    applicable Alzheimer's treatment rate of $226.30 for
8    hospitals located in Cook County and $116.21 for hospitals
9    located outside Cook County.
10    (d-2) Fee-for-service supplemental payments. Beginning
11January 1, 2023, each Illinois hospital shall receive an
12annual payment equal to the amounts listed below, to be paid in
1312 equal installments on or before the seventh State business
14day of each month, except that no payment shall be due within
1530 days after the later of the date of notification of federal
16approval of the payment methodologies required under this
17Section or any waiver required under 42 CFR 433.68, at which
18time the sum of amounts required under this Section prior to
19the date of notification is due and payable. The Department
20may adjust the rates in paragraphs (1) through (7) to comply
21with the federal upper payment limits, with such adjustments
22being determined so that the total estimated spending by
23hospital class, under such adjusted rates, remains
24substantially similar to the total estimated spending under
25the original rates set forth in this subsection.
26        (1) For critical access hospitals, as defined in

 

 

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1    subsection (f), $750 per covered inpatient day contained
2    in paid fee-for-service claims and $750 per paid
3    fee-for-service outpatient claim for dates of service in
4    Calendar Year 2019 in the Department's Enterprise Data
5    Warehouse as of August 6, 2021.
6        (2) For safety-net hospitals, as described in
7    subsection (f), $1,350 per inpatient day contained in paid
8    fee-for-service claims and $1,350 per paid fee-for-service
9    outpatient claim for dates of service in Calendar Year
10    2019 in the Department's Enterprise Data Warehouse as of
11    August 6, 2021.
12        (3) For long term acute care hospitals, $550 per
13    covered inpatient day contained in paid fee-for-service
14    claims for dates of service in Calendar Year 2019 in the
15    Department's Enterprise Data Warehouse as of August 6,
16    2021.
17        (4) For freestanding psychiatric hospitals, $200 per
18    covered inpatient day contained in paid fee-for-service
19    claims and $200 per paid fee-for-service outpatient claim
20    for dates of service in Calendar Year 2019 in the
21    Department's Enterprise Data Warehouse as of August 6,
22    2021.
23        (5) For freestanding rehabilitation hospitals, $550
24    per covered inpatient day contained in paid
25    fee-for-service claims and $125 per paid fee-for-service
26    outpatient claim for dates of service in Calendar Year

 

 

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1    2019 in the Department's Enterprise Data Warehouse as of
2    August 6, 2021.
3        (6) For all general acute care hospitals and high
4    Medicaid hospitals as defined in subsection (f), $500 per
5    covered inpatient day for dates of service in Calendar
6    Year 2019 contained in paid fee-for-service claims and
7    $500 per paid fee-for-service outpatient claim in the
8    Department's Enterprise Data Warehouse as of August 6,
9    2021.
10        (7) For public hospitals, as defined in subsection
11    (f), $275 per covered inpatient day contained in paid
12    fee-for-service claims and $275 per paid fee-for-service
13    outpatient claim for dates of service in Calendar Year
14    2019 in the Department's Enterprise Data Warehouse as of
15    August 6, 2021.
16        (8) Alzheimer's treatment access payment. Each
17    Illinois academic medical center or teaching hospital, as
18    defined in Section 5-5e.2 of this Code, that is identified
19    as the primary hospital affiliate of one of the Regional
20    Alzheimer's Disease Assistance Centers, as designated by
21    the Alzheimer's Disease Assistance Act and identified in
22    the Department of Public Health's Alzheimer's Disease
23    State Plan dated December 2016, shall be paid an
24    Alzheimer's treatment access payment equal to the product
25    of the qualifying hospital's Calendar Year 2019 total
26    inpatient fee-for-service days, in the Department's

 

 

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1    Enterprise Data Warehouse as of August 6, 2021, multiplied
2    by the applicable Alzheimer's treatment rate of $244.37
3    for hospitals located in Cook County and $312.03 for
4    hospitals located outside Cook County.
5    (e) The Department shall require managed care
6organizations (MCOs) to make directed payments and
7pass-through payments according to this Section. Each calendar
8year, the Department shall require MCOs to pay the maximum
9amount out of these funds as allowed as pass-through payments
10under federal regulations. The Department shall require MCOs
11to make such pass-through payments as specified in this
12Section. The Department shall require the MCOs to pay the
13remaining amounts as directed Payments as specified in this
14Section. The Department shall issue payments to the
15Comptroller by the seventh business day of each month for all
16MCOs that are sufficient for MCOs to make the directed
17payments and pass-through payments according to this Section.
18The Department shall require the MCOs to make pass-through
19payments and directed payments using electronic funds
20transfers (EFT), if the hospital provides the information
21necessary to process such EFTs, in accordance with directions
22provided monthly by the Department, within 7 business days of
23the date the funds are paid to the MCOs, as indicated by the
24"Paid Date" on the website of the Office of the Comptroller if
25the funds are paid by EFT and the MCOs have received directed
26payment instructions. If funds are not paid through the

 

 

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1Comptroller by EFT, payment must be made within 7 business
2days of the date actually received by the MCO. The MCO will be
3considered to have paid the pass-through payments when the
4payment remittance number is generated or the date the MCO
5sends the check to the hospital, if EFT information is not
6supplied. If an MCO is late in paying a pass-through payment or
7directed payment as required under this Section (including any
8extensions granted by the Department), it shall pay a penalty,
9unless waived by the Department for reasonable cause, to the
10Department equal to 5% of the amount of the pass-through
11payment or directed payment not paid on or before the due date
12plus 5% of the portion thereof remaining unpaid on the last day
13of each 30-day period thereafter. Payments to MCOs that would
14be paid consistent with actuarial certification and enrollment
15in the absence of the increased capitation payments under this
16Section shall not be reduced as a consequence of payments made
17under this subsection. The Department shall publish and
18maintain on its website for a period of no less than 8 calendar
19quarters, the quarterly calculation of directed payments and
20pass-through payments owed to each hospital from each MCO. All
21calculations and reports shall be posted no later than the
22first day of the quarter for which the payments are to be
23issued.
24    (f)(1) For purposes of allocating the funds included in
25capitation payments to MCOs, Illinois hospitals shall be
26divided into the following classes as defined in

 

 

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1administrative rules:
2        (A) Beginning July 1, 2020 through December 31, 2022,
3    critical access hospitals. Beginning January 1, 2023,
4    "critical access hospital" means a hospital designated by
5    the Department of Public Health as a critical access
6    hospital, excluding any hospital meeting the definition of
7    a public hospital in subparagraph (F).
8        (B) Safety-net hospitals, except that stand-alone
9    children's hospitals that are not specialty children's
10    hospitals will not be included. For the calendar year
11    beginning January 1, 2023, and each calendar year
12    thereafter, assignment to the safety-net class shall be
13    based on the annual safety-net rate year beginning 15
14    months before the beginning of the first Payout Quarter of
15    the calendar year.
16        (C) Long term acute care hospitals.
17        (D) Freestanding psychiatric hospitals.
18        (E) Freestanding rehabilitation hospitals.
19        (F) Beginning January 1, 2023, "public hospital" means
20    a hospital that is owned or operated by an Illinois
21    Government body or municipality, excluding a hospital
22    provider that is a State agency, a State university, or a
23    county with a population of 3,000,000 or more.
24        (G) High Medicaid hospitals.
25            (i) As used in this Section, "high Medicaid
26        hospital" means a general acute care hospital that:

 

 

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1                (I) For the payout periods July 1, 2020
2            through December 31, 2022, is not a safety-net
3            hospital or critical access hospital and that has
4            a Medicaid Inpatient Utilization Rate above 30% or
5            a hospital that had over 35,000 inpatient Medicaid
6            days during the applicable period. For the period
7            July 1, 2020 through December 31, 2020, the
8            applicable period for the Medicaid Inpatient
9            Utilization Rate (MIUR) is the rate year 2020 MIUR
10            and for the number of inpatient days it is State
11            fiscal year 2018. Beginning in calendar year 2021,
12            the Department shall use the most recently
13            determined MIUR, as defined in subsection (h) of
14            Section 5-5.02, and for the inpatient day
15            threshold, the State fiscal year ending 18 months
16            prior to the beginning of the calendar year. For
17            purposes of calculating MIUR under this Section,
18            children's hospitals and affiliated general acute
19            care hospitals shall be considered a single
20            hospital.
21                (II) For the calendar year beginning January
22            1, 2023, and each calendar year thereafter, is not
23            a public hospital, safety-net hospital, or
24            critical access hospital and that qualifies as a
25            regional high volume hospital or is a hospital
26            that has a Medicaid Inpatient Utilization Rate

 

 

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1            (MIUR) above 30%. As used in this item, "regional
2            high volume hospital" means a hospital which ranks
3            in the top 2 quartiles based on total hospital
4            services volume, of all eligible general acute
5            care hospitals, when ranked in descending order
6            based on total hospital services volume, within
7            the same Medicaid managed care region, as
8            designated by the Department, as of January 1,
9            2022. As used in this item, "total hospital
10            services volume" means the total of all Medical
11            Assistance hospital inpatient admissions plus all
12            Medical Assistance hospital outpatient visits. For
13            purposes of determining regional high volume
14            hospital inpatient admissions and outpatient
15            visits, the Department shall use dates of service
16            provided during State Fiscal Year 2020 for the
17            Payout Quarter beginning January 1, 2023. The
18            Department shall use dates of service from the
19            State fiscal year ending 18 month before the
20            beginning of the first Payout Quarter of the
21            subsequent annual determination period.
22            (ii) For the calendar year beginning January 1,
23        2023, the Department shall use the Rate Year 2022
24        Medicaid inpatient utilization rate (MIUR), as defined
25        in subsection (h) of Section 5-5.02. For each
26        subsequent annual determination, the Department shall

 

 

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1        use the MIUR applicable to the rate year ending
2        September 30 of the year preceding the beginning of
3        the calendar year.
4        (H) General acute care hospitals. As used under this
5    Section, "general acute care hospitals" means all other
6    Illinois hospitals not identified in subparagraphs (A)
7    through (G).
8    (2) Hospitals' qualification for each class shall be
9assessed prior to the beginning of each calendar year and the
10new class designation shall be effective January 1 of the next
11year. The Department shall publish by rule the process for
12establishing class determination.
13    (3) Beginning January 1, 2024, the Department may reassign
14hospitals or entire hospital classes as defined above, if
15federal limits on the payments to the class to which the
16hospitals are assigned based on the criteria in this
17subsection prevent the Department from making payments to the
18class that would otherwise be due under this Section. The
19Department shall publish the criteria and composition of each
20new class based on the reassignments, and the projected impact
21on payments to each hospital under the new classes on its
22website by November 15 of the year before the year in which the
23class changes become effective.
24    (g) Fixed pool directed payments. Beginning July 1, 2020,
25the Department shall issue payments to MCOs which shall be
26used to issue directed payments to qualified Illinois

 

 

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1safety-net hospitals and critical access hospitals on a
2monthly basis in accordance with this subsection. Prior to the
3beginning of each Payout Quarter beginning July 1, 2020, the
4Department shall use encounter claims data from the
5Determination Quarter, accepted by the Department's Medicaid
6Management Information System for inpatient and outpatient
7services rendered by safety-net hospitals and critical access
8hospitals to determine a quarterly uniform per unit add-on for
9each hospital class.
10        (1) Inpatient per unit add-on. A quarterly uniform per
11    diem add-on shall be derived by dividing the quarterly
12    Inpatient Directed Payments Pool amount allocated to the
13    applicable hospital class by the total inpatient days
14    contained on all encounter claims received during the
15    Determination Quarter, for all hospitals in the class.
16            (A) Each hospital in the class shall have a
17        quarterly inpatient directed payment calculated that
18        is equal to the product of the number of inpatient days
19        attributable to the hospital used in the calculation
20        of the quarterly uniform class per diem add-on,
21        multiplied by the calculated applicable quarterly
22        uniform class per diem add-on of the hospital class.
23            (B) Each hospital shall be paid 1/3 of its
24        quarterly inpatient directed payment in each of the 3
25        months of the Payout Quarter, in accordance with
26        directions provided to each MCO by the Department.

 

 

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1        (2) Outpatient per unit add-on. A quarterly uniform
2    per claim add-on shall be derived by dividing the
3    quarterly Outpatient Directed Payments Pool amount
4    allocated to the applicable hospital class by the total
5    outpatient encounter claims received during the
6    Determination Quarter, for all hospitals in the class.
7            (A) Each hospital in the class shall have a
8        quarterly outpatient directed payment calculated that
9        is equal to the product of the number of outpatient
10        encounter claims attributable to the hospital used in
11        the calculation of the quarterly uniform class per
12        claim add-on, multiplied by the calculated applicable
13        quarterly uniform class per claim add-on of the
14        hospital class.
15            (B) Each hospital shall be paid 1/3 of its
16        quarterly outpatient directed payment in each of the 3
17        months of the Payout Quarter, in accordance with
18        directions provided to each MCO by the Department.
19        (3) Each MCO shall pay each hospital the Monthly
20    Directed Payment as identified by the Department on its
21    quarterly determination report.
22        (4) Definitions. As used in this subsection:
23            (A) "Payout Quarter" means each 3 month calendar
24        quarter, beginning July 1, 2020.
25            (B) "Determination Quarter" means each 3 month
26        calendar quarter, which ends 3 months prior to the

 

 

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1        first day of each Payout Quarter.
2        (5) For the period July 1, 2020 through December 2020,
3    the following amounts shall be allocated to the following
4    hospital class directed payment pools for the quarterly
5    development of a uniform per unit add-on:
6            (A) $2,894,500 for hospital inpatient services for
7        critical access hospitals.
8            (B) $4,294,374 for hospital outpatient services
9        for critical access hospitals.
10            (C) $29,109,330 for hospital inpatient services
11        for safety-net hospitals.
12            (D) $35,041,218 for hospital outpatient services
13        for safety-net hospitals.
14        (6) For the period January 1, 2023 through December
15    31, 2023, the Department shall establish the amounts that
16    shall be allocated to the hospital class directed payment
17    fixed pools identified in this paragraph for the quarterly
18    development of a uniform per unit add-on. The Department
19    shall establish such amounts so that the total amount of
20    payments to each hospital under this Section in calendar
21    year 2023 is projected to be substantially similar to the
22    total amount of such payments received by the hospital
23    under this Section in calendar year 2021, adjusted for
24    increased funding provided for fixed pool directed
25    payments under subsection (g) in calendar year 2022,
26    assuming that the volume and acuity of claims are held

 

 

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1    constant. The Department shall publish the directed
2    payment fixed pool amounts to be established under this
3    paragraph on its website by November 15, 2022.
4            (A) Hospital inpatient services for critical
5        access hospitals.
6            (B) Hospital outpatient services for critical
7        access hospitals.
8            (C) Hospital inpatient services for public
9        hospitals.
10            (D) Hospital outpatient services for public
11        hospitals.
12            (E) Hospital inpatient services for safety-net
13        hospitals.
14            (F) Hospital outpatient services for safety-net
15        hospitals.
16        (7) Semi-annual rate maintenance review. The
17    Department shall ensure that hospitals assigned to the
18    fixed pools in paragraph (6) are paid no less than 95% of
19    the annual initial rate for each 6-month period of each
20    annual payout period. For each calendar year, the
21    Department shall calculate the annual initial rate per day
22    and per visit for each fixed pool hospital class listed in
23    paragraph (6), by dividing the total of all applicable
24    inpatient or outpatient directed payments issued in the
25    preceding calendar year to the hospitals in each fixed
26    pool class for the calendar year, plus any increase

 

 

10300SB1298ham002- 32 -LRB103 28018 KTG 62535 a

1    resulting from the annual adjustments described in
2    subsection (i), by the actual applicable total service
3    units for the preceding calendar year which were the basis
4    of the total applicable inpatient or outpatient directed
5    payments issued to the hospitals in each fixed pool class
6    in the calendar year, except that for calendar year 2023,
7    the service units from calendar year 2021 shall be used.
8            (A) The Department shall calculate the effective
9        rate, per day and per visit, for the payout periods of
10        January to June and July to December of each year, for
11        each fixed pool listed in paragraph (6), by dividing
12        50% of the annual pool by the total applicable
13        reported service units for the 2 applicable
14        determination quarters.
15            (B) If the effective rate calculated in
16        subparagraph (A) is less than 95% of the annual
17        initial rate assigned to the class for each pool under
18        paragraph (6), the Department shall adjust the payment
19        for each hospital to a level equal to no less than 95%
20        of the annual initial rate, by issuing a retroactive
21        adjustment payment for the 6-month period under review
22        as identified in subparagraph (A).
23    (h) Fixed rate directed payments. Effective July 1, 2020,
24the Department shall issue payments to MCOs which shall be
25used to issue directed payments to Illinois hospitals not
26identified in paragraph (g) on a monthly basis. Prior to the

 

 

10300SB1298ham002- 33 -LRB103 28018 KTG 62535 a

1beginning of each Payout Quarter beginning July 1, 2020, the
2Department shall use encounter claims data from the
3Determination Quarter, accepted by the Department's Medicaid
4Management Information System for inpatient and outpatient
5services rendered by hospitals in each hospital class
6identified in paragraph (f) and not identified in paragraph
7(g). For the period July 1, 2020 through December 2020, the
8Department shall direct MCOs to make payments as follows:
9        (1) For general acute care hospitals an amount equal
10    to $1,750 multiplied by the hospital's category of service
11    20 case mix index for the determination quarter multiplied
12    by the hospital's total number of inpatient admissions for
13    category of service 20 for the determination quarter.
14        (2) For general acute care hospitals an amount equal
15    to $160 multiplied by the hospital's category of service
16    21 case mix index for the determination quarter multiplied
17    by the hospital's total number of inpatient admissions for
18    category of service 21 for the determination quarter.
19        (3) For general acute care hospitals an amount equal
20    to $80 multiplied by the hospital's category of service 22
21    case mix index for the determination quarter multiplied by
22    the hospital's total number of inpatient admissions for
23    category of service 22 for the determination quarter.
24        (4) For general acute care hospitals an amount equal
25    to $375 multiplied by the hospital's category of service
26    24 case mix index for the determination quarter multiplied

 

 

10300SB1298ham002- 34 -LRB103 28018 KTG 62535 a

1    by the hospital's total number of category of service 24
2    paid EAPG (EAPGs) for the determination quarter.
3        (5) For general acute care hospitals an amount equal
4    to $240 multiplied by the hospital's category of service
5    27 and 28 case mix index for the determination quarter
6    multiplied by the hospital's total number of category of
7    service 27 and 28 paid EAPGs for the determination
8    quarter.
9        (6) For general acute care hospitals an amount equal
10    to $290 multiplied by the hospital's category of service
11    29 case mix index for the determination quarter multiplied
12    by the hospital's total number of category of service 29
13    paid EAPGs for the determination quarter.
14        (7) For high Medicaid hospitals an amount equal to
15    $1,800 multiplied by the hospital's category of service 20
16    case mix index for the determination quarter multiplied by
17    the hospital's total number of inpatient admissions for
18    category of service 20 for the determination quarter.
19        (8) For high Medicaid hospitals an amount equal to
20    $160 multiplied by the hospital's category of service 21
21    case mix index for the determination quarter multiplied by
22    the hospital's total number of inpatient admissions for
23    category of service 21 for the determination quarter.
24        (9) For high Medicaid hospitals an amount equal to $80
25    multiplied by the hospital's category of service 22 case
26    mix index for the determination quarter multiplied by the

 

 

10300SB1298ham002- 35 -LRB103 28018 KTG 62535 a

1    hospital's total number of inpatient admissions for
2    category of service 22 for the determination quarter.
3        (10) For high Medicaid hospitals an amount equal to
4    $400 multiplied by the hospital's category of service 24
5    case mix index for the determination quarter multiplied by
6    the hospital's total number of category of service 24 paid
7    EAPG outpatient claims for the determination quarter.
8        (11) For high Medicaid hospitals an amount equal to
9    $240 multiplied by the hospital's category of service 27
10    and 28 case mix index for the determination quarter
11    multiplied by the hospital's total number of category of
12    service 27 and 28 paid EAPGs for the determination
13    quarter.
14        (12) For high Medicaid hospitals an amount equal to
15    $290 multiplied by the hospital's category of service 29
16    case mix index for the determination quarter multiplied by
17    the hospital's total number of category of service 29 paid
18    EAPGs for the determination quarter.
19        (13) For long term acute care hospitals the amount of
20    $495 multiplied by the hospital's total number of
21    inpatient days for the determination quarter.
22        (14) For psychiatric hospitals the amount of $210
23    multiplied by the hospital's total number of inpatient
24    days for category of service 21 for the determination
25    quarter.
26        (15) For psychiatric hospitals the amount of $250

 

 

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1    multiplied by the hospital's total number of outpatient
2    claims for category of service 27 and 28 for the
3    determination quarter.
4        (16) For rehabilitation hospitals the amount of $410
5    multiplied by the hospital's total number of inpatient
6    days for category of service 22 for the determination
7    quarter.
8        (17) For rehabilitation hospitals the amount of $100
9    multiplied by the hospital's total number of outpatient
10    claims for category of service 29 for the determination
11    quarter.
12        (18) Effective for the Payout Quarter beginning
13    January 1, 2023, for the directed payments to hospitals
14    required under this subsection, the Department shall
15    establish the amounts that shall be used to calculate such
16    directed payments using the methodologies specified in
17    this paragraph. The Department shall use a single, uniform
18    rate, adjusted for acuity as specified in paragraphs (1)
19    through (12), for all categories of inpatient services
20    provided by each class of hospitals and a single uniform
21    rate, adjusted for acuity as specified in paragraphs (1)
22    through (12), for all categories of outpatient services
23    provided by each class of hospitals. The Department shall
24    establish such amounts so that the total amount of
25    payments to each hospital under this Section in calendar
26    year 2023 is projected to be substantially similar to the

 

 

10300SB1298ham002- 37 -LRB103 28018 KTG 62535 a

1    total amount of such payments received by the hospital
2    under this Section in calendar year 2021, adjusted for
3    increased funding provided for fixed pool directed
4    payments under subsection (g) in calendar year 2022,
5    assuming that the volume and acuity of claims are held
6    constant. The Department shall publish the directed
7    payment amounts to be established under this subsection on
8    its website by November 15, 2022.
9        (19) Each hospital shall be paid 1/3 of their
10    quarterly inpatient and outpatient directed payment in
11    each of the 3 months of the Payout Quarter, in accordance
12    with directions provided to each MCO by the Department.
13        20 Each MCO shall pay each hospital the Monthly
14    Directed Payment amount as identified by the Department on
15    its quarterly determination report.
16    Notwithstanding any other provision of this subsection, if
17the Department determines that the actual total hospital
18utilization data that is used to calculate the fixed rate
19directed payments is substantially different than anticipated
20when the rates in this subsection were initially determined
21for unforeseeable circumstances (such as the COVID-19 pandemic
22or some other public health emergency), the Department may
23adjust the rates specified in this subsection so that the
24total directed payments approximate the total spending amount
25anticipated when the rates were initially established.
26    Definitions. As used in this subsection:

 

 

10300SB1298ham002- 38 -LRB103 28018 KTG 62535 a

1            (A) "Payout Quarter" means each calendar quarter,
2        beginning July 1, 2020.
3            (B) "Determination Quarter" means each calendar
4        quarter which ends 3 months prior to the first day of
5        each Payout Quarter.
6            (C) "Case mix index" means a hospital specific
7        calculation. For inpatient claims the case mix index
8        is calculated each quarter by summing the relative
9        weight of all inpatient Diagnosis-Related Group (DRG)
10        claims for a category of service in the applicable
11        Determination Quarter and dividing the sum by the
12        number of sum total of all inpatient DRG admissions
13        for the category of service for the associated claims.
14        The case mix index for outpatient claims is calculated
15        each quarter by summing the relative weight of all
16        paid EAPGs in the applicable Determination Quarter and
17        dividing the sum by the sum total of paid EAPGs for the
18        associated claims.
19    (i) Beginning January 1, 2021, the rates for directed
20payments shall be recalculated in order to spend the
21additional funds for directed payments that result from
22reduction in the amount of pass-through payments allowed under
23federal regulations. The additional funds for directed
24payments shall be allocated proportionally to each class of
25hospitals based on that class' proportion of services.
26        (1) Beginning January 1, 2024, the fixed pool directed

 

 

10300SB1298ham002- 39 -LRB103 28018 KTG 62535 a

1    payment amounts and the associated annual initial rates
2    referenced in paragraph (6) of subsection (f) for each
3    hospital class shall be uniformly increased by a ratio of
4    not less than, the ratio of the total pass-through
5    reduction amount pursuant to paragraph (4) of subsection
6    (j), for the hospitals comprising the hospital fixed pool
7    directed payment class for the next calendar year, to the
8    total inpatient and outpatient directed payments for the
9    hospitals comprising the hospital fixed pool directed
10    payment class paid during the preceding calendar year.
11        (2) Beginning January 1, 2024, the fixed rates for the
12    directed payments referenced in paragraph (18) of
13    subsection (h) for each hospital class shall be uniformly
14    increased by a ratio of not less than, the ratio of the
15    total pass-through reduction amount pursuant to paragraph
16    (4) of subsection (j), for the hospitals comprising the
17    hospital directed payment class for the next calendar
18    year, to the total inpatient and outpatient directed
19    payments for the hospitals comprising the hospital fixed
20    rate directed payment class paid during the preceding
21    calendar year.
22    (j) Pass-through payments.
23        (1) For the period July 1, 2020 through December 31,
24    2020, the Department shall assign quarterly pass-through
25    payments to each class of hospitals equal to one-fourth of
26    the following annual allocations:

 

 

10300SB1298ham002- 40 -LRB103 28018 KTG 62535 a

1            (A) $390,487,095 to safety-net hospitals.
2            (B) $62,553,886 to critical access hospitals.
3            (C) $345,021,438 to high Medicaid hospitals.
4            (D) $551,429,071 to general acute care hospitals.
5            (E) $27,283,870 to long term acute care hospitals.
6            (F) $40,825,444 to freestanding psychiatric
7        hospitals.
8            (G) $9,652,108 to freestanding rehabilitation
9        hospitals.
10        (2) For the period of July 1, 2020 through December
11    31, 2020, the pass-through payments shall at a minimum
12    ensure hospitals receive a total amount of monthly
13    payments under this Section as received in calendar year
14    2019 in accordance with this Article and paragraph (1) of
15    subsection (d-5) of Section 14-12, exclusive of amounts
16    received through payments referenced in subsection (b).
17        (3) For the calendar year beginning January 1, 2023,
18    the Department shall establish the annual pass-through
19    allocation to each class of hospitals and the pass-through
20    payments to each hospital so that the total amount of
21    payments to each hospital under this Section in calendar
22    year 2023 is projected to be substantially similar to the
23    total amount of such payments received by the hospital
24    under this Section in calendar year 2021, adjusted for
25    increased funding provided for fixed pool directed
26    payments under subsection (g) in calendar year 2022,

 

 

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1    assuming that the volume and acuity of claims are held
2    constant. The Department shall publish the pass-through
3    allocation to each class and the pass-through payments to
4    each hospital to be established under this subsection on
5    its website by November 15, 2022.
6        (4) For the calendar years beginning January 1, 2021
7    and , January 1, 2022, and January 1, 2024, and each
8    calendar year thereafter, each hospital's pass-through
9    payment amount shall be reduced proportionally to the
10    reduction of all pass-through payments required by federal
11    regulations. Beginning January 1, 2024, the Department
12    shall reduce total pass-through payments by the minimum
13    amount necessary to comply with federal regulations.
14    Pass-through payments to safety-net hospitals as defined
15    in Section 5-5e.1 of this Code, shall not be reduced until
16    all pass-through payments to other hospitals have been
17    eliminated. All other hospitals shall have their
18    pass-through payments reduced proportionally.
19    (k) At least 30 days prior to each calendar year, the
20Department shall notify each hospital of changes to the
21payment methodologies in this Section, including, but not
22limited to, changes in the fixed rate directed payment rates,
23the aggregate pass-through payment amount for all hospitals,
24and the hospital's pass-through payment amount for the
25upcoming calendar year.
26    (l) Notwithstanding any other provisions of this Section,

 

 

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1the Department may adopt rules to change the methodology for
2directed and pass-through payments as set forth in this
3Section, but only to the extent necessary to obtain federal
4approval of a necessary State Plan amendment or Directed
5Payment Preprint or to otherwise conform to federal law or
6federal regulation.
7    (m) As used in this subsection, "managed care
8organization" or "MCO" means an entity which contracts with
9the Department to provide services where payment for medical
10services is made on a capitated basis, excluding contracted
11entities for dual eligible or Department of Children and
12Family Services youth populations.
13    (n) In order to address the escalating infant mortality
14rates among minority communities in Illinois, the State shall,
15subject to appropriation, create a pool of funding of at least
16$50,000,000 annually to be disbursed among safety-net
17hospitals that maintain perinatal designation from the
18Department of Public Health. The funding shall be used to
19preserve or enhance OB/GYN services or other specialty
20services at the receiving hospital, with the distribution of
21funding to be established by rule and with consideration to
22perinatal hospitals with safe birthing levels and quality
23metrics for healthy mothers and babies.
24    (o) In order to address the growing challenges of
25providing stable access to healthcare in rural Illinois,
26including perinatal services, behavioral healthcare including

 

 

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1substance use disorder services (SUDs) and other specialty
2services, and to expand access to telehealth services among
3rural communities in Illinois, the Department of Healthcare
4and Family Services, subject to appropriation, shall
5administer a program to provide at least $10,000,000 in
6financial support annually to critical access hospitals for
7delivery of perinatal and OB/GYN services, behavioral
8healthcare including SUDS, other specialty services and
9telehealth services. The funding shall be used to preserve or
10enhance perinatal and OB/GYN services, behavioral healthcare
11including SUDS, other specialty services, as well as the
12explanation of telehealth services by the receiving hospital,
13with the distribution of funding to be established by rule.
14    (p) For calendar year 2023, the final amounts, rates, and
15payments under subsections (c), (d-2), (g), (h), and (j) shall
16be established by the Department, so that the sum of the total
17estimated annual payments under subsections (c), (d-2), (g),
18(h), and (j) for each hospital class for calendar year 2023, is
19no less than:
20        (1) $858,260,000 to safety-net hospitals.
21        (2) $86,200,000 to critical access hospitals.
22        (3) $1,765,000,000 to high Medicaid hospitals.
23        (4) $673,860,000 to general acute care hospitals.
24        (5) $48,330,000 to long term acute care hospitals.
25        (6) $89,110,000 to freestanding psychiatric hospitals.
26        (7) $24,300,000 to freestanding rehabilitation

 

 

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1    hospitals.
2        (8) $32,570,000 to public hospitals.
3    (q) Hospital Pandemic Recovery Stabilization Payments. The
4Department shall disburse a pool of $460,000,000 in stability
5payments to hospitals prior to April 1, 2023. The allocation
6of the pool shall be based on the hospital directed payment
7classes and directed payments issued, during Calendar Year
82022 with added consideration to safety net hospitals, as
9defined in subdivision (f)(1)(B) of this Section, and critical
10access hospitals.
11(Source: P.A. 101-650, eff. 7-7-20; 102-4, eff. 4-27-21;
12102-16, eff. 6-17-21; 102-886, eff. 5-17-22; 102-1115, eff.
131-9-23.)
 
14    (305 ILCS 5/12-4.105)
15    Sec. 12-4.105. Human poison control center; payment
16program. Subject to funding availability resulting from
17transfers made from the Hospital Provider Fund to the
18Healthcare Provider Relief Fund as authorized under this Code,
19for State fiscal year 2017 and State fiscal year 2018, and for
20each State fiscal year thereafter in which the assessment
21under Section 5A-2 is imposed, the Department of Healthcare
22and Family Services shall pay to the human poison control
23center designated under the Poison Control System Act an
24amount of not less than $3,000,000 for each of State fiscal
25years 2017 through 2020, and for State fiscal years 2021

 

 

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1through 2023 2026 an amount of not less than $3,750,000 and for
2State fiscal years 2024 through 2026 an amount of not less than
3$4,000,000 and for the period July 1, 2026 through December
431, 2026 an amount of not less than $2,000,000 $1,875,000, if
5the human poison control center is in operation.
6(Source: P.A. 101-650, eff. 7-7-20; 102-886, eff. 5-17-22.)
 
7    (305 ILCS 5/14-12)
8    Sec. 14-12. Hospital rate reform payment system. The
9hospital payment system pursuant to Section 14-11 of this
10Article shall be as follows:
11    (a) Inpatient hospital services. Effective for discharges
12on and after July 1, 2014, reimbursement for inpatient general
13acute care services shall utilize the All Patient Refined
14Diagnosis Related Grouping (APR-DRG) software, version 30,
15distributed by 3MTM Health Information System.
16        (1) The Department shall establish Medicaid weighting
17    factors to be used in the reimbursement system established
18    under this subsection. Initial weighting factors shall be
19    the weighting factors as published by 3M Health
20    Information System, associated with Version 30.0 adjusted
21    for the Illinois experience.
22        (2) The Department shall establish a
23    statewide-standardized amount to be used in the inpatient
24    reimbursement system. The Department shall publish these
25    amounts on its website no later than 10 calendar days

 

 

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1    prior to their effective date.
2        (3) In addition to the statewide-standardized amount,
3    the Department shall develop adjusters to adjust the rate
4    of reimbursement for critical Medicaid providers or
5    services for trauma, transplantation services, perinatal
6    care, and Graduate Medical Education (GME).
7        (4) The Department shall develop add-on payments to
8    account for exceptionally costly inpatient stays,
9    consistent with Medicare outlier principles. Outlier fixed
10    loss thresholds may be updated to control for excessive
11    growth in outlier payments no more frequently than on an
12    annual basis, but at least once every 4 years. Upon
13    updating the fixed loss thresholds, the Department shall
14    be required to update base rates within 12 months.
15        (5) The Department shall define those hospitals or
16    distinct parts of hospitals that shall be exempt from the
17    APR-DRG reimbursement system established under this
18    Section. The Department shall publish these hospitals'
19    inpatient rates on its website no later than 10 calendar
20    days prior to their effective date.
21        (6) Beginning July 1, 2014 and ending on December 31,
22    2023 June 30, 2024, in addition to the
23    statewide-standardized amount, the Department shall
24    develop an adjustor to adjust the rate of reimbursement
25    for safety-net hospitals defined in Section 5-5e.1 of this
26    Code excluding pediatric hospitals.

 

 

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1        (7) Beginning July 1, 2014, in addition to the
2    statewide-standardized amount, the Department shall
3    develop an adjustor to adjust the rate of reimbursement
4    for Illinois freestanding inpatient psychiatric hospitals
5    that are not designated as children's hospitals by the
6    Department but are primarily treating patients under the
7    age of 21.
8        (7.5) (Blank).
9        (8) Beginning July 1, 2018, in addition to the
10    statewide-standardized amount, the Department shall adjust
11    the rate of reimbursement for hospitals designated by the
12    Department of Public Health as a Perinatal Level II or II+
13    center by applying the same adjustor that is applied to
14    Perinatal and Obstetrical care cases for Perinatal Level
15    III centers, as of December 31, 2017.
16        (9) Beginning July 1, 2018, in addition to the
17    statewide-standardized amount, the Department shall apply
18    the same adjustor that is applied to trauma cases as of
19    December 31, 2017 to inpatient claims to treat patients
20    with burns, including, but not limited to, APR-DRGs 841,
21    842, 843, and 844.
22        (10) Beginning July 1, 2018, the
23    statewide-standardized amount for inpatient general acute
24    care services shall be uniformly increased so that base
25    claims projected reimbursement is increased by an amount
26    equal to the funds allocated in paragraph (1) of

 

 

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1    subsection (b) of Section 5A-12.6, less the amount
2    allocated under paragraphs (8) and (9) of this subsection
3    and paragraphs (3) and (4) of subsection (b) multiplied by
4    40%.
5        (11) Beginning July 1, 2018, the reimbursement for
6    inpatient rehabilitation services shall be increased by
7    the addition of a $96 per day add-on.
8    (b) Outpatient hospital services. Effective for dates of
9service on and after July 1, 2014, reimbursement for
10outpatient services shall utilize the Enhanced Ambulatory
11Procedure Grouping (EAPG) software, version 3.7 distributed by
123MTM Health Information System.
13        (1) The Department shall establish Medicaid weighting
14    factors to be used in the reimbursement system established
15    under this subsection. The initial weighting factors shall
16    be the weighting factors as published by 3M Health
17    Information System, associated with Version 3.7.
18        (2) The Department shall establish service specific
19    statewide-standardized amounts to be used in the
20    reimbursement system.
21            (A) The initial statewide standardized amounts,
22        with the labor portion adjusted by the Calendar Year
23        2013 Medicare Outpatient Prospective Payment System
24        wage index with reclassifications, shall be published
25        by the Department on its website no later than 10
26        calendar days prior to their effective date.

 

 

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

 

 

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

 

 

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1    this subsection. It is the intent of the General Assembly
2    that the adjustments required under this paragraph (6) by
3    Public Act 100-1181 shall be applied retroactively to
4    claims for dates of service provided on or after July 1,
5    2018.
6        (7) Effective for dates of service on or after March
7    8, 2019 (the effective date of Public Act 100-1181), the
8    Department shall recalculate and implement an updated
9    statewide-standardized amount for outpatient services
10    provided by hospitals that are not Critical Access
11    Hospitals to reflect the applicable uniform percentage
12    determined pursuant to paragraph (5).
13            (1) Any recalculation to the
14        statewide-standardized amounts for outpatient services
15        provided by hospitals that are not Critical Access
16        Hospitals shall be the amount necessary to achieve the
17        increase in the statewide-standardized amounts for
18        outpatient services increased by a uniform percentage,
19        so that base claims projected reimbursement is
20        increased by an amount equal to no less than the funds
21        allocated in paragraph (1) of subsection (b) of
22        Section 5A-12.6, less the amount allocated under
23        paragraphs (8) and (9) of subsection (a) and
24        paragraphs (3) and (4) of this subsection, for all
25        hospitals that are not Critical Access Hospitals,
26        multiplied by 46%.

 

 

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

 

 

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1beginning with dates of service on and after January 1, 2023,
2any general acute care hospital with more than 500 outpatient
3psychiatric Medicaid services to persons under 19 years of age
4in any calendar year shall be paid the outpatient add-on
5payment of no less than $113.
6    (c) In consultation with the hospital community, the
7Department is authorized to replace 89 Ill. Adm. Admin. Code
8152.150 as published in 38 Ill. Reg. 4980 through 4986 within
912 months of June 16, 2014 (the effective date of Public Act
1098-651). If the Department does not replace these rules within
1112 months of June 16, 2014 (the effective date of Public Act
1298-651), the rules in effect for 152.150 as published in 38
13Ill. Reg. 4980 through 4986 shall remain in effect until
14modified by rule by the Department. Nothing in this subsection
15shall be construed to mandate that the Department file a
16replacement rule.
17    (d) Transition period. There shall be a transition period
18to the reimbursement systems authorized under this Section
19that shall begin on the effective date of these systems and
20continue until June 30, 2018, unless extended by rule by the
21Department. To help provide an orderly and predictable
22transition to the new reimbursement systems and to preserve
23and enhance access to the hospital services during this
24transition, the Department shall allocate a transitional
25hospital access pool of at least $290,000,000 annually so that
26transitional hospital access payments are made to hospitals.

 

 

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

 

 

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1    5A-16, in State fiscal years 2019 and 2020, an Illinois
2    hospital that received either a transitional hospital
3    access payment under subsection (d) or a supplemental
4    payment under subsection (f) of this Section in State
5    fiscal year 2018, shall receive a hospital transformation
6    payment as follows:
7            (A) If the hospital's Rate Year 2017 Medicaid
8        inpatient utilization rate is equal to or greater than
9        45%, the hospital transformation payment shall be
10        equal to 100% of the sum of its transitional hospital
11        access payment authorized under subsection (d) and any
12        supplemental payment authorized under subsection (f).
13            (B) If the hospital's Rate Year 2017 Medicaid
14        inpatient utilization rate is equal to or greater than
15        25% but less than 45%, the hospital transformation
16        payment shall be equal to 75% of the sum of its
17        transitional hospital access payment authorized under
18        subsection (d) and any supplemental payment authorized
19        under subsection (f).
20            (C) If the hospital's Rate Year 2017 Medicaid
21        inpatient utilization rate is less than 25%, the
22        hospital transformation payment shall be equal to 50%
23        of the sum of its transitional hospital access payment
24        authorized under subsection (d) and any supplemental
25        payment authorized under subsection (f).
26        (2) Phase 2.

 

 

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

 

 

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1        pending federal matching funds, to be allocated during
2        the specified fiscal years for the purpose of
3        facilitating hospital and health care transformation.
4        No disbursement of moneys for transformation projects
5        from the transformation funding pool described under
6        this Section shall be considered an award, a grant, or
7        an expenditure of grant funds. Funding agreements made
8        in accordance with the transformation program shall be
9        considered purchases of care under the Illinois
10        Procurement Code, and funds shall be expended by the
11        Department in a manner that maximizes federal funding
12        to expend the entire allocated amount.
13            The Department shall convene, within 30 days after
14        March 12, 2021 (the effective date of Public Act
15        101-655) this amendatory Act of the 101st General
16        Assembly, a workgroup that includes subject matter
17        experts on healthcare disparities and stakeholders
18        from distressed communities, which could be a
19        subcommittee of the Medicaid Advisory Committee, to
20        review and provide recommendations on how Department
21        policy, including health care transformation, can
22        improve health disparities and the impact on
23        communities disproportionately affected by COVID-19.
24        The workgroup shall consider and make recommendations
25        on the following issues: a community safety-net
26        designation of certain hospitals, racial equity, and a

 

 

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

 

 

10300SB1298ham002- 59 -LRB103 28018 KTG 62535 a

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

 

 

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

 

 

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1            particularly community safety-net hospitals, and
2            other providers and designed to address specific
3            healthcare disparities, $20,000,000 of
4            transformation funds to collaborations between
5            safety-net hospitals and a larger hospital partner
6            that increases specialty care in distressed
7            communities, $30,000,000 of transformation funds
8            to projects that are a collaboration between
9            hospitals and other providers in distressed areas
10            of the State designed to address specific
11            healthcare disparities, $15,000,000 to
12            collaborations between critical access hospitals
13            and other providers designed to address specific
14            healthcare disparities, and $15,000,000 to
15            cross-provider collaborations designed to address
16            specific healthcare disparities, and $5,000,000 to
17            collaborations that focus on workforce
18            development.
19                (iv) The Department may allocate up to
20            $5,000,000 for planning, racial equity analysis,
21            or consulting resources for the Department or
22            entities without the resources to develop a plan
23            to meet the criteria of this Section. Any contract
24            for consulting services issued by the Department
25            under this subparagraph shall comply with the
26            provisions of Section 5-45 of the State Officials

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1        milestones or metrics or Business Enterprise Program
2        commitments in its plan. The Department may reduce or
3        end payments, as set forth in transformation plans, if
4        milestones or metrics or Business Enterprise Program
5        commitments are not achieved. The Department shall
6        seek to make payments from the transformation fund in
7        a manner that is eligible for federal matching funds.
8            In reviewing the proposals, the Department shall
9        take into account the needs of the community, data
10        from the study commissioned by the Department from the
11        University of Illinois-Chicago if applicable, feedback
12        from public comment on the Department's website, as
13        well as how the proposal meets the criteria listed
14        under subparagraph (G). Alignment with the
15        Department's overall strategic initiatives shall be an
16        important factor. To the extent that fiscal year
17        funding is not adequate to fund all eligible projects
18        that apply, the Department shall prioritize
19        applications that most comprehensively and effectively
20        address the criteria listed under subparagraph (G).
21        (3) (Blank).
22        (4) Hospital Transformation Review Committee. There is
23    created the Hospital Transformation Review Committee. The
24    Committee shall consist of 14 members. No later than 30
25    days after March 12, 2018 (the effective date of Public
26    Act 100-581), the 4 legislative leaders shall each appoint

 

 

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

 

 

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1    Committee appointed by the legislative leaders shall be
2    subject to the jurisdiction of the Legislative Ethics
3    Commission, not the Executive Ethics Commission, and all
4    requests under the Freedom of Information Act shall be
5    directed to the applicable Freedom of Information officer
6    for the General Assembly. The Department shall provide
7    operational support to the Committee as necessary. The
8    Committee is dissolved on April 1, 2019.
9    (e) Beginning 36 months after initial implementation, the
10Department shall update the reimbursement components in
11subsections (a) and (b), including standardized amounts and
12weighting factors, and at least once every 4 years and no more
13frequently than annually thereafter. The Department shall
14publish these updates on its website no later than 30 calendar
15days prior to their effective date.
16    (f) Continuation of supplemental payments. Any
17supplemental payments authorized under Illinois Administrative
18Code 148 effective January 1, 2014 and that continue during
19the period of July 1, 2014 through December 31, 2014 shall
20remain in effect as long as the assessment imposed by Section
215A-2 that is in effect on December 31, 2017 remains in effect.
22    (g) Notwithstanding subsections (a) through (f) of this
23Section and notwithstanding the changes authorized under
24Section 5-5b.1, any updates to the system shall not result in
25any diminishment of the overall effective rates of
26reimbursement as of the implementation date of the new system

 

 

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1(July 1, 2014). These updates shall not preclude variations in
2any individual component of the system or hospital rate
3variations. Nothing in this Section shall prohibit the
4Department from increasing the rates of reimbursement or
5developing payments to ensure access to hospital services.
6Nothing in this Section shall be construed to guarantee a
7minimum amount of spending in the aggregate or per hospital as
8spending may be impacted by factors, including, but not
9limited to, the number of individuals in the medical
10assistance program and the severity of illness of the
11individuals.
12    (h) The Department shall have the authority to modify by
13rulemaking any changes to the rates or methodologies in this
14Section as required by the federal government to obtain
15federal financial participation for expenditures made under
16this Section.
17    (i) Except for subsections (g) and (h) of this Section,
18the Department shall, pursuant to subsection (c) of Section
195-40 of the Illinois Administrative Procedure Act, provide for
20presentation at the June 2014 hearing of the Joint Committee
21on Administrative Rules (JCAR) additional written notice to
22JCAR of the following rules in order to commence the second
23notice period for the following rules: rules published in the
24Illinois Register, rule dated February 21, 2014 at 38 Ill.
25Reg. 4559 (Medical Payment), 4628 (Specialized Health Care
26Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic

 

 

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1Related Grouping (DRG) Prospective Payment System (PPS)), and
24977 (Hospital Reimbursement Changes), and published in the
3Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
4(Specialized Health Care Delivery Systems) and 6505 (Hospital
5Services).
6    (j) Out-of-state hospitals. Beginning July 1, 2018, for
7purposes of determining for State fiscal years 2019 and 2020
8and subsequent fiscal years the hospitals eligible for the
9payments authorized under subsections (a) and (b) of this
10Section, the Department shall include out-of-state hospitals
11that are designated a Level I pediatric trauma center or a
12Level I trauma center by the Department of Public Health as of
13December 1, 2017.
14    (k) The Department shall notify each hospital and managed
15care organization, in writing, of the impact of the updates
16under this Section at least 30 calendar days prior to their
17effective date.
18    (l) This Section is subject to Section 14-12.5.
19(Source: P.A. 101-81, eff. 7-12-19; 101-650, eff. 7-7-20;
20101-655, eff. 3-12-21; 102-682, eff. 12-10-21; 102-1037, eff.
216-2-22; revised 8-22-22.)
 
22    (305 ILCS 5/14-12.5 new)
23    Sec. 14-12.5. Hospital rate updates.
24    (a) Notwithstanding any other provision of this Code, the
25hospital rates of reimbursement authorized under Sections

 

 

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

 

 

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

 

 

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

 

 

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1        rate sheet to each safety-net hospital, which
2        identifies the hospital psychiatric per diem rate
3        before and after the adjustment.
4            (C) The add-on adjustment shall not be considered
5        when setting the 90% minimum rate identified in
6        paragraph (2) of subsection (b).
7    (c) The Department shall take all actions necessary to
8ensure the changes authorized in this amendatory Act of the
9103rd General Assembly are in effect for dates of service on
10and after January 1, 2024, including publishing all
11appropriate public notices, applying for federal approval of
12amendments to the Illinois Title XIX State Plan, and adopting
13administrative rules if necessary.
14    (d) The Department of Healthcare and Family Services may
15adopt rules necessary to implement the changes made by this
16amendatory Act of the 103rd General Assembly through the use
17of emergency rulemaking in accordance with Section 5-45 of the
18Illinois Administrative Procedure Act. The 24-month limitation
19on the adoption of emergency rules does not apply to rules
20adopted under this Section. The General Assembly finds that
21the adoption of rules to implement the changes made by this
22amendatory Act of the 103rd General Assembly is deemed an
23emergency and necessary for the public interest, safety, and
24welfare.
25    (e) The Department shall ensure that all necessary
26adjustments to the managed care organization capitation base

 

 

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1rates necessitated by the adjustments in this Section are
2completed, published, and applied in accordance with Section
35-30.8 of this Code 90 days prior to the implementation date of
4the changes required under this amendatory Act of the 103rd
5General Assembly.
6    (f) The Department shall publish updated rate sheets for
7all hospitals 30 days prior to the effective date of the rate
8increase, or within 30 days after federal approval by the
9Centers for Medicare and Medicaid Services, whichever is
10later.
 
11    (305 ILCS 5/14-12.7 new)
12    Sec. 14-12.7. Public critical access hospital
13stabilization program.
14    (a) In order to address the growing challenges of
15providing stable access to healthcare in rural Illinois, by
16October 1, 2023, the Department shall adopt rules to implement
17for dates of service on and after January 1, 2024, subject to
18federal approval, a program to provide at least $3,500,000 in
19annual financial support to public, critical access hospitals
20in Illinois, for the delivery of perinatal and obstetrical or
21gynecological services, behavioral healthcare services,
22including substance use disorder services, telehealth
23services, and other specialty services.
24    (b) The funding allocation methodology shall provide added
25consideration to the services provided by qualifying hospitals

 

 

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1designated by the Department of Public Health as a perinatal
2center.
3    (c) Public critical access hospitals qualifying under this
4Section shall not be eligible for payment under subsection (o)
5of Section 5A-12.7 of this Code.
6    (d) As used in this Section, "public critical access
7hospital" means a hospital designated by the Department of
8Public Health as a critical access hospital and that is owned
9or operated by an Illinois Government body or municipality.
 
10
ARTICLE 15.

 
11    Section 15-5. The Illinois Public Aid Code is amended by
12changing Section 5-5 as follows:
 
13    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
14    Sec. 5-5. Medical services. The Illinois Department, by
15rule, shall determine the quantity and quality of and the rate
16of reimbursement for the medical assistance for which payment
17will be authorized, and the medical services to be provided,
18which may include all or part of the following: (1) inpatient
19hospital services; (2) outpatient hospital services; (3) other
20laboratory and X-ray services; (4) skilled nursing home
21services; (5) physicians' services whether furnished in the
22office, the patient's home, a hospital, a skilled nursing
23home, or elsewhere; (6) medical care, or any other type of

 

 

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1remedial care furnished by licensed practitioners; (7) home
2health care services; (8) private duty nursing service; (9)
3clinic services; (10) dental services, including prevention
4and treatment of periodontal disease and dental caries disease
5for pregnant individuals, provided by an individual licensed
6to practice dentistry or dental surgery; for purposes of this
7item (10), "dental services" means diagnostic, preventive, or
8corrective procedures provided by or under the supervision of
9a dentist in the practice of his or her profession; (11)
10physical therapy and related services; (12) prescribed drugs,
11dentures, and prosthetic devices; and eyeglasses prescribed by
12a physician skilled in the diseases of the eye, or by an
13optometrist, whichever the person may select; (13) other
14diagnostic, screening, preventive, and rehabilitative
15services, including to ensure that the individual's need for
16intervention or treatment of mental disorders or substance use
17disorders or co-occurring mental health and substance use
18disorders is determined using a uniform screening, assessment,
19and evaluation process inclusive of criteria, for children and
20adults; for purposes of this item (13), a uniform screening,
21assessment, and evaluation process refers to a process that
22includes an appropriate evaluation and, as warranted, a
23referral; "uniform" does not mean the use of a singular
24instrument, tool, or process that all must utilize; (14)
25transportation and such other expenses as may be necessary;
26(15) medical treatment of sexual assault survivors, as defined

 

 

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1in Section 1a of the Sexual Assault Survivors Emergency
2Treatment Act, for injuries sustained as a result of the
3sexual assault, including examinations and laboratory tests to
4discover evidence which may be used in criminal proceedings
5arising from the sexual assault; (16) the diagnosis and
6treatment of sickle cell anemia; (16.5) services performed by
7a chiropractic physician licensed under the Medical Practice
8Act of 1987 and acting within the scope of his or her license,
9including, but not limited to, chiropractic manipulative
10treatment; and (17) any other medical care, and any other type
11of remedial care recognized under the laws of this State. The
12term "any other type of remedial care" shall include nursing
13care and nursing home service for persons who rely on
14treatment by spiritual means alone through prayer for healing.
15    Notwithstanding any other provision of this Section, a
16comprehensive tobacco use cessation program that includes
17purchasing prescription drugs or prescription medical devices
18approved by the Food and Drug Administration shall be covered
19under the medical assistance program under this Article for
20persons who are otherwise eligible for assistance under this
21Article.
22    Notwithstanding any other provision of this Code,
23reproductive health care that is otherwise legal in Illinois
24shall be covered under the medical assistance program for
25persons who are otherwise eligible for medical assistance
26under this Article.

 

 

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1    Notwithstanding any other provision of this Section, all
2tobacco cessation medications approved by the United States
3Food and Drug Administration and all individual and group
4tobacco cessation counseling services and telephone-based
5counseling services and tobacco cessation medications provided
6through the Illinois Tobacco Quitline shall be covered under
7the medical assistance program for persons who are otherwise
8eligible for assistance under this Article. The Department
9shall comply with all federal requirements necessary to obtain
10federal financial participation, as specified in 42 CFR
11433.15(b)(7), for telephone-based counseling services provided
12through the Illinois Tobacco Quitline, including, but not
13limited to: (i) entering into a memorandum of understanding or
14interagency agreement with the Department of Public Health, as
15administrator of the Illinois Tobacco Quitline; and (ii)
16developing a cost allocation plan for Medicaid-allowable
17Illinois Tobacco Quitline services in accordance with 45 CFR
1895.507. The Department shall submit the memorandum of
19understanding or interagency agreement, the cost allocation
20plan, and all other necessary documentation to the Centers for
21Medicare and Medicaid Services for review and approval.
22Coverage under this paragraph shall be contingent upon federal
23approval.
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a

 

 

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

 

 

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

 

 

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1provided to persons under the age of 18 under the medical
2assistance program.
3    Notwithstanding any other provision of this Code and
4subject to federal approval, the Department may adopt rules to
5allow a dentist who is volunteering his or her service at no
6cost to render dental services through an enrolled
7not-for-profit health clinic without the dentist personally
8enrolling as a participating provider in the medical
9assistance program. A not-for-profit health clinic shall
10include a public health clinic or Federally Qualified Health
11Center or other enrolled provider, as determined by the
12Department, through which dental services covered under this
13Section are performed. The Department shall establish a
14process for payment of claims for reimbursement for covered
15dental services rendered under this provision.
16    On and after January 1, 2022, the Department of Healthcare
17and Family Services shall administer and regulate a
18school-based dental program that allows for the out-of-office
19delivery of preventative dental services in a school setting
20to children under 19 years of age. The Department shall
21establish, by rule, guidelines for participation by providers
22and set requirements for follow-up referral care based on the
23requirements established in the Dental Office Reference Manual
24published by the Department that establishes the requirements
25for dentists participating in the All Kids Dental School
26Program. Every effort shall be made by the Department when

 

 

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1developing the program requirements to consider the different
2geographic differences of both urban and rural areas of the
3State for initial treatment and necessary follow-up care. No
4provider shall be charged a fee by any unit of local government
5to participate in the school-based dental program administered
6by the Department. Nothing in this paragraph shall be
7construed to limit or preempt a home rule unit's or school
8district's authority to establish, change, or administer a
9school-based dental program in addition to, or independent of,
10the school-based dental program administered by the
11Department.
12    The Illinois Department, by rule, may distinguish and
13classify the medical services to be provided only in
14accordance with the classes of persons designated in Section
155-2.
16    The Department of Healthcare and Family Services must
17provide coverage and reimbursement for amino acid-based
18elemental formulas, regardless of delivery method, for the
19diagnosis and treatment of (i) eosinophilic disorders and (ii)
20short bowel syndrome when the prescribing physician has issued
21a written order stating that the amino acid-based elemental
22formula is medically necessary.
23    The Illinois Department shall authorize the provision of,
24and shall authorize payment for, screening by low-dose
25mammography for the presence of occult breast cancer for
26individuals 35 years of age or older who are eligible for

 

 

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1medical assistance under this Article, as follows:
2        (A) A baseline mammogram for individuals 35 to 39
3    years of age.
4        (B) An annual mammogram for individuals 40 years of
5    age or older.
6        (C) A mammogram at the age and intervals considered
7    medically necessary by the individual's health care
8    provider for individuals under 40 years of age and having
9    a family history of breast cancer, prior personal history
10    of breast cancer, positive genetic testing, or other risk
11    factors.
12        (D) A comprehensive ultrasound screening and MRI of an
13    entire breast or breasts if a mammogram demonstrates
14    heterogeneous or dense breast tissue or when medically
15    necessary as determined by a physician licensed to
16    practice medicine in all of its branches.
17        (E) A screening MRI when medically necessary, as
18    determined by a physician licensed to practice medicine in
19    all of its branches.
20        (F) A diagnostic mammogram when medically necessary,
21    as determined by a physician licensed to practice medicine
22    in all its branches, advanced practice registered nurse,
23    or physician assistant.
24    The Department shall not impose a deductible, coinsurance,
25copayment, or any other cost-sharing requirement on the
26coverage provided under this paragraph; except that this

 

 

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1sentence does not apply to coverage of diagnostic mammograms
2to the extent such coverage would disqualify a high-deductible
3health plan from eligibility for a health savings account
4pursuant to Section 223 of the Internal Revenue Code (26
5U.S.C. 223).
6    All screenings shall include a physical breast exam,
7instruction on self-examination and information regarding the
8frequency of self-examination and its value as a preventative
9tool.
10     For purposes of this Section:
11    "Diagnostic mammogram" means a mammogram obtained using
12diagnostic mammography.
13    "Diagnostic mammography" means a method of screening that
14is designed to evaluate an abnormality in a breast, including
15an abnormality seen or suspected on a screening mammogram or a
16subjective or objective abnormality otherwise detected in the
17breast.
18    "Low-dose mammography" means the x-ray examination of the
19breast using equipment dedicated specifically for mammography,
20including the x-ray tube, filter, compression device, and
21image receptor, with an average radiation exposure delivery of
22less than one rad per breast for 2 views of an average size
23breast. The term also includes digital mammography and
24includes breast tomosynthesis.
25    "Breast tomosynthesis" means a radiologic procedure that
26involves the acquisition of projection images over the

 

 

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1stationary breast to produce cross-sectional digital
2three-dimensional images of the breast.
3    If, at any time, the Secretary of the United States
4Department of Health and Human Services, or its successor
5agency, promulgates rules or regulations to be published in
6the Federal Register or publishes a comment in the Federal
7Register or issues an opinion, guidance, or other action that
8would require the State, pursuant to any provision of the
9Patient Protection and Affordable Care Act (Public Law
10111-148), including, but not limited to, 42 U.S.C.
1118031(d)(3)(B) or any successor provision, to defray the cost
12of any coverage for breast tomosynthesis outlined in this
13paragraph, then the requirement that an insurer cover breast
14tomosynthesis is inoperative other than any such coverage
15authorized under Section 1902 of the Social Security Act, 42
16U.S.C. 1396a, and the State shall not assume any obligation
17for the cost of coverage for breast tomosynthesis set forth in
18this paragraph.
19    On and after January 1, 2016, the Department shall ensure
20that all networks of care for adult clients of the Department
21include access to at least one breast imaging Center of
22Imaging Excellence as certified by the American College of
23Radiology.
24    On and after January 1, 2012, providers participating in a
25quality improvement program approved by the Department shall
26be reimbursed for screening and diagnostic mammography at the

 

 

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1same rate as the Medicare program's rates, including the
2increased reimbursement for digital mammography and, after
3January 1, 2023 (the effective date of Public Act 102-1018)
4this amendatory Act of the 102nd General Assembly, breast
5tomosynthesis.
6    The Department shall convene an expert panel including
7representatives of hospitals, free-standing mammography
8facilities, and doctors, including radiologists, to establish
9quality standards for mammography.
10    On and after January 1, 2017, providers participating in a
11breast cancer treatment quality improvement program approved
12by the Department shall be reimbursed for breast cancer
13treatment at a rate that is no lower than 95% of the Medicare
14program's rates for the data elements included in the breast
15cancer treatment quality program.
16    The Department shall convene an expert panel, including
17representatives of hospitals, free-standing breast cancer
18treatment centers, breast cancer quality organizations, and
19doctors, including breast surgeons, reconstructive breast
20surgeons, oncologists, and primary care providers to establish
21quality standards for breast cancer treatment.
22    Subject to federal approval, the Department shall
23establish a rate methodology for mammography at federally
24qualified health centers and other encounter-rate clinics.
25These clinics or centers may also collaborate with other
26hospital-based mammography facilities. By January 1, 2016, the

 

 

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1Department shall report to the General Assembly on the status
2of the provision set forth in this paragraph.
3    The Department shall establish a methodology to remind
4individuals who are age-appropriate for screening mammography,
5but who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening
7mammography. The Department shall work with experts in breast
8cancer outreach and patient navigation to optimize these
9reminders and shall establish a methodology for evaluating
10their effectiveness and modifying the methodology based on the
11evaluation.
12    The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18    The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot
21program in areas of the State with the highest incidence of
22mortality related to breast cancer. At least one pilot program
23site shall be in the metropolitan Chicago area and at least one
24site shall be outside the metropolitan Chicago area. On or
25after July 1, 2016, the pilot program shall be expanded to
26include one site in western Illinois, one site in southern

 

 

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1Illinois, one site in central Illinois, and 4 sites within
2metropolitan Chicago. An evaluation of the pilot program shall
3be carried out measuring health outcomes and cost of care for
4those served by the pilot program compared to similarly
5situated patients who are not served by the pilot program.
6    The Department shall require all networks of care to
7develop a means either internally or by contract with experts
8in navigation and community outreach to navigate cancer
9patients to comprehensive care in a timely fashion. The
10Department shall require all networks of care to include
11access for patients diagnosed with cancer to at least one
12academic commission on cancer-accredited cancer program as an
13in-network covered benefit.
14    The Department shall provide coverage and reimbursement
15for a human papillomavirus (HPV) vaccine that is approved for
16marketing by the federal Food and Drug Administration for all
17persons between the ages of 9 and 45 and persons of the age of
1846 and above who have been diagnosed with cervical dysplasia
19with a high risk of recurrence or progression. The Department
20shall disallow any preauthorization requirements for the
21administration of the human papillomavirus (HPV) vaccine.
22    On or after July 1, 2022, individuals who are otherwise
23eligible for medical assistance under this Article shall
24receive coverage for perinatal depression screenings for the
2512-month period beginning on the last day of their pregnancy.
26Medical assistance coverage under this paragraph shall be

 

 

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1conditioned on the use of a screening instrument approved by
2the Department.
3    Any medical or health care provider shall immediately
4recommend, to any pregnant individual who is being provided
5prenatal services and is suspected of having a substance use
6disorder as defined in the Substance Use Disorder Act,
7referral to a local substance use disorder treatment program
8licensed by the Department of Human Services or to a licensed
9hospital which provides substance abuse treatment services.
10The Department of Healthcare and Family Services shall assure
11coverage for the cost of treatment of the drug abuse or
12addiction for pregnant recipients in accordance with the
13Illinois Medicaid Program in conjunction with the Department
14of Human Services.
15    All medical providers providing medical assistance to
16pregnant individuals under this Code shall receive information
17from the Department on the availability of services under any
18program providing case management services for addicted
19individuals, including information on appropriate referrals
20for other social services that may be needed by addicted
21individuals in addition to treatment for addiction.
22    The Illinois Department, in cooperation with the
23Departments of Human Services (as successor to the Department
24of Alcoholism and Substance Abuse) and Public Health, through
25a public awareness campaign, may provide information
26concerning treatment for alcoholism and drug abuse and

 

 

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1addiction, prenatal health care, and other pertinent programs
2directed at reducing the number of drug-affected infants born
3to recipients of medical assistance.
4    Neither the Department of Healthcare and Family Services
5nor the Department of Human Services shall sanction the
6recipient solely on the basis of the recipient's substance
7abuse.
8    The Illinois Department shall establish such regulations
9governing the dispensing of health services under this Article
10as it shall deem appropriate. The Department should seek the
11advice of formal professional advisory committees appointed by
12the Director of the Illinois Department for the purpose of
13providing regular advice on policy and administrative matters,
14information dissemination and educational activities for
15medical and health care providers, and consistency in
16procedures to the Illinois Department.
17    The Illinois Department may develop and contract with
18Partnerships of medical providers to arrange medical services
19for persons eligible under Section 5-2 of this Code.
20Implementation of this Section may be by demonstration
21projects in certain geographic areas. The Partnership shall be
22represented by a sponsor organization. The Department, by
23rule, shall develop qualifications for sponsors of
24Partnerships. Nothing in this Section shall be construed to
25require that the sponsor organization be a medical
26organization.

 

 

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1    The sponsor must negotiate formal written contracts with
2medical providers for physician services, inpatient and
3outpatient hospital care, home health services, treatment for
4alcoholism and substance abuse, and other services determined
5necessary by the Illinois Department by rule for delivery by
6Partnerships. Physician services must include prenatal and
7obstetrical care. The Illinois Department shall reimburse
8medical services delivered by Partnership providers to clients
9in target areas according to provisions of this Article and
10the Illinois Health Finance Reform Act, except that:
11        (1) Physicians participating in a Partnership and
12    providing certain services, which shall be determined by
13    the Illinois Department, to persons in areas covered by
14    the Partnership may receive an additional surcharge for
15    such services.
16        (2) The Department may elect to consider and negotiate
17    financial incentives to encourage the development of
18    Partnerships and the efficient delivery of medical care.
19        (3) Persons receiving medical services through
20    Partnerships may receive medical and case management
21    services above the level usually offered through the
22    medical assistance program.
23    Medical providers shall be required to meet certain
24qualifications to participate in Partnerships to ensure the
25delivery of high quality medical services. These
26qualifications shall be determined by rule of the Illinois

 

 

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1Department and may be higher than qualifications for
2participation in the medical assistance program. Partnership
3sponsors may prescribe reasonable additional qualifications
4for participation by medical providers, only with the prior
5written approval of the Illinois Department.
6    Nothing in this Section shall limit the free choice of
7practitioners, hospitals, and other providers of medical
8services by clients. In order to ensure patient freedom of
9choice, the Illinois Department shall immediately promulgate
10all rules and take all other necessary actions so that
11provided services may be accessed from therapeutically
12certified optometrists to the full extent of the Illinois
13Optometric Practice Act of 1987 without discriminating between
14service providers.
15    The Department shall apply for a waiver from the United
16States Health Care Financing Administration to allow for the
17implementation of Partnerships under this Section.
18    The Illinois Department shall require health care
19providers to maintain records that document the medical care
20and services provided to recipients of Medical Assistance
21under this Article. Such records must be retained for a period
22of not less than 6 years from the date of service or as
23provided by applicable State law, whichever period is longer,
24except that if an audit is initiated within the required
25retention period then the records must be retained until the
26audit is completed and every exception is resolved. The

 

 

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1Illinois Department shall require health care providers to
2make available, when authorized by the patient, in writing,
3the medical records in a timely fashion to other health care
4providers who are treating or serving persons eligible for
5Medical Assistance under this Article. All dispensers of
6medical services shall be required to maintain and retain
7business and professional records sufficient to fully and
8accurately document the nature, scope, details and receipt of
9the health care provided to persons eligible for medical
10assistance under this Code, in accordance with regulations
11promulgated by the Illinois Department. The rules and
12regulations shall require that proof of the receipt of
13prescription drugs, dentures, prosthetic devices and
14eyeglasses by eligible persons under this Section accompany
15each claim for reimbursement submitted by the dispenser of
16such medical services. No such claims for reimbursement shall
17be approved for payment by the Illinois Department without
18such proof of receipt, unless the Illinois Department shall
19have put into effect and shall be operating a system of
20post-payment audit and review which shall, on a sampling
21basis, be deemed adequate by the Illinois Department to assure
22that such drugs, dentures, prosthetic devices and eyeglasses
23for which payment is being made are actually being received by
24eligible recipients. Within 90 days after September 16, 1984
25(the effective date of Public Act 83-1439), the Illinois
26Department shall establish a current list of acquisition costs

 

 

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1for all prosthetic devices and any other items recognized as
2medical equipment and supplies reimbursable under this Article
3and shall update such list on a quarterly basis, except that
4the acquisition costs of all prescription drugs shall be
5updated no less frequently than every 30 days as required by
6Section 5-5.12.
7    Notwithstanding any other law to the contrary, the
8Illinois Department shall, within 365 days after July 22, 2013
9(the effective date of Public Act 98-104), establish
10procedures to permit skilled care facilities licensed under
11the Nursing Home Care Act to submit monthly billing claims for
12reimbursement purposes. Following development of these
13procedures, the Department shall, by July 1, 2016, test the
14viability of the new system and implement any necessary
15operational or structural changes to its information
16technology platforms in order to allow for the direct
17acceptance and payment of nursing home claims.
18    Notwithstanding any other law to the contrary, the
19Illinois Department shall, within 365 days after August 15,
202014 (the effective date of Public Act 98-963), establish
21procedures to permit ID/DD facilities licensed under the ID/DD
22Community Care Act and MC/DD facilities licensed under the
23MC/DD Act to submit monthly billing claims for reimbursement
24purposes. Following development of these procedures, the
25Department shall have an additional 365 days to test the
26viability of the new system and to ensure that any necessary

 

 

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1operational or structural changes to its information
2technology platforms are implemented.
3    The Illinois Department shall require all dispensers of
4medical services, other than an individual practitioner or
5group of practitioners, desiring to participate in the Medical
6Assistance program established under this Article to disclose
7all financial, beneficial, ownership, equity, surety or other
8interests in any and all firms, corporations, partnerships,
9associations, business enterprises, joint ventures, agencies,
10institutions or other legal entities providing any form of
11health care services in this State under this Article.
12    The Illinois Department may require that all dispensers of
13medical services desiring to participate in the medical
14assistance program established under this Article disclose,
15under such terms and conditions as the Illinois Department may
16by rule establish, all inquiries from clients and attorneys
17regarding medical bills paid by the Illinois Department, which
18inquiries could indicate potential existence of claims or
19liens for the Illinois Department.
20    Enrollment of a vendor shall be subject to a provisional
21period and shall be conditional for one year. During the
22period of conditional enrollment, the Department may terminate
23the vendor's eligibility to participate in, or may disenroll
24the vendor from, the medical assistance program without cause.
25Unless otherwise specified, such termination of eligibility or
26disenrollment is not subject to the Department's hearing

 

 

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1process. However, a disenrolled vendor may reapply without
2penalty.
3    The Department has the discretion to limit the conditional
4enrollment period for vendors based upon the category of risk
5of the vendor.
6    Prior to enrollment and during the conditional enrollment
7period in the medical assistance program, all vendors shall be
8subject to enhanced oversight, screening, and review based on
9the risk of fraud, waste, and abuse that is posed by the
10category of risk of the vendor. The Illinois Department shall
11establish the procedures for oversight, screening, and review,
12which may include, but need not be limited to: criminal and
13financial background checks; fingerprinting; license,
14certification, and authorization verifications; unscheduled or
15unannounced site visits; database checks; prepayment audit
16reviews; audits; payment caps; payment suspensions; and other
17screening as required by federal or State law.
18    The Department shall define or specify the following: (i)
19by provider notice, the "category of risk of the vendor" for
20each type of vendor, which shall take into account the level of
21screening applicable to a particular category of vendor under
22federal law and regulations; (ii) by rule or provider notice,
23the maximum length of the conditional enrollment period for
24each category of risk of the vendor; and (iii) by rule, the
25hearing rights, if any, afforded to a vendor in each category
26of risk of the vendor that is terminated or disenrolled during

 

 

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1the conditional enrollment period.
2    To be eligible for payment consideration, a vendor's
3payment claim or bill, either as an initial claim or as a
4resubmitted claim following prior rejection, must be received
5by the Illinois Department, or its fiscal intermediary, no
6later than 180 days after the latest date on the claim on which
7medical goods or services were provided, with the following
8exceptions:
9        (1) In the case of a provider whose enrollment is in
10    process by the Illinois Department, the 180-day period
11    shall not begin until the date on the written notice from
12    the Illinois Department that the provider enrollment is
13    complete.
14        (2) In the case of errors attributable to the Illinois
15    Department or any of its claims processing intermediaries
16    which result in an inability to receive, process, or
17    adjudicate a claim, the 180-day period shall not begin
18    until the provider has been notified of the error.
19        (3) In the case of a provider for whom the Illinois
20    Department initiates the monthly billing process.
21        (4) In the case of a provider operated by a unit of
22    local government with a population exceeding 3,000,000
23    when local government funds finance federal participation
24    for claims payments.
25    For claims for services rendered during a period for which
26a recipient received retroactive eligibility, claims must be

 

 

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1filed within 180 days after the Department determines the
2applicant is eligible. For claims for which the Illinois
3Department is not the primary payer, claims must be submitted
4to the Illinois Department within 180 days after the final
5adjudication by the primary payer.
6    In the case of long term care facilities, within 120
7calendar days of receipt by the facility of required
8prescreening information, new admissions with associated
9admission documents shall be submitted through the Medical
10Electronic Data Interchange (MEDI) or the Recipient
11Eligibility Verification (REV) System or shall be submitted
12directly to the Department of Human Services using required
13admission forms. Effective September 1, 2014, admission
14documents, including all prescreening information, must be
15submitted through MEDI or REV. Confirmation numbers assigned
16to an accepted transaction shall be retained by a facility to
17verify timely submittal. Once an admission transaction has
18been completed, all resubmitted claims following prior
19rejection are subject to receipt no later than 180 days after
20the admission transaction has been completed.
21    Claims that are not submitted and received in compliance
22with the foregoing requirements shall not be eligible for
23payment under the medical assistance program, and the State
24shall have no liability for payment of those claims.
25    To the extent consistent with applicable information and
26privacy, security, and disclosure laws, State and federal

 

 

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1agencies and departments shall provide the Illinois Department
2access to confidential and other information and data
3necessary to perform eligibility and payment verifications and
4other Illinois Department functions. This includes, but is not
5limited to: information pertaining to licensure;
6certification; earnings; immigration status; citizenship; wage
7reporting; unearned and earned income; pension income;
8employment; supplemental security income; social security
9numbers; National Provider Identifier (NPI) numbers; the
10National Practitioner Data Bank (NPDB); program and agency
11exclusions; taxpayer identification numbers; tax delinquency;
12corporate information; and death records.
13    The Illinois Department shall enter into agreements with
14State agencies and departments, and is authorized to enter
15into agreements with federal agencies and departments, under
16which such agencies and departments shall share data necessary
17for medical assistance program integrity functions and
18oversight. The Illinois Department shall develop, in
19cooperation with other State departments and agencies, and in
20compliance with applicable federal laws and regulations,
21appropriate and effective methods to share such data. At a
22minimum, and to the extent necessary to provide data sharing,
23the Illinois Department shall enter into agreements with State
24agencies and departments, and is authorized to enter into
25agreements with federal agencies and departments, including,
26but not limited to: the Secretary of State; the Department of

 

 

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1Revenue; the Department of Public Health; the Department of
2Human Services; and the Department of Financial and
3Professional Regulation.
4    Beginning in fiscal year 2013, the Illinois Department
5shall set forth a request for information to identify the
6benefits of a pre-payment, post-adjudication, and post-edit
7claims system with the goals of streamlining claims processing
8and provider reimbursement, reducing the number of pending or
9rejected claims, and helping to ensure a more transparent
10adjudication process through the utilization of: (i) provider
11data verification and provider screening technology; and (ii)
12clinical code editing; and (iii) pre-pay, pre-adjudicated pre-
13or post-adjudicated predictive modeling with an integrated
14case management system with link analysis. Such a request for
15information shall not be considered as a request for proposal
16or as an obligation on the part of the Illinois Department to
17take any action or acquire any products or services.
18    The Illinois Department shall establish policies,
19procedures, standards and criteria by rule for the
20acquisition, repair and replacement of orthotic and prosthetic
21devices and durable medical equipment. Such rules shall
22provide, but not be limited to, the following services: (1)
23immediate repair or replacement of such devices by recipients;
24and (2) rental, lease, purchase or lease-purchase of durable
25medical equipment in a cost-effective manner, taking into
26consideration the recipient's medical prognosis, the extent of

 

 

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1the recipient's needs, and the requirements and costs for
2maintaining such equipment. Subject to prior approval, such
3rules shall enable a recipient to temporarily acquire and use
4alternative or substitute devices or equipment pending repairs
5or replacements of any device or equipment previously
6authorized for such recipient by the Department.
7Notwithstanding any provision of Section 5-5f to the contrary,
8the Department may, by rule, exempt certain replacement
9wheelchair parts from prior approval and, for wheelchairs,
10wheelchair parts, wheelchair accessories, and related seating
11and positioning items, determine the wholesale price by
12methods other than actual acquisition costs.
13    The Department shall require, by rule, all providers of
14durable medical equipment to be accredited by an accreditation
15organization approved by the federal Centers for Medicare and
16Medicaid Services and recognized by the Department in order to
17bill the Department for providing durable medical equipment to
18recipients. No later than 15 months after the effective date
19of the rule adopted pursuant to this paragraph, all providers
20must meet the accreditation requirement.
21    In order to promote environmental responsibility, meet the
22needs of recipients and enrollees, and achieve significant
23cost savings, the Department, or a managed care organization
24under contract with the Department, may provide recipients or
25managed care enrollees who have a prescription or Certificate
26of Medical Necessity access to refurbished durable medical

 

 

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1equipment under this Section (excluding prosthetic and
2orthotic devices as defined in the Orthotics, Prosthetics, and
3Pedorthics Practice Act and complex rehabilitation technology
4products and associated services) through the State's
5assistive technology program's reutilization program, using
6staff with the Assistive Technology Professional (ATP)
7Certification if the refurbished durable medical equipment:
8(i) is available; (ii) is less expensive, including shipping
9costs, than new durable medical equipment of the same type;
10(iii) is able to withstand at least 3 years of use; (iv) is
11cleaned, disinfected, sterilized, and safe in accordance with
12federal Food and Drug Administration regulations and guidance
13governing the reprocessing of medical devices in health care
14settings; and (v) equally meets the needs of the recipient or
15enrollee. The reutilization program shall confirm that the
16recipient or enrollee is not already in receipt of the same or
17similar equipment from another service provider, and that the
18refurbished durable medical equipment equally meets the needs
19of the recipient or enrollee. Nothing in this paragraph shall
20be construed to limit recipient or enrollee choice to obtain
21new durable medical equipment or place any additional prior
22authorization conditions on enrollees of managed care
23organizations.
24    The Department shall execute, relative to the nursing home
25prescreening project, written inter-agency agreements with the
26Department of Human Services and the Department on Aging, to

 

 

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1effect the following: (i) intake procedures and common
2eligibility criteria for those persons who are receiving
3non-institutional services; and (ii) the establishment and
4development of non-institutional services in areas of the
5State where they are not currently available or are
6undeveloped; and (iii) notwithstanding any other provision of
7law, subject to federal approval, on and after July 1, 2012, an
8increase in the determination of need (DON) scores from 29 to
937 for applicants for institutional and home and
10community-based long term care; if and only if federal
11approval is not granted, the Department may, in conjunction
12with other affected agencies, implement utilization controls
13or changes in benefit packages to effectuate a similar savings
14amount for this population; and (iv) no later than July 1,
152013, minimum level of care eligibility criteria for
16institutional and home and community-based long term care; and
17(v) no later than October 1, 2013, establish procedures to
18permit long term care providers access to eligibility scores
19for individuals with an admission date who are seeking or
20receiving services from the long term care provider. In order
21to select the minimum level of care eligibility criteria, the
22Governor shall establish a workgroup that includes affected
23agency representatives and stakeholders representing the
24institutional and home and community-based long term care
25interests. This Section shall not restrict the Department from
26implementing lower level of care eligibility criteria for

 

 

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1community-based services in circumstances where federal
2approval has been granted.
3    The Illinois Department shall develop and operate, in
4cooperation with other State Departments and agencies and in
5compliance with applicable federal laws and regulations,
6appropriate and effective systems of health care evaluation
7and programs for monitoring of utilization of health care
8services and facilities, as it affects persons eligible for
9medical assistance under this Code.
10    The Illinois Department shall report annually to the
11General Assembly, no later than the second Friday in April of
121979 and each year thereafter, in regard to:
13        (a) actual statistics and trends in utilization of
14    medical services by public aid recipients;
15        (b) actual statistics and trends in the provision of
16    the various medical services by medical vendors;
17        (c) current rate structures and proposed changes in
18    those rate structures for the various medical vendors; and
19        (d) efforts at utilization review and control by the
20    Illinois Department.
21    The period covered by each report shall be the 3 years
22ending on the June 30 prior to the report. The report shall
23include suggested legislation for consideration by the General
24Assembly. The requirement for reporting to the General
25Assembly shall be satisfied by filing copies of the report as
26required by Section 3.1 of the General Assembly Organization

 

 

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1Act, and filing such additional copies with the State
2Government Report Distribution Center for the General Assembly
3as is required under paragraph (t) of Section 7 of the State
4Library Act.
5    Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11    On and after July 1, 2012, the Department shall reduce any
12rate of reimbursement for services or other payments or alter
13any methodologies authorized by this Code to reduce any rate
14of reimbursement for services or other payments in accordance
15with Section 5-5e.
16    Because kidney transplantation can be an appropriate,
17cost-effective alternative to renal dialysis when medically
18necessary and notwithstanding the provisions of Section 1-11
19of this Code, beginning October 1, 2014, the Department shall
20cover kidney transplantation for noncitizens with end-stage
21renal disease who are not eligible for comprehensive medical
22benefits, who meet the residency requirements of Section 5-3
23of this Code, and who would otherwise meet the financial
24requirements of the appropriate class of eligible persons
25under Section 5-2 of this Code. To qualify for coverage of
26kidney transplantation, such person must be receiving

 

 

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1emergency renal dialysis services covered by the Department.
2Providers under this Section shall be prior approved and
3certified by the Department to perform kidney transplantation
4and the services under this Section shall be limited to
5services associated with kidney transplantation.
6    Notwithstanding any other provision of this Code to the
7contrary, on or after July 1, 2015, all FDA approved forms of
8medication assisted treatment prescribed for the treatment of
9alcohol dependence or treatment of opioid dependence shall be
10covered under both fee for service and managed care medical
11assistance programs for persons who are otherwise eligible for
12medical assistance under this Article and shall not be subject
13to any (1) utilization control, other than those established
14under the American Society of Addiction Medicine patient
15placement criteria, (2) prior authorization mandate, or (3)
16lifetime restriction limit mandate.
17    On or after July 1, 2015, opioid antagonists prescribed
18for the treatment of an opioid overdose, including the
19medication product, administration devices, and any pharmacy
20fees or hospital fees related to the dispensing, distribution,
21and administration of the opioid antagonist, shall be covered
22under the medical assistance program for persons who are
23otherwise eligible for medical assistance under this Article.
24As used in this Section, "opioid antagonist" means a drug that
25binds to opioid receptors and blocks or inhibits the effect of
26opioids acting on those receptors, including, but not limited

 

 

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1to, naloxone hydrochloride or any other similarly acting drug
2approved by the U.S. Food and Drug Administration. The
3Department shall not impose a copayment on the coverage
4provided for naloxone hydrochloride under the medical
5assistance program.
6    Upon federal approval, the Department shall provide
7coverage and reimbursement for all drugs that are approved for
8marketing by the federal Food and Drug Administration and that
9are recommended by the federal Public Health Service or the
10United States Centers for Disease Control and Prevention for
11pre-exposure prophylaxis and related pre-exposure prophylaxis
12services, including, but not limited to, HIV and sexually
13transmitted infection screening, treatment for sexually
14transmitted infections, medical monitoring, assorted labs, and
15counseling to reduce the likelihood of HIV infection among
16individuals who are not infected with HIV but who are at high
17risk of HIV infection.
18    A federally qualified health center, as defined in Section
191905(l)(2)(B) of the federal Social Security Act, shall be
20reimbursed by the Department in accordance with the federally
21qualified health center's encounter rate for services provided
22to medical assistance recipients that are performed by a
23dental hygienist, as defined under the Illinois Dental
24Practice Act, working under the general supervision of a
25dentist and employed by a federally qualified health center.
26    Within 90 days after October 8, 2021 (the effective date

 

 

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1of Public Act 102-665), the Department shall seek federal
2approval of a State Plan amendment to expand coverage for
3family planning services that includes presumptive eligibility
4to individuals whose income is at or below 208% of the federal
5poverty level. Coverage under this Section shall be effective
6beginning no later than December 1, 2022.
7    Subject to approval by the federal Centers for Medicare
8and Medicaid Services of a Title XIX State Plan amendment
9electing the Program of All-Inclusive Care for the Elderly
10(PACE) as a State Medicaid option, as provided for by Subtitle
11I (commencing with Section 4801) of Title IV of the Balanced
12Budget Act of 1997 (Public Law 105-33) and Part 460
13(commencing with Section 460.2) of Subchapter E of Title 42 of
14the Code of Federal Regulations, PACE program services shall
15become a covered benefit of the medical assistance program,
16subject to criteria established in accordance with all
17applicable laws.
18    Notwithstanding any other provision of this Code,
19community-based pediatric palliative care from a trained
20interdisciplinary team shall be covered under the medical
21assistance program as provided in Section 15 of the Pediatric
22Palliative Care Act.
23    Notwithstanding any other provision of this Code, within
2412 months after June 2, 2022 (the effective date of Public Act
25102-1037) this amendatory Act of the 102nd General Assembly
26and subject to federal approval, acupuncture services

 

 

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1performed by an acupuncturist licensed under the Acupuncture
2Practice Act who is acting within the scope of his or her
3license shall be covered under the medical assistance program.
4The Department shall apply for any federal waiver or State
5Plan amendment, if required, to implement this paragraph. The
6Department may adopt any rules, including standards and
7criteria, necessary to implement this paragraph.
8    Notwithstanding any other provision of this Code, subject
9to federal approval, cognitive assessment and care planning
10services provided to a person who experiences signs or
11symptoms of cognitive impairment, as defined by the Diagnostic
12and Statistical Manual of Mental Disorders, Fifth Edition,
13shall be covered under the medical assistance program for
14persons who are otherwise eligible for medical assistance
15under this Article.
16(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
17102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1835, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1955-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
20102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
211-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
22102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
231-1-23; revised 2-5-23.)
 
24
ARTICLE 20.

 

 

 

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1    Section 20-5. The Illinois Public Aid Code is amended by
2changing Section 5-5.01a as follows:
 
3    (305 ILCS 5/5-5.01a)
4    Sec. 5-5.01a. Supportive living facilities program.
5    (a) The Department shall establish and provide oversight
6for a program of supportive living facilities that seek to
7promote resident independence, dignity, respect, and
8well-being in the most cost-effective manner.
9    A supportive living facility is (i) a free-standing
10facility or (ii) a distinct physical and operational entity
11within a mixed-use building that meets the criteria
12established in subsection (d). A supportive living facility
13integrates housing with health, personal care, and supportive
14services and is a designated setting that offers residents
15their own separate, private, and distinct living units.
16    Sites for the operation of the program shall be selected
17by the Department based upon criteria that may include the
18need for services in a geographic area, the availability of
19funding, and the site's ability to meet the standards.
20    (b) Beginning July 1, 2014, subject to federal approval,
21the Medicaid rates for supportive living facilities shall be
22equal to the supportive living facility Medicaid rate
23effective on June 30, 2014 increased by 8.85%. Once the
24assessment imposed at Article V-G of this Code is determined
25to be a permissible tax under Title XIX of the Social Security

 

 

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1Act, the Department shall increase the Medicaid rates for
2supportive living facilities effective on July 1, 2014 by
39.09%. The Department shall apply this increase retroactively
4to coincide with the imposition of the assessment in Article
5V-G of this Code in accordance with the approval for federal
6financial participation by the Centers for Medicare and
7Medicaid Services.
8    The Medicaid rates for supportive living facilities
9effective on July 1, 2017 must be equal to the rates in effect
10for supportive living facilities on June 30, 2017 increased by
112.8%.
12    The Medicaid rates for supportive living facilities
13effective on July 1, 2018 must be equal to the rates in effect
14for supportive living facilities on June 30, 2018.
15    Subject to federal approval, the Medicaid rates for
16supportive living services on and after July 1, 2019 must be at
17least 54.3% of the average total nursing facility services per
18diem for the geographic areas defined by the Department while
19maintaining the rate differential for dementia care and must
20be updated whenever the total nursing facility service per
21diems are updated. Beginning July 1, 2022, upon the
22implementation of the Patient Driven Payment Model, Medicaid
23rates for supportive living services must be at least 54.3% of
24the average total nursing services per diem rate for the
25geographic areas. For purposes of this provision, the average
26total nursing services per diem rate shall include all add-ons

 

 

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1for nursing facilities for the geographic area provided for in
2Section 5-5.2. The rate differential for dementia care must be
3maintained in these rates and the rates shall be updated
4whenever nursing facility per diem rates are updated.
5    Effective upon federal approval, the dementia care rate
6for supportive living services must be no less than the
7non-dementia care supportive living services rate multiplied
8by 1.5.
9    (c) The Department may adopt rules to implement this
10Section. Rules that establish or modify the services,
11standards, and conditions for participation in the program
12shall be adopted by the Department in consultation with the
13Department on Aging, the Department of Rehabilitation
14Services, and the Department of Mental Health and
15Developmental Disabilities (or their successor agencies).
16    (d) Subject to federal approval by the Centers for
17Medicare and Medicaid Services, the Department shall accept
18for consideration of certification under the program any
19application for a site or building where distinct parts of the
20site or building are designated for purposes other than the
21provision of supportive living services, but only if:
22        (1) those distinct parts of the site or building are
23    not designated for the purpose of providing assisted
24    living services as required under the Assisted Living and
25    Shared Housing Act;
26        (2) those distinct parts of the site or building are

 

 

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1    completely separate from the part of the building used for
2    the provision of supportive living program services,
3    including separate entrances;
4        (3) those distinct parts of the site or building do
5    not share any common spaces with the part of the building
6    used for the provision of supportive living program
7    services; and
8        (4) those distinct parts of the site or building do
9    not share staffing with the part of the building used for
10    the provision of supportive living program services.
11    (e) Facilities or distinct parts of facilities which are
12selected as supportive living facilities and are in good
13standing with the Department's rules are exempt from the
14provisions of the Nursing Home Care Act and the Illinois
15Health Facilities Planning Act.
16    (f) Section 9817 of the American Rescue Plan Act of 2021
17(Public Law 117-2) authorizes a 10% enhanced federal medical
18assistance percentage for supportive living services for a
1912-month period from April 1, 2021 through March 31, 2022.
20Subject to federal approval, including the approval of any
21necessary waiver amendments or other federally required
22documents or assurances, for a 12-month period the Department
23must pay a supplemental $26 per diem rate to all supportive
24living facilities with the additional federal financial
25participation funds that result from the enhanced federal
26medical assistance percentage from April 1, 2021 through March

 

 

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131, 2022. The Department may issue parameters around how the
2supplemental payment should be spent, including quality
3improvement activities. The Department may alter the form,
4methods, or timeframes concerning the supplemental per diem
5rate to comply with any subsequent changes to federal law,
6changes made by guidance issued by the federal Centers for
7Medicare and Medicaid Services, or other changes necessary to
8receive the enhanced federal medical assistance percentage.
9(Source: P.A. 101-10, eff. 6-5-19; 102-43, eff. 7-6-21;
10102-699, eff. 4-19-22.)
 
11
ARTICLE 25.

 
12    Section 25-5. The Illinois Public Aid Code is amended by
13adding Section 12-4.57 as follows:
 
14    (305 ILCS 5/12-4.57 new)
15    Sec. 12-4.57. Prospective Payment System rates; increase
16for federally qualified health centers. Subject to federal
17approval, the Department of Healthcare and Family Services
18shall increase the Prospective Payment System rates for
19federally qualified health centers to a level calculated to
20spend an additional $50,000,000 in the first year of
21application using an alternative payment method acceptable to
22the Centers for Medicare and Medicaid Services and a trade
23association representing a majority of federally qualified

 

 

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1health centers operating in Illinois, including a rate
2increase that is an equal percentage increase to the rates
3paid to each federally qualified health center.
 
4
ARTICLE 30.

 
5    Section 30-5. The Specialized Mental Health Rehabilitation
6Act of 2013 is amended by changing Section 5-107 as follows:
 
7    (210 ILCS 49/5-107)
8    Sec. 5-107. Quality of life enhancement. Beginning on July
91, 2019, for improving the quality of life and the quality of
10care, an additional payment shall be awarded to a facility for
11their single occupancy rooms. This payment shall be in
12addition to the rate for recovery and rehabilitation. The
13additional rate for single room occupancy shall be no less
14than $10 per day, per single room occupancy. The Department of
15Healthcare and Family Services shall adjust payment to
16Medicaid managed care entities to cover these costs. Beginning
17July 1, 2022, for improving the quality of life and the quality
18of care, a payment of no less than $5 per day, per single room
19occupancy shall be added to the existing $10 additional per
20day, per single room occupancy rate for a total of at least $15
21per day, per single room occupancy. For improving the quality
22of life and the quality of care, on January 1, 2024, a payment
23of no less than $10.50 per day, per single room occupancy shall

 

 

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1be added to the existing $15 additional per day, per single
2room occupancy rate for a total of at least $25.50 per day, per
3single room occupancy. Beginning July 1, 2022, for improving
4the quality of life and the quality of care, an additional
5payment shall be awarded to a facility for its dual-occupancy
6rooms. This payment shall be in addition to the rate for
7recovery and rehabilitation. The additional rate for
8dual-occupancy rooms shall be no less than $10 per day, per
9Medicaid-occupied bed, in each dual-occupancy room. Beginning
10January 1, 2024, for improving the quality of life and the
11quality of care, a payment of no less than $4.50 per day, per
12dual-occupancy room shall be added to the existing $10
13additional per day, per dual-occupancy room rate for a total
14of at least $14.50, per Medicaid-occupied bed, in each
15dual-occupancy room. The Department of Healthcare and Family
16Services shall adjust payment to Medicaid managed care
17entities to cover these costs. As used in this Section,
18"dual-occupancy room" means a room that contains 2 resident
19beds.
20(Source: P.A. 101-10, eff. 6-5-19; 102-699, eff. 4-19-22.)
 
21
ARTICLE 35.

 
22    Section 35-5. The Illinois Public Aid Code is amended by
23changing Section 5-2b as follows:
 

 

 

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1    (305 ILCS 5/5-2b)
2    Sec. 5-2b. Medically fragile and technology dependent
3children eligibility and program; provider reimbursement
4rates.
5    (a) Notwithstanding any other provision of law except as
6provided in Section 5-30a, on and after September 1, 2012,
7subject to federal approval, medical assistance under this
8Article shall be available to children who qualify as persons
9with a disability, as defined under the federal Supplemental
10Security Income program and who are medically fragile and
11technology dependent. The program shall allow eligible
12children to receive the medical assistance provided under this
13Article in the community and must maximize, to the fullest
14extent permissible under federal law, federal reimbursement
15and family cost-sharing, including co-pays, premiums, or any
16other family contributions, except that the Department shall
17be permitted to incentivize the utilization of selected
18services through the use of cost-sharing adjustments. The
19Department shall establish the policies, procedures,
20standards, services, and criteria for this program by rule.
21    (b) Notwithstanding any other provision of this Code,
22subject to federal approval, the reimbursement rates for
23nursing paid through Nursing and Personal Care Services for
24non-waiver customers and to providers of private duty nursing
25services for children eligible for medical assistance under
26this Section shall be 20% higher than the reimbursement rates

 

 

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1in effect for nursing services on December 31, 2023.
2(Source: P.A. 100-990, eff. 1-1-19.)
 
3
ARTICLE 40.

 
4    Section 40-5. The Illinois Public Aid Code is amended by
5changing Section 5-5.2 as follows:
 
6    (305 ILCS 5/5-5.2)  (from Ch. 23, par. 5-5.2)
7    Sec. 5-5.2. Payment.
8    (a) All nursing facilities that are grouped pursuant to
9Section 5-5.1 of this Act shall receive the same rate of
10payment for similar services.
11    (b) It shall be a matter of State policy that the Illinois
12Department shall utilize a uniform billing cycle throughout
13the State for the long-term care providers.
14    (c) (Blank).
15    (c-1) Notwithstanding any other provisions of this Code,
16the methodologies for reimbursement of nursing services as
17provided under this Article shall no longer be applicable for
18bills payable for nursing services rendered on or after a new
19reimbursement system based on the Patient Driven Payment Model
20(PDPM) has been fully operationalized, which shall take effect
21for services provided on or after the implementation of the
22PDPM reimbursement system begins. For the purposes of this
23amendatory Act of the 102nd General Assembly, the

 

 

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1implementation date of the PDPM reimbursement system and all
2related provisions shall be July 1, 2022 if the following
3conditions are met: (i) the Centers for Medicare and Medicaid
4Services has approved corresponding changes in the
5reimbursement system and bed assessment; and (ii) the
6Department has filed rules to implement these changes no later
7than June 1, 2022. Failure of the Department to file rules to
8implement the changes provided in this amendatory Act of the
9102nd General Assembly no later than June 1, 2022 shall result
10in the implementation date being delayed to October 1, 2022.
11    (d) The new nursing services reimbursement methodology
12utilizing the Patient Driven Payment Model, which shall be
13referred to as the PDPM reimbursement system, taking effect
14July 1, 2022, upon federal approval by the Centers for
15Medicare and Medicaid Services, shall be based on the
16following:
17        (1) The methodology shall be resident-centered,
18    facility-specific, cost-based, and based on guidance from
19    the Centers for Medicare and Medicaid Services.
20        (2) Costs shall be annually rebased and case mix index
21    quarterly updated. The nursing services methodology will
22    be assigned to the Medicaid enrolled residents on record
23    as of 30 days prior to the beginning of the rate period in
24    the Department's Medicaid Management Information System
25    (MMIS) as present on the last day of the second quarter
26    preceding the rate period based upon the Assessment

 

 

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1    Reference Date of the Minimum Data Set (MDS).
2        (3) Regional wage adjustors based on the Health
3    Service Areas (HSA) groupings and adjusters in effect on
4    April 30, 2012 shall be included, except no adjuster shall
5    be lower than 1.06.
6        (4) PDPM nursing case mix indices in effect on March
7    1, 2022 shall be assigned to each resident class at no less
8    than 0.7858 of the Centers for Medicare and Medicaid
9    Services PDPM unadjusted case mix values, in effect on
10    March 1, 2022.
11        (5) The pool of funds available for distribution by
12    case mix and the base facility rate shall be determined
13    using the formula contained in subsection (d-1).
14        (6) The Department shall establish a variable per diem
15    staffing add-on in accordance with the most recent
16    available federal staffing report, currently the Payroll
17    Based Journal, for the same period of time, and if
18    applicable adjusted for acuity using the same quarter's
19    MDS. The Department shall rely on Payroll Based Journals
20    provided to the Department of Public Health to make a
21    determination of non-submission. If the Department is
22    notified by a facility of missing or inaccurate Payroll
23    Based Journal data or an incorrect calculation of
24    staffing, the Department must make a correction as soon as
25    the error is verified for the applicable quarter.
26        Facilities with at least 70% of the staffing indicated

 

 

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1    by the STRIVE study shall be paid a per diem add-on of $9,
2    increasing by equivalent steps for each whole percentage
3    point until the facilities reach a per diem of $14.88.
4    Facilities with at least 80% of the staffing indicated by
5    the STRIVE study shall be paid a per diem add-on of $14.88,
6    increasing by equivalent steps for each whole percentage
7    point until the facilities reach a per diem add-on of
8    $23.80. Facilities with at least 92% of the staffing
9    indicated by the STRIVE study shall be paid a per diem
10    add-on of $23.80, increasing by equivalent steps for each
11    whole percentage point until the facilities reach a per
12    diem add-on of $29.75. Facilities with at least 100% of
13    the staffing indicated by the STRIVE study shall be paid a
14    per diem add-on of $29.75, increasing by equivalent steps
15    for each whole percentage point until the facilities reach
16    a per diem add-on of $35.70. Facilities with at least 110%
17    of the staffing indicated by the STRIVE study shall be
18    paid a per diem add-on of $35.70, increasing by equivalent
19    steps for each whole percentage point until the facilities
20    reach a per diem add-on of $38.68. Facilities with at
21    least 125% or higher of the staffing indicated by the
22    STRIVE study shall be paid a per diem add-on of $38.68.
23    Beginning April 1, 2023, no nursing facility's variable
24    staffing per diem add-on shall be reduced by more than 5%
25    in 2 consecutive quarters. For the quarters beginning July
26    1, 2022 and October 1, 2022, no facility's variable per

 

 

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1    diem staffing add-on shall be calculated at a rate lower
2    than 85% of the staffing indicated by the STRIVE study. No
3    facility below 70% of the staffing indicated by the STRIVE
4    study shall receive a variable per diem staffing add-on
5    after December 31, 2022.
6        (7) For dates of services beginning July 1, 2022, the
7    PDPM nursing component per diem for each nursing facility
8    shall be the product of the facility's (i) statewide PDPM
9    nursing base per diem rate, $92.25, adjusted for the
10    facility average PDPM case mix index calculated quarterly
11    and (ii) the regional wage adjuster, and then add the
12    Medicaid access adjustment as defined in (e-3) of this
13    Section. Transition rates for services provided between
14    July 1, 2022 and October 1, 2023 shall be the greater of
15    the PDPM nursing component per diem or:
16            (A) for the quarter beginning July 1, 2022, the
17        RUG-IV nursing component per diem;
18            (B) for the quarter beginning October 1, 2022, the
19        sum of the RUG-IV nursing component per diem
20        multiplied by 0.80 and the PDPM nursing component per
21        diem multiplied by 0.20;
22            (C) for the quarter beginning January 1, 2023, the
23        sum of the RUG-IV nursing component per diem
24        multiplied by 0.60 and the PDPM nursing component per
25        diem multiplied by 0.40;
26            (D) for the quarter beginning April 1, 2023, the

 

 

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1        sum of the RUG-IV nursing component per diem
2        multiplied by 0.40 and the PDPM nursing component per
3        diem multiplied by 0.60;
4            (E) for the quarter beginning July 1, 2023, the
5        sum of the RUG-IV nursing component per diem
6        multiplied by 0.20 and the PDPM nursing component per
7        diem multiplied by 0.80; or
8            (F) for the quarter beginning October 1, 2023 and
9        each subsequent quarter, the transition rate shall end
10        and a nursing facility shall be paid 100% of the PDPM
11        nursing component per diem.
12    (d-1) Calculation of base year Statewide RUG-IV nursing
13base per diem rate.
14        (1) Base rate spending pool shall be:
15            (A) The base year resident days which are
16        calculated by multiplying the number of Medicaid
17        residents in each nursing home as indicated in the MDS
18        data defined in paragraph (4) by 365.
19            (B) Each facility's nursing component per diem in
20        effect on July 1, 2012 shall be multiplied by
21        subsection (A).
22            (C) Thirteen million is added to the product of
23        subparagraph (A) and subparagraph (B) to adjust for
24        the exclusion of nursing homes defined in paragraph
25        (5).
26        (2) For each nursing home with Medicaid residents as

 

 

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1    indicated by the MDS data defined in paragraph (4),
2    weighted days adjusted for case mix and regional wage
3    adjustment shall be calculated. For each home this
4    calculation is the product of:
5            (A) Base year resident days as calculated in
6        subparagraph (A) of paragraph (1).
7            (B) The nursing home's regional wage adjustor
8        based on the Health Service Areas (HSA) groupings and
9        adjustors in effect on April 30, 2012.
10            (C) Facility weighted case mix which is the number
11        of Medicaid residents as indicated by the MDS data
12        defined in paragraph (4) multiplied by the associated
13        case weight for the RUG-IV 48 grouper model using
14        standard RUG-IV procedures for index maximization.
15            (D) The sum of the products calculated for each
16        nursing home in subparagraphs (A) through (C) above
17        shall be the base year case mix, rate adjusted
18        weighted days.
19        (3) The Statewide RUG-IV nursing base per diem rate:
20            (A) on January 1, 2014 shall be the quotient of the
21        paragraph (1) divided by the sum calculated under
22        subparagraph (D) of paragraph (2);
23            (B) on and after July 1, 2014 and until July 1,
24        2022, shall be the amount calculated under
25        subparagraph (A) of this paragraph (3) plus $1.76; and
26            (C) beginning July 1, 2022 and thereafter, $7

 

 

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1        shall be added to the amount calculated under
2        subparagraph (B) of this paragraph (3) of this
3        Section.
4        (4) Minimum Data Set (MDS) comprehensive assessments
5    for Medicaid residents on the last day of the quarter used
6    to establish the base rate.
7        (5) Nursing facilities designated as of July 1, 2012
8    by the Department as "Institutions for Mental Disease"
9    shall be excluded from all calculations under this
10    subsection. The data from these facilities shall not be
11    used in the computations described in paragraphs (1)
12    through (4) above to establish the base rate.
13    (e) Beginning July 1, 2014, the Department shall allocate
14funding in the amount up to $10,000,000 for per diem add-ons to
15the RUGS methodology for dates of service on and after July 1,
162014:
17        (1) $0.63 for each resident who scores in I4200
18    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
19        (2) $2.67 for each resident who scores either a "1" or
20    "2" in any items S1200A through S1200I and also scores in
21    RUG groups PA1, PA2, BA1, or BA2.
22    (e-1) (Blank).
23    (e-2) For dates of services beginning January 1, 2014 and
24ending September 30, 2023, the RUG-IV nursing component per
25diem for a nursing home shall be the product of the statewide
26RUG-IV nursing base per diem rate, the facility average case

 

 

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1mix index, and the regional wage adjustor. For dates of
2service beginning July 1, 2022 and ending September 30, 2023,
3the Medicaid access adjustment described in subsection (e-3)
4shall be added to the product.
5    (e-3) A Medicaid Access Adjustment of $4 adjusted for the
6facility average PDPM case mix index calculated quarterly
7shall be added to the statewide PDPM nursing per diem for all
8facilities with annual Medicaid bed days of at least 70% of all
9occupied bed days adjusted quarterly. For each new calendar
10year and for the 6-month period beginning July 1, 2022, the
11percentage of a facility's occupied bed days comprised of
12Medicaid bed days shall be determined by the Department
13quarterly. For dates of service beginning January 1, 2023, the
14Medicaid Access Adjustment shall be increased to $4.75. This
15subsection shall be inoperative on and after January 1, 2028.
16    (f) (Blank).
17    (g) Notwithstanding any other provision of this Code, on
18and after July 1, 2012, for facilities not designated by the
19Department of Healthcare and Family Services as "Institutions
20for Mental Disease", rates effective May 1, 2011 shall be
21adjusted as follows:
22        (1) (Blank);
23        (2) (Blank);
24        (3) Facility rates for the capital and support
25    components shall be reduced by 1.7%.
26    (h) Notwithstanding any other provision of this Code, on

 

 

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1and after July 1, 2012, nursing facilities designated by the
2Department of Healthcare and Family Services as "Institutions
3for Mental Disease" and "Institutions for Mental Disease" that
4are facilities licensed under the Specialized Mental Health
5Rehabilitation Act of 2013 shall have the nursing,
6socio-developmental, capital, and support components of their
7reimbursement rate effective May 1, 2011 reduced in total by
82.7%.
9    (i) On and after July 1, 2014, the reimbursement rates for
10the support component of the nursing facility rate for
11facilities licensed under the Nursing Home Care Act as skilled
12or intermediate care facilities shall be the rate in effect on
13June 30, 2014 increased by 8.17%.
14    (i-1) Subject to federal approval, the reimbursement rates
15for the support component of the nursing facility rate for
16facilities licensed under the Nursing Home Care Act as skilled
17or intermediate care facilities shall be the rate in effect on
18June 30, 2023 increased by 12%.
19    (j) Notwithstanding any other provision of law, subject to
20federal approval, effective July 1, 2019, sufficient funds
21shall be allocated for changes to rates for facilities
22licensed under the Nursing Home Care Act as skilled nursing
23facilities or intermediate care facilities for dates of
24services on and after July 1, 2019: (i) to establish, through
25June 30, 2022 a per diem add-on to the direct care per diem
26rate not to exceed $70,000,000 annually in the aggregate

 

 

10300SB1298ham002- 130 -LRB103 28018 KTG 62535 a

1taking into account federal matching funds for the purpose of
2addressing the facility's unique staffing needs, adjusted
3quarterly and distributed by a weighted formula based on
4Medicaid bed days on the last day of the second quarter
5preceding the quarter for which the rate is being adjusted.
6Beginning July 1, 2022, the annual $70,000,000 described in
7the preceding sentence shall be dedicated to the variable per
8diem add-on for staffing under paragraph (6) of subsection
9(d); and (ii) in an amount not to exceed $170,000,000 annually
10in the aggregate taking into account federal matching funds to
11permit the support component of the nursing facility rate to
12be updated as follows:
13        (1) 80%, or $136,000,000, of the funds shall be used
14    to update each facility's rate in effect on June 30, 2019
15    using the most recent cost reports on file, which have had
16    a limited review conducted by the Department of Healthcare
17    and Family Services and will not hold up enacting the rate
18    increase, with the Department of Healthcare and Family
19    Services.
20        (2) After completing the calculation in paragraph (1),
21    any facility whose rate is less than the rate in effect on
22    June 30, 2019 shall have its rate restored to the rate in
23    effect on June 30, 2019 from the 20% of the funds set
24    aside.
25        (3) The remainder of the 20%, or $34,000,000, shall be
26    used to increase each facility's rate by an equal

 

 

10300SB1298ham002- 131 -LRB103 28018 KTG 62535 a

1    percentage.
2    (k) During the first quarter of State Fiscal Year 2020,
3the Department of Healthcare of Family Services must convene a
4technical advisory group consisting of members of all trade
5associations representing Illinois skilled nursing providers
6to discuss changes necessary with federal implementation of
7Medicare's Patient-Driven Payment Model. Implementation of
8Medicare's Patient-Driven Payment Model shall, by September 1,
92020, end the collection of the MDS data that is necessary to
10maintain the current RUG-IV Medicaid payment methodology. The
11technical advisory group must consider a revised reimbursement
12methodology that takes into account transparency,
13accountability, actual staffing as reported under the
14federally required Payroll Based Journal system, changes to
15the minimum wage, adequacy in coverage of the cost of care, and
16a quality component that rewards quality improvements.
17    (l) The Department shall establish per diem add-on
18payments to improve the quality of care delivered by
19facilities, including:
20        (1) Incentive payments determined by facility
21    performance on specified quality measures in an initial
22    amount of $70,000,000. Nothing in this subsection shall be
23    construed to limit the quality of care payments in the
24    aggregate statewide to $70,000,000, and, if quality of
25    care has improved across nursing facilities, the
26    Department shall adjust those add-on payments accordingly.

 

 

10300SB1298ham002- 132 -LRB103 28018 KTG 62535 a

1    The quality payment methodology described in this
2    subsection must be used for at least State Fiscal Year
3    2023. Beginning with the quarter starting July 1, 2023,
4    the Department may add, remove, or change quality metrics
5    and make associated changes to the quality payment
6    methodology as outlined in subparagraph (E). Facilities
7    designated by the Centers for Medicare and Medicaid
8    Services as a special focus facility or a hospital-based
9    nursing home do not qualify for quality payments.
10            (A) Each quality pool must be distributed by
11        assigning a quality weighted score for each nursing
12        home which is calculated by multiplying the nursing
13        home's quality base period Medicaid days by the
14        nursing home's star rating weight in that period.
15            (B) Star rating weights are assigned based on the
16        nursing home's star rating for the LTS quality star
17        rating. As used in this subparagraph, "LTS quality
18        star rating" means the long-term stay quality rating
19        for each nursing facility, as assigned by the Centers
20        for Medicare and Medicaid Services under the Five-Star
21        Quality Rating System. The rating is a number ranging
22        from 0 (lowest) to 5 (highest).
23                (i) Zero-star or one-star rating has a weight
24            of 0.
25                (ii) Two-star rating has a weight of 0.75.
26                (iii) Three-star rating has a weight of 1.5.

 

 

10300SB1298ham002- 133 -LRB103 28018 KTG 62535 a

1                (iv) Four-star rating has a weight of 2.5.
2                (v) Five-star rating has a weight of 3.5.
3            (C) Each nursing home's quality weight score is
4        divided by the sum of all quality weight scores for
5        qualifying nursing homes to determine the proportion
6        of the quality pool to be paid to the nursing home.
7            (D) The quality pool is no less than $70,000,000
8        annually or $17,500,000 per quarter. The Department
9        shall publish on its website the estimated payments
10        and the associated weights for each facility 45 days
11        prior to when the initial payments for the quarter are
12        to be paid. The Department shall assign each facility
13        the most recent and applicable quarter's STAR value
14        unless the facility notifies the Department within 15
15        days of an issue and the facility provides reasonable
16        evidence demonstrating its timely compliance with
17        federal data submission requirements for the quarter
18        of record. If such evidence cannot be provided to the
19        Department, the STAR rating assigned to the facility
20        shall be reduced by one from the prior quarter.
21            (E) The Department shall review quality metrics
22        used for payment of the quality pool and make
23        recommendations for any associated changes to the
24        methodology for distributing quality pool payments in
25        consultation with associations representing long-term
26        care providers, consumer advocates, organizations

 

 

10300SB1298ham002- 134 -LRB103 28018 KTG 62535 a

1        representing workers of long-term care facilities, and
2        payors. The Department may establish, by rule, changes
3        to the methodology for distributing quality pool
4        payments.
5            (F) The Department shall disburse quality pool
6        payments from the Long-Term Care Provider Fund on a
7        monthly basis in amounts proportional to the total
8        quality pool payment determined for the quarter.
9            (G) The Department shall publish any changes in
10        the methodology for distributing quality pool payments
11        prior to the beginning of the measurement period or
12        quality base period for any metric added to the
13        distribution's methodology.
14        (2) Payments based on CNA tenure, promotion, and CNA
15    training for the purpose of increasing CNA compensation.
16    It is the intent of this subsection that payments made in
17    accordance with this paragraph be directly incorporated
18    into increased compensation for CNAs. As used in this
19    paragraph, "CNA" means a certified nursing assistant as
20    that term is described in Section 3-206 of the Nursing
21    Home Care Act, Section 3-206 of the ID/DD Community Care
22    Act, and Section 3-206 of the MC/DD Act. The Department
23    shall establish, by rule, payments to nursing facilities
24    equal to Medicaid's share of the tenure wage increments
25    specified in this paragraph for all reported CNA employee
26    hours compensated according to a posted schedule

 

 

10300SB1298ham002- 135 -LRB103 28018 KTG 62535 a

1    consisting of increments at least as large as those
2    specified in this paragraph. The increments are as
3    follows: an additional $1.50 per hour for CNAs with at
4    least one and less than 2 years' experience plus another
5    $1 per hour for each additional year of experience up to a
6    maximum of $6.50 for CNAs with at least 6 years of
7    experience. For purposes of this paragraph, Medicaid's
8    share shall be the ratio determined by paid Medicaid bed
9    days divided by total bed days for the applicable time
10    period used in the calculation. In addition, and additive
11    to any tenure increments paid as specified in this
12    paragraph, the Department shall establish, by rule,
13    payments supporting Medicaid's share of the
14    promotion-based wage increments for CNA employee hours
15    compensated for that promotion with at least a $1.50
16    hourly increase. Medicaid's share shall be established as
17    it is for the tenure increments described in this
18    paragraph. Qualifying promotions shall be defined by the
19    Department in rules for an expected 10-15% subset of CNAs
20    assigned intermediate, specialized, or added roles such as
21    CNA trainers, CNA scheduling "captains", and CNA
22    specialists for resident conditions like dementia or
23    memory care or behavioral health.
24    (m) The Department shall work with nursing facility
25industry representatives to design policies and procedures to
26permit facilities to address the integrity of data from

 

 

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1federal reporting sites used by the Department in setting
2facility rates.
3(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19;
4102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff.
55-31-22; 102-1118, eff. 1-18-23.)
 
6
ARTICLE 45.

 
7    Section 45-5. The Illinois Act on the Aging is amended by
8changing Section 4.02 as follows:
 
9    (20 ILCS 105/4.02)  (from Ch. 23, par. 6104.02)
10    Sec. 4.02. Community Care Program. The Department shall
11establish a program of services to prevent unnecessary
12institutionalization of persons age 60 and older in need of
13long term care or who are established as persons who suffer
14from Alzheimer's disease or a related disorder under the
15Alzheimer's Disease Assistance Act, thereby enabling them to
16remain in their own homes or in other living arrangements.
17Such preventive services, which may be coordinated with other
18programs for the aged and monitored by area agencies on aging
19in cooperation with the Department, may include, but are not
20limited to, any or all of the following:
21        (a) (blank);
22        (b) (blank);
23        (c) home care aide services;

 

 

10300SB1298ham002- 137 -LRB103 28018 KTG 62535 a

1        (d) personal assistant services;
2        (e) adult day services;
3        (f) home-delivered meals;
4        (g) education in self-care;
5        (h) personal care services;
6        (i) adult day health services;
7        (j) habilitation services;
8        (k) respite care;
9        (k-5) community reintegration services;
10        (k-6) flexible senior services;
11        (k-7) medication management;
12        (k-8) emergency home response;
13        (l) other nonmedical social services that may enable
14    the person to become self-supporting; or
15        (m) clearinghouse for information provided by senior
16    citizen home owners who want to rent rooms to or share
17    living space with other senior citizens.
18    The Department shall establish eligibility standards for
19such services. In determining the amount and nature of
20services for which a person may qualify, consideration shall
21not be given to the value of cash, property or other assets
22held in the name of the person's spouse pursuant to a written
23agreement dividing marital property into equal but separate
24shares or pursuant to a transfer of the person's interest in a
25home to his spouse, provided that the spouse's share of the
26marital property is not made available to the person seeking

 

 

10300SB1298ham002- 138 -LRB103 28018 KTG 62535 a

1such services.
2    Beginning January 1, 2008, the Department shall require as
3a condition of eligibility that all new financially eligible
4applicants apply for and enroll in medical assistance under
5Article V of the Illinois Public Aid Code in accordance with
6rules promulgated by the Department.
7    The Department shall, in conjunction with the Department
8of Public Aid (now Department of Healthcare and Family
9Services), seek appropriate amendments under Sections 1915 and
101924 of the Social Security Act. The purpose of the amendments
11shall be to extend eligibility for home and community based
12services under Sections 1915 and 1924 of the Social Security
13Act to persons who transfer to or for the benefit of a spouse
14those amounts of income and resources allowed under Section
151924 of the Social Security Act. Subject to the approval of
16such amendments, the Department shall extend the provisions of
17Section 5-4 of the Illinois Public Aid Code to persons who, but
18for the provision of home or community-based services, would
19require the level of care provided in an institution, as is
20provided for in federal law. Those persons no longer found to
21be eligible for receiving noninstitutional services due to
22changes in the eligibility criteria shall be given 45 days
23notice prior to actual termination. Those persons receiving
24notice of termination may contact the Department and request
25the determination be appealed at any time during the 45 day
26notice period. The target population identified for the

 

 

10300SB1298ham002- 139 -LRB103 28018 KTG 62535 a

1purposes of this Section are persons age 60 and older with an
2identified service need. Priority shall be given to those who
3are at imminent risk of institutionalization. The services
4shall be provided to eligible persons age 60 and older to the
5extent that the cost of the services together with the other
6personal maintenance expenses of the persons are reasonably
7related to the standards established for care in a group
8facility appropriate to the person's condition. These
9non-institutional services, pilot projects or experimental
10facilities may be provided as part of or in addition to those
11authorized by federal law or those funded and administered by
12the Department of Human Services. The Departments of Human
13Services, Healthcare and Family Services, Public Health,
14Veterans' Affairs, and Commerce and Economic Opportunity and
15other appropriate agencies of State, federal and local
16governments shall cooperate with the Department on Aging in
17the establishment and development of the non-institutional
18services. The Department shall require an annual audit from
19all personal assistant and home care aide vendors contracting
20with the Department under this Section. The annual audit shall
21assure that each audited vendor's procedures are in compliance
22with Department's financial reporting guidelines requiring an
23administrative and employee wage and benefits cost split as
24defined in administrative rules. The audit is a public record
25under the Freedom of Information Act. The Department shall
26execute, relative to the nursing home prescreening project,

 

 

10300SB1298ham002- 140 -LRB103 28018 KTG 62535 a

1written inter-agency agreements with the Department of Human
2Services and the Department of Healthcare and Family Services,
3to effect the following: (1) intake procedures and common
4eligibility criteria for those persons who are receiving
5non-institutional services; and (2) the establishment and
6development of non-institutional services in areas of the
7State where they are not currently available or are
8undeveloped. On and after July 1, 1996, all nursing home
9prescreenings for individuals 60 years of age or older shall
10be conducted by the Department.
11    As part of the Department on Aging's routine training of
12case managers and case manager supervisors, the Department may
13include information on family futures planning for persons who
14are age 60 or older and who are caregivers of their adult
15children with developmental disabilities. The content of the
16training shall be at the Department's discretion.
17    The Department is authorized to establish a system of
18recipient copayment for services provided under this Section,
19such copayment to be based upon the recipient's ability to pay
20but in no case to exceed the actual cost of the services
21provided. Additionally, any portion of a person's income which
22is equal to or less than the federal poverty standard shall not
23be considered by the Department in determining the copayment.
24The level of such copayment shall be adjusted whenever
25necessary to reflect any change in the officially designated
26federal poverty standard.

 

 

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1    The Department, or the Department's authorized
2representative, may recover the amount of moneys expended for
3services provided to or in behalf of a person under this
4Section by a claim against the person's estate or against the
5estate of the person's surviving spouse, but no recovery may
6be had until after the death of the surviving spouse, if any,
7and then only at such time when there is no surviving child who
8is under age 21 or blind or who has a permanent and total
9disability. This paragraph, however, shall not bar recovery,
10at the death of the person, of moneys for services provided to
11the person or in behalf of the person under this Section to
12which the person was not entitled; provided that such recovery
13shall not be enforced against any real estate while it is
14occupied as a homestead by the surviving spouse or other
15dependent, if no claims by other creditors have been filed
16against the estate, or, if such claims have been filed, they
17remain dormant for failure of prosecution or failure of the
18claimant to compel administration of the estate for the
19purpose of payment. This paragraph shall not bar recovery from
20the estate of a spouse, under Sections 1915 and 1924 of the
21Social Security Act and Section 5-4 of the Illinois Public Aid
22Code, who precedes a person receiving services under this
23Section in death. All moneys for services paid to or in behalf
24of the person under this Section shall be claimed for recovery
25from the deceased spouse's estate. "Homestead", as used in
26this paragraph, means the dwelling house and contiguous real

 

 

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1estate occupied by a surviving spouse or relative, as defined
2by the rules and regulations of the Department of Healthcare
3and Family Services, regardless of the value of the property.
4    The Department shall increase the effectiveness of the
5existing Community Care Program by:
6        (1) ensuring that in-home services included in the
7    care plan are available on evenings and weekends;
8        (2) ensuring that care plans contain the services that
9    eligible participants need based on the number of days in
10    a month, not limited to specific blocks of time, as
11    identified by the comprehensive assessment tool selected
12    by the Department for use statewide, not to exceed the
13    total monthly service cost maximum allowed for each
14    service; the Department shall develop administrative rules
15    to implement this item (2);
16        (3) ensuring that the participants have the right to
17    choose the services contained in their care plan and to
18    direct how those services are provided, based on
19    administrative rules established by the Department;
20        (4) ensuring that the determination of need tool is
21    accurate in determining the participants' level of need;
22    to achieve this, the Department, in conjunction with the
23    Older Adult Services Advisory Committee, shall institute a
24    study of the relationship between the Determination of
25    Need scores, level of need, service cost maximums, and the
26    development and utilization of service plans no later than

 

 

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1    May 1, 2008; findings and recommendations shall be
2    presented to the Governor and the General Assembly no
3    later than January 1, 2009; recommendations shall include
4    all needed changes to the service cost maximums schedule
5    and additional covered services;
6        (5) ensuring that homemakers can provide personal care
7    services that may or may not involve contact with clients,
8    including but not limited to:
9            (A) bathing;
10            (B) grooming;
11            (C) toileting;
12            (D) nail care;
13            (E) transferring;
14            (F) respiratory services;
15            (G) exercise; or
16            (H) positioning;
17        (6) ensuring that homemaker program vendors are not
18    restricted from hiring homemakers who are family members
19    of clients or recommended by clients; the Department may
20    not, by rule or policy, require homemakers who are family
21    members of clients or recommended by clients to accept
22    assignments in homes other than the client;
23        (7) ensuring that the State may access maximum federal
24    matching funds by seeking approval for the Centers for
25    Medicare and Medicaid Services for modifications to the
26    State's home and community based services waiver and

 

 

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

 

 

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

 

 

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1requirements. All applicants shall be subject to the
2provisions of the Health Care Worker Background Check Act.
3    The Department shall develop procedures to enhance
4availability of services on evenings, weekends, and on an
5emergency basis to meet the respite needs of caregivers.
6Procedures shall be developed to permit the utilization of
7services in successive blocks of 24 hours up to the monthly
8maximum established by the Department. Workers providing these
9services shall be appropriately trained.
10    Beginning on the effective date of this amendatory Act of
111991, no person may perform chore/housekeeping and home care
12aide services under a program authorized by this Section
13unless that person has been issued a certificate of
14pre-service to do so by his or her employing agency.
15Information gathered to effect such certification shall
16include (i) the person's name, (ii) the date the person was
17hired by his or her current employer, and (iii) the training,
18including dates and levels. Persons engaged in the program
19authorized by this Section before the effective date of this
20amendatory Act of 1991 shall be issued a certificate of all
21pre- and in-service training from his or her employer upon
22submitting the necessary information. The employing agency
23shall be required to retain records of all staff pre- and
24in-service training, and shall provide such records to the
25Department upon request and upon termination of the employer's
26contract with the Department. In addition, the employing

 

 

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

 

 

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

 

 

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1assistance and staff support to the committee. Department
2representation shall not constitute membership of the
3committee. All Committee papers, issues, recommendations,
4reports, and meeting memoranda are advisory only. The
5Director, or his or her designee, shall make a written report,
6as requested by the Committee, regarding issues before the
7Committee.
8    The Department on Aging and the Department of Human
9Services shall cooperate in the development and submission of
10an annual report on programs and services provided under this
11Section. Such joint report shall be filed with the Governor
12and the General Assembly on or before September 30 each year.
13    The requirement for reporting to the General Assembly
14shall be satisfied by filing copies of the report as required
15by Section 3.1 of the General Assembly Organization Act and
16filing such additional copies with the State Government Report
17Distribution Center for the General Assembly as is required
18under paragraph (t) of Section 7 of the State Library Act.
19    Those persons previously found eligible for receiving
20non-institutional services whose services were discontinued
21under the Emergency Budget Act of Fiscal Year 1992, and who do
22not meet the eligibility standards in effect on or after July
231, 1992, shall remain ineligible on and after July 1, 1992.
24Those persons previously not required to cost-share and who
25were required to cost-share effective March 1, 1992, shall
26continue to meet cost-share requirements on and after July 1,

 

 

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11992. Beginning July 1, 1992, all clients will be required to
2meet eligibility, cost-share, and other requirements and will
3have services discontinued or altered when they fail to meet
4these requirements.
5    For the purposes of this Section, "flexible senior
6services" refers to services that require one-time or periodic
7expenditures including, but not limited to, respite care, home
8modification, assistive technology, housing assistance, and
9transportation.
10    The Department shall implement an electronic service
11verification based on global positioning systems or other
12cost-effective technology for the Community Care Program no
13later than January 1, 2014.
14    The Department shall require, as a condition of
15eligibility, enrollment in the medical assistance program
16under Article V of the Illinois Public Aid Code (i) beginning
17August 1, 2013, if the Auditor General has reported that the
18Department has failed to comply with the reporting
19requirements of Section 2-27 of the Illinois State Auditing
20Act; or (ii) beginning June 1, 2014, if the Auditor General has
21reported that the Department has not undertaken the required
22actions listed in the report required by subsection (a) of
23Section 2-27 of the Illinois State Auditing Act.
24    The Department shall delay Community Care Program services
25until an applicant is determined eligible for medical
26assistance under Article V of the Illinois Public Aid Code (i)

 

 

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1beginning August 1, 2013, if the Auditor General has reported
2that the Department has failed to comply with the reporting
3requirements of Section 2-27 of the Illinois State Auditing
4Act; or (ii) beginning June 1, 2014, if the Auditor General has
5reported that the Department has not undertaken the required
6actions listed in the report required by subsection (a) of
7Section 2-27 of the Illinois State Auditing Act.
8    The Department shall implement co-payments for the
9Community Care Program at the federally allowable maximum
10level (i) beginning August 1, 2013, if the Auditor General has
11reported that the Department has failed to comply with the
12reporting requirements of Section 2-27 of the Illinois State
13Auditing Act; or (ii) beginning June 1, 2014, if the Auditor
14General has reported that the Department has not undertaken
15the required actions listed in the report required by
16subsection (a) of Section 2-27 of the Illinois State Auditing
17Act.
18    The Department shall continue to provide other Community
19Care Program reports as required by statute.
20    The Department shall conduct a quarterly review of Care
21Coordination Unit performance and adherence to service
22guidelines. The quarterly review shall be reported to the
23Speaker of the House of Representatives, the Minority Leader
24of the House of Representatives, the President of the Senate,
25and the Minority Leader of the Senate. The Department shall
26collect and report longitudinal data on the performance of

 

 

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1each care coordination unit. Nothing in this paragraph shall
2be construed to require the Department to identify specific
3care coordination units.
4    In regard to community care providers, failure to comply
5with Department on Aging policies shall be cause for
6disciplinary action, including, but not limited to,
7disqualification from serving Community Care Program clients.
8Each provider, upon submission of any bill or invoice to the
9Department for payment for services rendered, shall include a
10notarized statement, under penalty of perjury pursuant to
11Section 1-109 of the Code of Civil Procedure, that the
12provider has complied with all Department policies.
13    The Director of the Department on Aging shall make
14information available to the State Board of Elections as may
15be required by an agreement the State Board of Elections has
16entered into with a multi-state voter registration list
17maintenance system.
18    Within 30 days after July 6, 2017 (the effective date of
19Public Act 100-23), rates shall be increased to $18.29 per
20hour, for the purpose of increasing, by at least $.72 per hour,
21the wages paid by those vendors to their employees who provide
22homemaker services. The Department shall pay an enhanced rate
23under the Community Care Program to those in-home service
24provider agencies that offer health insurance coverage as a
25benefit to their direct service worker employees consistent
26with the mandates of Public Act 95-713. For State fiscal years

 

 

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12018 and 2019, the enhanced rate shall be $1.77 per hour. The
2rate shall be adjusted using actuarial analysis based on the
3cost of care, but shall not be set below $1.77 per hour. The
4Department shall adopt rules, including emergency rules under
5subsections (y) and (bb) of Section 5-45 of the Illinois
6Administrative Procedure Act, to implement the provisions of
7this paragraph.
8    Subject to federal approval, rates for homemaker services
9shall be increased to $28.07 to sustain a minimum wage of $17
10per hour for direct service workers. Rates in subsequent State
11fiscal years shall be no lower than the rates put into effect
12upon federal approval. Providers of in-home services shall be
13required to certify to the Department that they remain in
14compliance with the mandated wage increase for direct service
15workers. Fringe benefits, including, but not limited to, paid
16time off and payment for training, health insurance, travel,
17or transportation, shall not be reduced in relation to the
18rate increases described in this paragraph.
19    The General Assembly finds it necessary to authorize an
20aggressive Medicaid enrollment initiative designed to maximize
21federal Medicaid funding for the Community Care Program which
22produces significant savings for the State of Illinois. The
23Department on Aging shall establish and implement a Community
24Care Program Medicaid Initiative. Under the Initiative, the
25Department on Aging shall, at a minimum: (i) provide an
26enhanced rate to adequately compensate care coordination units

 

 

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1to enroll eligible Community Care Program clients into
2Medicaid; (ii) use recommendations from a stakeholder
3committee on how best to implement the Initiative; and (iii)
4establish requirements for State agencies to make enrollment
5in the State's Medical Assistance program easier for seniors.
6    The Community Care Program Medicaid Enrollment Oversight
7Subcommittee is created as a subcommittee of the Older Adult
8Services Advisory Committee established in Section 35 of the
9Older Adult Services Act to make recommendations on how best
10to increase the number of medical assistance recipients who
11are enrolled in the Community Care Program. The Subcommittee
12shall consist of all of the following persons who must be
13appointed within 30 days after the effective date of this
14amendatory Act of the 100th General Assembly:
15        (1) The Director of Aging, or his or her designee, who
16    shall serve as the chairperson of the Subcommittee.
17        (2) One representative of the Department of Healthcare
18    and Family Services, appointed by the Director of
19    Healthcare and Family Services.
20        (3) One representative of the Department of Human
21    Services, appointed by the Secretary of Human Services.
22        (4) One individual representing a care coordination
23    unit, appointed by the Director of Aging.
24        (5) One individual from a non-governmental statewide
25    organization that advocates for seniors, appointed by the
26    Director of Aging.

 

 

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1        (6) One individual representing Area Agencies on
2    Aging, appointed by the Director of Aging.
3        (7) One individual from a statewide association
4    dedicated to Alzheimer's care, support, and research,
5    appointed by the Director of Aging.
6        (8) One individual from an organization that employs
7    persons who provide services under the Community Care
8    Program, appointed by the Director of Aging.
9        (9) One member of a trade or labor union representing
10    persons who provide services under the Community Care
11    Program, appointed by the Director of Aging.
12        (10) One member of the Senate, who shall serve as
13    co-chairperson, appointed by the President of the Senate.
14        (11) One member of the Senate, who shall serve as
15    co-chairperson, appointed by the Minority Leader of the
16    Senate.
17        (12) One member of the House of Representatives, who
18    shall serve as co-chairperson, appointed by the Speaker of
19    the House of Representatives.
20        (13) One member of the House of Representatives, who
21    shall serve as co-chairperson, appointed by the Minority
22    Leader of the House of Representatives.
23        (14) One individual appointed by a labor organization
24    representing frontline employees at the Department of
25    Human Services.
26    The Subcommittee shall provide oversight to the Community

 

 

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1Care Program Medicaid Initiative and shall meet quarterly. At
2each Subcommittee meeting the Department on Aging shall
3provide the following data sets to the Subcommittee: (A) the
4number of Illinois residents, categorized by planning and
5service area, who are receiving services under the Community
6Care Program and are enrolled in the State's Medical
7Assistance Program; (B) the number of Illinois residents,
8categorized by planning and service area, who are receiving
9services under the Community Care Program, but are not
10enrolled in the State's Medical Assistance Program; and (C)
11the number of Illinois residents, categorized by planning and
12service area, who are receiving services under the Community
13Care Program and are eligible for benefits under the State's
14Medical Assistance Program, but are not enrolled in the
15State's Medical Assistance Program. In addition to this data,
16the Department on Aging shall provide the Subcommittee with
17plans on how the Department on Aging will reduce the number of
18Illinois residents who are not enrolled in the State's Medical
19Assistance Program but who are eligible for medical assistance
20benefits. The Department on Aging shall enroll in the State's
21Medical Assistance Program those Illinois residents who
22receive services under the Community Care Program and are
23eligible for medical assistance benefits but are not enrolled
24in the State's Medicaid Assistance Program. The data provided
25to the Subcommittee shall be made available to the public via
26the Department on Aging's website.

 

 

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

 

 

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1    The Community Care Program Medicaid Initiative shall cease
2operation 5 years after the effective date of this amendatory
3Act of the 100th General Assembly, after which the
4Subcommittee shall dissolve.
5(Source: P.A. 101-10, eff. 6-5-19; 102-1071, eff. 6-10-22.)
 
6
ARTICLE 50.

 
7    Section 50-5. The Illinois Public Aid Code is amended by
8changing Section 5-5.2 as follows:
 
9    (305 ILCS 5/5-5.2)  (from Ch. 23, par. 5-5.2)
10    Sec. 5-5.2. Payment.
11    (a) All nursing facilities that are grouped pursuant to
12Section 5-5.1 of this Act shall receive the same rate of
13payment for similar services.
14    (b) It shall be a matter of State policy that the Illinois
15Department shall utilize a uniform billing cycle throughout
16the State for the long-term care providers.
17    (c) (Blank).
18    (c-1) Notwithstanding any other provisions of this Code,
19the methodologies for reimbursement of nursing services as
20provided under this Article shall no longer be applicable for
21bills payable for nursing services rendered on or after a new
22reimbursement system based on the Patient Driven Payment Model
23(PDPM) has been fully operationalized, which shall take effect

 

 

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1for services provided on or after the implementation of the
2PDPM reimbursement system begins. For the purposes of this
3amendatory Act of the 102nd General Assembly, the
4implementation date of the PDPM reimbursement system and all
5related provisions shall be July 1, 2022 if the following
6conditions are met: (i) the Centers for Medicare and Medicaid
7Services has approved corresponding changes in the
8reimbursement system and bed assessment; and (ii) the
9Department has filed rules to implement these changes no later
10than June 1, 2022. Failure of the Department to file rules to
11implement the changes provided in this amendatory Act of the
12102nd General Assembly no later than June 1, 2022 shall result
13in the implementation date being delayed to October 1, 2022.
14    (d) The new nursing services reimbursement methodology
15utilizing the Patient Driven Payment Model, which shall be
16referred to as the PDPM reimbursement system, taking effect
17July 1, 2022, upon federal approval by the Centers for
18Medicare and Medicaid Services, shall be based on the
19following:
20        (1) The methodology shall be resident-centered,
21    facility-specific, cost-based, and based on guidance from
22    the Centers for Medicare and Medicaid Services.
23        (2) Costs shall be annually rebased and case mix index
24    quarterly updated. The nursing services methodology will
25    be assigned to the Medicaid enrolled residents on record
26    as of 30 days prior to the beginning of the rate period in

 

 

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1    the Department's Medicaid Management Information System
2    (MMIS) as present on the last day of the second quarter
3    preceding the rate period based upon the Assessment
4    Reference Date of the Minimum Data Set (MDS).
5        (3) Regional wage adjustors based on the Health
6    Service Areas (HSA) groupings and adjusters in effect on
7    April 30, 2012 shall be included, except no adjuster shall
8    be lower than 1.06.
9        (4) PDPM nursing case mix indices in effect on March
10    1, 2022 shall be assigned to each resident class at no less
11    than 0.7858 of the Centers for Medicare and Medicaid
12    Services PDPM unadjusted case mix values, in effect on
13    March 1, 2022.
14        (5) The pool of funds available for distribution by
15    case mix and the base facility rate shall be determined
16    using the formula contained in subsection (d-1).
17        (6) The Department shall establish a variable per diem
18    staffing add-on in accordance with the most recent
19    available federal staffing report, currently the Payroll
20    Based Journal, for the same period of time, and if
21    applicable adjusted for acuity using the same quarter's
22    MDS. The Department shall rely on Payroll Based Journals
23    provided to the Department of Public Health to make a
24    determination of non-submission. If the Department is
25    notified by a facility of missing or inaccurate Payroll
26    Based Journal data or an incorrect calculation of

 

 

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1    staffing, the Department must make a correction as soon as
2    the error is verified for the applicable quarter.
3        Facilities with at least 70% of the staffing indicated
4    by the STRIVE study shall be paid a per diem add-on of $9,
5    increasing by equivalent steps for each whole percentage
6    point until the facilities reach a per diem of $14.88.
7    Facilities with at least 80% of the staffing indicated by
8    the STRIVE study shall be paid a per diem add-on of $14.88,
9    increasing by equivalent steps for each whole percentage
10    point until the facilities reach a per diem add-on of
11    $23.80. Facilities with at least 92% of the staffing
12    indicated by the STRIVE study shall be paid a per diem
13    add-on of $23.80, increasing by equivalent steps for each
14    whole percentage point until the facilities reach a per
15    diem add-on of $29.75. Facilities with at least 100% of
16    the staffing indicated by the STRIVE study shall be paid a
17    per diem add-on of $29.75, increasing by equivalent steps
18    for each whole percentage point until the facilities reach
19    a per diem add-on of $35.70. Facilities with at least 110%
20    of the staffing indicated by the STRIVE study shall be
21    paid a per diem add-on of $35.70, increasing by equivalent
22    steps for each whole percentage point until the facilities
23    reach a per diem add-on of $38.68. Facilities with at
24    least 125% or higher of the staffing indicated by the
25    STRIVE study shall be paid a per diem add-on of $38.68.
26    Beginning April 1, 2023, no nursing facility's variable

 

 

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1    staffing per diem add-on shall be reduced by more than 5%
2    in 2 consecutive quarters. For the quarters beginning July
3    1, 2022 and October 1, 2022, no facility's variable per
4    diem staffing add-on shall be calculated at a rate lower
5    than 85% of the staffing indicated by the STRIVE study. No
6    facility below 70% of the staffing indicated by the STRIVE
7    study shall receive a variable per diem staffing add-on
8    after December 31, 2022.
9        (7) For dates of services beginning July 1, 2022, the
10    PDPM nursing component per diem for each nursing facility
11    shall be the product of the facility's (i) statewide PDPM
12    nursing base per diem rate, $92.25, adjusted for the
13    facility average PDPM case mix index calculated quarterly
14    and (ii) the regional wage adjuster, and then add the
15    Medicaid access adjustment as defined in (e-3) of this
16    Section. Transition rates for services provided between
17    July 1, 2022 and October 1, 2023 shall be the greater of
18    the PDPM nursing component per diem or:
19            (A) for the quarter beginning July 1, 2022, the
20        RUG-IV nursing component per diem;
21            (B) for the quarter beginning October 1, 2022, the
22        sum of the RUG-IV nursing component per diem
23        multiplied by 0.80 and the PDPM nursing component per
24        diem multiplied by 0.20;
25            (C) for the quarter beginning January 1, 2023, the
26        sum of the RUG-IV nursing component per diem

 

 

10300SB1298ham002- 163 -LRB103 28018 KTG 62535 a

1        multiplied by 0.60 and the PDPM nursing component per
2        diem multiplied by 0.40;
3            (D) for the quarter beginning April 1, 2023, the
4        sum of the RUG-IV nursing component per diem
5        multiplied by 0.40 and the PDPM nursing component per
6        diem multiplied by 0.60;
7            (E) for the quarter beginning July 1, 2023, the
8        sum of the RUG-IV nursing component per diem
9        multiplied by 0.20 and the PDPM nursing component per
10        diem multiplied by 0.80; or
11            (F) for the quarter beginning October 1, 2023 and
12        each subsequent quarter, the transition rate shall end
13        and a nursing facility shall be paid 100% of the PDPM
14        nursing component per diem.
15    (d-1) Calculation of base year Statewide RUG-IV nursing
16base per diem rate.
17        (1) Base rate spending pool shall be:
18            (A) The base year resident days which are
19        calculated by multiplying the number of Medicaid
20        residents in each nursing home as indicated in the MDS
21        data defined in paragraph (4) by 365.
22            (B) Each facility's nursing component per diem in
23        effect on July 1, 2012 shall be multiplied by
24        subsection (A).
25            (C) Thirteen million is added to the product of
26        subparagraph (A) and subparagraph (B) to adjust for

 

 

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1        the exclusion of nursing homes defined in paragraph
2        (5).
3        (2) For each nursing home with Medicaid residents as
4    indicated by the MDS data defined in paragraph (4),
5    weighted days adjusted for case mix and regional wage
6    adjustment shall be calculated. For each home this
7    calculation is the product of:
8            (A) Base year resident days as calculated in
9        subparagraph (A) of paragraph (1).
10            (B) The nursing home's regional wage adjustor
11        based on the Health Service Areas (HSA) groupings and
12        adjustors in effect on April 30, 2012.
13            (C) Facility weighted case mix which is the number
14        of Medicaid residents as indicated by the MDS data
15        defined in paragraph (4) multiplied by the associated
16        case weight for the RUG-IV 48 grouper model using
17        standard RUG-IV procedures for index maximization.
18            (D) The sum of the products calculated for each
19        nursing home in subparagraphs (A) through (C) above
20        shall be the base year case mix, rate adjusted
21        weighted days.
22        (3) The Statewide RUG-IV nursing base per diem rate:
23            (A) on January 1, 2014 shall be the quotient of the
24        paragraph (1) divided by the sum calculated under
25        subparagraph (D) of paragraph (2);
26            (B) on and after July 1, 2014 and until July 1,

 

 

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1        2022, shall be the amount calculated under
2        subparagraph (A) of this paragraph (3) plus $1.76; and
3            (C) beginning July 1, 2022 and thereafter, $7
4        shall be added to the amount calculated under
5        subparagraph (B) of this paragraph (3) of this
6        Section.
7        (4) Minimum Data Set (MDS) comprehensive assessments
8    for Medicaid residents on the last day of the quarter used
9    to establish the base rate.
10        (5) Nursing facilities designated as of July 1, 2012
11    by the Department as "Institutions for Mental Disease"
12    shall be excluded from all calculations under this
13    subsection. The data from these facilities shall not be
14    used in the computations described in paragraphs (1)
15    through (4) above to establish the base rate.
16    (e) Beginning July 1, 2014, the Department shall allocate
17funding in the amount up to $10,000,000 for per diem add-ons to
18the RUGS methodology for dates of service on and after July 1,
192014:
20        (1) $0.63 for each resident who scores in I4200
21    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
22        (2) $2.67 for each resident who scores either a "1" or
23    "2" in any items S1200A through S1200I and also scores in
24    RUG groups PA1, PA2, BA1, or BA2.
25    (e-1) (Blank).
26    (e-2) For dates of services beginning January 1, 2014 and

 

 

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1ending September 30, 2023, the RUG-IV nursing component per
2diem for a nursing home shall be the product of the statewide
3RUG-IV nursing base per diem rate, the facility average case
4mix index, and the regional wage adjustor. For dates of
5service beginning July 1, 2022 and ending September 30, 2023,
6the Medicaid access adjustment described in subsection (e-3)
7shall be added to the product.
8    (e-3) A Medicaid Access Adjustment of $4 adjusted for the
9facility average PDPM case mix index calculated quarterly
10shall be added to the statewide PDPM nursing per diem for all
11facilities with annual Medicaid bed days of at least 70% of all
12occupied bed days adjusted quarterly. For each new calendar
13year and for the 6-month period beginning July 1, 2022, the
14percentage of a facility's occupied bed days comprised of
15Medicaid bed days shall be determined by the Department
16quarterly. For dates of service beginning January 1, 2023, the
17Medicaid Access Adjustment shall be increased to $4.75. This
18subsection shall be inoperative on and after January 1, 2028.
19    (e-4) Subject to federal approval, the Department shall
20increase the rate add-on at paragraph (7) subsection (a) under
2189 Ill. Adm. Code 147.335 for ventilator services from $208
22per day to $481 per day. Payment is subject to the criteria and
23requirements under 89 Ill. Adm. Code 147.335.
24    (f) (Blank).
25    (g) Notwithstanding any other provision of this Code, on
26and after July 1, 2012, for facilities not designated by the

 

 

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1Department of Healthcare and Family Services as "Institutions
2for Mental Disease", rates effective May 1, 2011 shall be
3adjusted as follows:
4        (1) (Blank);
5        (2) (Blank);
6        (3) Facility rates for the capital and support
7    components shall be reduced by 1.7%.
8    (h) Notwithstanding any other provision of this Code, on
9and after July 1, 2012, nursing facilities designated by the
10Department of Healthcare and Family Services as "Institutions
11for Mental Disease" and "Institutions for Mental Disease" that
12are facilities licensed under the Specialized Mental Health
13Rehabilitation Act of 2013 shall have the nursing,
14socio-developmental, capital, and support components of their
15reimbursement rate effective May 1, 2011 reduced in total by
162.7%.
17    (i) On and after July 1, 2014, the reimbursement rates for
18the support component of the nursing facility rate for
19facilities licensed under the Nursing Home Care Act as skilled
20or intermediate care facilities shall be the rate in effect on
21June 30, 2014 increased by 8.17%.
22    (j) Notwithstanding any other provision of law, subject to
23federal approval, effective July 1, 2019, sufficient funds
24shall be allocated for changes to rates for facilities
25licensed under the Nursing Home Care Act as skilled nursing
26facilities or intermediate care facilities for dates of

 

 

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1services on and after July 1, 2019: (i) to establish, through
2June 30, 2022 a per diem add-on to the direct care per diem
3rate not to exceed $70,000,000 annually in the aggregate
4taking into account federal matching funds for the purpose of
5addressing the facility's unique staffing needs, adjusted
6quarterly and distributed by a weighted formula based on
7Medicaid bed days on the last day of the second quarter
8preceding the quarter for which the rate is being adjusted.
9Beginning July 1, 2022, the annual $70,000,000 described in
10the preceding sentence shall be dedicated to the variable per
11diem add-on for staffing under paragraph (6) of subsection
12(d); and (ii) in an amount not to exceed $170,000,000 annually
13in the aggregate taking into account federal matching funds to
14permit the support component of the nursing facility rate to
15be updated as follows:
16        (1) 80%, or $136,000,000, of the funds shall be used
17    to update each facility's rate in effect on June 30, 2019
18    using the most recent cost reports on file, which have had
19    a limited review conducted by the Department of Healthcare
20    and Family Services and will not hold up enacting the rate
21    increase, with the Department of Healthcare and Family
22    Services.
23        (2) After completing the calculation in paragraph (1),
24    any facility whose rate is less than the rate in effect on
25    June 30, 2019 shall have its rate restored to the rate in
26    effect on June 30, 2019 from the 20% of the funds set

 

 

10300SB1298ham002- 169 -LRB103 28018 KTG 62535 a

1    aside.
2        (3) The remainder of the 20%, or $34,000,000, shall be
3    used to increase each facility's rate by an equal
4    percentage.
5    (k) During the first quarter of State Fiscal Year 2020,
6the Department of Healthcare of Family Services must convene a
7technical advisory group consisting of members of all trade
8associations representing Illinois skilled nursing providers
9to discuss changes necessary with federal implementation of
10Medicare's Patient-Driven Payment Model. Implementation of
11Medicare's Patient-Driven Payment Model shall, by September 1,
122020, end the collection of the MDS data that is necessary to
13maintain the current RUG-IV Medicaid payment methodology. The
14technical advisory group must consider a revised reimbursement
15methodology that takes into account transparency,
16accountability, actual staffing as reported under the
17federally required Payroll Based Journal system, changes to
18the minimum wage, adequacy in coverage of the cost of care, and
19a quality component that rewards quality improvements.
20    (l) The Department shall establish per diem add-on
21payments to improve the quality of care delivered by
22facilities, including:
23        (1) Incentive payments determined by facility
24    performance on specified quality measures in an initial
25    amount of $70,000,000. Nothing in this subsection shall be
26    construed to limit the quality of care payments in the

 

 

10300SB1298ham002- 170 -LRB103 28018 KTG 62535 a

1    aggregate statewide to $70,000,000, and, if quality of
2    care has improved across nursing facilities, the
3    Department shall adjust those add-on payments accordingly.
4    The quality payment methodology described in this
5    subsection must be used for at least State Fiscal Year
6    2023. Beginning with the quarter starting July 1, 2023,
7    the Department may add, remove, or change quality metrics
8    and make associated changes to the quality payment
9    methodology as outlined in subparagraph (E). Facilities
10    designated by the Centers for Medicare and Medicaid
11    Services as a special focus facility or a hospital-based
12    nursing home do not qualify for quality payments.
13            (A) Each quality pool must be distributed by
14        assigning a quality weighted score for each nursing
15        home which is calculated by multiplying the nursing
16        home's quality base period Medicaid days by the
17        nursing home's star rating weight in that period.
18            (B) Star rating weights are assigned based on the
19        nursing home's star rating for the LTS quality star
20        rating. As used in this subparagraph, "LTS quality
21        star rating" means the long-term stay quality rating
22        for each nursing facility, as assigned by the Centers
23        for Medicare and Medicaid Services under the Five-Star
24        Quality Rating System. The rating is a number ranging
25        from 0 (lowest) to 5 (highest).
26                (i) Zero-star or one-star rating has a weight

 

 

10300SB1298ham002- 171 -LRB103 28018 KTG 62535 a

1            of 0.
2                (ii) Two-star rating has a weight of 0.75.
3                (iii) Three-star rating has a weight of 1.5.
4                (iv) Four-star rating has a weight of 2.5.
5                (v) Five-star rating has a weight of 3.5.
6            (C) Each nursing home's quality weight score is
7        divided by the sum of all quality weight scores for
8        qualifying nursing homes to determine the proportion
9        of the quality pool to be paid to the nursing home.
10            (D) The quality pool is no less than $70,000,000
11        annually or $17,500,000 per quarter. The Department
12        shall publish on its website the estimated payments
13        and the associated weights for each facility 45 days
14        prior to when the initial payments for the quarter are
15        to be paid. The Department shall assign each facility
16        the most recent and applicable quarter's STAR value
17        unless the facility notifies the Department within 15
18        days of an issue and the facility provides reasonable
19        evidence demonstrating its timely compliance with
20        federal data submission requirements for the quarter
21        of record. If such evidence cannot be provided to the
22        Department, the STAR rating assigned to the facility
23        shall be reduced by one from the prior quarter.
24            (E) The Department shall review quality metrics
25        used for payment of the quality pool and make
26        recommendations for any associated changes to the

 

 

10300SB1298ham002- 172 -LRB103 28018 KTG 62535 a

1        methodology for distributing quality pool payments in
2        consultation with associations representing long-term
3        care providers, consumer advocates, organizations
4        representing workers of long-term care facilities, and
5        payors. The Department may establish, by rule, changes
6        to the methodology for distributing quality pool
7        payments.
8            (F) The Department shall disburse quality pool
9        payments from the Long-Term Care Provider Fund on a
10        monthly basis in amounts proportional to the total
11        quality pool payment determined for the quarter.
12            (G) The Department shall publish any changes in
13        the methodology for distributing quality pool payments
14        prior to the beginning of the measurement period or
15        quality base period for any metric added to the
16        distribution's methodology.
17        (2) Payments based on CNA tenure, promotion, and CNA
18    training for the purpose of increasing CNA compensation.
19    It is the intent of this subsection that payments made in
20    accordance with this paragraph be directly incorporated
21    into increased compensation for CNAs. As used in this
22    paragraph, "CNA" means a certified nursing assistant as
23    that term is described in Section 3-206 of the Nursing
24    Home Care Act, Section 3-206 of the ID/DD Community Care
25    Act, and Section 3-206 of the MC/DD Act. The Department
26    shall establish, by rule, payments to nursing facilities

 

 

10300SB1298ham002- 173 -LRB103 28018 KTG 62535 a

1    equal to Medicaid's share of the tenure wage increments
2    specified in this paragraph for all reported CNA employee
3    hours compensated according to a posted schedule
4    consisting of increments at least as large as those
5    specified in this paragraph. The increments are as
6    follows: an additional $1.50 per hour for CNAs with at
7    least one and less than 2 years' experience plus another
8    $1 per hour for each additional year of experience up to a
9    maximum of $6.50 for CNAs with at least 6 years of
10    experience. For purposes of this paragraph, Medicaid's
11    share shall be the ratio determined by paid Medicaid bed
12    days divided by total bed days for the applicable time
13    period used in the calculation. In addition, and additive
14    to any tenure increments paid as specified in this
15    paragraph, the Department shall establish, by rule,
16    payments supporting Medicaid's share of the
17    promotion-based wage increments for CNA employee hours
18    compensated for that promotion with at least a $1.50
19    hourly increase. Medicaid's share shall be established as
20    it is for the tenure increments described in this
21    paragraph. Qualifying promotions shall be defined by the
22    Department in rules for an expected 10-15% subset of CNAs
23    assigned intermediate, specialized, or added roles such as
24    CNA trainers, CNA scheduling "captains", and CNA
25    specialists for resident conditions like dementia or
26    memory care or behavioral health.

 

 

10300SB1298ham002- 174 -LRB103 28018 KTG 62535 a

1    (m) The Department shall work with nursing facility
2industry representatives to design policies and procedures to
3permit facilities to address the integrity of data from
4federal reporting sites used by the Department in setting
5facility rates.
6(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19;
7102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff.
85-31-22; 102-1118, eff. 1-18-23.)
 
9
ARTICLE 55.

 
10    Section 55-5. The Illinois Public Aid Code is amended by
11adding Section 5-5i as follows:
 
12    (305 ILCS 5/5-5i new)
13    Sec. 5-5i. Rate increase for speech, physical, and
14occupational therapy services. Effective upon federal
15approval, the Department shall increase reimbursement rates
16for speech therapy services, physical therapy services, and
17occupational therapy services provided by licensed
18speech-language pathologists and speech-language pathology
19assistants, physical therapists and physical therapy
20assistants, and occupational therapists and certified
21occupational therapy assistants, including those in their
22clinical fellowship, by 14.2%.
 

 

 

10300SB1298ham002- 175 -LRB103 28018 KTG 62535 a

1
ARTICLE 60.

 
2    Section 60-5. The Illinois Public Aid Code is amended by
3adding Section 5-35.5 as follows:
 
4    (305 ILCS 5/5-35.5 new)
5    Sec. 5-35.5. Personal needs allowance; nursing home
6residents. Subject to federal approval, for a person who is a
7resident in a facility licensed under the Nursing Home Care
8Act for whom payments are made under this Article throughout a
9month and who is determined to be eligible for medical
10assistance under this Article, the monthly personal needs
11allowance shall be $60.
 
12
ARTICLE 65.

 
13    Section 65-5. The Rebuild Illinois Mental Health Workforce
14Act is amended by changing Sections 20-10 and 20-20 and by
15adding Section 20-22 as follows:
 
16    (305 ILCS 66/20-10)
17    Sec. 20-10. Medicaid funding for community mental health
18services. Medicaid funding for the specific community mental
19health services listed in this Act shall be adjusted and paid
20as set forth in this Act. Such payments shall be paid in
21addition to the base Medicaid reimbursement rate and add-on

 

 

10300SB1298ham002- 176 -LRB103 28018 KTG 62535 a

1payment rates per service unit.
2    (a) The payment adjustments shall begin on July 1, 2022
3for State Fiscal Year 2023 and shall continue for every State
4fiscal year thereafter.
5        (1) Individual Therapy Medicaid Payment rate for
6    services provided under the H0004 Code:
7            (A) The Medicaid total payment rate for individual
8        therapy provided by a qualified mental health
9        professional shall be increased by no less than $9 per
10        service unit.
11            (B) The Medicaid total payment rate for individual
12        therapy provided by a mental health professional shall
13        be increased by no less than then $9 per service unit.
14        (2) Community Support - Individual Medicaid Payment
15    rate for services provided under the H2015 Code: All
16    community support - individual services shall be increased
17    by no less than $15 per service unit.
18        (3) Case Management Medicaid Add-on Payment for
19    services provided under the T1016 code: All case
20    management services rates shall be increased by no less
21    than $15 per service unit.
22        (4) Assertive Community Treatment Medicaid Add-on
23    Payment for services provided under the H0039 code: The
24    Medicaid total payment rate for assertive community
25    treatment services shall increase by no less than $8 per
26    service unit.

 

 

10300SB1298ham002- 177 -LRB103 28018 KTG 62535 a

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

 

 

10300SB1298ham002- 178 -LRB103 28018 KTG 62535 a

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

 

 

10300SB1298ham002- 179 -LRB103 28018 KTG 62535 a

1payment must be made in calendar year 2023 for community
2mental health services provided by community mental health
3providers. The one-time directed payment shall be for an
4amount appropriated for these purposes. The one-time directed
5payment shall be for services for Integrated Assessment and
6Treatment Planning and other intensive services, including,
7but not limited to, services for Mobile Crisis Response,
8crisis intervention, and medication monitoring. The amounts
9and services used for designing and distributing these
10one-time directed payments shall not be construed to require
11any future rate or funding increases for the same or other
12mental health services.
13    (c) The following payment adjustments shall be made:
14        (1) Subject to federal approval, the Department shall
15    introduce rate increases to behavioral health services no
16    less than by the following targeted pool for the specified
17    services provided by community mental health centers:
18            (A) Mobile Crisis Response, $6,800,000;
19            (B) Crisis Intervention, $4,000,000;
20            (C) Integrative Assessment and Treatment Planning
21        services, $10,500,000;
22            (D) Group Therapy, $1,200,000;
23            (E) Family Therapy, $500,000;
24            (F) Community Support Group, $4,000,000; and
25            (G) Medication Monitoring, $3,000,000.
26        (2) Rate increases shall be determined with

 

 

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1    significant input from Illinois behavioral health trade
2    associations and advocates. The Department must use
3    service units delivered under the fee-for-service and
4    managed care programs by community mental health centers
5    during State Fiscal Year 2022. These services are used for
6    distributing the targeted pools and setting rates but do
7    not prohibit the Department from paying providers not
8    enrolled as community mental health centers the same rate
9    if providing the same services.
10    (d) Rate simplification for team-based services.
11        (1) The Department shall work with stakeholders to
12    redesign reimbursement rates for behavioral health
13    team-based services established under the Rehabilitation
14    Option of the Illinois Medicaid State Plan supporting
15    individuals with chronic or complex behavioral health
16    conditions and crisis services. Subject to federal
17    approval, the redesigned rates shall seek to introduce
18    bundled payment systems that minimize provider claiming
19    activities while transitioning the focus of treatment
20    towards metrics and outcomes. Federally approved rate
21    models shall seek to ensure reimbursement levels are no
22    less than the State's total reimbursement for similar
23    services in calendar year 2023, including all service
24    level payments, add-ons, and all other payments specified
25    in this Section.
26        (2) In State Fiscal Year 2024, the Department shall

 

 

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1    identify an existing, or establish a new, Behavioral
2    Health Outcomes Stakeholder Workgroup to help inform the
3    identification of metrics and outcomes for team-based
4    services.
5        (3) In State Fiscal Year 2025, subject to federal
6    approval, the Department shall introduce a
7    pay-for-performance model for team-based services to be
8    informed by the Behavioral Health Outcomes Stakeholder
9    Workgroup.
10(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23;
11revised 1-23-23.)
 
12    (305 ILCS 66/20-20)
13    Sec. 20-20. Base Medicaid rates or add-on payments.
14    (a) For services under subsection (a) of Section 20-10: .
15     No base Medicaid rate or Medicaid rate add-on payment or
16any other payment for the provision of Medicaid community
17mental health services in place on July 1, 2021 shall be
18diminished or changed to make the reimbursement changes
19required by this Act. Any payments required under this Act
20that are delayed due to implementation challenges or federal
21approval shall be made retroactive to July 1, 2022 for the full
22amount required by this Act.
23    (b) For directed payments under subsection (b) of Section
2420-10: .
25     No base Medicaid rate payment or any other payment for the

 

 

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1provision of Medicaid community mental health services in
2place on January 1, 2023 shall be diminished or changed to make
3the reimbursement changes required by this Act. The Department
4of Healthcare and Family Services must pay the directed
5payment in one installment within 60 days of receiving federal
6approval.
7    (c) For directed payments under subsection (c) of Section
820-10:
9    No base Medicaid rate payment or any other payment for the
10provision of Medicaid community mental health services in
11place on January 1, 2023 shall be diminished or changed to make
12the reimbursement changes required by this amendatory Act of
13the 103rd General Assembly. Any payments required under this
14amendatory Act of the 103rd General Assembly that are delayed
15due to implementation challenges or federal approval shall be
16made retroactive to no later than January 1, 2024 for the full
17amount required by this amendatory Act of the 103rd General
18Assembly.
19(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23.)
 
20    (305 ILCS 66/20-22 new)
21    Sec. 20-22. Implementation plan for cost reporting.
22    (a) For the purpose of understanding behavioral health
23services cost structures and their impact on the Illinois
24Medical Assistance Program, the Department shall engage
25stakeholders to develop a plan for the regular collection of

 

 

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1cost reporting for all entity-based providers of behavioral
2health services reimbursed under the Rehabilitation or
3Prevention authorities of the Illinois Medicaid State Plan.
4Data shall be used to inform on the effectiveness and
5efficiency of Illinois Medicaid rates. The plan at minimum
6should consider the following:
7        (1) alignment with certified community behavioral
8    health clinic requirements, standards, policies, and
9    procedures;
10        (2) inclusion of prospective costs to measure what is
11    needed to increase services and capacity;
12        (3) consideration of differences in collection and
13    policies based on the size of providers;
14        (4) consideration of additional administrative time
15    and costs;
16        (5) goals, purposes, and usage of data collected from
17    cost reports;
18        (6) inclusion of qualitative data in addition to
19    quantitative data;
20        (7) technical assistance for providers for completing
21    cost reports including initial training by the Department
22    for providers; and
23        (8) an implementation timeline that allows an initial
24    grace period for providers to adjust internal procedures
25    and data collection.
26    Details from collected cost reports shall be made publicly

 

 

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1available on the Department's website and costs shall be used
2to ensure the effectiveness and efficiency of Illinois
3Medicaid rates.
4    (b) The Department and stakeholders shall develop a plan
5by April 1, 2024. The Department shall engage stakeholders on
6implementation of the plan.
 
7
ARTICLE 70.

 
8    Section 70-5. The Illinois Public Aid Code is amended by
9changing Section 5-4.2 as follows:
 
10    (305 ILCS 5/5-4.2)
11    Sec. 5-4.2. Ambulance services payments.
12    (a) For ambulance services provided to a recipient of aid
13under this Article on or after January 1, 1993, the Illinois
14Department shall reimburse ambulance service providers at
15rates calculated in accordance with this Section. It is the
16intent of the General Assembly to provide adequate
17reimbursement for ambulance services so as to ensure adequate
18access to services for recipients of aid under this Article
19and to provide appropriate incentives to ambulance service
20providers to provide services in an efficient and
21cost-effective manner. Thus, it is the intent of the General
22Assembly that the Illinois Department implement a
23reimbursement system for ambulance services that, to the

 

 

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1extent practicable and subject to the availability of funds
2appropriated by the General Assembly for this purpose, is
3consistent with the payment principles of Medicare. To ensure
4uniformity between the payment principles of Medicare and
5Medicaid, the Illinois Department shall follow, to the extent
6necessary and practicable and subject to the availability of
7funds appropriated by the General Assembly for this purpose,
8the statutes, laws, regulations, policies, procedures,
9principles, definitions, guidelines, and manuals used to
10determine the amounts paid to ambulance service providers
11under Title XVIII of the Social Security Act (Medicare).
12    (b) For ambulance services provided to a recipient of aid
13under this Article on or after January 1, 1996, the Illinois
14Department shall reimburse ambulance service providers based
15upon the actual distance traveled if a natural disaster,
16weather conditions, road repairs, or traffic congestion
17necessitates the use of a route other than the most direct
18route.
19    (c) For purposes of this Section, "ambulance services"
20includes medical transportation services provided by means of
21an ambulance, air ambulance, medi-car, service car, or taxi.
22    (c-1) For purposes of this Section, "ground ambulance
23service" means medical transportation services that are
24described as ground ambulance services by the Centers for
25Medicare and Medicaid Services and provided in a vehicle that
26is licensed as an ambulance by the Illinois Department of

 

 

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1Public Health pursuant to the Emergency Medical Services (EMS)
2Systems Act.
3    (c-2) For purposes of this Section, "ground ambulance
4service provider" means a vehicle service provider as
5described in the Emergency Medical Services (EMS) Systems Act
6that operates licensed ambulances for the purpose of providing
7emergency ambulance services, or non-emergency ambulance
8services, or both. For purposes of this Section, this includes
9both ambulance providers and ambulance suppliers as described
10by the Centers for Medicare and Medicaid Services.
11    (c-3) For purposes of this Section, "medi-car" means
12transportation services provided to a patient who is confined
13to a wheelchair and requires the use of a hydraulic or electric
14lift or ramp and wheelchair lockdown when the patient's
15condition does not require medical observation, medical
16supervision, medical equipment, the administration of
17medications, or the administration of oxygen.
18    (c-4) For purposes of this Section, "service car" means
19transportation services provided to a patient by a passenger
20vehicle where that patient does not require the specialized
21modes described in subsection (c-1) or (c-3).
22    (c-5) For purposes of this Section, "air ambulance
23service" means medical transport by helicopter or airplane for
24patients, as defined in 29 U.S.C. 1185f(c)(1), and any service
25that is described as an air ambulance service by the federal
26Centers for Medicare and Medicaid Services.

 

 

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1    (d) This Section does not prohibit separate billing by
2ambulance service providers for oxygen furnished while
3providing advanced life support services.
4    (e) Beginning with services rendered on or after July 1,
52008, all providers of non-emergency medi-car and service car
6transportation must certify that the driver and employee
7attendant, as applicable, have completed a safety program
8approved by the Department to protect both the patient and the
9driver, prior to transporting a patient. The provider must
10maintain this certification in its records. The provider shall
11produce such documentation upon demand by the Department or
12its representative. Failure to produce documentation of such
13training shall result in recovery of any payments made by the
14Department for services rendered by a non-certified driver or
15employee attendant. Medi-car and service car providers must
16maintain legible documentation in their records of the driver
17and, as applicable, employee attendant that actually
18transported the patient. Providers must recertify all drivers
19and employee attendants every 3 years. If they meet the
20established training components set forth by the Department,
21providers of non-emergency medi-car and service car
22transportation that are either directly or through an
23affiliated company licensed by the Department of Public Health
24shall be approved by the Department to have in-house safety
25programs for training their own staff.
26    Notwithstanding the requirements above, any public

 

 

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1transportation provider of medi-car and service car
2transportation that receives federal funding under 49 U.S.C.
35307 and 5311 need not certify its drivers and employee
4attendants under this Section, since safety training is
5already federally mandated.
6    (f) With respect to any policy or program administered by
7the Department or its agent regarding approval of
8non-emergency medical transportation by ground ambulance
9service providers, including, but not limited to, the
10Non-Emergency Transportation Services Prior Approval Program
11(NETSPAP), the Department shall establish by rule a process by
12which ground ambulance service providers of non-emergency
13medical transportation may appeal any decision by the
14Department or its agent for which no denial was received prior
15to the time of transport that either (i) denies a request for
16approval for payment of non-emergency transportation by means
17of ground ambulance service or (ii) grants a request for
18approval of non-emergency transportation by means of ground
19ambulance service at a level of service that entitles the
20ground ambulance service provider to a lower level of
21compensation from the Department than the ground ambulance
22service provider would have received as compensation for the
23level of service requested. The rule shall be filed by
24December 15, 2012 and shall provide that, for any decision
25rendered by the Department or its agent on or after the date
26the rule takes effect, the ground ambulance service provider

 

 

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1shall have 60 days from the date the decision is received to
2file an appeal. The rule established by the Department shall
3be, insofar as is practical, consistent with the Illinois
4Administrative Procedure Act. The Director's decision on an
5appeal under this Section shall be a final administrative
6decision subject to review under the Administrative Review
7Law.
8    (f-5) Beginning 90 days after July 20, 2012 (the effective
9date of Public Act 97-842), (i) no denial of a request for
10approval for payment of non-emergency transportation by means
11of ground ambulance service, and (ii) no approval of
12non-emergency transportation by means of ground ambulance
13service at a level of service that entitles the ground
14ambulance service provider to a lower level of compensation
15from the Department than would have been received at the level
16of service submitted by the ground ambulance service provider,
17may be issued by the Department or its agent unless the
18Department has submitted the criteria for determining the
19appropriateness of the transport for first notice publication
20in the Illinois Register pursuant to Section 5-40 of the
21Illinois Administrative Procedure Act.
22    (f-6) Within 90 days after the effective date of this
23amendatory Act of the 102nd General Assembly and subject to
24federal approval, the Department shall file rules to allow for
25the approval of ground ambulance services when the sole
26purpose of the transport is for the navigation of stairs or the

 

 

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1assisting or lifting of a patient at a medical facility or
2during a medical appointment in instances where the Department
3or a contracted Medicaid managed care organization or their
4transportation broker is unable to secure transportation
5through any other transportation provider.
6    (f-7) For non-emergency ground ambulance claims properly
7denied under Department policy at the time the claim is filed
8due to failure to submit a valid Medical Certification for
9Non-Emergency Ambulance on and after December 15, 2012 and
10prior to January 1, 2021, the Department shall allot
11$2,000,000 to a pool to reimburse such claims if the provider
12proves medical necessity for the service by other means.
13Providers must submit any such denied claims for which they
14seek compensation to the Department no later than December 31,
152021 along with documentation of medical necessity. No later
16than May 31, 2022, the Department shall determine for which
17claims medical necessity was established. Such claims for
18which medical necessity was established shall be paid at the
19rate in effect at the time of the service, provided the
20$2,000,000 is sufficient to pay at those rates. If the pool is
21not sufficient, claims shall be paid at a uniform percentage
22of the applicable rate such that the pool of $2,000,000 is
23exhausted. The appeal process described in subsection (f)
24shall not be applicable to the Department's determinations
25made in accordance with this subsection.
26    (g) Whenever a patient covered by a medical assistance

 

 

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1program under this Code or by another medical program
2administered by the Department, including a patient covered
3under the State's Medicaid managed care program, is being
4transported from a facility and requires non-emergency
5transportation including ground ambulance, medi-car, or
6service car transportation, a Physician Certification
7Statement as described in this Section shall be required for
8each patient. Facilities shall develop procedures for a
9licensed medical professional to provide a written and signed
10Physician Certification Statement. The Physician Certification
11Statement shall specify the level of transportation services
12needed and complete a medical certification establishing the
13criteria for approval of non-emergency ambulance
14transportation, as published by the Department of Healthcare
15and Family Services, that is met by the patient. This
16certification shall be completed prior to ordering the
17transportation service and prior to patient discharge. The
18Physician Certification Statement is not required prior to
19transport if a delay in transport can be expected to
20negatively affect the patient outcome. If the ground ambulance
21provider, medi-car provider, or service car provider is unable
22to obtain the required Physician Certification Statement
23within 10 calendar days following the date of the service, the
24ground ambulance provider, medi-car provider, or service car
25provider must document its attempt to obtain the requested
26certification and may then submit the claim for payment.

 

 

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1Acceptable documentation includes a signed return receipt from
2the U.S. Postal Service, facsimile receipt, email receipt, or
3other similar service that evidences that the ground ambulance
4provider, medi-car provider, or service car provider attempted
5to obtain the required Physician Certification Statement.
6    The medical certification specifying the level and type of
7non-emergency transportation needed shall be in the form of
8the Physician Certification Statement on a standardized form
9prescribed by the Department of Healthcare and Family
10Services. Within 75 days after July 27, 2018 (the effective
11date of Public Act 100-646), the Department of Healthcare and
12Family Services shall develop a standardized form of the
13Physician Certification Statement specifying the level and
14type of transportation services needed in consultation with
15the Department of Public Health, Medicaid managed care
16organizations, a statewide association representing ambulance
17providers, a statewide association representing hospitals, 3
18statewide associations representing nursing homes, and other
19stakeholders. The Physician Certification Statement shall
20include, but is not limited to, the criteria necessary to
21demonstrate medical necessity for the level of transport
22needed as required by (i) the Department of Healthcare and
23Family Services and (ii) the federal Centers for Medicare and
24Medicaid Services as outlined in the Centers for Medicare and
25Medicaid Services' Medicare Benefit Policy Manual, Pub.
26100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician

 

 

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1Certification Statement shall satisfy the obligations of
2hospitals under Section 6.22 of the Hospital Licensing Act and
3nursing homes under Section 2-217 of the Nursing Home Care
4Act. Implementation and acceptance of the Physician
5Certification Statement shall take place no later than 90 days
6after the issuance of the Physician Certification Statement by
7the Department of Healthcare and Family Services.
8    Pursuant to subsection (E) of Section 12-4.25 of this
9Code, the Department is entitled to recover overpayments paid
10to a provider or vendor, including, but not limited to, from
11the discharging physician, the discharging facility, and the
12ground ambulance service provider, in instances where a
13non-emergency ground ambulance service is rendered as the
14result of improper or false certification.
15    Beginning October 1, 2018, the Department of Healthcare
16and Family Services shall collect data from Medicaid managed
17care organizations and transportation brokers, including the
18Department's NETSPAP broker, regarding denials and appeals
19related to the missing or incomplete Physician Certification
20Statement forms and overall compliance with this subsection.
21The Department of Healthcare and Family Services shall publish
22quarterly results on its website within 15 days following the
23end of each quarter.
24    (h) On and after July 1, 2012, the Department shall reduce
25any rate of reimbursement for services or other payments or
26alter any methodologies authorized by this Code to reduce any

 

 

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1rate of reimbursement for services or other payments in
2accordance with Section 5-5e.
3    (i) On and after July 1, 2018, the Department shall
4increase the base rate of reimbursement for both base charges
5and mileage charges for ground ambulance service providers for
6medical transportation services provided by means of a ground
7ambulance to a level not lower than 112% of the base rate in
8effect as of June 30, 2018.
9    (j) Subject to federal approval, the Department shall
10increase the base rate of reimbursement for both base charges
11and mileage charges for medical transportation services
12provided by means of an air ambulance to a level not lower than
1350% of the Medicare ambulance fee schedule rates, by
14designated Medicare locality, in effect on January 1, 2023.
15(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20;
16102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff.
175-13-22; 102-1037, eff. 6-2-22.)
 
18
ARTICLE 75.

 
19    Section 75-5. The Illinois Public Aid Code is amended by
20changing Section 5-5.4h as follows:
 
21    (305 ILCS 5/5-5.4h)
22    Sec. 5-5.4h. Medicaid reimbursement for medically complex
23for the developmentally disabled facilities licensed under the

 

 

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1MC/DD Act.
2    (a) Facilities licensed as medically complex for the
3developmentally disabled facilities that serve severely and
4chronically ill patients shall have a specific reimbursement
5system designed to recognize the characteristics and needs of
6the patients they serve.
7    (b) For dates of services starting July 1, 2013 and until a
8new reimbursement system is designed, medically complex for
9the developmentally disabled facilities that meet the
10following criteria:
11        (1) serve exceptional care patients; and
12        (2) have 30% or more of their patients receiving
13    ventilator care;
14shall receive Medicaid reimbursement on a 30-day expedited
15schedule.
16    (c) Subject to federal approval of changes to the Title
17XIX State Plan, for dates of services starting July 1, 2014
18through March 31, 2019, medically complex for the
19developmentally disabled facilities which meet the criteria in
20subsection (b) of this Section shall receive a per diem rate
21for clinically complex residents of $304. Clinically complex
22residents on a ventilator shall receive a per diem rate of
23$669. Subject to federal approval of changes to the Title XIX
24State Plan, for dates of services starting April 1, 2019,
25medically complex for the developmentally disabled facilities
26must be reimbursed an exceptional care per diem rate, instead

 

 

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1of the base rate, for services to residents with complex or
2extensive medical needs. Exceptional care per diem rates must
3be paid for the conditions or services specified under
4subsection (f) at the following per diem rates: Tier 1 $326,
5Tier 2 $546, and Tier 3 $735. Subject to federal approval, each
6tier rate shall be increased 6% over the amount in effect on
7the effective date of this amendatory Act of the 103rd General
8Assembly. Any reimbursement increases applied to the base rate
9to providers licensed under the ID/DD Community Care Act must
10also be applied in an equivalent manner to each tier of
11exceptional care per diem rates for medically complex for the
12developmentally disabled facilities.
13    (d) For residents on a ventilator pursuant to subsection
14(c) or subsection (f), facilities shall have a policy
15documenting their method of routine assessment of a resident's
16weaning potential with interventions implemented noted in the
17resident's medical record.
18    (e) For services provided prior to April 1, 2019 and for
19the purposes of this Section, a resident is considered
20clinically complex if the resident requires at least one of
21the following medical services:
22        (1) Tracheostomy care with dependence on mechanical
23    ventilation for a minimum of 6 hours each day.
24        (2) Tracheostomy care requiring suctioning at least
25    every 6 hours, room air mist or oxygen as needed, and
26    dependence on one of the treatment procedures listed under

 

 

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1    paragraph (4) excluding the procedure listed in
2    subparagraph (A) of paragraph (4).
3        (3) Total parenteral nutrition or other intravenous
4    nutritional support and one of the treatment procedures
5    listed under paragraph (4).
6        (4) The following treatment procedures apply to the
7    conditions in paragraphs (2) and (3) of this subsection:
8            (A) Intermittent suctioning at least every 8 hours
9        and room air mist or oxygen as needed.
10            (B) Continuous intravenous therapy including
11        administration of therapeutic agents necessary for
12        hydration or of intravenous pharmaceuticals; or
13        intravenous pharmaceutical administration of more than
14        one agent via a peripheral or central line, without
15        continuous infusion.
16            (C) Peritoneal dialysis treatments requiring at
17        least 4 exchanges every 24 hours.
18            (D) Tube feeding via nasogastric or gastrostomy
19        tube.
20            (E) Other medical technologies required
21        continuously, which in the opinion of the attending
22        physician require the services of a professional
23        nurse.
24    (f) Complex or extensive medical needs for exceptional
25care reimbursement. The conditions and services used for the
26purposes of this Section have the same meanings as ascribed to

 

 

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1those conditions and services under the Minimum Data Set (MDS)
2Resident Assessment Instrument (RAI) and specified in the most
3recent manual. Instead of submitting minimum data set
4assessments to the Department, medically complex for the
5developmentally disabled facilities must document within each
6resident's medical record the conditions or services using the
7minimum data set documentation standards and requirements to
8qualify for exceptional care reimbursement.
9        (1) Tier 1 reimbursement is for residents who are
10    receiving at least 51% of their caloric intake via a
11    feeding tube.
12        (2) Tier 2 reimbursement is for residents who are
13    receiving tracheostomy care without a ventilator.
14        (3) Tier 3 reimbursement is for residents who are
15    receiving tracheostomy care and ventilator care.
16    (g) For dates of services starting April 1, 2019,
17reimbursement calculations and direct payment for services
18provided by medically complex for the developmentally disabled
19facilities are the responsibility of the Department of
20Healthcare and Family Services instead of the Department of
21Human Services. Appropriations for medically complex for the
22developmentally disabled facilities must be shifted from the
23Department of Human Services to the Department of Healthcare
24and Family Services. Nothing in this Section prohibits the
25Department of Healthcare and Family Services from paying more
26than the rates specified in this Section. The rates in this

 

 

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1Section must be interpreted as a minimum amount. Any
2reimbursement increases applied to providers licensed under
3the ID/DD Community Care Act must also be applied in an
4equivalent manner to medically complex for the developmentally
5disabled facilities.
6    (h) The Department of Healthcare and Family Services shall
7pay the rates in effect on March 31, 2019 until the changes
8made to this Section by this amendatory Act of the 100th
9General Assembly have been approved by the Centers for
10Medicare and Medicaid Services of the U.S. Department of
11Health and Human Services.
12    (i) The Department of Healthcare and Family Services may
13adopt rules as allowed by the Illinois Administrative
14Procedure Act to implement this Section; however, the
15requirements of this Section must be implemented by the
16Department of Healthcare and Family Services even if the
17Department of Healthcare and Family Services has not adopted
18rules by the implementation date of April 1, 2019.
19(Source: P.A. 100-646, eff. 7-27-18.)
 
20
ARTICLE 80.

 
21    Section 80-5. The Illinois Public Aid Code is amended by
22changing Section 5-4.2 as follows:
 
23    (305 ILCS 5/5-4.2)

 

 

10300SB1298ham002- 200 -LRB103 28018 KTG 62535 a

1    Sec. 5-4.2. Ambulance services payments.
2    (a) For ambulance services provided to a recipient of aid
3under this Article on or after January 1, 1993, the Illinois
4Department shall reimburse ambulance service providers at
5rates calculated in accordance with this Section. It is the
6intent of the General Assembly to provide adequate
7reimbursement for ambulance services so as to ensure adequate
8access to services for recipients of aid under this Article
9and to provide appropriate incentives to ambulance service
10providers to provide services in an efficient and
11cost-effective manner. Thus, it is the intent of the General
12Assembly that the Illinois Department implement a
13reimbursement system for ambulance services that, to the
14extent practicable and subject to the availability of funds
15appropriated by the General Assembly for this purpose, is
16consistent with the payment principles of Medicare. To ensure
17uniformity between the payment principles of Medicare and
18Medicaid, the Illinois Department shall follow, to the extent
19necessary and practicable and subject to the availability of
20funds appropriated by the General Assembly for this purpose,
21the statutes, laws, regulations, policies, procedures,
22principles, definitions, guidelines, and manuals used to
23determine the amounts paid to ambulance service providers
24under Title XVIII of the Social Security Act (Medicare).
25    (b) For ambulance services provided to a recipient of aid
26under this Article on or after January 1, 1996, the Illinois

 

 

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1Department shall reimburse ambulance service providers based
2upon the actual distance traveled if a natural disaster,
3weather conditions, road repairs, or traffic congestion
4necessitates the use of a route other than the most direct
5route.
6    (c) For purposes of this Section, "ambulance services"
7includes medical transportation services provided by means of
8an ambulance, medi-car, service car, or taxi.
9    (c-1) For purposes of this Section, "ground ambulance
10service" means medical transportation services that are
11described as ground ambulance services by the Centers for
12Medicare and Medicaid Services and provided in a vehicle that
13is licensed as an ambulance by the Illinois Department of
14Public Health pursuant to the Emergency Medical Services (EMS)
15Systems Act.
16    (c-2) For purposes of this Section, "ground ambulance
17service provider" means a vehicle service provider as
18described in the Emergency Medical Services (EMS) Systems Act
19that operates licensed ambulances for the purpose of providing
20emergency ambulance services, or non-emergency ambulance
21services, or both. For purposes of this Section, this includes
22both ambulance providers and ambulance suppliers as described
23by the Centers for Medicare and Medicaid Services.
24    (c-3) For purposes of this Section, "medi-car" means
25transportation services provided to a patient who is confined
26to a wheelchair and requires the use of a hydraulic or electric

 

 

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1lift or ramp and wheelchair lockdown when the patient's
2condition does not require medical observation, medical
3supervision, medical equipment, the administration of
4medications, or the administration of oxygen.
5    (c-4) For purposes of this Section, "service car" means
6transportation services provided to a patient by a passenger
7vehicle where that patient does not require the specialized
8modes described in subsection (c-1) or (c-3).
9    (d) This Section does not prohibit separate billing by
10ambulance service providers for oxygen furnished while
11providing advanced life support services.
12    (e) Beginning with services rendered on or after July 1,
132008, all providers of non-emergency medi-car and service car
14transportation must certify that the driver and employee
15attendant, as applicable, have completed a safety program
16approved by the Department to protect both the patient and the
17driver, prior to transporting a patient. The provider must
18maintain this certification in its records. The provider shall
19produce such documentation upon demand by the Department or
20its representative. Failure to produce documentation of such
21training shall result in recovery of any payments made by the
22Department for services rendered by a non-certified driver or
23employee attendant. Medi-car and service car providers must
24maintain legible documentation in their records of the driver
25and, as applicable, employee attendant that actually
26transported the patient. Providers must recertify all drivers

 

 

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1and employee attendants every 3 years. If they meet the
2established training components set forth by the Department,
3providers of non-emergency medi-car and service car
4transportation that are either directly or through an
5affiliated company licensed by the Department of Public Health
6shall be approved by the Department to have in-house safety
7programs for training their own staff.
8    Notwithstanding the requirements above, any public
9transportation provider of medi-car and service car
10transportation that receives federal funding under 49 U.S.C.
115307 and 5311 need not certify its drivers and employee
12attendants under this Section, since safety training is
13already federally mandated.
14    (f) With respect to any policy or program administered by
15the Department or its agent regarding approval of
16non-emergency medical transportation by ground ambulance
17service providers, including, but not limited to, the
18Non-Emergency Transportation Services Prior Approval Program
19(NETSPAP), the Department shall establish by rule a process by
20which ground ambulance service providers of non-emergency
21medical transportation may appeal any decision by the
22Department or its agent for which no denial was received prior
23to the time of transport that either (i) denies a request for
24approval for payment of non-emergency transportation by means
25of ground ambulance service or (ii) grants a request for
26approval of non-emergency transportation by means of ground

 

 

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1ambulance service at a level of service that entitles the
2ground ambulance service provider to a lower level of
3compensation from the Department than the ground ambulance
4service provider would have received as compensation for the
5level of service requested. The rule shall be filed by
6December 15, 2012 and shall provide that, for any decision
7rendered by the Department or its agent on or after the date
8the rule takes effect, the ground ambulance service provider
9shall have 60 days from the date the decision is received to
10file an appeal. The rule established by the Department shall
11be, insofar as is practical, consistent with the Illinois
12Administrative Procedure Act. The Director's decision on an
13appeal under this Section shall be a final administrative
14decision subject to review under the Administrative Review
15Law.
16    (f-5) Beginning 90 days after July 20, 2012 (the effective
17date of Public Act 97-842), (i) no denial of a request for
18approval for payment of non-emergency transportation by means
19of ground ambulance service, and (ii) no approval of
20non-emergency transportation by means of ground ambulance
21service at a level of service that entitles the ground
22ambulance service provider to a lower level of compensation
23from the Department than would have been received at the level
24of service submitted by the ground ambulance service provider,
25may be issued by the Department or its agent unless the
26Department has submitted the criteria for determining the

 

 

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1appropriateness of the transport for first notice publication
2in the Illinois Register pursuant to Section 5-40 of the
3Illinois Administrative Procedure Act.
4    (f-6) Within 90 days after the effective date of this
5amendatory Act of the 102nd General Assembly and subject to
6federal approval, the Department shall file rules to allow for
7the approval of ground ambulance services when the sole
8purpose of the transport is for the navigation of stairs or the
9assisting or lifting of a patient at a medical facility or
10during a medical appointment in instances where the Department
11or a contracted Medicaid managed care organization or their
12transportation broker is unable to secure transportation
13through any other transportation provider.
14    (f-7) For non-emergency ground ambulance claims properly
15denied under Department policy at the time the claim is filed
16due to failure to submit a valid Medical Certification for
17Non-Emergency Ambulance on and after December 15, 2012 and
18prior to January 1, 2021, the Department shall allot
19$2,000,000 to a pool to reimburse such claims if the provider
20proves medical necessity for the service by other means.
21Providers must submit any such denied claims for which they
22seek compensation to the Department no later than December 31,
232021 along with documentation of medical necessity. No later
24than May 31, 2022, the Department shall determine for which
25claims medical necessity was established. Such claims for
26which medical necessity was established shall be paid at the

 

 

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1rate in effect at the time of the service, provided the
2$2,000,000 is sufficient to pay at those rates. If the pool is
3not sufficient, claims shall be paid at a uniform percentage
4of the applicable rate such that the pool of $2,000,000 is
5exhausted. The appeal process described in subsection (f)
6shall not be applicable to the Department's determinations
7made in accordance with this subsection.
8    (g) Whenever a patient covered by a medical assistance
9program under this Code or by another medical program
10administered by the Department, including a patient covered
11under the State's Medicaid managed care program, is being
12transported from a facility and requires non-emergency
13transportation including ground ambulance, medi-car, or
14service car transportation, a Physician Certification
15Statement as described in this Section shall be required for
16each patient. Facilities shall develop procedures for a
17licensed medical professional to provide a written and signed
18Physician Certification Statement. The Physician Certification
19Statement shall specify the level of transportation services
20needed and complete a medical certification establishing the
21criteria for approval of non-emergency ambulance
22transportation, as published by the Department of Healthcare
23and Family Services, that is met by the patient. This
24certification shall be completed prior to ordering the
25transportation service and prior to patient discharge. The
26Physician Certification Statement is not required prior to

 

 

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1transport if a delay in transport can be expected to
2negatively affect the patient outcome. If the ground ambulance
3provider, medi-car provider, or service car provider is unable
4to obtain the required Physician Certification Statement
5within 10 calendar days following the date of the service, the
6ground ambulance provider, medi-car provider, or service car
7provider must document its attempt to obtain the requested
8certification and may then submit the claim for payment.
9Acceptable documentation includes a signed return receipt from
10the U.S. Postal Service, facsimile receipt, email receipt, or
11other similar service that evidences that the ground ambulance
12provider, medi-car provider, or service car provider attempted
13to obtain the required Physician Certification Statement.
14    The medical certification specifying the level and type of
15non-emergency transportation needed shall be in the form of
16the Physician Certification Statement on a standardized form
17prescribed by the Department of Healthcare and Family
18Services. Within 75 days after July 27, 2018 (the effective
19date of Public Act 100-646), the Department of Healthcare and
20Family Services shall develop a standardized form of the
21Physician Certification Statement specifying the level and
22type of transportation services needed in consultation with
23the Department of Public Health, Medicaid managed care
24organizations, a statewide association representing ambulance
25providers, a statewide association representing hospitals, 3
26statewide associations representing nursing homes, and other

 

 

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1stakeholders. The Physician Certification Statement shall
2include, but is not limited to, the criteria necessary to
3demonstrate medical necessity for the level of transport
4needed as required by (i) the Department of Healthcare and
5Family Services and (ii) the federal Centers for Medicare and
6Medicaid Services as outlined in the Centers for Medicare and
7Medicaid Services' Medicare Benefit Policy Manual, Pub.
8100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
9Certification Statement shall satisfy the obligations of
10hospitals under Section 6.22 of the Hospital Licensing Act and
11nursing homes under Section 2-217 of the Nursing Home Care
12Act. Implementation and acceptance of the Physician
13Certification Statement shall take place no later than 90 days
14after the issuance of the Physician Certification Statement by
15the Department of Healthcare and Family Services.
16    Pursuant to subsection (E) of Section 12-4.25 of this
17Code, the Department is entitled to recover overpayments paid
18to a provider or vendor, including, but not limited to, from
19the discharging physician, the discharging facility, and the
20ground ambulance service provider, in instances where a
21non-emergency ground ambulance service is rendered as the
22result of improper or false certification.
23    Beginning October 1, 2018, the Department of Healthcare
24and Family Services shall collect data from Medicaid managed
25care organizations and transportation brokers, including the
26Department's NETSPAP broker, regarding denials and appeals

 

 

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1related to the missing or incomplete Physician Certification
2Statement forms and overall compliance with this subsection.
3The Department of Healthcare and Family Services shall publish
4quarterly results on its website within 15 days following the
5end of each quarter.
6    (h) On and after July 1, 2012, the Department shall reduce
7any rate of reimbursement for services or other payments or
8alter any methodologies authorized by this Code to reduce any
9rate of reimbursement for services or other payments in
10accordance with Section 5-5e.
11    (i) Subject to federal approval, On and after July 1,
122018, the Department shall increase the base rate of
13reimbursement for both base charges and mileage charges for
14ground ambulance service providers not participating in the
15Ground Emergency Medical Transportation (GEMT) Program for
16medical transportation services provided by means of a ground
17ambulance to a level not lower than 140% 112% of the base rate
18in effect as of January 1, 2023 June 30, 2018.
19    (j) For the purpose of understanding ground ambulance
20transportation services cost structures and their impact on
21the Medical Assistance Program, the Department shall engage
22stakeholders, including, but not limited to, a statewide
23association representing private ground ambulance service
24providers in Illinois, to develop recommendations for a plan
25for the regular collection of cost data for all ground
26ambulance transportation providers reimbursed under the

 

 

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1Illinois Title XIX State Plan. Cost data obtained through this
2process shall be used to inform on and to ensure the
3effectiveness and efficiency of Illinois Medicaid rates. The
4Department shall establish a process to limit public
5availability of portions of the cost report data determined to
6be proprietary. This process shall be concluded and
7recommendations shall be provided no later than April 1, 2024.
8(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20;
9102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff.
105-13-22; 102-1037, eff. 6-2-22.)
 
11
ARTICLE 85.

 
12    Section 85-5. The Illinois Act on the Aging is amended by
13changing Sections 4.02 and 4.06 as follows:
 
14    (20 ILCS 105/4.02)  (from Ch. 23, par. 6104.02)
15    Sec. 4.02. Community Care Program. The Department shall
16establish a program of services to prevent unnecessary
17institutionalization of persons age 60 and older in need of
18long term care or who are established as persons who suffer
19from Alzheimer's disease or a related disorder under the
20Alzheimer's Disease Assistance Act, thereby enabling them to
21remain in their own homes or in other living arrangements.
22Such preventive services, which may be coordinated with other
23programs for the aged and monitored by area agencies on aging

 

 

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1in cooperation with the Department, may include, but are not
2limited to, any or all of the following:
3        (a) (blank);
4        (b) (blank);
5        (c) home care aide services;
6        (d) personal assistant services;
7        (e) adult day services;
8        (f) home-delivered meals;
9        (g) education in self-care;
10        (h) personal care services;
11        (i) adult day health services;
12        (j) habilitation services;
13        (k) respite care;
14        (k-5) community reintegration services;
15        (k-6) flexible senior services;
16        (k-7) medication management;
17        (k-8) emergency home response;
18        (l) other nonmedical social services that may enable
19    the person to become self-supporting; or
20        (m) clearinghouse for information provided by senior
21    citizen home owners who want to rent rooms to or share
22    living space with other senior citizens.
23    The Department shall establish eligibility standards for
24such services. In determining the amount and nature of
25services for which a person may qualify, consideration shall
26not be given to the value of cash, property or other assets

 

 

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1held in the name of the person's spouse pursuant to a written
2agreement dividing marital property into equal but separate
3shares or pursuant to a transfer of the person's interest in a
4home to his spouse, provided that the spouse's share of the
5marital property is not made available to the person seeking
6such services.
7    Beginning January 1, 2008, the Department shall require as
8a condition of eligibility that all new financially eligible
9applicants apply for and enroll in medical assistance under
10Article V of the Illinois Public Aid Code in accordance with
11rules promulgated by the Department.
12    The Department shall, in conjunction with the Department
13of Public Aid (now Department of Healthcare and Family
14Services), seek appropriate amendments under Sections 1915 and
151924 of the Social Security Act. The purpose of the amendments
16shall be to extend eligibility for home and community based
17services under Sections 1915 and 1924 of the Social Security </