SB1298 EnrolledLRB103 28018 CPF 54397 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
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
16Index-U from the previous year, not to exceed 5% in any State
17fiscal year, for licensed or certified substance use disorder
18treatment providers of ASAM Level 3 residential/inpatient
19services under community service grant programs for persons
20with substance use disorders.
21    If there is a decrease in the Consumer Price Index-U,
22rates shall remain unchanged for that State fiscal year. The

 

 

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1Department of Human Services shall increase the grant contract
2amount awarded to each eligible community-based substance use
3disorder treatment provider to ensure that the level and
4number of services provided under community service grant
5programs shall not be reduced by increasing the amount
6available to each provider under the community service grant
7programs to address the increased rate for each such service.
8    The Department shall adopt rules, including emergency
9rules in accordance with Section 5-45 of the Illinois
10Administrative Procedure Act, to implement the provisions of
11this Act.
12    As used in this Act, "Consumer Price Index-U" means the
13index published by the Bureau of Labor Statistics of the
14United States Department of Labor that measures the average
15change in prices of goods and services purchased by all urban
16consumers, United States city average, all items, 1982-84 =
17100.
 
18
ARTICLE 5.

 
19    Section 5-10. The Illinois Administrative Procedure Act is
20amended by adding Section 5-45.35 as follows:
 
21    (5 ILCS 100/5-45.35 new)
22    Sec. 5-45.35. Emergency rulemaking; Substance Use Disorder
23Residential and Detox Rate Equity. To provide for the

 

 

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1expeditious and timely implementation of the Substance Use
2Disorder Residential and Detox Rate Equity Act, emergency
3rules implementing the Substance Use Disorder Residential and
4Detox Rate Equity Act may be adopted in accordance with
5Section 5-45 by the Department of Human Services and the
6Department of Healthcare and Family Services. The adoption of
7emergency rules authorized by Section 5-45 and this Section is
8deemed to be necessary for the public interest, safety, and
9welfare.
10    This Section is repealed one year after the effective date
11of this amendatory Act of the 103rd General Assembly.
 
12    Section 5-15. The Substance Use Disorder Act is amended by
13changing Section 55-30 as follows:
 
14    (20 ILCS 301/55-30)
15    Sec. 55-30. Rate increase.
16    (a) The Department shall by rule develop the increased
17rate methodology and annualize the increased rate beginning
18with State fiscal year 2018 contracts to licensed providers of
19community-based substance use disorder intervention or
20treatment, based on the additional amounts appropriated for
21the purpose of providing a rate increase to licensed
22providers. The Department shall adopt rules, including
23emergency rules under subsection (y) of Section 5-45 of the
24Illinois Administrative Procedure Act, to implement the

 

 

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1provisions of this Section.
2    (b) (Blank).
3    (c) Beginning on July 1, 2022, the Division of Substance
4Use Prevention and Recovery shall increase reimbursement rates
5for all community-based substance use disorder treatment and
6intervention services by 47%, including, but not limited to,
7all of the following:
8        (1) Admission and Discharge Assessment.
9        (2) Level 1 (Individual).
10        (3) Level 1 (Group).
11        (4) Level 2 (Individual).
12        (5) Level 2 (Group).
13        (6) Case Management.
14        (7) Psychiatric Evaluation.
15        (8) Medication Assisted Recovery.
16        (9) Community Intervention.
17        (10) Early Intervention (Individual).
18        (11) Early Intervention (Group).
19    Beginning in State Fiscal Year 2023, and every State
20fiscal year thereafter, reimbursement rates for those
21community-based substance use disorder treatment and
22intervention services shall be adjusted upward by an amount
23equal to the Consumer Price Index-U from the previous year,
24not to exceed 2% in any State fiscal year. If there is a
25decrease in the Consumer Price Index-U, rates shall remain
26unchanged for that State fiscal year. The Department shall

 

 

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1adopt rules, including emergency rules in accordance with the
2Illinois Administrative Procedure Act, to implement the
3provisions of this Section.
4    As used in this subsection, "consumer price index-u" means
5the index published by the Bureau of Labor Statistics of the
6United States Department of Labor that measures the average
7change in prices of goods and services purchased by all urban
8consumers, United States city average, all items, 1982-84 =
9100.
10    (d) Beginning on January 1, 2024, subject to federal
11approval, the Division of Substance Use Prevention and
12Recovery shall increase reimbursement rates for all ASAM level
133 residential/inpatient substance use disorder treatment and
14intervention services by 30%, including, but not limited to,
15the following services:
16        (1) ASAM level 3.5 Clinically Managed High-Intensity
17    Residential Services for adults;
18        (2) ASAM level 3.5 Clinically Managed Medium-Intensity
19    Residential Services for adolescents;
20        (3) ASAM level 3.2 Clinically Managed Residential
21    Withdrawal Management;
22        (4) ASAM level 3.7 Medically Monitored Intensive
23    Inpatient Services for adults and Medically Monitored
24    High-Intensity Inpatient Services for adolescents; and
25        (5) ASAM level 3.1 Clinically Managed Low-Intensity
26    Residential Services for adults and adolescents.

 

 

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1(Source: P.A. 101-81, eff. 7-12-19; 102-699, eff. 4-19-22.)
 
2    Section 5-20. The Illinois Public Aid Code is amended by
3adding Section 5-47 as follows:
 
4    (305 ILCS 5/5-47 new)
5    Sec. 5-47. Medicaid reimbursement rates; substance use
6disorder treatment providers and facilities.
7    (a) Beginning on January 1, 2024, subject to federal
8approval, the Department of Healthcare and Family Services, in
9conjunction with the Department of Human Services' Division of
10Substance Use Prevention and Recovery, shall provide a 30%
11increase in reimbursement rates for all Medicaid-covered ASAM
12Level 3 residential/inpatient substance use disorder treatment
13services.
14    No existing or future reimbursement rates or add-ons shall
15be reduced or changed to address this proposed rate increase.
16No later than 3 months after the effective date of this
17amendatory Act of the 103rd General Assembly, the Department
18of Healthcare and Family Services shall submit any necessary
19application to the federal Centers for Medicare and Medicaid
20Services to implement the requirements of this Section.
21    (b) Parity in community-based behavioral health rates;
22implementation plan for cost reporting. For the purpose of
23understanding behavioral health services cost structures and
24their impact on the Medical Assistance Program, the Department

 

 

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1of Healthcare and Family Services shall engage stakeholders to
2develop a plan for the regular collection of cost reporting
3for all entity-based substance use disorder providers. Data
4shall be used to inform on the effectiveness and efficiency of
5Illinois Medicaid rates. The Department and stakeholders shall
6develop a plan by April 1, 2024. The Department shall engage
7stakeholders on implementation of the plan. The plan, at
8minimum, shall consider all of the following:
9        (1) Alignment with certified community behavioral
10    health clinic requirements, standards, policies, and
11    procedures.
12        (2) Inclusion of prospective costs to measure what is
13    needed to increase services and capacity.
14        (3) Consideration of differences in collection and
15    policies based on the size of providers.
16        (4) Consideration of additional administrative time
17    and costs.
18        (5) Goals, purposes, and usage of data collected from
19    cost reports.
20        (6) Inclusion of qualitative data in addition to
21    quantitative data.
22        (7) Technical assistance for providers for completing
23    cost reports including initial training by the Department
24    for providers.
25        (8) Implementation of a timeline which allows an
26    initial grace period for providers to adjust internal

 

 

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1    procedures and data collection.
2    Details from collected cost reports shall be made publicly
3available on the Department's website and costs shall be used
4to ensure the effectiveness and efficiency of Illinois
5Medicaid rates.
6    (c) Reporting; access to substance use disorder treatment
7services and recovery supports. By no later than April 1,
82024, the Department of Healthcare and Family Services, with
9input from the Department of Human Services' Division of
10Substance Use Prevention and Recovery, shall submit a report
11to the General Assembly regarding access to treatment services
12and recovery supports for persons diagnosed with a substance
13use disorder. The report shall include, but is not limited to,
14the following information:
15        (1) The number of providers enrolled in the Illinois
16    Medical Assistance Program certified to provide substance
17    use disorder treatment services, aggregated by ASAM level
18    of care, and recovery supports.
19        (2) The number of Medicaid customers in Illinois with
20    a diagnosed substance use disorder receiving substance use
21    disorder treatment, aggregated by provider type and ASAM
22    level of care.
23        (3) A comparison of Illinois' substance use disorder
24    licensure and certification requirements with those of
25    comparable state Medicaid programs.
26        (4) Recommendations for and an analysis of the impact

 

 

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1    of aligning reimbursement rates for outpatient substance
2    use disorder treatment services with reimbursement rates
3    for community-based mental health treatment services.
4        (5) Recommendations for expanding substance use
5    disorder treatment to other qualified provider entities
6    and licensed professionals of the healing arts. The
7    recommendations shall include an analysis of the
8    opportunities to maximize the flexibilities permitted by
9    the federal Centers for Medicare and Medicaid Services for
10    expanding access to the number and types of qualified
11    substance use disorder providers.
 
12
ARTICLE 10.

 
13    Section 10-1. The Illinois Administrative Procedure Act is
14amended by adding Section 5-45.36 as follows:
 
15    (5 ILCS 100/5-45.36 new)
16    Sec. 5-45.36. Emergency rulemaking; Medicaid reimbursement
17rates for hospital inpatient and outpatient services. To
18provide for the expeditious and timely implementation of the
19changes made by this amendatory Act of the 103rd General
20Assembly to Sections 5-5.05, 14-12, 14-12.5, and 14-12.7 of
21the Illinois Public Aid Code, emergency rules implementing the
22changes made by this amendatory Act of the 103rd General
23Assembly to Sections 5-5.05, 14-12, 14-12.5, and 14-12.7 of

 

 

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1the Illinois Public Aid Code may be adopted in accordance with
2Section 5-45 by the Department of Healthcare and Family
3Services. The adoption of emergency rules authorized by
4Section 5-45 and this Section is deemed to be necessary for the
5public interest, safety, and welfare.
6    This Section is repealed one year after the effective date
7of this amendatory Act of the 103rd General Assembly.
 
8    Section 10-5. The Illinois Public Aid Code is amended by
9changing Sections 5-5.05, 5A-12.7, 12-4.105, and 14-12 and by
10adding Sections 14-12.5 and 14-12.7 as follows:
 
11    (305 ILCS 5/5-5.05)
12    Sec. 5-5.05. Hospitals; psychiatric services.
13    (a) On and after January 1, 2024 July 1, 2008, the
14inpatient, per diem rate to be paid to a hospital for inpatient
15psychiatric services shall be not less than 90% of the per diem
16rate established in accordance with paragraph (b-5) of this
17section, subject to the provisions of Section 14-12.5 $363.77.
18    (b) For purposes of this Section, "hospital" means a the
19following:
20        (1) Advocate Christ Hospital, Oak Lawn, Illinois.
21        (2) Barnes-Jewish Hospital, St. Louis, Missouri.
22        (3) BroMenn Healthcare, Bloomington, Illinois.
23        (4) Jackson Park Hospital, Chicago, Illinois.
24        (5) Katherine Shaw Bethea Hospital, Dixon, Illinois.

 

 

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1        (6) Lawrence County Memorial Hospital, Lawrenceville,
2    Illinois.
3        (7) Advocate Lutheran General Hospital, Park Ridge,
4    Illinois.
5        (8) Mercy Hospital and Medical Center, Chicago,
6    Illinois.
7        (9) Methodist Medical Center of Illinois, Peoria,
8    Illinois.
9        (10) Provena United Samaritans Medical Center,
10    Danville, Illinois.
11        (11) Rockford Memorial Hospital, Rockford, Illinois.
12        (12) Sarah Bush Lincoln Health Center, Mattoon,
13    Illinois.
14        (13) Provena Covenant Medical Center, Urbana,
15    Illinois.
16        (14) Rush-Presbyterian-St. Luke's Medical Center,
17    Chicago, Illinois.
18        (15) Mt. Sinai Hospital, Chicago, Illinois.
19        (16) Gateway Regional Medical Center, Granite City,
20    Illinois.
21        (17) St. Mary of Nazareth Hospital, Chicago, Illinois.
22        (18) Provena St. Mary's Hospital, Kankakee, Illinois.
23        (19) St. Mary's Hospital, Decatur, Illinois.
24        (20) Memorial Hospital, Belleville, Illinois.
25        (21) Swedish Covenant Hospital, Chicago, Illinois.
26        (22) Trinity Medical Center, Rock Island, Illinois.

 

 

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1        (23) St. Elizabeth Hospital, Chicago, Illinois.
2        (24) Richland Memorial Hospital, Olney, Illinois.
3        (25) St. Elizabeth's Hospital, Belleville, Illinois.
4        (26) Samaritan Health System, Clinton, Iowa.
5        (27) St. John's Hospital, Springfield, Illinois.
6        (28) St. Mary's Hospital, Centralia, Illinois.
7        (29) Loretto Hospital, Chicago, Illinois.
8        (30) Kenneth Hall Regional Hospital, East St. Louis,
9    Illinois.
10        (31) Hinsdale Hospital, Hinsdale, Illinois.
11        (32) Pekin Hospital, Pekin, Illinois.
12        (33) University of Chicago Medical Center, Chicago,
13    Illinois.
14        (34) St. Anthony's Health Center, Alton, Illinois.
15        (35) OSF St. Francis Medical Center, Peoria, Illinois.
16        (36) Memorial Medical Center, Springfield, Illinois.
17        (37) A hospital with a distinct part unit for
18    psychiatric services that begins operating on or after
19    July 1, 2008.
20    For purposes of this Section, "inpatient psychiatric
21services" means those services provided to patients who are in
22need of short-term acute inpatient hospitalization for active
23treatment of an emotional or mental disorder.
24    (b-5) Notwithstanding any other provision of this Section,
25and subject to appropriation, the inpatient, per diem rate to
26be paid to all safety-net hospitals for inpatient psychiatric

 

 

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1services on and after January 1, 2021 shall be at least $630,
2subject to the provisions of Section 14-12.5.
3    (b-10) Notwithstanding any other provision of this
4Section, effective with dates of service on and after January
51, 2022, any general acute care hospital with more than 9,500
6inpatient psychiatric Medicaid days in any calendar year shall
7be paid the inpatient per diem rate of no less than $630,
8subject to the provisions of Section 14-12.5.
9    (c) No rules shall be promulgated to implement this
10Section. For purposes of this Section, "rules" is given the
11meaning contained in Section 1-70 of the Illinois
12Administrative Procedure Act.
13    (d) (Blank). This Section shall not be in effect during
14any period of time that the State has in place a fully
15operational hospital assessment plan that has been approved by
16the Centers for Medicare and Medicaid Services of the U.S.
17Department of Health and Human Services.
18    (e) On and after July 1, 2012, the Department shall reduce
19any rate of reimbursement for services or other payments or
20alter any methodologies authorized by this Code to reduce any
21rate of reimbursement for services or other payments in
22accordance with Section 5-5e.
23(Source: P.A. 102-4, eff. 4-27-21; 102-674, eff. 11-30-21.)
 
24    (305 ILCS 5/5A-12.7)
25    (Section scheduled to be repealed on December 31, 2026)

 

 

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1    Sec. 5A-12.7. Continuation of hospital access payments on
2and after July 1, 2020.
3    (a) To preserve and improve access to hospital services,
4for hospital services rendered on and after July 1, 2020, the
5Department shall, except for hospitals described in subsection
6(b) of Section 5A-3, make payments to hospitals or require
7capitated managed care organizations to make payments as set
8forth in this Section. Payments under this Section are not due
9and payable, however, until: (i) the methodologies described
10in this Section are approved by the federal government in an
11appropriate State Plan amendment or directed payment preprint;
12and (ii) the assessment imposed under this Article is
13determined to be a permissible tax under Title XIX of the
14Social Security Act. In determining the hospital access
15payments authorized under subsection (g) of this Section, if a
16hospital ceases to qualify for payments from the pool, the
17payments for all hospitals continuing to qualify for payments
18from such pool shall be uniformly adjusted to fully expend the
19aggregate net amount of the pool, with such adjustment being
20effective on the first day of the second month following the
21date the hospital ceases to receive payments from such pool.
22    (b) Amounts moved into claims-based rates and distributed
23in accordance with Section 14-12 shall remain in those
24claims-based rates.
25    (c) Graduate medical education.
26        (1) The calculation of graduate medical education

 

 

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1    payments shall be based on the hospital's Medicare cost
2    report ending in Calendar Year 2018, as reported in the
3    Healthcare Cost Report Information System file, release
4    date September 30, 2019. An Illinois hospital reporting
5    intern and resident cost on its Medicare cost report shall
6    be eligible for graduate medical education payments.
7        (2) Each hospital's annualized Medicaid Intern
8    Resident Cost is calculated using annualized intern and
9    resident total costs obtained from Worksheet B Part I,
10    Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
11    96-98, and 105-112 multiplied by the percentage that the
12    hospital's Medicaid days (Worksheet S3 Part I, Column 7,
13    Lines 2, 3, 4, 14, 16-18, and 32) comprise of the
14    hospital's total days (Worksheet S3 Part I, Column 8,
15    Lines 14, 16-18, and 32).
16        (3) An annualized Medicaid indirect medical education
17    (IME) payment is calculated for each hospital using its
18    IME payments (Worksheet E Part A, Line 29, Column 1)
19    multiplied by the percentage that its Medicaid days
20    (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18,
21    and 32) comprise of its Medicare days (Worksheet S3 Part
22    I, Column 6, Lines 2, 3, 4, 14, and 16-18).
23        (4) For each hospital, its annualized Medicaid Intern
24    Resident Cost and its annualized Medicaid IME payment are
25    summed, and, except as capped at 120% of the average cost
26    per intern and resident for all qualifying hospitals as

 

 

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1    calculated under this paragraph, is multiplied by the
2    applicable reimbursement factor as described in this
3    paragraph, to determine the hospital's final graduate
4    medical education payment. Each hospital's average cost
5    per intern and resident shall be calculated by summing its
6    total annualized Medicaid Intern Resident Cost plus its
7    annualized Medicaid IME payment and dividing that amount
8    by the hospital's total Full Time Equivalent Residents and
9    Interns. If the hospital's average per intern and resident
10    cost is greater than 120% of the same calculation for all
11    qualifying hospitals, the hospital's per intern and
12    resident cost shall be capped at 120% of the average cost
13    for all qualifying hospitals.
14            (A) For the period of July 1, 2020 through
15        December 31, 2022, the applicable reimbursement factor
16        shall be 22.6%.
17            (B) For the period of January 1, 2023 through
18        December 31, 2026, the applicable reimbursement factor
19        shall be 35% for all qualified safety-net hospitals,
20        as defined in Section 5-5e.1 of this Code, and all
21        hospitals with 100 or more Full Time Equivalent
22        Residents and Interns, as reported on the hospital's
23        Medicare cost report ending in Calendar Year 2018, and
24        for all other qualified hospitals the applicable
25        reimbursement factor shall be 30%.
26    (d) Fee-for-service supplemental payments. For the period

 

 

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1of July 1, 2020 through December 31, 2022, each Illinois
2hospital shall receive an annual payment equal to the amounts
3below, to be paid in 12 equal installments on or before the
4seventh State business day of each month, except that no
5payment shall be due within 30 days after the later of the date
6of notification of federal approval of the payment
7methodologies required under this Section or any waiver
8required under 42 CFR 433.68, at which time the sum of amounts
9required under this Section prior to the date of notification
10is due and payable.
11        (1) For critical access hospitals, $385 per covered
12    inpatient day contained in paid fee-for-service claims and
13    $530 per paid fee-for-service outpatient claim for dates
14    of service in Calendar Year 2019 in the Department's
15    Enterprise Data Warehouse as of May 11, 2020.
16        (2) For safety-net hospitals, $960 per covered
17    inpatient day contained in paid fee-for-service claims and
18    $625 per paid fee-for-service outpatient claim for dates
19    of service in Calendar Year 2019 in the Department's
20    Enterprise Data Warehouse as of May 11, 2020.
21        (3) For long term acute care hospitals, $295 per
22    covered inpatient day contained in paid fee-for-service
23    claims for dates of service in Calendar Year 2019 in the
24    Department's Enterprise Data Warehouse as of May 11, 2020.
25        (4) For freestanding psychiatric hospitals, $125 per
26    covered inpatient day contained in paid fee-for-service

 

 

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1    claims and $130 per paid fee-for-service outpatient claim
2    for dates of service in Calendar Year 2019 in the
3    Department's Enterprise Data Warehouse as of May 11, 2020.
4        (5) For freestanding rehabilitation hospitals, $355
5    per covered inpatient day contained in paid
6    fee-for-service claims for dates of service in Calendar
7    Year 2019 in the Department's Enterprise Data Warehouse as
8    of May 11, 2020.
9        (6) For all general acute care hospitals and high
10    Medicaid hospitals as defined in subsection (f), $350 per
11    covered inpatient day for dates of service in Calendar
12    Year 2019 contained in paid fee-for-service claims and
13    $620 per paid fee-for-service outpatient claim in the
14    Department's Enterprise Data Warehouse as of May 11, 2020.
15        (7) Alzheimer's treatment access payment. Each
16    Illinois academic medical center or teaching hospital, as
17    defined in Section 5-5e.2 of this Code, that is identified
18    as the primary hospital affiliate of one of the Regional
19    Alzheimer's Disease Assistance Centers, as designated by
20    the Alzheimer's Disease Assistance Act and identified in
21    the Department of Public Health's Alzheimer's Disease
22    State Plan dated December 2016, shall be paid an
23    Alzheimer's treatment access payment equal to the product
24    of the qualifying hospital's State Fiscal Year 2018 total
25    inpatient fee-for-service days multiplied by the
26    applicable Alzheimer's treatment rate of $226.30 for

 

 

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1    hospitals located in Cook County and $116.21 for hospitals
2    located outside Cook County.
3    (d-2) Fee-for-service supplemental payments. Beginning
4January 1, 2023, each Illinois hospital shall receive an
5annual payment equal to the amounts listed below, to be paid in
612 equal installments on or before the seventh State business
7day of each month, except that no payment shall be due within
830 days after the later of the date of notification of federal
9approval of the payment methodologies required under this
10Section or any waiver required under 42 CFR 433.68, at which
11time the sum of amounts required under this Section prior to
12the date of notification is due and payable. The Department
13may adjust the rates in paragraphs (1) through (7) to comply
14with the federal upper payment limits, with such adjustments
15being determined so that the total estimated spending by
16hospital class, under such adjusted rates, remains
17substantially similar to the total estimated spending under
18the original rates set forth in this subsection.
19        (1) For critical access hospitals, as defined in
20    subsection (f), $750 per covered inpatient day contained
21    in paid fee-for-service claims and $750 per paid
22    fee-for-service outpatient claim for dates of service in
23    Calendar Year 2019 in the Department's Enterprise Data
24    Warehouse as of August 6, 2021.
25        (2) For safety-net hospitals, as described in
26    subsection (f), $1,350 per inpatient day contained in paid

 

 

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1    fee-for-service claims and $1,350 per paid fee-for-service
2    outpatient claim for dates of service in Calendar Year
3    2019 in the Department's Enterprise Data Warehouse as of
4    August 6, 2021.
5        (3) For long term acute care hospitals, $550 per
6    covered inpatient day contained in paid fee-for-service
7    claims for dates of service in Calendar Year 2019 in the
8    Department's Enterprise Data Warehouse as of August 6,
9    2021.
10        (4) For freestanding psychiatric hospitals, $200 per
11    covered inpatient day contained in paid fee-for-service
12    claims and $200 per paid fee-for-service outpatient claim
13    for dates of service in Calendar Year 2019 in the
14    Department's Enterprise Data Warehouse as of August 6,
15    2021.
16        (5) For freestanding rehabilitation hospitals, $550
17    per covered inpatient day contained in paid
18    fee-for-service claims and $125 per paid fee-for-service
19    outpatient claim for dates of service in Calendar Year
20    2019 in the Department's Enterprise Data Warehouse as of
21    August 6, 2021.
22        (6) For all general acute care hospitals and high
23    Medicaid hospitals as defined in subsection (f), $500 per
24    covered inpatient day for dates of service in Calendar
25    Year 2019 contained in paid fee-for-service claims and
26    $500 per paid fee-for-service outpatient claim in the

 

 

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1    Department's Enterprise Data Warehouse as of August 6,
2    2021.
3        (7) For public hospitals, as defined in subsection
4    (f), $275 per covered inpatient day contained in paid
5    fee-for-service claims and $275 per paid fee-for-service
6    outpatient claim for dates of service in Calendar Year
7    2019 in the Department's Enterprise Data Warehouse as of
8    August 6, 2021.
9        (8) Alzheimer's treatment access payment. Each
10    Illinois academic medical center or teaching hospital, as
11    defined in Section 5-5e.2 of this Code, that is identified
12    as the primary hospital affiliate of one of the Regional
13    Alzheimer's Disease Assistance Centers, as designated by
14    the Alzheimer's Disease Assistance Act and identified in
15    the Department of Public Health's Alzheimer's Disease
16    State Plan dated December 2016, shall be paid an
17    Alzheimer's treatment access payment equal to the product
18    of the qualifying hospital's Calendar Year 2019 total
19    inpatient fee-for-service days, in the Department's
20    Enterprise Data Warehouse as of August 6, 2021, multiplied
21    by the applicable Alzheimer's treatment rate of $244.37
22    for hospitals located in Cook County and $312.03 for
23    hospitals located outside Cook County.
24    (e) The Department shall require managed care
25organizations (MCOs) to make directed payments and
26pass-through payments according to this Section. Each calendar

 

 

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1year, the Department shall require MCOs to pay the maximum
2amount out of these funds as allowed as pass-through payments
3under federal regulations. The Department shall require MCOs
4to make such pass-through payments as specified in this
5Section. The Department shall require the MCOs to pay the
6remaining amounts as directed Payments as specified in this
7Section. The Department shall issue payments to the
8Comptroller by the seventh business day of each month for all
9MCOs that are sufficient for MCOs to make the directed
10payments and pass-through payments according to this Section.
11The Department shall require the MCOs to make pass-through
12payments and directed payments using electronic funds
13transfers (EFT), if the hospital provides the information
14necessary to process such EFTs, in accordance with directions
15provided monthly by the Department, within 7 business days of
16the date the funds are paid to the MCOs, as indicated by the
17"Paid Date" on the website of the Office of the Comptroller if
18the funds are paid by EFT and the MCOs have received directed
19payment instructions. If funds are not paid through the
20Comptroller by EFT, payment must be made within 7 business
21days of the date actually received by the MCO. The MCO will be
22considered to have paid the pass-through payments when the
23payment remittance number is generated or the date the MCO
24sends the check to the hospital, if EFT information is not
25supplied. If an MCO is late in paying a pass-through payment or
26directed payment as required under this Section (including any

 

 

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1extensions granted by the Department), it shall pay a penalty,
2unless waived by the Department for reasonable cause, to the
3Department equal to 5% of the amount of the pass-through
4payment or directed payment not paid on or before the due date
5plus 5% of the portion thereof remaining unpaid on the last day
6of each 30-day period thereafter. Payments to MCOs that would
7be paid consistent with actuarial certification and enrollment
8in the absence of the increased capitation payments under this
9Section shall not be reduced as a consequence of payments made
10under this subsection. The Department shall publish and
11maintain on its website for a period of no less than 8 calendar
12quarters, the quarterly calculation of directed payments and
13pass-through payments owed to each hospital from each MCO. All
14calculations and reports shall be posted no later than the
15first day of the quarter for which the payments are to be
16issued.
17    (f)(1) For purposes of allocating the funds included in
18capitation payments to MCOs, Illinois hospitals shall be
19divided into the following classes as defined in
20administrative rules:
21        (A) Beginning July 1, 2020 through December 31, 2022,
22    critical access hospitals. Beginning January 1, 2023,
23    "critical access hospital" means a hospital designated by
24    the Department of Public Health as a critical access
25    hospital, excluding any hospital meeting the definition of
26    a public hospital in subparagraph (F).

 

 

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1        (B) Safety-net hospitals, except that stand-alone
2    children's hospitals that are not specialty children's
3    hospitals will not be included. For the calendar year
4    beginning January 1, 2023, and each calendar year
5    thereafter, assignment to the safety-net class shall be
6    based on the annual safety-net rate year beginning 15
7    months before the beginning of the first Payout Quarter of
8    the calendar year.
9        (C) Long term acute care hospitals.
10        (D) Freestanding psychiatric hospitals.
11        (E) Freestanding rehabilitation hospitals.
12        (F) Beginning January 1, 2023, "public hospital" means
13    a hospital that is owned or operated by an Illinois
14    Government body or municipality, excluding a hospital
15    provider that is a State agency, a State university, or a
16    county with a population of 3,000,000 or more.
17        (G) High Medicaid hospitals.
18            (i) As used in this Section, "high Medicaid
19        hospital" means a general acute care hospital that:
20                (I) For the payout periods July 1, 2020
21            through December 31, 2022, is not a safety-net
22            hospital or critical access hospital and that has
23            a Medicaid Inpatient Utilization Rate above 30% or
24            a hospital that had over 35,000 inpatient Medicaid
25            days during the applicable period. For the period
26            July 1, 2020 through December 31, 2020, the

 

 

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1            applicable period for the Medicaid Inpatient
2            Utilization Rate (MIUR) is the rate year 2020 MIUR
3            and for the number of inpatient days it is State
4            fiscal year 2018. Beginning in calendar year 2021,
5            the Department shall use the most recently
6            determined MIUR, as defined in subsection (h) of
7            Section 5-5.02, and for the inpatient day
8            threshold, the State fiscal year ending 18 months
9            prior to the beginning of the calendar year. For
10            purposes of calculating MIUR under this Section,
11            children's hospitals and affiliated general acute
12            care hospitals shall be considered a single
13            hospital.
14                (II) For the calendar year beginning January
15            1, 2023, and each calendar year thereafter, is not
16            a public hospital, safety-net hospital, or
17            critical access hospital and that qualifies as a
18            regional high volume hospital or is a hospital
19            that has a Medicaid Inpatient Utilization Rate
20            (MIUR) above 30%. As used in this item, "regional
21            high volume hospital" means a hospital which ranks
22            in the top 2 quartiles based on total hospital
23            services volume, of all eligible general acute
24            care hospitals, when ranked in descending order
25            based on total hospital services volume, within
26            the same Medicaid managed care region, as

 

 

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1            designated by the Department, as of January 1,
2            2022. As used in this item, "total hospital
3            services volume" means the total of all Medical
4            Assistance hospital inpatient admissions plus all
5            Medical Assistance hospital outpatient visits. For
6            purposes of determining regional high volume
7            hospital inpatient admissions and outpatient
8            visits, the Department shall use dates of service
9            provided during State Fiscal Year 2020 for the
10            Payout Quarter beginning January 1, 2023. The
11            Department shall use dates of service from the
12            State fiscal year ending 18 month before the
13            beginning of the first Payout Quarter of the
14            subsequent annual determination period.
15            (ii) For the calendar year beginning January 1,
16        2023, the Department shall use the Rate Year 2022
17        Medicaid inpatient utilization rate (MIUR), as defined
18        in subsection (h) of Section 5-5.02. For each
19        subsequent annual determination, the Department shall
20        use the MIUR applicable to the rate year ending
21        September 30 of the year preceding the beginning of
22        the calendar year.
23        (H) General acute care hospitals. As used under this
24    Section, "general acute care hospitals" means all other
25    Illinois hospitals not identified in subparagraphs (A)
26    through (G).

 

 

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1    (2) Hospitals' qualification for each class shall be
2assessed prior to the beginning of each calendar year and the
3new class designation shall be effective January 1 of the next
4year. The Department shall publish by rule the process for
5establishing class determination.
6    (3) Beginning January 1, 2024, the Department may reassign
7hospitals or entire hospital classes as defined above, if
8federal limits on the payments to the class to which the
9hospitals are assigned based on the criteria in this
10subsection prevent the Department from making payments to the
11class that would otherwise be due under this Section. The
12Department shall publish the criteria and composition of each
13new class based on the reassignments, and the projected impact
14on payments to each hospital under the new classes on its
15website by November 15 of the year before the year in which the
16class changes become effective.
17    (g) Fixed pool directed payments. Beginning July 1, 2020,
18the Department shall issue payments to MCOs which shall be
19used to issue directed payments to qualified Illinois
20safety-net hospitals and critical access hospitals on a
21monthly basis in accordance with this subsection. Prior to the
22beginning of each Payout Quarter beginning July 1, 2020, the
23Department shall use encounter claims data from the
24Determination Quarter, accepted by the Department's Medicaid
25Management Information System for inpatient and outpatient
26services rendered by safety-net hospitals and critical access

 

 

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1hospitals to determine a quarterly uniform per unit add-on for
2each hospital class.
3        (1) Inpatient per unit add-on. A quarterly uniform per
4    diem add-on shall be derived by dividing the quarterly
5    Inpatient Directed Payments Pool amount allocated to the
6    applicable hospital class by the total inpatient days
7    contained on all encounter claims received during the
8    Determination Quarter, for all hospitals in the class.
9            (A) Each hospital in the class shall have a
10        quarterly inpatient directed payment calculated that
11        is equal to the product of the number of inpatient days
12        attributable to the hospital used in the calculation
13        of the quarterly uniform class per diem add-on,
14        multiplied by the calculated applicable quarterly
15        uniform class per diem add-on of the hospital class.
16            (B) Each hospital shall be paid 1/3 of its
17        quarterly inpatient directed payment in each of the 3
18        months of the Payout Quarter, in accordance with
19        directions provided to each MCO by the Department.
20        (2) Outpatient per unit add-on. A quarterly uniform
21    per claim add-on shall be derived by dividing the
22    quarterly Outpatient Directed Payments Pool amount
23    allocated to the applicable hospital class by the total
24    outpatient encounter claims received during the
25    Determination Quarter, for all hospitals in the class.
26            (A) Each hospital in the class shall have a

 

 

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1        quarterly outpatient directed payment calculated that
2        is equal to the product of the number of outpatient
3        encounter claims attributable to the hospital used in
4        the calculation of the quarterly uniform class per
5        claim add-on, multiplied by the calculated applicable
6        quarterly uniform class per claim add-on of the
7        hospital class.
8            (B) Each hospital shall be paid 1/3 of its
9        quarterly outpatient directed payment in each of the 3
10        months of the Payout Quarter, in accordance with
11        directions provided to each MCO by the Department.
12        (3) Each MCO shall pay each hospital the Monthly
13    Directed Payment as identified by the Department on its
14    quarterly determination report.
15        (4) Definitions. As used in this subsection:
16            (A) "Payout Quarter" means each 3 month calendar
17        quarter, beginning July 1, 2020.
18            (B) "Determination Quarter" means each 3 month
19        calendar quarter, which ends 3 months prior to the
20        first day of each Payout Quarter.
21        (5) For the period July 1, 2020 through December 2020,
22    the following amounts shall be allocated to the following
23    hospital class directed payment pools for the quarterly
24    development of a uniform per unit add-on:
25            (A) $2,894,500 for hospital inpatient services for
26        critical access hospitals.

 

 

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

 

 

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1            (C) Hospital inpatient services for public
2        hospitals.
3            (D) Hospital outpatient services for public
4        hospitals.
5            (E) Hospital inpatient services for safety-net
6        hospitals.
7            (F) Hospital outpatient services for safety-net
8        hospitals.
9        (7) Semi-annual rate maintenance review. The
10    Department shall ensure that hospitals assigned to the
11    fixed pools in paragraph (6) are paid no less than 95% of
12    the annual initial rate for each 6-month period of each
13    annual payout period. For each calendar year, the
14    Department shall calculate the annual initial rate per day
15    and per visit for each fixed pool hospital class listed in
16    paragraph (6), by dividing the total of all applicable
17    inpatient or outpatient directed payments issued in the
18    preceding calendar year to the hospitals in each fixed
19    pool class for the calendar year, plus any increase
20    resulting from the annual adjustments described in
21    subsection (i), by the actual applicable total service
22    units for the preceding calendar year which were the basis
23    of the total applicable inpatient or outpatient directed
24    payments issued to the hospitals in each fixed pool class
25    in the calendar year, except that for calendar year 2023,
26    the service units from calendar year 2021 shall be used.

 

 

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1            (A) The Department shall calculate the effective
2        rate, per day and per visit, for the payout periods of
3        January to June and July to December of each year, for
4        each fixed pool listed in paragraph (6), by dividing
5        50% of the annual pool by the total applicable
6        reported service units for the 2 applicable
7        determination quarters.
8            (B) If the effective rate calculated in
9        subparagraph (A) is less than 95% of the annual
10        initial rate assigned to the class for each pool under
11        paragraph (6), the Department shall adjust the payment
12        for each hospital to a level equal to no less than 95%
13        of the annual initial rate, by issuing a retroactive
14        adjustment payment for the 6-month period under review
15        as identified in subparagraph (A).
16    (h) Fixed rate directed payments. Effective July 1, 2020,
17the Department shall issue payments to MCOs which shall be
18used to issue directed payments to Illinois hospitals not
19identified in paragraph (g) on a monthly basis. Prior to the
20beginning of each Payout Quarter beginning July 1, 2020, the
21Department shall use encounter claims data from the
22Determination Quarter, accepted by the Department's Medicaid
23Management Information System for inpatient and outpatient
24services rendered by hospitals in each hospital class
25identified in paragraph (f) and not identified in paragraph
26(g). For the period July 1, 2020 through December 2020, the

 

 

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1Department shall direct MCOs to make payments as follows:
2        (1) For general acute care hospitals an amount equal
3    to $1,750 multiplied by the hospital's category of service
4    20 case mix index for the determination quarter multiplied
5    by the hospital's total number of inpatient admissions for
6    category of service 20 for the determination quarter.
7        (2) For general acute care hospitals an amount equal
8    to $160 multiplied by the hospital's category of service
9    21 case mix index for the determination quarter multiplied
10    by the hospital's total number of inpatient admissions for
11    category of service 21 for the determination quarter.
12        (3) For general acute care hospitals an amount equal
13    to $80 multiplied by the hospital's category of service 22
14    case mix index for the determination quarter multiplied by
15    the hospital's total number of inpatient admissions for
16    category of service 22 for the determination quarter.
17        (4) For general acute care hospitals an amount equal
18    to $375 multiplied by the hospital's category of service
19    24 case mix index for the determination quarter multiplied
20    by the hospital's total number of category of service 24
21    paid EAPG (EAPGs) for the determination quarter.
22        (5) For general acute care hospitals an amount equal
23    to $240 multiplied by the hospital's category of service
24    27 and 28 case mix index for the determination quarter
25    multiplied by the hospital's total number of category of
26    service 27 and 28 paid EAPGs for the determination

 

 

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1    quarter.
2        (6) For general acute care hospitals an amount equal
3    to $290 multiplied by the hospital's category of service
4    29 case mix index for the determination quarter multiplied
5    by the hospital's total number of category of service 29
6    paid EAPGs for the determination quarter.
7        (7) For high Medicaid hospitals an amount equal to
8    $1,800 multiplied by the hospital's category of service 20
9    case mix index for the determination quarter multiplied by
10    the hospital's total number of inpatient admissions for
11    category of service 20 for the determination quarter.
12        (8) For high Medicaid hospitals an amount equal to
13    $160 multiplied by the hospital's category of service 21
14    case mix index for the determination quarter multiplied by
15    the hospital's total number of inpatient admissions for
16    category of service 21 for the determination quarter.
17        (9) For high Medicaid hospitals an amount equal to $80
18    multiplied by the hospital's category of service 22 case
19    mix index for the determination quarter multiplied by the
20    hospital's total number of inpatient admissions for
21    category of service 22 for the determination quarter.
22        (10) For high Medicaid hospitals an amount equal to
23    $400 multiplied by the hospital's category of service 24
24    case mix index for the determination quarter multiplied by
25    the hospital's total number of category of service 24 paid
26    EAPG outpatient claims for the determination quarter.

 

 

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1        (11) For high Medicaid hospitals an amount equal to
2    $240 multiplied by the hospital's category of service 27
3    and 28 case mix index for the determination quarter
4    multiplied by the hospital's total number of category of
5    service 27 and 28 paid EAPGs for the determination
6    quarter.
7        (12) For high Medicaid hospitals an amount equal to
8    $290 multiplied by the hospital's category of service 29
9    case mix index for the determination quarter multiplied by
10    the hospital's total number of category of service 29 paid
11    EAPGs for the determination quarter.
12        (13) For long term acute care hospitals the amount of
13    $495 multiplied by the hospital's total number of
14    inpatient days for the determination quarter.
15        (14) For psychiatric hospitals the amount of $210
16    multiplied by the hospital's total number of inpatient
17    days for category of service 21 for the determination
18    quarter.
19        (15) For psychiatric hospitals the amount of $250
20    multiplied by the hospital's total number of outpatient
21    claims for category of service 27 and 28 for the
22    determination quarter.
23        (16) For rehabilitation hospitals the amount of $410
24    multiplied by the hospital's total number of inpatient
25    days for category of service 22 for the determination
26    quarter.

 

 

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1        (17) For rehabilitation hospitals the amount of $100
2    multiplied by the hospital's total number of outpatient
3    claims for category of service 29 for the determination
4    quarter.
5        (18) Effective for the Payout Quarter beginning
6    January 1, 2023, for the directed payments to hospitals
7    required under this subsection, the Department shall
8    establish the amounts that shall be used to calculate such
9    directed payments using the methodologies specified in
10    this paragraph. The Department shall use a single, uniform
11    rate, adjusted for acuity as specified in paragraphs (1)
12    through (12), for all categories of inpatient services
13    provided by each class of hospitals and a single uniform
14    rate, adjusted for acuity as specified in paragraphs (1)
15    through (12), for all categories of outpatient services
16    provided by each class of hospitals. The Department shall
17    establish such amounts so that the total amount of
18    payments to each hospital under this Section in calendar
19    year 2023 is projected to be substantially similar to the
20    total amount of such payments received by the hospital
21    under this Section in calendar year 2021, adjusted for
22    increased funding provided for fixed pool directed
23    payments under subsection (g) in calendar year 2022,
24    assuming that the volume and acuity of claims are held
25    constant. The Department shall publish the directed
26    payment amounts to be established under this subsection on

 

 

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1    its website by November 15, 2022.
2        (19) Each hospital shall be paid 1/3 of their
3    quarterly inpatient and outpatient directed payment in
4    each of the 3 months of the Payout Quarter, in accordance
5    with directions provided to each MCO by the Department.
6        20 Each MCO shall pay each hospital the Monthly
7    Directed Payment amount as identified by the Department on
8    its quarterly determination report.
9    Notwithstanding any other provision of this subsection, if
10the Department determines that the actual total hospital
11utilization data that is used to calculate the fixed rate
12directed payments is substantially different than anticipated
13when the rates in this subsection were initially determined
14for unforeseeable circumstances (such as the COVID-19 pandemic
15or some other public health emergency), the Department may
16adjust the rates specified in this subsection so that the
17total directed payments approximate the total spending amount
18anticipated when the rates were initially established.
19    Definitions. As used in this subsection:
20            (A) "Payout Quarter" means each calendar quarter,
21        beginning July 1, 2020.
22            (B) "Determination Quarter" means each calendar
23        quarter which ends 3 months prior to the first day of
24        each Payout Quarter.
25            (C) "Case mix index" means a hospital specific
26        calculation. For inpatient claims the case mix index

 

 

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1        is calculated each quarter by summing the relative
2        weight of all inpatient Diagnosis-Related Group (DRG)
3        claims for a category of service in the applicable
4        Determination Quarter and dividing the sum by the
5        number of sum total of all inpatient DRG admissions
6        for the category of service for the associated claims.
7        The case mix index for outpatient claims is calculated
8        each quarter by summing the relative weight of all
9        paid EAPGs in the applicable Determination Quarter and
10        dividing the sum by the sum total of paid EAPGs for the
11        associated claims.
12    (i) Beginning January 1, 2021, the rates for directed
13payments shall be recalculated in order to spend the
14additional funds for directed payments that result from
15reduction in the amount of pass-through payments allowed under
16federal regulations. The additional funds for directed
17payments shall be allocated proportionally to each class of
18hospitals based on that class' proportion of services.
19        (1) Beginning January 1, 2024, the fixed pool directed
20    payment amounts and the associated annual initial rates
21    referenced in paragraph (6) of subsection (f) for each
22    hospital class shall be uniformly increased by a ratio of
23    not less than, the ratio of the total pass-through
24    reduction amount pursuant to paragraph (4) of subsection
25    (j), for the hospitals comprising the hospital fixed pool
26    directed payment class for the next calendar year, to the

 

 

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1    total inpatient and outpatient directed payments for the
2    hospitals comprising the hospital fixed pool directed
3    payment class paid during the preceding calendar year.
4        (2) Beginning January 1, 2024, the fixed rates for the
5    directed payments referenced in paragraph (18) of
6    subsection (h) for each hospital class shall be uniformly
7    increased by a ratio of not less than, the ratio of the
8    total pass-through reduction amount pursuant to paragraph
9    (4) of subsection (j), for the hospitals comprising the
10    hospital directed payment class for the next calendar
11    year, to the total inpatient and outpatient directed
12    payments for the hospitals comprising the hospital fixed
13    rate directed payment class paid during the preceding
14    calendar year.
15    (j) Pass-through payments.
16        (1) For the period July 1, 2020 through December 31,
17    2020, the Department shall assign quarterly pass-through
18    payments to each class of hospitals equal to one-fourth of
19    the following annual allocations:
20            (A) $390,487,095 to safety-net hospitals.
21            (B) $62,553,886 to critical access hospitals.
22            (C) $345,021,438 to high Medicaid hospitals.
23            (D) $551,429,071 to general acute care hospitals.
24            (E) $27,283,870 to long term acute care hospitals.
25            (F) $40,825,444 to freestanding psychiatric
26        hospitals.

 

 

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1            (G) $9,652,108 to freestanding rehabilitation
2        hospitals.
3        (2) For the period of July 1, 2020 through December
4    31, 2020, the pass-through payments shall at a minimum
5    ensure hospitals receive a total amount of monthly
6    payments under this Section as received in calendar year
7    2019 in accordance with this Article and paragraph (1) of
8    subsection (d-5) of Section 14-12, exclusive of amounts
9    received through payments referenced in subsection (b).
10        (3) For the calendar year beginning January 1, 2023,
11    the Department shall establish the annual pass-through
12    allocation to each class of hospitals and the pass-through
13    payments to each hospital so that the total amount of
14    payments to each hospital under this Section in calendar
15    year 2023 is projected to be substantially similar to the
16    total amount of such payments received by the hospital
17    under this Section in calendar year 2021, adjusted for
18    increased funding provided for fixed pool directed
19    payments under subsection (g) in calendar year 2022,
20    assuming that the volume and acuity of claims are held
21    constant. The Department shall publish the pass-through
22    allocation to each class and the pass-through payments to
23    each hospital to be established under this subsection on
24    its website by November 15, 2022.
25        (4) For the calendar years beginning January 1, 2021
26    and , January 1, 2022, and January 1, 2024, and each

 

 

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1    calendar year thereafter, each hospital's pass-through
2    payment amount shall be reduced proportionally to the
3    reduction of all pass-through payments required by federal
4    regulations. Beginning January 1, 2024, the Department
5    shall reduce total pass-through payments by the minimum
6    amount necessary to comply with federal regulations.
7    Pass-through payments to safety-net hospitals as defined
8    in Section 5-5e.1 of this Code, shall not be reduced until
9    all pass-through payments to other hospitals have been
10    eliminated. All other hospitals shall have their
11    pass-through payments reduced proportionally.
12    (k) At least 30 days prior to each calendar year, the
13Department shall notify each hospital of changes to the
14payment methodologies in this Section, including, but not
15limited to, changes in the fixed rate directed payment rates,
16the aggregate pass-through payment amount for all hospitals,
17and the hospital's pass-through payment amount for the
18upcoming calendar year.
19    (l) Notwithstanding any other provisions of this Section,
20the Department may adopt rules to change the methodology for
21directed and pass-through payments as set forth in this
22Section, but only to the extent necessary to obtain federal
23approval of a necessary State Plan amendment or Directed
24Payment Preprint or to otherwise conform to federal law or
25federal regulation.
26    (m) As used in this subsection, "managed care

 

 

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1organization" or "MCO" means an entity which contracts with
2the Department to provide services where payment for medical
3services is made on a capitated basis, excluding contracted
4entities for dual eligible or Department of Children and
5Family Services youth populations.
6    (n) In order to address the escalating infant mortality
7rates among minority communities in Illinois, the State shall,
8subject to appropriation, create a pool of funding of at least
9$50,000,000 annually to be disbursed among safety-net
10hospitals that maintain perinatal designation from the
11Department of Public Health. The funding shall be used to
12preserve or enhance OB/GYN services or other specialty
13services at the receiving hospital, with the distribution of
14funding to be established by rule and with consideration to
15perinatal hospitals with safe birthing levels and quality
16metrics for healthy mothers and babies.
17    (o) In order to address the growing challenges of
18providing stable access to healthcare in rural Illinois,
19including perinatal services, behavioral healthcare including
20substance use disorder services (SUDs) and other specialty
21services, and to expand access to telehealth services among
22rural communities in Illinois, the Department of Healthcare
23and Family Services, subject to appropriation, shall
24administer a program to provide at least $10,000,000 in
25financial support annually to critical access hospitals for
26delivery of perinatal and OB/GYN services, behavioral

 

 

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1healthcare including SUDS, other specialty services and
2telehealth services. The funding shall be used to preserve or
3enhance perinatal and OB/GYN services, behavioral healthcare
4including SUDS, other specialty services, as well as the
5explanation of telehealth services by the receiving hospital,
6with the distribution of funding to be established by rule.
7    (p) For calendar year 2023, the final amounts, rates, and
8payments under subsections (c), (d-2), (g), (h), and (j) shall
9be established by the Department, so that the sum of the total
10estimated annual payments under subsections (c), (d-2), (g),
11(h), and (j) for each hospital class for calendar year 2023, is
12no less than:
13        (1) $858,260,000 to safety-net hospitals.
14        (2) $86,200,000 to critical access hospitals.
15        (3) $1,765,000,000 to high Medicaid hospitals.
16        (4) $673,860,000 to general acute care hospitals.
17        (5) $48,330,000 to long term acute care hospitals.
18        (6) $89,110,000 to freestanding psychiatric hospitals.
19        (7) $24,300,000 to freestanding rehabilitation
20    hospitals.
21        (8) $32,570,000 to public hospitals.
22    (q) Hospital Pandemic Recovery Stabilization Payments. The
23Department shall disburse a pool of $460,000,000 in stability
24payments to hospitals prior to April 1, 2023. The allocation
25of the pool shall be based on the hospital directed payment
26classes and directed payments issued, during Calendar Year

 

 

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12022 with added consideration to safety net hospitals, as
2defined in subdivision (f)(1)(B) of this Section, and critical
3access hospitals.
4(Source: P.A. 101-650, eff. 7-7-20; 102-4, eff. 4-27-21;
5102-16, eff. 6-17-21; 102-886, eff. 5-17-22; 102-1115, eff.
61-9-23.)
 
7    (305 ILCS 5/12-4.105)
8    Sec. 12-4.105. Human poison control center; payment
9program. Subject to funding availability resulting from
10transfers made from the Hospital Provider Fund to the
11Healthcare Provider Relief Fund as authorized under this Code,
12for State fiscal year 2017 and State fiscal year 2018, and for
13each State fiscal year thereafter in which the assessment
14under Section 5A-2 is imposed, the Department of Healthcare
15and Family Services shall pay to the human poison control
16center designated under the Poison Control System Act an
17amount of not less than $3,000,000 for each of State fiscal
18years 2017 through 2020, and for State fiscal years 2021
19through 2023 2026 an amount of not less than $3,750,000 and for
20State fiscal years 2024 through 2026 an amount of not less than
21$4,000,000 and for the period July 1, 2026 through December
2231, 2026 an amount of not less than $2,000,000 $1,875,000, if
23the human poison control center is in operation.
24(Source: P.A. 101-650, eff. 7-7-20; 102-886, eff. 5-17-22.)
 

 

 

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1    (305 ILCS 5/14-12)
2    Sec. 14-12. Hospital rate reform payment system. The
3hospital payment system pursuant to Section 14-11 of this
4Article shall be as follows:
5    (a) Inpatient hospital services. Effective for discharges
6on and after July 1, 2014, reimbursement for inpatient general
7acute care services shall utilize the All Patient Refined
8Diagnosis Related Grouping (APR-DRG) software, version 30,
9distributed by 3MTM Health Information System.
10        (1) The Department shall establish Medicaid weighting
11    factors to be used in the reimbursement system established
12    under this subsection. Initial weighting factors shall be
13    the weighting factors as published by 3M Health
14    Information System, associated with Version 30.0 adjusted
15    for the Illinois experience.
16        (2) The Department shall establish a
17    statewide-standardized amount to be used in the inpatient
18    reimbursement system. The Department shall publish these
19    amounts on its website no later than 10 calendar days
20    prior to their effective date.
21        (3) In addition to the statewide-standardized amount,
22    the Department shall develop adjusters to adjust the rate
23    of reimbursement for critical Medicaid providers or
24    services for trauma, transplantation services, perinatal
25    care, and Graduate Medical Education (GME).
26        (4) The Department shall develop add-on payments to

 

 

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1    account for exceptionally costly inpatient stays,
2    consistent with Medicare outlier principles. Outlier fixed
3    loss thresholds may be updated to control for excessive
4    growth in outlier payments no more frequently than on an
5    annual basis, but at least once every 4 years. Upon
6    updating the fixed loss thresholds, the Department shall
7    be required to update base rates within 12 months.
8        (5) The Department shall define those hospitals or
9    distinct parts of hospitals that shall be exempt from the
10    APR-DRG reimbursement system established under this
11    Section. The Department shall publish these hospitals'
12    inpatient rates on its website no later than 10 calendar
13    days prior to their effective date.
14        (6) Beginning July 1, 2014 and ending on December 31,
15    2023 June 30, 2024, in addition to the
16    statewide-standardized amount, the Department shall
17    develop an adjustor to adjust the rate of reimbursement
18    for safety-net hospitals defined in Section 5-5e.1 of this
19    Code excluding pediatric hospitals.
20        (7) Beginning July 1, 2014, in addition to the
21    statewide-standardized amount, the Department shall
22    develop an adjustor to adjust the rate of reimbursement
23    for Illinois freestanding inpatient psychiatric hospitals
24    that are not designated as children's hospitals by the
25    Department but are primarily treating patients under the
26    age of 21.

 

 

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1        (7.5) (Blank).
2        (8) Beginning July 1, 2018, in addition to the
3    statewide-standardized amount, the Department shall adjust
4    the rate of reimbursement for hospitals designated by the
5    Department of Public Health as a Perinatal Level II or II+
6    center by applying the same adjustor that is applied to
7    Perinatal and Obstetrical care cases for Perinatal Level
8    III centers, as of December 31, 2017.
9        (9) Beginning July 1, 2018, in addition to the
10    statewide-standardized amount, the Department shall apply
11    the same adjustor that is applied to trauma cases as of
12    December 31, 2017 to inpatient claims to treat patients
13    with burns, including, but not limited to, APR-DRGs 841,
14    842, 843, and 844.
15        (10) Beginning July 1, 2018, the
16    statewide-standardized amount for inpatient general acute
17    care services shall be uniformly increased so that base
18    claims projected reimbursement is increased by an amount
19    equal to the funds allocated in paragraph (1) of
20    subsection (b) of Section 5A-12.6, less the amount
21    allocated under paragraphs (8) and (9) of this subsection
22    and paragraphs (3) and (4) of subsection (b) multiplied by
23    40%.
24        (11) Beginning July 1, 2018, the reimbursement for
25    inpatient rehabilitation services shall be increased by
26    the addition of a $96 per day add-on.

 

 

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1    (b) Outpatient hospital services. Effective for dates of
2service on and after July 1, 2014, reimbursement for
3outpatient services shall utilize the Enhanced Ambulatory
4Procedure Grouping (EAPG) software, version 3.7 distributed by
53MTM Health Information System.
6        (1) The Department shall establish Medicaid weighting
7    factors to be used in the reimbursement system established
8    under this subsection. The initial weighting factors shall
9    be the weighting factors as published by 3M Health
10    Information System, associated with Version 3.7.
11        (2) The Department shall establish service specific
12    statewide-standardized amounts to be used in the
13    reimbursement system.
14            (A) The initial statewide standardized amounts,
15        with the labor portion adjusted by the Calendar Year
16        2013 Medicare Outpatient Prospective Payment System
17        wage index with reclassifications, shall be published
18        by the Department on its website no later than 10
19        calendar days prior to their effective date.
20            (B) The Department shall establish adjustments to
21        the statewide-standardized amounts for each Critical
22        Access Hospital, as designated by the Department of
23        Public Health in accordance with 42 CFR 485, Subpart
24        F. For outpatient services provided on or before June
25        30, 2018, the EAPG standardized amounts are determined
26        separately for each critical access hospital such that

 

 

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1        simulated EAPG payments using outpatient base period
2        paid claim data plus payments under Section 5A-12.4 of
3        this Code net of the associated tax costs are equal to
4        the estimated costs of outpatient base period claims
5        data with a rate year cost inflation factor applied.
6        (3) In addition to the statewide-standardized amounts,
7    the Department shall develop adjusters to adjust the rate
8    of reimbursement for critical Medicaid hospital outpatient
9    providers or services, including outpatient high volume or
10    safety-net hospitals. Beginning July 1, 2018, the
11    outpatient high volume adjustor shall be increased to
12    increase annual expenditures associated with this adjustor
13    by $79,200,000, based on the State Fiscal Year 2015 base
14    year data and this adjustor shall apply to public
15    hospitals, except for large public hospitals, as defined
16    under 89 Ill. Adm. Code 148.25(a).
17        (4) Beginning July 1, 2018, in addition to the
18    statewide standardized amounts, the Department shall make
19    an add-on payment for outpatient expensive devices and
20    drugs. This add-on payment shall at least apply to claim
21    lines that: (i) are assigned with one of the following
22    EAPGs: 490, 1001 to 1020, and coded with one of the
23    following revenue codes: 0274 to 0276, 0278; or (ii) are
24    assigned with one of the following EAPGs: 430 to 441, 443,
25    444, 460 to 465, 495, 496, 1090. The add-on payment shall
26    be calculated as follows: the claim line's covered charges

 

 

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1    multiplied by the hospital's total acute cost to charge
2    ratio, less the claim line's EAPG payment plus $1,000,
3    multiplied by 0.8.
4        (5) Beginning July 1, 2018, the statewide-standardized
5    amounts for outpatient services shall be increased by a
6    uniform percentage so that base claims projected
7    reimbursement is increased by an amount equal to no less
8    than the funds allocated in paragraph (1) of subsection
9    (b) of Section 5A-12.6, less the amount allocated under
10    paragraphs (8) and (9) of subsection (a) and paragraphs
11    (3) and (4) of this subsection multiplied by 46%.
12        (6) Effective for dates of service on or after July 1,
13    2018, the Department shall establish adjustments to the
14    statewide-standardized amounts for each Critical Access
15    Hospital, as designated by the Department of Public Health
16    in accordance with 42 CFR 485, Subpart F, such that each
17    Critical Access Hospital's standardized amount for
18    outpatient services shall be increased by the applicable
19    uniform percentage determined pursuant to paragraph (5) of
20    this subsection. It is the intent of the General Assembly
21    that the adjustments required under this paragraph (6) by
22    Public Act 100-1181 shall be applied retroactively to
23    claims for dates of service provided on or after July 1,
24    2018.
25        (7) Effective for dates of service on or after March
26    8, 2019 (the effective date of Public Act 100-1181), the

 

 

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

 

 

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1        recalculation under this paragraph (7), issued to the
2        hospital for dates of service on or after July 1, 2018
3        and before March 8, 2019 (the effective date of Public
4        Act 100-1181), shall be permitted.
5        (8) The Department shall ensure that all necessary
6    adjustments to the managed care organization capitation
7    base rates necessitated by the adjustments under
8    subparagraph (6) or (7) of this subsection are completed
9    and applied retroactively in accordance with Section
10    5-30.8 of this Code within 90 days of March 8, 2019 (the
11    effective date of Public Act 100-1181).
12        (9) Within 60 days after federal approval of the
13    change made to the assessment in Section 5A-2 by Public
14    Act 101-650 this amendatory Act of the 101st General
15    Assembly, the Department shall incorporate into the EAPG
16    system for outpatient services those services performed by
17    hospitals currently billed through the Non-Institutional
18    Provider billing system.
19    (b-5) Notwithstanding any other provision of this Section,
20beginning with dates of service on and after January 1, 2023,
21any general acute care hospital with more than 500 outpatient
22psychiatric Medicaid services to persons under 19 years of age
23in any calendar year shall be paid the outpatient add-on
24payment of no less than $113.
25    (c) In consultation with the hospital community, the
26Department is authorized to replace 89 Ill. Adm. Admin. Code

 

 

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1152.150 as published in 38 Ill. Reg. 4980 through 4986 within
212 months of June 16, 2014 (the effective date of Public Act
398-651). If the Department does not replace these rules within
412 months of June 16, 2014 (the effective date of Public Act
598-651), the rules in effect for 152.150 as published in 38
6Ill. Reg. 4980 through 4986 shall remain in effect until
7modified by rule by the Department. Nothing in this subsection
8shall be construed to mandate that the Department file a
9replacement rule.
10    (d) Transition period. There shall be a transition period
11to the reimbursement systems authorized under this Section
12that shall begin on the effective date of these systems and
13continue until June 30, 2018, unless extended by rule by the
14Department. To help provide an orderly and predictable
15transition to the new reimbursement systems and to preserve
16and enhance access to the hospital services during this
17transition, the Department shall allocate a transitional
18hospital access pool of at least $290,000,000 annually so that
19transitional hospital access payments are made to hospitals.
20        (1) After the transition period, the Department may
21    begin incorporating the transitional hospital access pool
22    into the base rate structure; however, the transitional
23    hospital access payments in effect on June 30, 2018 shall
24    continue to be paid, if continued under Section 5A-16.
25        (2) After the transition period, if the Department
26    reduces payments from the transitional hospital access

 

 

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1    pool, it shall increase base rates, develop new adjustors,
2    adjust current adjustors, develop new hospital access
3    payments based on updated information, or any combination
4    thereof by an amount equal to the decreases proposed in
5    the transitional hospital access pool payments, ensuring
6    that the entire transitional hospital access pool amount
7    shall continue to be used for hospital payments.
8    (d-5) Hospital and health care transformation program. The
9Department shall develop a hospital and health care
10transformation program to provide financial assistance to
11hospitals in transforming their services and care models to
12better align with the needs of the communities they serve. The
13payments authorized in this Section shall be subject to
14approval by the federal government.
15        (1) Phase 1. In State fiscal years 2019 through 2020,
16    the Department shall allocate funds from the transitional
17    access hospital pool to create a hospital transformation
18    pool of at least $262,906,870 annually and make hospital
19    transformation payments to hospitals. Subject to Section
20    5A-16, in State fiscal years 2019 and 2020, an Illinois
21    hospital that received either a transitional hospital
22    access payment under subsection (d) or a supplemental
23    payment under subsection (f) of this Section in State
24    fiscal year 2018, shall receive a hospital transformation
25    payment as follows:
26            (A) If the hospital's Rate Year 2017 Medicaid

 

 

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1        inpatient utilization rate is equal to or greater than
2        45%, the hospital transformation payment shall be
3        equal to 100% of the sum of its transitional hospital
4        access payment authorized under subsection (d) and any
5        supplemental payment authorized under subsection (f).
6            (B) If the hospital's Rate Year 2017 Medicaid
7        inpatient utilization rate is equal to or greater than
8        25% but less than 45%, the hospital transformation
9        payment shall be equal to 75% of the sum of its
10        transitional hospital access payment authorized under
11        subsection (d) and any supplemental payment authorized
12        under subsection (f).
13            (C) If the hospital's Rate Year 2017 Medicaid
14        inpatient utilization rate is less than 25%, the
15        hospital transformation payment shall be equal to 50%
16        of the sum of its transitional hospital access payment
17        authorized under subsection (d) and any supplemental
18        payment authorized under subsection (f).
19        (2) Phase 2.
20            (A) The funding amount from phase one shall be
21        incorporated into directed payment and pass-through
22        payment methodologies described in Section 5A-12.7.
23            (B) Because there are communities in Illinois that
24        experience significant health care disparities due to
25        systemic racism, as recently emphasized by the
26        COVID-19 pandemic, aggravated by social determinants

 

 

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1        of health and a lack of sufficiently allocated
2        healthcare resources, particularly community-based
3        services, preventive care, obstetric care, chronic
4        disease management, and specialty care, the Department
5        shall establish a health care transformation program
6        that shall be supported by the transformation funding
7        pool. It is the intention of the General Assembly that
8        innovative partnerships funded by the pool must be
9        designed to establish or improve integrated health
10        care delivery systems that will provide significant
11        access to the Medicaid and uninsured populations in
12        their communities, as well as improve health care
13        equity. It is also the intention of the General
14        Assembly that partnerships recognize and address the
15        disparities revealed by the COVID-19 pandemic, as well
16        as the need for post-COVID care. During State fiscal
17        years 2021 through 2027, the hospital and health care
18        transformation program shall be supported by an annual
19        transformation funding pool of up to $150,000,000,
20        pending federal matching funds, to be allocated during
21        the specified fiscal years for the purpose of
22        facilitating hospital and health care transformation.
23        No disbursement of moneys for transformation projects
24        from the transformation funding pool described under
25        this Section shall be considered an award, a grant, or
26        an expenditure of grant funds. Funding agreements made

 

 

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1        in accordance with the transformation program shall be
2        considered purchases of care under the Illinois
3        Procurement Code, and funds shall be expended by the
4        Department in a manner that maximizes federal funding
5        to expend the entire allocated amount.
6            The Department shall convene, within 30 days after
7        March 12, 2021 (the effective date of Public Act
8        101-655) this amendatory Act of the 101st General
9        Assembly, a workgroup that includes subject matter
10        experts on healthcare disparities and stakeholders
11        from distressed communities, which could be a
12        subcommittee of the Medicaid Advisory Committee, to
13        review and provide recommendations on how Department
14        policy, including health care transformation, can
15        improve health disparities and the impact on
16        communities disproportionately affected by COVID-19.
17        The workgroup shall consider and make recommendations
18        on the following issues: a community safety-net
19        designation of certain hospitals, racial equity, and a
20        regional partnership to bring additional specialty
21        services to communities.
22            (C) As provided in paragraph (9) of Section 3 of
23        the Illinois Health Facilities Planning Act, any
24        hospital participating in the transformation program
25        may be excluded from the requirements of the Illinois
26        Health Facilities Planning Act for those projects

 

 

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1        related to the hospital's transformation. To be
2        eligible, the hospital must submit to the Health
3        Facilities and Services Review Board approval from the
4        Department that the project is a part of the
5        hospital's transformation.
6            (D) As provided in subsection (a-20) of Section
7        32.5 of the Emergency Medical Services (EMS) Systems
8        Act, a hospital that received hospital transformation
9        payments under this Section may convert to a
10        freestanding emergency center. To be eligible for such
11        a conversion, the hospital must submit to the
12        Department of Public Health approval from the
13        Department that the project is a part of the
14        hospital's transformation.
15            (E) Criteria for proposals. To be eligible for
16        funding under this Section, a transformation proposal
17        shall meet all of the following criteria:
18                (i) the proposal shall be designed based on
19            community needs assessment completed by either a
20            University partner or other qualified entity with
21            significant community input;
22                (ii) the proposal shall be a collaboration
23            among providers across the care and community
24            spectrum, including preventative care, primary
25            care specialty care, hospital services, mental
26            health and substance abuse services, as well as

 

 

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1            community-based entities that address the social
2            determinants of health;
3                (iii) the proposal shall be specifically
4            designed to improve healthcare outcomes and reduce
5            healthcare disparities, and improve the
6            coordination, effectiveness, and efficiency of
7            care delivery;
8                (iv) the proposal shall have specific
9            measurable metrics related to disparities that
10            will be tracked by the Department and made public
11            by the Department;
12                (v) the proposal shall include a commitment to
13            include Business Enterprise Program certified
14            vendors or other entities controlled and managed
15            by minorities or women; and
16                (vi) the proposal shall specifically increase
17            access to primary, preventive, or specialty care.
18            (F) Entities eligible to be funded.
19                (i) Proposals for funding should come from
20            collaborations operating in one of the most
21            distressed communities in Illinois as determined
22            by the U.S. Centers for Disease Control and
23            Prevention's Social Vulnerability Index for
24            Illinois and areas disproportionately impacted by
25            COVID-19 or from rural areas of Illinois.
26                (ii) The Department shall prioritize

 

 

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

 

 

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1            to projects that are a collaboration between
2            hospitals and other providers in distressed areas
3            of the State designed to address specific
4            healthcare disparities, $15,000,000 to
5            collaborations between critical access hospitals
6            and other providers designed to address specific
7            healthcare disparities, and $15,000,000 to
8            cross-provider collaborations designed to address
9            specific healthcare disparities, and $5,000,000 to
10            collaborations that focus on workforce
11            development.
12                (iv) The Department may allocate up to
13            $5,000,000 for planning, racial equity analysis,
14            or consulting resources for the Department or
15            entities without the resources to develop a plan
16            to meet the criteria of this Section. Any contract
17            for consulting services issued by the Department
18            under this subparagraph shall comply with the
19            provisions of Section 5-45 of the State Officials
20            and Employees Ethics Act. Based on availability of
21            federal funding, the Department may directly
22            procure consulting services or provide funding to
23            the collaboration. The provision of resources
24            under this subparagraph is not a guarantee that a
25            project will be approved.
26                (v) The Department shall take steps to ensure

 

 

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1            that safety-net hospitals operating in
2            under-resourced communities receive priority
3            access to hospital and healthcare transformation
4            funds, including consulting funds, as provided
5            under this Section.
6            (G) Process for submitting and approving projects
7        for distressed communities. The Department shall issue
8        a template for application. The Department shall post
9        any proposal received on the Department's website for
10        at least 2 weeks for public comment, and any such
11        public comment shall also be considered in the review
12        process. Applicants may request that proprietary
13        financial information be redacted from publicly posted
14        proposals and the Department in its discretion may
15        agree. Proposals for each distressed community must
16        include all of the following:
17                (i) A detailed description of how the project
18            intends to affect the goals outlined in this
19            subsection, describing new interventions, new
20            technology, new structures, and other changes to
21            the healthcare delivery system planned.
22                (ii) A detailed description of the racial and
23            ethnic makeup of the entities' board and
24            leadership positions and the salaries of the
25            executive staff of entities in the partnership
26            that is seeking to obtain funding under this

 

 

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1            Section.
2                (iii) A complete budget, including an overall
3            timeline and a detailed pathway to sustainability
4            within a 5-year period, specifying other sources
5            of funding, such as in-kind, cost-sharing, or
6            private donations, particularly for capital needs.
7            There is an expectation that parties to the
8            transformation project dedicate resources to the
9            extent they are able and that these expectations
10            are delineated separately for each entity in the
11            proposal.
12                (iv) A description of any new entities formed
13            or other legal relationships between collaborating
14            entities and how funds will be allocated among
15            participants.
16                (v) A timeline showing the evolution of sites
17            and specific services of the project over a 5-year
18            period, including services available to the
19            community by site.
20                (vi) Clear milestones indicating progress
21            toward the proposed goals of the proposal as
22            checkpoints along the way to continue receiving
23            funding. The Department is authorized to refine
24            these milestones in agreements, and is authorized
25            to impose reasonable penalties, including
26            repayment of funds, for substantial lack of

 

 

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1            progress.
2                (vii) A clear statement of the level of
3            commitment the project will include for minorities
4            and women in contracting opportunities, including
5            as equity partners where applicable, or as
6            subcontractors and suppliers in all phases of the
7            project.
8                (viii) If the community study utilized is not
9            the study commissioned and published by the
10            Department, the applicant must define the
11            methodology used, including documentation of clear
12            community participation.
13                (ix) A description of the process used in
14            collaborating with all levels of government in the
15            community served in the development of the
16            project, including, but not limited to,
17            legislators and officials of other units of local
18            government.
19                (x) Documentation of a community input process
20            in the community served, including links to
21            proposal materials on public websites.
22                (xi) Verifiable project milestones and quality
23            metrics that will be impacted by transformation.
24            These project milestones and quality metrics must
25            be identified with improvement targets that must
26            be met.

 

 

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1                (xii) Data on the number of existing employees
2            by various job categories and wage levels by the
3            zip code of the employees' residence and
4            benchmarks for the continued maintenance and
5            improvement of these levels. The proposal must
6            also describe any retraining or other workforce
7            development planned for the new project.
8                (xiii) If a new entity is created by the
9            project, a description of how the board will be
10            reflective of the community served by the
11            proposal.
12                (xiv) An explanation of how the proposal will
13            address the existing disparities that exacerbated
14            the impact of COVID-19 and the need for post-COVID
15            care in the community, if applicable.
16                (xv) An explanation of how the proposal is
17            designed to increase access to care, including
18            specialty care based upon the community's needs.
19            (H) The Department shall evaluate proposals for
20        compliance with the criteria listed under subparagraph
21        (G). Proposals meeting all of the criteria may be
22        eligible for funding with the areas of focus
23        prioritized as described in item (ii) of subparagraph
24        (F). Based on the funds available, the Department may
25        negotiate funding agreements with approved applicants
26        to maximize federal funding. Nothing in this

 

 

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1        subsection requires that an approved project be funded
2        to the level requested. Agreements shall specify the
3        amount of funding anticipated annually, the
4        methodology of payments, the limit on the number of
5        years such funding may be provided, and the milestones
6        and quality metrics that must be met by the projects in
7        order to continue to receive funding during each year
8        of the program. Agreements shall specify the terms and
9        conditions under which a health care facility that
10        receives funds under a purchase of care agreement and
11        closes in violation of the terms of the agreement must
12        pay an early closure fee no greater than 50% of the
13        funds it received under the agreement, prior to the
14        Health Facilities and Services Review Board
15        considering an application for closure of the
16        facility. Any project that is funded shall be required
17        to provide quarterly written progress reports, in a
18        form prescribed by the Department, and at a minimum
19        shall include the progress made in achieving any
20        milestones or metrics or Business Enterprise Program
21        commitments in its plan. The Department may reduce or
22        end payments, as set forth in transformation plans, if
23        milestones or metrics or Business Enterprise Program
24        commitments are not achieved. The Department shall
25        seek to make payments from the transformation fund in
26        a manner that is eligible for federal matching funds.

 

 

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1            In reviewing the proposals, the Department shall
2        take into account the needs of the community, data
3        from the study commissioned by the Department from the
4        University of Illinois-Chicago if applicable, feedback
5        from public comment on the Department's website, as
6        well as how the proposal meets the criteria listed
7        under subparagraph (G). Alignment with the
8        Department's overall strategic initiatives shall be an
9        important factor. To the extent that fiscal year
10        funding is not adequate to fund all eligible projects
11        that apply, the Department shall prioritize
12        applications that most comprehensively and effectively
13        address the criteria listed under subparagraph (G).
14        (3) (Blank).
15        (4) Hospital Transformation Review Committee. There is
16    created the Hospital Transformation Review Committee. The
17    Committee shall consist of 14 members. No later than 30
18    days after March 12, 2018 (the effective date of Public
19    Act 100-581), the 4 legislative leaders shall each appoint
20    3 members; the Governor shall appoint the Director of
21    Healthcare and Family Services, or his or her designee, as
22    a member; and the Director of Healthcare and Family
23    Services shall appoint one member. Any vacancy shall be
24    filled by the applicable appointing authority within 15
25    calendar days. The members of the Committee shall select a
26    Chair and a Vice-Chair from among its members, provided

 

 

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1    that the Chair and Vice-Chair cannot be appointed by the
2    same appointing authority and must be from different
3    political parties. The Chair shall have the authority to
4    establish a meeting schedule and convene meetings of the
5    Committee, and the Vice-Chair shall have the authority to
6    convene meetings in the absence of the Chair. The
7    Committee may establish its own rules with respect to
8    meeting schedule, notice of meetings, and the disclosure
9    of documents; however, the Committee shall not have the
10    power to subpoena individuals or documents and any rules
11    must be approved by 9 of the 14 members. The Committee
12    shall perform the functions described in this Section and
13    advise and consult with the Director in the administration
14    of this Section. In addition to reviewing and approving
15    the policies, procedures, and rules for the hospital and
16    health care transformation program, the Committee shall
17    consider and make recommendations related to qualifying
18    criteria and payment methodologies related to safety-net
19    hospitals and children's hospitals. Members of the
20    Committee appointed by the legislative leaders shall be
21    subject to the jurisdiction of the Legislative Ethics
22    Commission, not the Executive Ethics Commission, and all
23    requests under the Freedom of Information Act shall be
24    directed to the applicable Freedom of Information officer
25    for the General Assembly. The Department shall provide
26    operational support to the Committee as necessary. The

 

 

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1    Committee is dissolved on April 1, 2019.
2    (e) Beginning 36 months after initial implementation, the
3Department shall update the reimbursement components in
4subsections (a) and (b), including standardized amounts and
5weighting factors, and at least once every 4 years and no more
6frequently than annually thereafter. The Department shall
7publish these updates on its website no later than 30 calendar
8days prior to their effective date.
9    (f) Continuation of supplemental payments. Any
10supplemental payments authorized under Illinois Administrative
11Code 148 effective January 1, 2014 and that continue during
12the period of July 1, 2014 through December 31, 2014 shall
13remain in effect as long as the assessment imposed by Section
145A-2 that is in effect on December 31, 2017 remains in effect.
15    (g) Notwithstanding subsections (a) through (f) of this
16Section and notwithstanding the changes authorized under
17Section 5-5b.1, any updates to the system shall not result in
18any diminishment of the overall effective rates of
19reimbursement as of the implementation date of the new system
20(July 1, 2014). These updates shall not preclude variations in
21any individual component of the system or hospital rate
22variations. Nothing in this Section shall prohibit the
23Department from increasing the rates of reimbursement or
24developing payments to ensure access to hospital services.
25Nothing in this Section shall be construed to guarantee a
26minimum amount of spending in the aggregate or per hospital as

 

 

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1spending may be impacted by factors, including, but not
2limited to, the number of individuals in the medical
3assistance program and the severity of illness of the
4individuals.
5    (h) The Department shall have the authority to modify by
6rulemaking any changes to the rates or methodologies in this
7Section as required by the federal government to obtain
8federal financial participation for expenditures made under
9this Section.
10    (i) Except for subsections (g) and (h) of this Section,
11the Department shall, pursuant to subsection (c) of Section
125-40 of the Illinois Administrative Procedure Act, provide for
13presentation at the June 2014 hearing of the Joint Committee
14on Administrative Rules (JCAR) additional written notice to
15JCAR of the following rules in order to commence the second
16notice period for the following rules: rules published in the
17Illinois Register, rule dated February 21, 2014 at 38 Ill.
18Reg. 4559 (Medical Payment), 4628 (Specialized Health Care
19Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic
20Related Grouping (DRG) Prospective Payment System (PPS)), and
214977 (Hospital Reimbursement Changes), and published in the
22Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
23(Specialized Health Care Delivery Systems) and 6505 (Hospital
24Services).
25    (j) Out-of-state hospitals. Beginning July 1, 2018, for
26purposes of determining for State fiscal years 2019 and 2020

 

 

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1and subsequent fiscal years the hospitals eligible for the
2payments authorized under subsections (a) and (b) of this
3Section, the Department shall include out-of-state hospitals
4that are designated a Level I pediatric trauma center or a
5Level I trauma center by the Department of Public Health as of
6December 1, 2017.
7    (k) The Department shall notify each hospital and managed
8care organization, in writing, of the impact of the updates
9under this Section at least 30 calendar days prior to their
10effective date.
11    (l) This Section is subject to Section 14-12.5.
12(Source: P.A. 101-81, eff. 7-12-19; 101-650, eff. 7-7-20;
13101-655, eff. 3-12-21; 102-682, eff. 12-10-21; 102-1037, eff.
146-2-22; revised 8-22-22.)
 
15    (305 ILCS 5/14-12.5 new)
16    Sec. 14-12.5. Hospital rate updates.
17    (a) Notwithstanding any other provision of this Code, the
18hospital rates of reimbursement authorized under Sections
195-5.05, 14-12, and 14-13 of this Code shall be adjusted in
20accordance with the provisions of this Section.
21    (b) Notwithstanding any other provision of this Code,
22effective for dates of service on and after January 1, 2024,
23subject to federal approval, hospital reimbursement rates
24shall be revised as follows:
25        (1) For inpatient general acute care services, the

 

 

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

 

 

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

 

 

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1        (7) The per diem rate in effect January 1, 2023, as
2    authorized in subsection (a) of Section 14-13 of this
3    Article shall be increased by 10%.
4        (8) Beginning on and after January 1, 2024, subject to
5    federal approval, in addition to the statewide
6    standardized amount, an add-on payment of $210 shall be
7    paid for each inpatient General Acute and Psychiatric day
8    of care, excluding Medicare-Medicaid dual eligible
9    crossover days, for all safety-net hospitals defined in
10    Section 5-5e.1 of this Code.
11            (A) For Psychiatric days of care, the Department
12        may implement payment of this add-on by increasing the
13        hospital specific psychiatric per diem rate, adjusted
14        in accordance with subparagraph (A) of paragraph (2)
15        of subsection (b) by $210, or by a separate add-on
16        payment.
17            (B) If the add-on adjustment is added to the
18        hospital specific psychiatric per diem rate to
19        operationalize payment, the Department shall provide a
20        rate sheet to each safety-net hospital, which
21        identifies the hospital psychiatric per diem rate
22        before and after the adjustment.
23            (C) The add-on adjustment shall not be considered
24        when setting the 90% minimum rate identified in
25        paragraph (2) of subsection (b).
26    (c) The Department shall take all actions necessary to

 

 

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1ensure the changes authorized in this amendatory Act of the
2103rd General Assembly are in effect for dates of service on
3and after January 1, 2024, including publishing all
4appropriate public notices, applying for federal approval of
5amendments to the Illinois Title XIX State Plan, and adopting
6administrative rules if necessary.
7    (d) The Department of Healthcare and Family Services may
8adopt rules necessary to implement the changes made by this
9amendatory Act of the 103rd General Assembly through the use
10of emergency rulemaking in accordance with Section 5-45 of the
11Illinois Administrative Procedure Act. The 24-month limitation
12on the adoption of emergency rules does not apply to rules
13adopted under this Section. The General Assembly finds that
14the adoption of rules to implement the changes made by this
15amendatory Act of the 103rd General Assembly is deemed an
16emergency and necessary for the public interest, safety, and
17welfare.
18    (e) The Department shall ensure that all necessary
19adjustments to the managed care organization capitation base
20rates necessitated by the adjustments in this Section are
21completed, published, and applied in accordance with Section
225-30.8 of this Code 90 days prior to the implementation date of
23the changes required under this amendatory Act of the 103rd
24General Assembly.
25    (f) The Department shall publish updated rate sheets for
26all hospitals 30 days prior to the effective date of the rate

 

 

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1increase, or within 30 days after federal approval by the
2Centers for Medicare and Medicaid Services, whichever is
3later.
 
4    (305 ILCS 5/14-12.7 new)
5    Sec. 14-12.7. Public critical access hospital
6stabilization program.
7    (a) In order to address the growing challenges of
8providing stable access to healthcare in rural Illinois, by
9October 1, 2023, the Department shall adopt rules to implement
10for dates of service on and after January 1, 2024, subject to
11federal approval, a program to provide at least $3,500,000 in
12annual financial support to public, critical access hospitals
13in Illinois, for the delivery of perinatal and obstetrical or
14gynecological services, behavioral healthcare services,
15including substance use disorder services, telehealth
16services, and other specialty services.
17    (b) The funding allocation methodology shall provide added
18consideration to the services provided by qualifying hospitals
19designated by the Department of Public Health as a perinatal
20center.
21    (c) Public critical access hospitals qualifying under this
22Section shall not be eligible for payment under subsection (o)
23of Section 5A-12.7 of this Code.
24    (d) As used in this Section, "public critical access
25hospital" means a hospital designated by the Department of

 

 

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1Public Health as a critical access hospital and that is owned
2or operated by an Illinois Government body or municipality.
 
3
ARTICLE 15.

 
4    Section 15-5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
 
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing
16home, or elsewhere; (6) medical care, or any other type of
17remedial care furnished by licensed practitioners; (7) home
18health care services; (8) private duty nursing service; (9)
19clinic services; (10) dental services, including prevention
20and treatment of periodontal disease and dental caries disease
21for pregnant individuals, provided by an individual licensed
22to practice dentistry or dental surgery; for purposes of this
23item (10), "dental services" means diagnostic, preventive, or

 

 

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1corrective procedures provided by or under the supervision of
2a dentist in the practice of his or her profession; (11)
3physical therapy and related services; (12) prescribed drugs,
4dentures, and prosthetic devices; and eyeglasses prescribed by
5a physician skilled in the diseases of the eye, or by an
6optometrist, whichever the person may select; (13) other
7diagnostic, screening, preventive, and rehabilitative
8services, including to ensure that the individual's need for
9intervention or treatment of mental disorders or substance use
10disorders or co-occurring mental health and substance use
11disorders is determined using a uniform screening, assessment,
12and evaluation process inclusive of criteria, for children and
13adults; for purposes of this item (13), a uniform screening,
14assessment, and evaluation process refers to a process that
15includes an appropriate evaluation and, as warranted, a
16referral; "uniform" does not mean the use of a singular
17instrument, tool, or process that all must utilize; (14)
18transportation and such other expenses as may be necessary;
19(15) medical treatment of sexual assault survivors, as defined
20in Section 1a of the Sexual Assault Survivors Emergency
21Treatment Act, for injuries sustained as a result of the
22sexual assault, including examinations and laboratory tests to
23discover evidence which may be used in criminal proceedings
24arising from the sexual assault; (16) the diagnosis and
25treatment of sickle cell anemia; (16.5) services performed by
26a chiropractic physician licensed under the Medical Practice

 

 

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1Act of 1987 and acting within the scope of his or her license,
2including, but not limited to, chiropractic manipulative
3treatment; and (17) any other medical care, and any other type
4of remedial care recognized under the laws of this State. The
5term "any other type of remedial care" shall include nursing
6care and nursing home service for persons who rely on
7treatment by spiritual means alone through prayer for healing.
8    Notwithstanding any other provision of this Section, a
9comprehensive tobacco use cessation program that includes
10purchasing prescription drugs or prescription medical devices
11approved by the Food and Drug Administration shall be covered
12under the medical assistance program under this Article for
13persons who are otherwise eligible for assistance under this
14Article.
15    Notwithstanding any other provision of this Code,
16reproductive health care that is otherwise legal in Illinois
17shall be covered under the medical assistance program for
18persons who are otherwise eligible for medical assistance
19under this Article.
20    Notwithstanding any other provision of this Section, all
21tobacco cessation medications approved by the United States
22Food and Drug Administration and all individual and group
23tobacco cessation counseling services and telephone-based
24counseling services and tobacco cessation medications provided
25through the Illinois Tobacco Quitline shall be covered under
26the medical assistance program for persons who are otherwise

 

 

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1eligible for assistance under this Article. The Department
2shall comply with all federal requirements necessary to obtain
3federal financial participation, as specified in 42 CFR
4433.15(b)(7), for telephone-based counseling services provided
5through the Illinois Tobacco Quitline, including, but not
6limited to: (i) entering into a memorandum of understanding or
7interagency agreement with the Department of Public Health, as
8administrator of the Illinois Tobacco Quitline; and (ii)
9developing a cost allocation plan for Medicaid-allowable
10Illinois Tobacco Quitline services in accordance with 45 CFR
1195.507. The Department shall submit the memorandum of
12understanding or interagency agreement, the cost allocation
13plan, and all other necessary documentation to the Centers for
14Medicare and Medicaid Services for review and approval.
15Coverage under this paragraph shall be contingent upon federal
16approval.
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
23documentation.
24    Upon receipt of federal approval of an amendment to the
25Illinois Title XIX State Plan for this purpose, the Department
26shall authorize the Chicago Public Schools (CPS) to procure a

 

 

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1vendor or vendors to manufacture eyeglasses for individuals
2enrolled in a school within the CPS system. CPS shall ensure
3that its vendor or vendors are enrolled as providers in the
4medical assistance program and in any capitated Medicaid
5managed care entity (MCE) serving individuals enrolled in a
6school within the CPS system. Under any contract procured
7under this provision, the vendor or vendors must serve only
8individuals enrolled in a school within the CPS system. Claims
9for services provided by CPS's vendor or vendors to recipients
10of benefits in the medical assistance program under this Code,
11the Children's Health Insurance Program, or the Covering ALL
12KIDS Health Insurance Program shall be submitted to the
13Department or the MCE in which the individual is enrolled for
14payment and shall be reimbursed at the Department's or the
15MCE's established rates or rate methodologies for eyeglasses.
16    On and after July 1, 2012, the Department of Healthcare
17and Family Services may provide the following services to
18persons eligible for assistance under this Article who are
19participating in education, training or employment programs
20operated by the Department of Human Services as successor to
21the Department of Public Aid:
22        (1) dental services provided by or under the
23    supervision of a dentist; and
24        (2) eyeglasses prescribed by a physician skilled in
25    the diseases of the eye, or by an optometrist, whichever
26    the person may select.

 

 

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1    On and after July 1, 2018, the Department of Healthcare
2and Family Services shall provide dental services to any adult
3who is otherwise eligible for assistance under the medical
4assistance program. As used in this paragraph, "dental
5services" means diagnostic, preventative, restorative, or
6corrective procedures, including procedures and services for
7the prevention and treatment of periodontal disease and dental
8caries disease, provided by an individual who is licensed to
9practice dentistry or dental surgery or who is under the
10supervision of a dentist in the practice of his or her
11profession.
12    On and after July 1, 2018, targeted dental services, as
13set forth in Exhibit D of the Consent Decree entered by the
14United States District Court for the Northern District of
15Illinois, Eastern Division, in the matter of Memisovski v.
16Maram, Case No. 92 C 1982, that are provided to adults under
17the medical assistance program shall be established at no less
18than the rates set forth in the "New Rate" column in Exhibit D
19of the Consent Decree for targeted dental services that are
20provided to persons under the age of 18 under the medical
21assistance program.
22    Notwithstanding any other provision of this Code and
23subject to federal approval, the Department may adopt rules to
24allow a dentist who is volunteering his or her service at no
25cost to render dental services through an enrolled
26not-for-profit health clinic without the dentist personally

 

 

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1enrolling as a participating provider in the medical
2assistance program. A not-for-profit health clinic shall
3include a public health clinic or Federally Qualified Health
4Center or other enrolled provider, as determined by the
5Department, through which dental services covered under this
6Section are performed. The Department shall establish a
7process for payment of claims for reimbursement for covered
8dental services rendered under this provision.
9    On and after January 1, 2022, the Department of Healthcare
10and Family Services shall administer and regulate a
11school-based dental program that allows for the out-of-office
12delivery of preventative dental services in a school setting
13to children under 19 years of age. The Department shall
14establish, by rule, guidelines for participation by providers
15and set requirements for follow-up referral care based on the
16requirements established in the Dental Office Reference Manual
17published by the Department that establishes the requirements
18for dentists participating in the All Kids Dental School
19Program. Every effort shall be made by the Department when
20developing the program requirements to consider the different
21geographic differences of both urban and rural areas of the
22State for initial treatment and necessary follow-up care. No
23provider shall be charged a fee by any unit of local government
24to participate in the school-based dental program administered
25by the Department. Nothing in this paragraph shall be
26construed to limit or preempt a home rule unit's or school

 

 

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1district's authority to establish, change, or administer a
2school-based dental program in addition to, or independent of,
3the school-based dental program administered by the
4Department.
5    The Illinois Department, by rule, may distinguish and
6classify the medical services to be provided only in
7accordance with the classes of persons designated in Section
85-2.
9    The Department of Healthcare and Family Services must
10provide coverage and reimbursement for amino acid-based
11elemental formulas, regardless of delivery method, for the
12diagnosis and treatment of (i) eosinophilic disorders and (ii)
13short bowel syndrome when the prescribing physician has issued
14a written order stating that the amino acid-based elemental
15formula is medically necessary.
16    The Illinois Department shall authorize the provision of,
17and shall authorize payment for, screening by low-dose
18mammography for the presence of occult breast cancer for
19individuals 35 years of age or older who are eligible for
20medical assistance under this Article, as follows:
21        (A) A baseline mammogram for individuals 35 to 39
22    years of age.
23        (B) An annual mammogram for individuals 40 years of
24    age or older.
25        (C) A mammogram at the age and intervals considered
26    medically necessary by the individual's health care

 

 

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1    provider for individuals under 40 years of age and having
2    a family history of breast cancer, prior personal history
3    of breast cancer, positive genetic testing, or other risk
4    factors.
5        (D) A comprehensive ultrasound screening and MRI of an
6    entire breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue or when medically
8    necessary as determined by a physician licensed to
9    practice medicine in all of its branches.
10        (E) A screening MRI when medically necessary, as
11    determined by a physician licensed to practice medicine in
12    all of its branches.
13        (F) A diagnostic mammogram when medically necessary,
14    as determined by a physician licensed to practice medicine
15    in all its branches, advanced practice registered nurse,
16    or physician assistant.
17    The Department shall not impose a deductible, coinsurance,
18copayment, or any other cost-sharing requirement on the
19coverage provided under this paragraph; except that this
20sentence does not apply to coverage of diagnostic mammograms
21to the extent such coverage would disqualify a high-deductible
22health plan from eligibility for a health savings account
23pursuant to Section 223 of the Internal Revenue Code (26
24U.S.C. 223).
25    All screenings shall include a physical breast exam,
26instruction on self-examination and information regarding the

 

 

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1frequency of self-examination and its value as a preventative
2tool.
3     For purposes of this Section:
4    "Diagnostic mammogram" means a mammogram obtained using
5diagnostic mammography.
6    "Diagnostic mammography" means a method of screening that
7is designed to evaluate an abnormality in a breast, including
8an abnormality seen or suspected on a screening mammogram or a
9subjective or objective abnormality otherwise detected in the
10breast.
11    "Low-dose mammography" means the x-ray examination of the
12breast using equipment dedicated specifically for mammography,
13including the x-ray tube, filter, compression device, and
14image receptor, with an average radiation exposure delivery of
15less than one rad per breast for 2 views of an average size
16breast. The term also includes digital mammography and
17includes breast tomosynthesis.
18    "Breast tomosynthesis" means a radiologic procedure that
19involves the acquisition of projection images over the
20stationary breast to produce cross-sectional digital
21three-dimensional images of the breast.
22    If, at any time, the Secretary of the United States
23Department of Health and Human Services, or its successor
24agency, promulgates rules or regulations to be published in
25the Federal Register or publishes a comment in the Federal
26Register or issues an opinion, guidance, or other action that

 

 

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1would require the State, pursuant to any provision of the
2Patient Protection and Affordable Care Act (Public Law
3111-148), including, but not limited to, 42 U.S.C.
418031(d)(3)(B) or any successor provision, to defray the cost
5of any coverage for breast tomosynthesis outlined in this
6paragraph, then the requirement that an insurer cover breast
7tomosynthesis is inoperative other than any such coverage
8authorized under Section 1902 of the Social Security Act, 42
9U.S.C. 1396a, and the State shall not assume any obligation
10for the cost of coverage for breast tomosynthesis set forth in
11this paragraph.
12    On and after January 1, 2016, the Department shall ensure
13that all networks of care for adult clients of the Department
14include access to at least one breast imaging Center of
15Imaging Excellence as certified by the American College of
16Radiology.
17    On and after January 1, 2012, providers participating in a
18quality improvement program approved by the Department shall
19be reimbursed for screening and diagnostic mammography at the
20same rate as the Medicare program's rates, including the
21increased reimbursement for digital mammography and, after
22January 1, 2023 (the effective date of Public Act 102-1018)
23this amendatory Act of the 102nd General Assembly, breast
24tomosynthesis.
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography

 

 

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1facilities, and doctors, including radiologists, to establish
2quality standards for mammography.
3    On and after January 1, 2017, providers participating in a
4breast cancer treatment quality improvement program approved
5by the Department shall be reimbursed for breast cancer
6treatment at a rate that is no lower than 95% of the Medicare
7program's rates for the data elements included in the breast
8cancer treatment quality program.
9    The Department shall convene an expert panel, including
10representatives of hospitals, free-standing breast cancer
11treatment centers, breast cancer quality organizations, and
12doctors, including breast surgeons, reconstructive breast
13surgeons, oncologists, and primary care providers to establish
14quality standards for breast cancer treatment.
15    Subject to federal approval, the Department shall
16establish a rate methodology for mammography at federally
17qualified health centers and other encounter-rate clinics.
18These clinics or centers may also collaborate with other
19hospital-based mammography facilities. By January 1, 2016, the
20Department shall report to the General Assembly on the status
21of the provision set forth in this paragraph.
22    The Department shall establish a methodology to remind
23individuals who are age-appropriate for screening mammography,
24but who have not received a mammogram within the previous 18
25months, of the importance and benefit of screening
26mammography. The Department shall work with experts in breast

 

 

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1cancer outreach and patient navigation to optimize these
2reminders and shall establish a methodology for evaluating
3their effectiveness and modifying the methodology based on the
4evaluation.
5    The Department shall establish a performance goal for
6primary care providers with respect to their female patients
7over age 40 receiving an annual mammogram. This performance
8goal shall be used to provide additional reimbursement in the
9form of a quality performance bonus to primary care providers
10who meet that goal.
11    The Department shall devise a means of case-managing or
12patient navigation for beneficiaries diagnosed with breast
13cancer. This program shall initially operate as a pilot
14program in areas of the State with the highest incidence of
15mortality related to breast cancer. At least one pilot program
16site shall be in the metropolitan Chicago area and at least one
17site shall be outside the metropolitan Chicago area. On or
18after July 1, 2016, the pilot program shall be expanded to
19include one site in western Illinois, one site in southern
20Illinois, one site in central Illinois, and 4 sites within
21metropolitan Chicago. An evaluation of the pilot program shall
22be carried out measuring health outcomes and cost of care for
23those served by the pilot program compared to similarly
24situated patients who are not served by the pilot program.
25    The Department shall require all networks of care to
26develop a means either internally or by contract with experts

 

 

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1in navigation and community outreach to navigate cancer
2patients to comprehensive care in a timely fashion. The
3Department shall require all networks of care to include
4access for patients diagnosed with cancer to at least one
5academic commission on cancer-accredited cancer program as an
6in-network covered benefit.
7    The Department shall provide coverage and reimbursement
8for a human papillomavirus (HPV) vaccine that is approved for
9marketing by the federal Food and Drug Administration for all
10persons between the ages of 9 and 45 and persons of the age of
1146 and above who have been diagnosed with cervical dysplasia
12with a high risk of recurrence or progression. The Department
13shall disallow any preauthorization requirements for the
14administration of the human papillomavirus (HPV) vaccine.
15    On or after July 1, 2022, individuals who are otherwise
16eligible for medical assistance under this Article shall
17receive coverage for perinatal depression screenings for the
1812-month period beginning on the last day of their pregnancy.
19Medical assistance coverage under this paragraph shall be
20conditioned on the use of a screening instrument approved by
21the Department.
22    Any medical or health care provider shall immediately
23recommend, to any pregnant individual who is being provided
24prenatal services and is suspected of having a substance use
25disorder as defined in the Substance Use Disorder Act,
26referral to a local substance use disorder treatment program

 

 

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1licensed by the Department of Human Services or to a licensed
2hospital which provides substance abuse treatment services.
3The Department of Healthcare and Family Services shall assure
4coverage for the cost of treatment of the drug abuse or
5addiction for pregnant recipients in accordance with the
6Illinois Medicaid Program in conjunction with the Department
7of Human Services.
8    All medical providers providing medical assistance to
9pregnant individuals under this Code shall receive information
10from the Department on the availability of services under any
11program providing case management services for addicted
12individuals, including information on appropriate referrals
13for other social services that may be needed by addicted
14individuals in addition to treatment for addiction.
15    The Illinois Department, in cooperation with the
16Departments of Human Services (as successor to the Department
17of Alcoholism and Substance Abuse) and Public Health, through
18a public awareness campaign, may provide information
19concerning treatment for alcoholism and drug abuse and
20addiction, prenatal health care, and other pertinent programs
21directed at reducing the number of drug-affected infants born
22to recipients of medical assistance.
23    Neither the Department of Healthcare and Family Services
24nor the Department of Human Services shall sanction the
25recipient solely on the basis of the recipient's substance
26abuse.

 

 

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1    The Illinois Department shall establish such regulations
2governing the dispensing of health services under this Article
3as it shall deem appropriate. The Department should seek the
4advice of formal professional advisory committees appointed by
5the Director of the Illinois Department for the purpose of
6providing regular advice on policy and administrative matters,
7information dissemination and educational activities for
8medical and health care providers, and consistency in
9procedures to the Illinois Department.
10    The Illinois Department may develop and contract with
11Partnerships of medical providers to arrange medical services
12for persons eligible under Section 5-2 of this Code.
13Implementation of this Section may be by demonstration
14projects in certain geographic areas. The Partnership shall be
15represented by a sponsor organization. The Department, by
16rule, shall develop qualifications for sponsors of
17Partnerships. Nothing in this Section shall be construed to
18require that the sponsor organization be a medical
19organization.
20    The sponsor must negotiate formal written contracts with
21medical providers for physician services, inpatient and
22outpatient hospital care, home health services, treatment for
23alcoholism and substance abuse, and other services determined
24necessary by the Illinois Department by rule for delivery by
25Partnerships. Physician services must include prenatal and
26obstetrical care. The Illinois Department shall reimburse

 

 

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1medical services delivered by Partnership providers to clients
2in target areas according to provisions of this Article and
3the Illinois Health Finance Reform Act, except that:
4        (1) Physicians participating in a Partnership and
5    providing certain services, which shall be determined by
6    the Illinois Department, to persons in areas covered by
7    the Partnership may receive an additional surcharge for
8    such services.
9        (2) The Department may elect to consider and negotiate
10    financial incentives to encourage the development of
11    Partnerships and the efficient delivery of medical care.
12        (3) Persons receiving medical services through
13    Partnerships may receive medical and case management
14    services above the level usually offered through the
15    medical assistance program.
16    Medical providers shall be required to meet certain
17qualifications to participate in Partnerships to ensure the
18delivery of high quality medical services. These
19qualifications shall be determined by rule of the Illinois
20Department and may be higher than qualifications for
21participation in the medical assistance program. Partnership
22sponsors may prescribe reasonable additional qualifications
23for participation by medical providers, only with the prior
24written approval of the Illinois Department.
25    Nothing in this Section shall limit the free choice of
26practitioners, hospitals, and other providers of medical

 

 

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1services by clients. In order to ensure patient freedom of
2choice, the Illinois Department shall immediately promulgate
3all rules and take all other necessary actions so that
4provided services may be accessed from therapeutically
5certified optometrists to the full extent of the Illinois
6Optometric Practice Act of 1987 without discriminating between
7service providers.
8    The Department shall apply for a waiver from the United
9States Health Care Financing Administration to allow for the
10implementation of Partnerships under this Section.
11    The Illinois Department shall require health care
12providers to maintain records that document the medical care
13and services provided to recipients of Medical Assistance
14under this Article. Such records must be retained for a period
15of not less than 6 years from the date of service or as
16provided by applicable State law, whichever period is longer,
17except that if an audit is initiated within the required
18retention period then the records must be retained until the
19audit is completed and every exception is resolved. The
20Illinois Department shall require health care providers to
21make available, when authorized by the patient, in writing,
22the medical records in a timely fashion to other health care
23providers who are treating or serving persons eligible for
24Medical Assistance under this Article. All dispensers of
25medical services shall be required to maintain and retain
26business and professional records sufficient to fully and

 

 

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1accurately document the nature, scope, details and receipt of
2the health care provided to persons eligible for medical
3assistance under this Code, in accordance with regulations
4promulgated by the Illinois Department. The rules and
5regulations shall require that proof of the receipt of
6prescription drugs, dentures, prosthetic devices and
7eyeglasses by eligible persons under this Section accompany
8each claim for reimbursement submitted by the dispenser of
9such medical services. No such claims for reimbursement shall
10be approved for payment by the Illinois Department without
11such proof of receipt, unless the Illinois Department shall
12have put into effect and shall be operating a system of
13post-payment audit and review which shall, on a sampling
14basis, be deemed adequate by the Illinois Department to assure
15that such drugs, dentures, prosthetic devices and eyeglasses
16for which payment is being made are actually being received by
17eligible recipients. Within 90 days after September 16, 1984
18(the effective date of Public Act 83-1439), the Illinois
19Department shall establish a current list of acquisition costs
20for all prosthetic devices and any other items recognized as
21medical equipment and supplies reimbursable under this Article
22and shall update such list on a quarterly basis, except that
23the acquisition costs of all prescription drugs shall be
24updated no less frequently than every 30 days as required by
25Section 5-5.12.
26    Notwithstanding any other law to the contrary, the

 

 

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1Illinois Department shall, within 365 days after July 22, 2013
2(the effective date of Public Act 98-104), establish
3procedures to permit skilled care facilities licensed under
4the Nursing Home Care Act to submit monthly billing claims for
5reimbursement purposes. Following development of these
6procedures, the Department shall, by July 1, 2016, test the
7viability of the new system and implement any necessary
8operational or structural changes to its information
9technology platforms in order to allow for the direct
10acceptance and payment of nursing home claims.
11    Notwithstanding any other law to the contrary, the
12Illinois Department shall, within 365 days after August 15,
132014 (the effective date of Public Act 98-963), establish
14procedures to permit ID/DD facilities licensed under the ID/DD
15Community Care Act and MC/DD facilities licensed under the
16MC/DD Act to submit monthly billing claims for reimbursement
17purposes. Following development of these procedures, the
18Department shall have an additional 365 days to test the
19viability of the new system and to ensure that any necessary
20operational or structural changes to its information
21technology platforms are implemented.
22    The Illinois Department shall require all dispensers of
23medical services, other than an individual practitioner or
24group of practitioners, desiring to participate in the Medical
25Assistance program established under this Article to disclose
26all financial, beneficial, ownership, equity, surety or other

 

 

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1interests in any and all firms, corporations, partnerships,
2associations, business enterprises, joint ventures, agencies,
3institutions or other legal entities providing any form of
4health care services in this State under this Article.
5    The Illinois Department may require that all dispensers of
6medical services desiring to participate in the medical
7assistance program established under this Article disclose,
8under such terms and conditions as the Illinois Department may
9by rule establish, all inquiries from clients and attorneys
10regarding medical bills paid by the Illinois Department, which
11inquiries could indicate potential existence of claims or
12liens for the Illinois Department.
13    Enrollment of a vendor shall be subject to a provisional
14period and shall be conditional for one year. During the
15period of conditional enrollment, the Department may terminate
16the vendor's eligibility to participate in, or may disenroll
17the vendor from, the medical assistance program without cause.
18Unless otherwise specified, such termination of eligibility or
19disenrollment is not subject to the Department's hearing
20process. However, a disenrolled vendor may reapply without
21penalty.
22    The Department has the discretion to limit the conditional
23enrollment period for vendors based upon the category of risk
24of the vendor.
25    Prior to enrollment and during the conditional enrollment
26period in the medical assistance program, all vendors shall be

 

 

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1subject to enhanced oversight, screening, and review based on
2the risk of fraud, waste, and abuse that is posed by the
3category of risk of the vendor. The Illinois Department shall
4establish the procedures for oversight, screening, and review,
5which may include, but need not be limited to: criminal and
6financial background checks; fingerprinting; license,
7certification, and authorization verifications; unscheduled or
8unannounced site visits; database checks; prepayment audit
9reviews; audits; payment caps; payment suspensions; and other
10screening as required by federal or State law.
11    The Department shall define or specify the following: (i)
12by provider notice, the "category of risk of the vendor" for
13each type of vendor, which shall take into account the level of
14screening applicable to a particular category of vendor under
15federal law and regulations; (ii) by rule or provider notice,
16the maximum length of the conditional enrollment period for
17each category of risk of the vendor; and (iii) by rule, the
18hearing rights, if any, afforded to a vendor in each category
19of risk of the vendor that is terminated or disenrolled during
20the conditional enrollment period.
21    To be eligible for payment consideration, a vendor's
22payment claim or bill, either as an initial claim or as a
23resubmitted claim following prior rejection, must be received
24by the Illinois Department, or its fiscal intermediary, no
25later than 180 days after the latest date on the claim on which
26medical goods or services were provided, with the following

 

 

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1exceptions:
2        (1) In the case of a provider whose enrollment is in
3    process by the Illinois Department, the 180-day period
4    shall not begin until the date on the written notice from
5    the Illinois Department that the provider enrollment is
6    complete.
7        (2) In the case of errors attributable to the Illinois
8    Department or any of its claims processing intermediaries
9    which result in an inability to receive, process, or
10    adjudicate a claim, the 180-day period shall not begin
11    until the provider has been notified of the error.
12        (3) In the case of a provider for whom the Illinois
13    Department initiates the monthly billing process.
14        (4) In the case of a provider operated by a unit of
15    local government with a population exceeding 3,000,000
16    when local government funds finance federal participation
17    for claims payments.
18    For claims for services rendered during a period for which
19a recipient received retroactive eligibility, claims must be
20filed within 180 days after the Department determines the
21applicant is eligible. For claims for which the Illinois
22Department is not the primary payer, claims must be submitted
23to the Illinois Department within 180 days after the final
24adjudication by the primary payer.
25    In the case of long term care facilities, within 120
26calendar days of receipt by the facility of required

 

 

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1prescreening information, new admissions with associated
2admission documents shall be submitted through the Medical
3Electronic Data Interchange (MEDI) or the Recipient
4Eligibility Verification (REV) System or shall be submitted
5directly to the Department of Human Services using required
6admission forms. Effective September 1, 2014, admission
7documents, including all prescreening information, must be
8submitted through MEDI or REV. Confirmation numbers assigned
9to an accepted transaction shall be retained by a facility to
10verify timely submittal. Once an admission transaction has
11been completed, all resubmitted claims following prior
12rejection are subject to receipt no later than 180 days after
13the admission transaction has been completed.
14    Claims that are not submitted and received in compliance
15with the foregoing requirements shall not be eligible for
16payment under the medical assistance program, and the State
17shall have no liability for payment of those claims.
18    To the extent consistent with applicable information and
19privacy, security, and disclosure laws, State and federal
20agencies and departments shall provide the Illinois Department
21access to confidential and other information and data
22necessary to perform eligibility and payment verifications and
23other Illinois Department functions. This includes, but is not
24limited to: information pertaining to licensure;
25certification; earnings; immigration status; citizenship; wage
26reporting; unearned and earned income; pension income;

 

 

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1employment; supplemental security income; social security
2numbers; National Provider Identifier (NPI) numbers; the
3National Practitioner Data Bank (NPDB); program and agency
4exclusions; taxpayer identification numbers; tax delinquency;
5corporate information; and death records.
6    The Illinois Department shall enter into agreements with
7State agencies and departments, and is authorized to enter
8into agreements with federal agencies and departments, under
9which such agencies and departments shall share data necessary
10for medical assistance program integrity functions and
11oversight. The Illinois Department shall develop, in
12cooperation with other State departments and agencies, and in
13compliance with applicable federal laws and regulations,
14appropriate and effective methods to share such data. At a
15minimum, and to the extent necessary to provide data sharing,
16the Illinois Department shall enter into agreements with State
17agencies and departments, and is authorized to enter into
18agreements with federal agencies and departments, including,
19but not limited to: the Secretary of State; the Department of
20Revenue; the Department of Public Health; the Department of
21Human Services; and the Department of Financial and
22Professional Regulation.
23    Beginning in fiscal year 2013, the Illinois Department
24shall set forth a request for information to identify the
25benefits of a pre-payment, post-adjudication, and post-edit
26claims system with the goals of streamlining claims processing

 

 

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1and provider reimbursement, reducing the number of pending or
2rejected claims, and helping to ensure a more transparent
3adjudication process through the utilization of: (i) provider
4data verification and provider screening technology; and (ii)
5clinical code editing; and (iii) pre-pay, pre-adjudicated pre-
6or post-adjudicated predictive modeling with an integrated
7case management system with link analysis. Such a request for
8information shall not be considered as a request for proposal
9or as an obligation on the part of the Illinois Department to
10take any action or acquire any products or services.
11    The Illinois Department shall establish policies,
12procedures, standards and criteria by rule for the
13acquisition, repair and replacement of orthotic and prosthetic
14devices and durable medical equipment. Such rules shall
15provide, but not be limited to, the following services: (1)
16immediate repair or replacement of such devices by recipients;
17and (2) rental, lease, purchase or lease-purchase of durable
18medical equipment in a cost-effective manner, taking into
19consideration the recipient's medical prognosis, the extent of
20the recipient's needs, and the requirements and costs for
21maintaining such equipment. Subject to prior approval, such
22rules shall enable a recipient to temporarily acquire and use
23alternative or substitute devices or equipment pending repairs
24or replacements of any device or equipment previously
25authorized for such recipient by the Department.
26Notwithstanding any provision of Section 5-5f to the contrary,

 

 

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1the Department may, by rule, exempt certain replacement
2wheelchair parts from prior approval and, for wheelchairs,
3wheelchair parts, wheelchair accessories, and related seating
4and positioning items, determine the wholesale price by
5methods other than actual acquisition costs.
6    The Department shall require, by rule, all providers of
7durable medical equipment to be accredited by an accreditation
8organization approved by the federal Centers for Medicare and
9Medicaid Services and recognized by the Department in order to
10bill the Department for providing durable medical equipment to
11recipients. No later than 15 months after the effective date
12of the rule adopted pursuant to this paragraph, all providers
13must meet the accreditation requirement.
14    In order to promote environmental responsibility, meet the
15needs of recipients and enrollees, and achieve significant
16cost savings, the Department, or a managed care organization
17under contract with the Department, may provide recipients or
18managed care enrollees who have a prescription or Certificate
19of Medical Necessity access to refurbished durable medical
20equipment under this Section (excluding prosthetic and
21orthotic devices as defined in the Orthotics, Prosthetics, and
22Pedorthics Practice Act and complex rehabilitation technology
23products and associated services) through the State's
24assistive technology program's reutilization program, using
25staff with the Assistive Technology Professional (ATP)
26Certification if the refurbished durable medical equipment:

 

 

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1(i) is available; (ii) is less expensive, including shipping
2costs, than new durable medical equipment of the same type;
3(iii) is able to withstand at least 3 years of use; (iv) is
4cleaned, disinfected, sterilized, and safe in accordance with
5federal Food and Drug Administration regulations and guidance
6governing the reprocessing of medical devices in health care
7settings; and (v) equally meets the needs of the recipient or
8enrollee. The reutilization program shall confirm that the
9recipient or enrollee is not already in receipt of the same or
10similar equipment from another service provider, and that the
11refurbished durable medical equipment equally meets the needs
12of the recipient or enrollee. Nothing in this paragraph shall
13be construed to limit recipient or enrollee choice to obtain
14new durable medical equipment or place any additional prior
15authorization conditions on enrollees of managed care
16organizations.
17    The Department shall execute, relative to the nursing home
18prescreening project, written inter-agency agreements with the
19Department of Human Services and the Department on Aging, to
20effect the following: (i) intake procedures and common
21eligibility criteria for those persons who are receiving
22non-institutional services; and (ii) the establishment and
23development of non-institutional services in areas of the
24State where they are not currently available or are
25undeveloped; and (iii) notwithstanding any other provision of
26law, subject to federal approval, on and after July 1, 2012, an

 

 

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1increase in the determination of need (DON) scores from 29 to
237 for applicants for institutional and home and
3community-based long term care; if and only if federal
4approval is not granted, the Department may, in conjunction
5with other affected agencies, implement utilization controls
6or changes in benefit packages to effectuate a similar savings
7amount for this population; and (iv) no later than July 1,
82013, minimum level of care eligibility criteria for
9institutional and home and community-based long term care; and
10(v) no later than October 1, 2013, establish procedures to
11permit long term care providers access to eligibility scores
12for individuals with an admission date who are seeking or
13receiving services from the long term care provider. In order
14to select the minimum level of care eligibility criteria, the
15Governor shall establish a workgroup that includes affected
16agency representatives and stakeholders representing the
17institutional and home and community-based long term care
18interests. This Section shall not restrict the Department from
19implementing lower level of care eligibility criteria for
20community-based services in circumstances where federal
21approval has been granted.
22    The Illinois Department shall develop and operate, in
23cooperation with other State Departments and agencies and in
24compliance with applicable federal laws and regulations,
25appropriate and effective systems of health care evaluation
26and programs for monitoring of utilization of health care

 

 

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1services and facilities, as it affects persons eligible for
2medical assistance under this Code.
3    The Illinois Department shall report annually to the
4General Assembly, no later than the second Friday in April of
51979 and each year thereafter, in regard to:
6        (a) actual statistics and trends in utilization of
7    medical services by public aid recipients;
8        (b) actual statistics and trends in the provision of
9    the various medical services by medical vendors;
10        (c) current rate structures and proposed changes in
11    those rate structures for the various medical vendors; and
12        (d) efforts at utilization review and control by the
13    Illinois Department.
14    The period covered by each report shall be the 3 years
15ending on the June 30 prior to the report. The report shall
16include suggested legislation for consideration by the General
17Assembly. The requirement for reporting to the General
18Assembly shall be satisfied by filing copies of the report as
19required by Section 3.1 of the General Assembly Organization
20Act, and filing such additional copies with the State
21Government Report Distribution Center for the General Assembly
22as is required under paragraph (t) of Section 7 of the State
23Library Act.
24    Rulemaking authority to implement Public Act 95-1045, if
25any, is conditioned on the rules being adopted in accordance
26with all provisions of the Illinois Administrative Procedure

 

 

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1Act and all rules and procedures of the Joint Committee on
2Administrative Rules; any purported rule not so adopted, for
3whatever reason, is unauthorized.
4    On and after July 1, 2012, the Department shall reduce any
5rate of reimbursement for services or other payments or alter
6any methodologies authorized by this Code to reduce any rate
7of reimbursement for services or other payments in accordance
8with Section 5-5e.
9    Because kidney transplantation can be an appropriate,
10cost-effective alternative to renal dialysis when medically
11necessary and notwithstanding the provisions of Section 1-11
12of this Code, beginning October 1, 2014, the Department shall
13cover kidney transplantation for noncitizens with end-stage
14renal disease who are not eligible for comprehensive medical
15benefits, who meet the residency requirements of Section 5-3
16of this Code, and who would otherwise meet the financial
17requirements of the appropriate class of eligible persons
18under Section 5-2 of this Code. To qualify for coverage of
19kidney transplantation, such person must be receiving
20emergency renal dialysis services covered by the Department.
21Providers under this Section shall be prior approved and
22certified by the Department to perform kidney transplantation
23and the services under this Section shall be limited to
24services associated with kidney transplantation.
25    Notwithstanding any other provision of this Code to the
26contrary, on or after July 1, 2015, all FDA approved forms of

 

 

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1medication assisted treatment prescribed for the treatment of
2alcohol dependence or treatment of opioid dependence shall be
3covered under both fee for service and managed care medical
4assistance programs for persons who are otherwise eligible for
5medical assistance under this Article and shall not be subject
6to any (1) utilization control, other than those established
7under the American Society of Addiction Medicine patient
8placement criteria, (2) prior authorization mandate, or (3)
9lifetime restriction limit mandate.
10    On or after July 1, 2015, opioid antagonists prescribed
11for the treatment of an opioid overdose, including the
12medication product, administration devices, and any pharmacy
13fees or hospital fees related to the dispensing, distribution,
14and administration of the opioid antagonist, shall be covered
15under the medical assistance program for persons who are
16otherwise eligible for medical assistance under this Article.
17As used in this Section, "opioid antagonist" means a drug that
18binds to opioid receptors and blocks or inhibits the effect of
19opioids acting on those receptors, including, but not limited
20to, naloxone hydrochloride or any other similarly acting drug
21approved by the U.S. Food and Drug Administration. The
22Department shall not impose a copayment on the coverage
23provided for naloxone hydrochloride under the medical
24assistance program.
25    Upon federal approval, the Department shall provide
26coverage and reimbursement for all drugs that are approved for

 

 

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1marketing by the federal Food and Drug Administration and that
2are recommended by the federal Public Health Service or the
3United States Centers for Disease Control and Prevention for
4pre-exposure prophylaxis and related pre-exposure prophylaxis
5services, including, but not limited to, HIV and sexually
6transmitted infection screening, treatment for sexually
7transmitted infections, medical monitoring, assorted labs, and
8counseling to reduce the likelihood of HIV infection among
9individuals who are not infected with HIV but who are at high
10risk of HIV infection.
11    A federally qualified health center, as defined in Section
121905(l)(2)(B) of the federal Social Security Act, shall be
13reimbursed by the Department in accordance with the federally
14qualified health center's encounter rate for services provided
15to medical assistance recipients that are performed by a
16dental hygienist, as defined under the Illinois Dental
17Practice Act, working under the general supervision of a
18dentist and employed by a federally qualified health center.
19    Within 90 days after October 8, 2021 (the effective date
20of Public Act 102-665), the Department shall seek federal
21approval of a State Plan amendment to expand coverage for
22family planning services that includes presumptive eligibility
23to individuals whose income is at or below 208% of the federal
24poverty level. Coverage under this Section shall be effective
25beginning no later than December 1, 2022.
26    Subject to approval by the federal Centers for Medicare

 

 

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1and Medicaid Services of a Title XIX State Plan amendment
2electing the Program of All-Inclusive Care for the Elderly
3(PACE) as a State Medicaid option, as provided for by Subtitle
4I (commencing with Section 4801) of Title IV of the Balanced
5Budget Act of 1997 (Public Law 105-33) and Part 460
6(commencing with Section 460.2) of Subchapter E of Title 42 of
7the Code of Federal Regulations, PACE program services shall
8become a covered benefit of the medical assistance program,
9subject to criteria established in accordance with all
10applicable laws.
11    Notwithstanding any other provision of this Code,
12community-based pediatric palliative care from a trained
13interdisciplinary team shall be covered under the medical
14assistance program as provided in Section 15 of the Pediatric
15Palliative Care Act.
16    Notwithstanding any other provision of this Code, within
1712 months after June 2, 2022 (the effective date of Public Act
18102-1037) this amendatory Act of the 102nd General Assembly
19and subject to federal approval, acupuncture services
20performed by an acupuncturist licensed under the Acupuncture
21Practice Act who is acting within the scope of his or her
22license shall be covered under the medical assistance program.
23The Department shall apply for any federal waiver or State
24Plan amendment, if required, to implement this paragraph. The
25Department may adopt any rules, including standards and
26criteria, necessary to implement this paragraph.

 

 

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1    Notwithstanding any other provision of this Code,
2beginning on January 1, 2024, subject to federal approval,
3cognitive assessment and care planning services provided to a
4person who experiences signs or symptoms of cognitive
5impairment, as defined by the Diagnostic and Statistical
6Manual of Mental Disorders, Fifth Edition, shall be covered
7under the medical assistance program for persons who are
8otherwise eligible for medical assistance under this Article.
9(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
10102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1135, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1255-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
13102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
141-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
15102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
161-1-23; revised 2-5-23.)
 
17
ARTICLE 20.

 
18    Section 20-5. The Illinois Public Aid Code is amended by
19changing Section 5-5.01a as follows:
 
20    (305 ILCS 5/5-5.01a)
21    Sec. 5-5.01a. Supportive living facilities program.
22    (a) The Department shall establish and provide oversight
23for a program of supportive living facilities that seek to

 

 

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1promote resident independence, dignity, respect, and
2well-being in the most cost-effective manner.
3    A supportive living facility is (i) a free-standing
4facility or (ii) a distinct physical and operational entity
5within a mixed-use building that meets the criteria
6established in subsection (d). A supportive living facility
7integrates housing with health, personal care, and supportive
8services and is a designated setting that offers residents
9their own separate, private, and distinct living units.
10    Sites for the operation of the program shall be selected
11by the Department based upon criteria that may include the
12need for services in a geographic area, the availability of
13funding, and the site's ability to meet the standards.
14    (b) Beginning July 1, 2014, subject to federal approval,
15the Medicaid rates for supportive living facilities shall be
16equal to the supportive living facility Medicaid rate
17effective on June 30, 2014 increased by 8.85%. Once the
18assessment imposed at Article V-G of this Code is determined
19to be a permissible tax under Title XIX of the Social Security
20Act, the Department shall increase the Medicaid rates for
21supportive living facilities effective on July 1, 2014 by
229.09%. The Department shall apply this increase retroactively
23to coincide with the imposition of the assessment in Article
24V-G of this Code in accordance with the approval for federal
25financial participation by the Centers for Medicare and
26Medicaid Services.

 

 

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1    The Medicaid rates for supportive living facilities
2effective on July 1, 2017 must be equal to the rates in effect
3for supportive living facilities on June 30, 2017 increased by
42.8%.
5    The Medicaid rates for supportive living facilities
6effective on July 1, 2018 must be equal to the rates in effect
7for supportive living facilities on June 30, 2018.
8    Subject to federal approval, the Medicaid rates for
9supportive living services on and after July 1, 2019 must be at
10least 54.3% of the average total nursing facility services per
11diem for the geographic areas defined by the Department while
12maintaining the rate differential for dementia care and must
13be updated whenever the total nursing facility service per
14diems are updated. Beginning July 1, 2022, upon the
15implementation of the Patient Driven Payment Model, Medicaid
16rates for supportive living services must be at least 54.3% of
17the average total nursing services per diem rate for the
18geographic areas. For purposes of this provision, the average
19total nursing services per diem rate shall include all add-ons
20for nursing facilities for the geographic area provided for in
21Section 5-5.2. The rate differential for dementia care must be
22maintained in these rates and the rates shall be updated
23whenever nursing facility per diem rates are updated.
24    Subject to federal approval, beginning January 1, 2024,
25the dementia care rate for supportive living services must be
26no less than the non-dementia care supportive living services

 

 

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1rate multiplied by 1.5.
2    (c) The Department may adopt rules to implement this
3Section. Rules that establish or modify the services,
4standards, and conditions for participation in the program
5shall be adopted by the Department in consultation with the
6Department on Aging, the Department of Rehabilitation
7Services, and the Department of Mental Health and
8Developmental Disabilities (or their successor agencies).
9    (d) Subject to federal approval by the Centers for
10Medicare and Medicaid Services, the Department shall accept
11for consideration of certification under the program any
12application for a site or building where distinct parts of the
13site or building are designated for purposes other than the
14provision of supportive living services, but only if:
15        (1) those distinct parts of the site or building are
16    not designated for the purpose of providing assisted
17    living services as required under the Assisted Living and
18    Shared Housing Act;
19        (2) those distinct parts of the site or building are
20    completely separate from the part of the building used for
21    the provision of supportive living program services,
22    including separate entrances;
23        (3) those distinct parts of the site or building do
24    not share any common spaces with the part of the building
25    used for the provision of supportive living program
26    services; and

 

 

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1        (4) those distinct parts of the site or building do
2    not share staffing with the part of the building used for
3    the provision of supportive living program services.
4    (e) Facilities or distinct parts of facilities which are
5selected as supportive living facilities and are in good
6standing with the Department's rules are exempt from the
7provisions of the Nursing Home Care Act and the Illinois
8Health Facilities Planning Act.
9    (f) Section 9817 of the American Rescue Plan Act of 2021
10(Public Law 117-2) authorizes a 10% enhanced federal medical
11assistance percentage for supportive living services for a
1212-month period from April 1, 2021 through March 31, 2022.
13Subject to federal approval, including the approval of any
14necessary waiver amendments or other federally required
15documents or assurances, for a 12-month period the Department
16must pay a supplemental $26 per diem rate to all supportive
17living facilities with the additional federal financial
18participation funds that result from the enhanced federal
19medical assistance percentage from April 1, 2021 through March
2031, 2022. The Department may issue parameters around how the
21supplemental payment should be spent, including quality
22improvement activities. The Department may alter the form,
23methods, or timeframes concerning the supplemental per diem
24rate to comply with any subsequent changes to federal law,
25changes made by guidance issued by the federal Centers for
26Medicare and Medicaid Services, or other changes necessary to

 

 

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1receive the enhanced federal medical assistance percentage.
2(Source: P.A. 101-10, eff. 6-5-19; 102-43, eff. 7-6-21;
3102-699, eff. 4-19-22.)
 
4
ARTICLE 25.

 
5    Section 25-5. The Illinois Public Aid Code is amended by
6adding Section 12-4.57 as follows:
 
7    (305 ILCS 5/12-4.57 new)
8    Sec. 12-4.57. Prospective Payment System rates; increase
9for federally qualified health centers. Beginning January 1,
102024, subject to federal approval, the Department of
11Healthcare and Family Services shall increase the Prospective
12Payment System rates for federally qualified health centers to
13a level calculated to spend an additional $50,000,000 in the
14first year of application using an alternative payment method
15acceptable to the Centers for Medicare and Medicaid Services
16and a trade association representing a majority of federally
17qualified health centers operating in Illinois, including a
18rate increase that is an equal percentage increase to the
19rates paid to each federally qualified health center.
 
20
ARTICLE 30.

 
21    Section 30-5. The Specialized Mental Health Rehabilitation

 

 

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1Act of 2013 is amended by changing Section 5-107 as follows:
 
2    (210 ILCS 49/5-107)
3    Sec. 5-107. Quality of life enhancement. Beginning on July
41, 2019, for improving the quality of life and the quality of
5care, an additional payment shall be awarded to a facility for
6their single occupancy rooms. This payment shall be in
7addition to the rate for recovery and rehabilitation. The
8additional rate for single room occupancy shall be no less
9than $10 per day, per single room occupancy. The Department of
10Healthcare and Family Services shall adjust payment to
11Medicaid managed care entities to cover these costs. Beginning
12July 1, 2022, for improving the quality of life and the quality
13of care, a payment of no less than $5 per day, per single room
14occupancy shall be added to the existing $10 additional per
15day, per single room occupancy rate for a total of at least $15
16per day, per single room occupancy. For improving the quality
17of life and the quality of care, on January 1, 2024, a payment
18of no less than $10.50 per day, per single room occupancy shall
19be added to the existing $15 additional per day, per single
20room occupancy rate for a total of at least $25.50 per day, per
21single room occupancy. Beginning July 1, 2022, for improving
22the quality of life and the quality of care, an additional
23payment shall be awarded to a facility for its dual-occupancy
24rooms. This payment shall be in addition to the rate for
25recovery and rehabilitation. The additional rate for

 

 

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

 
15    Section 35-5. The Illinois Public Aid Code is amended by
16changing Section 5-2b as follows:
 
17    (305 ILCS 5/5-2b)
18    Sec. 5-2b. Medically fragile and technology dependent
19children eligibility and program; provider reimbursement
20rates.
21    (a) Notwithstanding any other provision of law except as
22provided in Section 5-30a, on and after September 1, 2012,
23subject to federal approval, medical assistance under this

 

 

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1Article shall be available to children who qualify as persons
2with a disability, as defined under the federal Supplemental
3Security Income program and who are medically fragile and
4technology dependent. The program shall allow eligible
5children to receive the medical assistance provided under this
6Article in the community and must maximize, to the fullest
7extent permissible under federal law, federal reimbursement
8and family cost-sharing, including co-pays, premiums, or any
9other family contributions, except that the Department shall
10be permitted to incentivize the utilization of selected
11services through the use of cost-sharing adjustments. The
12Department shall establish the policies, procedures,
13standards, services, and criteria for this program by rule.
14    (b) Notwithstanding any other provision of this Code,
15subject to federal approval, on and after January 1, 2024, the
16reimbursement rates for nursing paid through Nursing and
17Personal Care Services for non-waiver customers and to
18providers of private duty nursing services for children
19eligible for medical assistance under this Section shall be
2020% higher than the reimbursement rates in effect for nursing
21services on December 31, 2023.
22(Source: P.A. 100-990, eff. 1-1-19.)
 
23
ARTICLE 40.

 
24    Section 40-5. The Illinois Public Aid Code is amended by

 

 

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1changing Section 5-5.2 as follows:
 
2    (305 ILCS 5/5-5.2)  (from Ch. 23, par. 5-5.2)
3    Sec. 5-5.2. Payment.
4    (a) All nursing facilities that are grouped pursuant to
5Section 5-5.1 of this Act shall receive the same rate of
6payment for similar services.
7    (b) It shall be a matter of State policy that the Illinois
8Department shall utilize a uniform billing cycle throughout
9the State for the long-term care providers.
10    (c) (Blank).
11    (c-1) Notwithstanding any other provisions of this Code,
12the methodologies for reimbursement of nursing services as
13provided under this Article shall no longer be applicable for
14bills payable for nursing services rendered on or after a new
15reimbursement system based on the Patient Driven Payment Model
16(PDPM) has been fully operationalized, which shall take effect
17for services provided on or after the implementation of the
18PDPM reimbursement system begins. For the purposes of this
19amendatory Act of the 102nd General Assembly, the
20implementation date of the PDPM reimbursement system and all
21related provisions shall be July 1, 2022 if the following
22conditions are met: (i) the Centers for Medicare and Medicaid
23Services has approved corresponding changes in the
24reimbursement system and bed assessment; and (ii) the
25Department has filed rules to implement these changes no later

 

 

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1than June 1, 2022. Failure of the Department to file rules to
2implement the changes provided in this amendatory Act of the
3102nd General Assembly no later than June 1, 2022 shall result
4in the implementation date being delayed to October 1, 2022.
5    (d) The new nursing services reimbursement methodology
6utilizing the Patient Driven Payment Model, which shall be
7referred to as the PDPM reimbursement system, taking effect
8July 1, 2022, upon federal approval by the Centers for
9Medicare and Medicaid Services, shall be based on the
10following:
11        (1) The methodology shall be resident-centered,
12    facility-specific, cost-based, and based on guidance from
13    the Centers for Medicare and Medicaid Services.
14        (2) Costs shall be annually rebased and case mix index
15    quarterly updated. The nursing services methodology will
16    be assigned to the Medicaid enrolled residents on record
17    as of 30 days prior to the beginning of the rate period in
18    the Department's Medicaid Management Information System
19    (MMIS) as present on the last day of the second quarter
20    preceding the rate period based upon the Assessment
21    Reference Date of the Minimum Data Set (MDS).
22        (3) Regional wage adjustors based on the Health
23    Service Areas (HSA) groupings and adjusters in effect on
24    April 30, 2012 shall be included, except no adjuster shall
25    be lower than 1.06.
26        (4) PDPM nursing case mix indices in effect on March

 

 

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1    1, 2022 shall be assigned to each resident class at no less
2    than 0.7858 of the Centers for Medicare and Medicaid
3    Services PDPM unadjusted case mix values, in effect on
4    March 1, 2022.
5        (5) The pool of funds available for distribution by
6    case mix and the base facility rate shall be determined
7    using the formula contained in subsection (d-1).
8        (6) The Department shall establish a variable per diem
9    staffing add-on in accordance with the most recent
10    available federal staffing report, currently the Payroll
11    Based Journal, for the same period of time, and if
12    applicable adjusted for acuity using the same quarter's
13    MDS. The Department shall rely on Payroll Based Journals
14    provided to the Department of Public Health to make a
15    determination of non-submission. If the Department is
16    notified by a facility of missing or inaccurate Payroll
17    Based Journal data or an incorrect calculation of
18    staffing, the Department must make a correction as soon as
19    the error is verified for the applicable quarter.
20        Facilities with at least 70% of the staffing indicated
21    by the STRIVE study shall be paid a per diem add-on of $9,
22    increasing by equivalent steps for each whole percentage
23    point until the facilities reach a per diem of $14.88.
24    Facilities with at least 80% of the staffing indicated by
25    the STRIVE study shall be paid a per diem add-on of $14.88,
26    increasing by equivalent steps for each whole percentage

 

 

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1    point until the facilities reach a per diem add-on of
2    $23.80. Facilities with at least 92% of the staffing
3    indicated by the STRIVE study shall be paid a per diem
4    add-on of $23.80, increasing by equivalent steps for each
5    whole percentage point until the facilities reach a per
6    diem add-on of $29.75. Facilities with at least 100% of
7    the staffing indicated by the STRIVE study shall be paid a
8    per diem add-on of $29.75, increasing by equivalent steps
9    for each whole percentage point until the facilities reach
10    a per diem add-on of $35.70. Facilities with at least 110%
11    of the staffing indicated by the STRIVE study shall be
12    paid a per diem add-on of $35.70, increasing by equivalent
13    steps for each whole percentage point until the facilities
14    reach a per diem add-on of $38.68. Facilities with at
15    least 125% or higher of the staffing indicated by the
16    STRIVE study shall be paid a per diem add-on of $38.68.
17    Beginning April 1, 2023, no nursing facility's variable
18    staffing per diem add-on shall be reduced by more than 5%
19    in 2 consecutive quarters. For the quarters beginning July
20    1, 2022 and October 1, 2022, no facility's variable per
21    diem staffing add-on shall be calculated at a rate lower
22    than 85% of the staffing indicated by the STRIVE study. No
23    facility below 70% of the staffing indicated by the STRIVE
24    study shall receive a variable per diem staffing add-on
25    after December 31, 2022.
26        (7) For dates of services beginning July 1, 2022, the

 

 

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1    PDPM nursing component per diem for each nursing facility
2    shall be the product of the facility's (i) statewide PDPM
3    nursing base per diem rate, $92.25, adjusted for the
4    facility average PDPM case mix index calculated quarterly
5    and (ii) the regional wage adjuster, and then add the
6    Medicaid access adjustment as defined in (e-3) of this
7    Section. Transition rates for services provided between
8    July 1, 2022 and October 1, 2023 shall be the greater of
9    the PDPM nursing component per diem or:
10            (A) for the quarter beginning July 1, 2022, the
11        RUG-IV nursing component per diem;
12            (B) for the quarter beginning October 1, 2022, the
13        sum of the RUG-IV nursing component per diem
14        multiplied by 0.80 and the PDPM nursing component per
15        diem multiplied by 0.20;
16            (C) for the quarter beginning January 1, 2023, the
17        sum of the RUG-IV nursing component per diem
18        multiplied by 0.60 and the PDPM nursing component per
19        diem multiplied by 0.40;
20            (D) for the quarter beginning April 1, 2023, the
21        sum of the RUG-IV nursing component per diem
22        multiplied by 0.40 and the PDPM nursing component per
23        diem multiplied by 0.60;
24            (E) for the quarter beginning July 1, 2023, the
25        sum of the RUG-IV nursing component per diem
26        multiplied by 0.20 and the PDPM nursing component per

 

 

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

 

 

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

 

 

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1        (5) Nursing facilities designated as of July 1, 2012
2    by the Department as "Institutions for Mental Disease"
3    shall be excluded from all calculations under this
4    subsection. The data from these facilities shall not be
5    used in the computations described in paragraphs (1)
6    through (4) above to establish the base rate.
7    (e) Beginning July 1, 2014, the Department shall allocate
8funding in the amount up to $10,000,000 for per diem add-ons to
9the RUGS methodology for dates of service on and after July 1,
102014:
11        (1) $0.63 for each resident who scores in I4200
12    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
13        (2) $2.67 for each resident who scores either a "1" or
14    "2" in any items S1200A through S1200I and also scores in
15    RUG groups PA1, PA2, BA1, or BA2.
16    (e-1) (Blank).
17    (e-2) For dates of services beginning January 1, 2014 and
18ending September 30, 2023, the RUG-IV nursing component per
19diem for a nursing home shall be the product of the statewide
20RUG-IV nursing base per diem rate, the facility average case
21mix index, and the regional wage adjustor. For dates of
22service beginning July 1, 2022 and ending September 30, 2023,
23the Medicaid access adjustment described in subsection (e-3)
24shall be added to the product.
25    (e-3) A Medicaid Access Adjustment of $4 adjusted for the
26facility average PDPM case mix index calculated quarterly

 

 

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1shall be added to the statewide PDPM nursing per diem for all
2facilities with annual Medicaid bed days of at least 70% of all
3occupied bed days adjusted quarterly. For each new calendar
4year and for the 6-month period beginning July 1, 2022, the
5percentage of a facility's occupied bed days comprised of
6Medicaid bed days shall be determined by the Department
7quarterly. For dates of service beginning January 1, 2023, the
8Medicaid Access Adjustment shall be increased to $4.75. This
9subsection shall be inoperative on and after January 1, 2028.
10    (f) (Blank).
11    (g) Notwithstanding any other provision of this Code, on
12and after July 1, 2012, for facilities not designated by the
13Department of Healthcare and Family Services as "Institutions
14for Mental Disease", rates effective May 1, 2011 shall be
15adjusted as follows:
16        (1) (Blank);
17        (2) (Blank);
18        (3) Facility rates for the capital and support
19    components shall be reduced by 1.7%.
20    (h) Notwithstanding any other provision of this Code, on
21and after July 1, 2012, nursing facilities designated by the
22Department of Healthcare and Family Services as "Institutions
23for Mental Disease" and "Institutions for Mental Disease" that
24are facilities licensed under the Specialized Mental Health
25Rehabilitation Act of 2013 shall have the nursing,
26socio-developmental, capital, and support components of their

 

 

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1reimbursement rate effective May 1, 2011 reduced in total by
22.7%.
3    (i) On and after July 1, 2014, the reimbursement rates for
4the support component of the nursing facility rate for
5facilities licensed under the Nursing Home Care Act as skilled
6or intermediate care facilities shall be the rate in effect on
7June 30, 2014 increased by 8.17%.
8    (i-1) Subject to federal approval, on and after January 1,
92024, the reimbursement rates for the support component of the
10nursing facility rate for facilities licensed under the
11Nursing Home Care Act as skilled or intermediate care
12facilities shall be the rate in effect on June 30, 2023
13increased by 12%.
14    (j) Notwithstanding any other provision of law, subject to
15federal approval, effective July 1, 2019, sufficient funds
16shall be allocated for changes to rates for facilities
17licensed under the Nursing Home Care Act as skilled nursing
18facilities or intermediate care facilities for dates of
19services on and after July 1, 2019: (i) to establish, through
20June 30, 2022 a per diem add-on to the direct care per diem
21rate not to exceed $70,000,000 annually in the aggregate
22taking into account federal matching funds for the purpose of
23addressing the facility's unique staffing needs, adjusted
24quarterly and distributed by a weighted formula based on
25Medicaid bed days on the last day of the second quarter
26preceding the quarter for which the rate is being adjusted.

 

 

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1Beginning July 1, 2022, the annual $70,000,000 described in
2the preceding sentence shall be dedicated to the variable per
3diem add-on for staffing under paragraph (6) of subsection
4(d); and (ii) in an amount not to exceed $170,000,000 annually
5in the aggregate taking into account federal matching funds to
6permit the support component of the nursing facility rate to
7be updated as follows:
8        (1) 80%, or $136,000,000, of the funds shall be used
9    to update each facility's rate in effect on June 30, 2019
10    using the most recent cost reports on file, which have had
11    a limited review conducted by the Department of Healthcare
12    and Family Services and will not hold up enacting the rate
13    increase, with the Department of Healthcare and Family
14    Services.
15        (2) After completing the calculation in paragraph (1),
16    any facility whose rate is less than the rate in effect on
17    June 30, 2019 shall have its rate restored to the rate in
18    effect on June 30, 2019 from the 20% of the funds set
19    aside.
20        (3) The remainder of the 20%, or $34,000,000, shall be
21    used to increase each facility's rate by an equal
22    percentage.
23    (k) During the first quarter of State Fiscal Year 2020,
24the Department of Healthcare of Family Services must convene a
25technical advisory group consisting of members of all trade
26associations representing Illinois skilled nursing providers

 

 

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1to discuss changes necessary with federal implementation of
2Medicare's Patient-Driven Payment Model. Implementation of
3Medicare's Patient-Driven Payment Model shall, by September 1,
42020, end the collection of the MDS data that is necessary to
5maintain the current RUG-IV Medicaid payment methodology. The
6technical advisory group must consider a revised reimbursement
7methodology that takes into account transparency,
8accountability, actual staffing as reported under the
9federally required Payroll Based Journal system, changes to
10the minimum wage, adequacy in coverage of the cost of care, and
11a quality component that rewards quality improvements.
12    (l) The Department shall establish per diem add-on
13payments to improve the quality of care delivered by
14facilities, including:
15        (1) Incentive payments determined by facility
16    performance on specified quality measures in an initial
17    amount of $70,000,000. Nothing in this subsection shall be
18    construed to limit the quality of care payments in the
19    aggregate statewide to $70,000,000, and, if quality of
20    care has improved across nursing facilities, the
21    Department shall adjust those add-on payments accordingly.
22    The quality payment methodology described in this
23    subsection must be used for at least State Fiscal Year
24    2023. Beginning with the quarter starting July 1, 2023,
25    the Department may add, remove, or change quality metrics
26    and make associated changes to the quality payment

 

 

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1    methodology as outlined in subparagraph (E). Facilities
2    designated by the Centers for Medicare and Medicaid
3    Services as a special focus facility or a hospital-based
4    nursing home do not qualify for quality payments.
5            (A) Each quality pool must be distributed by
6        assigning a quality weighted score for each nursing
7        home which is calculated by multiplying the nursing
8        home's quality base period Medicaid days by the
9        nursing home's star rating weight in that period.
10            (B) Star rating weights are assigned based on the
11        nursing home's star rating for the LTS quality star
12        rating. As used in this subparagraph, "LTS quality
13        star rating" means the long-term stay quality rating
14        for each nursing facility, as assigned by the Centers
15        for Medicare and Medicaid Services under the Five-Star
16        Quality Rating System. The rating is a number ranging
17        from 0 (lowest) to 5 (highest).
18                (i) Zero-star or one-star rating has a weight
19            of 0.
20                (ii) Two-star rating has a weight of 0.75.
21                (iii) Three-star rating has a weight of 1.5.
22                (iv) Four-star rating has a weight of 2.5.
23                (v) Five-star rating has a weight of 3.5.
24            (C) Each nursing home's quality weight score is
25        divided by the sum of all quality weight scores for
26        qualifying nursing homes to determine the proportion

 

 

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

 

 

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1        payments from the Long-Term Care Provider Fund on a
2        monthly basis in amounts proportional to the total
3        quality pool payment determined for the quarter.
4            (G) The Department shall publish any changes in
5        the methodology for distributing quality pool payments
6        prior to the beginning of the measurement period or
7        quality base period for any metric added to the
8        distribution's methodology.
9        (2) Payments based on CNA tenure, promotion, and CNA
10    training for the purpose of increasing CNA compensation.
11    It is the intent of this subsection that payments made in
12    accordance with this paragraph be directly incorporated
13    into increased compensation for CNAs. As used in this
14    paragraph, "CNA" means a certified nursing assistant as
15    that term is described in Section 3-206 of the Nursing
16    Home Care Act, Section 3-206 of the ID/DD Community Care
17    Act, and Section 3-206 of the MC/DD Act. The Department
18    shall establish, by rule, payments to nursing facilities
19    equal to Medicaid's share of the tenure wage increments
20    specified in this paragraph for all reported CNA employee
21    hours compensated according to a posted schedule
22    consisting of increments at least as large as those
23    specified in this paragraph. The increments are as
24    follows: an additional $1.50 per hour for CNAs with at
25    least one and less than 2 years' experience plus another
26    $1 per hour for each additional year of experience up to a

 

 

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1    maximum of $6.50 for CNAs with at least 6 years of
2    experience. For purposes of this paragraph, Medicaid's
3    share shall be the ratio determined by paid Medicaid bed
4    days divided by total bed days for the applicable time
5    period used in the calculation. In addition, and additive
6    to any tenure increments paid as specified in this
7    paragraph, the Department shall establish, by rule,
8    payments supporting Medicaid's share of the
9    promotion-based wage increments for CNA employee hours
10    compensated for that promotion with at least a $1.50
11    hourly increase. Medicaid's share shall be established as
12    it is for the tenure increments described in this
13    paragraph. Qualifying promotions shall be defined by the
14    Department in rules for an expected 10-15% subset of CNAs
15    assigned intermediate, specialized, or added roles such as
16    CNA trainers, CNA scheduling "captains", and CNA
17    specialists for resident conditions like dementia or
18    memory care or behavioral health.
19    (m) The Department shall work with nursing facility
20industry representatives to design policies and procedures to
21permit facilities to address the integrity of data from
22federal reporting sites used by the Department in setting
23facility rates.
24(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19;
25102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff.
265-31-22; 102-1118, eff. 1-18-23.)
 

 

 

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1
ARTICLE 45.

 
2    Section 45-5. The Illinois Act on the Aging is amended by
3changing Section 4.02 as follows:
 
4    (20 ILCS 105/4.02)  (from Ch. 23, par. 6104.02)
5    Sec. 4.02. Community Care Program. The Department shall
6establish a program of services to prevent unnecessary
7institutionalization of persons age 60 and older in need of
8long term care or who are established as persons who suffer
9from Alzheimer's disease or a related disorder under the
10Alzheimer's Disease Assistance Act, thereby enabling them to
11remain in their own homes or in other living arrangements.
12Such preventive services, which may be coordinated with other
13programs for the aged and monitored by area agencies on aging
14in cooperation with the Department, may include, but are not
15limited to, any or all of the following:
16        (a) (blank);
17        (b) (blank);
18        (c) home care aide services;
19        (d) personal assistant services;
20        (e) adult day services;
21        (f) home-delivered meals;
22        (g) education in self-care;
23        (h) personal care services;

 

 

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1        (i) adult day health services;
2        (j) habilitation services;
3        (k) respite care;
4        (k-5) community reintegration services;
5        (k-6) flexible senior services;
6        (k-7) medication management;
7        (k-8) emergency home response;
8        (l) other nonmedical social services that may enable
9    the person to become self-supporting; or
10        (m) clearinghouse for information provided by senior
11    citizen home owners who want to rent rooms to or share
12    living space with other senior citizens.
13    The Department shall establish eligibility standards for
14such services. In determining the amount and nature of
15services for which a person may qualify, consideration shall
16not be given to the value of cash, property or other assets
17held in the name of the person's spouse pursuant to a written
18agreement dividing marital property into equal but separate
19shares or pursuant to a transfer of the person's interest in a
20home to his spouse, provided that the spouse's share of the
21marital property is not made available to the person seeking
22such services.
23    Beginning January 1, 2008, the Department shall require as
24a condition of eligibility that all new financially eligible
25applicants apply for and enroll in medical assistance under
26Article V of the Illinois Public Aid Code in accordance with

 

 

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1rules promulgated by the Department.
2    The Department shall, in conjunction with the Department
3of Public Aid (now Department of Healthcare and Family
4Services), seek appropriate amendments under Sections 1915 and
51924 of the Social Security Act. The purpose of the amendments
6shall be to extend eligibility for home and community based
7services under Sections 1915 and 1924 of the Social Security
8Act to persons who transfer to or for the benefit of a spouse
9those amounts of income and resources allowed under Section
101924 of the Social Security Act. Subject to the approval of
11such amendments, the Department shall extend the provisions of
12Section 5-4 of the Illinois Public Aid Code to persons who, but
13for the provision of home or community-based services, would
14require the level of care provided in an institution, as is
15provided for in federal law. Those persons no longer found to
16be eligible for receiving noninstitutional services due to
17changes in the eligibility criteria shall be given 45 days
18notice prior to actual termination. Those persons receiving
19notice of termination may contact the Department and request
20the determination be appealed at any time during the 45 day
21notice period. The target population identified for the
22purposes of this Section are persons age 60 and older with an
23identified service need. Priority shall be given to those who
24are at imminent risk of institutionalization. The services
25shall be provided to eligible persons age 60 and older to the
26extent that the cost of the services together with the other

 

 

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

 

 

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

 

 

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

 

 

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1        (1) ensuring that in-home services included in the
2    care plan are available on evenings and weekends;
3        (2) ensuring that care plans contain the services that
4    eligible participants need based on the number of days in
5    a month, not limited to specific blocks of time, as
6    identified by the comprehensive assessment tool selected
7    by the Department for use statewide, not to exceed the
8    total monthly service cost maximum allowed for each
9    service; the Department shall develop administrative rules
10    to implement this item (2);
11        (3) ensuring that the participants have the right to
12    choose the services contained in their care plan and to
13    direct how those services are provided, based on
14    administrative rules established by the Department;
15        (4) ensuring that the determination of need tool is
16    accurate in determining the participants' level of need;
17    to achieve this, the Department, in conjunction with the
18    Older Adult Services Advisory Committee, shall institute a
19    study of the relationship between the Determination of
20    Need scores, level of need, service cost maximums, and the
21    development and utilization of service plans no later than
22    May 1, 2008; findings and recommendations shall be
23    presented to the Governor and the General Assembly no
24    later than January 1, 2009; recommendations shall include
25    all needed changes to the service cost maximums schedule
26    and additional covered services;

 

 

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1        (5) ensuring that homemakers can provide personal care
2    services that may or may not involve contact with clients,
3    including but not limited to:
4            (A) bathing;
5            (B) grooming;
6            (C) toileting;
7            (D) nail care;
8            (E) transferring;
9            (F) respiratory services;
10            (G) exercise; or
11            (H) positioning;
12        (6) ensuring that homemaker program vendors are not
13    restricted from hiring homemakers who are family members
14    of clients or recommended by clients; the Department may
15    not, by rule or policy, require homemakers who are family
16    members of clients or recommended by clients to accept
17    assignments in homes other than the client;
18        (7) ensuring that the State may access maximum federal
19    matching funds by seeking approval for the Centers for
20    Medicare and Medicaid Services for modifications to the
21    State's home and community based services waiver and
22    additional waiver opportunities, including applying for
23    enrollment in the Balance Incentive Payment Program by May
24    1, 2013, in order to maximize federal matching funds; this
25    shall include, but not be limited to, modification that
26    reflects all changes in the Community Care Program

 

 

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

 

 

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1    January 1, 2014 in order to address these improvements;
2        (11) requiring home care service providers to comply
3    with the rounding of hours worked provisions under the
4    federal Fair Labor Standards Act (FLSA) and as set forth
5    in 29 CFR 785.48(b) by May 1, 2013;
6        (12) implementing any necessary policy changes or
7    promulgating any rules, no later than January 1, 2014, to
8    assist the Department of Healthcare and Family Services in
9    moving as many participants as possible, consistent with
10    federal regulations, into coordinated care plans if a care
11    coordination plan that covers long term care is available
12    in the recipient's area; and
13        (13) maintaining fiscal year 2014 rates at the same
14    level established on January 1, 2013.
15    By January 1, 2009 or as soon after the end of the Cash and
16Counseling Demonstration Project as is practicable, the
17Department may, based on its evaluation of the demonstration
18project, promulgate rules concerning personal assistant
19services, to include, but need not be limited to,
20qualifications, employment screening, rights under fair labor
21standards, training, fiduciary agent, and supervision
22requirements. All applicants shall be subject to the
23provisions of the Health Care Worker Background Check Act.
24    The Department shall develop procedures to enhance
25availability of services on evenings, weekends, and on an
26emergency basis to meet the respite needs of caregivers.

 

 

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1Procedures shall be developed to permit the utilization of
2services in successive blocks of 24 hours up to the monthly
3maximum established by the Department. Workers providing these
4services shall be appropriately trained.
5    Beginning on the effective date of this amendatory Act of
61991, no person may perform chore/housekeeping and home care
7aide services under a program authorized by this Section
8unless that person has been issued a certificate of
9pre-service to do so by his or her employing agency.
10Information gathered to effect such certification shall
11include (i) the person's name, (ii) the date the person was
12hired by his or her current employer, and (iii) the training,
13including dates and levels. Persons engaged in the program
14authorized by this Section before the effective date of this
15amendatory Act of 1991 shall be issued a certificate of all
16pre- and in-service training from his or her employer upon
17submitting the necessary information. The employing agency
18shall be required to retain records of all staff pre- and
19in-service training, and shall provide such records to the
20Department upon request and upon termination of the employer's
21contract with the Department. In addition, the employing
22agency is responsible for the issuance of certifications of
23in-service training completed to their employees.
24    The Department is required to develop a system to ensure
25that persons working as home care aides and personal
26assistants receive increases in their wages when the federal

 

 

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1minimum wage is increased by requiring vendors to certify that
2they are meeting the federal minimum wage statute for home
3care aides and personal assistants. An employer that cannot
4ensure that the minimum wage increase is being given to home
5care aides and personal assistants shall be denied any
6increase in reimbursement costs.
7    The Community Care Program Advisory Committee is created
8in the Department on Aging. The Director shall appoint
9individuals to serve in the Committee, who shall serve at
10their own expense. Members of the Committee must abide by all
11applicable ethics laws. The Committee shall advise the
12Department on issues related to the Department's program of
13services to prevent unnecessary institutionalization. The
14Committee shall meet on a bi-monthly basis and shall serve to
15identify and advise the Department on present and potential
16issues affecting the service delivery network, the program's
17clients, and the Department and to recommend solution
18strategies. Persons appointed to the Committee shall be
19appointed on, but not limited to, their own and their agency's
20experience with the program, geographic representation, and
21willingness to serve. The Director shall appoint members to
22the Committee to represent provider, advocacy, policy
23research, and other constituencies committed to the delivery
24of high quality home and community-based services to older
25adults. Representatives shall be appointed to ensure
26representation from community care providers including, but

 

 

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

 

 

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1as requested by the Committee, regarding issues before the
2Committee.
3    The Department on Aging and the Department of Human
4Services shall cooperate in the development and submission of
5an annual report on programs and services provided under this
6Section. Such joint report shall be filed with the Governor
7and the General Assembly on or before March 31 September 30
8each year.
9    The requirement for reporting to the General Assembly
10shall be satisfied by filing copies of the report as required
11by Section 3.1 of the General Assembly Organization Act and
12filing such additional copies with the State Government Report
13Distribution Center for the General Assembly as is required
14under paragraph (t) of Section 7 of the State Library Act.
15    Those persons previously found eligible for receiving
16non-institutional services whose services were discontinued
17under the Emergency Budget Act of Fiscal Year 1992, and who do
18not meet the eligibility standards in effect on or after July
191, 1992, shall remain ineligible on and after July 1, 1992.
20Those persons previously not required to cost-share and who
21were required to cost-share effective March 1, 1992, shall
22continue to meet cost-share requirements on and after July 1,
231992. Beginning July 1, 1992, all clients will be required to
24meet eligibility, cost-share, and other requirements and will
25have services discontinued or altered when they fail to meet
26these requirements.

 

 

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

 

 

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1reported that the Department has not undertaken the required
2actions listed in the report required by subsection (a) of
3Section 2-27 of the Illinois State Auditing Act.
4    The Department shall implement co-payments for the
5Community Care Program at the federally allowable maximum
6level (i) beginning August 1, 2013, if the Auditor General has
7reported that the Department has failed to comply with the
8reporting requirements of Section 2-27 of the Illinois State
9Auditing Act; or (ii) beginning June 1, 2014, if the Auditor
10General has reported that the Department has not undertaken
11the required actions listed in the report required by
12subsection (a) of Section 2-27 of the Illinois State Auditing
13Act.
14    The Department shall continue to provide other Community
15Care Program reports as required by statute.
16    The Department shall conduct a quarterly review of Care
17Coordination Unit performance and adherence to service
18guidelines. The quarterly review shall be reported to the
19Speaker of the House of Representatives, the Minority Leader
20of the House of Representatives, the President of the Senate,
21and the Minority Leader of the Senate. The Department shall
22collect and report longitudinal data on the performance of
23each care coordination unit. Nothing in this paragraph shall
24be construed to require the Department to identify specific
25care coordination units.
26    In regard to community care providers, failure to comply

 

 

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1with Department on Aging policies shall be cause for
2disciplinary action, including, but not limited to,
3disqualification from serving Community Care Program clients.
4Each provider, upon submission of any bill or invoice to the
5Department for payment for services rendered, shall include a
6notarized statement, under penalty of perjury pursuant to
7Section 1-109 of the Code of Civil Procedure, that the
8provider has complied with all Department policies.
9    The Director of the Department on Aging shall make
10information available to the State Board of Elections as may
11be required by an agreement the State Board of Elections has
12entered into with a multi-state voter registration list
13maintenance system.
14    Within 30 days after July 6, 2017 (the effective date of
15Public Act 100-23), rates shall be increased to $18.29 per
16hour, for the purpose of increasing, by at least $.72 per hour,
17the wages paid by those vendors to their employees who provide
18homemaker services. The Department shall pay an enhanced rate
19under the Community Care Program to those in-home service
20provider agencies that offer health insurance coverage as a
21benefit to their direct service worker employees consistent
22with the mandates of Public Act 95-713. For State fiscal years
232018 and 2019, the enhanced rate shall be $1.77 per hour. The
24rate shall be adjusted using actuarial analysis based on the
25cost of care, but shall not be set below $1.77 per hour. The
26Department shall adopt rules, including emergency rules under

 

 

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1subsections (y) and (bb) of Section 5-45 of the Illinois
2Administrative Procedure Act, to implement the provisions of
3this paragraph.
4    Subject to federal approval, on and after January 1, 2024,
5rates for homemaker services shall be increased to $28.07 to
6sustain a minimum wage of $17 per hour for direct service
7workers. Rates in subsequent State fiscal years shall be no
8lower than the rates put into effect upon federal approval.
9Providers of in-home services shall be required to certify to
10the Department that they remain in compliance with the
11mandated wage increase for direct service workers. Fringe
12benefits, including, but not limited to, paid time off and
13payment for training, health insurance, travel, or
14transportation, shall not be reduced in relation to the rate
15increases described in this paragraph.
16    The General Assembly finds it necessary to authorize an
17aggressive Medicaid enrollment initiative designed to maximize
18federal Medicaid funding for the Community Care Program which
19produces significant savings for the State of Illinois. The
20Department on Aging shall establish and implement a Community
21Care Program Medicaid Initiative. Under the Initiative, the
22Department on Aging shall, at a minimum: (i) provide an
23enhanced rate to adequately compensate care coordination units
24to enroll eligible Community Care Program clients into
25Medicaid; (ii) use recommendations from a stakeholder
26committee on how best to implement the Initiative; and (iii)

 

 

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

 

 

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

 

 

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

 

 

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1on how best to achieve the responsibilities of the Community
2Care Program Medicaid Initiative.
3    The Department on Aging, the Department of Human Services,
4and the Department of Healthcare and Family Services shall
5coordinate and implement a streamlined process for seniors to
6access benefits under the State's Medical Assistance Program.
7    The Subcommittee shall collaborate with the Department of
8Human Services on the adoption of a uniform application
9submission process. The Department of Human Services and any
10other State agency involved with processing the medical
11assistance application of any person enrolled in the Community
12Care Program shall include the appropriate care coordination
13unit in all communications related to the determination or
14status of the application.
15    The Community Care Program Medicaid Initiative shall
16provide targeted funding to care coordination units to help
17seniors complete their applications for medical assistance
18benefits. On and after July 1, 2019, care coordination units
19shall receive no less than $200 per completed application,
20which rate may be included in a bundled rate for initial intake
21services when Medicaid application assistance is provided in
22conjunction with the initial intake process for new program
23participants.
24    The Community Care Program Medicaid Initiative shall cease
25operation 5 years after the effective date of this amendatory
26Act of the 100th General Assembly, after which the

 

 

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1Subcommittee shall dissolve.
2(Source: P.A. 101-10, eff. 6-5-19; 102-1071, eff. 6-10-22.)
 
3
ARTICLE 50.

 
4    Section 50-5. 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    (e-4) Subject to federal approval, on and after January 1,
172024, the Department shall increase the rate add-on at
18paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
19for ventilator services from $208 per day to $481 per day.
20Payment is subject to the criteria and requirements under 89
21Ill. Adm. Code 147.335.
22    (f) (Blank).
23    (g) Notwithstanding any other provision of this Code, on
24and after July 1, 2012, for facilities not designated by the
25Department of Healthcare and Family Services as "Institutions
26for Mental Disease", rates effective May 1, 2011 shall be

 

 

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1adjusted as follows:
2        (1) (Blank);
3        (2) (Blank);
4        (3) Facility rates for the capital and support
5    components shall be reduced by 1.7%.
6    (h) Notwithstanding any other provision of this Code, on
7and after July 1, 2012, nursing facilities designated by the
8Department of Healthcare and Family Services as "Institutions
9for Mental Disease" and "Institutions for Mental Disease" that
10are facilities licensed under the Specialized Mental Health
11Rehabilitation Act of 2013 shall have the nursing,
12socio-developmental, capital, and support components of their
13reimbursement rate effective May 1, 2011 reduced in total by
142.7%.
15    (i) On and after July 1, 2014, the reimbursement rates for
16the support component of the nursing facility rate for
17facilities licensed under the Nursing Home Care Act as skilled
18or intermediate care facilities shall be the rate in effect on
19June 30, 2014 increased by 8.17%.
20    (j) Notwithstanding any other provision of law, subject to
21federal approval, effective July 1, 2019, sufficient funds
22shall be allocated for changes to rates for facilities
23licensed under the Nursing Home Care Act as skilled nursing
24facilities or intermediate care facilities for dates of
25services on and after July 1, 2019: (i) to establish, through
26June 30, 2022 a per diem add-on to the direct care per diem

 

 

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

 

 

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1    used to increase each facility's rate by an equal
2    percentage.
3    (k) During the first quarter of State Fiscal Year 2020,
4the Department of Healthcare of Family Services must convene a
5technical advisory group consisting of members of all trade
6associations representing Illinois skilled nursing providers
7to discuss changes necessary with federal implementation of
8Medicare's Patient-Driven Payment Model. Implementation of
9Medicare's Patient-Driven Payment Model shall, by September 1,
102020, end the collection of the MDS data that is necessary to
11maintain the current RUG-IV Medicaid payment methodology. The
12technical advisory group must consider a revised reimbursement
13methodology that takes into account transparency,
14accountability, actual staffing as reported under the
15federally required Payroll Based Journal system, changes to
16the minimum wage, adequacy in coverage of the cost of care, and
17a quality component that rewards quality improvements.
18    (l) The Department shall establish per diem add-on
19payments to improve the quality of care delivered by
20facilities, including:
21        (1) Incentive payments determined by facility
22    performance on specified quality measures in an initial
23    amount of $70,000,000. Nothing in this subsection shall be
24    construed to limit the quality of care payments in the
25    aggregate statewide to $70,000,000, and, if quality of
26    care has improved across nursing facilities, the

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1permit facilities to address the integrity of data from
2federal reporting sites used by the Department in setting
3facility rates.
4(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19;
5102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff.
65-31-22; 102-1118, eff. 1-18-23.)
 
7
ARTICLE 55.

 
8    Section 55-5. The Illinois Public Aid Code is amended by
9adding Section 5-5i as follows:
 
10    (305 ILCS 5/5-5i new)
11    Sec. 5-5i. Rate increase for speech, physical, and
12occupational therapy services. Subject to federal approval,
13beginning January 1, 2024, the Department shall increase
14reimbursement rates for speech therapy services, physical
15therapy services, and occupational therapy services provided
16by licensed speech-language pathologists and speech-language
17pathology assistants, physical therapists and physical therapy
18assistants, and occupational therapists and certified
19occupational therapy assistants, including those in their
20clinical fellowship, by 14.2%.
 
21
ARTICLE 60.

 

 

 

SB1298 Enrolled- 175 -LRB103 28018 CPF 54397 b

1    Section 60-5. The Illinois Public Aid Code is amended by
2adding Section 5-35.5 as follows:
 
3    (305 ILCS 5/5-35.5 new)
4    Sec. 5-35.5. Personal needs allowance; nursing home
5residents. Subject to federal approval, on and after January
61, 2024, for a person who is a resident in a facility licensed
7under the Nursing Home Care Act for whom payments are made
8under this Article throughout a month and who is determined to
9be eligible for medical assistance under this Article, the
10monthly personal needs allowance shall be $60.
 
11
ARTICLE 65.

 
12    Section 65-5. The Rebuild Illinois Mental Health Workforce
13Act is amended by changing Sections 20-10 and 20-20 and by
14adding Section 20-22 as follows:
 
15    (305 ILCS 66/20-10)
16    Sec. 20-10. Medicaid funding for community mental health
17services. Medicaid funding for the specific community mental
18health services listed in this Act shall be adjusted and paid
19as set forth in this Act. Such payments shall be paid in
20addition to the base Medicaid reimbursement rate and add-on
21payment rates per service unit.
22    (a) The payment adjustments shall begin on July 1, 2022

 

 

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

 

 

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

 

 

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

 

 

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1providers. The one-time directed payment shall be for an
2amount appropriated for these purposes. The one-time directed
3payment shall be for services for Integrated Assessment and
4Treatment Planning and other intensive services, including,
5but not limited to, services for Mobile Crisis Response,
6crisis intervention, and medication monitoring. The amounts
7and services used for designing and distributing these
8one-time directed payments shall not be construed to require
9any future rate or funding increases for the same or other
10mental health services.
11    (c) The following payment adjustments shall be made:
12        (1) Subject to federal approval, beginning on January
13    1, 2024, the Department shall introduce rate increases to
14    behavioral health services no less than by the following
15    targeted pool for the specified services provided by
16    community mental health centers:
17            (A) Mobile Crisis Response, $6,800,000;
18            (B) Crisis Intervention, $4,000,000;
19            (C) Integrative Assessment and Treatment Planning
20        services, $10,500,000;
21            (D) Group Therapy, $1,200,000;
22            (E) Family Therapy, $500,000;
23            (F) Community Support Group, $4,000,000; and
24            (G) Medication Monitoring, $3,000,000.
25        (2) Rate increases shall be determined with
26    significant input from Illinois behavioral health trade

 

 

SB1298 Enrolled- 180 -LRB103 28018 CPF 54397 b

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

 

 

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1    Health Outcomes Stakeholder Workgroup to help inform the
2    identification of metrics and outcomes for team-based
3    services.
4        (3) In State Fiscal Year 2025, subject to federal
5    approval, the Department shall introduce a
6    pay-for-performance model for team-based services to be
7    informed by the Behavioral Health Outcomes Stakeholder
8    Workgroup.
9(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23;
10revised 1-23-23.)
 
11    (305 ILCS 66/20-20)
12    Sec. 20-20. Base Medicaid rates or add-on payments.
13    (a) For services under subsection (a) of Section 20-10: .
14     No base Medicaid rate or Medicaid rate add-on payment or
15any other payment for the provision of Medicaid community
16mental health services in place on July 1, 2021 shall be
17diminished or changed to make the reimbursement changes
18required by this Act. Any payments required under this Act
19that are delayed due to implementation challenges or federal
20approval shall be made retroactive to July 1, 2022 for the full
21amount required by this Act.
22    (b) For directed payments under subsection (b) of Section
2320-10: .
24     No base Medicaid rate payment or any other payment for the
25provision of Medicaid community mental health services in

 

 

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1place on January 1, 2023 shall be diminished or changed to make
2the reimbursement changes required by this Act. The Department
3of Healthcare and Family Services must pay the directed
4payment in one installment within 60 days of receiving federal
5approval.
6    (c) For directed payments under subsection (c) of Section
720-10:
8    No base Medicaid rate payment or any other payment for the
9provision of Medicaid community mental health services in
10place on January 1, 2023 shall be diminished or changed to make
11the reimbursement changes required by this amendatory Act of
12the 103rd General Assembly. Any payments required under this
13amendatory Act of the 103rd General Assembly that are delayed
14due to implementation challenges or federal approval shall be
15made retroactive to no later than January 1, 2024 for the full
16amount required by this amendatory Act of the 103rd General
17Assembly.
18(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23.)
 
19    (305 ILCS 66/20-22 new)
20    Sec. 20-22. Implementation plan for cost reporting.
21    (a) For the purpose of understanding behavioral health
22services cost structures and their impact on the Illinois
23Medical Assistance Program, the Department shall engage
24stakeholders to develop a plan for the regular collection of
25cost reporting for all entity-based providers of behavioral

 

 

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

 

 

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

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

 

 

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

 

 

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

 

 

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1ambulance service providers for oxygen furnished while
2providing advanced life support services.
3    (e) Beginning with services rendered on or after July 1,
42008, all providers of non-emergency medi-car and service car
5transportation must certify that the driver and employee
6attendant, as applicable, have completed a safety program
7approved by the Department to protect both the patient and the
8driver, prior to transporting a patient. The provider must
9maintain this certification in its records. The provider shall
10produce such documentation upon demand by the Department or
11its representative. Failure to produce documentation of such
12training shall result in recovery of any payments made by the
13Department for services rendered by a non-certified driver or
14employee attendant. Medi-car and service car providers must
15maintain legible documentation in their records of the driver
16and, as applicable, employee attendant that actually
17transported the patient. Providers must recertify all drivers
18and employee attendants every 3 years. If they meet the
19established training components set forth by the Department,
20providers of non-emergency medi-car and service car
21transportation that are either directly or through an
22affiliated company licensed by the Department of Public Health
23shall be approved by the Department to have in-house safety
24programs for training their own staff.
25    Notwithstanding the requirements above, any public
26transportation provider of medi-car and service car

 

 

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1transportation that receives federal funding under 49 U.S.C.
25307 and 5311 need not certify its drivers and employee
3attendants under this Section, since safety training is
4already federally mandated.
5    (f) With respect to any policy or program administered by
6the Department or its agent regarding approval of
7non-emergency medical transportation by ground ambulance
8service providers, including, but not limited to, the
9Non-Emergency Transportation Services Prior Approval Program
10(NETSPAP), the Department shall establish by rule a process by
11which ground ambulance service providers of non-emergency
12medical transportation may appeal any decision by the
13Department or its agent for which no denial was received prior
14to the time of transport that either (i) denies a request for
15approval for payment of non-emergency transportation by means
16of ground ambulance service or (ii) grants a request for
17approval of non-emergency transportation by means of ground
18ambulance service at a level of service that entitles the
19ground ambulance service provider to a lower level of
20compensation from the Department than the ground ambulance
21service provider would have received as compensation for the
22level of service requested. The rule shall be filed by
23December 15, 2012 and shall provide that, for any decision
24rendered by the Department or its agent on or after the date
25the rule takes effect, the ground ambulance service provider
26shall have 60 days from the date the decision is received to

 

 

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

 

 

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1during a medical appointment in instances where the Department
2or a contracted Medicaid managed care organization or their
3transportation broker is unable to secure transportation
4through any other transportation provider.
5    (f-7) For non-emergency ground ambulance claims properly
6denied under Department policy at the time the claim is filed
7due to failure to submit a valid Medical Certification for
8Non-Emergency Ambulance on and after December 15, 2012 and
9prior to January 1, 2021, the Department shall allot
10$2,000,000 to a pool to reimburse such claims if the provider
11proves medical necessity for the service by other means.
12Providers must submit any such denied claims for which they
13seek compensation to the Department no later than December 31,
142021 along with documentation of medical necessity. No later
15than May 31, 2022, the Department shall determine for which
16claims medical necessity was established. Such claims for
17which medical necessity was established shall be paid at the
18rate in effect at the time of the service, provided the
19$2,000,000 is sufficient to pay at those rates. If the pool is
20not sufficient, claims shall be paid at a uniform percentage
21of the applicable rate such that the pool of $2,000,000 is
22exhausted. The appeal process described in subsection (f)
23shall not be applicable to the Department's determinations
24made in accordance with this subsection.
25    (g) Whenever a patient covered by a medical assistance
26program under this Code or by another medical program

 

 

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

 

 

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1the U.S. Postal Service, facsimile receipt, email receipt, or
2other similar service that evidences that the ground ambulance
3provider, medi-car provider, or service car provider attempted
4to obtain the required Physician Certification Statement.
5    The medical certification specifying the level and type of
6non-emergency transportation needed shall be in the form of
7the Physician Certification Statement on a standardized form
8prescribed by the Department of Healthcare and Family
9Services. Within 75 days after July 27, 2018 (the effective
10date of Public Act 100-646), the Department of Healthcare and
11Family Services shall develop a standardized form of the
12Physician Certification Statement specifying the level and
13type of transportation services needed in consultation with
14the Department of Public Health, Medicaid managed care
15organizations, a statewide association representing ambulance
16providers, a statewide association representing hospitals, 3
17statewide associations representing nursing homes, and other
18stakeholders. The Physician Certification Statement shall
19include, but is not limited to, the criteria necessary to
20demonstrate medical necessity for the level of transport
21needed as required by (i) the Department of Healthcare and
22Family Services and (ii) the federal Centers for Medicare and
23Medicaid Services as outlined in the Centers for Medicare and
24Medicaid Services' Medicare Benefit Policy Manual, Pub.
25100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
26Certification Statement shall satisfy the obligations of

 

 

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

 

 

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1accordance with Section 5-5e.
2    (i) On and after July 1, 2018, the Department shall
3increase the base rate of reimbursement for both base charges
4and mileage charges for ground ambulance service providers for
5medical transportation services provided by means of a ground
6ambulance to a level not lower than 112% of the base rate in
7effect as of June 30, 2018.
8    (j) Subject to federal approval, beginning on January 1,
92024, the Department shall increase the base rate of
10reimbursement for both base charges and mileage charges for
11medical transportation services provided by means of an air
12ambulance to a level not lower than 50% of the Medicare
13ambulance fee schedule rates, by designated Medicare locality,
14in 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, on
6and after January 1, 2024, each tier rate shall be increased 6%
7over the amount in effect on the effective date of this
8amendatory Act of the 103rd General Assembly. Any
9reimbursement increases applied to the base rate to providers
10licensed under the ID/DD Community Care Act must also be
11applied in an equivalent manner to each tier of exceptional
12care per diem rates for medically complex for the
13developmentally disabled facilities.
14    (d) For residents on a ventilator pursuant to subsection
15(c) or subsection (f), facilities shall have a policy
16documenting their method of routine assessment of a resident's
17weaning potential with interventions implemented noted in the
18resident's medical record.
19    (e) For services provided prior to April 1, 2019 and for
20the purposes of this Section, a resident is considered
21clinically complex if the resident requires at least one of
22the following medical services:
23        (1) Tracheostomy care with dependence on mechanical
24    ventilation for a minimum of 6 hours each day.
25        (2) Tracheostomy care requiring suctioning at least
26    every 6 hours, room air mist or oxygen as needed, and

 

 

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

 

 

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

 

 

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1than the rates specified in this Section. The rates in this
2Section must be interpreted as a minimum amount. Any
3reimbursement increases applied to providers licensed under
4the ID/DD Community Care Act must also be applied in an
5equivalent manner to medically complex for the developmentally
6disabled facilities.
7    (h) The Department of Healthcare and Family Services shall
8pay the rates in effect on March 31, 2019 until the changes
9made to this Section by this amendatory Act of the 100th
10General Assembly have been approved by the Centers for
11Medicare and Medicaid Services of the U.S. Department of
12Health and Human Services.
13    (i) The Department of Healthcare and Family Services may
14adopt rules as allowed by the Illinois Administrative
15Procedure Act to implement this Section; however, the
16requirements of this Section must be implemented by the
17Department of Healthcare and Family Services even if the
18Department of Healthcare and Family Services has not adopted
19rules by the implementation date of April 1, 2019.
20(Source: P.A. 100-646, eff. 7-27-18.)
 
21
ARTICLE 80.

 
22    Section 80-5. The Illinois Public Aid Code is amended by
23changing Section 5-4.2 as follows:
 

 

 

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1    (305 ILCS 5/5-4.2)
2    Sec. 5-4.2. Ambulance services payments.
3    (a) For ambulance services provided to a recipient of aid
4under this Article on or after January 1, 1993, the Illinois
5Department shall reimburse ambulance service providers at
6rates calculated in accordance with this Section. It is the
7intent of the General Assembly to provide adequate
8reimbursement for ambulance services so as to ensure adequate
9access to services for recipients of aid under this Article
10and to provide appropriate incentives to ambulance service
11providers to provide services in an efficient and
12cost-effective manner. Thus, it is the intent of the General
13Assembly that the Illinois Department implement a
14reimbursement system for ambulance services that, to the
15extent practicable and subject to the availability of funds
16appropriated by the General Assembly for this purpose, is
17consistent with the payment principles of Medicare. To ensure
18uniformity between the payment principles of Medicare and
19Medicaid, the Illinois Department shall follow, to the extent
20necessary and practicable and subject to the availability of
21funds appropriated by the General Assembly for this purpose,
22the statutes, laws, regulations, policies, procedures,
23principles, definitions, guidelines, and manuals used to
24determine the amounts paid to ambulance service providers
25under Title XVIII of the Social Security Act (Medicare).
26    (b) For ambulance services provided to a recipient of aid

 

 

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1under this Article on or after January 1, 1996, the Illinois
2Department shall reimburse ambulance service providers based
3upon the actual distance traveled if a natural disaster,
4weather conditions, road repairs, or traffic congestion
5necessitates the use of a route other than the most direct
6route.
7    (c) For purposes of this Section, "ambulance services"
8includes medical transportation services provided by means of
9an ambulance, medi-car, service car, or taxi.
10    (c-1) For purposes of this Section, "ground ambulance
11service" means medical transportation services that are
12described as ground ambulance services by the Centers for
13Medicare and Medicaid Services and provided in a vehicle that
14is licensed as an ambulance by the Illinois Department of
15Public Health pursuant to the Emergency Medical Services (EMS)
16Systems Act.
17    (c-2) For purposes of this Section, "ground ambulance
18service provider" means a vehicle service provider as
19described in the Emergency Medical Services (EMS) Systems Act
20that operates licensed ambulances for the purpose of providing
21emergency ambulance services, or non-emergency ambulance
22services, or both. For purposes of this Section, this includes
23both ambulance providers and ambulance suppliers as described
24by the Centers for Medicare and Medicaid Services.
25    (c-3) For purposes of this Section, "medi-car" means
26transportation services provided to a patient who is confined

 

 

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1to a wheelchair and requires the use of a hydraulic or electric
2lift or ramp and wheelchair lockdown when the patient's
3condition does not require medical observation, medical
4supervision, medical equipment, the administration of
5medications, or the administration of oxygen.
6    (c-4) For purposes of this Section, "service car" means
7transportation services provided to a patient by a passenger
8vehicle where that patient does not require the specialized
9modes described in subsection (c-1) or (c-3).
10    (d) This Section does not prohibit separate billing by
11ambulance service providers for oxygen furnished while
12providing advanced life support services.
13    (e) Beginning with services rendered on or after July 1,
142008, all providers of non-emergency medi-car and service car
15transportation must certify that the driver and employee
16attendant, as applicable, have completed a safety program
17approved by the Department to protect both the patient and the
18driver, prior to transporting a patient. The provider must
19maintain this certification in its records. The provider shall
20produce such documentation upon demand by the Department or
21its representative. Failure to produce documentation of such
22training shall result in recovery of any payments made by the
23Department for services rendered by a non-certified driver or
24employee attendant. Medi-car and service car providers must
25maintain legible documentation in their records of the driver
26and, as applicable, employee attendant that actually

 

 

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1transported the patient. Providers must recertify all drivers
2and employee attendants every 3 years. If they meet the
3established training components set forth by the Department,
4providers of non-emergency medi-car and service car
5transportation that are either directly or through an
6affiliated company licensed by the Department of Public Health
7shall be approved by the Department to have in-house safety
8programs for training their own staff.
9    Notwithstanding the requirements above, any public
10transportation provider of medi-car and service car
11transportation that receives federal funding under 49 U.S.C.
125307 and 5311 need not certify its drivers and employee
13attendants under this Section, since safety training is
14already federally mandated.
15    (f) With respect to any policy or program administered by
16the Department or its agent regarding approval of
17non-emergency medical transportation by ground ambulance
18service providers, including, but not limited to, the
19Non-Emergency Transportation Services Prior Approval Program
20(NETSPAP), the Department shall establish by rule a process by
21which ground ambulance service providers of non-emergency
22medical transportation may appeal any decision by the
23Department or its agent for which no denial was received prior
24to the time of transport that either (i) denies a request for
25approval for payment of non-emergency transportation by means
26of ground ambulance service or (ii) grants a request for

 

 

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

 

 

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1Department has submitted the criteria for determining the
2appropriateness of the transport for first notice publication
3in the Illinois Register pursuant to Section 5-40 of the
4Illinois Administrative Procedure Act.
5    (f-6) Within 90 days after the effective date of this
6amendatory Act of the 102nd General Assembly and subject to
7federal approval, the Department shall file rules to allow for
8the approval of ground ambulance services when the sole
9purpose of the transport is for the navigation of stairs or the
10assisting or lifting of a patient at a medical facility or
11during a medical appointment in instances where the Department
12or a contracted Medicaid managed care organization or their
13transportation broker is unable to secure transportation
14through any other transportation provider.
15    (f-7) For non-emergency ground ambulance claims properly
16denied under Department policy at the time the claim is filed
17due to failure to submit a valid Medical Certification for
18Non-Emergency Ambulance on and after December 15, 2012 and
19prior to January 1, 2021, the Department shall allot
20$2,000,000 to a pool to reimburse such claims if the provider
21proves medical necessity for the service by other means.
22Providers must submit any such denied claims for which they
23seek compensation to the Department no later than December 31,
242021 along with documentation of medical necessity. No later
25than May 31, 2022, the Department shall determine for which
26claims medical necessity was established. Such claims for

 

 

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

 

 

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1Physician Certification Statement is not required prior to
2transport if a delay in transport can be expected to
3negatively affect the patient outcome. If the ground ambulance
4provider, medi-car provider, or service car provider is unable
5to obtain the required Physician Certification Statement
6within 10 calendar days following the date of the service, the
7ground ambulance provider, medi-car provider, or service car
8provider must document its attempt to obtain the requested
9certification and may then submit the claim for payment.
10Acceptable documentation includes a signed return receipt from
11the U.S. Postal Service, facsimile receipt, email receipt, or
12other similar service that evidences that the ground ambulance
13provider, medi-car provider, or service car provider attempted
14to obtain the required Physician Certification Statement.
15    The medical certification specifying the level and type of
16non-emergency transportation needed shall be in the form of
17the Physician Certification Statement on a standardized form
18prescribed by the Department of Healthcare and Family
19Services. Within 75 days after July 27, 2018 (the effective
20date of Public Act 100-646), the Department of Healthcare and
21Family Services shall develop a standardized form of the
22Physician Certification Statement specifying the level and
23type of transportation services needed in consultation with
24the Department of Public Health, Medicaid managed care
25organizations, a statewide association representing ambulance
26providers, a statewide association representing hospitals, 3

 

 

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1statewide associations representing nursing homes, and other
2stakeholders. The Physician Certification Statement shall
3include, but is not limited to, the criteria necessary to
4demonstrate medical necessity for the level of transport
5needed as required by (i) the Department of Healthcare and
6Family Services and (ii) the federal Centers for Medicare and
7Medicaid Services as outlined in the Centers for Medicare and
8Medicaid Services' Medicare Benefit Policy Manual, Pub.
9100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
10Certification Statement shall satisfy the obligations of
11hospitals under Section 6.22 of the Hospital Licensing Act and
12nursing homes under Section 2-217 of the Nursing Home Care
13Act. Implementation and acceptance of the Physician
14Certification Statement shall take place no later than 90 days
15after the issuance of the Physician Certification Statement by
16the Department of Healthcare and Family Services.
17    Pursuant to subsection (E) of Section 12-4.25 of this
18Code, the Department is entitled to recover overpayments paid
19to a provider or vendor, including, but not limited to, from
20the discharging physician, the discharging facility, and the
21ground ambulance service provider, in instances where a
22non-emergency ground ambulance service is rendered as the
23result of improper or false certification.
24    Beginning October 1, 2018, the Department of Healthcare
25and Family Services shall collect data from Medicaid managed
26care organizations and transportation brokers, including the

 

 

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1Department's NETSPAP broker, regarding denials and appeals
2related to the missing or incomplete Physician Certification
3Statement forms and overall compliance with this subsection.
4The Department of Healthcare and Family Services shall publish
5quarterly results on its website within 15 days following the
6end of each quarter.
7    (h) On and after July 1, 2012, the Department shall reduce
8any rate of reimbursement for services or other payments or
9alter any methodologies authorized by this Code to reduce any
10rate of reimbursement for services or other payments in
11accordance with Section 5-5e.
12    (i) Subject to federal approval, on and after January 1,
132024 through June 30, 2026, On and after July 1, 2018, the
14Department shall increase the base rate of reimbursement for
15both base charges and mileage charges for ground ambulance
16service providers not participating in the Ground Emergency
17Medical Transportation (GEMT) Program for medical
18transportation services provided by means of a ground
19ambulance to a level not lower than 140% 112% of the base rate
20in effect as of January 1, 2023 June 30, 2018.
21    (j) For the purpose of understanding ground ambulance
22transportation services cost structures and their impact on
23the Medical Assistance Program, the Department shall engage
24stakeholders, including, but not limited to, a statewide
25association representing private ground ambulance service
26providers in Illinois, to develop recommendations for a plan

 

 

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1for the regular collection of cost data for all ground
2ambulance transportation providers reimbursed under the
3Illinois Title XIX State Plan. Cost data obtained through this
4process shall be used to inform on and to ensure the
5effectiveness and efficiency of Illinois Medicaid rates. The
6Department shall establish a process to limit public
7availability of portions of the cost report data determined to
8be proprietary. This process shall be concluded and
9recommendations shall be provided no later than April 1, 2024.
10(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20;
11102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff.
125-13-22; 102-1037, eff. 6-2-22.)
 
13
ARTICLE 85.

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

 

 

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

 

 

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1services for which a person may qualify, consideration shall
2not be given to the value of cash, property or other assets
3held in the name of the person's spouse pursuant to a written
4agreement dividing marital property into equal but separate
5shares or pursuant to a transfer of the person's interest in a
6home to his spouse, provided that the spouse's share of the
7marital property is not made available to the person seeking
8such services.
9    Beginning January 1, 2008, the Department shall require as
10a condition of eligibility that all new financially eligible
11applicants apply for and enroll in medical assistance under
12Article V of the Illinois Public Aid Code in accordance with
13rules promulgated by the Department.