Rep. Greg Harris

Filed: 5/27/2015

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 788

2    AMENDMENT NO. ______. Amend Senate Bill 788 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Emergency Medical Services (EMS) Systems
5Act is amended by changing Section 32.5 as follows:
 
6    (210 ILCS 50/32.5)
7    Sec. 32.5. Freestanding Emergency Center.
8    (a) The Department shall issue an annual Freestanding
9Emergency Center (FEC) license to any facility that has
10received a permit from the Health Facilities and Services
11Review Board to establish a Freestanding Emergency Center by
12January 1, 2015, and:
13        (1) is located: (A) in a municipality with a population
14    of 50,000 or fewer inhabitants; (B) within 50 miles of the
15    hospital that owns or controls the FEC; and (C) within 50
16    miles of the Resource Hospital affiliated with the FEC as

 

 

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1    part of the EMS System;
2        (2) is wholly owned or controlled by an Associate or
3    Resource Hospital, but is not a part of the hospital's
4    physical plant;
5        (3) meets the standards for licensed FECs, adopted by
6    rule of the Department, including, but not limited to:
7            (A) facility design, specification, operation, and
8        maintenance standards;
9            (B) equipment standards; and
10            (C) the number and qualifications of emergency
11        medical personnel and other staff, which must include
12        at least one board certified emergency physician
13        present at the FEC 24 hours per day.
14        (4) limits its participation in the EMS System strictly
15    to receiving a limited number of BLS runs by emergency
16    medical vehicles according to protocols developed by the
17    Resource Hospital within the FEC's designated EMS System
18    and approved by the Project Medical Director and the
19    Department;
20        (5) provides comprehensive emergency treatment
21    services, as defined in the rules adopted by the Department
22    pursuant to the Hospital Licensing Act, 24 hours per day,
23    on an outpatient basis;
24        (6) provides an ambulance and maintains on site
25    ambulance services staffed with paramedics 24 hours per
26    day;

 

 

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1        (7) (blank);
2        (8) complies with all State and federal patient rights
3    provisions, including, but not limited to, the Emergency
4    Medical Treatment Act and the federal Emergency Medical
5    Treatment and Active Labor Act;
6        (9) maintains a communications system that is fully
7    integrated with its Resource Hospital within the FEC's
8    designated EMS System;
9        (10) reports to the Department any patient transfers
10    from the FEC to a hospital within 48 hours of the transfer
11    plus any other data determined to be relevant by the
12    Department;
13        (11) submits to the Department, on a quarterly basis,
14    the FEC's morbidity and mortality rates for patients
15    treated at the FEC and other data determined to be relevant
16    by the Department;
17        (12) does not describe itself or hold itself out to the
18    general public as a full service hospital or hospital
19    emergency department in its advertising or marketing
20    activities;
21        (13) complies with any other rules adopted by the
22    Department under this Act that relate to FECs;
23        (14) passes the Department's site inspection for
24    compliance with the FEC requirements of this Act;
25        (15) submits a copy of the permit issued by the Health
26    Facilities and Services Review Board indicating that the

 

 

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1    facility has complied with the Illinois Health Facilities
2    Planning Act with respect to the health services to be
3    provided at the facility;
4        (16) submits an application for designation as an FEC
5    in a manner and form prescribed by the Department by rule;
6    and
7        (17) pays the annual license fee as determined by the
8    Department by rule.
9    (a-5) Notwithstanding any other provision of this Section,
10the Department may issue an annual FEC license to a facility
11that is located in a county that does not have a licensed
12general acute care hospital if the facility's application for a
13permit from the Illinois Health Facilities Planning Board has
14been deemed complete by the Department of Public Health by
15January 1, 2014 and if the facility complies with the
16requirements set forth in paragraphs (1) through (17) of
17subsection (a).
18    (a-10) Notwithstanding any other provision of this
19Section, the Department may issue an annual FEC license to a
20facility if the facility has, by January 1, 2014, filed a
21letter of intent to establish an FEC and if the facility
22complies with the requirements set forth in paragraphs (1)
23through (17) of subsection (a).
24    (a-15) Notwithstanding any other provision of this
25Section, the Department shall issue an annual FEC license to a
26facility located within a municipality with a population in

 

 

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1excess of 1,000,000 inhabitants if the facility (i) has, by
2January 1, 2016, filed a letter of intent to establish an FEC,
3(ii) has received a certificate of need from the Health
4Facilities and Services Review Board, and (iii) complies with
5all requirements set forth in paragraphs (3) through (17) of
6subsection (a) of this Section and all applicable
7administrative rules. Any FEC located in a municipality with a
8population in excess of 1,000,000 inhabitants shall not be
9required to be wholly owned or controlled by an Associate
10Hospital or Resource Hospital; however, all patients needing
11emergent or urgent evaluation or treatment beyond the FEC's
12ability shall be expeditiously transferred to the closest
13appropriate health care facility based on the patient's acuity
14and needs. The FEC shall have a transfer agreement in place
15with at least one acute care hospital in the FEC's service area
16within 30 minutes travel time of the FEC. The medical director
17of the FEC shall have full admitting privileges at a hospital
18with which the FEC has a transfer agreement and shall agree in
19writing to assume responsibility for all FEC patients requiring
20follow-up care in accordance with the transfer agreement. For
21an FEC established under this subsection (a-15), the facility
22shall have the authority to create up to 10 observation beds as
23further defined by rule. The Department shall issue no more
24than one such license in a municipality with a population in
25excess of 1,000,000 inhabitants and shall give consideration to
26underserved areas, particularly those that have recently lost

 

 

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1access to emergency care through the loss of an emergency care
2provider. An FEC qualifying under this subsection (a-15) shall
3fully participate with and function within a Department
4approved local EMS System.
5    (b) The Department shall:
6        (1) annually inspect facilities of initial FEC
7    applicants and licensed FECs, and issue annual licenses to
8    or annually relicense FECs that satisfy the Department's
9    licensure requirements as set forth in subsection (a);
10        (2) suspend, revoke, refuse to issue, or refuse to
11    renew the license of any FEC, after notice and an
12    opportunity for a hearing, when the Department finds that
13    the FEC has failed to comply with the standards and
14    requirements of the Act or rules adopted by the Department
15    under the Act;
16        (3) issue an Emergency Suspension Order for any FEC
17    when the Director or his or her designee has determined
18    that the continued operation of the FEC poses an immediate
19    and serious danger to the public health, safety, and
20    welfare. An opportunity for a hearing shall be promptly
21    initiated after an Emergency Suspension Order has been
22    issued; and
23        (4) adopt rules as needed to implement this Section.
24(Source: P.A. 96-23, eff. 6-30-09; 96-31, eff. 6-30-09; 96-883,
25eff. 3-1-10; 96-1000, eff. 7-2-10; 97-333, eff. 8-12-11;
2697-1112, eff. 8-27-12.)
 

 

 

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1    Section 15. The Illinois Public Aid Code is amended by
2changing Sections 5-5, 5-5.2, 5-30, 5A-2, 5A-12.2, 5A-12.5,
35A-13, 5G-10, 11-5.4, 12-13.1, and 14-11 and by adding Sections
45-5b.1a, 5-5b.2, 5-30.2, 5-30.3, 5-30.4, 5-30.5, 12-4.49, and
512-4.50 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 home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective
24procedures provided by or under the supervision of a dentist in

 

 

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1the practice of his or her profession; (11) physical therapy
2and related services; (12) prescribed drugs, dentures, and
3prosthetic devices; and eyeglasses prescribed by a physician
4skilled in the diseases of the eye, or by an optometrist,
5whichever the person may select; (13) other diagnostic,
6screening, preventive, and rehabilitative services, including
7to ensure that the individual's need for intervention or
8treatment of mental disorders or substance use disorders or
9co-occurring mental health and substance use disorders is
10determined using a uniform screening, assessment, and
11evaluation process inclusive of criteria, for children and
12adults; for purposes of this item (13), a uniform screening,
13assessment, and evaluation process refers to a process that
14includes an appropriate evaluation and, as warranted, a
15referral; "uniform" does not mean the use of a singular
16instrument, tool, or process that all must utilize; (14)
17transportation and such other expenses as may be necessary;
18(15) medical treatment of sexual assault survivors, as defined
19in Section 1a of the Sexual Assault Survivors Emergency
20Treatment Act, for injuries sustained as a result of the sexual
21assault, including examinations and laboratory tests to
22discover evidence which may be used in criminal proceedings
23arising from the sexual assault; (16) the diagnosis and
24treatment of sickle cell anemia; (16.5) services delivered by
25facilities licensed under the Specialized Mental Health
26Rehabilitation Act of 2013; and (17) any other medical care,

 

 

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1and any other type of remedial care recognized under the laws
2of this State, but not including abortions, or induced
3miscarriages or premature births, unless, in the opinion of a
4physician, such procedures are necessary for the preservation
5of the life of the woman seeking such treatment, or except an
6induced premature birth intended to produce a live viable child
7and such procedure is necessary for the health of the mother or
8her unborn child. The Illinois Department, by rule, shall
9prohibit any physician from providing medical assistance to
10anyone eligible therefor under this Code where such physician
11has been found guilty of performing an abortion procedure in a
12wilful and wanton manner upon a woman who was not pregnant at
13the time such abortion procedure was performed. The term "any
14other type of remedial care" shall include nursing care and
15nursing home service for persons who rely on treatment by
16spiritual means alone through prayer for healing.
17    Notwithstanding any other provision of this Section, a
18comprehensive tobacco use cessation program that includes
19purchasing prescription drugs or prescription medical devices
20approved by the Food and Drug Administration shall be covered
21under the medical assistance program under this Article for
22persons who are otherwise eligible for assistance under this
23Article.
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a

 

 

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

 

 

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1operated by the Department of Human Services as successor to
2the Department of Public Aid:
3        (1) dental services provided by or under the
4    supervision of a dentist; and
5        (2) eyeglasses prescribed by a physician skilled in the
6    diseases of the eye, or by an optometrist, whichever the
7    person may select.
8    Notwithstanding any other provision of this Code and
9subject to federal approval, the Department may adopt rules to
10allow a dentist who is volunteering his or her service at no
11cost to render dental services through an enrolled
12not-for-profit health clinic without the dentist personally
13enrolling as a participating provider in the medical assistance
14program. A not-for-profit health clinic shall include a public
15health clinic or Federally Qualified Health Center or other
16enrolled provider, as determined by the Department, through
17which dental services covered under this Section are performed.
18The Department shall establish a process for payment of claims
19for reimbursement for covered dental services rendered under
20this provision.
21    The Illinois Department, by rule, may distinguish and
22classify the medical services to be provided only in accordance
23with the classes of persons designated in Section 5-2.
24    The Department of Healthcare and Family Services must
25provide coverage and reimbursement for amino acid-based
26elemental formulas, regardless of delivery method, for the

 

 

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1diagnosis and treatment of (i) eosinophilic disorders and (ii)
2short bowel syndrome when the prescribing physician has issued
3a written order stating that the amino acid-based elemental
4formula is medically necessary.
5    The Illinois Department shall authorize the provision of,
6and shall authorize payment for, screening by low-dose
7mammography for the presence of occult breast cancer for women
835 years of age or older who are eligible for medical
9assistance under this Article, as follows:
10        (A) A baseline mammogram for women 35 to 39 years of
11    age.
12        (B) An annual mammogram for women 40 years of age or
13    older.
14        (C) A mammogram at the age and intervals considered
15    medically necessary by the woman's health care provider for
16    women under 40 years of age and having a family history of
17    breast cancer, prior personal history of breast cancer,
18    positive genetic testing, or other risk factors.
19        (D) A comprehensive ultrasound screening of an entire
20    breast or breasts if a mammogram demonstrates
21    heterogeneous or dense breast tissue, when medically
22    necessary as determined by a physician licensed to practice
23    medicine in all of its branches.
24    All screenings shall include a physical breast exam,
25instruction on self-examination and information regarding the
26frequency of self-examination and its value as a preventative

 

 

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1tool. For purposes of this Section, "low-dose mammography"
2means the x-ray examination of the breast using equipment
3dedicated specifically for mammography, including the x-ray
4tube, filter, compression device, and image receptor, with an
5average radiation exposure delivery of less than one rad per
6breast for 2 views of an average size breast. The term also
7includes digital mammography.
8    On and after January 1, 2012, providers participating in a
9quality improvement program approved by the Department shall be
10reimbursed for screening and diagnostic mammography at the same
11rate as the Medicare program's rates, including the increased
12reimbursement for digital mammography.
13    The Department shall convene an expert panel including
14representatives of hospitals, free-standing mammography
15facilities, and doctors, including radiologists, to establish
16quality standards.
17    Subject to federal approval, the Department shall
18establish a rate methodology for mammography at federally
19qualified health centers and other encounter-rate clinics.
20These clinics or centers may also collaborate with other
21hospital-based mammography facilities.
22    The Department shall establish a methodology to remind
23women who are age-appropriate for screening mammography, but
24who have not received a mammogram within the previous 18
25months, of the importance and benefit of screening mammography.
26    The Department shall establish a performance goal for

 

 

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1primary care providers with respect to their female patients
2over age 40 receiving an annual mammogram. This performance
3goal shall be used to provide additional reimbursement in the
4form of a quality performance bonus to primary care providers
5who meet that goal.
6    The Department shall devise a means of case-managing or
7patient navigation for beneficiaries diagnosed with breast
8cancer. This program shall initially operate as a pilot program
9in areas of the State with the highest incidence of mortality
10related to breast cancer. At least one pilot program site shall
11be in the metropolitan Chicago area and at least one site shall
12be outside the metropolitan Chicago area. An evaluation of the
13pilot program shall be carried out measuring health outcomes
14and cost of care for those served by the pilot program compared
15to similarly situated patients who are not served by the pilot
16program.
17    Any medical or health care provider shall immediately
18recommend, to any pregnant woman who is being provided prenatal
19services and is suspected of drug abuse or is addicted as
20defined in the Alcoholism and Other Drug Abuse and Dependency
21Act, referral to a local substance abuse treatment provider
22licensed by the Department of Human Services or to a licensed
23hospital which provides substance abuse treatment services.
24The Department of Healthcare and Family Services shall assure
25coverage for the cost of treatment of the drug abuse or
26addiction for pregnant recipients in accordance with the

 

 

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1Illinois Medicaid Program in conjunction with the Department of
2Human Services.
3    All medical providers providing medical assistance to
4pregnant women under this Code shall receive information from
5the Department on the availability of services under the Drug
6Free Families with a Future or any comparable program providing
7case management services for addicted women, including
8information on appropriate referrals for other social services
9that may be needed by addicted women in addition to treatment
10for addiction.
11    The Illinois Department, in cooperation with the
12Departments of Human Services (as successor to the Department
13of Alcoholism and Substance Abuse) and Public Health, through a
14public awareness campaign, may provide information concerning
15treatment for alcoholism and drug abuse and addiction, prenatal
16health care, and other pertinent programs directed at reducing
17the number of drug-affected infants born to recipients of
18medical assistance.
19    Neither the Department of Healthcare and Family Services
20nor the Department of Human Services shall sanction the
21recipient solely on the basis of her substance abuse.
22    The Illinois Department shall establish such regulations
23governing the dispensing of health services under this Article
24as it shall deem appropriate. The Department should seek the
25advice of formal professional advisory committees appointed by
26the Director of the Illinois Department for the purpose of

 

 

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1providing regular advice on policy and administrative matters,
2information dissemination and educational activities for
3medical and health care providers, and consistency in
4procedures to the Illinois Department.
5    The Illinois Department may develop and contract with
6Partnerships of medical providers to arrange medical services
7for persons eligible under Section 5-2 of this Code.
8Implementation of this Section may be by demonstration projects
9in certain geographic areas. The Partnership shall be
10represented by a sponsor organization. The Department, by rule,
11shall develop qualifications for sponsors of Partnerships.
12Nothing in this Section shall be construed to require that the
13sponsor organization be a medical organization.
14    The sponsor must negotiate formal written contracts with
15medical providers for physician services, inpatient and
16outpatient hospital care, home health services, treatment for
17alcoholism and substance abuse, and other services determined
18necessary by the Illinois Department by rule for delivery by
19Partnerships. Physician services must include prenatal and
20obstetrical care. The Illinois Department shall reimburse
21medical services delivered by Partnership providers to clients
22in target areas according to provisions of this Article and the
23Illinois Health Finance Reform Act, except that:
24        (1) Physicians participating in a Partnership and
25    providing certain services, which shall be determined by
26    the Illinois Department, to persons in areas covered by the

 

 

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1    Partnership may receive an additional surcharge for such
2    services.
3        (2) The Department may elect to consider and negotiate
4    financial incentives to encourage the development of
5    Partnerships and the efficient delivery of medical care.
6        (3) Persons receiving medical services through
7    Partnerships may receive medical and case management
8    services above the level usually offered through the
9    medical assistance program.
10    Medical providers shall be required to meet certain
11qualifications to participate in Partnerships to ensure the
12delivery of high quality medical services. These
13qualifications shall be determined by rule of the Illinois
14Department and may be higher than qualifications for
15participation in the medical assistance program. Partnership
16sponsors may prescribe reasonable additional qualifications
17for participation by medical providers, only with the prior
18written approval of the Illinois Department.
19    Nothing in this Section shall limit the free choice of
20practitioners, hospitals, and other providers of medical
21services by clients. In order to ensure patient freedom of
22choice, the Illinois Department shall immediately promulgate
23all rules and take all other necessary actions so that provided
24services may be accessed from therapeutically certified
25optometrists to the full extent of the Illinois Optometric
26Practice Act of 1987 without discriminating between service

 

 

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1providers.
2    The Department shall apply for a waiver from the United
3States Health Care Financing Administration to allow for the
4implementation of Partnerships under this Section.
5    The Illinois Department shall require health care
6providers to maintain records that document the medical care
7and services provided to recipients of Medical Assistance under
8this Article. Such records must be retained for a period of not
9less than 6 years from the date of service or as provided by
10applicable State law, whichever period is longer, except that
11if an audit is initiated within the required retention period
12then the records must be retained until the audit is completed
13and every exception is resolved. The Illinois Department shall
14require health care providers to make available, when
15authorized by the patient, in writing, the medical records in a
16timely fashion to other health care providers who are treating
17or serving persons eligible for Medical Assistance under this
18Article. All dispensers of medical services shall be required
19to maintain and retain business and professional records
20sufficient to fully and accurately document the nature, scope,
21details and receipt of the health care provided to persons
22eligible for medical assistance under this Code, in accordance
23with regulations promulgated by the Illinois Department. The
24rules and regulations shall require that proof of the receipt
25of prescription drugs, dentures, prosthetic devices and
26eyeglasses by eligible persons under this Section accompany

 

 

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1each claim for reimbursement submitted by the dispenser of such
2medical services. No such claims for reimbursement shall be
3approved for payment by the Illinois Department without such
4proof of receipt, unless the Illinois Department shall have put
5into effect and shall be operating a system of post-payment
6audit and review which shall, on a sampling basis, be deemed
7adequate by the Illinois Department to assure that such drugs,
8dentures, prosthetic devices and eyeglasses for which payment
9is being made are actually being received by eligible
10recipients. Within 90 days after the effective date of this
11amendatory Act of 1984, the Illinois Department shall establish
12a current list of acquisition costs for all prosthetic devices
13and any other items recognized as medical equipment and
14supplies reimbursable under this Article and shall update such
15list on a quarterly basis, except that the acquisition costs of
16all prescription drugs shall be updated no less frequently than
17every 30 days as required by Section 5-5.12.
18    The rules and regulations of the Illinois Department shall
19require that a written statement including the required opinion
20of a physician shall accompany any claim for reimbursement for
21abortions, or induced miscarriages or premature births. This
22statement shall indicate what procedures were used in providing
23such medical services.
24    Notwithstanding any other law to the contrary, the Illinois
25Department shall, by July 1, 2016, within 365 days after July
2622, 2013, (the effective date of Public Act 98-104), establish

 

 

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1procedures to permit skilled care facilities licensed under the
2Nursing Home Care Act to submit monthly billing claims for
3reimbursement purposes. Following development of these
4procedures, the Department shall have an additional 365 days to
5test the viability of the new system and to ensure that any
6necessary operational or structural changes to its information
7technology platforms are implemented.
8    Notwithstanding any other law to the contrary, the Illinois
9Department shall, by July 1, 2016, within 365 days after the
10effective date of this amendatory Act of the 98th General
11Assembly, establish procedures to permit ID/DD facilities
12licensed under the ID/DD Community Care Act to submit monthly
13billing claims for reimbursement purposes. Following
14development of these procedures, the Department shall have an
15additional 365 days to test the viability of the new system and
16to ensure that any necessary operational or structural changes
17to its information technology platforms are implemented.
18    The Illinois Department shall require all dispensers of
19medical services, other than an individual practitioner or
20group of practitioners, desiring to participate in the Medical
21Assistance program established under this Article to disclose
22all financial, beneficial, ownership, equity, surety or other
23interests in any and all firms, corporations, partnerships,
24associations, business enterprises, joint ventures, agencies,
25institutions or other legal entities providing any form of
26health care services in this State under this Article.

 

 

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1    The Illinois Department may require that all dispensers of
2medical services desiring to participate in the medical
3assistance program established under this Article disclose,
4under such terms and conditions as the Illinois Department may
5by rule establish, all inquiries from clients and attorneys
6regarding medical bills paid by the Illinois Department, which
7inquiries could indicate potential existence of claims or liens
8for the Illinois Department.
9    Enrollment of a vendor shall be subject to a provisional
10period and shall be conditional for one year. During the period
11of conditional enrollment, the Department may terminate the
12vendor's eligibility to participate in, or may disenroll the
13vendor from, the medical assistance program without cause.
14Unless otherwise specified, such termination of eligibility or
15disenrollment is not subject to the Department's hearing
16process. However, a disenrolled vendor may reapply without
17penalty.
18    The Department has the discretion to limit the conditional
19enrollment period for vendors based upon category of risk of
20the vendor.
21    Prior to enrollment and during the conditional enrollment
22period in the medical assistance program, all vendors shall be
23subject to enhanced oversight, screening, and review based on
24the risk of fraud, waste, and abuse that is posed by the
25category of risk of the vendor. The Illinois Department shall
26establish the procedures for oversight, screening, and review,

 

 

09900SB0788ham002- 22 -LRB099 05889 KTG 36238 a

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

 

 

09900SB0788ham002- 23 -LRB099 05889 KTG 36238 a

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

 

 

09900SB0788ham002- 24 -LRB099 05889 KTG 36238 a

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

 

 

09900SB0788ham002- 25 -LRB099 05889 KTG 36238 a

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

 

 

09900SB0788ham002- 26 -LRB099 05889 KTG 36238 a

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

 

 

09900SB0788ham002- 27 -LRB099 05889 KTG 36238 a

1prescreening project, written inter-agency agreements with the
2Department of Human Services and the Department on Aging, to
3effect the following: (i) intake procedures and common
4eligibility criteria for those persons who are receiving
5non-institutional services; and (ii) the establishment and
6development of non-institutional services in areas of the State
7where they are not currently available or are undeveloped; and
8(iii) notwithstanding any other provision of law, subject to
9federal approval, on and after July 1, 2012, an increase in the
10determination of need (DON) scores from 29 to 37 for applicants
11for institutional and home and community-based long term care;
12if and only if federal approval is not granted, the Department
13may, in conjunction with other affected agencies, implement
14utilization controls or changes in benefit packages to
15effectuate a similar savings amount for this population; and
16(iv) no later than July 1, 2013, minimum level of care
17eligibility criteria for institutional and home and
18community-based long term care; and (v) no later than October
191, 2013, establish procedures to permit long term care
20providers access to eligibility scores for individuals with an
21admission date who are seeking or receiving services from the
22long term care provider. In order to select the minimum level
23of care eligibility criteria, the Governor shall establish a
24workgroup that includes affected agency representatives and
25stakeholders representing the institutional and home and
26community-based long term care interests. This Section shall

 

 

09900SB0788ham002- 28 -LRB099 05889 KTG 36238 a

1not restrict the Department from implementing lower level of
2care eligibility criteria for community-based services in
3circumstances where federal approval has been granted.
4    The Illinois Department shall develop and operate, in
5cooperation with other State Departments and agencies and in
6compliance with applicable federal laws and regulations,
7appropriate and effective systems of health care evaluation and
8programs for monitoring of utilization of health care services
9and facilities, as it affects persons eligible for medical
10assistance under this Code.
11    The Illinois Department shall report annually to the
12General Assembly, no later than the second Friday in April of
131979 and each year thereafter, in regard to:
14        (a) actual statistics and trends in utilization of
15    medical services by public aid recipients;
16        (b) actual statistics and trends in the provision of
17    the various medical services by medical vendors;
18        (c) current rate structures and proposed changes in
19    those rate structures for the various medical vendors; and
20        (d) efforts at utilization review and control by the
21    Illinois Department.
22    The period covered by each report shall be the 3 years
23ending on the June 30 prior to the report. The report shall
24include suggested legislation for consideration by the General
25Assembly. The filing of one copy of the report with the
26Speaker, one copy with the Minority Leader and one copy with

 

 

09900SB0788ham002- 29 -LRB099 05889 KTG 36238 a

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

 

 

09900SB0788ham002- 30 -LRB099 05889 KTG 36238 a

1this Code, and who would otherwise meet the financial
2requirements of the appropriate class of eligible persons under
3Section 5-2 of this Code. To qualify for coverage of kidney
4transplantation, such person must be receiving emergency renal
5dialysis services covered by the Department for at least 2
6years. Providers under this Section shall be prior approved and
7certified by the Department to perform kidney transplantation
8and the services under this Section shall be limited to
9services associated with kidney transplantation.
10(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
11eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
129-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.
137-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651,
14eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14;
15revised 10-2-14.)
 
16    (305 ILCS 5/5-5.2)  (from Ch. 23, par. 5-5.2)
17    Sec. 5-5.2. Payment.
18    (a) All nursing facilities that are grouped pursuant to
19Section 5-5.1 of this Act shall receive the same rate of
20payment for similar services.
21    (b) It shall be a matter of State policy that the Illinois
22Department shall utilize a uniform billing cycle throughout the
23State for the long-term care providers.
24    (c) Notwithstanding any other provisions of this Code, the
25methodologies for reimbursement of nursing services as

 

 

09900SB0788ham002- 31 -LRB099 05889 KTG 36238 a

1provided under this Article shall no longer be applicable for
2bills payable for nursing services rendered on or after a new
3reimbursement system based on the Resource Utilization Groups
4(RUGs) has been fully operationalized, which shall take effect
5for services provided on or after January 1, 2014.
6    (d) The new nursing services reimbursement methodology
7utilizing RUG-IV 48 grouper model, which shall be referred to
8as the RUGs reimbursement system, taking effect January 1,
92014, shall be based on the following:
10        (1) The methodology shall be resident-driven,
11    facility-specific, and cost-based.
12        (2) Costs shall be annually rebased and case mix index
13    quarterly updated. The nursing services methodology will
14    be assigned to the Medicaid enrolled residents on record as
15    of 30 days prior to the beginning of the rate period in the
16    Department's Medicaid Management Information System (MMIS)
17    as present on the last day of the second quarter preceding
18    the rate period based upon the Assessment Reference Date of
19    the Minimum Data Set (MDS).
20        (3) Regional wage adjustors based on the Health Service
21    Areas (HSA) groupings and adjusters in effect on April 30,
22    2012 shall be included.
23        (4) Case mix index shall be assigned to each resident
24    class based on the Centers for Medicare and Medicaid
25    Services staff time measurement study in effect on July 1,
26    2013, utilizing an index maximization approach.

 

 

09900SB0788ham002- 32 -LRB099 05889 KTG 36238 a

1        (5) The pool of funds available for distribution by
2    case mix and the base facility rate shall be determined
3    using the formula contained in subsection (d-1).
4    (d-1) Calculation of base year Statewide RUG-IV nursing
5base per diem rate.
6        (1) Base rate spending pool shall be:
7            (A) The base year resident days which are
8        calculated by multiplying the number of Medicaid
9        residents in each nursing home as indicated in the MDS
10        data defined in paragraph (4) by 365.
11            (B) Each facility's nursing component per diem in
12        effect on July 1, 2012 shall be multiplied by
13        subsection (A).
14            (C) Thirteen million is added to the product of
15        subparagraph (A) and subparagraph (B) to adjust for the
16        exclusion of nursing homes defined in paragraph (5).
17        (2) For each nursing home with Medicaid residents as
18    indicated by the MDS data defined in paragraph (4),
19    weighted days adjusted for case mix and regional wage
20    adjustment shall be calculated. For each home this
21    calculation is the product of:
22            (A) Base year resident days as calculated in
23        subparagraph (A) of paragraph (1).
24            (B) The nursing home's regional wage adjustor
25        based on the Health Service Areas (HSA) groupings and
26        adjustors in effect on April 30, 2012.

 

 

09900SB0788ham002- 33 -LRB099 05889 KTG 36238 a

1            (C) Facility weighted case mix which is the number
2        of Medicaid residents as indicated by the MDS data
3        defined in paragraph (4) multiplied by the associated
4        case weight for the RUG-IV 48 grouper model using
5        standard RUG-IV procedures for index maximization.
6            (D) The sum of the products calculated for each
7        nursing home in subparagraphs (A) through (C) above
8        shall be the base year case mix, rate adjusted weighted
9        days.
10        (3) The Statewide RUG-IV nursing base per diem rate:
11            (A) on January 1, 2014 shall be the quotient of the
12        paragraph (1) divided by the sum calculated under
13        subparagraph (D) of paragraph (2); and
14            (B) on and after July 1, 2014, shall be the amount
15        calculated under subparagraph (A) of this paragraph
16        (3) plus $1.76.
17        (4) Minimum Data Set (MDS) comprehensive assessments
18    for Medicaid residents on the last day of the quarter used
19    to establish the base rate.
20        (5) Nursing facilities designated as of July 1, 2012 by
21    the Department as "Institutions for Mental Disease" shall
22    be excluded from all calculations under this subsection.
23    The data from these facilities shall not be used in the
24    computations described in paragraphs (1) through (4) above
25    to establish the base rate.
26    (e) Beginning July 1, 2014, the Department shall allocate

 

 

09900SB0788ham002- 34 -LRB099 05889 KTG 36238 a

1funding in the amount up to $10,000,000 for per diem add-ons to
2the RUGS methodology for dates of service on and after July 1,
32014:
4        (1) $0.63 for each resident who scores in I4200
5    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
6        (2) $2.67 for each resident who scores either a "1" or
7    "2" in any items S1200A through S1200I and also scores in
8    RUG groups PA1, PA2, BA1, or BA2.
9    (e-1) (Blank).
10    (e-2) For dates of services beginning January 1, 2014, the
11RUG-IV nursing component per diem for a nursing home shall be
12the product of the statewide RUG-IV nursing base per diem rate,
13the facility average case mix index, and the regional wage
14adjustor. Transition rates for services provided between
15January 1, 2014 and December 31, 2014 shall be as follows:
16        (1) The transition RUG-IV per diem nursing rate for
17    nursing homes whose rate calculated in this subsection
18    (e-2) is greater than the nursing component rate in effect
19    July 1, 2012 shall be paid the sum of:
20            (A) The nursing component rate in effect July 1,
21        2012; plus
22            (B) The difference of the RUG-IV nursing component
23        per diem calculated for the current quarter minus the
24        nursing component rate in effect July 1, 2012
25        multiplied by 0.88.
26        (2) The transition RUG-IV per diem nursing rate for

 

 

09900SB0788ham002- 35 -LRB099 05889 KTG 36238 a

1    nursing homes whose rate calculated in this subsection
2    (e-2) is less than the nursing component rate in effect
3    July 1, 2012 shall be paid the sum of:
4            (A) The nursing component rate in effect July 1,
5        2012; plus
6            (B) The difference of the RUG-IV nursing component
7        per diem calculated for the current quarter minus the
8        nursing component rate in effect July 1, 2012
9        multiplied by 0.13.
10    (f) Notwithstanding any other provision of this Code, on
11and after July 1, 2012, reimbursement rates associated with the
12nursing or support components of the current nursing facility
13rate methodology shall not increase beyond the level effective
14May 1, 2011 until a new reimbursement system based on the RUGs
15IV 48 grouper model has been fully operationalized.
16    (g) Notwithstanding any other provision of this Code, on
17and after July 1, 2012, for facilities not designated by the
18Department of Healthcare and Family Services as "Institutions
19for Mental Disease", rates effective May 1, 2011 shall be
20adjusted as follows:
21        (1) Individual nursing rates for residents classified
22    in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter
23    ending March 31, 2012 shall be reduced by 10%;
24        (2) Individual nursing rates for residents classified
25    in all other RUG IV groups shall be reduced by 1.0%;
26        (3) Facility rates for the capital and support

 

 

09900SB0788ham002- 36 -LRB099 05889 KTG 36238 a

1    components shall be reduced by 1.7%.
2    (h) Notwithstanding any other provision of this Code, on
3and after July 1, 2012, nursing facilities designated by the
4Department of Healthcare and Family Services as "Institutions
5for Mental Disease" and "Institutions for Mental Disease" that
6are facilities licensed under the Specialized Mental Health
7Rehabilitation Act of 2013 shall have the nursing,
8socio-developmental, capital, and support components of their
9reimbursement rate effective May 1, 2011 reduced in total by
102.7%.
11    (i) On and after July 1, 2014, the reimbursement rates for
12the support component of the nursing facility rate for
13facilities licensed under the Nursing Home Care Act as skilled
14or intermediate care facilities shall be the rate in effect on
15June 30, 2014 increased by 8.17%.
16    (j) The Department may contract with a third-party auditor
17to perform auditing to determine the accuracy of resident
18assessment information transmitted in the MDS that is relevant
19to the determination of reimbursement rates.
20(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section
216-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff.
227-22-13; 98-651, eff. 6-16-14; 98-727, eff. 7-16-14; 98-756,
23eff. 7-16-14; revised 10-2-14.)
 
24    (305 ILCS 5/5-5b.1a new)
25    Sec. 5-5b.1a. Pharmacy services; dispensing fees. For

 

 

09900SB0788ham002- 37 -LRB099 05889 KTG 36238 a

1pharmacy services limited to the dispensing fees reduced in
2State fiscal year 2015 under Section 5-5b.1, the dispensing
3fees in State fiscal year 2016 shall be $2.35 for brand name
4drugs and $5.38 for generic drugs. Reimbursement methodology
5for product shall not be reduced as a result of this Section.
6This Section does not prevent the Department from making
7customary adjustments to pharmacy product prices for the
8State's Maximum Allowable Cost list for generic prescription
9medicines.
 
10    (305 ILCS 5/5-5b.2 new)
11    Sec. 5-5b.2. Reimbursement rates; fiscal year 2016
12reductions.
13    (a) Except as provided in subsections (b) and (b-1),
14notwithstanding any other provision of this Code to the
15contrary, and subject to rescission if not federally approved,
16providers of the following services shall have their
17reimbursement rates or dispensing fees reduced for State fiscal
18year 2016. For each provider class, the Department must
19calculate a rate reduction which produces for each service type
20a total reduction in State fiscal year 2016 no greater than an
21amount equal to the product of 2.25% multiplied by the
22originally enacted State fiscal year 2015 appropriations from
23the General Revenue Fund for each medical service type. The
24Department must only use appropriations from the General
25Revenue Fund to calculate the rate reduction amount for each

 

 

09900SB0788ham002- 38 -LRB099 05889 KTG 36238 a

1service type. The rate reduction shall be applied equally to
2all services within the service type regardless of the fund
3from which payment is made. Medical services subject to rate
4reduction in State fiscal year 2016 are the following:
5        (1) Nursing facility services delivered by a nursing
6    facility licensed under the Nursing Home Care Act.
7        (2) Home health services.
8        (3) Services delivered by a supportive living facility
9    as defined in Section 5-5.01a.
10        (4) Services delivered by a specialized mental health
11    rehabilitation facility licensed under the Specialized
12    Mental Health Rehabilitation Act of 2013.
13        (5) Medical transportation services, including
14    services delivered by a hospital, provided by (i) emergency
15    and non-emergency ground and air ambulance, (ii) medi-car,
16    (iii) service car, and (iv) taxi cab.
17        (6) Capitation payment rates to managed care entities
18    shall include all reductions for those services as provided
19    in this Section, as well as reductions in the
20    administrative portion of the capitation rate. All
21    reductions shall be made in an actuarially sound manner.
22        (7) Services for the treatment of hemophilia.
23        (8) Physician services.
24        (9) Dental services.
25        (10) Optometric services.
26        (11) Podiatry services.

 

 

09900SB0788ham002- 39 -LRB099 05889 KTG 36238 a

1        (12) Laboratory services or services provided by
2    independent laboratories.
3        (13) Durable medical equipment and supplies.
4        (14) Renal dialysis services.
5        (15) Birth Center Services.
6        (16) Emergency services other than those offered by or
7    in a hospital.
8    (b) No provider shall be exempt from the rate reductions
9authorized under this Section, except that rates or payments,
10or the portion thereof, paid for private duty nursing services
11or paid to a provider that is operated by a unit of government
12that provides the non-federal share of such services shall not
13be reduced as provided in this Section.
14    (b-1) The Department shall develop a State fiscal year 2016
15blended rate for nursing services provided by facilities
16licensed under the Nursing Home Care Act that takes into
17account the State fiscal year 2016 appropriation from the
18Long-Term Care Provider Fund and the adjusted State fiscal year
192016 appropriation for nursing services from the General
20Revenue Fund. The State fiscal year 2016 blended rate shall
21produce a savings to the State for fiscal year 2016 no greater
22than an amount equal to the product of 2.25% multiplied by the
23originally enacted State fiscal year 2015 appropriations from
24the General Revenue Fund for nursing services. The State fiscal
25year 2016 blended rate shall be applied to all nursing services
26regardless of the source from which payment is made.

 

 

09900SB0788ham002- 40 -LRB099 05889 KTG 36238 a

1    (c) For any rates which the Department cannot reduce due to
2federal law, court order, or specific statutory exemptions, the
3Department must identify the sum of reductions which cannot be
4attained. The sum must be proportionally distributed and added
5into the originally enacted State fiscal year 2015
6appropriations from the General Revenue Fund for each medical
7service type prior to the calculation of the rate reduction
8specified in subsection (a). The Department may not
9redistribute reductions in any other manner.
10    The reductions required under this Section must be applied
11uniformly to all providers who deliver the same medical service
12type.
13    (d) In order to provide for the expeditious and timely
14implementation of the provisions of this Section, the
15Department shall adopt rules and may adopt emergency rules in
16accordance with subsection (s) of Section 5-45 of the Illinois
17Administrative Procedure Act.
 
18    (305 ILCS 5/5-30)
19    Sec. 5-30. Care coordination.
20    (a) At least 50% of recipients eligible for comprehensive
21medical benefits in all medical assistance programs or other
22health benefit programs administered by the Department,
23including the Children's Health Insurance Program Act and the
24Covering ALL KIDS Health Insurance Act, shall be enrolled in a
25care coordination program by no later than January 1, 2015. For

 

 

09900SB0788ham002- 41 -LRB099 05889 KTG 36238 a

1purposes of this Section, "coordinated care" or "care
2coordination" means delivery systems where recipients will
3receive their care from providers who participate under
4contract in integrated delivery systems that are responsible
5for providing or arranging the majority of care, including
6primary care physician services, referrals from primary care
7physicians, diagnostic and treatment services, behavioral
8health services, in-patient and outpatient hospital services,
9dental services, and rehabilitation and long-term care
10services. The Department shall designate or contract for such
11integrated delivery systems (i) to ensure enrollees have a
12choice of systems and of primary care providers within such
13systems; (ii) to ensure that enrollees receive quality care in
14a culturally and linguistically appropriate manner; and (iii)
15to ensure that coordinated care programs meet the diverse needs
16of enrollees with developmental, mental health, physical, and
17age-related disabilities.
18    (b) Payment for such coordinated care shall be based on
19arrangements where the State pays for performance related to
20health care outcomes, the use of evidence-based practices, the
21use of primary care delivered through comprehensive medical
22homes, the use of electronic medical records, and the
23appropriate exchange of health information electronically made
24either on a capitated basis in which a fixed monthly premium
25per recipient is paid and full financial risk is assumed for
26the delivery of services, or through other risk-based payment

 

 

09900SB0788ham002- 42 -LRB099 05889 KTG 36238 a

1arrangements.
2    (c) To qualify for compliance with this Section, the 50%
3goal shall be achieved by enrolling medical assistance
4enrollees from each medical assistance enrollment category,
5including parents, children, seniors, and people with
6disabilities to the extent that current State Medicaid payment
7laws would not limit federal matching funds for recipients in
8care coordination programs. In addition, services must be more
9comprehensively defined and more risk shall be assumed than in
10the Department's primary care case management program as of the
11effective date of this amendatory Act of the 96th General
12Assembly.
13    (d) The Department shall report to the General Assembly in
14a separate part of its annual medical assistance program
15report, beginning April, 2012 until April, 2016, on the
16progress and implementation of the care coordination program
17initiatives established by the provisions of this amendatory
18Act of the 96th General Assembly. The Department shall include
19in its April 2011 report a full analysis of federal laws or
20regulations regarding upper payment limitations to providers
21and the necessary revisions or adjustments in rate
22methodologies and payments to providers under this Code that
23would be necessary to implement coordinated care with full
24financial risk by a party other than the Department.
25    (e) Integrated Care Program for individuals with chronic
26mental health conditions.

 

 

09900SB0788ham002- 43 -LRB099 05889 KTG 36238 a

1        (1) The Integrated Care Program shall encompass
2    services administered to recipients of medical assistance
3    under this Article to prevent exacerbations and
4    complications using cost-effective, evidence-based
5    practice guidelines and mental health management
6    strategies.
7        (2) The Department may utilize and expand upon existing
8    contractual arrangements with integrated care plans under
9    the Integrated Care Program for providing the coordinated
10    care provisions of this Section.
11        (3) Payment for such coordinated care shall be based on
12    arrangements where the State pays for performance related
13    to mental health outcomes on a capitated basis in which a
14    fixed monthly premium per recipient is paid and full
15    financial risk is assumed for the delivery of services, or
16    through other risk-based payment arrangements such as
17    provider-based care coordination.
18        (4) The Department shall examine whether chronic
19    mental health management programs and services for
20    recipients with specific chronic mental health conditions
21    do any or all of the following:
22            (A) Improve the patient's overall mental health in
23        a more expeditious and cost-effective manner.
24            (B) Lower costs in other aspects of the medical
25        assistance program, such as hospital admissions,
26        emergency room visits, or more frequent and

 

 

09900SB0788ham002- 44 -LRB099 05889 KTG 36238 a

1        inappropriate psychotropic drug use.
2        (5) The Department shall work with the facilities and
3    any integrated care plan participating in the program to
4    identify and correct barriers to the successful
5    implementation of this subsection (e) prior to and during
6    the implementation to best facilitate the goals and
7    objectives of this subsection (e).
8    (f) A hospital that is located in a county of the State in
9which the Department mandates some or all of the beneficiaries
10of the Medical Assistance Program residing in the county to
11enroll in a Care Coordination Program, as set forth in Section
125-30 of this Code, shall not be eligible for any non-claims
13based payments not mandated by Article V-A of this Code for
14which it would otherwise be qualified to receive, unless the
15hospital is a Coordinated Care Participating Hospital no later
16than 60 days after the effective date of this amendatory Act of
17the 97th General Assembly or 60 days after the first mandatory
18enrollment of a beneficiary in a Coordinated Care program. For
19purposes of this subsection, "Coordinated Care Participating
20Hospital" means a hospital that meets one of the following
21criteria:
22        (1) The hospital has entered into a contract to provide
23    hospital services with one or more MCOs to enrollees of the
24    care coordination program.
25        (2) The hospital has not been offered a contract by a
26    care coordination plan that the Department has determined

 

 

09900SB0788ham002- 45 -LRB099 05889 KTG 36238 a

1    to be a good faith offer and that pays at least as much as
2    the Department would pay, on a fee-for-service basis, not
3    including disproportionate share hospital adjustment
4    payments or any other supplemental adjustment or add-on
5    payment to the base fee-for-service rate, except to the
6    extent such adjustments or add-on payments are
7    incorporated into the development of the applicable MCO
8    capitated rates.
9    As used in this subsection (f), "MCO" means any entity
10which contracts with the Department to provide services where
11payment for medical services is made on a capitated basis.
12    (g) No later than August 1, 2013, the Department shall
13issue a purchase of care solicitation for Accountable Care
14Entities (ACE) to serve any children and parents or caretaker
15relatives of children eligible for medical assistance under
16this Article. An ACE may be a single corporate structure or a
17network of providers organized through contractual
18relationships with a single corporate entity. The solicitation
19shall require that:
20        (1) An ACE operating in Cook County be capable of
21    serving at least 40,000 eligible individuals in that
22    county; an ACE operating in Lake, Kane, DuPage, or Will
23    Counties be capable of serving at least 20,000 eligible
24    individuals in those counties and an ACE operating in other
25    regions of the State be capable of serving at least 10,000
26    eligible individuals in the region in which it operates.

 

 

09900SB0788ham002- 46 -LRB099 05889 KTG 36238 a

1    During initial periods of mandatory enrollment, the
2    Department shall require its enrollment services
3    contractor to use a default assignment algorithm that
4    ensures if possible an ACE reaches the minimum enrollment
5    levels set forth in this paragraph.
6        (2) An ACE must include at a minimum the following
7    types of providers: primary care, specialty care,
8    hospitals, and behavioral healthcare.
9        (3) An ACE shall have a governance structure that
10    includes the major components of the health care delivery
11    system, including one representative from each of the
12    groups listed in paragraph (2).
13        (4) An ACE must be an integrated delivery system,
14    including a network able to provide the full range of
15    services needed by Medicaid beneficiaries and system
16    capacity to securely pass clinical information across
17    participating entities and to aggregate and analyze that
18    data in order to coordinate care.
19        (5) An ACE must be capable of providing both care
20    coordination and complex case management, as necessary, to
21    beneficiaries. To be responsive to the solicitation, a
22    potential ACE must outline its care coordination and
23    complex case management model and plan to reduce the cost
24    of care.
25        (6) In the first 18 months of operation, unless the ACE
26    selects a shorter period, an ACE shall be paid care

 

 

09900SB0788ham002- 47 -LRB099 05889 KTG 36238 a

1    coordination fees on a per member per month basis that are
2    projected to be cost neutral to the State during the term
3    of their payment and, subject to federal approval, be
4    eligible to share in additional savings generated by their
5    care coordination. For ACEs with a contract with the
6    Department as of January 1, 2015, their 18 month period of
7    operation shall begin on January 1, 2015 and the Department
8    shall pay a care coordination fee on a per member per month
9    basis at a rate no less than the amount paid as of January
10    1, 2015. Nothing in this provision prohibits the following:
11    (i) an ACE from partnering with another managed care
12    entity, (ii) an ACE from moving to capitation sooner than
13    the aforementioned timelines, and (iii) the Department
14    from sanctioning or terminating an ACE for substantive
15    contractual violations.
16        (7) In months 19 through 36 of operation, unless the
17    ACE selects a shorter period, an ACE shall be paid on a
18    pre-paid capitation basis for all medical assistance
19    covered services, under contract terms similar to Managed
20    Care Organizations (MCO), with the Department sharing the
21    risk through either stop-loss insurance for extremely high
22    cost individuals or corridors of shared risk based on the
23    overall cost of the total enrollment in the ACE. The ACE
24    shall be responsible for claims processing, encounter data
25    submission, utilization control, and quality assurance.
26    The Department shall evaluate the ACE readiness to accept

 

 

09900SB0788ham002- 48 -LRB099 05889 KTG 36238 a

1    capitation. The readiness review shall utilize written
2    criteria that are shared with the ACEs and shall be
3    completed 3 months prior to initiation of capitation
4    payments. The Department shall establish by rule an appeals
5    process for any ACE that has not met the Department's
6    criteria for accepting capitation payments.
7        (8) In the fourth and subsequent years of operation, an
8    ACE shall convert to a Managed Care Community Network
9    (MCCN), as defined in this Article, or Health Maintenance
10    Organization pursuant to the Illinois Insurance Code,
11    accepting full-risk capitation payments.
12    The Department shall allow potential ACE entities 5 months
13from the date of the posting of the solicitation to submit
14proposals. After the solicitation is released, in addition to
15the MCO rate development data available on the Department's
16website, subject to federal and State confidentiality and
17privacy laws and regulations, the Department shall provide 2
18years of de-identified summary service data on the targeted
19population, split between children and adults, showing the
20historical type and volume of services received and the cost of
21those services to those potential bidders that sign a data use
22agreement. The Department may add up to 2 non-state government
23employees with expertise in creating integrated delivery
24systems to its review team for the purchase of care
25solicitation described in this subsection. Any such
26individuals must sign a no-conflict disclosure and

 

 

09900SB0788ham002- 49 -LRB099 05889 KTG 36238 a

1confidentiality agreement and agree to act in accordance with
2all applicable State laws.
3    During the first 2 years of an ACE's operation, the
4Department shall provide claims data to the ACE on its
5enrollees on a periodic basis no less frequently than monthly.
6    Nothing in this subsection shall be construed to limit the
7Department's mandate to enroll 50% of its beneficiaries into
8care coordination systems by January 1, 2015, using all
9available care coordination delivery systems, including Care
10Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
11to affect the current CCEs, MCCNs, and MCOs selected to serve
12seniors and persons with disabilities prior to that date.
13    Nothing in this subsection precludes the Department from
14considering future proposals for new ACEs or expansion of
15existing ACEs at the discretion of the Department.
16    (h) Department contracts with MCOs and other entities
17reimbursed by risk based capitation shall have a minimum
18medical loss ratio of 85%, shall require the entity to
19establish an appeals and grievances process for consumers and
20providers, and shall require the entity to provide a quality
21assurance and utilization review program. Entities contracted
22with the Department to coordinate healthcare regardless of risk
23shall be measured utilizing the same quality metrics. The
24quality metrics may be population specific. Any contracted
25entity serving at least 5,000 seniors or people with
26disabilities or 15,000 individuals in other populations

 

 

09900SB0788ham002- 50 -LRB099 05889 KTG 36238 a

1covered by the Medical Assistance Program that has been
2receiving full-risk capitation for a year shall be accredited
3by a national accreditation organization authorized by the
4Department within 2 years after the date it is eligible to
5become accredited. The requirements of this subsection shall
6apply to contracts with MCOs entered into or renewed or
7extended after June 1, 2013.
8    (h-5) The Department shall monitor and enforce compliance
9by MCOs with agreements they have entered into with providers
10on issues that include, but are not limited to, timeliness of
11payment, payment rates, and processes for obtaining prior
12approval. The Department may impose sanctions on MCOs for
13violating provisions of those agreements that include, but are
14not limited to, financial penalties, suspension of enrollment
15of new enrollees, and termination of the MCO's contract with
16the Department. As used in this subsection (h-5), "MCO" has the
17meaning ascribed to that term in Section 5-30.1 of this Code.
18    (i) As used in this subsection:
19    "Care coordination entity" means a collaboration of
20providers and community agencies, governed by a lead entity,
21which receives a care coordination payment with a portion of
22the payment at risk for meeting quality outcome targets in
23order to provide care coordination services for its enrollees.
24    "CCE" means either a care coordination entity or a
25pediatric care coordination entity.
26    "Children with complex medical needs" means persons under

 

 

09900SB0788ham002- 51 -LRB099 05889 KTG 36238 a

121 years of age who are clients of medical assistance programs
2or other health benefit programs administered by the Department
3through the use of the 3MTM Clinical Risk Grouping Software
4(CRG) as Status 6.1 and above, through a clinical screening
5tool, or those who do not have sufficient claims data in order
6to be identified by the Department through the CRG software.
7    "Pediatric care coordination entity" means a collaboration
8of providers and community agencies, governed by a lead entity,
9serving primarily persons under 21 years of age which receives
10a care coordination payment with a portion of the payment at
11risk for meeting quality outcome targets in order to provide
12care coordination services for its enrollees.
13    "Pediatric care coordination plan" means a pediatric care
14coordination entity defined in this subsection or a
15pediatric-only managed care community network as defined in
16subsection (b) of Section 5-11.
17    Beginning on the effective date of this amendatory Act of
18the 99th General Assembly and until April 1, 2016, the
19Department, where available, shall offer newly eligible
20children with complex medical needs and currently eligible
21children with complex medical needs making their annual health
22plan choice the choice of enrollment in a pediatric care
23coordination entity as defined in this subsection. At any time,
24the Department may offer, where available, the choice of
25enrollment in a pediatric-only managed care community network
26as defined in subsection (b) of Section 5-11. On and after

 

 

09900SB0788ham002- 52 -LRB099 05889 KTG 36238 a

1April 1, 2016, the Department shall offer a pediatric care
2coordination plan, where available, but may require the plan to
3meet the requirements of subsection (b) of Section 5-11. This
4choice shall be in addition to otherwise available health
5maintenance organizations (HMOs), managed care community
6networks (MCCNs), and accountable care entities (ACEs).
7    Children with complex medical needs under 18 years of age
8shall be eligible to enroll in the pediatric care coordination
9plan as long as such children continue to maintain eligibility
10for medical assistance programs or other health benefit
11programs administered by the Department. The Department may
12choose to extend enrollment to individuals under 21 years of
13age for initial enrollment. Individuals may also be excluded if
14they are:
15        (1) enrolled in the Medically Fragile Technology
16    Dependent Waiver;
17        (2) receiving private duty nursing;
18        (3) eligible for high third-party liability coverage
19    as defined by the Department;
20        (4) residing in institutions, including pediatric
21    skilled nursing facilities;
22        (5) enrolled in the DSCC Core Program; or
23        (6) placed in foster care with the Department of
24    Children and Family Services.
25    The Department shall ensure that the parents of all
26eligible enrollees that are children with complex medical needs

 

 

09900SB0788ham002- 53 -LRB099 05889 KTG 36238 a

1shall receive notification of their eligibility and an
2explanation of how to elect the pediatric care coordination
3plan option. The Department shall ensure that any third-party
4enrollment broker is briefed on the pediatric care coordination
5plan option and that the broker shall ensure that all
6enrollment options are presented to the parents of children
7with complex medical needs.
8    The Department shall provide care coordination fees for
9care coordination entities for seniors and persons with
10disabilities and for pediatric care coordination entities for
11children with complex medical needs, except for a pediatric
12care coordination entity that had at least 1,500 enrollees as
13of March 1, 2015, for a period of at least 36 months of
14operation at a per member per month rate no less than the
15schedule of rates in effect as of January 1, 2015, or as agreed
16to by the CCE. The Department shall provide care coordination
17fees for pediatric care coordination entities for children with
18complex medical needs that had at least 1,500 enrollees as of
19March 1, 2015, until April 1, 2016, at a per member per month
20rate no less than the schedule of rates in effect as of January
211, 2015, or as agreed to by the CCE. After 24 months of
22operation, but before 36 months, the Department shall evaluate
23each CCE's performance in the areas of care coordination,
24clinical integration, quality measurement performance,
25including health care utilization, and health care
26expenditures. For purposes of this Section, a CCE's date of

 

 

09900SB0788ham002- 54 -LRB099 05889 KTG 36238 a

1operation shall be the month when care coordination payments
2were first paid. Nothing in this provision prohibits the
3following: (i) a CCE from partnering with another managed care
4entity, (ii) a CCE from moving to capitation sooner than the
5aforementioned timelines, and (iii) the Department from
6sanctioning or terminating a CCE for substantive contractual
7violations.
8(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13;
998-651, eff. 6-16-14.)
 
10    (305 ILCS 5/5-30.2 new)
11    Sec. 5-30.2. Managed care; automatic assignment. The
12Department shall, within a reasonable period of time after
13relevant data from managed care entities has been collected and
14analyzed, but no earlier than January 1, 2017, develop and
15implement within each enrollment region an algorithm that takes
16into account quality scores and other operational proficiency
17criteria developed, defined, and adopted by the Department, to
18automatically assign Medicaid enrollees served under the
19Family Health Plan and the Integrated Care Program and those
20Medicaid enrollees eligible for medical assistance pursuant to
21the Patient Protection and Affordable Care Act (Public Law
22111-148) into managed care entities, including Accountable
23Care Entities, Managed Care Community Networks, and Managed
24Care Organizations. The quality metrics used shall be
25measurable for all entities. The algorithm shall not use the

 

 

09900SB0788ham002- 55 -LRB099 05889 KTG 36238 a

1quality and proficiency metrics to reassign enrollees out of
2any plan that they are enrolled with at the time and shall only
3be used if the client has not voluntarily selected a primary
4care physician and a managed care entity or care coordination
5entity. Clients shall have one opportunity within 90 calendar
6days after auto assignment by algorithm to select a different
7managed care entity. The algorithm developed and implemented
8shall favor assignment into managed care entities with the
9highest quality scores and levels of compliance with the
10operational proficiency criteria established.
 
11    (305 ILCS 5/5-30.3 new)
12    Sec. 5-30.3. Managed care; wards of the Department of
13Children and Family Services. The Department shall seek a
14waiver from the federal Centers for Medicare and Medicaid
15Services to allow mandatory enrollment of wards of the
16Department of Children and Family Services into Medicaid
17managed care and care coordination plans. The Department must
18submit a waiver request to the federal Centers for Medicare and
19Medicaid Services no later than October 1, 2015 and shall take
20all necessary actions to obtain approval, including appeal of
21any denial. Beginning January 1, 2016, the Department shall
22report progress on the waiver required under this Section and
23shall report quarterly until the waiver request is approved or
24denied. Upon federal approval, the Department shall develop a
25process to ensure that all wards of the Department of Children

 

 

09900SB0788ham002- 56 -LRB099 05889 KTG 36238 a

1and Family Services are enrolled in Medicaid managed care and
2care coordination plans.
 
3    (305 ILCS 5/5-30.4 new)
4    Sec. 5-30.4. Managed care capitated rates; specialized
5mental health rehabilitation facilities. Services delivered by
6facilities licensed under the Specialized Mental Health
7Rehabilitation Act of 2013 shall be a covered Medicaid service
8for eligible Medicaid enrollees under both fee-for-service,
9managed care, and care-coordination arrangements. The
10Department shall ensure that all residents of facilities
11licensed under the Specialized Mental Health Rehabilitation
12Act of 2013 who are eligible for Medicaid are enrolled in
13Medicaid managed care.
 
14    (305 ILCS 5/5-30.5 new)
15    Sec. 5-30.5. Managed care policy manual.
16    (a) The Department by January 1, 2016 must make available
17on its website a managed care policy manual for providers. The
18manual must be updated no less than annually, but may be
19updated no more frequently than monthly and no changes shall be
20effective until at least 30 days after the publication of the
21change in the manual. The manual and updates shall be developed
22and issued only after the Department has consulted with
23representatives of providers and managed care entities,
24including the Statewide associations representing such

 

 

09900SB0788ham002- 57 -LRB099 05889 KTG 36238 a

1stakeholders. Manuals posted pursuant to this Section shall be
2consistent with the Managed Care Reform and Patient Rights Act,
3the Health Maintenance Organization Act, and the
4Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home
5Residents' Managed Care Rights Law, as applicable.
6    (b) The Department may post separate manuals based on the
7population served by the managed care coverage plan, such as
8seniors and people with disabilities. The Department must
9clearly distinguish any differences in information based on the
10managed care coverage plans.
11    (c) The manual must include no less than the following
12information: (i) the process for providers to appeal payment
13decisions made by the managed care plan, (ii) the process for
14enrollees to appeal decisions made by managed care entities,
15(iii) electronic links to information required for obtaining
16approval for services by each plan, (iv) the contact
17information for either a provider or an enrollee to file a
18complaint with the Department about a managed care plan, (v)
19the Department's requirements for each plan to provide services
20and timeliness of payment, (vi) all timeframes for each plan to
21approve or deny coverage, (vii) an electronic link to the
22information on identifying all the providers currently
23providing services for a managed care plan, (viii) the process
24and contact information for an enrollee to change managed care
25plans, (ix) contact information for an enrollee to change a
26primary care physician or correct personal information, and (x)

 

 

09900SB0788ham002- 58 -LRB099 05889 KTG 36238 a

1contact information for each plan for provider relations and
2customer service concerns.
 
3    (305 ILCS 5/5A-2)  (from Ch. 23, par. 5A-2)
4    (Section scheduled to be repealed on July 1, 2018)
5    Sec. 5A-2. Assessment.
6    (a) Subject to Sections 5A-3 and 5A-10, for State fiscal
7years 2009 through 2018, an annual assessment on inpatient
8services is imposed on each hospital provider in an amount
9equal to $218.38 multiplied by the difference of the hospital's
10occupied bed days less the hospital's Medicare bed days,
11provided, however, that the amount of $218.38 shall be
12increased by a uniform percentage to generate an amount equal
13to 75% of the State share of the payments authorized under
14Section 12-5, with such increase only taking effect upon the
15date that a State share for such payments is required under
16federal law. For the period of April through June 2015, the
17amount of $218.38 used to calculate the assessment under this
18paragraph shall, by emergency rule under subsection (s) of
19Section 5-45 of the Illinois Administrative Procedure Act, be
20increased by a uniform percentage to generate $20,250,000 in
21the aggregate for that period from all hospitals subject to the
22annual assessment under this paragraph. In lieu of a reduction
23in the reimbursement rates paid to hospitals under Section
245-5b.2 of this Code, for State fiscal year 2016, the amount of
25$218.38 used to calculate the assessment under this paragraph

 

 

09900SB0788ham002- 59 -LRB099 05889 KTG 36238 a

1shall, by emergency rule under subsection (s) of Section 5-45
2of the Illinois Administrative Procedure Act, be increased by a
3uniform percentage to generate $20,250,000 annually in the
4aggregate from all hospitals subject to the annual assessment
5under this paragraph.
6    For State fiscal years 2009 through 2014 and after, a
7hospital's occupied bed days and Medicare bed days shall be
8determined using the most recent data available from each
9hospital's 2005 Medicare cost report as contained in the
10Healthcare Cost Report Information System file, for the quarter
11ending on December 31, 2006, without regard to any subsequent
12adjustments or changes to such data. If a hospital's 2005
13Medicare cost report is not contained in the Healthcare Cost
14Report Information System, then the Illinois Department may
15obtain the hospital provider's occupied bed days and Medicare
16bed days from any source available, including, but not limited
17to, records maintained by the hospital provider, which may be
18inspected at all times during business hours of the day by the
19Illinois Department or its duly authorized agents and
20employees.
21    (b) (Blank).
22    (b-5) Subject to Sections 5A-3 and 5A-10, for the portion
23of State fiscal year 2012, beginning June 10, 2012 through June
2430, 2012, and for State fiscal years 2013 through 2018, an
25annual assessment on outpatient services is imposed on each
26hospital provider in an amount equal to .008766 multiplied by

 

 

09900SB0788ham002- 60 -LRB099 05889 KTG 36238 a

1the hospital's outpatient gross revenue, provided, however,
2that the amount of .008766 shall be increased by a uniform
3percentage to generate an amount equal to 25% of the State
4share of the payments authorized under Section 12-5, with such
5increase only taking effect upon the date that a State share
6for such payments is required under federal law. For the period
7beginning June 10, 2012 through June 30, 2012, the annual
8assessment on outpatient services shall be prorated by
9multiplying the assessment amount by a fraction, the numerator
10of which is 21 days and the denominator of which is 365 days.
11For the period of April through June 2015, the amount of
12.008766 used to calculate the assessment under this paragraph
13shall, by emergency rule under subsection (s) of Section 5-45
14of the Illinois Administrative Procedure Act, be increased by a
15uniform percentage to generate $6,750,000 in the aggregate for
16that period from all hospitals subject to the annual assessment
17under this paragraph. In lieu of a reduction in the
18reimbursement rates paid to hospitals under Section 5-5b.2 of
19this Code, for State fiscal year 2016, the amount of .008766
20used to calculate the assessment under this paragraph shall, by
21emergency rule under subsection (s) of Section 5-45 of the
22Illinois Administrative Procedure Act, be increased by a
23uniform percentage to generate $6,750,000 annually in the
24aggregate from all hospitals subject to the annual assessment
25under this paragraph.
26    For the portion of State fiscal year 2012, beginning June

 

 

09900SB0788ham002- 61 -LRB099 05889 KTG 36238 a

110, 2012 through June 30, 2012, and State fiscal years 2013
2through 2018, a hospital's outpatient gross revenue shall be
3determined using the most recent data available from each
4hospital's 2009 Medicare cost report as contained in the
5Healthcare Cost Report Information System file, for the quarter
6ending on June 30, 2011, without regard to any subsequent
7adjustments or changes to such data. If a hospital's 2009
8Medicare cost report is not contained in the Healthcare Cost
9Report Information System, then the Department may obtain the
10hospital provider's outpatient gross revenue from any source
11available, including, but not limited to, records maintained by
12the hospital provider, which may be inspected at all times
13during business hours of the day by the Department or its duly
14authorized agents and employees.
15    (c) (Blank).
16    (d) Notwithstanding any of the other provisions of this
17Section, the Department is authorized to adopt rules to reduce
18the rate of any annual assessment imposed under this Section,
19as authorized by Section 5-46.2 of the Illinois Administrative
20Procedure Act.
21    (e) Notwithstanding any other provision of this Section,
22any plan providing for an assessment on a hospital provider as
23a permissible tax under Title XIX of the federal Social
24Security Act and Medicaid-eligible payments to hospital
25providers from the revenues derived from that assessment shall
26be reviewed by the Illinois Department of Healthcare and Family

 

 

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1Services, as the Single State Medicaid Agency required by
2federal law, to determine whether those assessments and
3hospital provider payments meet federal Medicaid standards. If
4the Department determines that the elements of the plan may
5meet federal Medicaid standards and a related State Medicaid
6Plan Amendment is prepared in a manner and form suitable for
7submission, that State Plan Amendment shall be submitted in a
8timely manner for review by the Centers for Medicare and
9Medicaid Services of the United States Department of Health and
10Human Services and subject to approval by the Centers for
11Medicare and Medicaid Services of the United States Department
12of Health and Human Services. No such plan shall become
13effective without approval by the Illinois General Assembly by
14the enactment into law of related legislation. Notwithstanding
15any other provision of this Section, the Department is
16authorized to adopt rules to reduce the rate of any annual
17assessment imposed under this Section. Any such rules may be
18adopted by the Department under Section 5-50 of the Illinois
19Administrative Procedure Act.
20(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14; 99-2,
21eff. 3-26-15.)
 
22    (305 ILCS 5/5A-12.2)
23    (Section scheduled to be repealed on July 1, 2018)
24    Sec. 5A-12.2. Hospital access payments on or after July 1,
252008.

 

 

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1    (a) To preserve and improve access to hospital services,
2for hospital services rendered on or after July 1, 2008, the
3Illinois Department shall, except for hospitals described in
4subsection (b) of Section 5A-3, make payments to hospitals as
5set forth in this Section. These payments shall be paid in 12
6equal installments on or before the seventh State business day
7of each month, except that no payment shall be due within 100
8days 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. Payments under
13this Section are not due and payable, however, until (i) the
14methodologies described in this Section are approved by the
15federal government in an appropriate State Plan amendment and
16(ii) the assessment imposed under this Article is determined to
17be a permissible tax under Title XIX of the Social Security
18Act.
19    (a-5) The Illinois Department may, when practicable,
20accelerate the schedule upon which payments authorized under
21this Section are made.
22    (b) Across-the-board inpatient adjustment.
23        (1) In addition to rates paid for inpatient hospital
24    services, the Department shall pay to each Illinois general
25    acute care hospital an amount equal to 40% of the total
26    base inpatient payments paid to the hospital for services

 

 

09900SB0788ham002- 64 -LRB099 05889 KTG 36238 a

1    provided in State fiscal year 2005.
2        (2) In addition to rates paid for inpatient hospital
3    services, the Department shall pay to each freestanding
4    Illinois specialty care hospital as defined in 89 Ill. Adm.
5    Code 149.50(c)(1), (2), or (4) an amount equal to 60% of
6    the total base inpatient payments paid to the hospital for
7    services provided in State fiscal year 2005.
8        (3) In addition to rates paid for inpatient hospital
9    services, the Department shall pay to each freestanding
10    Illinois rehabilitation or psychiatric hospital an amount
11    equal to $1,000 per Medicaid inpatient day multiplied by
12    the increase in the hospital's Medicaid inpatient
13    utilization ratio (determined using the positive
14    percentage change from the rate year 2005 Medicaid
15    inpatient utilization ratio to the rate year 2007 Medicaid
16    inpatient utilization ratio, as calculated by the
17    Department for the disproportionate share determination).
18        (4) In addition to rates paid for inpatient hospital
19    services, the Department shall pay to each Illinois
20    children's hospital an amount equal to 20% of the total
21    base inpatient payments paid to the hospital for services
22    provided in State fiscal year 2005 and an additional amount
23    equal to 20% of the base inpatient payments paid to the
24    hospital for psychiatric services provided in State fiscal
25    year 2005.
26        (5) In addition to rates paid for inpatient hospital

 

 

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1    services, the Department shall pay to each Illinois
2    hospital eligible for a pediatric inpatient adjustment
3    payment under 89 Ill. Adm. Code 148.298, as in effect for
4    State fiscal year 2007, a supplemental pediatric inpatient
5    adjustment payment equal to:
6            (i) For freestanding children's hospitals as
7        defined in 89 Ill. Adm. Code 149.50(c)(3)(A), 2.5
8        multiplied by the hospital's pediatric inpatient
9        adjustment payment required under 89 Ill. Adm. Code
10        148.298, as in effect for State fiscal year 2008.
11            (ii) For hospitals other than freestanding
12        children's hospitals as defined in 89 Ill. Adm. Code
13        149.50(c)(3)(B), 1.0 multiplied by the hospital's
14        pediatric inpatient adjustment payment required under
15        89 Ill. Adm. Code 148.298, as in effect for State
16        fiscal year 2008.
17    (c) Outpatient adjustment.
18        (1) In addition to the rates paid for outpatient
19    hospital services, the Department shall pay each Illinois
20    hospital an amount equal to 2.2 multiplied by the
21    hospital's ambulatory procedure listing payments for
22    categories 1, 2, 3, and 4, as defined in 89 Ill. Adm. Code
23    148.140(b), for State fiscal year 2005.
24        (2) In addition to the rates paid for outpatient
25    hospital services, the Department shall pay each Illinois
26    freestanding psychiatric hospital an amount equal to 3.25

 

 

09900SB0788ham002- 66 -LRB099 05889 KTG 36238 a

1    multiplied by the hospital's ambulatory procedure listing
2    payments for category 5b, as defined in 89 Ill. Adm. Code
3    148.140(b)(1)(E), for State fiscal year 2005.
4    (d) Medicaid high volume adjustment. In addition to rates
5paid for inpatient hospital services, the Department shall pay
6to each Illinois general acute care hospital that provided more
7than 20,500 Medicaid inpatient days of care in State fiscal
8year 2005 amounts as follows:
9        (1) For hospitals with a case mix index equal to or
10    greater than the 85th percentile of hospital case mix
11    indices, $350 for each Medicaid inpatient day of care
12    provided during that period; and
13        (2) For hospitals with a case mix index less than the
14    85th percentile of hospital case mix indices, $100 for each
15    Medicaid inpatient day of care provided during that period.
16    (e) Capital adjustment. In addition to rates paid for
17inpatient hospital services, the Department shall pay an
18additional payment to each Illinois general acute care hospital
19that has a Medicaid inpatient utilization rate of at least 10%
20(as calculated by the Department for the rate year 2007
21disproportionate share determination) amounts as follows:
22        (1) For each Illinois general acute care hospital that
23    has a Medicaid inpatient utilization rate of at least 10%
24    and less than 36.94% and whose capital cost is less than
25    the 60th percentile of the capital costs of all Illinois
26    hospitals, the amount of such payment shall equal the

 

 

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1    hospital's Medicaid inpatient days multiplied by the
2    difference between the capital costs at the 60th percentile
3    of the capital costs of all Illinois hospitals and the
4    hospital's capital costs.
5        (2) For each Illinois general acute care hospital that
6    has a Medicaid inpatient utilization rate of at least
7    36.94% and whose capital cost is less than the 75th
8    percentile of the capital costs of all Illinois hospitals,
9    the amount of such payment shall equal the hospital's
10    Medicaid inpatient days multiplied by the difference
11    between the capital costs at the 75th percentile of the
12    capital costs of all Illinois hospitals and the hospital's
13    capital costs.
14    (f) Obstetrical care adjustment.
15        (1) In addition to rates paid for inpatient hospital
16    services, the Department shall pay $1,500 for each Medicaid
17    obstetrical day of care provided in State fiscal year 2005
18    by each Illinois rural hospital that had a Medicaid
19    obstetrical percentage (Medicaid obstetrical days divided
20    by Medicaid inpatient days) greater than 15% for State
21    fiscal year 2005.
22        (2) In addition to rates paid for inpatient hospital
23    services, the Department shall pay $1,350 for each Medicaid
24    obstetrical day of care provided in State fiscal year 2005
25    by each Illinois general acute care hospital that was
26    designated a level III perinatal center as of December 31,

 

 

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1    2006, and that had a case mix index equal to or greater
2    than the 45th percentile of the case mix indices for all
3    level III perinatal centers.
4        (3) In addition to rates paid for inpatient hospital
5    services, the Department shall pay $900 for each Medicaid
6    obstetrical day of care provided in State fiscal year 2005
7    by each Illinois general acute care hospital that was
8    designated a level II or II+ perinatal center as of
9    December 31, 2006, and that had a case mix index equal to
10    or greater than the 35th percentile of the case mix indices
11    for all level II and II+ perinatal centers.
12    (g) Trauma adjustment.
13        (1) In addition to rates paid for inpatient hospital
14    services, the Department shall pay each Illinois general
15    acute care hospital designated as a trauma center as of
16    July 1, 2007, a payment equal to 3.75 multiplied by the
17    hospital's State fiscal year 2005 Medicaid capital
18    payments.
19        (2) In addition to rates paid for inpatient hospital
20    services, the Department shall pay $400 for each Medicaid
21    acute inpatient day of care provided in State fiscal year
22    2005 by each Illinois general acute care hospital that was
23    designated a level II trauma center, as defined in 89 Ill.
24    Adm. Code 148.295(a)(3) and 148.295(a)(4), as of July 1,
25    2007.
26        (3) In addition to rates paid for inpatient hospital

 

 

09900SB0788ham002- 69 -LRB099 05889 KTG 36238 a

1    services, the Department shall pay $235 for each Illinois
2    Medicaid acute inpatient day of care provided in State
3    fiscal year 2005 by each level I pediatric trauma center
4    located outside of Illinois that had more than 8,000
5    Illinois Medicaid inpatient days in State fiscal year 2005.
6    (h) Supplemental tertiary care adjustment. In addition to
7rates paid for inpatient services, the Department shall pay to
8each Illinois hospital eligible for tertiary care adjustment
9payments under 89 Ill. Adm. Code 148.296, as in effect for
10State fiscal year 2007, a supplemental tertiary care adjustment
11payment equal to the tertiary care adjustment payment required
12under 89 Ill. Adm. Code 148.296, as in effect for State fiscal
13year 2007.
14    (i) Crossover adjustment. In addition to rates paid for
15inpatient services, the Department shall pay each Illinois
16general acute care hospital that had a ratio of crossover days
17to total inpatient days for medical assistance programs
18administered by the Department (utilizing information from
192005 paid claims) greater than 50%, and a case mix index
20greater than the 65th percentile of case mix indices for all
21Illinois hospitals, a rate of $1,125 for each Medicaid
22inpatient day including crossover days.
23    (j) Magnet hospital adjustment. In addition to rates paid
24for inpatient hospital services, the Department shall pay to
25each Illinois general acute care hospital and each Illinois
26freestanding children's hospital that, as of February 1, 2008,

 

 

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1was recognized as a Magnet hospital by the American Nurses
2Credentialing Center and that had a case mix index greater than
3the 75th percentile of case mix indices for all Illinois
4hospitals amounts as follows:
5        (1) For hospitals located in a county whose eligibility
6    growth factor is greater than the mean, $450 multiplied by
7    the eligibility growth factor for the county in which the
8    hospital is located for each Medicaid inpatient day of care
9    provided by the hospital during State fiscal year 2005.
10        (2) For hospitals located in a county whose eligibility
11    growth factor is less than or equal to the mean, $225
12    multiplied by the eligibility growth factor for the county
13    in which the hospital is located for each Medicaid
14    inpatient day of care provided by the hospital during State
15    fiscal year 2005.
16    For purposes of this subsection, "eligibility growth
17factor" means the percentage by which the number of Medicaid
18recipients in the county increased from State fiscal year 1998
19to State fiscal year 2005.
20    (k) For purposes of this Section, a hospital that is
21enrolled to provide Medicaid services during State fiscal year
222005 shall have its utilization and associated reimbursements
23annualized prior to the payment calculations being performed
24under this Section.
25    (l) For purposes of this Section, the terms "Medicaid
26days", "ambulatory procedure listing services", and

 

 

09900SB0788ham002- 71 -LRB099 05889 KTG 36238 a

1"ambulatory procedure listing payments" do not include any
2days, charges, or services for which Medicare or a managed care
3organization reimbursed on a capitated basis was liable for
4payment, except where explicitly stated otherwise in this
5Section.
6    (m) For purposes of this Section, in determining the
7percentile ranking of an Illinois hospital's case mix index or
8capital costs, hospitals described in subsection (b) of Section
95A-3 shall be excluded from the ranking.
10    (n) Definitions. Unless the context requires otherwise or
11unless provided otherwise in this Section, the terms used in
12this Section for qualifying criteria and payment calculations
13shall have the same meanings as those terms have been given in
14the Illinois Department's administrative rules as in effect on
15March 1, 2008. Other terms shall be defined by the Illinois
16Department by rule.
17    As used in this Section, unless the context requires
18otherwise:
19    "Base inpatient payments" means, for a given hospital, the
20sum of base payments for inpatient services made on a per diem
21or per admission (DRG) basis, excluding those portions of per
22admission payments that are classified as capital payments.
23Disproportionate share hospital adjustment payments, Medicaid
24Percentage Adjustments, Medicaid High Volume Adjustments, and
25outlier payments, as defined by rule by the Department as of
26January 1, 2008, are not base payments.

 

 

09900SB0788ham002- 72 -LRB099 05889 KTG 36238 a

1    "Capital costs" means, for a given hospital, the total
2capital costs determined using the most recent 2005 Medicare
3cost report as contained in the Healthcare Cost Report
4Information System file, for the quarter ending on December 31,
52006, divided by the total inpatient days from the same cost
6report to calculate a capital cost per day. The resulting
7capital cost per day is inflated to the midpoint of State
8fiscal year 2009 utilizing the national hospital market price
9proxies (DRI) hospital cost index. If a hospital's 2005
10Medicare cost report is not contained in the Healthcare Cost
11Report Information System, the Department may obtain the data
12necessary to compute the hospital's capital costs from any
13source available, including, but not limited to, records
14maintained by the hospital provider, which may be inspected at
15all times during business hours of the day by the Illinois
16Department or its duly authorized agents and employees.
17    "Case mix index" means, for a given hospital, the sum of
18the DRG relative weighting factors in effect on January 1,
192005, for all general acute care admissions for State fiscal
20year 2005, excluding Medicare crossover admissions and
21transplant admissions reimbursed under 89 Ill. Adm. Code
22148.82, divided by the total number of general acute care
23admissions for State fiscal year 2005, excluding Medicare
24crossover admissions and transplant admissions reimbursed
25under 89 Ill. Adm. Code 148.82.
26    "Medicaid inpatient day" means, for a given hospital, the

 

 

09900SB0788ham002- 73 -LRB099 05889 KTG 36238 a

1sum of days of inpatient hospital days provided to recipients
2of medical assistance under Title XIX of the federal Social
3Security Act, excluding days for individuals eligible for
4Medicare under Title XVIII of that Act (Medicaid/Medicare
5crossover days), as tabulated from the Department's paid claims
6data for admissions occurring during State fiscal year 2005
7that was adjudicated by the Department through March 23, 2007.
8    "Medicaid obstetrical day" means, for a given hospital, the
9sum of days of inpatient hospital days grouped by the
10Department to DRGs of 370 through 375 provided to recipients of
11medical assistance under Title XIX of the federal Social
12Security Act, excluding days for individuals eligible for
13Medicare under Title XVIII of that Act (Medicaid/Medicare
14crossover days), as tabulated from the Department's paid claims
15data for admissions occurring during State fiscal year 2005
16that was adjudicated by the Department through March 23, 2007.
17    "Outpatient ambulatory procedure listing payments" means,
18for a given hospital, the sum of payments for ambulatory
19procedure listing services, as described in 89 Ill. Adm. Code
20148.140(b), provided to recipients of medical assistance under
21Title XIX of the federal Social Security Act, excluding
22payments for individuals eligible for Medicare under Title
23XVIII of the Act (Medicaid/Medicare crossover days), as
24tabulated from the Department's paid claims data for services
25occurring in State fiscal year 2005 that were adjudicated by
26the Department through March 23, 2007.

 

 

09900SB0788ham002- 74 -LRB099 05889 KTG 36238 a

1    (o) The Department may adjust payments made under this
2Section 5A-12.2 to comply with federal law or regulations
3regarding hospital-specific payment limitations on
4government-owned or government-operated hospitals.
5    (p) Notwithstanding any of the other provisions of this
6Section, the Department is authorized to adopt rules that
7change the hospital access improvement payments specified in
8this Section, but only to the extent necessary to conform to
9any federally approved amendment to the Title XIX State plan.
10Any such rules shall be adopted by the Department as authorized
11by Section 5-50 of the Illinois Administrative Procedure Act.
12Notwithstanding any other provision of law, any changes
13implemented as a result of this subsection (p) shall be given
14retroactive effect so that they shall be deemed to have taken
15effect as of the effective date of this Section.
16    (q) (Blank).
17    (r) On and after July 1, 2012, the Department shall reduce
18any rate of reimbursement for services or other payments or
19alter any methodologies authorized by this Code to reduce any
20rate of reimbursement for services or other payments in
21accordance with Section 5-5e.
22    (s) On or after July 1, 2014, but no later than October 1,
232014, and no less than annually thereafter, the Department may
24increase capitation payments to capitated managed care
25organizations (MCOs) to equal the aggregate reduction of
26payments made in this Section and in Section 5A-12.4 by a

 

 

09900SB0788ham002- 75 -LRB099 05889 KTG 36238 a

1uniform percentage consistent with actuarial soundness on a
2regional basis to preserve access to hospital services for
3recipients under the Illinois Medical Assistance Program. The
4aggregate amount of all increased capitation payments to all
5MCOs for a fiscal year shall be an the amount needed to avoid
6reduction in payments authorized under Section 5A-15. Payments
7to MCOs under this Section shall be consistent with actuarial
8certification and shall be published by the Department each
9year. Each MCO shall only expend the increased capitation
10payments it receives under this Section to support the
11availability of hospital services and to ensure access to
12hospital services, with such expenditures being made within 15
13calendar days from when the MCO receives the increased
14capitation payment. The Department shall make available, on a
15monthly basis, a report of the capitation payments that are
16made to each MCO pursuant to this subsection, including the
17number of enrollees for which such payment is made, the per
18enrollee amount of the payment, and any adjustments that have
19been made. Payments made under this subsection shall be
20guaranteed by a surety bond obtained by the MCO in an amount
21established by the Department to approximate one month's
22liability of payments authorized under this subsection. The
23Department may advance the payments guaranteed by the surety
24bond. Payments to MCOs that would be paid consistent with
25actuarial certification and enrollment in the absence of the
26increased capitation payments under this Section shall not be

 

 

09900SB0788ham002- 76 -LRB099 05889 KTG 36238 a

1reduced as a consequence of payments made under this
2subsection.
3    As used in this subsection, "MCO" means an entity which
4contracts with the Department to provide services where payment
5for medical services is made on a capitated basis.
6    (t) On or after July 1, 2014, the Department shall may
7increase capitation payments to capitated managed care
8organizations (MCOs) to include the payments authorized equal
9the aggregate reduction of payments made in Section 5A-12.5 to
10preserve access to hospital services for recipients under the
11Illinois Medical Assistance Program. Payments to MCOs under
12this Section shall be consistent with actuarial certification
13and shall be published by the Department each year. Each MCO
14shall only expend the increased capitation payments it receives
15under this Section to support the availability of hospital
16services and to ensure access to hospital services, with such
17expenditures being made within 15 calendar days from when the
18MCO receives the increased capitation payment. The Department
19may advance the payments to hospitals under this subsection, in
20the event the MCO fails to make such payments. The Department
21shall make available, on a monthly basis, a report of the
22capitation payments that are made to each MCO pursuant to this
23subsection, including the number of enrollees for which such
24payment is made, the per enrollee amount of the payment, and
25any adjustments that have been made. Payments to MCOs that
26would be paid consistent with actuarial certification and

 

 

09900SB0788ham002- 77 -LRB099 05889 KTG 36238 a

1enrollment in the absence of the increased capitation payments
2under this subsection shall not be reduced as a consequence of
3payments made under this subsection.
4    As used in this subsection, "MCO" means an entity which
5contracts with the Department to provide services where payment
6for medical services is made on a capitated basis.
7(Source: P.A. 97-689, eff. 6-14-12; 98-651, eff. 6-16-14.)
 
8    (305 ILCS 5/5A-12.5)
9    Sec. 5A-12.5. Affordable Care Act adults; hospital access
10payments. The Department shall, subject to federal approval,
11mirror the Medical Assistance hospital reimbursement
12methodology, for recipients enrolled under a fee for service or
13capitated managed care program, including hospital access
14payments as defined in Section 5A-12.2 of this Article and
15hospital access improvement payments as defined in Section
165A-12.4 of this Article, as well as the amount of such payments
17pursuant to subsection (s) of Section 5A-12.2 of this Article,
18in compliance with the equivalent rate provisions of the
19Affordable Care Act. The Department shall make adjustments to
20the capitation payments made to MCOs for adults eligible for
21medical assistance pursuant to the Affordable Care Act for the
22hospital access payments authorized under this Section
23attributable to the earliest possible date for which federal
24financial participation is available.
25    As used in this Section, "Affordable Care Act" is the

 

 

09900SB0788ham002- 78 -LRB099 05889 KTG 36238 a

1collective term for the Patient Protection and Affordable Care
2Act (Pub. L. 111-148) and the Health Care and Education
3Reconciliation Act of 2010 (Pub. L. 111-152).
4(Source: P.A. 98-651, eff. 6-16-14.)
 
5    (305 ILCS 5/5A-13)
6    Sec. 5A-13. Emergency rulemaking.
7    (a) The Department of Healthcare and Family Services
8(formerly Department of Public Aid) may adopt rules necessary
9to implement this amendatory Act of the 94th General Assembly
10through the use of emergency rulemaking in accordance with
11Section 5-45 of the Illinois Administrative Procedure Act. For
12purposes of that Act, the General Assembly finds that the
13adoption of rules to implement this amendatory Act of the 94th
14General Assembly is deemed an emergency and necessary for the
15public interest, safety, and welfare.
16    (b) The Department of Healthcare and Family Services may
17adopt rules necessary to implement this amendatory Act of the
1897th General Assembly through the use of emergency rulemaking
19in accordance with Section 5-45 of the Illinois Administrative
20Procedure Act. For purposes of that Act, the General Assembly
21finds that the adoption of rules to implement this amendatory
22Act of the 97th General Assembly is deemed an emergency and
23necessary for the public interest, safety, and welfare.
24    (c) The Department of Healthcare and Family Services may
25adopt rules necessary to implement this amendatory Act of the

 

 

09900SB0788ham002- 79 -LRB099 05889 KTG 36238 a

199th General Assembly through the use of emergency rulemaking
2in accordance with Section 5-45 of the Illinois Administrative
3Procedure Act. For purposes of this Code, the General Assembly
4finds that the adoption of rules to implement this amendatory
5Act of the 99th General Assembly is deemed an emergency and
6necessary for the public interest, safety, and welfare. The
7Department shall, within 30 days after the effective date of
8this amendatory Act of the 99th General Assembly, take all
9actions necessary to implement this amendatory Act of the 99th
10General Assembly, including, but not limited to, the adoption
11of rules and the obtaining of any necessary approval of the
12federal government.
13(Source: P.A. 97-688, eff. 6-14-12.)
 
14    (305 ILCS 5/5G-10)
15    Sec. 5G-10. Assessment.
16    (a) Subject to Section 5G-45, beginning July 1, 2014, an
17annual assessment on health care services is imposed on each
18supportive living facility in an amount equal to $2.30
19multiplied by the supportive living facility's care days. This
20assessment shall not be billed or passed on to any resident of
21a supportive living facility.
22    (b) Nothing in this Section shall be construed to authorize
23any home rule unit or other unit of local government to license
24for revenue or impose a tax or assessment upon supportive
25living facilities or the occupation of operating a supportive

 

 

09900SB0788ham002- 80 -LRB099 05889 KTG 36238 a

1living facility, or a tax or assessment measured by the income
2or earnings or care days of a supportive living facility.
3    (c) The assessment imposed by this Section shall not be due
4and payable, however, until after the Department notifies the
5supportive living facilities, in writing, that the payment
6methodologies to supportive living facilities required under
7Section 5-5.01a of this Code have been approved by the Centers
8for Medicare and Medicaid Services of the U.S. Department of
9Health and Human Services and the waivers under 42 CFR 433.68
10for the assessment imposed by this Section, if necessary, have
11been granted by the Centers for Medicare and Medicaid Services
12of the U.S. Department of Health and Human Services.
13    (d) The Department must contest the interpretation of
14federal regulations on permissible provider taxes made by the
15Centers for Medicare and Medicaid Services as stated in
16correspondence dated January 20, 2015. The Department shall
17submit a report to the General Assembly no later than January
181, 2016 detailing all actions taken to meet the requirement of
19this subsection (d).
20(Source: P.A. 98-651, eff. 6-16-14.)
 
21    (305 ILCS 5/11-5.4)
22    Sec. 11-5.4. Expedited long-term care eligibility
23determination and enrollment.
24    (a) An expedited long-term care eligibility determination
25and enrollment system shall be established to reduce long-term

 

 

09900SB0788ham002- 81 -LRB099 05889 KTG 36238 a

1care determinations to 90 days or fewer by July 1, 2014 and
2streamline the long-term care enrollment process.
3Establishment of the system shall be a joint venture of the
4Department of Human Services and Healthcare and Family Services
5and the Department on Aging. The Governor shall name a lead
6agency no later than 30 days after the effective date of this
7amendatory Act of the 98th General Assembly to assume
8responsibility for the full implementation of the
9establishment and maintenance of the system. Project outcomes
10shall include an enhanced eligibility determination tracking
11system accessible to providers and a centralized application
12review and eligibility determination with all applicants
13reviewed within 90 days of receipt by the State of a complete
14application. If the Department of Healthcare and Family
15Services' Office of the Inspector General determines that there
16is a likelihood that a non-allowable transfer of assets has
17occurred, and the facility in which the applicant resides is
18notified, an extension of up to 90 days shall be permissible.
19On or before December 31, 2015, a streamlined application and
20enrollment process shall be put in place based on the following
21principles:
22        (1) Minimize the burden on applicants by collecting
23    only the data necessary to determine eligibility for
24    medical services, long-term care services, and spousal
25    impoverishment offset.
26        (2) Integrate online data sources to simplify the

 

 

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1    application process by reducing the amount of information
2    needed to be entered and to expedite eligibility
3    verification.
4        (3) Provide online prompts to alert the applicant that
5    information is missing or not complete.
6    (b) The Department shall, on or before July 1, 2014, assess
7the feasibility of incorporating all information needed to
8determine eligibility for long-term care services, including
9asset transfer and spousal impoverishment financials, into the
10State's integrated eligibility system identifying all
11resources needed and reasonable timeframes for achieving the
12specified integration.
13    (c) The lead agency shall file interim reports with the
14Chairs and Minority Spokespersons of the House and Senate Human
15Services Committees no later than September 1, 2013 and on
16February 1, 2014. The Department of Healthcare and Family
17Services shall include in the annual Medicaid report for State
18Fiscal Year 2014 and every fiscal year thereafter information
19concerning implementation of the provisions of this Section.
20    (d) No later than August 1, 2014, the Auditor General shall
21report to the General Assembly concerning the extent to which
22the timeframes specified in this Section have been met and the
23extent to which State staffing levels are adequate to meet the
24requirements of this Section.
25    (e) The Department of Healthcare and Family Services, the
26Department of Human Services, and the Department on Aging shall

 

 

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1take the following steps to achieve federally established
2timeframes for eligibility determinations for Medicaid and
3long-term care benefits and shall work toward the federal goal
4of real time determinations:
5        (1) The Departments shall review, in collaboration
6    with representatives of affected providers, all forms and
7    procedures currently in use, federal guidelines either
8    suggested or mandated, and staff deployment by September
9    30, 2014 to identify additional measures that can improve
10    long-term care eligibility processing and make adjustments
11    where possible.
12        (2) No later than June 30, 2014, the Department of
13    Healthcare and Family Services shall issue vouchers for
14    advance payments not to exceed $50,000,000 to nursing
15    facilities with significant outstanding Medicaid liability
16    associated with services provided to residents with
17    Medicaid applications pending and residents facing the
18    greatest delays. Each facility with an advance payment
19    shall state in writing whether its own recoupment schedule
20    will be in 3 or 6 equal monthly installments, as long as
21    all advances are recouped by June 30, 2016. Effective
22    February 28, 2015, the posting of recoupment installments
23    of the advance payments shall be suspended until January 1,
24    2016. Beginning January 1, 2016, recoupments shall resume
25    according to the schedule previously selected by the
26    facility until recoupment is complete 2015.

 

 

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1        (3) The Department of Healthcare and Family Services'
2    Office of Inspector General and the Department of Human
3    Services shall immediately forgo resource review and
4    review of transfers during the relevant look-back period
5    for applications that were submitted prior to September 1,
6    2013. An applicant who applied prior to September 1, 2013,
7    who was denied for failure to cooperate in providing
8    required information, and whose application was
9    incorrectly reviewed under the wrong look-back period
10    rules may request review and correction of the denial based
11    on this subsection. If found eligible upon review, such
12    applicants shall be retroactively enrolled.
13        (4) As soon as practicable, the Department of
14    Healthcare and Family Services shall implement policies
15    and promulgate rules to simplify financial eligibility
16    verification in the following instances: (A) for
17    applicants or recipients who are receiving Supplemental
18    Security Income payments or who had been receiving such
19    payments at the time they were admitted to a nursing
20    facility and (B) for applicants or recipients with verified
21    income at or below 100% of the federal poverty level when
22    the declared value of their countable resources is no
23    greater than the allowable amounts pursuant to Section 5-2
24    of this Code for classes of eligible persons for whom a
25    resource limit applies. Such simplified verification
26    policies shall apply to community cases as well as

 

 

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1    long-term care cases.
2        (5) As soon as practicable, but not later than July 1,
3    2014, the Department of Healthcare and Family Services and
4    the Department of Human Services shall jointly begin a
5    special enrollment project by using simplified eligibility
6    verification policies and by redeploying caseworkers
7    trained to handle long-term care cases to prioritize those
8    cases, until the backlog is eliminated and processing time
9    is within 90 days. This project shall apply to applications
10    for long-term care received by the State on or before May
11    15, 2014.
12        (6) As soon as practicable, but not later than
13    September 1, 2014, the Department on Aging shall make
14    available to long-term care facilities and community
15    providers upon request, through an electronic method, the
16    information contained within the Interagency Certification
17    of Screening Results completed by the pre-screener, in a
18    form and manner acceptable to the Department of Human
19    Services.
20        (7) Effective 30 days after the completion of 3
21    regionally based trainings, nursing facilities shall
22    submit all applications for medical assistance online via
23    the Application for Benefits Eligibility (ABE) website.
24    This requirement shall extend to scanning and uploading
25    with the online application any required additional forms
26    such as the Long Term Care Facility Notification and the

 

 

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1    Additional Financial Information for Long Term Care
2    Applicants as well as scanned copies of any supporting
3    documentation. Long-term care facility admission documents
4    must be submitted as required in Section 5-5 of this Code.
5    No local Department of Human Services office shall refuse
6    to accept an electronically filed application.
7        (8) Notwithstanding any other provision of this Code,
8    the Department of Human Services and the Department of
9    Healthcare and Family Services' Office of the Inspector
10    General shall, upon request, allow an applicant additional
11    time to submit information and documents needed as part of
12    a review of available resources or resources transferred
13    during the look-back period. The initial extension shall
14    not exceed 30 days. A second extension of 30 days may be
15    granted upon request. Any request for information issued by
16    the State to an applicant shall include the following: an
17    explanation of the information required and the date by
18    which the information must be submitted; a statement that
19    failure to respond in a timely manner can result in denial
20    of the application; a statement that the applicant or the
21    facility in the name of the applicant may seek an
22    extension; and the name and contact information of a
23    caseworker in case of questions. Any such request for
24    information shall also be sent to the facility. In deciding
25    whether to grant an extension, the Department of Human
26    Services or the Department of Healthcare and Family

 

 

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1    Services' Office of the Inspector General shall take into
2    account what is in the best interest of the applicant. The
3    time limits for processing an application shall be tolled
4    during the period of any extension granted under this
5    subsection.
6        (9) The Department of Human Services and the Department
7    of Healthcare and Family Services must jointly compile data
8    on pending applications and post a monthly report on each
9    Department's website for the purposes of monitoring
10    long-term care eligibility processing. The report must
11    specify the number of applications pending long-term care
12    eligibility determination and admission in the following
13    categories:
14            (A) Length of time application is pending - 0 to 90
15        days, 91 days to 180 days, 181 days to 12 months, over
16        12 months to 18 months, over 18 months to 24 months,
17        and over 24 months.
18            (B) Percentage of applications pending in the
19        Department of Human Services' Family Community
20        Resource Centers, in the Department of Human Services'
21        long-term care hubs, with the Department of Healthcare
22        and Family Services' Office of Inspector General, and
23        those applications which are being tolled due to
24        requests for extension of time for additional
25        information.
26            (C) Status of pending applications.

 

 

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1    (f) Long-term care services shall be covered to the same
2extent other medical assistance is covered for an individual
3entitled to temporary coverage under law or court order because
4the State failed to process the individual's application timely
5under State and federal law and the individual did not cause
6the delay. The Department of Healthcare and Family Services
7shall immediately add the person to the facility's roster for
8payment and notify the managed care organization of the
9resident's change in payment status, if the resident is in a
10managed care organization. If the applicant is subsequently
11found to be ineligible for long-term care services under the
12medical assistance program, the Department shall recover all
13payments made to long-term care providers for services provided
14to the individual during the temporary coverage period.
15(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14.)
 
16    (305 ILCS 5/12-4.49 new)
17    Sec. 12-4.49. Waiver proposal; working group. The
18Department of Healthcare and Family Services shall convene a
19working group in consultation with the Office of the Governor
20to discuss the development of a revised proposal for the
21research and demonstration project waiver proposal submitted
22to the U.S. Department of Health and Human Services on June 4,
232014 under Section 1115 of the Social Security Act. The working
24group shall include the following members:
25        (1) Three members of the General Assembly chosen by the

 

 

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1    Speaker of the House of Representatives.
2        (2) Three members of the General Assembly chosen by the
3    Minority Leader of the House of Representatives.
4        (3) Three members of the General Assembly chosen by the
5    President of the Senate.
6        (4) Three members of the General Assembly chosen by the
7    Minority Leader of the Senate.
8    The purpose of the working group shall be to provide input
9and advice to the Department and the Office of the Governor
10with regard to the development of the proposal to utilize a
11research and demonstration waiver. The working group shall meet
12initially at the call of the Governor and at least once each
13quarter year thereafter until the waiver either is approved by
14the U.S. Department of Health and Human Services or expires.
15The Department shall provide administrative support for the
16working group.
17    Members shall not be compensated for their participation in
18the working group but may receive reimbursement for travel
19expenses.
 
20    (305 ILCS 5/12-4.50 new)
21    Sec. 12-4.50. Program efficiencies. It is the intent of the
22General Assembly to improve efficiencies and coordinate care in
23order to maximize health outcomes and access to care. The
24Governor's Office shall direct the Department of Healthcare and
25Family Services, in conjunction with the Department of Human

 

 

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1Services, the Department on Aging, and the Department of Public
2Health, to initiate a review of all case management, care
3coordination programs, and public health programs for
4potential duplication of services. Each agency shall provide
5the Department of Healthcare and Family Services with a copy of
6its internal review by October 1, 2015. The Department shall
7provide the Governor and the General Assembly with a report of
8its findings by January 1, 2016. If duplicative services are
9identified, the Department of Healthcare and Family Services
10shall work in conjunction with the agencies providing
11duplicative services to develop a policy or policies to ensure
12efficient expenditure of State resources, to be completed by
13December 31, 2016.
 
14    (305 ILCS 5/12-13.1)
15    Sec. 12-13.1. Inspector General.
16    (a) The Governor shall appoint, and the Senate shall
17confirm, an Inspector General who shall function within the
18Illinois Department of Public Aid (now Healthcare and Family
19Services) and report to the Governor. The term of the Inspector
20General shall expire on the third Monday of January, 1997 and
21every 4 years thereafter.
22    (b) In order to prevent, detect, and eliminate fraud,
23waste, abuse, mismanagement, and misconduct, the Inspector
24General shall oversee the Department of Healthcare and Family
25Services' and the Department on Aging's integrity functions,

 

 

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1which include, but are not limited to, the following:
2        (1) Investigation of misconduct by employees, vendors,
3    contractors and medical providers, except for allegations
4    of violations of the State Officials and Employees Ethics
5    Act which shall be referred to the Office of the Governor's
6    Executive Inspector General for investigation.
7        (2) Prepayment and post-payment audits of medical
8    providers related to ensuring that appropriate payments
9    are made for services rendered and to the prevention and
10    recovery of overpayments.
11        (3) Monitoring of quality assurance programs
12    administered by the Department of Healthcare and Family
13    Services and the Community Care Program administered by the
14    Department on Aging.
15        (4) Quality control measurements of the programs
16    administered by the Department of Healthcare and Family
17    Services and the Community Care Program administered by the
18    Department on Aging.
19        (5) Investigations of fraud or intentional program
20    violations committed by clients of the Department of
21    Healthcare and Family Services and the Community Care
22    Program administered by the Department on Aging.
23        (6) Actions initiated against contractors, vendors, or
24    medical providers for any of the following reasons:
25            (A) Violations of the medical assistance program
26        and the Community Care Program administered by the

 

 

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1        Department on Aging.
2            (B) Sanctions against providers brought in
3        conjunction with the Department of Public Health or the
4        Department of Human Services (as successor to the
5        Department of Mental Health and Developmental
6        Disabilities).
7            (C) Recoveries of assessments against hospitals
8        and long-term care facilities.
9            (D) Sanctions mandated by the United States
10        Department of Health and Human Services against
11        medical providers.
12            (E) Violations of contracts related to any
13        programs administered by the Department of Healthcare
14        and Family Services and the Community Care Program
15        administered by the Department on Aging.
16        (7) Representation of the Department of Healthcare and
17    Family Services at hearings with the Illinois Department of
18    Financial and Professional Regulation in actions taken
19    against professional licenses held by persons who are in
20    violation of orders for child support payments.
21    (b-5) At the request of the Secretary of Human Services,
22the Inspector General shall, in relation to any function
23performed by the Department of Human Services as successor to
24the Department of Public Aid, exercise one or more of the
25powers provided under this Section as if those powers related
26to the Department of Human Services; in such matters, the

 

 

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1Inspector General shall report his or her findings to the
2Secretary of Human Services.
3    (c) Notwithstanding, and in addition to, any other
4provision of law, the Inspector General shall have access to
5all information, personnel and facilities of the Department of
6Healthcare and Family Services and the Department of Human
7Services (as successor to the Department of Public Aid), their
8employees, vendors, contractors and medical providers and any
9federal, State or local governmental agency that are necessary
10to perform the duties of the Office as directly related to
11public assistance programs administered by those departments.
12No medical provider shall be compelled, however, to provide
13individual medical records of patients who are not clients of
14the programs administered by the Department of Healthcare and
15Family Services. State and local governmental agencies are
16authorized and directed to provide the requested information,
17assistance or cooperation.
18    For purposes of enhanced program integrity functions and
19oversight, and to the extent consistent with applicable
20information and privacy, security, and disclosure laws, State
21agencies and departments shall provide the Office of Inspector
22General access to confidential and other information and data,
23and the Inspector General is authorized to enter into
24agreements with appropriate federal agencies and departments
25to secure similar data. This includes, but is not limited to,
26information pertaining to: licensure; certification; earnings;

 

 

09900SB0788ham002- 94 -LRB099 05889 KTG 36238 a

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

 

 

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1Revenue; the Department of Public Health; the Department of
2Human Services; and the Department of Financial and
3Professional Regulation.
4    The Inspector General shall have the authority to deny
5payment, prevent overpayments, and recover overpayments.
6    The Inspector General shall have the authority to deny or
7suspend payment to, and deny, terminate, or suspend the
8eligibility of, any vendor who fails to grant the Inspector
9General timely access to full and complete records, including
10records of recipients under the medical assistance program for
11the most recent 6 years, in accordance with Section 140.28 of
12Title 89 of the Illinois Administrative Code, and other
13information for the purpose of audits, investigations, or other
14program integrity functions, after reasonable written request
15by the Inspector General.
16    (d) The Inspector General shall serve as the Department of
17Healthcare and Family Services' primary liaison with law
18enforcement, investigatory and prosecutorial agencies,
19including but not limited to the following:
20        (1) The Department of State Police.
21        (2) The Federal Bureau of Investigation and other
22    federal law enforcement agencies.
23        (3) The various Inspectors General of federal agencies
24    overseeing the programs administered by the Department of
25    Healthcare and Family Services.
26        (4) The various Inspectors General of any other State

 

 

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1    agencies with responsibilities for portions of programs
2    primarily administered by the Department of Healthcare and
3    Family Services.
4        (5) The Offices of the several United States Attorneys
5    in Illinois.
6        (6) The several State's Attorneys.
7        (7) The offices of the Centers for Medicare and
8    Medicaid Services that administer the Medicare and
9    Medicaid integrity programs.
10    The Inspector General shall meet on a regular basis with
11these entities to share information regarding possible
12misconduct by any persons or entities involved with the public
13aid programs administered by the Department of Healthcare and
14Family Services.
15    (e) All investigations conducted by the Inspector General
16shall be conducted in a manner that ensures the preservation of
17evidence for use in criminal prosecutions. If the Inspector
18General determines that a possible criminal act relating to
19fraud in the provision or administration of the medical
20assistance program has been committed, the Inspector General
21shall immediately notify the Medicaid Fraud Control Unit. If
22the Inspector General determines that a possible criminal act
23has been committed within the jurisdiction of the Office, the
24Inspector General may request the special expertise of the
25Department of State Police. The Inspector General may present
26for prosecution the findings of any criminal investigation to

 

 

09900SB0788ham002- 97 -LRB099 05889 KTG 36238 a

1the Office of the Attorney General, the Offices of the several
2United States Attorneys in Illinois or the several State's
3Attorneys.
4    (f) To carry out his or her duties as described in this
5Section, the Inspector General and his or her designees shall
6have the power to compel by subpoena the attendance and
7testimony of witnesses and the production of books, electronic
8records and papers as directly related to public assistance
9programs administered by the Department of Healthcare and
10Family Services or the Department of Human Services (as
11successor to the Department of Public Aid). No medical provider
12shall be compelled, however, to provide individual medical
13records of patients who are not clients of the Medical
14Assistance Program.
15    (g) The Inspector General shall report all convictions,
16terminations, and suspensions taken against vendors,
17contractors and medical providers to the Department of
18Healthcare and Family Services and to any agency responsible
19for licensing or regulating those persons or entities.
20    (h) The Inspector General shall make annual reports,
21findings, and recommendations regarding the Office's
22investigations into reports of fraud, waste, abuse,
23mismanagement, or misconduct relating to any programs
24administered by the Department of Healthcare and Family
25Services or the Department of Human Services (as successor to
26the Department of Public Aid) to the General Assembly and the

 

 

09900SB0788ham002- 98 -LRB099 05889 KTG 36238 a

1Governor. These reports shall include, but not be limited to,
2the following information:
3        (1) Aggregate provider billing and payment
4    information, including the number of providers at various
5    Medicaid earning levels.
6        (2) The number of audits of the medical assistance
7    program and the dollar savings resulting from those audits.
8        (3) The number of prescriptions rejected annually
9    under the Department of Healthcare and Family Services'
10    Refill Too Soon program and the dollar savings resulting
11    from that program.
12        (4) Provider sanctions, in the aggregate, including
13    terminations and suspensions.
14        (5) A detailed summary of the investigations
15    undertaken in the previous fiscal year. These summaries
16    shall comply with all laws and rules regarding maintaining
17    confidentiality in the public aid programs.
18    (i) Nothing in this Section shall limit investigations by
19the Department of Healthcare and Family Services or the
20Department of Human Services that may otherwise be required by
21law or that may be necessary in their capacity as the central
22administrative authorities responsible for administration of
23their agency's programs in this State.
24    (j) The Inspector General may issue shields or other
25distinctive identification to his or her employees not
26exercising the powers of a peace officer if the Inspector

 

 

09900SB0788ham002- 99 -LRB099 05889 KTG 36238 a

1General determines that a shield or distinctive identification
2is needed by an employee to carry out his or her
3responsibilities.
4    (k) The Office of Inspector General must realign its
5resources toward activities with the greatest potential to
6reduce or avoid unnecessary, wasteful, or fraudulent
7expenditures.
8(Source: P.A. 97-689, eff. 6-14-12; 98-8, eff. 5-3-13.)
 
9    (305 ILCS 5/14-11)
10    Sec. 14-11. Hospital payment reform.
11    (a) The Department may, by rule, implement the All Patient
12Refined Diagnosis Related Groups (APR-DRG) payment system for
13inpatient services provided on or after July 1, 2013, in a
14manner consistent with the actions authorized in this Section.
15    (b) On or before October 1, 2012 and through June 30, 2013,
16the Department shall begin testing the APR-DRG system. During
17the testing period the Department shall process and price
18inpatient services using the APR-DRG system; however, actual
19payments for those inpatient services shall be made using the
20current reimbursement system. During the testing period, the
21Department, in collaboration with the statewide representative
22of hospitals, shall provide information and technical
23assistance to hospitals to encourage and facilitate their
24transition to the APR-DRG system.
25    (c) The Department may, by rule, implement the Enhanced

 

 

09900SB0788ham002- 100 -LRB099 05889 KTG 36238 a

1Ambulatory Procedure Grouping (EAPG) system for outpatient
2services provided on or after January 1, 2014, in a manner
3consistent with the actions authorized in this Section. On or
4before January 1, 2013 and through December 31, 2013, the
5Department shall begin testing the EAPG system. During the
6testing period the Department shall process and price
7outpatient services using the EAPG system; however, actual
8payments for those outpatient services shall be made using the
9current reimbursement system. During the testing period, the
10Department, in collaboration with the statewide representative
11of hospitals, shall provide information and technical
12assistance to hospitals to encourage and facilitate their
13transition to the EAPG system.
14    (d) The Department in consultation with the current
15hospital technical advisory group shall review the test claims
16for inpatient and outpatient services at least monthly,
17including the estimated impact on hospitals, and, in developing
18the rules, policies, and procedures to implement the new
19payment systems, shall consider at least the following issues:
20        (1) The use of national relative weights provided by
21    the vendor of the APR-DRG system, adjusted to reflect
22    characteristics of the Illinois Medical Assistance
23    population.
24        (2) An updated outlier payment methodology based on
25    current data and consistent with the APR-DRG system.
26        (3) The use of policy adjusters to enhance payments to

 

 

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1    hospitals treating a high percentage of individuals
2    covered by the Medical Assistance program and uninsured
3    patients.
4        (4) Reimbursement for inpatient specialty services
5    such as psychiatric, rehabilitation, and long-term acute
6    care using updated per diem rates that account for service
7    acuity.
8        (5) The creation of one or more transition funding
9    pools to preserve access to care and to ensure financial
10    stability as hospitals transition to the new payment
11    system.
12        (6) Whether, beginning July 1, 2014, some of the static
13    adjustment payments financed by General Revenue funds
14    should be used as part of the base payment system,
15    including as policy adjusters to recognize the additional
16    costs of certain services, such as pediatric or neonatal,
17    or providers, such as trauma centers, Critical Access
18    Hospitals, or high Medicaid hospitals, or for services to
19    uninsured patients.
20    (e) The Department shall provide the association
21representing the majority of hospitals in Illinois, as the
22statewide representative of the hospital community, with a
23monthly file of claims adjudicated under the test system for
24the purpose of review and analysis as part of the collaboration
25between the State and the hospital community. The file shall
26consist of a de-identified extract compliant with the Health

 

 

09900SB0788ham002- 102 -LRB099 05889 KTG 36238 a

1Insurance Portability and Accountability Act (HIPAA).
2    (f) The current hospital technical advisory group shall
3make recommendations for changes during the testing period and
4recommendations for changes prior to the effective dates of the
5new payment systems. The Department shall draft administrative
6rules to implement the new payment systems and provide them to
7the technical advisory group at least 90 days prior to the
8proposed effective dates of the new payment systems.
9    (g) The payments to hospitals financed by the current
10hospital assessment, authorized under Article V-A of this Code,
11are scheduled to sunset on June 30, 2014. The continuation of
12or revisions to the hospital assessment program shall take into
13consideration the impact on hospitals and access to care as a
14result of the changes to the hospital payment system.
15    (h) Beginning July 1, 2014, the Department may transition
16current General Revenue funded supplemental payments into the
17claims based system over a period of no less than 2 years from
18the implementation date of the new payment systems and no more
19than 4 years from the implementation date of the new payment
20systems, provided however that the Department may adopt, by
21rule, supplemental payments to help ensure access to care in a
22geographic area or to help ensure access to specialty services.
23For any supplemental payments that are adopted that are based
24on historic data, the data shall be no older than 3 years and
25the supplemental payment shall be effective for no longer than
262 years before requiring the data to be updated.

 

 

09900SB0788ham002- 103 -LRB099 05889 KTG 36238 a

1    (i) Any payments authorized under 89 Illinois
2Administrative Code 148 set to expire in State fiscal year 2012
3and that were paid out to hospitals in State fiscal year 2012
4or any payments authorized under 89 Illinois Administrative
5Code 148.299(b)(1)(A) and initially paid out to hospitals in
6State fiscal year 2015, shall remain in effect as long as the
7assessment imposed by Section 5A-2 is in effect.
8    (j) Subsections (a) and (c) of this Section shall remain
9operative unless the Auditor General has reported that: (i) the
10Department has not undertaken the required actions listed in
11the report required by subsection (a) of Section 2-20 of the
12Illinois State Auditing Act; or (ii) the Department has failed
13to comply with the reporting requirements of Section 2-20 of
14the Illinois State Auditing Act.
15    (k) Subsections (a) and (c) of this Section shall not be
16operative until final federal approval by the Centers for
17Medicare and Medicaid Services of the U.S. Department of Health
18and Human Services and implementation of all of the payments
19and assessments in Article V-A in its form as of the effective
20date of this amendatory Act of the 97th General Assembly or as
21it may be amended.
22(Source: P.A. 97-689, eff. 6-14-12.)
 
23    Section 99. Effective date. This Act takes effect upon
24becoming law.".