Full Text of HB1197 94th General Assembly
HB1197sam001 94TH GENERAL ASSEMBLY
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Sen. Donne E. Trotter
Filed: 5/30/2005
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| AMENDMENT TO HOUSE BILL 1197
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| AMENDMENT NO. ______. Amend House Bill 1197 by replacing | 3 |
| everything after the enacting clause with the following:
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| "Section 1. Short title. This Act may be cited as the | 5 |
| FY2006 Budget Implementation (Human Services) Act. | 6 |
| Section 5. Purpose. It is the purpose of this Act to | 7 |
| implement the Governor's FY2006 budget recommendations | 8 |
| concerning human services. | 9 |
| Section 10. The Illinois Administrative Procedure Act is | 10 |
| amended by changing Section 5-45 as follows:
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| (5 ILCS 100/5-45) (from Ch. 127, par. 1005-45)
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| Sec. 5-45. Emergency rulemaking.
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| (a) "Emergency" means the existence of any situation that | 14 |
| any agency
finds reasonably constitutes a threat to the public | 15 |
| interest, safety, or
welfare.
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| (b) If any agency finds that an
emergency exists that | 17 |
| requires adoption of a rule upon fewer days than
is required by | 18 |
| Section 5-40 and states in writing its reasons for that
| 19 |
| finding, the agency may adopt an emergency rule without prior | 20 |
| notice or
hearing upon filing a notice of emergency rulemaking | 21 |
| with the Secretary of
State under Section 5-70. The notice | 22 |
| shall include the text of the
emergency rule and shall be |
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| published in the Illinois Register. Consent
orders or other | 2 |
| court orders adopting settlements negotiated by an agency
may | 3 |
| be adopted under this Section. Subject to applicable | 4 |
| constitutional or
statutory provisions, an emergency rule | 5 |
| becomes effective immediately upon
filing under Section 5-65 or | 6 |
| at a stated date less than 10 days
thereafter. The agency's | 7 |
| finding and a statement of the specific reasons
for the finding | 8 |
| shall be filed with the rule. The agency shall take
reasonable | 9 |
| and appropriate measures to make emergency rules known to the
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| persons who may be affected by them.
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| (c) An emergency rule may be effective for a period of not | 12 |
| longer than
150 days, but the agency's authority to adopt an | 13 |
| identical rule under Section
5-40 is not precluded. No | 14 |
| emergency rule may be adopted more
than once in any 24 month | 15 |
| period, except that this limitation on the number
of emergency | 16 |
| rules that may be adopted in a 24 month period does not apply
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| to (i) emergency rules that make additions to and deletions | 18 |
| from the Drug
Manual under Section 5-5.16 of the Illinois | 19 |
| Public Aid Code or the
generic drug formulary under Section | 20 |
| 3.14 of the Illinois Food, Drug
and Cosmetic Act, (ii) | 21 |
| emergency rules adopted by the Pollution Control
Board before | 22 |
| July 1, 1997 to implement portions of the Livestock Management
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| Facilities Act , ; or (iii) emergency rules adopted by the | 24 |
| Illinois Department of Public Health under subsections (a) | 25 |
| through (i) of Section 2 of the Department of Public Health Act | 26 |
| when necessary to protect the public's health. Two or more | 27 |
| emergency rules having substantially the same
purpose and | 28 |
| effect shall be deemed to be a single rule for purposes of this
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| Section.
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| (d) In order to provide for the expeditious and timely | 31 |
| implementation
of the State's fiscal year 1999 budget, | 32 |
| emergency rules to implement any
provision of Public Act 90-587 | 33 |
| or 90-588
or any other budget initiative for fiscal year 1999 | 34 |
| may be adopted in
accordance with this Section by the agency |
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| charged with administering that
provision or initiative, | 2 |
| except that the 24-month limitation on the adoption
of | 3 |
| emergency rules and the provisions of Sections 5-115 and 5-125 | 4 |
| do not apply
to rules adopted under this subsection (d). The | 5 |
| adoption of emergency rules
authorized by this subsection (d) | 6 |
| shall be deemed to be necessary for the
public interest, | 7 |
| safety, and welfare.
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| (e) In order to provide for the expeditious and timely | 9 |
| implementation
of the State's fiscal year 2000 budget, | 10 |
| emergency rules to implement any
provision of this amendatory | 11 |
| Act of the 91st General Assembly
or any other budget initiative | 12 |
| for fiscal year 2000 may be adopted in
accordance with this | 13 |
| Section by the agency charged with administering that
provision | 14 |
| or initiative, except that the 24-month limitation on the | 15 |
| adoption
of emergency rules and the provisions of Sections | 16 |
| 5-115 and 5-125 do not apply
to rules adopted under this | 17 |
| subsection (e). The adoption of emergency rules
authorized by | 18 |
| this subsection (e) shall be deemed to be necessary for the
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| public interest, safety, and welfare.
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| (f) In order to provide for the expeditious and timely | 21 |
| implementation
of the State's fiscal year 2001 budget, | 22 |
| emergency rules to implement any
provision of this amendatory | 23 |
| Act of the 91st General Assembly
or any other budget initiative | 24 |
| for fiscal year 2001 may be adopted in
accordance with this | 25 |
| Section by the agency charged with administering that
provision | 26 |
| or initiative, except that the 24-month limitation on the | 27 |
| adoption
of emergency rules and the provisions of Sections | 28 |
| 5-115 and 5-125 do not apply
to rules adopted under this | 29 |
| subsection (f). The adoption of emergency rules
authorized by | 30 |
| this subsection (f) shall be deemed to be necessary for the
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| public interest, safety, and welfare.
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| (g) In order to provide for the expeditious and timely | 33 |
| implementation
of the State's fiscal year 2002 budget, | 34 |
| emergency rules to implement any
provision of this amendatory |
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| Act of the 92nd General Assembly
or any other budget initiative | 2 |
| for fiscal year 2002 may be adopted in
accordance with this | 3 |
| Section by the agency charged with administering that
provision | 4 |
| or initiative, except that the 24-month limitation on the | 5 |
| adoption
of emergency rules and the provisions of Sections | 6 |
| 5-115 and 5-125 do not apply
to rules adopted under this | 7 |
| subsection (g). The adoption of emergency rules
authorized by | 8 |
| this subsection (g) shall be deemed to be necessary for the
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| public interest, safety, and welfare.
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| (h) In order to provide for the expeditious and timely | 11 |
| implementation
of the State's fiscal year 2003 budget, | 12 |
| emergency rules to implement any
provision of this amendatory | 13 |
| Act of the 92nd General Assembly
or any other budget initiative | 14 |
| for fiscal year 2003 may be adopted in
accordance with this | 15 |
| Section by the agency charged with administering that
provision | 16 |
| or initiative, except that the 24-month limitation on the | 17 |
| adoption
of emergency rules and the provisions of Sections | 18 |
| 5-115 and 5-125 do not apply
to rules adopted under this | 19 |
| subsection (h). The adoption of emergency rules
authorized by | 20 |
| this subsection (h) shall be deemed to be necessary for the
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| public interest, safety, and welfare.
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| (i) In order to provide for the expeditious and timely | 23 |
| implementation
of the State's fiscal year 2004 budget, | 24 |
| emergency rules to implement any
provision of this amendatory | 25 |
| Act of the 93rd General Assembly
or any other budget initiative | 26 |
| for fiscal year 2004 may be adopted in
accordance with this | 27 |
| Section by the agency charged with administering that
provision | 28 |
| or initiative, except that the 24-month limitation on the | 29 |
| adoption
of emergency rules and the provisions of Sections | 30 |
| 5-115 and 5-125 do not apply
to rules adopted under this | 31 |
| subsection (i). The adoption of emergency rules
authorized by | 32 |
| this subsection (i) shall be deemed to be necessary for the
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| public interest, safety, and welfare.
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| (j) In order to provide for the expeditious and timely |
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| implementation of the provisions of the State's fiscal year | 2 |
| 2005 budget as provided under the Fiscal Year 2005 Budget | 3 |
| Implementation (Human Services) Act, emergency rules to | 4 |
| implement any provision of the Fiscal Year 2005 Budget | 5 |
| Implementation (Human Services) Act may be adopted in | 6 |
| accordance with this Section by the agency charged with | 7 |
| administering that provision, except that the 24-month | 8 |
| limitation on the adoption of emergency rules and the | 9 |
| provisions of Sections 5-115 and 5-125 do not apply to rules | 10 |
| adopted under this subsection (j). The Department of Public Aid | 11 |
| may also adopt rules under this subsection (j) necessary to | 12 |
| administer the Illinois Public Aid Code and the Children's | 13 |
| Health Insurance Program Act. The adoption of emergency rules | 14 |
| authorized by this subsection (j) shall be deemed to be | 15 |
| necessary for the public interest, safety, and welfare.
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| (k) In order to provide for the expeditious and timely | 17 |
| implementation of the provisions of the State's fiscal year | 18 |
| 2006 budget, emergency rules to implement any provision of this | 19 |
| amendatory Act of the 94th General Assembly or any other budget | 20 |
| initiative for fiscal year 2006 may be adopted in accordance | 21 |
| with this Section by the agency charged with administering that | 22 |
| provision or initiative, except that the 24-month limitation on | 23 |
| the adoption of emergency rules and the provisions of Sections | 24 |
| 5-115 and 5-125 do not apply to rules adopted under this | 25 |
| subsection (k). The Department of Public Aid may also adopt | 26 |
| rules under this subsection (k) necessary to administer the | 27 |
| Illinois Public Aid Code, the Senior Citizens and Disabled | 28 |
| Persons Property Tax Relief and Pharmaceutical Assistance Act, | 29 |
| the Senior Citizens and Disabled Persons Prescription Drug | 30 |
| Discount Program Act, and the Children's Health Insurance | 31 |
| Program Act. The adoption of emergency rules authorized by this | 32 |
| subsection (k) shall be deemed to be necessary for the public | 33 |
| interest, safety, and welfare.
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| (Source: P.A. 92-10, eff. 6-11-01; 92-597, eff. 6-28-02; 93-20, |
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| eff. 6-20-03; 93-829, eff. 7-28-04; 93-841, eff. 7-30-04; | 2 |
| revised 10-25-04.)
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| Section 12. The Illinois Act on the Aging is amended by | 4 |
| changing Section 4.02 as follows:
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| (20 ILCS 105/4.02) (from Ch. 23, par. 6104.02)
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| Sec. 4.02. The Department shall establish a program of | 7 |
| services to
prevent unnecessary institutionalization of | 8 |
| persons age 60 and older in
need of long term care or who are | 9 |
| established as persons who suffer from
Alzheimer's disease or a | 10 |
| related disorder under the Alzheimer's Disease
Assistance Act, | 11 |
| thereby enabling them
to remain in their own homes or in other | 12 |
| living arrangements. Such
preventive services, which may be | 13 |
| coordinated with other programs for the
aged and monitored by | 14 |
| area agencies on aging in cooperation with the
Department, may | 15 |
| include, but are not limited to, any or all of the following:
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| (a) home health services;
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| (b) home nursing services;
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| (c) homemaker services;
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| (d) chore and housekeeping services;
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| (e) day care services;
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| (f) home-delivered meals;
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| (g) education in self-care;
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| (h) personal care services;
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| (i) adult day health services;
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| (j) habilitation services;
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| (k) respite care;
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| (k-5) community reintegration services;
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| (l) other nonmedical social services that may enable | 29 |
| the person
to become self-supporting; or
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| (m) clearinghouse for information provided by senior | 31 |
| citizen home owners
who want to rent rooms to or share | 32 |
| living space with other senior citizens.
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| The Department shall establish eligibility standards for | 2 |
| such
services taking into consideration the unique economic and | 3 |
| social needs
of the target population for whom they are to be | 4 |
| provided. Such eligibility
standards shall be based on the | 5 |
| recipient's ability to pay for services;
provided, however, | 6 |
| that in determining the amount and nature of services
for which | 7 |
| a person may qualify, consideration shall not be given to the
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| value of cash, property or other assets held in the name of the | 9 |
| person's
spouse pursuant to a written agreement dividing | 10 |
| marital property into equal
but separate shares or pursuant to | 11 |
| a transfer of the person's interest in a
home to his spouse, | 12 |
| provided that the spouse's share of the marital
property is not | 13 |
| made available to the person seeking such services.
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| Beginning July 1, 2002, the Department shall require as a | 15 |
| condition of
eligibility that all financially eligible | 16 |
| applicants and recipients apply
for medical assistance
under | 17 |
| Article V of the Illinois Public Aid Code in accordance with | 18 |
| rules
promulgated by the Department.
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| The Department shall, in conjunction with the Department of | 20 |
| Public Aid,
seek appropriate amendments under Sections 1915 and | 21 |
| 1924 of the Social
Security Act. The purpose of the amendments | 22 |
| shall be to extend eligibility
for home and community based | 23 |
| services under Sections 1915 and 1924 of the
Social Security | 24 |
| Act to persons who transfer to or for the benefit of a
spouse | 25 |
| those amounts of income and resources allowed under Section | 26 |
| 1924 of
the Social Security Act. Subject to the approval of | 27 |
| such amendments, the
Department shall extend the provisions of | 28 |
| Section 5-4 of the Illinois
Public Aid Code to persons who, but | 29 |
| for the provision of home or
community-based services, would | 30 |
| require the level of care provided in an
institution, as is | 31 |
| provided for in federal law. Those persons no longer
found to | 32 |
| be eligible for receiving noninstitutional services due to | 33 |
| changes
in the eligibility criteria shall be given 60 days | 34 |
| notice prior to actual
termination. Those persons receiving |
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| notice of termination may contact the
Department and request | 2 |
| the determination be appealed at any time during the
60 day | 3 |
| notice period. With the exception of the lengthened notice and | 4 |
| time
frame for the appeal request, the appeal process shall | 5 |
| follow the normal
procedure. In addition, each person affected | 6 |
| regardless of the
circumstances for discontinued eligibility | 7 |
| shall be given notice and the
opportunity to purchase the | 8 |
| necessary services through the Community Care
Program. If the | 9 |
| individual does not elect to purchase services, the
Department | 10 |
| shall advise the individual of alternative services. The target
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| population identified for the purposes of this Section are | 12 |
| persons age 60
and older with an identified service need. | 13 |
| Priority shall be given to those
who are at imminent risk of | 14 |
| institutionalization. The services shall be
provided to | 15 |
| eligible persons age 60 and older to the extent that the cost
| 16 |
| of the services together with the other personal maintenance
| 17 |
| expenses of the persons are reasonably related to the standards
| 18 |
| established for care in a group facility appropriate to the | 19 |
| person's
condition. These non-institutional services, pilot | 20 |
| projects or
experimental facilities may be provided as part of | 21 |
| or in addition to
those authorized by federal law or those | 22 |
| funded and administered by the
Department of Human Services. | 23 |
| The Departments of Human Services, Public Aid,
Public Health, | 24 |
| Veterans' Affairs, and Commerce and Economic Opportunity and
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| other appropriate agencies of State, federal and local | 26 |
| governments shall
cooperate with the Department on Aging in the | 27 |
| establishment and development
of the non-institutional | 28 |
| services. The Department shall require an annual
audit from all | 29 |
| chore/housekeeping and homemaker vendors contracting with
the | 30 |
| Department under this Section. The annual audit shall assure | 31 |
| that each
audited vendor's procedures are in compliance with | 32 |
| Department's financial
reporting guidelines requiring an | 33 |
| administrative and employee wage and benefits cost split as | 34 |
| defined in administrative rules
a 27% administrative cost split |
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| and a 73%
employee wages and benefits cost split . The audit is | 2 |
| a public record under
the Freedom of Information Act. The | 3 |
| Department shall execute, relative to
the nursing home | 4 |
| prescreening project, written inter-agency
agreements with the | 5 |
| Department of Human Services and the Department
of Public Aid, | 6 |
| to effect the following: (1) intake procedures and common
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| eligibility criteria for those persons who are receiving | 8 |
| non-institutional
services; and (2) the establishment and | 9 |
| development of non-institutional
services in areas of the State | 10 |
| where they are not currently available or are
undeveloped. On | 11 |
| and after July 1, 1996, all nursing home prescreenings for
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| individuals 60 years of age or older shall be conducted by the | 13 |
| Department.
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| The Department is authorized to establish a system of | 15 |
| recipient copayment
for services provided under this Section, | 16 |
| such copayment to be based upon
the recipient's ability to pay | 17 |
| but in no case to exceed the actual cost of
the services | 18 |
| provided. Additionally, any portion of a person's income which
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| is equal to or less than the federal poverty standard shall not | 20 |
| be
considered by the Department in determining the copayment. | 21 |
| The level of
such copayment shall be adjusted whenever | 22 |
| necessary to reflect any change
in the officially designated | 23 |
| federal poverty standard.
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| The Department, or the Department's authorized | 25 |
| representative, shall
recover the amount of moneys expended for | 26 |
| services provided to or in
behalf of a person under this | 27 |
| Section by a claim against the person's
estate or against the | 28 |
| estate of the person's surviving spouse, but no
recovery may be | 29 |
| had until after the death of the surviving spouse, if
any, and | 30 |
| then only at such time when there is no surviving child who
is | 31 |
| under age 21, blind, or permanently and totally disabled. This
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| paragraph, however, shall not bar recovery, at the death of the | 33 |
| person, of
moneys for services provided to the person or in | 34 |
| behalf of the person under
this Section to which the person was |
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| not entitled;
provided that such recovery shall not be enforced | 2 |
| against any real estate while
it is occupied as a homestead by | 3 |
| the surviving spouse or other dependent, if no
claims by other | 4 |
| creditors have been filed against the estate, or, if such
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| claims have been filed, they remain dormant for failure of | 6 |
| prosecution or
failure of the claimant to compel administration | 7 |
| of the estate for the purpose
of payment. This paragraph shall | 8 |
| not bar recovery from the estate of a spouse,
under Sections | 9 |
| 1915 and 1924 of the Social Security Act and Section 5-4 of the
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| Illinois Public Aid Code, who precedes a person receiving | 11 |
| services under this
Section in death. All moneys for services
| 12 |
| paid to or in behalf of the person under this Section shall be | 13 |
| claimed for
recovery from the deceased spouse's estate. | 14 |
| "Homestead", as used
in this paragraph, means the dwelling | 15 |
| house and
contiguous real estate occupied by a surviving spouse
| 16 |
| or relative, as defined by the rules and regulations of the | 17 |
| Illinois Department
of Public Aid, regardless of the value of | 18 |
| the property.
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| The Department shall develop procedures to enhance | 20 |
| availability of
services on evenings, weekends, and on an | 21 |
| emergency basis to meet the
respite needs of caregivers. | 22 |
| Procedures shall be developed to permit the
utilization of | 23 |
| services in successive blocks of 24 hours up to the monthly
| 24 |
| maximum established by the Department. Workers providing these | 25 |
| services
shall be appropriately trained.
| 26 |
| Beginning on the effective date of this Amendatory Act of | 27 |
| 1991, no person
may perform chore/housekeeping and homemaker | 28 |
| services under a program
authorized by this Section unless that | 29 |
| person has been issued a certificate
of pre-service to do so by | 30 |
| his or her employing agency. Information
gathered to effect | 31 |
| such certification shall include (i) the person's name,
(ii) | 32 |
| the date the person was hired by his or her current employer, | 33 |
| and
(iii) the training, including dates and levels. Persons | 34 |
| engaged in the
program authorized by this Section before the |
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| effective date of this
amendatory Act of 1991 shall be issued a | 2 |
| certificate of all pre- and
in-service training from his or her | 3 |
| employer upon submitting the necessary
information. The | 4 |
| employing agency shall be required to retain records of
all | 5 |
| staff pre- and in-service training, and shall provide such | 6 |
| records to
the Department upon request and upon termination of | 7 |
| the employer's contract
with the Department. In addition, the | 8 |
| employing agency is responsible for
the issuance of | 9 |
| certifications of in-service training completed to their
| 10 |
| employees.
| 11 |
| The Department is required to develop a system to ensure | 12 |
| that persons
working as homemakers and chore housekeepers | 13 |
| receive increases in their
wages when the federal minimum wage | 14 |
| is increased by requiring vendors to
certify that they are | 15 |
| meeting the federal minimum wage statute for homemakers
and | 16 |
| chore housekeepers. An employer that cannot ensure that the | 17 |
| minimum
wage increase is being given to homemakers and chore | 18 |
| housekeepers
shall be denied any increase in reimbursement | 19 |
| costs.
| 20 |
| The Department on Aging and the Department of Human | 21 |
| Services
shall cooperate in the development and submission of | 22 |
| an annual report on
programs and services provided under this | 23 |
| Section. Such joint report
shall be filed with the Governor and | 24 |
| the General Assembly on or before
September 30 each year.
| 25 |
| The requirement for reporting to the General Assembly shall | 26 |
| be satisfied
by filing copies of the report with the Speaker, | 27 |
| the Minority Leader and
the Clerk of the House of | 28 |
| Representatives and the President, the Minority
Leader and the | 29 |
| Secretary of the Senate and the Legislative Research Unit,
as | 30 |
| required by Section 3.1 of the General Assembly Organization | 31 |
| Act and
filing such additional copies with the State Government | 32 |
| Report Distribution
Center for the General Assembly as is | 33 |
| required under paragraph (t) of
Section 7 of the State Library | 34 |
| Act.
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| Those persons previously found eligible for receiving | 2 |
| non-institutional
services whose services were discontinued | 3 |
| under the Emergency Budget Act of
Fiscal Year 1992, and who do | 4 |
| not meet the eligibility standards in effect
on or after July | 5 |
| 1, 1992, shall remain ineligible on and after July 1,
1992. | 6 |
| Those persons previously not required to cost-share and who | 7 |
| were
required to cost-share effective March 1, 1992, shall | 8 |
| continue to meet
cost-share requirements on and after July 1, | 9 |
| 1992. Beginning July 1, 1992,
all clients will be required to | 10 |
| meet
eligibility, cost-share, and other requirements and will | 11 |
| have services
discontinued or altered when they fail to meet | 12 |
| these requirements.
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| (Source: P.A. 92-597, eff. 6-28-02; 93-85, eff. 1-1-04; 93-902, | 14 |
| eff. 8-10-04.)
| 15 |
| Section 15. The Children's Health Insurance Program Act is | 16 |
| amended by changing Section 30 as follows:
| 17 |
| (215 ILCS 106/30)
| 18 |
| Sec. 30. Cost sharing.
| 19 |
| (a) Children enrolled in a health benefits program pursuant | 20 |
| to subdivision
(a)(2) of Section 25 and persons enrolled in a | 21 |
| health benefits waiver program pursuant to Section 40 shall be | 22 |
| subject to the following cost sharing
requirements:
| 23 |
| (1) There shall be no co-payment required for well-baby | 24 |
| or well-child
care, including age-appropriate | 25 |
| immunizations as required under
federal law.
| 26 |
| (2) Health insurance premiums for family members, | 27 |
| either children or adults, in families whose household
| 28 |
| income is above 150% of the federal poverty level shall be | 29 |
| payable
monthly, subject to rules promulgated by the | 30 |
| Department for grace periods and
advance payments, and | 31 |
| shall be as follows:
| 32 |
| (A) $15 per month for one family member
child .
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| (B) $25 per month for 2 family members
children .
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| (C) $30 per month for 3 family members
or more | 3 |
| children . | 4 |
| (D) $35 per month for 4 family members. | 5 |
| (E) $40 per month for 5 or more family members.
| 6 |
| (3) Co-payments for children or adults in families | 7 |
| whose income is at or below
150% of the federal poverty | 8 |
| level, at a minimum and to the extent permitted
under | 9 |
| federal law, shall be $2 for all medical visits and | 10 |
| prescriptions
provided under this Act.
| 11 |
| (4) Co-payments for children or adults in families | 12 |
| whose income is above 150%
of the federal poverty level, at | 13 |
| a minimum and to the extent permitted under
federal law | 14 |
| shall be as follows:
| 15 |
| (A) $5 for medical visits.
| 16 |
| (B) $3 for generic prescriptions and $5 for brand | 17 |
| name
prescriptions.
| 18 |
| (C) $25 for emergency room use for a non-emergency
| 19 |
| situation as defined by the Department by rule.
| 20 |
| (5) The maximum amount of out-of-pocket expenses for | 21 |
| co-payments shall be
$100 per family per year.
| 22 |
| (b) Individuals enrolled in a privately sponsored health | 23 |
| insurance plan
pursuant to subdivision (a)(1) of Section 25 | 24 |
| shall be subject to the cost
sharing provisions as stated in | 25 |
| the privately sponsored health insurance plan.
| 26 |
| (Source: P.A. 90-736, eff. 8-12-98; 91-266, eff. 7-23-99 .)
| 27 |
| Section 20. The Illinois Public Aid Code is amended by | 28 |
| changing Sections 5-5.4, 5-5.12, 5-11, and 12-4.35 as follows: | 29 |
| (305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4)
| 30 |
| Sec. 5-5.4. Standards of Payment - Department of Public | 31 |
| Aid.
The Department of Public Aid shall develop standards of | 32 |
| payment of skilled
nursing and intermediate care services in |
|
|
|
09400HB1197sam001 |
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|
| 1 |
| facilities providing such services
under this Article which:
| 2 |
| (1) Provide for the determination of a facility's payment
| 3 |
| for skilled nursing and intermediate care services on a | 4 |
| prospective basis.
The amount of the payment rate for all | 5 |
| nursing facilities certified by the
Department of Public Health | 6 |
| under the Nursing Home Care Act as Intermediate
Care for the | 7 |
| Developmentally Disabled facilities, Long Term Care for Under | 8 |
| Age
22 facilities, Skilled Nursing facilities, or Intermediate | 9 |
| Care facilities
under the
medical assistance program shall be | 10 |
| prospectively established annually on the
basis of historical, | 11 |
| financial, and statistical data reflecting actual costs
from | 12 |
| prior years, which shall be applied to the current rate year | 13 |
| and updated
for inflation, except that the capital cost element | 14 |
| for newly constructed
facilities shall be based upon projected | 15 |
| budgets. The annually established
payment rate shall take | 16 |
| effect on July 1 in 1984 and subsequent years. No rate
increase | 17 |
| and no
update for inflation shall be provided on or after July | 18 |
| 1, 1994 and before
July 1, 2006
2005 , unless specifically | 19 |
| provided for in this
Section.
The changes made by this | 20 |
| amendatory Act of the 93rd General Assembly extending the | 21 |
| duration of the prohibition against a rate increase or update | 22 |
| for inflation are effective retroactive to July 1, 2004.
| 23 |
| For facilities licensed by the Department of Public Health | 24 |
| under the Nursing
Home Care Act as Intermediate Care for the | 25 |
| Developmentally Disabled facilities
or Long Term Care for Under | 26 |
| Age 22 facilities, the rates taking effect on July
1, 1998 | 27 |
| shall include an increase of 3%. For facilities licensed by the
| 28 |
| Department of Public Health under the Nursing Home Care Act as | 29 |
| Skilled Nursing
facilities or Intermediate Care facilities, | 30 |
| the rates taking effect on July 1,
1998 shall include an | 31 |
| increase of 3% plus $1.10 per resident-day, as defined by
the | 32 |
| Department.
| 33 |
| For facilities licensed by the Department of Public Health | 34 |
| under the
Nursing Home Care Act as Intermediate Care for the |
|
|
|
09400HB1197sam001 |
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| 1 |
| Developmentally Disabled
facilities or Long Term Care for Under | 2 |
| Age 22 facilities, the rates taking
effect on July 1, 1999 | 3 |
| shall include an increase of 1.6% plus $3.00 per
resident-day, | 4 |
| as defined by the Department. For facilities licensed by the
| 5 |
| Department of Public Health under the Nursing Home Care Act as | 6 |
| Skilled Nursing
facilities or Intermediate Care facilities, | 7 |
| the rates taking effect on July 1,
1999 shall include an | 8 |
| increase of 1.6% and, for services provided on or after
October | 9 |
| 1, 1999, shall be increased by $4.00 per resident-day, as | 10 |
| defined by
the Department.
| 11 |
| For facilities licensed by the Department of Public Health | 12 |
| under the
Nursing Home Care Act as Intermediate Care for the | 13 |
| Developmentally Disabled
facilities or Long Term Care for Under | 14 |
| Age 22 facilities, the rates taking
effect on July 1, 2000 | 15 |
| shall include an increase of 2.5% per resident-day,
as defined | 16 |
| by the Department. For facilities licensed by the Department of
| 17 |
| Public Health under the Nursing Home Care Act as Skilled | 18 |
| Nursing facilities or
Intermediate Care facilities, the rates | 19 |
| taking effect on July 1, 2000 shall
include an increase of 2.5% | 20 |
| per resident-day, as defined by the Department.
| 21 |
| For facilities licensed by the Department of Public Health | 22 |
| under the
Nursing Home Care Act as skilled nursing facilities | 23 |
| or intermediate care
facilities, a new payment methodology must | 24 |
| be implemented for the nursing
component of the rate effective | 25 |
| July 1, 2003. The Department of Public Aid
shall develop the | 26 |
| new payment methodology using the Minimum Data Set
(MDS) as the | 27 |
| instrument to collect information concerning nursing home
| 28 |
| resident condition necessary to compute the rate. The | 29 |
| Department of Public Aid
shall develop the new payment | 30 |
| methodology to meet the unique needs of
Illinois nursing home | 31 |
| residents while remaining subject to the appropriations
| 32 |
| provided by the General Assembly.
A transition period from the | 33 |
| payment methodology in effect on June 30, 2003
to the payment | 34 |
| methodology in effect on July 1, 2003 shall be provided for a
|
|
|
|
09400HB1197sam001 |
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| 1 |
| period not exceeding 2 years after implementation of the new | 2 |
| payment
methodology as follows:
| 3 |
| (A) For a facility that would receive a lower
nursing | 4 |
| component rate per patient day under the new system than | 5 |
| the facility
received
effective on the date immediately | 6 |
| preceding the date that the Department
implements the new | 7 |
| payment methodology, the nursing component rate per | 8 |
| patient
day for the facility
shall be held at
the level in | 9 |
| effect on the date immediately preceding the date that the
| 10 |
| Department implements the new payment methodology until a | 11 |
| higher nursing
component rate of
reimbursement is achieved | 12 |
| by that
facility.
| 13 |
| (B) For a facility that would receive a higher nursing | 14 |
| component rate per
patient day under the payment | 15 |
| methodology in effect on July 1, 2003 than the
facility | 16 |
| received effective on the date immediately preceding the | 17 |
| date that the
Department implements the new payment | 18 |
| methodology, the nursing component rate
per patient day for | 19 |
| the facility shall be adjusted.
| 20 |
| (C) Notwithstanding paragraphs (A) and (B), the | 21 |
| nursing component rate per
patient day for the facility | 22 |
| shall be adjusted subject to appropriations
provided by the | 23 |
| General Assembly.
| 24 |
| For facilities licensed by the Department of Public Health | 25 |
| under the
Nursing Home Care Act as Intermediate Care for the | 26 |
| Developmentally Disabled
facilities or Long Term Care for Under | 27 |
| Age 22 facilities, the rates taking
effect on March 1, 2001 | 28 |
| shall include a statewide increase of 7.85%, as
defined by the | 29 |
| Department.
| 30 |
| For facilities licensed by the Department of Public Health | 31 |
| under the
Nursing Home Care Act as Intermediate Care for the | 32 |
| Developmentally Disabled
facilities or Long Term Care for Under | 33 |
| Age 22 facilities, the rates taking
effect on April 1, 2002 | 34 |
| shall include a statewide increase of 2.0%, as
defined by the |
|
|
|
09400HB1197sam001 |
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|
| 1 |
| Department.
This increase terminates on July 1, 2002;
beginning | 2 |
| July 1, 2002 these rates are reduced to the level of the rates
| 3 |
| in effect on March 31, 2002, as defined by the Department.
| 4 |
| For facilities licensed by the Department of Public Health | 5 |
| under the
Nursing Home Care Act as skilled nursing facilities | 6 |
| or intermediate care
facilities, the rates taking effect on | 7 |
| July 1, 2001 shall be computed using the most recent cost | 8 |
| reports
on file with the Department of Public Aid no later than | 9 |
| April 1, 2000,
updated for inflation to January 1, 2001. For | 10 |
| rates effective July 1, 2001
only, rates shall be the greater | 11 |
| of the rate computed for July 1, 2001
or the rate effective on | 12 |
| June 30, 2001.
| 13 |
| Notwithstanding any other provision of this Section, for | 14 |
| facilities
licensed by the Department of Public Health under | 15 |
| the Nursing Home Care Act
as skilled nursing facilities or | 16 |
| intermediate care facilities, the Illinois
Department shall | 17 |
| determine by rule the rates taking effect on July 1, 2002,
| 18 |
| which shall be 5.9% less than the rates in effect on June 30, | 19 |
| 2002.
| 20 |
| Notwithstanding any other provision of this Section, for | 21 |
| facilities
licensed by the Department of Public Health under | 22 |
| the Nursing Home Care Act as
skilled nursing
facilities or | 23 |
| intermediate care facilities, if the payment methodologies | 24 |
| required under Section 5A-12 and the waiver granted under 42 | 25 |
| CFR 433.68 are approved by the United States Centers for | 26 |
| Medicare and Medicaid Services, the rates taking effect on July | 27 |
| 1, 2004 shall be 3.0% greater than the rates in effect on June | 28 |
| 30, 2004. These rates shall take
effect only upon approval and
| 29 |
| implementation of the payment methodologies required under | 30 |
| Section 5A-12.
| 31 |
| Notwithstanding any other provisions of this Section, for | 32 |
| facilities licensed by the Department of Public Health under | 33 |
| the Nursing Home Care Act as skilled nursing facilities or | 34 |
| intermediate care facilities, the rates taking effect on |
|
|
|
09400HB1197sam001 |
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|
| 1 |
| January 1, 2005 shall be 3% more than the rates in effect on | 2 |
| December 31, 2004.
| 3 |
| For facilities
licensed
by the
Department of Public Health | 4 |
| under the Nursing Home Care Act as Intermediate
Care for
the | 5 |
| Developmentally Disabled facilities or as long-term care | 6 |
| facilities for
residents under 22 years of age, the rates | 7 |
| taking effect on July 1,
2003 shall
include a statewide | 8 |
| increase of 4%, as defined by the Department.
| 9 |
| Notwithstanding any other provision of this Section, for | 10 |
| facilities licensed by the Department of Public Health under | 11 |
| the Nursing Home Care Act as skilled nursing facilities or | 12 |
| intermediate care facilities, effective January 1, 2005, | 13 |
| facility rates shall be increased by the difference between (i) | 14 |
| a facility's per diem property, liability, and malpractice | 15 |
| insurance costs as reported in the cost report filed with the | 16 |
| Department of Public Aid and used to establish rates effective | 17 |
| July 1, 2001 and (ii) those same costs as reported in the | 18 |
| facility's 2002 cost report. These costs shall be passed | 19 |
| through to the facility without caps or limitations, except for | 20 |
| adjustments required under normal auditing procedures.
| 21 |
| Rates established effective each July 1 shall govern | 22 |
| payment
for services rendered throughout that fiscal year, | 23 |
| except that rates
established on July 1, 1996 shall be | 24 |
| increased by 6.8% for services
provided on or after January 1, | 25 |
| 1997. Such rates will be based
upon the rates calculated for | 26 |
| the year beginning July 1, 1990, and for
subsequent years | 27 |
| thereafter until June 30, 2001 shall be based on the
facility | 28 |
| cost reports
for the facility fiscal year ending at any point | 29 |
| in time during the previous
calendar year, updated to the | 30 |
| midpoint of the rate year. The cost report
shall be on file | 31 |
| with the Department no later than April 1 of the current
rate | 32 |
| year. Should the cost report not be on file by April 1, the | 33 |
| Department
shall base the rate on the latest cost report filed | 34 |
| by each skilled care
facility and intermediate care facility, |
|
|
|
09400HB1197sam001 |
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|
| 1 |
| updated to the midpoint of the
current rate year. In | 2 |
| determining rates for services rendered on and after
July 1, | 3 |
| 1985, fixed time shall not be computed at less than zero. The
| 4 |
| Department shall not make any alterations of regulations which | 5 |
| would reduce
any component of the Medicaid rate to a level | 6 |
| below what that component would
have been utilizing in the rate | 7 |
| effective on July 1, 1984.
| 8 |
| (2) Shall take into account the actual costs incurred by | 9 |
| facilities
in providing services for recipients of skilled | 10 |
| nursing and intermediate
care services under the medical | 11 |
| assistance program.
| 12 |
| (3) Shall take into account the medical and psycho-social
| 13 |
| characteristics and needs of the patients.
| 14 |
| (4) Shall take into account the actual costs incurred by | 15 |
| facilities in
meeting licensing and certification standards | 16 |
| imposed and prescribed by the
State of Illinois, any of its | 17 |
| political subdivisions or municipalities and by
the U.S. | 18 |
| Department of Health and Human Services pursuant to Title XIX | 19 |
| of the
Social Security Act.
| 20 |
| The Department of Public Aid shall develop precise | 21 |
| standards for
payments to reimburse nursing facilities for any | 22 |
| utilization of
appropriate rehabilitative personnel for the | 23 |
| provision of rehabilitative
services which is authorized by | 24 |
| federal regulations, including
reimbursement for services | 25 |
| provided by qualified therapists or qualified
assistants, and | 26 |
| which is in accordance with accepted professional
practices. | 27 |
| Reimbursement also may be made for utilization of other
| 28 |
| supportive personnel under appropriate supervision.
| 29 |
| (Source: P.A. 92-10, eff. 6-11-01; 92-31, eff. 6-28-01; 92-597, | 30 |
| eff. 6-28-02; 92-651, eff. 7-11-02; 92-848, eff. 1-1-03; 93-20, | 31 |
| eff. 6-20-03; 93-649, eff. 1-8-04; 93-659, eff. 2-3-04; 93-841, | 32 |
| eff. 7-30-04; 93-1087, eff. 2-28-05.)
| 33 |
| (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
|
|
|
|
09400HB1197sam001 |
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|
| 1 |
| Sec. 5-5.12. Pharmacy payments.
| 2 |
| (a) Every request submitted by a pharmacy for reimbursement | 3 |
| under this
Article for prescription drugs provided to a | 4 |
| recipient of aid under this
Article shall include the name of | 5 |
| the prescriber or an acceptable
identification number as | 6 |
| established by the Department.
| 7 |
| (b) Pharmacies providing prescription drugs under
this | 8 |
| Article shall be reimbursed at a rate which shall include
a | 9 |
| professional dispensing fee as determined by the Illinois
| 10 |
| Department, plus the current acquisition cost of the | 11 |
| prescription
drug dispensed. The Illinois Department shall | 12 |
| update its
information on the acquisition costs of all | 13 |
| prescription drugs
no less frequently than every 30 days. | 14 |
| However, the Illinois
Department may set the rate of | 15 |
| reimbursement for the acquisition
cost, by rule, at a | 16 |
| percentage of the current average wholesale
acquisition cost.
| 17 |
| (c) (Blank).
Reimbursement under this Article for | 18 |
| prescription drugs shall be
limited to reimbursement for 4 | 19 |
| brand-name prescription drugs per patient per
month. This | 20 |
| subsection applies only if (i) the brand-name drug was not
| 21 |
| prescribed for an acute or urgent condition, (ii) the | 22 |
| brand-name drug was not
prescribed for Alzheimer's disease, | 23 |
| arthritis, diabetes, HIV/AIDS, a mental
health condition, or | 24 |
| respiratory disease, and (iii) a therapeutically
equivalent | 25 |
| generic medication has been approved by the federal Food and | 26 |
| Drug
Administration.
| 27 |
| (d) The Department shall not impose requirements for prior | 28 |
| approval
based on a preferred drug list for anti-retroviral, | 29 |
| anti-hemophilic factor
concentrates,
or
any atypical | 30 |
| antipsychotics, conventional antipsychotics,
or | 31 |
| anticonvulsants used for the treatment of serious mental
| 32 |
| illnesses
until 30 days after it has conducted a study of the | 33 |
| impact of such
requirements on patient care and submitted a | 34 |
| report to the Speaker of the
House of Representatives and the |
|
|
|
09400HB1197sam001 |
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LRB094 06321 WGH 47439 a |
|
| 1 |
| President of the Senate.
| 2 |
| (Source: P.A. 92-597, eff. 6-28-02; 92-825, eff. 8-21-02; | 3 |
| 93-106, eff.
7-8-03.)
| 4 |
| (305 ILCS 5/5-11) (from Ch. 23, par. 5-11)
| 5 |
| Sec. 5-11. Co-operative arrangements; contracts with other | 6 |
| State
agencies, health care and rehabilitation organizations, | 7 |
| and fiscal
intermediaries.
| 8 |
| (a) The Illinois Department may enter into co-operative | 9 |
| arrangements
with
State agencies responsible for administering | 10 |
| or supervising the
administration of health services and | 11 |
| vocational rehabilitation services to
the end that there may be | 12 |
| maximum utilization of such services in the
provision of | 13 |
| medical assistance.
| 14 |
| The Illinois Department shall, not later than June 30, | 15 |
| 1993, enter into
one or more co-operative arrangements with the | 16 |
| Department of Mental Health
and Developmental Disabilities | 17 |
| providing that the Department of Mental
Health and | 18 |
| Developmental Disabilities will be responsible for | 19 |
| administering
or supervising all programs for services to | 20 |
| persons in community care
facilities for persons with | 21 |
| developmental disabilities, including but not
limited to | 22 |
| intermediate care facilities, that are supported by State funds | 23 |
| or
by funding under Title XIX of the federal Social Security | 24 |
| Act. The
responsibilities of the Department of Mental Health | 25 |
| and Developmental
Disabilities under these agreements are | 26 |
| transferred to the Department of
Human Services as provided in | 27 |
| the Department of Human Services Act.
| 28 |
| The Department may also contract with such State health and
| 29 |
| rehabilitation agencies and other public or private health care | 30 |
| and
rehabilitation organizations to act for it in supplying | 31 |
| designated medical
services to persons eligible therefor under | 32 |
| this Article. Any contracts
with health services or health | 33 |
| maintenance organizations shall be
restricted to organizations |
|
|
|
09400HB1197sam001 |
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LRB094 06321 WGH 47439 a |
|
| 1 |
| which have been certified as being in
compliance with standards | 2 |
| promulgated pursuant to the laws of this State
governing the | 3 |
| establishment and operation of health services or health
| 4 |
| maintenance organizations. The Department shall renegotiate | 5 |
| the contracts with health maintenance organizations and | 6 |
| managed care community
networks that took effect August 1, | 7 |
| 2003, so as to produce $70,000,000 savings to the Department | 8 |
| net of resulting increases to the fee-for-service program for | 9 |
| State fiscal year 2006. The Department may also contract with | 10 |
| insurance
companies or other corporate entities serving as | 11 |
| fiscal intermediaries in
this State for the Federal Government | 12 |
| in respect to Medicare payments under
Title XVIII of the | 13 |
| Federal Social Security Act to act for the Department in
paying | 14 |
| medical care suppliers. The provisions of Section 9 of "An Act | 15 |
| in
relation to State finance", approved June 10, 1919, as | 16 |
| amended,
notwithstanding, such contracts with State agencies, | 17 |
| other health care and
rehabilitation organizations, or fiscal | 18 |
| intermediaries may provide for
advance payments.
| 19 |
| (b) For purposes of this subsection (b), "managed care | 20 |
| community
network" means an entity, other than a health | 21 |
| maintenance organization, that
is owned, operated, or governed | 22 |
| by providers of health care services within
this State and that | 23 |
| provides or arranges primary, secondary, and tertiary
managed | 24 |
| health care services under contract with the Illinois | 25 |
| Department
exclusively to persons participating in programs | 26 |
| administered by the Illinois
Department.
| 27 |
| The Illinois Department may certify managed care community
| 28 |
| networks, including managed care community networks owned, | 29 |
| operated, managed,
or
governed by State-funded medical | 30 |
| schools, as risk-bearing entities eligible to
contract with the | 31 |
| Illinois Department as Medicaid managed care
organizations. | 32 |
| The Illinois Department may contract with those managed
care | 33 |
| community networks to furnish health care services to or | 34 |
| arrange those
services for individuals participating in |
|
|
|
09400HB1197sam001 |
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LRB094 06321 WGH 47439 a |
|
| 1 |
| programs administered by the Illinois
Department. The rates for | 2 |
| those provider-sponsored organizations may be
determined on a | 3 |
| prepaid, capitated basis. A managed care community
network may | 4 |
| choose to contract with the Illinois Department to provide only
| 5 |
| pediatric
health care services.
The
Illinois Department shall | 6 |
| by rule adopt the criteria, standards, and procedures
by
which | 7 |
| a managed care community network may be permitted to contract | 8 |
| with
the Illinois Department and shall consult with the | 9 |
| Department of Insurance in
adopting these rules.
| 10 |
| A county provider as defined in Section 15-1 of this Code | 11 |
| may
contract with the Illinois Department to provide primary, | 12 |
| secondary, or
tertiary managed health care services as a | 13 |
| managed care
community network without the need to establish a | 14 |
| separate entity and shall
be deemed a managed care community | 15 |
| network for purposes of this Code
only to the extent it | 16 |
| provides services to participating individuals. A county
| 17 |
| provider is entitled to contract with the Illinois Department | 18 |
| with respect to
any contracting region located in whole or in | 19 |
| part within the county. A
county provider is not required to | 20 |
| accept enrollees who do not reside within
the county.
| 21 |
| In order
to (i) accelerate and facilitate the development | 22 |
| of integrated health care in
contracting areas outside counties | 23 |
| with populations in excess of 3,000,000 and
counties adjacent | 24 |
| to those counties and (ii) maintain and sustain the high
| 25 |
| quality of education and residency programs coordinated and | 26 |
| associated with
local area hospitals, the Illinois Department | 27 |
| may develop and implement a
demonstration program from managed | 28 |
| care community networks owned, operated,
managed, or
governed | 29 |
| by State-funded medical schools. The Illinois Department shall
| 30 |
| prescribe by rule the criteria, standards, and procedures for | 31 |
| effecting this
demonstration program.
| 32 |
| A managed care community network that
contracts with the | 33 |
| Illinois Department to furnish health care services to or
| 34 |
| arrange those services for enrollees participating in programs |
|
|
|
09400HB1197sam001 |
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LRB094 06321 WGH 47439 a |
|
| 1 |
| administered by
the Illinois Department shall do all of the | 2 |
| following:
| 3 |
| (1) Provide that any provider affiliated with the | 4 |
| managed care community
network may also provide services on | 5 |
| a
fee-for-service basis to Illinois Department clients not | 6 |
| enrolled in such
managed care entities.
| 7 |
| (2) Provide client education services as determined | 8 |
| and approved by the
Illinois Department, including but not | 9 |
| limited to (i) education regarding
appropriate utilization | 10 |
| of health care services in a managed care system, (ii)
| 11 |
| written disclosure of treatment policies and restrictions | 12 |
| or limitations on
health services, including, but not | 13 |
| limited to, physical services, clinical
laboratory tests, | 14 |
| hospital and surgical procedures, prescription drugs and
| 15 |
| biologics, and radiological examinations, and (iii) | 16 |
| written notice that the
enrollee may receive from another | 17 |
| provider those covered services that are not
provided by | 18 |
| the managed care community network.
| 19 |
| (3) Provide that enrollees within the system may choose | 20 |
| the site for
provision of services and the panel of health | 21 |
| care providers.
| 22 |
| (4) Not discriminate in enrollment or disenrollment | 23 |
| practices among
recipients of medical services or | 24 |
| enrollees based on health status.
| 25 |
| (5) Provide a quality assurance and utilization review | 26 |
| program that
meets
the requirements established by the | 27 |
| Illinois Department in rules that
incorporate those | 28 |
| standards set forth in the Health Maintenance Organization
| 29 |
| Act.
| 30 |
| (6) Issue a managed care community network
| 31 |
| identification card to each enrollee upon enrollment. The | 32 |
| card
must contain all of the following:
| 33 |
| (A) The enrollee's health plan.
| 34 |
| (B) The name and telephone number of the enrollee's |
|
|
|
09400HB1197sam001 |
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LRB094 06321 WGH 47439 a |
|
| 1 |
| primary care
physician or the site for receiving | 2 |
| primary care services.
| 3 |
| (C) A telephone number to be used to confirm | 4 |
| eligibility for benefits
and authorization for | 5 |
| services that is available 24 hours per day, 7 days per
| 6 |
| week.
| 7 |
| (7) Ensure that every primary care physician and | 8 |
| pharmacy in the managed
care community network meets the | 9 |
| standards
established by the Illinois Department for | 10 |
| accessibility and quality of care.
The Illinois Department | 11 |
| shall arrange for and oversee an evaluation of the
| 12 |
| standards established under this paragraph (7) and may | 13 |
| recommend any necessary
changes to these standards.
| 14 |
| (8) Provide a procedure for handling complaints that
| 15 |
| meets the
requirements established by the Illinois | 16 |
| Department in rules that incorporate
those standards set | 17 |
| forth in the Health Maintenance Organization Act.
| 18 |
| (9) Maintain, retain, and make available to the | 19 |
| Illinois Department
records, data, and information, in a | 20 |
| uniform manner determined by the Illinois
Department, | 21 |
| sufficient for the Illinois Department to monitor | 22 |
| utilization,
accessibility, and quality of care.
| 23 |
| (10) Provide that the pharmacy formulary used by the | 24 |
| managed care
community
network and its contract providers | 25 |
| be no
more restrictive than the Illinois Department's | 26 |
| pharmaceutical program on the
effective date of this | 27 |
| amendatory Act of 1998 and as amended after that date.
| 28 |
| The Illinois Department shall contract with an entity or | 29 |
| entities to provide
external peer-based quality assurance | 30 |
| review for the managed health care
programs administered by the | 31 |
| Illinois Department. The entity shall be
representative of | 32 |
| Illinois physicians licensed to practice medicine in all its
| 33 |
| branches and have statewide geographic representation in all | 34 |
| specialities of
medical care that are provided in managed |
|
|
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| health care programs administered by
the Illinois Department. | 2 |
| The entity may not be a third party payer and shall
maintain | 3 |
| offices in locations around the State in order to provide | 4 |
| service and
continuing medical education to physician | 5 |
| participants within those managed
health care programs | 6 |
| administered by the Illinois Department. The review
process | 7 |
| shall be developed and conducted by Illinois physicians | 8 |
| licensed to
practice medicine in all its branches. In | 9 |
| consultation with the entity, the
Illinois Department may | 10 |
| contract with other entities for professional
peer-based | 11 |
| quality assurance review of individual
categories of services | 12 |
| other than services provided, supervised, or coordinated
by | 13 |
| physicians licensed to practice medicine in all its branches. | 14 |
| The Illinois
Department shall establish, by rule, criteria to | 15 |
| avoid conflicts of interest in
the conduct of quality assurance | 16 |
| activities consistent with professional
peer-review standards. | 17 |
| All quality assurance activities shall be coordinated
by the | 18 |
| Illinois Department.
| 19 |
| Each managed care community network must demonstrate its | 20 |
| ability to
bear the financial risk of serving individuals under | 21 |
| this program.
The Illinois Department shall by rule adopt | 22 |
| standards for assessing the
solvency and financial soundness of | 23 |
| each managed care community network.
Any solvency and financial | 24 |
| standards adopted for managed care community
networks
shall be | 25 |
| no more restrictive than the solvency and financial standards | 26 |
| adopted
under
Section 1856(a) of the Social Security Act for | 27 |
| provider-sponsored
organizations under Part C of Title XVIII of | 28 |
| the Social Security Act.
| 29 |
| The Illinois
Department may implement the amendatory | 30 |
| changes to this
Code made by this amendatory Act of 1998 | 31 |
| through the use of emergency
rules in accordance with Section | 32 |
| 5-45 of the Illinois Administrative Procedure
Act. For purposes | 33 |
| of that Act, the adoption of rules to implement these
changes | 34 |
| is deemed an emergency and necessary for the public interest,
|
|
|
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| safety, and welfare.
| 2 |
| (c) Not later than June 30, 1996, the Illinois Department | 3 |
| shall
enter into one or more cooperative arrangements with the | 4 |
| Department of Public
Health for the purpose of developing a | 5 |
| single survey for
nursing facilities, including but not limited | 6 |
| to facilities funded under Title
XVIII or Title XIX of the | 7 |
| federal Social Security Act or both, which shall be
| 8 |
| administered and conducted solely by the Department of Public | 9 |
| Health.
The Departments shall test the single survey process on | 10 |
| a pilot basis, with
both the Departments of Public Aid and | 11 |
| Public Health represented on the
consolidated survey team. The | 12 |
| pilot will sunset June 30, 1997. After June 30,
1997, unless | 13 |
| otherwise determined by the Governor, a single survey shall be
| 14 |
| implemented by the Department of Public Health which would not | 15 |
| preclude staff
from the Department of Public Aid from going | 16 |
| on-site to nursing facilities to
perform necessary audits and | 17 |
| reviews which shall not replicate the single State
agency | 18 |
| survey required by this Act. This Section shall not apply to | 19 |
| community
or intermediate care facilities for persons with | 20 |
| developmental disabilities.
| 21 |
| (d) Nothing in this Code in any way limits or otherwise | 22 |
| impairs the
authority or power of the Illinois Department to | 23 |
| enter into a negotiated
contract pursuant to this Section with | 24 |
| a managed care community network or
a health maintenance | 25 |
| organization, as defined in the Health Maintenance
| 26 |
| Organization Act, that provides for
termination or nonrenewal | 27 |
| of the contract without cause, upon notice as
provided in the | 28 |
| contract, and without a hearing.
| 29 |
| (Source: P.A. 92-370, eff. 8-15-01.)
| 30 |
| (305 ILCS 5/12-4.35)
| 31 |
| Sec. 12-4.35. Medical services for certain noncitizens.
| 32 |
| (a) Notwithstanding
Subject to specific appropriation for | 33 |
| this purpose, and notwithstanding
Section 1-11 of this Code or |
|
|
|
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| Section 20(a) of the Children's Health Insurance
Program Act, | 2 |
| the Department of Public Aid may provide medical services to
| 3 |
| noncitizens who have not yet attained 19 years of age and who | 4 |
| are not eligible
for medical assistance under Article V of this | 5 |
| Code or under the Children's
Health Insurance Program created | 6 |
| by the Children's Health Insurance Program Act
due to their not | 7 |
| meeting the otherwise applicable provisions of Section 1-11
of | 8 |
| this Code or Section 20(a) of the Children's Health Insurance | 9 |
| Program Act.
The medical services available, standards for | 10 |
| eligibility, and other conditions
of participation under this | 11 |
| Section shall be established by rule by the
Department; | 12 |
| however, any such rule shall be at least as restrictive as the
| 13 |
| rules for medical assistance under Article V of this Code or | 14 |
| the Children's
Health Insurance Program created by the | 15 |
| Children's Health Insurance Program
Act.
| 16 |
| (b) The Department is authorized to take any action, | 17 |
| including without
limitation cessation of enrollment, | 18 |
| reduction of available medical services,
and changing | 19 |
| standards for eligibility, that is deemed necessary by the
| 20 |
| Department during a State fiscal year to assure that payments | 21 |
| under this
Section do not exceed available funds
the amounts | 22 |
| appropriated for this purpose .
| 23 |
| (c) Continued
In the event that the appropriation in any | 24 |
| fiscal year for the
Children's Health Insurance Program created | 25 |
| by the Children's Health Insurance
Program Act is determined by | 26 |
| the Department to be insufficient to continue
enrollment of | 27 |
| otherwise eligible children under that Program during that | 28 |
| fiscal
year, the Department is authorized to use funds | 29 |
| appropriated for the purposes
of this Section to fund that | 30 |
| Program and to take any other action necessary to
continue the | 31 |
| operation of that Program. Furthermore, continued enrollment | 32 |
| of
individuals into the program created under this Section in | 33 |
| any fiscal year is
contingent upon continued enrollment of | 34 |
| individuals into the Children's Health
Insurance Program |
|
|
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| during that fiscal year.
| 2 |
| (d) (Blank).
The General Assembly finds that the adoption | 3 |
| of rules to meet the
purposes of subsections (a), (b), and (c) | 4 |
| is an emergency and necessary for
the public interest, safety, | 5 |
| and welfare. The Department may adopt such rules
through the | 6 |
| use of emergency rulemaking in accordance with Section 5-45 of | 7 |
| the
Illinois Administrative Procedure Act, except that the | 8 |
| limitation on the number
of emergency rules that may be adopted | 9 |
| in a 24-month period shall not apply.
| 10 |
| (Source: P.A. 90-588, eff. 7-1-98.)
| 11 |
| Section 25. The All-Inclusive Care for the Elderly Act is | 12 |
| amended by changing Sections 10 and 15 as follows:
| 13 |
| (320 ILCS 40/10) (from Ch. 23, par. 6910)
| 14 |
| Sec. 10. Services for eligible persons. Within the context | 15 |
| of the
PACE program established under this Act, the Illinois | 16 |
| Department of Public
Aid may include any or all of the services | 17 |
| in Article 5 of the Illinois
Public Aid Code.
| 18 |
| An eligible person may elect to receive services from the | 19 |
| PACE program.
If such an election is made, the eligible person | 20 |
| shall not remain eligible
for payment through the regular | 21 |
| Medicare or Medicaid program. All services
and programs | 22 |
| provided through the PACE program shall be provided in
| 23 |
| accordance with this Act. An eligible person may elect to | 24 |
| disenroll from
the PACE program at any time.
| 25 |
| For purposes of this Act, "eligible person" means a frail | 26 |
| elderly
individual who voluntarily enrolls in the PACE program, | 27 |
| whose income and
resources do not exceed limits established by | 28 |
| the Illinois Department of
Public Aid and for whom a licensed | 29 |
| physician certifies that such a program
provides an appropriate | 30 |
| alternative to institutionalized care. The term
"frail | 31 |
| elderly" means an individual who meets the age and functional | 32 |
| eligibility
requirements , as established by the Illinois |
|
|
|
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| Department of Public Aid and
the Department on Aging for | 2 |
| nursing home care, and who is 65 years of age
or older .
| 3 |
| (Source: P.A. 87-411.)
| 4 |
| (320 ILCS 40/15) (from Ch. 23, par. 6915)
| 5 |
| Sec. 15. Program implementation.
| 6 |
| (a) Upon receipt of federal approval
waivers , the Illinois | 7 |
| Department of Public
Aid shall implement the PACE program | 8 |
| pursuant to the provisions of the approved Title XIX State plan
| 9 |
| as a demonstration program to provide
the services set forth in | 10 |
| Section 10 to eligible persons, as defined in
Section 10, for a | 11 |
| period of 3 years. After the 3 year demonstration, the
General | 12 |
| Assembly shall reexamine the PACE program and determine if the
| 13 |
| program should be implemented on a permanent basis .
| 14 |
| (b) Using a risk-based financing model, the nonprofit | 15 |
| organization providing
the PACE program shall assume | 16 |
| responsibility for all costs generated by
the PACE program | 17 |
| participants, and it shall create and maintain a risk
reserve | 18 |
| fund that will cover any cost overages for any participant. The
| 19 |
| PACE program is responsible for the entire range of services in | 20 |
| the
consolidated service model, including hospital and nursing | 21 |
| home care,
according to participant need as determined by a | 22 |
| multidisciplinary team.
The nonprofit organization providing | 23 |
| the PACE program is responsible for
the full financial risk at | 24 |
| the conclusion of the demonstration period
and when permanent | 25 |
| waivers from the federal Health Care Financing
Administration | 26 |
| are granted . Specific arrangements of the risk-based
financing | 27 |
| model shall be adopted and negotiated by the federal Centers | 28 |
| for Medicare and Medicaid Services
Health Care
Financing | 29 |
| Administration , the nonprofit organization providing the PACE
| 30 |
| program, and the Illinois Department of Public Aid .
| 31 |
| (Source: P.A. 87-411.)
| 32 |
| Section 99. Effective date. This Act takes effect July 1, |
|
|
|
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| 2005.".
|
|