Full Text of SB0788 99th General Assembly
SB0788ham002 99TH GENERAL ASSEMBLY | 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 | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Emergency Medical Services (EMS) Systems | 5 | | Act 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 | 9 | | Emergency Center (FEC)
license to any facility that has | 10 | | received a permit from the Health Facilities and Services | 11 | | Review Board to establish a Freestanding Emergency Center by | 12 | | January 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, | 10 | | the Department may issue an annual FEC license to a facility | 11 | | that is located in a county that does not have a licensed | 12 | | general acute care hospital if the facility's application for a | 13 | | permit from the Illinois Health Facilities Planning Board has | 14 | | been deemed complete by the Department of Public Health by | 15 | | January 1, 2014 and if the facility complies with the | 16 | | requirements set forth in paragraphs (1) through (17) of | 17 | | subsection (a). | 18 | | (a-10) Notwithstanding any other provision of this | 19 | | Section, the Department may issue an annual FEC license to a | 20 | | facility if the facility has, by January 1, 2014, filed a | 21 | | letter of intent to establish an FEC and if the facility | 22 | | complies with the requirements set forth in paragraphs (1) | 23 | | through (17) of subsection (a). | 24 | | (a-15) Notwithstanding any other provision of this | 25 | | Section, the
Department shall issue an annual FEC license to a | 26 | | facility located within a
municipality with a population in |
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| 1 | | excess of 1,000,000 inhabitants if the facility (i) has, by
| 2 | | January 1, 2016, filed a letter of intent to establish an FEC, | 3 | | (ii) has received a certificate of need from the Health | 4 | | Facilities and Services Review Board, and (iii) complies with | 5 | | all requirements set forth in paragraphs (3) through
(17) of | 6 | | subsection (a) of this Section and all applicable | 7 | | administrative rules. Any FEC located in a
municipality with a | 8 | | population in excess of 1,000,000 inhabitants shall not be
| 9 | | required to be wholly owned or controlled by an Associate | 10 | | Hospital or Resource
Hospital; however, all patients needing | 11 | | emergent or urgent evaluation or
treatment beyond the FEC's | 12 | | ability shall be expeditiously transferred to
the closest | 13 | | appropriate health care facility based on the patient's acuity
| 14 | | and needs. The FEC shall have a transfer agreement in place | 15 | | with at least one acute care hospital in the FEC's service area | 16 | | within 30 minutes travel time of the FEC. The medical director | 17 | | of the FEC shall have full admitting privileges at a hospital | 18 | | with which the FEC has a transfer agreement and shall agree in | 19 | | writing to assume responsibility for all FEC patients requiring | 20 | | follow-up care in accordance with the transfer agreement. For | 21 | | an FEC established under this subsection (a-15), the facility
| 22 | | shall have the authority to create up to 10 observation beds as | 23 | | further
defined by rule. The Department shall issue no more | 24 | | than one such license
in a
municipality with a population in | 25 | | excess of 1,000,000 inhabitants
and shall give consideration to | 26 | | underserved areas, particularly those that have recently lost |
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| 1 | | access to emergency care through the loss of an emergency care | 2 | | provider. An FEC qualifying under this subsection (a-15) shall | 3 | | fully participate with and function within a Department | 4 | | approved 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, | 25 | | eff. 3-1-10; 96-1000, eff. 7-2-10; 97-333, eff. 8-12-11; | 26 | | 97-1112, eff. 8-27-12.)
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| 1 | | Section 15. The Illinois Public Aid Code is amended by | 2 | | changing Sections 5-5, 5-5.2, 5-30, 5A-2, 5A-12.2, 5A-12.5, | 3 | | 5A-13, 5G-10, 11-5.4, 12-13.1, and 14-11 and by adding Sections | 4 | | 5-5b.1a, 5-5b.2, 5-30.2, 5-30.3, 5-30.4, 5-30.5, 12-4.49, and | 5 | | 12-4.50 as follows:
| 6 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 7 | | Sec. 5-5. Medical services. The Illinois Department, by | 8 | | rule, shall
determine the quantity and quality of and the rate | 9 | | of reimbursement for the
medical assistance for which
payment | 10 | | will be authorized, and the medical services to be provided,
| 11 | | which may include all or part of the following: (1) inpatient | 12 | | hospital
services; (2) outpatient hospital services; (3) other | 13 | | laboratory and
X-ray services; (4) skilled nursing home | 14 | | services; (5) physicians'
services whether furnished in the | 15 | | office, the patient's home, a
hospital, a skilled nursing home, | 16 | | or elsewhere; (6) medical care, or any
other type of remedial | 17 | | care furnished by licensed practitioners; (7)
home health care | 18 | | services; (8) private duty nursing service; (9) clinic
| 19 | | services; (10) dental services, including prevention and | 20 | | treatment of periodontal disease and dental caries disease for | 21 | | pregnant women, provided by an individual licensed to practice | 22 | | dentistry or dental surgery; for purposes of this item (10), | 23 | | "dental services" means diagnostic, preventive, or corrective | 24 | | procedures provided by or under the supervision of a dentist in |
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| 1 | | the practice of his or her profession; (11) physical therapy | 2 | | and related
services; (12) prescribed drugs, dentures, and | 3 | | prosthetic devices; and
eyeglasses prescribed by a physician | 4 | | skilled in the diseases of the eye,
or by an optometrist, | 5 | | whichever the person may select; (13) other
diagnostic, | 6 | | screening, preventive, and rehabilitative services, including | 7 | | to ensure that the individual's need for intervention or | 8 | | treatment of mental disorders or substance use disorders or | 9 | | co-occurring mental health and substance use disorders is | 10 | | determined using a uniform screening, assessment, and | 11 | | evaluation process inclusive of criteria, for children and | 12 | | adults; for purposes of this item (13), a uniform screening, | 13 | | assessment, and evaluation process refers to a process that | 14 | | includes an appropriate evaluation and, as warranted, a | 15 | | referral; "uniform" does not mean the use of a singular | 16 | | instrument, tool, or process that all must utilize; (14)
| 17 | | transportation and such other expenses as may be necessary; | 18 | | (15) medical
treatment of sexual assault survivors, as defined | 19 | | in
Section 1a of the Sexual Assault Survivors Emergency | 20 | | Treatment Act, for
injuries sustained as a result of the sexual | 21 | | assault, including
examinations and laboratory tests to | 22 | | discover evidence which may be used in
criminal proceedings | 23 | | arising from the sexual assault; (16) the
diagnosis and | 24 | | treatment of sickle cell anemia; (16.5) services delivered by | 25 | | facilities licensed under the Specialized Mental Health | 26 | | Rehabilitation Act of 2013; and (17)
any other medical care, |
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| 1 | | and any other type of remedial care recognized
under the laws | 2 | | of this State, but not including abortions, or induced
| 3 | | miscarriages or premature births, unless, in the opinion of a | 4 | | physician,
such procedures are necessary for the preservation | 5 | | of the life of the
woman seeking such treatment, or except an | 6 | | induced premature birth
intended to produce a live viable child | 7 | | and such procedure is necessary
for the health of the mother or | 8 | | her unborn child. The Illinois Department,
by rule, shall | 9 | | prohibit any physician from providing medical assistance
to | 10 | | anyone eligible therefor under this Code where such physician | 11 | | has been
found guilty of performing an abortion procedure in a | 12 | | wilful and wanton
manner upon a woman who was not pregnant at | 13 | | the time such abortion
procedure was performed. The term "any | 14 | | other type of remedial care" shall
include nursing care and | 15 | | nursing home service for persons who rely on
treatment by | 16 | | spiritual means alone through prayer for healing.
| 17 | | Notwithstanding any other provision of this Section, a | 18 | | comprehensive
tobacco use cessation program that includes | 19 | | purchasing prescription drugs or
prescription medical devices | 20 | | approved by the Food and Drug Administration shall
be covered | 21 | | under the medical assistance
program under this Article for | 22 | | persons who are otherwise eligible for
assistance under this | 23 | | Article.
| 24 | | Notwithstanding any other provision of this Code, the | 25 | | Illinois
Department may not require, as a condition of payment | 26 | | for any laboratory
test authorized under this Article, that a |
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| 1 | | physician's handwritten signature
appear on the laboratory | 2 | | test order form. The Illinois Department may,
however, impose | 3 | | other appropriate requirements regarding laboratory test
order | 4 | | documentation.
| 5 | | Upon receipt of federal approval of an amendment to the | 6 | | Illinois Title XIX State Plan for this purpose, the Department | 7 | | shall authorize the Chicago Public Schools (CPS) to procure a | 8 | | vendor or vendors to manufacture eyeglasses for individuals | 9 | | enrolled in a school within the CPS system. CPS shall ensure | 10 | | that its vendor or vendors are enrolled as providers in the | 11 | | medical assistance program and in any capitated Medicaid | 12 | | managed care entity (MCE) serving individuals enrolled in a | 13 | | school within the CPS system. Under any contract procured under | 14 | | this provision, the vendor or vendors must serve only | 15 | | individuals enrolled in a school within the CPS system. Claims | 16 | | for services provided by CPS's vendor or vendors to recipients | 17 | | of benefits in the medical assistance program under this Code, | 18 | | the Children's Health Insurance Program, or the Covering ALL | 19 | | KIDS Health Insurance Program shall be submitted to the | 20 | | Department or the MCE in which the individual is enrolled for | 21 | | payment and shall be reimbursed at the Department's or the | 22 | | MCE's established rates or rate methodologies for eyeglasses. | 23 | | On and after July 1, 2012, the Department of Healthcare and | 24 | | Family Services may provide the following services to
persons
| 25 | | eligible for assistance under this Article who are | 26 | | participating in
education, training or employment programs |
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| 1 | | operated by the Department of Human
Services as successor to | 2 | | the 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 | 9 | | subject to federal approval, the Department may adopt rules to | 10 | | allow a dentist who is volunteering his or her service at no | 11 | | cost to render dental services through an enrolled | 12 | | not-for-profit health clinic without the dentist personally | 13 | | enrolling as a participating provider in the medical assistance | 14 | | program. A not-for-profit health clinic shall include a public | 15 | | health clinic or Federally Qualified Health Center or other | 16 | | enrolled provider, as determined by the Department, through | 17 | | which dental services covered under this Section are performed. | 18 | | The Department shall establish a process for payment of claims | 19 | | for reimbursement for covered dental services rendered under | 20 | | this provision. | 21 | | The Illinois Department, by rule, may distinguish and | 22 | | classify the
medical services to be provided only in accordance | 23 | | with the classes of
persons designated in Section 5-2.
| 24 | | The Department of Healthcare and Family Services must | 25 | | provide coverage and reimbursement for amino acid-based | 26 | | elemental formulas, regardless of delivery method, for the |
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| 1 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 2 | | short bowel syndrome when the prescribing physician has issued | 3 | | a written order stating that the amino acid-based elemental | 4 | | formula is medically necessary.
| 5 | | The Illinois Department shall authorize the provision of, | 6 | | and shall
authorize payment for, screening by low-dose | 7 | | mammography for the presence of
occult breast cancer for women | 8 | | 35 years of age or older who are eligible
for medical | 9 | | assistance 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, | 25 | | instruction on self-examination and
information regarding the | 26 | | frequency of self-examination and its value as a
preventative |
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| 1 | | tool. For purposes of this Section, "low-dose mammography" | 2 | | means
the x-ray examination of the breast using equipment | 3 | | dedicated specifically
for mammography, including the x-ray | 4 | | tube, filter, compression device,
and image receptor, with an | 5 | | average radiation exposure delivery
of less than one rad per | 6 | | breast for 2 views of an average size breast.
The term also | 7 | | includes digital mammography.
| 8 | | On and after January 1, 2012, providers participating in a | 9 | | quality improvement program approved by the Department shall be | 10 | | reimbursed for screening and diagnostic mammography at the same | 11 | | rate as the Medicare program's rates, including the increased | 12 | | reimbursement for digital mammography. | 13 | | The Department shall convene an expert panel including | 14 | | representatives of hospitals, free-standing mammography | 15 | | facilities, and doctors, including radiologists, to establish | 16 | | quality standards. | 17 | | Subject to federal approval, the Department shall | 18 | | establish a rate methodology for mammography at federally | 19 | | qualified health centers and other encounter-rate clinics. | 20 | | These clinics or centers may also collaborate with other | 21 | | hospital-based mammography facilities. | 22 | | The Department shall establish a methodology to remind | 23 | | women who are age-appropriate for screening mammography, but | 24 | | who have not received a mammogram within the previous 18 | 25 | | months, of the importance and benefit of screening mammography. | 26 | | The Department shall establish a performance goal for |
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| 1 | | primary care providers with respect to their female patients | 2 | | over age 40 receiving an annual mammogram. This performance | 3 | | goal shall be used to provide additional reimbursement in the | 4 | | form of a quality performance bonus to primary care providers | 5 | | who meet that goal. | 6 | | The Department shall devise a means of case-managing or | 7 | | patient navigation for beneficiaries diagnosed with breast | 8 | | cancer. This program shall initially operate as a pilot program | 9 | | in areas of the State with the highest incidence of mortality | 10 | | related to breast cancer. At least one pilot program site shall | 11 | | be in the metropolitan Chicago area and at least one site shall | 12 | | be outside the metropolitan Chicago area. An evaluation of the | 13 | | pilot program shall be carried out measuring health outcomes | 14 | | and cost of care for those served by the pilot program compared | 15 | | to similarly situated patients who are not served by the pilot | 16 | | program. | 17 | | Any medical or health care provider shall immediately | 18 | | recommend, to
any pregnant woman who is being provided prenatal | 19 | | services and is suspected
of drug abuse or is addicted as | 20 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 21 | | Act, referral to a local substance abuse treatment provider
| 22 | | licensed by the Department of Human Services or to a licensed
| 23 | | hospital which provides substance abuse treatment services. | 24 | | The Department of Healthcare and Family Services
shall assure | 25 | | coverage for the cost of treatment of the drug abuse or
| 26 | | addiction for pregnant recipients in accordance with the |
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| 1 | | Illinois Medicaid
Program in conjunction with the Department of | 2 | | Human Services.
| 3 | | All medical providers providing medical assistance to | 4 | | pregnant women
under this Code shall receive information from | 5 | | the Department on the
availability of services under the Drug | 6 | | Free Families with a Future or any
comparable program providing | 7 | | case management services for addicted women,
including | 8 | | information on appropriate referrals for other social services
| 9 | | that may be needed by addicted women in addition to treatment | 10 | | for addiction.
| 11 | | The Illinois Department, in cooperation with the | 12 | | Departments of Human
Services (as successor to the Department | 13 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 14 | | public awareness campaign, may
provide information concerning | 15 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 16 | | health care, and other pertinent programs directed at
reducing | 17 | | the number of drug-affected infants born to recipients of | 18 | | medical
assistance.
| 19 | | Neither the Department of Healthcare and Family Services | 20 | | nor the Department of Human
Services shall sanction the | 21 | | recipient solely on the basis of
her substance abuse.
| 22 | | The Illinois Department shall establish such regulations | 23 | | governing
the dispensing of health services under this Article | 24 | | as it shall deem
appropriate. The Department
should
seek the | 25 | | advice of formal professional advisory committees appointed by
| 26 | | the Director of the Illinois Department for the purpose of |
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| 1 | | providing regular
advice on policy and administrative matters, | 2 | | information dissemination and
educational activities for | 3 | | medical and health care providers, and
consistency in | 4 | | procedures to the Illinois Department.
| 5 | | The Illinois Department may develop and contract with | 6 | | Partnerships of
medical providers to arrange medical services | 7 | | for persons eligible under
Section 5-2 of this Code. | 8 | | Implementation of this Section may be by
demonstration projects | 9 | | in certain geographic areas. The Partnership shall
be | 10 | | represented by a sponsor organization. The Department, by rule, | 11 | | shall
develop qualifications for sponsors of Partnerships. | 12 | | Nothing in this
Section shall be construed to require that the | 13 | | sponsor organization be a
medical organization.
| 14 | | The sponsor must negotiate formal written contracts with | 15 | | medical
providers for physician services, inpatient and | 16 | | outpatient hospital care,
home health services, treatment for | 17 | | alcoholism and substance abuse, and
other services determined | 18 | | necessary by the Illinois Department by rule for
delivery by | 19 | | Partnerships. Physician services must include prenatal and
| 20 | | obstetrical care. The Illinois Department shall reimburse | 21 | | medical services
delivered by Partnership providers to clients | 22 | | in target areas according to
provisions of this Article and the | 23 | | Illinois 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 | 11 | | qualifications to
participate in Partnerships to ensure the | 12 | | delivery of high quality medical
services. These | 13 | | qualifications shall be determined by rule of the Illinois
| 14 | | Department and may be higher than qualifications for | 15 | | participation in the
medical assistance program. Partnership | 16 | | sponsors may prescribe reasonable
additional qualifications | 17 | | for participation by medical providers, only with
the prior | 18 | | written approval of the Illinois Department.
| 19 | | Nothing in this Section shall limit the free choice of | 20 | | practitioners,
hospitals, and other providers of medical | 21 | | services by clients.
In order to ensure patient freedom of | 22 | | choice, the Illinois Department shall
immediately promulgate | 23 | | all rules and take all other necessary actions so that
provided | 24 | | services may be accessed from therapeutically certified | 25 | | optometrists
to the full extent of the Illinois Optometric | 26 | | Practice Act of 1987 without
discriminating between service |
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| 1 | | providers.
| 2 | | The Department shall apply for a waiver from the United | 3 | | States Health
Care Financing Administration to allow for the | 4 | | implementation of
Partnerships under this Section.
| 5 | | The Illinois Department shall require health care | 6 | | providers to maintain
records that document the medical care | 7 | | and services provided to recipients
of Medical Assistance under | 8 | | this Article. Such records must be retained for a period of not | 9 | | less than 6 years from the date of service or as provided by | 10 | | applicable State law, whichever period is longer, except that | 11 | | if an audit is initiated within the required retention period | 12 | | then the records must be retained until the audit is completed | 13 | | and every exception is resolved. The Illinois Department shall
| 14 | | require health care providers to make available, when | 15 | | authorized by the
patient, in writing, the medical records in a | 16 | | timely fashion to other
health care providers who are treating | 17 | | or serving persons eligible for
Medical Assistance under this | 18 | | Article. All dispensers of medical services
shall be required | 19 | | to maintain and retain business and professional records
| 20 | | sufficient to fully and accurately document the nature, scope, | 21 | | details and
receipt of the health care provided to persons | 22 | | eligible for medical
assistance under this Code, in accordance | 23 | | with regulations promulgated by
the Illinois Department. The | 24 | | rules and regulations shall require that proof
of the receipt | 25 | | of prescription drugs, dentures, prosthetic devices and
| 26 | | eyeglasses by eligible persons under this Section accompany |
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| 1 | | each claim
for reimbursement submitted by the dispenser of such | 2 | | medical services.
No such claims for reimbursement shall be | 3 | | approved for payment by the Illinois
Department without such | 4 | | proof of receipt, unless the Illinois Department
shall have put | 5 | | into effect and shall be operating a system of post-payment
| 6 | | audit and review which shall, on a sampling basis, be deemed | 7 | | adequate by
the Illinois Department to assure that such drugs, | 8 | | dentures, prosthetic
devices and eyeglasses for which payment | 9 | | is being made are actually being
received by eligible | 10 | | recipients. Within 90 days after the effective date of
this | 11 | | amendatory Act of 1984, the Illinois Department shall establish | 12 | | a
current list of acquisition costs for all prosthetic devices | 13 | | and any
other items recognized as medical equipment and | 14 | | supplies reimbursable under
this Article and shall update such | 15 | | list on a quarterly basis, except that
the acquisition costs of | 16 | | all prescription drugs shall be updated no
less frequently than | 17 | | every 30 days as required by Section 5-5.12.
| 18 | | The rules and regulations of the Illinois Department shall | 19 | | require
that a written statement including the required opinion | 20 | | of a physician
shall accompany any claim for reimbursement for | 21 | | abortions, or induced
miscarriages or premature births. This | 22 | | statement shall indicate what
procedures were used in providing | 23 | | such medical services.
| 24 | | Notwithstanding any other law to the contrary, the Illinois | 25 | | Department shall, by July 1, 2016, within 365 days after July | 26 | | 22, 2013, (the effective date of Public Act 98-104), establish |
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| 1 | | procedures to permit skilled care facilities licensed under the | 2 | | Nursing Home Care Act to submit monthly billing claims for | 3 | | reimbursement purposes. Following development of these | 4 | | procedures, the Department shall have an additional 365 days to | 5 | | test the viability of the new system and to ensure that any | 6 | | necessary operational or structural changes to its information | 7 | | technology platforms are implemented. | 8 | | Notwithstanding any other law to the contrary, the Illinois | 9 | | Department shall, by July 1, 2016, within 365 days after the | 10 | | effective date of this amendatory Act of the 98th General | 11 | | Assembly, establish procedures to permit ID/DD facilities | 12 | | licensed under the ID/DD Community Care Act to submit monthly | 13 | | billing claims for reimbursement purposes. Following | 14 | | development of these procedures, the Department shall have an | 15 | | additional 365 days to test the viability of the new system and | 16 | | to ensure that any necessary operational or structural changes | 17 | | to its information technology platforms are implemented. | 18 | | The Illinois Department shall require all dispensers of | 19 | | medical
services, other than an individual practitioner or | 20 | | group of practitioners,
desiring to participate in the Medical | 21 | | Assistance program
established under this Article to disclose | 22 | | all financial, beneficial,
ownership, equity, surety or other | 23 | | interests in any and all firms,
corporations, partnerships, | 24 | | associations, business enterprises, joint
ventures, agencies, | 25 | | institutions or other legal entities providing any
form of | 26 | | health care services in this State under this Article.
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| 1 | | The Illinois Department may require that all dispensers of | 2 | | medical
services desiring to participate in the medical | 3 | | assistance program
established under this Article disclose, | 4 | | under such terms and conditions as
the Illinois Department may | 5 | | by rule establish, all inquiries from clients
and attorneys | 6 | | regarding medical bills paid by the Illinois Department, which
| 7 | | inquiries could indicate potential existence of claims or liens | 8 | | for the
Illinois Department.
| 9 | | Enrollment of a vendor
shall be
subject to a provisional | 10 | | period and shall be conditional for one year. During the period | 11 | | of conditional enrollment, the Department may
terminate the | 12 | | vendor's eligibility to participate in, or may disenroll the | 13 | | vendor from, the medical assistance
program without cause. | 14 | | Unless otherwise specified, such termination of eligibility or | 15 | | disenrollment is not subject to the
Department's hearing | 16 | | process.
However, a disenrolled vendor may reapply without | 17 | | penalty.
| 18 | | The Department has the discretion to limit the conditional | 19 | | enrollment period for vendors based upon category of risk of | 20 | | the vendor. | 21 | | Prior to enrollment and during the conditional enrollment | 22 | | period in the medical assistance program, all vendors shall be | 23 | | subject to enhanced oversight, screening, and review based on | 24 | | the risk of fraud, waste, and abuse that is posed by the | 25 | | category of risk of the vendor. The Illinois Department shall | 26 | | establish the procedures for oversight, screening, and review, |
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| 1 | | which may include, but need not be limited to: criminal and | 2 | | financial background checks; fingerprinting; license, | 3 | | certification, and authorization verifications; unscheduled or | 4 | | unannounced site visits; database checks; prepayment audit | 5 | | reviews; audits; payment caps; payment suspensions; and other | 6 | | screening as required by federal or State law. | 7 | | The Department shall define or specify the following: (i) | 8 | | by provider notice, the "category of risk of the vendor" for | 9 | | each type of vendor, which shall take into account the level of | 10 | | screening applicable to a particular category of vendor under | 11 | | federal law and regulations; (ii) by rule or provider notice, | 12 | | the maximum length of the conditional enrollment period for | 13 | | each category of risk of the vendor; and (iii) by rule, the | 14 | | hearing rights, if any, afforded to a vendor in each category | 15 | | of risk of the vendor that is terminated or disenrolled during | 16 | | the conditional enrollment period. | 17 | | To be eligible for payment consideration, a vendor's | 18 | | payment claim or bill, either as an initial claim or as a | 19 | | resubmitted claim following prior rejection, must be received | 20 | | by the Illinois Department, or its fiscal intermediary, no | 21 | | later than 180 days after the latest date on the claim on which | 22 | | medical goods or services were provided, with the following | 23 | | exceptions: | 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 |
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| 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 | 15 | | a recipient received retroactive eligibility, claims must be | 16 | | filed within 180 days after the Department determines the | 17 | | applicant is eligible. For claims for which the Illinois | 18 | | Department is not the primary payer, claims must be submitted | 19 | | to the Illinois Department within 180 days after the final | 20 | | adjudication by the primary payer. | 21 | | In the case of long term care facilities, within 5 days of | 22 | | receipt by the facility of required prescreening information, | 23 | | data for new admissions shall be entered into the Medical | 24 | | Electronic Data Interchange (MEDI) or the Recipient | 25 | | Eligibility Verification (REV) System or successor system, and | 26 | | within 15 days of receipt by the facility of required |
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| 1 | | prescreening information, admission documents shall be | 2 | | submitted through MEDI or REV or shall be submitted directly to | 3 | | the Department of Human Services using required admission | 4 | | forms. Effective September
1, 2014, admission documents, | 5 | | including all prescreening
information, must be submitted | 6 | | through MEDI or REV. Confirmation numbers assigned to an | 7 | | accepted transaction shall be retained by a facility to verify | 8 | | timely submittal. Once an admission transaction has been | 9 | | completed, all resubmitted claims following prior rejection | 10 | | are subject to receipt no later than 180 days after the | 11 | | admission transaction has been completed. | 12 | | Claims that are not submitted and received in compliance | 13 | | with the foregoing requirements shall not be eligible for | 14 | | payment under the medical assistance program, and the State | 15 | | shall have no liability for payment of those claims. | 16 | | To the extent consistent with applicable information and | 17 | | privacy, security, and disclosure laws, State and federal | 18 | | agencies and departments shall provide the Illinois Department | 19 | | access to confidential and other information and data necessary | 20 | | to perform eligibility and payment verifications and other | 21 | | Illinois Department functions. This includes, but is not | 22 | | limited to: information pertaining to licensure; | 23 | | certification; earnings; immigration status; citizenship; wage | 24 | | reporting; unearned and earned income; pension income; | 25 | | employment; supplemental security income; social security | 26 | | numbers; National Provider Identifier (NPI) numbers; the |
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| 1 | | National Practitioner Data Bank (NPDB); program and agency | 2 | | exclusions; taxpayer identification numbers; tax delinquency; | 3 | | corporate information; and death records. | 4 | | The Illinois Department shall enter into agreements with | 5 | | State agencies and departments, and is authorized to enter into | 6 | | agreements with federal agencies and departments, under which | 7 | | such agencies and departments shall share data necessary for | 8 | | medical assistance program integrity functions and oversight. | 9 | | The Illinois Department shall develop, in cooperation with | 10 | | other State departments and agencies, and in compliance with | 11 | | applicable federal laws and regulations, appropriate and | 12 | | effective methods to share such data. At a minimum, and to the | 13 | | extent necessary to provide data sharing, the Illinois | 14 | | Department shall enter into agreements with State agencies and | 15 | | departments, and is authorized to enter into agreements with | 16 | | federal agencies and departments, including but not limited to: | 17 | | the Secretary of State; the Department of Revenue; the | 18 | | Department of Public Health; the Department of Human Services; | 19 | | and the Department of Financial and Professional Regulation. | 20 | | Beginning in fiscal year 2013, the Illinois Department | 21 | | shall set forth a request for information to identify the | 22 | | benefits of a pre-payment, post-adjudication, and post-edit | 23 | | claims system with the goals of streamlining claims processing | 24 | | and provider reimbursement, reducing the number of pending or | 25 | | rejected claims, and helping to ensure a more transparent | 26 | | adjudication process through the utilization of: (i) provider |
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| 1 | | data verification and provider screening technology; and (ii) | 2 | | clinical code editing; and (iii) pre-pay, pre- or | 3 | | post-adjudicated predictive modeling with an integrated case | 4 | | management system with link analysis. Such a request for | 5 | | information shall not be considered as a request for proposal | 6 | | or as an obligation on the part of the Illinois Department to | 7 | | take any action or acquire any products or services. | 8 | | The Illinois Department shall establish policies, | 9 | | procedures,
standards and criteria by rule for the acquisition, | 10 | | repair and replacement
of orthotic and prosthetic devices and | 11 | | durable medical equipment. Such
rules shall provide, but not be | 12 | | limited to, the following services: (1)
immediate repair or | 13 | | replacement of such devices by recipients; and (2) rental, | 14 | | lease, purchase or lease-purchase of
durable medical equipment | 15 | | in a cost-effective manner, taking into
consideration the | 16 | | recipient's medical prognosis, the extent of the
recipient's | 17 | | needs, and the requirements and costs for maintaining such
| 18 | | equipment. Subject to prior approval, such rules shall enable a | 19 | | recipient to temporarily acquire and
use alternative or | 20 | | substitute devices or equipment pending repairs or
| 21 | | replacements of any device or equipment previously authorized | 22 | | for such
recipient by the Department. The Department may | 23 | | contract with one or more third-party vendors and suppliers to | 24 | | supply durable medical equipment in a more cost-effective | 25 | | manner.
| 26 | | The Department shall execute, relative to the nursing home |
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| 1 | | prescreening
project, written inter-agency agreements with the | 2 | | Department of Human
Services and the Department on Aging, to | 3 | | effect the following: (i) intake
procedures and common | 4 | | eligibility criteria for those persons who are receiving
| 5 | | non-institutional services; and (ii) the establishment and | 6 | | development of
non-institutional services in areas of the State | 7 | | where they are not currently
available or are undeveloped; and | 8 | | (iii) notwithstanding any other provision of law, subject to | 9 | | federal approval, on and after July 1, 2012, an increase in the | 10 | | determination of need (DON) scores from 29 to 37 for applicants | 11 | | for institutional and home and community-based long term care; | 12 | | if and only if federal approval is not granted, the Department | 13 | | may, in conjunction with other affected agencies, implement | 14 | | utilization controls or changes in benefit packages to | 15 | | effectuate a similar savings amount for this population; and | 16 | | (iv) no later than July 1, 2013, minimum level of care | 17 | | eligibility criteria for institutional and home and | 18 | | community-based long term care; and (v) no later than October | 19 | | 1, 2013, establish procedures to permit long term care | 20 | | providers access to eligibility scores for individuals with an | 21 | | admission date who are seeking or receiving services from the | 22 | | long term care provider. In order to select the minimum level | 23 | | of care eligibility criteria, the Governor shall establish a | 24 | | workgroup that includes affected agency representatives and | 25 | | stakeholders representing the institutional and home and | 26 | | community-based long term care interests. This Section shall |
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| 1 | | not restrict the Department from implementing lower level of | 2 | | care eligibility criteria for community-based services in | 3 | | circumstances where federal approval has been granted.
| 4 | | The Illinois Department shall develop and operate, in | 5 | | cooperation
with other State Departments and agencies and in | 6 | | compliance with
applicable federal laws and regulations, | 7 | | appropriate and effective
systems of health care evaluation and | 8 | | programs for monitoring of
utilization of health care services | 9 | | and facilities, as it affects
persons eligible for medical | 10 | | assistance under this Code.
| 11 | | The Illinois Department shall report annually to the | 12 | | General Assembly,
no later than the second Friday in April of | 13 | | 1979 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 | 23 | | ending on the June
30 prior to the report. The report shall | 24 | | include suggested legislation
for consideration by the General | 25 | | Assembly. The filing of one copy of the
report with the | 26 | | Speaker, one copy with the Minority Leader and one copy
with |
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| 1 | | the Clerk of the House of Representatives, one copy with the | 2 | | President,
one copy with the Minority Leader and one copy with | 3 | | the Secretary of the
Senate, one copy with the Legislative | 4 | | Research Unit, and such additional
copies
with the State | 5 | | Government Report Distribution Center for the General
Assembly | 6 | | as is required under paragraph (t) of Section 7 of the State
| 7 | | Library Act shall be deemed sufficient to comply with this | 8 | | Section.
| 9 | | Rulemaking authority to implement Public Act 95-1045, if | 10 | | any, is conditioned on the rules being adopted in accordance | 11 | | with all provisions of the Illinois Administrative Procedure | 12 | | Act and all rules and procedures of the Joint Committee on | 13 | | Administrative Rules; any purported rule not so adopted, for | 14 | | whatever reason, is unauthorized. | 15 | | On and after July 1, 2012, the Department shall reduce any | 16 | | rate of reimbursement for services or other payments or alter | 17 | | any methodologies authorized by this Code to reduce any rate of | 18 | | reimbursement for services or other payments in accordance with | 19 | | Section 5-5e. | 20 | | Because kidney transplantation can be an appropriate, cost | 21 | | effective
alternative to renal dialysis when medically | 22 | | necessary and notwithstanding the provisions of Section 1-11 of | 23 | | this Code, beginning October 1, 2014, the Department shall | 24 | | cover kidney transplantation for noncitizens with end-stage | 25 | | renal disease who are not eligible for comprehensive medical | 26 | | benefits, who meet the residency requirements of Section 5-3 of |
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| 1 | | this Code, and who would otherwise meet the financial | 2 | | requirements of the appropriate class of eligible persons under | 3 | | Section 5-2 of this Code. To qualify for coverage of kidney | 4 | | transplantation, such person must be receiving emergency renal | 5 | | dialysis services covered by the Department for at least 2 | 6 | | years . Providers under this Section shall be prior approved and | 7 | | certified by the Department to perform kidney transplantation | 8 | | and the services under this Section shall be limited to | 9 | | services associated with kidney transplantation. | 10 | | (Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, | 11 | | eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section | 12 | | 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. | 13 | | 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651, | 14 | | eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14; | 15 | | revised 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 | 19 | | Section
5-5.1 of this Act shall receive the same rate of | 20 | | payment for similar
services.
| 21 | | (b) It shall be a matter of State policy that the Illinois | 22 | | Department
shall utilize a uniform billing cycle throughout the | 23 | | State for the
long-term care providers.
| 24 | | (c) Notwithstanding any other provisions of this Code, the | 25 | | methodologies for reimbursement of nursing services as |
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| 1 | | provided under this Article shall no longer be applicable for | 2 | | bills payable for nursing services rendered on or after a new | 3 | | reimbursement system based on the Resource Utilization Groups | 4 | | (RUGs) has been fully operationalized, which shall take effect | 5 | | for services provided on or after January 1, 2014. | 6 | | (d) The new nursing services reimbursement methodology | 7 | | utilizing RUG-IV 48 grouper model, which shall be referred to | 8 | | as the RUGs reimbursement system, taking effect January 1, | 9 | | 2014, 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. |
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| 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 | 5 | | base 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. |
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| 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 |
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| 1 | | funding in the amount up to $10,000,000 for per diem add-ons to | 2 | | the RUGS methodology for dates of service on and after July 1, | 3 | | 2014: | 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 | 11 | | RUG-IV nursing component per diem for a nursing home shall be | 12 | | the product of the statewide RUG-IV nursing base per diem rate, | 13 | | the facility average case mix index, and the regional wage | 14 | | adjustor. Transition rates for services provided between | 15 | | January 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 |
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| 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 | 11 | | and after July 1, 2012, reimbursement rates associated with the | 12 | | nursing or support components of the current nursing facility | 13 | | rate methodology shall not increase beyond the level effective | 14 | | May 1, 2011 until a new reimbursement system based on the RUGs | 15 | | IV 48 grouper model has been fully operationalized. | 16 | | (g) Notwithstanding any other provision of this Code, on | 17 | | and after July 1, 2012, for facilities not designated by the | 18 | | Department of Healthcare and Family Services as "Institutions | 19 | | for Mental Disease", rates effective May 1, 2011 shall be | 20 | | adjusted 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 |
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| 1 | | components shall be reduced by 1.7%. | 2 | | (h) Notwithstanding any other provision of this Code, on | 3 | | and after July 1, 2012, nursing facilities designated by the | 4 | | Department of Healthcare and Family Services as "Institutions | 5 | | for Mental Disease" and "Institutions for Mental Disease" that | 6 | | are facilities licensed under the Specialized Mental Health | 7 | | Rehabilitation Act of 2013 shall have the nursing, | 8 | | socio-developmental, capital, and support components of their | 9 | | reimbursement rate effective May 1, 2011 reduced in total by | 10 | | 2.7%. | 11 | | (i) On and after July 1, 2014, the reimbursement rates for | 12 | | the support component of the nursing facility rate for | 13 | | facilities licensed under the Nursing Home Care Act as skilled | 14 | | or intermediate care facilities shall be the rate in effect on | 15 | | June 30, 2014 increased by 8.17%. | 16 | | (j) The Department may contract with a third-party auditor | 17 | | to perform auditing to determine the accuracy of resident | 18 | | assessment information transmitted in the MDS that is relevant | 19 | | to the determination of reimbursement rates. | 20 | | (Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section | 21 | | 6-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff. | 22 | | 7-22-13; 98-651, eff. 6-16-14; 98-727, eff. 7-16-14; 98-756, | 23 | | eff. 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 |
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| 1 | | pharmacy services limited to the dispensing fees reduced in | 2 | | State fiscal year 2015 under Section 5-5b.1, the dispensing | 3 | | fees in State fiscal year 2016 shall be $2.35 for brand name | 4 | | drugs and $5.38 for generic drugs. Reimbursement methodology | 5 | | for product shall not be reduced as a result of this Section. | 6 | | This Section does not prevent the Department from making | 7 | | customary adjustments to pharmacy product prices for the | 8 | | State's Maximum Allowable Cost list for generic prescription | 9 | | medicines. | 10 | | (305 ILCS 5/5-5b.2 new) | 11 | | Sec. 5-5b.2. Reimbursement rates; fiscal year 2016 | 12 | | reductions. | 13 | | (a) Except as provided in subsections (b) and (b-1), | 14 | | notwithstanding any other provision of this Code to the | 15 | | contrary, and subject to rescission if not federally approved, | 16 | | providers of the following services shall have their | 17 | | reimbursement rates or dispensing fees reduced for State fiscal | 18 | | year 2016. For each provider class, the Department must | 19 | | calculate a rate reduction which produces for each service type | 20 | | a total reduction in State fiscal year 2016 no greater than an | 21 | | amount equal to the product of 2.25% multiplied by the | 22 | | originally enacted State fiscal year 2015 appropriations from | 23 | | the General Revenue Fund for each medical service type. The | 24 | | Department must only use appropriations from the General | 25 | | Revenue Fund to calculate the rate reduction amount for each |
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| 1 | | service type. The rate reduction shall be applied equally to | 2 | | all services within the service type regardless of the fund | 3 | | from which payment is made. Medical services subject to rate | 4 | | reduction 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. |
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| 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 | 9 | | authorized under this Section, except that rates or payments, | 10 | | or the portion thereof, paid for private duty nursing services | 11 | | or paid to a provider that is operated by a unit of government | 12 | | that provides the non-federal share of such services shall not | 13 | | be reduced as provided in this Section. | 14 | | (b-1) The Department shall develop a State fiscal year 2016 | 15 | | blended rate for nursing services provided by facilities | 16 | | licensed under the Nursing Home Care Act that takes into | 17 | | account the State fiscal year 2016 appropriation from the | 18 | | Long-Term Care Provider Fund and the adjusted State fiscal year | 19 | | 2016 appropriation for nursing services from the General | 20 | | Revenue Fund. The State fiscal year 2016 blended rate shall | 21 | | produce a savings to the State for fiscal year 2016 no greater | 22 | | than an amount equal to the product of 2.25% multiplied by the | 23 | | originally enacted State fiscal year 2015 appropriations from | 24 | | the General Revenue Fund for nursing services. The State fiscal | 25 | | year 2016 blended rate shall be applied to all nursing services | 26 | | regardless of the source from which payment is made. |
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| 1 | | (c) For any rates which the Department cannot reduce due to | 2 | | federal law, court order, or specific statutory exemptions, the | 3 | | Department must identify the sum of reductions which cannot be | 4 | | attained. The sum must be proportionally distributed and added | 5 | | into the originally enacted State fiscal year 2015 | 6 | | appropriations from the General Revenue Fund for each medical | 7 | | service type prior to the calculation of the rate reduction | 8 | | specified in subsection (a). The Department may not | 9 | | redistribute reductions in any other manner. | 10 | | The reductions required under this Section must be applied | 11 | | uniformly to all providers who deliver the same medical service | 12 | | type. | 13 | | (d) In order to provide for the expeditious and timely | 14 | | implementation of the provisions of this Section, the | 15 | | Department shall adopt rules and may adopt emergency rules in | 16 | | accordance with subsection (s) of Section 5-45 of the Illinois | 17 | | Administrative Procedure Act. | 18 | | (305 ILCS 5/5-30) | 19 | | Sec. 5-30. Care coordination. | 20 | | (a) At least 50% of recipients eligible for comprehensive | 21 | | medical benefits in all medical assistance programs or other | 22 | | health benefit programs administered by the Department, | 23 | | including the Children's Health Insurance Program Act and the | 24 | | Covering ALL KIDS Health Insurance Act, shall be enrolled in a | 25 | | care coordination program by no later than January 1, 2015. For |
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| 1 | | purposes of this Section, "coordinated care" or "care | 2 | | coordination" means delivery systems where recipients will | 3 | | receive their care from providers who participate under | 4 | | contract in integrated delivery systems that are responsible | 5 | | for providing or arranging the majority of care, including | 6 | | primary care physician services, referrals from primary care | 7 | | physicians, diagnostic and treatment services, behavioral | 8 | | health services, in-patient and outpatient hospital services, | 9 | | dental services, and rehabilitation and long-term care | 10 | | services. The Department shall designate or contract for such | 11 | | integrated delivery systems (i) to ensure enrollees have a | 12 | | choice of systems and of primary care providers within such | 13 | | systems; (ii) to ensure that enrollees receive quality care in | 14 | | a culturally and linguistically appropriate manner; and (iii) | 15 | | to ensure that coordinated care programs meet the diverse needs | 16 | | of enrollees with developmental, mental health, physical, and | 17 | | age-related disabilities. | 18 | | (b) Payment for such coordinated care shall be based on | 19 | | arrangements where the State pays for performance related to | 20 | | health care outcomes, the use of evidence-based practices, the | 21 | | use of primary care delivered through comprehensive medical | 22 | | homes, the use of electronic medical records, and the | 23 | | appropriate exchange of health information electronically made | 24 | | either on a capitated basis in which a fixed monthly premium | 25 | | per recipient is paid and full financial risk is assumed for | 26 | | the delivery of services, or through other risk-based payment |
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| 1 | | arrangements. | 2 | | (c) To qualify for compliance with this Section, the 50% | 3 | | goal shall be achieved by enrolling medical assistance | 4 | | enrollees from each medical assistance enrollment category, | 5 | | including parents, children, seniors, and people with | 6 | | disabilities to the extent that current State Medicaid payment | 7 | | laws would not limit federal matching funds for recipients in | 8 | | care coordination programs. In addition, services must be more | 9 | | comprehensively defined and more risk shall be assumed than in | 10 | | the Department's primary care case management program as of the | 11 | | effective date of this amendatory Act of the 96th General | 12 | | Assembly. | 13 | | (d) The Department shall report to the General Assembly in | 14 | | a separate part of its annual medical assistance program | 15 | | report, beginning April, 2012 until April, 2016, on the | 16 | | progress and implementation of the care coordination program | 17 | | initiatives established by the provisions of this amendatory | 18 | | Act of the 96th General Assembly. The Department shall include | 19 | | in its April 2011 report a full analysis of federal laws or | 20 | | regulations regarding upper payment limitations to providers | 21 | | and the necessary revisions or adjustments in rate | 22 | | methodologies and payments to providers under this Code that | 23 | | would be necessary to implement coordinated care with full | 24 | | financial risk by a party other than the Department.
| 25 | | (e) Integrated Care Program for individuals with chronic | 26 | | mental health conditions. |
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| 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 |
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| 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 | 9 | | which the Department mandates some or all of the beneficiaries | 10 | | of the Medical Assistance Program residing in the county to | 11 | | enroll in a Care Coordination Program, as set forth in Section | 12 | | 5-30 of this Code, shall not be eligible for any non-claims | 13 | | based payments not mandated by Article V-A of this Code for | 14 | | which it would otherwise be qualified to receive, unless the | 15 | | hospital is a Coordinated Care Participating Hospital no later | 16 | | than 60 days after the effective date of this amendatory Act of | 17 | | the 97th General Assembly or 60 days after the first mandatory | 18 | | enrollment of a beneficiary in a Coordinated Care program. For | 19 | | purposes of this subsection, "Coordinated Care Participating | 20 | | Hospital" means a hospital that meets one of the following | 21 | | criteria: | 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 |
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| 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 | 10 | | which contracts with the Department to provide services where | 11 | | payment for medical services is made on a capitated basis. | 12 | | (g) No later than August 1, 2013, the Department shall | 13 | | issue a purchase of care solicitation for Accountable Care | 14 | | Entities (ACE) to serve any children and parents or caretaker | 15 | | relatives of children eligible for medical assistance under | 16 | | this Article. An ACE may be a single corporate structure or a | 17 | | network of providers organized through contractual | 18 | | relationships with a single corporate entity. The solicitation | 19 | | shall 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. |
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| 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 |
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| 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 |
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| 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 | 13 | | from the date of the posting of the solicitation to submit | 14 | | proposals. After the solicitation is released, in addition to | 15 | | the MCO rate development data available on the Department's | 16 | | website, subject to federal and State confidentiality and | 17 | | privacy laws and regulations, the Department shall provide 2 | 18 | | years of de-identified summary service data on the targeted | 19 | | population, split between children and adults, showing the | 20 | | historical type and volume of services received and the cost of | 21 | | those services to those potential bidders that sign a data use | 22 | | agreement. The Department may add up to 2 non-state government | 23 | | employees with expertise in creating integrated delivery | 24 | | systems to its review team for the purchase of care | 25 | | solicitation described in this subsection. Any such | 26 | | individuals must sign a no-conflict disclosure and |
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| 1 | | confidentiality agreement and agree to act in accordance with | 2 | | all applicable State laws. | 3 | | During the first 2 years of an ACE's operation, the | 4 | | Department shall provide claims data to the ACE on its | 5 | | enrollees on a periodic basis no less frequently than monthly. | 6 | | Nothing in this subsection shall be construed to limit the | 7 | | Department's mandate to enroll 50% of its beneficiaries into | 8 | | care coordination systems by January 1, 2015, using all | 9 | | available care coordination delivery systems, including Care | 10 | | Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | 11 | | to affect the current CCEs, MCCNs, and MCOs selected to serve | 12 | | seniors and persons with disabilities prior to that date. | 13 | | Nothing in this subsection precludes the Department from | 14 | | considering future proposals for new ACEs or expansion of | 15 | | existing ACEs at the discretion of the Department. | 16 | | (h) Department contracts with MCOs and other entities | 17 | | reimbursed by risk based capitation shall have a minimum | 18 | | medical loss ratio of 85%, shall require the entity to | 19 | | establish an appeals and grievances process for consumers and | 20 | | providers, and shall require the entity to provide a quality | 21 | | assurance and utilization review program. Entities contracted | 22 | | with the Department to coordinate healthcare regardless of risk | 23 | | shall be measured utilizing the same quality metrics. The | 24 | | quality metrics may be population specific. Any contracted | 25 | | entity serving at least 5,000 seniors or people with | 26 | | disabilities or 15,000 individuals in other populations |
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| 1 | | covered by the Medical Assistance Program that has been | 2 | | receiving full-risk capitation for a year shall be accredited | 3 | | by a national accreditation organization authorized by the | 4 | | Department within 2 years after the date it is eligible to | 5 | | become accredited. The requirements of this subsection shall | 6 | | apply to contracts with MCOs entered into or renewed or | 7 | | extended after June 1, 2013. | 8 | | (h-5) The Department shall monitor and enforce compliance | 9 | | by MCOs with agreements they have entered into with providers | 10 | | on issues that include, but are not limited to, timeliness of | 11 | | payment, payment rates, and processes for obtaining prior | 12 | | approval. The Department may impose sanctions on MCOs for | 13 | | violating provisions of those agreements that include, but are | 14 | | not limited to, financial penalties, suspension of enrollment | 15 | | of new enrollees, and termination of the MCO's contract with | 16 | | the Department. As used in this subsection (h-5), "MCO" has the | 17 | | meaning 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 | 20 | | providers and community agencies, governed by a lead entity, | 21 | | which receives a care coordination payment with a portion of | 22 | | the payment at risk for meeting quality outcome targets in | 23 | | order to provide care coordination services for its enrollees. | 24 | | "CCE" means either a care coordination entity or a | 25 | | pediatric care coordination entity. | 26 | | "Children with complex medical needs" means persons under |
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| 1 | | 21 years of age who are clients of medical assistance programs | 2 | | or other health benefit programs administered by the Department | 3 | | through the use of the 3M TM Clinical Risk Grouping Software | 4 | | (CRG) as Status 6.1 and above, through a clinical screening | 5 | | tool, or those who do not have sufficient claims data in order | 6 | | to be identified by the Department through the CRG software. | 7 | | "Pediatric care coordination entity" means a collaboration | 8 | | of providers and community agencies, governed by a lead entity, | 9 | | serving primarily persons under 21 years of age which receives | 10 | | a care coordination payment with a portion of the payment at | 11 | | risk for meeting quality outcome targets in order to provide | 12 | | care coordination services for its enrollees. | 13 | | "Pediatric care coordination plan" means a pediatric care | 14 | | coordination entity defined in this subsection or a | 15 | | pediatric-only managed care community network as defined in | 16 | | subsection (b) of Section 5-11. | 17 | | Beginning on the effective date of this amendatory Act of | 18 | | the 99th General Assembly and until April 1, 2016, the | 19 | | Department, where available, shall offer newly eligible | 20 | | children with complex medical needs and currently eligible | 21 | | children with complex medical needs making their annual health | 22 | | plan choice the choice of enrollment in a pediatric care | 23 | | coordination entity as defined in this subsection. At any time, | 24 | | the Department may offer, where available, the choice of | 25 | | enrollment in a pediatric-only managed care community network | 26 | | as defined in subsection (b) of Section 5-11. On and after |
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| 1 | | April 1, 2016, the Department shall offer a pediatric care | 2 | | coordination plan, where available, but may require the plan to | 3 | | meet the requirements of subsection (b) of Section 5-11. This | 4 | | choice shall be in addition to otherwise available health | 5 | | maintenance organizations (HMOs), managed care community | 6 | | networks (MCCNs), and accountable care entities (ACEs). | 7 | | Children with complex medical needs under 18 years of age | 8 | | shall be eligible to enroll in the pediatric care coordination | 9 | | plan as long as such children continue to maintain eligibility | 10 | | for medical assistance programs or other health benefit | 11 | | programs administered by the Department. The Department may | 12 | | choose to extend enrollment to individuals under 21 years of | 13 | | age for initial enrollment. Individuals may also be excluded if | 14 | | they 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 | 26 | | eligible enrollees that are children with complex medical needs |
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| 1 | | shall receive notification of their eligibility and an | 2 | | explanation of how to elect the pediatric care coordination | 3 | | plan option. The Department shall ensure that any third-party | 4 | | enrollment broker is briefed on the pediatric care coordination | 5 | | plan option and that the broker shall ensure that all | 6 | | enrollment options are presented to the parents of children | 7 | | with complex medical needs. | 8 | | The Department shall provide care coordination fees for | 9 | | care coordination entities for seniors and persons with | 10 | | disabilities and for pediatric care coordination entities for | 11 | | children with complex medical needs, except for a pediatric | 12 | | care coordination entity that had at least 1,500 enrollees as | 13 | | of March 1, 2015, for a period of at least 36 months of | 14 | | operation at a per member per month rate no less than the | 15 | | schedule of rates in effect as of January 1, 2015, or as agreed | 16 | | to by the CCE. The Department shall provide care coordination | 17 | | fees for pediatric care coordination entities for children with | 18 | | complex medical needs that had at least 1,500 enrollees as of | 19 | | March 1, 2015, until April 1, 2016, at a per member per month | 20 | | rate no less than the schedule of rates in effect as of January | 21 | | 1, 2015, or as agreed to by the CCE. After 24 months of | 22 | | operation, but before 36 months, the Department shall evaluate | 23 | | each CCE's performance in the areas of care coordination, | 24 | | clinical integration, quality measurement performance, | 25 | | including health care utilization, and health care | 26 | | expenditures. For purposes of this Section, a CCE's date of |
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| 1 | | operation shall be the month when care coordination payments | 2 | | were first paid. Nothing in this provision prohibits the | 3 | | following: (i) a CCE from partnering with another managed care | 4 | | entity, (ii) a CCE from moving to capitation sooner than the | 5 | | aforementioned timelines, and (iii) the Department from | 6 | | sanctioning or terminating a CCE for substantive contractual | 7 | | violations. | 8 | | (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13; | 9 | | 98-651, eff. 6-16-14.) | 10 | | (305 ILCS 5/5-30.2 new) | 11 | | Sec. 5-30.2. Managed care; automatic assignment. The | 12 | | Department shall, within a reasonable period of time after | 13 | | relevant data from managed care entities has been collected and | 14 | | analyzed, but no earlier than January 1, 2017, develop and | 15 | | implement within each enrollment region an algorithm that takes | 16 | | into account quality scores and other operational proficiency | 17 | | criteria developed, defined, and adopted by the Department, to | 18 | | automatically assign Medicaid enrollees served under the | 19 | | Family Health Plan and the Integrated Care Program and those | 20 | | Medicaid enrollees eligible for medical assistance pursuant to | 21 | | the Patient Protection and Affordable Care Act (Public Law | 22 | | 111-148) into managed care entities, including Accountable | 23 | | Care Entities, Managed Care Community Networks, and Managed | 24 | | Care Organizations. The quality metrics used shall be | 25 | | measurable for all entities. The algorithm shall not use the |
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| 1 | | quality and proficiency metrics to reassign enrollees out of | 2 | | any plan that they are enrolled with at the time and shall only | 3 | | be used if the client has not voluntarily selected a primary | 4 | | care physician and a managed care entity or care coordination | 5 | | entity. Clients shall have one opportunity within 90 calendar | 6 | | days after auto assignment by algorithm to select a different | 7 | | managed care entity. The algorithm developed and implemented | 8 | | shall favor assignment into managed care entities with the | 9 | | highest quality scores and levels of compliance with the | 10 | | operational proficiency criteria established. | 11 | | (305 ILCS 5/5-30.3 new) | 12 | | Sec. 5-30.3. Managed care; wards of the Department of | 13 | | Children and Family Services. The Department shall seek a | 14 | | waiver from the federal Centers for Medicare and Medicaid | 15 | | Services to allow mandatory enrollment of wards of the | 16 | | Department of Children and Family Services into Medicaid | 17 | | managed care and care coordination plans. The Department must | 18 | | submit a waiver request to the federal Centers for Medicare and | 19 | | Medicaid Services no later than October 1, 2015 and shall take | 20 | | all necessary actions to obtain approval, including appeal of | 21 | | any denial. Beginning January 1, 2016, the Department shall | 22 | | report progress on the waiver required under this Section and | 23 | | shall report quarterly until the waiver request is approved or | 24 | | denied. Upon federal approval, the Department shall develop a | 25 | | process to ensure that all wards of the Department of Children |
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| 1 | | and Family Services are enrolled in Medicaid managed care and | 2 | | care coordination plans. | 3 | | (305 ILCS 5/5-30.4 new) | 4 | | Sec. 5-30.4. Managed care capitated rates; specialized | 5 | | mental health rehabilitation facilities. Services delivered by | 6 | | facilities licensed under the Specialized Mental Health | 7 | | Rehabilitation Act of 2013 shall be a covered Medicaid service | 8 | | for eligible Medicaid enrollees under both fee-for-service, | 9 | | managed care, and care-coordination arrangements. The | 10 | | Department shall ensure that all residents of facilities | 11 | | licensed under the Specialized Mental Health Rehabilitation | 12 | | Act of 2013 who are eligible for Medicaid are enrolled in | 13 | | Medicaid 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 | 17 | | on its website a managed care policy manual for providers. The | 18 | | manual must be updated no less than annually, but may be | 19 | | updated no more frequently than monthly and no changes shall be | 20 | | effective until at least 30 days after the publication of the | 21 | | change in the manual. The manual and updates shall be developed | 22 | | and issued only after the Department has consulted with | 23 | | representatives of providers and managed care entities, | 24 | | including the Statewide associations representing such |
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| 1 | | stakeholders. Manuals posted pursuant to this Section shall be | 2 | | consistent with the Managed Care Reform and Patient Rights Act, | 3 | | the Health Maintenance Organization Act, and the | 4 | | Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home | 5 | | Residents' Managed Care Rights Law, as applicable. | 6 | | (b) The Department may post separate manuals based on the | 7 | | population served by the managed care coverage plan, such as | 8 | | seniors and people with disabilities. The Department must | 9 | | clearly distinguish any differences in information based on the | 10 | | managed care coverage plans. | 11 | | (c) The manual must include no less than the following | 12 | | information: (i) the process for providers to appeal payment | 13 | | decisions made by the managed care plan, (ii) the process for | 14 | | enrollees to appeal decisions made by managed care entities, | 15 | | (iii) electronic links to information required for obtaining | 16 | | approval for services by each plan, (iv) the contact | 17 | | information for either a provider or an enrollee to file a | 18 | | complaint with the Department about a managed care plan, (v) | 19 | | the Department's requirements for each plan to provide services | 20 | | and timeliness of payment, (vi) all timeframes for each plan to | 21 | | approve or deny coverage, (vii) an electronic link to the | 22 | | information on identifying all the providers currently | 23 | | providing services for a managed care plan, (viii) the process | 24 | | and contact information for an enrollee to change managed care | 25 | | plans, (ix) contact information for an enrollee to change a | 26 | | primary care physician or correct personal information, and (x) |
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| 1 | | contact information for each plan for provider relations and | 2 | | customer 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 | 7 | | years 2009 through 2018, an annual assessment on inpatient | 8 | | services is imposed on each hospital provider in an amount | 9 | | equal to $218.38 multiplied by the difference of the hospital's | 10 | | occupied bed days less the hospital's Medicare bed days, | 11 | | provided, however, that the amount of $218.38 shall be | 12 | | increased by a uniform percentage to generate an amount equal | 13 | | to 75% of the State share of the payments authorized under | 14 | | Section 12-5, with such increase only taking effect upon the | 15 | | date that a State share for such payments is required under | 16 | | federal law. For the period of April through June 2015, the | 17 | | amount of $218.38 used to calculate the assessment under this | 18 | | paragraph shall, by emergency rule under subsection (s) of | 19 | | Section 5-45 of the Illinois Administrative Procedure Act, be | 20 | | increased by a uniform percentage to generate $20,250,000 in | 21 | | the aggregate for that period from all hospitals subject to the | 22 | | annual assessment under this paragraph. In lieu of a reduction | 23 | | in the reimbursement rates paid to hospitals under Section | 24 | | 5-5b.2 of this Code, for State fiscal year 2016, the amount of | 25 | | $218.38 used to calculate the assessment under this paragraph |
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| 1 | | shall, by emergency rule under subsection (s) of Section 5-45 | 2 | | of the Illinois Administrative Procedure Act, be increased by a | 3 | | uniform percentage to generate $20,250,000 annually in the | 4 | | aggregate from all hospitals subject to the annual assessment | 5 | | under this paragraph. | 6 | | For State fiscal years 2009 through 2014 and after, a | 7 | | hospital's occupied bed days and Medicare bed days shall be | 8 | | determined using the most recent data available from each | 9 | | hospital's 2005 Medicare cost report as contained in the | 10 | | Healthcare Cost Report Information System file, for the quarter | 11 | | ending on December 31, 2006, without regard to any subsequent | 12 | | adjustments or changes to such data. If a hospital's 2005 | 13 | | Medicare cost report is not contained in the Healthcare Cost | 14 | | Report Information System, then the Illinois Department may | 15 | | obtain the hospital provider's occupied bed days and Medicare | 16 | | bed days from any source available, including, but not limited | 17 | | to, records maintained by the hospital provider, which may be | 18 | | inspected at all times during business hours of the day by the | 19 | | Illinois Department or its duly authorized agents and | 20 | | employees. | 21 | | (b) (Blank).
| 22 | | (b-5) Subject to Sections 5A-3 and 5A-10, for the portion | 23 | | of State fiscal year 2012, beginning June 10, 2012 through June | 24 | | 30, 2012, and for State fiscal years 2013 through 2018, an | 25 | | annual assessment on outpatient services is imposed on each | 26 | | hospital provider in an amount equal to .008766 multiplied by |
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| 1 | | the hospital's outpatient gross revenue, provided, however, | 2 | | that the amount of .008766 shall be increased by a uniform | 3 | | percentage to generate an amount equal to 25% of the State | 4 | | share of the payments authorized under Section 12-5, with such | 5 | | increase only taking effect upon the date that a State share | 6 | | for such payments is required under federal law. For the period | 7 | | beginning June 10, 2012 through June 30, 2012, the annual | 8 | | assessment on outpatient services shall be prorated by | 9 | | multiplying the assessment amount by a fraction, the numerator | 10 | | of which is 21 days and the denominator of which is 365 days. | 11 | | For the period of April through June 2015, the amount of | 12 | | .008766 used to calculate the assessment under this paragraph | 13 | | shall, by emergency rule under subsection (s) of Section 5-45 | 14 | | of the Illinois Administrative Procedure Act, be increased by a | 15 | | uniform percentage to generate $6,750,000 in the aggregate for | 16 | | that period from all hospitals subject to the annual assessment | 17 | | under this paragraph. In lieu of a reduction in the | 18 | | reimbursement rates paid to hospitals under Section 5-5b.2 of | 19 | | this Code, for State fiscal year 2016, the amount of .008766 | 20 | | used to calculate the assessment under this paragraph shall, by | 21 | | emergency rule under subsection (s) of Section 5-45 of the | 22 | | Illinois Administrative Procedure Act, be increased by a | 23 | | uniform percentage to generate $6,750,000 annually in the | 24 | | aggregate from all hospitals subject to the annual assessment | 25 | | under this paragraph. | 26 | | For the portion of State fiscal year 2012, beginning June |
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| 1 | | 10, 2012 through June 30, 2012, and State fiscal years 2013 | 2 | | through 2018, a hospital's outpatient gross revenue shall be | 3 | | determined using the most recent data available from each | 4 | | hospital's 2009 Medicare cost report as contained in the | 5 | | Healthcare Cost Report Information System file, for the quarter | 6 | | ending on June 30, 2011, without regard to any subsequent | 7 | | adjustments or changes to such data. If a hospital's 2009 | 8 | | Medicare cost report is not contained in the Healthcare Cost | 9 | | Report Information System, then the Department may obtain the | 10 | | hospital provider's outpatient gross revenue from any source | 11 | | available, including, but not limited to, records maintained by | 12 | | the hospital provider, which may be inspected at all times | 13 | | during business hours of the day by the Department or its duly | 14 | | authorized agents and employees. | 15 | | (c) (Blank).
| 16 | | (d) Notwithstanding any of the other provisions of this | 17 | | Section, the Department is authorized to adopt rules to reduce | 18 | | the rate of any annual assessment imposed under this Section, | 19 | | as authorized by Section 5-46.2 of the Illinois Administrative | 20 | | Procedure Act.
| 21 | | (e) Notwithstanding any other provision of this Section, | 22 | | any plan providing for an assessment on a hospital provider as | 23 | | a permissible tax under Title XIX of the federal Social | 24 | | Security Act and Medicaid-eligible payments to hospital | 25 | | providers from the revenues derived from that assessment shall | 26 | | be reviewed by the Illinois Department of Healthcare and Family |
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| 1 | | Services, as the Single State Medicaid Agency required by | 2 | | federal law, to determine whether those assessments and | 3 | | hospital provider payments meet federal Medicaid standards. If | 4 | | the Department determines that the elements of the plan may | 5 | | meet federal Medicaid standards and a related State Medicaid | 6 | | Plan Amendment is prepared in a manner and form suitable for | 7 | | submission, that State Plan Amendment shall be submitted in a | 8 | | timely manner for review by the Centers for Medicare and | 9 | | Medicaid Services of the United States Department of Health and | 10 | | Human Services and subject to approval by the Centers for | 11 | | Medicare and Medicaid Services of the United States Department | 12 | | of Health and Human Services. No such plan shall become | 13 | | effective without approval by the Illinois General Assembly by | 14 | | the enactment into law of related legislation. Notwithstanding | 15 | | any other provision of this Section, the Department is | 16 | | authorized to adopt rules to reduce the rate of any annual | 17 | | assessment imposed under this Section. Any such rules may be | 18 | | adopted by the Department under Section 5-50 of the Illinois | 19 | | Administrative Procedure Act. | 20 | | (Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14; 99-2, | 21 | | eff. 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, | 25 | | 2008. |
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| 1 | | (a) To preserve and improve access to hospital services, | 2 | | for hospital services rendered on or after July 1, 2008, the | 3 | | Illinois Department shall, except for hospitals described in | 4 | | subsection (b) of Section 5A-3, make payments to hospitals as | 5 | | set forth in this Section. These payments shall be paid in 12 | 6 | | equal installments on or before the seventh State business day | 7 | | of each month, except that no payment shall be due within 100 | 8 | | days after the later of the date of notification of federal | 9 | | approval of the payment methodologies required under this | 10 | | Section or any waiver required under 42 CFR 433.68, at which | 11 | | time the sum of amounts required under this Section prior to | 12 | | the date of notification is due and payable. Payments under | 13 | | this Section are not due and payable, however, until (i) the | 14 | | methodologies described in this Section are approved by the | 15 | | federal government in an appropriate State Plan amendment and | 16 | | (ii) the assessment imposed under this Article is determined to | 17 | | be a permissible tax under Title XIX of the Social Security | 18 | | Act. | 19 | | (a-5) The Illinois Department may, when practicable, | 20 | | accelerate the schedule upon which payments authorized under | 21 | | this 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 |
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| 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 |
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| 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 | 5 | | paid for inpatient hospital services, the Department shall pay | 6 | | to each Illinois general acute care hospital that provided more | 7 | | than 20,500 Medicaid inpatient days of care in State fiscal | 8 | | year 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 | 17 | | inpatient hospital services, the Department shall pay an | 18 | | additional payment to each Illinois general acute care hospital | 19 | | that has a Medicaid inpatient utilization rate of at least 10% | 20 | | (as calculated by the Department for the rate year 2007 | 21 | | disproportionate 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 |
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| 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 | 7 | | rates paid for inpatient services, the Department shall pay to | 8 | | each Illinois hospital eligible for tertiary care adjustment | 9 | | payments under 89 Ill. Adm. Code 148.296, as in effect for | 10 | | State fiscal year 2007, a supplemental tertiary care adjustment | 11 | | payment equal to the tertiary care adjustment payment required | 12 | | under 89 Ill. Adm. Code 148.296, as in effect for State fiscal | 13 | | year 2007. | 14 | | (i) Crossover adjustment. In addition to rates paid for | 15 | | inpatient services, the Department shall pay each Illinois | 16 | | general acute care hospital that had a ratio of crossover days | 17 | | to total inpatient days for medical assistance programs | 18 | | administered by the Department (utilizing information from | 19 | | 2005 paid claims) greater than 50%, and a case mix index | 20 | | greater than the 65th percentile of case mix indices for all | 21 | | Illinois hospitals, a rate of $1,125 for each Medicaid | 22 | | inpatient day including crossover days. | 23 | | (j) Magnet hospital adjustment. In addition to rates paid | 24 | | for inpatient hospital services, the Department shall pay to | 25 | | each Illinois general acute care hospital and each Illinois | 26 | | freestanding children's hospital that, as of February 1, 2008, |
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| 1 | | was recognized as a Magnet hospital by the American Nurses | 2 | | Credentialing Center and that had a case mix index greater than | 3 | | the 75th percentile of case mix indices for all Illinois | 4 | | hospitals 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 | 17 | | factor" means the percentage by which the number of Medicaid | 18 | | recipients in the county increased from State fiscal year 1998 | 19 | | to State fiscal year 2005. | 20 | | (k) For purposes of this Section, a hospital that is | 21 | | enrolled to provide Medicaid services during State fiscal year | 22 | | 2005 shall have its utilization and associated reimbursements | 23 | | annualized prior to the payment calculations being performed | 24 | | under this Section. | 25 | | (l) For purposes of this Section, the terms "Medicaid | 26 | | days", "ambulatory procedure listing services", and |
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| 1 | | "ambulatory procedure listing payments" do not include any | 2 | | days, charges, or services for which Medicare or a managed care | 3 | | organization reimbursed on a capitated basis was liable for | 4 | | payment, except where explicitly stated otherwise in this | 5 | | Section. | 6 | | (m) For purposes of this Section, in determining the | 7 | | percentile ranking of an Illinois hospital's case mix index or | 8 | | capital costs, hospitals described in subsection (b) of Section | 9 | | 5A-3 shall be excluded from the ranking. | 10 | | (n) Definitions. Unless the context requires otherwise or | 11 | | unless provided otherwise in this Section, the terms used in | 12 | | this Section for qualifying criteria and payment calculations | 13 | | shall have the same meanings as those terms have been given in | 14 | | the Illinois Department's administrative rules as in effect on | 15 | | March 1, 2008. Other terms shall be defined by the Illinois | 16 | | Department by rule. | 17 | | As used in this Section, unless the context requires | 18 | | otherwise: | 19 | | "Base inpatient payments" means, for a given hospital, the | 20 | | sum of base payments for inpatient services made on a per diem | 21 | | or per admission (DRG) basis, excluding those portions of per | 22 | | admission payments that are classified as capital payments. | 23 | | Disproportionate share hospital adjustment payments, Medicaid | 24 | | Percentage Adjustments, Medicaid High Volume Adjustments, and | 25 | | outlier payments, as defined by rule by the Department as of | 26 | | January 1, 2008, are not base payments. |
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| 1 | | "Capital costs" means, for a given hospital, the total | 2 | | capital costs determined using the most recent 2005 Medicare | 3 | | cost report as contained in the Healthcare Cost Report | 4 | | Information System file, for the quarter ending on December 31, | 5 | | 2006, divided by the total inpatient days from the same cost | 6 | | report to calculate a capital cost per day. The resulting | 7 | | capital cost per day is inflated to the midpoint of State | 8 | | fiscal year 2009 utilizing the national hospital market price | 9 | | proxies (DRI) hospital cost index. If a hospital's 2005 | 10 | | Medicare cost report is not contained in the Healthcare Cost | 11 | | Report Information System, the Department may obtain the data | 12 | | necessary to compute the hospital's capital costs from any | 13 | | source available, including, but not limited to, records | 14 | | maintained by the hospital provider, which may be inspected at | 15 | | all times during business hours of the day by the Illinois | 16 | | Department or its duly authorized agents and employees. | 17 | | "Case mix index" means, for a given hospital, the sum of | 18 | | the DRG relative weighting factors in effect on January 1, | 19 | | 2005, for all general acute care admissions for State fiscal | 20 | | year 2005, excluding Medicare crossover admissions and | 21 | | transplant admissions reimbursed under 89 Ill. Adm. Code | 22 | | 148.82, divided by the total number of general acute care | 23 | | admissions for State fiscal year 2005, excluding Medicare | 24 | | crossover admissions and transplant admissions reimbursed | 25 | | under 89 Ill. Adm. Code 148.82. | 26 | | "Medicaid inpatient day" means, for a given hospital, the |
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| 1 | | sum of days of inpatient hospital days provided to recipients | 2 | | of medical assistance under Title XIX of the federal Social | 3 | | Security Act, excluding days for individuals eligible for | 4 | | Medicare under Title XVIII of that Act (Medicaid/Medicare | 5 | | crossover days), as tabulated from the Department's paid claims | 6 | | data for admissions occurring during State fiscal year 2005 | 7 | | that was adjudicated by the Department through March 23, 2007. | 8 | | "Medicaid obstetrical day" means, for a given hospital, the | 9 | | sum of days of inpatient hospital days grouped by the | 10 | | Department to DRGs of 370 through 375 provided to recipients of | 11 | | medical assistance under Title XIX of the federal Social | 12 | | Security Act, excluding days for individuals eligible for | 13 | | Medicare under Title XVIII of that Act (Medicaid/Medicare | 14 | | crossover days), as tabulated from the Department's paid claims | 15 | | data for admissions occurring during State fiscal year 2005 | 16 | | that was adjudicated by the Department through March 23, 2007. | 17 | | "Outpatient ambulatory procedure listing payments" means, | 18 | | for a given hospital, the sum of payments for ambulatory | 19 | | procedure listing services, as described in 89 Ill. Adm. Code | 20 | | 148.140(b), provided to recipients of medical assistance under | 21 | | Title XIX of the federal Social Security Act, excluding | 22 | | payments for individuals eligible for Medicare under Title | 23 | | XVIII of the Act (Medicaid/Medicare crossover days), as | 24 | | tabulated from the Department's paid claims data for services | 25 | | occurring in State fiscal year 2005 that were adjudicated by | 26 | | the Department through March 23, 2007. |
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| 1 | | (o) The Department may adjust payments made under this | 2 | | Section 5A-12.2 to comply with federal law or regulations | 3 | | regarding hospital-specific payment limitations on | 4 | | government-owned or government-operated hospitals. | 5 | | (p) Notwithstanding any of the other provisions of this | 6 | | Section, the Department is authorized to adopt rules that | 7 | | change the hospital access improvement payments specified in | 8 | | this Section, but only to the extent necessary to conform to | 9 | | any federally approved amendment to the Title XIX State plan. | 10 | | Any such rules shall be adopted by the Department as authorized | 11 | | by Section 5-50 of the Illinois Administrative Procedure Act. | 12 | | Notwithstanding any other provision of law, any changes | 13 | | implemented as a result of this subsection (p) shall be given | 14 | | retroactive effect so that they shall be deemed to have taken | 15 | | effect as of the effective date of this Section. | 16 | | (q) (Blank). | 17 | | (r) On and after July 1, 2012, the Department shall reduce | 18 | | any rate of reimbursement for services or other payments or | 19 | | alter any methodologies authorized by this Code to reduce any | 20 | | rate of reimbursement for services or other payments in | 21 | | accordance with Section 5-5e. | 22 | | (s) On or after July 1, 2014, but no later than October 1, | 23 | | 2014, and no less than annually thereafter, the Department may | 24 | | increase capitation payments to capitated managed care | 25 | | organizations (MCOs) to equal the aggregate reduction of | 26 | | payments made in this Section and in Section 5A-12.4 by a |
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| 1 | | uniform percentage consistent with actuarial soundness on a | 2 | | regional basis to preserve access to hospital services for | 3 | | recipients under the Illinois Medical Assistance Program. The | 4 | | aggregate amount of all increased capitation payments to all | 5 | | MCOs for a fiscal year shall be an the amount needed to avoid | 6 | | reduction in payments authorized under Section 5A-15. Payments | 7 | | to MCOs under this Section shall be consistent with actuarial | 8 | | certification and shall be published by the Department each | 9 | | year. Each MCO shall only expend the increased capitation | 10 | | payments it receives under this Section to support the | 11 | | availability of hospital services and to ensure access to | 12 | | hospital services, with such expenditures being made within 15 | 13 | | calendar days from when the MCO receives the increased | 14 | | capitation payment. The Department shall make available, on a | 15 | | monthly basis, a report of the capitation payments that are | 16 | | made to each MCO pursuant to this subsection, including the | 17 | | number of enrollees for which such payment is made, the per | 18 | | enrollee amount of the payment, and any adjustments that have | 19 | | been made. Payments made under this subsection shall be | 20 | | guaranteed by a surety bond obtained by the MCO in an amount | 21 | | established by the Department to approximate one month's | 22 | | liability of payments authorized under this subsection. The | 23 | | Department may advance the payments guaranteed by the surety | 24 | | bond. Payments to MCOs that would be paid consistent with | 25 | | actuarial certification and enrollment in the absence of the | 26 | | increased capitation payments under this Section shall not be |
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| 1 | | reduced as a consequence of payments made under this | 2 | | subsection. | 3 | | As used in this subsection, "MCO" means an entity which | 4 | | contracts with the Department to provide services where payment | 5 | | for medical services is made on a capitated basis. | 6 | | (t) On or after July 1, 2014, the Department shall may | 7 | | increase capitation payments to capitated managed care | 8 | | organizations (MCOs) to include the payments authorized equal | 9 | | the aggregate reduction of payments made in Section 5A-12.5 to | 10 | | preserve access to hospital services for recipients under the | 11 | | Illinois Medical Assistance Program. Payments to MCOs under | 12 | | this Section shall be consistent with actuarial certification | 13 | | and shall be published by the Department each year. Each MCO | 14 | | shall only expend the increased capitation payments it receives | 15 | | under this Section to support the availability of hospital | 16 | | services and to ensure access to hospital services, with such | 17 | | expenditures being made within 15 calendar days from when the | 18 | | MCO receives the increased capitation payment. The Department | 19 | | may advance the payments to hospitals under this subsection, in | 20 | | the event the MCO fails to make such payments. The Department | 21 | | shall make available, on a monthly basis, a report of the | 22 | | capitation payments that are made to each MCO pursuant to this | 23 | | subsection, including the number of enrollees for which such | 24 | | payment is made, the per enrollee amount of the payment, and | 25 | | any adjustments that have been made. Payments to MCOs that | 26 | | would be paid consistent with actuarial certification and |
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| 1 | | enrollment in the absence of the increased capitation payments | 2 | | under this subsection shall not be reduced as a consequence of | 3 | | payments made under this subsection. | 4 | | As used in this subsection, "MCO" means an entity which | 5 | | contracts with the Department to provide services where payment | 6 | | for 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 | 10 | | payments. The Department shall, subject to federal approval, | 11 | | mirror the Medical Assistance hospital reimbursement | 12 | | methodology, for recipients enrolled under a fee for service or | 13 | | capitated managed care program, including hospital access | 14 | | payments as defined in Section 5A-12.2 of this Article and | 15 | | hospital access improvement payments as defined in Section | 16 | | 5A-12.4 of this Article , as well as the amount of such payments | 17 | | pursuant to subsection (s) of Section 5A-12.2 of this Article , | 18 | | in compliance with the equivalent rate provisions of the | 19 | | Affordable Care Act. The Department shall make adjustments to | 20 | | the capitation payments made to MCOs for adults eligible for | 21 | | medical assistance pursuant to the Affordable Care Act for the | 22 | | hospital access payments authorized under this Section | 23 | | attributable to the earliest possible date for which federal | 24 | | financial participation is available. | 25 | | As used in this Section, "Affordable Care Act" is the |
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| 1 | | collective term for the Patient Protection and Affordable Care | 2 | | Act (Pub. L. 111-148) and the Health Care and Education | 3 | | Reconciliation 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 | 9 | | to implement
this amendatory Act of the 94th General Assembly
| 10 | | through the use of emergency rulemaking in accordance with
| 11 | | Section 5-45 of the Illinois Administrative Procedure Act.
For | 12 | | purposes of that Act, the General Assembly finds that the
| 13 | | adoption of rules to implement this
amendatory Act of the 94th | 14 | | General Assembly is deemed an
emergency and necessary for the | 15 | | public interest, safety, and welfare.
| 16 | | (b) The Department of Healthcare and Family Services may | 17 | | adopt rules necessary to implement
this amendatory Act of the | 18 | | 97th General Assembly
through the use of emergency rulemaking | 19 | | in accordance with
Section 5-45 of the Illinois Administrative | 20 | | Procedure Act.
For purposes of that Act, the General Assembly | 21 | | finds that the
adoption of rules to implement this
amendatory | 22 | | Act of the 97th General Assembly is deemed an
emergency and | 23 | | necessary for the public interest, safety, and welfare. | 24 | | (c) The Department of Healthcare and Family Services may | 25 | | adopt rules necessary to implement this amendatory Act of the |
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| 1 | | 99th General Assembly through the use of emergency rulemaking | 2 | | in accordance with Section 5-45 of the Illinois Administrative | 3 | | Procedure Act. For purposes of this Code, the General Assembly | 4 | | finds that the adoption of rules to implement this amendatory | 5 | | Act of the 99th General Assembly is deemed an emergency and | 6 | | necessary for the public interest, safety, and welfare. The | 7 | | Department shall, within 30 days after the effective date of | 8 | | this amendatory Act of the 99th General Assembly, take all | 9 | | actions necessary to implement this amendatory Act of the 99th | 10 | | General Assembly, including, but not limited to, the adoption | 11 | | of rules and the obtaining of any necessary approval of the | 12 | | federal 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 | 17 | | annual assessment on health care services is imposed on each | 18 | | supportive living facility in an amount equal to $2.30 | 19 | | multiplied by the supportive living facility's care days. This
| 20 | | assessment shall not be billed or passed on to any resident of | 21 | | a supportive living facility. | 22 | | (b) Nothing in this Section shall be construed to authorize | 23 | | any home rule unit or other unit of local government to license | 24 | | for revenue or impose a tax or assessment upon supportive | 25 | | living facilities or the occupation of operating a supportive |
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| 1 | | living facility, or a tax or assessment measured by the income | 2 | | or earnings or care days of a supportive living facility. | 3 | | (c) The assessment imposed by this Section shall not be due | 4 | | and payable, however, until after the Department notifies the | 5 | | supportive living facilities, in writing, that the payment | 6 | | methodologies to supportive living facilities required under | 7 | | Section 5-5.01a of this Code have been approved by the Centers | 8 | | for Medicare and Medicaid Services of the U.S. Department of | 9 | | Health and Human Services and the waivers under 42 CFR 433.68 | 10 | | for the assessment imposed by this Section, if necessary, have | 11 | | been granted by the Centers for Medicare and Medicaid Services | 12 | | of the U.S. Department of Health and Human Services.
| 13 | | (d) The Department must contest the interpretation of | 14 | | federal regulations on permissible provider taxes made by the | 15 | | Centers for Medicare and Medicaid Services as stated in | 16 | | correspondence dated January 20, 2015. The Department shall | 17 | | submit a report to the General Assembly no later than January | 18 | | 1, 2016 detailing all actions taken to meet the requirement of | 19 | | this 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 | 23 | | determination and enrollment. | 24 | | (a) An expedited long-term care eligibility determination | 25 | | and enrollment system shall be established to reduce long-term |
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| 1 | | care determinations to 90 days or fewer by July 1, 2014 and | 2 | | streamline the long-term care enrollment process. | 3 | | Establishment of the system shall be a joint venture of the | 4 | | Department of Human Services and Healthcare and Family Services | 5 | | and the Department on Aging. The Governor shall name a lead | 6 | | agency no later than 30 days after the effective date of this | 7 | | amendatory Act of the 98th General Assembly to assume | 8 | | responsibility for the full implementation of the | 9 | | establishment and maintenance of the system. Project outcomes | 10 | | shall include an enhanced eligibility determination tracking | 11 | | system accessible to providers and a centralized application | 12 | | review and eligibility determination with all applicants | 13 | | reviewed within 90 days of receipt by the State of a complete | 14 | | application. If the Department of Healthcare and Family | 15 | | Services' Office of the Inspector General determines that there | 16 | | is a likelihood that a non-allowable transfer of assets has | 17 | | occurred, and the facility in which the applicant resides is | 18 | | notified, an extension of up to 90 days shall be permissible. | 19 | | On or before December 31, 2015, a streamlined application and | 20 | | enrollment process shall be put in place based on the following | 21 | | principles: | 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 | 7 | | the feasibility of incorporating all information needed to | 8 | | determine eligibility for long-term care services, including | 9 | | asset transfer and spousal impoverishment financials, into the | 10 | | State's integrated eligibility system identifying all | 11 | | resources needed and reasonable timeframes for achieving the | 12 | | specified integration. | 13 | | (c) The lead agency shall file interim reports with the | 14 | | Chairs and Minority Spokespersons of the House and Senate Human | 15 | | Services Committees no later than September 1, 2013 and on | 16 | | February 1, 2014. The Department of Healthcare and Family | 17 | | Services shall include in the annual Medicaid report for State | 18 | | Fiscal Year 2014 and every fiscal year thereafter information | 19 | | concerning implementation of the provisions of this Section. | 20 | | (d) No later than August 1, 2014, the Auditor General shall | 21 | | report to the General Assembly concerning the extent to which | 22 | | the timeframes specified in this Section have been met and the | 23 | | extent to which State staffing levels are adequate to meet the | 24 | | requirements of this Section.
| 25 | | (e) The Department of Healthcare and Family Services, the | 26 | | Department of Human Services, and the Department on Aging shall |
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| 1 | | take the following steps to achieve federally established | 2 | | timeframes for eligibility determinations for Medicaid and | 3 | | long-term care benefits and shall work toward the federal goal | 4 | | of 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 | 2 | | extent other medical assistance is covered for an individual | 3 | | entitled to temporary coverage under law or court order because | 4 | | the State failed to process the individual's application timely | 5 | | under State and federal law and the individual did not cause | 6 | | the delay. The Department of Healthcare and Family Services | 7 | | shall immediately add the person to the facility's roster for | 8 | | payment and notify the managed care organization of the | 9 | | resident's change in payment status, if the resident is in a | 10 | | managed care organization. If the applicant is subsequently | 11 | | found to be ineligible for long-term care services under the | 12 | | medical assistance program, the Department shall recover all | 13 | | payments made to long-term care providers for services provided | 14 | | to 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 | 18 | | Department of Healthcare and Family Services shall convene a | 19 | | working group in consultation with the Office of the Governor | 20 | | to discuss the development of a revised proposal for the | 21 | | research and demonstration project waiver proposal submitted | 22 | | to the U.S. Department of Health and Human Services on June 4, | 23 | | 2014 under Section 1115 of the Social Security Act. The working | 24 | | group 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 | 9 | | and advice to the Department and the Office of the Governor | 10 | | with regard to the development of the proposal to utilize a | 11 | | research and demonstration waiver. The working group shall meet | 12 | | initially at the call of the Governor and at least once each | 13 | | quarter year thereafter until the waiver either is approved by | 14 | | the U.S. Department of Health and Human Services or expires. | 15 | | The Department shall provide administrative support for the | 16 | | working group. | 17 | | Members shall not be compensated for their participation in | 18 | | the working group but may receive reimbursement for travel | 19 | | expenses. | 20 | | (305 ILCS 5/12-4.50 new) | 21 | | Sec. 12-4.50. Program efficiencies. It is the intent of the | 22 | | General Assembly to improve efficiencies and coordinate care in | 23 | | order to maximize health outcomes and access to care. The | 24 | | Governor's Office shall direct the Department of Healthcare and | 25 | | Family Services, in conjunction with the Department of Human |
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| 1 | | Services, the Department on Aging, and the Department of Public | 2 | | Health, to initiate a review of all case management, care | 3 | | coordination programs, and public health programs for | 4 | | potential duplication of services. Each agency shall provide | 5 | | the Department of Healthcare and Family Services with a copy of | 6 | | its internal review by October 1, 2015. The Department shall | 7 | | provide the Governor and the General Assembly with a report of | 8 | | its findings by January 1, 2016. If duplicative services are | 9 | | identified, the Department of Healthcare and Family Services | 10 | | shall work in conjunction with the agencies providing | 11 | | duplicative services to develop a policy or policies to ensure | 12 | | efficient expenditure of State resources, to be completed by | 13 | | December 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 | 17 | | confirm, an Inspector
General who shall function within the | 18 | | Illinois Department of Public Aid (now Healthcare and Family | 19 | | Services) and
report to the Governor. The term of the Inspector | 20 | | General shall expire on the
third Monday of January, 1997 and | 21 | | every 4 years thereafter.
| 22 | | (b) In order to prevent, detect, and eliminate fraud, | 23 | | waste, abuse,
mismanagement, and misconduct, the Inspector | 24 | | General shall oversee the
Department of Healthcare and Family | 25 | | Services' and the Department on Aging's integrity
functions, |
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| 1 | | which 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, | 22 | | the Inspector
General shall, in relation to any function | 23 | | performed by the Department of Human
Services as successor to | 24 | | the Department of Public Aid, exercise one or more
of the | 25 | | powers provided under this Section as if those powers related | 26 | | to the
Department of Human Services; in such matters, the |
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| 1 | | Inspector General shall
report his or her findings to the | 2 | | Secretary of Human Services.
| 3 | | (c) Notwithstanding, and in addition to, any other
| 4 | | provision of law, the Inspector General shall have access to | 5 | | all information, personnel
and facilities of the
Department of | 6 | | Healthcare and Family Services and the Department of
Human | 7 | | Services (as successor to the Department of Public Aid), their | 8 | | employees, vendors, contractors and medical providers and any | 9 | | federal,
State or local governmental agency that are necessary | 10 | | to perform the duties of
the Office as directly related to | 11 | | public assistance programs administered by
those departments. | 12 | | No medical provider shall
be compelled, however, to provide | 13 | | individual medical records of patients who
are not clients of | 14 | | the programs administered by the Department of Healthcare and
| 15 | | Family Services. State and local
governmental agencies are | 16 | | authorized and directed to provide the requested
information, | 17 | | assistance or cooperation.
| 18 | | For purposes of enhanced program integrity functions and
| 19 | | oversight, and to the extent consistent with applicable
| 20 | | information and privacy, security, and disclosure laws, State
| 21 | | agencies and departments shall provide the Office of Inspector | 22 | | General access to confidential and other information and data, | 23 | | and the Inspector General is authorized to enter into | 24 | | agreements with appropriate federal agencies and departments | 25 | | to secure similar data. This includes, but is not limited to, | 26 | | information pertaining to: licensure; certification; earnings; |
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| 1 | | immigration status; citizenship; wage reporting; unearned and | 2 | | earned income; pension income;
employment; supplemental | 3 | | security income; social security
numbers; National Provider | 4 | | Identifier (NPI) numbers; the
National Practitioner Data Bank | 5 | | (NPDB); program and agency
exclusions; taxpayer identification | 6 | | numbers; tax delinquency;
corporate information; and death | 7 | | records. | 8 | | The Inspector General shall enter into agreements with | 9 | | State agencies and departments, and is authorized to enter into | 10 | | agreements with federal agencies and departments, under which | 11 | | such agencies and departments shall share data necessary for | 12 | | medical assistance program integrity functions and oversight. | 13 | | The Inspector General shall enter into agreements with State | 14 | | agencies and departments, and is authorized to enter into | 15 | | agreements with federal agencies and departments, under which | 16 | | such agencies shall share data necessary for recipient and | 17 | | vendor screening, review, and investigation, including but not | 18 | | limited to vendor payment and recipient eligibility | 19 | | verification. The Inspector General shall develop, in | 20 | | cooperation with other State and federal agencies and | 21 | | departments, and in compliance with applicable federal laws and | 22 | | regulations, appropriate and effective
methods to share such | 23 | | data. The Inspector General shall enter into agreements with | 24 | | State agencies and departments, and is authorized to enter into | 25 | | agreements with federal agencies and departments, including, | 26 | | but not limited to: the Secretary of State; the
Department of |
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| 1 | | Revenue; the Department of Public Health; the
Department of | 2 | | Human Services; and the Department of Financial and | 3 | | Professional Regulation. | 4 | | The Inspector General shall have the authority to deny | 5 | | payment, prevent overpayments, and recover overpayments. | 6 | | The Inspector General shall have the authority to deny or
| 7 | | suspend payment to, and deny, terminate, or suspend the
| 8 | | eligibility of, any vendor who fails to grant the Inspector
| 9 | | General timely access to full and complete records, including | 10 | | records of recipients under the medical assistance program for | 11 | | the most recent 6 years, in accordance with Section 140.28 of | 12 | | Title 89 of the Illinois Administrative Code, and other | 13 | | information for the purpose of audits, investigations, or other | 14 | | program integrity functions, after reasonable written request | 15 | | by the Inspector General. | 16 | | (d) The Inspector General shall serve as the
Department of | 17 | | Healthcare and Family Services'
primary liaison with law | 18 | | enforcement,
investigatory and prosecutorial agencies, | 19 | | including 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 | 11 | | these entities to
share information regarding possible | 12 | | misconduct by any persons or entities
involved with the public | 13 | | aid programs administered by the Department
of Healthcare and | 14 | | Family Services.
| 15 | | (e) All investigations conducted by the Inspector General | 16 | | shall be conducted
in a manner that ensures the preservation of | 17 | | evidence for use in criminal
prosecutions. If the Inspector | 18 | | General determines that a possible criminal act
relating to | 19 | | fraud in the provision or administration of the medical | 20 | | assistance
program has been committed, the Inspector General | 21 | | shall immediately notify the
Medicaid Fraud Control Unit. If | 22 | | the Inspector General determines that a
possible criminal act | 23 | | has been committed within the jurisdiction of the Office,
the | 24 | | Inspector General may request the special expertise of the | 25 | | Department of
State Police. The Inspector General may present | 26 | | for prosecution the findings
of any criminal investigation to |
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| 1 | | the Office of the Attorney General, the
Offices of the several | 2 | | United States Attorneys in Illinois or the several
State's | 3 | | Attorneys.
| 4 | | (f) To carry out his or her duties as described in this | 5 | | Section, the
Inspector General and his or her designees shall | 6 | | have the power to compel
by subpoena the attendance and | 7 | | testimony of witnesses and the production
of books, electronic | 8 | | records and papers as directly related to public
assistance | 9 | | programs administered by the Department of Healthcare and | 10 | | Family Services or
the Department of Human Services (as | 11 | | successor to the Department of Public
Aid). No medical provider | 12 | | shall be compelled, however, to provide individual
medical | 13 | | records of patients who are not clients of the Medical | 14 | | Assistance
Program.
| 15 | | (g) The Inspector General shall report all convictions, | 16 | | terminations, and
suspensions taken against vendors, | 17 | | contractors and medical providers to the
Department of | 18 | | Healthcare and Family Services and to any agency responsible | 19 | | for
licensing or regulating those persons or entities.
| 20 | | (h) The Inspector General shall make annual
reports, | 21 | | findings, and recommendations regarding the Office's | 22 | | investigations
into reports of fraud, waste, abuse, | 23 | | mismanagement, or misconduct relating to
any programs | 24 | | administered by the Department
of Healthcare and Family | 25 | | Services or the Department of Human Services (as successor to | 26 | | the
Department of Public Aid) to the General Assembly and the |
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| 1 | | Governor. These
reports shall include, but not be limited to, | 2 | | the 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 | 19 | | the
Department of Healthcare and Family Services or the | 20 | | Department of Human Services that may
otherwise be required by | 21 | | law or that may be necessary in their capacity as the
central | 22 | | administrative authorities responsible for administration of | 23 | | their agency's
programs in this
State.
| 24 | | (j) The Inspector General may issue shields or other | 25 | | distinctive identification to his or her employees not | 26 | | exercising the powers of a peace officer if the Inspector |
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| 1 | | General determines that a shield or distinctive identification | 2 | | is needed by an employee to carry out his or her | 3 | | responsibilities. | 4 | | (k) The Office of Inspector General must realign its | 5 | | resources toward activities with the greatest potential to | 6 | | reduce or avoid unnecessary, wasteful, or fraudulent | 7 | | expenditures. | 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 | 12 | | Refined Diagnosis Related Groups (APR-DRG) payment system for | 13 | | inpatient services provided on or after July 1, 2013, in a | 14 | | manner consistent with the actions authorized in this Section. | 15 | | (b) On or before October 1, 2012 and through June 30, 2013, | 16 | | the Department shall begin testing the APR-DRG system. During | 17 | | the testing period the Department shall process and price | 18 | | inpatient services using the APR-DRG system; however, actual | 19 | | payments for those inpatient services shall be made using the | 20 | | current reimbursement system. During the testing period, the | 21 | | Department, in collaboration with the statewide representative | 22 | | of hospitals, shall provide information and technical | 23 | | assistance to hospitals to encourage and facilitate their | 24 | | transition to the APR-DRG system. | 25 | | (c) The Department may, by rule, implement the Enhanced |
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| 1 | | Ambulatory Procedure Grouping (EAPG) system for outpatient | 2 | | services provided on or after January 1, 2014, in a manner | 3 | | consistent with the actions authorized in this Section. On or | 4 | | before January 1, 2013 and through December 31, 2013, the | 5 | | Department shall begin testing the EAPG system. During the | 6 | | testing period the Department shall process and price | 7 | | outpatient services using the EAPG system; however, actual | 8 | | payments for those outpatient services shall be made using the | 9 | | current reimbursement system. During the testing period, the | 10 | | Department, in collaboration with the statewide representative | 11 | | of hospitals, shall provide information and technical | 12 | | assistance to hospitals to encourage and facilitate their | 13 | | transition to the EAPG system. | 14 | | (d) The Department in consultation with the current | 15 | | hospital technical advisory group shall review the test claims | 16 | | for inpatient and outpatient services at least monthly, | 17 | | including the estimated impact on hospitals, and, in developing | 18 | | the rules, policies, and procedures to implement the new | 19 | | payment 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 | 21 | | representing the majority of hospitals in Illinois, as the | 22 | | statewide representative of the hospital community, with a | 23 | | monthly file of claims adjudicated under the test system for | 24 | | the purpose of review and analysis as part of the collaboration | 25 | | between the State and the hospital community. The file shall | 26 | | consist of a de-identified extract compliant with the Health |
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| 1 | | Insurance Portability and Accountability Act (HIPAA). | 2 | | (f) The current hospital technical advisory group shall | 3 | | make recommendations for changes during the testing period and | 4 | | recommendations for changes prior to the effective dates of the | 5 | | new payment systems. The Department shall draft administrative | 6 | | rules to implement the new payment systems and provide them to | 7 | | the technical advisory group at least 90 days prior to the | 8 | | proposed effective dates of the new payment systems. | 9 | | (g) The payments to hospitals financed by the current | 10 | | hospital assessment, authorized under Article V-A of this Code, | 11 | | are scheduled to sunset on June 30, 2014. The continuation of | 12 | | or revisions to the hospital assessment program shall take into | 13 | | consideration the impact on hospitals and access to care as a | 14 | | result of the changes to the hospital payment system. | 15 | | (h) Beginning July 1, 2014, the Department may transition | 16 | | current General Revenue funded supplemental payments into the | 17 | | claims based system over a period of no less than 2 years from | 18 | | the implementation date of the new payment systems and no more | 19 | | than 4 years from the implementation date of the new payment | 20 | | systems, provided however that the Department may adopt, by | 21 | | rule, supplemental payments to help ensure access to care in a | 22 | | geographic area or to help ensure access to specialty services. | 23 | | For any supplemental payments that are adopted that are based | 24 | | on historic data, the data shall be no older than 3 years and | 25 | | the supplemental payment shall be effective for no longer than | 26 | | 2 years before requiring the data to be updated. |
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| 1 | | (i) Any payments authorized under 89 Illinois | 2 | | Administrative Code 148 set to expire in State fiscal year 2012 | 3 | | and that were paid out to hospitals in State fiscal year 2012 | 4 | | or any payments authorized under 89 Illinois Administrative | 5 | | Code 148.299(b)(1)(A) and initially paid out to hospitals in | 6 | | State fiscal year 2015, shall remain in effect as long as the | 7 | | assessment imposed by Section 5A-2 is in effect. | 8 | | (j) Subsections (a) and (c) of this Section shall remain | 9 | | operative unless the Auditor General has reported that: (i) the | 10 | | Department has not undertaken the required actions listed in | 11 | | the report required by subsection (a) of Section 2-20 of the | 12 | | Illinois State Auditing Act; or (ii) the Department has failed | 13 | | to comply with the reporting requirements of Section 2-20 of | 14 | | the Illinois State Auditing Act. | 15 | | (k) Subsections (a) and (c) of this Section shall not be | 16 | | operative until final federal approval by the Centers for | 17 | | Medicare and Medicaid Services of the U.S. Department of Health | 18 | | and Human Services and implementation of all of the payments | 19 | | and assessments in Article V-A in its form as of the effective | 20 | | date of this amendatory Act of the 97th General Assembly or as | 21 | | it may be amended.
| 22 | | (Source: P.A. 97-689, eff. 6-14-12.)
| 23 | | Section 99. Effective date. This Act takes effect upon | 24 | | becoming law.".
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