Bill Text: IL SB1321 | 2019-2020 | 101st General Assembly | Enrolled


Bill Title: Amends the Illinois Public Aid Code. Requires the Department of Human Services to promote the availability of the Child Care Assistance Program. Provides that the target audience for the Department's promotion efforts must include all families with children under age 13, families eligible for child care assistance, and child care providers. Requires the Department to adopt any rules necessary to implement the provision.

Spectrum: Moderate Partisan Bill (Democrat 19-5)

Status: (Enrolled) 2019-06-06 - Sent to the Governor [SB1321 Detail]

Download: Illinois-2019-SB1321-Enrolled.html



SB1321 EnrolledLRB101 10606 KTG 55712 b
1 AN ACT concerning public aid.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The Department of Healthcare and Family Services
5Law of the Civil Administrative Code of Illinois is amended by
6changing Section 2205-30 as follows:
7 (20 ILCS 2205/2205-30)
8 (Section scheduled to be repealed on December 1, 2020)
9 Sec. 2205-30. Long-term care services and supports
10comprehensive study and actuarial modeling.
11 (a) The Department of Healthcare and Family Services shall
12commission a comprehensive study of long-term care trends,
13future projections, and actuarial analysis of a new long-term
14services and supports benefit. Upon completion of the study,
15the Department shall prepare a report on the study that
16includes the following:
17 (1) an extensive analysis of long-term care trends in
18 Illinois, including the number of Illinoisans needing
19 long-term care, the number of paid and unpaid caregivers,
20 the existing long-term care programs' utilization and
21 impact on the State budget; out-of-pocket spending and
22 spend-down to qualify for medical assistance coverage, the
23 financial and health impacts of caregiving on the family,

SB1321 Enrolled- 2 -LRB101 10606 KTG 55712 b
1 wages of paid caregivers and the effects of compensation on
2 the availability of this workforce, the current market for
3 private long-term care insurance, and a brief assessment of
4 the existing system of long-term services and supports in
5 terms of health, well-being, and the ability of
6 participants to continue living in their communities;
7 (2) an analysis of long-term care costs and utilization
8 projections through at least 2050 and the estimated impact
9 of such costs and utilization projections on the State
10 budget, increases in the senior population; projections of
11 the number of paid and unpaid caregivers in relation to
12 demand for services, and projections of the impact of
13 housing cost burdens and a lack of affordable housing on
14 seniors and people with disabilities;
15 (3) an actuarial analysis of options for a new
16 long-term services and supports benefit program, including
17 an analysis of potential tax sources and necessary levels,
18 a vesting period, the maximum daily benefit dollar amount,
19 the total maximum dollar amount of the benefit, and the
20 duration of the benefit; and
21 (4) a qualitative analysis of a new benefit's impact on
22 seniors and people with disabilities, including their
23 families and caregivers, public and private long-term care
24 services, and the State budget.
25 The report must project under multiple possible
26configurations the numbers of persons covered year over year,

SB1321 Enrolled- 3 -LRB101 10606 KTG 55712 b
1utilization rates, total spending, and the benefit fund's ratio
2balance and solvency. The benefit fund must initially be
3structured to be solvent for 75 years. The report must detail
4the sensitivity of these projections to the level of care
5criteria that define long-term care need and examine the
6feasibility of setting a lower threshold, based on a lower need
7for ongoing assistance in routine life activities.
8 The report must also detail the amount of out-of-pocket
9costs avoided, the number of persons who delayed or avoided
10utilization of medical assistance benefits, an analysis on the
11projected increased utilization of home-based and
12community-based services over skilled nursing facilities and
13savings therewith, and savings to the State's existing
14long-term care programs due to the new long-term services and
15supports benefit.
16 (b) The entity chosen to conduct the actuarial analysis
17shall be a nationally-recognized organization with experience
18modeling public and private long-term care financing programs.
19 (c) The study shall begin after January 1, 2019, and be
20completed before December 1, 2020 2019. Upon completion, the
21report on the study shall be filed with the Clerk of the House
22of Representatives and the Secretary of the Senate in
23electronic form only, in the manner that the Clerk and the
24Secretary shall direct.
25 (d) This Section is repealed December 1, 2020.
26(Source: P.A. 100-587, eff. 6-4-18.)

SB1321 Enrolled- 4 -LRB101 10606 KTG 55712 b
1 Section 10. The Illinois Procurement Code is amended by
2adding Section 20-25.1 as follows:
3 (30 ILCS 500/20-25.1 new)
4 Sec. 20-25.1. Special expedited procurement.
5 (a) The Chief Procurement Officer shall work with the
6Department of Healthcare and Family Services to identify an
7appropriate method of source selection that will result in an
8executed contract for the technology required by Section
95-30.12 of the Illinois Public Aid Code no later than August 1,
102019 in order to target implementation of the technology to be
11procured by January 1, 2020. The method of source selection may
12be sole source, emergency, or other expedited process.
13 (b) Due to the negative impact on access to critical State
14health care services and the ability to draw federal match for
15services being reimbursed caused by issues with implementation
16of the Integrated Eligibility System by the Department of Human
17Services, the Department of Healthcare and Family Services, and
18the Department of Innovation and Technology, the General
19Assembly finds that a threat to public health exists and to
20prevent or minimize serious disruption in critical State
21services that affect health, an emergency purchase of a vendor
22shall be made by the Department of Healthcare and Family
23Services to assess the Integrated Eligibility System for
24critical gaps and processing errors and to monitor the

SB1321 Enrolled- 5 -LRB101 10606 KTG 55712 b
1performance of the Integrated Eligibility System vendor under
2the terms of its contract. The emergency purchase shall not
3exceed 2 years. Notwithstanding any other provision of this
4Code, such emergency purchase shall extend without a hearing
5required by Section 20-30 until the integrated eligibility
6system is stabilized and performing according to the needs of
7the State to ensure continued access to health care for
8eligible individuals.
9 Section 30. The Children's Health Insurance Program Act is
10amended by changing Section 7 as follows:
11 (215 ILCS 106/7)
12 Sec. 7. Eligibility verification. Notwithstanding any
13other provision of this Act, with respect to applications for
14benefits provided under the Program, eligibility shall be
15determined in a manner that ensures program integrity and that
16complies with federal law and regulations while minimizing
17unnecessary barriers to enrollment. To this end, as soon as
18practicable, and unless the Department receives written denial
19from the federal government, this Section shall be implemented:
20 (a) The Department of Healthcare and Family Services or its
21designees shall:
22 (1) By no later than July 1, 2011, require verification
23 of, at a minimum, one month's income from all sources
24 required for determining the eligibility of applicants to

SB1321 Enrolled- 6 -LRB101 10606 KTG 55712 b
1 the Program. Such verification shall take the form of pay
2 stubs, business or income and expense records for
3 self-employed persons, letters from employers, and any
4 other valid documentation of income including data
5 obtained electronically by the Department or its designees
6 from other sources as described in subsection (b) of this
7 Section.
8 (2) By no later than October 1, 2011, require
9 verification of, at a minimum, one month's income from all
10 sources required for determining the continued eligibility
11 of recipients at their annual review of eligibility under
12 the Program. Such verification shall take the form of pay
13 stubs, business or income and expense records for
14 self-employed persons, letters from employers, and any
15 other valid documentation of income including data
16 obtained electronically by the Department or its designees
17 from other sources as described in subsection (b) of this
18 Section. A month's income may be verified by a single pay
19 stub with the monthly income extrapolated from the time
20 period covered by the pay stub. The Department shall send a
21 notice to the recipient at least 60 days prior to the end
22 of the period of eligibility that informs them of the
23 requirements for continued eligibility. Information the
24 Department receives prior to the annual review, including
25 information available to the Department as a result of the
26 recipient's application for other non-health care

SB1321 Enrolled- 7 -LRB101 10606 KTG 55712 b
1 benefits, that is sufficient to make a determination of
2 continued eligibility for medical assistance or for
3 benefits provided under the Program may be reviewed and
4 verified, and subsequent action taken including client
5 notification of continued eligibility for medical
6 assistance or for benefits provided under the Program. The
7 date of client notification establishes the date for
8 subsequent annual eligibility reviews. If a recipient does
9 not fulfill the requirements for continued eligibility by
10 the deadline established in the notice, a notice of
11 cancellation shall be issued to the recipient and coverage
12 shall end no later than the last day of the month following
13 on the last day of the eligibility period. A recipient's
14 eligibility may be reinstated without requiring a new
15 application if the recipient fulfills the requirements for
16 continued eligibility prior to the end of the third month
17 following the last date of coverage (or longer period if
18 required by federal regulations). Nothing in this Section
19 shall prevent an individual whose coverage has been
20 cancelled from reapplying for health benefits at any time.
21 (3) By no later than July 1, 2011, require verification
22 of Illinois residency.
23 (b) The Department shall establish or continue cooperative
24arrangements with the Social Security Administration, the
25Illinois Secretary of State, the Department of Human Services,
26the Department of Revenue, the Department of Employment

SB1321 Enrolled- 8 -LRB101 10606 KTG 55712 b
1Security, and any other appropriate entity to gain electronic
2access, to the extent allowed by law, to information available
3to those entities that may be appropriate for electronically
4verifying any factor of eligibility for benefits under the
5Program. Data relevant to eligibility shall be provided for no
6other purpose than to verify the eligibility of new applicants
7or current recipients of health benefits under the Program.
8Data will be requested or provided for any new applicant or
9current recipient only insofar as that individual's
10circumstances are relevant to that individual's or another
11individual's eligibility.
12 (c) Within 90 days of the effective date of this amendatory
13Act of the 96th General Assembly, the Department of Healthcare
14and Family Services shall send notice to current recipients
15informing them of the changes regarding their eligibility
16verification.
17(Source: P.A. 98-651, eff. 6-16-14.)
18 Section 35. The Covering ALL KIDS Health Insurance Act is
19amended by changing Section 7 as follows:
20 (215 ILCS 170/7)
21 (Section scheduled to be repealed on October 1, 2019)
22 Sec. 7. Eligibility verification. Notwithstanding any
23other provision of this Act, with respect to applications for
24benefits provided under the Program, eligibility shall be

SB1321 Enrolled- 9 -LRB101 10606 KTG 55712 b
1determined in a manner that ensures program integrity and that
2complies with federal law and regulations while minimizing
3unnecessary barriers to enrollment. To this end, as soon as
4practicable, and unless the Department receives written denial
5from the federal government, this Section shall be implemented:
6 (a) The Department of Healthcare and Family Services or its
7designees shall:
8 (1) By July 1, 2011, require verification of, at a
9 minimum, one month's income from all sources required for
10 determining the eligibility of applicants to the Program.
11 Such verification shall take the form of pay stubs,
12 business or income and expense records for self-employed
13 persons, letters from employers, and any other valid
14 documentation of income including data obtained
15 electronically by the Department or its designees from
16 other sources as described in subsection (b) of this
17 Section.
18 (2) By October 1, 2011, require verification of, at a
19 minimum, one month's income from all sources required for
20 determining the continued eligibility of recipients at
21 their annual review of eligibility under the Program. Such
22 verification shall take the form of pay stubs, business or
23 income and expense records for self-employed persons,
24 letters from employers, and any other valid documentation
25 of income including data obtained electronically by the
26 Department or its designees from other sources as described

SB1321 Enrolled- 10 -LRB101 10606 KTG 55712 b
1 in subsection (b) of this Section. A month's income may be
2 verified by a single pay stub with the monthly income
3 extrapolated from the time period covered by the pay stub.
4 The Department shall send a notice to recipients at least
5 60 days prior to the end of their period of eligibility
6 that informs them of the requirements for continued
7 eligibility. Information the Department receives prior to
8 the annual review, including information available to the
9 Department as a result of the recipient's application for
10 other non-health care benefits, that is sufficient to make
11 a determination of continued eligibility for benefits
12 provided under this Act, the Children's Health Insurance
13 Program Act, or Article V of the Illinois Public Aid Code
14 may be reviewed and verified, and subsequent action taken
15 including client notification of continued eligibility for
16 benefits provided under this Act, the Children's Health
17 Insurance Program Act, or Article V of the Illinois Public
18 Aid Code. The date of client notification establishes the
19 date for subsequent annual eligibility reviews. If a
20 recipient does not fulfill the requirements for continued
21 eligibility by the deadline established in the notice, a
22 notice of cancellation shall be issued to the recipient and
23 coverage shall end no later than the last day of the month
24 following on the last day of the eligibility period. A
25 recipient's eligibility may be reinstated without
26 requiring a new application if the recipient fulfills the

SB1321 Enrolled- 11 -LRB101 10606 KTG 55712 b
1 requirements for continued eligibility prior to the end of
2 the third month following the last date of coverage (or
3 longer period if required by federal regulations). Nothing
4 in this Section shall prevent an individual whose coverage
5 has been cancelled from reapplying for health benefits at
6 any time.
7 (3) By July 1, 2011, require verification of Illinois
8 residency.
9 (b) The Department shall establish or continue cooperative
10arrangements with the Social Security Administration, the
11Illinois Secretary of State, the Department of Human Services,
12the Department of Revenue, the Department of Employment
13Security, and any other appropriate entity to gain electronic
14access, to the extent allowed by law, to information available
15to those entities that may be appropriate for electronically
16verifying any factor of eligibility for benefits under the
17Program. Data relevant to eligibility shall be provided for no
18other purpose than to verify the eligibility of new applicants
19or current recipients of health benefits under the Program.
20Data will be requested or provided for any new applicant or
21current recipient only insofar as that individual's
22circumstances are relevant to that individual's or another
23individual's eligibility.
24 (c) Within 90 days of the effective date of this amendatory
25Act of the 96th General Assembly, the Department of Healthcare
26and Family Services shall send notice to current recipients

SB1321 Enrolled- 12 -LRB101 10606 KTG 55712 b
1informing them of the changes regarding their eligibility
2verification.
3(Source: P.A. 98-651, eff. 6-16-14.)
4 Section 40. The Illinois Public Aid Code is amended by
5changing Sections 5-4.1, 5-5, 5-5f, 5-30.1, 5A-4, 11-5.1,
611-5.3, 11-5.4, and 12-4.42 and by adding Sections 5-5.10,
75-30.11, 5-30.12, and 14-13 as follows:
8 (305 ILCS 5/5-4.1) (from Ch. 23, par. 5-4.1)
9 Sec. 5-4.1. Co-payments. The Department may by rule provide
10that recipients under any Article of this Code shall pay a
11federally approved fee as a co-payment for services. No provide
12that recipients under any Article of this Code shall pay a fee
13as a co-payment for services. Co-payments shall be maximized to
14the extent permitted by federal law, except that the Department
15shall impose a co-pay of $2 on generic drugs. Provided,
16however, that any such rule must provide that no co-payment
17requirement can exist for renal dialysis, radiation therapy,
18cancer chemotherapy, or insulin, and other products necessary
19on a recurring basis, the absence of which would be life
20threatening, or where co-payment expenditures for required
21services and/or medications for chronic diseases that the
22Illinois Department shall by rule designate shall cause an
23extensive financial burden on the recipient, and provided no
24co-payment shall exist for emergency room encounters which are

SB1321 Enrolled- 13 -LRB101 10606 KTG 55712 b
1for medical emergencies. The Department shall seek approval of
2a State plan amendment that allows pharmacies to refuse to
3dispense drugs in circumstances where the recipient does not
4pay the required co-payment. Co-payments may not exceed $10 for
5emergency room use for a non-emergency situation as defined by
6the Department by rule and subject to federal approval.
7(Source: P.A. 96-1501, eff. 1-25-11; 97-74, eff. 6-30-11;
897-689, eff. 6-14-12.)
9 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
10 Sec. 5-5. Medical services. The Illinois Department, by
11rule, shall determine the quantity and quality of and the rate
12of reimbursement for the medical assistance for which payment
13will be authorized, and the medical services to be provided,
14which may include all or part of the following: (1) inpatient
15hospital services; (2) outpatient hospital services; (3) other
16laboratory and X-ray services; (4) skilled nursing home
17services; (5) physicians' services whether furnished in the
18office, the patient's home, a hospital, a skilled nursing home,
19or elsewhere; (6) medical care, or any other type of remedial
20care furnished by licensed practitioners; (7) home health care
21services; (8) private duty nursing service; (9) clinic
22services; (10) dental services, including prevention and
23treatment of periodontal disease and dental caries disease for
24pregnant women, provided by an individual licensed to practice
25dentistry or dental surgery; for purposes of this item (10),

SB1321 Enrolled- 14 -LRB101 10606 KTG 55712 b
1"dental services" means diagnostic, preventive, or corrective
2procedures provided by or under the supervision of a dentist in
3the practice of his or her profession; (11) physical therapy
4and related services; (12) prescribed drugs, dentures, and
5prosthetic devices; and eyeglasses prescribed by a physician
6skilled in the diseases of the eye, or by an optometrist,
7whichever the person may select; (13) other diagnostic,
8screening, preventive, and rehabilitative services, including
9to ensure that the individual's need for intervention or
10treatment of mental disorders or substance use disorders or
11co-occurring mental health and substance use disorders is
12determined using a uniform screening, assessment, and
13evaluation process inclusive of criteria, for children and
14adults; for purposes of this item (13), a uniform screening,
15assessment, and evaluation process refers to a process that
16includes an appropriate evaluation and, as warranted, a
17referral; "uniform" does not mean the use of a singular
18instrument, tool, or process that all must utilize; (14)
19transportation and such other expenses as may be necessary;
20(15) medical treatment of sexual assault survivors, as defined
21in Section 1a of the Sexual Assault Survivors Emergency
22Treatment Act, for injuries sustained as a result of the sexual
23assault, including examinations and laboratory tests to
24discover evidence which may be used in criminal proceedings
25arising from the sexual assault; (16) the diagnosis and
26treatment of sickle cell anemia; and (17) any other medical

SB1321 Enrolled- 15 -LRB101 10606 KTG 55712 b
1care, and any other type of remedial care recognized under the
2laws of this State. The term "any other type of remedial care"
3shall include nursing care and nursing home service for persons
4who rely on treatment by spiritual means alone through prayer
5for healing.
6 Notwithstanding any other provision of this Section, a
7comprehensive tobacco use cessation program that includes
8purchasing prescription drugs or prescription medical devices
9approved by the Food and Drug Administration shall be covered
10under the medical assistance program under this Article for
11persons who are otherwise eligible for assistance under this
12Article.
13 Notwithstanding any other provision of this Code,
14reproductive health care that is otherwise legal in Illinois
15shall be covered under the medical assistance program for
16persons who are otherwise eligible for medical assistance under
17this Article.
18 Notwithstanding any other provision of this Code, the
19Illinois Department may not require, as a condition of payment
20for any laboratory test authorized under this Article, that a
21physician's handwritten signature appear on the laboratory
22test order form. The Illinois Department may, however, impose
23other appropriate requirements regarding laboratory test order
24documentation.
25 Upon receipt of federal approval of an amendment to the
26Illinois Title XIX State Plan for this purpose, the Department

SB1321 Enrolled- 16 -LRB101 10606 KTG 55712 b
1shall authorize the Chicago Public Schools (CPS) to procure a
2vendor or vendors to manufacture eyeglasses for individuals
3enrolled in a school within the CPS system. CPS shall ensure
4that its vendor or vendors are enrolled as providers in the
5medical assistance program and in any capitated Medicaid
6managed care entity (MCE) serving individuals enrolled in a
7school within the CPS system. Under any contract procured under
8this provision, the vendor or vendors must serve only
9individuals enrolled in a school within the CPS system. Claims
10for services provided by CPS's vendor or vendors to recipients
11of benefits in the medical assistance program under this Code,
12the Children's Health Insurance Program, or the Covering ALL
13KIDS Health Insurance Program shall be submitted to the
14Department or the MCE in which the individual is enrolled for
15payment and shall be reimbursed at the Department's or the
16MCE's established rates or rate methodologies for eyeglasses.
17 On and after July 1, 2012, the Department of Healthcare and
18Family Services may provide the following services to persons
19eligible for assistance under this Article who are
20participating in education, training or employment programs
21operated by the Department of Human Services as successor to
22the Department of Public Aid:
23 (1) dental services provided by or under the
24 supervision of a dentist; and
25 (2) eyeglasses prescribed by a physician skilled in the
26 diseases of the eye, or by an optometrist, whichever the

SB1321 Enrolled- 17 -LRB101 10606 KTG 55712 b
1 person may select.
2 On and after July 1, 2018, the Department of Healthcare and
3Family Services shall provide dental services to any adult who
4is otherwise eligible for assistance under the medical
5assistance program. As used in this paragraph, "dental
6services" means diagnostic, preventative, restorative, or
7corrective procedures, including procedures and services for
8the prevention and treatment of periodontal disease and dental
9caries disease, provided by an individual who is licensed to
10practice dentistry or dental surgery or who is under the
11supervision of a dentist in the practice of his or her
12profession.
13 On and after July 1, 2018, targeted dental services, as set
14forth in Exhibit D of the Consent Decree entered by the United
15States District Court for the Northern District of Illinois,
16Eastern Division, in the matter of Memisovski v. Maram, Case
17No. 92 C 1982, that are provided to adults under the medical
18assistance program shall be established at no less than the
19rates set forth in the "New Rate" column in Exhibit D of the
20Consent Decree for targeted dental services that are provided
21to persons under the age of 18 under the medical assistance
22program.
23 Notwithstanding any other provision of this Code and
24subject to federal approval, the Department may adopt rules to
25allow a dentist who is volunteering his or her service at no
26cost to render dental services through an enrolled

SB1321 Enrolled- 18 -LRB101 10606 KTG 55712 b
1not-for-profit health clinic without the dentist personally
2enrolling as a participating provider in the medical assistance
3program. A not-for-profit health clinic shall include a public
4health clinic or Federally Qualified Health Center or other
5enrolled provider, as determined by the Department, through
6which dental services covered under this Section are performed.
7The Department shall establish a process for payment of claims
8for reimbursement for covered dental services rendered under
9this provision.
10 The Illinois Department, by rule, may distinguish and
11classify the medical services to be provided only in accordance
12with the classes of persons designated in Section 5-2.
13 The Department of Healthcare and Family Services must
14provide coverage and reimbursement for amino acid-based
15elemental formulas, regardless of delivery method, for the
16diagnosis and treatment of (i) eosinophilic disorders and (ii)
17short bowel syndrome when the prescribing physician has issued
18a written order stating that the amino acid-based elemental
19formula is medically necessary.
20 The Illinois Department shall authorize the provision of,
21and shall authorize payment for, screening by low-dose
22mammography for the presence of occult breast cancer for women
2335 years of age or older who are eligible for medical
24assistance under this Article, as follows:
25 (A) A baseline mammogram for women 35 to 39 years of
26 age.

SB1321 Enrolled- 19 -LRB101 10606 KTG 55712 b
1 (B) An annual mammogram for women 40 years of age or
2 older.
3 (C) A mammogram at the age and intervals considered
4 medically necessary by the woman's health care provider for
5 women under 40 years of age and having a family history of
6 breast cancer, prior personal history of breast cancer,
7 positive genetic testing, or other risk factors.
8 (D) A comprehensive ultrasound screening and MRI of an
9 entire breast or breasts if a mammogram demonstrates
10 heterogeneous or dense breast tissue, when medically
11 necessary as determined by a physician licensed to practice
12 medicine in all of its branches.
13 (E) A screening MRI when medically necessary, as
14 determined by a physician licensed to practice medicine in
15 all of its branches.
16 All screenings shall include a physical breast exam,
17instruction on self-examination and information regarding the
18frequency of self-examination and its value as a preventative
19tool. For purposes of this Section, "low-dose mammography"
20means the x-ray examination of the breast using equipment
21dedicated specifically for mammography, including the x-ray
22tube, filter, compression device, and image receptor, with an
23average radiation exposure delivery of less than one rad per
24breast for 2 views of an average size breast. The term also
25includes digital mammography and includes breast
26tomosynthesis. As used in this Section, the term "breast

SB1321 Enrolled- 20 -LRB101 10606 KTG 55712 b
1tomosynthesis" means a radiologic procedure that involves the
2acquisition of projection images over the stationary breast to
3produce cross-sectional digital three-dimensional images of
4the breast. If, at any time, the Secretary of the United States
5Department of Health and Human Services, or its successor
6agency, promulgates rules or regulations to be published in the
7Federal Register or publishes a comment in the Federal Register
8or issues an opinion, guidance, or other action that would
9require the State, pursuant to any provision of the Patient
10Protection and Affordable Care Act (Public Law 111-148),
11including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
12successor provision, to defray the cost of any coverage for
13breast tomosynthesis outlined in this paragraph, then the
14requirement that an insurer cover breast tomosynthesis is
15inoperative other than any such coverage authorized under
16Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
17the State shall not assume any obligation for the cost of
18coverage for breast tomosynthesis set forth in this paragraph.
19 On and after January 1, 2016, the Department shall ensure
20that all networks of care for adult clients of the Department
21include access to at least one breast imaging Center of Imaging
22Excellence as certified by the American College of Radiology.
23 On and after January 1, 2012, providers participating in a
24quality improvement program approved by the Department shall be
25reimbursed for screening and diagnostic mammography at the same
26rate as the Medicare program's rates, including the increased

SB1321 Enrolled- 21 -LRB101 10606 KTG 55712 b
1reimbursement for digital mammography.
2 The Department shall convene an expert panel including
3representatives of hospitals, free-standing mammography
4facilities, and doctors, including radiologists, to establish
5quality standards for mammography.
6 On and after January 1, 2017, providers participating in a
7breast cancer treatment quality improvement program approved
8by the Department shall be reimbursed for breast cancer
9treatment at a rate that is no lower than 95% of the Medicare
10program's rates for the data elements included in the breast
11cancer treatment quality program.
12 The Department shall convene an expert panel, including
13representatives of hospitals, free-standing breast cancer
14treatment centers, breast cancer quality organizations, and
15doctors, including breast surgeons, reconstructive breast
16surgeons, oncologists, and primary care providers to establish
17quality standards for breast cancer treatment.
18 Subject to federal approval, the Department shall
19establish a rate methodology for mammography at federally
20qualified health centers and other encounter-rate clinics.
21These clinics or centers may also collaborate with other
22hospital-based mammography facilities. By January 1, 2016, the
23Department shall report to the General Assembly on the status
24of the provision set forth in this paragraph.
25 The Department shall establish a methodology to remind
26women who are age-appropriate for screening mammography, but

SB1321 Enrolled- 22 -LRB101 10606 KTG 55712 b
1who have not received a mammogram within the previous 18
2months, of the importance and benefit of screening mammography.
3The Department shall work with experts in breast cancer
4outreach and patient navigation to optimize these reminders and
5shall establish a methodology for evaluating their
6effectiveness and modifying the methodology based on the
7evaluation.
8 The Department shall establish a performance goal for
9primary care providers with respect to their female patients
10over age 40 receiving an annual mammogram. This performance
11goal shall be used to provide additional reimbursement in the
12form of a quality performance bonus to primary care providers
13who meet that goal.
14 The Department shall devise a means of case-managing or
15patient navigation for beneficiaries diagnosed with breast
16cancer. This program shall initially operate as a pilot program
17in areas of the State with the highest incidence of mortality
18related to breast cancer. At least one pilot program site shall
19be in the metropolitan Chicago area and at least one site shall
20be outside the metropolitan Chicago area. On or after July 1,
212016, the pilot program shall be expanded to include one site
22in western Illinois, one site in southern Illinois, one site in
23central Illinois, and 4 sites within metropolitan Chicago. An
24evaluation of the pilot program shall be carried out measuring
25health outcomes and cost of care for those served by the pilot
26program compared to similarly situated patients who are not

SB1321 Enrolled- 23 -LRB101 10606 KTG 55712 b
1served by the pilot program.
2 The Department shall require all networks of care to
3develop a means either internally or by contract with experts
4in navigation and community outreach to navigate cancer
5patients to comprehensive care in a timely fashion. The
6Department shall require all networks of care to include access
7for patients diagnosed with cancer to at least one academic
8commission on cancer-accredited cancer program as an
9in-network covered benefit.
10 Any medical or health care provider shall immediately
11recommend, to any pregnant woman who is being provided prenatal
12services and is suspected of having a substance use disorder as
13defined in the Substance Use Disorder Act, referral to a local
14substance use disorder treatment program licensed by the
15Department of Human Services or to a licensed hospital which
16provides substance abuse treatment services. The Department of
17Healthcare and Family Services shall assure coverage for the
18cost of treatment of the drug abuse or addiction for pregnant
19recipients in accordance with the Illinois Medicaid Program in
20conjunction with the Department of Human Services.
21 All medical providers providing medical assistance to
22pregnant women under this Code shall receive information from
23the Department on the availability of services under any
24program providing case management services for addicted women,
25including information on appropriate referrals for other
26social services that may be needed by addicted women in

SB1321 Enrolled- 24 -LRB101 10606 KTG 55712 b
1addition to treatment for addiction.
2 The Illinois Department, in cooperation with the
3Departments of Human Services (as successor to the Department
4of Alcoholism and Substance Abuse) and Public Health, through a
5public awareness campaign, may provide information concerning
6treatment for alcoholism and drug abuse and addiction, prenatal
7health care, and other pertinent programs directed at reducing
8the number of drug-affected infants born to recipients of
9medical assistance.
10 Neither the Department of Healthcare and Family Services
11nor the Department of Human Services shall sanction the
12recipient solely on the basis of her substance abuse.
13 The Illinois Department shall establish such regulations
14governing the dispensing of health services under this Article
15as it shall deem appropriate. The Department should seek the
16advice of formal professional advisory committees appointed by
17the Director of the Illinois Department for the purpose of
18providing regular advice on policy and administrative matters,
19information dissemination and educational activities for
20medical and health care providers, and consistency in
21procedures to the Illinois Department.
22 The Illinois Department may develop and contract with
23Partnerships of medical providers to arrange medical services
24for persons eligible under Section 5-2 of this Code.
25Implementation of this Section may be by demonstration projects
26in certain geographic areas. The Partnership shall be

SB1321 Enrolled- 25 -LRB101 10606 KTG 55712 b
1represented by a sponsor organization. The Department, by rule,
2shall develop qualifications for sponsors of Partnerships.
3Nothing in this Section shall be construed to require that the
4sponsor organization be a medical organization.
5 The sponsor must negotiate formal written contracts with
6medical providers for physician services, inpatient and
7outpatient hospital care, home health services, treatment for
8alcoholism and substance abuse, and other services determined
9necessary by the Illinois Department by rule for delivery by
10Partnerships. Physician services must include prenatal and
11obstetrical care. The Illinois Department shall reimburse
12medical services delivered by Partnership providers to clients
13in target areas according to provisions of this Article and the
14Illinois Health Finance Reform Act, except that:
15 (1) Physicians participating in a Partnership and
16 providing certain services, which shall be determined by
17 the Illinois Department, to persons in areas covered by the
18 Partnership may receive an additional surcharge for such
19 services.
20 (2) The Department may elect to consider and negotiate
21 financial incentives to encourage the development of
22 Partnerships and the efficient delivery of medical care.
23 (3) Persons receiving medical services through
24 Partnerships may receive medical and case management
25 services above the level usually offered through the
26 medical assistance program.

SB1321 Enrolled- 26 -LRB101 10606 KTG 55712 b
1 Medical providers shall be required to meet certain
2qualifications to participate in Partnerships to ensure the
3delivery of high quality medical services. These
4qualifications shall be determined by rule of the Illinois
5Department and may be higher than qualifications for
6participation in the medical assistance program. Partnership
7sponsors may prescribe reasonable additional qualifications
8for participation by medical providers, only with the prior
9written approval of the Illinois Department.
10 Nothing in this Section shall limit the free choice of
11practitioners, hospitals, and other providers of medical
12services by clients. In order to ensure patient freedom of
13choice, the Illinois Department shall immediately promulgate
14all rules and take all other necessary actions so that provided
15services may be accessed from therapeutically certified
16optometrists to the full extent of the Illinois Optometric
17Practice Act of 1987 without discriminating between service
18providers.
19 The Department shall apply for a waiver from the United
20States Health Care Financing Administration to allow for the
21implementation of Partnerships under this Section.
22 The Illinois Department shall require health care
23providers to maintain records that document the medical care
24and services provided to recipients of Medical Assistance under
25this Article. Such records must be retained for a period of not
26less than 6 years from the date of service or as provided by

SB1321 Enrolled- 27 -LRB101 10606 KTG 55712 b
1applicable State law, whichever period is longer, except that
2if an audit is initiated within the required retention period
3then the records must be retained until the audit is completed
4and every exception is resolved. The Illinois Department shall
5require health care providers to make available, when
6authorized by the patient, in writing, the medical records in a
7timely fashion to other health care providers who are treating
8or serving persons eligible for Medical Assistance under this
9Article. All dispensers of medical services shall be required
10to maintain and retain business and professional records
11sufficient to fully and accurately document the nature, scope,
12details and receipt of the health care provided to persons
13eligible for medical assistance under this Code, in accordance
14with regulations promulgated by the Illinois Department. The
15rules and regulations shall require that proof of the receipt
16of prescription drugs, dentures, prosthetic devices and
17eyeglasses by eligible persons under this Section accompany
18each claim for reimbursement submitted by the dispenser of such
19medical services. No such claims for reimbursement shall be
20approved for payment by the Illinois Department without such
21proof of receipt, unless the Illinois Department shall have put
22into effect and shall be operating a system of post-payment
23audit and review which shall, on a sampling basis, be deemed
24adequate by the Illinois Department to assure that such drugs,
25dentures, prosthetic devices and eyeglasses for which payment
26is being made are actually being received by eligible

SB1321 Enrolled- 28 -LRB101 10606 KTG 55712 b
1recipients. Within 90 days after September 16, 1984 (the
2effective date of Public Act 83-1439), the Illinois Department
3shall establish a current list of acquisition costs for all
4prosthetic devices and any other items recognized as medical
5equipment and supplies reimbursable under this Article and
6shall update such list on a quarterly basis, except that the
7acquisition costs of all prescription drugs shall be updated no
8less frequently than every 30 days as required by Section
95-5.12.
10 Notwithstanding any other law to the contrary, the Illinois
11Department shall, within 365 days after July 22, 2013 (the
12effective date of Public Act 98-104), establish procedures to
13permit skilled care facilities licensed under the Nursing Home
14Care Act to submit monthly billing claims for reimbursement
15purposes. Following development of these procedures, the
16Department shall, by July 1, 2016, test the viability of the
17new system and implement any necessary operational or
18structural changes to its information technology platforms in
19order to allow for the direct acceptance and payment of nursing
20home claims.
21 Notwithstanding any other law to the contrary, the Illinois
22Department shall, within 365 days after August 15, 2014 (the
23effective date of Public Act 98-963), establish procedures to
24permit ID/DD facilities licensed under the ID/DD Community Care
25Act and MC/DD facilities licensed under the MC/DD Act to submit
26monthly billing claims for reimbursement purposes. Following

SB1321 Enrolled- 29 -LRB101 10606 KTG 55712 b
1development of these procedures, the Department shall have an
2additional 365 days to test the viability of the new system and
3to ensure that any necessary operational or structural changes
4to its information technology platforms are implemented.
5 The Illinois Department shall require all dispensers of
6medical services, other than an individual practitioner or
7group of practitioners, desiring to participate in the Medical
8Assistance program established under this Article to disclose
9all financial, beneficial, ownership, equity, surety or other
10interests in any and all firms, corporations, partnerships,
11associations, business enterprises, joint ventures, agencies,
12institutions or other legal entities providing any form of
13health care services in this State under this Article.
14 The Illinois Department may require that all dispensers of
15medical services desiring to participate in the medical
16assistance program established under this Article disclose,
17under such terms and conditions as the Illinois Department may
18by rule establish, all inquiries from clients and attorneys
19regarding medical bills paid by the Illinois Department, which
20inquiries could indicate potential existence of claims or liens
21for the Illinois Department.
22 Enrollment of a vendor shall be subject to a provisional
23period and shall be conditional for one year. During the period
24of conditional enrollment, the Department may terminate the
25vendor's eligibility to participate in, or may disenroll the
26vendor from, the medical assistance program without cause.

SB1321 Enrolled- 30 -LRB101 10606 KTG 55712 b
1Unless otherwise specified, such termination of eligibility or
2disenrollment is not subject to the Department's hearing
3process. However, a disenrolled vendor may reapply without
4penalty.
5 The Department has the discretion to limit the conditional
6enrollment period for vendors based upon category of risk of
7the vendor.
8 Prior to enrollment and during the conditional enrollment
9period in the medical assistance program, all vendors shall be
10subject to enhanced oversight, screening, and review based on
11the risk of fraud, waste, and abuse that is posed by the
12category of risk of the vendor. The Illinois Department shall
13establish the procedures for oversight, screening, and review,
14which may include, but need not be limited to: criminal and
15financial background checks; fingerprinting; license,
16certification, and authorization verifications; unscheduled or
17unannounced site visits; database checks; prepayment audit
18reviews; audits; payment caps; payment suspensions; and other
19screening as required by federal or State law.
20 The Department shall define or specify the following: (i)
21by provider notice, the "category of risk of the vendor" for
22each type of vendor, which shall take into account the level of
23screening applicable to a particular category of vendor under
24federal law and regulations; (ii) by rule or provider notice,
25the maximum length of the conditional enrollment period for
26each category of risk of the vendor; and (iii) by rule, the

SB1321 Enrolled- 31 -LRB101 10606 KTG 55712 b
1hearing rights, if any, afforded to a vendor in each category
2of risk of the vendor that is terminated or disenrolled during
3the conditional enrollment period.
4 To be eligible for payment consideration, a vendor's
5payment claim or bill, either as an initial claim or as a
6resubmitted claim following prior rejection, must be received
7by the Illinois Department, or its fiscal intermediary, no
8later than 180 days after the latest date on the claim on which
9medical goods or services were provided, with the following
10exceptions:
11 (1) In the case of a provider whose enrollment is in
12 process by the Illinois Department, the 180-day period
13 shall not begin until the date on the written notice from
14 the Illinois Department that the provider enrollment is
15 complete.
16 (2) In the case of errors attributable to the Illinois
17 Department or any of its claims processing intermediaries
18 which result in an inability to receive, process, or
19 adjudicate a claim, the 180-day period shall not begin
20 until the provider has been notified of the error.
21 (3) In the case of a provider for whom the Illinois
22 Department initiates the monthly billing process.
23 (4) In the case of a provider operated by a unit of
24 local government with a population exceeding 3,000,000
25 when local government funds finance federal participation
26 for claims payments.

SB1321 Enrolled- 32 -LRB101 10606 KTG 55712 b
1 For claims for services rendered during a period for which
2a recipient received retroactive eligibility, claims must be
3filed within 180 days after the Department determines the
4applicant is eligible. For claims for which the Illinois
5Department is not the primary payer, claims must be submitted
6to the Illinois Department within 180 days after the final
7adjudication by the primary payer.
8 In the case of long term care facilities, within 45
9calendar days of receipt by the facility of required
10prescreening information, new admissions with associated
11admission documents shall be submitted through the Medical
12Electronic Data Interchange (MEDI) or the Recipient
13Eligibility Verification (REV) System or shall be submitted
14directly to the Department of Human Services using required
15admission forms. Effective September 1, 2014, admission
16documents, including all prescreening information, must be
17submitted through MEDI or REV. Confirmation numbers assigned to
18an accepted transaction shall be retained by a facility to
19verify timely submittal. Once an admission transaction has been
20completed, all resubmitted claims following prior rejection
21are subject to receipt no later than 180 days after the
22admission transaction has been completed.
23 Claims that are not submitted and received in compliance
24with the foregoing requirements shall not be eligible for
25payment under the medical assistance program, and the State
26shall have no liability for payment of those claims.

SB1321 Enrolled- 33 -LRB101 10606 KTG 55712 b
1 To the extent consistent with applicable information and
2privacy, security, and disclosure laws, State and federal
3agencies and departments shall provide the Illinois Department
4access to confidential and other information and data necessary
5to perform eligibility and payment verifications and other
6Illinois Department functions. This includes, but is not
7limited to: information pertaining to licensure;
8certification; earnings; immigration status; citizenship; wage
9reporting; unearned and earned income; pension income;
10employment; supplemental security income; social security
11numbers; National Provider Identifier (NPI) numbers; the
12National Practitioner Data Bank (NPDB); program and agency
13exclusions; taxpayer identification numbers; tax delinquency;
14corporate information; and death records.
15 The Illinois Department shall enter into agreements with
16State agencies and departments, and is authorized to enter into
17agreements with federal agencies and departments, under which
18such agencies and departments shall share data necessary for
19medical assistance program integrity functions and oversight.
20The Illinois Department shall develop, in cooperation with
21other State departments and agencies, and in compliance with
22applicable federal laws and regulations, appropriate and
23effective methods to share such data. At a minimum, and to the
24extent necessary to provide data sharing, the Illinois
25Department shall enter into agreements with State agencies and
26departments, and is authorized to enter into agreements with

SB1321 Enrolled- 34 -LRB101 10606 KTG 55712 b
1federal agencies and departments, including but not limited to:
2the Secretary of State; the Department of Revenue; the
3Department of Public Health; the Department of Human Services;
4and the Department of Financial and Professional Regulation.
5 Beginning in fiscal year 2013, the Illinois Department
6shall set forth a request for information to identify the
7benefits of a pre-payment, post-adjudication, and post-edit
8claims system with the goals of streamlining claims processing
9and provider reimbursement, reducing the number of pending or
10rejected claims, and helping to ensure a more transparent
11adjudication process through the utilization of: (i) provider
12data verification and provider screening technology; and (ii)
13clinical code editing; and (iii) pre-pay, pre- or
14post-adjudicated predictive modeling with an integrated case
15management system with link analysis. Such a request for
16information shall not be considered as a request for proposal
17or as an obligation on the part of the Illinois Department to
18take any action or acquire any products or services.
19 The Illinois Department shall establish policies,
20procedures, standards and criteria by rule for the acquisition,
21repair and replacement of orthotic and prosthetic devices and
22durable medical equipment. Such rules shall provide, but not be
23limited to, the following services: (1) immediate repair or
24replacement of such devices by recipients; and (2) rental,
25lease, purchase or lease-purchase of durable medical equipment
26in a cost-effective manner, taking into consideration the

SB1321 Enrolled- 35 -LRB101 10606 KTG 55712 b
1recipient's medical prognosis, the extent of the recipient's
2needs, and the requirements and costs for maintaining such
3equipment. Subject to prior approval, such rules shall enable a
4recipient to temporarily acquire and use alternative or
5substitute devices or equipment pending repairs or
6replacements of any device or equipment previously authorized
7for such recipient by the Department. Notwithstanding any
8provision of Section 5-5f to the contrary, the Department may,
9by rule, exempt certain replacement wheelchair parts from prior
10approval and, for wheelchairs, wheelchair parts, wheelchair
11accessories, and related seating and positioning items,
12determine the wholesale price by methods other than actual
13acquisition costs.
14 The Department shall require, by rule, all providers of
15durable medical equipment to be accredited by an accreditation
16organization approved by the federal Centers for Medicare and
17Medicaid Services and recognized by the Department in order to
18bill the Department for providing durable medical equipment to
19recipients. No later than 15 months after the effective date of
20the rule adopted pursuant to this paragraph, all providers must
21meet the accreditation requirement.
22 In order to promote environmental responsibility, meet the
23needs of recipients and enrollees, and achieve significant cost
24savings, the Department, or a managed care organization under
25contract with the Department, may provide recipients or managed
26care enrollees who have a prescription or Certificate of

SB1321 Enrolled- 36 -LRB101 10606 KTG 55712 b
1Medical Necessity access to refurbished durable medical
2equipment under this Section (excluding prosthetic and
3orthotic devices as defined in the Orthotics, Prosthetics, and
4Pedorthics Practice Act and complex rehabilitation technology
5products and associated services) through the State's
6assistive technology program's reutilization program, using
7staff with the Assistive Technology Professional (ATP)
8Certification if the refurbished durable medical equipment:
9(i) is available; (ii) is less expensive, including shipping
10costs, than new durable medical equipment of the same type;
11(iii) is able to withstand at least 3 years of use; (iv) is
12cleaned, disinfected, sterilized, and safe in accordance with
13federal Food and Drug Administration regulations and guidance
14governing the reprocessing of medical devices in health care
15settings; and (v) equally meets the needs of the recipient or
16enrollee. The reutilization program shall confirm that the
17recipient or enrollee is not already in receipt of same or
18similar equipment from another service provider, and that the
19refurbished durable medical equipment equally meets the needs
20of the recipient or enrollee. Nothing in this paragraph shall
21be construed to limit recipient or enrollee choice to obtain
22new durable medical equipment or place any additional prior
23authorization conditions on enrollees of managed care
24organizations.
25 The Department shall execute, relative to the nursing home
26prescreening project, written inter-agency agreements with the

SB1321 Enrolled- 37 -LRB101 10606 KTG 55712 b
1Department of Human Services and the Department on Aging, to
2effect the following: (i) intake procedures and common
3eligibility criteria for those persons who are receiving
4non-institutional services; and (ii) the establishment and
5development of non-institutional services in areas of the State
6where they are not currently available or are undeveloped; and
7(iii) notwithstanding any other provision of law, subject to
8federal approval, on and after July 1, 2012, an increase in the
9determination of need (DON) scores from 29 to 37 for applicants
10for institutional and home and community-based long term care;
11if and only if federal approval is not granted, the Department
12may, in conjunction with other affected agencies, implement
13utilization controls or changes in benefit packages to
14effectuate a similar savings amount for this population; and
15(iv) no later than July 1, 2013, minimum level of care
16eligibility criteria for institutional and home and
17community-based long term care; and (v) no later than October
181, 2013, establish procedures to permit long term care
19providers access to eligibility scores for individuals with an
20admission date who are seeking or receiving services from the
21long term care provider. In order to select the minimum level
22of care eligibility criteria, the Governor shall establish a
23workgroup that includes affected agency representatives and
24stakeholders representing the institutional and home and
25community-based long term care interests. This Section shall
26not restrict the Department from implementing lower level of

SB1321 Enrolled- 38 -LRB101 10606 KTG 55712 b
1care eligibility criteria for community-based services in
2circumstances where federal approval has been granted.
3 The Illinois Department shall develop and operate, in
4cooperation with other State Departments and agencies and in
5compliance with applicable federal laws and regulations,
6appropriate and effective systems of health care evaluation and
7programs for monitoring of utilization of health care services
8and facilities, as it affects persons eligible for medical
9assistance under this Code.
10 The Illinois Department shall report annually to the
11General Assembly, no later than the second Friday in April of
121979 and each year thereafter, in regard to:
13 (a) actual statistics and trends in utilization of
14 medical services by public aid recipients;
15 (b) actual statistics and trends in the provision of
16 the various medical services by medical vendors;
17 (c) current rate structures and proposed changes in
18 those rate structures for the various medical vendors; and
19 (d) efforts at utilization review and control by the
20 Illinois Department.
21 The period covered by each report shall be the 3 years
22ending on the June 30 prior to the report. The report shall
23include suggested legislation for consideration by the General
24Assembly. The requirement for reporting to the General Assembly
25shall be satisfied by filing copies of the report as required
26by Section 3.1 of the General Assembly Organization Act, and

SB1321 Enrolled- 39 -LRB101 10606 KTG 55712 b
1filing such additional copies with the State Government Report
2Distribution Center for the General Assembly as is required
3under paragraph (t) of Section 7 of the State Library Act.
4 Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10 On and after July 1, 2012, the Department shall reduce any
11rate of reimbursement for services or other payments or alter
12any methodologies authorized by this Code to reduce any rate of
13reimbursement for services or other payments in accordance with
14Section 5-5e.
15 Because kidney transplantation can be an appropriate,
16cost-effective alternative to renal dialysis when medically
17necessary and notwithstanding the provisions of Section 1-11 of
18this Code, beginning October 1, 2014, the Department shall
19cover kidney transplantation for noncitizens with end-stage
20renal disease who are not eligible for comprehensive medical
21benefits, who meet the residency requirements of Section 5-3 of
22this Code, and who would otherwise meet the financial
23requirements of the appropriate class of eligible persons under
24Section 5-2 of this Code. To qualify for coverage of kidney
25transplantation, such person must be receiving emergency renal
26dialysis services covered by the Department. Providers under

SB1321 Enrolled- 40 -LRB101 10606 KTG 55712 b
1this Section shall be prior approved and certified by the
2Department to perform kidney transplantation and the services
3under this Section shall be limited to services associated with
4kidney transplantation.
5 Notwithstanding any other provision of this Code to the
6contrary, on or after July 1, 2015, all FDA approved forms of
7medication assisted treatment prescribed for the treatment of
8alcohol dependence or treatment of opioid dependence shall be
9covered under both fee for service and managed care medical
10assistance programs for persons who are otherwise eligible for
11medical assistance under this Article and shall not be subject
12to any (1) utilization control, other than those established
13under the American Society of Addiction Medicine patient
14placement criteria, (2) prior authorization mandate, or (3)
15lifetime restriction limit mandate.
16 On or after July 1, 2015, opioid antagonists prescribed for
17the treatment of an opioid overdose, including the medication
18product, administration devices, and any pharmacy fees related
19to the dispensing and administration of the opioid antagonist,
20shall be covered under the medical assistance program for
21persons who are otherwise eligible for medical assistance under
22this Article. As used in this Section, "opioid antagonist"
23means a drug that binds to opioid receptors and blocks or
24inhibits the effect of opioids acting on those receptors,
25including, but not limited to, naloxone hydrochloride or any
26other similarly acting drug approved by the U.S. Food and Drug

SB1321 Enrolled- 41 -LRB101 10606 KTG 55712 b
1Administration.
2 Upon federal approval, the Department shall provide
3coverage and reimbursement for all drugs that are approved for
4marketing by the federal Food and Drug Administration and that
5are recommended by the federal Public Health Service or the
6United States Centers for Disease Control and Prevention for
7pre-exposure prophylaxis and related pre-exposure prophylaxis
8services, including, but not limited to, HIV and sexually
9transmitted infection screening, treatment for sexually
10transmitted infections, medical monitoring, assorted labs, and
11counseling to reduce the likelihood of HIV infection among
12individuals who are not infected with HIV but who are at high
13risk of HIV infection.
14 A federally qualified health center, as defined in Section
151905(l)(2)(B) of the federal Social Security Act, shall be
16reimbursed by the Department in accordance with the federally
17qualified health center's encounter rate for services provided
18to medical assistance recipients that are performed by a dental
19hygienist, as defined under the Illinois Dental Practice Act,
20working under the general supervision of a dentist and employed
21by a federally qualified health center.
22 Notwithstanding any other provision of this Code, the
23Illinois Department shall authorize licensed dietitian
24nutritionists and certified diabetes educators to counsel
25senior diabetes patients in the senior diabetes patients' homes
26to remove the hurdle of transportation for senior diabetes

SB1321 Enrolled- 42 -LRB101 10606 KTG 55712 b
1patients to receive treatment.
2(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
399-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
4the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
599-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
67-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
7eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
8100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff.
91-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18;
10100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff.
1112-10-18.)
12 (305 ILCS 5/5-5.10 new)
13 Sec. 5-5.10. Value-based purchasing.
14 (a) The Department of Healthcare and Family Services, and,
15as appropriate, divisions within the Department of Human
16Services, shall confer with stakeholders to discuss
17development of alternative value-based payment models that
18move away from fee-for-service and reward health outcomes and
19improved quality and provide flexibility in how providers meet
20the needs of the individuals they serve. Stakeholders include
21providers, managed care organizations, and community-based and
22advocacy organizations. The approaches explored may be
23different for different types of services.
24 (b) The Department of Healthcare and Family Services and
25the Department of Human Services shall initiate discussions

SB1321 Enrolled- 43 -LRB101 10606 KTG 55712 b
1with mental health providers, substance abuse providers,
2managed care organizations, advocacy groups for individuals
3with behavioral health issues, and others, as appropriate, no
4later than July 1, 2019. A model for value-based purchasing for
5behavioral health providers shall be presented to the General
6Assembly by January 31, 2020. In developing this model, the
7Department of Healthcare and Family Services shall develop
8projections of the funding necessary for the model.
9 (305 ILCS 5/5-5f)
10 Sec. 5-5f. Elimination and limitations of medical
11assistance services. Notwithstanding any other provision of
12this Code to the contrary, on and after July 1, 2012:
13 (a) The following services shall no longer be a covered
14 service available under this Code: group psychotherapy for
15 residents of any facility licensed under the Nursing Home
16 Care Act or the Specialized Mental Health Rehabilitation
17 Act of 2013; and adult chiropractic services.
18 (b) The Department shall place the following
19 limitations on services: (i) the Department shall limit
20 adult eyeglasses to one pair every 2 years; however, the
21 limitation does not apply to an individual who needs
22 different eyeglasses following a surgical procedure such
23 as cataract surgery; (ii) the Department shall set an
24 annual limit of a maximum of 20 visits for each of the
25 following services: adult speech, hearing, and language

SB1321 Enrolled- 44 -LRB101 10606 KTG 55712 b
1 therapy services, adult occupational therapy services, and
2 physical therapy services; on or after October 1, 2014, the
3 annual maximum limit of 20 visits shall expire but the
4 Department may shall require prior approval for all
5 individuals for speech, hearing, and language therapy
6 services, occupational therapy services, and physical
7 therapy services; (iii) the Department shall limit adult
8 podiatry services to individuals with diabetes; on or after
9 October 1, 2014, podiatry services shall not be limited to
10 individuals with diabetes; (iv) the Department shall pay
11 for caesarean sections at the normal vaginal delivery rate
12 unless a caesarean section was medically necessary; (v) the
13 Department shall limit adult dental services to
14 emergencies; beginning July 1, 2013, the Department shall
15 ensure that the following conditions are recognized as
16 emergencies: (A) dental services necessary for an
17 individual in order for the individual to be cleared for a
18 medical procedure, such as a transplant; (B) extractions
19 and dentures necessary for a diabetic to receive proper
20 nutrition; (C) extractions and dentures necessary as a
21 result of cancer treatment; and (D) dental services
22 necessary for the health of a pregnant woman prior to
23 delivery of her baby; on or after July 1, 2014, adult
24 dental services shall no longer be limited to emergencies,
25 and dental services necessary for the health of a pregnant
26 woman prior to delivery of her baby shall continue to be

SB1321 Enrolled- 45 -LRB101 10606 KTG 55712 b
1 covered; and (vi) effective July 1, 2012, the Department
2 shall place limitations and require concurrent review on
3 every inpatient detoxification stay to prevent repeat
4 admissions to any hospital for detoxification within 60
5 days of a previous inpatient detoxification stay. The
6 Department shall convene a workgroup of hospitals,
7 substance abuse providers, care coordination entities,
8 managed care plans, and other stakeholders to develop
9 recommendations for quality standards, diversion to other
10 settings, and admission criteria for patients who need
11 inpatient detoxification, which shall be published on the
12 Department's website no later than September 1, 2013.
13 (c) The Department shall require prior approval of the
14 following services: wheelchair repairs costing more than
15 $400, coronary artery bypass graft, and bariatric surgery
16 consistent with Medicare standards concerning patient
17 responsibility. Wheelchair repair prior approval requests
18 shall be adjudicated within one business day of receipt of
19 complete supporting documentation. Providers may not break
20 wheelchair repairs into separate claims for purposes of
21 staying under the $400 threshold for requiring prior
22 approval. The wholesale price of manual and power
23 wheelchairs, durable medical equipment and supplies, and
24 complex rehabilitation technology products and services
25 shall be defined as actual acquisition cost including all
26 discounts.

SB1321 Enrolled- 46 -LRB101 10606 KTG 55712 b
1 (d) The Department shall establish benchmarks for
2 hospitals to measure and align payments to reduce
3 potentially preventable hospital readmissions, inpatient
4 complications, and unnecessary emergency room visits. In
5 doing so, the Department shall consider items, including,
6 but not limited to, historic and current acuity of care and
7 historic and current trends in readmission. The Department
8 shall publish provider-specific historical readmission
9 data and anticipated potentially preventable targets 60
10 days prior to the start of the program. In the instance of
11 readmissions, the Department shall adopt policies and
12 rates of reimbursement for services and other payments
13 provided under this Code to ensure that, by June 30, 2013,
14 expenditures to hospitals are reduced by, at a minimum,
15 $40,000,000.
16 (e) The Department shall establish utilization
17 controls for the hospice program such that it shall not pay
18 for other care services when an individual is in hospice.
19 (f) For home health services, the Department shall
20 require Medicare certification of providers participating
21 in the program and implement the Medicare face-to-face
22 encounter rule. The Department shall require providers to
23 implement auditable electronic service verification based
24 on global positioning systems or other cost-effective
25 technology.
26 (g) For the Home Services Program operated by the

SB1321 Enrolled- 47 -LRB101 10606 KTG 55712 b
1 Department of Human Services and the Community Care Program
2 operated by the Department on Aging, the Department of
3 Human Services, in cooperation with the Department on
4 Aging, shall implement an electronic service verification
5 based on global positioning systems or other
6 cost-effective technology.
7 (h) Effective with inpatient hospital admissions on or
8 after July 1, 2012, the Department shall reduce the payment
9 for a claim that indicates the occurrence of a
10 provider-preventable condition during the admission as
11 specified by the Department in rules. The Department shall
12 not pay for services related to an other
13 provider-preventable condition.
14 As used in this subsection (h):
15 "Provider-preventable condition" means a health care
16 acquired condition as defined under the federal Medicaid
17 regulation found at 42 CFR 447.26 or an other
18 provider-preventable condition.
19 "Other provider-preventable condition" means a wrong
20 surgical or other invasive procedure performed on a
21 patient, a surgical or other invasive procedure performed
22 on the wrong body part, or a surgical procedure or other
23 invasive procedure performed on the wrong patient.
24 (i) The Department shall implement cost savings
25 initiatives for advanced imaging services, cardiac imaging
26 services, pain management services, and back surgery. Such

SB1321 Enrolled- 48 -LRB101 10606 KTG 55712 b
1 initiatives shall be designed to achieve annual costs
2 savings.
3 (j) The Department shall ensure that beneficiaries
4 with a diagnosis of epilepsy or seizure disorder in
5 Department records will not require prior approval for
6 anticonvulsants.
7(Source: P.A. 100-135, eff. 8-18-17.)
8 (305 ILCS 5/5-30.1)
9 Sec. 5-30.1. Managed care protections.
10 (a) As used in this Section:
11 "Managed care organization" or "MCO" means any entity which
12contracts with the Department to provide services where payment
13for medical services is made on a capitated basis.
14 "Emergency services" include:
15 (1) emergency services, as defined by Section 10 of the
16 Managed Care Reform and Patient Rights Act;
17 (2) emergency medical screening examinations, as
18 defined by Section 10 of the Managed Care Reform and
19 Patient Rights Act;
20 (3) post-stabilization medical services, as defined by
21 Section 10 of the Managed Care Reform and Patient Rights
22 Act; and
23 (4) emergency medical conditions, as defined by
24 Section 10 of the Managed Care Reform and Patient Rights
25 Act.

SB1321 Enrolled- 49 -LRB101 10606 KTG 55712 b
1 (b) As provided by Section 5-16.12, managed care
2organizations are subject to the provisions of the Managed Care
3Reform and Patient Rights Act.
4 (c) An MCO shall pay any provider of emergency services
5that does not have in effect a contract with the contracted
6Medicaid MCO. The default rate of reimbursement shall be the
7rate paid under Illinois Medicaid fee-for-service program
8methodology, including all policy adjusters, including but not
9limited to Medicaid High Volume Adjustments, Medicaid
10Percentage Adjustments, Outpatient High Volume Adjustments,
11and all outlier add-on adjustments to the extent such
12adjustments are incorporated in the development of the
13applicable MCO capitated rates.
14 (d) An MCO shall pay for all post-stabilization services as
15a covered service in any of the following situations:
16 (1) the MCO authorized such services;
17 (2) such services were administered to maintain the
18 enrollee's stabilized condition within one hour after a
19 request to the MCO for authorization of further
20 post-stabilization services;
21 (3) the MCO did not respond to a request to authorize
22 such services within one hour;
23 (4) the MCO could not be contacted; or
24 (5) the MCO and the treating provider, if the treating
25 provider is a non-affiliated provider, could not reach an
26 agreement concerning the enrollee's care and an affiliated

SB1321 Enrolled- 50 -LRB101 10606 KTG 55712 b
1 provider was unavailable for a consultation, in which case
2 the MCO must pay for such services rendered by the treating
3 non-affiliated provider until an affiliated provider was
4 reached and either concurred with the treating
5 non-affiliated provider's plan of care or assumed
6 responsibility for the enrollee's care. Such payment shall
7 be made at the default rate of reimbursement paid under
8 Illinois Medicaid fee-for-service program methodology,
9 including all policy adjusters, including but not limited
10 to Medicaid High Volume Adjustments, Medicaid Percentage
11 Adjustments, Outpatient High Volume Adjustments and all
12 outlier add-on adjustments to the extent that such
13 adjustments are incorporated in the development of the
14 applicable MCO capitated rates.
15 (e) The following requirements apply to MCOs in determining
16payment for all emergency services:
17 (1) MCOs shall not impose any requirements for prior
18 approval of emergency services.
19 (2) The MCO shall cover emergency services provided to
20 enrollees who are temporarily away from their residence and
21 outside the contracting area to the extent that the
22 enrollees would be entitled to the emergency services if
23 they still were within the contracting area.
24 (3) The MCO shall have no obligation to cover medical
25 services provided on an emergency basis that are not
26 covered services under the contract.

SB1321 Enrolled- 51 -LRB101 10606 KTG 55712 b
1 (4) The MCO shall not condition coverage for emergency
2 services on the treating provider notifying the MCO of the
3 enrollee's screening and treatment within 10 days after
4 presentation for emergency services.
5 (5) The determination of the attending emergency
6 physician, or the provider actually treating the enrollee,
7 of whether an enrollee is sufficiently stabilized for
8 discharge or transfer to another facility, shall be binding
9 on the MCO. The MCO shall cover emergency services for all
10 enrollees whether the emergency services are provided by an
11 affiliated or non-affiliated provider.
12 (6) The MCO's financial responsibility for
13 post-stabilization care services it has not pre-approved
14 ends when:
15 (A) a plan physician with privileges at the
16 treating hospital assumes responsibility for the
17 enrollee's care;
18 (B) a plan physician assumes responsibility for
19 the enrollee's care through transfer;
20 (C) a contracting entity representative and the
21 treating physician reach an agreement concerning the
22 enrollee's care; or
23 (D) the enrollee is discharged.
24 (f) Network adequacy and transparency.
25 (1) The Department shall:
26 (A) ensure that an adequate provider network is in

SB1321 Enrolled- 52 -LRB101 10606 KTG 55712 b
1 place, taking into consideration health professional
2 shortage areas and medically underserved areas;
3 (B) publicly release an explanation of its process
4 for analyzing network adequacy;
5 (C) periodically ensure that an MCO continues to
6 have an adequate network in place; and
7 (D) require MCOs, including Medicaid Managed Care
8 Entities as defined in Section 5-30.2, to meet provider
9 directory requirements under Section 5-30.3.
10 (2) Each MCO shall confirm its receipt of information
11 submitted specific to physician or dentist additions or
12 physician or dentist deletions from the MCO's provider
13 network within 3 days after receiving all required
14 information from contracted physicians or dentists, and
15 electronic physician and dental directories must be
16 updated consistent with current rules as published by the
17 Centers for Medicare and Medicaid Services or its successor
18 agency.
19 (g) Timely payment of claims.
20 (1) The MCO shall pay a claim within 30 days of
21 receiving a claim that contains all the essential
22 information needed to adjudicate the claim.
23 (2) The MCO shall notify the billing party of its
24 inability to adjudicate a claim within 30 days of receiving
25 that claim.
26 (3) The MCO shall pay a penalty that is at least equal

SB1321 Enrolled- 53 -LRB101 10606 KTG 55712 b
1 to the timely payment interest penalty imposed under
2 Section 368a of the Illinois Insurance Code for any claims
3 not timely paid.
4 (A) When an MCO is required to pay a timely payment
5 interest penalty to a provider, the MCO must calculate
6 and pay the timely payment interest penalty that is due
7 to the provider within 30 days after the payment of the
8 claim. In no event shall a provider be required to
9 request or apply for payment of any owed timely payment
10 interest penalties.
11 (B) Such payments shall be reported separately
12 from the claim payment for services rendered to the
13 MCO's enrollee and clearly identified as interest
14 payments.
15 (4)(A) The Department shall require MCOs to expedite
16 payments to providers identified on the Department's
17 expedited provider list, determined in accordance with 89
18 Ill. Adm. Code 140.71(b), on a schedule at least as
19 frequently as the providers are paid under the Department's
20 fee-for-service expedited provider schedule.
21 (B) Compliance with the expedited provider requirement
22 may be satisfied by an MCO through the use of a Periodic
23 Interim Payment (PIP) program that has been mutually agreed
24 to and documented between the MCO and the provider, and the
25 PIP program ensures that any expedited provider receives
26 regular and periodic payments based on prior period payment

SB1321 Enrolled- 54 -LRB101 10606 KTG 55712 b
1 experience from that MCO. Total payments under the PIP
2 program may be reconciled against future PIP payments on a
3 schedule mutually agreed to between the MCO and the
4 provider.
5 (C) The Department shall share at least monthly its
6 expedited provider list and the frequency with which it
7 pays providers on the expedited list. The Department may
8 establish a process for MCOs to expedite payments to
9 providers based on criteria established by the Department.
10 (g-5) Recognizing that the rapid transformation of the
11Illinois Medicaid program may have unintended operational
12challenges for both payers and providers:
13 (1) in no instance shall a medically necessary covered
14 service rendered in good faith, based upon eligibility
15 information documented by the provider, be denied coverage
16 or diminished in payment amount if the eligibility or
17 coverage information available at the time the service was
18 rendered is later found to be inaccurate in the assignment
19 of coverage responsibility between MCOs or the
20 fee-for-service system, except for instances when an
21 individual is deemed to have not been eligible for coverage
22 under the Illinois Medicaid program; and
23 (2) the Department shall, by December 31, 2016, adopt
24 rules establishing policies that shall be included in the
25 Medicaid managed care policy and procedures manual
26 addressing payment resolutions in situations in which a

SB1321 Enrolled- 55 -LRB101 10606 KTG 55712 b
1 provider renders services based upon information obtained
2 after verifying a patient's eligibility and coverage plan
3 through either the Department's current enrollment system
4 or a system operated by the coverage plan identified by the
5 patient presenting for services:
6 (A) such medically necessary covered services
7 shall be considered rendered in good faith;
8 (B) such policies and procedures shall be
9 developed in consultation with industry
10 representatives of the Medicaid managed care health
11 plans and representatives of provider associations
12 representing the majority of providers within the
13 identified provider industry; and
14 (C) such rules shall be published for a review and
15 comment period of no less than 30 days on the
16 Department's website with final rules remaining
17 available on the Department's website.
18 (3) The rules on payment resolutions shall include, but not
19be limited to:
20 (A) the extension of the timely filing period;
21 (B) retroactive prior authorizations; and
22 (C) guaranteed minimum payment rate of no less than the
23 current, as of the date of service, fee-for-service rate,
24 plus all applicable add-ons, when the resulting service
25 relationship is out of network.
26 (4) The rules shall be applicable for both MCO coverage and

SB1321 Enrolled- 56 -LRB101 10606 KTG 55712 b
1fee-for-service coverage.
2 If the fee-for-service system is ultimately determined to
3have been responsible for coverage on the date of service, the
4Department shall provide for an extended period for claims
5submission outside the standard timely filing requirements.
6 (g-6) MCO Performance Metrics Report.
7 (1) The Department shall publish, on at least a
8 quarterly basis, each MCO's operational performance,
9 including, but not limited to, the following categories of
10 metrics:
11 (A) claims payment, including timeliness and
12 accuracy;
13 (B) prior authorizations;
14 (C) grievance and appeals;
15 (D) utilization statistics;
16 (E) provider disputes;
17 (F) provider credentialing; and
18 (G) member and provider customer service.
19 (2) The Department shall ensure that the metrics report
20 is accessible to providers online by January 1, 2017.
21 (3) The metrics shall be developed in consultation with
22 industry representatives of the Medicaid managed care
23 health plans and representatives of associations
24 representing the majority of providers within the
25 identified industry.
26 (4) Metrics shall be defined and incorporated into the

SB1321 Enrolled- 57 -LRB101 10606 KTG 55712 b
1 applicable Managed Care Policy Manual issued by the
2 Department.
3 (g-7) MCO claims processing and performance analysis. In
4order to monitor MCO payments to hospital providers, pursuant
5to this amendatory Act of the 100th General Assembly, the
6Department shall post an analysis of MCO claims processing and
7payment performance on its website every 6 months. Such
8analysis shall include a review and evaluation of a
9representative sample of hospital claims that are rejected and
10denied for clean and unclean claims and the top 5 reasons for
11such actions and timeliness of claims adjudication, which
12identifies the percentage of claims adjudicated within 30, 60,
1390, and over 90 days, and the dollar amounts associated with
14those claims. The Department shall post the contracted claims
15report required by HealthChoice Illinois on its website every 3
16months.
17 (g-8) Dispute resolution process. The Department shall
18maintain a provider complaint portal through which a provider
19can submit to the Department unresolved disputes with an MCO.
20An unresolved dispute means an MCO's decision that denies in
21whole or in part a claim for reimbursement to a provider for
22health care services rendered by the provider to an enrollee of
23the MCO with which the provider disagrees. Disputes shall not
24be submitted to the portal until the provider has availed
25itself of the MCO's internal dispute resolution process.
26Disputes that are submitted to the MCO internal dispute

SB1321 Enrolled- 58 -LRB101 10606 KTG 55712 b
1resolution process may be submitted to the Department of
2Healthcare and Family Services' complaint portal no sooner than
330 days after submitting to the MCO's internal process and not
4later than 30 days after the unsatisfactory resolution of the
5internal MCO process or 60 days after submitting the dispute to
6the MCO internal process. Multiple claim disputes involving the
7same MCO may be submitted in one complaint, regardless of
8whether the claims are for different enrollees, when the
9specific reason for non-payment of the claims involves a common
10question of fact or policy. Within 10 business days of receipt
11of a complaint, the Department shall present such disputes to
12the appropriate MCO, which shall then have 30 days to issue its
13written proposal to resolve the dispute. The Department may
14grant one 30-day extension of this time frame to one of the
15parties to resolve the dispute. If the dispute remains
16unresolved at the end of this time frame or the provider is not
17satisfied with the MCO's written proposal to resolve the
18dispute, the provider may, within 30 days, request the
19Department to review the dispute and make a final
20determination. Within 30 days of the request for Department
21review of the dispute, both the provider and the MCO shall
22present all relevant information to the Department for
23resolution and make individuals with knowledge of the issues
24available to the Department for further inquiry if needed.
25Within 30 days of receiving the relevant information on the
26dispute, or the lapse of the period for submitting such

SB1321 Enrolled- 59 -LRB101 10606 KTG 55712 b
1information, the Department shall issue a written decision on
2the dispute based on contractual terms between the provider and
3the MCO, contractual terms between the MCO and the Department
4of Healthcare and Family Services and applicable Medicaid
5policy. The decision of the Department shall be final. By
6January 1, 2020, the Department shall establish by rule further
7details of this dispute resolution process. Disputes between
8MCOs and providers presented to the Department for resolution
9are not contested cases, as defined in Section 1-30 of the
10Illinois Administrative Procedure Act, conferring any right to
11an administrative hearing.
12 (g-9)(1) The Department shall publish annually on its
13website a report on the calculation of each managed care
14organization's medical loss ratio showing the following:
15 (A) Premium revenue, with appropriate adjustments.
16 (B) Benefit expense, setting forth the aggregate
17 amount spent for the following:
18 (i) Direct paid claims.
19 (ii) Subcapitation payments.
20 (iii) Other claim payments.
21 (iv) Direct reserves.
22 (v) Gross recoveries.
23 (vi) Expenses for activities that improve health
24 care quality as allowed by the Department.
25 (2) The medical loss ratio shall be calculated consistent
26with federal law and regulation following a claims runout

SB1321 Enrolled- 60 -LRB101 10606 KTG 55712 b
1period determined by the Department.
2 (g-10)(1) "Liability effective date" means the date on
3which an MCO becomes responsible for payment for medically
4necessary and covered services rendered by a provider to one of
5its enrollees in accordance with the contract terms between the
6MCO and the provider. The liability effective date shall be the
7later of:
8 (A) The execution date of a network participation
9 contract agreement.
10 (B) The date the provider or its representative submits
11 to the MCO the complete and accurate standardized roster
12 form for the provider in the format approved by the
13 Department.
14 (C) The provider effective date contained within the
15 Department's provider enrollment subsystem within the
16 Illinois Medicaid Program Advanced Cloud Technology
17 (IMPACT) System.
18 (2) The standardized roster form may be submitted to the
19MCO at the same time that the provider submits an enrollment
20application to the Department through IMPACT.
21 (3) By October 1, 2019, the Department shall require all
22MCOs to update their provider directory with information for
23new practitioners of existing contracted providers within 30
24days of receipt of a complete and accurate standardized roster
25template in the format approved by the Department provided that
26the provider is effective in the Department's provider

SB1321 Enrolled- 61 -LRB101 10606 KTG 55712 b
1enrollment subsystem within the IMPACT system. Such provider
2directory shall be readily accessible for purposes of selecting
3an approved health care provider and comply with all other
4federal and State requirements.
5 (g-11) The Department shall work with relevant
6stakeholders on the development of operational guidelines to
7enhance and improve operational performance of Illinois'
8Medicaid managed care program, including, but not limited to,
9improving provider billing practices, reducing claim
10rejections and inappropriate payment denials, and
11standardizing processes, procedures, definitions, and response
12timelines, with the goal of reducing provider and MCO
13administrative burdens and conflict. The Department shall
14include a report on the progress of these program improvements
15and other topics in its Fiscal Year 2020 annual report to the
16General Assembly.
17 (h) The Department shall not expand mandatory MCO
18enrollment into new counties beyond those counties already
19designated by the Department as of June 1, 2014 for the
20individuals whose eligibility for medical assistance is not the
21seniors or people with disabilities population until the
22Department provides an opportunity for accountable care
23entities and MCOs to participate in such newly designated
24counties.
25 (i) The requirements of this Section apply to contracts
26with accountable care entities and MCOs entered into, amended,

SB1321 Enrolled- 62 -LRB101 10606 KTG 55712 b
1or renewed after June 16, 2014 (the effective date of Public
2Act 98-651).
3 (j) Health care information released to managed care
4organizations. A health care provider shall release to a
5Medicaid managed care organization, upon request, and subject
6to the Health Insurance Portability and Accountability Act of
71996 and any other law applicable to the release of health
8information, the health care information of the MCO's enrollee,
9if the enrollee has completed and signed a general release form
10that grants to the health care provider permission to release
11the recipient's health care information to the recipient's
12insurance carrier.
13(Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
14100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 100-587, eff.
156-4-18.)
16 (305 ILCS 5/5-30.11 new)
17 Sec. 5-30.11. Managed care reports; minority-owned and
18women-owned businesses. Each Medicaid managed care health plan
19shall submit a report to the Department by March 1, 2020, and
20every March 1 thereafter, that includes the following
21information:
22 (1) The administrative expenses paid to the Medicaid
23 managed care health plan.
24 (2) The amount of money the Medicaid managed care
25 health plan has spent with Business Enterprise Program

SB1321 Enrolled- 63 -LRB101 10606 KTG 55712 b
1 certified businesses.
2 (3) The amount of money the Medicaid managed care
3 health plan has spent with minority-owned and women-owned
4 businesses that are certified by other agencies or private
5 organizations.
6 (4) The amount of money the Medicaid managed care
7 health plan has spent with not-for-profit community-based
8 organizations serving predominantly minority communities,
9 as defined by the Department.
10 (5) The proportion of minorities, people with
11 disabilities, and women that make up the staff of the
12 Medicaid managed care health plan.
13 (6) Recommendations for increasing expenditures with
14 minority-owned and women-owned businesses.
15 (7) A list of the types of services to which the
16 Medicaid managed care health plan is contemplating adding
17 new vendors.
18 (8) The certifications the Medicaid managed care
19 health plan accepts for minority-owned and women-owned
20 businesses.
21 (9) The point of contact for potential vendors seeking
22 to do business with the Medicaid managed care health plan.
23 The Department shall publish the reports on its website and
24shall maintain each report on its website for 5 years. In May
25of 2020 and every May thereafter, the Department shall hold 2
26annual public workshops, one in Chicago and one in Springfield.

SB1321 Enrolled- 64 -LRB101 10606 KTG 55712 b
1The workshops shall include each Medicaid managed care health
2plan and shall be open to vendor communities to discuss the
3submitted plans and to seek to connect vendors with the
4Medicaid managed care health plans.
5 (305 ILCS 5/5-30.12 new)
6 Sec. 5-30.12. Managed care claim rejection and denial
7management.
8 (a) In order to provide greater transparency to managed
9care organizations (MCOs) and providers, the Department shall
10explore the availability of and, if reasonably available,
11procure technology that, for all electronic claims, with the
12exception of direct data entry claims, meets the following
13needs:
14 (1) The technology shall allow the Department to fully
15 analyze the root cause of claims denials in the Medicaid
16 managed care programs operated by the Department and
17 expedite solutions that reduce the number of denials to the
18 extent possible.
19 (2) The technology shall create a single electronic
20 pipeline through which all claims from all providers
21 submitted for adjudication by the Department or a managed
22 care organization under contract with the Department shall
23 be directed by clearing houses and providers or other
24 claims submitting entities not using clearing houses prior
25 to forwarding to the Department or the appropriate managed

SB1321 Enrolled- 65 -LRB101 10606 KTG 55712 b
1 care organization.
2 (3) The technology shall cause all HIPAA-compliant
3 responses to submitted claims, including rejections,
4 denials, and payments, returned to the submitting provider
5 to pass through the established single pipeline.
6 (4) The technology shall give the Department the
7 ability to create edits to be placed at the front end of
8 the pipeline that will reject claims back to the submitting
9 provider with an explanation of why the claim cannot be
10 properly adjudicated by the payer.
11 (5) The technology shall allow the Department to
12 customize the language used to explain why a claim is being
13 rejected and how the claim can be corrected for
14 adjudication.
15 (6) The technology shall send copies of all claims and
16 claim responses that pass through the pipeline, regardless
17 of the payer to whom they are directed, to the Department's
18 Enterprise Data Warehouse.
19 (b) If the Department chooses to implement front end edits
20or customized responses to claims submissions, the MCOs and
21other stakeholders shall be consulted prior to implementation
22and providers shall be notified of edits at least 30 days prior
23to their effective date.
24 (c) Neither the technology nor MCO policy shall require
25providers to submit claims through a process other than the
26pipeline. MCOs may request supplemental information needed for

SB1321 Enrolled- 66 -LRB101 10606 KTG 55712 b
1adjudication which cannot be contained in the claim file to be
2submitted separately to the MCOs.
3 (d) The technology shall allow the Department to fully
4analyze and report on MCO claims processing and payment
5performance by provider type.
6 (305 ILCS 5/5A-4) (from Ch. 23, par. 5A-4)
7 Sec. 5A-4. Payment of assessment; penalty.
8 (a) The assessment imposed by Section 5A-2 for State fiscal
9year 2009 through State fiscal year 2018 or as provided in
10Section 5A-16, shall be due and payable in monthly
11installments, each equaling one-twelfth of the assessment for
12the year, on the fourteenth State business day of each month.
13No installment payment of an assessment imposed by Section 5A-2
14shall be due and payable, however, until after the Comptroller
15has issued the payments required under this Article.
16 Except as provided in subsection (a-5) of this Section, the
17assessment imposed by subsection (b-5) of Section 5A-2 for the
18portion of State fiscal year 2012 beginning June 10, 2012
19through June 30, 2012, and for State fiscal year 2013 through
20State fiscal year 2018 or as provided in Section 5A-16, shall
21be due and payable in monthly installments, each equaling
22one-twelfth of the assessment for the year, on the 17th State
23business day of each month. No installment payment of an
24assessment imposed by subsection (b-5) of Section 5A-2 shall be
25due and payable, however, until after: (i) the Department

SB1321 Enrolled- 67 -LRB101 10606 KTG 55712 b
1notifies the hospital provider, in writing, that the payment
2methodologies to hospitals required under Section 5A-12.4,
3have been approved by the Centers for Medicare and Medicaid
4Services of the U.S. Department of Health and Human Services,
5and the waiver under 42 CFR 433.68 for the assessment imposed
6by subsection (b-5) of Section 5A-2, if necessary, has been
7granted by the Centers for Medicare and Medicaid Services of
8the U.S. Department of Health and Human Services; and (ii) the
9Comptroller has issued the payments required under Section
105A-12.4. Upon notification to the Department of approval of the
11payment methodologies required under Section 5A-12.4 and the
12waiver granted under 42 CFR 433.68, if necessary, all
13installments otherwise due under subsection (b-5) of Section
145A-2 prior to the date of notification shall be due and payable
15to the Department upon written direction from the Department
16and issuance by the Comptroller of the payments required under
17Section 5A-12.4.
18 Except as provided in subsection (a-5) of this Section, the
19assessment imposed under Section 5A-2 for State fiscal year
202019 and each subsequent State fiscal year shall be due and
21payable in monthly installments, each equaling one-twelfth of
22the assessment for the year, on the 17th 14th State business
23day of each month. No installment payment of an assessment
24imposed by Section 5A-2 shall be due and payable, however,
25until after: (i) the Department notifies the hospital provider,
26in writing, that the payment methodologies to hospitals

SB1321 Enrolled- 68 -LRB101 10606 KTG 55712 b
1required under Section 5A-12.6 have been approved by the
2Centers for Medicare and Medicaid Services of the U.S.
3Department of Health and Human Services, and the waiver under
442 CFR 433.68 for the assessment imposed by Section 5A-2, if
5necessary, has been granted by the Centers for Medicare and
6Medicaid Services of the U.S. Department of Health and Human
7Services; and (ii) the Comptroller has issued the payments
8required under Section 5A-12.6. Upon notification to the
9Department of approval of the payment methodologies required
10under Section 5A-12.6 and the waiver granted under 42 CFR
11433.68, if necessary, all installments otherwise due under
12Section 5A-2 prior to the date of notification shall be due and
13payable to the Department upon written direction from the
14Department and issuance by the Comptroller of the payments
15required under Section 5A-12.6.
16 (a-5) The Illinois Department may accelerate the schedule
17upon which assessment installments are due and payable by
18hospitals with a payment ratio greater than or equal to one.
19Such acceleration of due dates for payment of the assessment
20may be made only in conjunction with a corresponding
21acceleration in access payments identified in Section 5A-12.2,
22Section 5A-12.4, or Section 5A-12.6 to the same hospitals. For
23the purposes of this subsection (a-5), a hospital's payment
24ratio is defined as the quotient obtained by dividing the total
25payments for the State fiscal year, as authorized under Section
265A-12.2, Section 5A-12.4, or Section 5A-12.6, by the total

SB1321 Enrolled- 69 -LRB101 10606 KTG 55712 b
1assessment for the State fiscal year imposed under Section 5A-2
2or subsection (b-5) of Section 5A-2.
3 (b) The Illinois Department is authorized to establish
4delayed payment schedules for hospital providers that are
5unable to make installment payments when due under this Section
6due to financial difficulties, as determined by the Illinois
7Department.
8 (c) If a hospital provider fails to pay the full amount of
9an installment when due (including any extensions granted under
10subsection (b)), there shall, unless waived by the Illinois
11Department for reasonable cause, be added to the assessment
12imposed by Section 5A-2 a penalty assessment equal to the
13lesser of (i) 5% of the amount of the installment not paid on
14or before the due date plus 5% of the portion thereof remaining
15unpaid on the last day of each 30-day period thereafter or (ii)
16100% of the installment amount not paid on or before the due
17date. For purposes of this subsection, payments will be
18credited first to unpaid installment amounts (rather than to
19penalty or interest), beginning with the most delinquent
20installments.
21 (d) Any assessment amount that is due and payable to the
22Illinois Department more frequently than once per calendar
23quarter shall be remitted to the Illinois Department by the
24hospital provider by means of electronic funds transfer. The
25Illinois Department may provide for remittance by other means
26if (i) the amount due is less than $10,000 or (ii) electronic

SB1321 Enrolled- 70 -LRB101 10606 KTG 55712 b
1funds transfer is unavailable for this purpose.
2(Source: P.A. 100-581, eff. 3-12-18; 100-1181, eff. 3-8-19.)
3 (305 ILCS 5/11-5.1)
4 Sec. 11-5.1. Eligibility verification. Notwithstanding any
5other provision of this Code, with respect to applications for
6medical assistance provided under Article V of this Code,
7eligibility shall be determined in a manner that ensures
8program integrity and complies with federal laws and
9regulations while minimizing unnecessary barriers to
10enrollment. To this end, as soon as practicable, and unless the
11Department receives written denial from the federal
12government, this Section shall be implemented:
13 (a) The Department of Healthcare and Family Services or its
14designees shall:
15 (1) By no later than July 1, 2011, require verification
16 of, at a minimum, one month's income from all sources
17 required for determining the eligibility of applicants for
18 medical assistance under this Code. Such verification
19 shall take the form of pay stubs, business or income and
20 expense records for self-employed persons, letters from
21 employers, and any other valid documentation of income
22 including data obtained electronically by the Department
23 or its designees from other sources as described in
24 subsection (b) of this Section.
25 (2) By no later than October 1, 2011, require

SB1321 Enrolled- 71 -LRB101 10606 KTG 55712 b
1 verification of, at a minimum, one month's income from all
2 sources required for determining the continued eligibility
3 of recipients at their annual review of eligibility for
4 medical assistance under this Code. Information the
5 Department receives prior to the annual review, including
6 information available to the Department as a result of the
7 recipient's application for other non-Medicaid benefits,
8 that is sufficient to make a determination of continued
9 Medicaid eligibility may be reviewed and verified, and
10 subsequent action taken including client notification of
11 continued Medicaid eligibility. The date of client
12 notification establishes the date for subsequent annual
13 Medicaid eligibility reviews. Such verification shall take
14 the form of pay stubs, business or income and expense
15 records for self-employed persons, letters from employers,
16 and any other valid documentation of income including data
17 obtained electronically by the Department or its designees
18 from other sources as described in subsection (b) of this
19 Section. A month's income may be verified by a single pay
20 stub with the monthly income extrapolated from the time
21 period covered by the pay stub. The Department shall send a
22 notice to recipients at least 60 days prior to the end of
23 their period of eligibility that informs them of the
24 requirements for continued eligibility. If a recipient
25 does not fulfill the requirements for continued
26 eligibility by the deadline established in the notice a

SB1321 Enrolled- 72 -LRB101 10606 KTG 55712 b
1 notice of cancellation shall be issued to the recipient and
2 coverage shall end no later than the last day of the month
3 following on the last day of the eligibility period. A
4 recipient's eligibility may be reinstated without
5 requiring a new application if the recipient fulfills the
6 requirements for continued eligibility prior to the end of
7 the third month following the last date of coverage (or
8 longer period if required by federal regulations). Nothing
9 in this Section shall prevent an individual whose coverage
10 has been cancelled from reapplying for health benefits at
11 any time.
12 (3) By no later than July 1, 2011, require verification
13 of Illinois residency.
14 The Department, with federal approval, may choose to adopt
15continuous financial eligibility for a full 12 months for
16adults on Medicaid.
17 (b) The Department shall establish or continue cooperative
18arrangements with the Social Security Administration, the
19Illinois Secretary of State, the Department of Human Services,
20the Department of Revenue, the Department of Employment
21Security, and any other appropriate entity to gain electronic
22access, to the extent allowed by law, to information available
23to those entities that may be appropriate for electronically
24verifying any factor of eligibility for benefits under the
25Program. Data relevant to eligibility shall be provided for no
26other purpose than to verify the eligibility of new applicants

SB1321 Enrolled- 73 -LRB101 10606 KTG 55712 b
1or current recipients of health benefits under the Program.
2Data shall be requested or provided for any new applicant or
3current recipient only insofar as that individual's
4circumstances are relevant to that individual's or another
5individual's eligibility.
6 (c) Within 90 days of the effective date of this amendatory
7Act of the 96th General Assembly, the Department of Healthcare
8and Family Services shall send notice to current recipients
9informing them of the changes regarding their eligibility
10verification.
11 (d) As soon as practical if the data is reasonably
12available, but no later than January 1, 2017, the Department
13shall compile on a monthly basis data on eligibility
14redeterminations of beneficiaries of medical assistance
15provided under Article V of this Code. This data shall be
16posted on the Department's website, and data from prior months
17shall be retained and available on the Department's website.
18The data compiled and reported shall include the following:
19 (1) The total number of redetermination decisions made
20 in a month and, of that total number, the number of
21 decisions to continue or change benefits and the number of
22 decisions to cancel benefits.
23 (2) A breakdown of enrollee language preference for the
24 total number of redetermination decisions made in a month
25 and, of that total number, a breakdown of enrollee language
26 preference for the number of decisions to continue or

SB1321 Enrolled- 74 -LRB101 10606 KTG 55712 b
1 change benefits, and a breakdown of enrollee language
2 preference for the number of decisions to cancel benefits.
3 The language breakdown shall include, at a minimum,
4 English, Spanish, and the next 4 most commonly used
5 languages.
6 (3) The percentage of cancellation decisions made in a
7 month due to each of the following:
8 (A) The beneficiary's ineligibility due to excess
9 income.
10 (B) The beneficiary's ineligibility due to not
11 being an Illinois resident.
12 (C) The beneficiary's ineligibility due to being
13 deceased.
14 (D) The beneficiary's request to cancel benefits.
15 (E) The beneficiary's lack of response after
16 notices mailed to the beneficiary are returned to the
17 Department as undeliverable by the United States
18 Postal Service.
19 (F) The beneficiary's lack of response to a request
20 for additional information when reliable information
21 in the beneficiary's account, or other more current
22 information, is unavailable to the Department to make a
23 decision on whether to continue benefits.
24 (G) Other reasons tracked by the Department for the
25 purpose of ensuring program integrity.
26 (4) If a vendor is utilized to provide services in

SB1321 Enrolled- 75 -LRB101 10606 KTG 55712 b
1 support of the Department's redetermination decision
2 process, the total number of redetermination decisions
3 made in a month and, of that total number, the number of
4 decisions to continue or change benefits, and the number of
5 decisions to cancel benefits (i) with the involvement of
6 the vendor and (ii) without the involvement of the vendor.
7 (5) Of the total number of benefit cancellations in a
8 month, the number of beneficiaries who return from
9 cancellation within one month, the number of beneficiaries
10 who return from cancellation within 2 months, and the
11 number of beneficiaries who return from cancellation
12 within 3 months. Of the number of beneficiaries who return
13 from cancellation within 3 months, the percentage of those
14 cancellations due to each of the reasons listed under
15 paragraph (3) of this subsection.
16 (e) The Department shall conduct a complete review of the
17Medicaid redetermination process in order to identify changes
18that can increase the use of ex parte redetermination
19processing. This review shall be completed within 90 days after
20the effective date of this amendatory Act of the 101st General
21Assembly. Within 90 days of completion of the review, the
22Department shall seek written federal approval of policy
23changes the review recommended and implement once approved. The
24review shall specifically include, but not be limited to, use
25of ex parte redeterminations of the following populations:
26 (1) Recipients of developmental disabilities services.

SB1321 Enrolled- 76 -LRB101 10606 KTG 55712 b
1 (2) Recipients of benefits under the State's Aid to the
2 Aged, Blind, or Disabled program.
3 (3) Recipients of Medicaid long-term care services and
4 supports, including waiver services.
5 (4) All Modified Adjusted Gross Income (MAGI)
6 populations.
7 (5) Populations with no verifiable income.
8 (6) Self-employed people.
9 The report shall also outline populations and
10circumstances in which an ex parte redetermination is not a
11recommended option.
12 (f) The Department shall explore and implement, as
13practical and technologically possible, roles that
14stakeholders outside State agencies can play to assist in
15expediting eligibility determinations and redeterminations
16within 24 months after the effective date of this amendatory
17Act of the 101st General Assembly. Such practical roles to be
18explored to expedite the eligibility determination processes
19shall include the implementation of hospital presumptive
20eligibility, as authorized by the Patient Protection and
21Affordable Care Act.
22 (g) The Department or its designee shall seek federal
23approval to enhance the reasonable compatibility standard from
245% to 10%.
25 (h) Reporting. The Department of Healthcare and Family
26Services and the Department of Human Services shall publish

SB1321 Enrolled- 77 -LRB101 10606 KTG 55712 b
1quarterly reports on their progress in implementing policies
2and practices pursuant to this Section as modified by this
3amendatory Act of the 101st General Assembly.
4 (1) The reports shall include, but not be limited to,
5 the following:
6 (A) Medical application processing, including a
7 breakdown of the number of MAGI, non-MAGI, long-term
8 care, and other medical cases pending for various
9 incremental time frames between 0 to 181 or more days.
10 (B) Medical redeterminations completed, including:
11 (i) a breakdown of the number of households that were
12 redetermined ex parte and those that were not; (ii) the
13 reasons households were not redetermined ex parte; and
14 (iii) the relative percentages of these reasons.
15 (C) A narrative discussion on issues identified in
16 the functioning of the State's Integrated Eligibility
17 System and progress on addressing those issues, as well
18 as progress on implementing strategies to address
19 eligibility backlogs, including expanding ex parte
20 determinations to ensure timely eligibility
21 determinations and renewals.
22 (2) Initial reports shall be issued within 90 days
23 after the effective date of this amendatory Act of the
24 101st General Assembly.
25 (3) All reports shall be published on the Department's
26 website.

SB1321 Enrolled- 78 -LRB101 10606 KTG 55712 b
1(Source: P.A. 98-651, eff. 6-16-14; 99-86, eff. 7-21-15.)
2 (305 ILCS 5/11-5.3)
3 Sec. 11-5.3. Procurement of vendor to verify eligibility
4for assistance under Article V.
5 (a) No later than 60 days after the effective date of this
6amendatory Act of the 97th General Assembly, the Chief
7Procurement Officer for General Services, in consultation with
8the Department of Healthcare and Family Services, shall conduct
9and complete any procurement necessary to procure a vendor to
10verify eligibility for assistance under Article V of this Code.
11Such authority shall include procuring a vendor to assist the
12Chief Procurement Officer in conducting the procurement. The
13Chief Procurement Officer and the Department shall jointly
14negotiate final contract terms with a vendor selected by the
15Chief Procurement Officer. Within 30 days of selection of an
16eligibility verification vendor, the Department of Healthcare
17and Family Services shall enter into a contract with the
18selected vendor. The Department of Healthcare and Family
19Services and the Department of Human Services shall cooperate
20with and provide any information requested by the Chief
21Procurement Officer to conduct the procurement.
22 (b) Notwithstanding any other provision of law, any
23procurement or contract necessary to comply with this Section
24shall be exempt from: (i) the Illinois Procurement Code
25pursuant to Section 1-10(h) of the Illinois Procurement Code,

SB1321 Enrolled- 79 -LRB101 10606 KTG 55712 b
1except that bidders shall comply with the disclosure
2requirement in Sections 50-10.5(a) through (d), 50-13, 50-35,
3and 50-37 of the Illinois Procurement Code and a vendor awarded
4a contract under this Section shall comply with Section 50-37
5of the Illinois Procurement Code; (ii) any administrative rules
6of this State pertaining to procurement or contract formation;
7and (iii) any State or Department policies or procedures
8pertaining to procurement, contract formation, contract award,
9and Business Enterprise Program approval.
10 (c) Upon becoming operational, the contractor shall
11conduct data matches using the name, date of birth, address,
12and Social Security Number of each applicant and recipient
13against public records to verify eligibility. The contractor,
14upon preliminary determination that an enrollee is eligible or
15ineligible, shall notify the Department, except that the
16contractor shall not make preliminary determinations regarding
17the eligibility of persons residing in long term care
18facilities whose income and resources were at or below the
19applicable financial eligibility standards at the time of their
20last review. Within 20 business days of such notification, the
21Department shall accept the recommendation or reject it with a
22stated reason. The Department shall retain final authority over
23eligibility determinations. The contractor shall keep a record
24of all preliminary determinations of ineligibility
25communicated to the Department. Within 30 days of the end of
26each calendar quarter, the Department and contractor shall file

SB1321 Enrolled- 80 -LRB101 10606 KTG 55712 b
1a joint report on a quarterly basis to the Governor, the
2Speaker of the House of Representatives, the Minority Leader of
3the House of Representatives, the Senate President, and the
4Senate Minority Leader. The report shall include, but shall not
5be limited to, monthly recommendations of preliminary
6determinations of eligibility or ineligibility communicated by
7the contractor, the actions taken on those preliminary
8determinations by the Department, and the stated reasons for
9those recommendations that the Department rejected.
10 (d) An eligibility verification vendor contract shall be
11awarded for an initial 2-year period with up to a maximum of 2
12one-year renewal options. Nothing in this Section shall compel
13the award of a contract to a vendor that fails to meet the
14needs of the Department. A contract with a vendor to assist in
15the procurement shall be awarded for a period of time not to
16exceed 6 months.
17 (e) The provisions of this Section shall be administered in
18compliance with federal law.
19 (f) The State's Integrated Eligibility System shall be on a
203-year audit cycle by the Office of the Auditor General.
21(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
22 (305 ILCS 5/11-5.4)
23 (Text of Section from P.A. 100-665)
24 Sec. 11-5.4. Expedited long-term care eligibility
25determination and enrollment.

SB1321 Enrolled- 81 -LRB101 10606 KTG 55712 b
1 (a) Establishment of the expedited long-term care
2eligibility determination and enrollment system shall be a
3joint venture of the Departments of Human Services and
4Healthcare and Family Services and the Department on Aging.
5 (b) Streamlined application enrollment process; expedited
6eligibility process. The streamlined application and
7enrollment process must include, but need not be limited to,
8the following:
9 (1) On or before July 1, 2019, a streamlined
10 application and enrollment process shall be put in place
11 which must include, but need not be limited to, the
12 following:
13 (A) Minimize the burden on applicants by
14 collecting only the data necessary to determine
15 eligibility for medical services, long-term care
16 services, and spousal impoverishment offset.
17 (B) Integrate online data sources to simplify the
18 application process by reducing the amount of
19 information needed to be entered and to expedite
20 eligibility verification.
21 (C) Provide online prompts to alert the applicant
22 that information is missing or not complete.
23 (D) Provide training and step-by-step written
24 instructions for caseworkers, applicants, and
25 providers.
26 (2) The State must expedite the eligibility process for

SB1321 Enrolled- 82 -LRB101 10606 KTG 55712 b
1 applicants meeting specified guidelines, regardless of the
2 age of the application. The guidelines, subject to federal
3 approval, must include, but need not be limited to, the
4 following individually or collectively:
5 (A) Full Medicaid benefits in the community for a
6 specified period of time.
7 (B) No transfer of assets or resources during the
8 federally prescribed look-back period, as specified in
9 federal law.
10 (C) Receives Supplemental Security Income payments
11 or was receiving such payments at the time of admission
12 to a nursing facility.
13 (D) For applicants or recipients with verified
14 income at or below 100% of the federal poverty level
15 when the declared value of their countable resources is
16 no greater than the allowable amounts pursuant to
17 Section 5-2 of this Code for classes of eligible
18 persons for whom a resource limit applies. Such
19 simplified verification policies shall apply to
20 community cases as well as long-term care cases.
21 (3) Subject to federal approval, the Department of
22 Healthcare and Family Services must implement an ex parte
23 renewal process for Medicaid-eligible individuals residing
24 in long-term care facilities. "Renewal" has the same
25 meaning as "redetermination" in State policies,
26 administrative rule, and federal Medicaid law. The ex parte

SB1321 Enrolled- 83 -LRB101 10606 KTG 55712 b
1 renewal process must be fully operational on or before
2 January 1, 2019.
3 (4) The Department of Human Services must use the
4 standards and distribution requirements described in this
5 subsection and in Section 11-6 for notification of missing
6 supporting documents and information during all phases of
7 the application process: initial, renewal, and appeal.
8 (c) The Department of Human Services must adopt policies
9and procedures to improve communication between long-term care
10benefits central office personnel, applicants and their
11representatives, and facilities in which the applicants
12reside. Such policies and procedures must at a minimum permit
13applicants and their representatives and the facility in which
14the applicants reside to speak directly to an individual
15trained to take telephone inquiries and provide appropriate
16responses.
17 (d) Effective 30 days after the completion of 3 regionally
18based trainings, nursing facilities shall submit all
19applications for medical assistance online via the Application
20for Benefits Eligibility (ABE) website. This requirement shall
21extend to scanning and uploading with the online application
22any required additional forms such as the Long Term Care
23Facility Notification and the Additional Financial Information
24for Long Term Care Applicants as well as scanned copies of any
25supporting documentation. Long-term care facility admission
26documents must be submitted as required in Section 5-5 of this

SB1321 Enrolled- 84 -LRB101 10606 KTG 55712 b
1Code. No local Department of Human Services office shall refuse
2to accept an electronically filed application. No Department of
3Human Services office shall request submission of any document
4in hard copy.
5 (e) Notwithstanding any other provision of this Code, the
6Department of Human Services and the Department of Healthcare
7and Family Services' Office of the Inspector General shall,
8upon request, allow an applicant additional time to submit
9information and documents needed as part of a review of
10available resources or resources transferred during the
11look-back period. The initial extension shall not exceed 30
12days. A second extension of 30 days may be granted upon
13request. Any request for information issued by the State to an
14applicant shall include the following: an explanation of the
15information required and the date by which the information must
16be submitted; a statement that failure to respond in a timely
17manner can result in denial of the application; a statement
18that the applicant or the facility in the name of the applicant
19may seek an extension; and the name and contact information of
20a caseworker in case of questions. Any such request for
21information shall also be sent to the facility. In deciding
22whether to grant an extension, the Department of Human Services
23or the Department of Healthcare and Family Services' Office of
24the Inspector General shall take into account what is in the
25best interest of the applicant. The time limits for processing
26an application shall be tolled during the period of any

SB1321 Enrolled- 85 -LRB101 10606 KTG 55712 b
1extension granted under this subsection.
2 (f) The Department of Human Services and the Department of
3Healthcare and Family Services must jointly compile data on
4pending applications, denials, appeals, and redeterminations
5into a monthly report, which shall be posted on each
6Department's website for the purposes of monitoring long-term
7care eligibility processing. The report must specify the number
8of applications and redeterminations pending long-term care
9eligibility determination and admission and the number of
10appeals of denials in the following categories:
11 (A) Length of time applications, redeterminations, and
12 appeals are pending - 0 to 45 days, 46 days to 90 days, 91
13 days to 180 days, 181 days to 12 months, over 12 months to
14 18 months, over 18 months to 24 months, and over 24 months.
15 (B) Percentage of applications and redeterminations
16 pending in the Department of Human Services' Family
17 Community Resource Centers, in the Department of Human
18 Services' long-term care hubs, with the Department of
19 Healthcare and Family Services' Office of Inspector
20 General, and those applications which are being tolled due
21 to requests for extension of time for additional
22 information.
23 (C) Status of pending applications, denials, appeals,
24 and redeterminations.
25 (g) Beginning on July 1, 2017, the Auditor General shall
26report every 3 years to the General Assembly on the performance

SB1321 Enrolled- 86 -LRB101 10606 KTG 55712 b
1and compliance of the Department of Healthcare and Family
2Services, the Department of Human Services, and the Department
3on Aging in meeting the requirements of this Section and the
4federal requirements concerning eligibility determinations for
5Medicaid long-term care services and supports, and shall report
6any issues or deficiencies and make recommendations. The
7Auditor General shall, at a minimum, review, consider, and
8evaluate the following:
9 (1) compliance with federal regulations on furnishing
10 services as related to Medicaid long-term care services and
11 supports as provided under 42 CFR 435.930;
12 (2) compliance with federal regulations on the timely
13 determination of eligibility as provided under 42 CFR
14 435.912;
15 (3) the accuracy and completeness of the report
16 required under paragraph (9) of subsection (e);
17 (4) the efficacy and efficiency of the task-based
18 process used for making eligibility determinations in the
19 centralized offices of the Department of Human Services for
20 long-term care services, including the role of the State's
21 integrated eligibility system, as opposed to the
22 traditional caseworker-specific process from which these
23 central offices have converted; and
24 (5) any issues affecting eligibility determinations
25 related to the Department of Human Services' staff
26 completing Medicaid eligibility determinations instead of

SB1321 Enrolled- 87 -LRB101 10606 KTG 55712 b
1 the designated single-state Medicaid agency in Illinois,
2 the Department of Healthcare and Family Services.
3 The Auditor General's report shall include any and all
4other areas or issues which are identified through an annual
5review. Paragraphs (1) through (5) of this subsection shall not
6be construed to limit the scope of the annual review and the
7Auditor General's authority to thoroughly and completely
8evaluate any and all processes, policies, and procedures
9concerning compliance with federal and State law requirements
10on eligibility determinations for Medicaid long-term care
11services and supports.
12 (h) The Department of Healthcare and Family Services shall
13adopt any rules necessary to administer and enforce any
14provision of this Section. Rulemaking shall not delay the full
15implementation of this Section.
16(Source: P.A. 99-153, eff. 7-28-15; 100-380, eff. 8-25-17;
17100-665, eff. 8-2-18.)
18 (Text of Section from P.A. 100-1141)
19 Sec. 11-5.4. Expedited long-term care eligibility
20determination and enrollment.
21 (a) An expedited long-term care eligibility determination
22and enrollment system shall be established to reduce long-term
23care determinations to 90 days or fewer by July 1, 2014 and
24streamline the long-term care enrollment process.
25Establishment of the system shall be a joint venture of the

SB1321 Enrolled- 88 -LRB101 10606 KTG 55712 b
1Department of Human Services and Healthcare and Family Services
2and the Department on Aging. The Governor shall name a lead
3agency no later than 30 days after the effective date of this
4amendatory Act of the 98th General Assembly to assume
5responsibility for the full implementation of the
6establishment and maintenance of the system. Project outcomes
7shall include an enhanced eligibility determination tracking
8system accessible to providers and a centralized application
9review and eligibility determination with all applicants
10reviewed within 90 days of receipt by the State of a complete
11application. If the Department of Healthcare and Family
12Services' Office of the Inspector General determines that there
13is a likelihood that a non-allowable transfer of assets has
14occurred, and the facility in which the applicant resides is
15notified, an extension of up to 90 days shall be permissible.
16On or before December 31, 2015, a streamlined application and
17enrollment process shall be put in place based on the following
18principles:
19 (1) Minimize the burden on applicants by collecting
20 only the data necessary to determine eligibility for
21 medical services, long-term care services, and spousal
22 impoverishment offset.
23 (2) Integrate online data sources to simplify the
24 application process by reducing the amount of information
25 needed to be entered and to expedite eligibility
26 verification.

SB1321 Enrolled- 89 -LRB101 10606 KTG 55712 b
1 (3) Provide online prompts to alert the applicant that
2 information is missing or not complete.
3 (b) The Department shall, on or before July 1, 2014, assess
4the feasibility of incorporating all information needed to
5determine eligibility for long-term care services, including
6asset transfer and spousal impoverishment financials, into the
7State's integrated eligibility system identifying all
8resources needed and reasonable timeframes for achieving the
9specified integration.
10 (c) The lead agency shall file interim reports with the
11Chairs and Minority Spokespersons of the House and Senate Human
12Services Committees no later than September 1, 2013 and on
13February 1, 2014. The Department of Healthcare and Family
14Services shall include in the annual Medicaid report for State
15Fiscal Year 2014 and every fiscal year thereafter information
16concerning implementation of the provisions of this Section.
17 (d) No later than August 1, 2014, the Auditor General shall
18report to the General Assembly concerning the extent to which
19the timeframes specified in this Section have been met and the
20extent to which State staffing levels are adequate to meet the
21requirements of this Section.
22 (e) The Department of Healthcare and Family Services, the
23Department of Human Services, and the Department on Aging shall
24take the following steps to achieve federally established
25timeframes for eligibility determinations for Medicaid and
26long-term care benefits and shall work toward the federal goal

SB1321 Enrolled- 90 -LRB101 10606 KTG 55712 b
1of real time determinations:
2 (1) The Departments shall review, in collaboration
3 with representatives of affected providers, all forms and
4 procedures currently in use, federal guidelines either
5 suggested or mandated, and staff deployment by September
6 30, 2014 to identify additional measures that can improve
7 long-term care eligibility processing and make adjustments
8 where possible.
9 (2) No later than June 30, 2014, the Department of
10 Healthcare and Family Services shall issue vouchers for
11 advance payments not to exceed $50,000,000 to nursing
12 facilities with significant outstanding Medicaid liability
13 associated with services provided to residents with
14 Medicaid applications pending and residents facing the
15 greatest delays. Each facility with an advance payment
16 shall state in writing whether its own recoupment schedule
17 will be in 3 or 6 equal monthly installments, as long as
18 all advances are recouped by June 30, 2015.
19 (3) The Department of Healthcare and Family Services'
20 Office of Inspector General and the Department of Human
21 Services shall immediately forgo resource review and
22 review of transfers during the relevant look-back period
23 for applications that were submitted prior to September 1,
24 2013. An applicant who applied prior to September 1, 2013,
25 who was denied for failure to cooperate in providing
26 required information, and whose application was

SB1321 Enrolled- 91 -LRB101 10606 KTG 55712 b
1 incorrectly reviewed under the wrong look-back period
2 rules may request review and correction of the denial based
3 on this subsection. If found eligible upon review, such
4 applicants shall be retroactively enrolled.
5 (4) As soon as practicable, the Department of
6 Healthcare and Family Services shall implement policies
7 and promulgate rules to simplify financial eligibility
8 verification in the following instances: (A) for
9 applicants or recipients who are receiving Supplemental
10 Security Income payments or who had been receiving such
11 payments at the time they were admitted to a nursing
12 facility and (B) for applicants or recipients with verified
13 income at or below 100% of the federal poverty level when
14 the declared value of their countable resources is no
15 greater than the allowable amounts pursuant to Section 5-2
16 of this Code for classes of eligible persons for whom a
17 resource limit applies. Such simplified verification
18 policies shall apply to community cases as well as
19 long-term care cases.
20 (5) As soon as practicable, but not later than July 1,
21 2014, the Department of Healthcare and Family Services and
22 the Department of Human Services shall jointly begin a
23 special enrollment project by using simplified eligibility
24 verification policies and by redeploying caseworkers
25 trained to handle long-term care cases to prioritize those
26 cases, until the backlog is eliminated and processing time

SB1321 Enrolled- 92 -LRB101 10606 KTG 55712 b
1 is within 90 days. This project shall apply to applications
2 for long-term care received by the State on or before May
3 15, 2014.
4 (6) As soon as practicable, but not later than
5 September 1, 2014, the Department on Aging shall make
6 available to long-term care facilities and community
7 providers upon request, through an electronic method, the
8 information contained within the Interagency Certification
9 of Screening Results completed by the pre-screener, in a
10 form and manner acceptable to the Department of Human
11 Services.
12 (7) Effective 30 days after the completion of 3
13 regionally based trainings, nursing facilities shall
14 submit all applications for medical assistance online via
15 the Application for Benefits Eligibility (ABE) website.
16 This requirement shall extend to scanning and uploading
17 with the online application any required additional forms
18 such as the Long Term Care Facility Notification and the
19 Additional Financial Information for Long Term Care
20 Applicants as well as scanned copies of any supporting
21 documentation. Long-term care facility admission documents
22 must be submitted as required in Section 5-5 of this Code.
23 No local Department of Human Services office shall refuse
24 to accept an electronically filed application.
25 (8) Notwithstanding any other provision of this Code,
26 the Department of Human Services and the Department of

SB1321 Enrolled- 93 -LRB101 10606 KTG 55712 b
1 Healthcare and Family Services' Office of the Inspector
2 General shall, upon request, allow an applicant additional
3 time to submit information and documents needed as part of
4 a review of available resources or resources transferred
5 during the look-back period. The initial extension shall
6 not exceed 30 days. A second extension of 30 days may be
7 granted upon request. Any request for information issued by
8 the State to an applicant shall include the following: an
9 explanation of the information required and the date by
10 which the information must be submitted; a statement that
11 failure to respond in a timely manner can result in denial
12 of the application; a statement that the applicant or the
13 facility in the name of the applicant may seek an
14 extension; and the name and contact information of a
15 caseworker in case of questions. Any such request for
16 information shall also be sent to the facility. In deciding
17 whether to grant an extension, the Department of Human
18 Services or the Department of Healthcare and Family
19 Services' Office of the Inspector General shall take into
20 account what is in the best interest of the applicant. The
21 time limits for processing an application shall be tolled
22 during the period of any extension granted under this
23 subsection.
24 (9) The Department of Human Services and the Department
25 of Healthcare and Family Services must jointly compile data
26 on pending applications, denials, appeals, and

SB1321 Enrolled- 94 -LRB101 10606 KTG 55712 b
1 redeterminations into a monthly report, which shall be
2 posted on each Department's website for the purposes of
3 monitoring long-term care eligibility processing. The
4 report must specify the number of applications and
5 redeterminations pending long-term care eligibility
6 determination and admission and the number of appeals of
7 denials in the following categories:
8 (A) Length of time applications, redeterminations,
9 and appeals are pending - 0 to 45 days, 46 days to 90
10 days, 91 days to 180 days, 181 days to 12 months, over
11 12 months to 18 months, over 18 months to 24 months,
12 and over 24 months.
13 (B) Percentage of applications and
14 redeterminations pending in the Department of Human
15 Services' Family Community Resource Centers, in the
16 Department of Human Services' long-term care hubs,
17 with the Department of Healthcare and Family Services'
18 Office of Inspector General, and those applications
19 which are being tolled due to requests for extension of
20 time for additional information.
21 (C) Status of pending applications, denials,
22 appeals, and redeterminations.
23 (f) Beginning on July 1, 2017, the Auditor General shall
24report every 3 years to the General Assembly on the performance
25and compliance of the Department of Healthcare and Family
26Services, the Department of Human Services, and the Department

SB1321 Enrolled- 95 -LRB101 10606 KTG 55712 b
1on Aging in meeting the requirements of this Section and the
2federal requirements concerning eligibility determinations for
3Medicaid long-term care services and supports, and shall report
4any issues or deficiencies and make recommendations. The
5Auditor General shall, at a minimum, review, consider, and
6evaluate the following:
7 (1) compliance with federal regulations on furnishing
8 services as related to Medicaid long-term care services and
9 supports as provided under 42 CFR 435.930;
10 (2) compliance with federal regulations on the timely
11 determination of eligibility as provided under 42 CFR
12 435.912;
13 (3) the accuracy and completeness of the report
14 required under paragraph (9) of subsection (e);
15 (4) the efficacy and efficiency of the task-based
16 process used for making eligibility determinations in the
17 centralized offices of the Department of Human Services for
18 long-term care services, including the role of the State's
19 integrated eligibility system, as opposed to the
20 traditional caseworker-specific process from which these
21 central offices have converted; and
22 (5) any issues affecting eligibility determinations
23 related to the Department of Human Services' staff
24 completing Medicaid eligibility determinations instead of
25 the designated single-state Medicaid agency in Illinois,
26 the Department of Healthcare and Family Services.

SB1321 Enrolled- 96 -LRB101 10606 KTG 55712 b
1 The Auditor General's report shall include any and all
2other areas or issues which are identified through an annual
3review. Paragraphs (1) through (5) of this subsection shall not
4be construed to limit the scope of the annual review and the
5Auditor General's authority to thoroughly and completely
6evaluate any and all processes, policies, and procedures
7concerning compliance with federal and State law requirements
8on eligibility determinations for Medicaid long-term care
9services and supports.
10 (g) The Department shall adopt rules necessary to
11administer and enforce any provision of this Section.
12Rulemaking shall not delay the full implementation of this
13Section.
14 (h) Beginning on June 29, 2018, provisional eligibility for
15medical assistance under Article V of this Code, in the form of
16a recipient identification number and any other necessary
17credentials to permit an applicant to receive covered services
18under Article V benefits, must be issued to any applicant who
19has not received a final eligibility determination on his or
20her application for Medicaid and Medicaid long-term care
21services filed simultaneously or, if already Medicaid
22enrolled, application for or Medicaid long-term care services
23under Article V of this Code benefits or a notice of an
24opportunity for a hearing within the federally prescribed
25timeliness requirements for determinations on deadlines for
26the processing of such applications. The Department must

SB1321 Enrolled- 97 -LRB101 10606 KTG 55712 b
1maintain the applicant's provisional eligibility Medicaid
2enrollment status until a final eligibility determination is
3made on the individual's application for long-term care
4services approved or the applicant's appeal has been
5adjudicated and eligibility is denied. The Department or the
6managed care organization, if applicable, must reimburse
7providers for services rendered during an applicant's
8provisional eligibility period.
9 (1) Claims for services rendered to an applicant with
10 provisional eligibility status must be submitted and
11 processed in the same manner as those submitted on behalf
12 of beneficiaries determined to qualify for benefits.
13 (2) An applicant with provisional eligibility
14 enrollment status must have his or her long-term care
15 benefits paid for under the State's fee-for-service system
16 during the period of provisional eligibility until the
17 State makes a final determination on the applicant's
18 Medicaid or Medicaid long-term care application. If an
19 individual otherwise eligible for medical assistance under
20 Article V of this Code is enrolled with a managed care
21 organization for community benefits at the time the
22 individual's provisional eligibility for long-term care
23 services status is issued, the managed care organization is
24 only responsible for paying benefits covered under the
25 capitation payment received by the managed care
26 organization for the individual.

SB1321 Enrolled- 98 -LRB101 10606 KTG 55712 b
1 (3) The Department, within 10 business days of issuing
2 provisional eligibility to an applicant, must submit to the
3 Office of the Comptroller for payment a voucher for all
4 retroactive reimbursement due. The Department must clearly
5 identify such vouchers as provisional eligibility
6 vouchers.
7(Source: P.A. 99-153, eff. 7-28-15; 100-380, eff. 8-25-17;
8100-1141, eff. 11-28-18.)
9 (305 ILCS 5/12-4.42)
10 Sec. 12-4.42. Medicaid Revenue Maximization.
11 (a) Purpose. The General Assembly finds that there is a
12need to make changes to the administration of services provided
13by State and local governments in order to maximize federal
14financial participation.
15 (b) Definitions. As used in this Section:
16 "Community Medicaid mental health services" means all
17mental health services outlined in Part 132 of Title 59 of the
18Illinois Administrative Code that are funded through DHS,
19eligible for federal financial participation, and provided by a
20community-based provider.
21 "Community-based provider" means an entity enrolled as a
22provider pursuant to Sections 140.11 and 140.12 of Title 89 of
23the Illinois Administrative Code and certified to provide
24community Medicaid mental health services in accordance with
25Part 132 of Title 59 of the Illinois Administrative Code.

SB1321 Enrolled- 99 -LRB101 10606 KTG 55712 b
1 "DCFS" means the Department of Children and Family
2Services.
3 "Department" means the Illinois Department of Healthcare
4and Family Services.
5 "Care facility for persons with a developmental
6disability" means an intermediate care facility for persons
7with an intellectual disability within the meaning of Title XIX
8of the Social Security Act, whether public or private and
9whether organized for profit or not-for-profit, but shall not
10include any facility operated by the State.
11 "Care provider for persons with a developmental
12disability" means a person conducting, operating, or
13maintaining a care facility for persons with a developmental
14disability. For purposes of this definition, "person" means any
15political subdivision of the State, municipal corporation,
16individual, firm, partnership, corporation, company, limited
17liability company, association, joint stock association, or
18trust, or a receiver, executor, trustee, guardian, or other
19representative appointed by order of any court.
20 "DHS" means the Illinois Department of Human Services.
21 "Hospital" means an institution, place, building, or
22agency located in this State that is licensed as a general
23acute hospital by the Illinois Department of Public Health
24under the Hospital Licensing Act, whether public or private and
25whether organized for profit or not-for-profit.
26 "Long term care facility" means (i) a skilled nursing or

SB1321 Enrolled- 100 -LRB101 10606 KTG 55712 b
1intermediate long term care facility, whether public or private
2and whether organized for profit or not-for-profit, that is
3subject to licensure by the Illinois Department of Public
4Health under the Nursing Home Care Act, including a county
5nursing home directed and maintained under Section 5-1005 of
6the Counties Code, and (ii) a part of a hospital in which
7skilled or intermediate long term care services within the
8meaning of Title XVIII or XIX of the Social Security Act are
9provided; except that the term "long term care facility" does
10not include a facility operated solely as an intermediate care
11facility for the intellectually disabled within the meaning of
12Title XIX of the Social Security Act.
13 "Long term care provider" means (i) a person licensed by
14the Department of Public Health to operate and maintain a
15skilled nursing or intermediate long term care facility or (ii)
16a hospital provider that provides skilled or intermediate long
17term care services within the meaning of Title XVIII or XIX of
18the Social Security Act. For purposes of this definition,
19"person" means any political subdivision of the State,
20municipal corporation, individual, firm, partnership,
21corporation, company, limited liability company, association,
22joint stock association, or trust, or a receiver, executor,
23trustee, guardian, or other representative appointed by order
24of any court.
25 "State-operated facility for persons with a developmental
26disability" means an intermediate care facility for persons

SB1321 Enrolled- 101 -LRB101 10606 KTG 55712 b
1with an intellectual disability within the meaning of Title XIX
2of the Social Security Act operated by the State.
3 (c) Administration and deposit of Revenues. The Department
4shall coordinate the implementation of changes required by
5Public Act 96-1405 amongst the various State and local
6government bodies that administer programs referred to in this
7Section.
8 Revenues generated by program changes mandated by any
9provision in this Section, less reasonable administrative
10costs associated with the implementation of these program
11changes, which would otherwise be deposited into the General
12Revenue Fund shall be deposited into the Healthcare Provider
13Relief Fund.
14 The Department shall issue a report to the General Assembly
15detailing the implementation progress of Public Act 96-1405 as
16a part of the Department's Medical Programs annual report for
17fiscal years 2010 and 2011.
18 (d) Acceleration of payment vouchers. To the extent
19practicable and permissible under federal law, the Department
20shall create all vouchers for long term care facilities and
21facilities for persons with a developmental disability for
22dates of service in the month in which the enhanced federal
23medical assistance percentage (FMAP) originally set forth in
24the American Recovery and Reinvestment Act (ARRA) expires and
25for dates of service in the month prior to that month and
26shall, no later than the 15th of the month in which the

SB1321 Enrolled- 102 -LRB101 10606 KTG 55712 b
1enhanced FMAP expires, submit these vouchers to the Comptroller
2for payment.
3 The Department of Human Services shall create the necessary
4documentation for State-operated facilities for persons with a
5developmental disability so that the necessary data for all
6dates of service before the expiration of the enhanced FMAP
7originally set forth in the ARRA can be adjudicated by the
8Department no later than the 15th of the month in which the
9enhanced FMAP expires.
10 (e) Billing of DHS community Medicaid mental health
11services. No later than July 1, 2011, community Medicaid mental
12health services provided by a community-based provider must be
13billed directly to the Department.
14 (f) DCFS Medicaid services. The Department shall work with
15DCFS to identify existing programs, pending qualifying
16services, that can be converted in an economically feasible
17manner to Medicaid in order to secure federal financial
18revenue.
19 (g) (Blank). Third Party Liability recoveries. The
20Department shall contract with a vendor to support the
21Department in coordinating benefits for Medicaid enrollees.
22The scope of work shall include, at a minimum, the
23identification of other insurance for Medicaid enrollees and
24the recovery of funds paid by the Department when another payer
25was liable. The vendor may be paid a percentage of actual cash
26recovered when practical and subject to federal law.

SB1321 Enrolled- 103 -LRB101 10606 KTG 55712 b
1 (h) Public health departments. The Department shall
2identify unreimbursed costs for persons covered by Medicaid who
3are served by the Chicago Department of Public Health.
4 The Department shall assist the Chicago Department of
5Public Health in determining total unreimbursed costs
6associated with the provision of healthcare services to
7Medicaid enrollees.
8 The Department shall determine and draw the maximum
9allowable federal matching dollars associated with the cost of
10Chicago Department of Public Health services provided to
11Medicaid enrollees.
12 (i) Acceleration of hospital-based payments. The
13Department shall, by the 10th day of the month in which the
14enhanced FMAP originally set forth in the ARRA expires, create
15vouchers for all State fiscal year 2011 hospital payments
16exempt from the prompt payment requirements of the ARRA. The
17Department shall submit these vouchers to the Comptroller for
18payment.
19(Source: P.A. 99-143, eff. 7-27-15; 100-201, eff. 8-18-17.)
20 (305 ILCS 5/14-13 new)
21 Sec. 14-13. Reimbursement for inpatient stays extended
22beyond medical necessity.
23 (a) By October 1, 2019, the Department shall by rule
24implement a methodology effective for dates of service July 1,
252019 and later to reimburse hospitals for inpatient stays

SB1321 Enrolled- 104 -LRB101 10606 KTG 55712 b
1extended beyond medical necessity due to the inability of the
2Department or the managed care organization in which a
3recipient is enrolled or the hospital discharge planner to find
4an appropriate placement after discharge from the hospital.
5 (b) The methodology shall provide reasonable compensation
6for the services provided attributable to the days of the
7extended stay for which the prevailing rate methodology
8provides no reimbursement. The Department may use a day outlier
9program to satisfy this requirement. The reimbursement rate
10shall be set at a level so as not to act as an incentive to
11avoid transfer to the appropriate level of care needed or
12placement, after discharge.
13 (c) The Department shall require managed care
14organizations to adopt this methodology or an alternative
15methodology that pays at least as much as the Department's
16adopted methodology unless otherwise mutually agreed upon
17contractual language is developed by the provider and the
18managed care organization for a risk-based or innovative
19payment methodology.
20 (d) Days beyond medical necessity shall not be eligible for
21per diem add-on payments under the Medicaid High Volume
22Adjustment (MHVA) or the Medicaid Percentage Adjustment (MPA)
23programs.
24 (e) For services covered by the fee-for-service program,
25reimbursement under this Section shall only be made for days
26beyond medical necessity that occur after the hospital has

SB1321 Enrolled- 105 -LRB101 10606 KTG 55712 b
1notified the Department of the need for post-discharge
2placement. For services covered by a managed care organization,
3hospitals shall notify the appropriate managed care
4organization of an admission within 24 hours of admission. For
5every 24-hour period beyond the initial 24 hours after
6admission that the hospital fails to notify the managed care
7organization of the admission, reimbursement under this
8subsection shall be reduced by one day.
9 Section 45. The Illinois Public Aid Code is amended by
10reenacting and changing Section 5-5.07 as follows:
11 (305 ILCS 5/5-5.07)
12 Sec. 5-5.07. Inpatient psychiatric stay; DCFS per diem
13rate. The Department of Children and Family Services shall pay
14the DCFS per diem rate for inpatient psychiatric stay at a
15free-standing psychiatric hospital effective the 11th day when
16a child is in the hospital beyond medical necessity, and the
17parent or caregiver has denied the child access to the home and
18has refused or failed to make provisions for another living
19arrangement for the child or the child's discharge is being
20delayed due to a pending inquiry or investigation by the
21Department of Children and Family Services. If any portion of a
22hospital stay is reimbursed under this Section, the hospital
23stay shall not be eligible for payment under the provisions of
24Section 14-13 of this Code. This Section is inoperative on and

SB1321 Enrolled- 106 -LRB101 10606 KTG 55712 b
1after July 1, 2020. This Section is repealed 6 months after the
2effective date of this amendatory Act of the 100th General
3Assembly.
4(Source: P.A. 100-646, eff. 7-27-18.)
feedback