Bill Amendment: IL HB0238 | 2017-2018 | 100th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: LONG TERM CARE-ARBITRATION

Status: 2019-01-08 - Session Sine Die [HB0238 Detail]

Download: Illinois-2017-HB0238-Senate_Amendment_001.html

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Sen. Daniel Biss

Filed: 5/30/2017

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AMENDMENT TO HOUSE BILL 238
AMENDMENT NO. ______. Amend House Bill 238 by replacing
everything after the enacting clause with the following:
"Section 5. The Illinois Act on the Aging is amended by
changing Section 4.02 as follows:
(20 ILCS 105/4.02) (from Ch. 23, par. 6104.02)
Sec. 4.02. Community Care Program. The Department shall
establish a program of services to prevent unnecessary
institutionalization of persons age 60 and older in need of
long term care or who are established as persons who suffer
from Alzheimer's disease or a related disorder under the
Alzheimer's Disease Assistance Act, thereby enabling them to
remain in their own homes or in other living arrangements. Such
preventive services, which may be coordinated with other
programs for the aged and monitored by area agencies on aging
in cooperation with the Department, may include, but are not

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limited to, any or all of the following:
(a) (blank);
(b) (blank);
(c) home care aide services;
(d) personal assistant services;
(e) adult day services;
(f) home-delivered meals;
(g) education in self-care;
(h) personal care services;
(i) adult day health services;
(j) habilitation services;
(k) respite care;
(k-5) community reintegration services;
(k-6) flexible senior services;
(k-7) medication management;
(k-8) emergency home response;
(l) other nonmedical social services that may enable
the person to become self-supporting; or
(m) clearinghouse for information provided by senior
citizen home owners who want to rent rooms to or share
living space with other senior citizens.
Individuals who meet the following criteria shall have
equal access to services under the Community Care Program: The
Department shall establish eligibility standards for such
services.
(a) are 60 years old or older;

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(b) are U.S. citizens or legal aliens;
(c) are residents of Illinois;
(d) have non-exempt assets of $17,500 or less;
non-exempt assets do not include home, car, or personal
furnishings; and
(e) have an assessed need for long term care, as
provided in this Section, and are at risk for nursing
facility placement as measured by the determination of need
assessment tool or a future updated assessment tool.
In determining the amount and nature of services for which a
person may qualify, consideration shall not be given to the
value of cash, property or other assets held in the name of the
person's spouse pursuant to a written agreement dividing
marital property into equal but separate shares or pursuant to
a transfer of the person's interest in a home to his spouse,
provided that the spouse's share of the marital property is not
made available to the person seeking such services.
Need for long term care shall be determined as follows:
Individuals with a score of 29 or higher based on the
determination of need (DON) assessment tool shall be eligible
to receive institutional and home and community-based long term
care services until the State receives federal approval and
implements an updated assessment tool, and those individuals
are found to be ineligible under that updated assessment tool.
Anyone determined to be ineligible for services due to the
updated assessment tool shall continue to be eligible for

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services for at least one year following that determination and
must be reassessed no earlier than 11 months after that
determination. The Department must adopt rules through the
regular rulemaking process regarding the updated assessment
tool, and shall not adopt emergency or peremptory rules
regarding the updated assessment tool. The State shall not
implement an updated assessment tool that causes more than 1%
of then-current recipients to lose eligibility.
Service cost maximums shall be set at levels no lower than
the service cost maximums that were in effect as of January 1,
2016. Service cost maximums shall be increased accordingly to
reflect any rate increases.
Beginning January 1, 2008, the Department shall require as
a condition of eligibility that all new financially eligible
applicants apply for and enroll in medical assistance under
Article V of the Illinois Public Aid Code in accordance with
rules promulgated by the Department.
The Department shall not: (i) adopt any rule that restricts
eligibility under the Community Care Program to persons who
qualify for medical assistance under Article V of the Illinois
Public Aid Code; or (ii) establish, by rule, a separate program
of home and community-based long term care services for persons
who are otherwise eligible for services under the Community
Care Program but who do not qualify for medical assistance
under Article V of the Illinois Public Aid Code.
The Department shall, in conjunction with the Department of

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Public Aid (now Department of Healthcare and Family Services),
seek appropriate amendments under Sections 1915 and 1924 of the
Social Security Act. The purpose of the amendments shall be to
extend eligibility for home and community based services under
Sections 1915 and 1924 of the Social Security Act to persons
who transfer to or for the benefit of a spouse those amounts of
income and resources allowed under Section 1924 of the Social
Security Act. Subject to the approval of such amendments, the
Department shall extend the provisions of Section 5-4 of the
Illinois Public Aid Code to persons who, but for the provision
of home or community-based services, would require the level of
care provided in an institution, as is provided for in federal
law. Those persons no longer found to be eligible for receiving
noninstitutional services due to changes in the eligibility
criteria shall be given 45 days notice prior to actual
termination. Those persons receiving notice of termination may
contact the Department and request the determination be
appealed at any time during the 45 day notice period. The
target population identified for the purposes of this Section
are persons age 60 and older with an identified service need.
Priority shall be given to those who are at imminent risk of
institutionalization. The services shall be provided to
eligible persons age 60 and older to the extent that the cost
of the services together with the other personal maintenance
expenses of the persons are reasonably related to the standards
established for care in a group facility appropriate to the

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person's condition. These non-institutional services, pilot
projects or experimental facilities may be provided as part of
or in addition to those authorized by federal law or those
funded and administered by the Department of Human Services.
The Departments of Human Services, Healthcare and Family
Services, Public Health, Veterans' Affairs, and Commerce and
Economic Opportunity and other appropriate agencies of State,
federal and local governments shall cooperate with the
Department on Aging in the establishment and development of the
non-institutional services. The Department shall require an
annual audit from all personal assistant and home care aide
vendors contracting with the Department under this Section. The
annual audit shall assure that each audited vendor's procedures
are in compliance with Department's financial reporting
guidelines requiring an administrative and employee wage and
benefits cost split as defined in administrative rules. The
audit is a public record under the Freedom of Information Act.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department of Healthcare
and Family Services, to effect the following: (1) intake
procedures and common eligibility criteria for those persons
who are receiving non-institutional services; and (2) the
establishment and development of non-institutional services in
areas of the State where they are not currently available or
are undeveloped. On and after July 1, 1996, all nursing home

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prescreenings for individuals 60 years of age or older shall be
conducted by the Department.
As part of the Department on Aging's routine training of
case managers and case manager supervisors, the Department may
include information on family futures planning for persons who
are age 60 or older and who are caregivers of their adult
children with developmental disabilities. The content of the
training shall be at the Department's discretion.
The Department is authorized to establish a system of
recipient copayment for services provided under this Section,
such copayment to be based upon the recipient's ability to pay
but in no case to exceed the actual cost of the services
provided. Additionally, any portion of a person's income which
is equal to or less than the federal poverty standard shall not
be considered by the Department in determining the copayment.
The level of such copayment shall be adjusted whenever
necessary to reflect any change in the officially designated
federal poverty standard. The Department shall not increase
copayment levels to the levels that were in effect on January
1, 2016, except to make an adjustment for inflation.
The Department, or the Department's authorized
representative, may recover the amount of moneys expended for
services provided to or in behalf of a person under this
Section by a claim against the person's estate or against the
estate of the person's surviving spouse, but no recovery may be
had until after the death of the surviving spouse, if any, and

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

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

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services that may or may not involve contact with clients,
including but not limited to:
(A) bathing;
(B) grooming;
(C) toileting;
(D) nail care;
(E) transferring;
(F) respiratory services;
(G) exercise; or
(H) positioning;
(6) ensuring that homemaker program vendors are not
restricted from hiring homemakers who are family members of
clients or recommended by clients; the Department may not,
by rule or policy, require homemakers who are family
members of clients or recommended by clients to accept
assignments in homes other than the client;
(7) ensuring that the State may access maximum federal
matching funds by seeking approval for the Centers for
Medicare and Medicaid Services for modifications to the
State's home and community based services waiver and
additional waiver opportunities, including applying for
enrollment in the Balance Incentive Payment Program by May
1, 2013, in order to maximize federal matching funds; this
shall include, but not be limited to, modification that
reflects all changes in the Community Care Program services
and all increases in the services cost maximum;

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(8) ensuring that the determination of need tool
accurately reflects the service needs of individuals with
Alzheimer's disease and related dementia disorders;
(9) ensuring that services are authorized accurately
and consistently for the Community Care Program (CCP); the
Department shall implement a Service Authorization policy
directive; the purpose shall be to ensure that eligibility
and services are authorized accurately and consistently in
the CCP program; the policy directive shall clarify service
authorization guidelines to Care Coordination Units and
Community Care Program providers no later than May 1, 2013;
(10) working in conjunction with Care Coordination
Units, the Department of Healthcare and Family Services,
the Department of Human Services, Community Care Program
providers, and other stakeholders to make improvements to
the Medicaid claiming processes and the Medicaid
enrollment procedures or requirements as needed,
including, but not limited to, specific policy changes or
rules to improve the up-front enrollment of participants in
the Medicaid program and specific policy changes or rules
to insure more prompt submission of bills to the federal
government to secure maximum federal matching dollars as
promptly as possible; the Department on Aging shall have at
least 3 meetings with stakeholders by January 1, 2014 in
order to address these improvements;
(11) requiring home care service providers to comply

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with the rounding of hours worked provisions under the
federal Fair Labor Standards Act (FLSA) and as set forth in
29 CFR 785.48(b) by May 1, 2013;
(12) implementing any necessary policy changes or
promulgating any rules, no later than January 1, 2014, to
assist the Department of Healthcare and Family Services in
moving as many participants as possible, consistent with
federal regulations, into coordinated care plans if a care
coordination plan that covers long term care is available
in the recipient's area; and
(13) maintaining fiscal year 2014 rates at the same
level established on January 1, 2013.
By January 1, 2009 or as soon after the end of the Cash and
Counseling Demonstration Project as is practicable, the
Department may, based on its evaluation of the demonstration
project, promulgate rules concerning personal assistant
services, to include, but need not be limited to,
qualifications, employment screening, rights under fair labor
standards, training, fiduciary agent, and supervision
requirements. All applicants shall be subject to the provisions
of the Health Care Worker Background Check Act.
The Department shall develop procedures to enhance
availability of services on evenings, weekends, and on an
emergency basis to meet the respite needs of caregivers.
Procedures shall be developed to permit the utilization of
services in successive blocks of 24 hours up to the monthly

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maximum established by the Department. Workers providing these
services shall be appropriately trained.
Beginning on the effective date of this amendatory Act of
1991, no person may perform chore/housekeeping and home care
aide services under a program authorized by this Section unless
that person has been issued a certificate of pre-service to do
so by his or her employing agency. Information gathered to
effect such certification shall include (i) the person's name,
(ii) the date the person was hired by his or her current
employer, and (iii) the training, including dates and levels.
Persons engaged in the program authorized by this Section
before the effective date of this amendatory Act of 1991 shall
be issued a certificate of all pre- and in-service training
from his or her employer upon submitting the necessary
information. The employing agency shall be required to retain
records of all staff pre- and in-service training, and shall
provide such records to the Department upon request and upon
termination of the employer's contract with the Department. In
addition, the employing agency is responsible for the issuance
of certifications of in-service training completed to their
employees.
The Department is required to develop a system to ensure
that persons working as home care aides and personal assistants
receive increases in their wages when the federal minimum wage
is increased by requiring vendors to certify that they are
meeting the federal minimum wage statute for home care aides

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and personal assistants. An employer that cannot ensure that
the minimum wage increase is being given to home care aides and
personal assistants shall be denied any increase in
reimbursement costs.
The Community Care Program Advisory Committee is created in
the Department on Aging. The Director shall appoint individuals
to serve in the Committee, who shall serve at their own
expense. Members of the Committee must abide by all applicable
ethics laws. The Committee shall advise the Department on
issues related to the Department's program of services to
prevent unnecessary institutionalization. The Committee shall
meet on a bi-monthly basis and shall serve to identify and
advise the Department on present and potential issues affecting
the service delivery network, the program's clients, and the
Department and to recommend solution strategies. Persons
appointed to the Committee shall be appointed on, but not
limited to, their own and their agency's experience with the
program, geographic representation, and willingness to serve.
The Director shall appoint members to the Committee to
represent provider, advocacy, policy research, and other
constituencies committed to the delivery of high quality home
and community-based services to older adults. Representatives
shall be appointed to ensure representation from community care
providers including, but not limited to, adult day service
providers, homemaker providers, case coordination and case
management units, emergency home response providers, statewide

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trade or labor unions that represent home care aides and direct
care staff, area agencies on aging, adults over age 60,
membership organizations representing older adults, and other
organizational entities, providers of care, or individuals
with demonstrated interest and expertise in the field of home
and community care as determined by the Director.
Nominations may be presented from any agency or State
association with interest in the program. The Director, or his
or her designee, shall serve as the permanent co-chair of the
advisory committee. One other co-chair shall be nominated and
approved by the members of the committee on an annual basis.
Committee members' terms of appointment shall be for 4 years
with one-quarter of the appointees' terms expiring each year. A
member shall continue to serve until his or her replacement is
named. The Department shall fill vacancies that have a
remaining term of over one year, and this replacement shall
occur through the annual replacement of expiring terms. The
Director shall designate Department staff to provide technical
assistance and staff support to the committee. Department
representation shall not constitute membership of the
committee. All Committee papers, issues, recommendations,
reports, and meeting memoranda are advisory only. The Director,
or his or her designee, shall make a written report, as
requested by the Committee, regarding issues before the
Committee.
The Department on Aging and the Department of Human

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Services shall cooperate in the development and submission of
an annual report on programs and services provided under this
Section. Such joint report shall be filed with the Governor and
the General Assembly on or before September 30 each year.
The requirement for reporting to the General Assembly shall
be satisfied by filing copies of the report with the Speaker,
the Minority Leader and the Clerk of the House of
Representatives and the President, the Minority Leader and the
Secretary of the Senate and the Legislative Research Unit, as
required by Section 3.1 of the General Assembly Organization
Act and filing such additional copies with the State Government
Report Distribution Center for the General Assembly as is
required under paragraph (t) of Section 7 of the State Library
Act.
Those persons previously found eligible for receiving
non-institutional services whose services were discontinued
under the Emergency Budget Act of Fiscal Year 1992, and who do
not meet the eligibility standards in effect on or after July
1, 1992, shall remain ineligible on and after July 1, 1992.
Those persons previously not required to cost-share and who
were required to cost-share effective March 1, 1992, shall
continue to meet cost-share requirements on and after July 1,
1992. Beginning July 1, 1992, all clients will be required to
meet eligibility, cost-share, and other requirements and will
have services discontinued or altered when they fail to meet
these requirements.

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

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reported that the Department has not undertaken the required
actions listed in the report required by subsection (a) of
Section 2-27 of the Illinois State Auditing Act.
The Department shall implement co-payments for the
Community Care Program at the federally allowable maximum level
(i) beginning August 1, 2013, if the Auditor General has
reported that the Department has failed to comply with the
reporting requirements of Section 2-27 of the Illinois State
Auditing Act; or (ii) beginning June 1, 2014, if the Auditor
General has reported that the Department has not undertaken the
required actions listed in the report required by subsection
(a) of Section 2-27 of the Illinois State Auditing Act.
The Department shall provide a bi-monthly report on the
progress of the Community Care Program reforms set forth in
this amendatory Act of the 98th General Assembly to the
Governor, the Speaker of the House of Representatives, the
Minority Leader of the House of Representatives, the President
of the Senate, and the Minority Leader of the Senate.
The Department shall conduct a quarterly review of Care
Coordination Unit performance and adherence to service
guidelines. The quarterly review shall be reported to the
Speaker of the House of Representatives, the Minority Leader of
the House of Representatives, the President of the Senate, and
the Minority Leader of the Senate. The Department shall collect
and report longitudinal data on the performance of each care
coordination unit. Nothing in this paragraph shall be construed

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to require the Department to identify specific care
coordination units.
In regard to community care providers, failure to comply
with Department on Aging policies shall be cause for
disciplinary action, including, but not limited to,
disqualification from serving Community Care Program clients.
Each provider, upon submission of any bill or invoice to the
Department for payment for services rendered, shall include a
notarized statement, under penalty of perjury pursuant to
Section 1-109 of the Code of Civil Procedure, that the provider
has complied with all Department policies.
The Director of the Department on Aging shall make
information available to the State Board of Elections as may be
required by an agreement the State Board of Elections has
entered into with a multi-state voter registration list
maintenance system.
(Source: P.A. 98-8, eff. 5-3-13; 98-1171, eff. 6-1-15; 99-143,
eff. 7-27-15.)
Section 10. The Rehabilitation of Persons with
Disabilities Act is amended by changing Section 3 as follows:
(20 ILCS 2405/3) (from Ch. 23, par. 3434)
Sec. 3. Powers and duties. The Department shall have the
powers and duties enumerated herein:
(a) To co-operate with the federal government in the

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administration of the provisions of the federal Rehabilitation
Act of 1973, as amended, of the Workforce Investment Act of
1998, and of the federal Social Security Act to the extent and
in the manner provided in these Acts.
(b) To prescribe and supervise such courses of vocational
training and provide such other services as may be necessary
for the habilitation and rehabilitation of persons with one or
more disabilities, including the administrative activities
under subsection (e) of this Section, and to co-operate with
State and local school authorities and other recognized
agencies engaged in habilitation, rehabilitation and
comprehensive rehabilitation services; and to cooperate with
the Department of Children and Family Services regarding the
care and education of children with one or more disabilities.
(c) (Blank).
(d) To report in writing, to the Governor, annually on or
before the first day of December, and at such other times and
in such manner and upon such subjects as the Governor may
require. The annual report shall contain (1) a statement of the
existing condition of comprehensive rehabilitation services,
habilitation and rehabilitation in the State; (2) a statement
of suggestions and recommendations with reference to the
development of comprehensive rehabilitation services,
habilitation and rehabilitation in the State; and (3) an
itemized statement of the amounts of money received from
federal, State and other sources, and of the objects and

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purposes to which the respective items of these several amounts
have been devoted.
(e) (Blank).
(f) To establish a program of services to prevent the
unnecessary institutionalization of persons in need of long
term care and who meet the criteria for blindness or disability
as defined by the Social Security Act, thereby enabling them to
remain in their own homes. Such preventive services include any
or all of the following:
(1) personal assistant services;
(2) homemaker services;
(3) home-delivered meals;
(4) adult day care services;
(5) respite care;
(6) home modification or assistive equipment;
(7) home health services;
(8) electronic home response;
(9) brain injury behavioral/cognitive services;
(10) brain injury habilitation;
(11) brain injury pre-vocational services; or
(12) brain injury supported employment.
The Department shall establish eligibility standards for
such services taking into consideration the unique economic and
social needs of the population for whom they are to be
provided. Such eligibility standards may be based on the
recipient's ability to pay for services; provided, however,

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that any portion of a person's income that is equal to or less
than the "protected income" level shall not be considered by
the Department in determining eligibility. The "protected
income" level shall be determined by the Department, shall
never be less than the federal poverty standard, and shall be
adjusted each year to reflect changes in the Consumer Price
Index For All Urban Consumers as determined by the United
States Department of Labor. The standards must provide that a
person may not have more than $10,000 in assets to be eligible
for the services, and the Department may increase or decrease
the asset limitation by rule. The Department may not decrease
the asset level below $10,000.
Individuals with a score of 29 or higher based on the
determination of need (DON) assessment tool shall be eligible
to receive institutional and home and community-based long term
care services until the State receives federal approval and
implements an updated assessment tool, and those individuals
are found to be ineligible under that updated assessment tool.
Anyone determined to be ineligible for services due to the
updated assessment tool shall continue to be eligible for
services for at least one year following that determination and
must be reassessed no earlier than 11 months after that
determination. The Department must adopt rules through the
regular rulemaking process regarding the updated assessment
tool, and shall not adopt emergency or peremptory rules
regarding the updated assessment tool. The State shall not

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implement an updated assessment tool that causes more than 1%
of then-current recipients to lose eligibility.
Service cost maximums shall be set at levels no lower than
the service cost maximums that were in effect as of January 1,
2016. Service cost maximums shall be increased accordingly to
reflect any rate increases.
The services shall be provided, as established by the
Department by rule, to eligible persons to prevent unnecessary
or premature institutionalization, to the extent that the cost
of the services, together with the other personal maintenance
expenses of the persons, are reasonably related to the
standards established for care in a group facility appropriate
to their condition. These non-institutional services, pilot
projects or experimental facilities may be provided as part of
or in addition to those authorized by federal law or those
funded and administered by the Illinois Department on Aging.
The Department shall set rates and fees for services in a fair
and equitable manner. Services identical to those offered by
the Department on Aging shall be paid at the same rate.
Personal assistants shall be paid at a rate negotiated
between the State and an exclusive representative of personal
assistants under a collective bargaining agreement. In no case
shall the Department pay personal assistants an hourly wage
that is less than the federal minimum wage.
Solely for the purposes of coverage under the Illinois
Public Labor Relations Act (5 ILCS 315/), personal assistants

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providing services under the Department's Home Services
Program shall be considered to be public employees and the
State of Illinois shall be considered to be their employer as
of the effective date of this amendatory Act of the 93rd
General Assembly, but not before. Solely for the purposes of
coverage under the Illinois Public Labor Relations Act, home
care and home health workers who function as personal
assistants and individual maintenance home health workers and
who also provide services under the Department's Home Services
Program shall be considered to be public employees, no matter
whether the State provides such services through direct
fee-for-service arrangements, with the assistance of a managed
care organization or other intermediary, or otherwise, and the
State of Illinois shall be considered to be the employer of
those persons as of January 29, 2013 (the effective date of
Public Act 97-1158), but not before except as otherwise
provided under this subsection (f). The State shall engage in
collective bargaining with an exclusive representative of home
care and home health workers who function as personal
assistants and individual maintenance home health workers
working under the Home Services Program concerning their terms
and conditions of employment that are within the State's
control. Nothing in this paragraph shall be understood to limit
the right of the persons receiving services defined in this
Section to hire and fire home care and home health workers who
function as personal assistants and individual maintenance

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home health workers working under the Home Services Program or
to supervise them within the limitations set by the Home
Services Program. The State shall not be considered to be the
employer of home care and home health workers who function as
personal assistants and individual maintenance home health
workers working under the Home Services Program for any
purposes not specifically provided in Public Act 93-204 or
Public Act 97-1158, including but not limited to, purposes of
vicarious liability in tort and purposes of statutory
retirement or health insurance benefits. Home care and home
health workers who function as personal assistants and
individual maintenance home health workers and who also provide
services under the Department's Home Services Program shall not
be covered by the State Employees Group Insurance Act of 1971
(5 ILCS 375/).
The Department shall execute, relative to nursing home
prescreening, as authorized by Section 4.03 of the Illinois Act
on the Aging, written inter-agency agreements with the
Department on Aging and the Department of Healthcare and Family
Services, to effect the intake procedures and eligibility
criteria for those persons who may need long term care. On and
after July 1, 1996, all nursing home prescreenings for
individuals 18 through 59 years of age shall be conducted by
the Department, or a designee of the Department.
The Department is authorized to establish a system of
recipient cost-sharing for services provided under this

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Section. The cost-sharing shall be based upon the recipient's
ability to pay for services, but in no case shall the
recipient's share exceed the actual cost of the services
provided. Protected income shall not be considered by the
Department in its determination of the recipient's ability to
pay a share of the cost of services. The level of cost-sharing
shall be adjusted each year to reflect changes in the
"protected income" level. The Department shall deduct from the
recipient's share of the cost of services any money expended by
the recipient for disability-related expenses.
To the extent permitted under the federal Social Security
Act, the Department, or the Department's authorized
representative, may recover the amount of moneys expended for
services provided to or in behalf of a person under this
Section by a claim against the person's estate or against the
estate of the person's surviving spouse, but no recovery may be
had until after the death of the surviving spouse, if any, and
then only at such time when there is no surviving child who is
under age 21 or blind or who has a permanent and total
disability. This paragraph, however, shall not bar recovery, at
the death of the person, of moneys for services provided to the
person or in behalf of the person under this Section to which
the person was not entitled; provided that such recovery shall
not be enforced against any real estate while it is occupied as
a homestead by the surviving spouse or other dependent, if no
claims by other creditors have been filed against the estate,

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or, if such claims have been filed, they remain dormant for
failure of prosecution or failure of the claimant to compel
administration of the estate for the purpose of payment. This
paragraph shall not bar recovery from the estate of a spouse,
under Sections 1915 and 1924 of the Social Security Act and
Section 5-4 of the Illinois Public Aid Code, who precedes a
person receiving services under this Section in death. All
moneys for services paid to or in behalf of the person under
this Section shall be claimed for recovery from the deceased
spouse's estate. "Homestead", as used in this paragraph, means
the dwelling house and contiguous real estate occupied by a
surviving spouse or relative, as defined by the rules and
regulations of the Department of Healthcare and Family
Services, regardless of the value of the property.
The Department shall submit an annual report on programs
and services provided under this Section. The report shall be
filed with the Governor and the General Assembly on or before
March 30 each year.
The requirement for reporting to the General Assembly shall
be satisfied by filing copies of the report with the Speaker,
the Minority Leader and the Clerk of the House of
Representatives and the President, the Minority Leader and the
Secretary of the Senate and the Legislative Research Unit, as
required by Section 3.1 of the General Assembly Organization
Act, and filing additional copies with the State Government
Report Distribution Center for the General Assembly as required

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under paragraph (t) of Section 7 of the State Library Act.
(g) To establish such subdivisions of the Department as
shall be desirable and assign to the various subdivisions the
responsibilities and duties placed upon the Department by law.
(h) To cooperate and enter into any necessary agreements
with the Department of Employment Security for the provision of
job placement and job referral services to clients of the
Department, including job service registration of such clients
with Illinois Employment Security offices and making job
listings maintained by the Department of Employment Security
available to such clients.
(i) To possess all powers reasonable and necessary for the
exercise and administration of the powers, duties and
responsibilities of the Department which are provided for by
law.
(j) (Blank).
(k) (Blank).
(l) To establish, operate and maintain a Statewide Housing
Clearinghouse of information on available, government
subsidized housing accessible to persons with disabilities and
available privately owned housing accessible to persons with
disabilities. The information shall include but not be limited
to the location, rental requirements, access features and
proximity to public transportation of available housing. The
Clearinghouse shall consist of at least a computerized database
for the storage and retrieval of information and a separate or

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shared toll free telephone number for use by those seeking
information from the Clearinghouse. Department offices and
personnel throughout the State shall also assist in the
operation of the Statewide Housing Clearinghouse. Cooperation
with local, State and federal housing managers shall be sought
and extended in order to frequently and promptly update the
Clearinghouse's information.
(m) To assure that the names and case records of persons
who received or are receiving services from the Department,
including persons receiving vocational rehabilitation, home
services, or other services, and those attending one of the
Department's schools or other supervised facility shall be
confidential and not be open to the general public. Those case
records and reports or the information contained in those
records and reports shall be disclosed by the Director only to
proper law enforcement officials, individuals authorized by a
court, the General Assembly or any committee or commission of
the General Assembly, and other persons and for reasons as the
Director designates by rule. Disclosure by the Director may be
only in accordance with other applicable law.
(Source: P.A. 98-1004, eff. 8-18-14; 99-143, eff. 7-27-15.)
Section 13. The Nursing Home Care Act is amended by
changing Section 3-402 as follows:
(210 ILCS 45/3-402) (from Ch. 111 1/2, par. 4153-402)

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Sec. 3-402. Involuntary transfer or discharge.
Involuntary transfer or discharge of a resident from a
facility shall be preceded by the discussion required under
Section 3-408 and by a minimum written notice of 21 days,
except in one of the following instances:
(a) When an emergency transfer or discharge is ordered
by the resident's attending physician because of the
resident's health care needs.
(b) When the transfer or discharge is mandated by the
physical safety of other residents, the facility staff, or
facility visitors, as documented in the clinical record.
The Department shall be notified prior to any such
involuntary transfer or discharge. The Department shall
immediately offer transfer, or discharge and relocation
assistance to residents transferred or discharged under
this subparagraph (b), and the Department may place
relocation teams as provided in Section 3-419 of this Act.
(c) When an identified offender is within the
provisional admission period defined in Section 1-120.3.
If the Identified Offender Report and Recommendation
prepared under Section 2-201.6 shows that the identified
offender poses a serious threat or danger to the physical
safety of other residents, the facility staff, or facility
visitors in the admitting facility and the facility
determines that it is unable to provide a safe environment
for the other residents, the facility staff, or facility

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visitors, the facility shall transfer or discharge the
identified offender within 3 days after its receipt of the
Identified Offender Report and Recommendation.
No individual receiving care in an institutional setting
shall be involuntarily discharged as the result of the updated
determination of need (DON) assessment tool as provided in
Section 5-5 of the Illinois Public Aid Code until a transition
plan has been developed by the Department on Aging or its
designee and all care identified in the transition plan is
available to the resident immediately upon discharge.
(Source: P.A. 96-1372, eff. 7-29-10.)
Section 15. The Illinois Public Aid Code is amended by
changing Sections 5-5 and 5-5.01a as follows:
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing home,
or elsewhere; (6) medical care, or any other type of remedial

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care furnished by licensed practitioners; (7) home health care
services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and
treatment of periodontal disease and dental caries disease for
pregnant women, provided by an individual licensed to practice
dentistry or dental surgery; for purposes of this item (10),
"dental services" means diagnostic, preventive, or corrective
procedures provided by or under the supervision of a dentist in
the practice of his or her profession; (11) physical therapy
and related services; (12) prescribed drugs, dentures, and
prosthetic devices; and eyeglasses prescribed by a physician
skilled in the diseases of the eye, or by an optometrist,
whichever the person may select; (13) other diagnostic,
screening, preventive, and rehabilitative services, including
to ensure that the individual's need for intervention or
treatment of mental disorders or substance use disorders or
co-occurring mental health and substance use disorders is
determined using a uniform screening, assessment, and
evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined

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in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the sexual
assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; and (17) any other medical
care, and any other type of remedial care recognized under the
laws of this State, but not including abortions, or induced
miscarriages or premature births, unless, in the opinion of a
physician, such procedures are necessary for the preservation
of the life of the woman seeking such treatment, or except an
induced premature birth intended to produce a live viable child
and such procedure is necessary for the health of the mother or
her unborn child. The Illinois Department, by rule, shall
prohibit any physician from providing medical assistance to
anyone eligible therefor under this Code where such physician
has been found guilty of performing an abortion procedure in a
wilful and wanton manner upon a woman who was not pregnant at
the time such abortion procedure was performed. The term "any
other type of remedial care" shall include nursing care and
nursing home service for persons who rely on treatment by
spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered

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under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured under
this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for

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payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare and
Family Services may provide the following services to persons
eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in the
diseases of the eye, or by an optometrist, whichever the
person may select.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical assistance
program. A not-for-profit health clinic shall include a public
health clinic or Federally Qualified Health Center or other
enrolled provider, as determined by the Department, through
which dental services covered under this Section are performed.
The Department shall establish a process for payment of claims
for reimbursement for covered dental services rendered under
this provision.

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The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in accordance
with the classes of persons designated in Section 5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for women
35 years of age or older who are eligible for medical
assistance under this Article, as follows:
(A) A baseline mammogram for women 35 to 39 years of
age.
(B) An annual mammogram for women 40 years of age or
older.
(C) A mammogram at the age and intervals considered
medically necessary by the woman's health care provider for
women under 40 years of age and having a family history of
breast cancer, prior personal history of breast cancer,
positive genetic testing, or other risk factors.
(D) A comprehensive ultrasound screening of an entire
breast or breasts if a mammogram demonstrates

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heterogeneous or dense breast tissue, when medically
necessary as determined by a physician licensed to practice
medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool. For purposes of this Section, "low-dose mammography"
means the x-ray examination of the breast using equipment
dedicated specifically for mammography, including the x-ray
tube, filter, compression device, and image receptor, with an
average radiation exposure delivery of less than one rad per
breast for 2 views of an average size breast. The term also
includes digital mammography and includes breast
tomosynthesis. As used in this Section, the term "breast
tomosynthesis" means a radiologic procedure that involves the
acquisition of projection images over the stationary breast to
produce cross-sectional digital three-dimensional images of
the breast. If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in the
Federal Register or publishes a comment in the Federal Register
or issues an opinion, guidance, or other action that would
require the State, pursuant to any provision of the Patient

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Protection and Affordable Care Act (Public Law 111-148),
including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
successor provision, to defray the cost of any coverage for
breast tomosynthesis outlined in this paragraph, then the
requirement that an insurer cover breast tomosynthesis is
inoperative other than any such coverage authorized under
Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
the State shall not assume any obligation for the cost of
coverage for breast tomosynthesis set forth in this paragraph.
On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of Imaging
Excellence as certified by the American College of Radiology.
On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall be
reimbursed for screening and diagnostic mammography at the same
rate as the Medicare program's rates, including the increased
reimbursement for digital mammography.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare

10000HB0238sam001 - 39 - LRB100 00066 KTG 27369 a
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind
women who are age-appropriate for screening mammography, but
who have not received a mammogram within the previous 18
months, of the importance and benefit of screening mammography.
The Department shall work with experts in breast cancer
outreach and patient navigation to optimize these reminders and
shall establish a methodology for evaluating their
effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients

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over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot program
in areas of the State with the highest incidence of mortality
related to breast cancer. At least one pilot program site shall
be in the metropolitan Chicago area and at least one site shall
be outside the metropolitan Chicago area. On or after July 1,
2016, the pilot program shall be expanded to include one site
in western Illinois, one site in southern Illinois, one site in
central Illinois, and 4 sites within metropolitan Chicago. An
evaluation of the pilot program shall be carried out measuring
health outcomes and cost of care for those served by the pilot
program compared to similarly situated patients who are not
served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include access
for patients diagnosed with cancer to at least one academic
commission on cancer-accredited cancer program as an
in-network covered benefit.

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Any medical or health care provider shall immediately
recommend, to any pregnant woman who is being provided prenatal
services and is suspected of drug abuse or is addicted as
defined in the Alcoholism and Other Drug Abuse and Dependency
Act, referral to a local substance abuse treatment provider
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department of
Human Services.
All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under the Drug
Free Families with a Future or any comparable program providing
case management services for addicted women, including
information on appropriate referrals for other social services
that may be needed by addicted women in addition to treatment
for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through a
public awareness campaign, may provide information concerning
treatment for alcoholism and drug abuse and addiction, prenatal
health care, and other pertinent programs directed at reducing

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the number of drug-affected infants born to recipients of
medical assistance.
Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of her substance abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration projects
in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by rule,
shall develop qualifications for sponsors of Partnerships.
Nothing in this Section shall be construed to require that the
sponsor organization be a medical organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for

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alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and the
Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by the
Partnership may receive an additional surcharge for such
services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications

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for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that provided
services may be accessed from therapeutically certified
optometrists to the full extent of the Illinois Optometric
Practice Act of 1987 without discriminating between service
providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance under
this Article. Such records must be retained for a period of not
less than 6 years from the date of service or as provided by
applicable State law, whichever period is longer, except that
if an audit is initiated within the required retention period
then the records must be retained until the audit is completed
and every exception is resolved. The Illinois Department shall
require health care providers to make available, when
authorized by the patient, in writing, the medical records in a
timely fashion to other health care providers who are treating

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or serving persons eligible for Medical Assistance under this
Article. All dispensers of medical services shall be required
to maintain and retain business and professional records
sufficient to fully and accurately document the nature, scope,
details and receipt of the health care provided to persons
eligible for medical assistance under this Code, in accordance
with regulations promulgated by the Illinois Department. The
rules and regulations shall require that proof of the receipt
of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of such
medical services. No such claims for reimbursement shall be
approved for payment by the Illinois Department without such
proof of receipt, unless the Illinois Department shall have put
into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed
adequate by the Illinois Department to assure that such drugs,
dentures, prosthetic devices and eyeglasses for which payment
is being made are actually being received by eligible
recipients. Within 90 days after September 16, 1984 (the
effective date of Public Act 83-1439), the Illinois Department
shall establish a current list of acquisition costs for all
prosthetic devices and any other items recognized as medical
equipment and supplies reimbursable under this Article and
shall update such list on a quarterly basis, except that the
acquisition costs of all prescription drugs shall be updated no

10000HB0238sam001 - 46 - LRB100 00066 KTG 27369 a
less frequently than every 30 days as required by Section
5-5.12.
The rules and regulations of the Illinois Department shall
require that a written statement including the required opinion
of a physician shall accompany any claim for reimbursement for
abortions, or induced miscarriages or premature births. This
statement shall indicate what procedures were used in providing
such medical services.
Notwithstanding any other law to the contrary, the Illinois
Department shall, within 365 days after July 22, 2013 (the
effective date of Public Act 98-104), establish procedures to
permit skilled care facilities licensed under the Nursing Home
Care Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall, by July 1, 2016, test the viability of the
new system and implement any necessary operational or
structural changes to its information technology platforms in
order to allow for the direct acceptance and payment of nursing
home claims.
Notwithstanding any other law to the contrary, the Illinois
Department shall, within 365 days after August 15, 2014 (the
effective date of Public Act 98-963), establish procedures to
permit ID/DD facilities licensed under the ID/DD Community Care
Act and MC/DD facilities licensed under the MC/DD Act to submit
monthly billing claims for reimbursement purposes. Following
development of these procedures, the Department shall have an

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additional 365 days to test the viability of the new system and
to ensure that any necessary operational or structural changes
to its information technology platforms are implemented.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens
for the Illinois Department.
Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the period
of conditional enrollment, the Department may terminate the
vendor's eligibility to participate in, or may disenroll the
vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or

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disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
The Department has the discretion to limit the conditional
enrollment period for vendors based upon category of risk of
the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category

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of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000
when local government funds finance federal participation
for claims payments.
For claims for services rendered during a period for which

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a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
In the case of long term care facilities, within 5 days of
receipt by the facility of required prescreening information,
data for new admissions shall be entered into the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or successor system, and
within 15 days of receipt by the facility of required
prescreening information, admission documents shall be
submitted through MEDI or REV or shall be submitted directly to
the Department of Human Services using required admission
forms. Effective September 1, 2014, admission documents,
including all prescreening information, must be submitted
through MEDI or REV. Confirmation numbers assigned to an
accepted transaction shall be retained by a facility to verify
timely submittal. Once an admission transaction has been
completed, all resubmitted claims following prior rejection
are subject to receipt no later than 180 days after the
admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State

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shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data necessary
to perform eligibility and payment verifications and other
Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, under which
such agencies and departments shall share data necessary for
medical assistance program integrity functions and oversight.
The Illinois Department shall develop, in cooperation with
other State departments and agencies, and in compliance with
applicable federal laws and regulations, appropriate and
effective methods to share such data. At a minimum, and to the
extent necessary to provide data sharing, the Illinois
Department shall enter into agreements with State agencies and

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departments, and is authorized to enter into agreements with
federal agencies and departments, including but not limited to:
the Secretary of State; the Department of Revenue; the
Department of Public Health; the Department of Human Services;
and the Department of Financial and Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre- or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the acquisition,
repair and replacement of orthotic and prosthetic devices and
durable medical equipment. Such rules shall provide, but not be
limited to, the following services: (1) immediate repair or
replacement of such devices by recipients; and (2) rental,
lease, purchase or lease-purchase of durable medical equipment

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in a cost-effective manner, taking into consideration the
recipient's medical prognosis, the extent of the recipient's
needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such rules shall enable a
recipient to temporarily acquire and use alternative or
substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized
for such recipient by the Department. Notwithstanding any
provision of Section 5-5f to the contrary, the Department may,
by rule, exempt certain replacement wheelchair parts from prior
approval and, for wheelchairs, wheelchair parts, wheelchair
accessories, and related seating and positioning items,
determine the wholesale price by methods other than actual
acquisition costs.
The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date of
the rule adopted pursuant to this paragraph, all providers must
meet the accreditation requirement.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common

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eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the State
where they are not currently available or are undeveloped; and
(iii) notwithstanding any other provision of law, subject to
federal approval, on and after July 1, 2012, an increase in the
determination of need (DON) scores from 29 to 37 for applicants
for institutional and home and community-based long term care;
if and only if federal approval is not granted, the Department
may, in conjunction with other affected agencies, implement
utilization controls or changes in benefit packages to
effectuate a similar savings amount for this population; and
(iv) no later than July 1, 2013, minimum level of care
eligibility criteria for institutional and home and
community-based long term care; and (iv) (v) no later than
October 1, 2013, establish procedures to permit long term care
providers access to eligibility scores for individuals with an
admission date who are seeking or receiving services from the
long term care provider. In order to select the minimum level
of care eligibility criteria, the Governor shall establish a
workgroup that includes affected agency representatives and
stakeholders representing the institutional and home and
community-based long term care interests. This Section shall
not restrict the Department from implementing lower level of
care eligibility criteria for community-based services in
circumstances where federal approval has been granted.

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Individuals with a score of 29 or higher based on the
determination of need (DON) assessment tool shall be eligible
to receive institutional and home and community-based long term
care services until the State receives federal approval and
implements an updated assessment tool, and those individuals
are found to be ineligible under that updated assessment tool.
Anyone determined to be ineligible for services due to the
updated assessment tool shall continue to be eligible for
services for at least one year following that determination and
must be reassessed no earlier than 11 months after that
determination. The Department must adopt rules through the
regular rulemaking process regarding the updated assessment
tool, and shall not adopt emergency or peremptory rules
regarding the updated assessment tool. The State shall not
implement an updated assessment tool that causes more than 1%
of then-current recipients to lose eligibility. No individual
receiving care in an institutional setting shall be
involuntarily discharged as the result of the updated
assessment tool until a transition plan has been developed by
the Department on Aging or its designee and all care identified
in the transition plan is available to the resident immediately
upon discharge.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation and

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programs for monitoring of utilization of health care services
and facilities, as it affects persons eligible for medical
assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the
Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The filing of one copy of the report with the
Speaker, one copy with the Minority Leader and one copy with
the Clerk of the House of Representatives, one copy with the
President, one copy with the Minority Leader and one copy with
the Secretary of the Senate, one copy with the Legislative
Research Unit, and such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act shall be deemed sufficient to comply with this

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Section.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
Because kidney transplantation can be an appropriate, cost
effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11 of
this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3 of
this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons under
Section 5-2 of this Code. To qualify for coverage of kidney
transplantation, such person must be receiving emergency renal
dialysis services covered by the Department. Providers under
this Section shall be prior approved and certified by the
Department to perform kidney transplantation and the services

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under this Section shall be limited to services associated with
kidney transplantation.
Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee for service and managed care medical
assistance programs for persons who are otherwise eligible for
medical assistance under this Article and shall not be subject
to any (1) utilization control, other than those established
under the American Society of Addiction Medicine patient
placement criteria, (2) prior authorization mandate, or (3)
lifetime restriction limit mandate.
On or after July 1, 2015, opioid antagonists prescribed for
the treatment of an opioid overdose, including the medication
product, administration devices, and any pharmacy fees related
to the dispensing and administration of the opioid antagonist,
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance under
this Article. As used in this Section, "opioid antagonist"
means a drug that binds to opioid receptors and blocks or
inhibits the effect of opioids acting on those receptors,
including, but not limited to, naloxone hydrochloride or any
other similarly acting drug approved by the U.S. Food and Drug
Administration.
Upon federal approval, the Department shall provide

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coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
20 of P.A. 99-588 for the effective date of P.A. 99-407);
99-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
7-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
eff. 1-1-17; revised 9-20-16.)
(305 ILCS 5/5-5.01a)
Sec. 5-5.01a. Supportive living facilities program. The
Department shall establish and provide oversight for a program
of supportive living facilities that seek to promote resident
independence, dignity, respect, and well-being in the most

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cost-effective manner.
A supportive living facility is either a free-standing
facility or a distinct physical and operational entity within a
nursing facility. A supportive living facility integrates
housing with health, personal care, and supportive services and
is a designated setting that offers residents their own
separate, private, and distinct living units.
Sites for the operation of the program shall be selected by
the Department based upon criteria that may include the need
for services in a geographic area, the availability of funding,
and the site's ability to meet the standards.
Beginning July 1, 2014, subject to federal approval, the
Medicaid rates for supportive living facilities shall be equal
to the supportive living facility Medicaid rate effective on
June 30, 2014 increased by 8.85%. Once the assessment imposed
at Article V-G of this Code is determined to be a permissible
tax under Title XIX of the Social Security Act, the Department
shall increase the Medicaid rates for supportive living
facilities effective on July 1, 2014 by 9.09%. The Department
shall apply this increase retroactively to coincide with the
imposition of the assessment in Article V-G of this Code in
accordance with the approval for federal financial
participation by the Centers for Medicare and Medicaid
Services.
The Department may adopt rules to implement this Section.
Rules that establish or modify the services, standards, and

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conditions for participation in the program shall be adopted by
the Department in consultation with the Department on Aging,
the Department of Rehabilitation Services, and the Department
of Mental Health and Developmental Disabilities (or their
successor agencies).
Facilities or distinct parts of facilities which are
selected as supportive living facilities and are in good
standing with the Department's rules are exempt from the
provisions of the Nursing Home Care Act and the Illinois Health
Facilities Planning Act.
Individuals with a score of 29 or higher based on the
determination of need (DON) assessment tool shall be eligible
to receive institutional and home and community-based long term
care services until the State receives federal approval and
implements an updated assessment tool, and those individuals
are found to be ineligible under that updated assessment tool.
Anyone determined to be ineligible for services due to the
updated assessment tool shall continue to be eligible for
services for at least one year following that determination and
must be reassessed no earlier than 11 months after that
determination. The Department must adopt rules through the
regular rulemaking process regarding the updated assessment
tool, and shall not adopt emergency or peremptory rules
regarding the updated assessment tool. The State shall not
implement an updated assessment tool that causes more than 1%
of then-current recipients to lose eligibility. No individual

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receiving care in an institutional setting shall be
involuntarily discharged as the result of the updated
assessment tool until a transition plan has been developed by
the Department on Aging or its designee and all care identified
in the transition plan is available to the resident immediately
upon discharge.
(Source: P.A. 98-651, eff. 6-16-14.)
Section 99. Effective date. This Act takes effect upon
becoming law.".