(305 ILCS 5/5‑2) (from Ch. 23, par. 5‑2)
Sec. 5‑2. Classes of Persons Eligible. Medical assistance under this
Article shall be available to any of the following classes of persons in
respect to whom a plan for coverage has been submitted to the Governor
by the Illinois Department and approved by him:
1. Recipients of basic maintenance grants under
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2. Persons otherwise eligible for basic maintenance
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under Articles III and IV but who fail to qualify thereunder on the basis of need, and who have insufficient income and resources to meet the costs of necessary medical care, including but not limited to the following:
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(a) All persons otherwise eligible for basic
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maintenance under Article III but who fail to qualify under that Article on the basis of need and who meet either of the following requirements:
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(i) their income, as determined by the
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Illinois Department in accordance with any federal requirements, is equal to or less than 70% in fiscal year 2001, equal to or less than 85% in fiscal year 2002 and until a date to be determined by the Department by rule, and equal to or less than 100% beginning on the date determined by the Department by rule, of the nonfarm income official poverty line, as defined by the federal Office of Management and Budget and revised annually in accordance with Section 673(2) of the Omnibus Budget Reconciliation Act of 1981, applicable to families of the same size; or
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(ii) their income, after the deduction of
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costs incurred for medical care and for other types of remedial care, is equal to or less than 70% in fiscal year 2001, equal to or less than 85% in fiscal year 2002 and until a date to be determined by the Department by rule, and equal to or less than 100% beginning on the date determined by the Department by rule, of the nonfarm income official poverty line, as defined in item (i) of this subparagraph (a).
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(b) All persons who would be determined eligible
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for such basic maintenance under Article IV by disregarding the maximum earned income permitted by federal law.
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3. Persons who would otherwise qualify for Aid to the
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Medically Indigent under Article VII.
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4. Persons not eligible under any of the preceding
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paragraphs who fall sick, are injured, or die, not having sufficient money, property or other resources to meet the costs of necessary medical care or funeral and burial expenses.
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5.(a) Women during pregnancy, after the fact of
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pregnancy has been determined by medical diagnosis, and during the 60‑day period beginning on the last day of the pregnancy, together with their infants and children born after September 30, 1983, whose income and resources are insufficient to meet the costs of necessary medical care to the maximum extent possible under Title XIX of the Federal Social Security Act.
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(b) The Illinois Department and the Governor shall
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provide a plan for coverage of the persons eligible under paragraph 5(a) by April 1, 1990. Such plan shall provide ambulatory prenatal care to pregnant women during a presumptive eligibility period and establish an income eligibility standard that is equal to 133% of the nonfarm income official poverty line, as defined by the federal Office of Management and Budget and revised annually in accordance with Section 673(2) of the Omnibus Budget Reconciliation Act of 1981, applicable to families of the same size, provided that costs incurred for medical care are not taken into account in determining such income eligibility.
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(c) The Illinois Department may conduct a
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demonstration in at least one county that will provide medical assistance to pregnant women, together with their infants and children up to one year of age, where the income eligibility standard is set up to 185% of the nonfarm income official poverty line, as defined by the federal Office of Management and Budget. The Illinois Department shall seek and obtain necessary authorization provided under federal law to implement such a demonstration. Such demonstration may establish resource standards that are not more restrictive than those established under Article IV of this Code.
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6. Persons under the age of 18 who fail to qualify as
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dependent under Article IV and who have insufficient income and resources to meet the costs of necessary medical care to the maximum extent permitted under Title XIX of the Federal Social Security Act.
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7. Persons who are under 21 years of age and would
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qualify as disabled as defined under the Federal Supplemental Security Income Program, provided medical service for such persons would be eligible for Federal Financial Participation, and provided the Illinois Department determines that:
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(a) the person requires a level of care provided
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by a hospital, skilled nursing facility, or intermediate care facility, as determined by a physician licensed to practice medicine in all its branches;
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(b) it is appropriate to provide such care
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outside of an institution, as determined by a physician licensed to practice medicine in all its branches;
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(c) the estimated amount which would be expended
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for care outside the institution is not greater than the estimated amount which would be expended in an institution.
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8. Persons who become ineligible for basic
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maintenance assistance under Article IV of this Code in programs administered by the Illinois Department due to employment earnings and persons in assistance units comprised of adults and children who become ineligible for basic maintenance assistance under Article VI of this Code due to employment earnings. The plan for coverage for this class of persons shall:
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(a) extend the medical assistance coverage for
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up to 12 months following termination of basic maintenance assistance; and
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(b) offer persons who have initially received 6
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months of the coverage provided in paragraph (a) above, the option of receiving an additional 6 months of coverage, subject to the following:
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(i) such coverage shall be pursuant to
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provisions of the federal Social Security Act;
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(ii) such coverage shall include all
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services covered while the person was eligible for basic maintenance assistance;
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(iii) no premium shall be charged for such
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(iv) such coverage shall be suspended in the
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event of a person's failure without good cause to file in a timely fashion reports required for this coverage under the Social Security Act and coverage shall be reinstated upon the filing of such reports if the person remains otherwise eligible.
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9. Persons with acquired immunodeficiency syndrome
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(AIDS) or with AIDS‑related conditions with respect to whom there has been a determination that but for home or community‑based services such individuals would require the level of care provided in an inpatient hospital, skilled nursing facility or intermediate care facility the cost of which is reimbursed under this Article. Assistance shall be provided to such persons to the maximum extent permitted under Title XIX of the Federal Social Security Act.
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10. Participants in the long‑term care insurance
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partnership program established under the Partnership for Long‑Term Care Act who meet the qualifications for protection of resources described in Section 25 of that Act.
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11. Persons with disabilities who are employed and
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eligible for Medicaid, pursuant to Section 1902(a)(10)(A)(ii)(xv) of the Social Security Act, as provided by the Illinois Department by rule.
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12. Subject to federal approval, persons who are
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eligible for medical assistance coverage under applicable provisions of the federal Social Security Act and the federal Breast and Cervical Cancer Prevention and Treatment Act of 2000. Those eligible persons are defined to include, but not be limited to, the following persons:
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(1) persons who have been screened for breast or
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cervical cancer under the U.S. Centers for Disease Control and Prevention Breast and Cervical Cancer Program established under Title XV of the federal Public Health Services Act in accordance with the requirements of Section 1504 of that Act as administered by the Illinois Department of Public Health; and
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(2) persons whose screenings under the above
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program were funded in whole or in part by funds appropriated to the Illinois Department of Public Health for breast or cervical cancer screening.
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"Medical assistance" under this paragraph 12 shall be
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identical to the benefits provided under the State's approved plan under Title XIX of the Social Security Act. The Department must request federal approval of the coverage under this paragraph 12 within 30 days after the effective date of this amendatory Act of the 92nd General Assembly.
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13. Subject to appropriation and to federal approval,
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persons living with HIV/AIDS who are not otherwise eligible under this Article and who qualify for services covered under Section 5‑5.04 as provided by the Illinois Department by rule.
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The Illinois Department and the Governor shall provide a plan for
coverage of the persons eligible under paragraph 7 as soon as possible after
July 1, 1984.
The eligibility of any such person for medical assistance under this
Article is not affected by the payment of any grant under the Senior
Citizens and Disabled Persons Property Tax Relief and Pharmaceutical
Assistance Act or any distributions or items of income described under
subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act. The Department shall by rule establish the amounts of
assets to be disregarded in determining eligibility for medical assistance,
which shall at a minimum equal the amounts to be disregarded under the
Federal Supplemental Security Income Program. The amount of assets of a
single person to be disregarded
shall not be less than $2,000, and the amount of assets of a married couple
to be disregarded shall not be less than $3,000.
To the extent permitted under federal law, any person found guilty of a
second violation of Article VIIIA
shall be ineligible for medical assistance under this Article, as provided
in Section 8A‑8.
The eligibility of any person for medical assistance under this Article
shall not be affected by the receipt by the person of donations or benefits
from fundraisers held for the person in cases of serious illness,
as long as neither the person nor members of the person's family
have actual control over the donations or benefits or the disbursement
of the donations or benefits.
(Source: P.A. 93‑20, eff. 6‑20‑03; 94‑629, eff. 1‑1‑06.)
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(305 ILCS 5/5‑5) (from Ch. 23, par. 5‑5)
(Text of Section from P.A. 93‑841)
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 care furnished by licensed practitioners; (7)
home health care services; (8) private duty nursing service; (9) clinic
services; (10) dental services; (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; (14)
transportation and such other expenses as may be necessary; (15) medical
treatment of sexual assault survivors, as defined 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 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.
The Illinois Department of Public Aid shall 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, which shall include but not be
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limited to prosthodontics; and
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(2) eyeglasses prescribed by a physician skilled in
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the diseases of the eye, or by an optometrist, whichever the person may select.
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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 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 baseline
mammogram for women 35 to 39 years of age and an
annual mammogram for women 40 years of age or older. 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. As used in 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,
image receptor, and cassettes, with an average radiation exposure delivery
of less than one rad mid‑breast, with 2 views for each breast.
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
Public Aid 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 the number of drug‑affected infants born to recipients of medical
assistance.
Neither the Illinois Department of Public Aid 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 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
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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.
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(2) The Department may elect to consider and
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negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.
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(3) Persons receiving medical services through
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Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.
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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 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. 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 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 the effective date of
this amendatory Act of 1984, 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
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.
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 that provides non‑emergency medical transportation,
defined by the Department by rule,
shall be
conditional for 180 days. During that time, the Department of Public Aid may
terminate the vendor's eligibility to participate in the medical assistance
program without cause. That termination of eligibility is not subject to the
Department's hearing process.
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 without
medical authorization; and (2) rental, lease, purchase or lease‑purchase of
durable medical equipment 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. 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.
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 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.
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 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
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medical services by public aid recipients;
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(b) actual statistics and trends in the provision of
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the various medical services by medical vendors;
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(c) current rate structures and proposed changes in
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those rate structures for the various medical vendors; and
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(d) efforts at utilization review and control by the
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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 Section.
(Source: P.A. 92‑16, eff. 6‑28‑01; 92‑651, eff. 7‑11‑02; 92‑789, eff. 8‑6‑02; 93‑632, eff. 2‑1‑04; 93‑841, eff. 7‑30‑04.)
(Text of Section from P.A. 93‑981)
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 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; (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; (14)
transportation and such other expenses as may be necessary; (15) medical
treatment of sexual assault survivors, as defined 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 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.
The Illinois Department of Public Aid shall 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, which shall include but not be
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limited to prosthodontics; and
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(2) eyeglasses prescribed by a physician skilled in
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the diseases of the eye, or by an optometrist, whichever the person may select.
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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 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 baseline
mammogram for women 35 to 39 years of age and an
annual mammogram for women 40 years of age or older. 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. As used in 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,
image receptor, and cassettes, with an average radiation exposure delivery
of less than one rad mid‑breast, with 2 views for each breast.
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
Public Aid 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 the number of drug‑affected infants born to recipients of medical
assistance.
Neither the Illinois Department of Public Aid 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 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
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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.
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(2) The Department may elect to consider and
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negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.
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(3) Persons receiving medical services through
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Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.
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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 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. 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 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 the effective date of
this amendatory Act of 1984, 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
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.
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 that provides non‑emergency medical transportation,
defined by the Department by rule,
shall be
conditional for 180 days. During that time, the Department of Public Aid may
terminate the vendor's eligibility to participate in the medical assistance
program without cause. That termination of eligibility is not subject to the
Department's hearing process.
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 without
medical authorization; and (2) rental, lease, purchase or lease‑purchase of
durable medical equipment 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. 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. Rules under clause (2) above shall not provide
for purchase or lease‑purchase of durable medical equipment or supplies
used for the purpose of oxygen delivery and respiratory care.
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 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.
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 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
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medical services by public aid recipients;
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(b) actual statistics and trends in the provision of
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the various medical services by medical vendors;
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(c) current rate structures and proposed changes in
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those rate structures for the various medical vendors; and
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(d) efforts at utilization review and control by the
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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 Section.
(Source: P.A. 92‑16, eff. 6‑28‑01; 92‑651, eff. 7‑11‑02; 92‑789, eff. 8‑6‑02; 93‑632, eff. 2‑1‑04; 93‑981, eff. 8‑23‑04.)
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(305 ILCS 5/5‑5.02) (from Ch. 23, par. 5‑5.02)
Sec. 5‑5.02.
Hospital reimbursements.
(a) Reimbursement to Hospitals; July 1, 1992 through September 30, 1992.
Notwithstanding any other provisions of this Code or the Illinois
Department's Rules promulgated under the Illinois Administrative Procedure
Act, reimbursement to hospitals for services provided during the period
July 1, 1992 through September 30, 1992, shall be as follows:
(1) For inpatient hospital services rendered, or if
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applicable, for inpatient hospital discharges occurring, on or after July 1, 1992 and on or before September 30, 1992, the Illinois Department shall reimburse hospitals for inpatient services under the reimbursement methodologies in effect for each hospital, and at the inpatient payment rate calculated for each hospital, as of June 30, 1992. For purposes of this paragraph, "reimbursement methodologies" means all reimbursement methodologies that pertain to the provision of inpatient hospital services, including, but not limited to, any adjustments for disproportionate share, targeted access, critical care access and uncompensated care, as defined by the Illinois Department on June 30, 1992.
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(2) For the purpose of calculating the inpatient
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payment rate for each hospital eligible to receive quarterly adjustment payments for targeted access and critical care, as defined by the Illinois Department on June 30, 1992, the adjustment payment for the period July 1, 1992 through September 30, 1992, shall be 25% of the annual adjustment payments calculated for each eligible hospital, as of June 30, 1992. The Illinois Department shall determine by rule the adjustment payments for targeted access and critical care beginning October 1, 1992.
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(3) For the purpose of calculating the inpatient
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payment rate for each hospital eligible to receive quarterly adjustment payments for uncompensated care, as defined by the Illinois Department on June 30, 1992, the adjustment payment for the period August 1, 1992 through September 30, 1992, shall be one‑sixth of the total uncompensated care adjustment payments calculated for each eligible hospital for the uncompensated care rate year, as defined by the Illinois Department, ending on July 31, 1992. The Illinois Department shall determine by rule the adjustment payments for uncompensated care beginning October 1, 1992.
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(b) Inpatient payments. For inpatient services provided on or after October
1, 1993, in addition to rates paid for hospital inpatient services pursuant to
the Illinois Health Finance Reform Act, as now or hereafter amended, or the
Illinois Department's prospective reimbursement methodology, or any other
methodology used by the Illinois Department for inpatient services, the
Illinois Department shall make adjustment payments, in an amount calculated
pursuant to the methodology described in paragraph (c) of this Section, to
hospitals that the Illinois Department determines satisfy any one of the
following requirements:
(1) Hospitals that are described in Section 1923 of
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the federal Social Security Act, as now or hereafter amended; or
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(2) Illinois hospitals that have a Medicaid
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inpatient utilization rate which is at least one‑half a standard deviation above the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Illinois Department; or
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(3) Illinois hospitals that on July 1, 1991 had a
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Medicaid inpatient utilization rate, as defined in paragraph (h) of this Section, that was at least the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Illinois Department and which were located in a planning area with one‑third or fewer excess beds as determined by the Illinois Health Facilities Planning Board, and that, as of June 30, 1992, were located in a federally designated Health Manpower Shortage Area; or
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(4) Illinois hospitals that:
(A) have a Medicaid inpatient utilization rate
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that is at least equal to the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Department; and
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(B) also have a Medicaid obstetrical inpatient
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utilization rate that is at least one standard deviation above the mean Medicaid obstetrical inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Department for obstetrical services; or
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(5) Any children's hospital, which means a hospital
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devoted exclusively to caring for children. A hospital which includes a facility devoted exclusively to caring for children shall be considered a children's hospital to the degree that the hospital's Medicaid care is provided to children if either (i) the facility devoted exclusively to caring for children is separately licensed as a hospital by a municipality prior to September 30, 1998 or (ii) the hospital has been designated by the State as a Level III perinatal care facility, has a Medicaid Inpatient Utilization rate greater than 55% for the rate year 2003 disproportionate share determination, and has more than 10,000 qualified children days as defined by the Department in rulemaking.
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(c) Inpatient adjustment payments. The adjustment payments required by
paragraph (b) shall be calculated based upon the hospital's Medicaid
inpatient utilization rate as follows:
(1) hospitals with a Medicaid inpatient utilization
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rate below the mean shall receive a per day adjustment payment equal to $25;
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(2) hospitals with a Medicaid inpatient utilization
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rate that is equal to or greater than the mean Medicaid inpatient utilization rate but less than one standard deviation above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $25 plus $1 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds the mean Medicaid inpatient utilization rate;
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(3) hospitals with a Medicaid inpatient utilization
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rate that is equal to or greater than one standard deviation above the mean Medicaid inpatient utilization rate but less than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $40 plus $7 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds one standard deviation above the mean Medicaid inpatient utilization rate; and
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(4) hospitals with a Medicaid inpatient utilization
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rate that is equal to or greater than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $90 plus $2 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds 1.5 standard deviations above the mean Medicaid inpatient utilization rate.
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(d) Supplemental adjustment payments. In addition to the adjustment
payments described in paragraph (c), hospitals as defined in clauses
(1) through (5) of paragraph (b), excluding county hospitals (as defined in
subsection (c) of Section 15‑1 of this Code) and a hospital organized under the
University of Illinois Hospital Act, shall be paid supplemental inpatient
adjustment payments of $60 per day. For purposes of Title XIX of the federal
Social Security Act, these supplemental adjustment payments shall not be
classified as adjustment payments to disproportionate share hospitals.
(e) The inpatient adjustment payments described in paragraphs (c) and (d)
shall be increased on October 1, 1993 and annually thereafter by a percentage
equal to the lesser of (i) the increase in the DRI hospital cost index for the
most recent 12 month period for which data are available, or (ii) the
percentage increase in the statewide average hospital payment rate over the
previous year's statewide average hospital payment rate. The sum of the
inpatient adjustment payments under paragraphs (c) and (d) to a hospital, other
than a county hospital (as defined in subsection (c) of Section 15‑1 of this
Code) or a hospital organized under the University of Illinois Hospital Act,
however, shall not exceed $275 per day; that limit shall be increased on
October 1, 1993 and annually thereafter by a percentage equal to the lesser of
(i) the increase in the DRI hospital cost index for the most recent 12‑month
period for which data are available or (ii) the percentage increase in the
statewide average hospital payment rate over the previous year's statewide
average hospital payment rate.
(f) Children's hospital inpatient adjustment payments. For children's
hospitals, as defined in clause (5) of paragraph (b), the adjustment payments
required pursuant to paragraphs (c) and (d) shall be multiplied by 2.0.
(g) County hospital inpatient adjustment payments. For county hospitals,
as defined in subsection (c) of Section 15‑1 of this Code, there shall be an
adjustment payment as determined by rules issued by the Illinois Department.
(h) For the purposes of this Section the following terms shall be defined
as follows:
(1) "Medicaid inpatient utilization rate" means a
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fraction, the numerator of which is the number of a hospital's inpatient days provided in a given 12‑month period to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act, and the denominator of which is the total number of the hospital's inpatient days in that same period.
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(2) "Mean Medicaid inpatient utilization rate" means
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the total number of Medicaid inpatient days provided by all Illinois Medicaid‑participating hospitals divided by the total number of inpatient days provided by those same hospitals.
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(3) "Medicaid obstetrical inpatient utilization
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rate" means the ratio of Medicaid obstetrical inpatient days to total Medicaid inpatient days for all Illinois hospitals receiving Medicaid payments from the Illinois Department.
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(i) Inpatient adjustment payment limit. In order to meet the limits
of Public Law 102‑234 and Public Law 103‑66, the
Illinois Department shall by rule adjust
disproportionate share adjustment payments.
(j) University of Illinois Hospital inpatient adjustment payments. For
hospitals organized under the University of Illinois Hospital Act, there shall
be an adjustment payment as determined by rules adopted by the Illinois
Department.
(k) The Illinois Department may by rule establish criteria for and develop
methodologies for adjustment payments to hospitals participating under this
Article.
(Source: P.A. 93‑40, eff. 6‑27‑03.)
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(305 ILCS 5/5‑5.4) (from Ch. 23, par. 5‑5.4)
Sec. 5‑5.4. Standards of Payment ‑ Department of Public Aid.
The Department of Public Aid shall develop standards of payment of skilled
nursing and intermediate care services in facilities providing such services
under this Article which:
(1) Provide for the determination of a facility's payment
for skilled nursing and intermediate care services on a prospective basis.
The amount of the payment rate for all nursing facilities certified by the
Department of Public Health under the Nursing Home Care Act as Intermediate
Care for the Developmentally Disabled facilities, Long Term Care for Under Age
22 facilities, Skilled Nursing facilities, or Intermediate Care facilities
under the
medical assistance program shall be prospectively established annually on the
basis of historical, financial, and statistical data reflecting actual costs
from prior years, which shall be applied to the current rate year and updated
for inflation, except that the capital cost element for newly constructed
facilities shall be based upon projected budgets. The annually established
payment rate shall take effect on July 1 in 1984 and subsequent years. No rate
increase and no
update for inflation shall be provided on or after July 1, 1994 and before
July 1, 2006, unless specifically provided for in this
Section.
The changes made by this amendatory Act of the 93rd General Assembly extending the duration of the prohibition against a rate increase or update for inflation are effective retroactive to July 1, 2004.
For facilities licensed by the Department of Public Health under the Nursing
Home Care Act as Intermediate Care for the Developmentally Disabled facilities
or Long Term Care for Under Age 22 facilities, the rates taking effect on July
1, 1998 shall include an increase of 3%. For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as Skilled Nursing
facilities or Intermediate Care facilities, the rates taking effect on July 1,
1998 shall include an increase of 3% plus $1.10 per resident‑day, as defined by
the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January 1, 2006 shall include an increase of 3%.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on July 1, 1999 shall include an increase of 1.6% plus $3.00 per
resident‑day, as defined by the Department. For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as Skilled Nursing
facilities or Intermediate Care facilities, the rates taking effect on July 1,
1999 shall include an increase of 1.6% and, for services provided on or after
October 1, 1999, shall be increased by $4.00 per resident‑day, as defined by
the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on July 1, 2000 shall include an increase of 2.5% per resident‑day,
as defined by the Department. For facilities licensed by the Department of
Public Health under the Nursing Home Care Act as Skilled Nursing facilities or
Intermediate Care facilities, the rates taking effect on July 1, 2000 shall
include an increase of 2.5% per resident‑day, as defined by the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as skilled nursing facilities or intermediate care
facilities, a new payment methodology must be implemented for the nursing
component of the rate effective July 1, 2003. The Department of Public Aid
shall develop the new payment methodology using the Minimum Data Set
(MDS) as the instrument to collect information concerning nursing home
resident condition necessary to compute the rate. The Department of Public Aid
shall develop the new payment methodology to meet the unique needs of
Illinois nursing home residents while remaining subject to the appropriations
provided by the General Assembly.
A transition period from the payment methodology in effect on June 30, 2003
to the payment methodology in effect on July 1, 2003 shall be provided for a
period not exceeding 3 years after implementation of the new payment
methodology as follows:
(A) For a facility that would receive a lower nursing
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component rate per patient day under the new system than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be held at the level in effect on the date immediately preceding the date that the Department implements the new payment methodology until a higher nursing component rate of reimbursement is achieved by that facility.
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(B) For a facility that would receive a higher
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nursing component rate per patient day under the payment methodology in effect on July 1, 2003 than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be adjusted.
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(C) Notwithstanding paragraphs (A) and (B), the
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nursing component rate per patient day for the facility shall be adjusted subject to appropriations provided by the General Assembly.
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For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on March 1, 2001 shall include a statewide increase of 7.85%, as
defined by the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on April 1, 2002 shall include a statewide increase of 2.0%, as
defined by the Department.
This increase terminates on July 1, 2002;
beginning July 1, 2002 these rates are reduced to the level of the rates
in effect on March 31, 2002, as defined by the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as skilled nursing facilities or intermediate care
facilities, the rates taking effect on July 1, 2001 shall be computed using the most recent cost reports
on file with the Department of Public Aid no later than April 1, 2000,
updated for inflation to January 1, 2001. For rates effective July 1, 2001
only, rates shall be the greater of the rate computed for July 1, 2001
or the rate effective on June 30, 2001.
Notwithstanding any other provision of this Section, for facilities
licensed by the Department of Public Health under the Nursing Home Care Act
as skilled nursing facilities or intermediate care facilities, the Illinois
Department shall determine by rule the rates taking effect on July 1, 2002,
which shall be 5.9% less than the rates in effect on June 30, 2002.
Notwithstanding any other provision of this Section, for facilities
licensed by the Department of Public Health under the Nursing Home Care Act as
skilled nursing
facilities or intermediate care facilities, if the payment methodologies required under Section 5A‑12 and the waiver granted under 42 CFR 433.68 are approved by the United States Centers for Medicare and Medicaid Services, the rates taking effect on July 1, 2004 shall be 3.0% greater than the rates in effect on June 30, 2004. These rates shall take
effect only upon approval and
implementation of the payment methodologies required under Section 5A‑12.
Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on January 1, 2005 shall be 3% more than the rates in effect on December 31, 2004.
For facilities
licensed
by the
Department of Public Health under the Nursing Home Care Act as Intermediate
Care for
the Developmentally Disabled facilities or as long‑term care facilities for
residents under 22 years of age, the rates taking effect on July 1,
2003 shall
include a statewide increase of 4%, as defined by the Department.
Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January 1, 2005, facility rates shall be increased by the difference between (i) a facility's per diem property, liability, and malpractice insurance costs as reported in the cost report filed with the Department of Public Aid and used to establish rates effective July 1, 2001 and (ii) those same costs as reported in the facility's 2002 cost report. These costs shall be passed through to the facility without caps or limitations, except for adjustments required under normal auditing procedures.
Rates established effective each July 1 shall govern payment
for services rendered throughout that fiscal year, except that rates
established on July 1, 1996 shall be increased by 6.8% for services
provided on or after January 1, 1997. Such rates will be based
upon the rates calculated for the year beginning July 1, 1990, and for
subsequent years thereafter until June 30, 2001 shall be based on the
facility cost reports
for the facility fiscal year ending at any point in time during the previous
calendar year, updated to the midpoint of the rate year. The cost report
shall be on file with the Department no later than April 1 of the current
rate year. Should the cost report not be on file by April 1, the Department
shall base the rate on the latest cost report filed by each skilled care
facility and intermediate care facility, updated to the midpoint of the
current rate year. In determining rates for services rendered on and after
July 1, 1985, fixed time shall not be computed at less than zero. The
Department shall not make any alterations of regulations which would reduce
any component of the Medicaid rate to a level below what that component would
have been utilizing in the rate effective on July 1, 1984.
(2) Shall take into account the actual costs incurred by facilities
in providing services for recipients of skilled nursing and intermediate
care services under the medical assistance program.
(3) Shall take into account the medical and psycho‑social
characteristics and needs of the patients.
(4) Shall take into account the actual costs incurred by facilities in
meeting licensing and certification standards imposed and prescribed by the
State of Illinois, any of its political subdivisions or municipalities and by
the U.S. Department of Health and Human Services pursuant to Title XIX of the
Social Security Act.
The Department of Public Aid shall develop precise standards for
payments to reimburse nursing facilities for any utilization of
appropriate rehabilitative personnel for the provision of rehabilitative
services which is authorized by federal regulations, including
reimbursement for services provided by qualified therapists or qualified
assistants, and which is in accordance with accepted professional
practices. Reimbursement also may be made for utilization of other
supportive personnel under appropriate supervision.
(Source: P.A. 93‑20, eff. 6‑20‑03; 93‑649, eff. 1‑8‑04; 93‑659, eff. 2‑3‑04; 93‑841, eff. 7‑30‑04; 93‑1087, eff. 2‑28‑05; 94‑48, eff. 7‑1‑05; 94‑85, eff. 6‑28‑05; 94‑697, eff. 11‑21‑05.)
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(305 ILCS 5/5‑5.5) (from Ch. 23, par. 5‑5.5)
Sec. 5‑5.5. Elements of Payment Rate.
(a) The Department of Public Aid shall develop a prospective method for
determining payment rates for skilled nursing and intermediate care
services in nursing facilities composed of the following cost elements:
(1) Standard Services, with the cost of this |
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component being determined by taking into account the actual costs to the facilities of these services subject to cost ceilings to be defined in the Department's rules.
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(2) Resident Services, with the cost of this
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component being determined by taking into account the actual costs, needs and utilization of these services, as derived from an assessment of the resident needs in the nursing facilities. The Department shall adopt rules governing reimbursement for resident services as listed in Section 5‑1.1. Surveys or assessments of resident needs under this Section shall include a review by the facility of the results of such assessments and a discussion of issues in dispute with authorized survey staff, unless the facility elects not to participate in such a review process. Surveys or assessments of resident needs under this Section may be conducted semi‑annually and payment rates relating to resident services may be changed on a semi‑annual basis. The Illinois Department shall initiate a project, either on a pilot basis or Statewide, to reimburse the cost of resident services based on a methodology which utilizes an assessment of resident needs to determine the level of reimbursement. This methodology shall be different from the payment criteria for resident services utilized by the Illinois Department on July 1, 1981. On March 1, 1982, and each year thereafter, until such time when the Illinois Department adopts the methodology used in such project for use statewide, the Illinois Department shall report to the General Assembly on the implementation and progress of such project. The report shall include:
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(A) A statement of the Illinois Department's
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goals and objectives for such project;
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(B) A description of such project, including the
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number and type of nursing facilities involved in the project;
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(C) A description of the methodology used in such
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(D) A description of the Illinois Department's
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application of the methodology;
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(E) A statement on the methodology's effect on
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the quality of care given to residents in the sample nursing facilities; and
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(F) A statement on the cost of the methodology
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used in such project and a comparison of this cost with the cost of the current payment criteria.
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(3) Ancillary Services, with the payment rate being
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developed for each individual type of service. Payment shall be made only when authorized under procedures developed by the Department of Public Aid.
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(4) Nurse's Aide Training, with the cost of this
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component being determined by taking into account the actual cost to the facilities of such training.
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(5) Real Estate Taxes, with the cost of this
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component being determined by taking into account the figures contained in the most currently available cost reports (with no imposition of maximums) updated to the midpoint of the current rate year for long term care services rendered between July 1, 1984 and June 30, 1985, and with the cost of this component being determined by taking into account the actual 1983 taxes for which the nursing homes were assessed (with no imposition of maximums) updated to the midpoint of the current rate year for long term care services rendered between July 1, 1985 and June 30, 1986.
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(b) In developing a prospective method for determining payment rates
for skilled nursing and intermediate care services in nursing facilities,
the Department of Public Aid shall consider the following cost elements:
(1) Reasonable capital cost determined by utilizing
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incurred interest rate and the current value of the investment, including land, utilizing composite rates, or by utilizing such other reasonable cost related methods determined by the Department. However, beginning with the rate reimbursement period effective July 1, 1987, the Department shall be prohibited from establishing, including, and implementing any depreciation factor in calculating the capital cost element.
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(2) Profit, with the actual amount being produced and
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accruing to the providers in the form of a return on their total investment, on the basis of their ability to economically and efficiently deliver a type of service. The method of payment may assure the opportunity for a profit, but shall not guarantee or establish a specific amount as a cost.
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(c) The Illinois Department may implement the amendatory changes to
this Section made by this amendatory Act of 1991 through the use of
emergency rules in accordance with the provisions of Section 5.02 of the
Illinois Administrative Procedure Act. For purposes of the Illinois
Administrative Procedure Act, the adoption of rules to implement the
amendatory changes to this Section made by this amendatory
Act of 1991 shall be deemed an emergency and necessary for the public
interest, safety and welfare.
(d) No later than January 1, 2001, the Department of Public Aid shall file
with the Joint Committee on Administrative Rules, pursuant to the Illinois
Administrative Procedure
Act,
a proposed rule, or a proposed amendment to an existing rule, regarding payment
for appropriate services, including assessment, care planning, discharge
planning, and treatment
provided by nursing facilities to residents who have a serious mental
illness.
(Source: P.A. 93‑632, eff. 2‑1‑04.)
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(305 ILCS 5/5‑11) (from Ch. 23, par. 5‑11)
Sec. 5‑11. Co‑operative arrangements; contracts with other State
agencies, health care and rehabilitation organizations, and fiscal
intermediaries.
(a) The Illinois Department may enter into co‑operative arrangements
with
State agencies responsible for administering or supervising the
administration of health services and vocational rehabilitation services to
the end that there may be maximum utilization of such services in the
provision of medical assistance.
The Illinois Department shall, not later than June 30, 1993, enter into
one or more co‑operative arrangements with the Department of Mental Health
and Developmental Disabilities providing that the Department of Mental
Health and Developmental Disabilities will be responsible for administering
or supervising all programs for services to persons in community care
facilities for persons with developmental disabilities, including but not
limited to intermediate care facilities, that are supported by State funds or
by funding under Title XIX of the federal Social Security Act. The
responsibilities of the Department of Mental Health and Developmental
Disabilities under these agreements are transferred to the Department of
Human Services as provided in the Department of Human Services Act.
The Department may also contract with such State health and
rehabilitation agencies and other public or private health care and
rehabilitation organizations to act for it in supplying designated medical
services to persons eligible therefor under this Article. Any contracts
with health services or health maintenance organizations shall be
restricted to organizations which have been certified as being in
compliance with standards promulgated pursuant to the laws of this State
governing the establishment and operation of health services or health
maintenance organizations. The Department shall renegotiate the contracts with health maintenance organizations and managed care community
networks that took effect August 1, 2003, so as to produce $70,000,000 savings to the Department net of resulting increases to the fee‑for‑service program for State fiscal year 2006. The Department may also contract with insurance
companies or other corporate entities serving as fiscal intermediaries in
this State for the Federal Government in respect to Medicare payments under
Title XVIII of the Federal Social Security Act to act for the Department in
paying medical care suppliers. The provisions of Section 9 of "An Act in
relation to State finance", approved June 10, 1919, as amended,
notwithstanding, such contracts with State agencies, other health care and
rehabilitation organizations, or fiscal intermediaries may provide for
advance payments.
(b) For purposes of this subsection (b), "managed care community
network" means an entity, other than a health maintenance organization, that
is owned, operated, or governed by providers of health care services within
this State and that provides or arranges primary, secondary, and tertiary
managed health care services under contract with the Illinois Department
exclusively to persons participating in programs administered by the Illinois
Department.
The Illinois Department may certify managed care community
networks, including managed care community networks owned, operated, managed,
or
governed by State‑funded medical schools, as risk‑bearing entities eligible to
contract with the Illinois Department as Medicaid managed care
organizations. The Illinois Department may contract with those managed
care community networks to furnish health care services to or arrange those
services for individuals participating in programs administered by the Illinois
Department. The rates for those provider‑sponsored organizations may be
determined on a prepaid, capitated basis. A managed care community
network may choose to contract with the Illinois Department to provide only
pediatric
health care services.
The
Illinois Department shall by rule adopt the criteria, standards, and procedures
by
which a managed care community network may be permitted to contract with
the Illinois Department and shall consult with the Department of Insurance in
adopting these rules.
A county provider as defined in Section 15‑1 of this Code may
contract with the Illinois Department to provide primary, secondary, or
tertiary managed health care services as a managed care
community network without the need to establish a separate entity and shall
be deemed a managed care community network for purposes of this Code
only to the extent it provides services to participating individuals. A county
provider is entitled to contract with the Illinois Department with respect to
any contracting region located in whole or in part within the county. A
county provider is not required to accept enrollees who do not reside within
the county.
In order
to (i) accelerate and facilitate the development of integrated health care in
contracting areas outside counties with populations in excess of 3,000,000 and
counties adjacent to those counties and (ii) maintain and sustain the high
quality of education and residency programs coordinated and associated with
local area hospitals, the Illinois Department may develop and implement a
demonstration program from managed care community networks owned, operated,
managed, or
governed by State‑funded medical schools. The Illinois Department shall
prescribe by rule the criteria, standards, and procedures for effecting this
demonstration program.
A managed care community network that
contracts with the Illinois Department to furnish health care services to or
arrange those services for enrollees participating in programs administered by
the Illinois Department shall do all of the following:
(1) Provide that any provider affiliated with the
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managed care community network may also provide services on a fee‑for‑service basis to Illinois Department clients not enrolled in such managed care entities.
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(2) Provide client education services as determined
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and approved by the Illinois Department, including but not limited to (i) education regarding appropriate utilization of health care services in a managed care system, (ii) written disclosure of treatment policies and restrictions or limitations on health services, including, but not limited to, physical services, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologics, and radiological examinations, and (iii) written notice that the enrollee may receive from another provider those covered services that are not provided by the managed care community network.
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(3) Provide that enrollees within the system may
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choose the site for provision of services and the panel of health care providers.
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(4) Not discriminate in enrollment or disenrollment
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practices among recipients of medical services or enrollees based on health status.
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(5) Provide a quality assurance and utilization
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review program that meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.
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(6) Issue a managed care community network
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identification card to each enrollee upon enrollment. The card must contain all of the following:
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(A) The enrollee's health plan.
(B) The name and telephone number of the
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enrollee's primary care physician or the site for receiving primary care services.
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(C) A telephone number to be used to confirm
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eligibility for benefits and authorization for services that is available 24 hours per day, 7 days per week.
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(7) Ensure that every primary care physician and
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pharmacy in the managed care community network meets the standards established by the Illinois Department for accessibility and quality of care. The Illinois Department shall arrange for and oversee an evaluation of the standards established under this paragraph (7) and may recommend any necessary changes to these standards.
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(8) Provide a procedure for handling complaints that
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meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.
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(9) Maintain, retain, and make available to the
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Illinois Department records, data, and information, in a uniform manner determined by the Illinois Department, sufficient for the Illinois Department to monitor utilization, accessibility, and quality of care.
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(10) Provide that the pharmacy formulary used by the
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managed care community network and its contract providers be no more restrictive than the Illinois Department's pharmaceutical program on the effective date of this amendatory Act of 1998 and as amended after that date.
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The Illinois Department shall contract with an entity or entities to provide
external peer‑based quality assurance review for the managed health care
programs administered by the Illinois Department. The entity shall be
representative of Illinois physicians licensed to practice medicine in all its
branches and have statewide geographic representation in all specialities of
medical care that are provided in managed health care programs administered by
the Illinois Department. The entity may not be a third party payer and shall
maintain offices in locations around the State in order to provide service and
continuing medical education to physician participants within those managed
health care programs administered by the Illinois Department. The review
process shall be developed and conducted by Illinois physicians licensed to
practice medicine in all its branches. In consultation with the entity, the
Illinois Department may contract with other entities for professional
peer‑based quality assurance review of individual
categories of services other than services provided, supervised, or coordinated
by physicians licensed to practice medicine in all its branches. The Illinois
Department shall establish, by rule, criteria to avoid conflicts of interest in
the conduct of quality assurance activities consistent with professional
peer‑review standards. All quality assurance activities shall be coordinated
by the Illinois Department.
Each managed care community network must demonstrate its ability to
bear the financial risk of serving individuals under this program.
The Illinois Department shall by rule adopt standards for assessing the
solvency and financial soundness of each managed care community network.
Any solvency and financial standards adopted for managed care community
networks
shall be no more restrictive than the solvency and financial standards adopted
under
Section 1856(a) of the Social Security Act for provider‑sponsored
organizations under Part C of Title XVIII of the Social Security Act.
The Illinois
Department may implement the amendatory changes to this
Code made by this amendatory Act of 1998 through the use of emergency
rules in accordance with Section 5‑45 of the Illinois Administrative Procedure
Act. For purposes of that Act, the adoption of rules to implement these
changes is deemed an emergency and necessary for the public interest,
safety, and welfare.
(c) Not later than June 30, 1996, the Illinois Department shall
enter into one or more cooperative arrangements with the Department of Public
Health for the purpose of developing a single survey for
nursing facilities, including but not limited to facilities funded under Title
XVIII or Title XIX of the federal Social Security Act or both, which shall be
administered and conducted solely by the Department of Public Health.
The Departments shall test the single survey process on a pilot basis, with
both the Departments of Public Aid and Public Health represented on the
consolidated survey team. The pilot will sunset June 30, 1997. After June 30,
1997, unless otherwise determined by the Governor, a single survey shall be
implemented by the Department of Public Health which would not preclude staff
from the Department of Public Aid from going on‑site to nursing facilities to
perform necessary audits and reviews which shall not replicate the single State
agency survey required by this Act. This Section shall not apply to community
or intermediate care facilities for persons with developmental disabilities.
(d) Nothing in this Code in any way limits or otherwise impairs the
authority or power of the Illinois Department to enter into a negotiated
contract pursuant to this Section with a managed care community network or
a health maintenance organization, as defined in the Health Maintenance
Organization Act, that provides for
termination or nonrenewal of the contract without cause, upon notice as
provided in the contract, and without a hearing.
(Source: P.A. 94‑48, eff. 7‑1‑05.)
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(305 ILCS 5/5‑16) (from Ch. 23, par. 5‑16)
Sec. 5‑16.
Managed Care.
The Illinois Department may develop and implement
a Primary Care Sponsor System consistent with the provisions of this Section.
The purpose of this managed care delivery system shall be to contain the costs
of providing medical care to Medicaid recipients by having one provider
responsible for managing all aspects of a recipient's medical care. This
managed care system shall have the following characteristics:
(a) The Department, by rule, shall establish |
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criteria to determine which clients must participate in this program;
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(b) Providers participating in the program may be
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paid an amount per patient per month, to be set by the Illinois Department, for managing each recipient's medical care;
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(c) Providers eligible to participate in the program
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shall be physicians licensed to practice medicine in all its branches, and the Illinois Department may terminate a provider's participation if the provider is determined to have failed to comply with any applicable program standard or procedure established by the Illinois Department;
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(d) Each recipient required to participate in the
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program must select from a panel of primary care providers or networks established by the Department in their communities;
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(e) A recipient may change his designated primary
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(1) when the designated source becomes
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unavailable, as the Illinois Department shall determine by rule; or
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(2) when the designated primary care provider
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notifies the Illinois Department that it wishes to withdraw from any obligation as primary care provider; or
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(3) in other situations, as the Illinois
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Department shall provide by rule;
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(f) The Illinois Department shall, by rule,
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establish procedures for providing medical services when the designated source becomes unavailable or wishes to withdraw from any obligation as primary care provider taking into consideration the need for emergency or temporary medical assistance and ensuring that the recipient has continuous and unrestricted access to medical care from the date on which such unavailability or withdrawal becomes effective until such time as the recipient designates a primary care source;
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(g) Only medical care services authorized by a
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recipient's designated provider, except for emergency services, services performed by a provider that is owned or operated by a county and that provides non‑emergency services without regard to ability to pay and such other services as provided by the Illinois Department, shall be subject to payment by the Illinois Department. The Illinois Department shall enter into an intergovernmental agreement with each county that owns or operates such a provider to develop and implement policies to minimize the provision of medical care services provided by county owned or operated providers pursuant to the foregoing exception.
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The Illinois Department shall seek and obtain necessary authorization
provided under federal law to implement such a program including the waiver of
any federal regulations.
The Illinois Department may implement the amendatory changes to
this Section made by this amendatory Act of 1991 through the use of emergency
rules in accordance with the provisions of Section 5.02 of the Illinois
Administrative Procedure Act. For purposes of the Illinois Administrative
Procedure Act, the adoption of rules to implement the amendatory changes to
this Section made by this amendatory Act of 1991 shall be deemed an emergency
and necessary for the public interest, safety and welfare.
The Illinois Department may establish a managed care system demonstration
program, on a limited basis, as described in this Section. The demonstration
program shall terminate on June 30, 1997. Within 30 days after the end of each
year of the demonstration program's operation, the Illinois Department shall
report to the Governor and the General Assembly concerning the operation of the
demonstration program.
(Source: P.A. 87‑14; 88‑490.)
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(305 ILCS 5/5‑16.1) (from Ch. 23, par. 5‑16.1)
Sec. 5‑16.1.
Case Management Services.
The Illinois Department may
develop, implement and evaluate a Case Management Services Program which
provides services consistent with the provisions of this Section, and the
Inter‑Agency Agreement between the Department of Public Aid and the
Department of Public Health, for a targeted population on a less than
Statewide basis in the State of Illinois. The purpose of this Case
Management Services Program shall be to assist eligible participants in
gaining access to needed medical, social, educational and other services
thereby reducing the likelihood of long‑term welfare dependency. The Case
Management Services Program shall have the following characteristics:
(a) It shall be conducted for a period of no less |
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than 5 consecutive fiscal years in one urban area containing a high proportion, as determined by Department of Public Aid and Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment and in one rural area containing a high proportion, as determined by Department of Public Aid and Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment.
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(b) Providers participating in the program shall be
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paid an amount per patient per month, to be set by the Illinois Department, for the case management services provided.
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(c) Providers eligible to participate in the program
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shall be nurses or social workers, licensed to practice in Illinois, who comply with the rules and regulations established by the Illinois Department and the Inter‑Agency Agreement between the Department of Public Aid and the Department of Public Health. The Illinois Department may terminate a provider's participation in the program if the provider is determined to have failed to comply with any applicable program standard or procedure established by the Illinois Department.
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(d) Each eligible participant in an area where the
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Case Management Services Program is being conducted may voluntarily designate a case manager, of her own choosing to assume responsibility for her care.
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(e) A participant may change her designated case
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manager provided that she informs the Illinois Department by the 20th day of the month in order for the change to be effective in the following month.
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(f) The Illinois Department shall, by rule,
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establish procedures for providing case management services when the designated source becomes unavailable or wishes to withdraw from any obligation as case management services provider.
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(g) In accordance with rules adopted by the Illinois
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Department, a participant may discontinue participation in the program upon timely notice to the Illinois Department, in which case the participant shall remain eligible for assistance under all applicable provisions of Article V of this Code.
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The Illinois Department shall take any necessary steps to obtain
authorization or waiver under federal law to implement a Case Management
Services Program. Participation shall be voluntary for the provider and
the recipient.
(Source: P.A. 87‑685.)
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(305 ILCS 5/5‑19) (from Ch. 23, par. 5‑19)
Sec. 5‑19.
Healthy Kids Program.
(a) Any child under the age of 21 eligible to receive Medical Assistance
from the Illinois Department under Article V of this Code shall be eligible
for Early and Periodic Screening, Diagnosis and Treatment services provided
by the Healthy Kids Program of the Illinois Department under the Social
Security Act, 42 U.S.C. 1396d(r).
(b) Enrollment of Children in Medicaid. The Illinois Department shall
provide for receipt and initial processing of applications for Medical
Assistance for all pregnant women and children under the age of 21 at
locations in addition to those used for processing applications for cash
assistance, including disproportionate share hospitals, federally qualified
health centers and other sites as selected by the Illinois Department.
(c) Healthy Kids Examinations. The Illinois Department shall consider
any examination of a child eligible for the Healthy Kids services provided
by a medical provider meeting the requirements and complying with the rules
and regulations of the Illinois Department to be reimbursed as a Healthy
Kids examination.
(d) Medical Screening Examinations.
(1) The Illinois Department shall insure Medicaid |
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coverage for periodic health, vision, hearing, and dental screenings for children eligible for Healthy Kids services scheduled from a child's birth up until the child turns 21 years. The Illinois Department shall pay for vision, hearing, dental and health screening examinations for any child eligible for Healthy Kids services by qualified providers at intervals established by Department rules.
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(2) The Illinois Department shall pay for an
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interperiodic health, vision, hearing, or dental screening examination for any child eligible for Healthy Kids services whenever an examination is:
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(A) requested by a child's parent, guardian, or
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custodian, or is determined to be necessary or appropriate by social services, developmental, health, or educational personnel; or
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(B) necessary for enrollment in school; or
(C) necessary for enrollment in a licensed day
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care program, including Head Start; or
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(D) necessary for placement in a licensed child
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welfare facility, including a foster home, group home or child care institution; or
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(E) necessary for attendance at a camping
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(F) necessary for participation in an organized
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(G) necessary for enrollment in an early
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childhood education program recognized by the Illinois State Board of Education; or
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(H) necessary for participation in a Women,
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Infant, and Children (WIC) program; or
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(I) deemed appropriate by the Illinois
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(e) Minimum Screening Protocols For Periodic Health Screening
Examinations. Health Screening Examinations must include the following
services:
(1) Comprehensive Health and Development Assessment
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(A) Development/Mental Health/Psychosocial
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(B) Assessment of nutritional status including
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tests for iron deficiency and anemia for children at the following ages: 9 months, 2 years, 8 years, and 18 years;
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(2) Comprehensive unclothed physical exam;
(3) Appropriate immunizations at a minimum, as
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required by the Secretary of the U.S. Department of Health and Human Services under 42 U.S.C. 1396d(r).
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(4) Appropriate laboratory tests including blood
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lead levels appropriate for age and risk factors.
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(A) Anemia test.
(B) Sickle cell test.
(C) Tuberculin test at 12 months of age and
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every 1‑2 years thereafter unless the treating health care professional determines that testing is medically contraindicated.
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(D) Other ‑‑ The Illinois Department shall
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insure that testing for HIV, drug exposure, and sexually transmitted diseases is provided for as clinically indicated.
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(5) Health Education. The Illinois Department shall
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require providers to provide anticipatory guidance as recommended by the American Academy of Pediatrics.
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(6) Vision Screening. The Illinois Department shall
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require providers to provide vision screenings consistent with those set forth in the Department of Public Health's Administrative Rules.
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(7) Hearing Screening. The Illinois Department
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shall require providers to provide hearing screenings consistent with those set forth in the Department of Public Health's Administrative Rules.
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(8) Dental Screening. The Illinois Department shall
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require providers to provide dental screenings consistent with those set forth in the Department of Public Health's Administrative Rules.
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(f) Covered Medical Services. The Illinois Department shall provide
coverage for all necessary health care, diagnostic services, treatment and
other measures to correct or ameliorate defects, physical and mental
illnesses, and conditions whether discovered by the screening services or
not for all children eligible for Medical Assistance under Article V of
this Code.
(g) Notice of Healthy Kids Services.
(1) The Illinois Department shall inform any child
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eligible for Healthy Kids services and the child's family about the benefits provided under the Healthy Kids Program, including, but not limited to, the following: what services are available under Healthy Kids, including discussion of the periodicity schedules and immunization schedules, that services are provided at no cost to eligible children, the benefits of preventive health care, where the services are available, how to obtain them, and that necessary transportation and scheduling assistance is available.
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(2) The Illinois Department shall widely disseminate
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information regarding the availability of the Healthy Kids Program throughout the State by outreach activities which shall include, but not be limited to, (i) the development of cooperation agreements with local school districts, public health agencies, clinics, hospitals and other health care providers, including developmental disability and mental health providers, and with charities, to notify the constituents of each of the Program and assist individuals, as feasible, with applying for the Program, (ii) using the media for public service announcements and advertisements of the Program, and (iii) developing posters advertising the Program for display in hospital and clinic waiting rooms.
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(3) The Illinois Department shall utilize accepted
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methods for informing persons who are illiterate, blind, deaf, or cannot understand the English language, including but not limited to public services announcements and advertisements in the foreign language media of radio, television and newspapers.
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(4) The Illinois Department shall provide notice of
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the Healthy Kids Program to every child eligible for Healthy Kids services and his or her family at the following times:
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(A) orally by the intake worker and in writing
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at the time of application for Medical Assistance;
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(B) at the time the applicant is informed that
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he or she is eligible for Medical Assistance benefits; and
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(C) at least 20 days before the date of any
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periodic health, vision, hearing, and dental examination for any child eligible for Healthy Kids services. Notice given under this subparagraph (C) must state that a screening examination is due under the periodicity schedules and must advise the eligible child and his or her family that the Illinois Department will provide assistance in scheduling an appointment and arranging medical transportation.
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(h) Data Collection. The Illinois Department shall collect data in a
usable form to track utilization of Healthy Kids screening examinations by
children eligible for Healthy Kids services, including but not limited to
data showing screening examinations and immunizations received, a summary
of follow‑up treatment received by children eligible for Healthy Kids
services and the number of children receiving dental, hearing and vision
services.
(Source: P.A. 87‑630; 87‑895.)
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(305 ILCS 5/5‑22)
Sec. 5‑22.
Healthy Moms/Healthy Kids reporting requirement.
The Illinois
Department shall submit a report concerning the Healthy Moms/Healthy Kids
Program on July 31, 1994 and on that day each year thereafter. The report
shall contain the following information:
(1) A list of each Primary Care Provider participating in the Healthy
Moms/Healthy Kids Managed Care Program and the following information for each
listed provider:
(A) zip code;
(B) specialty (as indicated on their HMHK Managed |
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Care Provider Agreement);
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(C) total number of patients that the provider has
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agreed to enroll each month under the signed agreement including the total number of pregnant women and the total number of children each provider has agreed to serve; and
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(D) total number of unduplicated patients the
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provider has enrolled (by month and for the year) under the signed agreement including the number of pregnant women and the total number of children.
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(2) The unduplicated number of children who are Medicaid enrolled in the
Healthy Moms/Healthy Kids Managed Care Program's target area during the year.
(3) The unduplicated number of children who were enrolled in the Healthy
Moms/Healthy Kids Managed Care Program during the year:
(A) The unduplicated number of children who were
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assigned to a Primary Care Provider enrolled physician.
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(B) The unduplicated number of children who were
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assigned to a Federally Qualified Health Center (number of FQHC name).
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(C) The unduplicated number of children who were
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assigned to a hospital outpatient or other clinic type (number of hospital outpatient or other clinic name).
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(D) The unduplicated number of children who were
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assigned to an HMO (number of HMO name).
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(4) The unduplicated number of known pregnant women who are Medicaid
enrolled during their pregnancy in the Healthy Moms/Healthy Kids Managed Care
Program's target area during the year.
(5) The unduplicated number of pregnant women who were enrolled in the
Healthy Moms/Healthy Kids Managed Care Program during the year:
(A) The unduplicated number of pregnant women who
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were assigned to a Primary Care Provider enrolled physician.
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(B) The unduplicated number of pregnant women who
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were assigned to a Federally Qualified Health Center (number by FQHC name).
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(C) The unduplicated number of pregnant women who
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were assigned to a hospital outpatient or other clinic type (number of hospital outpatient or other clinic name).
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(D) The unduplicated number of women who were
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pregnant at the time of assignment to an HMO (number of HMO name).
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(6) The number of unduplicated children who were Medicaid enrolled in the
Healthy Moms/Healthy Kids Managed Care Program's target area, but who were not
enrolled with one of the Primary Care Provider types or an HMO during the year.
(7) The number of known unduplicated pregnant women who were Medicaid
enrolled in the Healthy Moms/Healthy Kids Managed Care Program's target area
but who were not enrolled with one of the Primary Care Provider types or an HMO
during the year.
(8) The number of unduplicated children enrolled in the Healthy Moms/Healthy
Kids Managed Care Program who were referred to a specialist, indicating the
number of children by specialty, as identified in the Medicaid Provider
Enrollment system.
(9) The number of unduplicated pregnant women enrolled in the Healthy
Moms/Healthy Kids Managed Care Program who were referred to a specialist,
indicating the number of pregnant women by specialty, as identified in the
Medicaid Provider Enrollment system.
(10) A list of each case management agency participating in the Healthy
Moms/Healthy Kids Managed Care Program and the following information for each
listed agency:
(A) name;
(B) address and zip code;
(C) the number of cases assigned by category (i.e.
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families with pregnant women; families with infants; families with children over age one) by month and an unduplicated total for the year; and
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(D) the amount of payment for case management
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services by month and a total for the year.
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(11) A list of each case management agency participating in the Healthy
Moms/Healthy Kids Program (outside of the target Healthy Moms/Healthy Kids
Managed Care Program area) and the following information for each listed
agency:
(A) name;
(B) address and zip code;
(B‑5) county/area served;
(C) the number of cases assigned by category (i.e.
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families with pregnant women; families with infants; families with children over age one) by month and an unduplicated total for the year; and
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(D) the amount of payment for case management
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services by month and an unduplicated total for the year.
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(12) The total number of physicians by county, who have signed Healthy
Moms/Healthy Kids Provider Agreements (outside of the target Healthy
Moms/Healthy Kids Managed Care Program area).
(Source: P.A. 90‑655, eff. 7‑30‑98.)
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