2005 Illinois 305 ILCS 5/ Illinois Public Aid Code. Article V - Medical Assistance

(305 ILCS 5/5‑1) (from Ch. 23, par. 5‑1)
Sec. 5‑1. Declaration of purpose. It is the purpose of this Article to provide a program of essential medical care and rehabilitative services for persons receiving basic maintenance grants under this Code and for other persons who are unable, because of inadequate resources, to meet their essential medical needs.
Preservation of health, alleviation of sickness, and correction of handicapping conditions for persons requiring maintenance support are essential if they are to have an opportunity to become self‑supporting or to attain a greater capacity for self‑care. For persons who are medically indigent but otherwise able to provide themselves with a livelihood, it is of special importance to maintain their incentives for continued independence and preserve their limited resources for ordinary maintenance needs to prevent their total or substantial dependency.
(Source: Laws 1967, p. 122 .)

(305 ILCS 5/5‑1.1) (from Ch. 23, par. 5‑1.1)
Sec. 5‑1.1. Definitions. The terms defined in this Section shall have the meanings ascribed to them, except when the context otherwise requires.
(a) "Skilled nursing facility" means a nursing home eligible to participate as a skilled nursing facility under Title XIX of the federal Social Security Act.
(b) "Intermediate care facility" means a nursing home eligible to participate as an intermediate care facility under Title XIX of the federal Social Security Act.
(c) "Standard services" means those services required for the care of all patients in the facility and shall as a minimum include the following: (1) administration; (2) dietary (standard); (3) housekeeping; (4) laundry and linen; (5) maintenance of property and equipment, including utilities; (6) medical records; (7) training of employees; (8) utilization review; (9) activities services; (10) social services; (11) disability services; and all other similar services required by either the laws of the State of Illinois or one of its political subdivisions or municipalities or by Title XIX of the Social Security Act.
(d) "Patient services" means those which vary with the number of personnel; professional and para‑professional skills of the personnel; specialized equipment, and reflect the intensity of the medical and psycho‑social needs of the patients. Patient services shall as a minimum include: (1) physical services; (2) nursing services, including restorative nursing; (3) medical direction and patient care planning; (4) health related supportive and habilitative services and all similar services required by either the laws of the State of Illinois or one of its political subdivisions or municipalities or by Title XIX of the Social Security Act.
(e) "Ancillary services" means those services which require a specific physician's order and defined as under the medical assistance program as not being routine in nature for skilled nursing and intermediate care facilities. Such services generally must be authorized prior to delivery and payment as provided for under the rules of the Department of Public Aid.
(f) "Capital" means the investment in a facility's assets for both debt and non‑debt funds. Non‑debt capital is the difference between an adjusted replacement value of the assets and the actual amount of debt capital.
(g) "Profit" means the amount which shall accrue to a facility as a result of its revenues exceeding its expenses as determined in accordance with generally accepted accounting principles.
(h) "Non‑institutional services" means those services provided under paragraph (f) of Section 3 of the Disabled Persons Rehabilitation Act and those services provided under Section 4.02 of the Illinois Act on the Aging.
(i) "Exceptional medical care" means the level of medical care required by persons who are medically stable for discharge from a hospital but who require acute intensity hospital level care for physician, nurse and ancillary specialist services, including persons with acquired immunodeficiency syndrome (AIDS) or a related condition. Such care shall consist of those services which the Department shall determine by rule.
(j) "Institutionalized person" means an individual who is an inpatient in an intermediate care or skilled nursing facility, or who is an inpatient in a medical institution receiving a level of care equivalent to that of an intermediate care or skilled nursing facility, or who is receiving services under Section 1915(c) of the Social Security Act.
(k) "Institutionalized spouse" means an institutionalized person who is expected to receive services at the same level of care for at least 30 days and is married to a spouse who is not an institutionalized person.
(l) "Community spouse" is the spouse of an institutionalized spouse.
(Source: P.A. 89‑626, eff. 8‑9‑96.)

(305 ILCS 5/5‑1.2)
Sec. 5‑1.2. Recipient eligibility verification.
(a) The Illinois Department shall initiate a statewide system by which providers and sites of medical care can electronically verify recipient eligibility for aid under this Article. High‑volume providers and sites of medical care, as defined by the Illinois Department by rule, shall be required to participate in the eligibility verification system. Every non‑high‑volume provider and site of medical care shall be afforded the opportunity to participate in the eligibility verification system. The Illinois Department shall provide by rule for implementation of the system, which may be accomplished in phases over time and by geographic region, recipient classification, and provider type. The system shall initially be implemented in, but not limited to, the following zip codes in Cook County: 60601, 60602, 60603, 60604, 60605, 60606, 60607, 60608, 60609, 60612, and 60616. The system shall be implemented within 6 months after approval by the federal government. The Illinois Department shall report to the General Assembly by December 31, 1994 on the status of the Illinois Department's application to the federal government for approval of this system. The recipient eligibility verification system may be coordinated with the Electronic Benefits Transfer system established by Section 11‑3.1 of this Code and compatible with any of the methods for the delivery of medical care and services authorized by this Article. The system shall make available to providers the history of claims for medical services submitted to the Illinois Department for those services provided to the recipient. The Illinois Department shall develop safeguards to protect each recipient's health information from misuse or unauthorized disclosure.
(b) The Illinois Department shall conduct a demonstration project in at least 2 geographic locations for the purpose of assessing the effectiveness of a recipient photo identification card in reducing abuses in the provision of services under this Article. In order to receive medical care, recipients included in this demonstration project must present a Medicaid card and photo identification card. The Illinois Department shall apply for any federal waivers or approvals necessary to conduct this demonstration project. The demonstration project shall become operational (i) 12 months after the effective date of this amendatory Act of 1994 or (ii) after the Illinois Department's receipt of all necessary federal waivers and approvals, whichever occurs later, and shall operate for 12 months.
(Source: P.A. 88‑554, eff. 7‑26‑94.)

(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

Articles III and IV. 2. Persons otherwise eligible for basic maintenance

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:

(a) All persons otherwise eligible for basic

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:

(i) their income, as determined by the

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

(ii) their income, after the deduction of

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).

(b) All persons who would be determined eligible

for such basic maintenance under Article IV by disregarding the maximum earned income permitted by federal law.

3. Persons who would otherwise qualify for Aid to the Medically Indigent under Article VII. 4. Persons not eligible under any of the preceding

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.

5.(a) Women during pregnancy, after the fact of

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.

(b) The Illinois Department and the Governor shall

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.

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.

6. Persons under the age of 18 who fail to qualify as

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.

7. Persons who are under 21 years of age and would

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:

(a) the person requires a level of care provided

by a hospital, skilled nursing facility, or intermediate care facility, as determined by a physician licensed to practice medicine in all its branches;

(b) it is appropriate to provide such care

outside of an institution, as determined by a physician licensed to practice medicine in all its branches;

for care outside the institution is not greater than the estimated amount which would be expended in an institution.

8. Persons who become ineligible for basic

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:

(a) extend the medical assistance coverage for up to 12 months following termination of basic maintenance assistance; and (b) offer persons who have initially received 6

months of the coverage provided in paragraph (a) above, the option of receiving an additional 6 months of coverage, subject to the following:

(i) such coverage shall be pursuant to provisions of the federal Social Security Act; (ii) such coverage shall include all services covered while the person was eligible for basic maintenance assistance; (iii) no premium shall be charged for such coverage; and (iv) such coverage shall be suspended in the

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.

9. Persons with acquired immunodeficiency syndrome

(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.

10. Participants in the long‑term care insurance

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.

11. Persons with disabilities who are employed and

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.

12. Subject to federal approval, persons who are

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:

(1) persons who have been screened for breast or

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

(2) persons whose screenings under the above

program were funded in whole or in part by funds appropriated to the Illinois Department of Public Health for breast or cervical cancer screening.

"Medical assistance" under this paragraph 12 shall be

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.

13. Subject to appropriation and to federal approval,

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.

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.)

(305 ILCS 5/5‑2.05)
Sec. 5‑2.05. Disabled children.
(a) The Department of Public Aid may offer, to children with developmental disabilities and severely mentally ill or emotionally disturbed children who otherwise would not qualify for medical assistance under this Article due to family income, home‑based and community‑based services instead of institutional placement, as allowed under paragraph 7 of Section 5‑2.
(b) The Department of Public Aid, in conjunction with the Department of Human Services and the Division of Specialized Care for Children, University of Illinois‑Chicago, shall also report to the Governor and the General Assembly no later than January 1, 2004 regarding the status of existing services offered under paragraph 7 of Section 5‑2. This report shall include, but not be limited to, the following information:
(1) The number of persons eligible for these

(2) The number of persons who applied for these (3) The number of persons who currently receive these services. (4) The nature, scope, and cost of services provided under paragraph 7 of Section 5‑2. (5) The comparative cost of providing those services in a hospital, skilled nursing facility, or intermediate care facility. (6) The funding sources for the provision of services, including federal financial participation. (7) The qualifications, skills, and availability of caregivers for children receiving services.

The report shall also include information regarding the extent to which the existing programs could provide coverage for mentally disabled children who are currently being provided services in an institution who could otherwise be served in a less‑restrictive, community‑based setting for the same or a lower cost.
(Source: P.A. 93‑599, eff. 8‑26‑03.)

(305 ILCS 5/5‑2.1) (from Ch. 23, par. 5‑2.1)
Sec. 5‑2.1. Property transfers.
(a) To the extent required under federal law, a person shall not make or have made a voluntary or involuntary assignment or transfer of any legal or equitable interests in real property or in personal property, whether vested, contingent or inchoate, for less than fair market value. A person's interest in real or personal property includes all income and assets to which the person is entitled or to which the person would be entitled if the person had not taken action to avoid receiving the interest.
(b) (Blank).
(c) (Blank).
(d) (Blank).
(e) (Blank).
(Source: P.A. 92‑84, eff. 7‑1‑02.)

(305 ILCS 5/5‑2.1a)
Sec. 5‑2.1a. Treatment of trust amounts. To the extent required by federal law, the Illinois Department shall provide by rule for the consideration of trusts and similar legal instruments or devices established by a person in the Illinois Department's determination of the person's eligibility for and the amount of assistance provided under this Article. This Section shall be enforced by the Department of Human Services, acting as successor to the Department of Public Aid under the Department of Human Services Act.
(Source: P.A. 88‑554, eff. 7‑26‑94; 89‑507, eff. 7‑1‑97.)

(305 ILCS 5/5‑2.2) (from Ch. 23, par. 5‑2.2)
Sec. 5‑2.2. Cooperation in establishing support obligation. A parent or other person having custody of the child or a spouse who fails or refuses to comply with the requirements of Title XIX of the federal Social Security Act, and the regulations duly promulgated thereunder, regarding establishment and enforcement of the child or spousal support obligation shall be ineligible for medical assistance and shall remain ineligible for medical assistance for as long as the failure or refusal persists.
In addition to any other definition of failure or refusal to comply with the requirements of Title XIX of the federal Social Security Act, in the case of failure to attend court hearings, the parent or other person can show cooperation by attending a court hearing or, if a court hearing cannot be scheduled within 30 days following the court hearing that was missed, by signing a statement that the parent or other person is now willing to cooperate in the child support enforcement process and will appear at any later scheduled court date. The parent or other person can show cooperation by signing such a statement only once. If failure to attend the court hearing or other failure to cooperate results in the case being dismissed, such a statement may be signed after 2 months.
No denial or termination of medical assistance pursuant to this Section shall commence during pregnancy of the parent or other person having custody of the child or for 30 days after the termination of such pregnancy. The termination of medical assistance may commence thereafter if the Illinois Department determines that the failure or refusal to comply with this Section persists. Postponement of denial or termination of medical assistance during pregnancy under this paragraph shall be effective only to the extent it does not conflict with federal law or regulation.
(Source: P.A. 85‑1155.)

(305 ILCS 5/5‑2.3)
Sec. 5‑2.3. Notice of rights concerning institutionalization. The Illinois Department shall prepare a notice to be given to every applicant for and recipient of medical assistance under this Article when the applicant or recipient, or the spouse of the applicant or recipient, or a person for whom the applicant or recipient is the primary caretaker, becomes an institutionalized person. The notice shall fully and completely inform the institutionalized person (and that person's spouse or primary caretaker, if applicable) of each individual's rights and obligations under this Code with respect to that institutionalization.
(Source: P.A. 88‑162.)

(305 ILCS 5/5‑2.07)
Sec. 5‑2.07. Use of Medicaid spend‑down. No later than July 1, 2007, subject to federal approval of a State Medicaid Plan amendment, which shall be sought by the Department of Healthcare and Family Services or its successor agency, persons described in item 2(a) of Section 5‑2, who fail to qualify for basic maintenance under Article III of this Code on the basis of need because of excess income or assets, or both, may establish eligibility for medical assistance by paying the amount of their monthly spend‑down under this Article (as described in 42 CFR 435.831) to the Department of Healthcare and Family Services or its successor agency or by having a third party pay that amount to the Department on their behalf.
(Source: P.A. 94‑847, eff. 1‑1‑07.)

(305 ILCS 5/5‑3) (from Ch. 23, par. 5‑3)
Sec. 5‑3. Residence.) Any person who has established his residence in this State and lives therein, including any person who is a migrant worker, may qualify for medical assistance. A person who, while temporarily in this State, suffers injury or illness endangering his life and health and necessitating emergency care, may also qualify.
Temporary absence from the State shall not disqualify a person from maintaining his eligibility under this Article.
As used in this Section, "migrant worker" means any person residing temporarily and employed in Illinois who moves seasonally from one place to another for the purpose of employment in agricultural activities, including the planting, raising or harvesting of any agricultural or horticultural commodities and the handling, packing or processing of such commodities on the farm where produced or at the point of first processing, in animal husbandry, or in other activities connected with the care of animals. Dependents of such person shall be considered eligible if they are living with the person during his or her temporary residence and employment in Illinois.
In order to be eligible for medical assistance under this section, each migrant worker shall show proof of citizenship or legal alien status.
(Source: P.A. 81‑746.)

(305 ILCS 5/5‑4) (from Ch. 23, par. 5‑4)
Sec. 5‑4. Amount and nature of medical assistance. The amount and nature of medical assistance shall be determined by the County Departments in accordance with the standards, rules, and regulations of the Illinois Department of Public Aid, with due regard to the requirements and conditions in each case, including contributions available from legally responsible relatives. However, the amount and nature of such medical assistance shall not be 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 amount and nature of medical assistance shall not be affected by the receipt of donations or benefits from fundraisers 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.
In determining the income and assets available to the institutionalized spouse and to the community spouse, the Illinois Department of Public Aid shall follow the procedures established by federal law. The community spouse resource allowance shall be established and maintained at the maximum level permitted pursuant to Section 1924(f)(2) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing, whichever is greater. The monthly maintenance allowance for the community spouse shall be established and maintained at the maximum level permitted pursuant to Section 1924(d)(3)(C) of the Social Security Act, as now or hereafter amended. Subject to the approval of the Secretary of the United States Department of Health and Human Services, the provisions of this Section shall be extended to persons who but for the provision of home or community‑based services under Section 4.02 of the Illinois Act on the Aging, would require the level of care provided in an institution, as is provided for in federal law.
The Department of Human Services shall notify in writing each institutionalized spouse who is a recipient of medical assistance under this Article, and each such person's community spouse, of the changes in treatment of income and resources, including provisions for protecting income for a community spouse and permitting the transfer of resources to a community spouse, required by enactment of the federal Medicare Catastrophic Coverage Act of 1988 (Public Law 100‑360). The notification shall be in language likely to be easily understood by those persons. The Department of Human Services also shall reassess the amount of medical assistance for which each such recipient is eligible as a result of the enactment of that federal Act, whether or not a recipient requests such a reassessment.
(Source: P.A. 90‑655, eff. 7‑30‑98; 91‑676, eff. 12‑23‑99.)

(305 ILCS 5/5‑4.1) (from Ch. 23, par. 5‑4.1)
Sec. 5‑4.1. Co‑payments. The Department may by rule provide that recipients under any Article of this Code shall pay a fee as a co‑payment for services. Co‑payments may not exceed $3 for brand name drugs, $1 for other pharmacy services other than for generic drugs, and $2 for physicians services, dental services, optical services and supplies, chiropractic services, podiatry services, and encounter rate clinic services. There shall be no co‑payment for generic drugs. Co‑payments may not exceed $3 for hospital outpatient and clinic services. Provided, however, that any such rule must provide that no co‑payment requirement can exist for renal dialysis, radiation therapy, cancer chemotherapy, or insulin, and other products necessary on a recurring basis, the absence of which would be life threatening, or where co‑payment expenditures for required services and/or medications for chronic diseases that the Illinois Department shall by rule designate shall cause an extensive financial burden on the recipient, and provided no co‑payment shall exist for emergency room encounters which are for medical emergencies.
(Source: P.A. 92‑597, eff. 6‑28‑02; 93‑593, eff. 8‑25‑03 .)

(305 ILCS 5/5‑4.2) (from Ch. 23, par. 5‑4.2)
Sec. 5‑4.2. Ambulance services payments. For ambulance services provided to a recipient of aid under this Article on or after January 1, 1993, the Illinois Department shall reimburse ambulance service providers at rates calculated in accordance with this Section. It is the intent of the General Assembly to provide adequate reimbursement for ambulance services so as to ensure adequate access to services for recipients of aid under this Article and to provide appropriate incentives to ambulance service providers to provide services in an efficient and cost‑effective manner. Thus, it is the intent of the General Assembly that the Illinois Department implement a reimbursement system for ambulance services that, to the extent practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, is consistent with the payment principles of Medicare. To ensure uniformity between the payment principles of Medicare and Medicaid, the Illinois Department shall follow, to the extent necessary and practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, the statutes, laws, regulations, policies, procedures, principles, definitions, guidelines, and manuals used to determine the amounts paid to ambulance service providers under Title XVIII of the Social Security Act (Medicare).
For ambulance services provided to a recipient of aid under this Article on or after January 1, 1996, the Illinois Department shall reimburse ambulance service providers based upon the actual distance traveled if a natural disaster, weather conditions, road repairs, or traffic congestion necessitates the use of a route other than the most direct route.
For purposes of this Section, "ambulance services" includes medical transportation services provided by means of an ambulance, medi‑car, service car, or taxi.
This Section does not prohibit separate billing by ambulance service providers for oxygen furnished while providing advanced life support services.
(Source: P.A. 88‑104; 89‑43, eff. 1‑1‑96.)

(305 ILCS 5/5‑4.20) (from Ch. 23, par. 5‑4.20)
Sec. 5‑4.20. Definitions. As used in this Section and in Sections 5‑4.21 through 5‑4.29:
"Fund" means the Medicaid Developmentally Disabled Provider Participation Fee Trust Fund.
"Fee" means a provider participation fee paid by facilities under Sections 5‑4.21 through 5‑4.29.
"Facility" means a medicaid certified intermediate care facility for persons with a developmental disability or intermediate care facility for persons with a developmental disability of 16 beds or less, but shall not include state‑operated facilities.
"Gross Receipts" means all payments for medical services delivered under Title XIX of the Social Security Act and Article V of this Code and shall mean any and all payments made by the Illinois Department, or a Division thereof, to a Medical Assistance Program provider certified to participate in the Illinois Medical Assistance Program, for services rendered eligible for Medical Assistance under Article V of this Code, State regulations and the federal Medicaid Program as defined in Title XIX of the Social Security Act and federal regulations.
(Source: P.A. 87‑13; 88‑380.)

(305 ILCS 5/5‑4.21) (from Ch. 23, par. 5‑4.21)
Sec. 5‑4.21. Medicaid Provider Participation Fee Trust Fund for Persons With a Developmental Disability.
(a) There is created in the State Treasury the Medicaid Provider Participation Fee Trust Fund for Persons With a Developmental Disability. Interest earned by the Fund shall be credited to the Fund. The monies in the Fund shall be matched with federal Medicaid program dollars in accordance with the provisions of this Section and shall be exempt from any State budget reduction Acts. The Fund shall not be used to replace any funds appropriated to the Medicaid program by the General Assembly.
(b) The Fund is created for the purpose of receiving and disbursing monies in accordance with Sections 5‑4.20 through 5‑4.29 of this Code. Disbursements from the Fund shall be made only:
(1) for payments to intermediate care facilities for

persons with a developmental disability under Title XIX of the Social Security Act and Article V of this Code;

(2) for the reimbursement of monies collected by the Illinois Department through error or mistake; (3) for payment of administrative expenses incurred

by the Illinois Department or its agent in performing the activities authorized by Sections 5‑4.20 through 5‑4.29 of this Code;

(4) for maintaining contingency reserves of no more than 3% of the total monies collected in any one year; (5) for payments of any amounts which are

reimbursable to the federal government for payments from this Fund which are required to be paid by State warrant; and

(6) (Blank).
Disbursements from this Fund shall be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Illinois Department.
(c) The Fund shall consist of:
(1) all monies collected or received by the Illinois

Department under Section 5‑4.22 of this Code; (2) all federal matching funds received by the

Illinois Department as a result of expenditures made by the Illinois Department as required by Section 5‑4.27 of this Code, that are attributable to monies deposited in the Fund;

(3) any interest or penalty levied in conjunction with the administration of the Fund; and (4) all other monies received for the Fund from any other source, including interest earned thereon.

(d) All payments received by the Illinois Department shall be credited first to any interest or penalty, and then to the fee due.
(Source: P.A. 89‑626, eff. 8‑9‑96; 90‑372, eff. 7‑1‑98.)

(305 ILCS 5/5‑4.22) (from Ch. 23, par. 5‑4.22)
Sec. 5‑4.22. Provider Participation Fees. For the period July 1, 1991 through June 30, 1992, a fee is imposed upon each facility in an amount equal to 15% of the provider's gross receipts for services provided for the previous State fiscal year as determined and reported by the Illinois Department. This fee is imposed pursuant to the authority granted by Sections 1 and 2 of Article IX of the Illinois Constitution of 1970.
(Source: P.A. 87‑13; 87‑861.)

(305 ILCS 5/5‑4.23) (from Ch. 23, par. 5‑4.23)
Sec. 5‑4.23. Payment of Fees Due.
(a) The fees described in Section 5‑4.22 shall be due and payable on a calendar quarterly basis.
(b) The fee shall be payable to and collected by the Illinois Department in equal quarterly amounts due on the first business day of each calendar quarter. All monies collected under Section 5‑4.22 shall be deposited into the Fund.
(c) The Director of the Illinois Department is authorized to establish delayed payment schedules for facilities that are unable to make timely payments under this subsection due to financial difficulties. The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate. The interest may be waived by the Director for good cause shown.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.24) (from Ch. 23, par. 5‑4.24)
Sec. 5‑4.24. Notification. The Illinois Department shall notify each provider of the results of its calculations under Section 5‑4.22 of this Code. If a facility, so notified, does not submit a request for reconsideration, the calculations shall be considered final. The notification shall be in writing.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.25) (from Ch. 23, par. 5‑4.25)
Sec. 5‑4.25. Procedures for Reconsideration and Final Reconciliation. Each facility shall have the right to reconsideration of the amount of its fee. The Illinois Department shall conduct a final reconciliation. Each facility shall be entitled to receive enhanced reimbursement through disbursements made under Section 5‑4.27 in an amount at least equal to the amount of the fee imposed on the facility under Section 5‑4.22.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.26) (from Ch. 23, par. 5‑4.26)
Sec. 5‑4.26. Penalties.
(a) Any facility that fails to pay the fee when due or pays less than the full amount due, shall be assessed a penalty of 10% of the delinquency or deficiency for each month, or any fraction thereof, computed on the full amount of the delinquency or deficiency, from the time the fee was due.
(b) In addition, the Illinois Department may take action to notify the Office of the Comptroller to collect any amount of monies owed under Sections 5‑4.20 through 5‑4.29 of this Code, pursuant to Section 10.05 of the State Comptroller Act, or may suspend payments to, or cancel or refuse to issue, extend, or reinstate a Provider Agreement to, any facility which has failed to pay any delinquent fee or penalty.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.27) (from Ch. 23, par. 5‑4.27)
Sec. 5‑4.27. Disbursements to Facilities.
(a) The Illinois Department shall develop a reimbursement methodology which shall enhance reimbursement to facilities sufficiently to expend the fee monies described in Section 5‑4.22 of this Code, and the federal matching funds received by the Illinois Department as a result of expenditures made by the Illinois Department as required by this Section and Section 5‑4.21 that are attributable to fee monies deposited in the Fund.
(b) All payments to facilities under this Section are conditional on:
(1) expiration of the time limitations for

reconsiderations under Section 5‑4.25 of this Code; and (2) the availability of sufficient monies in the

Fund to make the payments required by this Section after the final reconciliation determined under Section 5‑4.25 of this Code.

(c) If amounts in the Fund are insufficient to make the total amount of payments for which facilities are eligible, the Illinois Department shall reduce the amount of each payment by the percentage by which the amounts are insufficient. Any amounts not paid when due shall be paid to facilities as soon as monies are available in the Fund.
(d) If one or more facilities files suit in any court challenging any part of Sections 5‑4.20 through 5‑4.29 of this Code, payments to facilities under these Sections shall be made only to the extent that sufficient monies are available in the Fund and only to the extent that any monies in the Fund are not prohibited from disbursement under any order of the Court.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.28) (from Ch. 23, par. 5‑4.28)
Sec. 5‑4.28. Annual Audit.
(a) The Illinois Department shall conduct an annual audit of the Fund to determine that amounts received from or paid to facilities were correct. If such an audit identifies amounts that a facility should not have been required to pay but did pay, a facility should have been required to pay but did not pay, a facility should not have received but did receive, or a facility should have received but did not receive, the Illinois Department shall:
(1) Make required payments to any such facility, or
(2) Take action to recover required amounts from any

such facility, including recoupment from future payments.

(b) Amounts recovered from a facility shall be credited to the Fund. A facility is entitled to recover amounts paid to the Department and to receive refunds and payments from the Department under this Section only to the extent that monies are available in the Fund.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.29) (from Ch. 23, par. 5‑4.29)
Sec. 5‑4.29. Applicability. No fee is imposed by Section 5‑4.22 for periods beginning on or after July 1, 1992; however, Sections 5‑4.20 through 5‑4.28 shall continue in effect for the purpose of collecting fees imposed for periods ending before July 1, 1992, performing reconciliations and audits, and disbursing moneys in the Fund.
(Source: P.A. 87‑13; 87‑861.)

(305 ILCS 5/5‑4.30) (from Ch. 23, par. 5‑4.30)
Sec. 5‑4.30. Definitions. As used in this Section and in Sections 5‑4.31 through 5‑4.39:
"Fund" means the Medicaid Long Term Care Provider Participation Fee Trust Fund.
"Fee" means a provider participation fee paid by facilities under Sections 5‑4.31 through 5‑4.39.
"Facility" means a skilled or intermediate nursing facility, including county nursing homes directed and maintained pursuant to Section 5‑1005 of the Counties Code, but shall not include state‑operated facilities and shall not include an intermediate care facility for persons with a developmental disability.
"Gross Receipts" means all payments for medical services delivered under Title XIX of the Social Security Act and Article V of this Code and shall mean any and all payments made by the Illinois Department, or a Division thereof, to a Medical Assistance Program provider certified to participate in the Illinois Medical Assistance Program, for services rendered eligible for Medical Assistance under Article V of this Code, State regulations and the federal Medicaid Program as defined in Title XIX of the Social Security Act and federal regulations.
(Source: P.A. 87‑13; 88‑380.)

(305 ILCS 5/5‑4.31) (from Ch. 23, par. 5‑4.31)
Sec. 5‑4.31. Medicaid Long Term Care Provider Participation Fee Trust Fund.
(a) There is created in the State Treasury the Medicaid Long Term Care Provider Participation Fee Trust Fund. Interest earned by the Fund shall be credited to the Fund. The monies in the Fund shall be matched with federal Medicaid program dollars in accordance with the provisions of this Section and shall be exempt from any State budget reduction Acts. The Fund shall not be used to replace any funds appropriated to the Medicaid program by the General Assembly.
(b) The Fund is created for the purpose of receiving and disbursing monies in accordance with Sections 5‑4.30 through 5‑4.39 of this Code. Disbursements from the Fund shall be made only:
(1) for payments to skilled or intermediate nursing

facilities, including county nursing facilities, excluding state‑operated facilities, under Title XIX of the Social Security Act and Article V of this Code;

(2) for the reimbursement of monies collected by the Illinois Department through error or mistake; (3) for payment of administrative expenses incurred

by the Illinois Department or its agent in performing the activities authorized by Sections 5‑4.30 through 5‑4.39 of this Code;

(4) for maintaining contingency reserves of no more than 3% of the total monies collected in any one year; (5) for payments of any amounts which are

reimbursable to the federal government for payments from this Fund which are required to be paid by State warrant; and

Department under Section 5‑4.32 of this Code; (2) all federal matching funds received by the

Illinois Department as a result of expenditures made by the Illinois Department as required by Section 5‑4.37 of this Code, that are attributable to monies deposited in the Fund;

(3) any interest or penalty levied in conjunction with the administration of the Fund; and (4) all other monies received for the Fund from any other source, including interest earned thereon.

(d) All payments received by the Illinois Department shall be credited first to any interest or penalty, and then to the fee due.
(Source: P.A. 89‑626, eff. 8‑9‑96; 90‑372, eff. 7‑1‑98.)

(305 ILCS 5/5‑4.32) (from Ch. 23, par. 5‑4.32)
Sec. 5‑4.32. Provider Participation Fee. For the period July 1, 1991, through June 30, 1992, a fee is imposed upon each facility in an amount equal to 15% of the facility's gross receipts for services provided for the previous State fiscal year as determined and reported by the Illinois Department. This fee is imposed pursuant to the authority granted by Sections 1 and 2 of Article IX of the Illinois Constitution of 1970.
(Source: P.A. 87‑13; 87‑861.)

(305 ILCS 5/5‑4.33) (from Ch. 23, par. 5‑4.33)
Sec. 5‑4.33. Payment of Fees Due.
(a) The fees described in Section 5‑4.32 shall be due and payable on a calendar quarterly basis. The Illinois Department may provide that county nursing homes directed and maintained pursuant to Section 5‑1005 of the Counties Code may meet their fee obligation by certifying to the Illinois Department that county expenditures have been obligated for the operation of the county nursing home in an amount at least equal to the amount of the fee.
(b) The fee shall be payable to and collected by the Illinois Department in equal quarterly amounts due on the first business day of each calendar quarter. All monies collected under Section 5‑4.32 shall be deposited into the Fund.
(c) The Director of the Illinois Department is authorized to establish delayed payment schedules for facilities that are unable to make timely payments under this subsection due to financial difficulties. The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate. The interest may be waived by the Director for good cause shown.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.34) (from Ch. 23, par. 5‑4.34)
Sec. 5‑4.34. Notification. The Illinois Department shall notify each provider of the results of its calculations under Section 5‑4.32 of this Code. If a facility, so notified, does not submit a request for reconsideration, the calculations shall be considered final. The notification shall be in writing.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.35) (from Ch. 23, par. 5‑4.35)
Sec. 5‑4.35. Procedures for Reconsideration and Final Reconciliation. Each facility shall have the right to reconsideration of the amount of its fee. The Illinois Department shall conduct a final reconciliation.
Each facility shall be entitled to receive enhanced reimbursement through disbursements made under Section 5‑4.37 in an amount at least equal to the amount of the fee imposed on the facility under Section 5‑4.32.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.36) (from Ch. 23, par. 5‑4.36)
Sec. 5‑4.36. Penalties.
(a) Any facility that fails to pay the fee when due or pays less than the full amount due, shall be assessed a penalty of 10% of the delinquency or deficiency for each month, or any fraction thereof, computed on the full amount of the delinquency or deficiency, from the time the fee was due.
(b) In addition, the Illinois Department may take action to notify the Office of the Comptroller to collect any amount of monies owed under Sections 5‑4.30 through 5‑4.39 of this Code, pursuant to Section 10.05 of the State Comptroller Act, or may suspend payments to, or cancel or refuse to issue, extend, or reinstate a Provider Agreement to, any facility which has failed to pay any delinquent fee or penalty.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.37) (from Ch. 23, par. 5‑4.37)
Sec. 5‑4.37. Disbursements to Facilities.
(a) The Illinois Department shall develop a reimbursement methodology which shall enhance reimbursement to facilities sufficiently to expend the fee monies described in Section 5‑4.32 of this Code, and the federal matching funds received by the Illinois Department as a result of expenditures made by the Illinois Department as required by this Section and Section 5‑4.31 that are attributable to fee monies deposited in the Fund.
(b) All payments to facilities under this Section are conditional on:
(1) expiration of the time limitations for

reconsiderations under Section 5‑4.35 of this Code; and (2) the availability of sufficient monies in the

Fund to make the payments required by this Section after the final reconciliation determined under Section 5‑4.35 of this Code.

(c) If amounts in the Fund are insufficient to make the total amount of payments for which facilities are eligible, the Illinois Department shall reduce the amount of each payment by the percentage by which the amounts are insufficient. Any amounts not paid when due shall be paid to facilities as soon as monies are available in the Fund.
(d) If one or more facilities files suit in any court challenging any part of Sections 5‑4.30 through 5‑4.39 of this Code, payments to facilities under these Sections shall be made only to the extent that sufficient monies are available in the Fund and only to the extent that any monies in the Fund are not prohibited from disbursement under any order of the Court.
(Source: P.A. 87‑13.)

(305 ILCS 5/5‑4.38) (from Ch. 23, par. 5‑4.38)
Sec. 5‑4.38. Annual Audit.
(a) The Illinois Department shall conduct an annual audit of the Fund to determine that amounts received from or paid to facilities were correct. If such an audit identifies amounts that a facility should not have been required to pay but did pay, a facility should have been required to pay but did not pay, a facility should not have received but did receive, or a facility should have received but did not receive, the Illinois Department shall:
(1) Make required payments to any such facility, or
(2) Take action to recover required amounts from any

such facility, including recoupment from future payments.

(305 ILCS 5/5‑4.39) (from Ch. 23, par. 5‑4.39)
Sec. 5‑4.39. Applicability. No fee is imposed by Section 5‑4.32 for periods beginning on or after July 1, 1992; however Sections 5‑4.30 through 5‑4.38 shall continue in effect for the purpose of collecting fees imposed for periods ending before July 1, 1992, performing reconciliations and audits, and disbursing moneys in the Fund.
(Source: P.A. 87‑13; 87‑861.)

(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

limited to prosthodontics; and (2) eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select.

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

providing certain services, which shall be determined by the Illinois Department, to persons in areas covered by the Partnership may receive an additional surcharge for such services.

(2) The Department may elect to consider and

negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.

(3) Persons receiving medical services through

Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.

Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications 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

medical services by public aid recipients; (b) actual statistics and trends in the provision of the various medical services by medical vendors; (c) current rate structures and proposed changes in those rate structures for the various medical vendors; and (d) efforts at utilization review and control by the Illinois Department.

The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The filing of one copy of the report with the Speaker, one copy with the Minority Leader and one copy with the Clerk of the House of Representatives, one copy with the President, one copy with the Minority Leader and one copy with the Secretary of the Senate, one copy with the Legislative Research Unit, and such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act shall be deemed sufficient to comply with this 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

limited to prosthodontics; and (2) eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select.

providing certain services, which shall be determined by the Illinois Department, to persons in areas covered by the Partnership may receive an additional surcharge for such services.

(2) The Department may elect to consider and

negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.

(3) Persons receiving medical services through

Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.

Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications 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

(305 ILCS 5/5‑5.01) (from Ch. 23, par. 5‑5.01)
Sec. 5‑5.01. The Department of Public Aid may establish and implement a pilot project for determining the feasibility of authorizing medical assistance payments for the costs of diagnosis and treatment of Alzheimer's disease.
(Source: P.A. 84‑773.)

(305 ILCS 5/5‑5.01a)
Sec. 5‑5.01a. Supportive living facilities program. The Department shall establish and provide oversight for a program of supportive living facilities that seek to promote resident independence, dignity, respect, and well‑being in the most cost‑effective manner.
A supportive living facility is either a free‑standing facility or a distinct physical and operational entity within a nursing facility. A supportive living facility integrates housing with health, personal care, and supportive services and is a designated setting that offers residents their own separate, private, and distinct living units.
Sites for the operation of the program shall be selected by the Department based upon criteria that may include the need for services in a geographic area, the availability of funding, and the site's ability to meet the standards.
The Department may adopt rules to implement this Section. Rules that establish or modify the services, standards, and conditions for participation in the program shall be adopted by the Department in consultation with the Department on Aging, the Department of Rehabilitation Services, and the Department of Mental Health and Developmental Disabilities (or their successor agencies).
Facilities or distinct parts of facilities which are selected as supportive living facilities and are in good standing with the Department's rules are exempt from the provisions of the Nursing Home Care Act and the Illinois Health Facilities Planning Act.
(Source: P.A. 94‑342, eff. 7‑26‑05.)

(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

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.

(2) For the purpose of calculating the inpatient

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.

(3) For the purpose of calculating the inpatient

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.

(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

the federal Social Security Act, as now or hereafter amended; or (2) Illinois hospitals that have a Medicaid

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

(3) Illinois hospitals that on July 1, 1991 had a

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

(4) Illinois hospitals that:
(A) have a Medicaid inpatient utilization rate

that is at least equal to the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Department; and

(B) also have a Medicaid obstetrical inpatient

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

(5) Any children's hospital, which means a hospital

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.

(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

rate below the mean shall receive a per day adjustment payment equal to $25; (2) hospitals with a Medicaid inpatient utilization

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;

(3) hospitals with a Medicaid inpatient utilization

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

(4) hospitals with a Medicaid inpatient utilization

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.

(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

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.

(2) "Mean Medicaid inpatient utilization rate" means

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.

(3) "Medicaid obstetrical inpatient utilization

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.

(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 .)

(305 ILCS 5/5‑5.03)
Sec. 5‑5.03. Trauma center adjustment.
(a) For inpatient admissions on or after October 1, 1992 for trauma injuries as defined in the Emergency Medical Services (EMS) Systems Act, in addition to any other payments made under this Code, the Illinois Department shall make adjustment payments, in an amount calculated under subsection (b) of this Section, to hospitals located in the State of Illinois that are recognized as Level I trauma centers (adult or pediatric) and to certain Level II trauma centers as determined by the Illinois Department.
(b) Trauma center adjustment calculation.
(1) The funds used to make trauma center adjustment

payments to qualifying trauma centers shall consist of: (A) At least 50% of the amount of moneys deposited each State fiscal year into the Trauma Center Fund created in the State treasury; and (B) All federal matching funds received by the

Illinois Department as a result of expenditures made by the Illinois Department as required by this Section.

(2) The trauma center adjustment payments shall be

made to qualifying trauma centers on a quarterly basis. In determining the payment methodology for trauma center adjustment payments, the Illinois Department shall divide the available funds from the Trauma Center Fund for each quarter by the total number of the Medicaid trauma admissions as determined by the Illinois Department for the same quarter of the Trauma Center base year. The result of that calculation shall be the amount of the quarterly trauma center adjustment payment to be paid to qualifying trauma centers.

(3) Disbursements from the Trauma Center Fund shall

be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Illinois Department.

(4) Trauma center adjustment payments shall not be

treated as payments for hospital services under Title XIX of the Social Security Act for purposes of the calculation of the intergovernmental transfer provided for in Section 15‑3(a) of the Code.

(c) Definitions. As used in this Section, unless the context requires otherwise:
"Trauma center adjustment year" means, beginning October 1, 1992, the 12 month period beginning on October 1 of the year and ending September 30 of the following year.
"Trauma center base year" means State Fiscal Year 1991 for trauma center adjustment payments calculated for the October 1, 1992 trauma center adjustment year, State Fiscal Year 1992 for trauma center adjustment payments calculated for the October 1, 1993 trauma center adjustment year, and so on for each succeeding State Fiscal Year for trauma center adjustment payments calculated for the trauma center adjustment year beginning October 1 of that State Fiscal Year.
(Source: P.A. 87‑1229.)

(305 ILCS 5/5‑5.04)
Sec. 5‑5.04. Persons living with HIV/AIDS. The Department of Public Aid may seek federal approval to expand access to health care for persons living with HIV/AIDS. Implementation of this Section is subject to appropriation.
(Source: P.A. 94‑629, eff. 1‑1‑06.)

(305 ILCS 5/5‑5.1) (from Ch. 23, par. 5‑5.1)
Sec. 5‑5.1. Grouping of Facilities. The Department of Public Aid shall, for purposes of payment, provide for groupings of nursing facilities. Factors to be considered in grouping facilities may include, but are not limited to, size, age, patient mix or geographical area.
The groupings developed under this Section shall be considered in determining reasonable cost reimbursement formulas. However, this Section shall not preclude the Department from recognizing and evaluating the cost of capital on a facility‑by‑facility basis.
(Source: P.A. 80‑1142.)

(305 ILCS 5/5‑5.2) (from Ch. 23, par. 5‑5.2)
Sec. 5‑5.2. Payment.
(a) All Skilled Nursing Facilities that are grouped pursuant to Section 5‑5.1 of this Act shall receive the same rate of payment for similar services. All Intermediate Care Facilities that are grouped pursuant to Section 5‑5.1 of this Act shall receive the same rate of payment for similar services.
(b) It shall be a matter of State policy that the Illinois Department shall utilize a uniform billing cycle throughout the State for the following long‑term care providers: skilled nursing facilities, intermediate care facilities, and intermediate care facilities for persons with a developmental disability. The Illinois Department shall establish billing cycles on a calendar month basis for all long‑term care providers no later than July 1, 1992.
(Source: P.A. 87‑809; 88‑380.)

(305 ILCS 5/5‑5.3) (from Ch. 23, par. 5‑5.3)
Sec. 5‑5.3. Conditions of Payment ‑ Prospective Rates ‑ Accounting Principles. This amendatory Act establishes certain conditions for the Department of Public Aid in instituting rates for the care of recipients of medical assistance in skilled nursing facilities and intermediate care facilities. Such conditions shall assure a method under which the payment for skilled nursing and intermediate care services, provided to recipients under the Medical Assistance Program shall be on a reasonable cost related basis, which is prospectively determined annually by the Department of Public Aid. The annually established payment rate shall take effect on July 1 in 1984 and subsequent years. There shall be no rate increase during calendar year 1983 and the first six months of calendar year 1984.
The determination of the payment shall be made on the basis of generally accepted accounting principles that shall take into account the actual costs to the facility of providing skilled nursing and intermediate care services to recipients under the medical assistance program.
The resultant total rate for a specified type of service shall be an amount which shall have been determined to be adequate to reimburse allowable costs of a facility that is economically and efficiently operated. The Department shall establish an effective date for each facility or group of facilities after which rates shall be paid on a reasonable cost related basis which shall be no sooner than the effective date of this amendatory Act of 1977.
(Source: P.A. 91‑357, eff. 7‑29‑99.)

(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

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.

(B) For a facility that would receive a higher

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.

nursing component rate per patient day for the facility shall be adjusted subject to appropriations provided by the General Assembly.

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.)

(305 ILCS 5/5‑5.4a)
Sec. 5‑5.4a. Intermediate Care Facility for the Developmentally Disabled; bed reserve payments.
The Department of Public Aid shall promulgate rules by October 1, 1993 which establish a policy of bed reserve payments to Intermediate Care Facilities for the Developmentally Disabled which addresses the needs of residents of Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) and their families.
(a) When a resident of an Intermediate Care Facility for the Developmentally Disabled (ICF/DD) is absent from the ICF/DD in which he or she is a resident for purposes of physician authorized in‑patient admission to a hospital, the Department's rules shall, at a minimum, provide (1) bed reserve payments at a daily rate which is 100% of the client's current per diem rate, for a period not exceeding 10 consecutive days; (2) bed reserve payments at a daily rate which is 75% of a client's current per diem rate, for a period which exceeds 10 consecutive days but does not exceed 30 consecutive days; and (3) bed reserve payments at a daily rate which is 50% of a client's current per diem rate for a period which exceeds thirty consecutive days but does not exceed 45 consecutive days.
(b) When a resident of an Intermediate Care Facility for the Developmentally Disabled (ICF/DD) is absent from the ICF/DD in which he or she is a resident for purposes of a home visit with a family member the Department's rules shall, at a minimum, provide (1) bed reserve payments at a rate which is 100% of a client's current per diem rate, for a period not exceeding 10 days per State fiscal year; and (2) bed reserve payments at a rate which is 75% of a client's current per diem rate, for a period which exceeds 10 days per State fiscal year but does not exceed 30 days per State fiscal year.
(c) No Department rule regarding bed reserve payments shall require an ICF/DD to have a specified percentage of total facility occupancy as a requirement for receiving bed reserve payments.
This Section 5‑5.4a shall not apply to any State operated facilities.
(Source: P.A. 91‑357, eff. 7‑29‑99.)

(305 ILCS 5/5‑5.4b)
Sec. 5‑5.4b. Publicly owned or publicly operated nursing facilities. The Illinois Department may by rule establish alternative reimbursement methodologies for nursing facilities that are owned or operated by a county, a township, a municipality, a hospital district, or any other local government in Illinois.
(Source: P.A. 93‑20, eff. 6‑20‑03.)

(305 ILCS 5/5‑5.4c)
Sec. 5‑5.4c. Bed reserves; approval. The Department of Public Aid shall approve bed reserves at a daily rate of 75% of an individual's current Medicaid per diem, for nursing facilities 90% or more of whose residents are Medicaid recipients and that have occupancy levels of at least 93% for resident bed reserves not exceeding 10 days.
(Source: P.A. 93‑841, eff. 7‑30‑04.)

(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

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.

(2) Resident Services, with the cost of this

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:

(A) A statement of the Illinois Department's goals and objectives for such project; (B) A description of such project, including the number and type of nursing facilities involved in the project; (C) A description of the methodology used in such (D) A description of the Illinois Department's application of the methodology; (E) A statement on the methodology's effect on the quality of care given to residents in the sample nursing facilities; and (F) A statement on the cost of the methodology used in such project and a comparison of this cost with the cost of the current payment criteria. (3) Ancillary Services, with the payment rate being

developed for each individual type of service. Payment shall be made only when authorized under procedures developed by the Department of Public Aid.

(4) Nurse's Aide Training, with the cost of this

component being determined by taking into account the actual cost to the facilities of such training.

(5) Real Estate Taxes, with the cost of this

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.

(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

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.

(2) Profit, with the actual amount being produced and

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.

(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.)

(305 ILCS 5/5‑5.5a) (from Ch. 23, par. 5‑5.5a)
Sec. 5‑5.5a. Kosher kitchen and food service.
(a) The Department of Public Aid may develop in its rate structure for skilled nursing facilities and intermediate care facilities an accommodation for fully kosher kitchen and food service operations, rabbinically approved or certified on an annual basis for a facility in which the only kitchen or all kitchens are fully kosher (a fully kosher facility). Beginning in the fiscal year after the fiscal year when this amendatory Act of 1990 becomes effective, the rate structure may provide for an additional payment to such facility not to exceed 50 cents per resident per day if 60% or more of the residents in the facility request kosher foods or food products prepared in accordance with Jewish religious dietary requirements for religious purposes in a fully kosher facility. Based upon food cost reports of the Illinois Department of Agriculture regarding kosher and non‑kosher food available in the various regions of the State, this rate structure may be periodically adjusted by the Department but may not exceed the maximum authorized under this subsection (a).
(b) The Department shall by rule determine how a facility with a fully kosher kitchen and food service may be determined to be eligible and apply for the rate accommodation specified in subsection (a).
(Source: P.A. 86‑1464.)

(305 ILCS 5/5‑5.6) (from Ch. 23, par. 5‑5.6)
Sec. 5‑5.6. Federal Requirements. All reimbursement rates established pursuant to this Act must be consistent with the criteria for nursing facility reimbursement established by the Federal government for approval of matching funds under Title XIX of the Federal Social Security Act.
(Source: P.A. 80‑1142.)

(305 ILCS 5/5‑5.6a) (from Ch. 23, par. 5‑5.6a)
Sec. 5‑5.6a. Promulgation of payment conditions, standards and elements. (a) Conditions of payment for skilled nursing and intermediate care services in nursing facilities under Section 5‑5.3, standards of payment to such facilities under Section 5‑5.4 and the cost elements of payments to such facilities under Section 5‑5.5, promulgated and effective on June 30, 1981, shall be null and void on July 1, 1982. The Illinois Department shall promulgate new conditions, standards and elements to be effective no later than July 1, 1982, for payment for the care of recipients of medical assistance in skilled or intermediate care facilities, excluding skilled nursing facilities for pediatrics and intermediate care facilities for the mentally retarded, that are consistent with the criteria for nursing facility reimbursement under Title XIX of the federal Social Security Act, as determined by the federal Department of Health and Human Services.
(b) Conditions of payment for skilled nursing facilities for pediatrics and intermediate care facilities for the mentally retarded under Section 5‑5.3, standards of payment to such facilities under Section 5‑5.4, and the cost elements of payments to such facilities under Section 5‑5.5, promulgated and effective on December 31, 1984, shall be null and void on January 1, 1985. The Illinois Department shall promulgate conditions, standards and elements to be effective no later than January 1, 1985, for payment for the care of recipients of medical assistance in skilled nursing facilities for pediatrics and intermediate care facilities for the mentally retarded, that are consistent with the criteria for nursing facility reimbursement under Title XIX of the federal Social Security Act, as determined by the federal Department of Health and Human Services.
(Source: P.A. 85‑1440.)

(305 ILCS 5/5‑5.6b) (from Ch. 23, par. 5‑5.6b)
Sec. 5‑5.6b. Prohibition against double payment. If any resident of a skilled nursing facility or intermediate care facility is admitted to such facility on the basis that the charges for such resident's care will be paid from private funds, and the source of payment for such care thereafter changes from private funds to payments under this Article, the facility shall, upon receiving the first such payment under this Article, notify the Illinois Department of such source of private funds for such recipient and repay to the source of private funds any amounts received from such source as payment for care for which payment also was made under this Article. Private funds shall not include third party resources such as insurance or Medicare benefits or payments made by responsible relatives.
(Source: P.A. 85‑824.)

(305 ILCS 5/5‑5.7) (from Ch. 23, par. 5‑5.7)
Sec. 5‑5.7. Cost Reports ‑ Audits. The Department of Public Aid shall work with the Department of Public Health to use cost report information currently being collected under provisions of the "Nursing Home Care Act", approved August 23, 1979, as amended. The Department of Public Aid may, in conjunction with the Department of Public Health, develop in accordance with generally accepted accounting principles a uniform chart of accounts which each facility providing services under the medical assistance program shall adopt, after a reasonable period.
Nursing homes licensed under the Nursing Home Care Act and providers of adult developmental training services certified by the Department of Human Services pursuant to Section 15.2 of the Mental Health and Developmental Disabilities Administrative Act which provide services to clients eligible for medical assistance under this Article are responsible for submitting the required annual cost report to the Department of Public Aid.
The Department of Public Aid shall audit the financial and statistical records of each provider participating in the medical assistance program as a skilled nursing or intermediate care facility over a 3 year period, beginning with the close of the first cost reporting year. Following the end of this 3‑year term, audits of the financial and statistical records will be performed each year in at least 20% of the facilities participating in the medical assistance program with at least 10% being selected on a random sample basis, and the remainder selected on the basis of exceptional profiles. All audits shall be conducted in accordance with generally accepted auditing standards.
The Department of Public Aid shall establish prospective payment rates for categories of service needed within the skilled nursing and intermediate care levels of services, in order to more appropriately recognize the individual needs of patients in nursing facilities.
The Department of Public Aid shall provide, during the process of establishing the payment rate for skilled nursing and intermediate care services, or when a substantial change in rates is proposed, an opportunity for public review and comment on the proposed rates prior to their becoming effective.
(Source: P.A. 89‑507, eff. 7‑1‑97.)

(305 ILCS 5/5‑5.8) (from Ch. 23, par. 5‑5.8)
Sec. 5‑5.8. Report on nursing home reimbursement. The Illinois Department shall report annually to the General Assembly, no later than the first Monday in April of 1982, and each year thereafter, in regard to:
(a) the rate structure used by the Illinois Department to reimburse nursing facilities;
(b) changes in the rate structure for reimbursing nursing facilities;
(c) the administrative and program costs of reimbursing nursing facilities;
(d) the availability of beds in nursing facilities for public aid recipients; and
(e) the number of closings of nursing facilities, and the reasons for those closings.
The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader and the Clerk of the House of Representatives and the President, the Minority Leader and the Secretary of the Senate and the Legislative Research Unit, as required by Section 3.1 of "An Act to revise the law in relation to the General Assembly", approved February 25, 1874, as amended, and filing such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act.
(Source: P.A. 84‑1438.)

(305 ILCS 5/5‑5.8a) (from Ch. 23, par. 5‑5.8a)
Sec. 5‑5.8a. Payment for exceptional care.
(a) For the provision of exceptional medical care, the Illinois Department of Public Aid may make payments only to skilled nursing facilities that substantially meet the licensure and certification requirements prescribed by the Department of Public Health. Only the Department of Public Health shall be responsible for determining whether licensure and certification requirements for skilled nursing care facilities have been substantially met. The rate of payment shall be negotiated with the facilities offering to provide the exceptional medical care. A facility's costs of providing exceptional care shall not be considered in determining the rate of payment to skilled nursing facilities under Sections 5‑5.3 through 5‑5.5. Payment for exceptional medical care shall not exceed the rate that the Illinois Department would be required to pay under the Medical Assistance Program for the same care in a hospital.
(b) The Illinois Department shall adopt rules and regulations under the Illinois Administrative Procedure Act to implement this Section. Those rules and regulations shall set forth the procedures to be followed by facilities when submitting an initial exceptional medical care certification request and exceptional medical care payment requests. The rules and regulations shall also include the procedures and criteria used by the Illinois Department in determining whether to approve a skilled nursing facility's initial exceptional medical care certification request and exceptional medical care payment requests. The rules shall provide that the Illinois Department, upon receipt of a facility's request for payment for exceptional medical care and all necessary documentation, shall, after negotiations between the Illinois Department and the facility are completed, determine and notify the facility whether the request has been approved or denied.
(Source: P.A. 88‑412.)

(305 ILCS 5/5‑5.8b) (from Ch. 23, par. 5‑5.8b)
Sec. 5‑5.8b. Payment to Campus Facilities. There is hereby established a separate payment category for campus facilities. A "campus facility" is defined as an entity which consists of a long term care facility (or group of facilities if the facilities are on the same contiguous parcel of real estate) which meets all of the following criteria as of May 1, 1987: the entity provides care for both children and adults; residents of the entity reside in three or more separate buildings with congregate and small group living arrangements on a single campus; the entity provides three or more separate licensed levels of care; the entity (or a part of the entity) is enrolled with the Department of Public Aid as a provider of long term care services and receives payments from the Department of Public Aid; the entity (or a part of the entity) receives funding from the Department of Mental Health and Developmental Disabilities (now the Department of Human Services); and the entity (or a part of the entity) holds a current license as a child care institution issued by the Department of Children and Family Services.
The Department of Public Aid, the Department of Human Services, and the Department of Children and Family Services shall develop jointly a rate methodology or methodologies for campus facilities. Such methodology or methodologies may establish a single rate to be paid by all the agencies, or a separate rate to be paid by each agency, or separate components to be paid to different parts of the campus facility. All campus facilities shall receive the same rate of payment for similar services. Any methodology developed pursuant to this section shall take into account the actual costs to the facility of providing services to residents, and shall be adequate to reimburse the allowable costs of a campus facility which is economically and efficiently operated. Any methodology shall be established on the basis of historical, financial, and statistical data submitted by campus facilities, and shall take into account the actual costs incurred by campus facilities in providing services, and in meeting licensing and certification standards imposed and prescribed by the State of Illinois, any of its political subdivisions or municipalities and by the United States Department of Health and Human Services. Rates may be established on a prospective or retrospective basis. Any methodology shall provide reimbursement for appropriate payment elements, including the following: standard services, patient services, real estate taxes, and capital costs.
(Source: P.A. 89‑507, eff. 7‑1‑97.)

(305 ILCS 5/5‑5.11) (from Ch. 23, par. 5‑5.11)
Sec. 5‑5.11. Payments for Fiscal Year 1983 Services. Interim rate payments for fiscal year 1983 services made from the available fiscal year 1983 appropriation shall be reconciled to each hospital's rates. Said reconciliation shall be made from the fiscal year 1984 appropriation; preliminary settlement shall be made on or before July 15, 1983 or 60 days after a hospital files its cost report with the Department or its fiscal intermediary covering any part of fiscal year 1983, whichever is later and final settlement shall be made on or before 90 days after said cost report is filed or July 15, 1983, whichever is later. In no event shall any hospital be paid more than the amount to be calculated by multiplying the hospital's rates by the number of outpatient visits and clinic visits, and by the lesser of the actual number of inpatient days or allowable inpatient days of care provided by such hospital. Total reconciliation payments in fiscal year 1984 shall not exceed $170 million.
The Auditor General shall conduct a post audit to determine if the Illinois Department has complied with the requirements of Public Act 82‑787.
(Source: P.A. 83‑748.)

(305 ILCS 5/5‑5.12) (from Ch. 23, par. 5‑5.12)
Sec. 5‑5.12. Pharmacy payments.
(a) Every request submitted by a pharmacy for reimbursement under this Article for prescription drugs provided to a recipient of aid under this Article shall include the name of the prescriber or an acceptable identification number as established by the Department.
(b) Pharmacies providing prescription drugs under this Article shall be reimbursed at a rate which shall include a professional dispensing fee as determined by the Illinois Department, plus the current acquisition cost of the prescription drug dispensed. The Illinois Department shall update its information on the acquisition costs of all prescription drugs no less frequently than every 30 days. However, the Illinois Department may set the rate of reimbursement for the acquisition cost, by rule, at a percentage of the current average wholesale acquisition cost.
(c) (Blank).
(d) The Department shall not impose requirements for prior approval based on a preferred drug list for anti‑retroviral, anti‑hemophilic factor concentrates, or any atypical antipsychotics, conventional antipsychotics, or anticonvulsants used for the treatment of serious mental illnesses until 30 days after it has conducted a study of the impact of such requirements on patient care and submitted a report to the Speaker of the House of Representatives and the President of the Senate.
(Source: P.A. 93‑106, eff. 7‑8‑03; 94‑48, eff. 7‑1‑05.)

(305 ILCS 5/5‑5.12a)
Sec. 5‑5.12a. Title XIX waiver; pharmacy assistance program. The Illinois Department may seek a waiver of otherwise applicable requirements of Title XIX of the federal Social Security Act in order to claim federal financial participation for a pharmacy assistance program for persons aged 65 and over with income levels at or less than 250% of the federal poverty level. The Illinois Department may provide by rule for all other requirements of the program, including cost sharing, as permitted by an approved waiver and without regard to any provision of this Code to the contrary. The benefits may be no more restrictive than the Pharmacy Assistance Program in effect on May 31, 2001. Benefits provided under the waiver are subject to appropriation.
The Illinois Department may not implement the waiver until cost neutrality is demonstrated for the State relative to the final Pharmacy Assistance Program appropriation for the fiscal year beginning July 1, 2001. Implementation of the waiver shall terminate on June 30, 2007.
(Source: P.A. 92‑10, eff. 6‑11‑01.)

(305 ILCS 5/5‑5.13) (from Ch. 23, par. 5‑5.13)
Sec. 5‑5.13. The Illinois Department shall establish procedures for the expedited review, for purposes of inclusion in the Illinois Public Aid formulary, of any drug for the treatment of acquired immunodeficiency syndrome (AIDS) which the federal Food and Drug Administration has indicated is subject to a treatment investigational new drug application.
(Source: P.A. 88‑85.)

(305 ILCS 5/5‑5.14)
Sec. 5‑5.14. (Repealed).
(Source: Repealed by P.A. 88‑85.)

(305 ILCS 5/5‑5.15) (from Ch. 23, par. 5‑5.15)
Sec. 5‑5.15. The Illinois Department shall not implement any additional plan or program which provides for any form of prepaid capitation for prescription pharmaceuticals when the percentage of public aid recipients who receive prescription pharmaceuticals through prepaid capitation plans exceeds 30% of the number of all public aid recipients who receive prescription pharmaceuticals, unless the Department receives the results of an evaluation of delivery of prescription pharmaceuticals through prepaid capitation plans, performed by an ad hoc committee appointed by the Illinois Department. If the ad hoc committee shall fail to deliver to the Illinois Department its evaluation within 90 days of the Department's request to the ad hoc committee for such an evaluation, the ad hoc committee shall be deemed to have had no objection to the implementation of such additional plan or program. The ad hoc committee shall include representatives of the Illinois Department, the Illinois State Medical Society, the Illinois Hospital Association, the Illinois Pharmacists Association, the Illinois Nurses Association, the Illinois Retail Merchants Association, the Illinois Arthritis Foundation, the Illinois Pharmaceutical Manufacturing Group, and the Council of Medical Specialty Societies.
The Department shall report the results of the evaluation to the House and Senate Appropriations Committees of the General Assembly.
This Section shall apply to all programs for which the Illinois Department provides reimbursement for prescription pharmaceuticals.
(Source: P.A. 83‑1509.)

(305 ILCS 5/5‑5.16) (from Ch. 23, par. 5‑5.16)
Sec. 5‑5.16. (Repealed).
(Source: P.A. 90‑372, eff. 7‑1‑98. Repealed internally, eff. 7‑1‑98.)

(305 ILCS 5/5‑5.17) (from Ch. 23, par. 5‑5.17)
Sec. 5‑5.17. Separate reimbursement rate. The Illinois Department may by rule establish a separate reimbursement rate to be paid to long term care facilities for adult developmental training services as defined in Section 15.2 of the Mental Health and Developmental Disabilities Administrative Act which are provided to mentally retarded residents of such facilities who receive aid under this Article. Any such reimbursement shall be based upon cost reports submitted by the providers of such services and shall be paid by the long term care facility to the provider within such time as the Illinois Department shall prescribe by rule, but in no case less than 3 business days after receipt of the reimbursement by such facility from the Illinois Department. The Illinois Department may impose a penalty upon a facility which does not make payment to the provider of adult developmental training services within the time so prescribed, up to the amount of payment not made to the provider.
(Source: P.A. 89‑507, eff. 7‑1‑97.)

(305 ILCS 5/5‑5.18)
Sec. 5‑5.18. Diagnosis accompanying request for reimbursement. Every request submitted by a physician for reimbursement under this Article for services provided to a recipient of aid under this Article shall include the physician's diagnosis of the recipient's illness or other condition requiring those services. The diagnosis shall be either written out or expressed in a code approved by the Illinois Department.
(Source: P.A. 88‑554, eff. 7‑26‑94.)

(305 ILCS 5/5‑5.19)
Sec. 5‑5.19. Reimbursement request records. The Illinois Department shall file all requests for reimbursement for medical services provided under this Article according to both (i) the name of the service provider and (ii) the name of the recipient of aid under this Article to whom the medical services were provided.
(Source: P.A. 88‑554, eff. 7‑26‑94.)

(305 ILCS 5/5‑5.20)
Sec. 5‑5.20. Clinic payments. For services provided by federally qualified health centers as defined in Section 1905 (l)(2)(B) of the federal Social Security Act, on or after April 1, 1989, and as long as required by federal law, the Illinois Department shall reimburse those health centers for those services according to a prospective cost‑reimbursement methodology.
(Source: P.A. 89‑38, eff. 1‑1‑96.)

(305 ILCS 5/5‑5.21)
Sec. 5‑5.21. Reimbursement methodology. The Department shall form a workgroup comprised of representatives of the Department, the Illinois Department of Public Health, and members of the long‑term care provider community to implement a reimbursement methodology based upon the federally mandated resident assessment instrument. No later than January 1, 1997, the Illinois Department in conjunction with the work group will recommend to the Governor a methodology for determining payment rates for services in nursing facilities based upon the federally mandated resident assessment instrument. No later than June 30, 1997, the Illinois Department shall implement a methodology for determining payment rates for services in nursing facilities based upon federal requirements.
(Source: P.A. 89‑415, eff. 1‑1‑96.)

(305 ILCS 5/5‑5.22)
Sec. 5‑5.22. (Repealed).
(Source: P.A. 92‑725, eff. 7‑25‑02. Repealed by P.A. 94‑838, eff. 6‑6‑06.)

(305 ILCS 5/5‑5.23)
(Text of Section from P.A. 93‑495)
Sec. 5‑5.23. Children's mental health services.
(a) The Department of Public Aid, by rule, shall require the screening and assessment of a child prior to any Medicaid‑funded admission to an inpatient hospital for psychiatric services to be funded by Medicaid. The screening and assessment shall include a determination of the appropriateness and availability of out‑patient support services for necessary treatment. The Department, by rule, shall establish methods and standards of payment for the screening, assessment, and necessary alternative support services.
(b) The Department of Public Aid, to the extent allowable under federal law, shall secure federal financial participation for Individual Care Grant expenditures made by the Department of Human Services for the Medicaid optional service authorized under Section 1905(h) of the federal Social Security Act, pursuant to the provisions of Section 7.1 of the Mental Health and Developmental Disabilities Administrative Act.
(c) The Department of Public Aid shall work jointly with the Department of Human Services to implement subsections (a) and (b).
(Source: P.A. 93‑495, eff. 8‑8‑03.)

(Text of Section from P.A. 93‑536)
Sec. 5‑5.23. Prenatal and perinatal care. The Department of Public Aid may provide reimbursement under this Article for all prenatal and perinatal health care services that are provided for the purpose of preventing low‑birthweight infants, reducing the need for neonatal intensive care hospital services, and promoting perinatal health. These services may include comprehensive risk assessments for pregnant women, women with infants, and infants, lactation counseling, nutrition counseling, childbirth support, psychosocial counseling, treatment and prevention of periodontal disease, and other support services that have been proven to improve birth outcomes. The Department shall maximize the use of preventive prenatal and perinatal health care services consistent with federal statutes, rules, and regulations. The Department shall develop a plan for prenatal and perinatal preventive health care and shall present the plan to the General Assembly by January 1, 2004. On or before January 1, 2006 and every 2 years thereafter, the Department shall report to the General Assembly concerning the effectiveness of prenatal and perinatal health care services reimbursed under this Section in preventing low‑birthweight infants and reducing the need for neonatal intensive care hospital services. Each such report shall include an evaluation of how the ratio of expenditures for treating low‑birthweight infants compared with the investment in promoting healthy births and infants in local community areas throughout Illinois relates to healthy infant development in those areas.
(Source: P.A. 93‑536, eff. 8‑18‑03.)

(305 ILCS 5/5‑5a) (from Ch. 23, par. 5‑5a)
Sec. 5‑5a. Waiver for home and community‑based services. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow payment for home and community‑based services under this Article.
The Department, in cooperation with the Department on Aging, the Department of Human Services and any other relevant State, local or federal government agency, may establish a nursing home pre‑screening program to determine whether the applicant, eligible for medical assistance under this Article, may use home and community‑based services as a reasonable, lower‑cost alternative form of care. For the purpose of this Section, "home and community‑based services" may include, but are not limited to, those services provided under subsection (f) of Section 3 of the Disabled Persons Rehabilitation Act and Section 4 of the Illinois Act on the Aging.
(Source: P.A. 89‑507, eff. 7‑1‑97; 89‑626, eff. 8‑9‑96.)

(305 ILCS 5/5‑5b) (from Ch. 23, par. 5‑5b)
Sec. 5‑5b. Payment Reductions.
(a) Notwithstanding any other Section in this Code establishing a methodology for determining payment rates or dispensing fees for non‑institutional services provided under this Code, the Illinois Department is authorized to reduce those payment rates or dispensing fees with due regard for and subject to budgetary limitations to the extent permitted by federal law.
(b) The Illinois Department may implement this Section as added 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 this Section as added by this amendatory Act of 1991 shall be deemed an emergency and necessary for the public interest, safety and welfare.
(Source: P.A. 87‑14.)

(305 ILCS 5/5‑5c)
Sec. 5‑5c. Waiver for home and community‑based services for traumatic brain injury (TBI) patients. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow payment for home and community‑based services under this Article for traumatic brain injury patients.
The Department shall submit a Home and Community‑Based Services TBI Waiver request to the United States Health Care Financing Administration by January 1, 1998. The waiver shall be requested pursuant to Section 1915(c) of the Social Security Act. The Department shall request a waiver of Section 1902(a)(10)(B) of the Social Security Act in order to target home and community‑based services to individuals with a traumatic brain injury meeting the Medicaid eligibility criteria set forth in appendices to the Prototype Waiver request.
Under the waiver, the Department, in cooperation with the Department of Human Services and any other relevant State, local, or federal government agency, may establish a nursing facility pre‑screening program to determine whether an applicant who is eligible for medical assistance under this Article and has a traumatic brain injury may use home and community‑based services as a reasonable, lower‑cost alternative form of care. If a waiver request has not been submitted by January 1, 1998 the Department shall submit the TBI Prototype Waiver request to the United States Health Care Financing Administration.
(Source: P.A. 90‑335, eff. 8‑8‑97.)

(305 ILCS 5/5‑5d)
(Text of Section from P.A. 93‑902)
Sec. 5‑5d. Transition services. The Department of Public Aid shall apply for any necessary waivers pursuant to Section 1915(c) of the Social Security Act to facilitate transition services. Nothing in this Section shall be construed as limiting current similar programs by the Department of Human Services or the Department on Aging.
(Source: P.A. 93‑902, eff. 8‑10‑04.)

(Text of Section from P.A. 93‑1031)
Sec. 5‑5d. Enhanced transition and follow‑up services. The Department of Public Aid shall apply for any necessary waivers pursuant to Section 1915(c) of the Social Security Act to facilitate the transition from one residential setting to another and follow‑up services. Nothing in this Section shall be considered as limiting current similar programs by the Department of Human Services or the Department on Aging.
(Source: P.A. 93‑1031, eff. 8‑27‑04.)

(305 ILCS 5/5‑6) (from Ch. 23, par. 5‑6)
Sec. 5‑6. Obligations incurred prior to death of a recipient. Obligations incurred but not paid for at the time of a recipient's death for services authorized under Section 5‑5, including medical and other care in group care facilities as defined in the "Nursing Home Care Act", approved August 23, 1979, as amended, or in like facilities not required to be licensed under that Act, may be paid, subject to the rules and regulations of the Illinois Department, after the death of the recipient.
(Source: P.A. 86‑820.)

(305 ILCS 5/5‑7) (from Ch. 23, par. 5‑7)
Sec. 5‑7. (Repealed).
(Source: P.A. 81‑487. Repealed by P.A. 93‑20, eff. 6‑20‑03.)

(305 ILCS 5/5‑8) (from Ch. 23, par. 5‑8)
Sec. 5‑8. Practitioners. In supplying medical assistance, the Illinois Department may provide for the legally authorized services of persons licensed under the Medical Practice Act of 1987, as amended, except as hereafter in this Section stated, whether under a general or limited license, and of persons licensed or registered under other laws of this State to provide dental, medical, pharmaceutical, optometric, podiatric, or nursing services, or other remedial care recognized under State law. The Department may not provide for legally authorized services of any physician who has been convicted of having performed an abortion procedure in a wilful and wanton manner on a woman who was not pregnant at the time such abortion procedure was performed. The utilization of the services of persons engaged in the treatment or care of the sick, which persons are not required to be licensed or registered under the laws of this State, is not prohibited by this Section.
(Source: P.A. 85‑1209.)

(305 ILCS 5/5‑9) (from Ch. 23, par. 5‑9)
Sec. 5‑9. Choice of Medical Dispensers. Applicants and recipients shall be entitled to free choice of those qualified practitioners, hospitals, nursing homes, and other dispensers of medical services meeting the requirements and complying with the rules and regulations of the Illinois Department. However, the Director of Public Aid may, after providing reasonable notice and opportunity for hearing, deny, suspend or terminate any otherwise qualified person, firm, corporation, association, agency, institution, or other legal entity, from participation as a vendor of goods or services under the medical assistance program authorized by this Article if the Director finds such vendor of medical services in violation of this Act or the policy or rules and regulations issued pursuant to this Act. Any physician who has been convicted 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 shall be automatically removed from the list of physicians qualified to participate as a vendor of medical services under the medical assistance program authorized by this Article.
(Source: P.A. 82‑263.)

(305 ILCS 5/5‑10) (from Ch. 23, par. 5‑10)
Sec. 5‑10. Entitlement to Social Services. Persons receiving medical assistance shall be entitled to receive, under Article IX and the Illinois Act on the Aging, such rehabilitative, training or other social services as are appropriate to their condition.
(Source: P.A. 92‑651, eff. 7‑11‑02.)

(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

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.

(2) Provide client education services as determined

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.

(3) Provide that enrollees within the system may choose the site for provision of services and the panel of health care providers. (4) Not discriminate in enrollment or disenrollment practices among recipients of medical services or enrollees based on health status. (5) Provide a quality assurance and utilization

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.

(6) Issue a managed care community network identification card to each enrollee upon enrollment. The card must contain all of the following: (A) The enrollee's health plan.
(B) The name and telephone number of the enrollee's primary care physician or the site for receiving primary care services. (C) A telephone number to be used to confirm

eligibility for benefits and authorization for services that is available 24 hours per day, 7 days per week.

(7) Ensure that every primary care physician and

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.

(8) Provide a procedure for handling complaints that

meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.

(9) Maintain, retain, and make available to the

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.

(10) Provide that the pharmacy formulary used by the

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.

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.)

(305 ILCS 5/5‑11.1)
Sec. 5‑11.1. Cooperative arrangements; contracts. The Illinois Department may enter into cooperative arrangements with State agencies responsible for administering or supervising the administration of health services and vocational rehabilitation services to maximize utilization of these services in the provision of medical assistance.
The Illinois Department shall, not later than June 30, 1994, enter into one or more cooperative 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 mental illness, 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 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 under this Section. 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 under the laws of this State governing the establishment and operation of health services or health maintenance organizations. 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. Nothing in this Section shall be construed to abrogate any existing doctor/patient relationships with Illinois Department of Public Aid recipients or the free choice of clients or their guardians to select a physician to provide medical care. The provisions of Section 9 of the State Finance Act notwithstanding, such contracts with State agencies, other health care and rehabilitation organizations, or fiscal intermediaries may provide for advance payments.
(Source: P.A. 91‑357, eff. 7‑29‑99.)

(305 ILCS 5/5‑12) (from Ch. 23, par. 5‑12)
Sec. 5‑12. Funeral and burial. Upon the death of a recipient who qualified under class 2, 3 or 4 of Section 5‑2, if his estate is insufficient to pay his funeral and burial expenses and if no other resources, including assistance from legally responsible relatives, are available for such purposes, there shall be paid, in accordance with the standards, rules and regulations of the Illinois Department of Human Services, such reasonable amounts as may be necessary to meet the costs of the funeral, burial space, and cemetery charges, or to reimburse any person not financially responsible for the deceased who has voluntarily made expenditures for such costs.
(Source: P.A. 92‑651, eff. 7‑11‑02.)

(305 ILCS 5/5‑13) (from Ch. 23, par. 5‑13)
Sec. 5‑13. Claim against estate of recipients. To the extent permitted under the federal Social Security Act, the amount expended under this Article (1) for a person of any age who is an inpatient in a nursing facility, an intermediate care facility for the mentally retarded, or other medical institution, or (2) for a person aged 55 or more, shall be a claim against the person's estate or a claim against the estate of the person's spouse, regardless of the order of death, but no recovery may be had thereon until after the death of the surviving spouse, if any, and then only at such time when there is no surviving child who is under age 21, or blind, or permanently and totally disabled. This Section, however, shall not bar recovery at the death of the person of amounts of medical assistance paid to or in his behalf to which he was not entitled; provided that such recovery shall not be enforced against any real estate while it is occupied as a homestead by the surviving spouse or other dependent, if no claims by other creditors have been filed against the estate, or if such claims have been filed, they remain dormant for failure of prosecution or failure of the claimant to compel administration of the estate for the purpose of payment. The term "estate", as used in this Section, with respect to a deceased person, means all real and personal property and other assets included within the person's estate, as that term is used in the Probate Act of 1975; however, in the case of a deceased person who has received (or is entitled to receive) benefits under a long‑term care insurance policy in connection with which assets or resources are disregarded to the extent that payments are made or because the deceased person received (or was entitled to receive) benefits under a long‑term care insurance policy, "estate" also includes any other real and personal property and other assets in which the deceased person had any legal title or interest at the time of his or her death (to the extent of that interest), including assets conveyed to a survivor, heir, or assignee of the deceased person through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement. The term "homestead", as used in this Section, means the dwelling house and contiguous real estate occupied by a surviving spouse or relative, as defined by the rules and regulations of the Illinois Department, regardless of the value of the property.
A claim arising under this Section against assets conveyed to a survivor, heir, or assignee of the deceased person through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement is not effective until the claim is recorded or filed in the manner provided for a notice of lien in Section 3‑10.2. The claim is subject to the same requirements and conditions to which liens on real property interests are subject under Sections 3‑10.1 through 3‑10.10. A claim arising under this Section attaches to interests owned or subsequently acquired by the estate of a recipient or the estate of a recipient's surviving spouse. The transfer or conveyance of any real or personal property of the estate as defined in this Section shall be subject to the fraudulent transfer conditions that apply to real property in Section 3‑11 of this Code.
The provisions of this Section shall not affect the validity of claims against estates for medical assistance provided prior to January 1, 1966 to aged, blind, or disabled persons receiving aid under Articles V, VII and VII‑A of the 1949 Code.
(Source: P.A. 88‑85; 88‑554, eff. 7‑26‑94; 89‑21, eff. 7‑1‑95; 89‑437, eff. 12‑15‑95; 89‑686, eff. 12‑31‑96.)

(305 ILCS 5/5‑13.2)
Sec. 5‑13.2. Notice of claim for payment or against estate. If the Illinois Department determines, more than 120 days after a person becomes an institutionalized person, that (i) the institutionalized person, the institutionalized person's spouse, or any other person is required under this Code to reimburse the Illinois Department for any part of the amount of medical assistance provided under this Article to or on behalf of the institutionalized person or (ii) the institutionalized person's estate is liable for any amount of medical assistance provided to or on behalf of the institutionalized person, the Illinois Department shall not make any claim for payment of that amount on demand, but rather shall establish, in cooperation with the institutionalized person (and that person's spouse or primary caretaker, if applicable), a schedule for payment of the amount owed to the Illinois Department.
(Source: P.A. 88‑162; 88‑670, eff. 12‑2‑94.)

(305 ILCS 5/5‑13.5)
Sec. 5‑13.5. Lien on real property interests. The State shall have a lien on all legal and equitable interests of recipients in real property, whether vested or contingent, including legal and equitable rights and interests of the recipient to coal, gas, oil, iron, and other underground mineral resources, for medical assistance paid under this Article and for payments made to preserve the lien, to the extent those liens are allowed under the federal Social Security Act. The lien shall attach to those interests owned or subsequently acquired by persons who were recipients on or after the effective date of this amendatory Act of 1993. The liens shall be recorded and filed and are otherwise subject to all the conditions of Sections 3‑10.1 through 3‑10.10 of this Code.
(Source: P.A. 88‑85; 88‑670, eff. 12‑2‑94.)

(305 ILCS 5/5‑14) (from Ch. 23, par. 5‑14)
Sec. 5‑14. Exemption for Townships. Nothing in this Article shall be construed as requiring townships to provide, in whole or in part, medical assistance to persons who are not residents of the State of Illinois.
In all instances under this Article where medical aid or assistance to a person who is not a resident of this State would otherwise be in whole or in part, the responsibility of a township, the Illinois Department shall be responsible for such aid or assistance.
The Illinois Department shall, by rule or regulation, insure that provision of such aid or assistance to a non‑resident is identical to the uniform standard of eligibility established by the Illinois Department.
(Source: P.A. 81‑519.)

(305 ILCS 5/5‑15) (from Ch. 23, par. 5‑15)
Sec. 5‑15. (a) The Illinois Department is authorized to contract with community based organizations serving low income communities for a three year period to demonstrate how and the extent to which preventive health programs can decrease utilization of medical care services and/or improve health status.
(b) As used in this Section (1) a community based organization is an organization established as a not‑for‑profit corporation under laws of the State of Illinois which serves a defined geographic community and is governed by members of that community; and (2) a preventive health program is any program, service or intervention the purpose of which is to identify, resolve, or ameliorate problems which contribute to the utilization of medical services.
(c) The Illinois Department is authorized, for evaluation purposes, to release names of recipients and other pertinent identification and medical utilization information to the community organizations under contract.
(d) Contractors shall maintain strict confidentiality of information released by the Illinois Department by following guidelines established by the Illinois Department, which shall require that recipients sign a release for any further use or disclosure of such information.
(Source: P.A. 93‑632, eff. 2‑1‑04.)

(305 ILCS 5/5‑15.5)
Sec. 5‑15.5. Preventive physical examinations; demonstration program.
(a) The Illinois Department may establish and implement a demonstration program of preventive physical examinations over a 3‑year period commencing on January 1, 1994, for persons receiving assistance under Article IV of this Code and persons eligible for assistance under this Article who are otherwise eligible for assistance under Article IV but who fail to qualify for cash assistance under Article IV on the basis of need. Notwithstanding any other provision of this Section, however, persons who are pregnant or who are less than 21 years of age shall not be eligible to participate in the demonstration program. The demonstration program may be implemented for recipients in at least 2 counties, one with a population of not more than 650,000 as determined by the 1990 federal census, and one with a population of not more than 100,000 as determined by the 1990 federal census. The Illinois Department may establish by rule the nature and scope of the preventive physical examinations required under this Section, except that the services may include, as appropriate, blood pressure reading, complete blood test appropriate to the population and risk factors, family planning, nutrition counselling, smoking evaluation, temperature, urinalysis, chest x‑ray, tuberculosis screening, and appropriate referrals.
(b) Participation in the demonstration program shall be voluntary, and eligible recipients shall not be subject to sanctions for refusing or failing to submit to a preventive physical examination or any portion of such an examination. The Illinois Department may by rule limit each eligible recipient to one examination during the demonstration period.
(c) For the purpose of carrying out its responsibilities under this Section, the Illinois Department is authorized to enter into cooperative arrangements with for‑profit and non‑profit medical clinics and hospitals, local health departments, and other providers of medical services. The Illinois Department of Public Health shall cooperate in the development and establishment of this demonstration program. During the period of the demonstration program, the Illinois Department of Public Aid shall study the cost benefit of providing preventive physical examinations to the targeted group of recipients of public aid.
(d) Implementation of the demonstration program shall be contingent on the receipt of all necessary federal waivers.
(Source: P.A. 88‑396.)

(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

criteria to determine which clients must participate in this program; (b) Providers participating in the program may be

paid an amount per patient per month, to be set by the Illinois Department, for managing each recipient's medical care;

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;

(d) Each recipient required to participate in the

program must select from a panel of primary care providers or networks established by the Department in their communities;

(e) A recipient may change his designated primary care provider: (1) when the designated source becomes unavailable, as the Illinois Department shall determine by rule; or (2) when the designated primary care provider

notifies the Illinois Department that it wishes to withdraw from any obligation as primary care provider; or

(3) in other situations, as the Illinois Department shall provide by rule; (f) The Illinois Department shall, by rule,

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;

(g) Only medical care services authorized by a

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.

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.)

(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

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.

(b) Providers participating in the program shall be

paid an amount per patient per month, to be set by the Illinois Department, for the case management services provided.

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.

(d) Each eligible participant in an area where the

Case Management Services Program is being conducted may voluntarily designate a case manager, of her own choosing to assume responsibility for her care.

(e) A participant may change her designated case

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.

(f) The Illinois Department shall, by rule,

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.

(g) In accordance with rules adopted by the Illinois

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.

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.)

(305 ILCS 5/5‑16.2)
Sec. 5‑16.2. Long range plan for case management. The Illinois Department shall develop a long range plan for the implementation of case management services, as defined in Section 5‑16.1 of this Act, throughout Illinois. The long range plan shall include: (i) a geographic overview of the State and the proportion, as determined by the Department of Public Aid and the Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment; (ii) identification of high proportion areas; (iii) goals for reducing the likelihood of long‑term welfare dependency; (iv) the time frames for accomplishing the identified goals; and (v) specific recommendations for administrative or legislative policies and programs necessary to complete the identified goals. The long range plan shall take into consideration other resources currently serving the identified population. The long range plan shall be completed no later than July 1, 1994, and provided to the Governor and the General Assembly in the form of a written report.
(Source: P.A. 88‑70.)

(305 ILCS 5/5‑16.3)
Sec. 5‑16.3. (Repealed).
(Source: P.A. 90‑742, eff. 8‑13‑98. Repealed by P.A. 92‑370, eff. 8‑15‑01.)

(305 ILCS 5/5‑16.4)
Sec. 5‑16.4. Medical Assistance Provider Payment Fund.
(a) There is created in the State treasury the Medical Assistance Provider Payment Fund. Interest earned by the Fund shall be credited to the Fund.
(b) The Fund is created for the purpose of disbursing moneys as follows:
(1) For medical services provided to recipients of

aid under Articles V, VI, and XII. (2) For payment of administrative expenses incurred by the Illinois Department or its agent in performing the activities authorized by this Section. (3) For making transfers to the General Obligation

Bond Retirement and Interest Fund, as those transfers are authorized in the proceedings authorizing debt under the Medicaid Liability Liquidity Borrowing Act, but transfers made under this paragraph (3) may not exceed the principal amount of debt issued under that Act.

Disbursements from the Fund, other than transfers to the General Obligation Bond Retirement and Interest Fund (which shall be made in accordance with the provisions of the Medicaid Liability Liquidity Borrowing Act), shall be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Illinois Department.
(c) The Fund shall consist of the following:
(1) All federal matching funds received by the

Illinois Department as a result of expenditures made by the Illinois Department that are attributable to moneys deposited into the Fund.

(2) Proceeds from any short‑term borrowing directed to the Fund by the Governor pursuant to the Medicaid Liability Liquidity Borrowing Act. (3) Amounts transferred into the Fund under subsection (d) of this Section. (4) All other moneys received for the Fund from any other source, including interest earned on those moneys.

(d) Beginning July 1, 1995, on the 13th and 26th days of each month the State Comptroller and Treasurer shall transfer from the General Revenue Fund to the Medical Assistance Provider Payment Fund an amount equal to 1/48th of the annual Medical Assistance appropriation to the Illinois Department of Public Aid from the Medical Assistance Provider Payment Fund, plus cumulative deficiencies from those prior transfers. In addition to those transfers, the State Comptroller and Treasurer may transfer from the General Revenue Fund to the Medical Assistance Provider Payment Fund as much as is necessary to pay claims pursuant to the new twice‑monthly payment schedule established in Section 5‑16.5 and to avoid interest liabilities under the State Prompt Payment Act. No transfers made pursuant to this subsection shall interfere with the timely payment of the general State aid payment made pursuant to Section 18‑11 of the School Code.
(Source: P.A. 88‑554, eff. 7‑26‑94.)

(305 ILCS 5/5‑16.5)
Sec. 5‑16.5. Expedited payments.
(a) (Blank).
(b) In a county with a population of 3,000,000 or more, a managed care community network shall receive expedited payment of its capitated reimbursement for each of its managed care enrollees if both of the following criteria are met:
(1) At least 75% of its membership is composed of

hospitals that are qualified on or after July 1, 1994 as disproportionate share hospitals. (2) At least 75% of its managed care enrollees receive services at the disproportionate share hospitals or those hospitals' affiliated sites.

(c) For counties whose population is less than 3,000,000, the Illinois Department shall establish by rule the terms and conditions under which a managed care community network shall receive expedited payment, including a determination of the qualifying percentage criteria for disproportionate share hospitals and managed care enrollees within a network receiving services at disproportionate share hospitals or their affiliated sites.
(Source: P.A. 88‑554, eff. 7‑26‑94; 89‑21, eff. 7‑1‑95.)

(305 ILCS 5/5‑16.6)
Sec. 5‑16.6. Provider compliance with certain requirements. The Illinois Department shall inquire of appropriate State agencies concerning the status of all providers' compliance with State income tax requirements, child support payments in accordance with Article X of this Code, and educational loans guaranteed by the Illinois State Scholarship Commission. The Illinois Department may suspend from participation in the medical assistance program, after reasonable notice and opportunity for a hearing in accordance with Section 12‑4.25 of this Code, those providers not in compliance with these requirements, unless payment arrangements acceptable to the appropriate State agency are made.
(Source: P.A. 90‑655, eff. 7‑30‑98.)

(305 ILCS 5/5‑16.7)
Sec. 5‑16.7. Post‑parturition care. The medical assistance program shall provide the post‑parturition care benefits required to be covered by a policy of accident and health insurance under Section 356s of the Illinois Insurance Code.
(Source: P.A. 89‑513, eff. 9‑15‑96; 90‑14, eff. 7‑1‑97.)

(305 ILCS 5/5‑16.7a)
Sec. 5‑16.7a. Reimbursement for epidural anesthesia services. In addition to other procedures authorized by the Department under this Code, the Department shall provide reimbursement to medical providers for epidural anesthesia services when ordered by the attending practitioner at the time of delivery.
(Source: P.A. 93‑981, eff. 8‑23‑04.)

(305 ILCS 5/5‑16.8)
(Text of Section from P.A. 93‑853)
Sec. 5‑16.8. Required health benefits. The medical assistance program shall provide the post‑mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356u, 356w, 356x and 356z.6 of the Illinois Insurance Code.
(Source: P.A. 93‑853, eff. 1‑1‑05.)

(Text of Section from P.A. 93‑1000)
Sec. 5‑16.8. Required health benefits. The medical assistance program shall (i) provide the post‑mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356u, 356w, and 356x of the Illinois Insurance Code and (ii) be subject to the provisions of Section 364.01 of the Illinois Insurance Code.
(Source: P.A. 93‑1000, eff. 1‑1‑05.)

(305 ILCS 5/5‑16.9)
Sec. 5‑16.9. Woman's health care provider. The medical assistance program is subject to the provisions of Section 356r of the Illinois Insurance Code. The Illinois Department shall adopt rules to implement the requirements of Section 356r of the Illinois Insurance Code in the medical assistance program including managed care components.
(Source: P.A. 92‑370, eff. 8‑15‑01.)

(305 ILCS 5/5‑16.10)
Sec. 5‑16.10. Managed care entities; marketing. A managed health care entity providing services under this Article V may not engage in door‑to‑door marketing activities or marketing activities at an office of the Illinois Department or a county department in order to enroll recipients in the entity's health care delivery system. The Department shall adopt rules defining "marketing activities" prohibited by this Section.
Before a managed health care entity providing services under this Article V may market its health care delivery system to recipients, the Illinois Department must approve a marketing plan submitted by the entity to the Illinois Department. The Illinois Department shall adopt guidelines for approving marketing plans submitted by managed health care entities under this Section. Besides prohibiting door‑to‑door marketing activities and marketing activities at public aid offices, the guidelines shall include at least the following:
(1) A managed health care entity may not offer or

provide any gift, favor, or other inducement in marketing its health care delivery system to integrated health care program enrollees. A managed health care entity may provide health care related items that are of nominal value and pre‑approved by the Department to prospective enrollees. A managed health care entity may also provide to enrollees health care related items that have been pre‑approved by the Department as an incentive to manage their health care appropriately.

(2) All persons employed or otherwise engaged by a

managed health care entity to market the entity's health care delivery system to recipients or to supervise that marketing shall register with the Illinois Department.

The Inspector General appointed under Section 12‑13.1 may conduct investigations to determine whether the marketing practices of managed health care entities providing services under this Article V comply with the guidelines.
(Source: P.A. 90‑538, eff. 12‑1‑97.)

(305 ILCS 5/5‑16.11)
Sec. 5‑16.11. Uniform standards applied to managed care entities. Any managed care entity providing services under this Code shall use a pharmacy formulary that is no more restrictive than the Illinois Department's pharmaceutical program.
(Source: P.A. 92‑370, eff. 8‑15‑01.)

(305 ILCS 5/5‑16.12)
Sec. 5‑16.12. Managed Care Reform and Patient Rights Act. The medical assistance program and other programs administered by the Department are subject to the provisions of the Managed Care Reform and Patient Rights Act. The Department may adopt rules to implement those provisions. These rules shall require compliance with that Act in the medical assistance managed care programs and other programs administered by the Department. The medical assistance fee‑for‑service program is not subject to the provisions of the Managed Care Reform and Patient Rights Act.
Nothing in the Managed Care Reform and Patient Rights Act shall be construed to mean that the Department is a health care plan as defined in that Act simply because the Department enters into contractual relationships with health care plans.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

(305 ILCS 5/5‑16.13)
Sec. 5‑16.13. (Repealed).
(Source: P.A. 93‑674, eff. 6‑10‑04. Repealed internally, eff. 12‑31‑04.)

(305 ILCS 5/5‑17) (from Ch. 23, par. 5‑17)
Sec. 5‑17. Programs to improve access to hospital care.
(a) (1) The General Assembly finds:
(A) That while hospitals have traditionally

provided charitable care to indigent patients, this burden is not equally borne by all hospitals operating in this State. Some hospitals continue to provide significant amounts of care to low‑income persons while others provide very little such care; and

(B) That access to hospital care in this State

by the indigent citizens of Illinois would be seriously impaired by the closing of hospitals that provide significant amounts of care to low‑income persons.

(2) To help expand the availability of hospital care

for all citizens of this State, it is the policy of the State to implement programs that more equitably distribute the burden of providing hospital care to Illinois' low‑income population and that improve access to health care in Illinois.

(3) The Illinois Department may develop and

implement a program that lessens the burden of providing hospital care to Illinois' low‑income population, taking into account the costs that must be incurred by hospitals providing significant amounts of care to low‑income persons, and may develop adjustments to increase rates to improve access to health care in Illinois. The Illinois Department shall prescribe by rule the criteria, standards and procedures for effecting such adjustments in the rates of hospital payments for services provided to eligible low‑income persons (under Articles V, VI and VII of this Code) under this Article.

(b) The Illinois Department shall require hospitals certified to participate in the federal Medicaid program to:
(1) provide equal access to available services to

low‑income persons who are eligible for assistance under Articles V, VI and VII of this Code; (2) provide data and reports on the provision of uncompensated care.

(c) From the effective date of this amendatory Act of 1992 until July 1, 1992, nothing in this Section 5‑17 shall be construed as creating a private right of action on behalf of any individual.
(Source: P.A. 87‑13; 87‑838.)

(305 ILCS 5/5‑18) (from Ch. 23, par. 5‑18)
Sec. 5‑18. (Repealed).
(Source: P.A. 87‑895. Repealed by P.A. 92‑275, eff. 8‑7‑01.)

(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

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.

(2) The Illinois Department shall pay for an

interperiodic health, vision, hearing, or dental screening examination for any child eligible for Healthy Kids services whenever an examination is:

(A) requested by a child's parent, guardian, or

custodian, or is determined to be necessary or appropriate by social services, developmental, health, or educational personnel; or