Chapter 305, PUBLIC AID

(305 ILCS 5/5-5.12e) Sec. 5-5.12e. Managed care organization prior authorization of health care services. (a) As used in this Section, "health care service" has the meaning given to that term in the Prior Authorization Reform Act. (b) Notwithstanding any other provision of law to…

(305 ILCS 5/5-5.12f) (Text of Section before amendment by P.A. 104-742) Sec. 5-5.12f. Prescription drugs for mental illness; no utilization or prior approval mandates. (a) Notwithstanding any other provision of this Code to the contrary, except as otherwise provided in subsection…

(305 ILCS 5/5-5.12g) (This Section may contain text from a Public Act with a delayed effective date) Sec. 5-5.12g. Compliance with the Transparency in Downcoding Act. Notwithstanding any other provision of law to the contrary, all managed care organizations shall comply with the …

(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) whic…

(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…

(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…

(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 unde…

(305 ILCS 5/5-5.2) (Text of Section from P.A. 104-470) Sec. 5-5.2. Payment. (a) All nursing 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 De…

(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 …

(305 ILCS 5/5-5.23) (Text of Section before amendment by P.A. 104-742) Sec. 5-5.23. Children's mental health services. (a) The Department of Healthcare and Family Services, by rule, shall require the screening and assessment of a child prior to any Medicaid-funded admission to an…

(305 ILCS 5/5-5.24) Sec. 5-5.24. Prenatal and perinatal care. (a) The Department of Healthcare and Family Services may provide reimbursement under this Article for all prenatal and perinatal health care services that are provided for the purpose of preventing low-birthweight infa…

(305 ILCS 5/5-5.24a) Sec. 5-5.24a. Remote ultrasounds and remote fetal nonstress tests; reimbursement. (a) Subject to federal approval, for dates of service beginning on and after January 1, 2025, the Department shall reimburse for remote ultrasound procedures and remote fetal no…

(305 ILCS 5/5-5.24b) Sec. 5-5.24b. Coverage for at-home pregnancy tests. Beginning January 1, 2025, the medical assistance program shall provide coverage for at-home, urine-based pregnancy tests that are ordered directly by a clinician or furnished through a standing order for pa…

(305 ILCS 5/5-5.25) (Text of Section before amendment by P.A. 104-742) Sec. 5-5.25. Access to behavioral health, medical, and epilepsy treatment services. (a) The General Assembly finds that providing access to behavioral health, medical, and epilepsy treatment services in a time…

(305 ILCS 5/5-5.25a) Sec. 5-5.25a. Coverage for seizure detection devices. (a) As used in this Section, "seizure detection device" means a monitoring device cleared by the United States Food and Drug Administration, and any related technology, application, service, or subscriptio…

(305 ILCS 5/5-5.26) Sec. 5-5.26. Multiple sclerosis; home services; waiver. The Department of Healthcare and Family Services shall apply for a waiver of federal law and regulations to the extent necessary to claim federal financial participation for medical assistance for service…

(305 ILCS 5/5-5.27) Sec. 5-5.27. Coverage for clinical trials. (a) The medical assistance program shall provide coverage for routine care costs that are incurred in the course of an approved clinical trial if the medical assistance program would provide coverage for the same rout…

(305 ILCS 5/5-5.28) Sec. 5-5.28. Rulemaking authority. The Department of Healthcare and Family Services may adopt rules to implement the applicable provisions of this amendatory Act of the 104th General Assembly to managed care organizations, managed care community networks, and,…

(305 ILCS 5/5-5.2a) Sec. 5-5.2a. Cottage style nursing home reimbursement adjustment. (a) As used in this Section, "cottage style nursing home" means a nursing home meeting the requirements under Article IIIB of the Nursing Home Care Act. (b) Subject to any necessary federal appr…

(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 Healthcare and Family Services in instituting rates for the care of recipients of m…

(305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4) (Text of Section from P.A. 104-466) Sec. 5-5.4. Standards of payment; Department of Healthcare and Family Services. The Department of Healthcare and Family Services shall develop standards of payment of nursing facility and ICF/DD serv…

(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 dis…

(305 ILCS 5/5-5.4d) Sec. 5-5.4d. MDS payment methodology; quarterly rate adjustments. (a) On and after July 1, 2009, and until April 1, 2011, the nursing component of the nursing facility medical assistance rate computed under the Minimum Data Set (MDS) payment methodology shall …

(305 ILCS 5/5-5.4e) Sec. 5-5.4e. Nursing facilities; ventilator rates. On and after October 1, 2009, the Department of Healthcare and Family Services shall adopt rules to provide medical assistance reimbursement under this Article for the care of persons on ventilators in skilled…

(305 ILCS 5/5-5.4f) Sec. 5-5.4f. Intermediate care facilities for persons with developmental disabilities quality workforce initiative. (a) Legislative intent. Individuals with developmental disabilities who live in community-based settings rely on direct support staff for a vari…

(305 ILCS 5/5-5.4g) Sec. 5-5.4g. Minimum Data Set (MDS) Compliance Review; preliminary findings. The Department shall establish by rule a procedure for sharing preliminary Minimum Data Set (MDS) Compliance Review findings with nursing facilities prior to completion of the on-site…

(305 ILCS 5/5-5.4h) Sec. 5-5.4h. Medicaid reimbursement for medically complex for the developmentally disabled facilities licensed under the MC/DD Act. (a) Facilities licensed as medically complex for the developmentally disabled facilities that serve severely and chronically ill…

(305 ILCS 5/5-5.4i) Sec. 5-5.4i. Rates and reimbursements. (a) Within 30 days after July 6, 2017 (the effective date of Public Act 100-23), the Department shall increase rates and reimbursements to fund a minimum of a $0.75 per hour wage increase for front-line personnel, includi…

(305 ILCS 5/5-5.4j) Sec. 5-5.4j. ID/DD targeted Medicaid rate enhancement. Within 30 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall increase the Medicaid per diem rate by $21.15 for facilities with more than 16 beds licens…

(305 ILCS 5/5-5.4k) Sec. 5-5.4k. Payments for long-acting injectable medications for mental health or substance use disorders. Notwithstanding any other provision of this Code, effective for dates of service on and after January 1, 2022, the medical assistance program shall separ…

(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 Healthcare and Family Services shall develop a prospective method for determining payment rates for nursing facility and ICF/DD services in nursing facilities composed of the …

(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 Healthcare and Family Services may develop in its rate structure for nursing facilities an accommodation for fully kosher kitchen and food service operations, rabbin…

(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 und…

(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 nursing facility or ICF/DD 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 p…

(305 ILCS 5/5-5.7) (from Ch. 23, par. 5-5.7) Sec. 5-5.7. Cost reports - audits. The Department of Healthcare and Family Services shall work with the Department of Public Health to use cost report information currently being collected under provisions of the Nursing Home Care Act,…

(305 ILCS 5/5-5.7a) Sec. 5-5.7a. Pandemic related stability payments for health care providers. Notwithstanding other provisions of law, and in accordance with the Illinois Emergency Management Agency, the Department of Healthcare and Family Services shall develop a process to di…

(305 ILCS 5/5-5.7b) Sec. 5-5.7b. Pandemic related stability payments to ambulance service providers in response to COVID-19. (a) Definitions. As used in this Section: "Ambulance Services Industry" means the industry that is comprised of "Qualifying Ground Ambulance Service Provid…

(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 us…

(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…

(305 ILCS 5/5-50) (Text of Section before amendment by P.A. 104-742) Sec. 5-50. Coverage for mental health and substance use disorder telehealth services. (a) As used in this Section: "Behavioral health care professional" has the meaning given to "health care professional" in Sec…

(305 ILCS 5/5-51) Sec. 5-51. Proton beam therapy; managed care. Notwithstanding any other provision of this Article, a managed care organization under contract with the Department to provide services to recipients of medical assistance shall provide coverage for proton beam thera…

(305 ILCS 5/5-52) Sec. 5-52. Custom prosthetic and orthotic devices; reimbursement rates. Subject to federal approval, for dates of service beginning on and after January 1, 2025, the Department shall increase the current 2024 Medicaid rate by 7% under the medical assistance prog…

(305 ILCS 5/5-53) Sec. 5-53. Coverage for self-measure blood pressure monitoring services. Subject to federal approval and notwithstanding any other provision of this Code, for services on and after January 1, 2025, the following self-measure blood pressure monitoring services sh…

(305 ILCS 5/5-54) Sec. 5-54. Coverage for proteomic blood tests. (a) The medical assistance program shall provide coverage and reimbursement for a prescribed proteomic blood test, with clinical trial proof of improved infant outcomes published in peer-reviewed journals, that iden…

(305 ILCS 5/5-55) Sec. 5-55. Reimbursement for music therapy services. Subject to federal approval, for dates of service beginning on and after July 1, 2027, the Department shall reimburse music therapy services provided by licensed professional music therapists. To be eligible f…

(305 ILCS 5/5-56) Sec. 5-56. Coverage for hormonal therapy to treat menopause. The medical assistance program shall provide coverage for medically necessary hormone therapy treatment to treat menopause that has been induced by a hysterectomy. (Source: P.A. 103-703, eff. 1-1-26; 1…

(305 ILCS 5/5-57) Sec. 5-57. Genetic testing and evidence-based screenings for an inherited gene mutation. (a) In this Section, "genetic testing for an inherited mutation" means germline multi-gene testing for an inherited mutation associated with an increased risk of cancer in a…

(305 ILCS 5/5-58) Sec. 5-58. Illinois Medicaid Preferred Drug List; nonopioid drugs. In establishing and maintaining the Illinois Medicaid Preferred Drug List as described in Section 5-30.14, the Department shall ensure that nonopioid drugs on the Department's preferred drug list…

(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 D…

(305 ILCS 5/5-5a.1) Sec. 5-5a.1. Telehealth services for persons with intellectual and developmental disabilities. The Department shall file an amendment to the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities authorized under Section 19…