This bill establishes a minimum reimbursement standard for pharmacies that are not classified as critical access care facilities, requiring Medicaid managed care organizations to pay at least the same rates as the traditional fee-for-service program. The law mandates that these payments cover both the professional dispensing fee and the acquisition cost of the medication, regardless of whether the managed care organization pays the pharmacy directly or uses a third-party pharmacy benefit manager. Additionally, the bill directs the state Department of Healthcare Finance to implement various cost-control measures, such as limiting the number of prescriptions for certain drugs within a 30-day period and requiring prior approval for specific high-cost medications.
Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to seek a State Plan amendment from the Centers for Medicare and Medicaid Services regarding a prospective cost-reimbursement methodology for services provided by federally qualified health centers (FQHC) and FQHC Look-Alikes (LALs). Requires the State Plan amendment to include the following: (1) Prospective Payment System (PPS) rates for FQHCs; (2) a rate adjustment process; (3) a rate setting for new FQHCs; (4) payment in the event of Medicaid managed care; (5) payment in the event of dual enrollment in Medicare and Medicaid; and (6) appeal rights.
Amends the Illinois Certified Community Behavioral Health Clinics Act. Establishes a limited and targeted expansion mechanism to admit certain federally certified Community Behavioral Health Clinics into the Illinois Certified Community Behavioral Health Clinic Medicaid Demonstration program. Provides that the Illinois CCBHC prospective payment system methodology, as specified, shall be used to reimburse providers under the program. Prohibits the general expansion of the Illinois Certified Community Behavioral Health Clinic Medicaid Demonstration program beyond providers meeting the established eligibility criteria. Grants the Department of Healthcare and Family Services rulemaking authority, so long as the rules do not impose additional eligibility requirements beyond those expressly stated. Effective immediately.
Urges the Illinois Department of Healthcare and Family Services (HFS) to ensure that pharmacies participating in Medicaid managed care networks are reimbursed for covered outpatient prescription drugs at a rate no less than the reimbursement that would be paid under the Illinois Medicaid fee-for-service pharmacy program. Urges HFS to implement such reimbursement parity through Medicaid managed care organization contracts and pharmacy benefit manager agreements. Urges HFS to monitor and report to the General Assembly on the impact of reimbursement parity on pharmacy network participation, patient access to medications, and pharmacy closures within the State. Encourages HFS to evaluate the effect of reimbursement parity on pharmacy deserts, rural health access, and Medicaid beneficiary access to pharmacist-provided patient care services.
Creates the Community Supported Living Arrangement Services Act. Provides that the Department of Human Services, Division of Developmental Disabilities shall work in coordination with the Department of Healthcare and Family Services to develop, implement, and operate, and to submit, through the Department of Healthcare and Family Services, amendments to the Illinois Adults with Developmental Disabilities Section 1915(c) Home and Community-Based Services Waiver, subject to approval by the Centers for Medicare and Medicaid Services. Provides for establishment of provider licensing, certification, and oversight standards for Community Supported Living-24 Hour services consistent with existing State authority for community-based residential services, but with the person's own home not requiring licensing or Bureau of Accreditation, Licensure and Certification reviews. Provides for 24-hour availability of trained personnel for individuals with intense physical, medical, or behavioral support needs. Contains provisions regarding: covered services; enrollment; the use of tools such as the Health Risk Screening Tool; housing independence; staffing and workforce standards; phased implementation; Person-Centered Plans; dignity of risk; compliance with mandates; quality assurance; evaluations; a Community Supported Living Advisory Council; reports; fiscal issues; administrative issues; and other matters. Effective immediately.
Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that any person who was initially determined to be eligible for medical assistance and is receiving institutional services or home and community-based services as authorized under the Article shall be presumed eligible for a continuation of coverage for such services during any redetermination process. Requires the Department of Healthcare and Family Services to continue to make payments for such services unless the person experiences a material change in financial circumstances that results in the loss of eligibility. Provides that if the person experiences a material change in financial circumstances that results in the loss of eligibility, the person, or the person's designated caregiver or responsible party, shall notify the Department. Provides that if the Department subsequently conducts a redetermination of eligibility, the Department must provide written notice to the person (i) before the commencement of the redetermination; and (ii) upon conclusion of the redetermination. Requires the Department to develop a process to facilitate the written notifications. Provides that no later than October 1, 2026, the Department shall seek federal authorization to exempt persons with disabilities who are eligible for medical assistance from annual redeterminations of eligibility, except that a full redetermination shall be conducted at least once every 5 years, regardless of whether a material change in financial circumstances has occurred. Effective immediately.
Amends the Medical Assistance Article of the Illinois Public Aid Code. Sets per diem add-on rates, beginning January 1, 2027, for nursing facilities based on a facility's STRIVE study staffing levels. Provides that no nursing facility's variable staffing per diem add-on shall be reduced by more than 5% in 2 consecutive quarters; and that no facility below 73% of the staffing indicated by the STRIVE study shall receive a variable per diem staffing add-on after December 31, 2026. Provides that beginning January 1, 2027, the Department of Healthcare and Family Services must split the support rate into its cost report based parts, general services and general administration. Provides that the general services portion shall be referred to as "Support - non-nurse staff" and the general administration portion shall be referred to as "Support - Administrative". Makes other changes. Effective immediately.
Amends the Hospital Services Trust Fund Article of the Illinois Public Aid Code. In provisions requiring the Department of Healthcare and Family Services to (i) pay safety-net hospitals a health care equity add-on payment that is based on such hospitals' Medicaid inpatient utilization rate and (ii) pay safety-net hospitals a low volume add-on payment of $200 for each inpatient General Acute and Psychiatric day of care, removes the December 31, 2026 sunset dates for such add-on payments. Effective immediately.
Amends the Medicaid Technical Assistance Act. Requires the Medicaid Technical Assistance Center to collaborate with public and private partners throughout the State to identify, establish, and maintain best practices necessary for health providers to ensure their capacity to participate in the Illinois Medical Assistance Program (rather than ensure their capacity to participate in HealthChoice Illinois or YouthCare). Requires the Medicaid Technical Assistance Center to promote equitable delivery systems, remaining committed to the principle that all Medicaid recipients have accessible and equitable physical and mental health care services. Removes provisions concerning the Medicaid Technical Assistance Center's administration of network adequacy reports, and instead requires the Medicaid Technical Assistance Center to administer a network recruitment plan. Provides that by using reports and data provided by the Department of Healthcare and Family Services’ External Quality Review Organization on network adequacy, provider service deserts, and health care disparities by race and ethnicity, the Medicaid Technical Assistance Center shall propose for Department review and approval an annual plan for recruiting providers to participate in the Illinois Medical Assistance Program and report on outcomes of its recruitment efforts to the Department for continuous improvement. Repeals a provision requiring the Department to maximize federal financial participation for any moneys appropriated to the Department for the Medicaid Technical Assistance Center and to deposit all federal financial participation funds into the Medicaid Technical Assistance Center Fund. Repeals a provision creating the Medicaid Technical Assistance Center Fund. Amends the State Finance Act. Provides for the dissolution of the Medicaid Technical Assistance Center Fund on July 1, 2026, or as soon thereafter as practical, after the transfer of all remaining funds into the Healthcare Provider Relief Fund. Effective July 1, 2026.
Amends the Medical Assistance Article of the Illinois Public Aid Code. Increases the rate of reimbursement by 20% for providers of private duty nursing services for medically fragile and technology dependent children and for nursing and personal care services for non-waiver customers beginning January 1, 2027, subject to federal approval. Effective immediately.
