Public Act 096-0156
 		





SB1497 Enrolled
LRB096 04200 DRJ 14244 b






    AN ACT concerning public aid.

 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:



 
    Section 5. The Illinois Public Aid Code is amended  by 
changing Section 5-5 as follows:
 
    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)

    Sec. 5-5. Medical services.  The Illinois Department, by 
rule, shall
determine the quantity and quality of and the rate 
of reimbursement for the
medical assistance for which
payment 
will be authorized, and the medical services to be provided,

which may include all or part of the following: (1) inpatient 
hospital
services; (2) outpatient hospital services; (3) other 
laboratory and
X-ray services; (4) skilled nursing home 
services; (5) physicians'
services whether furnished in the 
office, the patient's home, a
hospital, a skilled nursing home, 
or elsewhere; (6) medical care, or any
other type of remedial 
care furnished by licensed practitioners; (7)
home health care 
services; (8) private duty nursing service; (9) clinic

services; (10) dental services, including prevention and 
treatment of periodontal disease and dental caries disease for 
pregnant women, provided by an individual licensed to practice 
dentistry or dental surgery; for purposes of this item (10), 
"dental services" means diagnostic, preventive, or corrective 
procedures provided by or under the supervision of a dentist in 
the practice of his or her profession; (11) physical therapy 
and related
services; (12) prescribed drugs, dentures, and 
prosthetic devices; and
eyeglasses prescribed by a physician 
skilled in the diseases of the eye,
or by an optometrist, 
whichever the person may select; (13) other
diagnostic, 
screening, preventive, and rehabilitative services; (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 Department of Healthcare and Family Services 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 provided by or under the 
    supervision of a dentist , 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 Department of Healthcare and Family Services must 
provide coverage and reimbursement for amino acid-based 
elemental formulas, regardless of delivery method, for the 
diagnosis and treatment of (i) eosinophilic disorders and (ii) 
short bowel syndrome when the prescribing physician has issued 
a written order stating that the amino acid-based elemental 
formula is medically necessary.

    The Illinois Department shall authorize the provision of, 
and shall
authorize payment for, screening by low-dose 
mammography for the presence of
occult breast cancer for women 
35 years of age or older who are eligible
for medical 
assistance under this Article, as follows:  a 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 Healthcare and Family Services

shall assure 
coverage for the cost of treatment of the drug abuse or

addiction for pregnant recipients in accordance with the 
Illinois Medicaid
Program in conjunction with the Department of 
Human Services.


    All medical providers providing medical assistance to 
pregnant women
under this Code shall receive information from 
the Department on the
availability of services under the Drug 
Free Families with a Future or any
comparable program providing 
case management services for addicted women,
including 
information on appropriate referrals for other social services

that may be needed by addicted women in addition to treatment 
for addiction.


    The Illinois Department, in cooperation with the 
Departments of Human
Services (as successor to the Department 
of Alcoholism and Substance
Abuse) and Public Health, through a 
public awareness campaign, may
provide information concerning 
treatment for alcoholism and drug abuse and
addiction, prenatal 
health care, and other pertinent programs directed at
reducing 
the number of drug-affected infants born to recipients of 
medical
assistance.


    Neither the Department of Healthcare and Family Services 
nor the Department of Human
Services shall sanction the 
recipient solely on the basis of
her substance abuse.


    The Illinois Department shall establish such regulations 
governing
the dispensing of health services under this Article 
as it shall deem
appropriate.  The Department
should
seek the 
advice of formal professional advisory committees appointed by

the Director of the Illinois Department for the purpose of 
providing regular
advice on policy and administrative matters, 
information dissemination and
educational activities for 
medical and health care providers, and
consistency in 
procedures to the Illinois Department.


    The Illinois Department may develop and contract with 
Partnerships of
medical providers to arrange medical services 
for persons eligible under
Section 5-2 of this Code.  
Implementation of this Section may be by
demonstration projects 
in certain geographic areas.  The Partnership shall
be 
represented by a sponsor organization.  The Department, by rule, 
shall
develop qualifications for sponsors of Partnerships.  
Nothing in this
Section shall be construed to require that the 
sponsor organization be a
medical organization.


    The sponsor must negotiate formal written contracts with 
medical
providers for physician services, inpatient and 
outpatient hospital care,
home health services, treatment for 
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 
Healthcare and Family Services 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. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)