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91_HB0931
LRB9101119SMpr
1 AN ACT to amend the Illinois Public Aid Code by changing
2 Section 5-5.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Public Aid Code is amended by
6 changing Section 5-5 as follows:
7 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
8 Sec. 5-5. Medical services. The Illinois Department, by
9 rule, shall determine the quantity and quality of and the
10 rate of reimbursement for the medical assistance for which
11 payment will be authorized, and the medical services to be
12 provided, which may include all or part of the following: (1)
13 inpatient hospital services; (2) outpatient hospital
14 services; (3) other laboratory and X-ray services; (4)
15 skilled nursing home services; (5) physicians' services
16 whether furnished in the office, the patient's home, a
17 hospital, a skilled nursing home, or elsewhere; (6) medical
18 care, or any other type of remedial care furnished by
19 licensed practitioners; (7) home health care services; (8)
20 private duty nursing service; (9) clinic services; (10)
21 dental services; (11) physical therapy and related services;
22 (12) prescribed drugs, dentures, and prosthetic devices; and
23 eyeglasses prescribed by a physician skilled in the diseases
24 of the eye, or by an optometrist, whichever the person may
25 select; (13) other diagnostic, screening, preventive, and
26 rehabilitative services; (14) transportation and such other
27 expenses as may be necessary; (15) medical treatment of
28 sexual assault survivors, as defined in Section 1a of the
29 Sexual Assault Survivors Emergency Treatment Act, for
30 injuries sustained as a result of the sexual assault,
31 including examinations and laboratory tests to discover
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1 evidence which may be used in criminal proceedings arising
2 from the sexual assault; (16) the diagnosis and treatment of
3 sickle cell anemia; and (17) any other medical care, and any
4 other type of remedial care recognized under the laws of this
5 State, but not including abortions, or induced miscarriages
6 or premature births, unless, in the opinion of a physician,
7 such procedures are necessary for the preservation of the
8 life of the woman seeking such treatment, or except an
9 induced premature birth intended to produce a live viable
10 child and such procedure is necessary for the health of the
11 mother or her unborn child. The Illinois Department, by rule,
12 shall prohibit any physician from providing medical
13 assistance to anyone eligible therefor under this Code where
14 such physician has been found guilty of performing an
15 abortion procedure in a wilful and wanton manner upon a woman
16 who was not pregnant at the time such abortion procedure was
17 performed. The term "any other type of remedial care" shall
18 include nursing care and nursing home service for persons who
19 rely on treatment by spiritual means alone through prayer for
20 healing.
21 Notwithstanding any other provision of this Section,
22 dental services shall be covered under the medical assistance
23 program under this Article for persons 21 years of age or
24 older who are otherwise eligible for assistance under this
25 Code.
26 The Illinois Department of Public Aid shall provide the
27 following services to persons eligible for assistance under
28 this Article who are participating in education, training or
29 employment programs operated by the Department of Human
30 Services as successor to the Department of Public Aid:
31 (1) dental services, which shall include but not be
32 limited to prosthodontics; and
33 (2) eyeglasses prescribed by a physician skilled in
34 the diseases of the eye, or by an optometrist, whichever
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1 the person may select.
2 The Illinois Department, by rule, may distinguish and
3 classify the medical services to be provided only in
4 accordance with the classes of persons designated in Section
5 5-2.
6 The Illinois Department shall authorize the provision of,
7 and shall authorize payment for, screening by low-dose
8 mammography for the presence of occult breast cancer for
9 women 35 years of age or older who are eligible for medical
10 assistance under this Article, as follows: a baseline
11 mammogram for women 35 to 39 years of age and an annual
12 mammogram for women 40 years of age or older. All screenings
13 shall include a physical breast exam, instruction on
14 self-examination and information regarding the frequency of
15 self-examination and its value as a preventative tool. As
16 used in this Section, "low-dose mammography" means the x-ray
17 examination of the breast using equipment dedicated
18 specifically for mammography, including the x-ray tube,
19 filter, compression device, image receptor, and cassettes,
20 with an average radiation exposure delivery of less than one
21 rad mid-breast, with 2 views for each breast.
22 Any medical or health care provider shall immediately
23 recommend, to any pregnant woman who is being provided
24 prenatal services and is suspected of drug abuse or is
25 addicted as defined in the Alcoholism and Other Drug Abuse
26 and Dependency Act, referral to a local substance abuse
27 treatment provider licensed by the Department of Human
28 Services or to a licensed hospital which provides substance
29 abuse treatment services. The Department of Public Aid shall
30 assure coverage for the cost of treatment of the drug abuse
31 or addiction for pregnant recipients in accordance with the
32 Illinois Medicaid Program in conjunction with the Department
33 of Human Services.
34 All medical providers providing medical assistance to
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1 pregnant women under this Code shall receive information from
2 the Department on the availability of services under the Drug
3 Free Families with a Future or any comparable program
4 providing case management services for addicted women,
5 including information on appropriate referrals for other
6 social services that may be needed by addicted women in
7 addition to treatment for addiction.
8 The Illinois Department, in cooperation with the
9 Departments of Human Services (as successor to the Department
10 of Alcoholism and Substance Abuse) and Public Health, through
11 a public awareness campaign, may provide information
12 concerning treatment for alcoholism and drug abuse and
13 addiction, prenatal health care, and other pertinent programs
14 directed at reducing the number of drug-affected infants born
15 to recipients of medical assistance.
16 Neither the Illinois Department of Public Aid nor the
17 Department of Human Services shall sanction the recipient
18 solely on the basis of her substance abuse.
19 The Illinois Department shall establish such regulations
20 governing the dispensing of health services under this
21 Article as it shall deem appropriate. In formulating these
22 regulations the Illinois Department shall consult with and
23 give substantial weight to the recommendations offered by the
24 Citizens Assembly/Council on Public Aid. The Department
25 should seek the advice of formal professional advisory
26 committees appointed by the Director of the Illinois
27 Department for the purpose of providing regular advice on
28 policy and administrative matters, information dissemination
29 and educational activities for medical and health care
30 providers, and consistency in procedures to the Illinois
31 Department.
32 The Illinois Department may develop and contract with
33 Partnerships of medical providers to arrange medical services
34 for persons eligible under Section 5-2 of this Code.
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1 Implementation of this Section may be by demonstration
2 projects in certain geographic areas. The Partnership shall
3 be represented by a sponsor organization. The Department, by
4 rule, shall develop qualifications for sponsors of
5 Partnerships. Nothing in this Section shall be construed to
6 require that the sponsor organization be a medical
7 organization.
8 The sponsor must negotiate formal written contracts with
9 medical providers for physician services, inpatient and
10 outpatient hospital care, home health services, treatment for
11 alcoholism and substance abuse, and other services determined
12 necessary by the Illinois Department by rule for delivery by
13 Partnerships. Physician services must include prenatal and
14 obstetrical care. The Illinois Department shall reimburse
15 medical services delivered by Partnership providers to
16 clients in target areas according to provisions of this
17 Article and the Illinois Health Finance Reform Act, except
18 that:
19 (1) Physicians participating in a Partnership and
20 providing certain services, which shall be determined by
21 the Illinois Department, to persons in areas covered by
22 the Partnership may receive an additional surcharge for
23 such services.
24 (2) The Department may elect to consider and
25 negotiate financial incentives to encourage the
26 development of Partnerships and the efficient delivery of
27 medical care.
28 (3) Persons receiving medical services through
29 Partnerships may receive medical and case management
30 services above the level usually offered through the
31 medical assistance program.
32 Medical providers shall be required to meet certain
33 qualifications to participate in Partnerships to ensure the
34 delivery of high quality medical services. These
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1 qualifications shall be determined by rule of the Illinois
2 Department and may be higher than qualifications for
3 participation in the medical assistance program. Partnership
4 sponsors may prescribe reasonable additional qualifications
5 for participation by medical providers, only with the prior
6 written approval of the Illinois Department.
7 Nothing in this Section shall limit the free choice of
8 practitioners, hospitals, and other providers of medical
9 services by clients.
10 The Department shall apply for a waiver from the United
11 States Health Care Financing Administration to allow for the
12 implementation of Partnerships under this Section.
13 The Illinois Department shall require health care
14 providers to maintain records that document the medical care
15 and services provided to recipients of Medical Assistance
16 under this Article. The Illinois Department shall require
17 health care providers to make available, when authorized by
18 the patient, in writing, the medical records in a timely
19 fashion to other health care providers who are treating or
20 serving persons eligible for Medical Assistance under this
21 Article. All dispensers of medical services shall be
22 required to maintain and retain business and professional
23 records sufficient to fully and accurately document the
24 nature, scope, details and receipt of the health care
25 provided to persons eligible for medical assistance under
26 this Code, in accordance with regulations promulgated by the
27 Illinois Department. The rules and regulations shall require
28 that proof of the receipt of prescription drugs, dentures,
29 prosthetic devices and eyeglasses by eligible persons under
30 this Section accompany each claim for reimbursement submitted
31 by the dispenser of such medical services. No such claims for
32 reimbursement shall be approved for payment by the Illinois
33 Department without such proof of receipt, unless the Illinois
34 Department shall have put into effect and shall be operating
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1 a system of post-payment audit and review which shall, on a
2 sampling basis, be deemed adequate by the Illinois Department
3 to assure that such drugs, dentures, prosthetic devices and
4 eyeglasses for which payment is being made are actually being
5 received by eligible recipients. Within 90 days after the
6 effective date of this amendatory Act of 1984, the Illinois
7 Department shall establish a current list of acquisition
8 costs for all prosthetic devices and any other items
9 recognized as medical equipment and supplies reimbursable
10 under this Article and shall update such list on a quarterly
11 basis, except that the acquisition costs of all prescription
12 drugs shall be updated no less frequently than every 30 days
13 as required by Section 5-5.12.
14 The rules and regulations of the Illinois Department
15 shall require that a written statement including the required
16 opinion of a physician shall accompany any claim for
17 reimbursement for abortions, or induced miscarriages or
18 premature births. This statement shall indicate what
19 procedures were used in providing such medical services.
20 The Illinois Department shall require that all dispensers
21 of medical services, other than an individual practitioner or
22 group of practitioners, desiring to participate in the
23 Medical Assistance program established under this Article to
24 disclose all financial, beneficial, ownership, equity, surety
25 or other interests in any and all firms, corporations,
26 partnerships, associations, business enterprises, joint
27 ventures, agencies, institutions or other legal entities
28 providing any form of health care services in this State
29 under this Article.
30 The Illinois Department may require that all dispensers
31 of medical services desiring to participate in the medical
32 assistance program established under this Article disclose,
33 under such terms and conditions as the Illinois Department
34 may by rule establish, all inquiries from clients and
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1 attorneys regarding medical bills paid by the Illinois
2 Department, which inquiries could indicate potential
3 existence of claims or liens for the Illinois Department.
4 The Illinois Department shall establish policies,
5 procedures, standards and criteria by rule for the
6 acquisition, repair and replacement of orthotic and
7 prosthetic devices and durable medical equipment. Such rules
8 shall provide, but not be limited to, the following services:
9 (1) immediate repair or replacement of such devices by
10 recipients without medical authorization; and (2) rental,
11 lease, purchase or lease-purchase of durable medical
12 equipment in a cost-effective manner, taking into
13 consideration the recipient's medical prognosis, the extent
14 of the recipient's needs, and the requirements and costs for
15 maintaining such equipment. Such rules shall enable a
16 recipient to temporarily acquire and use alternative or
17 substitute devices or equipment pending repairs or
18 replacements of any device or equipment previously authorized
19 for such recipient by the Department. Rules under clause (2)
20 above shall not provide for purchase or lease-purchase of
21 durable medical equipment or supplies used for the purpose of
22 oxygen delivery and respiratory care.
23 The Department shall execute, relative to the nursing
24 home prescreening project, written inter-agency agreements
25 with the Department of Human Services and the Department on
26 Aging, to effect the following: (i) intake procedures and
27 common eligibility criteria for those persons who are
28 receiving non-institutional services; and (ii) the
29 establishment and development of non-institutional services
30 in areas of the State where they are not currently available
31 or are undeveloped.
32 The Illinois Department shall develop and operate, in
33 cooperation with other State Departments and agencies and in
34 compliance with applicable federal laws and regulations,
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1 appropriate and effective systems of health care evaluation
2 and programs for monitoring of utilization of health care
3 services and facilities, as it affects persons eligible for
4 medical assistance under this Code. The Illinois Department
5 shall report regularly the results of the operation of such
6 systems and programs to the Citizens Assembly/Council on
7 Public Aid to enable the Committee to ensure, from time to
8 time, that these programs are effective and meaningful.
9 The Illinois Department shall report annually to the
10 General Assembly, no later than the second Friday in April of
11 1979 and each year thereafter, in regard to:
12 (a) actual statistics and trends in utilization of
13 medical services by public aid recipients;
14 (b) actual statistics and trends in the provision
15 of the various medical services by medical vendors;
16 (c) current rate structures and proposed changes in
17 those rate structures for the various medical vendors;
18 and
19 (d) efforts at utilization review and control by
20 the Illinois Department.
21 The period covered by each report shall be the 3 years
22 ending on the June 30 prior to the report. The report shall
23 include suggested legislation for consideration by the
24 General Assembly. The filing of one copy of the report with
25 the Speaker, one copy with the Minority Leader and one copy
26 with the Clerk of the House of Representatives, one copy with
27 the President, one copy with the Minority Leader and one copy
28 with the Secretary of the Senate, one copy with the
29 Legislative Research Unit, such additional copies with the
30 State Government Report Distribution Center for the General
31 Assembly as is required under paragraph (t) of Section 7 of
32 the State Library Act and one copy with the Citizens
33 Assembly/Council on Public Aid or its successor shall be
34 deemed sufficient to comply with this Section.
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1 (Source: P.A. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97;
2 89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.)
3 Section 99. Effective date. This Act takes effect upon
4 becoming law.