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91_HB1832
LRB9103252SMdv
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, a
22 comprehensive tobacco use cessation program that includes
23 purchasing prescription drugs, human biological products, or
24 medical devices approved by the Food and Drug Administration
25 or otherwise legally marketed under the federal Food, Drug
26 and Cosmetic Act or the federal Public Health Service Act for
27 use as smoking cessation therapies or aids shall be covered
28 under the medical assistance program under this Article for
29 persons who are otherwise eligible for assistance under this
30 Article.
31 The Illinois Department of Public Aid shall provide the
32 following services to persons eligible for assistance under
33 this Article who are participating in education, training or
34 employment programs operated by the Department of Human
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1 Services as successor to the Department of Public Aid:
2 (1) dental services, which shall include but not be
3 limited to prosthodontics; and
4 (2) eyeglasses prescribed by a physician skilled in
5 the diseases of the eye, or by an optometrist, whichever
6 the person may select.
7 The Illinois Department, by rule, may distinguish and
8 classify the medical services to be provided only in
9 accordance with the classes of persons designated in Section
10 5-2.
11 The Illinois Department shall authorize the provision of,
12 and shall authorize payment for, screening by low-dose
13 mammography for the presence of occult breast cancer for
14 women 35 years of age or older who are eligible for medical
15 assistance under this Article, as follows: a baseline
16 mammogram for women 35 to 39 years of age and an annual
17 mammogram for women 40 years of age or older. All screenings
18 shall include a physical breast exam, instruction on
19 self-examination and information regarding the frequency of
20 self-examination and its value as a preventative tool. As
21 used in this Section, "low-dose mammography" means the x-ray
22 examination of the breast using equipment dedicated
23 specifically for mammography, including the x-ray tube,
24 filter, compression device, image receptor, and cassettes,
25 with an average radiation exposure delivery of less than one
26 rad mid-breast, with 2 views for each breast.
27 Any medical or health care provider shall immediately
28 recommend, to any pregnant woman who is being provided
29 prenatal services and is suspected of drug abuse or is
30 addicted as defined in the Alcoholism and Other Drug Abuse
31 and Dependency Act, referral to a local substance abuse
32 treatment provider licensed by the Department of Human
33 Services or to a licensed hospital which provides substance
34 abuse treatment services. The Department of Public Aid shall
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1 assure coverage for the cost of treatment of the drug abuse
2 or addiction for pregnant recipients in accordance with the
3 Illinois Medicaid Program in conjunction with the Department
4 of Human Services.
5 All medical providers providing medical assistance to
6 pregnant women under this Code shall receive information from
7 the Department on the availability of services under the Drug
8 Free Families with a Future or any comparable program
9 providing case management services for addicted women,
10 including information on appropriate referrals for other
11 social services that may be needed by addicted women in
12 addition to treatment for addiction.
13 The Illinois Department, in cooperation with the
14 Departments of Human Services (as successor to the Department
15 of Alcoholism and Substance Abuse) and Public Health, through
16 a public awareness campaign, may provide information
17 concerning treatment for alcoholism and drug abuse and
18 addiction, prenatal health care, and other pertinent programs
19 directed at reducing the number of drug-affected infants born
20 to recipients of medical assistance.
21 Neither the Illinois Department of Public Aid nor the
22 Department of Human Services shall sanction the recipient
23 solely on the basis of her substance abuse.
24 The Illinois Department shall establish such regulations
25 governing the dispensing of health services under this
26 Article as it shall deem appropriate. In formulating these
27 regulations the Illinois Department shall consult with and
28 give substantial weight to the recommendations offered by the
29 Citizens Assembly/Council on Public Aid. The Department
30 should seek the advice of formal professional advisory
31 committees appointed by the Director of the Illinois
32 Department for the purpose of providing regular advice on
33 policy and administrative matters, information dissemination
34 and educational activities for medical and health care
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1 providers, and consistency in procedures to the Illinois
2 Department.
3 The Illinois Department may develop and contract with
4 Partnerships of medical providers to arrange medical services
5 for persons eligible under Section 5-2 of this Code.
6 Implementation of this Section may be by demonstration
7 projects in certain geographic areas. The Partnership shall
8 be represented by a sponsor organization. The Department, by
9 rule, shall develop qualifications for sponsors of
10 Partnerships. Nothing in this Section shall be construed to
11 require that the sponsor organization be a medical
12 organization.
13 The sponsor must negotiate formal written contracts with
14 medical providers for physician services, inpatient and
15 outpatient hospital care, home health services, treatment for
16 alcoholism and substance abuse, and other services determined
17 necessary by the Illinois Department by rule for delivery by
18 Partnerships. Physician services must include prenatal and
19 obstetrical care. The Illinois Department shall reimburse
20 medical services delivered by Partnership providers to
21 clients in target areas according to provisions of this
22 Article and the Illinois Health Finance Reform Act, except
23 that:
24 (1) Physicians participating in a Partnership and
25 providing certain services, which shall be determined by
26 the Illinois Department, to persons in areas covered by
27 the Partnership may receive an additional surcharge for
28 such services.
29 (2) The Department may elect to consider and
30 negotiate financial incentives to encourage the
31 development of Partnerships and the efficient delivery of
32 medical care.
33 (3) Persons receiving medical services through
34 Partnerships may receive medical and case management
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1 services above the level usually offered through the
2 medical assistance program.
3 Medical providers shall be required to meet certain
4 qualifications to participate in Partnerships to ensure the
5 delivery of high quality medical services. These
6 qualifications shall be determined by rule of the Illinois
7 Department and may be higher than qualifications for
8 participation in the medical assistance program. Partnership
9 sponsors may prescribe reasonable additional qualifications
10 for participation by medical providers, only with the prior
11 written approval of the Illinois Department.
12 Nothing in this Section shall limit the free choice of
13 practitioners, hospitals, and other providers of medical
14 services by clients.
15 The Department shall apply for a waiver from the United
16 States Health Care Financing Administration to allow for the
17 implementation of Partnerships under this Section.
18 The Illinois Department shall require health care
19 providers to maintain records that document the medical care
20 and services provided to recipients of Medical Assistance
21 under this Article. The Illinois Department shall require
22 health care providers to make available, when authorized by
23 the patient, in writing, the medical records in a timely
24 fashion to other health care providers who are treating or
25 serving persons eligible for Medical Assistance under this
26 Article. All dispensers of medical services shall be
27 required to maintain and retain business and professional
28 records sufficient to fully and accurately document the
29 nature, scope, details and receipt of the health care
30 provided to persons eligible for medical assistance under
31 this Code, in accordance with regulations promulgated by the
32 Illinois Department. The rules and regulations shall require
33 that proof of the receipt of prescription drugs, dentures,
34 prosthetic devices and eyeglasses by eligible persons under
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1 this Section accompany each claim for reimbursement submitted
2 by the dispenser of such medical services. No such claims for
3 reimbursement shall be approved for payment by the Illinois
4 Department without such proof of receipt, unless the Illinois
5 Department shall have put into effect and shall be operating
6 a system of post-payment audit and review which shall, on a
7 sampling basis, be deemed adequate by the Illinois Department
8 to assure that such drugs, dentures, prosthetic devices and
9 eyeglasses for which payment is being made are actually being
10 received by eligible recipients. Within 90 days after the
11 effective date of this amendatory Act of 1984, the Illinois
12 Department shall establish a current list of acquisition
13 costs for all prosthetic devices and any other items
14 recognized as medical equipment and supplies reimbursable
15 under this Article and shall update such list on a quarterly
16 basis, except that the acquisition costs of all prescription
17 drugs shall be updated no less frequently than every 30 days
18 as required by Section 5-5.12.
19 The rules and regulations of the Illinois Department
20 shall require that a written statement including the required
21 opinion of a physician shall accompany any claim for
22 reimbursement for abortions, or induced miscarriages or
23 premature births. This statement shall indicate what
24 procedures were used in providing such medical services.
25 The Illinois Department shall require that all dispensers
26 of medical services, other than an individual practitioner or
27 group of practitioners, desiring to participate in the
28 Medical Assistance program established under this Article to
29 disclose all financial, beneficial, ownership, equity, surety
30 or other interests in any and all firms, corporations,
31 partnerships, associations, business enterprises, joint
32 ventures, agencies, institutions or other legal entities
33 providing any form of health care services in this State
34 under this Article.
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1 The Illinois Department may require that all dispensers
2 of medical services desiring to participate in the medical
3 assistance program established under this Article disclose,
4 under such terms and conditions as the Illinois Department
5 may by rule establish, all inquiries from clients and
6 attorneys regarding medical bills paid by the Illinois
7 Department, which inquiries could indicate potential
8 existence of claims or liens for the Illinois Department.
9 The Illinois Department shall establish policies,
10 procedures, standards and criteria by rule for the
11 acquisition, repair and replacement of orthotic and
12 prosthetic devices and durable medical equipment. Such rules
13 shall provide, but not be limited to, the following services:
14 (1) immediate repair or replacement of such devices by
15 recipients without medical authorization; and (2) rental,
16 lease, purchase or lease-purchase of durable medical
17 equipment in a cost-effective manner, taking into
18 consideration the recipient's medical prognosis, the extent
19 of the recipient's needs, and the requirements and costs for
20 maintaining such equipment. Such rules shall enable a
21 recipient to temporarily acquire and use alternative or
22 substitute devices or equipment pending repairs or
23 replacements of any device or equipment previously authorized
24 for such recipient by the Department. Rules under clause (2)
25 above shall not provide for purchase or lease-purchase of
26 durable medical equipment or supplies used for the purpose of
27 oxygen delivery and respiratory care.
28 The Department shall execute, relative to the nursing
29 home prescreening project, written inter-agency agreements
30 with the Department of Human Services and the Department on
31 Aging, to effect the following: (i) intake procedures and
32 common eligibility criteria for those persons who are
33 receiving non-institutional services; and (ii) the
34 establishment and development of non-institutional services
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1 in areas of the State where they are not currently available
2 or are undeveloped.
3 The Illinois Department shall develop and operate, in
4 cooperation with other State Departments and agencies and in
5 compliance with applicable federal laws and regulations,
6 appropriate and effective systems of health care evaluation
7 and programs for monitoring of utilization of health care
8 services and facilities, as it affects persons eligible for
9 medical assistance under this Code. The Illinois Department
10 shall report regularly the results of the operation of such
11 systems and programs to the Citizens Assembly/Council on
12 Public Aid to enable the Committee to ensure, from time to
13 time, that these programs are effective and meaningful.
14 The Illinois Department shall report annually to the
15 General Assembly, no later than the second Friday in April of
16 1979 and each year thereafter, in regard to:
17 (a) actual statistics and trends in utilization of
18 medical services by public aid recipients;
19 (b) actual statistics and trends in the provision
20 of the various medical services by medical vendors;
21 (c) current rate structures and proposed changes in
22 those rate structures for the various medical vendors;
23 and
24 (d) efforts at utilization review and control by
25 the Illinois Department.
26 The period covered by each report shall be the 3 years
27 ending on the June 30 prior to the report. The report shall
28 include suggested legislation for consideration by the
29 General Assembly. The filing of one copy of the report with
30 the Speaker, one copy with the Minority Leader and one copy
31 with the Clerk of the House of Representatives, one copy with
32 the President, one copy with the Minority Leader and one copy
33 with the Secretary of the Senate, one copy with the
34 Legislative Research Unit, such additional copies with the
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1 State Government Report Distribution Center for the General
2 Assembly as is required under paragraph (t) of Section 7 of
3 the State Library Act and one copy with the Citizens
4 Assembly/Council on Public Aid or its successor shall be
5 deemed sufficient to comply with this Section.
6 (Source: P.A. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97;
7 89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.)