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91_HB2753
LRB9102526WHdv
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 Code, the
22 Illinois Department may not require, as a condition of
23 payment for any laboratory test authorized under this
24 Article, that a physician's handwritten signature appear on
25 the laboratory test order form. The Illinois Department may,
26 however, impose other appropriate requirements regarding
27 laboratory test order documentation.
28 The Illinois Department of Public Aid shall provide the
29 following services to persons eligible for assistance under
30 this Article who are participating in education, training or
31 employment programs operated by the Department of Human
32 Services as successor to the Department of Public Aid:
33 (1) dental services, which shall include but not be
34 limited to prosthodontics; and
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1 (2) eyeglasses prescribed by a physician skilled in
2 the diseases of the eye, or by an optometrist, whichever
3 the person may select.
4 The Illinois Department, by rule, may distinguish and
5 classify the medical services to be provided only in
6 accordance with the classes of persons designated in Section
7 5-2.
8 The Illinois Department shall authorize the provision of,
9 and shall authorize payment for, screening by low-dose
10 mammography for the presence of occult breast cancer for
11 women 35 years of age or older who are eligible for medical
12 assistance under this Article, as follows: a baseline
13 mammogram for women 35 to 39 years of age and an annual
14 mammogram for women 40 years of age or older. All screenings
15 shall include a physical breast exam, instruction on
16 self-examination and information regarding the frequency of
17 self-examination and its value as a preventative tool. As
18 used in this Section, "low-dose mammography" means the x-ray
19 examination of the breast using equipment dedicated
20 specifically for mammography, including the x-ray tube,
21 filter, compression device, image receptor, and cassettes,
22 with an average radiation exposure delivery of less than one
23 rad mid-breast, with 2 views for each breast.
24 Any medical or health care provider shall immediately
25 recommend, to any pregnant woman who is being provided
26 prenatal services and is suspected of drug abuse or is
27 addicted as defined in the Alcoholism and Other Drug Abuse
28 and Dependency Act, referral to a local substance abuse
29 treatment provider licensed by the Department of Human
30 Services or to a licensed hospital which provides substance
31 abuse treatment services. The Department of Public Aid shall
32 assure coverage for the cost of treatment of the drug abuse
33 or addiction for pregnant recipients in accordance with the
34 Illinois Medicaid Program in conjunction with the Department
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1 of Human Services.
2 All medical providers providing medical assistance to
3 pregnant women under this Code shall receive information from
4 the Department on the availability of services under the Drug
5 Free Families with a Future or any comparable program
6 providing case management services for addicted women,
7 including information on appropriate referrals for other
8 social services that may be needed by addicted women in
9 addition to treatment for addiction.
10 The Illinois Department, in cooperation with the
11 Departments of Human Services (as successor to the Department
12 of Alcoholism and Substance Abuse) and Public Health, through
13 a public awareness campaign, may provide information
14 concerning treatment for alcoholism and drug abuse and
15 addiction, prenatal health care, and other pertinent programs
16 directed at reducing the number of drug-affected infants born
17 to recipients of medical assistance.
18 Neither the Illinois Department of Public Aid nor the
19 Department of Human Services shall sanction the recipient
20 solely on the basis of her substance abuse.
21 The Illinois Department shall establish such regulations
22 governing the dispensing of health services under this
23 Article as it shall deem appropriate. In formulating these
24 regulations the Illinois Department shall consult with and
25 give substantial weight to the recommendations offered by the
26 Citizens Assembly/Council on Public Aid. The Department
27 should seek the advice of formal professional advisory
28 committees appointed by the Director of the Illinois
29 Department for the purpose of providing regular advice on
30 policy and administrative matters, information dissemination
31 and educational activities for medical and health care
32 providers, and consistency in procedures to the Illinois
33 Department.
34 The Illinois Department may develop and contract with
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1 Partnerships of medical providers to arrange medical services
2 for persons eligible under Section 5-2 of this Code.
3 Implementation of this Section may be by demonstration
4 projects in certain geographic areas. The Partnership shall
5 be represented by a sponsor organization. The Department, by
6 rule, shall develop qualifications for sponsors of
7 Partnerships. Nothing in this Section shall be construed to
8 require that the sponsor organization be a medical
9 organization.
10 The sponsor must negotiate formal written contracts with
11 medical providers for physician services, inpatient and
12 outpatient hospital care, home health services, treatment for
13 alcoholism and substance abuse, and other services determined
14 necessary by the Illinois Department by rule for delivery by
15 Partnerships. Physician services must include prenatal and
16 obstetrical care. The Illinois Department shall reimburse
17 medical services delivered by Partnership providers to
18 clients in target areas according to provisions of this
19 Article and the Illinois Health Finance Reform Act, except
20 that:
21 (1) Physicians participating in a Partnership and
22 providing certain services, which shall be determined by
23 the Illinois Department, to persons in areas covered by
24 the Partnership may receive an additional surcharge for
25 such services.
26 (2) The Department may elect to consider and
27 negotiate financial incentives to encourage the
28 development of Partnerships and the efficient delivery of
29 medical care.
30 (3) Persons receiving medical services through
31 Partnerships may receive medical and case management
32 services above the level usually offered through the
33 medical assistance program.
34 Medical providers shall be required to meet certain
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1 qualifications to participate in Partnerships to ensure the
2 delivery of high quality medical services. These
3 qualifications shall be determined by rule of the Illinois
4 Department and may be higher than qualifications for
5 participation in the medical assistance program. Partnership
6 sponsors may prescribe reasonable additional qualifications
7 for participation by medical providers, only with the prior
8 written approval of the Illinois Department.
9 Nothing in this Section shall limit the free choice of
10 practitioners, hospitals, and other providers of medical
11 services by clients.
12 The Department shall apply for a waiver from the United
13 States Health Care Financing Administration to allow for the
14 implementation of Partnerships under this Section.
15 The Illinois Department shall require health care
16 providers to maintain records that document the medical care
17 and services provided to recipients of Medical Assistance
18 under this Article. The Illinois Department shall require
19 health care providers to make available, when authorized by
20 the patient, in writing, the medical records in a timely
21 fashion to other health care providers who are treating or
22 serving persons eligible for Medical Assistance under this
23 Article. All dispensers of medical services shall be
24 required to maintain and retain business and professional
25 records sufficient to fully and accurately document the
26 nature, scope, details and receipt of the health care
27 provided to persons eligible for medical assistance under
28 this Code, in accordance with regulations promulgated by the
29 Illinois Department. The rules and regulations shall require
30 that proof of the receipt of prescription drugs, dentures,
31 prosthetic devices and eyeglasses by eligible persons under
32 this Section accompany each claim for reimbursement submitted
33 by the dispenser of such medical services. No such claims for
34 reimbursement shall be approved for payment by the Illinois
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1 Department without such proof of receipt, unless the Illinois
2 Department shall have put into effect and shall be operating
3 a system of post-payment audit and review which shall, on a
4 sampling basis, be deemed adequate by the Illinois Department
5 to assure that such drugs, dentures, prosthetic devices and
6 eyeglasses for which payment is being made are actually being
7 received by eligible recipients. Within 90 days after the
8 effective date of this amendatory Act of 1984, the Illinois
9 Department shall establish a current list of acquisition
10 costs for all prosthetic devices and any other items
11 recognized as medical equipment and supplies reimbursable
12 under this Article and shall update such list on a quarterly
13 basis, except that the acquisition costs of all prescription
14 drugs shall be updated no less frequently than every 30 days
15 as required by Section 5-5.12.
16 The rules and regulations of the Illinois Department
17 shall require that a written statement including the required
18 opinion of a physician shall accompany any claim for
19 reimbursement for abortions, or induced miscarriages or
20 premature births. This statement shall indicate what
21 procedures were used in providing such medical services.
22 The Illinois Department shall require that all dispensers
23 of medical services, other than an individual practitioner or
24 group of practitioners, desiring to participate in the
25 Medical Assistance program established under this Article to
26 disclose all financial, beneficial, ownership, equity, surety
27 or other interests in any and all firms, corporations,
28 partnerships, associations, business enterprises, joint
29 ventures, agencies, institutions or other legal entities
30 providing any form of health care services in this State
31 under this Article.
32 The Illinois Department may require that all dispensers
33 of medical services desiring to participate in the medical
34 assistance program established under this Article disclose,
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1 under such terms and conditions as the Illinois Department
2 may by rule establish, all inquiries from clients and
3 attorneys regarding medical bills paid by the Illinois
4 Department, which inquiries could indicate potential
5 existence of claims or liens for the Illinois Department.
6 The Illinois Department shall establish policies,
7 procedures, standards and criteria by rule for the
8 acquisition, repair and replacement of orthotic and
9 prosthetic devices and durable medical equipment. Such rules
10 shall provide, but not be limited to, the following services:
11 (1) immediate repair or replacement of such devices by
12 recipients without medical authorization; and (2) rental,
13 lease, purchase or lease-purchase of durable medical
14 equipment in a cost-effective manner, taking into
15 consideration the recipient's medical prognosis, the extent
16 of the recipient's needs, and the requirements and costs for
17 maintaining such equipment. Such rules shall enable a
18 recipient to temporarily acquire and use alternative or
19 substitute devices or equipment pending repairs or
20 replacements of any device or equipment previously authorized
21 for such recipient by the Department. Rules under clause (2)
22 above shall not provide for purchase or lease-purchase of
23 durable medical equipment or supplies used for the purpose of
24 oxygen delivery and respiratory care.
25 The Department shall execute, relative to the nursing
26 home prescreening project, written inter-agency agreements
27 with the Department of Human Services and the Department on
28 Aging, to effect the following: (i) intake procedures and
29 common eligibility criteria for those persons who are
30 receiving non-institutional services; and (ii) the
31 establishment and development of non-institutional services
32 in areas of the State where they are not currently available
33 or are undeveloped.
34 The Illinois Department shall develop and operate, in
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1 cooperation with other State Departments and agencies and in
2 compliance with applicable federal laws and regulations,
3 appropriate and effective systems of health care evaluation
4 and programs for monitoring of utilization of health care
5 services and facilities, as it affects persons eligible for
6 medical assistance under this Code. The Illinois Department
7 shall report regularly the results of the operation of such
8 systems and programs to the Citizens Assembly/Council on
9 Public Aid to enable the Committee to ensure, from time to
10 time, that these programs are effective and meaningful.
11 The Illinois Department shall report annually to the
12 General Assembly, no later than the second Friday in April of
13 1979 and each year thereafter, in regard to:
14 (a) actual statistics and trends in utilization of
15 medical services by public aid recipients;
16 (b) actual statistics and trends in the provision
17 of the various medical services by medical vendors;
18 (c) current rate structures and proposed changes in
19 those rate structures for the various medical vendors;
20 and
21 (d) efforts at utilization review and control by
22 the Illinois Department.
23 The period covered by each report shall be the 3 years
24 ending on the June 30 prior to the report. The report shall
25 include suggested legislation for consideration by the
26 General Assembly. The filing of one copy of the report with
27 the Speaker, one copy with the Minority Leader and one copy
28 with the Clerk of the House of Representatives, one copy with
29 the President, one copy with the Minority Leader and one copy
30 with the Secretary of the Senate, one copy with the
31 Legislative Research Unit, such additional copies with the
32 State Government Report Distribution Center for the General
33 Assembly as is required under paragraph (t) of Section 7 of
34 the State Library Act and one copy with the Citizens
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1 Assembly/Council on Public Aid or its successor shall be
2 deemed sufficient to comply with this Section.
3 (Source: P.A. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97;
4 89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.)