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| [ Introduced ] | [ House Amendment 001 ] |
92_HB1807eng HB1807 Engrossed LRB9204967DJgcA 1 AN ACT in relation to health. 2 Be it enacted by the People of the State of Illinois, 3 represented in the General Assembly: 4 Section 1. Short title. This Act may be cited as the 5 Anti-Obesity and Related Comorbidities Therapy Act. 6 Section 5. Public policy. It is declared that for the 7 benefit of the people of the State of Illinois, the 8 Department of Public Health, in cooperation with other State 9 agencies, shall be responsible for supporting programs aimed 10 at reducing the incidence and effects of obesity and its 11 related comorbidities. The State acknowledges that obesity 12 is the second-leading cause of death in the United States 13 after smoking, resulting in more than 300,000 preventable 14 deaths each year. There is a causal relationship between 15 obesity and other serious health complications, including, 16 but not limited to, coronary heart disease, cerebrovascular 17 disease (stroke), type II diabetes mellitus, hypertension, 18 sleep apnea, dyslipidemia, gallbladder disease, gastric 19 reflux disease, gout, osteoarthritis of the hips and knees, 20 cancer, infertility, and respiratory difficulties, all of 21 which lead to an increase in obesity-related morbidity and 22 mortality. In addition to the health implications, the 23 economic consequences of the skyrocketing incidence of 24 obesity rates are substantial. The direct cost of diagnosis, 25 treatment, and management of obesity and obesity-related 26 diseases is estimated to be $45.8 billion, or 6.8% of total 27 national health care expenditures. The reduction in workplace 28 productivity due to an increase in the number of sick days 29 and physical limitations is estimated to have an annual 30 impact on our economy of $52 billion per year. 31 Obesity continues to dramatically increase both in the HB1807 Engrossed -2- LRB9204967DJgcA 1 United States and in Illinois. One-third of the U.S. 2 population is considered to be obese. The Centers for 3 Disease Control and Prevention reported that 33.5% of the 4 Illinois population was obese in 1998. Obesity, while on the 5 rise in all adult demographic categories, is more prevalent 6 among African-American and Hispanic populations. Among 7 children, there has been a 42% increase in childhood obesity 8 rates since 1980, placing children at an increased risk for 9 diabetes, hypertension, heart disease, and stroke later in 10 life. 11 It is clear that obesity has a significant impact on the 12 health of people in Illinois, and the State economy, by 13 reducing productivity dramatically increasing avoidable 14 medical costs. Clinical studies demonstrate that weight loss 15 in overweight and obese individuals decreases the risk for 16 developing serious health conditions and leads to improvement 17 in health for many persons with those conditions. By 18 investing in programs aimed at reducing obesity and its 19 related comorbidities, the State can improve the physical 20 health of a significant portion of its citizenry and control 21 the skyrocketing costs of health care attributed to obesity's 22 comorbidities. For example, research begun in 1995 23 demonstrates that intentional weight loss in overweight women 24 with existing obesity-related diseases led to a 20% reduction 25 in total mortality, a 40-50% reduction in mortality from 26 obesity-related cancers and a 30-40% reduction in 27 diabetes-related deaths. 28 In recent years, new scientific breakthroughs have led to 29 new drug therapies that are both safe and effective in 30 treating both obesity and its related comorbidities. These 31 innovative drug therapies assist obese individuals in losing 32 weight, improving their health, and reducing their need for 33 complex and costly medical services that are paid for by the 34 State's medical assistance program. It is the policy of this HB1807 Engrossed -3- LRB9204967DJgcA 1 State that where prophylactic therapies actually reduce 2 health care costs and improve patient health, those therapies 3 must be supported. The legislature finds that there is 4 sufficient scientific and empirical evidence to establish 5 that existing FDA-approved anti-obesity drug therapies, when 6 properly supervised by a qualified physician, fit these 7 criteria. 8 Section 10. Definitions. In this Act: 9 (1) "At-risk overweight" means having a body mass index 10 greater than or equal to 27 kilograms per square meter but 11 less than 30 kilograms per square meter and having one or 12 more of the following comorbidities: 13 (1) Coronary heart disease. 14 (2) Cerebrovascular disease (stroke). 15 (3) Dyslipidemia. 16 (4) Cancer. 17 (5) Hypertension. 18 (6) Sleep apnea. 19 (7) Type II diabetes mellitus. 20 "Body mass index" is a mathematical formula used to 21 determine a person's body weight in relation to height as 22 measured by dividing a person's weight in kilograms by height 23 in meters squared. 24 "Chronic treatment" means any daily drug therapy 25 indicated by labeling approved by the federal Food and Drug 26 Administration for use for more than 60 days. 27 "Medically indigent patients" means persons who are 28 determined to be eligible for medical assistance under 29 Article V of the Illinois Public Aid Code. 30 "Obese" means having a body mass index greater than or 31 equal to 30 kilograms per square meter. 32 Section 15. Anti-obesity program. The Department of HB1807 Engrossed -4- LRB9204967DJgcA 1 Public Health, in conjunction with the Department of Public 2 Aid and other appropriate State agencies, shall develop a 3 program to provide obese or at-risk overweight medically 4 indigent patients with services for the treatment and 5 prevention of obesity and its related comorbidities. The 6 program shall include education, monitoring, and outpatient 7 prescription drug coverage of anti-obesity drug therapies 8 that are approved by the United States Food and Drug 9 Administration if the patient's treating physician prescribes 10 the therapy as being medically necessary to his or her 11 healthcare. 12 Section 20. Rules. The Department of Public Health may 13 adopt rules to enable it to carry out the provisions of this 14 Act and may coordinate its actions with other State or 15 federal agencies to comply with this Act. The provisions of 16 the Illinois Administrative Procedure Act are expressly 17 adopted and apply to all administrative rules and procedures 18 adopted by the Department under this Act, except that Section 19 5-35 of the Illinois Administrative Procedure Act relating 20 to procedures for rule-making does not apply to the 21 adoption of any rule required by federal law in connection 22 with which the Department is precluded by law from 23 exercising any discretion. 24 Section 90. The Illinois Public Aid Code is amended by 25 changing Section 5-5 as follows: 26 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5) 27 Sec. 5-5. Medical services. The Illinois Department, by 28 rule, shall determine the quantity and quality of and the 29 rate of reimbursement for the medical assistance for which 30 payment will be authorized, and the medical services to be 31 provided, which may include all or part of the following: (1) HB1807 Engrossed -5- LRB9204967DJgcA 1 inpatient hospital services; (2) outpatient hospital 2 services; (3) other laboratory and X-ray services; (4) 3 skilled nursing home services; (5) physicians' services 4 whether furnished in the office, the patient's home, a 5 hospital, a skilled nursing home, or elsewhere; (6) medical 6 care, or any other type of remedial care furnished by 7 licensed practitioners; (7) home health care services; (8) 8 private duty nursing service; (9) clinic services; (10) 9 dental services; (11) physical therapy and related services; 10 (12) prescribed drugs, dentures, and prosthetic devices; and 11 eyeglasses prescribed by a physician skilled in the diseases 12 of the eye, or by an optometrist, whichever the person may 13 select; (13) other diagnostic, screening, preventive, and 14 rehabilitative services; (14) transportation and such other 15 expenses as may be necessary; (15) medical treatment of 16 sexual assault survivors, as defined in Section 1a of the 17 Sexual Assault Survivors Emergency Treatment Act, for 18 injuries sustained as a result of the sexual assault, 19 including examinations and laboratory tests to discover 20 evidence which may be used in criminal proceedings arising 21 from the sexual assault; (16) the diagnosis and treatment of 22 sickle cell anemia; and (17) any other medical care, and any 23 other type of remedial care recognized under the laws of this 24 State, but not including abortions, or induced miscarriages 25 or premature births, unless, in the opinion of a physician, 26 such procedures are necessary for the preservation of the 27 life of the woman seeking such treatment, or except an 28 induced premature birth intended to produce a live viable 29 child and such procedure is necessary for the health of the 30 mother or her unborn child. The Illinois Department, by rule, 31 shall prohibit any physician from providing medical 32 assistance to anyone eligible therefor under this Code where 33 such physician has been found guilty of performing an 34 abortion procedure in a wilful and wanton manner upon a woman HB1807 Engrossed -6- LRB9204967DJgcA 1 who was not pregnant at the time such abortion procedure was 2 performed. The term "any other type of remedial care" shall 3 include nursing care and nursing home service for persons who 4 rely on treatment by spiritual means alone through prayer for 5 healing. 6 Notwithstanding any other provision of this Section, a 7 comprehensive tobacco use cessation program that includes 8 purchasing prescription drugs or prescription medical devices 9 approved by the Food and Drug administration shall be covered 10 under the medical assistance program under this Article for 11 persons who are otherwise eligible for assistance under this 12 Article. 13 Notwithstanding any other provision of this Code, the 14 Illinois Department may not require, as a condition of 15 payment for any laboratory test authorized under this 16 Article, that a physician's handwritten signature appear on 17 the laboratory test order form. The Illinois Department may, 18 however, impose other appropriate requirements regarding 19 laboratory test order documentation. 20 The Illinois Department of Public Aid shall provide the 21 following services to persons eligible for assistance under 22 this Article who are participating in education, training or 23 employment programs operated by the Department of Human 24 Services as successor to the Department of Public Aid: 25 (1) dental services, which shall include but not be 26 limited to prosthodontics; and 27 (2) eyeglasses prescribed by a physician skilled in 28 the diseases of the eye, or by an optometrist, whichever 29 the person may select. 30 The Illinois Department shall provide services for the 31 treatment and prevention of obesity and its related 32 comorbidities, including education, monitoring, and 33 outpatient prescription drug coverage of anti-obesity drug 34 therapies that are approved by the United States Food and HB1807 Engrossed -7- LRB9204967DJgcA 1 Drug Administration if the patient's treating physician 2 prescribes the therapy as being medically necessary to his or 3 her healthcare and the patient is otherwise eligible for 4 medical assistance under this Article. 5 The Illinois Department, by rule, may distinguish and 6 classify the medical services to be provided only in 7 accordance with the classes of persons designated in Section 8 5-2. 9 The Illinois Department shall authorize the provision of, 10 and shall authorize payment for, screening by low-dose 11 mammography for the presence of occult breast cancer for 12 women 35 years of age or older who are eligible for medical 13 assistance under this Article, as follows: a baseline 14 mammogram for women 35 to 39 years of age and an annual 15 mammogram for women 40 years of age or older. All screenings 16 shall include a physical breast exam, instruction on 17 self-examination and information regarding the frequency of 18 self-examination and its value as a preventative tool. As 19 used in this Section, "low-dose mammography" means the x-ray 20 examination of the breast using equipment dedicated 21 specifically for mammography, including the x-ray tube, 22 filter, compression device, image receptor, and cassettes, 23 with an average radiation exposure delivery of less than one 24 rad mid-breast, with 2 views for each breast. 25 Any medical or health care provider shall immediately 26 recommend, to any pregnant woman who is being provided 27 prenatal services and is suspected of drug abuse or is 28 addicted as defined in the Alcoholism and Other Drug Abuse 29 and Dependency Act, referral to a local substance abuse 30 treatment provider licensed by the Department of Human 31 Services or to a licensed hospital which provides substance 32 abuse treatment services. The Department of Public Aid shall 33 assure coverage for the cost of treatment of the drug abuse 34 or addiction for pregnant recipients in accordance with the HB1807 Engrossed -8- LRB9204967DJgcA 1 Illinois Medicaid Program in conjunction with the Department 2 of Human Services. 3 All medical providers providing medical assistance to 4 pregnant women under this Code shall receive information from 5 the Department on the availability of services under the Drug 6 Free Families with a Future or any comparable program 7 providing case management services for addicted women, 8 including information on appropriate referrals for other 9 social services that may be needed by addicted women in 10 addition to treatment for addiction. 11 The Illinois Department, in cooperation with the 12 Departments of Human Services (as successor to the Department 13 of Alcoholism and Substance Abuse) and Public Health, through 14 a public awareness campaign, may provide information 15 concerning treatment for alcoholism and drug abuse and 16 addiction, prenatal health care, and other pertinent programs 17 directed at reducing the number of drug-affected infants born 18 to recipients of medical assistance. 19 Neither the Illinois Department of Public Aid nor the 20 Department of Human Services shall sanction the recipient 21 solely on the basis of her substance abuse. 22 The Illinois Department shall establish such regulations 23 governing the dispensing of health services under this 24 Article as it shall deem appropriate. In formulating these 25 regulations the Illinois Department shall consult with and 26 give substantial weight to the recommendations offered by the 27 Citizens Assembly/Council on Public Aid. The Department 28 should seek the advice of formal professional advisory 29 committees appointed by the Director of the Illinois 30 Department for the purpose of providing regular advice on 31 policy and administrative matters, information dissemination 32 and educational activities for medical and health care 33 providers, and consistency in procedures to the Illinois 34 Department. HB1807 Engrossed -9- LRB9204967DJgcA 1 The Illinois Department may develop and contract with 2 Partnerships of medical providers to arrange medical services 3 for persons eligible under Section 5-2 of this Code. 4 Implementation of this Section may be by demonstration 5 projects in certain geographic areas. The Partnership shall 6 be represented by a sponsor organization. The Department, by 7 rule, shall develop qualifications for sponsors of 8 Partnerships. Nothing in this Section shall be construed to 9 require that the sponsor organization be a medical 10 organization. 11 The sponsor must negotiate formal written contracts with 12 medical providers for physician services, inpatient and 13 outpatient hospital care, home health services, treatment for 14 alcoholism and substance abuse, and other services determined 15 necessary by the Illinois Department by rule for delivery by 16 Partnerships. Physician services must include prenatal and 17 obstetrical care. The Illinois Department shall reimburse 18 medical services delivered by Partnership providers to 19 clients in target areas according to provisions of this 20 Article and the Illinois Health Finance Reform Act, except 21 that: 22 (1) Physicians participating in a Partnership and 23 providing certain services, which shall be determined by 24 the Illinois Department, to persons in areas covered by 25 the Partnership may receive an additional surcharge for 26 such services. 27 (2) The Department may elect to consider and 28 negotiate financial incentives to encourage the 29 development of Partnerships and the efficient delivery of 30 medical care. 31 (3) Persons receiving medical services through 32 Partnerships may receive medical and case management 33 services above the level usually offered through the 34 medical assistance program. HB1807 Engrossed -10- LRB9204967DJgcA 1 Medical providers shall be required to meet certain 2 qualifications to participate in Partnerships to ensure the 3 delivery of high quality medical services. These 4 qualifications shall be determined by rule of the Illinois 5 Department and may be higher than qualifications for 6 participation in the medical assistance program. Partnership 7 sponsors may prescribe reasonable additional qualifications 8 for participation by medical providers, only with the prior 9 written approval of the Illinois Department. 10 Nothing in this Section shall limit the free choice of 11 practitioners, hospitals, and other providers of medical 12 services by clients. In order to ensure patient freedom of 13 choice, the Illinois Department shall immediately promulgate 14 all rules and take all other necessary actions so that 15 provided services may be accessed from therapeutically 16 certified optometrists to the full extent of the Illinois 17 Optometric Practice Act of 1987 without discriminating 18 between service providers. 19 The Department shall apply for a waiver from the United 20 States Health Care Financing Administration to allow for the 21 implementation of Partnerships under this Section. 22 The Illinois Department shall require health care 23 providers to maintain records that document the medical care 24 and services provided to recipients of Medical Assistance 25 under this Article. The Illinois Department shall require 26 health care providers to make available, when authorized by 27 the patient, in writing, the medical records in a timely 28 fashion to other health care providers who are treating or 29 serving persons eligible for Medical Assistance under this 30 Article. All dispensers of medical services shall be 31 required to maintain and retain business and professional 32 records sufficient to fully and accurately document the 33 nature, scope, details and receipt of the health care 34 provided to persons eligible for medical assistance under HB1807 Engrossed -11- LRB9204967DJgcA 1 this Code, in accordance with regulations promulgated by the 2 Illinois Department. The rules and regulations shall require 3 that proof of the receipt of prescription drugs, dentures, 4 prosthetic devices and eyeglasses by eligible persons under 5 this Section accompany each claim for reimbursement submitted 6 by the dispenser of such medical services. No such claims for 7 reimbursement shall be approved for payment by the Illinois 8 Department without such proof of receipt, unless the Illinois 9 Department shall have put into effect and shall be operating 10 a system of post-payment audit and review which shall, on a 11 sampling basis, be deemed adequate by the Illinois Department 12 to assure that such drugs, dentures, prosthetic devices and 13 eyeglasses for which payment is being made are actually being 14 received by eligible recipients. Within 90 days after the 15 effective date of this amendatory Act of 1984, the Illinois 16 Department shall establish a current list of acquisition 17 costs for all prosthetic devices and any other items 18 recognized as medical equipment and supplies reimbursable 19 under this Article and shall update such list on a quarterly 20 basis, except that the acquisition costs of all prescription 21 drugs shall be updated no less frequently than every 30 days 22 as required by Section 5-5.12. 23 The rules and regulations of the Illinois Department 24 shall require that a written statement including the required 25 opinion of a physician shall accompany any claim for 26 reimbursement for abortions, or induced miscarriages or 27 premature births. This statement shall indicate what 28 procedures were used in providing such medical services. 29 The Illinois Department shall require that all dispensers 30 of medical services, other than an individual practitioner or 31 group of practitioners, desiring to participate in the 32 Medical Assistance program established under this Article to 33 disclose all financial, beneficial, ownership, equity, surety 34 or other interests in any and all firms, corporations, HB1807 Engrossed -12- LRB9204967DJgcA 1 partnerships, associations, business enterprises, joint 2 ventures, agencies, institutions or other legal entities 3 providing any form of health care services in this State 4 under this Article. 5 The Illinois Department may require that all dispensers 6 of medical services desiring to participate in the medical 7 assistance program established under this Article disclose, 8 under such terms and conditions as the Illinois Department 9 may by rule establish, all inquiries from clients and 10 attorneys regarding medical bills paid by the Illinois 11 Department, which inquiries could indicate potential 12 existence of claims or liens for the Illinois Department. 13 The Illinois Department shall establish policies, 14 procedures, standards and criteria by rule for the 15 acquisition, repair and replacement of orthotic and 16 prosthetic devices and durable medical equipment. Such rules 17 shall provide, but not be limited to, the following services: 18 (1) immediate repair or replacement of such devices by 19 recipients without medical authorization; and (2) rental, 20 lease, purchase or lease-purchase of durable medical 21 equipment in a cost-effective manner, taking into 22 consideration the recipient's medical prognosis, the extent 23 of the recipient's needs, and the requirements and costs for 24 maintaining such equipment. Such rules shall enable a 25 recipient to temporarily acquire and use alternative or 26 substitute devices or equipment pending repairs or 27 replacements of any device or equipment previously authorized 28 for such recipient by the Department. Rules under clause (2) 29 above shall not provide for purchase or lease-purchase of 30 durable medical equipment or supplies used for the purpose of 31 oxygen delivery and respiratory care. 32 The Department shall execute, relative to the nursing 33 home prescreening project, written inter-agency agreements 34 with the Department of Human Services and the Department on HB1807 Engrossed -13- LRB9204967DJgcA 1 Aging, to effect the following: (i) intake procedures and 2 common eligibility criteria for those persons who are 3 receiving non-institutional services; and (ii) the 4 establishment and development of non-institutional services 5 in areas of the State where they are not currently available 6 or are undeveloped. 7 The Illinois Department shall develop and operate, in 8 cooperation with other State Departments and agencies and in 9 compliance with applicable federal laws and regulations, 10 appropriate and effective systems of health care evaluation 11 and programs for monitoring of utilization of health care 12 services and facilities, as it affects persons eligible for 13 medical assistance under this Code. The Illinois Department 14 shall report regularly the results of the operation of such 15 systems and programs to the Citizens Assembly/Council on 16 Public Aid to enable the Committee to ensure, from time to 17 time, that these programs are effective and meaningful. 18 The Illinois Department shall report annually to the 19 General Assembly, no later than the second Friday in April of 20 1979 and each year thereafter, in regard to: 21 (a) actual statistics and trends in utilization of 22 medical services by public aid recipients; 23 (b) actual statistics and trends in the provision 24 of the various medical services by medical vendors; 25 (c) current rate structures and proposed changes in 26 those rate structures for the various medical vendors; 27 and 28 (d) efforts at utilization review and control by 29 the Illinois Department. 30 The period covered by each report shall be the 3 years 31 ending on the June 30 prior to the report. The report shall 32 include suggested legislation for consideration by the 33 General Assembly. The filing of one copy of the report with 34 the Speaker, one copy with the Minority Leader and one copy HB1807 Engrossed -14- LRB9204967DJgcA 1 with the Clerk of the House of Representatives, one copy with 2 the President, one copy with the Minority Leader and one copy 3 with the Secretary of the Senate, one copy with the 4 Legislative Research Unit, such additional copies with the 5 State Government Report Distribution Center for the General 6 Assembly as is required under paragraph (t) of Section 7 of 7 the State Library Act and one copy with the Citizens 8 Assembly/Council on Public Aid or its successor shall be 9 deemed sufficient to comply with this Section. 10 (Source: P.A. 90-7, eff. 6-10-97; 90-14, eff. 7-1-97; 91-344, 11 eff. 1-1-00; 91-462, eff. 8-6-99; 91-666, eff. 12-22-99; 12 revised 1-6-00.) 4967 13 Section 99. Effective date. This Act takes effect upon 14 becoming law.