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92_SB0461
LRB9207772DJmb
1 AN ACT in relation to children.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Early Intervention Services System Act is
5 amended by changing Sections 3, 11, and 13 and adding Section
6 10.5 and Sections 13.5 through 13.35 as follows:
7 (325 ILCS 20/3) (from Ch. 23, par. 4153)
8 Sec. 3. Definitions. As used in this Act:
9 (a) "Eligible infants and toddlers" means infants and
10 toddlers under 36 months of age with any of the following
11 conditions:
12 (1) Developmental delays as defined by the
13 Department by rule.
14 (2) A physical or mental condition which typically
15 results in developmental delay.
16 (3) Being at risk of having substantial
17 developmental delays based on informed clinical judgment.
18 (b) "Developmental delay" means a delay in one or more
19 of the following areas of childhood development as measured
20 by appropriate diagnostic instruments and standard
21 procedures: cognitive; physical, including vision and
22 hearing; language, speech and communication; psycho-social;
23 or self-help skills.
24 (c) "Physical or mental condition which typically
25 results in developmental delay" means:
26 (1) a diagnosed medical disorder bearing a
27 relatively well known expectancy for developmental
28 outcomes within varying ranges of developmental
29 disabilities; or
30 (2) a history of prenatal, perinatal, neonatal or
31 early developmental events suggestive of biological
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1 insults to the developing central nervous system and
2 which either singly or collectively increase the
3 probability of developing a disability or delay based on
4 a medical history.
5 (d) "Informed clinical judgment" means both clinical
6 observations and parental participation to determine
7 eligibility by a consensus of a multidisciplinary team of 2
8 or more members based on their professional experience and
9 expertise.
10 (e) "Early intervention services" means services which:
11 (1) are designed to meet the developmental needs of
12 each child eligible under this Act and the needs of his
13 or her family;
14 (2) are selected in collaboration with the child's
15 family;
16 (3) are provided under public supervision;
17 (4) are provided at no cost except where a schedule
18 of sliding scale fees or other system of payments by
19 families has been adopted in accordance with State and
20 federal law;
21 (5) are designed to meet an infant's or toddler's
22 developmental needs in any of the following areas:
23 (A) physical development, including vision and
24 hearing,
25 (B) cognitive development,
26 (C) communication development,
27 (D) social or emotional development, or
28 (E) adaptive development;
29 (6) meet the standards of the State, including the
30 requirements of this Act;
31 (7) include one or more of the following:
32 (A) family training,
33 (B) social work services, including
34 counseling, and home visits,
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1 (C) special instruction,
2 (D) speech, language pathology and audiology,
3 (E) occupational therapy,
4 (F) physical therapy,
5 (G) psychological services,
6 (H) service coordination services,
7 (I) medical services only for diagnostic or
8 evaluation purposes,
9 (J) early identification, screening, and
10 assessment services,
11 (K) health services specified by the lead
12 agency as necessary to enable the infant or toddler
13 to benefit from the other early intervention
14 services,
15 (L) vision services,
16 (M) transportation, and
17 (N) assistive technology devices and services;
18 (8) are provided by qualified personnel, including
19 but not limited to:
20 (A) child development specialists or special
21 educators,
22 (B) speech and language pathologists and
23 audiologists,
24 (C) occupational therapists,
25 (D) physical therapists,
26 (E) social workers,
27 (F) nurses,
28 (G) nutritionists,
29 (H) optometrists,
30 (I) psychologists, and
31 (J) physicians;
32 (9) are provided in conformity with an
33 Individualized Family Service Plan;
34 (10) are provided throughout the year; and
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1 (11) are provided in natural environments,
2 including the home and community settings in which
3 infants and toddlers without disabilities would
4 participate to the extent determined by the
5 multidisciplinary Individualized Family Service Plan.
6 (f) "Individualized Family Service Plan" or "Plan" means
7 a written plan for providing early intervention services to a
8 child eligible under this Act and the child's family, as set
9 forth in Section 11.
10 (g) "Local interagency agreement" means an agreement
11 entered into by local community and State and regional
12 agencies receiving early intervention funds directly from the
13 State and made in accordance with State interagency
14 agreements providing for the delivery of early intervention
15 services within a local community area.
16 (h) "Council" means the Illinois Interagency Council on
17 Early Intervention established under Section 4.
18 (i) "Lead agency" means the State agency responsible for
19 administering this Act and receiving and disbursing public
20 funds received in accordance with State and federal law and
21 rules.
22 (i-5) "Central billing office" means the central billing
23 office created by the lead agency under Section 13.
24 (j) "Child find" means a service which identifies
25 eligible infants and toddlers.
26 (k) "Qualified person" means an individual providing
27 early intervention services who has attained the highest
28 requirements in the State applicable to the profession or
29 discipline in which he or she is providing early intervention
30 services and who is suitably qualified to provide early
31 intervention services to eligible children and their
32 families.
33 (l) "Suitably qualified" means the following:
34 (1) In the case of personnel including, but not
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1 limited to, audiologists, speech-language pathologists,
2 occupational therapists, and physical therapists,
3 "suitably qualified" means having qualifications that
4 meet the University of Illinois Division of Specialized
5 Care for Children approval standards for providers under
6 Title V of the Social Security Act that were in effect on
7 February 1, 2001 for an individual's speciality:
8 (A) within one year after the effective date
9 of this amendatory Act of the 92nd General Assembly,
10 for an individual who is already enrolled as a
11 credentialed specialist on the effective date of
12 this amendatory Act of the 92nd General Assembly;
13 and
14 (B) at the time of enrollment, for an
15 individual seeking enrollment as a credentialed
16 specialist on or after the effective date of this
17 amendatory Act of the 92nd General Assembly.
18 Notwithstanding any other provision of this
19 paragraph (1), however, to be "suitably qualified", an
20 individual's level of experience must be with infants and
21 toddlers from birth to age 3.
22 (2) In the case of other personnel who provide
23 early intervention services, including, but not limited
24 to, service coordinators, developmental therapists, and
25 family support specialists, "suitably qualified" means
26 having at least a bachelor's degree in early childhood
27 education, early childhood special education, special
28 education, child development, orientation, and mobility,
29 or applied psychology or the equivalent:
30 (A) within one year after the effective date
31 of this amendatory Act of the 92nd General Assembly,
32 for an individual who is already enrolled as a
33 credentialed specialist on the effective date of
34 this amendatory Act of the 92nd General Assembly;
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1 and
2 (B) at the time of enrollment, for an
3 individual seeking enrollment as a credentialed
4 specialist on or after the effective date of this
5 amendatory Act of the 92nd General Assembly.
6 (3) In the case of audiologists, speech-language
7 pathologists, occupational therapists, physical
8 therapists, service coordinators, developmental
9 therapists, and family support specialists, "suitably
10 qualified" means having completed no less than 20
11 contact hours of continuing education in birth-to-age-3
12 evaluation and treatment, or its equivalent:
13 (A) within one year after the effective date
14 of this amendatory Act of the 92nd General Assembly,
15 for an individual who is already enrolled as an
16 early intervention provider on the effective date of
17 this amendatory Act of the 92nd General Assembly;
18 and
19 (B) at the time of enrollment, for an
20 individual seeking enrollment as one of these
21 specialists on or after the effective date of this
22 amendatory Act of the 92nd General Assembly.
23 (Source: P.A. 90-158, eff. 1-1-98; 91-538, eff. 8-13-99.)
24 (325 ILCS 20/10.5 new)
25 Sec. 10.5. Service providers; qualifications.
26 (a) An individual who is not suitably qualified as
27 defined in Section 3 may provide early intervention services
28 on a provisional basis for no more than 6 months, so long as
29 it is anticipated that the individual will become suitably
30 qualified within those 6 months. During those 6 months, the
31 individual may work only under the direction and supervision
32 of an individual who is a qualified person as defined in
33 Section 3 and who is suitably qualified within the same
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1 specialty area or areas as the individual who is providing
2 services on a provisional basis. This direction and
3 supervision must include, at a minimum, the co-signature of
4 the supervising specialist on progress reports and treatment
5 recommendations of the individual who is providing services
6 on a provisional basis.
7 (b) To maintain enrollment as an individual early
8 intervention services provider in any specialty area listed
9 in the definition of "suitably qualified" in Section 3, or
10 any other area designated by the lead agency by rule, an
11 individual must certify that he or she has completed, every 2
12 years, no less than 20 additional contact hours of continuing
13 education in birth-to-age-3 evaluation and treatment. A
14 regional intake entity may seek a waiver of this provision
15 from the lead agency as to one or more types of personnel,
16 based on shortages of specialists in the region who meet the
17 necessary qualifications. The waiver must specify education
18 and training requirements, including continuing education for
19 birth-to-age-3 evaluation and treatment, within the area of
20 specialization, that are required to remain an enrolled
21 provider in that region.
22 (c) Neither a 6-month provisional credential under
23 subsection (a), nor a waiver under subsection (b), shall
24 extend to any personnel who assess infants and toddlers or
25 participate on multidisciplinary teams to develop or modify
26 an individualized family service plan under Section 11.
27 (325 ILCS 20/11) (from Ch. 23, par. 4161)
28 Sec. 11. Individualized Family Service Plans.
29 (a) Each eligible infant or toddler and that infant's or
30 toddler's family shall receive:
31 (1) (a) timely, comprehensive, multidisciplinary
32 assessment of the unique needs of each eligible infant
33 and toddler, and assessment of the concerns and
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1 priorities of the families to appropriately assist them
2 in meeting their needs and identify services to meet
3 those needs; and
4 (2) (b) a written Individualized Family Service
5 Plan developed by a multidisciplinary team which includes
6 the parent or guardian.
7 (b) The Individualized Family Service Plan shall be
8 evaluated once a year and the family shall be provided a
9 review of the Plan at 6 month intervals or more often where
10 appropriate based on infant or toddler and family needs.
11 (c) The evaluation and initial assessment and initial
12 Plan meeting must be held within 45 days after the initial
13 contact with the early intervention services system. With
14 parental consent, early intervention services may commence
15 before the completion of the comprehensive assessment and
16 development of the Plan.
17 (d) Parents must be informed that, at their discretion,
18 early intervention services shall be provided to each
19 eligible infant and toddler in the natural environment, which
20 may include the home or other community settings. Parents
21 shall make the final decision to accept or decline early
22 intervention services. A decision to decline such services
23 shall not be a basis for administrative determination of
24 parental fitness, or other findings or sanctions against the
25 parents. Parameters of the Plan shall be set forth in rules.
26 (e) The regional intake offices shall explain to each
27 family, orally and in writing, all of the following:
28 (1) That the early intervention program will pay
29 for all early intervention services in the individualized
30 family service plan that are not covered or paid under
31 the family's private insurance plan or policy.
32 (2) That services will not be delayed due to any
33 rules or restrictions under the family's insurance plan
34 or policy.
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1 (3) That, based on a sliding scale of family
2 income, the family's obligation to make insurance
3 co-payments will be limited to the amount of its family
4 fee obligation under that scale.
5 (4) That the family may request, at the regional
6 intake entity, a determination of an exemption from
7 private insurance use under Section 13.25.
8 (f) The individualized family service plan must state
9 whether the family has private insurance coverage and, if the
10 family has such coverage, must include all of the following
11 information:
12 (1) The name, address, and telephone number of the
13 insurance carrier.
14 (2) The contract number and policy number of the
15 insurance plan.
16 (3) The name, address and social security number of
17 the primary insured.
18 (g) A copy of the individualized family service plan
19 must be provided to each enrolled provider who is providing
20 early intervention services to the child who is the subject
21 of that plan.
22 (Source: P.A. 91-538, eff. 8-13-99.)
23 (325 ILCS 20/13) (from Ch. 23, par. 4163)
24 Sec. 13. Funding and Fiscal Responsibility.
25 (a) The lead agency and every other participating State
26 agency may receive and expend funds appropriated by the
27 General Assembly to implement the early intervention services
28 system as required by this Act.
29 (b) The lead agency and each participating State agency
30 shall identify and report on an annual basis to the Council
31 the State agency funds utilized for the provision of early
32 intervention services to eligible infants and toddlers.
33 (c) Funds provided under Section 633 of the Individuals
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1 with Disabilities Education Act (20 United States Code 1433)
2 and State funds designated or appropriated for early
3 intervention services or programs may not be used to satisfy
4 a financial commitment for services which would have been
5 paid for from another public or private source but for the
6 enactment of this Act, except whenever considered necessary
7 to prevent delay in receiving appropriate early intervention
8 services by the eligible infant or toddler or family in a
9 timely manner. Funds provided under Section 633 of the
10 Individuals with Disabilities Education Act and State funds
11 designated or appropriated for early intervention services or
12 programs may be used by the lead agency to pay the provider
13 of services pending reimbursement from the appropriate State
14 agency or other payor if (i) the claim for payment is denied
15 by the other public or private source, or would be denied
16 under the terms of the public program or plan or private
17 plan, or (ii) use of private insurance for the service has
18 been exempted under Section 13.25.
19 (d) Nothing in this Act shall be construed to permit the
20 State to reduce medical or other assistance available or to
21 alter eligibility under Title V and Title XIX of the Social
22 Security Act relating to the Maternal Child Health Program
23 and Medicaid for eligible infants and toddlers in this State.
24 (e) The lead agency shall create a central billing
25 office to receive and dispense all relevant State and federal
26 resources, as well as local government or independent
27 resources available, for early intervention services. This
28 office shall assure that maximum federal resources are
29 utilized and that providers receive funds with minimal
30 duplications or interagency reporting and with consolidated
31 audit procedures.
32 (f) The lead agency shall, by rule, may also create a
33 system of payments by families, including a schedule of fees.
34 No fees, however, may be charged for: implementing child
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1 find, evaluation and assessment, service coordination,
2 administrative and coordination activities related to the
3 development, review, and evaluation of Individualized Family
4 Service Plans, or the implementation of procedural safeguards
5 and other administrative components of the statewide early
6 intervention system.
7 The system of payments shall be structured on a sliding
8 scale based on family income. A family who has no insurance
9 coverage or less than full coverage under a public or private
10 insurance plan or policy and who has the same family income
11 as a family with full insurance coverage shall pay the same
12 amount per year for early intervention services as the family
13 with full insurance coverage.
14 A family without insurance coverage shall not be required
15 to pay fees under the schedule that families with insurance
16 coverage would not be required to pay. While the payment of
17 insurance co-payments shall offset the family fee obligation,
18 use of a family's insurance plan or policy for coverage of
19 early intervention services, by itself, does not offset the
20 family's fee obligation. Family fee obligations shall be
21 established annually, and shall be paid in quarterly
22 installments. Payment of the family fee obligation by
23 families with public or private insurance plans or policies
24 is governed by Section 13.20. The rules adopted under this
25 subsection shall also establish procedures that ensure that
26 families with extraordinary expenses or other catastrophic
27 circumstances are not denied early intervention services
28 because of an inability to pay the fees under the family fee
29 schedule or to pay co-payments up to the amount of the family
30 fee obligation.
31 (g) To ensure that early intervention funds are used as
32 the payor of last resort for early intervention services, the
33 lead agency shall determine at the point of early
34 intervention intake, and again at any periodic review of
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1 eligibility thereafter, whether the family is eligible for or
2 enrolled in any program for which payment is made directly or
3 through public or private insurance for any or all of the
4 early intervention services made available under this Act.
5 The lead agency shall establish procedures to ensure that
6 payments are made either directly from these public and
7 private sources instead of from State or federal early
8 intervention funds, or as reimbursement for payments
9 previously made from State or federal early intervention
10 funds.
11 (Source: P.A. 91-538, eff. 8-13-99.)
12 (325 ILCS 20/13.5 new)
13 Sec. 13.5. Other programs.
14 (a) An application for early intervention services shall
15 serve as an application for (i) medical assistance under
16 Article V of the Illinois Public Aid Code, (ii) children's
17 health insurance program (KidCare) benefits under the
18 Children's Health Insurance Program Act, and (iii) Title V
19 maternal and child health services provided through the
20 Division of Specialized Care for Children of the University
21 of Illinois. A child enrolled in an early intervention
22 program shall automatically be enrolled in any of these other
23 programs for which the child is also eligible.
24 (b) For purposes of determining family fees under
25 subsection (f) of Section 13 and determining eligibility for
26 the other programs and services specified in items (i)
27 through (iii) of subsection (a), the lead agency shall
28 develop and use, within 60 days after the effective date of
29 this amendatory Act of the 92nd General Assembly, with the
30 cooperation of the Department of Public Aid and the Division
31 of Specialized Care for Children of the University of
32 Illinois, a single application form that provides sufficient
33 information for the early intervention regional intake
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1 entities or other agencies to establish eligibility for those
2 other programs.
3 (c) With the cooperation of the Department of Public
4 Aid, the lead agency shall establish procedures that ensure
5 the timely and maximum allowable recovery of payments for all
6 early intervention services and allowable administrative
7 costs under Article V of the Illinois Public Aid Code, the
8 Children's Health Insurance Program Act, and Title V of the
9 Social Security Act.
10 (d) For purposes of determining eligibility for medical
11 assistance under Article V of the Illinois Public Aid Code,
12 the lead agency and the Department of Public Aid shall treat
13 the regional intake entities as "qualified entities" within
14 the meaning of 42 U.S.C. 1396r-1a.
15 (e) For purposes of determining eligibility for benefits
16 under the Children's Health Insurance Program Act, the lead
17 agency and the Department of Public Aid shall enroll each
18 early intervention regional intake entity as a "KidCare
19 agent" in order for the entity to enroll eligible children in
20 the program under Section 22 of the Children's Health
21 Insurance Program Act.
22 (f) For purposes of services covered under Title V of
23 the Social Security Act, the lead agency, in conjunction with
24 the Division of Specialized Care for Children of the
25 University of Illinois, shall establish procedures whereby
26 the early intervention regional intake entities may determine
27 eligibility for those services.
28 (325 ILCS 20/13.10 new)
29 Sec. 13.10. Private health insurance; assignment. No
30 later than 90 days after the effective date of this
31 amendatory Act of the 92nd General Assembly, the lead agency
32 shall determine, at the point of application for early
33 intervention services at the regional intake offices, whether
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1 a child is insured under a private health insurance plan or
2 policy. An application for early intervention services shall
3 serve as a secondary assignment to the lead agency of the
4 right of recovery against a private health insurance plan or
5 policy for any covered early intervention services provided
6 to a child covered under the plan or policy. The primary
7 assignees are each of the providers who provide early
8 intervention services to the child.
9 (325 ILCS 20/13.15 new)
10 Sec. 13.15. Billing of insurance carrier.
11 (a) Subject to the restrictions against private
12 insurance use on the basis of material risk of loss of
13 coverage, as determined under Section 13.25, each enrolled
14 provider who is providing a family with early intervention
15 services may bill the child's insurance carrier for each unit
16 of early intervention service for which coverage may be
17 available. Any time limit on a provider's filing of a claim
18 with the central billing office that is imposed through a
19 policy, procedure, or rule of the lead agency shall be tolled
20 until the provider receives an explanation of benefits or
21 other final determination of the claim it files with the
22 child's insurance carrier.
23 (b) For purposes of data collection, a provider must
24 provide the central billing office with a copy of the child's
25 insurance carrier's explanation of benefits for each child
26 the provider served for whom payments were received from the
27 insurance carrier. Within 120 days after the effective date
28 of this amendatory Act of the 92nd General Assembly, the lead
29 agency shall seek recovery for early intervention services
30 that are covered under an insurance plan or policy and for
31 which the provider has failed to bill the insurance carrier
32 and instead billed the central billing office. All such
33 recoveries shall be deposited into the Early Intervention
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1 Services Revolving Fund. The lead agency may seek these
2 recoveries itself or through the Department of Public Aid or
3 the Division of Specialized Care for Children of the
4 University of Illinois, or may contract with a third party
5 whose fee shall be paid according to an agreed percentage of
6 the insurance proceeds it recovers.
7 (325 ILCS 20/13.20 new)
8 Sec. 13.20. Families with insurance coverage; payment for
9 services.
10 (a) Families of children with insurance coverage,
11 whether public or private, shall incur no greater or less
12 direct out-of-pocket expenses for early intervention services
13 than families who are not insured.
14 (b) The lead agency shall require families to pay their
15 own co-payments for early intervention services as required
16 under their public or private insurance plan or policy, but
17 only up to the amount of their payment obligation under the
18 family fee schedule established under subsection (f) of
19 Section 13. At the time of enrollment in the early
20 intervention program, regional intake entities shall provide
21 each family who is required to pay family fees and who also
22 has insurance coverage with an envelope that states the
23 quarterly family fee obligation. A provider who collects a
24 co-payment from the family shall provide the family with a
25 receipt for each co-payment paid to the provider, and shall
26 note on the envelope the amount and date of the payment.
27 When the family fee obligation has been met through the
28 making of co-payments, the family shall, within 14 days after
29 the end of the calendar quarter, forward the envelope to the
30 central billing office as proof that its family fee
31 obligation has been paid. When the quarterly family fee
32 obligation has not been met in full through the payment of
33 co-payments during a particular calendar quarter, the family
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1 must remit to the central billing office the difference
2 between the family fee obligation and the amount paid in
3 co-payments.
4 (c) When the deductible on a family's insurance plan or
5 policy has not yet been met in full under the terms of the
6 plan or policy, the provider must first bill the insurance
7 carrier. If the claim is denied in whole or in part, the
8 provider must then bill the central billing office. The
9 provider shall be paid the difference for the services up to
10 the amount payable under the State's early intervention
11 fee-for-service rates.
12 (325 ILCS 20/13.25 new)
13 Sec. 13.25. Private insurance; exemption.
14 (a) No later than 90 days after the effective date of
15 this amendatory Act of the 92nd General Assembly, the lead
16 agency shall adopt rules to establish procedures by which a
17 family whose child is eligible to receive early intervention
18 services may apply for an exemption restricting the use of
19 its private insurance plan or policy based on material risk
20 of loss of coverage.
21 (b) The lead agency shall rule on a claim for an
22 exemption within 30 days after a family files a written
23 request for an exemption at the regional intake entity.
24 During that 30 days, no claims may be filed against the
25 insurance plan or policy. If the exemption is granted, it
26 shall be noted on the individualized family service plan, and
27 the family and the providers serving the family shall be
28 notified in writing of the exemption.
29 (c) Rulings on claims for exemptions shall be made on a
30 case-by-case basis with the goal of ensuring, both in the
31 case of a child covered under one private insurance plan or
32 policy, and in the case of a child covered under more than
33 one plan or policy, that as to each plan or policy used to
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1 pay in whole or in part for early intervention services, the
2 family is not placed at material risk of loss of coverage.
3 In considering a request for an exemption based on material
4 risk of loss of coverage, the lead agency may take the
5 following factors into consideration:
6 (1) Whether there is a material risk of an
7 unreasonable decrease in available lifetime coverage, as
8 defined by the lead agency, based on objective factors
9 such as the amount of the annual or lifetime cap on the
10 plan or policy, the likely annual or lifetime demand on
11 the plan or policy given the child's diagnosis or other
12 factors relating the child's demands on the plan or
13 policy, the percentage of the cap that claims for early
14 intervention services would use, and any other factors
15 that can be shown to put current, annual, or future use
16 of the plan or policy by the family at material risk.
17 (2) Whether billing the plan or policy would cause
18 the family to pay out-of-pocket for other services for
19 the child that would otherwise be covered by the plan or
20 policy.
21 (3) Whether there is a material risk of increased
22 premiums or the discontinuation of insurance due to
23 billing for early intervention services.
24 (d) The lead agency may establish and apply a general
25 policy on the factors enumerated in subsection (c); may
26 consider only the assertions and proof provided by a family
27 on a case-by-case basis that, due to one or more of those
28 factors, the family's plan or policy should not be used; and
29 may establish presumptions as to relative risks under those
30 and other factors.
31 (e) An exemption under this Section may apply to all
32 early intervention services and all plans or policies
33 insuring the child, may be limited to one or more plans or
34 policies, or may be limited to one or more types of early
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1 intervention services in the child's individualized family
2 services plan.
3 (325 ILCS 20/13.30 new)
4 Sec. 13.30. Training events. Within 90 days after the
5 effective date of this amendatory Act of the 92nd General
6 Assembly, the lead agency shall hold no fewer than 4 training
7 events, throughout the State, to explain to provider agencies
8 and individuals how to put systems in place to bill and
9 recover payments from private insurance companies. The lead
10 agency may conduct these training events directly or may
11 contract with a third party to conduct the events.
12 (325 ILCS 20/13.35 new)
13 Sec. 13.35. Report to General Assembly. No later than
14 July 31 of each year, the lead agency shall provide to the
15 General Assembly a report that states the total number of
16 children receiving any early intervention services, by month,
17 and in each region. For each month, broken down by region,
18 the report shall state the number of enrolled children
19 financially eligible for, and the number actually enrolled
20 in, the medical assistance program under Article V of the
21 Illinois Public Aid Code, the children's health insurance
22 program under the Children's Health Insurance Program Act,
23 and maternal and child health services under Title V of the
24 Social Security Act (separately stated); the number of
25 children with private insurance coverage; and the early
26 intervention costs offset by medical assistance, by the
27 children's health insurance program, by services provided
28 under Title V, and by insurance recoveries or payments. The
29 offsetting costs shall be further broken down by each type of
30 early intervention service, such as physical therapy, case
31 management, and transportation.
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1 Section 10. The Specialized Care for Children Act is
2 amended by adding Section 4 as follows:
3 (110 ILCS 345/4 new)
4 Sec. 4. Application for services; early intervention
5 services. An application for early intervention services
6 under the Early Intervention Services System Act shall serve
7 as an application for services under Title V of the Social
8 Security Act from the Division of Specialized Care for
9 Children. A child enrolled in an early intervention program
10 shall automatically be enrolled in any Title V services
11 program administered by the Division of Specialized Care for
12 Children for which the child is eligible. The Division of
13 Specialized Care for Children shall cooperate with the lead
14 agency under the Early Intervention Services System Act to
15 establish procedures whereby the early intervention regional
16 intake entities may determine eligibility for Title V
17 services.
18 Section 15. The Children's Health Insurance Program Act
19 is amended by changing 22 as follows:
20 (215 ILCS 106/22)
21 (Section scheduled to be repealed on July 1, 2002)
22 Sec. 22. Enrollment in program.
23 (a) The Department shall develop procedures to allow
24 community providers, and schools, youth service agencies,
25 employers, labor unions, local chambers of commerce, and
26 religious organizations to assist in enrolling children in
27 the Program.
28 (b) An application for early intervention services under
29 the Early Intervention Services System Act shall serve as an
30 application for enrollment in the program. A child enrolled
31 in an early intervention program shall automatically be
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1 enrolled in the program under this Act if the child is
2 eligible for participation in the program under this Act.
3 The Department shall cooperate with the lead agency under the
4 Early Intervention Services System Act to establish
5 procedures whereby the early intervention regional intake
6 entities may determine eligibility for participation in the
7 program under this Act.
8 (Source: P.A. 91-470, eff. 8-10-99; 91-471, eff. 8-10-99;
9 revised 6-23-00.)
10 Section 20. The Illinois Public Aid Code is amended by
11 adding Section 5-2.4 and changing Section 5-5 as follows:
12 (305 ILCS 5/5-2.4 new)
13 Sec. 5-2.4. Application for assistance; early
14 intervention services. An application for early intervention
15 services under the Early Intervention Services System Act
16 shall serve as an application for medical assistance under
17 this Article. A child enrolled in an early intervention
18 program shall automatically be enrolled in the medical
19 assistance program if the child is eligible for medical
20 assistance. The Illinois Department shall cooperate with the
21 lead agency under the Early Intervention Services System Act
22 to establish procedures whereby the early intervention
23 regional intake entities may determine eligibility for
24 medical assistance under this Article.
25 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
26 Sec. 5-5. Medical services. The Illinois Department, by
27 rule, shall determine the quantity and quality of and the
28 rate of reimbursement for the medical assistance for which
29 payment will be authorized, and the medical services to be
30 provided, which may include all or part of the following: (1)
31 inpatient hospital services; (2) outpatient hospital
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1 services; (3) other laboratory and X-ray services; (4)
2 skilled nursing home services; (5) physicians' services
3 whether furnished in the office, the patient's home, a
4 hospital, a skilled nursing home, or elsewhere; (6) medical
5 care, or any other type of remedial care furnished by
6 licensed practitioners; (7) home health care services; (8)
7 private duty nursing service; (9) clinic services; (10)
8 dental services; (11) physical therapy and related services;
9 (12) prescribed drugs, dentures, and prosthetic devices; and
10 eyeglasses prescribed by a physician skilled in the diseases
11 of the eye, or by an optometrist, whichever the person may
12 select; (13) other diagnostic, screening, preventive, and
13 rehabilitative services; (14) transportation and such other
14 expenses as may be necessary; (15) medical treatment of
15 sexual assault survivors, as defined in Section 1a of the
16 Sexual Assault Survivors Emergency Treatment Act, for
17 injuries sustained as a result of the sexual assault,
18 including examinations and laboratory tests to discover
19 evidence which may be used in criminal proceedings arising
20 from the sexual assault; (16) the diagnosis and treatment of
21 sickle cell anemia; and (17) any other medical care, and any
22 other type of remedial care recognized under the laws of this
23 State, but not including abortions, or induced miscarriages
24 or premature births, unless, in the opinion of a physician,
25 such procedures are necessary for the preservation of the
26 life of the woman seeking such treatment, or except an
27 induced premature birth intended to produce a live viable
28 child and such procedure is necessary for the health of the
29 mother or her unborn child. The Illinois Department, by rule,
30 shall prohibit any physician from providing medical
31 assistance to anyone eligible therefor under this Code where
32 such physician has been found guilty of performing an
33 abortion procedure in a wilful and wanton manner upon a woman
34 who was not pregnant at the time such abortion procedure was
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1 performed. The term "any other type of remedial care" shall
2 include nursing care and nursing home service for persons who
3 rely on treatment by spiritual means alone through prayer for
4 healing.
5 Notwithstanding any other provision of this Section, a
6 comprehensive tobacco use cessation program that includes
7 purchasing prescription drugs or prescription medical devices
8 approved by the Food and Drug administration shall be covered
9 under the medical assistance program under this Article for
10 persons who are otherwise eligible for assistance under this
11 Article.
12 Notwithstanding any other provision of this Code, the
13 Illinois Department may not require, as a condition of
14 payment for any laboratory test authorized under this
15 Article, that a physician's handwritten signature appear on
16 the laboratory test order form. The Illinois Department may,
17 however, impose other appropriate requirements regarding
18 laboratory test order documentation.
19 The Illinois Department shall provide coverage of all
20 "early intervention services" as defined in the Illinois
21 Early Intervention Services System Act or as defined in 20
22 U.S.C. 1432 that are provided to persons who are eligible for
23 assistance under this Article.
24 The Illinois Department of Public Aid shall provide the
25 following services to persons eligible for assistance under
26 this Article who are participating in education, training or
27 employment programs operated by the Department of Human
28 Services as successor to the Department of Public Aid:
29 (1) dental services, which shall include but not be
30 limited to prosthodontics; and
31 (2) eyeglasses prescribed by a physician skilled in
32 the diseases of the eye, or by an optometrist, whichever
33 the person may select.
34 The Illinois Department, by rule, may distinguish and
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1 classify the medical services to be provided only in
2 accordance with the classes of persons designated in Section
3 5-2.
4 The Illinois Department shall authorize the provision of,
5 and shall authorize payment for, screening by low-dose
6 mammography for the presence of occult breast cancer for
7 women 35 years of age or older who are eligible for medical
8 assistance under this Article, as follows: a baseline
9 mammogram for women 35 to 39 years of age and an annual
10 mammogram for women 40 years of age or older. All screenings
11 shall include a physical breast exam, instruction on
12 self-examination and information regarding the frequency of
13 self-examination and its value as a preventative tool. As
14 used in this Section, "low-dose mammography" means the x-ray
15 examination of the breast using equipment dedicated
16 specifically for mammography, including the x-ray tube,
17 filter, compression device, image receptor, and cassettes,
18 with an average radiation exposure delivery of less than one
19 rad mid-breast, with 2 views for each breast.
20 Any medical or health care provider shall immediately
21 recommend, to any pregnant woman who is being provided
22 prenatal services and is suspected of drug abuse or is
23 addicted as defined in the Alcoholism and Other Drug Abuse
24 and Dependency Act, referral to a local substance abuse
25 treatment provider licensed by the Department of Human
26 Services or to a licensed hospital which provides substance
27 abuse treatment services. The Department of Public Aid shall
28 assure coverage for the cost of treatment of the drug abuse
29 or addiction for pregnant recipients in accordance with the
30 Illinois Medicaid Program in conjunction with the Department
31 of Human Services.
32 All medical providers providing medical assistance to
33 pregnant women under this Code shall receive information from
34 the Department on the availability of services under the Drug
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1 Free Families with a Future or any comparable program
2 providing case management services for addicted women,
3 including information on appropriate referrals for other
4 social services that may be needed by addicted women in
5 addition to treatment for addiction.
6 The Illinois Department, in cooperation with the
7 Departments of Human Services (as successor to the Department
8 of Alcoholism and Substance Abuse) and Public Health, through
9 a public awareness campaign, may provide information
10 concerning treatment for alcoholism and drug abuse and
11 addiction, prenatal health care, and other pertinent programs
12 directed at reducing the number of drug-affected infants born
13 to recipients of medical assistance.
14 Neither the Illinois Department of Public Aid nor the
15 Department of Human Services shall sanction the recipient
16 solely on the basis of her substance abuse.
17 The Illinois Department shall establish such regulations
18 governing the dispensing of health services under this
19 Article as it shall deem appropriate. In formulating these
20 regulations the Illinois Department shall consult with and
21 give substantial weight to the recommendations offered by the
22 Citizens Assembly/Council on Public Aid. The Department
23 should seek the advice of formal professional advisory
24 committees appointed by the Director of the Illinois
25 Department for the purpose of providing regular advice on
26 policy and administrative matters, information dissemination
27 and educational activities for medical and health care
28 providers, and consistency in procedures to the Illinois
29 Department.
30 The Illinois Department may develop and contract with
31 Partnerships of medical providers to arrange medical services
32 for persons eligible under Section 5-2 of this Code.
33 Implementation of this Section may be by demonstration
34 projects in certain geographic areas. The Partnership shall
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1 be represented by a sponsor organization. The Department, by
2 rule, shall develop qualifications for sponsors of
3 Partnerships. Nothing in this Section shall be construed to
4 require that the sponsor organization be a medical
5 organization.
6 The sponsor must negotiate formal written contracts with
7 medical providers for physician services, inpatient and
8 outpatient hospital care, home health services, treatment for
9 alcoholism and substance abuse, and other services determined
10 necessary by the Illinois Department by rule for delivery by
11 Partnerships. Physician services must include prenatal and
12 obstetrical care. The Illinois Department shall reimburse
13 medical services delivered by Partnership providers to
14 clients in target areas according to provisions of this
15 Article and the Illinois Health Finance Reform Act, except
16 that:
17 (1) Physicians participating in a Partnership and
18 providing certain services, which shall be determined by
19 the Illinois Department, to persons in areas covered by
20 the Partnership may receive an additional surcharge for
21 such services.
22 (2) The Department may elect to consider and
23 negotiate financial incentives to encourage the
24 development of Partnerships and the efficient delivery of
25 medical care.
26 (3) Persons receiving medical services through
27 Partnerships may receive medical and case management
28 services above the level usually offered through the
29 medical assistance program.
30 Medical providers shall be required to meet certain
31 qualifications to participate in Partnerships to ensure the
32 delivery of high quality medical services. These
33 qualifications shall be determined by rule of the Illinois
34 Department and may be higher than qualifications for
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1 participation in the medical assistance program. Partnership
2 sponsors may prescribe reasonable additional qualifications
3 for participation by medical providers, only with the prior
4 written approval of the Illinois Department.
5 Nothing in this Section shall limit the free choice of
6 practitioners, hospitals, and other providers of medical
7 services by clients. In order to ensure patient freedom of
8 choice, the Illinois Department shall immediately promulgate
9 all rules and take all other necessary actions so that
10 provided services may be accessed from therapeutically
11 certified optometrists to the full extent of the Illinois
12 Optometric Practice Act of 1987 without discriminating
13 between service providers.
14 The Department shall apply for a waiver from the United
15 States Health Care Financing Administration to allow for the
16 implementation of Partnerships under this Section.
17 The Illinois Department shall require health care
18 providers to maintain records that document the medical care
19 and services provided to recipients of Medical Assistance
20 under this Article. The Illinois Department shall require
21 health care providers to make available, when authorized by
22 the patient, in writing, the medical records in a timely
23 fashion to other health care providers who are treating or
24 serving persons eligible for Medical Assistance under this
25 Article. All dispensers of medical services shall be
26 required to maintain and retain business and professional
27 records sufficient to fully and accurately document the
28 nature, scope, details and receipt of the health care
29 provided to persons eligible for medical assistance under
30 this Code, in accordance with regulations promulgated by the
31 Illinois Department. The rules and regulations shall require
32 that proof of the receipt of prescription drugs, dentures,
33 prosthetic devices and eyeglasses by eligible persons under
34 this Section accompany each claim for reimbursement submitted
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1 by the dispenser of such medical services. No such claims for
2 reimbursement shall be approved for payment by the Illinois
3 Department without such proof of receipt, unless the Illinois
4 Department shall have put into effect and shall be operating
5 a system of post-payment audit and review which shall, on a
6 sampling basis, be deemed adequate by the Illinois Department
7 to assure that such drugs, dentures, prosthetic devices and
8 eyeglasses for which payment is being made are actually being
9 received by eligible recipients. Within 90 days after the
10 effective date of this amendatory Act of 1984, the Illinois
11 Department shall establish a current list of acquisition
12 costs for all prosthetic devices and any other items
13 recognized as medical equipment and supplies reimbursable
14 under this Article and shall update such list on a quarterly
15 basis, except that the acquisition costs of all prescription
16 drugs shall be updated no less frequently than every 30 days
17 as required by Section 5-5.12.
18 The rules and regulations of the Illinois Department
19 shall require that a written statement including the required
20 opinion of a physician shall accompany any claim for
21 reimbursement for abortions, or induced miscarriages or
22 premature births. This statement shall indicate what
23 procedures were used in providing such medical services.
24 The Illinois Department shall require that all dispensers
25 of medical services, other than an individual practitioner or
26 group of practitioners, desiring to participate in the
27 Medical Assistance program established under this Article to
28 disclose all financial, beneficial, ownership, equity, surety
29 or other interests in any and all firms, corporations,
30 partnerships, associations, business enterprises, joint
31 ventures, agencies, institutions or other legal entities
32 providing any form of health care services in this State
33 under this Article.
34 The Illinois Department may require that all dispensers
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1 of medical services desiring to participate in the medical
2 assistance program established under this Article disclose,
3 under such terms and conditions as the Illinois Department
4 may by rule establish, all inquiries from clients and
5 attorneys regarding medical bills paid by the Illinois
6 Department, which inquiries could indicate potential
7 existence of claims or liens for the Illinois Department.
8 The Illinois Department shall establish policies,
9 procedures, standards and criteria by rule for the
10 acquisition, repair and replacement of orthotic and
11 prosthetic devices and durable medical equipment. Such rules
12 shall provide, but not be limited to, the following services:
13 (1) immediate repair or replacement of such devices by
14 recipients without medical authorization; and (2) rental,
15 lease, purchase or lease-purchase of durable medical
16 equipment in a cost-effective manner, taking into
17 consideration the recipient's medical prognosis, the extent
18 of the recipient's needs, and the requirements and costs for
19 maintaining such equipment. Such rules shall enable a
20 recipient to temporarily acquire and use alternative or
21 substitute devices or equipment pending repairs or
22 replacements of any device or equipment previously authorized
23 for such recipient by the Department. Rules under clause (2)
24 above shall not provide for purchase or lease-purchase of
25 durable medical equipment or supplies used for the purpose of
26 oxygen delivery and respiratory care.
27 The Department shall execute, relative to the nursing
28 home prescreening project, written inter-agency agreements
29 with the Department of Human Services and the Department on
30 Aging, to effect the following: (i) intake procedures and
31 common eligibility criteria for those persons who are
32 receiving non-institutional services; and (ii) the
33 establishment and development of non-institutional services
34 in areas of the State where they are not currently available
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1 or are undeveloped.
2 The Illinois Department shall develop and operate, in
3 cooperation with other State Departments and agencies and in
4 compliance with applicable federal laws and regulations,
5 appropriate and effective systems of health care evaluation
6 and programs for monitoring of utilization of health care
7 services and facilities, as it affects persons eligible for
8 medical assistance under this Code. The Illinois Department
9 shall report regularly the results of the operation of such
10 systems and programs to the Citizens Assembly/Council on
11 Public Aid to enable the Committee to ensure, from time to
12 time, that these programs are effective and meaningful.
13 The Illinois Department shall report annually to the
14 General Assembly, no later than the second Friday in April of
15 1979 and each year thereafter, in regard to:
16 (a) actual statistics and trends in utilization of
17 medical services by public aid recipients;
18 (b) actual statistics and trends in the provision
19 of the various medical services by medical vendors;
20 (c) current rate structures and proposed changes in
21 those rate structures for the various medical vendors;
22 and
23 (d) efforts at utilization review and control by
24 the Illinois Department.
25 The period covered by each report shall be the 3 years
26 ending on the June 30 prior to the report. The report shall
27 include suggested legislation for consideration by the
28 General Assembly. The filing of one copy of the report with
29 the Speaker, one copy with the Minority Leader and one copy
30 with the Clerk of the House of Representatives, one copy with
31 the President, one copy with the Minority Leader and one copy
32 with the Secretary of the Senate, one copy with the
33 Legislative Research Unit, such additional copies with the
34 State Government Report Distribution Center for the General
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1 Assembly as is required under paragraph (t) of Section 7 of
2 the State Library Act and one copy with the Citizens
3 Assembly/Council on Public Aid or its successor shall be
4 deemed sufficient to comply with this Section.
5 (Source: P.A. 90-7, eff. 6-10-97; 90-14, eff. 7-1-97; 91-344,
6 eff. 1-1-00; 91-462, eff. 8-6-99; 91-666, eff. 12-22-99;
7 revised 1-6-00.)
8 Section 99. Effective date. This Act takes effect upon
9 becoming law.