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92_SB0461eng SB461 Engrossed 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 SB461 Engrossed -2- LRB9207772DJmb 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, SB461 Engrossed -3- LRB9207772DJmb 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 SB461 Engrossed -4- LRB9207772DJmb 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 SB461 Engrossed -5- LRB9207772DJmb 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; SB461 Engrossed -6- LRB9207772DJmb 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 SB461 Engrossed -7- LRB9207772DJmb 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 SB461 Engrossed -8- LRB9207772DJmb 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. SB461 Engrossed -9- LRB9207772DJmb 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 SB461 Engrossed -10- LRB9207772DJmb 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,mayalso create a 33 system of payments by families, including a schedule of fees. 34 No fees, however, may be charged for: implementing child SB461 Engrossed -11- LRB9207772DJmb 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 SB461 Engrossed -12- LRB9207772DJmb 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 SB461 Engrossed -13- LRB9207772DJmb 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 SB461 Engrossed -14- LRB9207772DJmb 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 SB461 Engrossed -15- LRB9207772DJmb 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 SB461 Engrossed -16- LRB9207772DJmb 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 SB461 Engrossed -17- LRB9207772DJmb 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 SB461 Engrossed -18- LRB9207772DJmb 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. SB461 Engrossed -19- LRB9207772DJmb 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 Section 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,andschools, 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 SB461 Engrossed -20- LRB9207772DJmb 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 SB461 Engrossed -21- LRB9207772DJmb 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 SB461 Engrossed -22- LRB9207772DJmb 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 SB461 Engrossed -23- LRB9207772DJmb 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 SB461 Engrossed -24- LRB9207772DJmb 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 SB461 Engrossed -25- LRB9207772DJmb 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 SB461 Engrossed -26- LRB9207772DJmb 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 SB461 Engrossed -27- LRB9207772DJmb 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 SB461 Engrossed -28- LRB9207772DJmb 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 SB461 Engrossed -29- LRB9207772DJmb 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 SB461 Engrossed -30- LRB9207772DJmb 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.