HB5859 Engrossed LRB096 16574 KTG 31847 b

1     AN ACT concerning public aid.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Public Aid Code is amended by
5 changing Section 5-5 as follows:
 
6     (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7     (Text of Section before amendment by P.A. 96-806)
8     Sec. 5-5. Medical services. The Illinois Department, by
9 rule, shall determine the quantity and quality of and the rate
10 of reimbursement for the medical assistance for which payment
11 will be authorized, and the medical services to be provided,
12 which may include all or part of the following: (1) inpatient
13 hospital services; (2) outpatient hospital services; (3) other
14 laboratory and X-ray services; (4) skilled nursing home
15 services; (5) physicians' services whether furnished in the
16 office, the patient's home, a hospital, a skilled nursing home,
17 or elsewhere; (6) medical care, or any other type of remedial
18 care furnished by licensed practitioners; (7) home health care
19 services; (8) private duty nursing service; (9) clinic
20 services; (10) dental services, including prevention and
21 treatment of periodontal disease and dental caries disease for
22 pregnant women, provided by an individual licensed to practice
23 dentistry or dental surgery; for purposes of this item (10),

 

 

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1 "dental services" means diagnostic, preventive, or corrective
2 procedures provided by or under the supervision of a dentist in
3 the practice of his or her profession; (11) physical therapy
4 and related services; (12) prescribed drugs, dentures, and
5 prosthetic devices; and eyeglasses prescribed by a physician
6 skilled in the diseases of the eye, or by an optometrist,
7 whichever the person may select; (13) other diagnostic,
8 screening, preventive, and rehabilitative services; (14)
9 transportation and such other expenses as may be necessary;
10 (15) medical treatment of sexual assault survivors, as defined
11 in Section 1a of the Sexual Assault Survivors Emergency
12 Treatment Act, for injuries sustained as a result of the sexual
13 assault, including examinations and laboratory tests to
14 discover evidence which may be used in criminal proceedings
15 arising from the sexual assault; (16) the diagnosis and
16 treatment of sickle cell anemia; and (17) any other medical
17 care, and any other type of remedial care recognized under the
18 laws of this State, but not including abortions, or induced
19 miscarriages or premature births, unless, in the opinion of a
20 physician, such procedures are necessary for the preservation
21 of the life of the woman seeking such treatment, or except an
22 induced premature birth intended to produce a live viable child
23 and such procedure is necessary for the health of the mother or
24 her unborn child. The Illinois Department, by rule, shall
25 prohibit any physician from providing medical assistance to
26 anyone eligible therefor under this Code where such physician

 

 

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1 has been found guilty of performing an abortion procedure in a
2 wilful and wanton manner upon a woman who was not pregnant at
3 the time such abortion procedure was performed. The term "any
4 other type of remedial care" shall include nursing care and
5 nursing home service for persons who rely on treatment by
6 spiritual means alone through prayer for healing.
7     Notwithstanding any other provision of this Section, a
8 comprehensive tobacco use cessation program that includes
9 purchasing prescription drugs or prescription medical devices
10 approved by the Food and Drug administration shall be covered
11 under the medical assistance program under this Article for
12 persons who are otherwise eligible for assistance under this
13 Article.
14     Notwithstanding any other provision of this Code, the
15 Illinois Department may not require, as a condition of payment
16 for any laboratory test authorized under this Article, that a
17 physician's handwritten signature appear on the laboratory
18 test order form. The Illinois Department may, however, impose
19 other appropriate requirements regarding laboratory test order
20 documentation.
21     The Department of Healthcare and Family Services shall
22 provide the following services to persons eligible for
23 assistance under this Article who are participating in
24 education, training or employment programs operated by the
25 Department of Human Services as successor to the Department of
26 Public Aid:

 

 

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1         (1) dental services provided by or under the
2     supervision of a dentist; and
3         (2) eyeglasses prescribed by a physician skilled in the
4     diseases of the eye, or by an optometrist, whichever the
5     person may select.
6     Notwithstanding any other provision of this Code and
7 subject to federal approval, the Department may adopt rules to
8 allow a dentist who is volunteering his or her service at no
9 cost to render dental services through an enrolled
10 not-for-profit health clinic without the dentist personally
11 enrolling as a participating provider in the medical assistance
12 program. A not-for-profit health clinic shall include a public
13 health clinic or Federally Qualified Health Center or other
14 enrolled provider, as determined by the Department, through
15 which dental services covered under this Section are performed.
16 The Department shall establish a process for payment of claims
17 for reimbursement for covered dental services rendered under
18 this provision.
19     The Illinois Department, by rule, may distinguish and
20 classify the medical services to be provided only in accordance
21 with the classes of persons designated in Section 5-2.
22     The Department of Healthcare and Family Services must
23 provide coverage and reimbursement for amino acid-based
24 elemental formulas, regardless of delivery method, for the
25 diagnosis and treatment of (i) eosinophilic disorders and (ii)
26 short bowel syndrome when the prescribing physician has issued

 

 

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1 a written order stating that the amino acid-based elemental
2 formula is medically necessary.
3     The Illinois Department shall authorize the provision of,
4 and shall authorize payment for, screening by low-dose
5 mammography for the presence of occult breast cancer for women
6 35 years of age or older who are eligible for medical
7 assistance under this Article, as follows:
8         (A) A baseline mammogram for women 35 to 39 years of
9     age.
10         (B) An annual mammogram for women 40 years of age or
11     older.
12         (C) A mammogram at the age and intervals considered
13     medically necessary by the woman's health care provider for
14     women under 40 years of age and having a family history of
15     breast cancer, prior personal history of breast cancer,
16     positive genetic testing, or other risk factors.
17         (D) A comprehensive ultrasound screening of an entire
18     breast or breasts if a mammogram demonstrates
19     heterogeneous or dense breast tissue, when medically
20     necessary as determined by a physician licensed to practice
21     medicine in all of its branches.
22     All screenings shall include a physical breast exam,
23 instruction on self-examination and information regarding the
24 frequency of self-examination and its value as a preventative
25 tool. For purposes of this Section, "low-dose mammography"
26 means the x-ray examination of the breast using equipment

 

 

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1 dedicated specifically for mammography, including the x-ray
2 tube, filter, compression device, and image receptor, with an
3 average radiation exposure delivery of less than one rad per
4 breast for 2 views of an average size breast. The term also
5 includes digital mammography.
6     On and after July 1, 2008, screening and diagnostic
7 mammography shall be reimbursed at the same rate as the
8 Medicare program's rates, including the increased
9 reimbursement for digital mammography.
10     The Department shall convene an expert panel including
11 representatives of hospitals, free-standing mammography
12 facilities, and doctors, including radiologists, to establish
13 quality standards. Based on these quality standards, the
14 Department shall provide for bonus payments to mammography
15 facilities meeting the standards for screening and diagnosis.
16 The bonus payments shall be at least 15% higher than the
17 Medicare rates for mammography.
18     Subject to federal approval, the Department shall
19 establish a rate methodology for mammography at federally
20 qualified health centers and other encounter-rate clinics.
21 These clinics or centers may also collaborate with other
22 hospital-based mammography facilities.
23     The Department shall establish a methodology to remind
24 women who are age-appropriate for screening mammography, but
25 who have not received a mammogram within the previous 18
26 months, of the importance and benefit of screening mammography.

 

 

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1     The Department shall establish a performance goal for
2 primary care providers with respect to their female patients
3 over age 40 receiving an annual mammogram. This performance
4 goal shall be used to provide additional reimbursement in the
5 form of a quality performance bonus to primary care providers
6 who meet that goal.
7     The Department shall devise a means of case-managing or
8 patient navigation for beneficiaries diagnosed with breast
9 cancer. This program shall initially operate as a pilot program
10 in areas of the State with the highest incidence of mortality
11 related to breast cancer. At least one pilot program site shall
12 be in the metropolitan Chicago area and at least one site shall
13 be outside the metropolitan Chicago area. An evaluation of the
14 pilot program shall be carried out measuring health outcomes
15 and cost of care for those served by the pilot program compared
16 to similarly situated patients who are not served by the pilot
17 program.
18     Any medical or health care provider shall immediately
19 recommend, to any pregnant woman who is being provided prenatal
20 services and is suspected of drug abuse or is addicted as
21 defined in the Alcoholism and Other Drug Abuse and Dependency
22 Act, referral to a local substance abuse treatment provider
23 licensed by the Department of Human Services or to a licensed
24 hospital which provides substance abuse treatment services.
25 The Department of Healthcare and Family Services shall assure
26 coverage for the cost of treatment of the drug abuse or

 

 

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1 addiction for pregnant recipients in accordance with the
2 Illinois Medicaid Program in conjunction with the Department of
3 Human Services.
4     All medical providers providing medical assistance to
5 pregnant women under this Code shall receive information from
6 the Department on the availability of services under the Drug
7 Free Families with a Future or any comparable program providing
8 case management services for addicted women, including
9 information on appropriate referrals for other social services
10 that may be needed by addicted women in addition to treatment
11 for addiction.
12     The Illinois Department, in cooperation with the
13 Departments of Human Services (as successor to the Department
14 of Alcoholism and Substance Abuse) and Public Health, through a
15 public awareness campaign, may provide information concerning
16 treatment for alcoholism and drug abuse and addiction, prenatal
17 health care, and other pertinent programs directed at reducing
18 the number of drug-affected infants born to recipients of
19 medical assistance.
20     Neither the Department of Healthcare and Family Services
21 nor the Department of Human Services shall sanction the
22 recipient solely on the basis of her substance abuse.
23     The Illinois Department shall establish such regulations
24 governing the dispensing of health services under this Article
25 as it shall deem appropriate. The Department should seek the
26 advice of formal professional advisory committees appointed by

 

 

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1 the Director of the Illinois Department for the purpose of
2 providing regular advice on policy and administrative matters,
3 information dissemination and educational activities for
4 medical and health care providers, and consistency in
5 procedures to the Illinois Department.
6     The Illinois Department may develop and contract with
7 Partnerships of medical providers to arrange medical services
8 for persons eligible under Section 5-2 of this Code.
9 Implementation of this Section may be by demonstration projects
10 in certain geographic areas. The Partnership shall be
11 represented by a sponsor organization. The Department, by rule,
12 shall develop qualifications for sponsors of Partnerships.
13 Nothing in this Section shall be construed to require that the
14 sponsor organization be a medical organization.
15     The sponsor must negotiate formal written contracts with
16 medical providers for physician services, inpatient and
17 outpatient hospital care, home health services, treatment for
18 alcoholism and substance abuse, and other services determined
19 necessary by the Illinois Department by rule for delivery by
20 Partnerships. Physician services must include prenatal and
21 obstetrical care. The Illinois Department shall reimburse
22 medical services delivered by Partnership providers to clients
23 in target areas according to provisions of this Article and the
24 Illinois Health Finance Reform Act, except that:
25         (1) Physicians participating in a Partnership and
26     providing certain services, which shall be determined by

 

 

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1     the Illinois Department, to persons in areas covered by the
2     Partnership may receive an additional surcharge for such
3     services.
4         (2) The Department may elect to consider and negotiate
5     financial incentives to encourage the development of
6     Partnerships and the efficient delivery of medical care.
7         (3) Persons receiving medical services through
8     Partnerships may receive medical and case management
9     services above the level usually offered through the
10     medical assistance program.
11     Medical providers shall be required to meet certain
12 qualifications to participate in Partnerships to ensure the
13 delivery of high quality medical services. These
14 qualifications shall be determined by rule of the Illinois
15 Department and may be higher than qualifications for
16 participation in the medical assistance program. Partnership
17 sponsors may prescribe reasonable additional qualifications
18 for participation by medical providers, only with the prior
19 written approval of the Illinois Department.
20     Nothing in this Section shall limit the free choice of
21 practitioners, hospitals, and other providers of medical
22 services by clients. In order to ensure patient freedom of
23 choice, the Illinois Department shall immediately promulgate
24 all rules and take all other necessary actions so that provided
25 services may be accessed from therapeutically certified
26 optometrists to the full extent of the Illinois Optometric

 

 

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1 Practice Act of 1987 without discriminating between service
2 providers.
3     The Department shall apply for a waiver from the United
4 States Health Care Financing Administration to allow for the
5 implementation of Partnerships under this Section.
6     The Illinois Department shall require health care
7 providers to maintain records that document the medical care
8 and services provided to recipients of Medical Assistance under
9 this Article. The Illinois Department shall require health care
10 providers to make available, when authorized by the patient, in
11 writing, the medical records in a timely fashion to other
12 health care providers who are treating or serving persons
13 eligible for Medical Assistance under this Article. All
14 dispensers of medical services shall be required to maintain
15 and retain business and professional records sufficient to
16 fully and accurately document the nature, scope, details and
17 receipt of the health care provided to persons eligible for
18 medical assistance under this Code, in accordance with
19 regulations promulgated by the Illinois Department. The rules
20 and regulations shall require that proof of the receipt of
21 prescription drugs, dentures, prosthetic devices and
22 eyeglasses by eligible persons under this Section accompany
23 each claim for reimbursement submitted by the dispenser of such
24 medical services. No such claims for reimbursement shall be
25 approved for payment by the Illinois Department without such
26 proof of receipt, unless the Illinois Department shall have put

 

 

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1 into effect and shall be operating a system of post-payment
2 audit and review which shall, on a sampling basis, be deemed
3 adequate by the Illinois Department to assure that such drugs,
4 dentures, prosthetic devices and eyeglasses for which payment
5 is being made are actually being received by eligible
6 recipients. Within 90 days after the effective date of this
7 amendatory Act of 1984, the Illinois Department shall establish
8 a current list of acquisition costs for all prosthetic devices
9 and any other items recognized as medical equipment and
10 supplies reimbursable under this Article and shall update such
11 list on a quarterly basis, except that the acquisition costs of
12 all prescription drugs shall be updated no less frequently than
13 every 30 days as required by Section 5-5.12.
14     The rules and regulations of the Illinois Department shall
15 require that a written statement including the required opinion
16 of a physician shall accompany any claim for reimbursement for
17 abortions, or induced miscarriages or premature births. This
18 statement shall indicate what procedures were used in providing
19 such medical services.
20     The Illinois Department shall require all dispensers of
21 medical services, other than an individual practitioner or
22 group of practitioners, desiring to participate in the Medical
23 Assistance program established under this Article to disclose
24 all financial, beneficial, ownership, equity, surety or other
25 interests in any and all firms, corporations, partnerships,
26 associations, business enterprises, joint ventures, agencies,

 

 

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1 institutions or other legal entities providing any form of
2 health care services in this State under this Article.
3     The Illinois Department may require that all dispensers of
4 medical services desiring to participate in the medical
5 assistance program established under this Article disclose,
6 under such terms and conditions as the Illinois Department may
7 by rule establish, all inquiries from clients and attorneys
8 regarding medical bills paid by the Illinois Department, which
9 inquiries could indicate potential existence of claims or liens
10 for the Illinois Department.
11     Enrollment of a vendor that provides non-emergency medical
12 transportation, defined by the Department by rule, shall be
13 conditional for 180 days. During that time, the Department of
14 Healthcare and Family Services may terminate the vendor's
15 eligibility to participate in the medical assistance program
16 without cause. That termination of eligibility is not subject
17 to the Department's hearing process.
18     The Illinois Department shall establish policies,
19 procedures, standards and criteria by rule for the acquisition,
20 repair and replacement of orthotic and prosthetic devices and
21 durable medical equipment. Such rules shall provide, but not be
22 limited to, the following services: (1) immediate repair or
23 replacement of such devices by recipients without medical
24 authorization; and (2) rental, lease, purchase or
25 lease-purchase of durable medical equipment in a
26 cost-effective manner, taking into consideration the

 

 

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1 recipient's medical prognosis, the extent of the recipient's
2 needs, and the requirements and costs for maintaining such
3 equipment. Such rules shall enable a recipient to temporarily
4 acquire and use alternative or substitute devices or equipment
5 pending repairs or replacements of any device or equipment
6 previously authorized for such recipient by the Department.
7     The Department shall execute, relative to the nursing home
8 prescreening project, written inter-agency agreements with the
9 Department of Human Services and the Department on Aging, to
10 effect the following: (i) intake procedures and common
11 eligibility criteria for those persons who are receiving
12 non-institutional services; and (ii) the establishment and
13 development of non-institutional services in areas of the State
14 where they are not currently available or are undeveloped.
15     The Illinois Department shall develop and operate, in
16 cooperation with other State Departments and agencies and in
17 compliance with applicable federal laws and regulations,
18 appropriate and effective systems of health care evaluation and
19 programs for monitoring of utilization of health care services
20 and facilities, as it affects persons eligible for medical
21 assistance under this Code.
22     The Illinois Department shall report annually to the
23 General Assembly, no later than the second Friday in April of
24 1979 and each year thereafter, in regard to:
25         (a) actual statistics and trends in utilization of
26     medical services by public aid recipients;

 

 

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1         (b) actual statistics and trends in the provision of
2     the various medical services by medical vendors;
3         (c) current rate structures and proposed changes in
4     those rate structures for the various medical vendors; and
5         (d) efforts at utilization review and control by the
6     Illinois Department.
7     The period covered by each report shall be the 3 years
8 ending on the June 30 prior to the report. The report shall
9 include suggested legislation for consideration by the General
10 Assembly. The filing of one copy of the report with the
11 Speaker, one copy with the Minority Leader and one copy with
12 the Clerk of the House of Representatives, one copy with the
13 President, one copy with the Minority Leader and one copy with
14 the Secretary of the Senate, one copy with the Legislative
15 Research Unit, and such additional copies with the State
16 Government Report Distribution Center for the General Assembly
17 as is required under paragraph (t) of Section 7 of the State
18 Library Act shall be deemed sufficient to comply with this
19 Section.
20     Rulemaking authority to implement Public Act 95-1045 this
21 amendatory Act of the 95th General Assembly, if any, is
22 conditioned on the rules being adopted in accordance with all
23 provisions of the Illinois Administrative Procedure Act and all
24 rules and procedures of the Joint Committee on Administrative
25 Rules; any purported rule not so adopted, for whatever reason,
26 is unauthorized.

 

 

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1 (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07;
2 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; revised 11-4-09.)
 
3     (Text of Section after amendment by P.A. 96-806)
4     Sec. 5-5. Medical services. The Illinois Department, by
5 rule, shall determine the quantity and quality of and the rate
6 of reimbursement for the medical assistance for which payment
7 will be authorized, and the medical services to be provided,
8 which may include all or part of the following: (1) inpatient
9 hospital services; (2) outpatient hospital services; (3) other
10 laboratory and X-ray services; (4) skilled nursing home
11 services; (5) physicians' services whether furnished in the
12 office, the patient's home, a hospital, a skilled nursing home,
13 or elsewhere; (6) medical care, or any other type of remedial
14 care furnished by licensed practitioners; (7) home health care
15 services; (8) private duty nursing service; (9) clinic
16 services; (10) dental services, including prevention and
17 treatment of periodontal disease and dental caries disease for
18 pregnant women, provided by an individual licensed to practice
19 dentistry or dental surgery; for purposes of this item (10),
20 "dental services" means diagnostic, preventive, or corrective
21 procedures provided by or under the supervision of a dentist in
22 the practice of his or her profession; (11) physical therapy
23 and related services; (12) prescribed drugs, dentures, and
24 prosthetic devices; and eyeglasses prescribed by a physician
25 skilled in the diseases of the eye, or by an optometrist,

 

 

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1 whichever the person may select; (13) other diagnostic,
2 screening, preventive, and rehabilitative services; (14)
3 transportation and such other expenses as may be necessary;
4 (15) medical treatment of sexual assault survivors, as defined
5 in Section 1a of the Sexual Assault Survivors Emergency
6 Treatment Act, for injuries sustained as a result of the sexual
7 assault, including examinations and laboratory tests to
8 discover evidence which may be used in criminal proceedings
9 arising from the sexual assault; (16) the diagnosis and
10 treatment of sickle cell anemia; and (17) any other medical
11 care, and any other type of remedial care recognized under the
12 laws of this State, but not including abortions, or induced
13 miscarriages or premature births, unless, in the opinion of a
14 physician, such procedures are necessary for the preservation
15 of the life of the woman seeking such treatment, or except an
16 induced premature birth intended to produce a live viable child
17 and such procedure is necessary for the health of the mother or
18 her unborn child. The Illinois Department, by rule, shall
19 prohibit any physician from providing medical assistance to
20 anyone eligible therefor under this Code where such physician
21 has been found guilty of performing an abortion procedure in a
22 wilful and wanton manner upon a woman who was not pregnant at
23 the time such abortion procedure was performed. The term "any
24 other type of remedial care" shall include nursing care and
25 nursing home service for persons who rely on treatment by
26 spiritual means alone through prayer for healing.

 

 

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1     Notwithstanding any other provision of this Section, a
2 comprehensive tobacco use cessation program that includes
3 purchasing prescription drugs or prescription medical devices
4 approved by the Food and Drug administration shall be covered
5 under the medical assistance program under this Article for
6 persons who are otherwise eligible for assistance under this
7 Article.
8     Notwithstanding any other provision of this Code, the
9 Illinois Department may not require, as a condition of payment
10 for any laboratory test authorized under this Article, that a
11 physician's handwritten signature appear on the laboratory
12 test order form. The Illinois Department may, however, impose
13 other appropriate requirements regarding laboratory test order
14 documentation.
15     The Department of Healthcare and Family Services shall
16 provide the following services to persons eligible for
17 assistance under this Article who are participating in
18 education, training or employment programs operated by the
19 Department of Human Services as successor to the Department of
20 Public Aid:
21         (1) dental services provided by or under the
22     supervision of a dentist; and
23         (2) eyeglasses prescribed by a physician skilled in the
24     diseases of the eye, or by an optometrist, whichever the
25     person may select.
26     Notwithstanding any other provision of this Code and

 

 

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1 subject to federal approval, the Department may adopt rules to
2 allow a dentist who is volunteering his or her service at no
3 cost to render dental services through an enrolled
4 not-for-profit health clinic without the dentist personally
5 enrolling as a participating provider in the medical assistance
6 program. A not-for-profit health clinic shall include a public
7 health clinic or Federally Qualified Health Center or other
8 enrolled provider, as determined by the Department, through
9 which dental services covered under this Section are performed.
10 The Department shall establish a process for payment of claims
11 for reimbursement for covered dental services rendered under
12 this provision.
13     The Illinois Department, by rule, may distinguish and
14 classify the medical services to be provided only in accordance
15 with the classes of persons designated in Section 5-2.
16     The Department of Healthcare and Family Services must
17 provide coverage and reimbursement for amino acid-based
18 elemental formulas, regardless of delivery method, for the
19 diagnosis and treatment of (i) eosinophilic disorders and (ii)
20 short bowel syndrome when the prescribing physician has issued
21 a written order stating that the amino acid-based elemental
22 formula is medically necessary.
23     The Illinois Department shall authorize the provision of,
24 and shall authorize payment for, screening by low-dose
25 mammography for the presence of occult breast cancer for women
26 35 years of age or older who are eligible for medical

 

 

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1 assistance under this Article, as follows:
2         (A) A baseline mammogram for women 35 to 39 years of
3     age.
4         (B) An annual mammogram for women 40 years of age or
5     older.
6         (C) A mammogram at the age and intervals considered
7     medically necessary by the woman's health care provider for
8     women under 40 years of age and having a family history of
9     breast cancer, prior personal history of breast cancer,
10     positive genetic testing, or other risk factors.
11         (D) A comprehensive ultrasound screening of an entire
12     breast or breasts if a mammogram demonstrates
13     heterogeneous or dense breast tissue, when medically
14     necessary as determined by a physician licensed to practice
15     medicine in all of its branches.
16     All screenings shall include a physical breast exam,
17 instruction on self-examination and information regarding the
18 frequency of self-examination and its value as a preventative
19 tool. For purposes of this Section, "low-dose mammography"
20 means the x-ray examination of the breast using equipment
21 dedicated specifically for mammography, including the x-ray
22 tube, filter, compression device, and image receptor, with an
23 average radiation exposure delivery of less than one rad per
24 breast for 2 views of an average size breast. The term also
25 includes digital mammography.
26     On and after July 1, 2008, screening and diagnostic

 

 

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1 mammography shall be reimbursed at the same rate as the
2 Medicare program's rates, including the increased
3 reimbursement for digital mammography.
4     The Department shall convene an expert panel including
5 representatives of hospitals, free-standing mammography
6 facilities, and doctors, including radiologists, to establish
7 quality standards. Based on these quality standards, the
8 Department shall provide for bonus payments to mammography
9 facilities meeting the standards for screening and diagnosis.
10 The bonus payments shall be at least 15% higher than the
11 Medicare rates for mammography.
12     Subject to federal approval, the Department shall
13 establish a rate methodology for mammography at federally
14 qualified health centers and other encounter-rate clinics.
15 These clinics or centers may also collaborate with other
16 hospital-based mammography facilities.
17     The Department shall establish a methodology to remind
18 women who are age-appropriate for screening mammography, but
19 who have not received a mammogram within the previous 18
20 months, of the importance and benefit of screening mammography.
21     The Department shall establish a performance goal for
22 primary care providers with respect to their female patients
23 over age 40 receiving an annual mammogram. This performance
24 goal shall be used to provide additional reimbursement in the
25 form of a quality performance bonus to primary care providers
26 who meet that goal.

 

 

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1     The Department shall devise a means of case-managing or
2 patient navigation for beneficiaries diagnosed with breast
3 cancer. This program shall initially operate as a pilot program
4 in areas of the State with the highest incidence of mortality
5 related to breast cancer. At least one pilot program site shall
6 be in the metropolitan Chicago area and at least one site shall
7 be outside the metropolitan Chicago area. An evaluation of the
8 pilot program shall be carried out measuring health outcomes
9 and cost of care for those served by the pilot program compared
10 to similarly situated patients who are not served by the pilot
11 program.
12     Any medical or health care provider shall immediately
13 recommend, to any pregnant woman who is being provided prenatal
14 services and is suspected of drug abuse or is addicted as
15 defined in the Alcoholism and Other Drug Abuse and Dependency
16 Act, referral to a local substance abuse treatment provider
17 licensed by the Department of Human Services or to a licensed
18 hospital which provides substance abuse treatment services.
19 The Department of Healthcare and Family Services shall assure
20 coverage for the cost of treatment of the drug abuse or
21 addiction for pregnant recipients in accordance with the
22 Illinois Medicaid Program in conjunction with the Department of
23 Human Services.
24     All medical providers providing medical assistance to
25 pregnant women under this Code shall receive information from
26 the Department on the availability of services under the Drug

 

 

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1 Free Families with a Future or any comparable program providing
2 case management services for addicted women, including
3 information on appropriate referrals for other social services
4 that may be needed by addicted women in addition to treatment
5 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 a
9 public awareness campaign, may provide information concerning
10 treatment for alcoholism and drug abuse and addiction, prenatal
11 health care, and other pertinent programs directed at reducing
12 the number of drug-affected infants born to recipients of
13 medical assistance.
14     Neither the Department of Healthcare and Family Services
15 nor the Department of Human Services shall sanction the
16 recipient 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 Article
19 as it shall deem appropriate. The Department should seek the
20 advice of formal professional advisory committees appointed by
21 the Director of the Illinois Department for the purpose of
22 providing regular advice on policy and administrative matters,
23 information dissemination and educational activities for
24 medical and health care providers, and consistency in
25 procedures to the Illinois Department.
26     Notwithstanding any other provision of law, a health care

 

 

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1 provider under the medical assistance program may elect, in
2 lieu of receiving direct payment for services provided under
3 that program, to participate in the State Employees Deferred
4 Compensation Plan adopted under Article 24 of the Illinois
5 Pension Code. A health care provider who elects to participate
6 in the plan does not have a cause of action against the State
7 for any damages allegedly suffered by the provider as a result
8 of any delay by the State in crediting the amount of any
9 contribution to the provider's plan account.
10     The Illinois Department may develop and contract with
11 Partnerships of medical providers to arrange medical services
12 for persons eligible under Section 5-2 of this Code.
13 Implementation of this Section may be by demonstration projects
14 in certain geographic areas. The Partnership shall be
15 represented by a sponsor organization. The Department, by rule,
16 shall develop qualifications for sponsors of Partnerships.
17 Nothing in this Section shall be construed to require that the
18 sponsor organization be a medical organization.
19     The sponsor must negotiate formal written contracts with
20 medical providers for physician services, inpatient and
21 outpatient hospital care, home health services, treatment for
22 alcoholism and substance abuse, and other services determined
23 necessary by the Illinois Department by rule for delivery by
24 Partnerships. Physician services must include prenatal and
25 obstetrical care. The Illinois Department shall reimburse
26 medical services delivered by Partnership providers to clients

 

 

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1 in target areas according to provisions of this Article and the
2 Illinois Health Finance Reform Act, except that:
3         (1) Physicians participating in a Partnership and
4     providing certain services, which shall be determined by
5     the Illinois Department, to persons in areas covered by the
6     Partnership may receive an additional surcharge for such
7     services.
8         (2) The Department may elect to consider and negotiate
9     financial incentives to encourage the development of
10     Partnerships and the efficient delivery of medical care.
11         (3) Persons receiving medical services through
12     Partnerships may receive medical and case management
13     services above the level usually offered through the
14     medical assistance program.
15     Medical providers shall be required to meet certain
16 qualifications to participate in Partnerships to ensure the
17 delivery of high quality medical services. These
18 qualifications shall be determined by rule of the Illinois
19 Department and may be higher than qualifications for
20 participation in the medical assistance program. Partnership
21 sponsors may prescribe reasonable additional qualifications
22 for participation by medical providers, only with the prior
23 written approval of the Illinois Department.
24     Nothing in this Section shall limit the free choice of
25 practitioners, hospitals, and other providers of medical
26 services by clients. In order to ensure patient freedom of

 

 

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1 choice, the Illinois Department shall immediately promulgate
2 all rules and take all other necessary actions so that provided
3 services may be accessed from therapeutically certified
4 optometrists to the full extent of the Illinois Optometric
5 Practice Act of 1987 without discriminating between service
6 providers.
7     The Department shall apply for a waiver from the United
8 States Health Care Financing Administration to allow for the
9 implementation of Partnerships under this Section.
10     The Illinois Department shall require health care
11 providers to maintain records that document the medical care
12 and services provided to recipients of Medical Assistance under
13 this Article. The Illinois Department shall require health care
14 providers to make available, when authorized by the patient, in
15 writing, the medical records in a timely fashion to other
16 health care providers who are treating or serving persons
17 eligible for Medical Assistance under this Article. All
18 dispensers of medical services shall be required to maintain
19 and retain business and professional records sufficient to
20 fully and accurately document the nature, scope, details and
21 receipt of the health care provided to persons eligible for
22 medical assistance under this Code, in accordance with
23 regulations promulgated by the Illinois Department. The rules
24 and regulations shall require that proof of the receipt of
25 prescription drugs, dentures, prosthetic devices and
26 eyeglasses by eligible persons under this Section accompany

 

 

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1 each claim for reimbursement submitted by the dispenser of such
2 medical services. No such claims for reimbursement shall be
3 approved for payment by the Illinois Department without such
4 proof of receipt, unless the Illinois Department shall have put
5 into effect and shall be operating a system of post-payment
6 audit and review which shall, on a sampling basis, be deemed
7 adequate by the Illinois Department to assure that such drugs,
8 dentures, prosthetic devices and eyeglasses for which payment
9 is being made are actually being received by eligible
10 recipients. Within 90 days after the effective date of this
11 amendatory Act of 1984, the Illinois Department shall establish
12 a current list of acquisition costs for all prosthetic devices
13 and any other items recognized as medical equipment and
14 supplies reimbursable under this Article and shall update such
15 list on a quarterly basis, except that the acquisition costs of
16 all prescription drugs shall be updated no less frequently than
17 every 30 days as required by Section 5-5.12.
18     The rules and regulations of the Illinois Department shall
19 require that a written statement including the required opinion
20 of a physician shall accompany any claim for reimbursement for
21 abortions, or induced miscarriages or premature births. This
22 statement shall indicate what procedures were used in providing
23 such medical services.
24     The Illinois Department shall require all dispensers of
25 medical services, other than an individual practitioner or
26 group of practitioners, desiring to participate in the Medical

 

 

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1 Assistance program established under this Article to disclose
2 all financial, beneficial, ownership, equity, surety or other
3 interests in any and all firms, corporations, partnerships,
4 associations, business enterprises, joint ventures, agencies,
5 institutions or other legal entities providing any form of
6 health care services in this State under this Article.
7     The Illinois Department may require that all dispensers of
8 medical services desiring to participate in the medical
9 assistance program established under this Article disclose,
10 under such terms and conditions as the Illinois Department may
11 by rule establish, all inquiries from clients and attorneys
12 regarding medical bills paid by the Illinois Department, which
13 inquiries could indicate potential existence of claims or liens
14 for the Illinois Department.
15     Enrollment of a vendor that provides non-emergency medical
16 transportation, defined by the Department by rule, shall be
17 conditional for 180 days. During that time, the Department of
18 Healthcare and Family Services may terminate the vendor's
19 eligibility to participate in the medical assistance program
20 without cause. That termination of eligibility is not subject
21 to the Department's hearing process.
22     The Illinois Department shall establish policies,
23 procedures, standards and criteria by rule for the acquisition,
24 repair and replacement of orthotic and prosthetic devices and
25 durable medical equipment. Such rules shall provide, but not be
26 limited to, the following services: (1) immediate repair or

 

 

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1 replacement of such devices by recipients without medical
2 authorization; and (2) rental, lease, purchase or
3 lease-purchase of durable medical equipment in a
4 cost-effective manner, taking into consideration the
5 recipient's medical prognosis, the extent of the recipient's
6 needs, and the requirements and costs for maintaining such
7 equipment. Such rules shall enable a recipient to temporarily
8 acquire and use alternative or substitute devices or equipment
9 pending repairs or replacements of any device or equipment
10 previously authorized for such recipient by the Department.
11     The Department shall execute, relative to the nursing home
12 prescreening project, written inter-agency agreements with the
13 Department of Human Services and the Department on Aging, to
14 effect the following: (i) intake procedures and common
15 eligibility criteria for those persons who are receiving
16 non-institutional services; and (ii) the establishment and
17 development of non-institutional services in areas of the State
18 where they are not currently available or are undeveloped.
19     The Illinois Department shall develop and operate, in
20 cooperation with other State Departments and agencies and in
21 compliance with applicable federal laws and regulations,
22 appropriate and effective systems of health care evaluation and
23 programs for monitoring of utilization of health care services
24 and facilities, as it affects persons eligible for medical
25 assistance under this Code.
26     The Illinois Department shall report annually to the

 

 

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1 General Assembly, no later than the second Friday in April of
2 1979 and each year thereafter, in regard to:
3         (a) actual statistics and trends in utilization of
4     medical services by public aid recipients;
5         (b) actual statistics and trends in the provision of
6     the various medical services by medical vendors;
7         (c) current rate structures and proposed changes in
8     those rate structures for the various medical vendors; and
9         (d) efforts at utilization review and control by the
10     Illinois Department.
11     The period covered by each report shall be the 3 years
12 ending on the June 30 prior to the report. The report shall
13 include suggested legislation for consideration by the General
14 Assembly. The filing of one copy of the report with the
15 Speaker, one copy with the Minority Leader and one copy with
16 the Clerk of the House of Representatives, one copy with the
17 President, one copy with the Minority Leader and one copy with
18 the Secretary of the Senate, one copy with the Legislative
19 Research Unit, and such additional copies with the State
20 Government Report Distribution Center for the General Assembly
21 as is required under paragraph (t) of Section 7 of the State
22 Library Act shall be deemed sufficient to comply with this
23 Section.
24     Rulemaking authority to implement Public Act 95-1045 this
25 amendatory Act of the 95th General Assembly, if any, is
26 conditioned on the rules being adopted in accordance with all

 

 

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1 provisions of the Illinois Administrative Procedure Act and all
2 rules and procedures of the Joint Committee on Administrative
3 Rules; any purported rule not so adopted, for whatever reason,
4 is unauthorized.
5 (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07;
6 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; 96-806, eff.
7 7-1-10; revised 11-4-09.)