96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
SB1778

 

Introduced 2/20/2009, by Sen. Mattie Hunter

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5   from Ch. 23, par. 5-5

    Amends the Illinois Public Aid Code. Makes a technical change in a Section concerning medical services.


LRB096 08399 DRJ 18511 b

 

 

A BILL FOR

 

SB1778 LRB096 08399 DRJ 18511 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     Sec. 5-5. Medical services. The Illinois Department, by
8 rule, shall determine the the quantity and quality of and the
9 rate of reimbursement for the medical assistance for which
10 payment will be authorized, and the medical services to be
11 provided, which may include all or part of the following: (1)
12 inpatient hospital services; (2) outpatient hospital services;
13 (3) other laboratory and X-ray services; (4) skilled nursing
14 home services; (5) physicians' services whether furnished in
15 the office, the patient's home, a hospital, a skilled nursing
16 home, or elsewhere; (6) medical care, or any other type of
17 remedial care furnished by licensed practitioners; (7) home
18 health care services; (8) private duty nursing service; (9)
19 clinic services; (10) dental services, including prevention
20 and treatment of periodontal disease and dental caries disease
21 for pregnant women; (11) physical therapy and related services;
22 (12) prescribed drugs, dentures, and prosthetic devices; and
23 eyeglasses prescribed by a physician skilled in the diseases of

 

 

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

 

 

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

 

 

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1     The Illinois Department, by rule, may distinguish and
2 classify the medical services to be provided only in accordance
3 with the classes of persons designated in Section 5-2.
4     The Department of Healthcare and Family Services must
5 provide coverage and reimbursement for amino acid-based
6 elemental formulas, regardless of delivery method, for the
7 diagnosis and treatment of (i) eosinophilic disorders and (ii)
8 short bowel syndrome when the prescribing physician has issued
9 a written order stating that the amino acid-based elemental
10 formula is medically necessary.
11     The Illinois Department shall authorize the provision of,
12 and shall authorize payment for, screening by low-dose
13 mammography for the presence of occult breast cancer for women
14 35 years of age or older who are eligible for medical
15 assistance under this Article, as follows: a baseline mammogram
16 for women 35 to 39 years of age and an annual mammogram for
17 women 40 years of age or older. All screenings shall include a
18 physical breast exam, instruction on self-examination and
19 information regarding the frequency of self-examination and
20 its value as a preventative tool. As used in this Section,
21 "low-dose mammography" means the x-ray examination of the
22 breast using equipment dedicated specifically for mammography,
23 including the x-ray tube, filter, compression device, image
24 receptor, and cassettes, with an average radiation exposure
25 delivery of less than one rad mid-breast, with 2 views for each
26 breast.

 

 

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1     Any medical or health care provider shall immediately
2 recommend, to any pregnant woman who is being provided prenatal
3 services and is suspected of drug abuse or is addicted as
4 defined in the Alcoholism and Other Drug Abuse and Dependency
5 Act, referral to a local substance abuse treatment provider
6 licensed by the Department of Human Services or to a licensed
7 hospital which provides substance abuse treatment services.
8 The Department of Healthcare and Family Services shall assure
9 coverage for the cost of treatment of the drug abuse or
10 addiction for pregnant recipients in accordance with the
11 Illinois Medicaid Program in conjunction with the Department of
12 Human Services.
13     All medical providers providing medical assistance to
14 pregnant women under this Code shall receive information from
15 the Department on the availability of services under the Drug
16 Free Families with a Future or any comparable program providing
17 case management services for addicted women, including
18 information on appropriate referrals for other social services
19 that may be needed by addicted women in addition to treatment
20 for addiction.
21     The Illinois Department, in cooperation with the
22 Departments of Human Services (as successor to the Department
23 of Alcoholism and Substance Abuse) and Public Health, through a
24 public awareness campaign, may provide information concerning
25 treatment for alcoholism and drug abuse and addiction, prenatal
26 health care, and other pertinent programs directed at reducing

 

 

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1 the number of drug-affected infants born to recipients of
2 medical assistance.
3     Neither the Department of Healthcare and Family Services
4 nor the Department of Human Services shall sanction the
5 recipient solely on the basis of her substance abuse.
6     The Illinois Department shall establish such regulations
7 governing the dispensing of health services under this Article
8 as it shall deem appropriate. The Department should seek the
9 advice of formal professional advisory committees appointed by
10 the Director of the Illinois Department for the purpose of
11 providing regular advice on policy and administrative matters,
12 information dissemination and educational activities for
13 medical and health care providers, and consistency in
14 procedures to the Illinois Department.
15     The Illinois Department may develop and contract with
16 Partnerships of medical providers to arrange medical services
17 for persons eligible under Section 5-2 of this Code.
18 Implementation of this Section may be by demonstration projects
19 in certain geographic areas. The Partnership shall be
20 represented by a sponsor organization. The Department, by rule,
21 shall develop qualifications for sponsors of Partnerships.
22 Nothing in this Section shall be construed to require that the
23 sponsor organization be a medical organization.
24     The sponsor must negotiate formal written contracts with
25 medical providers for physician services, inpatient and
26 outpatient hospital care, home health services, treatment for

 

 

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1 alcoholism and substance abuse, and other services determined
2 necessary by the Illinois Department by rule for delivery by
3 Partnerships. Physician services must include prenatal and
4 obstetrical care. The Illinois Department shall reimburse
5 medical services delivered by Partnership providers to clients
6 in target areas according to provisions of this Article and the
7 Illinois Health Finance Reform Act, except that:
8         (1) Physicians participating in a Partnership and
9     providing certain services, which shall be determined by
10     the Illinois Department, to persons in areas covered by the
11     Partnership may receive an additional surcharge for such
12     services.
13         (2) The Department may elect to consider and negotiate
14     financial incentives to encourage the development of
15     Partnerships and the efficient delivery of medical care.
16         (3) Persons receiving medical services through
17     Partnerships may receive medical and case management
18     services above the level usually offered through the
19     medical assistance program.
20     Medical providers shall be required to meet certain
21 qualifications to participate in Partnerships to ensure the
22 delivery of high quality medical services. These
23 qualifications shall be determined by rule of the Illinois
24 Department and may be higher than qualifications for
25 participation in the medical assistance program. Partnership
26 sponsors may prescribe reasonable additional qualifications

 

 

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1 for participation by medical providers, only with the prior
2 written approval of the Illinois Department.
3     Nothing in this Section shall limit the free choice of
4 practitioners, hospitals, and other providers of medical
5 services by clients. In order to ensure patient freedom of
6 choice, the Illinois Department shall immediately promulgate
7 all rules and take all other necessary actions so that provided
8 services may be accessed from therapeutically certified
9 optometrists to the full extent of the Illinois Optometric
10 Practice Act of 1987 without discriminating between service
11 providers.
12     The Department shall apply for a waiver from the United
13 States Health Care Financing Administration to allow for the
14 implementation of Partnerships under this Section.
15     The Illinois Department shall require health care
16 providers to maintain records that document the medical care
17 and services provided to recipients of Medical Assistance under
18 this Article. The Illinois Department shall require health care
19 providers to make available, when authorized by the patient, in
20 writing, the medical records in a timely fashion to other
21 health care providers who are treating or serving persons
22 eligible for Medical Assistance under this Article. All
23 dispensers of medical services shall be required to maintain
24 and retain business and professional records sufficient to
25 fully and accurately document the nature, scope, details and
26 receipt of the health care provided to persons eligible for

 

 

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

 

 

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

 

 

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

 

 

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1 appropriate and effective systems of health care evaluation and
2 programs for monitoring of utilization of health care services
3 and facilities, as it affects persons eligible for medical
4 assistance under this Code.
5     The Illinois Department shall report annually to the
6 General Assembly, no later than the second Friday in April of
7 1979 and each year thereafter, in regard to:
8         (a) actual statistics and trends in utilization of
9     medical services by public aid recipients;
10         (b) actual statistics and trends in the provision of
11     the various medical services by medical vendors;
12         (c) current rate structures and proposed changes in
13     those rate structures for the various medical vendors; and
14         (d) efforts at utilization review and control by the
15     Illinois Department.
16     The period covered by each report shall be the 3 years
17 ending on the June 30 prior to the report. The report shall
18 include suggested legislation for consideration by the General
19 Assembly. The filing of one copy of the report with the
20 Speaker, one copy with the Minority Leader and one copy with
21 the Clerk of the House of Representatives, one copy with the
22 President, one copy with the Minority Leader and one copy with
23 the Secretary of the Senate, one copy with the Legislative
24 Research Unit, and such additional copies with the State
25 Government Report Distribution Center for the General Assembly
26 as is required under paragraph (t) of Section 7 of the State

 

 

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1 Library Act shall be deemed sufficient to comply with this
2 Section.
3 (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)