97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
SB3486

 

Introduced 2/7/2012, by Sen. William Delgado

 

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

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that a dental desensitization program that aims to allay the fears and anxieties of dental patients, age 5 through 21, who have a developmental disability or mental illness by familiarizing such patients with the surroundings, tools, and procedures of the dental office or clinic during a comprehensive patient walk-through shall be covered under the State's medical assistance program for persons who are otherwise eligible for medical assistance under the Code. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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

 

 

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

 

 

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1performing an abortion procedure in a wilful and wanton manner
2upon a woman who was not pregnant at the time such abortion
3procedure was performed. The term "any other type of remedial
4care" shall include nursing care and nursing home service for
5persons who rely on treatment by spiritual means alone through
6prayer for healing.
7    Notwithstanding any other provision of this Section, a
8comprehensive tobacco use cessation program that includes
9purchasing prescription drugs or prescription medical devices
10approved by the Food and Drug Administration shall be covered
11under the medical assistance program under this Article for
12persons who are otherwise eligible for assistance under this
13Article.
14    Notwithstanding any other provision of this Code, the
15Illinois Department may not require, as a condition of payment
16for any laboratory test authorized under this Article, that a
17physician's handwritten signature appear on the laboratory
18test order form. The Illinois Department may, however, impose
19other appropriate requirements regarding laboratory test order
20documentation.
21    The Department of Healthcare and Family Services shall
22provide the following services to persons eligible for
23assistance under this Article who are participating in
24education, training or employment programs operated by the
25Department of Human Services as successor to the Department of
26Public 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
7subject to federal approval, the Department may adopt rules to
8allow a dentist who is volunteering his or her service at no
9cost to render dental services through an enrolled
10not-for-profit health clinic without the dentist personally
11enrolling as a participating provider in the medical assistance
12program. A not-for-profit health clinic shall include a public
13health clinic or Federally Qualified Health Center or other
14enrolled provider, as determined by the Department, through
15which dental services covered under this Section are performed.
16The Department shall establish a process for payment of claims
17for reimbursement for covered dental services rendered under
18this provision.
19    Notwithstanding any other provision of this Section, a
20dental desensitization program that aims to allay the fears and
21anxieties of dental patients, age 5 through 21, who have a
22developmental disability or mental illness by familiarizing
23such patients with the surroundings, tools, and procedures of
24the dental office or clinic during a comprehensive patient
25walk-through shall be covered under the medical assistance
26program under this Article for persons who are otherwise

 

 

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1eligible for medical assistance under this Article.
2    The Illinois Department, by rule, may distinguish and
3classify the medical services to be provided only in accordance
4with the classes of persons designated in Section 5-2.
5    The Department of Healthcare and Family Services must
6provide coverage and reimbursement for amino acid-based
7elemental formulas, regardless of delivery method, for the
8diagnosis and treatment of (i) eosinophilic disorders and (ii)
9short bowel syndrome when the prescribing physician has issued
10a written order stating that the amino acid-based elemental
11formula is medically necessary.
12    The Illinois Department shall authorize the provision of,
13and shall authorize payment for, screening by low-dose
14mammography for the presence of occult breast cancer for women
1535 years of age or older who are eligible for medical
16assistance under this Article, as follows:
17        (A) A baseline mammogram for women 35 to 39 years of
18    age.
19        (B) An annual mammogram for women 40 years of age or
20    older.
21        (C) A mammogram at the age and intervals considered
22    medically necessary by the woman's health care provider for
23    women under 40 years of age and having a family history of
24    breast cancer, prior personal history of breast cancer,
25    positive genetic testing, or other risk factors.
26        (D) A comprehensive ultrasound screening of an entire

 

 

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1    breast or breasts if a mammogram demonstrates
2    heterogeneous or dense breast tissue, when medically
3    necessary as determined by a physician licensed to practice
4    medicine in all of its branches.
5    All screenings shall include a physical breast exam,
6instruction on self-examination and information regarding the
7frequency of self-examination and its value as a preventative
8tool. For purposes of this Section, "low-dose mammography"
9means the x-ray examination of the breast using equipment
10dedicated specifically for mammography, including the x-ray
11tube, filter, compression device, and image receptor, with an
12average radiation exposure delivery of less than one rad per
13breast for 2 views of an average size breast. The term also
14includes digital mammography.
15    On and after January 1, 2012, providers participating in a
16quality improvement program approved by the Department shall be
17reimbursed for screening and diagnostic mammography at the same
18rate as the Medicare program's rates, including the increased
19reimbursement for digital mammography.
20    The Department shall convene an expert panel including
21representatives of hospitals, free-standing mammography
22facilities, and doctors, including radiologists, to establish
23quality standards.
24    Subject to federal approval, the Department shall
25establish a rate methodology for mammography at federally
26qualified health centers and other encounter-rate clinics.

 

 

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1These clinics or centers may also collaborate with other
2hospital-based mammography facilities.
3    The Department shall establish a methodology to remind
4women who are age-appropriate for screening mammography, but
5who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening mammography.
7    The Department shall establish a performance goal for
8primary care providers with respect to their female patients
9over age 40 receiving an annual mammogram. This performance
10goal shall be used to provide additional reimbursement in the
11form of a quality performance bonus to primary care providers
12who meet that goal.
13    The Department shall devise a means of case-managing or
14patient navigation for beneficiaries diagnosed with breast
15cancer. This program shall initially operate as a pilot program
16in areas of the State with the highest incidence of mortality
17related to breast cancer. At least one pilot program site shall
18be in the metropolitan Chicago area and at least one site shall
19be outside the metropolitan Chicago area. An evaluation of the
20pilot program shall be carried out measuring health outcomes
21and cost of care for those served by the pilot program compared
22to similarly situated patients who are not served by the pilot
23program.
24    Any medical or health care provider shall immediately
25recommend, to any pregnant woman who is being provided prenatal
26services and is suspected of drug abuse or is addicted as

 

 

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1defined in the Alcoholism and Other Drug Abuse and Dependency
2Act, referral to a local substance abuse treatment provider
3licensed by the Department of Human Services or to a licensed
4hospital which provides substance abuse treatment services.
5The Department of Healthcare and Family Services shall assure
6coverage for the cost of treatment of the drug abuse or
7addiction for pregnant recipients in accordance with the
8Illinois Medicaid Program in conjunction with the Department of
9Human Services.
10    All medical providers providing medical assistance to
11pregnant women under this Code shall receive information from
12the Department on the availability of services under the Drug
13Free Families with a Future or any comparable program providing
14case management services for addicted women, including
15information on appropriate referrals for other social services
16that may be needed by addicted women in addition to treatment
17for addiction.
18    The Illinois Department, in cooperation with the
19Departments of Human Services (as successor to the Department
20of Alcoholism and Substance Abuse) and Public Health, through a
21public awareness campaign, may provide information concerning
22treatment for alcoholism and drug abuse and addiction, prenatal
23health care, and other pertinent programs directed at reducing
24the number of drug-affected infants born to recipients of
25medical assistance.
26    Neither the Department of Healthcare and Family Services

 

 

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1nor the Department of Human Services shall sanction the
2recipient solely on the basis of her substance abuse.
3    The Illinois Department shall establish such regulations
4governing the dispensing of health services under this Article
5as it shall deem appropriate. The Department should seek the
6advice of formal professional advisory committees appointed by
7the Director of the Illinois Department for the purpose of
8providing regular advice on policy and administrative matters,
9information dissemination and educational activities for
10medical and health care providers, and consistency in
11procedures to the Illinois Department.
12    Notwithstanding any other provision of law, a health care
13provider under the medical assistance program may elect, in
14lieu of receiving direct payment for services provided under
15that program, to participate in the State Employees Deferred
16Compensation Plan adopted under Article 24 of the Illinois
17Pension Code. A health care provider who elects to participate
18in the plan does not have a cause of action against the State
19for any damages allegedly suffered by the provider as a result
20of any delay by the State in crediting the amount of any
21contribution to the provider's plan account.
22    The Illinois Department may develop and contract with
23Partnerships of medical providers to arrange medical services
24for persons eligible under Section 5-2 of this Code.
25Implementation of this Section may be by demonstration projects
26in certain geographic areas. The Partnership shall be

 

 

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1represented by a sponsor organization. The Department, by rule,
2shall develop qualifications for sponsors of Partnerships.
3Nothing in this Section shall be construed to require that the
4sponsor organization be a medical organization.
5    The sponsor must negotiate formal written contracts with
6medical providers for physician services, inpatient and
7outpatient hospital care, home health services, treatment for
8alcoholism and substance abuse, and other services determined
9necessary by the Illinois Department by rule for delivery by
10Partnerships. Physician services must include prenatal and
11obstetrical care. The Illinois Department shall reimburse
12medical services delivered by Partnership providers to clients
13in target areas according to provisions of this Article and the
14Illinois Health Finance Reform Act, except that:
15        (1) Physicians participating in a Partnership and
16    providing certain services, which shall be determined by
17    the Illinois Department, to persons in areas covered by the
18    Partnership may receive an additional surcharge for such
19    services.
20        (2) The Department may elect to consider and negotiate
21    financial incentives to encourage the development of
22    Partnerships and the efficient delivery of medical care.
23        (3) Persons receiving medical services through
24    Partnerships may receive medical and case management
25    services above the level usually offered through the
26    medical assistance program.

 

 

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1    Medical providers shall be required to meet certain
2qualifications to participate in Partnerships to ensure the
3delivery of high quality medical services. These
4qualifications shall be determined by rule of the Illinois
5Department and may be higher than qualifications for
6participation in the medical assistance program. Partnership
7sponsors may prescribe reasonable additional qualifications
8for participation by medical providers, only with the prior
9written approval of the Illinois Department.
10    Nothing in this Section shall limit the free choice of
11practitioners, hospitals, and other providers of medical
12services by clients. In order to ensure patient freedom of
13choice, the Illinois Department shall immediately promulgate
14all rules and take all other necessary actions so that provided
15services may be accessed from therapeutically certified
16optometrists to the full extent of the Illinois Optometric
17Practice Act of 1987 without discriminating between service
18providers.
19    The Department shall apply for a waiver from the United
20States Health Care Financing Administration to allow for the
21implementation of Partnerships under this Section.
22    The Illinois Department shall require health care
23providers to maintain records that document the medical care
24and services provided to recipients of Medical Assistance under
25this Article. Such records must be retained for a period of not
26less than 6 years from the date of service or as provided by

 

 

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1applicable State law, whichever period is longer, except that
2if an audit is initiated within the required retention period
3then the records must be retained until the audit is completed
4and every exception is resolved. The Illinois Department shall
5require health care providers to make available, when
6authorized by the patient, in writing, the medical records in a
7timely fashion to other health care providers who are treating
8or serving persons eligible for Medical Assistance under this
9Article. All dispensers of medical services shall be required
10to maintain and retain business and professional records
11sufficient to fully and accurately document the nature, scope,
12details and receipt of the health care provided to persons
13eligible for medical assistance under this Code, in accordance
14with regulations promulgated by the Illinois Department. The
15rules and regulations shall require that proof of the receipt
16of prescription drugs, dentures, prosthetic devices and
17eyeglasses by eligible persons under this Section accompany
18each claim for reimbursement submitted by the dispenser of such
19medical services. No such claims for reimbursement shall be
20approved for payment by the Illinois Department without such
21proof of receipt, unless the Illinois Department shall have put
22into effect and shall be operating a system of post-payment
23audit and review which shall, on a sampling basis, be deemed
24adequate by the Illinois Department to assure that such drugs,
25dentures, prosthetic devices and eyeglasses for which payment
26is being made are actually being received by eligible

 

 

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

 

 

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

 

 

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1previously authorized for such recipient by the Department.
2    The Department shall execute, relative to the nursing home
3prescreening project, written inter-agency agreements with the
4Department of Human Services and the Department on Aging, to
5effect the following: (i) intake procedures and common
6eligibility criteria for those persons who are receiving
7non-institutional services; and (ii) the establishment and
8development of non-institutional services in areas of the State
9where they are not currently available or are undeveloped.
10    The Illinois Department shall develop and operate, in
11cooperation with other State Departments and agencies and in
12compliance with applicable federal laws and regulations,
13appropriate and effective systems of health care evaluation and
14programs for monitoring of utilization of health care services
15and facilities, as it affects persons eligible for medical
16assistance under this Code.
17    The Illinois Department shall report annually to the
18General Assembly, no later than the second Friday in April of
191979 and each year thereafter, in regard to:
20        (a) actual statistics and trends in utilization of
21    medical services by public aid recipients;
22        (b) actual statistics and trends in the provision of
23    the various medical services by medical vendors;
24        (c) current rate structures and proposed changes in
25    those rate structures for the various medical vendors; and
26        (d) efforts at utilization review and control by the

 

 

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1    Illinois Department.
2    The period covered by each report shall be the 3 years
3ending on the June 30 prior to the report. The report shall
4include suggested legislation for consideration by the General
5Assembly. The filing of one copy of the report with the
6Speaker, one copy with the Minority Leader and one copy with
7the Clerk of the House of Representatives, one copy with the
8President, one copy with the Minority Leader and one copy with
9the Secretary of the Senate, one copy with the Legislative
10Research Unit, and such additional copies with the State
11Government Report Distribution Center for the General Assembly
12as is required under paragraph (t) of Section 7 of the State
13Library Act shall be deemed sufficient to comply with this
14Section.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,
22eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638,
23eff. 1-1-12.)
 
24    Section 99. Effective date. This Act takes effect upon
25becoming law.