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92_HB2154 LRB9206174DJgc 1 AN ACT in relation to 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 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 13 services; (3) other laboratory and X-ray services; (4) 14 skilled nursing home services; (5) physicians' services 15 whether furnished in the office, the patient's home, a 16 hospital, a skilled nursing home, or elsewhere; (6) medical 17 care, or any other type of remedial care furnished by 18 licensed practitioners; (7) home health care services; (8) 19 private duty nursing service; (9) clinic services; (10) 20 dental services; (11) physical therapy and related services; 21 (12) prescribed drugs, dentures, and prosthetic devices; and 22 eyeglasses prescribed by a physician skilled in the diseases 23 of the eye, or by an optometrist, whichever the person may 24 select; (13) other diagnostic, screening, preventive, and 25 rehabilitative services; (14) transportation and such other 26 expenses as may be necessary; (15) medical treatment of 27 sexual assault survivors, as defined in Section 1a of the 28 Sexual Assault Survivors Emergency Treatment Act, for 29 injuries sustained as a result of the sexual assault, 30 including examinations and laboratory tests to discover 31 evidence which may be used in criminal proceedings arising -2- LRB9206174DJgc 1 from the sexual assault; (16) the diagnosis and treatment of 2 sickle cell anemia; and (17) any other medical care, and any 3 other type of remedial care recognized under the laws of this 4 State, but not including abortions, or induced miscarriages 5 or premature births, unless, in the opinion of a physician, 6 such procedures are necessary for the preservation of the 7 life of the woman seeking such treatment, or except an 8 induced premature birth intended to produce a live viable 9 child and such procedure is necessary for the health of the 10 mother or her unborn child. The Illinois Department, by rule, 11 shall prohibit any physician from providing medical 12 assistance to anyone eligible therefor under this Code where 13 such physician has been found guilty of performing an 14 abortion procedure in a wilful and wanton manner upon a woman 15 who was not pregnant at the time such abortion procedure was 16 performed. The term "any other type of remedial care" shall 17 include nursing care and nursing home service for persons who 18 rely on treatment by spiritual means alone through prayer for 19 healing. 20 Notwithstanding any other provision of this Section, a 21 comprehensive tobacco use cessation program that includes 22 purchasing prescription drugs or prescription medical devices 23 approved by the Food and Drug administration shall be covered 24 under the medical assistance program under this Article for 25 persons who are otherwise eligible for assistance under this 26 Article. 27 Notwithstanding any other provision of this Code, the 28 Illinois Department may not require, as a condition of 29 payment for any laboratory test authorized under this 30 Article, that a physician's handwritten signature appear on 31 the laboratory test order form. The Illinois Department may, 32 however, impose other appropriate requirements regarding 33 laboratory test order documentation. 34 If a recipient of medical assistance under this Article -3- LRB9206174DJgc 1 undergoes an organ transplantation procedure, all drugs 2 necessary to prevent the recipient's body from rejecting the 3 transplanted organ shall also be covered under the medical 4 assistance program. 5 The Illinois Department of Public Aid shall provide the 6 following services to persons eligible for assistance under 7 this Article who are participating in education, training or 8 employment programs operated by the Department of Human 9 Services as successor to the Department of Public Aid: 10 (1) dental services, which shall include but not be 11 limited to prosthodontics; and 12 (2) eyeglasses prescribed by a physician skilled in 13 the diseases of the eye, or by an optometrist, whichever 14 the person may select. 15 The Illinois Department, by rule, may distinguish and 16 classify the medical services to be provided only in 17 accordance with the classes of persons designated in Section 18 5-2. 19 The Illinois Department shall authorize the provision of, 20 and shall authorize payment for, screening by low-dose 21 mammography for the presence of occult breast cancer for 22 women 35 years of age or older who are eligible for medical 23 assistance under this Article, as follows: a baseline 24 mammogram for women 35 to 39 years of age and an annual 25 mammogram for women 40 years of age or older. All screenings 26 shall include a physical breast exam, instruction on 27 self-examination and information regarding the frequency of 28 self-examination and its value as a preventative tool. As 29 used in this Section, "low-dose mammography" means the x-ray 30 examination of the breast using equipment dedicated 31 specifically for mammography, including the x-ray tube, 32 filter, compression device, image receptor, and cassettes, 33 with an average radiation exposure delivery of less than one 34 rad mid-breast, with 2 views for each breast. -4- LRB9206174DJgc 1 Any medical or health care provider shall immediately 2 recommend, to any pregnant woman who is being provided 3 prenatal services and is suspected of drug abuse or is 4 addicted as defined in the Alcoholism and Other Drug Abuse 5 and Dependency Act, referral to a local substance abuse 6 treatment provider licensed by the Department of Human 7 Services or to a licensed hospital which provides substance 8 abuse treatment services. The Department of Public Aid shall 9 assure coverage for the cost of treatment of the drug abuse 10 or addiction for pregnant recipients in accordance with the 11 Illinois Medicaid Program in conjunction with the Department 12 of 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 17 providing case management services for addicted women, 18 including information on appropriate referrals for other 19 social services that may be needed by addicted women in 20 addition to treatment 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 24 a public awareness campaign, may provide information 25 concerning treatment for alcoholism and drug abuse and 26 addiction, prenatal health care, and other pertinent programs 27 directed at reducing the number of drug-affected infants born 28 to recipients of medical assistance. 29 Neither the Illinois Department of Public Aid nor the 30 Department of Human Services shall sanction the recipient 31 solely on the basis of her substance abuse. 32 The Illinois Department shall establish such regulations 33 governing the dispensing of health services under this 34 Article as it shall deem appropriate. In formulating these -5- LRB9206174DJgc 1 regulations the Illinois Department shall consult with and 2 give substantial weight to the recommendations offered by the 3 Citizens Assembly/Council on Public Aid. The Department 4 should seek the advice of formal professional advisory 5 committees appointed by the Director of the Illinois 6 Department for the purpose of providing regular advice on 7 policy and administrative matters, information dissemination 8 and educational activities for medical and health care 9 providers, and consistency in procedures to the Illinois 10 Department. 11 The Illinois Department may develop and contract with 12 Partnerships of medical providers to arrange medical services 13 for persons eligible under Section 5-2 of this Code. 14 Implementation of this Section may be by demonstration 15 projects in certain geographic areas. The Partnership shall 16 be represented by a sponsor organization. The Department, by 17 rule, shall develop qualifications for sponsors of 18 Partnerships. Nothing in this Section shall be construed to 19 require that the sponsor organization be a medical 20 organization. 21 The sponsor must negotiate formal written contracts with 22 medical providers for physician services, inpatient and 23 outpatient hospital care, home health services, treatment for 24 alcoholism and substance abuse, and other services determined 25 necessary by the Illinois Department by rule for delivery by 26 Partnerships. Physician services must include prenatal and 27 obstetrical care. The Illinois Department shall reimburse 28 medical services delivered by Partnership providers to 29 clients in target areas according to provisions of this 30 Article and the Illinois Health Finance Reform Act, except 31 that: 32 (1) Physicians participating in a Partnership and 33 providing certain services, which shall be determined by 34 the Illinois Department, to persons in areas covered by -6- LRB9206174DJgc 1 the Partnership may receive an additional surcharge for 2 such services. 3 (2) The Department may elect to consider and 4 negotiate financial incentives to encourage the 5 development of Partnerships and the efficient delivery of 6 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 25 provided services may be accessed from therapeutically 26 certified optometrists to the full extent of the Illinois 27 Optometric Practice Act of 1987 without discriminating 28 between service providers. 29 The Department shall apply for a waiver from the United 30 States Health Care Financing Administration to allow for the 31 implementation of Partnerships under this Section. 32 The Illinois Department shall require health care 33 providers to maintain records that document the medical care 34 and services provided to recipients of Medical Assistance -7- LRB9206174DJgc 1 under this Article. The Illinois Department shall require 2 health care providers to make available, when authorized by 3 the patient, in writing, the medical records in a timely 4 fashion to other health care providers who are treating or 5 serving persons eligible for Medical Assistance under this 6 Article. All dispensers of medical services shall be 7 required to maintain and retain business and professional 8 records sufficient to fully and accurately document the 9 nature, scope, details and receipt of the health care 10 provided to persons eligible for medical assistance under 11 this Code, in accordance with regulations promulgated by the 12 Illinois Department. The rules and regulations shall require 13 that proof of the receipt of prescription drugs, dentures, 14 prosthetic devices and eyeglasses by eligible persons under 15 this Section accompany each claim for reimbursement submitted 16 by the dispenser of such medical services. No such claims for 17 reimbursement shall be approved for payment by the Illinois 18 Department without such proof of receipt, unless the Illinois 19 Department shall have put into effect and shall be operating 20 a system of post-payment audit and review which shall, on a 21 sampling basis, be deemed adequate by the Illinois Department 22 to assure that such drugs, dentures, prosthetic devices and 23 eyeglasses for which payment is being made are actually being 24 received by eligible recipients. Within 90 days after the 25 effective date of this amendatory Act of 1984, the Illinois 26 Department shall establish a current list of acquisition 27 costs for all prosthetic devices and any other items 28 recognized as medical equipment and supplies reimbursable 29 under this Article and shall update such list on a quarterly 30 basis, except that the acquisition costs of all prescription 31 drugs shall be updated no less frequently than every 30 days 32 as required by Section 5-5.12. 33 The rules and regulations of the Illinois Department 34 shall require that a written statement including the required -8- LRB9206174DJgc 1 opinion of a physician shall accompany any claim for 2 reimbursement for abortions, or induced miscarriages or 3 premature births. This statement shall indicate what 4 procedures were used in providing such medical services. 5 The Illinois Department shall require that all dispensers 6 of medical services, other than an individual practitioner or 7 group of practitioners, desiring to participate in the 8 Medical Assistance program established under this Article to 9 disclose all financial, beneficial, ownership, equity, surety 10 or other interests in any and all firms, corporations, 11 partnerships, associations, business enterprises, joint 12 ventures, agencies, institutions or other legal entities 13 providing any form of health care services in this State 14 under this Article. 15 The Illinois Department may require that all dispensers 16 of medical services desiring to participate in the medical 17 assistance program established under this Article disclose, 18 under such terms and conditions as the Illinois Department 19 may by rule establish, all inquiries from clients and 20 attorneys regarding medical bills paid by the Illinois 21 Department, which inquiries could indicate potential 22 existence of claims or liens for the Illinois Department. 23 The Illinois Department shall establish policies, 24 procedures, standards and criteria by rule for the 25 acquisition, repair and replacement of orthotic and 26 prosthetic devices and durable medical equipment. Such rules 27 shall provide, but not be limited to, the following services: 28 (1) immediate repair or replacement of such devices by 29 recipients without medical authorization; and (2) rental, 30 lease, purchase or lease-purchase of durable medical 31 equipment in a cost-effective manner, taking into 32 consideration the recipient's medical prognosis, the extent 33 of the recipient's needs, and the requirements and costs for 34 maintaining such equipment. Such rules shall enable a -9- LRB9206174DJgc 1 recipient to temporarily acquire and use alternative or 2 substitute devices or equipment pending repairs or 3 replacements of any device or equipment previously authorized 4 for such recipient by the Department. Rules under clause (2) 5 above shall not provide for purchase or lease-purchase of 6 durable medical equipment or supplies used for the purpose of 7 oxygen delivery and respiratory care. 8 The Department shall execute, relative to the nursing 9 home prescreening project, written inter-agency agreements 10 with the Department of Human Services and the Department on 11 Aging, to effect the following: (i) intake procedures and 12 common eligibility criteria for those persons who are 13 receiving non-institutional services; and (ii) the 14 establishment and development of non-institutional services 15 in areas of the State where they are not currently available 16 or are undeveloped. 17 The Illinois Department shall develop and operate, in 18 cooperation with other State Departments and agencies and in 19 compliance with applicable federal laws and regulations, 20 appropriate and effective systems of health care evaluation 21 and programs for monitoring of utilization of health care 22 services and facilities, as it affects persons eligible for 23 medical assistance under this Code. The Illinois Department 24 shall report regularly the results of the operation of such 25 systems and programs to the Citizens Assembly/Council on 26 Public Aid to enable the Committee to ensure, from time to 27 time, that these programs are effective and meaningful. 28 The Illinois Department shall report annually to the 29 General Assembly, no later than the second Friday in April of 30 1979 and each year thereafter, in regard to: 31 (a) actual statistics and trends in utilization of 32 medical services by public aid recipients; 33 (b) actual statistics and trends in the provision 34 of the various medical services by medical vendors; -10- LRB9206174DJgc 1 (c) current rate structures and proposed changes in 2 those rate structures for the various medical vendors; 3 and 4 (d) efforts at utilization review and control by 5 the Illinois Department. 6 The period covered by each report shall be the 3 years 7 ending on the June 30 prior to the report. The report shall 8 include suggested legislation for consideration by the 9 General Assembly. The filing of one copy of the report with 10 the Speaker, one copy with the Minority Leader and one copy 11 with the Clerk of the House of Representatives, one copy with 12 the President, one copy with the Minority Leader and one copy 13 with the Secretary of the Senate, one copy with the 14 Legislative Research Unit, such additional copies with the 15 State Government Report Distribution Center for the General 16 Assembly as is required under paragraph (t) of Section 7 of 17 the State Library Act and one copy with the Citizens 18 Assembly/Council on Public Aid or its successor shall be 19 deemed sufficient to comply with this Section. 20 (Source: P.A. 90-7, eff. 6-10-97; 90-14, eff. 7-1-97; 91-344, 21 eff. 1-1-00; 91-462, eff. 8-6-99; 91-666, eff. 12-22-99; 22 revised 1-6-00.) 23 Section 99. Effective date. This Act takes effect upon 24 becoming law.
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