State of Illinois
91st General Assembly
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Public Act 91-0462

SB498 Enrolled                                 LRB9101554SMdv

    AN ACT to amend the Illinois Public Aid Code by  changing
Section 5-5.

    Be  it  enacted  by  the People of the State of Illinois,
represented in the General Assembly:


    Section 5.  The Illinois Public Aid Code  is  amended  by
changing Section 5-5 as follows:

    (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
    Sec.  5-5.  Medical services. The Illinois Department, by
rule, shall determine the quantity and  quality  of  and  the
rate  of  reimbursement  for the medical assistance for which
payment will be authorized, and the medical  services  to  be
provided, which may include all or part of the following: (1)
inpatient   hospital   services;   (2)   outpatient  hospital
services;  (3)  other  laboratory  and  X-ray  services;  (4)
skilled  nursing  home  services;  (5)  physicians'  services
whether furnished  in  the  office,  the  patient's  home,  a
hospital,  a  skilled nursing home, or elsewhere; (6) medical
care, or  any  other  type  of  remedial  care  furnished  by
licensed  practitioners;  (7)  home health care services; (8)
private duty  nursing  service;  (9)  clinic  services;  (10)
dental  services; (11) physical therapy and related services;
(12) prescribed drugs, dentures, and prosthetic devices;  and
eyeglasses  prescribed by a physician skilled in the diseases
of the eye, or by an optometrist, whichever  the  person  may
select;  (13)  other  diagnostic,  screening, preventive, and
rehabilitative services; (14) transportation and  such  other
expenses  as  may  be  necessary;  (15)  medical treatment of
sexual assault survivors, as defined in  Section  1a  of  the
Sexual   Assault   Survivors  Emergency  Treatment  Act,  for
injuries  sustained  as  a  result  of  the  sexual  assault,
including  examinations  and  laboratory  tests  to  discover
evidence which may be used in  criminal  proceedings  arising
from  the sexual assault; (16) the diagnosis and treatment of
sickle cell anemia; and (17) any other medical care, and  any
other type of remedial care recognized under the laws of this
State,  but  not including abortions, or induced miscarriages
or premature births, unless, in the opinion of  a  physician,
such  procedures  are  necessary  for the preservation of the
life of the  woman  seeking  such  treatment,  or  except  an
induced  premature  birth  intended  to produce a live viable
child and such procedure is necessary for the health  of  the
mother or her unborn child. The Illinois Department, by rule,
shall   prohibit   any   physician   from  providing  medical
assistance to anyone eligible therefor under this Code  where
such  physician  has  been  found  guilty  of  performing  an
abortion procedure in a wilful and wanton manner upon a woman
who  was not pregnant at the time such abortion procedure was
performed. The term "any other type of remedial  care"  shall
include nursing care and nursing home service for persons who
rely on treatment by spiritual means alone through prayer for
healing.
    The  Illinois  Department of Public Aid shall provide the
following services to persons eligible for  assistance  under
this  Article who are participating in education, training or
employment programs  operated  by  the  Department  of  Human
Services as successor to the Department of Public Aid:
         (1)  dental services, which shall include but not be
    limited to prosthodontics; and
         (2)  eyeglasses prescribed by a physician skilled in
    the  diseases of the eye, or by an optometrist, whichever
    the person may select.
    The Illinois Department, by  rule,  may  distinguish  and
classify   the  medical  services  to  be  provided  only  in
accordance with the classes of persons designated in  Section
5-2.
    The Illinois Department shall authorize the provision of,
and  shall  authorize  payment  for,  screening  by  low-dose
mammography  for  the  presence  of  occult breast cancer for
women 35 years of age or older who are eligible  for  medical
assistance  under  this  Article,  as  follows:   a  baseline
mammogram  for  women  35  to  39  years of age and an annual
mammogram for women 40 years of age or older.  All screenings
shall  include  a  physical  breast  exam,   instruction   on
self-examination  and  information regarding the frequency of
self-examination and its value as a  preventative  tool.   As
used  in this Section, "low-dose mammography" means the x-ray
examination  of  the   breast   using   equipment   dedicated
specifically  for  mammography,  including  the  x-ray  tube,
filter,  compression  device,  image receptor, and cassettes,
with an average radiation exposure delivery of less than  one
rad mid-breast, with 2 views for each breast.
    Any  medical  or  health  care provider shall immediately
recommend, to  any  pregnant  woman  who  is  being  provided
prenatal  services  and  is  suspected  of  drug  abuse or is
addicted as defined in the Alcoholism and  Other  Drug  Abuse
and  Dependency  Act,  referral  to  a  local substance abuse
treatment  provider  licensed  by  the  Department  of  Human
Services or to a licensed hospital which  provides  substance
abuse treatment services.  The Department of Public Aid shall
assure  coverage  for the cost of treatment of the drug abuse
or addiction for pregnant recipients in accordance  with  the
Illinois  Medicaid Program in conjunction with the Department
of Human Services.
    All medical providers  providing  medical  assistance  to
pregnant women under this Code shall receive information from
the Department on the availability of services under the Drug
Free  Families  with  a  Future  or  any  comparable  program
providing   case  management  services  for  addicted  women,
including information  on  appropriate  referrals  for  other
social  services  that  may  be  needed  by addicted women in
addition to treatment for addiction.
    The  Illinois  Department,  in   cooperation   with   the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a   public   awareness   campaign,  may  provide  information
concerning  treatment  for  alcoholism  and  drug  abuse  and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
    Neither the Illinois Department of  Public  Aid  nor  the
Department  of  Human  Services  shall sanction the recipient
solely on the basis of her substance abuse.
    The Illinois Department shall establish such  regulations
governing  the  dispensing  of  health  services  under  this
Article  as  it shall deem appropriate.  In formulating these
regulations the Illinois Department shall  consult  with  and
give substantial weight to the recommendations offered by the
Citizens  Assembly/Council  on  Public  Aid.  The  Department
should  seek  the  advice  of  formal  professional  advisory
committees   appointed   by  the  Director  of  the  Illinois
Department for the purpose of  providing  regular  advice  on
policy  and administrative matters, information dissemination
and  educational  activities  for  medical  and  health  care
providers, and consistency  in  procedures  to  the  Illinois
Department.
    The  Illinois  Department  may  develop and contract with
Partnerships of medical providers to arrange medical services
for  persons  eligible  under  Section  5-2  of  this   Code.
Implementation  of  this  Section  may  be  by  demonstration
projects  in certain geographic areas.  The Partnership shall
be represented by a sponsor organization.  The Department, by
rule,  shall   develop   qualifications   for   sponsors   of
Partnerships.   Nothing in this Section shall be construed to
require  that  the  sponsor   organization   be   a   medical
organization.
    The  sponsor must negotiate formal written contracts with
medical  providers  for  physician  services,  inpatient  and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery  by
Partnerships.   Physician  services must include prenatal and
obstetrical care.  The Illinois  Department  shall  reimburse
medical   services  delivered  by  Partnership  providers  to
clients in target  areas  according  to  provisions  of  this
Article  and  the  Illinois Health Finance Reform Act, except
that:
         (1)  Physicians participating in a  Partnership  and
    providing  certain services, which shall be determined by
    the Illinois Department, to persons in areas  covered  by
    the  Partnership  may receive an additional surcharge for
    such services.
         (2)  The  Department  may  elect  to  consider   and
    negotiate   financial   incentives   to   encourage   the
    development of Partnerships and the efficient delivery of
    medical care.
         (3)  Persons   receiving  medical  services  through
    Partnerships may  receive  medical  and  case  management
    services  above  the  level  usually  offered through the
    medical assistance program.
    Medical providers  shall  be  required  to  meet  certain
qualifications  to  participate in Partnerships to ensure the
delivery   of   high   quality   medical   services.    These
qualifications shall be determined by rule  of  the  Illinois
Department   and   may  be  higher  than  qualifications  for
participation in the medical assistance program.  Partnership
sponsors may prescribe reasonable  additional  qualifications
for  participation  by medical providers, only with the prior
written approval of the Illinois Department.
    Nothing in this Section shall limit the  free  choice  of
practitioners,  hospitals,  and  other  providers  of medical
services by clients. In order to ensure  patient  freedom  of
choice,  the Illinois Department shall immediately promulgate
all rules and  take  all  other  necessary  actions  so  that
provided   services  may  be  accessed  from  therapeutically
certified optometrists to the full  extent  of  the  Illinois
Optometric   Practice  Act  of  1987  without  discriminating
between service providers.
    The Department shall apply for a waiver from  the  United
States  Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
    The  Illinois  Department  shall  require   health   care
providers  to maintain records that document the medical care
and services provided to  recipients  of  Medical  Assistance
under  this  Article.   The Illinois Department shall require
health care providers to make available, when  authorized  by
the  patient,  in  writing,  the  medical records in a timely
fashion to other health care providers who  are  treating  or
serving  persons  eligible  for Medical Assistance under this
Article.   All  dispensers  of  medical  services  shall   be
required  to  maintain  and  retain business and professional
records sufficient  to  fully  and  accurately  document  the
nature,  scope,  details  and  receipt  of  the  health  care
provided  to  persons  eligible  for medical assistance under
this Code, in accordance with regulations promulgated by  the
Illinois  Department. The rules and regulations shall require
that proof of the receipt of  prescription  drugs,  dentures,
prosthetic  devices  and eyeglasses by eligible persons under
this Section accompany each claim for reimbursement submitted
by the dispenser of such medical services. No such claims for
reimbursement shall be approved for payment by  the  Illinois
Department without such proof of receipt, unless the Illinois
Department  shall have put into effect and shall be operating
a system of post-payment audit and review which shall,  on  a
sampling basis, be deemed adequate by the Illinois Department
to  assure  that such drugs, dentures, prosthetic devices and
eyeglasses for which payment is being made are actually being
received by eligible recipients. Within  90  days  after  the
effective  date  of this amendatory Act of 1984, the Illinois
Department shall establish  a  current  list  of  acquisition
costs   for  all  prosthetic  devices  and  any  other  items
recognized as medical  equipment  and  supplies  reimbursable
under  this Article and shall update such list on a quarterly
basis, except that the acquisition costs of all  prescription
drugs  shall be updated no less frequently than every 30 days
as required by Section 5-5.12.
    The rules and  regulations  of  the  Illinois  Department
shall require that a written statement including the required
opinion   of  a  physician  shall  accompany  any  claim  for
reimbursement  for  abortions,  or  induced  miscarriages  or
premature  births.   This  statement  shall   indicate   what
procedures were used in providing such medical services.
    The Illinois Department shall require that all dispensers
of medical services, other than an individual practitioner or
group  of  practitioners,  desiring  to  participate  in  the
Medical  Assistance program established under this Article to
disclose all financial, beneficial, ownership, equity, surety
or other  interests  in  any  and  all  firms,  corporations,
partnerships,   associations,   business  enterprises,  joint
ventures, agencies,  institutions  or  other  legal  entities
providing  any  form  of  health  care services in this State
under this Article.
    The Illinois Department may require that  all  dispensers
of  medical  services  desiring to participate in the medical
assistance program established under this  Article  disclose,
under  such  terms  and conditions as the Illinois Department
may  by  rule  establish,  all  inquiries  from  clients  and
attorneys  regarding  medical  bills  paid  by  the  Illinois
Department,  which   inquiries   could   indicate   potential
existence of claims or liens for the Illinois Department.
    The   Illinois   Department   shall  establish  policies,
procedures,  standards  and  criteria   by   rule   for   the
acquisition,   repair   and   replacement   of  orthotic  and
prosthetic devices and durable medical equipment.  Such rules
shall provide, but not be limited to, the following services:
(1) immediate  repair  or  replacement  of  such  devices  by
recipients  without  medical  authorization;  and (2) rental,
lease,  purchase  or  lease-purchase   of   durable   medical
equipment   in   a   cost-effective   manner,   taking   into
consideration  the  recipient's medical prognosis, the extent
of the recipient's needs, and the requirements and costs  for
maintaining  such  equipment.   Such  rules  shall  enable  a
recipient  to  temporarily  acquire  and  use  alternative or
substitute  devices   or   equipment   pending   repairs   or
replacements of any device or equipment previously authorized
for  such recipient by the Department. Rules under clause (2)
above shall not provide for  purchase  or  lease-purchase  of
durable medical equipment or supplies used for the purpose of
oxygen delivery and respiratory care.
    The  Department  shall  execute,  relative to the nursing
home prescreening project,  written  inter-agency  agreements
with  the  Department of Human Services and the Department on
Aging, to effect the following:  (i)  intake  procedures  and
common   eligibility  criteria  for  those  persons  who  are
receiving   non-institutional   services;   and   (ii)    the
establishment  and  development of non-institutional services
in areas of the State where they are not currently  available
or are undeveloped.
    The  Illinois  Department  shall  develop and operate, in
cooperation with other State Departments and agencies and  in
compliance  with  applicable  federal  laws  and regulations,
appropriate and effective systems of health  care  evaluation
and  programs  for  monitoring  of utilization of health care
services and facilities, as it affects persons  eligible  for
medical  assistance  under this Code. The Illinois Department
shall report regularly the results of the operation  of  such
systems  and  programs  to  the  Citizens Assembly/Council on
Public Aid to enable the Committee to ensure,  from  time  to
time, that these programs are effective and meaningful.
    The  Illinois  Department  shall  report  annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
         (a)  actual statistics and trends in utilization  of
    medical services by public aid recipients;
         (b)  actual  statistics  and trends in the provision
    of the various medical services by medical vendors;
         (c)  current rate structures and proposed changes in
    those rate structures for the  various  medical  vendors;
    and
         (d)  efforts  at  utilization  review and control by
    the Illinois Department.
    The period covered by each report shall be  the  3  years
ending  on the June 30 prior to the report.  The report shall
include  suggested  legislation  for  consideration  by   the
General  Assembly.  The filing of one copy of the report with
the Speaker, one copy with the Minority Leader and  one  copy
with the Clerk of the House of Representatives, one copy with
the President, one copy with the Minority Leader and one copy
with   the  Secretary  of  the  Senate,  one  copy  with  the
Legislative Research Unit, such additional  copies  with  the
State  Government  Report Distribution Center for the General
Assembly as is required under paragraph (t) of Section  7  of
the  State  Library  Act  and  one  copy  with  the  Citizens
Assembly/Council  on  Public  Aid  or  its successor shall be
deemed sufficient to comply with this Section.
(Source:  P.A.  89-21,  eff.  7-1-95;  89-507,  eff.  7-1-97;
89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.)

    Section 99.  Effective date.  This Act takes effect  upon
becoming law.

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