Sen. Donne E. Trotter

Filed: 4/27/2004

 

 


 

 


 
09300HB0486sam002 LRB093 05218 DRJ 49973 a

1
AMENDMENT TO HOUSE BILL 0486

2     AMENDMENT NO. ______. Amend House Bill 486, AS AMENDED,
3 with reference to page and line numbers of Senate Amendment
4 No.1, on page 1, by replacing line 20 with the following:
5 "changing Section 5-5 and adding Section 5-16.7a 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 rate
9 of reimbursement for the medical assistance for which payment
10 will be authorized, and the medical services to be provided,
11 which may include all or part of the following: (1) inpatient
12 hospital services; (2) outpatient hospital services; (3) other
13 laboratory and X-ray services; (4) skilled nursing home
14 services; (5) physicians' services whether furnished in the
15 office, the patient's home, a hospital, a skilled nursing home,
16 or elsewhere; (6) medical care, or any other type of remedial
17 care furnished by licensed practitioners; (7) home health care
18 services; (8) private duty nursing service; (9) clinic
19 services; (10) dental services, including prevention and
20 treatment of periodontal disease and dental caries disease for
21 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
24 the eye, or by an optometrist, whichever the person may select;
25 (13) other diagnostic, screening, preventive, and

 

 

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

 

 

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1 for any laboratory test authorized under this Article, that a
2 physician's handwritten signature appear on the laboratory
3 test order form. The Illinois Department may, however, impose
4 other appropriate requirements regarding laboratory test order
5 documentation.
6     The Illinois Department of Public Aid shall provide the
7 following services to persons eligible for assistance under
8 this Article who are participating in education, training or
9 employment programs operated by the Department of Human
10 Services as successor to the Department of Public Aid:
11         (1) dental services, which shall include but not be
12 limited to prosthodontics; and
13         (2) eyeglasses prescribed by a physician skilled in the
14 diseases of the eye, or by an optometrist, whichever the
15 person may select.
16     The Illinois Department, by rule, may distinguish and
17 classify the medical services to be provided only in accordance
18 with the classes of persons designated in Section 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 women
22 35 years of age or older who are eligible for medical
23 assistance under this Article, as follows: a baseline mammogram
24 for women 35 to 39 years of age and an annual mammogram for
25 women 40 years of age or older. All screenings shall include a
26 physical breast exam, instruction on self-examination and
27 information regarding the frequency of self-examination and
28 its value as a preventative tool. As used in this Section,
29 "low-dose mammography" means the x-ray examination of the
30 breast using equipment dedicated specifically for mammography,
31 including the x-ray tube, filter, compression device, image
32 receptor, and cassettes, with an average radiation exposure
33 delivery of less than one rad mid-breast, with 2 views for each
34 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 Public Aid shall assure coverage for the cost
9 of treatment of the drug abuse or addiction for pregnant
10 recipients in accordance with the Illinois Medicaid Program in
11 conjunction with the Department of Human Services.
12     All medical providers providing medical assistance to
13 pregnant women under this Code shall receive information from
14 the Department on the availability of services under the Drug
15 Free Families with a Future or any comparable program providing
16 case management services for addicted women, including
17 information on appropriate referrals for other social services
18 that may be needed by addicted women in addition to treatment
19 for addiction.
20     The Illinois Department, in cooperation with the
21 Departments of Human Services (as successor to the Department
22 of Alcoholism and Substance Abuse) and Public Health, through a
23 public awareness campaign, may provide information concerning
24 treatment for alcoholism and drug abuse and addiction, prenatal
25 health care, and other pertinent programs directed at reducing
26 the number of drug-affected infants born to recipients of
27 medical assistance.
28     Neither the Illinois Department of Public Aid nor the
29 Department of Human Services shall sanction the recipient
30 solely on the basis of her substance abuse.
31     The Illinois Department shall establish such regulations
32 governing the dispensing of health services under this Article
33 as it shall deem appropriate. The Department should seek the
34 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
27 the Illinois Department, to persons in areas covered by the
28 Partnership may receive an additional surcharge for such
29 services.
30         (2) The Department may elect to consider and negotiate
31 financial incentives to encourage the development of
32 Partnerships and the efficient delivery of medical care.
33         (3) Persons receiving medical services through
34 Partnerships may receive medical and case management

 

 

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

 

 

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

 

 

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1 interests in any and all firms, corporations, partnerships,
2 associations, business enterprises, joint ventures, agencies,
3 institutions or other legal entities providing any form of
4 health care services in this State under this Article.
5     The Illinois Department may require that all dispensers of
6 medical services desiring to participate in the medical
7 assistance program established under this Article disclose,
8 under such terms and conditions as the Illinois Department may
9 by rule establish, all inquiries from clients and attorneys
10 regarding medical bills paid by the Illinois Department, which
11 inquiries could indicate potential existence of claims or liens
12 for the Illinois Department.
13     Enrollment of a vendor that provides non-emergency medical
14 transportation, defined by the Department by rule, shall be
15 conditional for 180 days. During that time, the Department of
16 Public Aid may terminate the vendor's eligibility to
17 participate in the medical assistance program without cause.
18 That termination of eligibility is not subject to the
19 Department's hearing process.
20     The Illinois Department shall establish policies,
21 procedures, standards and criteria by rule for the acquisition,
22 repair and replacement of orthotic and prosthetic devices and
23 durable medical equipment. Such rules shall provide, but not be
24 limited to, the following services: (1) immediate repair or
25 replacement of such devices by recipients without medical
26 authorization; and (2) rental, lease, purchase or
27 lease-purchase of durable medical equipment in a
28 cost-effective manner, taking into consideration the
29 recipient's medical prognosis, the extent of the recipient's
30 needs, and the requirements and costs for maintaining such
31 equipment. Such rules shall enable a recipient to temporarily
32 acquire and use alternative or substitute devices or equipment
33 pending repairs or replacements of any device or equipment
34 previously authorized for such recipient by the Department.

 

 

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1 Rules under clause (2) above shall not provide for purchase or
2 lease-purchase of durable medical equipment or supplies used
3 for the purpose of oxygen delivery and respiratory care.
4     The Department shall execute, relative to the nursing home
5 prescreening project, written inter-agency agreements with the
6 Department of Human Services and the Department on Aging, to
7 effect the following: (i) intake procedures and common
8 eligibility criteria for those persons who are receiving
9 non-institutional services; and (ii) the establishment and
10 development of non-institutional services in areas of the State
11 where they are not currently available or are undeveloped.
12     The Illinois Department shall develop and operate, in
13 cooperation with other State Departments and agencies and in
14 compliance with applicable federal laws and regulations,
15 appropriate and effective systems of health care evaluation and
16 programs for monitoring of utilization of health care services
17 and facilities, as it affects persons eligible for medical
18 assistance under this Code.
19     The Illinois Department shall report annually to the
20 General Assembly, no later than the second Friday in April of
21 1979 and each year thereafter, in regard to:
22         (a) actual statistics and trends in utilization of
23 medical services by public aid recipients;
24         (b) actual statistics and trends in the provision of
25 the various medical services by medical vendors;
26         (c) current rate structures and proposed changes in
27 those rate structures for the various medical vendors; and
28         (d) efforts at utilization review and control by the
29 Illinois Department.
30     The period covered by each report shall be the 3 years
31 ending on the June 30 prior to the report. The report shall
32 include suggested legislation for consideration by the General
33 Assembly. The filing of one copy of the report with the
34 Speaker, one copy with the Minority Leader and one copy with

 

 

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1 the Clerk of the House of Representatives, one copy with the
2 President, one copy with the Minority Leader and one copy with
3 the Secretary of the Senate, one copy with the Legislative
4 Research Unit, and such additional copies with the State
5 Government Report Distribution Center for the General Assembly
6 as is required under paragraph (t) of Section 7 of the State
7 Library Act shall be deemed sufficient to comply with this
8 Section.
9 (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02;
10 92-789, eff. 8-6-02; 93-632, eff. 2-1-04.)".