Rep. Elizabeth Hernandez

Filed: 5/28/2008

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 2348

2     AMENDMENT NO. ______. Amend Senate Bill 2348, AS AMENDED,
3 by replacing everything after the enacting clause with the
4 following:
 
 
5     "Section 5. The Illinois Public Aid Code is amended by
6 changing Section 5-5 as follows:
 
7     (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
8     Sec. 5-5. Medical services. The Illinois Department, by
9 rule, shall determine the quantity and quality of and the rate
10 of reimbursement for the medical assistance for which payment
11 will be authorized, and the medical services to be provided,
12 which may include all or part of the following: (1) inpatient
13 hospital services; (2) outpatient hospital services; (3) other
14 laboratory and X-ray services; (4) skilled nursing home
15 services; (5) physicians' services whether furnished in the

 

 

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1 office, the patient's home, a hospital, a skilled nursing home,
2 or elsewhere; (6) medical care, or any other type of remedial
3 care furnished by licensed practitioners; (7) home health care
4 services; (8) private duty nursing service; (9) clinic
5 services; (10) dental services, including prevention and
6 treatment of periodontal disease and dental caries disease for
7 pregnant women; (11) physical therapy and related services;
8 (12) prescribed drugs, dentures, and prosthetic devices; and
9 eyeglasses prescribed by a physician skilled in the diseases of
10 the eye, or by an optometrist, whichever the person may select;
11 (13) other diagnostic, screening, preventive, and
12 rehabilitative services; (14) transportation and such other
13 expenses as may be necessary; (15) medical treatment of sexual
14 assault survivors, as defined in Section 1a of the Sexual
15 Assault Survivors Emergency Treatment Act, for injuries
16 sustained as a result of the sexual assault, including
17 examinations and laboratory tests to discover evidence which
18 may be used in criminal proceedings arising from the sexual
19 assault; (16) the diagnosis and treatment of sickle cell
20 anemia; and (17) any other medical care, and any other type of
21 remedial care recognized under the laws of this State, but not
22 including abortions, or induced miscarriages or premature
23 births, unless, in the opinion of a physician, such procedures
24 are necessary for the preservation of the life of the woman
25 seeking such treatment, or except an induced premature birth
26 intended to produce a live viable child and such procedure is

 

 

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1 necessary for the health of the mother or her unborn child. The
2 Illinois Department, by rule, shall prohibit any physician from
3 providing medical assistance to anyone eligible therefor under
4 this Code where such physician has been found guilty of
5 performing an abortion procedure in a wilful and wanton manner
6 upon a woman who was not pregnant at the time such abortion
7 procedure was performed. The term "any other type of remedial
8 care" shall include nursing care and nursing home service for
9 persons who rely on treatment by spiritual means alone through
10 prayer for healing.
11     Notwithstanding any other provision of this Section, a
12 comprehensive tobacco use cessation program that includes
13 purchasing prescription drugs or prescription medical devices
14 approved by the Food and Drug administration shall be covered
15 under the medical assistance program under this Article for
16 persons who are otherwise eligible for assistance under this
17 Article.
18     Notwithstanding any other provision of this Code, the
19 Illinois Department may not require, as a condition of payment
20 for any laboratory test authorized under this Article, that a
21 physician's handwritten signature appear on the laboratory
22 test order form. The Illinois Department may, however, impose
23 other appropriate requirements regarding laboratory test order
24 documentation.
25     The Department of Healthcare and Family Services shall
26 provide the following services to persons eligible for

 

 

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1 assistance under this Article who are participating in
2 education, training or employment programs operated by the
3 Department of Human Services as successor to the Department of
4 Public Aid:
5         (1) dental services, which shall include but not be
6     limited to prosthodontics; and
7         (2) eyeglasses prescribed by a physician skilled in the
8     diseases of the eye, or by an optometrist, whichever the
9     person may select.
10     The Illinois Department, by rule, may distinguish and
11 classify the medical services to be provided only in accordance
12 with the classes of persons designated in Section 5-2.
13     The Department of Healthcare and Family Services must
14 provide coverage and reimbursement for amino acid-based
15 elemental formulas, regardless of delivery method, for the
16 diagnosis and treatment of (i) eosinophilic disorders and (ii)
17 short bowel syndrome when the prescribing physician has issued
18 a written order stating that the amino acid-based elemental
19 formula is medically necessary.
20     The Illinois Department shall authorize the provision of,
21 and shall authorize payment for, screening by low-dose
22 mammography for the presence of occult breast cancer for women
23 35 years of age or older who are eligible for medical
24 assistance under this Article, as follows: a baseline mammogram
25 for women 35 to 39 years of age and an annual mammogram for
26 women 40 years of age or older. All screenings shall include a

 

 

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1 physical breast exam, instruction on self-examination and
2 information regarding the frequency of self-examination and
3 its value as a preventative tool. As used in this Section,
4 "low-dose mammography" means the x-ray examination of the
5 breast using equipment dedicated specifically for mammography,
6 including the x-ray tube, filter, compression device, image
7 receptor, and cassettes, with an average radiation exposure
8 delivery of less than one rad mid-breast, with 2 views for each
9 breast.
10     Any medical or health care provider shall immediately
11 recommend, to any pregnant woman who is being provided prenatal
12 services and is suspected of drug abuse or is addicted as
13 defined in the Alcoholism and Other Drug Abuse and Dependency
14 Act, referral to a local substance abuse treatment provider
15 licensed by the Department of Human Services or to a licensed
16 hospital which provides substance abuse treatment services.
17 The Department of Healthcare and Family Services shall assure
18 coverage for the cost of treatment of the drug abuse or
19 addiction for pregnant recipients in accordance with the
20 Illinois Medicaid Program in conjunction with the Department of
21 Human Services.
22     All medical providers providing medical assistance to
23 pregnant women under this Code shall receive information from
24 the Department on the availability of services under the Drug
25 Free Families with a Future or any comparable program providing
26 case management services for addicted women, including

 

 

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1 information on appropriate referrals for other social services
2 that may be needed by addicted women in addition to treatment
3 for addiction.
4     The Illinois Department, in cooperation with the
5 Departments of Human Services (as successor to the Department
6 of Alcoholism and Substance Abuse) and Public Health, through a
7 public awareness campaign, may provide information concerning
8 treatment for alcoholism and drug abuse and addiction, prenatal
9 health care, and other pertinent programs directed at reducing
10 the number of drug-affected infants born to recipients of
11 medical assistance.
12     Neither the Department of Healthcare and Family Services
13 nor the Department of Human Services shall sanction the
14 recipient solely on the basis of her substance abuse.
15     The Illinois Department shall establish such regulations
16 governing the dispensing of health services under this Article
17 as it shall deem appropriate. The Department should seek the
18 advice of formal professional advisory committees appointed by
19 the Director of the Illinois Department for the purpose of
20 providing regular advice on policy and administrative matters,
21 information dissemination and educational activities for
22 medical and health care providers, and consistency in
23 procedures to the Illinois Department.
24     Notwithstanding any other provision of law, a medical or
25 health care provider under the medical assistance program may
26 elect, in lieu of receiving direct payment for goods or

 

 

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1 services provided under that program, to participate in the
2 Illinois State Employees Deferred Compensation Plan adopted
3 under Article 24 of the Illinois Pension Code. A medical or
4 health care provider who elects to participate in that Plan
5 shall, for purposes of that participation, be deemed an
6 "employee" as defined in Section 24-102 of the Illinois Pension
7 Code. A medical or health care provider who elects to
8 participate in the Plan does not have a cause of action against
9 the State for any damages allegedly suffered by the provider as
10 a result of any delay by the State in crediting the amount of
11 any contribution to the provider's Plan account.
12     The Illinois Department may develop and contract with
13 Partnerships of medical providers to arrange medical services
14 for persons eligible under Section 5-2 of this Code.
15 Implementation of this Section may be by demonstration projects
16 in certain geographic areas. The Partnership shall be
17 represented by a sponsor organization. The Department, by rule,
18 shall develop qualifications for sponsors of Partnerships.
19 Nothing in this Section shall be construed to require that the
20 sponsor organization be a medical 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

 

 

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1 obstetrical care. The Illinois Department shall reimburse
2 medical services delivered by Partnership providers to clients
3 in target areas according to provisions of this Article and the
4 Illinois Health Finance Reform Act, except that:
5         (1) Physicians participating in a Partnership and
6     providing certain services, which shall be determined by
7     the Illinois Department, to persons in areas covered by the
8     Partnership may receive an additional surcharge for such
9     services.
10         (2) The Department may elect to consider and negotiate
11     financial incentives to encourage the development of
12     Partnerships and the efficient delivery of medical care.
13         (3) Persons receiving medical services through
14     Partnerships may receive medical and case management
15     services above the level usually offered through the
16     medical assistance program.
17     Medical providers shall be required to meet certain
18 qualifications to participate in Partnerships to ensure the
19 delivery of high quality medical services. These
20 qualifications shall be determined by rule of the Illinois
21 Department and may be higher than qualifications for
22 participation in the medical assistance program. Partnership
23 sponsors may prescribe reasonable additional qualifications
24 for participation by medical providers, only with the prior
25 written approval of the Illinois Department.
26     Nothing in this Section shall limit the free choice of

 

 

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1 practitioners, hospitals, and other providers of medical
2 services by clients. In order to ensure patient freedom of
3 choice, the Illinois Department shall immediately promulgate
4 all rules and take all other necessary actions so that provided
5 services may be accessed from therapeutically certified
6 optometrists to the full extent of the Illinois Optometric
7 Practice Act of 1987 without discriminating between service
8 providers.
9     The Department shall apply for a waiver from the United
10 States Health Care Financing Administration to allow for the
11 implementation of Partnerships under this Section.
12     The Illinois Department shall require health care
13 providers to maintain records that document the medical care
14 and services provided to recipients of Medical Assistance under
15 this Article. The Illinois Department shall require health care
16 providers to make available, when authorized by the patient, in
17 writing, the medical records in a timely fashion to other
18 health care providers who are treating or serving persons
19 eligible for Medical Assistance under this Article. All
20 dispensers of medical services shall be required to maintain
21 and retain business and professional records sufficient to
22 fully and accurately document the nature, scope, details and
23 receipt of the health care provided to persons eligible for
24 medical assistance under this Code, in accordance with
25 regulations promulgated by the Illinois Department. The rules
26 and regulations shall require that proof of the receipt of

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1 exist, neither the Governor nor any agency or agency head under
2 the jurisdiction of the Governor has any authority to make or
3 promulgate rules to implement or enforce the provisions of this
4 amendatory Act of the 95th General Assembly. If, however, the
5 Governor believes that rules are necessary to implement or
6 enforce the provisions of this amendatory Act of the 95th
7 General Assembly, the Governor may suggest rules to the General
8 Assembly by filing them with the Clerk of the House and
9 Secretary of the Senate and by requesting that the General
10 Assembly authorize such rulemaking by law, enact those
11 suggested rules into law, or take any other appropriate action
12 in the General Assembly's discretion. Nothing contained in this
13 amendatory Act of the 95th General Assembly shall be
14 interpreted to grant rulemaking authority under any other
15 Illinois statute where such authority is not otherwise
16 explicitly given. For the purposes of this amendatory Act of
17 the 95th General Assembly, "rules" is given the meaning
18 contained in Section 1-70 of the Illinois Administrative
19 Procedure Act, and "agency" and "agency head" are given the
20 meanings contained in Sections 1-20 and 1-25 of the Illinois
21 Administrative Procedure Act to the extent that such
22 definitions apply to agencies or agency heads under the
23 jurisdiction of the Governor.
24 (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)".