Sen. William Delgado

Filed: 4/27/2009

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 917

2     AMENDMENT NO. ______. Amend House Bill 917 by replacing
3 everything after the enacting clause with the following:
 
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 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

 

 

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

 

 

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

 

 

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1 Department of Human Services as successor to the Department of
2 Public Aid:
3         (1) dental services, which shall include but not be
4     limited to prosthodontics; and
5         (2) eyeglasses prescribed by a physician skilled in the
6     diseases of the eye, or by an optometrist, whichever the
7     person may select.
8     Notwithstanding any other provisions of this Code, the
9 Department of Healthcare and Family Services shall adopt rules
10 for payment of claims for reimbursement for covered dental
11 services that allow a qualified provider of such services to
12 designate an alternate payee. Such an alternate payee may be a
13 public health clinic or Federally Qualified Health Center where
14 dental services covered under this Section are performed. If a
15 qualified provider of covered dental services designates an
16 alternate payee, the provider shall not be required to
17 individually enroll as a participating vendor in the medical
18 assistance program and the Department shall establish a process
19 for making reimbursement payments to the alternate payee.
20     The Illinois Department, by rule, may distinguish and
21 classify the medical services to be provided only in accordance
22 with the classes of persons designated in Section 5-2.
23     The Department of Healthcare and Family Services must
24 provide coverage and reimbursement for amino acid-based
25 elemental formulas, regardless of delivery method, for the
26 diagnosis and treatment of (i) eosinophilic disorders and (ii)

 

 

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1 short bowel syndrome when the prescribing physician has issued
2 a written order stating that the amino acid-based elemental
3 formula is medically necessary.
4     The Illinois Department shall authorize the provision of,
5 and shall authorize payment for, screening by low-dose
6 mammography for the presence of occult breast cancer for women
7 35 years of age or older who are eligible for medical
8 assistance under this Article, as follows:
9         (A) A baseline mammogram for women 35 to 39 years of
10     age.
11         (B) An annual mammogram for women 40 years of age or
12     older.
13         (C) A mammogram at the age and intervals considered
14     medically necessary by the woman's health care provider for
15     women under 40 years of age and having a family history of
16     breast cancer, prior personal history of breast cancer,
17     positive genetic testing, or other risk factors.
18         (D) A comprehensive ultrasound screening of an entire
19     breast or breasts if a mammogram demonstrates
20     heterogeneous or dense breast tissue, when medically
21     necessary as determined by a physician licensed to practice
22     medicine in all of its branches.
23     All screenings shall include a physical breast exam,
24 instruction on self-examination and information regarding the
25 frequency of self-examination and its value as a preventative
26 tool. For purposes of this Section, "low-dose mammography"

 

 

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1 means the x-ray examination of the breast using equipment
2 dedicated specifically for mammography, including the x-ray
3 tube, filter, compression device, and image receptor, with an
4 average radiation exposure delivery of less than one rad per
5 breast for 2 views of an average size breast. The term also
6 includes digital mammography.
7     On and after July 1, 2008, screening and diagnostic
8 mammography shall be reimbursed at the same rate as the
9 Medicare program's rates, including the increased
10 reimbursement for digital mammography.
11     The Department shall convene an expert panel including
12 representatives of hospitals, free-standing mammography
13 facilities, and doctors, including radiologists, to establish
14 quality standards. Based on these quality standards, the
15 Department shall provide for bonus payments to mammography
16 facilities meeting the standards for screening and diagnosis.
17 The bonus payments shall be at least 15% higher than the
18 Medicare rates for mammography.
19     Subject to federal approval, the Department shall
20 establish a rate methodology for mammography at federally
21 qualified health centers and other encounter-rate clinics.
22 These clinics or centers may also collaborate with other
23 hospital-based mammography facilities.
24     The Department shall establish a methodology to remind
25 women who are age-appropriate for screening mammography, but
26 who have not received a mammogram within the previous 18

 

 

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1 months, of the importance and benefit of screening mammography.
2     The Department shall establish a performance goal for
3 primary care providers with respect to their female patients
4 over age 40 receiving an annual mammogram. This performance
5 goal shall be used to provide additional reimbursement in the
6 form of a quality performance bonus to primary care providers
7 who meet that goal.
8     The Department shall devise a means of case-managing or
9 patient navigation for beneficiaries diagnosed with breast
10 cancer. This program shall initially operate as a pilot program
11 in areas of the State with the highest incidence of mortality
12 related to breast cancer. At least one pilot program site shall
13 be in the metropolitan Chicago area and at least one site shall
14 be outside the metropolitan Chicago area. An evaluation of the
15 pilot program shall be carried out measuring health outcomes
16 and cost of care for those served by the pilot program compared
17 to similarly situated patients who are not served by the pilot
18 program.
19     Any medical or health care provider shall immediately
20 recommend, to any pregnant woman who is being provided prenatal
21 services and is suspected of drug abuse or is addicted as
22 defined in the Alcoholism and Other Drug Abuse and Dependency
23 Act, referral to a local substance abuse treatment provider
24 licensed by the Department of Human Services or to a licensed
25 hospital which provides substance abuse treatment services.
26 The Department of Healthcare and Family Services shall assure

 

 

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1 coverage for the cost of treatment of the drug abuse or
2 addiction for pregnant recipients in accordance with the
3 Illinois Medicaid Program in conjunction with the Department of
4 Human Services.
5     All medical providers providing medical assistance to
6 pregnant women under this Code shall receive information from
7 the Department on the availability of services under the Drug
8 Free Families with a Future or any comparable program providing
9 case management services for addicted women, including
10 information on appropriate referrals for other social services
11 that may be needed by addicted women in addition to treatment
12 for addiction.
13     The Illinois Department, in cooperation with the
14 Departments of Human Services (as successor to the Department
15 of Alcoholism and Substance Abuse) and Public Health, through a
16 public awareness campaign, may provide information concerning
17 treatment for alcoholism and drug abuse and addiction, prenatal
18 health care, and other pertinent programs directed at reducing
19 the number of drug-affected infants born to recipients of
20 medical assistance.
21     Neither the Department of Healthcare and Family Services
22 nor the Department of Human Services shall sanction the
23 recipient solely on the basis of her substance abuse.
24     The Illinois Department shall establish such regulations
25 governing the dispensing of health services under this Article
26 as it shall deem appropriate. The Department should seek the

 

 

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1 advice of formal professional advisory committees appointed by
2 the Director of the Illinois Department for the purpose of
3 providing regular advice on policy and administrative matters,
4 information dissemination and educational activities for
5 medical and health care providers, and consistency in
6 procedures to the Illinois Department.
7     The Illinois Department may develop and contract with
8 Partnerships of medical providers to arrange medical services
9 for persons eligible under Section 5-2 of this Code.
10 Implementation of this Section may be by demonstration projects
11 in certain geographic areas. The Partnership shall be
12 represented by a sponsor organization. The Department, by rule,
13 shall develop qualifications for sponsors of Partnerships.
14 Nothing in this Section shall be construed to require that the
15 sponsor organization be a medical organization.
16     The sponsor must negotiate formal written contracts with
17 medical providers for physician services, inpatient and
18 outpatient hospital care, home health services, treatment for
19 alcoholism and substance abuse, and other services determined
20 necessary by the Illinois Department by rule for delivery by
21 Partnerships. Physician services must include prenatal and
22 obstetrical care. The Illinois Department shall reimburse
23 medical services delivered by Partnership providers to clients
24 in target areas according to provisions of this Article and the
25 Illinois Health Finance Reform Act, except that:
26         (1) Physicians participating in a Partnership and

 

 

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1     providing certain services, which shall be determined by
2     the Illinois Department, to persons in areas covered by the
3     Partnership may receive an additional surcharge for such
4     services.
5         (2) The Department may elect to consider and negotiate
6     financial incentives to encourage the development of
7     Partnerships and the efficient delivery of medical care.
8         (3) Persons receiving medical services through
9     Partnerships may receive medical and case management
10     services above the level usually offered through the
11     medical assistance program.
12     Medical providers shall be required to meet certain
13 qualifications to participate in Partnerships to ensure the
14 delivery of high quality medical services. These
15 qualifications shall be determined by rule of the Illinois
16 Department and may be higher than qualifications for
17 participation in the medical assistance program. Partnership
18 sponsors may prescribe reasonable additional qualifications
19 for participation by medical providers, only with the prior
20 written approval of the Illinois Department.
21     Nothing in this Section shall limit the free choice of
22 practitioners, hospitals, and other providers of medical
23 services by clients. In order to ensure patient freedom of
24 choice, the Illinois Department shall immediately promulgate
25 all rules and take all other necessary actions so that provided
26 services may be accessed from therapeutically certified

 

 

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1 optometrists to the full extent of the Illinois Optometric
2 Practice Act of 1987 without discriminating between service
3 providers.
4     The Department shall apply for a waiver from the United
5 States Health Care Financing Administration to allow for the
6 implementation of Partnerships under this Section.
7     The Illinois Department shall require health care
8 providers to maintain records that document the medical care
9 and services provided to recipients of Medical Assistance under
10 this Article. The Illinois Department shall require health care
11 providers to make available, when authorized by the patient, in
12 writing, the medical records in a timely fashion to other
13 health care providers who are treating or serving persons
14 eligible for Medical Assistance under this Article. All
15 dispensers of medical services shall be required to maintain
16 and retain business and professional records sufficient to
17 fully and accurately document the nature, scope, details and
18 receipt of the health care provided to persons eligible for
19 medical assistance under this Code, in accordance with
20 regulations promulgated by the Illinois Department. The rules
21 and regulations shall require that proof of the receipt of
22 prescription drugs, dentures, prosthetic devices and
23 eyeglasses by eligible persons under this Section accompany
24 each claim for reimbursement submitted by the dispenser of such
25 medical services. No such claims for reimbursement shall be
26 approved for payment by the Illinois Department without such

 

 

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1 proof of receipt, unless the Illinois Department shall have put
2 into effect and shall be operating a system of post-payment
3 audit and review which shall, on a sampling basis, be deemed
4 adequate by the Illinois Department to assure that such drugs,
5 dentures, prosthetic devices and eyeglasses for which payment
6 is being made are actually being received by eligible
7 recipients. Within 90 days after the effective date of this
8 amendatory Act of 1984, the Illinois Department shall establish
9 a current list of acquisition costs for all prosthetic devices
10 and any other items recognized as medical equipment and
11 supplies reimbursable under this Article and shall update such
12 list on a quarterly basis, except that the acquisition costs of
13 all prescription drugs shall be updated no less frequently than
14 every 30 days as required by Section 5-5.12.
15     The rules and regulations of the Illinois Department shall
16 require that a written statement including the required opinion
17 of a physician shall accompany any claim for reimbursement for
18 abortions, or induced miscarriages or premature births. This
19 statement shall indicate what procedures were used in providing
20 such medical services.
21     The Illinois Department shall require all dispensers of
22 medical services, other than an individual practitioner or
23 group of practitioners, desiring to participate in the Medical
24 Assistance program established under this Article to disclose
25 all financial, beneficial, ownership, equity, surety or other
26 interests in any and all firms, corporations, partnerships,

 

 

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1 associations, business enterprises, joint ventures, agencies,
2 institutions or other legal entities providing any form of
3 health care services in this State under this Article.
4     The Illinois Department may require that all dispensers of
5 medical services desiring to participate in the medical
6 assistance program established under this Article disclose,
7 under such terms and conditions as the Illinois Department may
8 by rule establish, all inquiries from clients and attorneys
9 regarding medical bills paid by the Illinois Department, which
10 inquiries could indicate potential existence of claims or liens
11 for the Illinois Department.
12     Enrollment of a vendor that provides non-emergency medical
13 transportation, defined by the Department by rule, shall be
14 conditional for 180 days. During that time, the Department of
15 Healthcare and Family Services may terminate the vendor's
16 eligibility to participate in the medical assistance program
17 without cause. That termination of eligibility is not subject
18 to the Department's hearing process.
19     The Illinois Department shall establish policies,
20 procedures, standards and criteria by rule for the acquisition,
21 repair and replacement of orthotic and prosthetic devices and
22 durable medical equipment. Such rules shall provide, but not be
23 limited to, the following services: (1) immediate repair or
24 replacement of such devices by recipients without medical
25 authorization; and (2) rental, lease, purchase or
26 lease-purchase of durable medical equipment in a

 

 

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1 cost-effective manner, taking into consideration the
2 recipient's medical prognosis, the extent of the recipient's
3 needs, and the requirements and costs for maintaining such
4 equipment. Such rules shall enable a recipient to temporarily
5 acquire and use alternative or substitute devices or equipment
6 pending repairs or replacements of any device or equipment
7 previously authorized for such recipient by the Department.
8     The Department shall execute, relative to the nursing home
9 prescreening project, written inter-agency agreements with the
10 Department of Human Services and the Department on Aging, to
11 effect the following: (i) intake procedures and common
12 eligibility criteria for those persons who are receiving
13 non-institutional services; and (ii) the establishment and
14 development of non-institutional services in areas of the State
15 where they are not currently available or are undeveloped.
16     The Illinois Department shall develop and operate, in
17 cooperation with other State Departments and agencies and in
18 compliance with applicable federal laws and regulations,
19 appropriate and effective systems of health care evaluation and
20 programs for monitoring of utilization of health care services
21 and facilities, as it affects persons eligible for medical
22 assistance under this Code.
23     The Illinois Department shall report annually to the
24 General Assembly, no later than the second Friday in April of
25 1979 and each year thereafter, in regard to:
26         (a) actual statistics and trends in utilization of

 

 

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1     medical services by public aid recipients;
2         (b) actual statistics and trends in the provision of
3     the various medical services by medical vendors;
4         (c) current rate structures and proposed changes in
5     those rate structures for the various medical vendors; and
6         (d) efforts at utilization review and control by the
7     Illinois Department.
8     The period covered by each report shall be the 3 years
9 ending on the June 30 prior to the report. The report shall
10 include suggested legislation for consideration by the General
11 Assembly. The filing of one copy of the report with the
12 Speaker, one copy with the Minority Leader and one copy with
13 the Clerk of the House of Representatives, one copy with the
14 President, one copy with the Minority Leader and one copy with
15 the Secretary of the Senate, one copy with the Legislative
16 Research Unit, and such additional copies with the State
17 Government Report Distribution Center for the General Assembly
18 as is required under paragraph (t) of Section 7 of the State
19 Library Act shall be deemed sufficient to comply with this
20 Section.
21     Rulemaking authority to implement this amendatory Act of
22 the 95th General Assembly, if any, is conditioned on the rules
23 being adopted in accordance with all provisions of the Illinois
24 Administrative Procedure Act and all rules and procedures of
25 the Joint Committee on Administrative Rules; any purported rule
26 not so adopted, for whatever reason, is unauthorized.

 

 

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1 (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07;
2 95-1045, eff. 3-27-09.)".