Illinois General Assembly - Full Text of SB2502
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Full Text of SB2502  97th General Assembly




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1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing 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
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective



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



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



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1        (1) dental services provided by or under the
2    supervision of a dentist; and
3        (2) eyeglasses prescribed by a physician skilled in the
4    diseases of the eye, or by an optometrist, whichever the
5    person may select.
6    Notwithstanding any other provision of this Code and
7subject to federal approval, the Department may adopt rules to
8allow a dentist who is volunteering his or her service at no
9cost to render dental services through an enrolled
10not-for-profit health clinic without the dentist personally
11enrolling as a participating provider in the medical assistance
12program. A not-for-profit health clinic shall include a public
13health clinic or Federally Qualified Health Center or other
14enrolled provider, as determined by the Department, through
15which dental services covered under this Section are performed.
16The Department shall establish a process for payment of claims
17for reimbursement for covered dental services rendered under
18this provision.
19    The Illinois Department, by rule, may distinguish and
20classify the medical services to be provided only in accordance
21with the classes of persons designated in Section 5-2.
22    The Department of Healthcare and Family Services must
23provide coverage and reimbursement for amino acid-based
24elemental formulas, regardless of delivery method, for the
25diagnosis and treatment of (i) eosinophilic disorders and (ii)
26short bowel syndrome when the prescribing physician has issued



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



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1dedicated specifically for mammography, including the x-ray
2tube, filter, compression device, and image receptor, with an
3average radiation exposure delivery of less than one rad per
4breast for 2 views of an average size breast. The term also
5includes digital mammography.
6    On and after January 1, 2012, providers participating in a
7quality improvement program approved by the Department shall be
8reimbursed for screening and diagnostic mammography at the same
9rate as the Medicare program's rates, including the increased
10reimbursement for digital mammography. On and after July 1,
112008, screening and diagnostic mammography shall be reimbursed
12at the same rate as the Medicare program's rates, including the
13increased reimbursement for digital mammography.
14    The Department shall convene an expert panel including
15representatives of hospitals, free-standing mammography
16facilities, and doctors, including radiologists, to establish
17quality standards. Based on these quality standards, the
18Department shall provide for bonus payments to mammography
19facilities meeting the standards for screening and diagnosis.
20The bonus payments shall be at least 15% higher than the
21Medicare rates for mammography.
22    Subject to federal approval, the Department shall
23establish a rate methodology for mammography at federally
24qualified health centers and other encounter-rate clinics.
25These clinics or centers may also collaborate with other
26hospital-based mammography facilities.



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



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



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1    The Illinois Department shall establish such regulations
2governing the dispensing of health services under this Article
3as it shall deem appropriate. The Department should seek the
4advice of formal professional advisory committees appointed by
5the Director of the Illinois Department for the purpose of
6providing regular advice on policy and administrative matters,
7information dissemination and educational activities for
8medical and health care providers, and consistency in
9procedures to the Illinois Department.
10    Notwithstanding any other provision of law, a health care
11provider under the medical assistance program may elect, in
12lieu of receiving direct payment for services provided under
13that program, to participate in the State Employees Deferred
14Compensation Plan adopted under Article 24 of the Illinois
15Pension Code. A health care provider who elects to participate
16in the plan does not have a cause of action against the State
17for any damages allegedly suffered by the provider as a result
18of any delay by the State in crediting the amount of any
19contribution to the provider's plan account.
20    The Illinois Department may develop and contract with
21Partnerships of medical providers to arrange medical services
22for persons eligible under Section 5-2 of this Code.
23Implementation of this Section may be by demonstration projects
24in certain geographic areas. The Partnership shall be
25represented by a sponsor organization. The Department, by rule,
26shall develop qualifications for sponsors of Partnerships.



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1Nothing in this Section shall be construed to require that the
2sponsor organization be a medical organization.
3    The sponsor must negotiate formal written contracts with
4medical providers for physician services, inpatient and
5outpatient hospital care, home health services, treatment for
6alcoholism and substance abuse, and other services determined
7necessary by the Illinois Department by rule for delivery by
8Partnerships. Physician services must include prenatal and
9obstetrical care. The Illinois Department shall reimburse
10medical services delivered by Partnership providers to clients
11in target areas according to provisions of this Article and the
12Illinois Health Finance Reform Act, except that:
13        (1) Physicians participating in a Partnership and
14    providing certain services, which shall be determined by
15    the Illinois Department, to persons in areas covered by the
16    Partnership may receive an additional surcharge for such
17    services.
18        (2) The Department may elect to consider and negotiate
19    financial incentives to encourage the development of
20    Partnerships and the efficient delivery of medical care.
21        (3) Persons receiving medical services through
22    Partnerships may receive medical and case management
23    services above the level usually offered through the
24    medical assistance program.
25    Medical providers shall be required to meet certain
26qualifications to participate in Partnerships to ensure the



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1delivery of high quality medical services. These
2qualifications shall be determined by rule of the Illinois
3Department and may be higher than qualifications for
4participation in the medical assistance program. Partnership
5sponsors may prescribe reasonable additional qualifications
6for participation by medical providers, only with the prior
7written approval of the Illinois Department.
8    Nothing in this Section shall limit the free choice of
9practitioners, hospitals, and other providers of medical
10services by clients. In order to ensure patient freedom of
11choice, the Illinois Department shall immediately promulgate
12all rules and take all other necessary actions so that provided
13services may be accessed from therapeutically certified
14optometrists to the full extent of the Illinois Optometric
15Practice Act of 1987 without discriminating between service
17    The Department shall apply for a waiver from the United
18States Health Care Financing Administration to allow for the
19implementation of Partnerships under this Section.
20    The Illinois Department shall require health care
21providers to maintain records that document the medical care
22and services provided to recipients of Medical Assistance under
23this Article. Such records must be retained for a period of not
24less than 6 years from the date of service or as provided by
25applicable State law, whichever period is longer, except that
26if an audit is initiated within the required retention period



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1then the records must be retained until the audit is completed
2and every exception is resolved. The Illinois Department shall
3require health care providers to make available, when
4authorized by the patient, in writing, the medical records in a
5timely fashion to other health care providers who are treating
6or serving persons eligible for Medical Assistance under this
7Article. All dispensers of medical services shall be required
8to maintain and retain business and professional records
9sufficient to fully and accurately document the nature, scope,
10details and receipt of the health care provided to persons
11eligible for medical assistance under this Code, in accordance
12with regulations promulgated by the Illinois Department. The
13rules and regulations shall require that proof of the receipt
14of prescription drugs, dentures, prosthetic devices and
15eyeglasses by eligible persons under this Section accompany
16each claim for reimbursement submitted by the dispenser of such
17medical services. No such claims for reimbursement shall be
18approved for payment by the Illinois Department without such
19proof of receipt, unless the Illinois Department shall have put
20into effect and shall be operating a system of post-payment
21audit and review which shall, on a sampling basis, be deemed
22adequate by the Illinois Department to assure that such drugs,
23dentures, prosthetic devices and eyeglasses for which payment
24is being made are actually being received by eligible
25recipients. Within 90 days after the effective date of this
26amendatory Act of 1984, the Illinois Department shall establish



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1a current list of acquisition costs for all prosthetic devices
2and any other items recognized as medical equipment and
3supplies reimbursable under this Article and shall update such
4list on a quarterly basis, except that the acquisition costs of
5all prescription drugs shall be updated no less frequently than
6every 30 days as required by Section 5-5.12.
7    The rules and regulations of the Illinois Department shall
8require that a written statement including the required opinion
9of a physician shall accompany any claim for reimbursement for
10abortions, or induced miscarriages or premature births. This
11statement shall indicate what procedures were used in providing
12such medical services.
13    The Illinois Department shall require all dispensers of
14medical services, other than an individual practitioner or
15group of practitioners, desiring to participate in the Medical
16Assistance program established under this Article to disclose
17all financial, beneficial, ownership, equity, surety or other
18interests in any and all firms, corporations, partnerships,
19associations, business enterprises, joint ventures, agencies,
20institutions or other legal entities providing any form of
21health care services in this State under this Article.
22    The Illinois Department may require that all dispensers of
23medical services desiring to participate in the medical
24assistance program established under this Article disclose,
25under such terms and conditions as the Illinois Department may
26by rule establish, all inquiries from clients and attorneys



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1regarding medical bills paid by the Illinois Department, which
2inquiries could indicate potential existence of claims or liens
3for the Illinois Department.
4    Enrollment of a vendor that provides non-emergency medical
5transportation, defined by the Department by rule, shall be
6conditional for 180 days. During that time, the Department of
7Healthcare and Family Services may terminate the vendor's
8eligibility to participate in the medical assistance program
9without cause. That termination of eligibility is not subject
10to the Department's hearing process.
11    The Illinois Department shall establish policies,
12procedures, standards and criteria by rule for the acquisition,
13repair and replacement of orthotic and prosthetic devices and
14durable medical equipment. Such rules shall provide, but not be
15limited to, the following services: (1) immediate repair or
16replacement of such devices by recipients without medical
17authorization; and (2) rental, lease, purchase or
18lease-purchase of durable medical equipment in a
19cost-effective manner, taking into consideration the
20recipient's medical prognosis, the extent of the recipient's
21needs, and the requirements and costs for maintaining such
22equipment. Such rules shall enable a recipient to temporarily
23acquire and use alternative or substitute devices or equipment
24pending repairs or replacements of any device or equipment
25previously authorized for such recipient by the Department.
26    The Department shall execute, relative to the nursing home



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1prescreening project, written inter-agency agreements with the
2Department of Human Services and the Department on Aging, to
3effect the following: (i) intake procedures and common
4eligibility criteria for those persons who are receiving
5non-institutional services; and (ii) the establishment and
6development of non-institutional services in areas of the State
7where they are not currently available or are undeveloped.
8    The Illinois Department shall develop and operate, in
9cooperation with other State Departments and agencies and in
10compliance with applicable federal laws and regulations,
11appropriate and effective systems of health care evaluation and
12programs for monitoring of utilization of health care services
13and facilities, as it affects persons eligible for medical
14assistance under this Code.
15    The Illinois Department shall report annually to the
16General Assembly, no later than the second Friday in April of
171979 and each year thereafter, in regard to:
18        (a) actual statistics and trends in utilization of
19    medical services by public aid recipients;
20        (b) actual statistics and trends in the provision of
21    the various medical services by medical vendors;
22        (c) current rate structures and proposed changes in
23    those rate structures for the various medical vendors; and
24        (d) efforts at utilization review and control by the
25    Illinois Department.
26    The period covered by each report shall be the 3 years



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1ending on the June 30 prior to the report. The report shall
2include suggested legislation for consideration by the General
3Assembly. The filing of one copy of the report with the
4Speaker, one copy with the Minority Leader and one copy with
5the Clerk of the House of Representatives, one copy with the
6President, one copy with the Minority Leader and one copy with
7the Secretary of the Senate, one copy with the Legislative
8Research Unit, and such additional copies with the State
9Government Report Distribution Center for the General Assembly
10as is required under paragraph (t) of Section 7 of the State
11Library Act shall be deemed sufficient to comply with this
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,
20eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11.)
21    Section 99. Effective date. This Act takes effect January
221, 2012.