Full Text of HB1191 97th General Assembly
HB1191ham001 97TH GENERAL ASSEMBLY | Rep. Greg Harris Filed: 3/3/2011
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| 1 | | AMENDMENT TO HOUSE BILL 1191
| 2 | | AMENDMENT NO. ______. Amend House Bill 1191 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The State Employees Group Insurance Act of 1971 | 5 | | is amended by
changing Section 6.11 as follows:
| 6 | | (5 ILCS 375/6.11)
| 7 | | Sec. 6.11. Required health benefits; Illinois Insurance | 8 | | Code
requirements. The program of health
benefits shall provide | 9 | | the post-mastectomy care benefits required to be covered
by a | 10 | | policy of accident and health insurance under Section 356t of | 11 | | the Illinois
Insurance Code. The program of health benefits | 12 | | shall provide the coverage
required under Sections 356g, | 13 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 15 | | 356z.14, 356z.15, and 356z.17 , 356z.19, and 364.01 of the
| 16 | | Illinois Insurance Code.
The program of health benefits must |
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| 1 | | comply with Section 155.37 of the
Illinois Insurance Code.
| 2 | | Rulemaking authority to implement Public Act 95-1045, if | 3 | | any, is conditioned on the rules being adopted in accordance | 4 | | with all provisions of the Illinois Administrative Procedure | 5 | | Act and all rules and procedures of the Joint Committee on | 6 | | Administrative Rules; any purported rule not so adopted, for | 7 | | whatever reason, is unauthorized. | 8 | | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 9 | | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | 10 | | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, | 11 | | eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | 12 | | 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; | 13 | | 96-1000, eff. 7-2-10.)
| 14 | | Section 10. The Counties Code is amended by changing | 15 | | Section 5-1069.3 as
follows:
| 16 | | (55 ILCS 5/5-1069.3)
| 17 | | Sec. 5-1069.3. Required health benefits. If a county, | 18 | | including a home
rule
county, is a self-insurer for purposes of | 19 | | providing health insurance coverage
for its employees, the | 20 | | coverage shall include coverage for the post-mastectomy
care | 21 | | benefits required to be covered by a policy of accident and | 22 | | health
insurance under Section 356t and the coverage required | 23 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 24 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
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| 1 | | 356z.14, and 356z.15 , 356z.19, and 364.01 of
the Illinois | 2 | | Insurance Code. The requirement that health benefits be covered
| 3 | | as provided in this Section is an
exclusive power and function | 4 | | of the State and is a denial and limitation under
Article VII, | 5 | | Section 6, subsection (h) of the Illinois Constitution. A home
| 6 | | rule county to which this Section applies must comply with | 7 | | every provision of
this Section.
| 8 | | Rulemaking authority to implement Public Act 95-1045, if | 9 | | any, is conditioned on the rules being adopted in accordance | 10 | | with all provisions of the Illinois Administrative Procedure | 11 | | Act and all rules and procedures of the Joint Committee on | 12 | | Administrative Rules; any purported rule not so adopted, for | 13 | | whatever reason, is unauthorized. | 14 | | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 15 | | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | 16 | | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, | 17 | | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | 18 | | 96-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
| 19 | | Section 15. The Illinois Municipal Code is amended by | 20 | | changing Section
10-4-2.3 as follows:
| 21 | | (65 ILCS 5/10-4-2.3)
| 22 | | Sec. 10-4-2.3. Required health benefits. If a | 23 | | municipality, including a
home rule municipality, is a | 24 | | self-insurer for purposes of providing health
insurance |
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| 1 | | coverage for its employees, the coverage shall include coverage | 2 | | for
the post-mastectomy care benefits required to be covered by | 3 | | a policy of
accident and health insurance under Section 356t | 4 | | and the coverage required
under Sections 356g, 356g.5, | 5 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 6 | | 356z.11, 356z.12, 356z.13, 356z.14, and 356z.15 , 356z.19, and | 7 | | 364.01 of the Illinois
Insurance
Code. The requirement that | 8 | | health
benefits be covered as provided in this is an exclusive | 9 | | power and function of
the State and is a denial and limitation | 10 | | under Article VII, Section 6,
subsection (h) of the Illinois | 11 | | Constitution. A home rule municipality to which
this Section | 12 | | applies must comply with every provision of this Section.
| 13 | | Rulemaking authority to implement Public Act 95-1045, if | 14 | | any, is conditioned on the rules being adopted in accordance | 15 | | with all provisions of the Illinois Administrative Procedure | 16 | | Act and all rules and procedures of the Joint Committee on | 17 | | Administrative Rules; any purported rule not so adopted, for | 18 | | whatever reason, is unauthorized. | 19 | | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 20 | | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | 21 | | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, | 22 | | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | 23 | | 96-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
| 24 | | Section 20. The School Code is amended by changing Section | 25 | | 10-22.3f as
follows:
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| 1 | | (105 ILCS 5/10-22.3f)
| 2 | | Sec. 10-22.3f. Required health benefits. Insurance | 3 | | protection and
benefits
for employees shall provide the | 4 | | post-mastectomy care benefits required to be
covered by a | 5 | | policy of accident and health insurance under Section 356t and | 6 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 7 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 8 | | 356z.13, 356z.14, and 356z.15 , 356z.19, and 364.01 of
the
| 9 | | Illinois Insurance Code.
| 10 | | Rulemaking authority to implement Public Act 95-1045, if | 11 | | any, is conditioned on the rules being adopted in accordance | 12 | | with all provisions of the Illinois Administrative Procedure | 13 | | Act and all rules and procedures of the Joint Committee on | 14 | | Administrative Rules; any purported rule not so adopted, for | 15 | | whatever reason, is unauthorized. | 16 | | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 17 | | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | 18 | | 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | 19 | | 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-1000, | 20 | | eff. 7-2-10.)
| 21 | | Section 25. The Illinois Insurance Code is amended by | 22 | | changing Section 364.01 and by adding Section
356z.19
as
| 23 | | follows:
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| 1 | | (215 ILCS 5/356z.19 new)
| 2 | | Sec. 356z.19. Routine patient care. | 3 | | (a) For the purposes of this Section, the term "qualified | 4 | | individual" means an individual who is a participant or | 5 | | beneficiary in a health plan or with coverage described in | 6 | | paragraph (1) of subsection (c) and who meets the following | 7 | | conditions: | 8 | | (1) the individual is eligible to participate in an | 9 | | approved clinical trial according to the trial protocol | 10 | | with respect to treatment of cancer or other | 11 | | life-threatening disease or condition; and | 12 | | (2) either: | 13 | | (A) the referring health care professional is a | 14 | | participating health care provider and has concluded | 15 | | that the individual's participation in such trial | 16 | | would be appropriate based upon the individual meeting | 17 | | the conditions described in paragraph (1) of this | 18 | | subsection; or | 19 | | (B) the participant or beneficiary provides | 20 | | medical and scientific information establishing that | 21 | | the individual's participation in such trial would be | 22 | | appropriate based upon the individual meeting the | 23 | | conditions described in paragraph (1) of this | 24 | | subsection. | 25 | | (b) For the purposes of this Section, the term | 26 | | "life-threatening condition" or "life-threatening disease" |
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| 1 | | means any condition or disease from which the likelihood of | 2 | | death is probable unless the course of the disease or condition | 3 | | is interrupted. | 4 | | (c) Coverage for routine patient care must comply with the | 5 | | following provisions: | 6 | | (1) If a group health plan or a health insurance issuer | 7 | | offering group or individual health insurance coverage | 8 | | provides coverage to a qualified individual, then such plan | 9 | | or issuer: | 10 | | (A) may not deny the individual participation in | 11 | | the clinical trial referred to in subsection (a) of | 12 | | this Section; | 13 | | (B) subject to subsection (d) of this Section, may | 14 | | not deny or limit or impose additional conditions on | 15 | | the coverage of routine patient care costs for items | 16 | | and services furnished in connection with | 17 | | participation in the trial; and | 18 | | (C) may not discriminate against the individual on | 19 | | the basis of the individual's participation in the | 20 | | trial. | 21 | | (2) The following provisions concerning routine | 22 | | patient costs shall apply: | 23 | | (A) For purposes of and, subject to subparagraph | 24 | | (B) of paragraph (1) of this subsection, routine | 25 | | patient care costs include all items and services | 26 | | consistent with the coverage provided in the plan or |
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| 1 | | coverage that is typically provided for a qualified | 2 | | individual who is not enrolled in a clinical trial. | 3 | | (B) For purposes of subparagraph (B) of paragraph | 4 | | (1) of this subsection, routine patient care costs do | 5 | | not include the following: | 6 | | (i) the investigational item, device, or | 7 | | service itself; | 8 | | (ii) items and services that are provided | 9 | | solely to satisfy data collection and analysis | 10 | | needs and that are not used in the direct clinical | 11 | | management of the patient; or | 12 | | (iii) a service that is clearly inconsistent | 13 | | with widely accepted and established standards of | 14 | | care for a particular diagnosis. | 15 | | (3) If one or more participating providers are | 16 | | participating in a clinical trial, then nothing in | 17 | | paragraph (1) of this subsection shall be construed as | 18 | | preventing a plan or issuer from requiring that a qualified | 19 | | individual participate in the trial through a | 20 | | participating provider if the provider will accept the | 21 | | individual as a participant in the trial. | 22 | | (4) Notwithstanding paragraph (3) of this subsection, | 23 | | paragraph (1) shall apply to a qualified individual | 24 | | participating in an approved clinical trial that is | 25 | | conducted outside the state in which the qualified | 26 | | individual resides. |
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| 1 | | (d) This Section shall not be construed to require a group | 2 | | health plan or a health insurance issuer offering group or | 3 | | individual health insurance coverage to provide benefits for | 4 | | routine patient care services provided outside of the plan's or | 5 | | coverage's health care provider network unless out-of-network | 6 | | benefits are otherwise provided under the plan or coverage. | 7 | | (e) The following provisions concerning approved clinical | 8 | | trials shall apply: | 9 | | (1) In this Section, the term "approved clinical trial" | 10 | | means a phase I, phase II, phase III, or phase IV clinical | 11 | | trial that is conducted in relation to the prevention, | 12 | | detection, or treatment of cancer or other | 13 | | life-threatening disease or condition and is described in | 14 | | any of the following provisions: | 15 | | (A) The study or investigation is approved or | 16 | | funded (which may include funding through in-kind | 17 | | contributions) by one or more of the following: | 18 | | (i) The National Institutes of Health. | 19 | | (ii) The Centers for Disease Control and | 20 | | Prevention. | 21 | | (iii) The Agency for Health Care Research and | 22 | | Quality. | 23 | | (iv) The Centers for Medicare and Medicaid | 24 | | Services. | 25 | | (v) A cooperative group or center of any of the | 26 | | entities described in items (i) through (iv) of |
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| 1 | | this subparagraph or the U.S. Department of | 2 | | Defense or Department of Veterans Affairs. | 3 | | (vi) A qualified non-governmental research | 4 | | entity identified in the guidelines issued by the | 5 | | National Institutes of Health for center support | 6 | | grants. | 7 | | (vii) Any of the following if the conditions | 8 | | described in paragraph (2) of this subsection are | 9 | | met: | 10 | | (I) The U.S. Department of Veterans | 11 | | Affairs. | 12 | | (II) The U.S. Department of Defense. | 13 | | (III) The U.S. Department of Energy. | 14 | | (B) The study or investigation is conducted under | 15 | | an investigational new drug application reviewed by | 16 | | the U.S. Food and Drug Administration. | 17 | | (C) The study or investigation is a drug trial that | 18 | | is exempt from having such an investigational new drug | 19 | | application. | 20 | | (2) A study or investigation under item (1)(A)(vii) of | 21 | | this subsection is subject to the condition that it must be | 22 | | reviewed and approved through a system of peer review that: | 23 | | (A) is comparable to the system of peer review of | 24 | | studies and investigations used by the National | 25 | | Institutes of Health; and | 26 | | (B) ensures unbiased review of the highest |
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| 1 | | scientific standard by qualified individuals who have | 2 | | no interest in the outcome of the review. | 3 | | (f) Nothing in this Section shall be construed to limit a | 4 | | plan's or issuer's coverage with respect to clinical trials. | 5 | | (215 ILCS 5/364.01) | 6 | | Sec. 364.01. Qualified clinical cancer trials. | 7 | | (a) No individual or group policy of accident and health | 8 | | insurance issued or renewed in this State may be cancelled or | 9 | | non-renewed for any individual based on that individual's | 10 | | participation in a qualified clinical cancer trial. | 11 | | (b) Qualified clinical cancer trials must meet the | 12 | | following criteria: | 13 | | (1) the effectiveness of the treatment has not been | 14 | | determined relative to established therapies; | 15 | | (2) the trial is under clinical investigation as part | 16 | | of an approved cancer research trial in Phase II, Phase | 17 | | III, or Phase IV of investigation; | 18 | | (3) the trial is: | 19 | | (A) approved by the Food and Drug Administration; | 20 | | or | 21 | | (B) approved and funded by the National Institutes | 22 | | of Health, the Centers for Disease Control and | 23 | | Prevention, the Agency for Healthcare Research and | 24 | | Quality, the United States Department of Defense, the | 25 | | United States Department of Veterans Affairs, or the |
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| 1 | | United States Department of Energy in the form of an | 2 | | investigational new drug application, or a cooperative | 3 | | group or center of any entity described in this | 4 | | subdivision (B); and
| 5 | | (4) the patient's primary care physician, if any, is | 6 | | involved in the coordination of care.
| 7 | | (c) No group policy of accident and health insurance shall | 8 | | exclude coverage for any routine patient care administered to | 9 | | an insured who is a qualified individual participating in a | 10 | | qualified clinical cancer trial if the policy covers that same | 11 | | routine patient care of insureds not enrolled in a qualified | 12 | | clinical cancer trial. | 13 | | (d) The coverage that may not be excluded under subsection | 14 | | (c) of this Section is subject to all terms, conditions, | 15 | | restrictions, exclusions, and limitations that apply to the | 16 | | same routine patient care received by an insured not enrolled | 17 | | in a qualified clinical cancer trial, including the application | 18 | | of any authorization requirement, utilization review, or | 19 | | medical management practices. The insured or enrollee shall | 20 | | incur no greater out-of-pocket liability than had the insured | 21 | | or enrollee not enrolled in a qualified clinical cancer trial. | 22 | | (e) If the group policy of accident and health insurance | 23 | | uses a preferred provider program and a preferred provider | 24 | | provides routine patient care in connection with a qualified | 25 | | clinical cancer trial, then the insurer may require the insured | 26 | | to use the preferred provider if the preferred provider agrees |
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| 1 | | to provide to the insured that routine patient care. | 2 | | (f) A qualified clinical cancer trial may not pay or refuse | 3 | | to pay for routine patient care of a individual participating | 4 | | in the trial, based in whole or in part on the person's having | 5 | | or not having coverage for routine patient care under a group | 6 | | policy of accident and health insurance. | 7 | | (g) Nothing in this Section shall be construed to limit an | 8 | | insurer's coverage with respect to clinical trials. | 9 | | (h) Nothing in this Section shall require coverage for | 10 | | out-of-network services where the underlying health benefit | 11 | | plan does not provide coverage for out-of-network services. | 12 | | (i) As used in this Section, "routine patient care" means | 13 | | all health care services provided in the qualified clinical | 14 | | cancer trial that are otherwise generally covered under the | 15 | | policy if those items or services were not provided in | 16 | | connection with a qualified clinical cancer trial consistent | 17 | | with the standard of care for the treatment of cancer, | 18 | | including the type and frequency of any diagnostic modality, | 19 | | that a provider typically provides to a cancer patient who is | 20 | | not enrolled in a qualified clinical cancer trial. "Routine | 21 | | patient care" does not include, and a group policy of accident | 22 | | and health insurance may exclude, coverage for: | 23 | | (1) a health care service, item, or drug that is the | 24 | | subject of the cancer clinical trial; | 25 | | (2) a health care service, item, or drug provided | 26 | | solely to satisfy data collection and analysis needs for |
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| 1 | | the qualified clinical cancer trial that is not used in the | 2 | | direct clinical management of the patient; | 3 | | (3) an investigational drug or device that has not been | 4 | | approved for market by the United States Food and Drug | 5 | | Administration; | 6 | | (4) transportation, lodging, food, or other expenses | 7 | | for the patient or a family member or companion of the | 8 | | patient that are associated with the travel to or from a | 9 | | facility providing the qualified clinical cancer trial, | 10 | | unless the policy covers these expenses for a cancer | 11 | | patient who is not enrolled in a qualified clinical cancer | 12 | | trial; | 13 | | (5) a health care service, item, or drug customarily | 14 | | provided by the qualified clinical cancer trial sponsors | 15 | | free of charge for any patient; | 16 | | (6) a health care service or item that, except for the | 17 | | fact that it is being provided in a qualified clinical | 18 | | cancer trial, is otherwise specifically excluded from | 19 | | coverage under the insured's policy, including: | 20 | | (A) costs of extra treatments, services, | 21 | | procedures, tests, or drugs that would not be performed | 22 | | or administered except for the fact that the insured is | 23 | | participating in the cancer clinical trial; and | 24 | | (B) costs of nonhealth care services that the | 25 | | patient is required to receive as a result of | 26 | | participation in the approved cancer clinical trial; |
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| 1 | | (7) costs for services, items, or drugs that are | 2 | | eligible for reimbursement from a source other than a | 3 | | patient's contract or policy providing for third-party | 4 | | payment or prepayment of health or medical expenses, | 5 | | including the sponsor of the approved cancer clinical | 6 | | trial; or | 7 | | (8) costs associated with approved cancer clinical | 8 | | trials designed exclusively to test toxicity or disease | 9 | | pathophysiology, unless the policy covers these expenses | 10 | | for a cancer patient who is not enrolled in a qualified | 11 | | clinical cancer trial; or | 12 | | (9) a health care service or item that is eligible for | 13 | | reimbursement by a source other than the insured's policy, | 14 | | including the sponsor of the qualified clinical cancer | 15 | | trial. | 16 | | The definitions of the terms "health care services", | 17 | | "Non-Preferred Provider", "Preferred Provider", and "Preferred | 18 | | Provider Program", stated in 50 IL Adm. Code Part 2051 | 19 | | Preferred Provider Programs apply to these terms in this | 20 | | Section. | 21 | | (j) The external review procedures established under the | 22 | | Health Carrier External Review Act shall apply to the | 23 | | provisions under this Section. | 24 | | (Source: P.A. 93-1000, eff. 1-1-05.)
| 25 | | Section 30. The Health Maintenance Organization Act is |
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| 1 | | amended by changing
Section 5-3 as follows:
| 2 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 3 | | Sec. 5-3. Insurance Code provisions.
| 4 | | (a) Health Maintenance Organizations
shall be subject to | 5 | | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 6 | | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 7 | | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | 8 | | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | 9 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | 10 | | 356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, | 11 | | 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, | 12 | | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | 13 | | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | 14 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| 15 | | (b) For purposes of the Illinois Insurance Code, except for | 16 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 17 | | Maintenance Organizations in
the following categories are | 18 | | deemed to be "domestic companies":
| 19 | | (1) a corporation authorized under the
Dental Service | 20 | | Plan Act or the Voluntary Health Services Plans Act;
| 21 | | (2) a corporation organized under the laws of this | 22 | | State; or
| 23 | | (3) a corporation organized under the laws of another | 24 | | state, 30% or more
of the enrollees of which are residents | 25 | | of this State, except a
corporation subject to |
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| 1 | | substantially the same requirements in its state of
| 2 | | organization as is a "domestic company" under Article VIII | 3 | | 1/2 of the
Illinois Insurance Code.
| 4 | | (c) In considering the merger, consolidation, or other | 5 | | acquisition of
control of a Health Maintenance Organization | 6 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 7 | | (1) the Director shall give primary consideration to | 8 | | the continuation of
benefits to enrollees and the financial | 9 | | conditions of the acquired Health
Maintenance Organization | 10 | | after the merger, consolidation, or other
acquisition of | 11 | | control takes effect;
| 12 | | (2)(i) the criteria specified in subsection (1)(b) of | 13 | | Section 131.8 of
the Illinois Insurance Code shall not | 14 | | apply and (ii) the Director, in making
his determination | 15 | | with respect to the merger, consolidation, or other
| 16 | | acquisition of control, need not take into account the | 17 | | effect on
competition of the merger, consolidation, or | 18 | | other acquisition of control;
| 19 | | (3) the Director shall have the power to require the | 20 | | following
information:
| 21 | | (A) certification by an independent actuary of the | 22 | | adequacy
of the reserves of the Health Maintenance | 23 | | Organization sought to be acquired;
| 24 | | (B) pro forma financial statements reflecting the | 25 | | combined balance
sheets of the acquiring company and | 26 | | the Health Maintenance Organization sought
to be |
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| 1 | | acquired as of the end of the preceding year and as of | 2 | | a date 90 days
prior to the acquisition, as well as pro | 3 | | forma financial statements
reflecting projected | 4 | | combined operation for a period of 2 years;
| 5 | | (C) a pro forma business plan detailing an | 6 | | acquiring party's plans with
respect to the operation | 7 | | of the Health Maintenance Organization sought to
be | 8 | | acquired for a period of not less than 3 years; and
| 9 | | (D) such other information as the Director shall | 10 | | require.
| 11 | | (d) The provisions of Article VIII 1/2 of the Illinois | 12 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 13 | | any health maintenance
organization of greater than 10% of its
| 14 | | enrollee population (including without limitation the health | 15 | | maintenance
organization's right, title, and interest in and to | 16 | | its health care
certificates).
| 17 | | (e) In considering any management contract or service | 18 | | agreement subject
to Section 141.1 of the Illinois Insurance | 19 | | Code, the Director (i) shall, in
addition to the criteria | 20 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 21 | | into account the effect of the management contract or
service | 22 | | agreement on the continuation of benefits to enrollees and the
| 23 | | financial condition of the health maintenance organization to | 24 | | be managed or
serviced, and (ii) need not take into account the | 25 | | effect of the management
contract or service agreement on | 26 | | competition.
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| 1 | | (f) Except for small employer groups as defined in the | 2 | | Small Employer
Rating, Renewability and Portability Health | 3 | | Insurance Act and except for
medicare supplement policies as | 4 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 5 | | Maintenance Organization may by contract agree with a
group or | 6 | | other enrollment unit to effect refunds or charge additional | 7 | | premiums
under the following terms and conditions:
| 8 | | (i) the amount of, and other terms and conditions with | 9 | | respect to, the
refund or additional premium are set forth | 10 | | in the group or enrollment unit
contract agreed in advance | 11 | | of the period for which a refund is to be paid or
| 12 | | additional premium is to be charged (which period shall not | 13 | | be less than one
year); and
| 14 | | (ii) the amount of the refund or additional premium | 15 | | shall not exceed 20%
of the Health Maintenance | 16 | | Organization's profitable or unprofitable experience
with | 17 | | respect to the group or other enrollment unit for the | 18 | | period (and, for
purposes of a refund or additional | 19 | | premium, the profitable or unprofitable
experience shall | 20 | | be calculated taking into account a pro rata share of the
| 21 | | Health Maintenance Organization's administrative and | 22 | | marketing expenses, but
shall not include any refund to be | 23 | | made or additional premium to be paid
pursuant to this | 24 | | subsection (f)). The Health Maintenance Organization and | 25 | | the
group or enrollment unit may agree that the profitable | 26 | | or unprofitable
experience may be calculated taking into |
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| 1 | | account the refund period and the
immediately preceding 2 | 2 | | plan years.
| 3 | | The Health Maintenance Organization shall include a | 4 | | statement in the
evidence of coverage issued to each enrollee | 5 | | describing the possibility of a
refund or additional premium, | 6 | | and upon request of any group or enrollment unit,
provide to | 7 | | the group or enrollment unit a description of the method used | 8 | | to
calculate (1) the Health Maintenance Organization's | 9 | | profitable experience with
respect to the group or enrollment | 10 | | unit and the resulting refund to the group
or enrollment unit | 11 | | or (2) the Health Maintenance Organization's unprofitable
| 12 | | experience with respect to the group or enrollment unit and the | 13 | | resulting
additional premium to be paid by the group or | 14 | | enrollment unit.
| 15 | | In no event shall the Illinois Health Maintenance | 16 | | Organization
Guaranty Association be liable to pay any | 17 | | contractual obligation of an
insolvent organization to pay any | 18 | | refund authorized under this Section.
| 19 | | (g) Rulemaking authority to implement Public Act 95-1045, | 20 | | if any, is conditioned on the rules being adopted in accordance | 21 | | with all provisions of the Illinois Administrative Procedure | 22 | | Act and all rules and procedures of the Joint Committee on | 23 | | Administrative Rules; any purported rule not so adopted, for | 24 | | whatever reason, is unauthorized. | 25 | | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | 26 | | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
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| 1 | | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | 2 | | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | 3 | | 6-1-10; 96-1000, eff. 7-2-10.)
| 4 | | Section 35. The Voluntary Health Services Plans Act is | 5 | | amended by changing
Section 10 as follows:
| 6 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
| 7 | | Sec. 10. Application of Insurance Code provisions. Health | 8 | | services
plan corporations and all persons interested therein | 9 | | or dealing therewith
shall be subject to the provisions of | 10 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | 11 | | 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | 12 | | 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | 13 | | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | 14 | | 356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401, | 15 | | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | 16 | | and (15) of Section 367 of the Illinois
Insurance Code.
| 17 | | Rulemaking authority to implement Public Act 95-1045, if | 18 | | any, is conditioned on the rules being adopted in accordance | 19 | | with all provisions of the Illinois Administrative Procedure | 20 | | Act and all rules and procedures of the Joint Committee on | 21 | | Administrative Rules; any purported rule not so adopted, for | 22 | | whatever reason, is unauthorized. | 23 | | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | 24 | | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
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| 1 | | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | 2 | | eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | 3 | | 96-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff. | 4 | | 7-2-10.)
| 5 | | Section 40. 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 | 16 | | office, the patient's home, a
hospital, a skilled nursing home, | 17 | | or elsewhere; (6) medical care, or any
other type of remedial | 18 | | care furnished by licensed practitioners; (7)
home health care | 19 | | services; (8) private duty nursing service; (9) clinic
| 20 | | services; (10) dental services, including prevention and | 21 | | treatment of periodontal disease and dental caries disease for | 22 | | pregnant women, provided by an individual licensed to practice | 23 | | dentistry or dental surgery; for purposes of this item (10), | 24 | | "dental services" means diagnostic, preventive, or corrective |
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| 1 | | procedures provided by or under the supervision of a dentist in | 2 | | the practice of his or her profession; (11) physical therapy | 3 | | and related
services; (12) prescribed drugs, dentures, and | 4 | | prosthetic devices; and
eyeglasses prescribed by a physician | 5 | | skilled in the diseases of the eye,
or by an optometrist, | 6 | | whichever the person may select; (13) other
diagnostic, | 7 | | screening, preventive, and rehabilitative services; (14)
| 8 | | transportation and such other expenses as may be necessary; | 9 | | (15) medical
treatment of sexual assault survivors, as defined | 10 | | in
Section 1a of the Sexual Assault Survivors Emergency | 11 | | Treatment Act, for
injuries sustained as a result of the sexual | 12 | | assault, including
examinations and laboratory tests to | 13 | | discover evidence which may be used in
criminal proceedings | 14 | | arising from the sexual assault; (16) the
diagnosis and | 15 | | treatment of sickle cell anemia; and (17)
any other medical | 16 | | care, and any other type of remedial care recognized
under the | 17 | | laws of this State, but not including abortions, or induced
| 18 | | miscarriages or premature births, unless, in the opinion of a | 19 | | physician,
such procedures are necessary for the preservation | 20 | | of the life of the
woman seeking such treatment, or except an | 21 | | induced premature birth
intended to produce a live viable child | 22 | | and such procedure is necessary
for the health of the mother or | 23 | | her unborn child. The Illinois Department,
by rule, shall | 24 | | prohibit any physician from providing medical assistance
to | 25 | | anyone eligible therefor under this Code where such physician | 26 | | has been
found guilty of performing an abortion procedure in a |
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| 1 | | wilful and wanton
manner upon a woman who was not pregnant at | 2 | | the time such abortion
procedure was performed. The term "any | 3 | | other type of remedial care" shall
include nursing care and | 4 | | nursing home service for persons who rely on
treatment by | 5 | | spiritual means alone through prayer for healing.
| 6 | | Notwithstanding any other provision of this Section, a | 7 | | comprehensive
tobacco use cessation program that includes | 8 | | purchasing prescription drugs or
prescription medical devices | 9 | | approved by the Food and Drug Administration shall
be covered | 10 | | under the medical assistance
program under this Article for | 11 | | persons who are otherwise eligible for
assistance under this | 12 | | Article.
| 13 | | Notwithstanding any other provision of this Code, the | 14 | | Illinois
Department may not require, as a condition of payment | 15 | | for any laboratory
test authorized under this Article, that a | 16 | | physician's handwritten signature
appear on the laboratory | 17 | | test order form. The Illinois Department may,
however, impose | 18 | | other appropriate requirements regarding laboratory test
order | 19 | | documentation.
| 20 | | The Department of Healthcare and Family Services shall | 21 | | provide the following services to
persons
eligible for | 22 | | assistance under this Article who are participating in
| 23 | | education, training or employment programs operated by the | 24 | | Department of Human
Services as successor to the Department of | 25 | | Public Aid:
| 26 | | (1) dental services provided by or under the |
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| 1 | | supervision of a dentist; and
| 2 | | (2) eyeglasses prescribed by a physician skilled in the | 3 | | diseases of the
eye, or by an optometrist, whichever the | 4 | | person may select.
| 5 | | Notwithstanding any other provision of this Code and | 6 | | subject to federal approval, the Department may adopt rules to | 7 | | allow a dentist who is volunteering his or her service at no | 8 | | cost to render dental services through an enrolled | 9 | | not-for-profit health clinic without the dentist personally | 10 | | enrolling as a participating provider in the medical assistance | 11 | | program. A not-for-profit health clinic shall include a public | 12 | | health clinic or Federally Qualified Health Center or other | 13 | | enrolled provider, as determined by the Department, through | 14 | | which dental services covered under this Section are performed. | 15 | | The Department shall establish a process for payment of claims | 16 | | for reimbursement for covered dental services rendered under | 17 | | this provision. | 18 | | Notwithstanding any other provision of this Code, the | 19 | | Illinois Department shall ensure that cancer patients in need | 20 | | of dental treatment prior to the administration of chemotherapy | 21 | | have access to such dental services and shall ensure that | 22 | | treatment is not delayed due to an inability to locate a | 23 | | provider willing to accept the Department's rates. The | 24 | | Department shall ensure that healthcare providers treating | 25 | | such patients, including medical oncologists, cancer centers, | 26 | | and cancer advocacy organizations, are aware of the mechanisms |
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| 1 | | available to the Department to ensure such access. | 2 | | The Illinois Department shall develop a mechanism whereby | 3 | | mammography providers may download a standing order via the | 4 | | Internet for screening mammography for any woman eligible for | 5 | | mammography coverage who has not had a screening mammogram | 6 | | within the last 12 months. This mechanism shall be available | 7 | | for all women covered by any program administered by this State | 8 | | that includes mammography coverage. | 9 | | The Illinois Department, by rule, may distinguish and | 10 | | classify the
medical services to be provided only in accordance | 11 | | with the classes of
persons designated in Section 5-2.
| 12 | | The Department of Healthcare and Family Services must | 13 | | provide coverage and reimbursement for amino acid-based | 14 | | elemental formulas, regardless of delivery method, for the | 15 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 16 | | short bowel syndrome when the prescribing physician has issued | 17 | | a written order stating that the amino acid-based elemental | 18 | | formula is medically necessary.
| 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: | 24 | | (A) A baseline
mammogram for women 35 to 39 years of | 25 | | age.
| 26 | | (B) An annual mammogram for women 40 years of age or |
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| 1 | | older. | 2 | | (C) A mammogram at the age and intervals considered | 3 | | medically necessary by the woman's health care provider for | 4 | | women under 40 years of age and having a family history of | 5 | | breast cancer, prior personal history of breast cancer, | 6 | | positive genetic testing, or other risk factors. | 7 | | (D) A comprehensive ultrasound screening of an entire | 8 | | breast or breasts if a mammogram demonstrates | 9 | | heterogeneous or dense breast tissue, when medically | 10 | | necessary as determined by a physician licensed to practice | 11 | | medicine in all of its branches. | 12 | | All screenings
shall
include a physical breast exam, | 13 | | instruction on self-examination and
information regarding the | 14 | | frequency of self-examination and its value as a
preventative | 15 | | tool. For purposes of this Section, "low-dose mammography" | 16 | | means
the x-ray examination of the breast using equipment | 17 | | dedicated specifically
for mammography, including the x-ray | 18 | | tube, filter, compression device,
and image receptor, with an | 19 | | average radiation exposure delivery
of less than one rad per | 20 | | breast for 2 views of an average size breast.
The term also | 21 | | includes digital mammography.
| 22 | | On and after July 1, 2008, screening and diagnostic | 23 | | mammography shall be reimbursed at the same rate as the | 24 | | Medicare program's rates, including the increased | 25 | | reimbursement for digital mammography. | 26 | | The Department shall convene an expert panel including |
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| 1 | | representatives of hospitals, free-standing mammography | 2 | | facilities, and doctors, including radiologists, to establish | 3 | | quality standards. Based on these quality standards, the | 4 | | Department shall provide for bonus payments to mammography | 5 | | facilities meeting the standards for screening and diagnosis. | 6 | | The bonus payments shall be at least 15% higher than the | 7 | | Medicare rates for mammography. | 8 | | Subject to federal approval, the Department shall | 9 | | establish a rate methodology for mammography at federally | 10 | | qualified health centers and other encounter-rate clinics. | 11 | | These clinics or centers may also collaborate with other | 12 | | hospital-based mammography facilities. | 13 | | The Department shall establish a methodology to remind | 14 | | women who are age-appropriate for screening mammography, but | 15 | | who have not received a mammogram within the previous 18 | 16 | | months, of the importance and benefit of screening mammography. | 17 | | The Department shall establish a performance goal for | 18 | | primary care providers with respect to their female patients | 19 | | over age 40 receiving an annual mammogram. This performance | 20 | | goal shall be used to provide additional reimbursement in the | 21 | | form of a quality performance bonus to primary care providers | 22 | | who meet that goal. | 23 | | The Department shall devise a means of case-managing or | 24 | | patient navigation for beneficiaries diagnosed with breast | 25 | | cancer. This program shall initially operate as a pilot program | 26 | | in areas of the State with the highest incidence of mortality |
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| 1 | | related to breast cancer. At least one pilot program site shall | 2 | | be in the metropolitan Chicago area and at least one site shall | 3 | | be outside the metropolitan Chicago area. An evaluation of the | 4 | | pilot program shall be carried out measuring health outcomes | 5 | | and cost of care for those served by the pilot program compared | 6 | | to similarly situated patients who are not served by the pilot | 7 | | program. | 8 | | Any medical or health care provider shall immediately | 9 | | recommend, to
any pregnant woman who is being provided prenatal | 10 | | services and is suspected
of drug abuse or is addicted as | 11 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 12 | | Act, referral to a local substance abuse treatment provider
| 13 | | licensed by the Department of Human Services or to a licensed
| 14 | | hospital which provides substance abuse treatment services. | 15 | | The Department of Healthcare and Family Services
shall assure | 16 | | coverage for the cost of treatment of the drug abuse or
| 17 | | addiction for pregnant recipients in accordance with the | 18 | | Illinois Medicaid
Program in conjunction with the Department of | 19 | | Human Services.
| 20 | | All medical providers providing medical assistance to | 21 | | pregnant women
under this Code shall receive information from | 22 | | the Department on the
availability of services under the Drug | 23 | | Free Families with a Future or any
comparable program providing | 24 | | case management services for addicted women,
including | 25 | | information on appropriate referrals for other social services
| 26 | | that may be needed by addicted women in addition to treatment |
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| 1 | | for addiction.
| 2 | | The Illinois Department, in cooperation with the | 3 | | Departments of Human
Services (as successor to the Department | 4 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 5 | | public awareness campaign, may
provide information concerning | 6 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 7 | | health care, and other pertinent programs directed at
reducing | 8 | | the number of drug-affected infants born to recipients of | 9 | | medical
assistance.
| 10 | | Neither the Department of Healthcare and Family Services | 11 | | nor the Department of Human
Services shall sanction the | 12 | | recipient solely on the basis of
her substance abuse.
| 13 | | The Illinois Department shall establish such regulations | 14 | | governing
the dispensing of health services under this Article | 15 | | as it shall deem
appropriate. The Department
should
seek the | 16 | | advice of formal professional advisory committees appointed by
| 17 | | the Director of the Illinois Department for the purpose of | 18 | | providing regular
advice on policy and administrative matters, | 19 | | information dissemination and
educational activities for | 20 | | medical and health care providers, and
consistency in | 21 | | procedures to the Illinois Department.
| 22 | | Notwithstanding any other provision of law, a health care | 23 | | provider under the medical assistance program may elect, in | 24 | | lieu of receiving direct payment for services provided under | 25 | | that program, to participate in the State Employees Deferred | 26 | | Compensation Plan adopted under Article 24 of the Illinois |
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| 1 | | Pension Code. A health care provider who elects to participate | 2 | | in the plan does not have a cause of action against the State | 3 | | for any damages allegedly suffered by the provider as a result | 4 | | of any delay by the State in crediting the amount of any | 5 | | contribution to the provider's plan account. | 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 |
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| 1 | | the Illinois Department, to persons
in areas covered by the | 2 | | Partnership may receive an additional surcharge
for such | 3 | | services.
| 4 | | (2) The Department may elect to consider and negotiate | 5 | | financial
incentives to encourage the development of | 6 | | Partnerships and the efficient
delivery of medical care.
| 7 | | (3) Persons receiving medical services through | 8 | | Partnerships may receive
medical and case management | 9 | | services above the level usually offered
through the | 10 | | medical assistance program.
| 11 | | Medical providers shall be required to meet certain | 12 | | qualifications to
participate in Partnerships to ensure the | 13 | | delivery of high quality medical
services. These | 14 | | qualifications shall be determined by rule of the Illinois
| 15 | | Department and may be higher than qualifications for | 16 | | participation in the
medical assistance program. Partnership | 17 | | sponsors may prescribe reasonable
additional qualifications | 18 | | for participation by medical providers, only with
the prior | 19 | | written approval of the Illinois Department.
| 20 | | Nothing in this Section shall limit the free choice of | 21 | | practitioners,
hospitals, and other providers of medical | 22 | | services by clients.
In order to ensure patient freedom of | 23 | | choice, the Illinois Department shall
immediately promulgate | 24 | | all rules and take all other necessary actions so that
provided | 25 | | services may be accessed from therapeutically certified | 26 | | optometrists
to the full extent of the Illinois Optometric |
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| 1 | | Practice Act of 1987 without
discriminating between service | 2 | | providers.
| 3 | | The Department shall apply for a waiver from the United | 4 | | States Health
Care Financing Administration to allow for the | 5 | | implementation of
Partnerships under this Section.
| 6 | | The Illinois Department shall require health care | 7 | | providers to maintain
records that document the medical care | 8 | | and services provided to recipients
of Medical Assistance under | 9 | | this Article. The Illinois Department shall
require health care | 10 | | providers to make available, when authorized by the
patient, in | 11 | | writing, the medical records in a timely fashion to other
| 12 | | health care providers who are treating or serving persons | 13 | | eligible for
Medical Assistance under this Article. All | 14 | | dispensers of medical services
shall be required to maintain | 15 | | and retain business and professional records
sufficient to | 16 | | fully and accurately document the nature, scope, details and
| 17 | | receipt of the health care provided to persons eligible for | 18 | | medical
assistance under this Code, in accordance with | 19 | | regulations promulgated by
the Illinois Department. The rules | 20 | | and regulations shall require that proof
of the receipt of | 21 | | prescription drugs, dentures, prosthetic devices and
| 22 | | eyeglasses by eligible persons under this Section accompany | 23 | | each claim
for reimbursement submitted by the dispenser of such | 24 | | medical services.
No such claims for reimbursement shall be | 25 | | approved for payment by the Illinois
Department without such | 26 | | proof of receipt, unless the Illinois Department
shall have put |
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| 1 | | into effect and shall be operating a system of post-payment
| 2 | | audit and review which shall, on a sampling basis, be deemed | 3 | | adequate by
the Illinois Department to assure that such drugs, | 4 | | dentures, prosthetic
devices and eyeglasses for which payment | 5 | | is being made are actually being
received by eligible | 6 | | recipients. Within 90 days after the effective date of
this | 7 | | amendatory Act of 1984, the Illinois Department shall establish | 8 | | a
current list of acquisition costs for all prosthetic devices | 9 | | and any
other items recognized as medical equipment and | 10 | | supplies reimbursable under
this Article and shall update such | 11 | | list on a quarterly basis, except that
the acquisition costs of | 12 | | all prescription drugs shall be updated no
less frequently than | 13 | | every 30 days as required by Section 5-5.12.
| 14 | | The rules and regulations of the Illinois Department shall | 15 | | require
that a written statement including the required opinion | 16 | | of a physician
shall accompany any claim for reimbursement for | 17 | | abortions, or induced
miscarriages or premature births. This | 18 | | statement shall indicate what
procedures were used in providing | 19 | | such medical services.
| 20 | | The Illinois Department shall require all dispensers of | 21 | | medical
services, other than an individual practitioner or | 22 | | group of practitioners,
desiring to participate in the Medical | 23 | | Assistance program
established under this Article to disclose | 24 | | all financial, beneficial,
ownership, equity, surety or other | 25 | | interests in any and all firms,
corporations, partnerships, | 26 | | associations, business enterprises, joint
ventures, agencies, |
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| 1 | | institutions or other legal entities providing any
form of | 2 | | health care services in this State under this Article.
| 3 | | The Illinois Department may require that all dispensers of | 4 | | medical
services desiring to participate in the medical | 5 | | assistance program
established under this Article disclose, | 6 | | under such terms and conditions as
the Illinois Department may | 7 | | by rule establish, all inquiries from clients
and attorneys | 8 | | regarding medical bills paid by the Illinois Department, which
| 9 | | inquiries could indicate potential existence of claims or liens | 10 | | for the
Illinois Department.
| 11 | | Enrollment of a vendor that provides non-emergency medical | 12 | | transportation,
defined by the Department by rule,
shall be
| 13 | | conditional for 180 days. During that time, the Department of | 14 | | Healthcare and Family Services may
terminate the vendor's | 15 | | eligibility to participate in the medical assistance
program | 16 | | without cause. That termination of eligibility is not subject | 17 | | to the
Department's hearing process.
| 18 | | The Illinois Department shall establish policies, | 19 | | procedures,
standards and criteria by rule for the acquisition, | 20 | | repair and replacement
of orthotic and prosthetic devices and | 21 | | durable medical equipment. Such
rules shall provide, but not be | 22 | | limited to, the following services: (1)
immediate repair or | 23 | | replacement of such devices by recipients without
medical | 24 | | authorization; and (2) rental, lease, purchase or | 25 | | lease-purchase of
durable medical equipment in a | 26 | | cost-effective manner, taking into
consideration the |
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| 1 | | recipient's medical prognosis, the extent of the
recipient's | 2 | | needs, and the requirements and costs for maintaining such
| 3 | | equipment. Such rules shall enable a recipient to temporarily | 4 | | acquire and
use alternative or substitute devices or equipment | 5 | | pending repairs or
replacements of any device or equipment | 6 | | previously authorized for such
recipient by the Department.
| 7 | | The Department shall execute, relative to the nursing home | 8 | | prescreening
project, written inter-agency agreements with the | 9 | | Department of Human
Services and the Department on Aging, to | 10 | | effect the following: (i) intake
procedures and common | 11 | | eligibility criteria for those persons who are receiving
| 12 | | non-institutional services; and (ii) the establishment and | 13 | | development of
non-institutional services in areas of the State | 14 | | where they are not currently
available or are undeveloped.
| 15 | | The Illinois Department shall develop and operate, in | 16 | | cooperation
with other State Departments and agencies and in | 17 | | compliance with
applicable federal laws and regulations, | 18 | | appropriate and effective
systems of health care evaluation and | 19 | | programs for monitoring of
utilization of health care services | 20 | | and facilities, as it affects
persons eligible for medical | 21 | | assistance under this Code.
| 22 | | The Illinois Department shall report annually to the | 23 | | General Assembly,
no later than the second Friday in April of | 24 | | 1979 and each year
thereafter, in regard to:
| 25 | | (a) actual statistics and trends in utilization of | 26 | | medical services by
public aid recipients;
|
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| 1 | | (b) actual statistics and trends in the provision of | 2 | | the various medical
services by medical vendors;
| 3 | | (c) current rate structures and proposed changes in | 4 | | those rate structures
for the various medical vendors; and
| 5 | | (d) efforts at utilization review and control by the | 6 | | Illinois Department.
| 7 | | The period covered by each report shall be the 3 years | 8 | | ending on the June
30 prior to the report. The report shall | 9 | | include suggested legislation
for consideration by the General | 10 | | Assembly. The filing of one copy of the
report with the | 11 | | Speaker, one copy with the Minority Leader and one copy
with | 12 | | the Clerk of the House of Representatives, one copy with the | 13 | | President,
one copy with the Minority Leader and one copy with | 14 | | the Secretary of the
Senate, one copy with the Legislative | 15 | | Research Unit, and such additional
copies
with the State | 16 | | Government Report Distribution Center for the General
Assembly | 17 | | as is required under paragraph (t) of Section 7 of the State
| 18 | | Library Act shall be deemed sufficient to comply with this | 19 | | Section.
| 20 | | Rulemaking authority to implement Public Act 95-1045, if | 21 | | any, is conditioned on the rules being adopted in accordance | 22 | | with all provisions of the Illinois Administrative Procedure | 23 | | Act and all rules and procedures of the Joint Committee on | 24 | | Administrative Rules; any purported rule not so adopted, for | 25 | | whatever reason, is unauthorized. | 26 | | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; |
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| 1 | | 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; 96-806, eff. | 2 | | 7-1-10; 96-926, eff. 1-1-11; 96-1000, eff. 7-2-10 .) | 3 | | Section 45. The Radiation Protection Act of 1990 is amended | 4 | | by changing Section 5 as follows:
| 5 | | (420 ILCS 40/5) (from Ch. 111 1/2, par. 210-5)
| 6 | | (Section scheduled to be repealed on January 1, 2021)
| 7 | | Sec. 5. Limitations on application of radiation to human | 8 | | beings and
requirements for radiation installation operators | 9 | | providing mammography
services. | 10 | | (a) No person shall intentionally administer radiation to a | 11 | | human being
unless such person is licensed to practice a | 12 | | treatment of human ailments by
virtue of the Illinois Medical, | 13 | | Dental or Podiatric Medical Practice Acts,
or, as physician | 14 | | assistant, advanced practice nurse, technician, nurse,
or | 15 | | other assistant, is
acting under the
supervision, prescription | 16 | | or direction of such licensed person. However,
no such | 17 | | physician assistant, advanced practice nurse, technician,
| 18 | | nurse, or other assistant
acting under the supervision
of a | 19 | | person licensed under the Medical Practice Act of 1987, shall
| 20 | | administer radiation to human beings unless accredited by the | 21 | | Agency, except that persons enrolled in a course of education
| 22 | | approved by the Agency may apply ionizing radiation
to human | 23 | | beings as required by their course of study when under the | 24 | | direct
supervision of a person licensed under the Medical |
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| 1 | | Practice Act of 1987.
No person authorized by this Section to | 2 | | apply ionizing radiation shall apply
such radiation except to | 3 | | those parts of the human body specified in the Act
under which | 4 | | such person or his supervisor is licensed.
No person may | 5 | | operate a radiation installation where ionizing radiation is
| 6 | | administered to human beings unless all persons who administer | 7 | | ionizing
radiation in that radiation installation are | 8 | | licensed, accredited, or
exempted in accordance with this | 9 | | Section. Nothing in this Section shall be
deemed to relieve a | 10 | | person from complying with the provisions of Section 10.
| 11 | | (b) In addition, no person shall provide mammography | 12 | | services unless
all of the following requirements are met:
| 13 | | (1) the mammography procedures are performed using a | 14 | | radiation machine
that is specifically designed for | 15 | | mammography;
| 16 | | (2) the mammography procedures are performed using a | 17 | | radiation machine
that is used solely for performing | 18 | | mammography procedures;
| 19 | | (3) the mammography procedures are performed using | 20 | | equipment that has
been subjected to a quality assurance | 21 | | program that satisfies quality
assurance requirements | 22 | | which the Agency shall establish by rule;
| 23 | | (4) beginning one year after the effective date of this | 24 | | amendatory Act
of 1991, if the mammography procedure is | 25 | | performed by a radiologic
technologist, that technologist, | 26 | | in addition to being accredited by the
Agency to perform |
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| 1 | | radiography, has satisfied training requirements
specific | 2 | | to mammography, which the Agency shall establish by rule.
| 3 | | (c) Every operator of a radiation installation at which | 4 | | mammography
services are provided shall ensure and have | 5 | | confirmed by each mammography
patient that the patient is | 6 | | provided with a pamphlet which is orally reviewed
with the | 7 | | patient and which contains the following:
| 8 | | (1) how to perform breast self-examination;
| 9 | | (2) that early detection of breast cancer is maximized | 10 | | through a combined
approach, using monthly breast | 11 | | self-examination, a thorough physical
examination | 12 | | performed by a physician, and mammography performed at | 13 | | recommended
intervals;
| 14 | | (3) that mammography is the most accurate method for | 15 | | making an early
detection of breast cancer, however, no | 16 | | diagnostic tool is 100% effective;
| 17 | | (4) that if the patient is self-referred and does not | 18 | | have a primary care
physician, or if the patient is | 19 | | unfamiliar with the breast examination
procedures, that | 20 | | the patient has received information regarding public | 21 | | health
services where she can obtain a breast examination | 22 | | and instructions.
| 23 | | (d) Each facility that performs mammograms shall upon | 24 | | request by or on behalf of the patient permanently or | 25 | | temporarily transfer the original mammograms and copies of the | 26 | | patient's reports to a medical institution or to a physician or |
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| 1 | | health care provider of the patient or to the patient directly | 2 | | without charge to the patient. Such a transfer must be done | 3 | | within 2 weeks after the request or within one week if the | 4 | | patient has already had a mammogram that shows potential | 5 | | abnormality. Transfer may not be delayed as a means of debt | 6 | | collection. | 7 | | (Source: P.A. 93-149, eff. 7-10-03; 94-104, eff. 7-1-05 .)".
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