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


Sen. Mattie Hunter

Filed: 10/27/2011





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2    AMENDMENT NO. ______. Amend Senate Bill 2502 by replacing
3everything after the enacting clause with the following:
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



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1care furnished by licensed practitioners; (7) home health care
2services; (8) private duty nursing service; (9) clinic
3services; (10) dental services, including prevention and
4treatment of periodontal disease and dental caries disease for
5pregnant women, provided by an individual licensed to practice
6dentistry or dental surgery; for purposes of this item (10),
7"dental services" means diagnostic, preventive, or corrective
8procedures provided by or under the supervision of a dentist in
9the practice of his or her profession; (11) physical therapy
10and related services; (12) prescribed drugs, dentures, and
11prosthetic devices; and eyeglasses prescribed by a physician
12skilled in the diseases of the eye, or by an optometrist,
13whichever the person may select; (13) other diagnostic,
14screening, preventive, and rehabilitative services, for
15children and adults; (14) transportation and such other
16expenses as may be necessary; (15) medical treatment of sexual
17assault survivors, as defined in Section 1a of the Sexual
18Assault Survivors Emergency Treatment Act, for injuries
19sustained as a result of the sexual assault, including
20examinations and laboratory tests to discover evidence which
21may be used in criminal proceedings arising from the sexual
22assault; (16) the diagnosis and treatment of sickle cell
23anemia; and (17) any other medical care, and any other type of
24remedial care recognized under the laws of this State, but not
25including abortions, or induced miscarriages or premature
26births, unless, in the opinion of a physician, such procedures



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



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2    The Department of Healthcare and Family Services shall
3provide the following services to persons eligible for
4assistance under this Article who are participating in
5education, training or employment programs operated by the
6Department of Human Services as successor to the Department of
7Public Aid:
8        (1) dental services provided by or under the
9    supervision of a dentist; and
10        (2) eyeglasses prescribed by a physician skilled in the
11    diseases of the eye, or by an optometrist, whichever the
12    person may select.
13    Notwithstanding any other provision of this Code and
14subject to federal approval, the Department may adopt rules to
15allow a dentist who is volunteering his or her service at no
16cost to render dental services through an enrolled
17not-for-profit health clinic without the dentist personally
18enrolling as a participating provider in the medical assistance
19program. A not-for-profit health clinic shall include a public
20health clinic or Federally Qualified Health Center or other
21enrolled provider, as determined by the Department, through
22which dental services covered under this Section are performed.
23The Department shall establish a process for payment of claims
24for reimbursement for covered dental services rendered under
25this provision.
26    The Illinois Department, by rule, may distinguish and



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1classify the medical services to be provided only in accordance
2with the classes of persons designated in Section 5-2.
3    The Department of Healthcare and Family Services must
4provide coverage and reimbursement for amino acid-based
5elemental formulas, regardless of delivery method, for the
6diagnosis and treatment of (i) eosinophilic disorders and (ii)
7short bowel syndrome when the prescribing physician has issued
8a written order stating that the amino acid-based elemental
9formula is medically necessary.
10    The Illinois Department shall authorize the provision of,
11and shall authorize payment for, screening by low-dose
12mammography for the presence of occult breast cancer for women
1335 years of age or older who are eligible for medical
14assistance under this Article, as follows:
15        (A) A baseline mammogram for women 35 to 39 years of
16    age.
17        (B) An annual mammogram for women 40 years of age or
18    older.
19        (C) A mammogram at the age and intervals considered
20    medically necessary by the woman's health care provider for
21    women under 40 years of age and having a family history of
22    breast cancer, prior personal history of breast cancer,
23    positive genetic testing, or other risk factors.
24        (D) A comprehensive ultrasound screening of an entire
25    breast or breasts if a mammogram demonstrates
26    heterogeneous or dense breast tissue, when medically



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1    necessary as determined by a physician licensed to practice
2    medicine in all of its branches.
3    All screenings shall include a physical breast exam,
4instruction on self-examination and information regarding the
5frequency of self-examination and its value as a preventative
6tool. For purposes of this Section, "low-dose mammography"
7means the x-ray examination of the breast using equipment
8dedicated specifically for mammography, including the x-ray
9tube, filter, compression device, and image receptor, with an
10average radiation exposure delivery of less than one rad per
11breast for 2 views of an average size breast. The term also
12includes digital mammography.
13    On and after January 1, 2012, providers participating in a
14quality improvement program approved by the Department shall be
15reimbursed for screening and diagnostic mammography at the same
16rate as the Medicare program's rates, including the increased
17reimbursement for digital mammography. On and after July 1,
182008, screening and diagnostic mammography shall be reimbursed
19at the same rate as the Medicare program's rates, including the
20increased reimbursement for digital mammography.
21    The Department shall convene an expert panel including
22representatives of hospitals, free-standing mammography
23facilities, and doctors, including radiologists, to establish
24quality standards. Based on these quality standards, the
25Department shall provide for bonus payments to mammography
26facilities meeting the standards for screening and diagnosis.



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1The bonus payments shall be at least 15% higher than the
2Medicare rates for mammography.
3    Subject to federal approval, the Department shall
4establish a rate methodology for mammography at federally
5qualified health centers and other encounter-rate clinics.
6These clinics or centers may also collaborate with other
7hospital-based mammography facilities.
8    The Department shall establish a methodology to remind
9women who are age-appropriate for screening mammography, but
10who have not received a mammogram within the previous 18
11months, of the importance and benefit of screening mammography.
12    The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18    The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot program
21in areas of the State with the highest incidence of mortality
22related to breast cancer. At least one pilot program site shall
23be in the metropolitan Chicago area and at least one site shall
24be outside the metropolitan Chicago area. An evaluation of the
25pilot program shall be carried out measuring health outcomes
26and cost of care for those served by the pilot program compared



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1to similarly situated patients who are not served by the pilot
3    Any medical or health care provider shall immediately
4recommend, to any pregnant woman who is being provided prenatal
5services and is suspected of drug abuse or is addicted as
6defined in the Alcoholism and Other Drug Abuse and Dependency
7Act, referral to a local substance abuse treatment provider
8licensed by the Department of Human Services or to a licensed
9hospital which provides substance abuse treatment services.
10The Department of Healthcare and Family Services shall assure
11coverage for the cost of treatment of the drug abuse or
12addiction for pregnant recipients in accordance with the
13Illinois Medicaid Program in conjunction with the Department of
14Human Services.
15    All medical providers providing medical assistance to
16pregnant women under this Code shall receive information from
17the Department on the availability of services under the Drug
18Free Families with a Future or any comparable program providing
19case management services for addicted women, including
20information on appropriate referrals for other social services
21that may be needed by addicted women in addition to treatment
22for addiction.
23    The Illinois Department, in cooperation with the
24Departments of Human Services (as successor to the Department
25of Alcoholism and Substance Abuse) and Public Health, through a
26public awareness campaign, may provide information concerning



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1treatment for alcoholism and drug abuse and addiction, prenatal
2health care, and other pertinent programs directed at reducing
3the number of drug-affected infants born to recipients of
4medical assistance.
5    Neither the Department of Healthcare and Family Services
6nor the Department of Human Services shall sanction the
7recipient solely on the basis of her substance abuse.
8    The Illinois Department shall establish such regulations
9governing the dispensing of health services under this Article
10as it shall deem appropriate. The Department should seek the
11advice of formal professional advisory committees appointed by
12the Director of the Illinois Department for the purpose of
13providing regular advice on policy and administrative matters,
14information dissemination and educational activities for
15medical and health care providers, and consistency in
16procedures to the Illinois Department.
17    Notwithstanding any other provision of law, a health care
18provider under the medical assistance program may elect, in
19lieu of receiving direct payment for services provided under
20that program, to participate in the State Employees Deferred
21Compensation Plan adopted under Article 24 of the Illinois
22Pension Code. A health care provider who elects to participate
23in the plan does not have a cause of action against the State
24for any damages allegedly suffered by the provider as a result
25of any delay by the State in crediting the amount of any
26contribution to the provider's plan account.



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1    The Illinois Department may develop and contract with
2Partnerships of medical providers to arrange medical services
3for persons eligible under Section 5-2 of this Code.
4Implementation of this Section may be by demonstration projects
5in certain geographic areas. The Partnership shall be
6represented by a sponsor organization. The Department, by rule,
7shall develop qualifications for sponsors of Partnerships.
8Nothing in this Section shall be construed to require that the
9sponsor organization be a medical organization.
10    The sponsor must negotiate formal written contracts with
11medical providers for physician services, inpatient and
12outpatient hospital care, home health services, treatment for
13alcoholism and substance abuse, and other services determined
14necessary by the Illinois Department by rule for delivery by
15Partnerships. Physician services must include prenatal and
16obstetrical care. The Illinois Department shall reimburse
17medical services delivered by Partnership providers to clients
18in target areas according to provisions of this Article and the
19Illinois Health Finance Reform Act, except that:
20        (1) Physicians participating in a Partnership and
21    providing certain services, which shall be determined by
22    the Illinois Department, to persons in areas covered by the
23    Partnership may receive an additional surcharge for such
24    services.
25        (2) The Department may elect to consider and negotiate
26    financial incentives to encourage the development of



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1    Partnerships and the efficient delivery of medical care.
2        (3) Persons receiving medical services through
3    Partnerships may receive medical and case management
4    services above the level usually offered through the
5    medical assistance program.
6    Medical providers shall be required to meet certain
7qualifications to participate in Partnerships to ensure the
8delivery of high quality medical services. These
9qualifications shall be determined by rule of the Illinois
10Department and may be higher than qualifications for
11participation in the medical assistance program. Partnership
12sponsors may prescribe reasonable additional qualifications
13for participation by medical providers, only with the prior
14written approval of the Illinois Department.
15    Nothing in this Section shall limit the free choice of
16practitioners, hospitals, and other providers of medical
17services by clients. In order to ensure patient freedom of
18choice, the Illinois Department shall immediately promulgate
19all rules and take all other necessary actions so that provided
20services may be accessed from therapeutically certified
21optometrists to the full extent of the Illinois Optometric
22Practice Act of 1987 without discriminating between service
24    The Department shall apply for a waiver from the United
25States Health Care Financing Administration to allow for the
26implementation of Partnerships under this Section.



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1    The Illinois Department shall require health care
2providers to maintain records that document the medical care
3and services provided to recipients of Medical Assistance under
4this Article. Such records must be retained for a period of not
5less than 6 years from the date of service or as provided by
6applicable State law, whichever period is longer, except that
7if an audit is initiated within the required retention period
8then the records must be retained until the audit is completed
9and every exception is resolved. The Illinois Department shall
10require health care providers to make available, when
11authorized by the patient, in writing, the medical records in a
12timely fashion to other health care providers who are treating
13or serving persons eligible for Medical Assistance under this
14Article. All dispensers of medical services shall be required
15to maintain and retain business and professional records
16sufficient to fully and accurately document the nature, scope,
17details and receipt of the health care provided to persons
18eligible for medical assistance under this Code, in accordance
19with regulations promulgated by the Illinois Department. The
20rules and regulations shall require that proof of the receipt
21of prescription drugs, dentures, prosthetic devices and
22eyeglasses by eligible persons under this Section accompany
23each claim for reimbursement submitted by the dispenser of such
24medical services. No such claims for reimbursement shall be
25approved for payment by the Illinois Department without such
26proof of receipt, unless the Illinois Department shall have put



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



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



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1recipient's medical prognosis, the extent of the recipient's
2needs, and the requirements and costs for maintaining such
3equipment. Such rules shall enable a recipient to temporarily
4acquire and use alternative or substitute devices or equipment
5pending repairs or replacements of any device or equipment
6previously authorized for such recipient by the Department.
7    The Department shall execute, relative to the nursing home
8prescreening project, written inter-agency agreements with the
9Department of Human Services and the Department on Aging, to
10effect the following: (i) intake procedures and common
11eligibility criteria for those persons who are receiving
12non-institutional services; and (ii) the establishment and
13development of non-institutional services in areas of the State
14where they are not currently available or are undeveloped.
15    The Illinois Department shall develop and operate, in
16cooperation with other State Departments and agencies and in
17compliance with applicable federal laws and regulations,
18appropriate and effective systems of health care evaluation and
19programs for monitoring of utilization of health care services
20and facilities, as it affects persons eligible for medical
21assistance under this Code.
22    The Illinois Department shall report annually to the
23General Assembly, no later than the second Friday in April of
241979 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
8ending on the June 30 prior to the report. The report shall
9include suggested legislation for consideration by the General
10Assembly. The filing of one copy of the report with the
11Speaker, one copy with the Minority Leader and one copy with
12the Clerk of the House of Representatives, one copy with the
13President, one copy with the Minority Leader and one copy with
14the Secretary of the Senate, one copy with the Legislative
15Research Unit, and such additional copies with the State
16Government Report Distribution Center for the General Assembly
17as is required under paragraph (t) of Section 7 of the State
18Library Act shall be deemed sufficient to comply with this
20    Rulemaking authority to implement Public Act 95-1045, if
21any, is conditioned on the rules being adopted in accordance
22with all provisions of the Illinois Administrative Procedure
23Act and all rules and procedures of the Joint Committee on
24Administrative Rules; any purported rule not so adopted, for
25whatever reason, is unauthorized.
26(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,



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1eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11.)
2    Section 99. Effective date. This Act takes effect January
31, 2012.".