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91_HB0931eng HB0931 Engrossed LRB9101119SMpr 1 AN ACT to amend the Illinois Public Aid Code by changing 2 Section 5-5. 3 Be it enacted by the People of the State of Illinois, 4 represented in the General Assembly: 5 Section 5. The Illinois Public Aid Code is amended by 6 changing Section 5-5 as follows: 7 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5) 8 Sec. 5-5. Medical services. The Illinois Department, by 9 rule, shall determine the quantity and quality of and the 10 rate of reimbursement for the medical assistance for which 11 payment will be authorized, and the medical services to be 12 provided, which may include all or part of the following: (1) 13 inpatient hospital services; (2) outpatient hospital 14 services; (3) other laboratory and X-ray services; (4) 15 skilled nursing home services; (5) physicians' services 16 whether furnished in the office, the patient's home, a 17 hospital, a skilled nursing home, or elsewhere; (6) medical 18 care, or any other type of remedial care furnished by 19 licensed practitioners; (7) home health care services; (8) 20 private duty nursing service; (9) clinic services; (10) 21 dental services; (11) physical therapy and related services; 22 (12) prescribed drugs, dentures, and prosthetic devices; and 23 eyeglasses prescribed by a physician skilled in the diseases 24 of the eye, or by an optometrist, whichever the person may 25 select; (13) other diagnostic, screening, preventive, and 26 rehabilitative services; (14) transportation and such other 27 expenses as may be necessary; (15) medical treatment of 28 sexual assault survivors, as defined in Section 1a of the 29 Sexual Assault Survivors Emergency Treatment Act, for 30 injuries sustained as a result of the sexual assault, 31 including examinations and laboratory tests to discover HB0931 Engrossed -2- LRB9101119SMpr 1 evidence which may be used in criminal proceedings arising 2 from the sexual assault; (16) the diagnosis and treatment of 3 sickle cell anemia; and (17) any other medical care, and any 4 other type of remedial care recognized under the laws of this 5 State, but not including abortions, or induced miscarriages 6 or premature births, unless, in the opinion of a physician, 7 such procedures are necessary for the preservation of the 8 life of the woman seeking such treatment, or except an 9 induced premature birth intended to produce a live viable 10 child and such procedure is necessary for the health of the 11 mother or her unborn child. The Illinois Department, by rule, 12 shall prohibit any physician from providing medical 13 assistance to anyone eligible therefor under this Code where 14 such physician has been found guilty of performing an 15 abortion procedure in a wilful and wanton manner upon a woman 16 who was not pregnant at the time such abortion procedure was 17 performed. The term "any other type of remedial care" shall 18 include nursing care and nursing home service for persons who 19 rely on treatment by spiritual means alone through prayer for 20 healing. 21 Notwithstanding any other provision of this Section, 22 dental services shall be covered under the medical assistance 23 program under this Article for persons 21 years of age or 24 older who are otherwise eligible for assistance under this 25 Code. 26 The Illinois Department of Public Aid shall provide the 27 following services to persons eligible for assistance under 28 this Article who are participating in education, training or 29 employment programs operated by the Department of Human 30 Services as successor to the Department of Public Aid: 31 (1) dental services, which shall include but not be 32 limited to prosthodontics; and 33 (2) eyeglasses prescribed by a physician skilled in 34 the diseases of the eye, or by an optometrist, whichever HB0931 Engrossed -3- LRB9101119SMpr 1 the person may select. 2 The Illinois Department, by rule, may distinguish and 3 classify the medical services to be provided only in 4 accordance with the classes of persons designated in Section 5 5-2. 6 The Illinois Department shall authorize the provision of, 7 and shall authorize payment for, screening by low-dose 8 mammography for the presence of occult breast cancer for 9 women 35 years of age or older who are eligible for medical 10 assistance under this Article, as follows: a baseline 11 mammogram for women 35 to 39 years of age and an annual 12 mammogram for women 40 years of age or older. All screenings 13 shall include a physical breast exam, instruction on 14 self-examination and information regarding the frequency of 15 self-examination and its value as a preventative tool. As 16 used in this Section, "low-dose mammography" means the x-ray 17 examination of the breast using equipment dedicated 18 specifically for mammography, including the x-ray tube, 19 filter, compression device, image receptor, and cassettes, 20 with an average radiation exposure delivery of less than one 21 rad mid-breast, with 2 views for each breast. 22 Any medical or health care provider shall immediately 23 recommend, to any pregnant woman who is being provided 24 prenatal services and is suspected of drug abuse or is 25 addicted as defined in the Alcoholism and Other Drug Abuse 26 and Dependency Act, referral to a local substance abuse 27 treatment provider licensed by the Department of Human 28 Services or to a licensed hospital which provides substance 29 abuse treatment services. The Department of Public Aid shall 30 assure coverage for the cost of treatment of the drug abuse 31 or addiction for pregnant recipients in accordance with the 32 Illinois Medicaid Program in conjunction with the Department 33 of Human Services. 34 All medical providers providing medical assistance to HB0931 Engrossed -4- LRB9101119SMpr 1 pregnant women under this Code shall receive information from 2 the Department on the availability of services under the Drug 3 Free Families with a Future or any comparable program 4 providing case management services for addicted women, 5 including information on appropriate referrals for other 6 social services that may be needed by addicted women in 7 addition to treatment for addiction. 8 The Illinois Department, in cooperation with the 9 Departments of Human Services (as successor to the Department 10 of Alcoholism and Substance Abuse) and Public Health, through 11 a public awareness campaign, may provide information 12 concerning treatment for alcoholism and drug abuse and 13 addiction, prenatal health care, and other pertinent programs 14 directed at reducing the number of drug-affected infants born 15 to recipients of medical assistance. 16 Neither the Illinois Department of Public Aid nor the 17 Department of Human Services shall sanction the recipient 18 solely on the basis of her substance abuse. 19 The Illinois Department shall establish such regulations 20 governing the dispensing of health services under this 21 Article as it shall deem appropriate. In formulating these 22 regulations the Illinois Department shall consult with and 23 give substantial weight to the recommendations offered by the 24 Citizens Assembly/Council on Public Aid. The Department 25 should seek the advice of formal professional advisory 26 committees appointed by the Director of the Illinois 27 Department for the purpose of providing regular advice on 28 policy and administrative matters, information dissemination 29 and educational activities for medical and health care 30 providers, and consistency in procedures to the Illinois 31 Department. 32 The Illinois Department may develop and contract with 33 Partnerships of medical providers to arrange medical services 34 for persons eligible under Section 5-2 of this Code. HB0931 Engrossed -5- LRB9101119SMpr 1 Implementation of this Section may be by demonstration 2 projects in certain geographic areas. The Partnership shall 3 be represented by a sponsor organization. The Department, by 4 rule, shall develop qualifications for sponsors of 5 Partnerships. Nothing in this Section shall be construed to 6 require that the sponsor organization be a medical 7 organization. 8 The sponsor must negotiate formal written contracts with 9 medical providers for physician services, inpatient and 10 outpatient hospital care, home health services, treatment for 11 alcoholism and substance abuse, and other services determined 12 necessary by the Illinois Department by rule for delivery by 13 Partnerships. Physician services must include prenatal and 14 obstetrical care. The Illinois Department shall reimburse 15 medical services delivered by Partnership providers to 16 clients in target areas according to provisions of this 17 Article and the Illinois Health Finance Reform Act, except 18 that: 19 (1) Physicians participating in a Partnership and 20 providing certain services, which shall be determined by 21 the Illinois Department, to persons in areas covered by 22 the Partnership may receive an additional surcharge for 23 such services. 24 (2) The Department may elect to consider and 25 negotiate financial incentives to encourage the 26 development of Partnerships and the efficient delivery of 27 medical care. 28 (3) Persons receiving medical services through 29 Partnerships may receive medical and case management 30 services above the level usually offered through the 31 medical assistance program. 32 Medical providers shall be required to meet certain 33 qualifications to participate in Partnerships to ensure the 34 delivery of high quality medical services. These HB0931 Engrossed -6- LRB9101119SMpr 1 qualifications shall be determined by rule of the Illinois 2 Department and may be higher than qualifications for 3 participation in the medical assistance program. Partnership 4 sponsors may prescribe reasonable additional qualifications 5 for participation by medical providers, only with the prior 6 written approval of the Illinois Department. 7 Nothing in this Section shall limit the free choice of 8 practitioners, hospitals, and other providers of medical 9 services by clients. 10 The Department shall apply for a waiver from the United 11 States Health Care Financing Administration to allow for the 12 implementation of Partnerships under this Section. 13 The Illinois Department shall require health care 14 providers to maintain records that document the medical care 15 and services provided to recipients of Medical Assistance 16 under this Article. The Illinois Department shall require 17 health care providers to make available, when authorized by 18 the patient, in writing, the medical records in a timely 19 fashion to other health care providers who are treating or 20 serving persons eligible for Medical Assistance under this 21 Article. All dispensers of medical services shall be 22 required to maintain and retain business and professional 23 records sufficient to fully and accurately document the 24 nature, scope, details and receipt of the health care 25 provided to persons eligible for medical assistance under 26 this Code, in accordance with regulations promulgated by the 27 Illinois Department. The rules and regulations shall require 28 that proof of the receipt of prescription drugs, dentures, 29 prosthetic devices and eyeglasses by eligible persons under 30 this Section accompany each claim for reimbursement submitted 31 by the dispenser of such medical services. No such claims for 32 reimbursement shall be approved for payment by the Illinois 33 Department without such proof of receipt, unless the Illinois 34 Department shall have put into effect and shall be operating HB0931 Engrossed -7- LRB9101119SMpr 1 a system of post-payment audit and review which shall, on a 2 sampling basis, be deemed adequate by the Illinois Department 3 to assure that such drugs, dentures, prosthetic devices and 4 eyeglasses for which payment is being made are actually being 5 received by eligible recipients. Within 90 days after the 6 effective date of this amendatory Act of 1984, the Illinois 7 Department shall establish a current list of acquisition 8 costs for all prosthetic devices and any other items 9 recognized as medical equipment and supplies reimbursable 10 under this Article and shall update such list on a quarterly 11 basis, except that the acquisition costs of all prescription 12 drugs shall be updated no less frequently than every 30 days 13 as required by Section 5-5.12. 14 The rules and regulations of the Illinois Department 15 shall require that a written statement including the required 16 opinion of a physician shall accompany any claim for 17 reimbursement for abortions, or induced miscarriages or 18 premature births. This statement shall indicate what 19 procedures were used in providing such medical services. 20 The Illinois Department shall require that all dispensers 21 of medical services, other than an individual practitioner or 22 group of practitioners, desiring to participate in the 23 Medical Assistance program established under this Article to 24 disclose all financial, beneficial, ownership, equity, surety 25 or other interests in any and all firms, corporations, 26 partnerships, associations, business enterprises, joint 27 ventures, agencies, institutions or other legal entities 28 providing any form of health care services in this State 29 under this Article. 30 The Illinois Department may require that all dispensers 31 of medical services desiring to participate in the medical 32 assistance program established under this Article disclose, 33 under such terms and conditions as the Illinois Department 34 may by rule establish, all inquiries from clients and HB0931 Engrossed -8- LRB9101119SMpr 1 attorneys regarding medical bills paid by the Illinois 2 Department, which inquiries could indicate potential 3 existence of claims or liens for the Illinois Department. 4 The Illinois Department shall establish policies, 5 procedures, standards and criteria by rule for the 6 acquisition, repair and replacement of orthotic and 7 prosthetic devices and durable medical equipment. Such rules 8 shall provide, but not be limited to, the following services: 9 (1) immediate repair or replacement of such devices by 10 recipients without medical authorization; and (2) rental, 11 lease, purchase or lease-purchase of durable medical 12 equipment in a cost-effective manner, taking into 13 consideration the recipient's medical prognosis, the extent 14 of the recipient's needs, and the requirements and costs for 15 maintaining such equipment. Such rules shall enable a 16 recipient to temporarily acquire and use alternative or 17 substitute devices or equipment pending repairs or 18 replacements of any device or equipment previously authorized 19 for such recipient by the Department. Rules under clause (2) 20 above shall not provide for purchase or lease-purchase of 21 durable medical equipment or supplies used for the purpose of 22 oxygen delivery and respiratory care. 23 The Department shall execute, relative to the nursing 24 home prescreening project, written inter-agency agreements 25 with the Department of Human Services and the Department on 26 Aging, to effect the following: (i) intake procedures and 27 common eligibility criteria for those persons who are 28 receiving non-institutional services; and (ii) the 29 establishment and development of non-institutional services 30 in areas of the State where they are not currently available 31 or are undeveloped. 32 The Illinois Department shall develop and operate, in 33 cooperation with other State Departments and agencies and in 34 compliance with applicable federal laws and regulations, HB0931 Engrossed -9- LRB9101119SMpr 1 appropriate and effective systems of health care evaluation 2 and programs for monitoring of utilization of health care 3 services and facilities, as it affects persons eligible for 4 medical assistance under this Code. The Illinois Department 5 shall report regularly the results of the operation of such 6 systems and programs to the Citizens Assembly/Council on 7 Public Aid to enable the Committee to ensure, from time to 8 time, that these programs are effective and meaningful. 9 The Illinois Department shall report annually to the 10 General Assembly, no later than the second Friday in April of 11 1979 and each year thereafter, in regard to: 12 (a) actual statistics and trends in utilization of 13 medical services by public aid recipients; 14 (b) actual statistics and trends in the provision 15 of the various medical services by medical vendors; 16 (c) current rate structures and proposed changes in 17 those rate structures for the various medical vendors; 18 and 19 (d) efforts at utilization review and control by 20 the Illinois Department. 21 The period covered by each report shall be the 3 years 22 ending on the June 30 prior to the report. The report shall 23 include suggested legislation for consideration by the 24 General Assembly. The filing of one copy of the report with 25 the Speaker, one copy with the Minority Leader and one copy 26 with the Clerk of the House of Representatives, one copy with 27 the President, one copy with the Minority Leader and one copy 28 with the Secretary of the Senate, one copy with the 29 Legislative Research Unit, such additional copies with the 30 State Government Report Distribution Center for the General 31 Assembly as is required under paragraph (t) of Section 7 of 32 the State Library Act and one copy with the Citizens 33 Assembly/Council on Public Aid or its successor shall be 34 deemed sufficient to comply with this Section. HB0931 Engrossed -10- LRB9101119SMpr 1 (Source: P.A. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97; 2 89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.) 3 Section 99. Effective date. This Act takes effect upon 4 becoming law.