State of Illinois
91st General Assembly

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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.

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