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91_HB1438eng HB1438 Engrossed LRB9103894SMdv 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 HB1438 Engrossed -2- LRB9103894SMdv 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 medically necessary organ transplants shall be covered under 23 the medical assistance program under this Article for persons 24 who are otherwise eligible for assistance under this Article, 25 as well as for legal aliens residing in Illinois whose income 26 and assets render them eligible for assistance under this 27 Article, regardless of whether they meet the other 28 eligibility requirements under this Article. 29 The Illinois Department of Public Aid shall provide the 30 following services to persons eligible for assistance under 31 this Article who are participating in education, training or 32 employment programs operated by the Department of Human 33 Services as successor to the Department of Public Aid: 34 (1) dental services, which shall include but not be HB1438 Engrossed -3- LRB9103894SMdv 1 limited to prosthodontics; and 2 (2) eyeglasses prescribed by a physician skilled in 3 the diseases of the eye, or by an optometrist, whichever 4 the person may select. 5 The Illinois Department, by rule, may distinguish and 6 classify the medical services to be provided only in 7 accordance with the classes of persons designated in Section 8 5-2. 9 The Illinois Department shall authorize the provision of, 10 and shall authorize payment for, screening by low-dose 11 mammography for the presence of occult breast cancer for 12 women 35 years of age or older who are eligible for medical 13 assistance under this Article, as follows: a baseline 14 mammogram for women 35 to 39 years of age and an annual 15 mammogram for women 40 years of age or older. All screenings 16 shall include a physical breast exam, instruction on 17 self-examination and information regarding the frequency of 18 self-examination and its value as a preventative tool. As 19 used in this Section, "low-dose mammography" means the x-ray 20 examination of the breast using equipment dedicated 21 specifically for mammography, including the x-ray tube, 22 filter, compression device, image receptor, and cassettes, 23 with an average radiation exposure delivery of less than one 24 rad mid-breast, with 2 views for each breast. 25 Any medical or health care provider shall immediately 26 recommend, to any pregnant woman who is being provided 27 prenatal services and is suspected of drug abuse or is 28 addicted as defined in the Alcoholism and Other Drug Abuse 29 and Dependency Act, referral to a local substance abuse 30 treatment provider licensed by the Department of Human 31 Services or to a licensed hospital which provides substance 32 abuse treatment services. The Department of Public Aid shall 33 assure coverage for the cost of treatment of the drug abuse 34 or addiction for pregnant recipients in accordance with the HB1438 Engrossed -4- LRB9103894SMdv 1 Illinois Medicaid Program in conjunction with the Department 2 of Human Services. 3 All medical providers providing medical assistance to 4 pregnant women under this Code shall receive information from 5 the Department on the availability of services under the Drug 6 Free Families with a Future or any comparable program 7 providing case management services for addicted women, 8 including information on appropriate referrals for other 9 social services that may be needed by addicted women in 10 addition to treatment for addiction. 11 The Illinois Department, in cooperation with the 12 Departments of Human Services (as successor to the Department 13 of Alcoholism and Substance Abuse) and Public Health, through 14 a public awareness campaign, may provide information 15 concerning treatment for alcoholism and drug abuse and 16 addiction, prenatal health care, and other pertinent programs 17 directed at reducing the number of drug-affected infants born 18 to recipients of medical assistance. 19 Neither the Illinois Department of Public Aid nor the 20 Department of Human Services shall sanction the recipient 21 solely on the basis of her substance abuse. 22 The Illinois Department shall establish such regulations 23 governing the dispensing of health services under this 24 Article as it shall deem appropriate. In formulating these 25 regulations the Illinois Department shall consult with and 26 give substantial weight to the recommendations offered by the 27 Citizens Assembly/Council on Public Aid. The Department 28 should seek the advice of formal professional advisory 29 committees appointed by the Director of the Illinois 30 Department for the purpose of providing regular advice on 31 policy and administrative matters, information dissemination 32 and educational activities for medical and health care 33 providers, and consistency in procedures to the Illinois 34 Department. HB1438 Engrossed -5- LRB9103894SMdv 1 The Illinois Department may develop and contract with 2 Partnerships of medical providers to arrange medical services 3 for persons eligible under Section 5-2 of this Code. 4 Implementation of this Section may be by demonstration 5 projects in certain geographic areas. The Partnership shall 6 be represented by a sponsor organization. The Department, by 7 rule, shall develop qualifications for sponsors of 8 Partnerships. Nothing in this Section shall be construed to 9 require that the sponsor organization be a medical 10 organization. 11 The sponsor must negotiate formal written contracts with 12 medical providers for physician services, inpatient and 13 outpatient hospital care, home health services, treatment for 14 alcoholism and substance abuse, and other services determined 15 necessary by the Illinois Department by rule for delivery by 16 Partnerships. Physician services must include prenatal and 17 obstetrical care. The Illinois Department shall reimburse 18 medical services delivered by Partnership providers to 19 clients in target areas according to provisions of this 20 Article and the Illinois Health Finance Reform Act, except 21 that: 22 (1) Physicians participating in a Partnership and 23 providing certain services, which shall be determined by 24 the Illinois Department, to persons in areas covered by 25 the Partnership may receive an additional surcharge for 26 such services. 27 (2) The Department may elect to consider and 28 negotiate financial incentives to encourage the 29 development of Partnerships and the efficient delivery of 30 medical care. 31 (3) Persons receiving medical services through 32 Partnerships may receive medical and case management 33 services above the level usually offered through the 34 medical assistance program. HB1438 Engrossed -6- LRB9103894SMdv 1 Medical providers shall be required to meet certain 2 qualifications to participate in Partnerships to ensure the 3 delivery of high quality medical services. These 4 qualifications shall be determined by rule of the Illinois 5 Department and may be higher than qualifications for 6 participation in the medical assistance program. Partnership 7 sponsors may prescribe reasonable additional qualifications 8 for participation by medical providers, only with the prior 9 written approval of the Illinois Department. 10 Nothing in this Section shall limit the free choice of 11 practitioners, hospitals, and other providers of medical 12 services by clients. 13 The Department shall apply for a waiver from the United 14 States Health Care Financing Administration to allow for the 15 implementation of Partnerships under this Section. 16 The Illinois Department shall require health care 17 providers to maintain records that document the medical care 18 and services provided to recipients of Medical Assistance 19 under this Article. The Illinois Department shall require 20 health care providers to make available, when authorized by 21 the patient, in writing, the medical records in a timely 22 fashion to other health care providers who are treating or 23 serving persons eligible for Medical Assistance under this 24 Article. All dispensers of medical services shall be 25 required to maintain and retain business and professional 26 records sufficient to fully and accurately document the 27 nature, scope, details and receipt of the health care 28 provided to persons eligible for medical assistance under 29 this Code, in accordance with regulations promulgated by the 30 Illinois Department. The rules and regulations shall require 31 that proof of the receipt of prescription drugs, dentures, 32 prosthetic devices and eyeglasses by eligible persons under 33 this Section accompany each claim for reimbursement submitted 34 by the dispenser of such medical services. No such claims for HB1438 Engrossed -7- LRB9103894SMdv 1 reimbursement shall be approved for payment by the Illinois 2 Department without such proof of receipt, unless the Illinois 3 Department shall have put into effect and shall be operating 4 a system of post-payment audit and review which shall, on a 5 sampling basis, be deemed adequate by the Illinois Department 6 to assure that such drugs, dentures, prosthetic devices and 7 eyeglasses for which payment is being made are actually being 8 received by eligible recipients. Within 90 days after the 9 effective date of this amendatory Act of 1984, the Illinois 10 Department shall establish a current list of acquisition 11 costs for all prosthetic devices and any other items 12 recognized as medical equipment and supplies reimbursable 13 under this Article and shall update such list on a quarterly 14 basis, except that the acquisition costs of all prescription 15 drugs shall be updated no less frequently than every 30 days 16 as required by Section 5-5.12. 17 The rules and regulations of the Illinois Department 18 shall require that a written statement including the required 19 opinion of a physician shall accompany any claim for 20 reimbursement for abortions, or induced miscarriages or 21 premature births. This statement shall indicate what 22 procedures were used in providing such medical services. 23 The Illinois Department shall require that all dispensers 24 of medical services, other than an individual practitioner or 25 group of practitioners, desiring to participate in the 26 Medical Assistance program established under this Article to 27 disclose all financial, beneficial, ownership, equity, surety 28 or other interests in any and all firms, corporations, 29 partnerships, associations, business enterprises, joint 30 ventures, agencies, institutions or other legal entities 31 providing any form of health care services in this State 32 under this Article. 33 The Illinois Department may require that all dispensers 34 of medical services desiring to participate in the medical HB1438 Engrossed -8- LRB9103894SMdv 1 assistance program established under this Article disclose, 2 under such terms and conditions as the Illinois Department 3 may by rule establish, all inquiries from clients and 4 attorneys regarding medical bills paid by the Illinois 5 Department, which inquiries could indicate potential 6 existence of claims or liens for the Illinois Department. 7 The Illinois Department shall establish policies, 8 procedures, standards and criteria by rule for the 9 acquisition, repair and replacement of orthotic and 10 prosthetic devices and durable medical equipment. Such rules 11 shall provide, but not be limited to, the following services: 12 (1) immediate repair or replacement of such devices by 13 recipients without medical authorization; and (2) rental, 14 lease, purchase or lease-purchase of durable medical 15 equipment in a cost-effective manner, taking into 16 consideration the recipient's medical prognosis, the extent 17 of the recipient's needs, and the requirements and costs for 18 maintaining such equipment. Such rules shall enable a 19 recipient to temporarily acquire and use alternative or 20 substitute devices or equipment pending repairs or 21 replacements of any device or equipment previously authorized 22 for such recipient by the Department. Rules under clause (2) 23 above shall not provide for purchase or lease-purchase of 24 durable medical equipment or supplies used for the purpose of 25 oxygen delivery and respiratory care. 26 The Department shall execute, relative to the nursing 27 home prescreening project, written inter-agency agreements 28 with the Department of Human Services and the Department on 29 Aging, to effect the following: (i) intake procedures and 30 common eligibility criteria for those persons who are 31 receiving non-institutional services; and (ii) the 32 establishment and development of non-institutional services 33 in areas of the State where they are not currently available 34 or are undeveloped. HB1438 Engrossed -9- LRB9103894SMdv 1 The Illinois Department shall develop and operate, in 2 cooperation with other State Departments and agencies and in 3 compliance with applicable federal laws and regulations, 4 appropriate and effective systems of health care evaluation 5 and programs for monitoring of utilization of health care 6 services and facilities, as it affects persons eligible for 7 medical assistance under this Code. The Illinois Department 8 shall report regularly the results of the operation of such 9 systems and programs to the Citizens Assembly/Council on 10 Public Aid to enable the Committee to ensure, from time to 11 time, that these programs are effective and meaningful. 12 The Illinois Department shall report annually to the 13 General Assembly, no later than the second Friday in April of 14 1979 and each year thereafter, in regard to: 15 (a) actual statistics and trends in utilization of 16 medical services by public aid recipients; 17 (b) actual statistics and trends in the provision 18 of the various medical services by medical vendors; 19 (c) current rate structures and proposed changes in 20 those rate structures for the various medical vendors; 21 and 22 (d) efforts at utilization review and control by 23 the Illinois Department. 24 The period covered by each report shall be the 3 years 25 ending on the June 30 prior to the report. The report shall 26 include suggested legislation for consideration by the 27 General Assembly. The filing of one copy of the report with 28 the Speaker, one copy with the Minority Leader and one copy 29 with the Clerk of the House of Representatives, one copy with 30 the President, one copy with the Minority Leader and one copy 31 with the Secretary of the Senate, one copy with the 32 Legislative Research Unit, such additional copies with the 33 State Government Report Distribution Center for the General 34 Assembly as is required under paragraph (t) of Section 7 of HB1438 Engrossed -10- LRB9103894SMdv 1 the State Library Act and one copy with the Citizens 2 Assembly/Council on Public Aid or its successor shall be 3 deemed sufficient to comply with this Section. 4 (Source: P.A. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97; 5 89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.) 6 Section 99. Effective date. This Act takes effect upon 7 becoming law.