State of Illinois
91st General Assembly
Legislation

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[ Senate Amendment 001 ]

91_HB1832

 
                                               LRB9103252SMdv

 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
 
                            -2-                LRB9103252SMdv
 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,  a
22    comprehensive  tobacco  use  cessation  program that includes
23    purchasing prescription drugs, human biological products,  or
24    medical  devices approved by the Food and Drug Administration
25    or otherwise legally marketed under the  federal  Food,  Drug
26    and Cosmetic Act or the federal Public Health Service Act for
27    use  as  smoking cessation therapies or aids shall be covered
28    under the medical assistance program under this  Article  for
29    persons  who are otherwise eligible for assistance under this
30    Article.
31        The Illinois Department of Public Aid shall  provide  the
32    following  services  to persons eligible for assistance under
33    this Article who are participating in education, training  or
34    employment  programs  operated  by  the  Department  of Human
 
                            -3-                LRB9103252SMdv
 1    Services as successor to the Department of Public Aid:
 2             (1)  dental services, which shall include but not be
 3        limited to prosthodontics; and
 4             (2)  eyeglasses prescribed by a physician skilled in
 5        the diseases of the eye, or by an optometrist,  whichever
 6        the person may select.
 7        The  Illinois  Department,  by  rule, may distinguish and
 8    classify  the  medical  services  to  be  provided  only   in
 9    accordance  with the classes of persons designated in Section
10    5-2.
11        The Illinois Department shall authorize the provision of,
12    and  shall  authorize  payment  for,  screening  by  low-dose
13    mammography for the presence  of  occult  breast  cancer  for
14    women  35  years of age or older who are eligible for medical
15    assistance  under  this  Article,  as  follows:   a  baseline
16    mammogram for women 35 to 39  years  of  age  and  an  annual
17    mammogram for women 40 years of age or older.  All screenings
18    shall   include   a  physical  breast  exam,  instruction  on
19    self-examination and information regarding the  frequency  of
20    self-examination  and  its  value as a preventative tool.  As
21    used in this Section, "low-dose mammography" means the  x-ray
22    examination   of   the   breast   using  equipment  dedicated
23    specifically  for  mammography,  including  the  x-ray  tube,
24    filter, compression device, image  receptor,  and  cassettes,
25    with  an average radiation exposure delivery of less than one
26    rad mid-breast, with 2 views for each breast.
27        Any medical or health  care  provider  shall  immediately
28    recommend,  to  any  pregnant  woman  who  is  being provided
29    prenatal services and  is  suspected  of  drug  abuse  or  is
30    addicted  as  defined  in the Alcoholism and Other Drug Abuse
31    and Dependency Act,  referral  to  a  local  substance  abuse
32    treatment  provider  licensed  by  the  Department  of  Human
33    Services  or  to a licensed hospital which provides substance
34    abuse treatment services.  The Department of Public Aid shall
 
                            -4-                LRB9103252SMdv
 1    assure coverage for the cost of treatment of the  drug  abuse
 2    or  addiction  for pregnant recipients in accordance with the
 3    Illinois Medicaid Program in conjunction with the  Department
 4    of Human Services.
 5        All  medical  providers  providing  medical assistance to
 6    pregnant women under this Code shall receive information from
 7    the Department on the availability of services under the Drug
 8    Free  Families  with  a  Future  or  any  comparable  program
 9    providing  case  management  services  for  addicted   women,
10    including  information  on  appropriate  referrals  for other
11    social services that may  be  needed  by  addicted  women  in
12    addition to treatment for addiction.
13        The   Illinois   Department,   in  cooperation  with  the
14    Departments of Human Services (as successor to the Department
15    of Alcoholism and Substance Abuse) and Public Health, through
16    a  public  awareness  campaign,   may   provide   information
17    concerning  treatment  for  alcoholism  and  drug  abuse  and
18    addiction, prenatal health care, and other pertinent programs
19    directed at reducing the number of drug-affected infants born
20    to recipients of medical assistance.
21        Neither  the  Illinois  Department  of Public Aid nor the
22    Department of Human Services  shall  sanction  the  recipient
23    solely on the basis of her substance abuse.
24        The  Illinois Department shall establish such regulations
25    governing  the  dispensing  of  health  services  under  this
26    Article as it shall deem appropriate.  In  formulating  these
27    regulations  the  Illinois  Department shall consult with and
28    give substantial weight to the recommendations offered by the
29    Citizens  Assembly/Council  on  Public  Aid.  The  Department
30    should  seek  the  advice  of  formal  professional  advisory
31    committees  appointed  by  the  Director  of   the   Illinois
32    Department  for  the  purpose  of providing regular advice on
33    policy and administrative matters, information  dissemination
34    and  educational  activities  for  medical  and  health  care
 
                            -5-                LRB9103252SMdv
 1    providers,  and  consistency  in  procedures  to the Illinois
 2    Department.
 3        The Illinois Department may  develop  and  contract  with
 4    Partnerships of medical providers to arrange medical services
 5    for   persons  eligible  under  Section  5-2  of  this  Code.
 6    Implementation  of  this  Section  may  be  by  demonstration
 7    projects in certain geographic areas.  The Partnership  shall
 8    be represented by a sponsor organization.  The Department, by
 9    rule,   shall   develop   qualifications   for   sponsors  of
10    Partnerships.  Nothing in this Section shall be construed  to
11    require   that   the   sponsor   organization  be  a  medical
12    organization.
13        The sponsor must negotiate formal written contracts  with
14    medical  providers  for  physician  services,  inpatient  and
15    outpatient hospital care, home health services, treatment for
16    alcoholism and substance abuse, and other services determined
17    necessary  by the Illinois Department by rule for delivery by
18    Partnerships.  Physician services must include  prenatal  and
19    obstetrical  care.   The  Illinois Department shall reimburse
20    medical  services  delivered  by  Partnership  providers   to
21    clients  in  target  areas  according  to  provisions of this
22    Article and the Illinois Health Finance  Reform  Act,  except
23    that:
24             (1)  Physicians  participating  in a Partnership and
25        providing certain services, which shall be determined  by
26        the  Illinois  Department, to persons in areas covered by
27        the Partnership may receive an additional  surcharge  for
28        such services.
29             (2)  The   Department  may  elect  to  consider  and
30        negotiate   financial   incentives   to   encourage   the
31        development of Partnerships and the efficient delivery of
32        medical care.
33             (3)  Persons  receiving  medical  services   through
34        Partnerships  may  receive  medical  and  case management
 
                            -6-                LRB9103252SMdv
 1        services above the  level  usually  offered  through  the
 2        medical assistance program.
 3        Medical  providers  shall  be  required  to  meet certain
 4    qualifications to participate in Partnerships to  ensure  the
 5    delivery   of   high   quality   medical   services.    These
 6    qualifications  shall  be  determined by rule of the Illinois
 7    Department  and  may  be  higher  than   qualifications   for
 8    participation in the medical assistance program.  Partnership
 9    sponsors  may  prescribe reasonable additional qualifications
10    for participation by medical providers, only with  the  prior
11    written approval of the Illinois Department.
12        Nothing  in  this  Section shall limit the free choice of
13    practitioners, hospitals,  and  other  providers  of  medical
14    services by clients.
15        The  Department  shall apply for a waiver from the United
16    States Health Care Financing Administration to allow for  the
17    implementation of Partnerships under this Section.
18        The   Illinois   Department  shall  require  health  care
19    providers to maintain records that document the medical  care
20    and  services  provided  to  recipients of Medical Assistance
21    under this Article.  The Illinois  Department  shall  require
22    health  care  providers to make available, when authorized by
23    the patient, in writing, the  medical  records  in  a  timely
24    fashion  to  other  health care providers who are treating or
25    serving persons eligible for Medical  Assistance  under  this
26    Article.    All  dispensers  of  medical  services  shall  be
27    required to maintain and  retain  business  and  professional
28    records  sufficient  to  fully  and  accurately  document the
29    nature,  scope,  details  and  receipt  of  the  health  care
30    provided to persons eligible  for  medical  assistance  under
31    this  Code, in accordance with regulations promulgated by the
32    Illinois Department. The rules and regulations shall  require
33    that  proof  of  the receipt of prescription drugs, dentures,
34    prosthetic devices and eyeglasses by eligible  persons  under
 
                            -7-                LRB9103252SMdv
 1    this Section accompany each claim for reimbursement submitted
 2    by the dispenser of such medical services. No such claims for
 3    reimbursement  shall  be approved for payment by the Illinois
 4    Department without such proof of receipt, unless the Illinois
 5    Department shall have put into effect and shall be  operating
 6    a  system  of post-payment audit and review which shall, on a
 7    sampling basis, be deemed adequate by the Illinois Department
 8    to assure that such drugs, dentures, prosthetic  devices  and
 9    eyeglasses for which payment is being made are actually being
10    received  by  eligible  recipients.  Within 90 days after the
11    effective date of this amendatory Act of 1984,  the  Illinois
12    Department  shall  establish  a  current  list of acquisition
13    costs  for  all  prosthetic  devices  and  any  other   items
14    recognized  as  medical  equipment  and supplies reimbursable
15    under this Article and shall update such list on a  quarterly
16    basis,  except that the acquisition costs of all prescription
17    drugs shall be updated no less frequently than every 30  days
18    as required by Section 5-5.12.
19        The  rules  and  regulations  of  the Illinois Department
20    shall require that a written statement including the required
21    opinion  of  a  physician  shall  accompany  any  claim   for
22    reimbursement  for  abortions,  or  induced  miscarriages  or
23    premature   births.    This  statement  shall  indicate  what
24    procedures were used in providing such medical services.
25        The Illinois Department shall require that all dispensers
26    of medical services, other than an individual practitioner or
27    group  of  practitioners,  desiring  to  participate  in  the
28    Medical Assistance program established under this Article  to
29    disclose all financial, beneficial, ownership, equity, surety
30    or  other  interests  in  any  and  all  firms, corporations,
31    partnerships,  associations,  business   enterprises,   joint
32    ventures,  agencies,  institutions  or  other  legal entities
33    providing any form of health  care  services  in  this  State
34    under this Article.
 
                            -8-                LRB9103252SMdv
 1        The  Illinois  Department may require that all dispensers
 2    of medical services desiring to participate  in  the  medical
 3    assistance  program  established under this Article disclose,
 4    under such terms and conditions as  the  Illinois  Department
 5    may  by  rule  establish,  all  inquiries  from  clients  and
 6    attorneys  regarding  medical  bills  paid  by  the  Illinois
 7    Department,   which   inquiries   could   indicate  potential
 8    existence of claims or liens for the Illinois Department.
 9        The  Illinois  Department   shall   establish   policies,
10    procedures,   standards   and   criteria   by  rule  for  the
11    acquisition,  repair  and   replacement   of   orthotic   and
12    prosthetic devices and durable medical equipment.  Such rules
13    shall provide, but not be limited to, the following services:
14    (1)  immediate  repair  or  replacement  of  such  devices by
15    recipients without medical  authorization;  and  (2)  rental,
16    lease,   purchase   or   lease-purchase  of  durable  medical
17    equipment   in   a   cost-effective   manner,   taking   into
18    consideration the recipient's medical prognosis,  the  extent
19    of  the recipient's needs, and the requirements and costs for
20    maintaining  such  equipment.   Such  rules  shall  enable  a
21    recipient to  temporarily  acquire  and  use  alternative  or
22    substitute   devices   or   equipment   pending   repairs  or
23    replacements of any device or equipment previously authorized
24    for such recipient by the Department. Rules under clause  (2)
25    above  shall  not  provide  for purchase or lease-purchase of
26    durable medical equipment or supplies used for the purpose of
27    oxygen delivery and respiratory care.
28        The Department shall execute,  relative  to  the  nursing
29    home  prescreening  project,  written inter-agency agreements
30    with the Department of Human Services and the  Department  on
31    Aging,  to  effect  the  following: (i) intake procedures and
32    common  eligibility  criteria  for  those  persons  who   are
33    receiving    non-institutional   services;   and   (ii)   the
34    establishment and development of  non-institutional  services
 
                            -9-                LRB9103252SMdv
 1    in  areas of the State where they are not currently available
 2    or are undeveloped.
 3        The Illinois Department shall  develop  and  operate,  in
 4    cooperation  with other State Departments and agencies and in
 5    compliance with  applicable  federal  laws  and  regulations,
 6    appropriate  and  effective systems of health care evaluation
 7    and programs for monitoring of  utilization  of  health  care
 8    services  and  facilities, as it affects persons eligible for
 9    medical assistance under this Code. The  Illinois  Department
10    shall  report  regularly the results of the operation of such
11    systems and programs  to  the  Citizens  Assembly/Council  on
12    Public  Aid  to  enable the Committee to ensure, from time to
13    time, that these programs are effective and meaningful.
14        The Illinois Department  shall  report  annually  to  the
15    General Assembly, no later than the second Friday in April of
16    1979 and each year thereafter, in regard to:
17             (a)  actual  statistics and trends in utilization of
18        medical services by public aid recipients;
19             (b)  actual statistics and trends in  the  provision
20        of the various medical services by medical vendors;
21             (c)  current rate structures and proposed changes in
22        those  rate  structures  for the various medical vendors;
23        and
24             (d)  efforts at utilization review  and  control  by
25        the Illinois Department.
26        The  period  covered  by each report shall be the 3 years
27    ending on the June 30 prior to the report.  The report  shall
28    include   suggested  legislation  for  consideration  by  the
29    General Assembly.  The filing of one copy of the report  with
30    the  Speaker,  one copy with the Minority Leader and one copy
31    with the Clerk of the House of Representatives, one copy with
32    the President, one copy with the Minority Leader and one copy
33    with  the  Secretary  of  the  Senate,  one  copy  with   the
34    Legislative  Research  Unit,  such additional copies with the
 
                            -10-               LRB9103252SMdv
 1    State Government Report Distribution Center for  the  General
 2    Assembly  as  is required under paragraph (t) of Section 7 of
 3    the  State  Library  Act  and  one  copy  with  the  Citizens
 4    Assembly/Council on Public Aid  or  its  successor  shall  be
 5    deemed sufficient to comply with this Section.
 6    (Source:  P.A.  89-21,  eff.  7-1-95;  89-507,  eff.  7-1-97;
 7    89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.)

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