State of Illinois
91st General Assembly

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[ Senate Amendment 001 ]


HB1832 Re-Enrolled                             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
HB1832 Re-Enrolled         -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 or prescription medical devices
24    approved by the Food and Drug administration shall be covered
25    under the medical assistance program under this  Article  for
26    persons  who are otherwise eligible for assistance under this
27    Article.
28        The Illinois Department of Public Aid shall  provide  the
29    following  services  to persons eligible for assistance under
30    this Article who are participating in education, training  or
31    employment  programs  operated  by  the  Department  of Human
32    Services as successor to the Department of Public Aid:
33             (1)  dental services, which shall include but not be
34        limited to prosthodontics; and
HB1832 Re-Enrolled         -3-                 LRB9103252SMdv
 1             (2)  eyeglasses prescribed by a physician skilled in
 2        the diseases of the eye, or by an optometrist,  whichever
 3        the person may select.
 4        The  Illinois  Department,  by  rule, may distinguish and
 5    classify  the  medical  services  to  be  provided  only   in
 6    accordance  with the classes of persons designated in Section
 7    5-2.
 8        The Illinois Department shall authorize the provision of,
 9    and  shall  authorize  payment  for,  screening  by  low-dose
10    mammography for the presence  of  occult  breast  cancer  for
11    women  35  years of age or older who are eligible for medical
12    assistance  under  this  Article,  as  follows:   a  baseline
13    mammogram for women 35 to 39  years  of  age  and  an  annual
14    mammogram for women 40 years of age or older.  All screenings
15    shall   include   a  physical  breast  exam,  instruction  on
16    self-examination and information regarding the  frequency  of
17    self-examination  and  its  value as a preventative tool.  As
18    used in this Section, "low-dose mammography" means the  x-ray
19    examination   of   the   breast   using  equipment  dedicated
20    specifically  for  mammography,  including  the  x-ray  tube,
21    filter, compression device, image  receptor,  and  cassettes,
22    with  an average radiation exposure delivery of less than one
23    rad mid-breast, with 2 views for each breast.
24        Any medical or health  care  provider  shall  immediately
25    recommend,  to  any  pregnant  woman  who  is  being provided
26    prenatal services and  is  suspected  of  drug  abuse  or  is
27    addicted  as  defined  in the Alcoholism and Other Drug Abuse
28    and Dependency Act,  referral  to  a  local  substance  abuse
29    treatment  provider  licensed  by  the  Department  of  Human
30    Services  or  to a licensed hospital which provides substance
31    abuse treatment services.  The Department of Public Aid shall
32    assure coverage for the cost of treatment of the  drug  abuse
33    or  addiction  for pregnant recipients in accordance with the
34    Illinois Medicaid Program in conjunction with the  Department
HB1832 Re-Enrolled         -4-                 LRB9103252SMdv
 1    of Human Services.
 2        All  medical  providers  providing  medical assistance to
 3    pregnant women under this Code shall receive information from
 4    the Department on the availability of services under the Drug
 5    Free  Families  with  a  Future  or  any  comparable  program
 6    providing  case  management  services  for  addicted   women,
 7    including  information  on  appropriate  referrals  for other
 8    social services that may  be  needed  by  addicted  women  in
 9    addition to treatment for addiction.
10        The   Illinois   Department,   in  cooperation  with  the
11    Departments of Human Services (as successor to the Department
12    of Alcoholism and Substance Abuse) and Public Health, through
13    a  public  awareness  campaign,   may   provide   information
14    concerning  treatment  for  alcoholism  and  drug  abuse  and
15    addiction, prenatal health care, and other pertinent programs
16    directed at reducing the number of drug-affected infants born
17    to recipients of medical assistance.
18        Neither  the  Illinois  Department  of Public Aid nor the
19    Department of Human Services  shall  sanction  the  recipient
20    solely on the basis of her substance abuse.
21        The  Illinois Department shall establish such regulations
22    governing  the  dispensing  of  health  services  under  this
23    Article as it shall deem appropriate.  In  formulating  these
24    regulations  the  Illinois  Department shall consult with and
25    give substantial weight to the recommendations offered by the
26    Citizens  Assembly/Council  on  Public  Aid.  The  Department
27    should  seek  the  advice  of  formal  professional  advisory
28    committees  appointed  by  the  Director  of   the   Illinois
29    Department  for  the  purpose  of providing regular advice on
30    policy and administrative matters, information  dissemination
31    and  educational  activities  for  medical  and  health  care
32    providers,  and  consistency  in  procedures  to the Illinois
33    Department.
34        The Illinois Department may  develop  and  contract  with
HB1832 Re-Enrolled         -5-                 LRB9103252SMdv
 1    Partnerships of medical providers to arrange medical services
 2    for   persons  eligible  under  Section  5-2  of  this  Code.
 3    Implementation  of  this  Section  may  be  by  demonstration
 4    projects in certain geographic areas.  The Partnership  shall
 5    be represented by a sponsor organization.  The Department, by
 6    rule,   shall   develop   qualifications   for   sponsors  of
 7    Partnerships.  Nothing in this Section shall be construed  to
 8    require   that   the   sponsor   organization  be  a  medical
 9    organization.
10        The sponsor must negotiate formal written contracts  with
11    medical  providers  for  physician  services,  inpatient  and
12    outpatient hospital care, home health services, treatment for
13    alcoholism and substance abuse, and other services determined
14    necessary  by the Illinois Department by rule for delivery by
15    Partnerships.  Physician services must include  prenatal  and
16    obstetrical  care.   The  Illinois Department shall reimburse
17    medical  services  delivered  by  Partnership  providers   to
18    clients  in  target  areas  according  to  provisions of this
19    Article and the Illinois Health Finance  Reform  Act,  except
20    that:
21             (1)  Physicians  participating  in a Partnership and
22        providing certain services, which shall be determined  by
23        the  Illinois  Department, to persons in areas covered by
24        the Partnership may receive an additional  surcharge  for
25        such services.
26             (2)  The   Department  may  elect  to  consider  and
27        negotiate   financial   incentives   to   encourage   the
28        development of Partnerships and the efficient delivery of
29        medical care.
30             (3)  Persons  receiving  medical  services   through
31        Partnerships  may  receive  medical  and  case management
32        services above the  level  usually  offered  through  the
33        medical assistance program.
34        Medical  providers  shall  be  required  to  meet certain
HB1832 Re-Enrolled         -6-                 LRB9103252SMdv
 1    qualifications to participate in Partnerships to  ensure  the
 2    delivery   of   high   quality   medical   services.    These
 3    qualifications  shall  be  determined by rule of the Illinois
 4    Department  and  may  be  higher  than   qualifications   for
 5    participation in the medical assistance program.  Partnership
 6    sponsors  may  prescribe reasonable additional qualifications
 7    for participation by medical providers, only with  the  prior
 8    written approval of the Illinois Department.
 9        Nothing  in  this  Section shall limit the free choice of
10    practitioners, hospitals,  and  other  providers  of  medical
11    services by clients.
12        The  Department  shall apply for a waiver from the United
13    States Health Care Financing Administration to allow for  the
14    implementation of Partnerships under this Section.
15        The   Illinois   Department  shall  require  health  care
16    providers to maintain records that document the medical  care
17    and  services  provided  to  recipients of Medical Assistance
18    under this Article.  The Illinois  Department  shall  require
19    health  care  providers to make available, when authorized by
20    the patient, in writing, the  medical  records  in  a  timely
21    fashion  to  other  health care providers who are treating or
22    serving persons eligible for Medical  Assistance  under  this
23    Article.    All  dispensers  of  medical  services  shall  be
24    required to maintain and  retain  business  and  professional
25    records  sufficient  to  fully  and  accurately  document the
26    nature,  scope,  details  and  receipt  of  the  health  care
27    provided to persons eligible  for  medical  assistance  under
28    this  Code, in accordance with regulations promulgated by the
29    Illinois Department. The rules and regulations shall  require
30    that  proof  of  the receipt of prescription drugs, dentures,
31    prosthetic devices and eyeglasses by eligible  persons  under
32    this Section accompany each claim for reimbursement submitted
33    by the dispenser of such medical services. No such claims for
34    reimbursement  shall  be approved for payment by the Illinois
HB1832 Re-Enrolled         -7-                 LRB9103252SMdv
 1    Department without such proof of receipt, unless the Illinois
 2    Department shall have put into effect and shall be  operating
 3    a  system  of post-payment audit and review which shall, on a
 4    sampling basis, be deemed adequate by the Illinois Department
 5    to assure that such drugs, dentures, prosthetic  devices  and
 6    eyeglasses for which payment is being made are actually being
 7    received  by  eligible  recipients.  Within 90 days after the
 8    effective date of this amendatory Act of 1984,  the  Illinois
 9    Department  shall  establish  a  current  list of acquisition
10    costs  for  all  prosthetic  devices  and  any  other   items
11    recognized  as  medical  equipment  and supplies reimbursable
12    under this Article and shall update such list on a  quarterly
13    basis,  except that the acquisition costs of all prescription
14    drugs shall be updated no less frequently than every 30  days
15    as required by Section 5-5.12.
16        The  rules  and  regulations  of  the Illinois Department
17    shall require that a written statement including the required
18    opinion  of  a  physician  shall  accompany  any  claim   for
19    reimbursement  for  abortions,  or  induced  miscarriages  or
20    premature   births.    This  statement  shall  indicate  what
21    procedures were used in providing such medical services.
22        The Illinois Department shall require that all dispensers
23    of medical services, other than an individual practitioner or
24    group  of  practitioners,  desiring  to  participate  in  the
25    Medical Assistance program established under this Article  to
26    disclose all financial, beneficial, ownership, equity, surety
27    or  other  interests  in  any  and  all  firms, corporations,
28    partnerships,  associations,  business   enterprises,   joint
29    ventures,  agencies,  institutions  or  other  legal entities
30    providing any form of health  care  services  in  this  State
31    under this Article.
32        The  Illinois  Department may require that all dispensers
33    of medical services desiring to participate  in  the  medical
34    assistance  program  established under this Article disclose,
HB1832 Re-Enrolled         -8-                 LRB9103252SMdv
 1    under such terms and conditions as  the  Illinois  Department
 2    may  by  rule  establish,  all  inquiries  from  clients  and
 3    attorneys  regarding  medical  bills  paid  by  the  Illinois
 4    Department,   which   inquiries   could   indicate  potential
 5    existence of claims or liens for the Illinois Department.
 6        The  Illinois  Department   shall   establish   policies,
 7    procedures,   standards   and   criteria   by  rule  for  the
 8    acquisition,  repair  and   replacement   of   orthotic   and
 9    prosthetic devices and durable medical equipment.  Such rules
10    shall provide, but not be limited to, the following services:
11    (1)  immediate  repair  or  replacement  of  such  devices by
12    recipients without medical  authorization;  and  (2)  rental,
13    lease,   purchase   or   lease-purchase  of  durable  medical
14    equipment   in   a   cost-effective   manner,   taking   into
15    consideration the recipient's medical prognosis,  the  extent
16    of  the recipient's needs, and the requirements and costs for
17    maintaining  such  equipment.   Such  rules  shall  enable  a
18    recipient to  temporarily  acquire  and  use  alternative  or
19    substitute   devices   or   equipment   pending   repairs  or
20    replacements of any device or equipment previously authorized
21    for such recipient by the Department. Rules under clause  (2)
22    above  shall  not  provide  for purchase or lease-purchase of
23    durable medical equipment or supplies used for the purpose of
24    oxygen delivery and respiratory care.
25        The Department shall execute,  relative  to  the  nursing
26    home  prescreening  project,  written inter-agency agreements
27    with the Department of Human Services and the  Department  on
28    Aging,  to  effect  the  following: (i) intake procedures and
29    common  eligibility  criteria  for  those  persons  who   are
30    receiving    non-institutional   services;   and   (ii)   the
31    establishment and development of  non-institutional  services
32    in  areas of the State where they are not currently available
33    or are undeveloped.
34        The Illinois Department shall  develop  and  operate,  in
HB1832 Re-Enrolled         -9-                 LRB9103252SMdv
 1    cooperation  with other State Departments and agencies and in
 2    compliance with  applicable  federal  laws  and  regulations,
 3    appropriate  and  effective systems of health care evaluation
 4    and programs for monitoring of  utilization  of  health  care
 5    services  and  facilities, as it affects persons eligible for
 6    medical assistance under this Code. The  Illinois  Department
 7    shall  report  regularly the results of the operation of such
 8    systems and programs  to  the  Citizens  Assembly/Council  on
 9    Public  Aid  to  enable the Committee to ensure, from time to
10    time, that these programs are effective and meaningful.
11        The Illinois Department  shall  report  annually  to  the
12    General Assembly, no later than the second Friday in April of
13    1979 and each year thereafter, in regard to:
14             (a)  actual  statistics and trends in utilization of
15        medical services by public aid recipients;
16             (b)  actual statistics and trends in  the  provision
17        of the various medical services by medical vendors;
18             (c)  current rate structures and proposed changes in
19        those  rate  structures  for the various medical vendors;
20        and
21             (d)  efforts at utilization review  and  control  by
22        the Illinois Department.
23        The  period  covered  by each report shall be the 3 years
24    ending on the June 30 prior to the report.  The report  shall
25    include   suggested  legislation  for  consideration  by  the
26    General Assembly.  The filing of one copy of the report  with
27    the  Speaker,  one copy with the Minority Leader and one copy
28    with the Clerk of the House of Representatives, one copy with
29    the President, one copy with the Minority Leader and one copy
30    with  the  Secretary  of  the  Senate,  one  copy  with   the
31    Legislative  Research  Unit,  such additional copies with the
32    State Government Report Distribution Center for  the  General
33    Assembly  as  is required under paragraph (t) of Section 7 of
34    the  State  Library  Act  and  one  copy  with  the  Citizens
HB1832 Re-Enrolled         -10-                LRB9103252SMdv
 1    Assembly/Council on Public Aid  or  its  successor  shall  be
 2    deemed sufficient to comply with this Section.
 3    (Source:  P.A.  89-21,  eff.  7-1-95;  89-507,  eff.  7-1-97;
 4    89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.)

 5        Section  99.  Effective date.  This Act takes effect upon
 6    becoming law.

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