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| [ Senate Amendment 001 ] |
91_HB1832eng HB1832 Engrossed 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 Engrossed -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 HB1832 Engrossed -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 HB1832 Engrossed -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 HB1832 Engrossed -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 HB1832 Engrossed -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 HB1832 Engrossed -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. HB1832 Engrossed -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 HB1832 Engrossed -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 HB1832 Engrossed -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.)