State of Illinois
91st General Assembly
Legislation

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[ Introduced ][ Engrossed ][ Senate Amendment 001 ]

91_SB0498enr

 
SB498 Enrolled                                 LRB9101554SMdv

 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,
 
SB498 Enrolled              -2-                LRB9101554SMdv
 1    including  examinations  and  laboratory  tests  to  discover
 2    evidence  which  may  be used in criminal proceedings arising
 3    from the sexual assault; (16) the diagnosis and treatment  of
 4    sickle  cell anemia; and (17) any other medical care, and any
 5    other type of remedial care recognized under the laws of this
 6    State, but not including abortions, or  induced  miscarriages
 7    or  premature  births, unless, in the opinion of a physician,
 8    such procedures are necessary for  the  preservation  of  the
 9    life  of  the  woman  seeking  such  treatment,  or except an
10    induced premature birth intended to  produce  a  live  viable
11    child  and  such procedure is necessary for the health of the
12    mother or her unborn child. The Illinois Department, by rule,
13    shall  prohibit  any   physician   from   providing   medical
14    assistance  to anyone eligible therefor under this Code where
15    such  physician  has  been  found  guilty  of  performing  an
16    abortion procedure in a wilful and wanton manner upon a woman
17    who was not pregnant at the time such abortion procedure  was
18    performed.  The  term "any other type of remedial care" shall
19    include nursing care and nursing home service for persons who
20    rely on treatment by spiritual means alone through prayer for
21    healing.
22        The Illinois Department of Public Aid shall  provide  the
23    following  services  to persons eligible for assistance under
24    this Article who are participating in education, training  or
25    employment  programs  operated  by  the  Department  of Human
26    Services as successor to the Department of Public Aid:
27             (1)  dental services, which shall include but not be
28        limited to prosthodontics; and
29             (2)  eyeglasses prescribed by a physician skilled in
30        the diseases of the eye, or by an optometrist,  whichever
31        the person may select.
32        The  Illinois  Department,  by  rule, may distinguish and
33    classify  the  medical  services  to  be  provided  only   in
34    accordance  with the classes of persons designated in Section
 
SB498 Enrolled              -3-                LRB9101554SMdv
 1    5-2.
 2        The Illinois Department shall authorize the provision of,
 3    and  shall  authorize  payment  for,  screening  by  low-dose
 4    mammography for the presence  of  occult  breast  cancer  for
 5    women  35  years of age or older who are eligible for medical
 6    assistance  under  this  Article,  as  follows:   a  baseline
 7    mammogram for women 35 to 39  years  of  age  and  an  annual
 8    mammogram for women 40 years of age or older.  All screenings
 9    shall   include   a  physical  breast  exam,  instruction  on
10    self-examination and information regarding the  frequency  of
11    self-examination  and  its  value as a preventative tool.  As
12    used in this Section, "low-dose mammography" means the  x-ray
13    examination   of   the   breast   using  equipment  dedicated
14    specifically  for  mammography,  including  the  x-ray  tube,
15    filter, compression device, image  receptor,  and  cassettes,
16    with  an average radiation exposure delivery of less than one
17    rad mid-breast, with 2 views for each breast.
18        Any medical or health  care  provider  shall  immediately
19    recommend,  to  any  pregnant  woman  who  is  being provided
20    prenatal services and  is  suspected  of  drug  abuse  or  is
21    addicted  as  defined  in the Alcoholism and Other Drug Abuse
22    and Dependency Act,  referral  to  a  local  substance  abuse
23    treatment  provider  licensed  by  the  Department  of  Human
24    Services  or  to a licensed hospital which provides substance
25    abuse treatment services.  The Department of Public Aid shall
26    assure coverage for the cost of treatment of the  drug  abuse
27    or  addiction  for pregnant recipients in accordance with the
28    Illinois Medicaid Program in conjunction with the  Department
29    of Human Services.
30        All  medical  providers  providing  medical assistance to
31    pregnant women under this Code shall receive information from
32    the Department on the availability of services under the Drug
33    Free  Families  with  a  Future  or  any  comparable  program
34    providing  case  management  services  for  addicted   women,
 
SB498 Enrolled              -4-                LRB9101554SMdv
 1    including  information  on  appropriate  referrals  for other
 2    social services that may  be  needed  by  addicted  women  in
 3    addition to treatment for addiction.
 4        The   Illinois   Department,   in  cooperation  with  the
 5    Departments of Human Services (as successor to the Department
 6    of Alcoholism and Substance Abuse) and Public Health, through
 7    a  public  awareness  campaign,   may   provide   information
 8    concerning  treatment  for  alcoholism  and  drug  abuse  and
 9    addiction, prenatal health care, and other pertinent programs
10    directed at reducing the number of drug-affected infants born
11    to recipients of medical assistance.
12        Neither  the  Illinois  Department  of Public Aid nor the
13    Department of Human Services  shall  sanction  the  recipient
14    solely on the basis of her substance abuse.
15        The  Illinois Department shall establish such regulations
16    governing  the  dispensing  of  health  services  under  this
17    Article as it shall deem appropriate.  In  formulating  these
18    regulations  the  Illinois  Department shall consult with and
19    give substantial weight to the recommendations offered by the
20    Citizens  Assembly/Council  on  Public  Aid.  The  Department
21    should  seek  the  advice  of  formal  professional  advisory
22    committees  appointed  by  the  Director  of   the   Illinois
23    Department  for  the  purpose  of providing regular advice on
24    policy and administrative matters, information  dissemination
25    and  educational  activities  for  medical  and  health  care
26    providers,  and  consistency  in  procedures  to the Illinois
27    Department.
28        The Illinois Department may  develop  and  contract  with
29    Partnerships of medical providers to arrange medical services
30    for   persons  eligible  under  Section  5-2  of  this  Code.
31    Implementation  of  this  Section  may  be  by  demonstration
32    projects in certain geographic areas.  The Partnership  shall
33    be represented by a sponsor organization.  The Department, by
34    rule,   shall   develop   qualifications   for   sponsors  of
 
SB498 Enrolled              -5-                LRB9101554SMdv
 1    Partnerships.  Nothing in this Section shall be construed  to
 2    require   that   the   sponsor   organization  be  a  medical
 3    organization.
 4        The sponsor must negotiate formal written contracts  with
 5    medical  providers  for  physician  services,  inpatient  and
 6    outpatient hospital care, home health services, treatment for
 7    alcoholism and substance abuse, and other services determined
 8    necessary  by the Illinois Department by rule for delivery by
 9    Partnerships.  Physician services must include  prenatal  and
10    obstetrical  care.   The  Illinois Department shall reimburse
11    medical  services  delivered  by  Partnership  providers   to
12    clients  in  target  areas  according  to  provisions of this
13    Article and the Illinois Health Finance  Reform  Act,  except
14    that:
15             (1)  Physicians  participating  in a Partnership and
16        providing certain services, which shall be determined  by
17        the  Illinois  Department, to persons in areas covered by
18        the Partnership may receive an additional  surcharge  for
19        such services.
20             (2)  The   Department  may  elect  to  consider  and
21        negotiate   financial   incentives   to   encourage   the
22        development of Partnerships and the efficient delivery of
23        medical care.
24             (3)  Persons  receiving  medical  services   through
25        Partnerships  may  receive  medical  and  case management
26        services above the  level  usually  offered  through  the
27        medical assistance program.
28        Medical  providers  shall  be  required  to  meet certain
29    qualifications to participate in Partnerships to  ensure  the
30    delivery   of   high   quality   medical   services.    These
31    qualifications  shall  be  determined by rule of the Illinois
32    Department  and  may  be  higher  than   qualifications   for
33    participation in the medical assistance program.  Partnership
34    sponsors  may  prescribe reasonable additional qualifications
 
SB498 Enrolled              -6-                LRB9101554SMdv
 1    for participation by medical providers, only with  the  prior
 2    written approval of the Illinois Department.
 3        Nothing  in  this  Section shall limit the free choice of
 4    practitioners, hospitals,  and  other  providers  of  medical
 5    services  by  clients.  In order to ensure patient freedom of
 6    choice, the Illinois Department shall immediately  promulgate
 7    all  rules  and  take  all  other  necessary  actions so that
 8    provided  services  may  be  accessed  from   therapeutically
 9    certified  optometrists  to  the  full extent of the Illinois
10    Optometric  Practice  Act  of  1987  without   discriminating
11    between service providers.
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
 
SB498 Enrolled              -7-                LRB9101554SMdv
 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,
 
SB498 Enrolled              -8-                LRB9101554SMdv
 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
 
SB498 Enrolled              -9-                LRB9101554SMdv
 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
 
SB498 Enrolled              -10-               LRB9101554SMdv
 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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