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92_HB2154
LRB9206174DJgc
1 AN ACT in relation to public aid.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5 changing Section 5-5 as follows:
6 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
7 Sec. 5-5. Medical services. The Illinois Department, by
8 rule, shall determine the quantity and quality of and the
9 rate of reimbursement for the medical assistance for which
10 payment will be authorized, and the medical services to be
11 provided, which may include all or part of the following: (1)
12 inpatient hospital services; (2) outpatient hospital
13 services; (3) other laboratory and X-ray services; (4)
14 skilled nursing home services; (5) physicians' services
15 whether furnished in the office, the patient's home, a
16 hospital, a skilled nursing home, or elsewhere; (6) medical
17 care, or any other type of remedial care furnished by
18 licensed practitioners; (7) home health care services; (8)
19 private duty nursing service; (9) clinic services; (10)
20 dental services; (11) physical therapy and related services;
21 (12) prescribed drugs, dentures, and prosthetic devices; and
22 eyeglasses prescribed by a physician skilled in the diseases
23 of the eye, or by an optometrist, whichever the person may
24 select; (13) other diagnostic, screening, preventive, and
25 rehabilitative services; (14) transportation and such other
26 expenses as may be necessary; (15) medical treatment of
27 sexual assault survivors, as defined in Section 1a of the
28 Sexual Assault Survivors Emergency Treatment Act, for
29 injuries sustained as a result of the sexual assault,
30 including examinations and laboratory tests to discover
31 evidence which may be used in criminal proceedings arising
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1 from the sexual assault; (16) the diagnosis and treatment of
2 sickle cell anemia; and (17) any other medical care, and any
3 other type of remedial care recognized under the laws of this
4 State, but not including abortions, or induced miscarriages
5 or premature births, unless, in the opinion of a physician,
6 such procedures are necessary for the preservation of the
7 life of the woman seeking such treatment, or except an
8 induced premature birth intended to produce a live viable
9 child and such procedure is necessary for the health of the
10 mother or her unborn child. The Illinois Department, by rule,
11 shall prohibit any physician from providing medical
12 assistance to anyone eligible therefor under this Code where
13 such physician has been found guilty of performing an
14 abortion procedure in a wilful and wanton manner upon a woman
15 who was not pregnant at the time such abortion procedure was
16 performed. The term "any other type of remedial care" shall
17 include nursing care and nursing home service for persons who
18 rely on treatment by spiritual means alone through prayer for
19 healing.
20 Notwithstanding any other provision of this Section, a
21 comprehensive tobacco use cessation program that includes
22 purchasing prescription drugs or prescription medical devices
23 approved by the Food and Drug administration shall be covered
24 under the medical assistance program under this Article for
25 persons who are otherwise eligible for assistance under this
26 Article.
27 Notwithstanding any other provision of this Code, the
28 Illinois Department may not require, as a condition of
29 payment for any laboratory test authorized under this
30 Article, that a physician's handwritten signature appear on
31 the laboratory test order form. The Illinois Department may,
32 however, impose other appropriate requirements regarding
33 laboratory test order documentation.
34 If a recipient of medical assistance under this Article
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1 undergoes an organ transplantation procedure, all drugs
2 necessary to prevent the recipient's body from rejecting the
3 transplanted organ shall also be covered under the medical
4 assistance program.
5 The Illinois Department of Public Aid shall provide the
6 following services to persons eligible for assistance under
7 this Article who are participating in education, training or
8 employment programs operated by the Department of Human
9 Services as successor to the Department of Public Aid:
10 (1) dental services, which shall include but not be
11 limited to prosthodontics; and
12 (2) eyeglasses prescribed by a physician skilled in
13 the diseases of the eye, or by an optometrist, whichever
14 the person may select.
15 The Illinois Department, by rule, may distinguish and
16 classify the medical services to be provided only in
17 accordance with the classes of persons designated in Section
18 5-2.
19 The Illinois Department shall authorize the provision of,
20 and shall authorize payment for, screening by low-dose
21 mammography for the presence of occult breast cancer for
22 women 35 years of age or older who are eligible for medical
23 assistance under this Article, as follows: a baseline
24 mammogram for women 35 to 39 years of age and an annual
25 mammogram for women 40 years of age or older. All screenings
26 shall include a physical breast exam, instruction on
27 self-examination and information regarding the frequency of
28 self-examination and its value as a preventative tool. As
29 used in this Section, "low-dose mammography" means the x-ray
30 examination of the breast using equipment dedicated
31 specifically for mammography, including the x-ray tube,
32 filter, compression device, image receptor, and cassettes,
33 with an average radiation exposure delivery of less than one
34 rad mid-breast, with 2 views for each breast.
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1 Any medical or health care provider shall immediately
2 recommend, to any pregnant woman who is being provided
3 prenatal services and is suspected of drug abuse or is
4 addicted as defined in the Alcoholism and Other Drug Abuse
5 and Dependency Act, referral to a local substance abuse
6 treatment provider licensed by the Department of Human
7 Services or to a licensed hospital which provides substance
8 abuse treatment services. The Department of Public Aid shall
9 assure coverage for the cost of treatment of the drug abuse
10 or addiction for pregnant recipients in accordance with the
11 Illinois Medicaid Program in conjunction with the Department
12 of Human Services.
13 All medical providers providing medical assistance to
14 pregnant women under this Code shall receive information from
15 the Department on the availability of services under the Drug
16 Free Families with a Future or any comparable program
17 providing case management services for addicted women,
18 including information on appropriate referrals for other
19 social services that may be needed by addicted women in
20 addition to treatment for addiction.
21 The Illinois Department, in cooperation with the
22 Departments of Human Services (as successor to the Department
23 of Alcoholism and Substance Abuse) and Public Health, through
24 a public awareness campaign, may provide information
25 concerning treatment for alcoholism and drug abuse and
26 addiction, prenatal health care, and other pertinent programs
27 directed at reducing the number of drug-affected infants born
28 to recipients of medical assistance.
29 Neither the Illinois Department of Public Aid nor the
30 Department of Human Services shall sanction the recipient
31 solely on the basis of her substance abuse.
32 The Illinois Department shall establish such regulations
33 governing the dispensing of health services under this
34 Article as it shall deem appropriate. In formulating these
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1 regulations the Illinois Department shall consult with and
2 give substantial weight to the recommendations offered by the
3 Citizens Assembly/Council on Public Aid. The Department
4 should seek the advice of formal professional advisory
5 committees appointed by the Director of the Illinois
6 Department for the purpose of providing regular advice on
7 policy and administrative matters, information dissemination
8 and educational activities for medical and health care
9 providers, and consistency in procedures to the Illinois
10 Department.
11 The Illinois Department may develop and contract with
12 Partnerships of medical providers to arrange medical services
13 for persons eligible under Section 5-2 of this Code.
14 Implementation of this Section may be by demonstration
15 projects in certain geographic areas. The Partnership shall
16 be represented by a sponsor organization. The Department, by
17 rule, shall develop qualifications for sponsors of
18 Partnerships. Nothing in this Section shall be construed to
19 require that the sponsor organization be a medical
20 organization.
21 The sponsor must negotiate formal written contracts with
22 medical providers for physician services, inpatient and
23 outpatient hospital care, home health services, treatment for
24 alcoholism and substance abuse, and other services determined
25 necessary by the Illinois Department by rule for delivery by
26 Partnerships. Physician services must include prenatal and
27 obstetrical care. The Illinois Department shall reimburse
28 medical services delivered by Partnership providers to
29 clients in target areas according to provisions of this
30 Article and the Illinois Health Finance Reform Act, except
31 that:
32 (1) Physicians participating in a Partnership and
33 providing certain services, which shall be determined by
34 the Illinois Department, to persons in areas covered by
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1 the Partnership may receive an additional surcharge for
2 such services.
3 (2) The Department may elect to consider and
4 negotiate financial incentives to encourage the
5 development of Partnerships and the efficient delivery of
6 medical care.
7 (3) Persons receiving medical services through
8 Partnerships may receive medical and case management
9 services above the level usually offered through the
10 medical assistance program.
11 Medical providers shall be required to meet certain
12 qualifications to participate in Partnerships to ensure the
13 delivery of high quality medical services. These
14 qualifications shall be determined by rule of the Illinois
15 Department and may be higher than qualifications for
16 participation in the medical assistance program. Partnership
17 sponsors may prescribe reasonable additional qualifications
18 for participation by medical providers, only with the prior
19 written approval of the Illinois Department.
20 Nothing in this Section shall limit the free choice of
21 practitioners, hospitals, and other providers of medical
22 services by clients. In order to ensure patient freedom of
23 choice, the Illinois Department shall immediately promulgate
24 all rules and take all other necessary actions so that
25 provided services may be accessed from therapeutically
26 certified optometrists to the full extent of the Illinois
27 Optometric Practice Act of 1987 without discriminating
28 between service providers.
29 The Department shall apply for a waiver from the United
30 States Health Care Financing Administration to allow for the
31 implementation of Partnerships under this Section.
32 The Illinois Department shall require health care
33 providers to maintain records that document the medical care
34 and services provided to recipients of Medical Assistance
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1 under this Article. The Illinois Department shall require
2 health care providers to make available, when authorized by
3 the patient, in writing, the medical records in a timely
4 fashion to other health care providers who are treating or
5 serving persons eligible for Medical Assistance under this
6 Article. All dispensers of medical services shall be
7 required to maintain and retain business and professional
8 records sufficient to fully and accurately document the
9 nature, scope, details and receipt of the health care
10 provided to persons eligible for medical assistance under
11 this Code, in accordance with regulations promulgated by the
12 Illinois Department. The rules and regulations shall require
13 that proof of the receipt of prescription drugs, dentures,
14 prosthetic devices and eyeglasses by eligible persons under
15 this Section accompany each claim for reimbursement submitted
16 by the dispenser of such medical services. No such claims for
17 reimbursement shall be approved for payment by the Illinois
18 Department without such proof of receipt, unless the Illinois
19 Department shall have put into effect and shall be operating
20 a system of post-payment audit and review which shall, on a
21 sampling basis, be deemed adequate by the Illinois Department
22 to assure that such drugs, dentures, prosthetic devices and
23 eyeglasses for which payment is being made are actually being
24 received by eligible recipients. Within 90 days after the
25 effective date of this amendatory Act of 1984, the Illinois
26 Department shall establish a current list of acquisition
27 costs for all prosthetic devices and any other items
28 recognized as medical equipment and supplies reimbursable
29 under this Article and shall update such list on a quarterly
30 basis, except that the acquisition costs of all prescription
31 drugs shall be updated no less frequently than every 30 days
32 as required by Section 5-5.12.
33 The rules and regulations of the Illinois Department
34 shall require that a written statement including the required
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1 opinion of a physician shall accompany any claim for
2 reimbursement for abortions, or induced miscarriages or
3 premature births. This statement shall indicate what
4 procedures were used in providing such medical services.
5 The Illinois Department shall require that all dispensers
6 of medical services, other than an individual practitioner or
7 group of practitioners, desiring to participate in the
8 Medical Assistance program established under this Article to
9 disclose all financial, beneficial, ownership, equity, surety
10 or other interests in any and all firms, corporations,
11 partnerships, associations, business enterprises, joint
12 ventures, agencies, institutions or other legal entities
13 providing any form of health care services in this State
14 under this Article.
15 The Illinois Department may require that all dispensers
16 of medical services desiring to participate in the medical
17 assistance program established under this Article disclose,
18 under such terms and conditions as the Illinois Department
19 may by rule establish, all inquiries from clients and
20 attorneys regarding medical bills paid by the Illinois
21 Department, which inquiries could indicate potential
22 existence of claims or liens for the Illinois Department.
23 The Illinois Department shall establish policies,
24 procedures, standards and criteria by rule for the
25 acquisition, repair and replacement of orthotic and
26 prosthetic devices and durable medical equipment. Such rules
27 shall provide, but not be limited to, the following services:
28 (1) immediate repair or replacement of such devices by
29 recipients without medical authorization; and (2) rental,
30 lease, purchase or lease-purchase of durable medical
31 equipment in a cost-effective manner, taking into
32 consideration the recipient's medical prognosis, the extent
33 of the recipient's needs, and the requirements and costs for
34 maintaining such equipment. Such rules shall enable a
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1 recipient to temporarily acquire and use alternative or
2 substitute devices or equipment pending repairs or
3 replacements of any device or equipment previously authorized
4 for such recipient by the Department. Rules under clause (2)
5 above shall not provide for purchase or lease-purchase of
6 durable medical equipment or supplies used for the purpose of
7 oxygen delivery and respiratory care.
8 The Department shall execute, relative to the nursing
9 home prescreening project, written inter-agency agreements
10 with the Department of Human Services and the Department on
11 Aging, to effect the following: (i) intake procedures and
12 common eligibility criteria for those persons who are
13 receiving non-institutional services; and (ii) the
14 establishment and development of non-institutional services
15 in areas of the State where they are not currently available
16 or are undeveloped.
17 The Illinois Department shall develop and operate, in
18 cooperation with other State Departments and agencies and in
19 compliance with applicable federal laws and regulations,
20 appropriate and effective systems of health care evaluation
21 and programs for monitoring of utilization of health care
22 services and facilities, as it affects persons eligible for
23 medical assistance under this Code. The Illinois Department
24 shall report regularly the results of the operation of such
25 systems and programs to the Citizens Assembly/Council on
26 Public Aid to enable the Committee to ensure, from time to
27 time, that these programs are effective and meaningful.
28 The Illinois Department shall report annually to the
29 General Assembly, no later than the second Friday in April of
30 1979 and each year thereafter, in regard to:
31 (a) actual statistics and trends in utilization of
32 medical services by public aid recipients;
33 (b) actual statistics and trends in the provision
34 of the various medical services by medical vendors;
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1 (c) current rate structures and proposed changes in
2 those rate structures for the various medical vendors;
3 and
4 (d) efforts at utilization review and control by
5 the Illinois Department.
6 The period covered by each report shall be the 3 years
7 ending on the June 30 prior to the report. The report shall
8 include suggested legislation for consideration by the
9 General Assembly. The filing of one copy of the report with
10 the Speaker, one copy with the Minority Leader and one copy
11 with the Clerk of the House of Representatives, one copy with
12 the President, one copy with the Minority Leader and one copy
13 with the Secretary of the Senate, one copy with the
14 Legislative Research Unit, such additional copies with the
15 State Government Report Distribution Center for the General
16 Assembly as is required under paragraph (t) of Section 7 of
17 the State Library Act and one copy with the Citizens
18 Assembly/Council on Public Aid or its successor shall be
19 deemed sufficient to comply with this Section.
20 (Source: P.A. 90-7, eff. 6-10-97; 90-14, eff. 7-1-97; 91-344,
21 eff. 1-1-00; 91-462, eff. 8-6-99; 91-666, eff. 12-22-99;
22 revised 1-6-00.)
23 Section 99. Effective date. This Act takes effect upon
24 becoming law.