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92_SB1745 LRB9215772DJgc 1 AN ACT concerning 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 including, without limitation, the following: 21 periodontal scaling (American Medical Association current 22 procedural terminology (CPT) Code 04341), periodontal 23 maintenance (CPT Code 04910), patient instruction (CPT Code 24 01340), adult prophylaxis (CPT Code D1110), adult fluoride 25 (CPT Code D1204), and partial dentures (CPT Codes D5211, 26 D5212, D5213, D5214, and D5281); (11) physical therapy and 27 related services; (12) prescribed drugs, dentures, and 28 prosthetic devices; and eyeglasses prescribed by a physician 29 skilled in the diseases of the eye, or by an optometrist, 30 whichever the person may select; (13) other diagnostic, 31 screening, preventive, and rehabilitative services; (14) -2- LRB9215772DJgc 1 transportation and such other expenses as may be necessary; 2 (15) medical treatment of sexual assault survivors, as 3 defined in Section 1a of the Sexual Assault Survivors 4 Emergency Treatment Act, for injuries sustained as a result 5 of the sexual assault, including examinations and laboratory 6 tests to discover evidence which may be used in criminal 7 proceedings arising from the sexual assault; (16) the 8 diagnosis and treatment of sickle cell anemia; and (17) any 9 other medical care, and any other type of remedial care 10 recognized under the laws of this State, but not including 11 abortions, or induced miscarriages or premature births, 12 unless, in the opinion of a physician, such procedures are 13 necessary for the preservation of the life of the woman 14 seeking such treatment, or except an induced premature birth 15 intended to produce a live viable child and such procedure is 16 necessary for the health of the mother or her unborn child. 17 The Illinois Department, by rule, shall prohibit any 18 physician from providing medical assistance to anyone 19 eligible therefor under this Code where such physician has 20 been found guilty of performing an abortion procedure in a 21 wilful and wanton manner upon a woman who was not pregnant at 22 the time such abortion procedure was performed. The term "any 23 other type of remedial care" shall include nursing care and 24 nursing home service for persons who rely on treatment by 25 spiritual means alone through prayer for healing. 26 Notwithstanding any other provision of this Section, a 27 comprehensive tobacco use cessation program that includes 28 purchasing prescription drugs or prescription medical devices 29 approved by the Food and Drug administration shall be covered 30 under the medical assistance program under this Article for 31 persons who are otherwise eligible for assistance under this 32 Article. 33 Notwithstanding any other provision of this Code, the 34 Illinois Department may not require, as a condition of -3- LRB9215772DJgc 1 payment for any laboratory test authorized under this 2 Article, that a physician's handwritten signature appear on 3 the laboratory test order form. The Illinois Department may, 4 however, impose other appropriate requirements regarding 5 laboratory test order documentation. 6 The Illinois Department of Public Aid shall provide the 7 following services to persons eligible for assistance under 8 this Article who are participating in education, training or 9 employment programs operated by the Department of Human 10 Services as successor to the Department of Public Aid: 11 (1) dental services, which shall include but not be 12 limited to prosthodontics and the following: periodontal 13 scaling (American Medical Association current procedural 14 terminology (CPT) Code 04341), periodontal maintenance 15 (CPT Code 04910), patient instruction (CPT Code 01340), 16 adult prophylaxis (CPT Code D1110), adult fluoride (CPT 17 Code D1204), and partial dentures (CPT Codes D5211, 18 D5212, D5213, D5214, and D5281); and 19 (2) eyeglasses prescribed by a physician skilled in 20 the diseases of the eye, or by an optometrist, whichever 21 the person may select. 22 The Illinois Department, by rule, may distinguish and 23 classify the medical services to be provided only in 24 accordance with the classes of persons designated in Section 25 5-2. 26 The Illinois Department shall authorize the provision of, 27 and shall authorize payment for, screening by low-dose 28 mammography for the presence of occult breast cancer for 29 women 35 years of age or older who are eligible for medical 30 assistance under this Article, as follows: a baseline 31 mammogram for women 35 to 39 years of age and an annual 32 mammogram for women 40 years of age or older. All screenings 33 shall include a physical breast exam, instruction on 34 self-examination and information regarding the frequency of -4- LRB9215772DJgc 1 self-examination and its value as a preventative tool. As 2 used in this Section, "low-dose mammography" means the x-ray 3 examination of the breast using equipment dedicated 4 specifically for mammography, including the x-ray tube, 5 filter, compression device, image receptor, and cassettes, 6 with an average radiation exposure delivery of less than one 7 rad mid-breast, with 2 views for each breast. 8 Any medical or health care provider shall immediately 9 recommend, to any pregnant woman who is being provided 10 prenatal services and is suspected of drug abuse or is 11 addicted as defined in the Alcoholism and Other Drug Abuse 12 and Dependency Act, referral to a local substance abuse 13 treatment provider licensed by the Department of Human 14 Services or to a licensed hospital which provides substance 15 abuse treatment services. The Department of Public Aid shall 16 assure coverage for the cost of treatment of the drug abuse 17 or addiction for pregnant recipients in accordance with the 18 Illinois Medicaid Program in conjunction with the Department 19 of Human Services. 20 All medical providers providing medical assistance to 21 pregnant women under this Code shall receive information from 22 the Department on the availability of services under the Drug 23 Free Families with a Future or any comparable program 24 providing case management services for addicted women, 25 including information on appropriate referrals for other 26 social services that may be needed by addicted women in 27 addition to treatment for addiction. 28 The Illinois Department, in cooperation with the 29 Departments of Human Services (as successor to the Department 30 of Alcoholism and Substance Abuse) and Public Health, through 31 a public awareness campaign, may provide information 32 concerning treatment for alcoholism and drug abuse and 33 addiction, prenatal health care, and other pertinent programs 34 directed at reducing the number of drug-affected infants born -5- LRB9215772DJgc 1 to recipients of medical assistance. 2 Neither the Illinois Department of Public Aid nor the 3 Department of Human Services shall sanction the recipient 4 solely on the basis of her substance abuse. 5 The Illinois Department shall establish such regulations 6 governing the dispensing of health services under this 7 Article as it shall deem appropriate. In formulating these 8 regulations the Illinois Department shall consult with and 9 give substantial weight to the recommendations offered by the 10 Citizens Assembly/Council on Public Aid. The Department 11 should seek the advice of formal professional advisory 12 committees appointed by the Director of the Illinois 13 Department for the purpose of providing regular advice on 14 policy and administrative matters, information dissemination 15 and educational activities for medical and health care 16 providers, and consistency in procedures to the Illinois 17 Department. 18 The Illinois Department may develop and contract with 19 Partnerships of medical providers to arrange medical services 20 for persons eligible under Section 5-2 of this Code. 21 Implementation of this Section may be by demonstration 22 projects in certain geographic areas. The Partnership shall 23 be represented by a sponsor organization. The Department, by 24 rule, shall develop qualifications for sponsors of 25 Partnerships. Nothing in this Section shall be construed to 26 require that the sponsor organization be a medical 27 organization. 28 The sponsor must negotiate formal written contracts with 29 medical providers for physician services, inpatient and 30 outpatient hospital care, home health services, treatment for 31 alcoholism and substance abuse, and other services determined 32 necessary by the Illinois Department by rule for delivery by 33 Partnerships. Physician services must include prenatal and 34 obstetrical care. The Illinois Department shall reimburse -6- LRB9215772DJgc 1 medical services delivered by Partnership providers to 2 clients in target areas according to provisions of this 3 Article and the Illinois Health Finance Reform Act, except 4 that: 5 (1) Physicians participating in a Partnership and 6 providing certain services, which shall be determined by 7 the Illinois Department, to persons in areas covered by 8 the Partnership may receive an additional surcharge for 9 such services. 10 (2) The Department may elect to consider and 11 negotiate financial incentives to encourage the 12 development of Partnerships and the efficient delivery of 13 medical care. 14 (3) Persons receiving medical services through 15 Partnerships may receive medical and case management 16 services above the level usually offered through the 17 medical assistance program. 18 Medical providers shall be required to meet certain 19 qualifications to participate in Partnerships to ensure the 20 delivery of high quality medical services. These 21 qualifications shall be determined by rule of the Illinois 22 Department and may be higher than qualifications for 23 participation in the medical assistance program. Partnership 24 sponsors may prescribe reasonable additional qualifications 25 for participation by medical providers, only with the prior 26 written approval of the Illinois Department. 27 Nothing in this Section shall limit the free choice of 28 practitioners, hospitals, and other providers of medical 29 services by clients. In order to ensure patient freedom of 30 choice, the Illinois Department shall immediately promulgate 31 all rules and take all other necessary actions so that 32 provided services may be accessed from therapeutically 33 certified optometrists to the full extent of the Illinois 34 Optometric Practice Act of 1987 without discriminating -7- LRB9215772DJgc 1 between service providers. 2 The Department shall apply for a waiver from the United 3 States Health Care Financing Administration to allow for the 4 implementation of Partnerships under this Section. 5 The Illinois Department shall require health care 6 providers to maintain records that document the medical care 7 and services provided to recipients of Medical Assistance 8 under this Article. The Illinois Department shall require 9 health care providers to make available, when authorized by 10 the patient, in writing, the medical records in a timely 11 fashion to other health care providers who are treating or 12 serving persons eligible for Medical Assistance under this 13 Article. All dispensers of medical services shall be 14 required to maintain and retain business and professional 15 records sufficient to fully and accurately document the 16 nature, scope, details and receipt of the health care 17 provided to persons eligible for medical assistance under 18 this Code, in accordance with regulations promulgated by the 19 Illinois Department. The rules and regulations shall require 20 that proof of the receipt of prescription drugs, dentures, 21 prosthetic devices and eyeglasses by eligible persons under 22 this Section accompany each claim for reimbursement submitted 23 by the dispenser of such medical services. No such claims for 24 reimbursement shall be approved for payment by the Illinois 25 Department without such proof of receipt, unless the Illinois 26 Department shall have put into effect and shall be operating 27 a system of post-payment audit and review which shall, on a 28 sampling basis, be deemed adequate by the Illinois Department 29 to assure that such drugs, dentures, prosthetic devices and 30 eyeglasses for which payment is being made are actually being 31 received by eligible recipients. Within 90 days after the 32 effective date of this amendatory Act of 1984, the Illinois 33 Department shall establish a current list of acquisition 34 costs for all prosthetic devices and any other items -8- LRB9215772DJgc 1 recognized as medical equipment and supplies reimbursable 2 under this Article and shall update such list on a quarterly 3 basis, except that the acquisition costs of all prescription 4 drugs shall be updated no less frequently than every 30 days 5 as required by Section 5-5.12. 6 The rules and regulations of the Illinois Department 7 shall require that a written statement including the required 8 opinion of a physician shall accompany any claim for 9 reimbursement for abortions, or induced miscarriages or 10 premature births. This statement shall indicate what 11 procedures were used in providing such medical services. 12 The Illinois Department shall require
thatall dispensers 13 of medical services, other than an individual practitioner or 14 group of practitioners, desiring to participate in the 15 Medical Assistance program established under this Article to 16 disclose all financial, beneficial, ownership, equity, surety 17 or other interests in any and all firms, corporations, 18 partnerships, associations, business enterprises, joint 19 ventures, agencies, institutions or other legal entities 20 providing any form of health care services in this State 21 under this Article. 22 The Illinois Department may require that all dispensers 23 of medical services desiring to participate in the medical 24 assistance program established under this Article disclose, 25 under such terms and conditions as the Illinois Department 26 may by rule establish, all inquiries from clients and 27 attorneys regarding medical bills paid by the Illinois 28 Department, which inquiries could indicate potential 29 existence of claims or liens for the Illinois Department. 30 The Illinois Department shall establish policies, 31 procedures, standards and criteria by rule for the 32 acquisition, repair and replacement of orthotic and 33 prosthetic devices and durable medical equipment. Such rules 34 shall provide, but not be limited to, the following services: -9- LRB9215772DJgc 1 (1) immediate repair or replacement of such devices by 2 recipients without medical authorization; and (2) rental, 3 lease, purchase or lease-purchase of durable medical 4 equipment in a cost-effective manner, taking into 5 consideration the recipient's medical prognosis, the extent 6 of the recipient's needs, and the requirements and costs for 7 maintaining such equipment. Such rules shall enable a 8 recipient to temporarily acquire and use alternative or 9 substitute devices or equipment pending repairs or 10 replacements of any device or equipment previously authorized 11 for such recipient by the Department. Rules under clause (2) 12 above shall not provide for purchase or lease-purchase of 13 durable medical equipment or supplies used for the purpose of 14 oxygen delivery and respiratory care. 15 The Department shall execute, relative to the nursing 16 home prescreening project, written inter-agency agreements 17 with the Department of Human Services and the Department on 18 Aging, to effect the following: (i) intake procedures and 19 common eligibility criteria for those persons who are 20 receiving non-institutional services; and (ii) the 21 establishment and development of non-institutional services 22 in areas of the State where they are not currently available 23 or are undeveloped. 24 The Illinois Department shall develop and operate, in 25 cooperation with other State Departments and agencies and in 26 compliance with applicable federal laws and regulations, 27 appropriate and effective systems of health care evaluation 28 and programs for monitoring of utilization of health care 29 services and facilities, as it affects persons eligible for 30 medical assistance under this Code. The Illinois Department 31 shall report regularly the results of the operation of such 32 systems and programs to the Citizens Assembly/Council on 33 Public Aid to enable the Committee to ensure, from time to 34 time, that these programs are effective and meaningful. -10- LRB9215772DJgc 1 The Illinois Department shall report annually to the 2 General Assembly, no later than the second Friday in April of 3 1979 and each year thereafter, in regard to: 4 (a) actual statistics and trends in utilization of 5 medical services by public aid recipients; 6 (b) actual statistics and trends in the provision 7 of the various medical services by medical vendors; 8 (c) current rate structures and proposed changes in 9 those rate structures for the various medical vendors; 10 and 11 (d) efforts at utilization review and control by 12 the Illinois Department. 13 The period covered by each report shall be the 3 years 14 ending on the June 30 prior to the report. The report shall 15 include suggested legislation for consideration by the 16 General Assembly. The filing of one copy of the report with 17 the Speaker, one copy with the Minority Leader and one copy 18 with the Clerk of the House of Representatives, one copy with 19 the President, one copy with the Minority Leader and one copy 20 with the Secretary of the Senate, one copy with the 21 Legislative Research Unit, such additional copies with the 22 State Government Report Distribution Center for the General 23 Assembly as is required under paragraph (t) of Section 7 of 24 the State Library Act and one copy with the Citizens 25 Assembly/Council on Public Aid or its successor shall be 26 deemed sufficient to comply with this Section. 27 (Source: P.A. 91-344, eff. 1-1-00; 91-462, eff. 8-6-99; 28 91-666, eff. 12-22-99; 92-16, eff. 6-28-01; revised 29 12-13-01.) 30 Section 99. Effective date. This Act takes effect on 31 July 1, 2002.
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