State of Illinois
92nd General Assembly

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 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 that all 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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