Sen. Donne E. Trotter
Filed: 4/27/2004
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1 | AMENDMENT TO HOUSE BILL 0486
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2 | AMENDMENT NO. ______. Amend House Bill 486, AS AMENDED, | ||||||
3 | with reference to page and line numbers of Senate Amendment | ||||||
4 | No.1, on page 1, by replacing line 20 with the following:
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5 | "changing Section 5-5 and adding Section 5-16.7a as follows: | ||||||
6 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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7 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
8 | rule, shall
determine the quantity and quality of and the rate | ||||||
9 | of reimbursement for the
medical assistance for which
payment | ||||||
10 | will be authorized, and the medical services to be provided,
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11 | which may include all or part of the following: (1) inpatient | ||||||
12 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
13 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
14 | services; (5) physicians'
services whether furnished in the | ||||||
15 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
16 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
17 | care furnished by licensed practitioners; (7)
home health care | ||||||
18 | services; (8) private duty nursing service; (9) clinic
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19 | services; (10) dental services , including prevention and | ||||||
20 | treatment of periodontal disease and dental caries disease for | ||||||
21 | pregnant women ; (11) physical therapy and related
services; | ||||||
22 | (12) prescribed drugs, dentures, and prosthetic devices; and
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23 | eyeglasses prescribed by a physician skilled in the diseases of | ||||||
24 | the eye,
or by an optometrist, whichever the person may select; | ||||||
25 | (13) other
diagnostic, screening, preventive, and |
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1 | rehabilitative services; (14)
transportation and such other | ||||||
2 | expenses as may be necessary; (15) medical
treatment of sexual | ||||||
3 | assault survivors, as defined in
Section 1a of the Sexual | ||||||
4 | Assault Survivors Emergency Treatment Act, for
injuries | ||||||
5 | sustained as a result of the sexual assault, including
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6 | examinations and laboratory tests to discover evidence which | ||||||
7 | may be used in
criminal proceedings arising from the sexual | ||||||
8 | assault; (16) the
diagnosis and treatment of sickle cell | ||||||
9 | anemia; and (17)
any other medical care, and any other type of | ||||||
10 | remedial care recognized
under the laws of this State, but not | ||||||
11 | including abortions, or induced
miscarriages or premature | ||||||
12 | births, unless, in the opinion of a physician,
such procedures | ||||||
13 | are necessary for the preservation of the life of the
woman | ||||||
14 | seeking such treatment, or except an induced premature birth
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15 | intended to produce a live viable child and such procedure is | ||||||
16 | necessary
for the health of the mother or her unborn child. The | ||||||
17 | Illinois Department,
by rule, shall prohibit any physician from | ||||||
18 | providing medical assistance
to anyone eligible therefor under | ||||||
19 | this Code where such physician has been
found guilty of | ||||||
20 | performing an abortion procedure in a wilful and wanton
manner | ||||||
21 | upon a woman who was not pregnant at the time such abortion
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22 | procedure was performed. The term "any other type of remedial | ||||||
23 | care" shall
include nursing care and nursing home service for | ||||||
24 | persons who rely on
treatment by spiritual means alone through | ||||||
25 | prayer for healing.
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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.
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33 | Notwithstanding any other provision of this Code, the | ||||||
34 | Illinois
Department may not require, as a condition of payment |
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1 | for any laboratory
test authorized under this Article, that a | ||||||
2 | physician's handwritten signature
appear on the laboratory | ||||||
3 | test order form. The Illinois Department may,
however, impose | ||||||
4 | other appropriate requirements regarding laboratory test
order | ||||||
5 | documentation.
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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
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10 | Services as successor to the Department of Public Aid:
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11 | (1) dental services, which shall include but not be | ||||||
12 | limited to
prosthodontics; and
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13 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
14 | diseases of the
eye, or by an optometrist, whichever the | ||||||
15 | person may select.
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16 | The Illinois Department, by rule, may distinguish and | ||||||
17 | classify the
medical services to be provided only in accordance | ||||||
18 | with the classes of
persons designated in Section 5-2.
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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 women | ||||||
22 | 35 years of age or older who are eligible
for medical | ||||||
23 | assistance under this Article, as follows: a baseline
mammogram | ||||||
24 | for women 35 to 39 years of age and an
annual mammogram for | ||||||
25 | women 40 years of age or older. All screenings
shall
include a | ||||||
26 | physical breast exam, instruction on self-examination and
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27 | information regarding the frequency of self-examination and | ||||||
28 | its value as a
preventative tool. As used in this Section, | ||||||
29 | "low-dose mammography" means
the x-ray examination of the | ||||||
30 | breast using equipment dedicated specifically
for mammography, | ||||||
31 | including the x-ray tube, filter, compression device,
image | ||||||
32 | receptor, and cassettes, with an average radiation exposure | ||||||
33 | delivery
of less than one rad mid-breast, with 2 views for each | ||||||
34 | breast.
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1 | Any medical or health care provider shall immediately | ||||||
2 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
3 | services and is suspected
of drug abuse or is addicted as | ||||||
4 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
5 | Act, referral to a local substance abuse treatment provider
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6 | licensed by the Department of Human Services or to a licensed
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7 | hospital which provides substance abuse treatment services. | ||||||
8 | The Department of
Public Aid shall assure coverage for the cost | ||||||
9 | of treatment of the drug abuse or
addiction for pregnant | ||||||
10 | recipients in accordance with the Illinois Medicaid
Program in | ||||||
11 | conjunction with the Department of Human Services.
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12 | All medical providers providing medical assistance to | ||||||
13 | pregnant women
under this Code shall receive information from | ||||||
14 | the Department on the
availability of services under the Drug | ||||||
15 | Free Families with a Future or any
comparable program providing | ||||||
16 | case management services for addicted women,
including | ||||||
17 | information on appropriate referrals for other social services
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18 | that may be needed by addicted women in addition to treatment | ||||||
19 | for addiction.
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20 | The Illinois Department, in cooperation with the | ||||||
21 | Departments of Human
Services (as successor to the Department | ||||||
22 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
23 | public awareness campaign, may
provide information concerning | ||||||
24 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
25 | health care, and other pertinent programs directed at
reducing | ||||||
26 | the number of drug-affected infants born to recipients of | ||||||
27 | medical
assistance.
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28 | Neither the Illinois Department of Public Aid nor the | ||||||
29 | Department of Human
Services shall sanction the recipient | ||||||
30 | solely on the basis of
her substance abuse.
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31 | The Illinois Department shall establish such regulations | ||||||
32 | governing
the dispensing of health services under this Article | ||||||
33 | as it shall deem
appropriate. The Department
should
seek the | ||||||
34 | advice of formal professional advisory committees appointed by
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1 | the Director of the Illinois Department for the purpose of | ||||||
2 | providing regular
advice on policy and administrative matters, | ||||||
3 | information dissemination and
educational activities for | ||||||
4 | medical and health care providers, and
consistency in | ||||||
5 | procedures to the Illinois Department.
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6 | The Illinois Department may develop and contract with | ||||||
7 | Partnerships of
medical providers to arrange medical services | ||||||
8 | for persons eligible under
Section 5-2 of this Code. | ||||||
9 | Implementation of this Section may be by
demonstration projects | ||||||
10 | in certain geographic areas. The Partnership shall
be | ||||||
11 | represented by a sponsor organization. The Department, by rule, | ||||||
12 | shall
develop qualifications for sponsors of Partnerships. | ||||||
13 | Nothing in this
Section shall be construed to require that the | ||||||
14 | sponsor organization be a
medical organization.
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15 | The sponsor must negotiate formal written contracts with | ||||||
16 | medical
providers for physician services, inpatient and | ||||||
17 | outpatient hospital care,
home health services, treatment for | ||||||
18 | alcoholism and substance abuse, and
other services determined | ||||||
19 | necessary by the Illinois Department by rule for
delivery by | ||||||
20 | Partnerships. Physician services must include prenatal and
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21 | obstetrical care. The Illinois Department shall reimburse | ||||||
22 | medical services
delivered by Partnership providers to clients | ||||||
23 | in target areas according to
provisions of this Article and the | ||||||
24 | Illinois Health Finance Reform Act,
except that:
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25 | (1) Physicians participating in a Partnership and | ||||||
26 | providing certain
services, which shall be determined by | ||||||
27 | the Illinois Department, to persons
in areas covered by the | ||||||
28 | Partnership may receive an additional surcharge
for such | ||||||
29 | services.
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30 | (2) The Department may elect to consider and negotiate | ||||||
31 | financial
incentives to encourage the development of | ||||||
32 | Partnerships and the efficient
delivery of medical care.
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33 | (3) Persons receiving medical services through | ||||||
34 | Partnerships may receive
medical and case management |
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1 | services above the level usually offered
through the | ||||||
2 | medical assistance program.
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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
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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.
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12 | Nothing in this Section shall limit the free choice of | ||||||
13 | practitioners,
hospitals, and other providers of medical | ||||||
14 | services by clients.
In order to ensure patient freedom of | ||||||
15 | choice, the Illinois Department shall
immediately promulgate | ||||||
16 | all rules and take all other necessary actions so that
provided | ||||||
17 | services may be accessed from therapeutically certified | ||||||
18 | optometrists
to the full extent of the Illinois Optometric | ||||||
19 | Practice Act of 1987 without
discriminating between service | ||||||
20 | providers.
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21 | The Department shall apply for a waiver from the United | ||||||
22 | States Health
Care Financing Administration to allow for the | ||||||
23 | implementation of
Partnerships under this Section.
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24 | The Illinois Department shall require health care | ||||||
25 | providers to maintain
records that document the medical care | ||||||
26 | and services provided to recipients
of Medical Assistance under | ||||||
27 | this Article. The Illinois Department shall
require health care | ||||||
28 | providers to make available, when authorized by the
patient, in | ||||||
29 | writing, the medical records in a timely fashion to other
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30 | health care providers who are treating or serving persons | ||||||
31 | eligible for
Medical Assistance under this Article. All | ||||||
32 | dispensers of medical services
shall be required to maintain | ||||||
33 | and retain business and professional records
sufficient to | ||||||
34 | fully and accurately document the nature, scope, details and
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1 | receipt of the health care provided to persons eligible for | ||||||
2 | medical
assistance under this Code, in accordance with | ||||||
3 | regulations promulgated by
the Illinois Department. The rules | ||||||
4 | and regulations shall require that proof
of the receipt of | ||||||
5 | prescription drugs, dentures, prosthetic devices and
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6 | eyeglasses by eligible persons under this Section accompany | ||||||
7 | each claim
for reimbursement submitted by the dispenser of such | ||||||
8 | medical services.
No such claims for reimbursement shall be | ||||||
9 | approved for payment by the Illinois
Department without such | ||||||
10 | proof of receipt, unless the Illinois Department
shall have put | ||||||
11 | into effect and shall be operating a system of post-payment
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12 | audit and review which shall, on a sampling basis, be deemed | ||||||
13 | adequate by
the Illinois Department to assure that such drugs, | ||||||
14 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
15 | is being made are actually being
received by eligible | ||||||
16 | recipients. Within 90 days after the effective date of
this | ||||||
17 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
18 | a
current list of acquisition costs for all prosthetic devices | ||||||
19 | and any
other items recognized as medical equipment and | ||||||
20 | supplies reimbursable under
this Article and shall update such | ||||||
21 | list on a quarterly basis, except that
the acquisition costs of | ||||||
22 | all prescription drugs shall be updated no
less frequently than | ||||||
23 | every 30 days as required by Section 5-5.12.
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24 | The rules and regulations of the Illinois Department shall | ||||||
25 | require
that a written statement including the required opinion | ||||||
26 | of a physician
shall accompany any claim for reimbursement for | ||||||
27 | abortions, or induced
miscarriages or premature births. This | ||||||
28 | statement shall indicate what
procedures were used in providing | ||||||
29 | such medical services.
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30 | The Illinois Department shall require all dispensers of | ||||||
31 | medical
services, other than an individual practitioner or | ||||||
32 | group of practitioners,
desiring to participate in the Medical | ||||||
33 | Assistance program
established under this Article to disclose | ||||||
34 | all financial, beneficial,
ownership, equity, surety or other |
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1 | interests in any and all firms,
corporations, partnerships, | ||||||
2 | associations, business enterprises, joint
ventures, agencies, | ||||||
3 | institutions or other legal entities providing any
form of | ||||||
4 | health care services in this State under this Article.
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5 | The Illinois Department may require that all dispensers of | ||||||
6 | medical
services desiring to participate in the medical | ||||||
7 | assistance program
established under this Article disclose, | ||||||
8 | under such terms and conditions as
the Illinois Department may | ||||||
9 | by rule establish, all inquiries from clients
and attorneys | ||||||
10 | regarding medical bills paid by the Illinois Department, which
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11 | inquiries could indicate potential existence of claims or liens | ||||||
12 | for the
Illinois Department.
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13 | Enrollment of a vendor that provides non-emergency medical | ||||||
14 | transportation,
defined by the Department by rule,
shall be
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15 | conditional for 180 days. During that time, the Department of | ||||||
16 | Public Aid may
terminate the vendor's eligibility to | ||||||
17 | participate in the medical assistance
program without cause. | ||||||
18 | That termination of eligibility is not subject to the
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19 | Department's hearing process.
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20 | The Illinois Department shall establish policies, | ||||||
21 | procedures,
standards and criteria by rule for the acquisition, | ||||||
22 | repair and replacement
of orthotic and prosthetic devices and | ||||||
23 | durable medical equipment. Such
rules shall provide, but not be | ||||||
24 | limited to, the following services: (1)
immediate repair or | ||||||
25 | replacement of such devices by recipients without
medical | ||||||
26 | authorization; and (2) rental, lease, purchase or | ||||||
27 | lease-purchase of
durable medical equipment in a | ||||||
28 | cost-effective manner, taking into
consideration the | ||||||
29 | recipient's medical prognosis, the extent of the
recipient's | ||||||
30 | needs, and the requirements and costs for maintaining such
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31 | equipment. Such rules shall enable a recipient to temporarily | ||||||
32 | acquire and
use alternative or substitute devices or equipment | ||||||
33 | pending repairs or
replacements of any device or equipment | ||||||
34 | previously authorized for such
recipient by the Department. |
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1 | Rules under clause (2) above shall not provide
for purchase or | ||||||
2 | lease-purchase of durable medical equipment or supplies
used | ||||||
3 | for the purpose of oxygen delivery and respiratory care.
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4 | The Department shall execute, relative to the nursing home | ||||||
5 | prescreening
project, written inter-agency agreements with the | ||||||
6 | Department of Human
Services and the Department on Aging, to | ||||||
7 | effect the following: (i) intake
procedures and common | ||||||
8 | eligibility criteria for those persons who are receiving
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9 | non-institutional services; and (ii) the establishment and | ||||||
10 | development of
non-institutional services in areas of the State | ||||||
11 | where they are not currently
available or are undeveloped.
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12 | The Illinois Department shall develop and operate, in | ||||||
13 | cooperation
with other State Departments and agencies and in | ||||||
14 | compliance with
applicable federal laws and regulations, | ||||||
15 | appropriate and effective
systems of health care evaluation and | ||||||
16 | programs for monitoring of
utilization of health care services | ||||||
17 | and facilities, as it affects
persons eligible for medical | ||||||
18 | assistance under this Code.
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19 | The Illinois Department shall report annually to the | ||||||
20 | General Assembly,
no later than the second Friday in April of | ||||||
21 | 1979 and each year
thereafter, in regard to:
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22 | (a) actual statistics and trends in utilization of | ||||||
23 | medical services by
public aid recipients;
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24 | (b) actual statistics and trends in the provision of | ||||||
25 | the various medical
services by medical vendors;
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26 | (c) current rate structures and proposed changes in | ||||||
27 | those rate structures
for the various medical vendors; and
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28 | (d) efforts at utilization review and control by the | ||||||
29 | Illinois Department.
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30 | The period covered by each report shall be the 3 years | ||||||
31 | ending on the June
30 prior to the report. The report shall | ||||||
32 | include suggested legislation
for consideration by the General | ||||||
33 | Assembly. The filing of one copy of the
report with the | ||||||
34 | Speaker, one copy with the Minority Leader and one copy
with |
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1 | the Clerk of the House of Representatives, one copy with the | ||||||
2 | President,
one copy with the Minority Leader and one copy with | ||||||
3 | the Secretary of the
Senate, one copy with the Legislative | ||||||
4 | Research Unit, and such additional
copies
with the State | ||||||
5 | Government Report Distribution Center for the General
Assembly | ||||||
6 | as is required under paragraph (t) of Section 7 of the State
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7 | Library Act shall be deemed sufficient to comply with this | ||||||
8 | Section.
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9 | (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02; | ||||||
10 | 92-789, eff. 8-6-02; 93-632, eff. 2-1-04.)".
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