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1 | AN ACT concerning insurance.
| ||||||||||||||||||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| ||||||||||||||||||||||||||||||||||||||||
3 | represented in the General Assembly:
| ||||||||||||||||||||||||||||||||||||||||
4 | Section 5. The State Employees Group Insurance Act of 1971 | ||||||||||||||||||||||||||||||||||||||||
5 | is amended by changing Section 6.11 as follows:
| ||||||||||||||||||||||||||||||||||||||||
6 | (5 ILCS 375/6.11)
| ||||||||||||||||||||||||||||||||||||||||
7 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||||||||||||||||||||||||||||||||||||
8 | Code
requirements. The program of health
benefits shall provide | ||||||||||||||||||||||||||||||||||||||||
9 | the post-mastectomy care benefits required to be covered
by a | ||||||||||||||||||||||||||||||||||||||||
10 | policy of accident and health insurance under Section 356t of | ||||||||||||||||||||||||||||||||||||||||
11 | the Illinois
Insurance Code. The program of health benefits | ||||||||||||||||||||||||||||||||||||||||
12 | shall provide the coverage
required under Sections 356u, 356w, | ||||||||||||||||||||||||||||||||||||||||
13 | 356x, 356z.2, and 356z.4 , and 356z.6 of the
Illinois Insurance | ||||||||||||||||||||||||||||||||||||||||
14 | Code.
The program of health benefits must comply with Section | ||||||||||||||||||||||||||||||||||||||||
15 | 155.37 of the
Illinois Insurance Code.
| ||||||||||||||||||||||||||||||||||||||||
16 | (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03; | ||||||||||||||||||||||||||||||||||||||||
17 | 93-102, eff. 1-1-04.)
| ||||||||||||||||||||||||||||||||||||||||
18 | Section 10. The Counties Code is amended by changing | ||||||||||||||||||||||||||||||||||||||||
19 | Section 5-1069.3 as follows:
| ||||||||||||||||||||||||||||||||||||||||
20 | (55 ILCS 5/5-1069.3)
| ||||||||||||||||||||||||||||||||||||||||
21 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||||||||||||||||||||||||||||||||||||
22 | including a home
rule
county, is a self-insurer for purposes of | ||||||||||||||||||||||||||||||||||||||||
23 | providing health insurance coverage
for its employees, the | ||||||||||||||||||||||||||||||||||||||||
24 | coverage shall include coverage for the post-mastectomy
care | ||||||||||||||||||||||||||||||||||||||||
25 | benefits required to be covered by a policy of accident and | ||||||||||||||||||||||||||||||||||||||||
26 | health
insurance under Section 356t and the coverage required | ||||||||||||||||||||||||||||||||||||||||
27 | under Sections 356u, 356w, and 356x , and 356z.6 of
the Illinois | ||||||||||||||||||||||||||||||||||||||||
28 | Insurance Code. The requirement that health benefits be covered
| ||||||||||||||||||||||||||||||||||||||||
29 | as provided in this Section is an
exclusive power and function | ||||||||||||||||||||||||||||||||||||||||
30 | of the State and is a denial and limitation under
Article VII, |
| |||||||
| |||||||
1 | Section 6, subsection (h) of the Illinois Constitution. A home
| ||||||
2 | rule county to which this Section applies must comply with | ||||||
3 | every provision of
this Section.
| ||||||
4 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
| ||||||
5 | Section 15. The Illinois Municipal Code is amended by | ||||||
6 | changing Section 10-4-2.3 as follows:
| ||||||
7 | (65 ILCS 5/10-4-2.3)
| ||||||
8 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
9 | municipality, including a
home rule municipality, is a | ||||||
10 | self-insurer for purposes of providing health
insurance | ||||||
11 | coverage for its employees, the coverage shall include coverage | ||||||
12 | for
the post-mastectomy care benefits required to be covered by | ||||||
13 | a policy of
accident and health insurance under Section 356t | ||||||
14 | and the coverage required
under Sections 356u, 356w, and 356x , | ||||||
15 | and 356z.6 of the Illinois
Insurance
Code. The requirement that | ||||||
16 | health
benefits be covered as provided in this is an exclusive | ||||||
17 | power and function of
the State and is a denial and limitation | ||||||
18 | under Article VII, Section 6,
subsection (h) of the Illinois | ||||||
19 | Constitution. A home rule municipality to which
this Section | ||||||
20 | applies must comply with every provision of this Section.
| ||||||
21 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
| ||||||
22 | Section 20. The School Code is amended by changing Section | ||||||
23 | 10-22.3f as follows:
| ||||||
24 | (105 ILCS 5/10-22.3f)
| ||||||
25 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
26 | protection and
benefits
for employees shall provide the | ||||||
27 | post-mastectomy care benefits required to be
covered by a | ||||||
28 | policy of accident and health insurance under Section 356t and | ||||||
29 | the
coverage required under Sections 356u, 356w, and 356x , and | ||||||
30 | 356z.6 of
the
Illinois Insurance Code.
| ||||||
31 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
|
| |||||||
| |||||||
1 | Section 25. The Illinois Insurance Code is amended by | ||||||
2 | adding Section 356z.6 as follows: | ||||||
3 | (215 ILCS 5/356z.6 new)
| ||||||
4 | Sec. 356z.6. Athletic Trainers. A group or individual | ||||||
5 | policy of accident and health insurance or managed care plan | ||||||
6 | amended, delivered, issued, or renewed after the effective date | ||||||
7 | of this amendatory Act of the 93rd General Assembly must | ||||||
8 | provide coverage for services rendered by a licensed athletic | ||||||
9 | trainer in accordance with the Illinois Athletic Trainers | ||||||
10 | Practice Act if those services are ordered by a physician | ||||||
11 | licensed to practice medicine in all of its branches.
| ||||||
12 | Section 30. The Comprehensive Health Insurance Plan Act is | ||||||
13 | amended by changing Section 8 as follows:
| ||||||
14 | (215 ILCS 105/8) (from Ch. 73, par. 1308)
| ||||||
15 | Sec. 8. Minimum benefits.
| ||||||
16 | a. Availability. The Plan shall offer in an
annually | ||||||
17 | renewable policy major medical expense coverage to every | ||||||
18 | eligible
person who is not eligible for Medicare. Major medical
| ||||||
19 | expense coverage offered by the Plan shall pay an eligible | ||||||
20 | person's
covered expenses, subject to limit on the deductible | ||||||
21 | and coinsurance
payments authorized under paragraph (4) of | ||||||
22 | subsection d of this Section,
up to a lifetime benefit limit of | ||||||
23 | $1,000,000 per covered
individual. The maximum
limit under this | ||||||
24 | subsection shall not be altered by the Board, and no
actuarial | ||||||
25 | equivalent benefit may be substituted by the Board.
Any person | ||||||
26 | who otherwise would qualify for coverage under the Plan, but
is | ||||||
27 | excluded because he or she is eligible for Medicare, shall be | ||||||
28 | eligible
for any separate Medicare supplement policy or | ||||||
29 | policies which the Board may
offer.
| ||||||
30 | b. Outline of benefits. Covered expenses shall be
limited | ||||||
31 | to the usual and customary charge, including negotiated fees, | ||||||
32 | in
the locality for the following services and articles when | ||||||
33 | prescribed by a
physician and determined by the Plan to be |
| |||||||
| |||||||
1 | medically necessary
for the following areas of services, | ||||||
2 | subject to such separate deductibles,
co-payments, exclusions, | ||||||
3 | and other limitations on benefits as the Board shall
establish | ||||||
4 | and approve, and the other provisions of this Section:
| ||||||
5 | (1) Hospital
services, except that
any services | ||||||
6 | provided by a hospital that is
located more than 75 miles | ||||||
7 | outside the State of Illinois shall be covered only
for a | ||||||
8 | maximum of 45 days in any calendar year. With respect to | ||||||
9 | covered
expenses incurred during any calendar year ending | ||||||
10 | on or after December 31,
1999, inpatient hospitalization of | ||||||
11 | an eligible person for the
treatment of mental illness at a | ||||||
12 | hospital located within the State of
Illinois
shall be | ||||||
13 | subject to the same terms and conditions as for any other | ||||||
14 | illness.
| ||||||
15 | (2) Professional services for the diagnosis or | ||||||
16 | treatment of injuries,
illnesses or conditions, other than | ||||||
17 | dental and mental
and
nervous disorders as
described in | ||||||
18 | paragraph (17), which are rendered by a physician, or by | ||||||
19 | other
licensed professionals at the physician's
direction. | ||||||
20 | This includes reconstruction of the breast on which a | ||||||
21 | mastectomy
was performed; surgery and reconstruction of | ||||||
22 | the other breast to produce a
symmetrical appearance; and | ||||||
23 | prostheses and treatment of physical complications
at all | ||||||
24 | stages of the mastectomy, including lymphedemas.
| ||||||
25 | (2.5) Professional services provided by a physician to | ||||||
26 | children under
the age of 16 years for physical | ||||||
27 | examinations and age appropriate
immunizations ordered by | ||||||
28 | a physician licensed to practice medicine in all its
| ||||||
29 | branches.
| ||||||
30 | (3) (Blank).
| ||||||
31 | (4) Outpatient prescription drugs that by law require
a
| ||||||
32 | prescription
written by a physician licensed to practice | ||||||
33 | medicine in all its branches
subject to such separate | ||||||
34 | deductible, copayment, and other limitations or
| ||||||
35 | restrictions as the Board shall approve, including the use | ||||||
36 | of a prescription
drug card or any other program, or both.
|
| |||||||
| |||||||
1 | (5) Skilled nursing services of a licensed
skilled
| ||||||
2 | nursing facility for not more than 120 days during a policy | ||||||
3 | year.
| ||||||
4 | (6) Services of a home health agency in accord with a | ||||||
5 | home health care
plan, up to a maximum of 270 visits per | ||||||
6 | year.
| ||||||
7 | (7) Services of a licensed hospice for not more than | ||||||
8 | 180
days during a policy year.
| ||||||
9 | (8) Use of radium or other radioactive materials.
| ||||||
10 | (9) Oxygen.
| ||||||
11 | (10) Anesthetics.
| ||||||
12 | (11) Orthoses and prostheses other than dental.
| ||||||
13 | (12) Rental or purchase in accordance with Board | ||||||
14 | policies or
procedures of durable medical equipment, other | ||||||
15 | than eyeglasses or hearing
aids, for which there is no | ||||||
16 | personal use in the absence of the condition
for which it | ||||||
17 | is prescribed.
| ||||||
18 | (13) Diagnostic x-rays and laboratory tests.
| ||||||
19 | (14) Oral surgery (i) for excision of partially or | ||||||
20 | completely unerupted
impacted teeth when not performed in
| ||||||
21 | connection with the routine extraction or repair of teeth; | ||||||
22 | (ii) for excision
of tumors or cysts of the jaws, cheeks, | ||||||
23 | lips, tongue, and roof and floor of the
mouth; (iii) | ||||||
24 | required for correction of cleft lip and palate
and
other | ||||||
25 | craniofacial and maxillofacial birth defects; or (iv) for | ||||||
26 | treatment of injuries to natural teeth or a fractured jaw | ||||||
27 | due to an accident.
| ||||||
28 | (15) Physical, speech, and functional occupational | ||||||
29 | therapy as
medically necessary and provided by appropriate | ||||||
30 | licensed professionals.
| ||||||
31 | (16) Emergency and other medically necessary | ||||||
32 | transportation provided
by a licensed ambulance service to | ||||||
33 | the
nearest health care facility qualified to treat a | ||||||
34 | covered
illness, injury, or condition, subject to the | ||||||
35 | provisions of the
Emergency Medical Systems (EMS) Act.
| ||||||
36 | (17) Outpatient services for
diagnosis and
treatment |
| |||||||
| |||||||
1 | of mental and nervous disorders provided that a
covered | ||||||
2 | person shall be required to make a copayment not to exceed | ||||||
3 | 50% and that
the Plan's payment shall not exceed such | ||||||
4 | amounts as are established by the
Board.
| ||||||
5 | (18) Human organ or tissue transplants specified by the | ||||||
6 | Board that
are performed at a hospital designated by the | ||||||
7 | Board as a participating
transplant center for that | ||||||
8 | specific organ or tissue transplant.
| ||||||
9 | (19) Naprapathic services, as appropriate, provided by | ||||||
10 | a licensed
naprapathic practitioner.
| ||||||
11 | (20) Services rendered by a licensed athletic trainer | ||||||
12 | in accordance with the Illinois Athletic Trainers Practice | ||||||
13 | Act if those services are ordered by a physician licensed | ||||||
14 | to practice medicine in all of its branches.
| ||||||
15 | c. Exclusions. Covered expenses of the Plan shall not
| ||||||
16 | include the following:
| ||||||
17 | (1) Any charge for treatment for cosmetic purposes | ||||||
18 | other than for
reconstructive surgery when the service is | ||||||
19 | incidental to or follows
surgery resulting from injury, | ||||||
20 | sickness or other diseases of the involved
part or surgery | ||||||
21 | for the repair or treatment of a congenital bodily defect
| ||||||
22 | to restore normal bodily functions.
| ||||||
23 | (2) Any charge for care that is primarily for rest,
| ||||||
24 | custodial, educational, or domiciliary purposes.
| ||||||
25 | (3) Any charge for services in a private room to the | ||||||
26 | extent it is in
excess of the institution's charge for its | ||||||
27 | most common semiprivate room,
unless a private room is | ||||||
28 | prescribed as medically necessary by a physician.
| ||||||
29 | (4) That part of any charge for room and board or for | ||||||
30 | services
rendered or articles prescribed by a physician, | ||||||
31 | dentist, or other health
care personnel that exceeds the | ||||||
32 | reasonable and customary charge in the
locality or for any | ||||||
33 | services or supplies not medically necessary for the
| ||||||
34 | diagnosed injury or illness.
| ||||||
35 | (5) Any charge for services or articles the provision | ||||||
36 | of which is not
within the scope of licensure of the |
| |||||||
| |||||||
1 | institution or individual
providing the services or | ||||||
2 | articles.
| ||||||
3 | (6) Any expense incurred prior to the effective date of | ||||||
4 | coverage by the
Plan for the person on whose behalf the | ||||||
5 | expense is incurred.
| ||||||
6 | (7) Dental care, dental surgery, dental treatment, any | ||||||
7 | other dental
procedure involving the teeth or | ||||||
8 | periodontium, or any dental appliances,
including crowns, | ||||||
9 | bridges, implants, or partial or complete dentures,
except
| ||||||
10 | as specifically provided in paragraph
(14) of subsection b | ||||||
11 | of this Section.
| ||||||
12 | (8) Eyeglasses, contact lenses, hearing aids or their | ||||||
13 | fitting.
| ||||||
14 | (9) Illness or injury due to acts of war.
| ||||||
15 | (10) Services of blood donors and any fee for failure | ||||||
16 | to replace the
first 3 pints of blood
provided to a covered | ||||||
17 | person each policy year.
| ||||||
18 | (11) Personal supplies or services provided by a | ||||||
19 | hospital or nursing
home, or any other nonmedical or | ||||||
20 | nonprescribed supply or service.
| ||||||
21 | (12) Routine maternity charges for a pregnancy, except | ||||||
22 | where added as
optional coverage with payment of an | ||||||
23 | additional premium for pregnancy
resulting from conception | ||||||
24 | occurring after the effective date of the
optional | ||||||
25 | coverage.
| ||||||
26 | (13) (Blank).
| ||||||
27 | (14) Any expense or charge for services, drugs, or | ||||||
28 | supplies that are:
(i) not provided in accord with | ||||||
29 | generally accepted standards of current
medical practice; | ||||||
30 | (ii) for procedures, treatments, equipment, transplants,
| ||||||
31 | or implants, any of which are investigational, | ||||||
32 | experimental, or for
research purposes; (iii) | ||||||
33 | investigative and not proven safe and effective;
or (iv) | ||||||
34 | for, or resulting from, a gender
transformation operation.
| ||||||
35 | (15) Any expense or charge for routine physical | ||||||
36 | examinations or tests
except as provided in item (2.5) of |
| |||||||
| |||||||
1 | subsection b of this Section.
| ||||||
2 | (16) Any expense for which a charge is not made in the | ||||||
3 | absence of
insurance or for which there is no legal | ||||||
4 | obligation on the part of the
patient to pay.
| ||||||
5 | (17) Any expense incurred for benefits provided under | ||||||
6 | the laws of the
United States and this State, including | ||||||
7 | Medicare, Medicaid, and
other
medical assistance, maternal | ||||||
8 | and child health services and any other program
that is | ||||||
9 | administered or funded by the Department of Human Services, | ||||||
10 | Department
of Public Aid, or Department of Public Health, | ||||||
11 | military service-connected
disability payments, medical
| ||||||
12 | services provided for members of the armed forces and their | ||||||
13 | dependents or
employees of the armed forces of the United | ||||||
14 | States, and medical services
financed on behalf of all | ||||||
15 | citizens by the United States.
| ||||||
16 | (18) Any expense or charge for in vitro fertilization, | ||||||
17 | artificial
insemination, or any other artificial means | ||||||
18 | used to cause pregnancy.
| ||||||
19 | (19) Any expense or charge for oral contraceptives used | ||||||
20 | for birth
control or any other temporary birth control | ||||||
21 | measures.
| ||||||
22 | (20) Any expense or charge for sterilization or | ||||||
23 | sterilization reversals.
| ||||||
24 | (21) Any expense or charge for weight loss programs, | ||||||
25 | exercise
equipment, or treatment of obesity, except when | ||||||
26 | certified by a physician as
morbid obesity (at least 2 | ||||||
27 | times normal body weight).
| ||||||
28 | (22) Any expense or charge for acupuncture treatment | ||||||
29 | unless used as an
anesthetic agent for a covered surgery.
| ||||||
30 | (23) Any expense or charge for or related to organ or | ||||||
31 | tissue
transplants other than those performed at a hospital | ||||||
32 | with a Board approved
organ transplant program that has | ||||||
33 | been designated by the Board as a
preferred or exclusive | ||||||
34 | provider organization for that specific organ or tissue
| ||||||
35 | transplant.
| ||||||
36 | (24) Any expense or charge for procedures, treatments, |
| |||||||
| |||||||
1 | equipment, or
services that are provided in special | ||||||
2 | settings for research purposes or in
a controlled | ||||||
3 | environment, are being studied for safety, efficiency, and
| ||||||
4 | effectiveness, and are awaiting endorsement by the | ||||||
5 | appropriate national
medical speciality college for | ||||||
6 | general use within the medical community.
| ||||||
7 | d. Deductibles and coinsurance.
| ||||||
8 | The Plan coverage defined in Section 6 shall provide for a | ||||||
9 | choice
of
deductibles per individual as authorized by the | ||||||
10 | Board. If 2 individual members
of the same family
household, | ||||||
11 | who are both covered persons under the Plan, satisfy the
same | ||||||
12 | applicable deductibles, no other member of that family who is
| ||||||
13 | also a covered person under the Plan shall be
required to
meet | ||||||
14 | any deductibles for the balance of that calendar year. The
| ||||||
15 | deductibles must be applied first to the authorized amount of | ||||||
16 | covered expenses
incurred by the
covered person. A mandatory | ||||||
17 | coinsurance requirement shall be imposed at
the rate authorized | ||||||
18 | by the Board in excess of the mandatory
deductible, the | ||||||
19 | coinsurance
in the aggregate not to exceed such amounts as are | ||||||
20 | authorized by the Board
per annum. At its discretion the Board | ||||||
21 | may, however, offer catastrophic
coverages or other policies | ||||||
22 | that provide for larger deductibles with or
without coinsurance | ||||||
23 | requirements. The deductibles and coinsurance
factors may be | ||||||
24 | adjusted annually according to the Medical Component of the
| ||||||
25 | Consumer Price Index.
| ||||||
26 | e. Scope of coverage.
| ||||||
27 | (1) In approving any of the benefit plans to be offered | ||||||
28 | by the Plan, the
Board shall establish such benefit levels, | ||||||
29 | deductibles, coinsurance factors,
exclusions, and | ||||||
30 | limitations as it may deem appropriate and that it believes | ||||||
31 | to
be generally reflective of and commensurate with health | ||||||
32 | insurance coverage that
is provided in the individual | ||||||
33 | market in this State.
| ||||||
34 | (2) The benefit plans approved by the Board may also | ||||||
35 | provide for and
employ
various cost containment measures | ||||||
36 | and other requirements including, but not
limited to, |
| |||||||
| |||||||
1 | preadmission certification, prior approval, second | ||||||
2 | surgical
opinions, concurrent utilization review programs, | ||||||
3 | individual case management,
preferred provider | ||||||
4 | organizations, health maintenance organizations, and other
| ||||||
5 | cost effective arrangements for paying for covered | ||||||
6 | expenses.
| ||||||
7 | f. Preexisting conditions.
| ||||||
8 | (1) Except for federally eligible individuals | ||||||
9 | qualifying for Plan
coverage under Section 15 of this Act
| ||||||
10 | or eligible persons who qualify
for the waiver authorized | ||||||
11 | in paragraph (3) of this subsection,
plan coverage shall | ||||||
12 | exclude charges or expenses incurred
during the first 6 | ||||||
13 | months following the effective date of coverage as to
any | ||||||
14 | condition for which medical advice, care or treatment was | ||||||
15 | recommended or
received during the 6 month period
| ||||||
16 | immediately preceding the effective date
of coverage.
| ||||||
17 | (2) (Blank).
| ||||||
18 | (3) Waiver: The preexisting condition exclusions as | ||||||
19 | set forth in
paragraph (1) of this subsection shall be | ||||||
20 | waived to the extent to which
the eligible person (a) has | ||||||
21 | satisfied similar exclusions under any prior
individual | ||||||
22 | health insurance policy that was involuntarily terminated
| ||||||
23 | because of the insolvency of the issuer of the policy and | ||||||
24 | (b) has applied
for Plan coverage within 90 days following | ||||||
25 | the involuntary
termination of that individual health | ||||||
26 | insurance coverage.
| ||||||
27 | g. Other sources primary; nonduplication of benefits.
| ||||||
28 | (1) The Plan shall be the last payor of benefits | ||||||
29 | whenever any other
benefit or source of third party payment | ||||||
30 | is available. Subject to the
provisions of subsection e of | ||||||
31 | Section 7, benefits
otherwise payable under Plan coverage | ||||||
32 | shall be reduced by
all amounts paid or payable by Medicare | ||||||
33 | or any other government program
or through any health | ||||||
34 | insurance coverage or group health plan,
whether by | ||||||
35 | insurance, reimbursement, or otherwise, or through
any | ||||||
36 | third party liability,
settlement, judgment, or award,
|
| |||||||
| |||||||
1 | regardless of the date of the settlement, judgment, or | ||||||
2 | award, whether the
settlement, judgment, or award is in the | ||||||
3 | form of a contract, agreement, or
trust on behalf of a | ||||||
4 | minor or otherwise and whether the settlement,
judgment, or | ||||||
5 | award is payable to the covered person, his or her | ||||||
6 | dependent,
estate, personal representative, or guardian in | ||||||
7 | a lump sum or over time,
and by all hospital or medical | ||||||
8 | expense benefits
paid or payable under any worker's | ||||||
9 | compensation coverage, automobile
medical payment, or | ||||||
10 | liability insurance, whether provided on the basis of
fault | ||||||
11 | or nonfault, and by any hospital or medical benefits paid | ||||||
12 | or payable
under or provided pursuant to any State or | ||||||
13 | federal law or program.
| ||||||
14 | (2) The Plan shall have a cause of action against any
| ||||||
15 | covered person or any other person or entity for
the | ||||||
16 | recovery of any amount paid to the extent
the amount was | ||||||
17 | for treatment, services, or supplies not covered in this
| ||||||
18 | Section or in excess of benefits as set forth in this | ||||||
19 | Section.
| ||||||
20 | (3) Whenever benefits are due from the Plan because of | ||||||
21 | sickness or
an injury to a covered person resulting from a | ||||||
22 | third party's wrongful act
or negligence and the covered | ||||||
23 | person has recovered or may recover damages
from a third | ||||||
24 | party or its insurer, the Plan shall have the right to | ||||||
25 | reduce
benefits or to refuse to pay benefits that otherwise | ||||||
26 | may be payable by the
amount of damages that the covered | ||||||
27 | person has recovered or may recover
regardless of the date | ||||||
28 | of the sickness or injury or the date of any
settlement, | ||||||
29 | judgment, or award resulting from that sickness or injury.
| ||||||
30 | During the pendency of any action or claim that is | ||||||
31 | brought by or on
behalf of a covered person against a third | ||||||
32 | party or its insurer, any
benefits that would otherwise be | ||||||
33 | payable except for the provisions of this
paragraph (3) | ||||||
34 | shall be paid if payment by or for the third party has not | ||||||
35 | yet
been made and the covered person or, if incapable, that | ||||||
36 | person's legal
representative agrees in writing to pay back |
| |||||||
| |||||||
1 | promptly the benefits paid as
a result of the sickness or | ||||||
2 | injury to the extent of any future payments
made by or for | ||||||
3 | the third party for the sickness or injury. This agreement
| ||||||
4 | is to apply whether or not liability for the payments is | ||||||
5 | established or
admitted by the third party or whether those | ||||||
6 | payments are itemized.
| ||||||
7 | Any amounts due the plan to repay benefits may be | ||||||
8 | deducted from other
benefits payable by the Plan after | ||||||
9 | payments by or for the third party are made.
| ||||||
10 | (4) Benefits due from the Plan may be reduced or | ||||||
11 | refused as an offset
against any amount otherwise | ||||||
12 | recoverable under this Section.
| ||||||
13 | h. Right of subrogation; recoveries.
| ||||||
14 | (1) Whenever the Plan has paid benefits because of | ||||||
15 | sickness or an
injury to any covered person resulting from | ||||||
16 | a third party's wrongful act or
negligence, or for which an | ||||||
17 | insurer is liable in accordance with the
provisions of any | ||||||
18 | policy of insurance, and the covered person has recovered
| ||||||
19 | or may recover damages from a third party that is liable | ||||||
20 | for the damages,
the Plan shall have the right to recover | ||||||
21 | the benefits it paid from any
amounts that the covered | ||||||
22 | person has received or may receive regardless of
the date | ||||||
23 | of the sickness or injury or the date of any settlement, | ||||||
24 | judgment,
or award resulting from that sickness
or injury. | ||||||
25 | The Plan shall be subrogated to any right of recovery the
| ||||||
26 | covered person may have under the terms of any private or | ||||||
27 | public health
care coverage or liability coverage, | ||||||
28 | including coverage under the Workers'
Compensation Act or | ||||||
29 | the Workers' Occupational Diseases Act, without the
| ||||||
30 | necessity of assignment of claim or other authorization to | ||||||
31 | secure the right
of recovery. To enforce its subrogation | ||||||
32 | right, the Plan may (i) intervene
or join in an action or | ||||||
33 | proceeding brought by the covered person or his
personal | ||||||
34 | representative, including his guardian, conservator, | ||||||
35 | estate,
dependents, or survivors,
against any third party | ||||||
36 | or the third party's insurer that may be liable or
(ii) |
| |||||||
| |||||||
1 | institute and prosecute legal proceedings against any | ||||||
2 | third party or
the third party's insurer that may be liable | ||||||
3 | for the sickness or injury in
an appropriate court either | ||||||
4 | in the name of the Plan or in the name of the
covered | ||||||
5 | person or his personal representative, including his | ||||||
6 | guardian,
conservator, estate, dependents, or survivors.
| ||||||
7 | (2) If any action or claim is brought by or on behalf | ||||||
8 | of a covered
person against a third party or the third | ||||||
9 | party's insurer, the covered
person or his personal | ||||||
10 | representative, including his guardian,
conservator, | ||||||
11 | estate, dependents, or survivors, shall notify the Plan by
| ||||||
12 | personal service or registered mail of the action or claim | ||||||
13 | and of the name
of the court in which the action or claim | ||||||
14 | is brought, filing proof thereof
in the action or claim. | ||||||
15 | The Plan may, at any time thereafter, join in the
action or | ||||||
16 | claim upon its motion so that all orders of court after | ||||||
17 | hearing
and judgment shall be made for its protection. No | ||||||
18 | release or settlement of
a claim for damages and no | ||||||
19 | satisfaction of judgment in the action shall be
valid | ||||||
20 | without the written consent of the Plan to the extent of | ||||||
21 | its interest
in the settlement or judgment and of the | ||||||
22 | covered person or his
personal representative.
| ||||||
23 | (3) In the event that the covered person or his | ||||||
24 | personal
representative fails to institute a proceeding | ||||||
25 | against any appropriate
third party before the fifth month | ||||||
26 | before the action would be barred, the
Plan may, in its own | ||||||
27 | name or in the name of the covered person or personal
| ||||||
28 | representative, commence a proceeding against any | ||||||
29 | appropriate third party
for the recovery of damages on | ||||||
30 | account of any sickness, injury, or death to
the covered | ||||||
31 | person. The covered person shall cooperate in doing what is
| ||||||
32 | reasonably necessary to assist the Plan in any recovery and | ||||||
33 | shall not take
any action that would prejudice the Plan's | ||||||
34 | right to recovery. The Plan
shall pay to the covered person | ||||||
35 | or his personal representative all sums
collected from any | ||||||
36 | third party by judgment or otherwise in excess of
amounts |
| |||||||
| |||||||
1 | paid in benefits under the Plan and amounts paid or to be | ||||||
2 | paid as
costs, attorneys fees, and reasonable expenses | ||||||
3 | incurred by the Plan in
making the collection or enforcing | ||||||
4 | the judgment.
| ||||||
5 | (4) In the event that a covered person or his personal | ||||||
6 | representative,
including his guardian, conservator, | ||||||
7 | estate, dependents, or survivors,
recovers damages from a | ||||||
8 | third party for sickness or injury caused to the
covered | ||||||
9 | person, the covered person or the personal representative | ||||||
10 | shall pay to the Plan
from the damages recovered the amount | ||||||
11 | of benefits paid or to be paid on
behalf of the covered | ||||||
12 | person.
| ||||||
13 | (5) When the action or claim is brought by the covered | ||||||
14 | person alone
and the covered person incurs a personal | ||||||
15 | liability to pay attorney's fees
and costs of litigation, | ||||||
16 | the Plan's claim for reimbursement of the benefits
provided | ||||||
17 | to the covered person shall be the full amount of benefits | ||||||
18 | paid to
or on behalf of the covered person under this Act | ||||||
19 | less a pro rata share
that represents the Plan's reasonable | ||||||
20 | share of attorney's fees paid by the
covered person and | ||||||
21 | that portion of the cost of litigation expenses
determined | ||||||
22 | by multiplying by the ratio of the full amount of the
| ||||||
23 | expenditures to the full amount of the judgement, award, or | ||||||
24 | settlement.
| ||||||
25 | (6) In the event of judgment or award in a suit or | ||||||
26 | claim against a
third party or insurer, the court shall | ||||||
27 | first order paid from any judgement
or award the reasonable | ||||||
28 | litigation expenses incurred in preparation and
| ||||||
29 | prosecution of the action or claim, together with | ||||||
30 | reasonable attorney's
fees. After payment of those | ||||||
31 | expenses and attorney's fees, the court shall
apply out of | ||||||
32 | the balance of the judgment or award an amount sufficient | ||||||
33 | to
reimburse the Plan the full amount of benefits paid on | ||||||
34 | behalf of the
covered person under this Act, provided the | ||||||
35 | court may reduce and apportion
the Plan's portion of the | ||||||
36 | judgement proportionate to the recovery of the
covered |
| |||||||
| |||||||
1 | person. The burden of producing evidence sufficient to | ||||||
2 | support the
exercise by the court of its discretion to | ||||||
3 | reduce
the amount of a proven charge sought to be enforced | ||||||
4 | against the recovery
shall rest with the party seeking the | ||||||
5 | reduction. The court may consider
the nature and extent of | ||||||
6 | the injury, economic and non-economic loss,
settlement | ||||||
7 | offers, comparative negligence as it applies to the case at
| ||||||
8 | hand, hospital costs, physician costs, and all other | ||||||
9 | appropriate costs.
The Plan shall pay its pro rata share of | ||||||
10 | the attorney fees based on the
Plan's recovery as it | ||||||
11 | compares to the total judgment. Any reimbursement
rights of | ||||||
12 | the Plan shall take priority over all other liens and | ||||||
13 | charges
existing under the laws of this State with the | ||||||
14 | exception of any attorney
liens filed under the Attorneys | ||||||
15 | Lien Act.
| ||||||
16 | (7) The Plan may compromise or settle and release any | ||||||
17 | claim for
benefits provided under this Act or waive any | ||||||
18 | claims for benefits, in whole
or in part, for the | ||||||
19 | convenience of the Plan or if the Plan determines that
| ||||||
20 | collection would result in undue hardship upon the covered | ||||||
21 | person.
| ||||||
22 | (Source: P.A. 91-639, eff. 8-20-99; 91-735, eff. 6-2-00; 92-2, | ||||||
23 | eff.
5-1-01; 92-630, eff. 7-11-02.)
| ||||||
24 | Section 35. The Health Maintenance Organization Act is | ||||||
25 | amended by changing Section 5-3 as follows:
| ||||||
26 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
27 | Sec. 5-3. Insurance Code provisions.
| ||||||
28 | (a) Health Maintenance Organizations
shall be subject to | ||||||
29 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
30 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
31 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
32 | 356y,
356z.2, 356z.4, 356z.5,
356z.6, 367.2, 367.2-5, 367i, | ||||||
33 | 368a, 368b, 368c, 368d, 368e,
401, 401.1, 402, 403, 403A,
408, | ||||||
34 | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection |
| |||||||
| |||||||
1 | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | ||||||
2 | XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| ||||||
3 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
4 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
5 | Maintenance Organizations in
the following categories are | ||||||
6 | deemed to be "domestic companies":
| ||||||
7 | (1) a corporation authorized under the
Dental Service | ||||||
8 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
9 | (2) a corporation organized under the laws of this | ||||||
10 | State; or
| ||||||
11 | (3) a corporation organized under the laws of another | ||||||
12 | state, 30% or more
of the enrollees of which are residents | ||||||
13 | of this State, except a
corporation subject to | ||||||
14 | substantially the same requirements in its state of
| ||||||
15 | organization as is a "domestic company" under Article VIII | ||||||
16 | 1/2 of the
Illinois Insurance Code.
| ||||||
17 | (c) In considering the merger, consolidation, or other | ||||||
18 | acquisition of
control of a Health Maintenance Organization | ||||||
19 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
20 | (1) the Director shall give primary consideration to | ||||||
21 | the continuation of
benefits to enrollees and the financial | ||||||
22 | conditions of the acquired Health
Maintenance Organization | ||||||
23 | after the merger, consolidation, or other
acquisition of | ||||||
24 | control takes effect;
| ||||||
25 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
26 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
27 | apply and (ii) the Director, in making
his determination | ||||||
28 | with respect to the merger, consolidation, or other
| ||||||
29 | acquisition of control, need not take into account the | ||||||
30 | effect on
competition of the merger, consolidation, or | ||||||
31 | other acquisition of control;
| ||||||
32 | (3) the Director shall have the power to require the | ||||||
33 | following
information:
| ||||||
34 | (A) certification by an independent actuary of the | ||||||
35 | adequacy
of the reserves of the Health Maintenance | ||||||
36 | Organization sought to be acquired;
|
| |||||||
| |||||||
1 | (B) pro forma financial statements reflecting the | ||||||
2 | combined balance
sheets of the acquiring company and | ||||||
3 | the Health Maintenance Organization sought
to be | ||||||
4 | acquired as of the end of the preceding year and as of | ||||||
5 | a date 90 days
prior to the acquisition, as well as pro | ||||||
6 | forma financial statements
reflecting projected | ||||||
7 | combined operation for a period of 2 years;
| ||||||
8 | (C) a pro forma business plan detailing an | ||||||
9 | acquiring party's plans with
respect to the operation | ||||||
10 | of the Health Maintenance Organization sought to
be | ||||||
11 | acquired for a period of not less than 3 years; and
| ||||||
12 | (D) such other information as the Director shall | ||||||
13 | require.
| ||||||
14 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
15 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
16 | any health maintenance
organization of greater than 10% of its
| ||||||
17 | enrollee population (including without limitation the health | ||||||
18 | maintenance
organization's right, title, and interest in and to | ||||||
19 | its health care
certificates).
| ||||||
20 | (e) In considering any management contract or service | ||||||
21 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
22 | Code, the Director (i) shall, in
addition to the criteria | ||||||
23 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
24 | into account the effect of the management contract or
service | ||||||
25 | agreement on the continuation of benefits to enrollees and the
| ||||||
26 | financial condition of the health maintenance organization to | ||||||
27 | be managed or
serviced, and (ii) need not take into account the | ||||||
28 | effect of the management
contract or service agreement on | ||||||
29 | competition.
| ||||||
30 | (f) Except for small employer groups as defined in the | ||||||
31 | Small Employer
Rating, Renewability and Portability Health | ||||||
32 | Insurance Act and except for
medicare supplement policies as | ||||||
33 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
34 | Maintenance Organization may by contract agree with a
group or | ||||||
35 | other enrollment unit to effect refunds or charge additional | ||||||
36 | premiums
under the following terms and conditions:
|
| |||||||
| |||||||
1 | (i) the amount of, and other terms and conditions with | ||||||
2 | respect to, the
refund or additional premium are set forth | ||||||
3 | in the group or enrollment unit
contract agreed in advance | ||||||
4 | of the period for which a refund is to be paid or
| ||||||
5 | additional premium is to be charged (which period shall not | ||||||
6 | be less than one
year); and
| ||||||
7 | (ii) the amount of the refund or additional premium | ||||||
8 | shall not exceed 20%
of the Health Maintenance | ||||||
9 | Organization's profitable or unprofitable experience
with | ||||||
10 | respect to the group or other enrollment unit for the | ||||||
11 | period (and, for
purposes of a refund or additional | ||||||
12 | premium, the profitable or unprofitable
experience shall | ||||||
13 | be calculated taking into account a pro rata share of the
| ||||||
14 | Health Maintenance Organization's administrative and | ||||||
15 | marketing expenses, but
shall not include any refund to be | ||||||
16 | made or additional premium to be paid
pursuant to this | ||||||
17 | subsection (f)). The Health Maintenance Organization and | ||||||
18 | the
group or enrollment unit may agree that the profitable | ||||||
19 | or unprofitable
experience may be calculated taking into | ||||||
20 | account the refund period and the
immediately preceding 2 | ||||||
21 | plan years.
| ||||||
22 | The Health Maintenance Organization shall include a | ||||||
23 | statement in the
evidence of coverage issued to each enrollee | ||||||
24 | describing the possibility of a
refund or additional premium, | ||||||
25 | and upon request of any group or enrollment unit,
provide to | ||||||
26 | the group or enrollment unit a description of the method used | ||||||
27 | to
calculate (1) the Health Maintenance Organization's | ||||||
28 | profitable experience with
respect to the group or enrollment | ||||||
29 | unit and the resulting refund to the group
or enrollment unit | ||||||
30 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
31 | experience with respect to the group or enrollment unit and the | ||||||
32 | resulting
additional premium to be paid by the group or | ||||||
33 | enrollment unit.
| ||||||
34 | In no event shall the Illinois Health Maintenance | ||||||
35 | Organization
Guaranty Association be liable to pay any | ||||||
36 | contractual obligation of an
insolvent organization to pay any |
| |||||||
| |||||||
1 | refund authorized under this Section.
| ||||||
2 | (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, | ||||||
3 | eff. 1-1-04;
93-477, eff. 8-8-03; 93-529, eff. 8-14-03; revised | ||||||
4 | 9-25-03.)
| ||||||
5 | Section 40. The Voluntary Health Services Plans Act is | ||||||
6 | amended by changing Section 10 as follows:
| ||||||
7 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
8 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
9 | services
plan corporations and all persons interested therein | ||||||
10 | or dealing therewith
shall be subject to the provisions of | ||||||
11 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
12 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
13 | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 367.2, 368a, 401, | ||||||
14 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
15 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
16 | (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
| ||||||
17 | 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; | ||||||
18 | 93-529, eff.
8-14-03; revised 9-25-03.)
| ||||||
19 | Section 45. The Illinois Public Aid Code is amended by | ||||||
20 | changing Section 5-5 as follows: | ||||||
21 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| ||||||
22 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
23 | rule, shall
determine the quantity and quality of and the rate | ||||||
24 | of reimbursement for the
medical assistance for which
payment | ||||||
25 | will be authorized, and the medical services to be provided,
| ||||||
26 | which may include all or part of the following: (1) inpatient | ||||||
27 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
28 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
29 | services; (5) physicians'
services whether furnished in the | ||||||
30 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
31 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
32 | care furnished by licensed practitioners; (7)
home health care |
| |||||||
| |||||||
1 | services; (8) private duty nursing service; (9) clinic
| ||||||
2 | services; (10) dental services; (11) physical therapy and | ||||||
3 | related
services; (12) prescribed drugs, dentures, and | ||||||
4 | prosthetic devices; and
eyeglasses prescribed by a physician | ||||||
5 | skilled in the diseases of the eye,
or by an optometrist, | ||||||
6 | whichever the person may select; (13) other
diagnostic, | ||||||
7 | screening, preventive, and rehabilitative services; (14)
| ||||||
8 | transportation and such other expenses as may be necessary; | ||||||
9 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
10 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
11 | Treatment Act, for
injuries sustained as a result of the sexual | ||||||
12 | assault, including
examinations and laboratory tests to | ||||||
13 | discover evidence which may be used in
criminal proceedings | ||||||
14 | arising from the sexual assault; (16) the
diagnosis and | ||||||
15 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
16 | care, and any other type of remedial care recognized
under the | ||||||
17 | laws of this State, but not including abortions, or induced
| ||||||
18 | miscarriages or premature births, unless, in the opinion of a | ||||||
19 | physician,
such procedures are necessary for the preservation | ||||||
20 | of the life of the
woman seeking such treatment, or except an | ||||||
21 | induced premature birth
intended to produce a live viable child | ||||||
22 | and such procedure is necessary
for the health of the mother or | ||||||
23 | her unborn child. The Illinois Department,
by rule, shall | ||||||
24 | prohibit any physician from providing medical assistance
to | ||||||
25 | anyone eligible therefor under this Code where such physician | ||||||
26 | has been
found guilty of performing an abortion procedure in a | ||||||
27 | wilful and wanton
manner upon a woman who was not pregnant at | ||||||
28 | the time such abortion
procedure was performed. The term "any | ||||||
29 | other type of remedial care" shall
include nursing care and | ||||||
30 | nursing home service for persons who rely on
treatment by | ||||||
31 | spiritual means alone through prayer for healing.
| ||||||
32 | Notwithstanding any other provision of this Section, a | ||||||
33 | comprehensive
tobacco use cessation program that includes | ||||||
34 | purchasing prescription drugs or
prescription medical devices | ||||||
35 | approved by the Food and Drug administration shall
be covered | ||||||
36 | under the medical assistance
program under this Article for |
| |||||||
| |||||||
1 | persons who are otherwise eligible for
assistance under this | ||||||
2 | Article.
| ||||||
3 | For persons eligible for assistance under this Article, the | ||||||
4 | Illinois Department shall require coverage for services | ||||||
5 | rendered by a licensed athletic trainer in accordance with the | ||||||
6 | Illinois Athletic Trainers Practice Act if those services are | ||||||
7 | ordered by a physician licensed to practice medicine in all of | ||||||
8 | its branches.
| ||||||
9 | Notwithstanding any other provision of this Code, the | ||||||
10 | Illinois
Department may not require, as a condition of payment | ||||||
11 | for any laboratory
test authorized under this Article, that a | ||||||
12 | physician's handwritten signature
appear on the laboratory | ||||||
13 | test order form. The Illinois Department may,
however, impose | ||||||
14 | other appropriate requirements regarding laboratory test
order | ||||||
15 | documentation.
| ||||||
16 | The Illinois Department of Public Aid shall provide the | ||||||
17 | following services to
persons
eligible for assistance under | ||||||
18 | this Article who are participating in
education, training or | ||||||
19 | employment programs operated by the Department of Human
| ||||||
20 | Services as successor to the Department of Public Aid:
| ||||||
21 | (1) dental services, which shall include but not be | ||||||
22 | limited to
prosthodontics; and
| ||||||
23 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
24 | diseases of the
eye, or by an optometrist, whichever the | ||||||
25 | person may select.
| ||||||
26 | The Illinois Department, by rule, may distinguish and | ||||||
27 | classify the
medical services to be provided only in accordance | ||||||
28 | with the classes of
persons designated in Section 5-2.
| ||||||
29 | The Illinois Department shall authorize the provision of, | ||||||
30 | and shall
authorize payment for, screening by low-dose | ||||||
31 | mammography for the presence of
occult breast cancer for women | ||||||
32 | 35 years of age or older who are eligible
for medical | ||||||
33 | assistance under this Article, as follows: a baseline
mammogram | ||||||
34 | for women 35 to 39 years of age and an
annual mammogram for | ||||||
35 | women 40 years of age or older. All screenings
shall
include a | ||||||
36 | physical breast exam, instruction on self-examination and
|
| |||||||
| |||||||
1 | information regarding the frequency of self-examination and | ||||||
2 | its value as a
preventative tool. As used in this Section, | ||||||
3 | "low-dose mammography" means
the x-ray examination of the | ||||||
4 | breast using equipment dedicated specifically
for mammography, | ||||||
5 | including the x-ray tube, filter, compression device,
image | ||||||
6 | receptor, and cassettes, with an average radiation exposure | ||||||
7 | delivery
of less than one rad mid-breast, with 2 views for each | ||||||
8 | breast.
| ||||||
9 | Any medical or health care provider shall immediately | ||||||
10 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
11 | services and is suspected
of drug abuse or is addicted as | ||||||
12 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
13 | Act, referral to a local substance abuse treatment provider
| ||||||
14 | licensed by the Department of Human Services or to a licensed
| ||||||
15 | hospital which provides substance abuse treatment services. | ||||||
16 | The Department of
Public Aid shall assure coverage for the cost | ||||||
17 | of treatment of the drug abuse or
addiction for pregnant | ||||||
18 | recipients in accordance with the Illinois Medicaid
Program in | ||||||
19 | conjunction with the Department 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 providing | ||||||
24 | case management services for addicted women,
including | ||||||
25 | information on appropriate referrals for other social services
| ||||||
26 | that may be needed by addicted women in addition to treatment | ||||||
27 | 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 a | ||||||
31 | public awareness campaign, may
provide information concerning | ||||||
32 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
33 | health care, and other pertinent programs directed at
reducing | ||||||
34 | the number of drug-affected infants born to recipients of | ||||||
35 | medical
assistance.
| ||||||
36 | Neither the Illinois Department of Public Aid nor the |
| |||||||
| |||||||
1 | Department of Human
Services shall sanction the recipient | ||||||
2 | solely on the basis of
her substance abuse.
| ||||||
3 | The Illinois Department shall establish such regulations | ||||||
4 | governing
the dispensing of health services under this Article | ||||||
5 | as it shall deem
appropriate. The Department
should
seek the | ||||||
6 | advice of formal professional advisory committees appointed by
| ||||||
7 | the Director of the Illinois Department for the purpose of | ||||||
8 | providing regular
advice on policy and administrative matters, | ||||||
9 | information dissemination and
educational activities for | ||||||
10 | medical and health care providers, and
consistency in | ||||||
11 | procedures to the Illinois Department.
| ||||||
12 | The Illinois Department may develop and contract with | ||||||
13 | Partnerships of
medical providers to arrange medical services | ||||||
14 | for persons eligible under
Section 5-2 of this Code. | ||||||
15 | Implementation of this Section may be by
demonstration projects | ||||||
16 | in certain geographic areas. The Partnership shall
be | ||||||
17 | represented by a sponsor organization. The Department, by rule, | ||||||
18 | shall
develop qualifications for sponsors of Partnerships. | ||||||
19 | Nothing in this
Section shall be construed to require that the | ||||||
20 | sponsor organization be a
medical 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 clients | ||||||
29 | in target areas according to
provisions of this Article and the | ||||||
30 | Illinois Health Finance Reform Act,
except that:
| ||||||
31 | (1) Physicians participating in a Partnership and | ||||||
32 | providing certain
services, which shall be determined by | ||||||
33 | the Illinois Department, to persons
in areas covered by the | ||||||
34 | Partnership may receive an additional surcharge
for such | ||||||
35 | services.
| ||||||
36 | (2) The Department may elect to consider and negotiate |
| |||||||
| |||||||
1 | financial
incentives to encourage the development of | ||||||
2 | Partnerships and the efficient
delivery of medical care.
| ||||||
3 | (3) Persons receiving medical services through | ||||||
4 | Partnerships may receive
medical and case management | ||||||
5 | services above the level usually offered
through the | ||||||
6 | medical assistance program.
| ||||||
7 | Medical providers shall be required to meet certain | ||||||
8 | qualifications to
participate in Partnerships to ensure the | ||||||
9 | delivery of high quality medical
services. These | ||||||
10 | qualifications shall be determined by rule of the Illinois
| ||||||
11 | Department and may be higher than qualifications for | ||||||
12 | participation in the
medical assistance program. Partnership | ||||||
13 | sponsors may prescribe reasonable
additional qualifications | ||||||
14 | for participation by medical providers, only with
the prior | ||||||
15 | written approval of the Illinois Department.
| ||||||
16 | Nothing in this Section shall limit the free choice of | ||||||
17 | practitioners,
hospitals, and other providers of medical | ||||||
18 | services by clients.
In order to ensure patient freedom of | ||||||
19 | choice, the Illinois Department shall
immediately promulgate | ||||||
20 | all rules and take all other necessary actions so that
provided | ||||||
21 | services may be accessed from therapeutically certified | ||||||
22 | optometrists
to the full extent of the Illinois Optometric | ||||||
23 | Practice Act of 1987 without
discriminating between service | ||||||
24 | providers.
| ||||||
25 | The Department shall apply for a waiver from the United | ||||||
26 | States Health
Care Financing Administration to allow for the | ||||||
27 | implementation of
Partnerships under this Section.
| ||||||
28 | The Illinois Department shall require health care | ||||||
29 | providers to maintain
records that document the medical care | ||||||
30 | and services provided to recipients
of Medical Assistance under | ||||||
31 | this Article. The Illinois Department shall
require health care | ||||||
32 | providers to make available, when authorized by the
patient, in | ||||||
33 | writing, the medical records in a timely fashion to other
| ||||||
34 | health care providers who are treating or serving persons | ||||||
35 | eligible for
Medical Assistance under this Article. All | ||||||
36 | dispensers of medical services
shall be required to maintain |
| |||||||
| |||||||
1 | and retain business and professional records
sufficient to | ||||||
2 | fully and accurately document the nature, scope, details and
| ||||||
3 | receipt of the health care provided to persons eligible for | ||||||
4 | medical
assistance under this Code, in accordance with | ||||||
5 | regulations promulgated by
the Illinois Department. The rules | ||||||
6 | and regulations shall require that proof
of the receipt of | ||||||
7 | prescription drugs, dentures, prosthetic devices and
| ||||||
8 | eyeglasses by eligible persons under this Section accompany | ||||||
9 | each claim
for reimbursement submitted by the dispenser of such | ||||||
10 | medical services.
No such claims for reimbursement shall be | ||||||
11 | approved for payment by the Illinois
Department without such | ||||||
12 | proof of receipt, unless the Illinois Department
shall have put | ||||||
13 | into effect and shall be operating a system of post-payment
| ||||||
14 | audit and review which shall, on a sampling basis, be deemed | ||||||
15 | adequate by
the Illinois Department to assure that such drugs, | ||||||
16 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
17 | is being made are actually being
received by eligible | ||||||
18 | recipients. Within 90 days after the effective date of
this | ||||||
19 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
20 | a
current list of acquisition costs for all prosthetic devices | ||||||
21 | and any
other items recognized as medical equipment and | ||||||
22 | supplies reimbursable under
this Article and shall update such | ||||||
23 | list on a quarterly basis, except that
the acquisition costs of | ||||||
24 | all prescription drugs shall be updated no
less frequently than | ||||||
25 | every 30 days as required by Section 5-5.12.
| ||||||
26 | The rules and regulations of the Illinois Department shall | ||||||
27 | require
that a written statement including the required opinion | ||||||
28 | of a physician
shall accompany any claim for reimbursement for | ||||||
29 | abortions, or induced
miscarriages or premature births. This | ||||||
30 | statement shall indicate what
procedures were used in providing | ||||||
31 | such medical services.
| ||||||
32 | The Illinois Department shall require all dispensers of | ||||||
33 | medical
services, other than an individual practitioner or | ||||||
34 | group of practitioners,
desiring to participate in the Medical | ||||||
35 | Assistance program
established under this Article to disclose | ||||||
36 | all financial, beneficial,
ownership, equity, surety or other |
| |||||||
| |||||||
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.
| ||||||
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
| ||||||
11 | inquiries could indicate potential existence of claims or liens | ||||||
12 | for the
Illinois Department.
| ||||||
13 | Enrollment of a vendor that provides non-emergency medical | ||||||
14 | transportation,
defined by the Department by rule,
shall be
| ||||||
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
| ||||||
19 | Department's hearing process.
| ||||||
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
| ||||||
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. | ||||||
35 | Rules under clause (2) above shall not provide
for purchase or | ||||||
36 | lease-purchase of durable medical equipment or supplies
used |
| |||||||
| |||||||
1 | for the purpose of oxygen delivery and respiratory care.
| ||||||
2 | The Department shall execute, relative to the nursing home | ||||||
3 | prescreening
project, written inter-agency agreements with the | ||||||
4 | Department of Human
Services and the Department on Aging, to | ||||||
5 | effect the following: (i) intake
procedures and common | ||||||
6 | eligibility criteria for those persons who are receiving
| ||||||
7 | non-institutional services; and (ii) the establishment and | ||||||
8 | development of
non-institutional services in areas of the State | ||||||
9 | where they are not currently
available or are undeveloped.
| ||||||
10 | The Illinois Department shall develop and operate, in | ||||||
11 | cooperation
with other State Departments and agencies and in | ||||||
12 | compliance with
applicable federal laws and regulations, | ||||||
13 | appropriate and effective
systems of health care evaluation and | ||||||
14 | programs for monitoring of
utilization of health care services | ||||||
15 | and facilities, as it affects
persons eligible for medical | ||||||
16 | assistance under this Code.
| ||||||
17 | The Illinois Department shall report annually to the | ||||||
18 | General Assembly,
no later than the second Friday in April of | ||||||
19 | 1979 and each year
thereafter, in regard to:
| ||||||
20 | (a) actual statistics and trends in utilization of | ||||||
21 | medical services by
public aid recipients;
| ||||||
22 | (b) actual statistics and trends in the provision of | ||||||
23 | the various medical
services by medical vendors;
| ||||||
24 | (c) current rate structures and proposed changes in | ||||||
25 | those rate structures
for the various medical vendors; and
| ||||||
26 | (d) efforts at utilization review and control by the | ||||||
27 | Illinois Department.
| ||||||
28 | The period covered by each report shall be the 3 years | ||||||
29 | ending on the June
30 prior to the report. The report shall | ||||||
30 | include suggested legislation
for consideration by the General | ||||||
31 | Assembly. The filing of one copy of the
report with the | ||||||
32 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
33 | the Clerk of the House of Representatives, one copy with the | ||||||
34 | President,
one copy with the Minority Leader and one copy with | ||||||
35 | the Secretary of the
Senate, one copy with the Legislative | ||||||
36 | Research Unit, and such additional
copies
with the State |
| |||||||
| |||||||
1 | Government Report Distribution Center for the General
Assembly | ||||||
2 | as is required under paragraph (t) of Section 7 of the State
| ||||||
3 | Library Act shall be deemed sufficient to comply with this | ||||||
4 | Section.
| ||||||
5 | (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02; | ||||||
6 | 92-789, eff. 8-6-02; 93-632, eff. 2-1-04.)
| ||||||
7 | Section 99. Effective date. This Act takes effect upon | ||||||
8 | becoming law.
|