093_SB1779
LRB093 10992 DRJ 11617 b
1 AN ACT in relation to public aid.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5 changing Section 5-5 as follows:
6 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
7 Sec. 5-5. Medical services. The Illinois Department, by
8 rule, shall determine the quantity and quality of and the
9 rate of reimbursement for the medical assistance for which
10 payment will be authorized, and the medical services to be
11 provided, which may include all or part of the following: (1)
12 inpatient hospital services; (2) outpatient hospital
13 services; (3) other laboratory and X-ray services; (4)
14 skilled nursing home services; (5) physicians' services
15 whether furnished in the office, the patient's home, a
16 hospital, a skilled nursing home, or elsewhere; (6) medical
17 care, or any other type of remedial care furnished by
18 licensed practitioners; (7) home health care services; (8)
19 private duty nursing service; (9) clinic services; (10)
20 dental services; (11) physical therapy and related services;
21 (12) prescribed drugs, dentures, and prosthetic devices; and
22 eyeglasses prescribed by a physician skilled in the diseases
23 of the eye, or by an optometrist, whichever the person may
24 select; (13) other diagnostic, screening, preventive, and
25 rehabilitative services; (14) transportation and such other
26 expenses as may be necessary; (15) medical treatment of
27 sexual assault survivors, as defined in Section 1a of the
28 Sexual Assault Survivors Emergency Treatment Act, for
29 injuries sustained as a result of the sexual assault,
30 including examinations and laboratory tests to discover
31 evidence which may be used in criminal proceedings arising
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1 from the sexual assault; (16) the diagnosis and treatment of
2 sickle cell anemia; and (17) any other medical care, and any
3 other type of remedial care recognized under the laws of this
4 State, but not including abortions, or induced miscarriages
5 or premature births, unless, in the opinion of a physician,
6 such procedures are necessary for the preservation of the
7 life of the woman seeking such treatment, or except an
8 induced premature birth intended to produce a live viable
9 child and such procedure is necessary for the health of the
10 mother or her unborn child. The Illinois Department, by rule,
11 shall prohibit any physician from providing medical
12 assistance to anyone eligible therefor under this Code where
13 such physician has been found guilty of performing an
14 abortion procedure in a wilful and wanton manner upon a woman
15 who was not pregnant at the time such abortion procedure was
16 performed. The term "any other type of remedial care" shall
17 include nursing care and nursing home service for persons who
18 rely on treatment by spiritual means alone through prayer for
19 healing.
20 Notwithstanding any other provision of this Section, a
21 comprehensive tobacco use cessation program that includes
22 purchasing prescription drugs or prescription medical devices
23 approved by the Food and Drug administration shall be covered
24 under the medical assistance program under this Article for
25 persons who are otherwise eligible for assistance under this
26 Article.
27 Notwithstanding any other provision of this Code, the
28 Illinois Department may not require, as a condition of
29 payment for any laboratory test authorized under this
30 Article, that a physician's handwritten signature appear on
31 the laboratory test order form. The Illinois Department may,
32 however, impose other appropriate requirements regarding
33 laboratory test order documentation.
34 The Illinois Department of Public Aid shall provide the
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1 following services to persons eligible for assistance under
2 this Article who are participating in education, training or
3 employment programs operated by the Department of Human
4 Services as successor to the Department of Public Aid:
5 (1) dental services, which shall include but not be
6 limited to prosthodontics; and
7 (2) eyeglasses prescribed by a physician skilled in
8 the diseases of the eye, or by an optometrist, whichever
9 the person may select.
10 The Illinois Department, by rule, may distinguish and
11 classify the medical services to be provided only in
12 accordance with the classes of persons designated in Section
13 5-2.
14 The Illinois Department shall authorize the provision of,
15 and shall authorize payment for, screening by low-dose
16 mammography for the presence of occult breast cancer for
17 women 35 years of age or older who are eligible for medical
18 assistance under this Article, as follows: a baseline
19 mammogram for women 35 to 39 years of age and an annual
20 mammogram for women 40 years of age or older. All screenings
21 shall include a physical breast exam, instruction on
22 self-examination and information regarding the frequency of
23 self-examination and its value as a preventative tool. As
24 used in this Section, "low-dose mammography" means the x-ray
25 examination of the breast using equipment dedicated
26 specifically for mammography, including the x-ray tube,
27 filter, compression device, image receptor, and cassettes,
28 with an average radiation exposure delivery of less than one
29 rad mid-breast, with 2 views for each breast.
30 Any medical or health care provider shall immediately
31 recommend, to any pregnant woman who is being provided
32 prenatal services and is suspected of drug abuse or is
33 addicted as defined in the Alcoholism and Other Drug Abuse
34 and Dependency Act, referral to a local substance abuse
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1 treatment provider licensed by the Department of Human
2 Services or to a licensed hospital which provides substance
3 abuse treatment services. The Department of Public Aid shall
4 assure coverage for the cost of treatment of the drug abuse
5 or addiction for pregnant recipients in accordance with the
6 Illinois Medicaid Program in conjunction with the Department
7 of Human Services.
8 All medical providers providing medical assistance to
9 pregnant women under this Code shall receive information from
10 the Department on the availability of services under the Drug
11 Free Families with a Future or any comparable program
12 providing case management services for addicted women,
13 including information on appropriate referrals for other
14 social services that may be needed by addicted women in
15 addition to treatment for addiction.
16 The Illinois Department, in cooperation with the
17 Departments of Human Services (as successor to the Department
18 of Alcoholism and Substance Abuse) and Public Health, through
19 a public awareness campaign, may provide information
20 concerning treatment for alcoholism and drug abuse and
21 addiction, prenatal health care, and other pertinent programs
22 directed at reducing the number of drug-affected infants born
23 to recipients of medical assistance.
24 Neither the Illinois Department of Public Aid nor the
25 Department of Human Services shall sanction the recipient
26 solely on the basis of her substance abuse.
27 The Illinois Department shall establish such regulations
28 governing the dispensing of health services under this
29 Article as it shall deem appropriate. In formulating these
30 regulations the Illinois Department shall consult with and
31 give substantial weight to the recommendations offered by the
32 Citizens Assembly/Council on Public Aid. The Department
33 should seek the advice of formal professional advisory
34 committees appointed by the Director of the Illinois
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1 Department for the purpose of providing regular advice on
2 policy and administrative matters, information dissemination
3 and educational activities for medical and health care
4 providers, and consistency in procedures to the Illinois
5 Department.
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
10 projects in certain geographic areas. The Partnership shall
11 be represented by a sponsor organization. The Department, by
12 rule, shall develop qualifications for sponsors of
13 Partnerships. Nothing in this Section shall be construed to
14 require that the sponsor organization be a medical
15 organization.
16 The sponsor must negotiate formal written contracts with
17 medical providers for physician services, inpatient and
18 outpatient hospital care, home health services, treatment for
19 alcoholism and substance abuse, and other services determined
20 necessary by the Illinois Department by rule for delivery by
21 Partnerships. Physician services must include prenatal and
22 obstetrical care. The Illinois Department shall reimburse
23 medical services delivered by Partnership providers to
24 clients in target areas according to provisions of this
25 Article and the Illinois Health Finance Reform Act, except
26 that:
27 (1) Physicians participating in a Partnership and
28 providing certain services, which shall be determined by
29 the Illinois Department, to persons in areas covered by
30 the Partnership may receive an additional surcharge for
31 such services.
32 (2) The Department may elect to consider and
33 negotiate financial incentives to encourage the
34 development of Partnerships and the efficient delivery of
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1 medical care.
2 (3) Persons receiving medical services through
3 Partnerships may receive medical and case management
4 services above the level usually offered through the
5 medical assistance program.
6 Medical providers shall be required to meet certain
7 qualifications to participate in Partnerships to ensure the
8 delivery of high quality medical services. These
9 qualifications shall be determined by rule of the Illinois
10 Department and may be higher than qualifications for
11 participation in the medical assistance program. Partnership
12 sponsors may prescribe reasonable additional qualifications
13 for participation by medical providers, only with the prior
14 written approval of the Illinois Department.
15 Nothing in this Section shall limit the free choice of
16 practitioners, hospitals, and other providers of medical
17 services by clients. In order to ensure patient freedom of
18 choice, the Illinois Department shall immediately promulgate
19 all rules and take all other necessary actions so that
20 provided services may be accessed from therapeutically
21 certified optometrists to the full extent of the Illinois
22 Optometric Practice Act of 1987 without discriminating
23 between service providers.
24 The Department shall apply for a waiver from the United
25 States Health Care Financing Administration to allow for the
26 implementation of Partnerships under this Section.
27 The Illinois Department shall require health care
28 providers to maintain records that document the medical care
29 and services provided to recipients of Medical Assistance
30 under this Article. The Illinois Department shall require
31 health care providers to make available, when authorized by
32 the patient, in writing, the medical records in a timely
33 fashion to other health care providers who are treating or
34 serving persons eligible for Medical Assistance under this
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1 Article. All dispensers of medical services shall be
2 required to maintain and retain business and professional
3 records sufficient to fully and accurately document the
4 nature, scope, details and receipt of the health care
5 provided to persons eligible for medical assistance under
6 this Code, in accordance with regulations promulgated by the
7 Illinois Department. The rules and regulations shall require
8 that proof of the receipt of prescription drugs, dentures,
9 prosthetic devices and eyeglasses by eligible persons under
10 this Section accompany each claim for reimbursement submitted
11 by the dispenser of such medical services. No such claims for
12 reimbursement shall be approved for payment by the Illinois
13 Department without such proof of receipt, unless the Illinois
14 Department shall have put into effect and shall be operating
15 a system of post-payment audit and review which shall, on a
16 sampling basis, be deemed adequate by the Illinois Department
17 to assure that such drugs, dentures, prosthetic devices and
18 eyeglasses for which payment is being made are actually being
19 received by eligible recipients. Within 90 days after the
20 effective date of this amendatory Act of 1984, the Illinois
21 Department shall establish a current list of acquisition
22 costs for all prosthetic devices and any other items
23 recognized as medical equipment and supplies reimbursable
24 under this Article and shall update such list on a quarterly
25 basis, except that the acquisition costs of all prescription
26 drugs shall be updated no less frequently than every 30 days
27 as required by Section 5-5.12.
28 The rules and regulations of the Illinois Department
29 shall require that a written statement including the required
30 opinion of a physician shall accompany any claim for
31 reimbursement for abortions, or induced miscarriages or
32 premature births. This statement shall indicate what
33 procedures were used in providing such medical services.
34 The Illinois Department shall require all dispensers of
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1 medical services, other than an individual practitioner or
2 group of practitioners, desiring to participate in the
3 Medical Assistance program established under this Article to
4 disclose all financial, beneficial, ownership, equity, surety
5 or other interests in any and all firms, corporations,
6 partnerships, associations, business enterprises, joint
7 ventures, agencies, institutions or other legal entities
8 providing any form of health care services in this State
9 under this Article.
10 The Illinois Department may require that all dispensers
11 of medical services desiring to participate in the medical
12 assistance program established under this Article disclose,
13 under such terms and conditions as the Illinois Department
14 may by rule establish, all inquiries from clients and
15 attorneys regarding medical bills paid by the Illinois
16 Department, which inquiries could indicate potential
17 existence of claims or liens for the Illinois Department.
18 The Department of Public Aid shall pay providers of
19 transportation services authorized under this Article on a
20 reasonable-cost-related basis, prospectively determined
21 according to generally accepted accounting principles.
22 Enrollment of a vendor that provides non-emergency
23 medical transportation, defined by the Department by rule,
24 shall be conditional for 180 days. During that time, the
25 Department of Public Aid may terminate the vendor's
26 eligibility to participate in the medical assistance program
27 without cause. That termination of eligibility is not
28 subject to the Department's hearing process.
29 The Illinois Department shall establish policies,
30 procedures, standards and criteria by rule for the
31 acquisition, repair and replacement of orthotic and
32 prosthetic devices and durable medical equipment. Such rules
33 shall provide, but not be limited to, the following services:
34 (1) immediate repair or replacement of such devices by
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1 recipients without medical authorization; and (2) rental,
2 lease, purchase or lease-purchase of durable medical
3 equipment in a cost-effective manner, taking into
4 consideration the recipient's medical prognosis, the extent
5 of the recipient's needs, and the requirements and costs for
6 maintaining such equipment. Such rules shall enable a
7 recipient to temporarily acquire and use alternative or
8 substitute devices or equipment pending repairs or
9 replacements of any device or equipment previously authorized
10 for such recipient by the Department. Rules under clause (2)
11 above shall not provide for purchase or lease-purchase of
12 durable medical equipment or supplies used for the purpose of
13 oxygen delivery and respiratory care.
14 The Department shall execute, relative to the nursing
15 home prescreening project, written inter-agency agreements
16 with the Department of Human Services and the Department on
17 Aging, to effect the following: (i) intake procedures and
18 common eligibility criteria for those persons who are
19 receiving non-institutional services; and (ii) the
20 establishment and development of non-institutional services
21 in areas of the State where they are not currently available
22 or are undeveloped.
23 The Illinois Department shall develop and operate, in
24 cooperation with other State Departments and agencies and in
25 compliance with applicable federal laws and regulations,
26 appropriate and effective systems of health care evaluation
27 and programs for monitoring of utilization of health care
28 services and facilities, as it affects persons eligible for
29 medical assistance under this Code. The Illinois Department
30 shall report regularly the results of the operation of such
31 systems and programs to the Citizens Assembly/Council on
32 Public Aid to enable the Committee to ensure, from time to
33 time, that these programs are effective and meaningful.
34 The Illinois Department shall report annually to the
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1 General Assembly, no later than the second Friday in April of
2 1979 and each year thereafter, in regard to:
3 (a) actual statistics and trends in utilization of
4 medical services by public aid recipients;
5 (b) actual statistics and trends in the provision
6 of the various medical services by medical vendors;
7 (c) current rate structures and proposed changes in
8 those rate structures for the various medical vendors;
9 and
10 (d) efforts at utilization review and control by
11 the Illinois Department.
12 The period covered by each report shall be the 3 years
13 ending on the June 30 prior to the report. The report shall
14 include suggested legislation for consideration by the
15 General Assembly. The filing of one copy of the report with
16 the Speaker, one copy with the Minority Leader and one copy
17 with the Clerk of the House of Representatives, one copy with
18 the President, one copy with the Minority Leader and one copy
19 with the Secretary of the Senate, one copy with the
20 Legislative Research Unit, such additional copies with the
21 State Government Report Distribution Center for the General
22 Assembly as is required under paragraph (t) of Section 7 of
23 the State Library Act and one copy with the Citizens
24 Assembly/Council on Public Aid or its successor shall be
25 deemed sufficient to comply with this Section.
26 (Source: P.A. 91-344, eff. 1-1-00; 91-462, eff. 8-6-99;
27 91-666, eff. 12-22-99; 92-16, eff. 6-28-01; 92-651, eff.
28 7-11-02; 92-789, eff. 8-6-02.)
29 Section 99. Effective date. This Act takes effect upon
30 becoming law.