Health Care Availability and Access Committee
Filed: 3/20/2007
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1 | AMENDMENT TO HOUSE BILL 1560
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2 | AMENDMENT NO. ______. Amend House Bill 1560 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The State Employees Group Insurance Act of 1971 | ||||||
5 | is amended by changing Section 6.11 as follows:
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6 | (5 ILCS 375/6.11)
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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, 356z.4, and 356z.6 , and 356z.9 of the
Illinois | ||||||
14 | Insurance Code.
The program of health benefits must comply with | ||||||
15 | Section 155.37 of the
Illinois Insurance Code.
| ||||||
16 | (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03; |
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| |||||||
1 | 93-102, eff. 1-1-04; 93-853, eff. 1-1-05.)
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2 | Section 10. The Counties Code is amended by changing | ||||||
3 | Section 5-1069.3 as follows: | ||||||
4 | (55 ILCS 5/5-1069.3)
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5 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
6 | including a home
rule
county, is a self-insurer for purposes of | ||||||
7 | providing health insurance coverage
for its employees, the | ||||||
8 | coverage shall include coverage for the post-mastectomy
care | ||||||
9 | benefits required to be covered by a policy of accident and | ||||||
10 | health
insurance under Section 356t and the coverage required | ||||||
11 | under Sections 356u,
356w, 356x ,
and 356z.6 , and 356z.9 of
the | ||||||
12 | Illinois Insurance Code. The requirement that health benefits | ||||||
13 | be covered
as provided in this Section is an
exclusive power | ||||||
14 | and function of the State and is a denial and limitation under
| ||||||
15 | Article VII, Section 6, subsection (h) of the Illinois | ||||||
16 | Constitution. A home
rule county to which this Section applies | ||||||
17 | must comply with every provision of
this Section.
| ||||||
18 | (Source: P.A. 93-853, eff. 1-1-05.)
| ||||||
19 | Section 15. The Illinois Municipal Code is amended by | ||||||
20 | changing Section 10-4-2.3 as follows: | ||||||
21 | (65 ILCS 5/10-4-2.3)
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22 | Sec. 10-4-2.3. Required health benefits. If a |
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1 | municipality, including a
home rule municipality, is a | ||||||
2 | self-insurer for purposes of providing health
insurance | ||||||
3 | coverage for its employees, the coverage shall include coverage | ||||||
4 | for
the post-mastectomy care benefits required to be covered by | ||||||
5 | a policy of
accident and health insurance under Section 356t | ||||||
6 | and the coverage required
under Sections 356u, 356w, 356x ,
and
| ||||||
7 | 356z.6 , and 356z.9 of the Illinois
Insurance
Code. The | ||||||
8 | requirement that health
benefits be covered as provided in this | ||||||
9 | is an exclusive power and function of
the State and is a denial | ||||||
10 | and limitation under Article VII, Section 6,
subsection (h) of | ||||||
11 | the Illinois Constitution. A home rule municipality to which
| ||||||
12 | this Section applies must comply with every provision of this | ||||||
13 | Section.
| ||||||
14 | (Source: P.A. 93-853, eff. 1-1-05.)
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15 | Section 20. The Illinois Insurance Code is amended by | ||||||
16 | adding Section 365z.9 as follows: | ||||||
17 | (215 ILCS 5/365z.9 new) | ||||||
18 | Sec. 365z.9. Amino acid-based elemental formulas. | ||||||
19 | (a) A group or individual policy of accident and health | ||||||
20 | insurance or managed care plan amended, delivered, issued, or | ||||||
21 | renewed after the effective date of this amendatory Act of the | ||||||
22 | 95th General Assembly must provide coverage for | ||||||
23 | nonprescription amino acid-based elemental formulas, | ||||||
24 | regardless of delivery method, for the diagnosis and treatment |
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1 | of (i) milk protein allergies and intolerances, (ii) | ||||||
2 | eosinophilic disorders, and (iii) impaired absorption of | ||||||
3 | nutrients caused by disorders affecting the absorptive | ||||||
4 | surface, functional length, and motility of the | ||||||
5 | gastrointestinal tract, when the prescribing physician has | ||||||
6 | issued a written order stating that the amino acid-based | ||||||
7 | elemental formula is medically necessary for the treatment of a | ||||||
8 | disease or disorder and is the least restrictive and most | ||||||
9 | cost-effective means for meeting the needs of the patient. | ||||||
10 | (b) A group or individual policy of accident and health | ||||||
11 | insurance or managed care plan amended, delivered, issued, or | ||||||
12 | renewed after the effective date of this amendatory Act of the | ||||||
13 | 95th General Assembly must provide coverage for specialized | ||||||
14 | amino acid-based elemental formulas, regardless of delivery | ||||||
15 | method, when the prescribing physician has issued a written | ||||||
16 | order stating that such specialized amino acid-based elemental | ||||||
17 | formula is medically necessary for the treatment of a disease | ||||||
18 | or disorder and is the least restrictive and most | ||||||
19 | cost-effective means for meeting the needs of the patient.
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20 | Section 25. The Health Maintenance Organization Act is | ||||||
21 | amended by changing Section 5-3 as follows:
| ||||||
22 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
23 | Sec. 5-3. Insurance Code provisions.
| ||||||
24 | (a) Health Maintenance Organizations
shall be subject to |
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| |||||||
1 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
2 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
3 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
4 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 364.01, | ||||||
5 | 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, | ||||||
6 | 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
| ||||||
7 | paragraph (c) of subsection (2) of Section 367, and Articles | ||||||
8 | IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | ||||||
9 | the Illinois Insurance Code.
| ||||||
10 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
11 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
12 | Maintenance Organizations in
the following categories are | ||||||
13 | deemed to be "domestic companies":
| ||||||
14 | (1) a corporation authorized under the
Dental Service | ||||||
15 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
16 | (2) a corporation organized under the laws of this | ||||||
17 | State; or
| ||||||
18 | (3) a corporation organized under the laws of another | ||||||
19 | state, 30% or more
of the enrollees of which are residents | ||||||
20 | of this State, except a
corporation subject to | ||||||
21 | substantially the same requirements in its state of
| ||||||
22 | organization as is a "domestic company" under Article VIII | ||||||
23 | 1/2 of the
Illinois Insurance Code.
| ||||||
24 | (c) In considering the merger, consolidation, or other | ||||||
25 | acquisition of
control of a Health Maintenance Organization | ||||||
26 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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1 | (1) the Director shall give primary consideration to | ||||||
2 | the continuation of
benefits to enrollees and the financial | ||||||
3 | conditions of the acquired Health
Maintenance Organization | ||||||
4 | after the merger, consolidation, or other
acquisition of | ||||||
5 | control takes effect;
| ||||||
6 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
7 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
8 | apply and (ii) the Director, in making
his determination | ||||||
9 | with respect to the merger, consolidation, or other
| ||||||
10 | acquisition of control, need not take into account the | ||||||
11 | effect on
competition of the merger, consolidation, or | ||||||
12 | other acquisition of control;
| ||||||
13 | (3) the Director shall have the power to require the | ||||||
14 | following
information:
| ||||||
15 | (A) certification by an independent actuary of the | ||||||
16 | adequacy
of the reserves of the Health Maintenance | ||||||
17 | Organization sought to be acquired;
| ||||||
18 | (B) pro forma financial statements reflecting the | ||||||
19 | combined balance
sheets of the acquiring company and | ||||||
20 | the Health Maintenance Organization sought
to be | ||||||
21 | acquired as of the end of the preceding year and as of | ||||||
22 | a date 90 days
prior to the acquisition, as well as pro | ||||||
23 | forma financial statements
reflecting projected | ||||||
24 | combined operation for a period of 2 years;
| ||||||
25 | (C) a pro forma business plan detailing an | ||||||
26 | acquiring party's plans with
respect to the operation |
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1 | of the Health Maintenance Organization sought to
be | ||||||
2 | acquired for a period of not less than 3 years; and
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3 | (D) such other information as the Director shall | ||||||
4 | require.
| ||||||
5 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
6 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
7 | any health maintenance
organization of greater than 10% of its
| ||||||
8 | enrollee population (including without limitation the health | ||||||
9 | maintenance
organization's right, title, and interest in and to | ||||||
10 | its health care
certificates).
| ||||||
11 | (e) In considering any management contract or service | ||||||
12 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
13 | Code, the Director (i) shall, in
addition to the criteria | ||||||
14 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
15 | into account the effect of the management contract or
service | ||||||
16 | agreement on the continuation of benefits to enrollees and the
| ||||||
17 | financial condition of the health maintenance organization to | ||||||
18 | be managed or
serviced, and (ii) need not take into account the | ||||||
19 | effect of the management
contract or service agreement on | ||||||
20 | competition.
| ||||||
21 | (f) Except for small employer groups as defined in the | ||||||
22 | Small Employer
Rating, Renewability and Portability Health | ||||||
23 | Insurance Act and except for
medicare supplement policies as | ||||||
24 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
25 | Maintenance Organization may by contract agree with a
group or | ||||||
26 | other enrollment unit to effect refunds or charge additional |
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1 | premiums
under the following terms and conditions:
| ||||||
2 | (i) the amount of, and other terms and conditions with | ||||||
3 | respect to, the
refund or additional premium are set forth | ||||||
4 | in the group or enrollment unit
contract agreed in advance | ||||||
5 | of the period for which a refund is to be paid or
| ||||||
6 | additional premium is to be charged (which period shall not | ||||||
7 | be less than one
year); and
| ||||||
8 | (ii) the amount of the refund or additional premium | ||||||
9 | shall not exceed 20%
of the Health Maintenance | ||||||
10 | Organization's profitable or unprofitable experience
with | ||||||
11 | respect to the group or other enrollment unit for the | ||||||
12 | period (and, for
purposes of a refund or additional | ||||||
13 | premium, the profitable or unprofitable
experience shall | ||||||
14 | be calculated taking into account a pro rata share of the
| ||||||
15 | Health Maintenance Organization's administrative and | ||||||
16 | marketing expenses, but
shall not include any refund to be | ||||||
17 | made or additional premium to be paid
pursuant to this | ||||||
18 | subsection (f)). The Health Maintenance Organization and | ||||||
19 | the
group or enrollment unit may agree that the profitable | ||||||
20 | or unprofitable
experience may be calculated taking into | ||||||
21 | account the refund period and the
immediately preceding 2 | ||||||
22 | plan years.
| ||||||
23 | The Health Maintenance Organization shall include a | ||||||
24 | statement in the
evidence of coverage issued to each enrollee | ||||||
25 | describing the possibility of a
refund or additional premium, | ||||||
26 | and upon request of any group or enrollment unit,
provide to |
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| |||||||
1 | the group or enrollment unit a description of the method used | ||||||
2 | to
calculate (1) the Health Maintenance Organization's | ||||||
3 | profitable experience with
respect to the group or enrollment | ||||||
4 | unit and the resulting refund to the group
or enrollment unit | ||||||
5 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
6 | experience with respect to the group or enrollment unit and the | ||||||
7 | resulting
additional premium to be paid by the group or | ||||||
8 | enrollment unit.
| ||||||
9 | In no event shall the Illinois Health Maintenance | ||||||
10 | Organization
Guaranty Association be liable to pay any | ||||||
11 | contractual obligation of an
insolvent organization to pay any | ||||||
12 | refund authorized under this Section.
| ||||||
13 | (Source: P.A. 93-102, eff. 1-1-04; 93-261, eff. 1-1-04; 93-477, | ||||||
14 | eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; | ||||||
15 | 93-1000, eff. 1-1-05; 94-906, eff. 1-1-07; 94-1076, eff. | ||||||
16 | 12-29-06; revised 1-5-07.)
| ||||||
17 | Section 30. The Limited Health Service Organization Act is | ||||||
18 | amended by changing Section 4003 as follows:
| ||||||
19 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| ||||||
20 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
21 | health service
organizations shall be subject to the provisions | ||||||
22 | of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | ||||||
23 | 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | ||||||
24 | 155.04, 155.37, 355.2, 356v, 356z.9, 368a, 401, 401.1,
402,
|
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| |||||||
1 | 403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and Articles | ||||||
2 | IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and XXVI of | ||||||
3 | the Illinois Insurance Code. For purposes of the
Illinois | ||||||
4 | Insurance Code, except for Sections 444 and 444.1 and Articles | ||||||
5 | XIII
and XIII 1/2, limited health service organizations in the | ||||||
6 | following categories
are deemed to be domestic companies:
| ||||||
7 | (1) a corporation under the laws of this State; or
| ||||||
8 | (2) a corporation organized under the laws of another | ||||||
9 | state, 30% of more
of the enrollees of which are residents | ||||||
10 | of this State, except a corporation
subject to | ||||||
11 | substantially the same requirements in its state of | ||||||
12 | organization as
is a domestic company under Article VIII | ||||||
13 | 1/2 of the Illinois Insurance Code.
| ||||||
14 | (Source: P.A. 91-549, eff. 8-14-99; 91-605, eff. 12-14-99; | ||||||
15 | 91-788, eff.
6-9-00; 92-440, eff. 8-17-01.)
| ||||||
16 | Section 35. The Voluntary Health Services Plans Act is | ||||||
17 | amended by changing Section 10 as follows:
| ||||||
18 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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19 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
20 | services
plan corporations and all persons interested therein | ||||||
21 | or dealing therewith
shall be subject to the provisions of | ||||||
22 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
23 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
24 | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
|
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| |||||||
1 | 364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, | ||||||
2 | and 412, and paragraphs (7) and (15) of Section 367 of the | ||||||
3 | Illinois
Insurance Code.
| ||||||
4 | (Source: P.A. 93-102, eff. 1-1-04; 93-529, eff. 8-14-03; | ||||||
5 | 93-853, eff. 1-1-05; 93-1000, eff. 1-1-05; 94-1076, eff. | ||||||
6 | 12-29-06.)
| ||||||
7 | Section 40. The Illinois Public Aid Code is amended by | ||||||
8 | changing Section 5-5 as follows: | ||||||
9 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| ||||||
10 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
11 | rule, shall
determine the quantity and quality of and the rate | ||||||
12 | of reimbursement for the
medical assistance for which
payment | ||||||
13 | will be authorized, and the medical services to be provided,
| ||||||
14 | which may include all or part of the following: (1) inpatient | ||||||
15 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
16 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
17 | services; (5) physicians'
services whether furnished in the | ||||||
18 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
19 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
20 | care furnished by licensed practitioners; (7)
home health care | ||||||
21 | services; (8) private duty nursing service; (9) clinic
| ||||||
22 | services; (10) dental services, including prevention and | ||||||
23 | treatment of periodontal disease and dental caries disease for | ||||||
24 | pregnant women; (11) physical therapy and related
services; |
| |||||||
| |||||||
1 | (12) prescribed drugs, dentures, and prosthetic devices; and
| ||||||
2 | eyeglasses prescribed by a physician skilled in the diseases of | ||||||
3 | the eye,
or by an optometrist, whichever the person may select; | ||||||
4 | (13) other
diagnostic, screening, preventive, and | ||||||
5 | rehabilitative services; (14)
transportation and such other | ||||||
6 | expenses as may be necessary; (15) medical
treatment of sexual | ||||||
7 | assault survivors, as defined in
Section 1a of the Sexual | ||||||
8 | Assault Survivors Emergency Treatment Act, for
injuries | ||||||
9 | sustained as a result of the sexual assault, including
| ||||||
10 | examinations and laboratory tests to discover evidence which | ||||||
11 | may be used in
criminal proceedings arising from the sexual | ||||||
12 | assault; (16) the
diagnosis and treatment of sickle cell | ||||||
13 | anemia; and (17)
any other medical care, and any other type of | ||||||
14 | remedial care recognized
under the laws of this State, but not | ||||||
15 | including abortions, or induced
miscarriages or premature | ||||||
16 | births, unless, in the opinion of a physician,
such procedures | ||||||
17 | are necessary for the preservation of the life of the
woman | ||||||
18 | seeking such treatment, or except an induced premature birth
| ||||||
19 | intended to produce a live viable child and such procedure is | ||||||
20 | necessary
for the health of the mother or her unborn child. The | ||||||
21 | Illinois Department,
by rule, shall prohibit any physician from | ||||||
22 | providing medical assistance
to anyone eligible therefor under | ||||||
23 | this Code where such physician has been
found guilty of | ||||||
24 | performing an abortion procedure in a wilful and wanton
manner | ||||||
25 | upon a woman who was not pregnant at the time such abortion
| ||||||
26 | procedure was performed. The term "any other type of remedial |
| |||||||
| |||||||
1 | care" shall
include nursing care and nursing home service for | ||||||
2 | persons who rely on
treatment by spiritual means alone through | ||||||
3 | prayer for healing.
| ||||||
4 | Notwithstanding any other provision of this Section, a | ||||||
5 | comprehensive
tobacco use cessation program that includes | ||||||
6 | purchasing prescription drugs or
prescription medical devices | ||||||
7 | approved by the Food and Drug administration shall
be covered | ||||||
8 | under the medical assistance
program under this Article for | ||||||
9 | persons who are otherwise eligible for
assistance under this | ||||||
10 | Article.
| ||||||
11 | Notwithstanding any other provision of this Code, the | ||||||
12 | Illinois
Department may not require, as a condition of payment | ||||||
13 | for any laboratory
test authorized under this Article, that a | ||||||
14 | physician's handwritten signature
appear on the laboratory | ||||||
15 | test order form. The Illinois Department may,
however, impose | ||||||
16 | other appropriate requirements regarding laboratory test
order | ||||||
17 | documentation.
| ||||||
18 | The Illinois Department of Healthcare and Family Services
| ||||||
19 | Public Aid shall provide the following services to
persons
| ||||||
20 | eligible for assistance under this Article who are | ||||||
21 | participating in
education, training or employment programs | ||||||
22 | operated by the Department of Human
Services as successor to | ||||||
23 | the Department of Public Aid:
| ||||||
24 | (1) dental services, which shall include but not be | ||||||
25 | limited to
prosthodontics; and
| ||||||
26 | (2) eyeglasses prescribed by a physician skilled in the |
| |||||||
| |||||||
1 | diseases of the
eye, or by an optometrist, whichever the | ||||||
2 | person may select.
| ||||||
3 | The Illinois Department, by rule, may distinguish and | ||||||
4 | classify the
medical services to be provided only in accordance | ||||||
5 | with the classes of
persons designated in Section 5-2.
| ||||||
6 | The Department of Healthcare and Family Services must | ||||||
7 | provide coverage for nonprescription amino acid-based | ||||||
8 | elemental formulas, regardless of delivery method, for the | ||||||
9 | diagnosis and treatment of (i) milk protein allergies and | ||||||
10 | intolerances, (ii) eosinophilic disorders, and (iii) impaired | ||||||
11 | absorption of nutrients caused by disorders affecting the | ||||||
12 | absorptive surface, functional length, and motility of the | ||||||
13 | gastrointestinal tract, when the prescribing physician has | ||||||
14 | issued a written order stating that the amino acid-based | ||||||
15 | elemental formula is medically necessary for the treatment of a | ||||||
16 | disease or disorder and is the least restrictive and most | ||||||
17 | cost-effective means for meeting the needs of the patient. | ||||||
18 | The Department of Healthcare and Family Services must | ||||||
19 | provide coverage for specialized amino acid-based elemental | ||||||
20 | formulas, regardless of delivery method, when the prescribing | ||||||
21 | physician has issued a written order stating that such | ||||||
22 | specialized amino acid-based elemental formula is medically | ||||||
23 | necessary for the treatment of a disease or disorder and is the | ||||||
24 | least restrictive and most cost-effective means for meeting the | ||||||
25 | needs of the patient.
| ||||||
26 | The Illinois Department shall authorize the provision of, |
| |||||||
| |||||||
1 | and shall
authorize payment for, screening by low-dose | ||||||
2 | mammography for the presence of
occult breast cancer for women | ||||||
3 | 35 years of age or older who are eligible
for medical | ||||||
4 | assistance under this Article, as follows: a baseline
mammogram | ||||||
5 | for women 35 to 39 years of age and an
annual mammogram for | ||||||
6 | women 40 years of age or older. All screenings
shall
include a | ||||||
7 | physical breast exam, instruction on self-examination and
| ||||||
8 | information regarding the frequency of self-examination and | ||||||
9 | its value as a
preventative tool. As used in this Section, | ||||||
10 | "low-dose mammography" means
the x-ray examination of the | ||||||
11 | breast using equipment dedicated specifically
for mammography, | ||||||
12 | including the x-ray tube, filter, compression device,
image | ||||||
13 | receptor, and cassettes, with an average radiation exposure | ||||||
14 | delivery
of less than one rad mid-breast, with 2 views for each | ||||||
15 | breast.
| ||||||
16 | Any medical or health care provider shall immediately | ||||||
17 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
18 | services and is suspected
of drug abuse or is addicted as | ||||||
19 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
20 | Act, referral to a local substance abuse treatment provider
| ||||||
21 | licensed by the Department of Human Services or to a licensed
| ||||||
22 | hospital which provides substance abuse treatment services. | ||||||
23 | The Department of Healthcare and Family Services
Public Aid
| ||||||
24 | shall assure coverage for the cost of treatment of the drug | ||||||
25 | abuse or
addiction for pregnant recipients in accordance with | ||||||
26 | the Illinois Medicaid
Program in conjunction with the |
| |||||||
| |||||||
1 | Department of Human Services.
| ||||||
2 | All medical providers providing medical assistance to | ||||||
3 | pregnant women
under this Code shall receive information from | ||||||
4 | the Department on the
availability of services under the Drug | ||||||
5 | Free Families with a Future or any
comparable program providing | ||||||
6 | case management services for addicted women,
including | ||||||
7 | information on appropriate referrals for other social services
| ||||||
8 | that may be needed by addicted women in addition to treatment | ||||||
9 | for addiction.
| ||||||
10 | The Illinois Department, in cooperation with the | ||||||
11 | Departments of Human
Services (as successor to the Department | ||||||
12 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
13 | public awareness campaign, may
provide information concerning | ||||||
14 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
15 | health care, and other pertinent programs directed at
reducing | ||||||
16 | the number of drug-affected infants born to recipients of | ||||||
17 | medical
assistance.
| ||||||
18 | Neither the Illinois Department of Healthcare and Family | ||||||
19 | Services
Public Aid nor the Department of Human
Services shall | ||||||
20 | sanction the recipient solely on the basis of
her substance | ||||||
21 | abuse.
| ||||||
22 | The Illinois Department shall establish such regulations | ||||||
23 | governing
the dispensing of health services under this Article | ||||||
24 | as it shall deem
appropriate. The Department
should
seek the | ||||||
25 | advice of formal professional advisory committees appointed by
| ||||||
26 | the Director of the Illinois Department for the purpose of |
| |||||||
| |||||||
1 | providing regular
advice on policy and administrative matters, | ||||||
2 | information dissemination and
educational activities for | ||||||
3 | medical and health care providers, and
consistency in | ||||||
4 | procedures to the Illinois Department.
| ||||||
5 | The Illinois Department may develop and contract with | ||||||
6 | Partnerships of
medical providers to arrange medical services | ||||||
7 | for persons eligible under
Section 5-2 of this Code. | ||||||
8 | Implementation of this Section may be by
demonstration projects | ||||||
9 | in certain geographic areas. The Partnership shall
be | ||||||
10 | represented by a sponsor organization. The Department, by rule, | ||||||
11 | shall
develop qualifications for sponsors of Partnerships. | ||||||
12 | Nothing in this
Section shall be construed to require that the | ||||||
13 | sponsor organization be a
medical organization.
| ||||||
14 | The sponsor must negotiate formal written contracts with | ||||||
15 | medical
providers for physician services, inpatient and | ||||||
16 | outpatient hospital care,
home health services, treatment for | ||||||
17 | alcoholism and substance abuse, and
other services determined | ||||||
18 | necessary by the Illinois Department by rule for
delivery by | ||||||
19 | Partnerships. Physician services must include prenatal and
| ||||||
20 | obstetrical care. The Illinois Department shall reimburse | ||||||
21 | medical services
delivered by Partnership providers to clients | ||||||
22 | in target areas according to
provisions of this Article and the | ||||||
23 | Illinois Health Finance Reform Act,
except that:
| ||||||
24 | (1) Physicians participating in a Partnership and | ||||||
25 | providing certain
services, which shall be determined by | ||||||
26 | the Illinois Department, to persons
in areas covered by the |
| |||||||
| |||||||
1 | Partnership may receive an additional surcharge
for such | ||||||
2 | services.
| ||||||
3 | (2) The Department may elect to consider and negotiate | ||||||
4 | financial
incentives to encourage the development of | ||||||
5 | Partnerships and the efficient
delivery of medical care.
| ||||||
6 | (3) Persons receiving medical services through | ||||||
7 | Partnerships may receive
medical and case management | ||||||
8 | services above the level usually offered
through the | ||||||
9 | medical assistance program.
| ||||||
10 | Medical providers shall be required to meet certain | ||||||
11 | qualifications to
participate in Partnerships to ensure the | ||||||
12 | delivery of high quality medical
services. These | ||||||
13 | qualifications shall be determined by rule of the Illinois
| ||||||
14 | Department and may be higher than qualifications for | ||||||
15 | participation in the
medical assistance program. Partnership | ||||||
16 | sponsors may prescribe reasonable
additional qualifications | ||||||
17 | for participation by medical providers, only with
the prior | ||||||
18 | written approval of the Illinois Department.
| ||||||
19 | Nothing in this Section shall limit the free choice of | ||||||
20 | practitioners,
hospitals, and other providers of medical | ||||||
21 | services by clients.
In order to ensure patient freedom of | ||||||
22 | choice, the Illinois Department shall
immediately promulgate | ||||||
23 | all rules and take all other necessary actions so that
provided | ||||||
24 | services may be accessed from therapeutically certified | ||||||
25 | optometrists
to the full extent of the Illinois Optometric | ||||||
26 | Practice Act of 1987 without
discriminating between service |
| |||||||
| |||||||
1 | providers.
| ||||||
2 | The Department shall apply for a waiver from the United | ||||||
3 | States Health
Care Financing Administration to allow for the | ||||||
4 | implementation of
Partnerships under this Section.
| ||||||
5 | The Illinois Department shall require health care | ||||||
6 | providers to maintain
records that document the medical care | ||||||
7 | and services provided to recipients
of Medical Assistance under | ||||||
8 | this Article. The Illinois Department shall
require health care | ||||||
9 | providers to make available, when authorized by the
patient, in | ||||||
10 | writing, the medical records in a timely fashion to other
| ||||||
11 | health care providers who are treating or serving persons | ||||||
12 | eligible for
Medical Assistance under this Article. All | ||||||
13 | dispensers of medical services
shall be required to maintain | ||||||
14 | and retain business and professional records
sufficient to | ||||||
15 | fully and accurately document the nature, scope, details and
| ||||||
16 | receipt of the health care provided to persons eligible for | ||||||
17 | medical
assistance under this Code, in accordance with | ||||||
18 | regulations promulgated by
the Illinois Department. The rules | ||||||
19 | and regulations shall require that proof
of the receipt of | ||||||
20 | prescription drugs, dentures, prosthetic devices and
| ||||||
21 | eyeglasses by eligible persons under this Section accompany | ||||||
22 | each claim
for reimbursement submitted by the dispenser of such | ||||||
23 | medical services.
No such claims for reimbursement shall be | ||||||
24 | approved for payment by the Illinois
Department without such | ||||||
25 | proof of receipt, unless the Illinois Department
shall have put | ||||||
26 | into effect and shall be operating a system of post-payment
|
| |||||||
| |||||||
1 | audit and review which shall, on a sampling basis, be deemed | ||||||
2 | adequate by
the Illinois Department to assure that such drugs, | ||||||
3 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
4 | is being made are actually being
received by eligible | ||||||
5 | recipients. Within 90 days after the effective date of
this | ||||||
6 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
7 | a
current list of acquisition costs for all prosthetic devices | ||||||
8 | and any
other items recognized as medical equipment and | ||||||
9 | supplies reimbursable under
this Article and shall update such | ||||||
10 | list on a quarterly basis, except that
the acquisition costs of | ||||||
11 | all prescription drugs shall be updated no
less frequently than | ||||||
12 | every 30 days as required by Section 5-5.12.
| ||||||
13 | The rules and regulations of the Illinois Department shall | ||||||
14 | require
that a written statement including the required opinion | ||||||
15 | of a physician
shall accompany any claim for reimbursement for | ||||||
16 | abortions, or induced
miscarriages or premature births. This | ||||||
17 | statement shall indicate what
procedures were used in providing | ||||||
18 | such medical services.
| ||||||
19 | The Illinois Department shall require all dispensers of | ||||||
20 | medical
services, other than an individual practitioner or | ||||||
21 | group of practitioners,
desiring to participate in the Medical | ||||||
22 | Assistance program
established under this Article to disclose | ||||||
23 | all financial, beneficial,
ownership, equity, surety or other | ||||||
24 | interests in any and all firms,
corporations, partnerships, | ||||||
25 | associations, business enterprises, joint
ventures, agencies, | ||||||
26 | institutions or other legal entities providing any
form of |
| |||||||
| |||||||
1 | health care services in this State under this Article.
| ||||||
2 | The Illinois Department may require that all dispensers of | ||||||
3 | medical
services desiring to participate in the medical | ||||||
4 | assistance program
established under this Article disclose, | ||||||
5 | under such terms and conditions as
the Illinois Department may | ||||||
6 | by rule establish, all inquiries from clients
and attorneys | ||||||
7 | regarding medical bills paid by the Illinois Department, which
| ||||||
8 | inquiries could indicate potential existence of claims or liens | ||||||
9 | for the
Illinois Department.
| ||||||
10 | Enrollment of a vendor that provides non-emergency medical | ||||||
11 | transportation,
defined by the Department by rule,
shall be
| ||||||
12 | conditional for 180 days. During that time, the Department of | ||||||
13 | Healthcare and Family Services
Public Aid may
terminate the | ||||||
14 | vendor's eligibility to participate in the medical assistance
| ||||||
15 | program without cause. That termination of eligibility is not | ||||||
16 | subject to the
Department's hearing process.
| ||||||
17 | The Illinois Department shall establish policies, | ||||||
18 | procedures,
standards and criteria by rule for the acquisition, | ||||||
19 | repair and replacement
of orthotic and prosthetic devices and | ||||||
20 | durable medical equipment. Such
rules shall provide, but not be | ||||||
21 | limited to, the following services: (1)
immediate repair or | ||||||
22 | replacement of such devices by recipients without
medical | ||||||
23 | authorization; and (2) rental, lease, purchase or | ||||||
24 | lease-purchase of
durable medical equipment in a | ||||||
25 | cost-effective manner, taking into
consideration the | ||||||
26 | recipient's medical prognosis, the extent of the
recipient's |
| |||||||
| |||||||
1 | needs, and the requirements and costs for maintaining such
| ||||||
2 | equipment. Such rules shall enable a recipient to temporarily | ||||||
3 | acquire and
use alternative or substitute devices or equipment | ||||||
4 | pending repairs or
replacements of any device or equipment | ||||||
5 | previously authorized for such
recipient by the Department.
| ||||||
6 | The Department shall execute, relative to the nursing home | ||||||
7 | prescreening
project, written inter-agency agreements with the | ||||||
8 | Department of Human
Services and the Department on Aging, to | ||||||
9 | effect the following: (i) intake
procedures and common | ||||||
10 | eligibility criteria for those persons who are receiving
| ||||||
11 | non-institutional services; and (ii) the establishment and | ||||||
12 | development of
non-institutional services in areas of the State | ||||||
13 | where they are not currently
available or are undeveloped.
| ||||||
14 | The Illinois Department shall develop and operate, in | ||||||
15 | cooperation
with other State Departments and agencies and in | ||||||
16 | compliance with
applicable federal laws and regulations, | ||||||
17 | appropriate and effective
systems of health care evaluation and | ||||||
18 | programs for monitoring of
utilization of health care services | ||||||
19 | and facilities, as it affects
persons eligible for medical | ||||||
20 | assistance under this Code.
| ||||||
21 | The Illinois Department shall report annually to the | ||||||
22 | General Assembly,
no later than the second Friday in April of | ||||||
23 | 1979 and each year
thereafter, in regard to:
| ||||||
24 | (a) actual statistics and trends in utilization of | ||||||
25 | medical services by
public aid recipients;
| ||||||
26 | (b) actual statistics and trends in the provision of |
| |||||||
| |||||||
1 | the various medical
services by medical vendors;
| ||||||
2 | (c) current rate structures and proposed changes in | ||||||
3 | those rate structures
for the various medical vendors; and
| ||||||
4 | (d) efforts at utilization review and control by the | ||||||
5 | Illinois Department.
| ||||||
6 | The period covered by each report shall be the 3 years | ||||||
7 | ending on the June
30 prior to the report. The report shall | ||||||
8 | include suggested legislation
for consideration by the General | ||||||
9 | Assembly. The filing of one copy of the
report with the | ||||||
10 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
11 | the Clerk of the House of Representatives, one copy with the | ||||||
12 | President,
one copy with the Minority Leader and one copy with | ||||||
13 | the Secretary of the
Senate, one copy with the Legislative | ||||||
14 | Research Unit, and such additional
copies
with the State | ||||||
15 | Government Report Distribution Center for the General
Assembly | ||||||
16 | as is required under paragraph (t) of Section 7 of the State
| ||||||
17 | Library Act shall be deemed sufficient to comply with this | ||||||
18 | Section.
| ||||||
19 | (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02; | ||||||
20 | 92-789, eff. 8-6-02; 93-632, eff. 2-1-04; 93-841, eff. 7-30-04; | ||||||
21 | 93-981, eff. 8-23-04; revised 12-15-05.)
| ||||||
22 | Section 99. Effective date. This Act takes effect upon | ||||||
23 | becoming law.".
|