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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Covering ALL KIDS Health Insurance Act is | ||||||||||||||||||||||||||||||||
5 | amended by changing Sections 40 and 50 and by adding Sections | ||||||||||||||||||||||||||||||||
6 | 47, 52, and 53 as follows: | ||||||||||||||||||||||||||||||||
7 | (215 ILCS 170/40) | ||||||||||||||||||||||||||||||||
8 | (Section scheduled to be repealed on July 1, 2011)
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9 | Sec. 40. Cost-sharing. | ||||||||||||||||||||||||||||||||
10 | (a) Children enrolled in the Program under subsection (a) | ||||||||||||||||||||||||||||||||
11 | of Section 35 are subject to the following cost-sharing | ||||||||||||||||||||||||||||||||
12 | requirements:
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13 | (1) The Department, by rule, shall set forth | ||||||||||||||||||||||||||||||||
14 | requirements concerning co-payments and coinsurance for | ||||||||||||||||||||||||||||||||
15 | health care services and monthly premiums. This | ||||||||||||||||||||||||||||||||
16 | cost-sharing shall be on a sliding scale based on family | ||||||||||||||||||||||||||||||||
17 | income. The Department may periodically modify such | ||||||||||||||||||||||||||||||||
18 | cost-sharing.
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19 | (2) There
Notwithstanding paragraph (1), there shall | ||||||||||||||||||||||||||||||||
20 | be no co-payment or coinsurance required for any services | ||||||||||||||||||||||||||||||||
21 | under the Program
well-baby or well-child health care, | ||||||||||||||||||||||||||||||||
22 | including, but not limited to, age-appropriate | ||||||||||||||||||||||||||||||||
23 | immunizations as required under State or federal law .
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1 | (b) Children enrolled in a privately sponsored health | ||||||
2 | insurance plan under subsection (b) of Section 35 are subject | ||||||
3 | to the cost-sharing provisions stated in the privately | ||||||
4 | sponsored health insurance plan.
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5 | (c) Notwithstanding any other provision of law, rates paid | ||||||
6 | by the Department shall not be used in any way to determine the | ||||||
7 | usual and customary or reasonable charge, which is the charge | ||||||
8 | for health care that is consistent with the average rate or | ||||||
9 | charge for similar services furnished by similar providers in a | ||||||
10 | certain geographic area.
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11 | (Source: P.A. 94-693, eff. 7-1-06 .) | ||||||
12 | (215 ILCS 170/47 new)
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13 | Sec. 47. Program Information. The Department shall report | ||||||
14 | to the General Assembly no later than September 1 of each year | ||||||
15 | beginning in 2007, all of the following information: | ||||||
16 | (a) The number of professionals serving in the primary care | ||||||
17 | case management program, by licensed profession and by county, | ||||||
18 | and, for counties with a population of 100,000 or greater, by | ||||||
19 | geo zip code. | ||||||
20 | (b) The number of non-primary care providers accepting | ||||||
21 | referrals, by specialty designation, by licensed profession | ||||||
22 | and by county, and, for counties with a population of 100,000 | ||||||
23 | or greater, by geo zip code.
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24 | (c) The number of individuals enrolled in the Covering ALL | ||||||
25 | KIDS Health Insurance Program by income or premium level and by |
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1 | county, and, for counties with a population of 100,000 or | ||||||
2 | greater, by geo zip code. | ||||||
3 | (215 ILCS 170/50) | ||||||
4 | (Section scheduled to be repealed on July 1, 2011)
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5 | Sec. 50. Consultation with stakeholders. The Department | ||||||
6 | shall present details regarding implementation of the Program | ||||||
7 | to the Medicaid Advisory Committee, and the Committee shall | ||||||
8 | serve as the forum for healthcare providers, advocates, | ||||||
9 | consumers, and other interested parties to advise the | ||||||
10 | Department with respect to the Program. The Department shall | ||||||
11 | consult with stakeholders on the rules for healthcare | ||||||
12 | professional participation in the Program pursuant to Sections | ||||||
13 | 52 and 53 of this Act.
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14 | (Source: P.A. 94-693, eff. 7-1-06 .) | ||||||
15 | (215 ILCS 170/52 new) | ||||||
16 | Sec. 52. Adequate access to specialty care. | ||||||
17 | (a) The Department shall ensure adequate access to | ||||||
18 | specialty physician care for Program participants by allowing | ||||||
19 | referrals to be accomplished without undue delay. | ||||||
20 | (b) The Department shall allow a primary care provider to | ||||||
21 | make appropriate referrals to specialist physicians or other | ||||||
22 | healthcare providers for an enrollee who has a condition that | ||||||
23 | requires care from a specialist physician or other healthcare | ||||||
24 | provider. A referral shall be effective for the period |
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1 | necessary to provide the referred services or one year, | ||||||
2 | whichever is less. A primary care provider may renew and | ||||||
3 | re-renew a referral. | ||||||
4 | (c) The enrollee's primary care provider shall remain | ||||||
5 | responsible for coordinating the care of an enrollee who has | ||||||
6 | received a standing referral to a specialist physician or other | ||||||
7 | healthcare provider. If a secondary referral is necessary, the | ||||||
8 | specialist physician or other healthcare provider shall advise | ||||||
9 | the primary care physician. The specialist physician shall be | ||||||
10 | responsible for making the secondary referral. In addition, the | ||||||
11 | Department shall require the specialist physician or other | ||||||
12 | healthcare provider to provide regular updates to the | ||||||
13 | enrollee's primary care provider. | ||||||
14 | (215 ILCS 170/53 new) | ||||||
15 | Sec. 53. Program standards. | ||||||
16 | (a) Any disease management program implemented by the | ||||||
17 | Department must be or must have been developed in consultation | ||||||
18 | with physician organizations, such as State, national, and | ||||||
19 | specialty medical societies, and any available standards or | ||||||
20 | guidelines of these organizations. These programs must be based | ||||||
21 | on evidence-based, scientifically sound principles that are | ||||||
22 | accepted by the medical community. An enrollee must be excused | ||||||
23 | from participation in a disease management program if the | ||||||
24 | enrollee's physician licensed to practice medicine in all its | ||||||
25 | branches, in his or her professional judgment, determines that |
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1 | participation is not beneficial to the enrollee. | ||||||
2 | (b) Any performance measures, such as primary care provider | ||||||
3 | monitoring, implemented by the Department must be or must have | ||||||
4 | been developed on consultation with physician organizations, | ||||||
5 | such as State, national, and specialty medical societies, and | ||||||
6 | any available standards or guidelines of these organizations. | ||||||
7 | These measures must be based on evidence-based, scientifically | ||||||
8 | sound principles that are accepted by the medical community. | ||||||
9 | (c) The Department shall adopt variance procedures for the | ||||||
10 | application of any disease management program or any | ||||||
11 | performance measures to an individual enrollee.
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