94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB1298

 

Introduced 02/09/05, by Rep. Constance A. Howard

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5   from Ch. 23, par. 5-5

    Amends the Illinois Public Aid Code. Requires the Department of Public Aid to provide coverage of comprehensive and appropriate substance abuse treatment services to persons who are eligible for Medicaid. Provides that a person who is eligible for Medicaid is entitled to receive comprehensive and appropriate substance abuse treatment services on demand, without being placed on a waiting list other than as required by the schedule of the provider of the services. Provides that the services may be provided by a local substance abuse treatment provider licensed by the Department of Human Services or by a licensed hospital that provides substance abuse treatment services. Effective January 1, 2006.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB1298 LRB094 07258 DRJ 37414 b

1     AN ACT concerning 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 rate
9 of reimbursement for the medical assistance for which payment
10 will be authorized, and the medical services to be provided,
11 which may include all or part of the following: (1) inpatient
12 hospital services; (2) outpatient hospital services; (3) other
13 laboratory and X-ray services; (4) skilled nursing home
14 services; (5) physicians' services whether furnished in the
15 office, the patient's home, a hospital, a skilled nursing home,
16 or elsewhere; (6) medical care, or any other type of remedial
17 care furnished by licensed practitioners; (7) home health care
18 services; (8) private duty nursing service; (9) clinic
19 services; (10) dental services, including prevention and
20 treatment of periodontal disease and dental caries disease for
21 pregnant women; (11) physical therapy and related services;
22 (12) prescribed drugs, dentures, and prosthetic devices; and
23 eyeglasses prescribed by a physician skilled in the diseases of
24 the eye, or by an optometrist, whichever the person may select;
25 (13) other diagnostic, screening, preventive, and
26 rehabilitative services; (14) transportation and such other
27 expenses as may be necessary; (15) medical treatment of sexual
28 assault survivors, as defined in Section 1a of the Sexual
29 Assault Survivors Emergency Treatment Act, for injuries
30 sustained as a result of the sexual assault, including
31 examinations and laboratory tests to discover evidence which
32 may be used in criminal proceedings arising from the sexual

 

 

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1 assault; (16) the diagnosis and treatment of sickle cell
2 anemia; and (17) any other medical care, and any other type of
3 remedial care recognized under the laws of this State, but not
4 including abortions, or induced miscarriages or premature
5 births, unless, in the opinion of a physician, such procedures
6 are necessary for the preservation of the life of the woman
7 seeking such treatment, or except an induced premature birth
8 intended to produce a live viable child and such procedure is
9 necessary for the health of the mother or her unborn child. The
10 Illinois Department, by rule, shall prohibit any physician from
11 providing medical assistance to anyone eligible therefor under
12 this Code where such physician has been found guilty of
13 performing an abortion procedure in a wilful and wanton manner
14 upon a woman who was not pregnant at the time such abortion
15 procedure was performed. The term "any other type of remedial
16 care" shall include nursing care and nursing home service for
17 persons who rely on treatment by spiritual means alone through
18 prayer for healing.
19     Notwithstanding any other provision of this Section, a
20 comprehensive tobacco use cessation program that includes
21 purchasing prescription drugs or prescription medical devices
22 approved by the Food and Drug administration shall be covered
23 under the medical assistance program under this Article for
24 persons who are otherwise eligible for assistance under this
25 Article.
26     Notwithstanding any other provision of this Code, the
27 Illinois Department may not require, as a condition of payment
28 for any laboratory test authorized under this Article, that a
29 physician's handwritten signature appear on the laboratory
30 test order form. The Illinois Department may, however, impose
31 other appropriate requirements regarding laboratory test order
32 documentation.
33     The Illinois Department of Public Aid shall provide the
34 following services to persons eligible for assistance under
35 this Article who are participating in education, training or
36 employment programs operated by the Department of Human

 

 

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1 Services as successor to the Department of Public Aid:
2         (1) dental services, which shall include but not be
3     limited to prosthodontics; and
4         (2) eyeglasses prescribed by a physician skilled in the
5     diseases of the eye, or by an optometrist, whichever the
6     person may select.
7     The Illinois Department, by rule, may distinguish and
8 classify the medical services to be provided only in accordance
9 with the classes of persons designated in Section 5-2.
10     The Illinois Department shall authorize the provision of,
11 and shall authorize payment for, screening by low-dose
12 mammography for the presence of occult breast cancer for women
13 35 years of age or older who are eligible for medical
14 assistance under this Article, as follows: a baseline mammogram
15 for women 35 to 39 years of age and an annual mammogram for
16 women 40 years of age or older. All screenings shall include a
17 physical breast exam, instruction on self-examination and
18 information regarding the frequency of self-examination and
19 its value as a preventative tool. As used in this Section,
20 "low-dose mammography" means the x-ray examination of the
21 breast using equipment dedicated specifically for mammography,
22 including the x-ray tube, filter, compression device, image
23 receptor, and cassettes, with an average radiation exposure
24 delivery of less than one rad mid-breast, with 2 views for each
25 breast.
26     The Department of Public Aid shall provide coverage of
27 comprehensive and appropriate substance abuse treatment
28 services to persons who are eligible for medical assistance
29 under this Article. A person who is eligible for medical
30 assistance under this Article is entitled to receive
31 comprehensive and appropriate substance abuse treatment
32 services on demand, without being placed on a waiting list
33 other than as required by the schedule of the provider of the
34 services. The services may be provided by a local substance
35 abuse treatment provider licensed by the Department of Human
36 Services or by a licensed hospital that provides substance

 

 

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1 abuse treatment services.
2     Any medical or health care provider shall immediately
3 recommend, to any pregnant woman who is being provided prenatal
4 services and is suspected of drug abuse or is addicted as
5 defined in the Alcoholism and Other Drug Abuse and Dependency
6 Act, referral to a local substance abuse treatment provider
7 licensed by the Department of Human Services or to a licensed
8 hospital which provides substance abuse treatment services.
9 The Department of Public Aid shall assure coverage for the cost
10 of treatment of the drug abuse or addiction for pregnant
11 recipients in accordance with the Illinois Medicaid Program in
12 conjunction with the Department of Human Services.
13     All medical providers providing medical assistance to
14 pregnant women under this Code shall receive information from
15 the Department on the availability of services under the Drug
16 Free Families with a Future or any comparable program providing
17 case management services for addicted women, including
18 information on appropriate referrals for other social services
19 that may be needed by addicted women in addition to treatment
20 for addiction.
21     The Illinois Department, in cooperation with the
22 Departments of Human Services (as successor to the Department
23 of Alcoholism and Substance Abuse) and Public Health, through a
24 public awareness campaign, may provide information concerning
25 treatment for alcoholism and drug abuse and addiction, prenatal
26 health care, and other pertinent programs directed at reducing
27 the number of drug-affected infants born to recipients of
28 medical assistance.
29     Neither the Illinois Department of Public Aid nor the
30 Department of Human Services shall sanction the recipient
31 solely on the basis of her substance abuse.
32     The Illinois Department shall establish such regulations
33 governing the dispensing of health services under this Article
34 as it shall deem appropriate. The Department should seek the
35 advice of formal professional advisory committees appointed by
36 the Director of the Illinois Department for the purpose of

 

 

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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
27     Partnership may receive an additional surcharge for such
28     services.
29         (2) The Department may elect to consider and negotiate
30     financial incentives to encourage the development of
31     Partnerships and the efficient delivery of medical care.
32         (3) Persons receiving medical services through
33     Partnerships may receive medical and case management
34     services above the level usually offered through the
35     medical assistance program.
36     Medical providers shall be required to meet certain

 

 

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1 qualifications to participate in Partnerships to ensure the
2 delivery of high quality medical services. These
3 qualifications shall be determined by rule of the Illinois
4 Department and may be higher than qualifications for
5 participation in the medical assistance program. Partnership
6 sponsors may prescribe reasonable additional qualifications
7 for participation by medical providers, only with the prior
8 written approval of the Illinois Department.
9     Nothing in this Section shall limit the free choice of
10 practitioners, hospitals, and other providers of medical
11 services by clients. In order to ensure patient freedom of
12 choice, the Illinois Department shall immediately promulgate
13 all rules and take all other necessary actions so that provided
14 services may be accessed from therapeutically certified
15 optometrists to the full extent of the Illinois Optometric
16 Practice Act of 1987 without discriminating between service
17 providers.
18     The Department shall apply for a waiver from the United
19 States Health Care Financing Administration to allow for the
20 implementation of Partnerships under this Section.
21     The Illinois Department shall require health care
22 providers to maintain records that document the medical care
23 and services provided to recipients of Medical Assistance under
24 this Article. The Illinois Department shall require health care
25 providers to make available, when authorized by the patient, in
26 writing, the medical records in a timely fashion to other
27 health care providers who are treating or serving persons
28 eligible for Medical Assistance under this Article. All
29 dispensers of medical services shall be required to maintain
30 and retain business and professional records sufficient to
31 fully and accurately document the nature, scope, details and
32 receipt of the health care provided to persons eligible for
33 medical assistance under this Code, in accordance with
34 regulations promulgated by the Illinois Department. The rules
35 and regulations shall require that proof of the receipt of
36 prescription drugs, dentures, prosthetic devices and

 

 

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1 eyeglasses by eligible persons under this Section accompany
2 each claim for reimbursement submitted by the dispenser of such
3 medical services. No such claims for reimbursement shall be
4 approved for payment by the Illinois Department without such
5 proof of receipt, unless the Illinois Department shall have put
6 into effect and shall be operating a system of post-payment
7 audit and review which shall, on a sampling basis, be deemed
8 adequate by the Illinois Department to assure that such drugs,
9 dentures, prosthetic devices and eyeglasses for which payment
10 is being made are actually being received by eligible
11 recipients. Within 90 days after the effective date of this
12 amendatory Act of 1984, the Illinois Department shall establish
13 a current list of acquisition costs for all prosthetic devices
14 and any other items recognized as medical equipment and
15 supplies reimbursable under this Article and shall update such
16 list on a quarterly basis, except that the acquisition costs of
17 all prescription drugs shall be updated no less frequently than
18 every 30 days as required by Section 5-5.12.
19     The rules and regulations of the Illinois Department shall
20 require that a written statement including the required opinion
21 of a physician shall accompany any claim for reimbursement for
22 abortions, or induced miscarriages or premature births. This
23 statement shall indicate what procedures were used in providing
24 such medical services.
25     The Illinois Department shall require all dispensers of
26 medical services, other than an individual practitioner or
27 group of practitioners, desiring to participate in the Medical
28 Assistance program established under this Article to disclose
29 all financial, beneficial, ownership, equity, surety or other
30 interests in any and all firms, corporations, partnerships,
31 associations, business enterprises, joint ventures, agencies,
32 institutions or other legal entities providing any form of
33 health care services in this State under this Article.
34     The Illinois Department may require that all dispensers of
35 medical services desiring to participate in the medical
36 assistance program established under this Article disclose,

 

 

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1 under such terms and conditions as the Illinois Department may
2 by rule establish, all inquiries from clients and attorneys
3 regarding medical bills paid by the Illinois Department, which
4 inquiries could indicate potential existence of claims or liens
5 for the Illinois Department.
6     Enrollment of a vendor that provides non-emergency medical
7 transportation, defined by the Department by rule, shall be
8 conditional for 180 days. During that time, the Department of
9 Public Aid may terminate the vendor's eligibility to
10 participate in the medical assistance program without cause.
11 That termination of eligibility is not subject to the
12 Department's hearing process.
13     The Illinois Department shall establish policies,
14 procedures, standards and criteria by rule for the acquisition,
15 repair and replacement of orthotic and prosthetic devices and
16 durable medical equipment. Such rules shall provide, but not be
17 limited to, the following services: (1) immediate repair or
18 replacement of such devices by recipients without medical
19 authorization; and (2) rental, lease, purchase or
20 lease-purchase of durable medical equipment in a
21 cost-effective manner, taking into consideration the
22 recipient's medical prognosis, the extent of the recipient's
23 needs, and the requirements and costs for maintaining such
24 equipment. Such rules shall enable a recipient to temporarily
25 acquire and use alternative or substitute devices or equipment
26 pending repairs or replacements of any device or equipment
27 previously authorized for such recipient by the Department.
28     The Department shall execute, relative to the nursing home
29 prescreening project, written inter-agency agreements with the
30 Department of Human Services and the Department on Aging, to
31 effect the following: (i) intake procedures and common
32 eligibility criteria for those persons who are receiving
33 non-institutional services; and (ii) the establishment and
34 development of non-institutional services in areas of the State
35 where they are not currently available or are undeveloped.
36     The Illinois Department shall develop and operate, in

 

 

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1 cooperation with other State Departments and agencies and in
2 compliance with applicable federal laws and regulations,
3 appropriate and effective systems of health care evaluation and
4 programs for monitoring of utilization of health care services
5 and facilities, as it affects persons eligible for medical
6 assistance under this Code.
7     The Illinois Department shall report annually to the
8 General Assembly, no later than the second Friday in April of
9 1979 and each year thereafter, in regard to:
10         (a) actual statistics and trends in utilization of
11     medical services by public aid recipients;
12         (b) actual statistics and trends in the provision of
13     the various medical services by medical vendors;
14         (c) current rate structures and proposed changes in
15     those rate structures for the various medical vendors; and
16         (d) efforts at utilization review and control by the
17     Illinois Department.
18     The period covered by each report shall be the 3 years
19 ending on the June 30 prior to the report. The report shall
20 include suggested legislation for consideration by the General
21 Assembly. The filing of one copy of the report with the
22 Speaker, one copy with the Minority Leader and one copy with
23 the Clerk of the House of Representatives, one copy with the
24 President, one copy with the Minority Leader and one copy with
25 the Secretary of the Senate, one copy with the Legislative
26 Research Unit, and such additional copies with the State
27 Government Report Distribution Center for the General Assembly
28 as is required under paragraph (t) of Section 7 of the State
29 Library Act shall be deemed sufficient to comply with this
30 Section.
31 (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02;
32 92-789, eff. 8-6-02; 93-632, eff. 2-1-04; 93-841, eff. 7-30-04;
33 93-981, eff. 8-23-04; revised 10-22-04.)
 
34     Section 99. Effective date. This Act takes effect January
35 1, 2006.