Full Text of HB5331 96th General Assembly
HB5331eng 96TH GENERAL ASSEMBLY
|
|
|
HB5331 Engrossed |
|
LRB096 18929 KTG 34317 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 Sections 5-4.2 and 5-5 as follows:
| 6 |
| (305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)
| 7 |
| Sec. 5-4.2. Ground ambulance Ambulance services payments. | 8 |
| (a) For purposes of this Section, the following terms have | 9 |
| the following meanings: | 10 |
| "Department" means the Illinois Department of Healthcare | 11 |
| and Family Services. | 12 |
| "Ground ambulance services" means medical transportation | 13 |
| services that are described as ground ambulance services by the | 14 |
| Centers for Medicare and Medicaid Services and provided in a | 15 |
| vehicle that is licensed as an ambulance by the Illinois | 16 |
| Department of Public Health pursuant to the Emergency Medical | 17 |
| Services (EMS) Systems Act. | 18 |
| "Ground ambulance services provider" means a vehicle | 19 |
| service provider as described in the Emergency Medical Services | 20 |
| (EMS) Systems Act that operates licensed ambulances for the | 21 |
| purpose of providing emergency ambulance services, or | 22 |
| non-emergency ambulance services, or both. For purposes of this | 23 |
| Section, this includes both ambulance providers and ambulance |
|
|
|
HB5331 Engrossed |
- 2 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| suppliers as described by the Centers for Medicare and Medicaid | 2 |
| Services. | 3 |
| "Rural county" means: any county not located in a U.S. | 4 |
| Bureau of the Census Metropolitan Statistical Area (MSA); or | 5 |
| any county located within a U.S. Bureau of the Census | 6 |
| Metropolitan Statistical Area but having a population of 60,000 | 7 |
| or less. | 8 |
| (b) It is the intent of the General Assembly to provide for | 9 |
| the payment for ground ambulance services as part of the State | 10 |
| Medicaid plan and to provide adequate payment for ground | 11 |
| ambulance services under the State Medicaid plan so as to | 12 |
| ensure adequate access to ground ambulance services for both | 13 |
| recipients of aid under this Article and for the general | 14 |
| population of Illinois. Unless otherwise indicated in this | 15 |
| Section, the practices of the Department concerning payments | 16 |
| for ground ambulance services provided to recipients of aid | 17 |
| under this Article shall be consistent with the payment | 18 |
| principles of Medicare, including the statutes, regulations, | 19 |
| policies, procedures, principles, definitions, guidelines, | 20 |
| coding systems, including the ambulance condition coding | 21 |
| system, and manuals used by the Centers for Medicare and | 22 |
| Medicaid Services and the Medicare Part B Carrier or the | 23 |
| Medicare Administrative Contractor for the State of Illinois to | 24 |
| determine the payment system to ground ambulance services | 25 |
| providers under Title XVIII of the Social Security Act. | 26 |
| (c) For ground ambulance services provided to a recipient |
|
|
|
HB5331 Engrossed |
- 3 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| of aid under this Article on or after July 1, 2010, the | 2 |
| Department shall provide payment to ground ambulance services | 3 |
| providers for base charges and mileage charges based upon the | 4 |
| lesser of the provider's charge, as reflected on the provider's | 5 |
| claim form, or the Illinois Medicaid Ambulance Fee Schedule | 6 |
| payment rates calculated in accordance with this Section. | 7 |
| Effective July 1, 2010, the Illinois Medicaid Ambulance Fee | 8 |
| Schedule shall be established and shall include only the ground | 9 |
| ambulance services payment rates outlined in the Medicare | 10 |
| Ambulance Fee Schedule as promulgated by the Centers for | 11 |
| Medicare and Medicaid Services in effect as of July 1, 2010 and | 12 |
| adjusted for the 4 Medicare Localities in Illinois, with an | 13 |
| adjustment of 100% of the Medicare Ambulance Fee Schedule | 14 |
| payment rates, by Medicare Locality, for both base rates and | 15 |
| mileage for rural counties, and an adjustment of 80% of the | 16 |
| Medicare Ambulance Fee Schedule payment rates, by Medicare | 17 |
| Locality, for both base rates and mileage for all other | 18 |
| counties. The transition from the current payment system to the | 19 |
| Illinois Medicaid Ambulance Fee Schedule shall be by a 2-year | 20 |
| phase-in as follows: | 21 |
| (1) Effective for dates of service from July 1, 2010 | 22 |
| through June 30, 2011, for each individual base rate and | 23 |
| mileage rate, the payment rate for ground ambulance | 24 |
| services shall be based on 50% of the Medicaid payment rate | 25 |
| in effect as of January 1, 2010 and 50% of the Illinois | 26 |
| Medicaid Ambulance Fee Schedule amount in effect on July 1, |
|
|
|
HB5331 Engrossed |
- 4 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| 2010 for the designated Medicare Locality, except that any | 2 |
| payment rate that was previously approved by the Department | 3 |
| that exceeds this amount shall remain in force. | 4 |
| (2) Effective for dates of service on or after July 1, | 5 |
| 2011, for each individual base rate and mileage rate, the | 6 |
| payment rate for ground ambulance services shall be based | 7 |
| on 100% of the Illinois Medicaid Ambulance Fee Schedule | 8 |
| amount in effect on July 1, 2011 for the designated | 9 |
| Medicare Locality, except that any payment rate that was | 10 |
| previously approved by the Department that exceeds this | 11 |
| amount shall remain in force. | 12 |
| Effective for dates of service on or after July 1, 2011, | 13 |
| the Department shall update the Illinois Medicaid Ambulance Fee | 14 |
| Schedule payment rates so that they comply with the Medicare | 15 |
| Ambulance Fee Schedule payment rates for ground ambulance | 16 |
| services in effect at the time of the update, in the manner | 17 |
| prescribed in the second paragraph of this subsection (c). | 18 |
| (d) Payment for mileage shall be per loaded mile with no | 19 |
| loaded mileage included in the base rate. If a natural | 20 |
| disaster, weather, road repairs, traffic congestion, or other | 21 |
| conditions necessitate a route other than the most direct | 22 |
| route, payment shall be based upon the actual distance | 23 |
| traveled. Notwithstanding the payment principles in subsection | 24 |
| (b) of this Section, the Department shall develop the Illinois | 25 |
| Medicaid Ambulance Fee Schedule using the ground mileage | 26 |
| payment rate, as defined by the Centers for Medicare and |
|
|
|
HB5331 Engrossed |
- 5 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| Medicaid Services, and no other mileage rates which act as | 2 |
| enhancements to the ground mileage rate, whether permanent or | 3 |
| temporary, shall be recognized by the Department. When a ground | 4 |
| ambulance services provider provides transport pursuant to an | 5 |
| emergency call as defined by the Centers for Medicare and | 6 |
| Medicaid Services, no reduction in the mileage payment shall be | 7 |
| made based upon the fact that a closer facility may have been | 8 |
| available, so long as the ground ambulance services provider | 9 |
| provided transport to the recipient's facility of choice within | 10 |
| the scope of the Illinois Emergency Medical Services (EMS) | 11 |
| Systems Act and associated rules and the policies and | 12 |
| procedures of the EMS System of which the provider is a member. | 13 |
| (e) The Department shall provide payment for emergency | 14 |
| ground ambulance services provided to a recipient of aid under | 15 |
| this Article according to the requirements provided in | 16 |
| subsection (b) of this Section when those services are provided | 17 |
| pursuant to a request made through a 9-1-1 or equivalent | 18 |
| emergency telephone number for evaluation, treatment, and | 19 |
| transport from or on behalf of an individual with a condition | 20 |
| of such a nature that a prudent layperson would have reasonably | 21 |
| expected that a delay in seeking immediate medical attention | 22 |
| would have been hazardous to life or health. This standard is | 23 |
| deemed to be met if there is an emergency medical condition | 24 |
| manifesting itself by acute symptoms of sufficient severity, | 25 |
| including but not limited to severe pain, such that a prudent | 26 |
| layperson who possesses an average knowledge of medicine and |
|
|
|
HB5331 Engrossed |
- 6 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| health can reasonably expect that the absence of immediate | 2 |
| medical attention could result in placing the health of the | 3 |
| individual or, with respect to a pregnant woman, the health of | 4 |
| the woman or her unborn child, in serious jeopardy, cause | 5 |
| serious impairment to bodily functions, or cause serious | 6 |
| dysfunction of any bodily organ or part. | 7 |
| (f) For ground ambulance services provided to a recipient | 8 |
| enrolled in a Medicaid managed care plan by a ground ambulance | 9 |
| services provider that is not a contracted provider to the | 10 |
| Medicaid managed care plan in question, the amount of the | 11 |
| payment for ground ambulance services by the Medicaid managed | 12 |
| care plan shall be the lesser of the provider's charge, as | 13 |
| reflected on the provider's claim form, or the Illinois | 14 |
| Medicaid Ambulance Fee Schedule payment rates calculated in | 15 |
| accordance with this Section. | 16 |
| (g) Nothing in this Section prohibits the Department from | 17 |
| setting payment rates for out-of-State ground ambulance | 18 |
| services providers by administrative rule. | 19 |
| (h) Effective for dates of service on or after July 1, | 20 |
| 2010, payments for stretcher van services provided by ground | 21 |
| ambulance services providers shall be as follows: | 22 |
| (1) For each individual base rate, the amount of the | 23 |
| payment shall be the lesser of the provider's charge, as | 24 |
| reflected on the provider's claim form, or 80% of the | 25 |
| Illinois Medicaid Ambulance Fee Schedule payment rate for | 26 |
| the basic life support non-emergency base rate. |
|
|
|
HB5331 Engrossed |
- 7 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| (2) For each loaded mile, the amount of the payment | 2 |
| shall be the lesser of the provider's charge, as reflected | 3 |
| on the provider's claim form, or 80% of the Illinois | 4 |
| Medicaid Ambulance Fee Schedule payment rate for mileage. | 5 |
| (i) All payments under subsections (a) through (h) of this | 6 |
| Section are subject to the availability of appropriations for | 7 |
| those purposes. | 8 |
| For
ambulance
services provided to a recipient of aid under | 9 |
| this Article on or after
January 1, 1993, the Illinois | 10 |
| Department shall reimburse ambulance service
providers at | 11 |
| rates calculated in accordance with this Section. It is the | 12 |
| intent
of the General Assembly to provide adequate | 13 |
| reimbursement for ambulance
services so as to ensure adequate | 14 |
| access to services for recipients of aid
under this Article and | 15 |
| to provide appropriate incentives to ambulance service
| 16 |
| providers to provide services in an efficient and | 17 |
| cost-effective manner. Thus,
it is the intent of the General | 18 |
| Assembly that the Illinois Department implement
a | 19 |
| reimbursement system for ambulance services that, to the extent | 20 |
| practicable
and subject to the availability of funds | 21 |
| appropriated by the General Assembly
for this purpose, is | 22 |
| consistent with the payment principles of Medicare. To
ensure | 23 |
| uniformity between the payment principles of Medicare and | 24 |
| Medicaid, the
Illinois Department shall follow, to the extent | 25 |
| necessary and practicable and
subject to the availability of | 26 |
| funds appropriated by the General Assembly for
this purpose, |
|
|
|
HB5331 Engrossed |
- 8 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| the statutes, laws, regulations, policies, procedures,
| 2 |
| principles, definitions, guidelines, and manuals used to | 3 |
| determine the amounts
paid to ambulance service providers under | 4 |
| Title XVIII of the Social Security
Act (Medicare).
| 5 |
| For ambulance services provided to a recipient of aid under | 6 |
| this Article
on or after January 1, 1996, the Illinois | 7 |
| Department shall reimburse ambulance
service providers based | 8 |
| upon the actual distance traveled if a natural
disaster, | 9 |
| weather conditions, road repairs, or traffic congestion | 10 |
| necessitates
the use of a
route other than the most direct | 11 |
| route.
| 12 |
| For purposes of this Section, "ambulance services" | 13 |
| includes medical
transportation services provided by means of | 14 |
| an ambulance, medi-car, service
car, or
taxi.
| 15 |
| This Section does not prohibit separate billing by | 16 |
| ambulance service
providers for oxygen furnished while | 17 |
| providing advanced life support
services.
| 18 |
| (j) Beginning with services rendered on or after July 1, | 19 |
| 2008, all providers of non-emergency medi-car and service car | 20 |
| transportation must certify that the driver and employee | 21 |
| attendant, as applicable, have completed a safety program | 22 |
| approved by the Department to protect both the patient and the | 23 |
| driver, prior to transporting a patient.
The provider must | 24 |
| maintain this certification in its records. The provider shall | 25 |
| produce such documentation upon demand by the Department or its | 26 |
| representative. Failure to produce documentation of such |
|
|
|
HB5331 Engrossed |
- 9 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| training shall result in recovery of any payments made by the | 2 |
| Department for services rendered by a non-certified driver or | 3 |
| employee attendant. Medi-car and service car providers must | 4 |
| maintain legible documentation in their records of the driver | 5 |
| and, as applicable, employee attendant that actually | 6 |
| transported the patient. Providers must recertify all drivers | 7 |
| and employee attendants every 3 years.
| 8 |
| Notwithstanding the requirements above, any public | 9 |
| transportation provider of medi-car and service car | 10 |
| transportation that receives federal funding under 49 U.S.C. | 11 |
| 5307 and 5311 need not certify its drivers and employee | 12 |
| attendants under this Section, since safety training is already | 13 |
| federally mandated.
| 14 |
| (Source: P.A. 95-501, eff. 8-28-07.)
| 15 |
| (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 16 |
| (Text of Section before amendment by P.A. 96-806 ) | 17 |
| Sec. 5-5. Medical services. The Illinois Department, by | 18 |
| rule, shall
determine the quantity and quality of and the rate | 19 |
| of reimbursement for the
medical assistance for which
payment | 20 |
| will be authorized, and the medical services to be provided,
| 21 |
| which may include all or part of the following: (1) inpatient | 22 |
| hospital
services; (2) outpatient hospital services; (3) other | 23 |
| laboratory and
X-ray services; (4) skilled nursing home | 24 |
| services; (5) physicians'
services whether furnished in the | 25 |
| office, the patient's home, a
hospital, a skilled nursing home, |
|
|
|
HB5331 Engrossed |
- 10 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| or elsewhere; (6) medical care, or any
other type of remedial | 2 |
| care furnished by licensed practitioners; (7)
home health care | 3 |
| services; (8) private duty nursing service; (9) clinic
| 4 |
| services; (10) dental services, including prevention and | 5 |
| treatment of periodontal disease and dental caries disease for | 6 |
| pregnant women, provided by an individual licensed to practice | 7 |
| dentistry or dental surgery; for purposes of this item (10), | 8 |
| "dental services" means diagnostic, preventive, or corrective | 9 |
| procedures provided by or under the supervision of a dentist in | 10 |
| the practice of his or her profession; (11) physical therapy | 11 |
| and related
services; (12) prescribed drugs, dentures, and | 12 |
| prosthetic devices; and
eyeglasses prescribed by a physician | 13 |
| skilled in the diseases of the eye,
or by an optometrist, | 14 |
| whichever the person may select; (13) other
diagnostic, | 15 |
| screening, preventive, and rehabilitative services; (14)
| 16 |
| transportation and such other expenses as may be necessary , | 17 |
| provided that payment for ground ambulance services shall be as | 18 |
| provided in Section 5-4.2 ; (15) medical
treatment of sexual | 19 |
| assault survivors, as defined in
Section 1a of the Sexual | 20 |
| Assault Survivors Emergency Treatment Act, for
injuries | 21 |
| sustained as a result of the sexual assault, including
| 22 |
| examinations and laboratory tests to discover evidence which | 23 |
| may be used in
criminal proceedings arising from the sexual | 24 |
| assault; (16) the
diagnosis and treatment of sickle cell | 25 |
| anemia; and (17)
any other medical care, and any other type of | 26 |
| remedial care recognized
under the laws of this State, but not |
|
|
|
HB5331 Engrossed |
- 11 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| including abortions, or induced
miscarriages or premature | 2 |
| births, unless, in the opinion of a physician,
such procedures | 3 |
| are necessary for the preservation of the life of the
woman | 4 |
| seeking such treatment, or except an induced premature birth
| 5 |
| intended to produce a live viable child and such procedure is | 6 |
| necessary
for the health of the mother or her unborn child. The | 7 |
| Illinois Department,
by rule, shall prohibit any physician from | 8 |
| providing medical assistance
to anyone eligible therefor under | 9 |
| this Code where such physician has been
found guilty of | 10 |
| performing an abortion procedure in a wilful and wanton
manner | 11 |
| upon a woman who was not pregnant at the time such abortion
| 12 |
| procedure was performed. The term "any other type of remedial | 13 |
| care" shall
include nursing care and nursing home service for | 14 |
| persons who rely on
treatment by spiritual means alone through | 15 |
| prayer for healing.
| 16 |
| Notwithstanding any other provision of this Section, a | 17 |
| comprehensive
tobacco use cessation program that includes | 18 |
| purchasing prescription drugs or
prescription medical devices | 19 |
| approved by the Food and Drug administration shall
be covered | 20 |
| under the medical assistance
program under this Article for | 21 |
| persons who are otherwise eligible for
assistance under this | 22 |
| Article.
| 23 |
| Notwithstanding any other provision of this Code, the | 24 |
| Illinois
Department may not require, as a condition of payment | 25 |
| for any laboratory
test authorized under this Article, that a | 26 |
| physician's handwritten signature
appear on the laboratory |
|
|
|
HB5331 Engrossed |
- 12 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| test order form. The Illinois Department may,
however, impose | 2 |
| other appropriate requirements regarding laboratory test
order | 3 |
| documentation.
| 4 |
| The Department of Healthcare and Family Services shall | 5 |
| provide the following services to
persons
eligible for | 6 |
| assistance under this Article who are participating in
| 7 |
| education, training or employment programs operated by the | 8 |
| Department of Human
Services as successor to the Department of | 9 |
| Public Aid:
| 10 |
| (1) dental services provided by or under the | 11 |
| supervision of a dentist; and
| 12 |
| (2) eyeglasses prescribed by a physician skilled in the | 13 |
| diseases of the
eye, or by an optometrist, whichever the | 14 |
| person may select.
| 15 |
| The Illinois Department, by rule, may distinguish and | 16 |
| classify the
medical services to be provided only in accordance | 17 |
| with the classes of
persons designated in Section 5-2.
| 18 |
| The Department of Healthcare and Family Services must | 19 |
| provide coverage and reimbursement for amino acid-based | 20 |
| elemental formulas, regardless of delivery method, for the | 21 |
| diagnosis and treatment of (i) eosinophilic disorders and (ii) | 22 |
| short bowel syndrome when the prescribing physician has issued | 23 |
| a written order stating that the amino acid-based elemental | 24 |
| formula is medically necessary.
| 25 |
| The Illinois Department shall authorize the provision of, | 26 |
| and shall
authorize payment for, screening by low-dose |
|
|
|
HB5331 Engrossed |
- 13 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| mammography for the presence of
occult breast cancer for women | 2 |
| 35 years of age or older who are eligible
for medical | 3 |
| assistance under this Article, as follows: | 4 |
| (A) A baseline
mammogram for women 35 to 39 years of | 5 |
| age.
| 6 |
| (B) An annual mammogram for women 40 years of age or | 7 |
| older. | 8 |
| (C) A mammogram at the age and intervals considered | 9 |
| medically necessary by the woman's health care provider for | 10 |
| women under 40 years of age and having a family history of | 11 |
| breast cancer, prior personal history of breast cancer, | 12 |
| positive genetic testing, or other risk factors. | 13 |
| (D) A comprehensive ultrasound screening of an entire | 14 |
| breast or breasts if a mammogram demonstrates | 15 |
| heterogeneous or dense breast tissue, when medically | 16 |
| necessary as determined by a physician licensed to practice | 17 |
| medicine in all of its branches. | 18 |
| All screenings
shall
include a physical breast exam, | 19 |
| instruction on self-examination and
information regarding the | 20 |
| frequency of self-examination and its value as a
preventative | 21 |
| tool. For purposes of this Section, "low-dose mammography" | 22 |
| means
the x-ray examination of the breast using equipment | 23 |
| dedicated specifically
for mammography, including the x-ray | 24 |
| tube, filter, compression device,
and image receptor, with an | 25 |
| average radiation exposure delivery
of less than one rad per | 26 |
| breast for 2 views of an average size breast.
The term also |
|
|
|
HB5331 Engrossed |
- 14 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| includes digital mammography.
| 2 |
| On and after July 1, 2008, screening and diagnostic | 3 |
| mammography shall be reimbursed at the same rate as the | 4 |
| Medicare program's rates, including the increased | 5 |
| reimbursement for digital mammography. | 6 |
| The Department shall convene an expert panel including | 7 |
| representatives of hospitals, free-standing mammography | 8 |
| facilities, and doctors, including radiologists, to establish | 9 |
| quality standards. Based on these quality standards, the | 10 |
| Department shall provide for bonus payments to mammography | 11 |
| facilities meeting the standards for screening and diagnosis. | 12 |
| The bonus payments shall be at least 15% higher than the | 13 |
| Medicare rates for mammography. | 14 |
| Subject to federal approval, the Department shall | 15 |
| establish a rate methodology for mammography at federally | 16 |
| qualified health centers and other encounter-rate clinics. | 17 |
| These clinics or centers may also collaborate with other | 18 |
| hospital-based mammography facilities. | 19 |
| The Department shall establish a methodology to remind | 20 |
| women who are age-appropriate for screening mammography, but | 21 |
| who have not received a mammogram within the previous 18 | 22 |
| months, of the importance and benefit of screening mammography. | 23 |
| The Department shall establish a performance goal for | 24 |
| primary care providers with respect to their female patients | 25 |
| over age 40 receiving an annual mammogram. This performance | 26 |
| goal shall be used to provide additional reimbursement in the |
|
|
|
HB5331 Engrossed |
- 15 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| form of a quality performance bonus to primary care providers | 2 |
| who meet that goal. | 3 |
| The Department shall devise a means of case-managing or | 4 |
| patient navigation for beneficiaries diagnosed with breast | 5 |
| cancer. This program shall initially operate as a pilot program | 6 |
| in areas of the State with the highest incidence of mortality | 7 |
| related to breast cancer. At least one pilot program site shall | 8 |
| be in the metropolitan Chicago area and at least one site shall | 9 |
| be outside the metropolitan Chicago area. An evaluation of the | 10 |
| pilot program shall be carried out measuring health outcomes | 11 |
| and cost of care for those served by the pilot program compared | 12 |
| to similarly situated patients who are not served by the pilot | 13 |
| program. | 14 |
| Any medical or health care provider shall immediately | 15 |
| recommend, to
any pregnant woman who is being provided prenatal | 16 |
| services and is suspected
of drug abuse or is addicted as | 17 |
| defined in the Alcoholism and Other Drug Abuse
and Dependency | 18 |
| Act, referral to a local substance abuse treatment provider
| 19 |
| licensed by the Department of Human Services or to a licensed
| 20 |
| hospital which provides substance abuse treatment services. | 21 |
| The Department of Healthcare and Family Services
shall assure | 22 |
| coverage for the cost of treatment of the drug abuse or
| 23 |
| addiction for pregnant recipients in accordance with the | 24 |
| Illinois Medicaid
Program in conjunction with the Department of | 25 |
| Human Services.
| 26 |
| All medical providers providing medical assistance to |
|
|
|
HB5331 Engrossed |
- 16 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| pregnant women
under this Code shall receive information from | 2 |
| the Department on the
availability of services under the Drug | 3 |
| Free Families with a Future or any
comparable program providing | 4 |
| case management services for addicted women,
including | 5 |
| information on appropriate referrals for other social services
| 6 |
| that may be needed by addicted women in addition to treatment | 7 |
| for addiction.
| 8 |
| The Illinois Department, in cooperation with the | 9 |
| Departments of Human
Services (as successor to the Department | 10 |
| of Alcoholism and Substance
Abuse) and Public Health, through a | 11 |
| public awareness campaign, may
provide information concerning | 12 |
| treatment for alcoholism and drug abuse and
addiction, prenatal | 13 |
| health care, and other pertinent programs directed at
reducing | 14 |
| the number of drug-affected infants born to recipients of | 15 |
| medical
assistance.
| 16 |
| Neither the Department of Healthcare and Family Services | 17 |
| nor the Department of Human
Services shall sanction the | 18 |
| recipient solely on the basis of
her substance abuse.
| 19 |
| The Illinois Department shall establish such regulations | 20 |
| governing
the dispensing of health services under this Article | 21 |
| as it shall deem
appropriate. The Department
should
seek the | 22 |
| advice of formal professional advisory committees appointed by
| 23 |
| the Director of the Illinois Department for the purpose of | 24 |
| providing regular
advice on policy and administrative matters, | 25 |
| information dissemination and
educational activities for | 26 |
| medical and health care providers, and
consistency in |
|
|
|
HB5331 Engrossed |
- 17 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| procedures to the Illinois Department.
| 2 |
| The Illinois Department may develop and contract with | 3 |
| Partnerships of
medical providers to arrange medical services | 4 |
| for persons eligible under
Section 5-2 of this Code. | 5 |
| Implementation of this Section may be by
demonstration projects | 6 |
| in certain geographic areas. The Partnership shall
be | 7 |
| represented by a sponsor organization. The Department, by rule, | 8 |
| shall
develop qualifications for sponsors of Partnerships. | 9 |
| Nothing in this
Section shall be construed to require that the | 10 |
| sponsor organization be a
medical organization.
| 11 |
| The sponsor must negotiate formal written contracts with | 12 |
| medical
providers for physician services, inpatient and | 13 |
| outpatient hospital care,
home health services, treatment for | 14 |
| alcoholism and substance abuse, and
other services determined | 15 |
| necessary by the Illinois Department by rule for
delivery by | 16 |
| Partnerships. Physician services must include prenatal and
| 17 |
| obstetrical care. The Illinois Department shall reimburse | 18 |
| medical services
delivered by Partnership providers to clients | 19 |
| in target areas according to
provisions of this Article and the | 20 |
| Illinois Health Finance Reform Act,
except that:
| 21 |
| (1) Physicians participating in a Partnership and | 22 |
| providing certain
services, which shall be determined by | 23 |
| the Illinois Department, to persons
in areas covered by the | 24 |
| Partnership may receive an additional surcharge
for such | 25 |
| services.
| 26 |
| (2) The Department may elect to consider and negotiate |
|
|
|
HB5331 Engrossed |
- 18 - |
LRB096 18929 KTG 34317 b |
|
| 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 |
|
|
|
HB5331 Engrossed |
- 19 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| implementation of
Partnerships under this Section.
| 2 |
| The Illinois Department shall require health care | 3 |
| providers to maintain
records that document the medical care | 4 |
| and services provided to recipients
of Medical Assistance under | 5 |
| this Article. The Illinois Department shall
require health care | 6 |
| providers to make available, when authorized by the
patient, in | 7 |
| writing, the medical records in a timely fashion to other
| 8 |
| health care providers who are treating or serving persons | 9 |
| eligible for
Medical Assistance under this Article. All | 10 |
| dispensers of medical services
shall be required to maintain | 11 |
| and retain business and professional records
sufficient to | 12 |
| fully and accurately document the nature, scope, details and
| 13 |
| receipt of the health care provided to persons eligible for | 14 |
| medical
assistance under this Code, in accordance with | 15 |
| regulations promulgated by
the Illinois Department. The rules | 16 |
| and regulations shall require that proof
of the receipt of | 17 |
| prescription drugs, dentures, prosthetic devices and
| 18 |
| eyeglasses by eligible persons under this Section accompany | 19 |
| each claim
for reimbursement submitted by the dispenser of such | 20 |
| medical services.
No such claims for reimbursement shall be | 21 |
| approved for payment by the Illinois
Department without such | 22 |
| proof of receipt, unless the Illinois Department
shall have put | 23 |
| into effect and shall be operating a system of post-payment
| 24 |
| audit and review which shall, on a sampling basis, be deemed | 25 |
| adequate by
the Illinois Department to assure that such drugs, | 26 |
| dentures, prosthetic
devices and eyeglasses for which payment |
|
|
|
HB5331 Engrossed |
- 20 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| is being made are actually being
received by eligible | 2 |
| recipients. Within 90 days after the effective date of
this | 3 |
| amendatory Act of 1984, the Illinois Department shall establish | 4 |
| a
current list of acquisition costs for all prosthetic devices | 5 |
| and any
other items recognized as medical equipment and | 6 |
| supplies reimbursable under
this Article and shall update such | 7 |
| list on a quarterly basis, except that
the acquisition costs of | 8 |
| all prescription drugs shall be updated no
less frequently than | 9 |
| every 30 days as required by Section 5-5.12.
| 10 |
| The rules and regulations of the Illinois Department shall | 11 |
| require
that a written statement including the required opinion | 12 |
| of a physician
shall accompany any claim for reimbursement for | 13 |
| abortions, or induced
miscarriages or premature births. This | 14 |
| statement shall indicate what
procedures were used in providing | 15 |
| such medical services.
| 16 |
| The Illinois Department shall require all dispensers of | 17 |
| medical
services, other than an individual practitioner or | 18 |
| group of practitioners,
desiring to participate in the Medical | 19 |
| Assistance program
established under this Article to disclose | 20 |
| all financial, beneficial,
ownership, equity, surety or other | 21 |
| interests in any and all firms,
corporations, partnerships, | 22 |
| associations, business enterprises, joint
ventures, agencies, | 23 |
| institutions or other legal entities providing any
form of | 24 |
| health care services in this State under this Article.
| 25 |
| The Illinois Department may require that all dispensers of | 26 |
| medical
services desiring to participate in the medical |
|
|
|
HB5331 Engrossed |
- 21 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| assistance program
established under this Article disclose, | 2 |
| under such terms and conditions as
the Illinois Department may | 3 |
| by rule establish, all inquiries from clients
and attorneys | 4 |
| regarding medical bills paid by the Illinois Department, which
| 5 |
| inquiries could indicate potential existence of claims or liens | 6 |
| for the
Illinois Department.
| 7 |
| Enrollment of a vendor that provides non-emergency medical | 8 |
| transportation,
defined by the Department by rule,
shall be
| 9 |
| conditional for 180 days. During that time, the Department of | 10 |
| Healthcare and Family Services may
terminate the vendor's | 11 |
| eligibility to participate in the medical assistance
program | 12 |
| without cause. That termination of eligibility is not subject | 13 |
| to the
Department's hearing process.
| 14 |
| The Illinois Department shall establish policies, | 15 |
| procedures,
standards and criteria by rule for the acquisition, | 16 |
| repair and replacement
of orthotic and prosthetic devices and | 17 |
| durable medical equipment. Such
rules shall provide, but not be | 18 |
| limited to, the following services: (1)
immediate repair or | 19 |
| replacement of such devices by recipients without
medical | 20 |
| authorization; and (2) rental, lease, purchase or | 21 |
| lease-purchase of
durable medical equipment in a | 22 |
| cost-effective manner, taking into
consideration the | 23 |
| recipient's medical prognosis, the extent of the
recipient's | 24 |
| needs, and the requirements and costs for maintaining such
| 25 |
| equipment. Such rules shall enable a recipient to temporarily | 26 |
| acquire and
use alternative or substitute devices or equipment |
|
|
|
HB5331 Engrossed |
- 22 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| pending repairs or
replacements of any device or equipment | 2 |
| previously authorized for such
recipient by the Department.
| 3 |
| The Department shall execute, relative to the nursing home | 4 |
| prescreening
project, written inter-agency agreements with the | 5 |
| Department of Human
Services and the Department on Aging, to | 6 |
| effect the following: (i) intake
procedures and common | 7 |
| eligibility criteria for those persons who are receiving
| 8 |
| non-institutional services; and (ii) the establishment and | 9 |
| development of
non-institutional services in areas of the State | 10 |
| where they are not currently
available or are undeveloped.
| 11 |
| The Illinois Department shall develop and operate, in | 12 |
| cooperation
with other State Departments and agencies and in | 13 |
| compliance with
applicable federal laws and regulations, | 14 |
| appropriate and effective
systems of health care evaluation and | 15 |
| programs for monitoring of
utilization of health care services | 16 |
| and facilities, as it affects
persons eligible for medical | 17 |
| assistance under this Code.
| 18 |
| The Illinois Department shall report annually to the | 19 |
| General Assembly,
no later than the second Friday in April of | 20 |
| 1979 and each year
thereafter, in regard to:
| 21 |
| (a) actual statistics and trends in utilization of | 22 |
| medical services by
public aid recipients;
| 23 |
| (b) actual statistics and trends in the provision of | 24 |
| the various medical
services by medical vendors;
| 25 |
| (c) current rate structures and proposed changes in | 26 |
| those rate structures
for the various medical vendors; and
|
|
|
|
HB5331 Engrossed |
- 23 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| (d) efforts at utilization review and control by the | 2 |
| Illinois Department.
| 3 |
| The period covered by each report shall be the 3 years | 4 |
| ending on the June
30 prior to the report. The report shall | 5 |
| include suggested legislation
for consideration by the General | 6 |
| Assembly. The filing of one copy of the
report with the | 7 |
| Speaker, one copy with the Minority Leader and one copy
with | 8 |
| the Clerk of the House of Representatives, one copy with the | 9 |
| President,
one copy with the Minority Leader and one copy with | 10 |
| the Secretary of the
Senate, one copy with the Legislative | 11 |
| Research Unit, and such additional
copies
with the State | 12 |
| Government Report Distribution Center for the General
Assembly | 13 |
| as is required under paragraph (t) of Section 7 of the State
| 14 |
| Library Act shall be deemed sufficient to comply with this | 15 |
| Section.
| 16 |
| Rulemaking authority to implement Public Act 95-1045 this | 17 |
| amendatory Act of the 95th General Assembly , if any, is | 18 |
| conditioned on the rules being adopted in accordance with all | 19 |
| provisions of the Illinois Administrative Procedure Act and all | 20 |
| rules and procedures of the Joint Committee on Administrative | 21 |
| Rules; any purported rule not so adopted, for whatever reason, | 22 |
| is unauthorized. | 23 |
| (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | 24 |
| 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; revised 11-4-09.)
| 25 |
| (Text of Section after amendment by P.A. 96-806 ) |
|
|
|
HB5331 Engrossed |
- 24 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| Sec. 5-5. Medical services. The Illinois Department, by | 2 |
| rule, shall
determine the quantity and quality of and the rate | 3 |
| of reimbursement for the
medical assistance for which
payment | 4 |
| will be authorized, and the medical services to be provided,
| 5 |
| which may include all or part of the following: (1) inpatient | 6 |
| hospital
services; (2) outpatient hospital services; (3) other | 7 |
| laboratory and
X-ray services; (4) skilled nursing home | 8 |
| services; (5) physicians'
services whether furnished in the | 9 |
| office, the patient's home, a
hospital, a skilled nursing home, | 10 |
| or elsewhere; (6) medical care, or any
other type of remedial | 11 |
| care furnished by licensed practitioners; (7)
home health care | 12 |
| services; (8) private duty nursing service; (9) clinic
| 13 |
| services; (10) dental services, including prevention and | 14 |
| treatment of periodontal disease and dental caries disease for | 15 |
| pregnant women, provided by an individual licensed to practice | 16 |
| dentistry or dental surgery; for purposes of this item (10), | 17 |
| "dental services" means diagnostic, preventive, or corrective | 18 |
| procedures provided by or under the supervision of a dentist in | 19 |
| the practice of his or her profession; (11) physical therapy | 20 |
| and related
services; (12) prescribed drugs, dentures, and | 21 |
| prosthetic devices; and
eyeglasses prescribed by a physician | 22 |
| skilled in the diseases of the eye,
or by an optometrist, | 23 |
| whichever the person may select; (13) other
diagnostic, | 24 |
| screening, preventive, and rehabilitative services; (14)
| 25 |
| transportation and such other expenses as may be necessary , | 26 |
| provided that payment for ground ambulance services shall be as |
|
|
|
HB5331 Engrossed |
- 25 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| provided in Section 5-4.2 ; (15) medical
treatment of sexual | 2 |
| assault survivors, as defined in
Section 1a of the Sexual | 3 |
| Assault Survivors Emergency Treatment Act, for
injuries | 4 |
| sustained as a result of the sexual assault, including
| 5 |
| examinations and laboratory tests to discover evidence which | 6 |
| may be used in
criminal proceedings arising from the sexual | 7 |
| assault; (16) the
diagnosis and treatment of sickle cell | 8 |
| anemia; and (17)
any other medical care, and any other type of | 9 |
| remedial care recognized
under the laws of this State, but not | 10 |
| including abortions, or induced
miscarriages or premature | 11 |
| births, unless, in the opinion of a physician,
such procedures | 12 |
| are necessary for the preservation of the life of the
woman | 13 |
| seeking such treatment, or except an induced premature birth
| 14 |
| intended to produce a live viable child and such procedure is | 15 |
| necessary
for the health of the mother or her unborn child. The | 16 |
| Illinois Department,
by rule, shall prohibit any physician from | 17 |
| providing medical assistance
to anyone eligible therefor under | 18 |
| this Code where such physician has been
found guilty of | 19 |
| performing an abortion procedure in a wilful and wanton
manner | 20 |
| upon a woman who was not pregnant at the time such abortion
| 21 |
| procedure was performed. The term "any other type of remedial | 22 |
| care" shall
include nursing care and nursing home service for | 23 |
| persons who rely on
treatment by spiritual means alone through | 24 |
| prayer for healing.
| 25 |
| Notwithstanding any other provision of this Section, a | 26 |
| comprehensive
tobacco use cessation program that includes |
|
|
|
HB5331 Engrossed |
- 26 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| purchasing prescription drugs or
prescription medical devices | 2 |
| approved by the Food and Drug administration shall
be covered | 3 |
| under the medical assistance
program under this Article for | 4 |
| persons who are otherwise eligible for
assistance under this | 5 |
| Article.
| 6 |
| Notwithstanding any other provision of this Code, the | 7 |
| Illinois
Department may not require, as a condition of payment | 8 |
| for any laboratory
test authorized under this Article, that a | 9 |
| physician's handwritten signature
appear on the laboratory | 10 |
| test order form. The Illinois Department may,
however, impose | 11 |
| other appropriate requirements regarding laboratory test
order | 12 |
| documentation.
| 13 |
| The Department of Healthcare and Family Services shall | 14 |
| provide the following services to
persons
eligible for | 15 |
| assistance under this Article who are participating in
| 16 |
| education, training or employment programs operated by the | 17 |
| Department of Human
Services as successor to the Department of | 18 |
| Public Aid:
| 19 |
| (1) dental services provided by or under the | 20 |
| supervision of a dentist; and
| 21 |
| (2) eyeglasses prescribed by a physician skilled in the | 22 |
| diseases of the
eye, or by an optometrist, whichever the | 23 |
| person may select.
| 24 |
| The Illinois Department, by rule, may distinguish and | 25 |
| classify the
medical services to be provided only in accordance | 26 |
| with the classes of
persons designated in Section 5-2.
|
|
|
|
HB5331 Engrossed |
- 27 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| The Department of Healthcare and Family Services must | 2 |
| provide coverage and reimbursement for amino acid-based | 3 |
| elemental formulas, regardless of delivery method, for the | 4 |
| diagnosis and treatment of (i) eosinophilic disorders and (ii) | 5 |
| short bowel syndrome when the prescribing physician has issued | 6 |
| a written order stating that the amino acid-based elemental | 7 |
| formula is medically necessary.
| 8 |
| The Illinois Department shall authorize the provision of, | 9 |
| and shall
authorize payment for, screening by low-dose | 10 |
| mammography for the presence of
occult breast cancer for women | 11 |
| 35 years of age or older who are eligible
for medical | 12 |
| assistance under this Article, as follows: | 13 |
| (A) A baseline
mammogram for women 35 to 39 years of | 14 |
| age.
| 15 |
| (B) An annual mammogram for women 40 years of age or | 16 |
| older. | 17 |
| (C) A mammogram at the age and intervals considered | 18 |
| medically necessary by the woman's health care provider for | 19 |
| women under 40 years of age and having a family history of | 20 |
| breast cancer, prior personal history of breast cancer, | 21 |
| positive genetic testing, or other risk factors. | 22 |
| (D) A comprehensive ultrasound screening of an entire | 23 |
| breast or breasts if a mammogram demonstrates | 24 |
| heterogeneous or dense breast tissue, when medically | 25 |
| necessary as determined by a physician licensed to practice | 26 |
| medicine in all of its branches. |
|
|
|
HB5331 Engrossed |
- 28 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| All screenings
shall
include a physical breast exam, | 2 |
| instruction on self-examination and
information regarding the | 3 |
| frequency of self-examination and its value as a
preventative | 4 |
| tool. For purposes of this Section, "low-dose mammography" | 5 |
| means
the x-ray examination of the breast using equipment | 6 |
| dedicated specifically
for mammography, including the x-ray | 7 |
| tube, filter, compression device,
and image receptor, with an | 8 |
| average radiation exposure delivery
of less than one rad per | 9 |
| breast for 2 views of an average size breast.
The term also | 10 |
| includes digital mammography.
| 11 |
| On and after July 1, 2008, screening and diagnostic | 12 |
| mammography shall be reimbursed at the same rate as the | 13 |
| Medicare program's rates, including the increased | 14 |
| reimbursement for digital mammography. | 15 |
| The Department shall convene an expert panel including | 16 |
| representatives of hospitals, free-standing mammography | 17 |
| facilities, and doctors, including radiologists, to establish | 18 |
| quality standards. Based on these quality standards, the | 19 |
| Department shall provide for bonus payments to mammography | 20 |
| facilities meeting the standards for screening and diagnosis. | 21 |
| The bonus payments shall be at least 15% higher than the | 22 |
| Medicare rates for mammography. | 23 |
| Subject to federal approval, the Department shall | 24 |
| establish a rate methodology for mammography at federally | 25 |
| qualified health centers and other encounter-rate clinics. | 26 |
| These clinics or centers may also collaborate with other |
|
|
|
HB5331 Engrossed |
- 29 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| hospital-based mammography facilities. | 2 |
| The Department shall establish a methodology to remind | 3 |
| women who are age-appropriate for screening mammography, but | 4 |
| who have not received a mammogram within the previous 18 | 5 |
| months, of the importance and benefit of screening mammography. | 6 |
| The Department shall establish a performance goal for | 7 |
| primary care providers with respect to their female patients | 8 |
| over age 40 receiving an annual mammogram. This performance | 9 |
| goal shall be used to provide additional reimbursement in the | 10 |
| form of a quality performance bonus to primary care providers | 11 |
| who meet that goal. | 12 |
| The Department shall devise a means of case-managing or | 13 |
| patient navigation for beneficiaries diagnosed with breast | 14 |
| cancer. This program shall initially operate as a pilot program | 15 |
| in areas of the State with the highest incidence of mortality | 16 |
| related to breast cancer. At least one pilot program site shall | 17 |
| be in the metropolitan Chicago area and at least one site shall | 18 |
| be outside the metropolitan Chicago area. An evaluation of the | 19 |
| pilot program shall be carried out measuring health outcomes | 20 |
| and cost of care for those served by the pilot program compared | 21 |
| to similarly situated patients who are not served by the pilot | 22 |
| program. | 23 |
| Any medical or health care provider shall immediately | 24 |
| recommend, to
any pregnant woman who is being provided prenatal | 25 |
| services and is suspected
of drug abuse or is addicted as | 26 |
| defined in the Alcoholism and Other Drug Abuse
and Dependency |
|
|
|
HB5331 Engrossed |
- 30 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| Act, referral to a local substance abuse treatment provider
| 2 |
| licensed by the Department of Human Services or to a licensed
| 3 |
| hospital which provides substance abuse treatment services. | 4 |
| The Department of Healthcare and Family Services
shall assure | 5 |
| coverage for the cost of treatment of the drug abuse or
| 6 |
| addiction for pregnant recipients in accordance with the | 7 |
| Illinois Medicaid
Program in conjunction with the Department of | 8 |
| Human Services.
| 9 |
| All medical providers providing medical assistance to | 10 |
| pregnant women
under this Code shall receive information from | 11 |
| the Department on the
availability of services under the Drug | 12 |
| Free Families with a Future or any
comparable program providing | 13 |
| case management services for addicted women,
including | 14 |
| information on appropriate referrals for other social services
| 15 |
| that may be needed by addicted women in addition to treatment | 16 |
| for addiction.
| 17 |
| The Illinois Department, in cooperation with the | 18 |
| Departments of Human
Services (as successor to the Department | 19 |
| of Alcoholism and Substance
Abuse) and Public Health, through a | 20 |
| public awareness campaign, may
provide information concerning | 21 |
| treatment for alcoholism and drug abuse and
addiction, prenatal | 22 |
| health care, and other pertinent programs directed at
reducing | 23 |
| the number of drug-affected infants born to recipients of | 24 |
| medical
assistance.
| 25 |
| Neither the Department of Healthcare and Family Services | 26 |
| nor the Department of Human
Services shall sanction the |
|
|
|
HB5331 Engrossed |
- 31 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| recipient solely on the basis of
her substance abuse.
| 2 |
| The Illinois Department shall establish such regulations | 3 |
| governing
the dispensing of health services under this Article | 4 |
| as it shall deem
appropriate. The Department
should
seek the | 5 |
| advice of formal professional advisory committees appointed by
| 6 |
| the Director of the Illinois Department for the purpose of | 7 |
| providing regular
advice on policy and administrative matters, | 8 |
| information dissemination and
educational activities for | 9 |
| medical and health care providers, and
consistency in | 10 |
| procedures to the Illinois Department.
| 11 |
| Notwithstanding any other provision of law, a health care | 12 |
| provider under the medical assistance program may elect, in | 13 |
| lieu of receiving direct payment for services provided under | 14 |
| that program, to participate in the State Employees Deferred | 15 |
| Compensation Plan adopted under Article 24 of the Illinois | 16 |
| Pension Code. A health care provider who elects to participate | 17 |
| in the plan does not have a cause of action against the State | 18 |
| for any damages allegedly suffered by the provider as a result | 19 |
| of any delay by the State in crediting the amount of any | 20 |
| contribution to the provider's plan account. | 21 |
| The Illinois Department may develop and contract with | 22 |
| Partnerships of
medical providers to arrange medical services | 23 |
| for persons eligible under
Section 5-2 of this Code. | 24 |
| Implementation of this Section may be by
demonstration projects | 25 |
| in certain geographic areas. The Partnership shall
be | 26 |
| represented by a sponsor organization. The Department, by rule, |
|
|
|
HB5331 Engrossed |
- 32 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| shall
develop qualifications for sponsors of Partnerships. | 2 |
| Nothing in this
Section shall be construed to require that the | 3 |
| sponsor organization be a
medical organization.
| 4 |
| The sponsor must negotiate formal written contracts with | 5 |
| medical
providers for physician services, inpatient and | 6 |
| outpatient hospital care,
home health services, treatment for | 7 |
| alcoholism and substance abuse, and
other services determined | 8 |
| necessary by the Illinois Department by rule for
delivery by | 9 |
| Partnerships. Physician services must include prenatal and
| 10 |
| obstetrical care. The Illinois Department shall reimburse | 11 |
| medical services
delivered by Partnership providers to clients | 12 |
| in target areas according to
provisions of this Article and the | 13 |
| Illinois Health Finance Reform Act,
except that:
| 14 |
| (1) Physicians participating in a Partnership and | 15 |
| providing certain
services, which shall be determined by | 16 |
| the Illinois Department, to persons
in areas covered by the | 17 |
| Partnership may receive an additional surcharge
for such | 18 |
| services.
| 19 |
| (2) The Department may elect to consider and negotiate | 20 |
| financial
incentives to encourage the development of | 21 |
| Partnerships and the efficient
delivery of medical care.
| 22 |
| (3) Persons receiving medical services through | 23 |
| Partnerships may receive
medical and case management | 24 |
| services above the level usually offered
through the | 25 |
| medical assistance program.
| 26 |
| Medical providers shall be required to meet certain |
|
|
|
HB5331 Engrossed |
- 33 - |
LRB096 18929 KTG 34317 b |
|
| 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
|
|
|
|
HB5331 Engrossed |
- 34 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| health care providers who are treating or serving persons | 2 |
| eligible for
Medical Assistance under this Article. All | 3 |
| dispensers of medical services
shall be required to maintain | 4 |
| and retain business and professional records
sufficient to | 5 |
| fully and accurately document the nature, scope, details and
| 6 |
| receipt of the health care provided to persons eligible for | 7 |
| medical
assistance under this Code, in accordance with | 8 |
| regulations promulgated by
the Illinois Department. The rules | 9 |
| and regulations shall require that proof
of the receipt of | 10 |
| prescription drugs, dentures, prosthetic devices and
| 11 |
| eyeglasses by eligible persons under this Section accompany | 12 |
| each claim
for reimbursement submitted by the dispenser of such | 13 |
| medical services.
No such claims for reimbursement shall be | 14 |
| approved for payment by the Illinois
Department without such | 15 |
| proof of receipt, unless the Illinois Department
shall have put | 16 |
| into effect and shall be operating a system of post-payment
| 17 |
| audit and review which shall, on a sampling basis, be deemed | 18 |
| adequate by
the Illinois Department to assure that such drugs, | 19 |
| dentures, prosthetic
devices and eyeglasses for which payment | 20 |
| is being made are actually being
received by eligible | 21 |
| recipients. Within 90 days after the effective date of
this | 22 |
| amendatory Act of 1984, the Illinois Department shall establish | 23 |
| a
current list of acquisition costs for all prosthetic devices | 24 |
| and any
other items recognized as medical equipment and | 25 |
| supplies reimbursable under
this Article and shall update such | 26 |
| list on a quarterly basis, except that
the acquisition costs of |
|
|
|
HB5331 Engrossed |
- 35 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| all prescription drugs shall be updated no
less frequently than | 2 |
| every 30 days as required by Section 5-5.12.
| 3 |
| The rules and regulations of the Illinois Department shall | 4 |
| require
that a written statement including the required opinion | 5 |
| of a physician
shall accompany any claim for reimbursement for | 6 |
| abortions, or induced
miscarriages or premature births. This | 7 |
| statement shall indicate what
procedures were used in providing | 8 |
| such medical services.
| 9 |
| The Illinois Department shall require all dispensers of | 10 |
| medical
services, other than an individual practitioner or | 11 |
| group of practitioners,
desiring to participate in the Medical | 12 |
| Assistance program
established under this Article to disclose | 13 |
| all financial, beneficial,
ownership, equity, surety or other | 14 |
| interests in any and all firms,
corporations, partnerships, | 15 |
| associations, business enterprises, joint
ventures, agencies, | 16 |
| institutions or other legal entities providing any
form of | 17 |
| health care services in this State under this Article.
| 18 |
| The Illinois Department may require that all dispensers of | 19 |
| medical
services desiring to participate in the medical | 20 |
| assistance program
established under this Article disclose, | 21 |
| under such terms and conditions as
the Illinois Department may | 22 |
| by rule establish, all inquiries from clients
and attorneys | 23 |
| regarding medical bills paid by the Illinois Department, which
| 24 |
| inquiries could indicate potential existence of claims or liens | 25 |
| for the
Illinois Department.
| 26 |
| Enrollment of a vendor that provides non-emergency medical |
|
|
|
HB5331 Engrossed |
- 36 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| transportation,
defined by the Department by rule,
shall be
| 2 |
| conditional for 180 days. During that time, the Department of | 3 |
| Healthcare and Family Services may
terminate the vendor's | 4 |
| eligibility to participate in the medical assistance
program | 5 |
| without cause. That termination of eligibility is not subject | 6 |
| to the
Department's hearing process.
| 7 |
| The Illinois Department shall establish policies, | 8 |
| procedures,
standards and criteria by rule for the acquisition, | 9 |
| repair and replacement
of orthotic and prosthetic devices and | 10 |
| durable medical equipment. Such
rules shall provide, but not be | 11 |
| limited to, the following services: (1)
immediate repair or | 12 |
| replacement of such devices by recipients without
medical | 13 |
| authorization; and (2) rental, lease, purchase or | 14 |
| lease-purchase of
durable medical equipment in a | 15 |
| cost-effective manner, taking into
consideration the | 16 |
| recipient's medical prognosis, the extent of the
recipient's | 17 |
| needs, and the requirements and costs for maintaining such
| 18 |
| equipment. Such rules shall enable a recipient to temporarily | 19 |
| acquire and
use alternative or substitute devices or equipment | 20 |
| pending repairs or
replacements of any device or equipment | 21 |
| previously authorized for such
recipient by the Department.
| 22 |
| The Department shall execute, relative to the nursing home | 23 |
| prescreening
project, written inter-agency agreements with the | 24 |
| Department of Human
Services and the Department on Aging, to | 25 |
| effect the following: (i) intake
procedures and common | 26 |
| eligibility criteria for those persons who are receiving
|
|
|
|
HB5331 Engrossed |
- 37 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| non-institutional services; and (ii) the establishment and | 2 |
| development of
non-institutional services in areas of the State | 3 |
| where they are not currently
available or are undeveloped.
| 4 |
| The Illinois Department shall develop and operate, in | 5 |
| cooperation
with other State Departments and agencies and in | 6 |
| compliance with
applicable federal laws and regulations, | 7 |
| appropriate and effective
systems of health care evaluation and | 8 |
| programs for monitoring of
utilization of health care services | 9 |
| and facilities, as it affects
persons eligible for medical | 10 |
| assistance under this Code.
| 11 |
| The Illinois Department shall report annually to the | 12 |
| General Assembly,
no later than the second Friday in April of | 13 |
| 1979 and each year
thereafter, in regard to:
| 14 |
| (a) actual statistics and trends in utilization of | 15 |
| medical services by
public aid recipients;
| 16 |
| (b) actual statistics and trends in the provision of | 17 |
| the various medical
services by medical vendors;
| 18 |
| (c) current rate structures and proposed changes in | 19 |
| those rate structures
for the various medical vendors; and
| 20 |
| (d) efforts at utilization review and control by the | 21 |
| Illinois Department.
| 22 |
| The period covered by each report shall be the 3 years | 23 |
| ending on the June
30 prior to the report. The report shall | 24 |
| include suggested legislation
for consideration by the General | 25 |
| Assembly. The filing of one copy of the
report with the | 26 |
| Speaker, one copy with the Minority Leader and one copy
with |
|
|
|
HB5331 Engrossed |
- 38 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| the Clerk of the House of Representatives, one copy with the | 2 |
| President,
one copy with the Minority Leader and one copy with | 3 |
| the Secretary of the
Senate, one copy with the Legislative | 4 |
| Research Unit, and such additional
copies
with the State | 5 |
| Government Report Distribution Center for the General
Assembly | 6 |
| as is required under paragraph (t) of Section 7 of the State
| 7 |
| Library Act shall be deemed sufficient to comply with this | 8 |
| Section.
| 9 |
| Rulemaking authority to implement Public Act 95-1045 this | 10 |
| amendatory Act of the 95th General Assembly , if any, is | 11 |
| conditioned on the rules being adopted in accordance with all | 12 |
| provisions of the Illinois Administrative Procedure Act and all | 13 |
| rules and procedures of the Joint Committee on Administrative | 14 |
| Rules; any purported rule not so adopted, for whatever reason, | 15 |
| is unauthorized. | 16 |
| (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | 17 |
| 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; 96-806, eff. | 18 |
| 7-1-10; revised 11-4-09.) | 19 |
| Section 95. No acceleration or delay. Where this Act makes | 20 |
| changes in a statute that is represented in this Act by text | 21 |
| that is not yet or no longer in effect (for example, a Section | 22 |
| represented by multiple versions), the use of that text does | 23 |
| not accelerate or delay the taking effect of (i) the changes | 24 |
| made by this Act or (ii) provisions derived from any other | 25 |
| Public Act.
|
|
|
|
HB5331 Engrossed |
- 39 - |
LRB096 18929 KTG 34317 b |
|
| 1 |
| Section 99. Effective date. This Act takes effect upon | 2 |
| becoming law.
|
|