Full Text of HB5859 96th General Assembly
HB5859enr 96TH GENERAL ASSEMBLY
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| AN ACT concerning public aid.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| 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)
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| (Text of Section before amendment by P.A. 96-806 ) | 8 |
| Sec. 5-5. Medical services. The Illinois Department, by | 9 |
| rule, shall
determine the quantity and quality of and the rate | 10 |
| of reimbursement for the
medical assistance for which
payment | 11 |
| will be authorized, and the medical services to be provided,
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| which may include all or part of the following: (1) inpatient | 13 |
| hospital
services; (2) outpatient hospital services; (3) other | 14 |
| laboratory and
X-ray services; (4) skilled nursing home | 15 |
| services; (5) physicians'
services whether furnished in the | 16 |
| office, the patient's home, a
hospital, a skilled nursing home, | 17 |
| or elsewhere; (6) medical care, or any
other type of remedial | 18 |
| care furnished by licensed practitioners; (7)
home health care | 19 |
| services; (8) private duty nursing service; (9) clinic
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| services; (10) dental services, including prevention and | 21 |
| treatment of periodontal disease and dental caries disease for | 22 |
| pregnant women, provided by an individual licensed to practice | 23 |
| dentistry or dental surgery; for purposes of this item (10), |
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| "dental services" means diagnostic, preventive, or corrective | 2 |
| procedures provided by or under the supervision of a dentist in | 3 |
| the practice of his or her profession; (11) physical therapy | 4 |
| and related
services; (12) prescribed drugs, dentures, and | 5 |
| prosthetic devices; and
eyeglasses prescribed by a physician | 6 |
| skilled in the diseases of the eye,
or by an optometrist, | 7 |
| whichever the person may select; (13) other
diagnostic, | 8 |
| screening, preventive, and rehabilitative services; (14)
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| transportation and such other expenses as may be necessary; | 10 |
| (15) medical
treatment of sexual assault survivors, as defined | 11 |
| in
Section 1a of the Sexual Assault Survivors Emergency | 12 |
| Treatment Act, for
injuries sustained as a result of the sexual | 13 |
| assault, including
examinations and laboratory tests to | 14 |
| discover evidence which may be used in
criminal proceedings | 15 |
| arising from the sexual assault; (16) the
diagnosis and | 16 |
| treatment of sickle cell anemia; and (17)
any other medical | 17 |
| care, and any other type of remedial care recognized
under the | 18 |
| laws of this State, but not including abortions, or induced
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| miscarriages or premature births, unless, in the opinion of a | 20 |
| physician,
such procedures are necessary for the preservation | 21 |
| of the life of the
woman seeking such treatment, or except an | 22 |
| induced premature birth
intended to produce a live viable child | 23 |
| and such procedure is necessary
for the health of the mother or | 24 |
| her unborn child. The Illinois Department,
by rule, shall | 25 |
| prohibit any physician from providing medical assistance
to | 26 |
| anyone eligible therefor under this Code where such physician |
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| has been
found guilty of performing an abortion procedure in a | 2 |
| wilful and wanton
manner upon a woman who was not pregnant at | 3 |
| the time such abortion
procedure was performed. The term "any | 4 |
| other type of remedial care" shall
include nursing care and | 5 |
| nursing home service for persons who rely on
treatment by | 6 |
| spiritual means alone through prayer for healing.
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| Notwithstanding any other provision of this Section, a | 8 |
| comprehensive
tobacco use cessation program that includes | 9 |
| purchasing prescription drugs or
prescription medical devices | 10 |
| approved by the Food and Drug administration shall
be covered | 11 |
| under the medical assistance
program under this Article for | 12 |
| persons who are otherwise eligible for
assistance under this | 13 |
| Article.
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| Notwithstanding any other provision of this Code, the | 15 |
| Illinois
Department may not require, as a condition of payment | 16 |
| for any laboratory
test authorized under this Article, that a | 17 |
| physician's handwritten signature
appear on the laboratory | 18 |
| test order form. The Illinois Department may,
however, impose | 19 |
| other appropriate requirements regarding laboratory test
order | 20 |
| documentation.
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| The Department of Healthcare and Family Services shall | 22 |
| provide the following services to
persons
eligible for | 23 |
| assistance under this Article who are participating in
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| education, training or employment programs operated by the | 25 |
| Department of Human
Services as successor to the Department of | 26 |
| Public Aid:
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| (1) dental services provided by or under the | 2 |
| supervision of a dentist; and
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| (2) eyeglasses prescribed by a physician skilled in the | 4 |
| diseases of the
eye, or by an optometrist, whichever the | 5 |
| person may select.
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| Notwithstanding any other provision of this Code and | 7 |
| subject to federal approval, the Department may adopt rules to | 8 |
| allow a dentist who is volunteering his or her service at no | 9 |
| cost to render dental services through an enrolled | 10 |
| not-for-profit health clinic without the dentist personally | 11 |
| enrolling as a participating provider in the medical assistance | 12 |
| program. A not-for-profit health clinic shall include a public | 13 |
| health clinic or Federally Qualified Health Center or other | 14 |
| enrolled provider, as determined by the Department, through | 15 |
| which dental services covered under this Section are performed. | 16 |
| The Department shall establish a process for payment of claims | 17 |
| for reimbursement for covered dental services rendered under | 18 |
| this provision. | 19 |
| The Illinois Department, by rule, may distinguish and | 20 |
| classify the
medical services to be provided only in accordance | 21 |
| with the classes of
persons designated in Section 5-2.
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| The Department of Healthcare and Family Services must | 23 |
| provide coverage and reimbursement for amino acid-based | 24 |
| elemental formulas, regardless of delivery method, for the | 25 |
| diagnosis and treatment of (i) eosinophilic disorders and (ii) | 26 |
| short bowel syndrome when the prescribing physician has issued |
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| a written order stating that the amino acid-based elemental | 2 |
| formula is medically necessary.
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| The Illinois Department shall authorize the provision of, | 4 |
| and shall
authorize payment for, screening by low-dose | 5 |
| mammography for the presence of
occult breast cancer for women | 6 |
| 35 years of age or older who are eligible
for medical | 7 |
| assistance under this Article, as follows: | 8 |
| (A) A baseline
mammogram for women 35 to 39 years of | 9 |
| age.
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| (B) An annual mammogram for women 40 years of age or | 11 |
| older. | 12 |
| (C) A mammogram at the age and intervals considered | 13 |
| medically necessary by the woman's health care provider for | 14 |
| women under 40 years of age and having a family history of | 15 |
| breast cancer, prior personal history of breast cancer, | 16 |
| positive genetic testing, or other risk factors. | 17 |
| (D) A comprehensive ultrasound screening of an entire | 18 |
| breast or breasts if a mammogram demonstrates | 19 |
| heterogeneous or dense breast tissue, when medically | 20 |
| necessary as determined by a physician licensed to practice | 21 |
| medicine in all of its branches. | 22 |
| All screenings
shall
include a physical breast exam, | 23 |
| instruction on self-examination and
information regarding the | 24 |
| frequency of self-examination and its value as a
preventative | 25 |
| tool. For purposes of this Section, "low-dose mammography" | 26 |
| means
the x-ray examination of the breast using equipment |
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| dedicated specifically
for mammography, including the x-ray | 2 |
| tube, filter, compression device,
and image receptor, with an | 3 |
| average radiation exposure delivery
of less than one rad per | 4 |
| breast for 2 views of an average size breast.
The term also | 5 |
| includes digital mammography.
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| On and after July 1, 2008, screening and diagnostic | 7 |
| mammography shall be reimbursed at the same rate as the | 8 |
| Medicare program's rates, including the increased | 9 |
| reimbursement for digital mammography. | 10 |
| The Department shall convene an expert panel including | 11 |
| representatives of hospitals, free-standing mammography | 12 |
| facilities, and doctors, including radiologists, to establish | 13 |
| quality standards. Based on these quality standards, the | 14 |
| Department shall provide for bonus payments to mammography | 15 |
| facilities meeting the standards for screening and diagnosis. | 16 |
| The bonus payments shall be at least 15% higher than the | 17 |
| Medicare rates for mammography. | 18 |
| Subject to federal approval, the Department shall | 19 |
| establish a rate methodology for mammography at federally | 20 |
| qualified health centers and other encounter-rate clinics. | 21 |
| These clinics or centers may also collaborate with other | 22 |
| hospital-based mammography facilities. | 23 |
| The Department shall establish a methodology to remind | 24 |
| women who are age-appropriate for screening mammography, but | 25 |
| who have not received a mammogram within the previous 18 | 26 |
| months, of the importance and benefit of screening mammography. |
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| The Department shall establish a performance goal for | 2 |
| primary care providers with respect to their female patients | 3 |
| over age 40 receiving an annual mammogram. This performance | 4 |
| goal shall be used to provide additional reimbursement in the | 5 |
| form of a quality performance bonus to primary care providers | 6 |
| who meet that goal. | 7 |
| The Department shall devise a means of case-managing or | 8 |
| patient navigation for beneficiaries diagnosed with breast | 9 |
| cancer. This program shall initially operate as a pilot program | 10 |
| in areas of the State with the highest incidence of mortality | 11 |
| related to breast cancer. At least one pilot program site shall | 12 |
| be in the metropolitan Chicago area and at least one site shall | 13 |
| be outside the metropolitan Chicago area. An evaluation of the | 14 |
| pilot program shall be carried out measuring health outcomes | 15 |
| and cost of care for those served by the pilot program compared | 16 |
| to similarly situated patients who are not served by the pilot | 17 |
| program. | 18 |
| Any medical or health care provider shall immediately | 19 |
| recommend, to
any pregnant woman who is being provided prenatal | 20 |
| services and is suspected
of drug abuse or is addicted as | 21 |
| defined in the Alcoholism and Other Drug Abuse
and Dependency | 22 |
| Act, referral to a local substance abuse treatment provider
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| licensed by the Department of Human Services or to a licensed
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| hospital which provides substance abuse treatment services. | 25 |
| The Department of Healthcare and Family Services
shall assure | 26 |
| coverage for the cost of treatment of the drug abuse or
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| addiction for pregnant recipients in accordance with the | 2 |
| Illinois Medicaid
Program in conjunction with the Department of | 3 |
| Human Services.
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| All medical providers providing medical assistance to | 5 |
| pregnant women
under this Code shall receive information from | 6 |
| the Department on the
availability of services under the Drug | 7 |
| Free Families with a Future or any
comparable program providing | 8 |
| case management services for addicted women,
including | 9 |
| information on appropriate referrals for other social services
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| that may be needed by addicted women in addition to treatment | 11 |
| for addiction.
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| The Illinois Department, in cooperation with the | 13 |
| Departments of Human
Services (as successor to the Department | 14 |
| of Alcoholism and Substance
Abuse) and Public Health, through a | 15 |
| public awareness campaign, may
provide information concerning | 16 |
| treatment for alcoholism and drug abuse and
addiction, prenatal | 17 |
| health care, and other pertinent programs directed at
reducing | 18 |
| the number of drug-affected infants born to recipients of | 19 |
| medical
assistance.
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| Neither the Department of Healthcare and Family Services | 21 |
| nor the Department of Human
Services shall sanction the | 22 |
| recipient solely on the basis of
her substance abuse.
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| The Illinois Department shall establish such regulations | 24 |
| governing
the dispensing of health services under this Article | 25 |
| as it shall deem
appropriate. The Department
should
seek the | 26 |
| advice of formal professional advisory committees appointed by
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| the Director of the Illinois Department for the purpose of | 2 |
| providing regular
advice on policy and administrative matters, | 3 |
| information dissemination and
educational activities for | 4 |
| medical and health care providers, and
consistency in | 5 |
| procedures to the Illinois Department.
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| The Illinois Department may develop and contract with | 7 |
| Partnerships of
medical providers to arrange medical services | 8 |
| for persons eligible under
Section 5-2 of this Code. | 9 |
| Implementation of this Section may be by
demonstration projects | 10 |
| in certain geographic areas. The Partnership shall
be | 11 |
| represented by a sponsor organization. The Department, by rule, | 12 |
| shall
develop qualifications for sponsors of Partnerships. | 13 |
| Nothing in this
Section shall be construed to require that the | 14 |
| sponsor organization be a
medical organization.
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| The sponsor must negotiate formal written contracts with | 16 |
| medical
providers for physician services, inpatient and | 17 |
| outpatient hospital care,
home health services, treatment for | 18 |
| alcoholism and substance abuse, and
other services determined | 19 |
| necessary by the Illinois Department by rule for
delivery by | 20 |
| Partnerships. Physician services must include prenatal and
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| obstetrical care. The Illinois Department shall reimburse | 22 |
| medical services
delivered by Partnership providers to clients | 23 |
| in target areas according to
provisions of this Article and the | 24 |
| Illinois Health Finance Reform Act,
except that:
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| (1) Physicians participating in a Partnership and | 26 |
| providing certain
services, which shall be determined by |
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| the Illinois Department, to persons
in areas covered by the | 2 |
| Partnership may receive an additional surcharge
for such | 3 |
| services.
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| (2) The Department may elect to consider and negotiate | 5 |
| financial
incentives to encourage the development of | 6 |
| Partnerships and the efficient
delivery of medical care.
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| (3) Persons receiving medical services through | 8 |
| Partnerships may receive
medical and case management | 9 |
| services above the level usually offered
through the | 10 |
| medical assistance program.
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| Medical providers shall be required to meet certain | 12 |
| qualifications to
participate in Partnerships to ensure the | 13 |
| delivery of high quality medical
services. These | 14 |
| qualifications shall be determined by rule of the Illinois
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| Department and may be higher than qualifications for | 16 |
| participation in the
medical assistance program. Partnership | 17 |
| sponsors may prescribe reasonable
additional qualifications | 18 |
| for participation by medical providers, only with
the prior | 19 |
| written approval of the Illinois Department.
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| Nothing in this Section shall limit the free choice of | 21 |
| practitioners,
hospitals, and other providers of medical | 22 |
| services by clients.
In order to ensure patient freedom of | 23 |
| choice, the Illinois Department shall
immediately promulgate | 24 |
| all rules and take all other necessary actions so that
provided | 25 |
| services may be accessed from therapeutically certified | 26 |
| optometrists
to the full extent of the Illinois Optometric |
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| Practice Act of 1987 without
discriminating between service | 2 |
| providers.
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| The Department shall apply for a waiver from the United | 4 |
| States Health
Care Financing Administration to allow for the | 5 |
| implementation of
Partnerships under this Section.
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| The Illinois Department shall require health care | 7 |
| providers to maintain
records that document the medical care | 8 |
| and services provided to recipients
of Medical Assistance under | 9 |
| this Article. The Illinois Department shall
require health care | 10 |
| providers to make available, when authorized by the
patient, in | 11 |
| writing, the medical records in a timely fashion to other
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| health care providers who are treating or serving persons | 13 |
| eligible for
Medical Assistance under this Article. All | 14 |
| dispensers of medical services
shall be required to maintain | 15 |
| and retain business and professional records
sufficient to | 16 |
| fully and accurately document the nature, scope, details and
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| receipt of the health care provided to persons eligible for | 18 |
| medical
assistance under this Code, in accordance with | 19 |
| regulations promulgated by
the Illinois Department. The rules | 20 |
| and regulations shall require that proof
of the receipt of | 21 |
| prescription drugs, dentures, prosthetic devices and
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| eyeglasses by eligible persons under this Section accompany | 23 |
| each claim
for reimbursement submitted by the dispenser of such | 24 |
| medical services.
No such claims for reimbursement shall be | 25 |
| approved for payment by the Illinois
Department without such | 26 |
| proof of receipt, unless the Illinois Department
shall have put |
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| into effect and shall be operating a system of post-payment
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| audit and review which shall, on a sampling basis, be deemed | 3 |
| adequate by
the Illinois Department to assure that such drugs, | 4 |
| dentures, prosthetic
devices and eyeglasses for which payment | 5 |
| is being made are actually being
received by eligible | 6 |
| recipients. Within 90 days after the effective date of
this | 7 |
| amendatory Act of 1984, the Illinois Department shall establish | 8 |
| a
current list of acquisition costs for all prosthetic devices | 9 |
| and any
other items recognized as medical equipment and | 10 |
| supplies reimbursable under
this Article and shall update such | 11 |
| list on a quarterly basis, except that
the acquisition costs of | 12 |
| all prescription drugs shall be updated no
less frequently than | 13 |
| every 30 days as required by Section 5-5.12.
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| The rules and regulations of the Illinois Department shall | 15 |
| require
that a written statement including the required opinion | 16 |
| of a physician
shall accompany any claim for reimbursement for | 17 |
| abortions, or induced
miscarriages or premature births. This | 18 |
| statement shall indicate what
procedures were used in providing | 19 |
| such medical services.
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| The Illinois Department shall require all dispensers of | 21 |
| medical
services, other than an individual practitioner or | 22 |
| group of practitioners,
desiring to participate in the Medical | 23 |
| Assistance program
established under this Article to disclose | 24 |
| all financial, beneficial,
ownership, equity, surety or other | 25 |
| interests in any and all firms,
corporations, partnerships, | 26 |
| associations, business enterprises, joint
ventures, agencies, |
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| institutions or other legal entities providing any
form of | 2 |
| health care services in this State under this Article.
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| The Illinois Department may require that all dispensers of | 4 |
| medical
services desiring to participate in the medical | 5 |
| assistance program
established under this Article disclose, | 6 |
| under such terms and conditions as
the Illinois Department may | 7 |
| by rule establish, all inquiries from clients
and attorneys | 8 |
| regarding medical bills paid by the Illinois Department, which
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| inquiries could indicate potential existence of claims or liens | 10 |
| for the
Illinois Department.
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| Enrollment of a vendor that provides non-emergency medical | 12 |
| transportation,
defined by the Department by rule,
shall be
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| conditional for 180 days. During that time, the Department of | 14 |
| Healthcare and Family Services may
terminate the vendor's | 15 |
| eligibility to participate in the medical assistance
program | 16 |
| without cause. That termination of eligibility is not subject | 17 |
| to the
Department's hearing process.
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| The Illinois Department shall establish policies, | 19 |
| procedures,
standards and criteria by rule for the acquisition, | 20 |
| repair and replacement
of orthotic and prosthetic devices and | 21 |
| durable medical equipment. Such
rules shall provide, but not be | 22 |
| limited to, the following services: (1)
immediate repair or | 23 |
| replacement of such devices by recipients without
medical | 24 |
| authorization; and (2) rental, lease, purchase or | 25 |
| lease-purchase of
durable medical equipment in a | 26 |
| cost-effective manner, taking into
consideration the |
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| recipient's medical prognosis, the extent of the
recipient's | 2 |
| needs, and the requirements and costs for maintaining such
| 3 |
| equipment. Such rules shall enable a recipient to temporarily | 4 |
| acquire and
use alternative or substitute devices or equipment | 5 |
| pending repairs or
replacements of any device or equipment | 6 |
| previously authorized for such
recipient by the Department.
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| The Department shall execute, relative to the nursing home | 8 |
| prescreening
project, written inter-agency agreements with the | 9 |
| Department of Human
Services and the Department on Aging, to | 10 |
| effect the following: (i) intake
procedures and common | 11 |
| eligibility criteria for those persons who are receiving
| 12 |
| non-institutional services; and (ii) the establishment and | 13 |
| development of
non-institutional services in areas of the State | 14 |
| where they are not currently
available or are undeveloped.
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| The Illinois Department shall develop and operate, in | 16 |
| cooperation
with other State Departments and agencies and in | 17 |
| compliance with
applicable federal laws and regulations, | 18 |
| appropriate and effective
systems of health care evaluation and | 19 |
| programs for monitoring of
utilization of health care services | 20 |
| and facilities, as it affects
persons eligible for medical | 21 |
| assistance under this Code.
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| The Illinois Department shall report annually to the | 23 |
| General Assembly,
no later than the second Friday in April of | 24 |
| 1979 and each year
thereafter, in regard to:
| 25 |
| (a) actual statistics and trends in utilization of | 26 |
| medical services by
public aid recipients;
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| (b) actual statistics and trends in the provision of | 2 |
| the various medical
services by medical vendors;
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| (c) current rate structures and proposed changes in | 4 |
| those rate structures
for the various medical vendors; and
| 5 |
| (d) efforts at utilization review and control by the | 6 |
| Illinois Department.
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| The period covered by each report shall be the 3 years | 8 |
| ending on the June
30 prior to the report. The report shall | 9 |
| include suggested legislation
for consideration by the General | 10 |
| Assembly. The filing of one copy of the
report with the | 11 |
| Speaker, one copy with the Minority Leader and one copy
with | 12 |
| the Clerk of the House of Representatives, one copy with the | 13 |
| President,
one copy with the Minority Leader and one copy with | 14 |
| the Secretary of the
Senate, one copy with the Legislative | 15 |
| Research Unit, and such additional
copies
with the State | 16 |
| Government Report Distribution Center for the General
Assembly | 17 |
| as is required under paragraph (t) of Section 7 of the State
| 18 |
| Library Act shall be deemed sufficient to comply with this | 19 |
| Section.
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| Rulemaking authority to implement Public Act 95-1045 this | 21 |
| amendatory Act of the 95th General Assembly , if any, is | 22 |
| conditioned on the rules being adopted in accordance with all | 23 |
| provisions of the Illinois Administrative Procedure Act and all | 24 |
| rules and procedures of the Joint Committee on Administrative | 25 |
| Rules; any purported rule not so adopted, for whatever reason, | 26 |
| is unauthorized. |
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HB5859 Enrolled |
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| (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | 2 |
| 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; revised 11-4-09.)
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| (Text of Section after amendment by P.A. 96-806 ) | 4 |
| Sec. 5-5. Medical services. The Illinois Department, by | 5 |
| rule, shall
determine the quantity and quality of and the rate | 6 |
| of reimbursement for the
medical assistance for which
payment | 7 |
| will be authorized, and the medical services to be provided,
| 8 |
| which may include all or part of the following: (1) inpatient | 9 |
| hospital
services; (2) outpatient hospital services; (3) other | 10 |
| laboratory and
X-ray services; (4) skilled nursing home | 11 |
| services; (5) physicians'
services whether furnished in the | 12 |
| office, the patient's home, a
hospital, a skilled nursing home, | 13 |
| or elsewhere; (6) medical care, or any
other type of remedial | 14 |
| care furnished by licensed practitioners; (7)
home health care | 15 |
| services; (8) private duty nursing service; (9) clinic
| 16 |
| services; (10) dental services, including prevention and | 17 |
| treatment of periodontal disease and dental caries disease for | 18 |
| pregnant women, provided by an individual licensed to practice | 19 |
| dentistry or dental surgery; for purposes of this item (10), | 20 |
| "dental services" means diagnostic, preventive, or corrective | 21 |
| procedures provided by or under the supervision of a dentist in | 22 |
| the practice of his or her profession; (11) physical therapy | 23 |
| and related
services; (12) prescribed drugs, dentures, and | 24 |
| prosthetic devices; and
eyeglasses prescribed by a physician | 25 |
| skilled in the diseases of the eye,
or by an optometrist, |
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HB5859 Enrolled |
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| whichever the person may select; (13) other
diagnostic, | 2 |
| screening, preventive, and rehabilitative services; (14)
| 3 |
| transportation and such other expenses as may be necessary; | 4 |
| (15) medical
treatment of sexual assault survivors, as defined | 5 |
| in
Section 1a of the Sexual Assault Survivors Emergency | 6 |
| Treatment Act, for
injuries sustained as a result of the sexual | 7 |
| assault, including
examinations and laboratory tests to | 8 |
| discover evidence which may be used in
criminal proceedings | 9 |
| arising from the sexual assault; (16) the
diagnosis and | 10 |
| treatment of sickle cell anemia; and (17)
any other medical | 11 |
| care, and any other type of remedial care recognized
under the | 12 |
| laws of this State, but not including abortions, or induced
| 13 |
| miscarriages or premature births, unless, in the opinion of a | 14 |
| physician,
such procedures are necessary for the preservation | 15 |
| of the life of the
woman seeking such treatment, or except an | 16 |
| induced premature birth
intended to produce a live viable child | 17 |
| and such procedure is necessary
for the health of the mother or | 18 |
| her unborn child. The Illinois Department,
by rule, shall | 19 |
| prohibit any physician from providing medical assistance
to | 20 |
| anyone eligible therefor under this Code where such physician | 21 |
| has been
found guilty of performing an abortion procedure in a | 22 |
| wilful and wanton
manner upon a woman who was not pregnant at | 23 |
| the time such abortion
procedure was performed. The term "any | 24 |
| other type of remedial care" shall
include nursing care and | 25 |
| nursing home service for persons who rely on
treatment by | 26 |
| spiritual means alone through prayer for healing.
|
|
|
|
HB5859 Enrolled |
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LRB096 16574 KTG 31847 b |
|
| 1 |
| Notwithstanding any other provision of this Section, a | 2 |
| comprehensive
tobacco use cessation program that includes | 3 |
| purchasing prescription drugs or
prescription medical devices | 4 |
| approved by the Food and Drug administration shall
be covered | 5 |
| under the medical assistance
program under this Article for | 6 |
| persons who are otherwise eligible for
assistance under this | 7 |
| Article.
| 8 |
| Notwithstanding any other provision of this Code, the | 9 |
| Illinois
Department may not require, as a condition of payment | 10 |
| for any laboratory
test authorized under this Article, that a | 11 |
| physician's handwritten signature
appear on the laboratory | 12 |
| test order form. The Illinois Department may,
however, impose | 13 |
| other appropriate requirements regarding laboratory test
order | 14 |
| documentation.
| 15 |
| The Department of Healthcare and Family Services shall | 16 |
| provide the following services to
persons
eligible for | 17 |
| assistance under this Article who are participating in
| 18 |
| education, training or employment programs operated by the | 19 |
| Department of Human
Services as successor to the Department of | 20 |
| Public Aid:
| 21 |
| (1) dental services provided by or under the | 22 |
| supervision of a dentist; and
| 23 |
| (2) eyeglasses prescribed by a physician skilled in the | 24 |
| diseases of the
eye, or by an optometrist, whichever the | 25 |
| person may select.
| 26 |
| Notwithstanding any other provision of this Code and |
|
|
|
HB5859 Enrolled |
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LRB096 16574 KTG 31847 b |
|
| 1 |
| subject to federal approval, the Department may adopt rules to | 2 |
| allow a dentist who is volunteering his or her service at no | 3 |
| cost to render dental services through an enrolled | 4 |
| not-for-profit health clinic without the dentist personally | 5 |
| enrolling as a participating provider in the medical assistance | 6 |
| program. A not-for-profit health clinic shall include a public | 7 |
| health clinic or Federally Qualified Health Center or other | 8 |
| enrolled provider, as determined by the Department, through | 9 |
| which dental services covered under this Section are performed. | 10 |
| The Department shall establish a process for payment of claims | 11 |
| for reimbursement for covered dental services rendered under | 12 |
| this provision. | 13 |
| The Illinois Department, by rule, may distinguish and | 14 |
| classify the
medical services to be provided only in accordance | 15 |
| with the classes of
persons designated in Section 5-2.
| 16 |
| The Department of Healthcare and Family Services must | 17 |
| provide coverage and reimbursement for amino acid-based | 18 |
| elemental formulas, regardless of delivery method, for the | 19 |
| diagnosis and treatment of (i) eosinophilic disorders and (ii) | 20 |
| short bowel syndrome when the prescribing physician has issued | 21 |
| a written order stating that the amino acid-based elemental | 22 |
| formula is medically necessary.
| 23 |
| The Illinois Department shall authorize the provision of, | 24 |
| and shall
authorize payment for, screening by low-dose | 25 |
| mammography for the presence of
occult breast cancer for women | 26 |
| 35 years of age or older who are eligible
for medical |
|
|
|
HB5859 Enrolled |
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LRB096 16574 KTG 31847 b |
|
| 1 |
| assistance under this Article, as follows: | 2 |
| (A) A baseline
mammogram for women 35 to 39 years of | 3 |
| age.
| 4 |
| (B) An annual mammogram for women 40 years of age or | 5 |
| older. | 6 |
| (C) A mammogram at the age and intervals considered | 7 |
| medically necessary by the woman's health care provider for | 8 |
| women under 40 years of age and having a family history of | 9 |
| breast cancer, prior personal history of breast cancer, | 10 |
| positive genetic testing, or other risk factors. | 11 |
| (D) A comprehensive ultrasound screening of an entire | 12 |
| breast or breasts if a mammogram demonstrates | 13 |
| heterogeneous or dense breast tissue, when medically | 14 |
| necessary as determined by a physician licensed to practice | 15 |
| medicine in all of its branches. | 16 |
| All screenings
shall
include a physical breast exam, | 17 |
| instruction on self-examination and
information regarding the | 18 |
| frequency of self-examination and its value as a
preventative | 19 |
| tool. For purposes of this Section, "low-dose mammography" | 20 |
| means
the x-ray examination of the breast using equipment | 21 |
| dedicated specifically
for mammography, including the x-ray | 22 |
| tube, filter, compression device,
and image receptor, with an | 23 |
| average radiation exposure delivery
of less than one rad per | 24 |
| breast for 2 views of an average size breast.
The term also | 25 |
| includes digital mammography.
| 26 |
| On and after July 1, 2008, screening and diagnostic |
|
|
|
HB5859 Enrolled |
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LRB096 16574 KTG 31847 b |
|
| 1 |
| mammography shall be reimbursed at the same rate as the | 2 |
| Medicare program's rates, including the increased | 3 |
| reimbursement for digital mammography. | 4 |
| The Department shall convene an expert panel including | 5 |
| representatives of hospitals, free-standing mammography | 6 |
| facilities, and doctors, including radiologists, to establish | 7 |
| quality standards. Based on these quality standards, the | 8 |
| Department shall provide for bonus payments to mammography | 9 |
| facilities meeting the standards for screening and diagnosis. | 10 |
| The bonus payments shall be at least 15% higher than the | 11 |
| Medicare rates for mammography. | 12 |
| Subject to federal approval, the Department shall | 13 |
| establish a rate methodology for mammography at federally | 14 |
| qualified health centers and other encounter-rate clinics. | 15 |
| These clinics or centers may also collaborate with other | 16 |
| hospital-based mammography facilities. | 17 |
| The Department shall establish a methodology to remind | 18 |
| women who are age-appropriate for screening mammography, but | 19 |
| who have not received a mammogram within the previous 18 | 20 |
| months, of the importance and benefit of screening mammography. | 21 |
| The Department shall establish a performance goal for | 22 |
| primary care providers with respect to their female patients | 23 |
| over age 40 receiving an annual mammogram. This performance | 24 |
| goal shall be used to provide additional reimbursement in the | 25 |
| form of a quality performance bonus to primary care providers | 26 |
| who meet that goal. |
|
|
|
HB5859 Enrolled |
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LRB096 16574 KTG 31847 b |
|
| 1 |
| The Department shall devise a means of case-managing or | 2 |
| patient navigation for beneficiaries diagnosed with breast | 3 |
| cancer. This program shall initially operate as a pilot program | 4 |
| in areas of the State with the highest incidence of mortality | 5 |
| related to breast cancer. At least one pilot program site shall | 6 |
| be in the metropolitan Chicago area and at least one site shall | 7 |
| be outside the metropolitan Chicago area. An evaluation of the | 8 |
| pilot program shall be carried out measuring health outcomes | 9 |
| and cost of care for those served by the pilot program compared | 10 |
| to similarly situated patients who are not served by the pilot | 11 |
| program. | 12 |
| Any medical or health care provider shall immediately | 13 |
| recommend, to
any pregnant woman who is being provided prenatal | 14 |
| services and is suspected
of drug abuse or is addicted as | 15 |
| defined in the Alcoholism and Other Drug Abuse
and Dependency | 16 |
| Act, referral to a local substance abuse treatment provider
| 17 |
| licensed by the Department of Human Services or to a licensed
| 18 |
| hospital which provides substance abuse treatment services. | 19 |
| The Department of Healthcare and Family Services
shall assure | 20 |
| coverage for the cost of treatment of the drug abuse or
| 21 |
| addiction for pregnant recipients in accordance with the | 22 |
| Illinois Medicaid
Program in conjunction with the Department of | 23 |
| Human Services.
| 24 |
| All medical providers providing medical assistance to | 25 |
| pregnant women
under this Code shall receive information from | 26 |
| the Department on the
availability of services under the Drug |
|
|
|
HB5859 Enrolled |
- 23 - |
LRB096 16574 KTG 31847 b |
|
| 1 |
| Free Families with a Future or any
comparable program providing | 2 |
| case management services for addicted women,
including | 3 |
| information on appropriate referrals for other social services
| 4 |
| that may be needed by addicted women in addition to treatment | 5 |
| for addiction.
| 6 |
| The Illinois Department, in cooperation with the | 7 |
| Departments of Human
Services (as successor to the Department | 8 |
| of Alcoholism and Substance
Abuse) and Public Health, through a | 9 |
| public awareness campaign, may
provide information concerning | 10 |
| treatment for alcoholism and drug abuse and
addiction, prenatal | 11 |
| health care, and other pertinent programs directed at
reducing | 12 |
| the number of drug-affected infants born to recipients of | 13 |
| medical
assistance.
| 14 |
| Neither the Department of Healthcare and Family Services | 15 |
| nor the Department of Human
Services shall sanction the | 16 |
| recipient solely on the basis of
her substance abuse.
| 17 |
| The Illinois Department shall establish such regulations | 18 |
| governing
the dispensing of health services under this Article | 19 |
| as it shall deem
appropriate. The Department
should
seek the | 20 |
| advice of formal professional advisory committees appointed by
| 21 |
| the Director of the Illinois Department for the purpose of | 22 |
| providing regular
advice on policy and administrative matters, | 23 |
| information dissemination and
educational activities for | 24 |
| medical and health care providers, and
consistency in | 25 |
| procedures to the Illinois Department.
| 26 |
| Notwithstanding any other provision of law, a health care |
|
|
|
HB5859 Enrolled |
- 24 - |
LRB096 16574 KTG 31847 b |
|
| 1 |
| provider under the medical assistance program may elect, in | 2 |
| lieu of receiving direct payment for services provided under | 3 |
| that program, to participate in the State Employees Deferred | 4 |
| Compensation Plan adopted under Article 24 of the Illinois | 5 |
| Pension Code. A health care provider who elects to participate | 6 |
| in the plan does not have a cause of action against the State | 7 |
| for any damages allegedly suffered by the provider as a result | 8 |
| of any delay by the State in crediting the amount of any | 9 |
| contribution to the provider's plan account. | 10 |
| The Illinois Department may develop and contract with | 11 |
| Partnerships of
medical providers to arrange medical services | 12 |
| for persons eligible under
Section 5-2 of this Code. | 13 |
| Implementation of this Section may be by
demonstration projects | 14 |
| in certain geographic areas. The Partnership shall
be | 15 |
| represented by a sponsor organization. The Department, by rule, | 16 |
| shall
develop qualifications for sponsors of Partnerships. | 17 |
| Nothing in this
Section shall be construed to require that the | 18 |
| sponsor organization be a
medical organization.
| 19 |
| The sponsor must negotiate formal written contracts with | 20 |
| medical
providers for physician services, inpatient and | 21 |
| outpatient hospital care,
home health services, treatment for | 22 |
| alcoholism and substance abuse, and
other services determined | 23 |
| necessary by the Illinois Department by rule for
delivery by | 24 |
| Partnerships. Physician services must include prenatal and
| 25 |
| obstetrical care. The Illinois Department shall reimburse | 26 |
| medical services
delivered by Partnership providers to clients |
|
|
|
HB5859 Enrolled |
- 25 - |
LRB096 16574 KTG 31847 b |
|
| 1 |
| in target areas according to
provisions of this Article and the | 2 |
| Illinois Health Finance Reform Act,
except that:
| 3 |
| (1) Physicians participating in a Partnership and | 4 |
| providing certain
services, which shall be determined by | 5 |
| the Illinois Department, to persons
in areas covered by the | 6 |
| Partnership may receive an additional surcharge
for such | 7 |
| services.
| 8 |
| (2) The Department may elect to consider and negotiate | 9 |
| financial
incentives to encourage the development of | 10 |
| Partnerships and the efficient
delivery of medical care.
| 11 |
| (3) Persons receiving medical services through | 12 |
| Partnerships may receive
medical and case management | 13 |
| services above the level usually offered
through the | 14 |
| medical assistance program.
| 15 |
| Medical providers shall be required to meet certain | 16 |
| qualifications to
participate in Partnerships to ensure the | 17 |
| delivery of high quality medical
services. These | 18 |
| qualifications shall be determined by rule of the Illinois
| 19 |
| Department and may be higher than qualifications for | 20 |
| participation in the
medical assistance program. Partnership | 21 |
| sponsors may prescribe reasonable
additional qualifications | 22 |
| for participation by medical providers, only with
the prior | 23 |
| written approval of the Illinois Department.
| 24 |
| Nothing in this Section shall limit the free choice of | 25 |
| practitioners,
hospitals, and other providers of medical | 26 |
| services by clients.
In order to ensure patient freedom of |
|
|
|
HB5859 Enrolled |
- 26 - |
LRB096 16574 KTG 31847 b |
|
| 1 |
| choice, the Illinois Department shall
immediately promulgate | 2 |
| all rules and take all other necessary actions so that
provided | 3 |
| services may be accessed from therapeutically certified | 4 |
| optometrists
to the full extent of the Illinois Optometric | 5 |
| Practice Act of 1987 without
discriminating between service | 6 |
| providers.
| 7 |
| The Department shall apply for a waiver from the United | 8 |
| States Health
Care Financing Administration to allow for the | 9 |
| implementation of
Partnerships under this Section.
| 10 |
| The Illinois Department shall require health care | 11 |
| providers to maintain
records that document the medical care | 12 |
| and services provided to recipients
of Medical Assistance under | 13 |
| this Article. The Illinois Department shall
require health care | 14 |
| providers to make available, when authorized by the
patient, in | 15 |
| writing, the medical records in a timely fashion to other
| 16 |
| health care providers who are treating or serving persons | 17 |
| eligible for
Medical Assistance under this Article. All | 18 |
| dispensers of medical services
shall be required to maintain | 19 |
| and retain business and professional records
sufficient to | 20 |
| fully and accurately document the nature, scope, details and
| 21 |
| receipt of the health care provided to persons eligible for | 22 |
| medical
assistance under this Code, in accordance with | 23 |
| regulations promulgated by
the Illinois Department. The rules | 24 |
| and regulations shall require that proof
of the receipt of | 25 |
| prescription drugs, dentures, prosthetic devices and
| 26 |
| eyeglasses by eligible persons under this Section accompany |
|
|
|
HB5859 Enrolled |
- 27 - |
LRB096 16574 KTG 31847 b |
|
| 1 |
| each claim
for reimbursement submitted by the dispenser of such | 2 |
| medical services.
No such claims for reimbursement shall be | 3 |
| approved for payment by the Illinois
Department without such | 4 |
| proof of receipt, unless the Illinois Department
shall have put | 5 |
| into effect and shall be operating a system of post-payment
| 6 |
| audit and review which shall, on a sampling basis, be deemed | 7 |
| adequate by
the Illinois Department to assure that such drugs, | 8 |
| dentures, prosthetic
devices and eyeglasses for which payment | 9 |
| is being made are actually being
received by eligible | 10 |
| recipients. Within 90 days after the effective date of
this | 11 |
| amendatory Act of 1984, the Illinois Department shall establish | 12 |
| a
current list of acquisition costs for all prosthetic devices | 13 |
| and any
other items recognized as medical equipment and | 14 |
| supplies reimbursable under
this Article and shall update such | 15 |
| list on a quarterly basis, except that
the acquisition costs of | 16 |
| all prescription drugs shall be updated no
less frequently than | 17 |
| every 30 days as required by Section 5-5.12.
| 18 |
| The rules and regulations of the Illinois Department shall | 19 |
| require
that a written statement including the required opinion | 20 |
| of a physician
shall accompany any claim for reimbursement for | 21 |
| abortions, or induced
miscarriages or premature births. This | 22 |
| statement shall indicate what
procedures were used in providing | 23 |
| such medical services.
| 24 |
| The Illinois Department shall require all dispensers of | 25 |
| medical
services, other than an individual practitioner or | 26 |
| group of practitioners,
desiring to participate in the Medical |
|
|
|
HB5859 Enrolled |
- 28 - |
LRB096 16574 KTG 31847 b |
|
| 1 |
| Assistance program
established under this Article to disclose | 2 |
| all financial, beneficial,
ownership, equity, surety or other | 3 |
| interests in any and all firms,
corporations, partnerships, | 4 |
| associations, business enterprises, joint
ventures, agencies, | 5 |
| institutions or other legal entities providing any
form of | 6 |
| health care services in this State under this Article.
| 7 |
| The Illinois Department may require that all dispensers of | 8 |
| medical
services desiring to participate in the medical | 9 |
| assistance program
established under this Article disclose, | 10 |
| under such terms and conditions as
the Illinois Department may | 11 |
| by rule establish, all inquiries from clients
and attorneys | 12 |
| regarding medical bills paid by the Illinois Department, which
| 13 |
| inquiries could indicate potential existence of claims or liens | 14 |
| for the
Illinois Department.
| 15 |
| Enrollment of a vendor that provides non-emergency medical | 16 |
| transportation,
defined by the Department by rule,
shall be
| 17 |
| conditional for 180 days. During that time, the Department of | 18 |
| Healthcare and Family Services may
terminate the vendor's | 19 |
| eligibility to participate in the medical assistance
program | 20 |
| without cause. That termination of eligibility is not subject | 21 |
| to the
Department's hearing process.
| 22 |
| The Illinois Department shall establish policies, | 23 |
| procedures,
standards and criteria by rule for the acquisition, | 24 |
| repair and replacement
of orthotic and prosthetic devices and | 25 |
| durable medical equipment. Such
rules shall provide, but not be | 26 |
| limited to, the following services: (1)
immediate repair or |
|
|
|
HB5859 Enrolled |
- 29 - |
LRB096 16574 KTG 31847 b |
|
| 1 |
| replacement of such devices by recipients without
medical | 2 |
| authorization; and (2) rental, lease, purchase or | 3 |
| lease-purchase of
durable medical equipment in a | 4 |
| cost-effective manner, taking into
consideration the | 5 |
| recipient's medical prognosis, the extent of the
recipient's | 6 |
| needs, and the requirements and costs for maintaining such
| 7 |
| equipment. Such rules shall enable a recipient to temporarily | 8 |
| acquire and
use alternative or substitute devices or equipment | 9 |
| pending repairs or
replacements of any device or equipment | 10 |
| previously authorized for such
recipient by the Department.
| 11 |
| The Department shall execute, relative to the nursing home | 12 |
| prescreening
project, written inter-agency agreements with the | 13 |
| Department of Human
Services and the Department on Aging, to | 14 |
| effect the following: (i) intake
procedures and common | 15 |
| eligibility criteria for those persons who are receiving
| 16 |
| non-institutional services; and (ii) the establishment and | 17 |
| development of
non-institutional services in areas of the State | 18 |
| where they are not currently
available or are undeveloped.
| 19 |
| The Illinois Department shall develop and operate, in | 20 |
| cooperation
with other State Departments and agencies and in | 21 |
| compliance with
applicable federal laws and regulations, | 22 |
| appropriate and effective
systems of health care evaluation and | 23 |
| programs for monitoring of
utilization of health care services | 24 |
| and facilities, as it affects
persons eligible for medical | 25 |
| assistance under this Code.
| 26 |
| The Illinois Department shall report annually to the |
|
|
|
HB5859 Enrolled |
- 30 - |
LRB096 16574 KTG 31847 b |
|
| 1 |
| General Assembly,
no later than the second Friday in April of | 2 |
| 1979 and each year
thereafter, in regard to:
| 3 |
| (a) actual statistics and trends in utilization of | 4 |
| medical services by
public aid recipients;
| 5 |
| (b) actual statistics and trends in the provision of | 6 |
| the various medical
services by medical vendors;
| 7 |
| (c) current rate structures and proposed changes in | 8 |
| those rate structures
for the various medical vendors; and
| 9 |
| (d) efforts at utilization review and control by the | 10 |
| Illinois Department.
| 11 |
| The period covered by each report shall be the 3 years | 12 |
| ending on the June
30 prior to the report. The report shall | 13 |
| include suggested legislation
for consideration by the General | 14 |
| Assembly. The filing of one copy of the
report with the | 15 |
| Speaker, one copy with the Minority Leader and one copy
with | 16 |
| the Clerk of the House of Representatives, one copy with the | 17 |
| President,
one copy with the Minority Leader and one copy with | 18 |
| the Secretary of the
Senate, one copy with the Legislative | 19 |
| Research Unit, and such additional
copies
with the State | 20 |
| Government Report Distribution Center for the General
Assembly | 21 |
| as is required under paragraph (t) of Section 7 of the State
| 22 |
| Library Act shall be deemed sufficient to comply with this | 23 |
| Section.
| 24 |
| Rulemaking authority to implement Public Act 95-1045 this | 25 |
| amendatory Act of the 95th General Assembly , if any, is | 26 |
| conditioned on the rules being adopted in accordance with all |
|
|
|
HB5859 Enrolled |
- 31 - |
LRB096 16574 KTG 31847 b |
|
| 1 |
| provisions of the Illinois Administrative Procedure Act and all | 2 |
| rules and procedures of the Joint Committee on Administrative | 3 |
| Rules; any purported rule not so adopted, for whatever reason, | 4 |
| is unauthorized. | 5 |
| (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | 6 |
| 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; 96-806, eff. | 7 |
| 7-1-10; revised 11-4-09.)
|
|