Illinois General Assembly - Full Text of HB1560
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Full Text of HB1560  95th General Assembly

HB1560eng 95TH GENERAL ASSEMBLY



 


 
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1     AN ACT concerning insurance.
 
2     WHEREAS, Hundreds of children in this State are born every
3 year with gastrointestinal disorders, such as Gastrointestinal
4 Reflux Disease (GERD), Eosinophilic Esophagitis (EE), and
5 others or inherited diseases of amino acid, organic acid, or
6 dairy protein allergies, which prevent proper digestion or
7 result in a negative reaction to certain natural milk or soy
8 products, formulas, and multiple foods;
9     WHEREAS, These conditions and others create a situation
10 where a natural sustained existence is virtually impossible and
11 threaten a child's ability to thrive;
12     WHEREAS, As many of these children are unable to process
13 any natural nutritional substance, parents, at the advice and
14 direction of a licensed health care professional, must seek
15 enteral or oral elemental formulas, such as amino acid modified
16 formulas and other specialized formulas, to provide proper and
17 medically necessary nutrition;
18     WHEREAS, Amino acid based elemental formulas and food
19 products are widely available, but expensive in nature due to a
20 complicated scientific manufacturing process;
21     WHEREAS, Health insurance policies currently only cover
22 the cost of specialized amino acid based elemental formulas
23 when administered by tube feeding even though tube feeding is
24 not always the least medically invasive or most cost effective
25 option available;
26     WHEREAS, Proper infant and child nutrition significantly

 

 

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1 reduces digestion problems and other developmental and
2 physical conditions, as well as the need for future, more
3 expensive medical treatments; and
4     WHEREAS, The State of Illinois is committed to giving each
5 and every child proper nutrition and a high quality of life,
6 therefore
 
7     Be it enacted by the People of the State of Illinois,
8 represented in the General Assembly:
 
9     Section 5. The State Employees Group Insurance Act of 1971
10 is amended by changing Section 6.11 as follows:
 
11     (5 ILCS 375/6.11)
12     Sec. 6.11. Required health benefits; Illinois Insurance
13 Code requirements. The program of health benefits shall provide
14 the post-mastectomy care benefits required to be covered by a
15 policy of accident and health insurance under Section 356t of
16 the Illinois Insurance Code. The program of health benefits
17 shall provide the coverage required under Sections 356u, 356w,
18 356x, 356z.2, 356z.4, and 356z.6, and 356z.9 of the Illinois
19 Insurance Code. The program of health benefits must comply with
20 Section 155.37 of the Illinois Insurance Code.
21 (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03;
22 93-102, eff. 1-1-04; 93-853, eff. 1-1-05.)
 

 

 

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1     Section 10. The Counties Code is amended by changing
2 Section 5-1069.3 as follows:
 
3     (55 ILCS 5/5-1069.3)
4     Sec. 5-1069.3. Required health benefits. If a county,
5 including a home rule county, is a self-insurer for purposes of
6 providing health insurance coverage for its employees, the
7 coverage shall include coverage for the post-mastectomy care
8 benefits required to be covered by a policy of accident and
9 health insurance under Section 356t and the coverage required
10 under Sections 356u, 356w, 356x, and 356z.6, and 356z.9 of the
11 Illinois Insurance Code. The requirement that health benefits
12 be covered as provided in this Section is an exclusive power
13 and function of the State and is a denial and limitation under
14 Article VII, Section 6, subsection (h) of the Illinois
15 Constitution. A home rule county to which this Section applies
16 must comply with every provision of this Section.
17 (Source: P.A. 93-853, eff. 1-1-05.)
 
18     Section 15. The Illinois Municipal Code is amended by
19 changing Section 10-4-2.3 as follows:
 
20     (65 ILCS 5/10-4-2.3)
21     Sec. 10-4-2.3. Required health benefits. If a
22 municipality, including a home rule municipality, is a
23 self-insurer for purposes of providing health insurance

 

 

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1 coverage for its employees, the coverage shall include coverage
2 for the post-mastectomy care benefits required to be covered by
3 a policy of accident and health insurance under Section 356t
4 and the coverage required under Sections 356u, 356w, 356x, and
5 356z.6, and 356z.9 of the Illinois Insurance Code. The
6 requirement that health benefits be covered as provided in this
7 is an exclusive power and function of the State and is a denial
8 and limitation under Article VII, Section 6, subsection (h) of
9 the Illinois Constitution. A home rule municipality to which
10 this Section applies must comply with every provision of this
11 Section.
12 (Source: P.A. 93-853, eff. 1-1-05.)
 
13     Section 20. The Illinois Insurance Code is amended by
14 adding Section 365z.9 as follows:
 
15     (215 ILCS 5/365z.9 new)
16     Sec. 365z.9. Amino acid-based elemental formulas.
17     (a) A group or individual policy of accident and health
18 insurance or managed care plan amended, delivered, issued, or
19 renewed after the effective date of this amendatory Act of the
20 95th General Assembly must provide coverage and reimbursement
21 when documentation is presented demonstrating a medical
22 necessity and treatment plan for amino acid-based elemental
23 formulas, regardless of delivery method, for the diagnosis and
24 treatment of (i) an individual with multiple food allergies or

 

 

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1 intolerances making amino acid-based elemental formulas a
2 medically necessary treatment, (ii) eosinophilic disorders,
3 and (iii) short bowel syndrome, when the prescribing physician
4 or dietician has issued a written order stating that the amino
5 acid-based elemental formula is medically necessary for the
6 treatment of a disease or disorder.
 
7     Section 25. The Health Maintenance Organization Act is
8 amended by changing Section 5-3 as follows:
 
9     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
10     Sec. 5-3. Insurance Code provisions.
11     (a) Health Maintenance Organizations shall be subject to
12 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
13 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
14 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
15 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 364.01,
16 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 401,
17 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
18 paragraph (c) of subsection (2) of Section 367, and Articles
19 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
20 the Illinois Insurance Code.
21     (b) For purposes of the Illinois Insurance Code, except for
22 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
23 Maintenance Organizations in the following categories are
24 deemed to be "domestic companies":

 

 

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1         (1) a corporation authorized under the Dental Service
2     Plan Act or the Voluntary Health Services Plans Act;
3         (2) a corporation organized under the laws of this
4     State; or
5         (3) a corporation organized under the laws of another
6     state, 30% or more of the enrollees of which are residents
7     of this State, except a corporation subject to
8     substantially the same requirements in its state of
9     organization as is a "domestic company" under Article VIII
10     1/2 of the Illinois Insurance Code.
11     (c) In considering the merger, consolidation, or other
12 acquisition of control of a Health Maintenance Organization
13 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
14         (1) the Director shall give primary consideration to
15     the continuation of benefits to enrollees and the financial
16     conditions of the acquired Health Maintenance Organization
17     after the merger, consolidation, or other acquisition of
18     control takes effect;
19         (2)(i) the criteria specified in subsection (1)(b) of
20     Section 131.8 of the Illinois Insurance Code shall not
21     apply and (ii) the Director, in making his determination
22     with respect to the merger, consolidation, or other
23     acquisition of control, need not take into account the
24     effect on competition of the merger, consolidation, or
25     other acquisition of control;
26         (3) the Director shall have the power to require the

 

 

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1     following information:
2             (A) certification by an independent actuary of the
3         adequacy of the reserves of the Health Maintenance
4         Organization sought to be acquired;
5             (B) pro forma financial statements reflecting the
6         combined balance sheets of the acquiring company and
7         the Health Maintenance Organization sought to be
8         acquired as of the end of the preceding year and as of
9         a date 90 days prior to the acquisition, as well as pro
10         forma financial statements reflecting projected
11         combined operation for a period of 2 years;
12             (C) a pro forma business plan detailing an
13         acquiring party's plans with respect to the operation
14         of the Health Maintenance Organization sought to be
15         acquired for a period of not less than 3 years; and
16             (D) such other information as the Director shall
17         require.
18     (d) The provisions of Article VIII 1/2 of the Illinois
19 Insurance Code and this Section 5-3 shall apply to the sale by
20 any health maintenance organization of greater than 10% of its
21 enrollee population (including without limitation the health
22 maintenance organization's right, title, and interest in and to
23 its health care certificates).
24     (e) In considering any management contract or service
25 agreement subject to Section 141.1 of the Illinois Insurance
26 Code, the Director (i) shall, in addition to the criteria

 

 

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1 specified in Section 141.2 of the Illinois Insurance Code, take
2 into account the effect of the management contract or service
3 agreement on the continuation of benefits to enrollees and the
4 financial condition of the health maintenance organization to
5 be managed or serviced, and (ii) need not take into account the
6 effect of the management contract or service agreement on
7 competition.
8     (f) Except for small employer groups as defined in the
9 Small Employer Rating, Renewability and Portability Health
10 Insurance Act and except for medicare supplement policies as
11 defined in Section 363 of the Illinois Insurance Code, a Health
12 Maintenance Organization may by contract agree with a group or
13 other enrollment unit to effect refunds or charge additional
14 premiums under the following terms and conditions:
15         (i) the amount of, and other terms and conditions with
16     respect to, the refund or additional premium are set forth
17     in the group or enrollment unit contract agreed in advance
18     of the period for which a refund is to be paid or
19     additional premium is to be charged (which period shall not
20     be less than one year); and
21         (ii) the amount of the refund or additional premium
22     shall not exceed 20% of the Health Maintenance
23     Organization's profitable or unprofitable experience with
24     respect to the group or other enrollment unit for the
25     period (and, for purposes of a refund or additional
26     premium, the profitable or unprofitable experience shall

 

 

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1     be calculated taking into account a pro rata share of the
2     Health Maintenance Organization's administrative and
3     marketing expenses, but shall not include any refund to be
4     made or additional premium to be paid pursuant to this
5     subsection (f)). The Health Maintenance Organization and
6     the group or enrollment unit may agree that the profitable
7     or unprofitable experience may be calculated taking into
8     account the refund period and the immediately preceding 2
9     plan years.
10     The Health Maintenance Organization shall include a
11 statement in the evidence of coverage issued to each enrollee
12 describing the possibility of a refund or additional premium,
13 and upon request of any group or enrollment unit, provide to
14 the group or enrollment unit a description of the method used
15 to calculate (1) the Health Maintenance Organization's
16 profitable experience with respect to the group or enrollment
17 unit and the resulting refund to the group or enrollment unit
18 or (2) the Health Maintenance Organization's unprofitable
19 experience with respect to the group or enrollment unit and the
20 resulting additional premium to be paid by the group or
21 enrollment unit.
22     In no event shall the Illinois Health Maintenance
23 Organization Guaranty Association be liable to pay any
24 contractual obligation of an insolvent organization to pay any
25 refund authorized under this Section.
26 (Source: P.A. 93-102, eff. 1-1-04; 93-261, eff. 1-1-04; 93-477,

 

 

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1 eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, eff. 1-1-05;
2 93-1000, eff. 1-1-05; 94-906, eff. 1-1-07; 94-1076, eff.
3 12-29-06; revised 1-5-07.)
 
4     Section 30. The Limited Health Service Organization Act is
5 amended by changing Section 4003 as follows:
 
6     (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
7     Sec. 4003. Illinois Insurance Code provisions. Limited
8 health service organizations shall be subject to the provisions
9 of Sections 133, 134, 137, 140, 141.1, 141.2, 141.3, 143, 143c,
10 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6, 154.7, 154.8,
11 155.04, 155.37, 355.2, 356v, 356z.9, 368a, 401, 401.1, 402,
12 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles
13 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
14 the Illinois Insurance Code. For purposes of the Illinois
15 Insurance Code, except for Sections 444 and 444.1 and Articles
16 XIII and XIII 1/2, limited health service organizations in the
17 following categories are deemed to be domestic companies:
18         (1) a corporation under the laws of this State; or
19         (2) a corporation organized under the laws of another
20     state, 30% of more of the enrollees of which are residents
21     of this State, except a corporation subject to
22     substantially the same requirements in its state of
23     organization as is a domestic company under Article VIII
24     1/2 of the Illinois Insurance Code.

 

 

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1 (Source: P.A. 91-549, eff. 8-14-99; 91-605, eff. 12-14-99;
2 91-788, eff. 6-9-00; 92-440, eff. 8-17-01.)
 
3     Section 35. The Voluntary Health Services Plans Act is
4 amended by changing Section 10 as follows:
 
5     (215 ILCS 165/10)  (from Ch. 32, par. 604)
6     Sec. 10. Application of Insurance Code provisions. Health
7 services plan corporations and all persons interested therein
8 or dealing therewith shall be subject to the provisions of
9 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
10 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v, 356w, 356x,
11 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
12 364.01, 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2,
13 and 412, and paragraphs (7) and (15) of Section 367 of the
14 Illinois Insurance Code.
15 (Source: P.A. 93-102, eff. 1-1-04; 93-529, eff. 8-14-03;
16 93-853, eff. 1-1-05; 93-1000, eff. 1-1-05; 94-1076, eff.
17 12-29-06.)
 
18     Section 40. The Illinois Public Aid Code is amended by
19 changing Section 5-5 as follows:
 
20     (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
21     Sec. 5-5. Medical services. The Illinois Department, by
22 rule, shall determine the quantity and quality of and the rate

 

 

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

 

 

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1 remedial care recognized under the laws of this State, but not
2 including abortions, or induced miscarriages or premature
3 births, unless, in the opinion of a physician, such procedures
4 are necessary for the preservation of the life of the woman
5 seeking such treatment, or except an induced premature birth
6 intended to produce a live viable child and such procedure is
7 necessary for the health of the mother or her unborn child. The
8 Illinois Department, by rule, shall prohibit any physician from
9 providing medical assistance to anyone eligible therefor under
10 this Code where such physician has been found guilty of
11 performing an abortion procedure in a wilful and wanton manner
12 upon a woman who was not pregnant at the time such abortion
13 procedure was performed. The term "any other type of remedial
14 care" shall include nursing care and nursing home service for
15 persons who rely on treatment by spiritual means alone through
16 prayer for healing.
17     Notwithstanding any other provision of this Section, a
18 comprehensive tobacco use cessation program that includes
19 purchasing prescription drugs or prescription medical devices
20 approved by the Food and Drug administration shall be covered
21 under the medical assistance program under this Article for
22 persons who are otherwise eligible for assistance under this
23 Article.
24     Notwithstanding any other provision of this Code, the
25 Illinois Department may not require, as a condition of payment
26 for any laboratory test authorized under this Article, that a

 

 

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1 physician's handwritten signature appear on the laboratory
2 test order form. The Illinois Department may, however, impose
3 other appropriate requirements regarding laboratory test order
4 documentation.
5     The Illinois Department of Healthcare and Family Services
6 Public Aid shall provide the following services to persons
7 eligible for assistance under this Article who are
8 participating in education, training or employment programs
9 operated by the Department of Human Services as successor to
10 the Department of Public Aid:
11         (1) dental services, which shall include but not be
12     limited to prosthodontics; and
13         (2) eyeglasses prescribed by a physician skilled in the
14     diseases of the eye, or by an optometrist, whichever the
15     person may select.
16     The Illinois Department, by rule, may distinguish and
17 classify the medical services to be provided only in accordance
18 with the classes of persons designated in Section 5-2.
19     The Department of Healthcare and Family Services must
20 provide coverage and reimbursement when documentation is
21 presented demonstrating a medical necessity and treatment plan
22 for amino acid-based elemental formulas, regardless of
23 delivery method, for the diagnosis and treatment of (i) an
24 individual with multiple food allergies or intolerances making
25 amino acid-based elemental formulas a medically necessary
26 treatment, (ii) eosinophilic disorders, and (iii) short bowel

 

 

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1 syndrome, when the prescribing physician or dietician has
2 issued a written order stating that the amino acid-based
3 elemental formula is medically necessary for the treatment of a
4 disease or disorder.
5     The Illinois Department shall authorize the provision of,
6 and shall authorize payment for, screening by low-dose
7 mammography for the presence of occult breast cancer for women
8 35 years of age or older who are eligible for medical
9 assistance under this Article, as follows: a baseline mammogram
10 for women 35 to 39 years of age and an annual mammogram for
11 women 40 years of age or older. All screenings shall include a
12 physical breast exam, instruction on self-examination and
13 information regarding the frequency of self-examination and
14 its value as a preventative tool. As used in this Section,
15 "low-dose mammography" means the x-ray examination of the
16 breast using equipment dedicated specifically for mammography,
17 including the x-ray tube, filter, compression device, image
18 receptor, and cassettes, with an average radiation exposure
19 delivery of less than one rad mid-breast, with 2 views for each
20 breast.
21     Any medical or health care provider shall immediately
22 recommend, to any pregnant woman who is being provided prenatal
23 services and is suspected of drug abuse or is addicted as
24 defined in the Alcoholism and Other Drug Abuse and Dependency
25 Act, referral to a local substance abuse treatment provider
26 licensed by the Department of Human Services or to a licensed

 

 

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1 hospital which provides substance abuse treatment services.
2 The Department of Healthcare and Family Services Public Aid
3 shall assure coverage for the cost of treatment of the drug
4 abuse or addiction for pregnant recipients in accordance with
5 the Illinois Medicaid Program in conjunction with the
6 Department of Human Services.
7     All medical providers providing medical assistance to
8 pregnant women under this Code shall receive information from
9 the Department on the availability of services under the Drug
10 Free Families with a Future or any comparable program providing
11 case management services for addicted women, including
12 information on appropriate referrals for other social services
13 that may be needed by addicted women in addition to treatment
14 for addiction.
15     The Illinois Department, in cooperation with the
16 Departments of Human Services (as successor to the Department
17 of Alcoholism and Substance Abuse) and Public Health, through a
18 public awareness campaign, may provide information concerning
19 treatment for alcoholism and drug abuse and addiction, prenatal
20 health care, and other pertinent programs directed at reducing
21 the number of drug-affected infants born to recipients of
22 medical assistance.
23     Neither the Illinois Department of Healthcare and Family
24 Services Public Aid nor the Department of Human Services shall
25 sanction the recipient solely on the basis of her substance
26 abuse.

 

 

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1     The Illinois Department shall establish such regulations
2 governing the dispensing of health services under this Article
3 as it shall deem appropriate. The Department should seek the
4 advice of formal professional advisory committees appointed by
5 the Director of the Illinois Department for the purpose of
6 providing regular advice on policy and administrative matters,
7 information dissemination and educational activities for
8 medical and health care providers, and consistency in
9 procedures to the Illinois Department.
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

 

 

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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

 

 

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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

 

 

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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

 

 

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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 Public Aid may terminate the
19 vendor's eligibility to participate in the medical assistance
20 program without cause. That termination of eligibility is not
21 subject 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

 

 

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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

 

 

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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 (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02;
25 92-789, eff. 8-6-02; 93-632, eff. 2-1-04; 93-841, eff. 7-30-04;
26 93-981, eff. 8-23-04; revised 12-15-05.)
 

 

 

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1     Section 99. Effective date. This Act takes effect upon
2 becoming law.