Full Text of HB1560 95th General Assembly
HB1560eng 95TH GENERAL ASSEMBLY
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| AN ACT concerning insurance.
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| 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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| 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,
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| represented in the General Assembly:
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| Section 5. The State Employees Group Insurance Act of 1971 | 10 |
| is amended by changing Section 6.11 as follows:
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| (5 ILCS 375/6.11)
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| 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.
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| (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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| Section 10. The Counties Code is amended by changing | 2 |
| Section 5-1069.3 as follows: | 3 |
| (55 ILCS 5/5-1069.3)
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| 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
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| 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.
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| (Source: P.A. 93-853, eff. 1-1-05.)
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| 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)
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| 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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| 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
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| 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
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| this Section applies must comply with every provision of this | 11 |
| Section.
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| (Source: P.A. 93-853, eff. 1-1-05.)
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| 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.
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| (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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| 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:
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| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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| Sec. 5-3. Insurance Code provisions.
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| (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,
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| 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.
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| (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) a corporation authorized under the
Dental Service | 2 |
| Plan Act or the Voluntary Health Services Plans Act;
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| (2) a corporation organized under the laws of this | 4 |
| State; or
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| (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
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| organization as is a "domestic company" under Article VIII | 10 |
| 1/2 of the
Illinois Insurance Code.
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| (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,
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| (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;
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| (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
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| acquisition of control, need not take into account the | 24 |
| effect on
competition of the merger, consolidation, or | 25 |
| other acquisition of control;
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| (3) the Director shall have the power to require the |
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| following
information:
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| (A) certification by an independent actuary of the | 3 |
| adequacy
of the reserves of the Health Maintenance | 4 |
| Organization sought to be acquired;
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| (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;
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| (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
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| (D) such other information as the Director shall | 17 |
| require.
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| (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
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| enrollee population (including without limitation the health | 22 |
| maintenance
organization's right, title, and interest in and to | 23 |
| its health care
certificates).
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| (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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| 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
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| 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.
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| (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:
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| (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
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| additional premium is to be charged (which period shall not | 20 |
| be less than one
year); and
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| (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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| be calculated taking into account a pro rata share of the
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| 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.
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| 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
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| 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.
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| 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.
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| (Source: P.A. 93-102, eff. 1-1-04; 93-261, eff. 1-1-04; 93-477, |
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| 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.)
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| Section 30. The Limited Health Service Organization Act is | 5 |
| amended by changing Section 4003 as follows:
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| (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
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| 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,
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| 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:
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| (1) a corporation under the laws of this State; or
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| (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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| (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.)
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| Section 35. The Voluntary Health Services Plans Act is | 4 |
| amended by changing Section 10 as follows:
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| (215 ILCS 165/10) (from Ch. 32, par. 604)
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| 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,
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| 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.
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| (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.)
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| 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)
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| 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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| of reimbursement for the
medical assistance for which
payment | 2 |
| 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 | 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
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| 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
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| 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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| 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.
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| 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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| 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.
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| 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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| 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.
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| 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.
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| 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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| 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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LRB095 09733 KBJ 29937 b |
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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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HB1560 Engrossed |
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LRB095 09733 KBJ 29937 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 |
|
|
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HB1560 Engrossed |
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LRB095 09733 KBJ 29937 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 |
|
|
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HB1560 Engrossed |
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LRB095 09733 KBJ 29937 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 |
|
|
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LRB095 09733 KBJ 29937 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
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 |
|
|
|
HB1560 Engrossed |
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LRB095 09733 KBJ 29937 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 |
|
|
|
HB1560 Engrossed |
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LRB095 09733 KBJ 29937 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 |
| (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.)
|
|
|
|
HB1560 Engrossed |
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LRB095 09733 KBJ 29937 b |
|
| 1 |
| Section 99. Effective date. This Act takes effect upon | 2 |
| becoming law. |
|