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90_HB1881sam001
LRB9000419JSksam
1 AMENDMENT TO HOUSE BILL 1881
2 AMENDMENT NO. . Amend House Bill 1881 by replacing
3 the title with the following:
4 "AN ACT relating to medical services, amending named
5 Acts."; and
6 by replacing everything after the enacting clause with the
7 following:
8 "Section 5. The State Employees Group Insurance Act of
9 1971 is amended by adding Section 6.9 as follows:
10 (5 ILCS 375/6.9 new)
11 Sec. 6.9. Required health benefits. The program of
12 health benefits shall provide the post-mastectomy care
13 benefits required to be covered by a policy of accident and
14 health insurance under Section 356t of the Illinois Insurance
15 Code.
16 Section 10. The State Mandates Act is amended by adding
17 Section 8.21 as follows:
18 (30 ILCS 805/8.21 new)
19 Sec. 8.21. Exempt mandate. Notwithstanding Sections 6
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1 and 8 of this Act, no reimbursement by the State is required
2 for the implementation of any mandate created by this
3 amendatory Act of 1997.
4 Section 15. The Counties Code is amended by changing
5 Section 5-1069 and adding Section 5-1069.3 as follows:
6 (55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
7 Sec. 5-1069. Group life, health, accident, hospital, and
8 medical insurance.
9 (a) The county board of any county may arrange to
10 provide, for the benefit of employees of the county, group
11 life, health, accident, hospital, and medical insurance, or
12 any one or any combination of those types of insurance, or
13 the county board may self-insure, for the benefit of its
14 employees, all or a portion of the employees' group life,
15 health, accident, hospital, and medical insurance, or any one
16 or any combination of those types of insurance, including a
17 combination of self-insurance and other types of insurance
18 authorized by this Section, provided that the county board
19 complies with all other requirements of this Section. The
20 insurance may include provision for employees who rely on
21 treatment by prayer or spiritual means alone for healing in
22 accordance with the tenets and practice of a well recognized
23 religious denomination. The county board may provide for
24 payment by the county of a portion or all of the premium or
25 charge for the insurance with the employee paying the balance
26 of the premium or charge, if any. If the county board
27 undertakes a plan under which the county pays only a portion
28 of the premium or charge, the county board shall provide for
29 withholding and deducting from the compensation of those
30 employees who consent to join the plan the balance of the
31 premium or charge for the insurance.
32 (b) If the county board does not provide for
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1 self-insurance or for a plan under which the county pays a
2 portion or all of the premium or charge for a group insurance
3 plan, the county board may provide for withholding and
4 deducting from the compensation of those employees who
5 consent thereto the total premium or charge for any group
6 life, health, accident, hospital, and medical insurance.
7 (c) The county board may exercise the powers granted in
8 this Section only if it provides for self-insurance or, where
9 it makes arrangements to provide group insurance through an
10 insurance carrier, if the kinds of group insurance are
11 obtained from an insurance company authorized to do business
12 in the State of Illinois. The county board may enact an
13 ordinance prescribing the method of operation of the
14 insurance program.
15 (d) If a county, including a home rule county, is a
16 self-insurer for purposes of providing health insurance
17 coverage for its employees, the insurance coverage shall
18 include screening by low-dose mammography for all women 35
19 years of age or older for the presence of occult breast
20 cancer unless the county elects to provide mammograms itself
21 under Section 5-1069.1. The coverage shall be as follows:
22 (1) A baseline mammogram for women 35 to 39 years
23 of age.
24 (2) A mammogram every one to 2 years, even if no
25 symptoms are present, for women 40 to 49 years of age.
26 (3) An annual mammogram for women 40 50 years of
27 age or older.
28 Those benefits shall be at least as favorable as for
29 other radiological examinations and subject to the same
30 dollar limits, deductibles, and co-insurance factors. For
31 purposes of this subsection, "low-dose mammography" means the
32 x-ray examination of the breast using equipment dedicated
33 specifically for mammography, including the x-ray tube,
34 filter, compression device, screens, and image receptors,
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1 with an average radiation exposure delivery of less than one
2 rad mid-breast, with 2 views for each breast. The requirement
3 that mammograms be included in health insurance coverage as
4 provided in this subsection (d) is an exclusive power and
5 function of the State and is a denial and limitation under
6 Article VII, Section 6, subsection (h) of the Illinois
7 Constitution of home rule county powers. A home rule county
8 to which this subsection applies must comply with every
9 provision of this subsection.
10 (e) The term "employees" as used in this Section
11 includes elected or appointed officials but does not include
12 temporary employees.
13 (Source: P.A. 86-962; 87-780.)
14 (55 ILCS 5/5-1069.3 new)
15 Sec. 5-1069.3. Required health benefits. If a county,
16 including a home rule county, is a self-insurer for purposes
17 of providing health insurance coverage for its employees, the
18 coverage shall include coverage for the post-mastectomy care
19 benefits required to be covered by a policy of accident and
20 health insurance under Section 356t of the Illinois Insurance
21 Code. The requirement that post-mastectomy care be covered
22 as provided in this Section is an exclusive power and
23 function of the State and is a denial and limitation under
24 Article VII, Section 6, subsection (h) of the Illinois
25 Constitution. A home rule county to which this Section
26 applies must comply with every provision of this Section.
27 Section 20. The Illinois Municipal Code is amended by
28 changing Section 10-4-2 and adding Section 10-4-2.3 as
29 follows:
30 (65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
31 Sec. 10-4-2. Group insurance.
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1 (a) The corporate authorities of any municipality may
2 arrange to provide, for the benefit of employees of the
3 municipality, group life, health, accident, hospital, and
4 medical insurance, or any one or any combination of those
5 types of insurance, and may arrange to provide that insurance
6 for the benefit of the spouses or dependents of those
7 employees. The insurance may include provision for employees
8 or other insured persons who rely on treatment by prayer or
9 spiritual means alone for healing in accordance with the
10 tenets and practice of a well recognized religious
11 denomination. The corporate authorities may provide for
12 payment by the municipality of a portion of the premium or
13 charge for the insurance with the employee paying the balance
14 of the premium or charge. If the corporate authorities
15 undertake a plan under which the municipality pays a portion
16 of the premium or charge, the corporate authorities shall
17 provide for withholding and deducting from the compensation
18 of those municipal employees who consent to join the plan the
19 balance of the premium or charge for the insurance.
20 (b) If the corporate authorities do not provide for a
21 plan under which the municipality pays a portion of the
22 premium or charge for a group insurance plan, the corporate
23 authorities may provide for withholding and deducting from
24 the compensation of those employees who consent thereto the
25 premium or charge for any group life, health, accident,
26 hospital, and medical insurance.
27 (c) The corporate authorities may exercise the powers
28 granted in this Section only if the kinds of group insurance
29 are obtained from an insurance company authorized to do
30 business in the State of Illinois. The corporate authorities
31 may enact an ordinance prescribing the method of operation of
32 the insurance program.
33 (d) If a municipality, including a home rule
34 municipality, is a self-insurer for purposes of providing
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1 health insurance coverage for its employees, the insurance
2 coverage shall include screening by low-dose mammography for
3 all women 35 years of age or older for the presence of occult
4 breast cancer unless the municipality elects to provide
5 mammograms itself under Section 10-4-2.1. The coverage shall
6 be as follows:
7 (1) A baseline mammogram for women 35 to 39 years
8 of age.
9 (2) A mammogram every one to 2 years, even if no
10 symptoms are present, for women 40 to 49 years of age.
11 (3) An annual mammogram for women 40 50 years of
12 age or older.
13 Those benefits shall be at least as favorable as for
14 other radiological examinations and subject to the same
15 dollar limits, deductibles, and co-insurance factors. For
16 purposes of this subsection, "low-dose mammography" means the
17 x-ray examination of the breast using equipment dedicated
18 specifically for mammography, including the x-ray tube,
19 filter, compression device, screens, and image receptors,
20 with an average radiation exposure delivery of less than one
21 rad mid-breast, with 2 views for each breast. The requirement
22 that mammograms be included in health insurance coverage as
23 provided in this subsection (d) is an exclusive power and
24 function of the State and is a denial and limitation under
25 Article VII, Section 6, subsection (h) of the Illinois
26 Constitution of home rule municipality powers. A home rule
27 municipality to which this subsection applies must comply
28 with every provision of this subsection.
29 (Source: P.A. 86-1475; 87-780.)
30 (65 ILCS 5/10-4-2.3 new)
31 Sec. 10-4-2.3. Required health benefits. If a
32 municipality, including a home rule municipality, is a
33 self-insurer for purposes of providing health insurance
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1 coverage for its employees, the coverage shall include
2 coverage for the post-mastectomy care benefits required to be
3 covered by a policy of accident and health insurance under
4 Section 356t of the Illinois Insurance Code. The requirement
5 that post-mastectomy care be covered as provided in this is
6 an exclusive power and function of the State and is a denial
7 and limitation under Article VII, Section 6, subsection (h)
8 of the Illinois Constitution. A home rule municipality to
9 which this Section applies must comply with every provision
10 of this Section.
11 Section 25. The School Code is amended by adding Section
12 10-22.3f as follows:
13 (105 ILCS 5/10-22.3f new)
14 Sec. 10-22.3f. Required health benefits. Insurance
15 protection and benefits for employees shall provide the
16 post-mastectomy care benefits required to be covered by a
17 policy of accident and health insurance under Section 356t of
18 the Illinois Insurance Code.
19 Section 30. The Illinois Insurance Code is amended by
20 changing Section 356g and adding Section 356t as follows:
21 (215 ILCS 5/356g) (from Ch. 73, par. 968g)
22 Sec. 356g. (a) Every insurer shall provide in each group
23 or individual policy, contract, or certificate of insurance
24 issued or renewed for persons who are residents of this
25 State, coverage for screening by low-dose mammography for all
26 women 35 years of age or older for the presence of occult
27 breast cancer within the provisions of the policy, contract,
28 or certificate. The coverage shall be as follows:
29 (1) A baseline mammogram for women 35 to 39 years
30 of age.
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1 (2) An mammogram every 1 to 2 years, even if no
2 symptoms are present, for women 40 to 49 years of age.
3 (3) An annual mammogram for women 40 50 years of
4 age or older.
5 These benefits shall be at least as favorable as for
6 other radiological examinations and subject to the same
7 dollar limits, deductibles, and co-insurance factors. For
8 purposes of this Section, "low-dose mammography" means the
9 x-ray examination of the breast using equipment dedicated
10 specifically for mammography, including the x-ray tube,
11 filter, compression device, and image receptor, with
12 radiation exposure delivery of less than 1 rad per breast for
13 2 views of an average size breast.
14 (b) No policy of accident or health insurance that
15 provides for the surgical procedure known as a mastectomy
16 shall be issued, amended, delivered or renewed in this State
17 on or after July 1, 1981, unless coverage is also offered for
18 prosthetic devices or reconstructive surgery incident to the
19 mastectomy, providing that the mastectomy is performed after
20 July 1, 1981. The offered coverage for prosthetic devices and
21 reconstructive surgery shall be subject to the deductible and
22 coinsurance conditions applied to the mastectomy, and all
23 other terms and conditions applicable to other benefits.
24 When a mastectomy is performed and there is no evidence of
25 malignancy then the offered coverage may be limited to the
26 provision of prosthetic devices and reconstructive surgery to
27 within 2 years after the date of the mastectomy. As used in
28 this Section, "mastectomy" means the removal of all or part
29 of the breast for medically necessary reasons, as determined
30 by a licensed physician.
31 (Source: P.A. 86-899; 87-518.)
32 (215 ILCS 5/356t new)
33 Sec. 356t. Post-mastectomy care. An individual or group
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1 policy of accident and health insurance or managed care plan
2 that provides surgical coverage and is amended, delivered,
3 issued, or renewed after the effective date of this
4 amendatory Act of 1997 shall provide inpatient coverage
5 following a mastectomy for a length of time determined by the
6 attending physician to be medically necessary and in
7 accordance with protocols and guidelines based on sound
8 scientific evidence and upon evaluation of the patient and
9 the coverage for and availability of a post-discharge
10 physician office visit or in-home nurse visit to verify the
11 condition of the patient in the first 48 hours after
12 discharge.
13 Section 35. The Health Maintenance Organization Act is
14 amended by changing Section 4-6.1 and adding Section 4-6.5 as
15 follows:
16 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
17 Sec. 4-6.1. (a) Every contract or evidence of coverage
18 issued by a Health Maintenance Organization for persons who
19 are residents of this State shall contain coverage for
20 screening by low-dose mammography for all women 35 years of
21 age or older for the presence of occult breast cancer. The
22 coverage shall be as follows:
23 (1) A baseline mammogram for women 35 to 39 years
24 of age.
25 (2) A mammogram every 1 to 2 years, even if no
26 symptoms are present, for women 40 to 49 years of age.
27 (3) An annual mammogram for women 40 50 years of
28 age or older.
29 These benefits shall be at least as favorable as for
30 other radiological examinations and subject to the same
31 dollar limits, deductibles, and co-insurance factors. For
32 purposes of this Section, "low-dose mammography" means the
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1 x-ray examination of the breast using equipment dedicated
2 specifically for mammography, including the x-ray tube,
3 filter, compression device, and image receptor, with
4 radiation exposure delivery of less than 1 rad per breast for
5 2 views of an average size breast.
6 (Source: P.A. 86-899; 86-1028; 87-518.)
7 (215 ILCS 125/4-6.5 new)
8 Sec. 4-6.5. Required health benefits. A health
9 maintenance organization is subject to the provisions of
10 Section 356t of the Illinois Insurance Code.
11 Section 40. The Voluntary Health Services Plans Act is
12 amended by changing Section 10 as follows:
13 (215 ILCS 165/10) (from Ch. 32, par. 604)
14 Sec. 10. Application of Insurance Code provisions.
15 Health services plan corporations and all persons interested
16 therein or dealing therewith shall be subject to the
17 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
18 143, 143c, 149, 354, 355.2, 356r, 356t, 367.2, 401, 401.1,
19 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
20 (15) of Section 367 of the Illinois Insurance Code.
21 (Source: P.A. 89-514, eff. 7-17-96.)
22 Section 45. The Illinois Public Aid Code is amended by
23 changing Section 5-5 and adding Section 5-16.8 as follows:
24 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
25 (Text of Section before amendment by P.A. 89-507)
26 Sec. 5-5. Medical services. The Illinois Department, by
27 rule, shall determine the quantity and quality of and the
28 rate of reimbursement for the medical assistance for which
29 payment will be authorized, and the medical services to be
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1 provided, which may include all or part of the following: (1)
2 inpatient hospital services; (2) outpatient hospital
3 services; (3) other laboratory and X-ray services; (4)
4 skilled nursing home services; (5) physicians' services
5 whether furnished in the office, the patient's home, a
6 hospital, a skilled nursing home, or elsewhere; (6) medical
7 care, or any other type of remedial care furnished by
8 licensed practitioners; (7) home health care services; (8)
9 private duty nursing service; (9) clinic services; (10)
10 dental services; (11) physical therapy and related services;
11 (12) prescribed drugs, dentures, and prosthetic devices; and
12 eyeglasses prescribed by a physician skilled in the diseases
13 of the eye, or by an optometrist, whichever the person may
14 select; (13) other diagnostic, screening, preventive, and
15 rehabilitative services; (14) transportation and such other
16 expenses as may be necessary; (15) medical treatment of
17 sexual assault survivors, as defined in Section 1a of the
18 Sexual Assault Survivors Emergency Treatment Act, for
19 injuries sustained as a result of the sexual assault,
20 including examinations and laboratory tests to discover
21 evidence which may be used in criminal proceedings arising
22 from the sexual assault; (16) the diagnosis and treatment of
23 sickle cell anemia; and (17) any other medical care, and any
24 other type of remedial care recognized under the laws of this
25 State, but not including abortions, or induced miscarriages
26 or premature births, unless, in the opinion of a physician,
27 such procedures are necessary for the preservation of the
28 life of the woman seeking such treatment, or except an
29 induced premature birth intended to produce a live viable
30 child and such procedure is necessary for the health of the
31 mother or her unborn child. The Illinois Department, by rule,
32 shall prohibit any physician from providing medical
33 assistance to anyone eligible therefor under this Code where
34 such physician has been found guilty of performing an
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1 abortion procedure in a wilful and wanton manner upon a woman
2 who was not pregnant at the time such abortion procedure was
3 performed. The term "any other type of remedial care" shall
4 include nursing care and nursing home service for persons who
5 rely on treatment by spiritual means alone through prayer for
6 healing.
7 The Illinois Department shall provide the following
8 services to persons eligible for assistance under this
9 Article who are participating in education, training or
10 employment programs:
11 (1) dental services, which shall include but not be
12 limited to prosthodontics; and
13 (2) eyeglasses prescribed by a physician skilled in
14 the diseases of the eye, or by an optometrist, whichever
15 the person may select.
16 The Illinois Department, by rule, may distinguish and
17 classify the medical services to be provided only in
18 accordance with the classes of persons designated in Section
19 5-2.
20 The Illinois Department shall authorize the provision of,
21 and shall authorize payment for, screening by low-dose
22 mammography for the presence of occult breast cancer for
23 women 35 years of age or older who are eligible for medical
24 assistance under this Article, as follows: a baseline
25 mammogram for women 35 to 39 years of age; a mammogram every
26 1 to 2 years, even if no symptoms are present, for women 40
27 to 49 years of age; and an annual mammogram for women 40 50
28 years of age or older. All screenings shall include a
29 physical breast exam, instruction on self-examination and
30 information regarding the frequency of self-examination and
31 its value as a preventative tool. As used in this Section,
32 "low-dose mammography" means the x-ray examination of the
33 breast using equipment dedicated specifically for
34 mammography, including the x-ray tube, filter, compression
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1 device, image receptor, and cassettes, with an average
2 radiation exposure delivery of less than one rad mid-breast,
3 with 2 views for each breast.
4 Any medical or health care provider shall immediately
5 recommend, to any pregnant woman who is being provided
6 prenatal services and is suspected of drug abuse or is
7 addicted as defined in the Alcoholism and Other Drug Abuse
8 and Dependency Act, referral to a local substance abuse
9 treatment provider licensed by the Department of Alcoholism
10 and Substance Abuse or to a licensed hospital which provides
11 substance abuse treatment services. The Department of Public
12 Aid shall assure coverage for the cost of treatment of the
13 drug abuse or addiction for pregnant recipients in accordance
14 with the Illinois Medicaid Program in conjunction with the
15 Department of Alcoholism and Substance Abuse.
16 All medical providers providing medical assistance to
17 pregnant women under this Code shall receive information from
18 the Department on the availability of services under the Drug
19 Free Families with a Future or any comparable program
20 providing case management services for addicted women,
21 including information on appropriate referrals for other
22 social services that may be needed by addicted women in
23 addition to treatment for addiction.
24 The Illinois Department, in cooperation with the
25 Departments of Alcoholism and Substance Abuse and Public
26 Health, through a public awareness campaign, may provide
27 information concerning treatment for alcoholism and drug
28 abuse and addiction, prenatal health care, and other
29 pertinent programs directed at reducing the number of
30 drug-affected infants born to recipients of medical
31 assistance.
32 The Department shall not sanction the recipient solely on
33 the basis of her substance abuse.
34 The Illinois Department shall establish such regulations
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1 governing the dispensing of health services under this
2 Article as it shall deem appropriate. In formulating these
3 regulations the Illinois Department shall consult with and
4 give substantial weight to the recommendations offered by the
5 Citizens Assembly/Council on Public Aid. The Department
6 should seek the advice of formal professional advisory
7 committees appointed by the Director of the Illinois
8 Department for the purpose of providing regular advice on
9 policy and administrative matters, information dissemination
10 and educational activities for medical and health care
11 providers, and consistency in procedures to the Illinois
12 Department.
13 The Illinois Department may develop and contract with
14 Partnerships of medical providers to arrange medical services
15 for persons eligible under Section 5-2 of this Code.
16 Implementation of this Section may be by demonstration
17 projects in certain geographic areas. The Partnership shall
18 be represented by a sponsor organization. The Department, by
19 rule, shall develop qualifications for sponsors of
20 Partnerships. Nothing in this Section shall be construed to
21 require that the sponsor organization be a medical
22 organization.
23 The sponsor must negotiate formal written contracts with
24 medical providers for physician services, inpatient and
25 outpatient hospital care, home health services, treatment for
26 alcoholism and substance abuse, and other services determined
27 necessary by the Illinois Department by rule for delivery by
28 Partnerships. Physician services must include prenatal and
29 obstetrical care. The Illinois Department shall reimburse
30 medical services delivered by Partnership providers to
31 clients in target areas according to provisions of this
32 Article and the Illinois Health Finance Reform Act, except
33 that:
34 (1) Physicians participating in a Partnership and
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1 providing certain services, which shall be determined by
2 the Illinois Department, to persons in areas covered by
3 the Partnership may receive an additional surcharge for
4 such services.
5 (2) The Department may elect to consider and
6 negotiate financial incentives to encourage the
7 development of Partnerships and the efficient delivery of
8 medical care.
9 (3) Persons receiving medical services through
10 Partnerships may receive medical and case management
11 services above the level usually offered through the
12 medical assistance program.
13 Medical providers shall be required to meet certain
14 qualifications to participate in Partnerships to ensure the
15 delivery of high quality medical services. These
16 qualifications shall be determined by rule of the Illinois
17 Department and may be higher than qualifications for
18 participation in the medical assistance program. Partnership
19 sponsors may prescribe reasonable additional qualifications
20 for participation by medical providers, only with the prior
21 written approval of the Illinois Department.
22 Nothing in this Section shall limit the free choice of
23 practitioners, hospitals, and other providers of medical
24 services by clients.
25 The Department shall apply for a waiver from the United
26 States Health Care Financing Administration to allow for the
27 implementation of Partnerships under this Section.
28 The Illinois Department shall require health care
29 providers to maintain records that document the medical care
30 and services provided to recipients of Medical Assistance
31 under this Article. The Illinois Department shall require
32 health care providers to make available, when authorized by
33 the patient, in writing, the medical records in a timely
34 fashion to other health care providers who are treating or
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1 serving persons eligible for Medical Assistance under this
2 Article. All dispensers of medical services shall be
3 required to maintain and retain business and professional
4 records sufficient to fully and accurately document the
5 nature, scope, details and receipt of the health care
6 provided to persons eligible for medical assistance under
7 this Code, in accordance with regulations promulgated by the
8 Illinois Department. The rules and regulations shall require
9 that proof of the receipt of prescription drugs, dentures,
10 prosthetic devices and eyeglasses by eligible persons under
11 this Section accompany each claim for reimbursement submitted
12 by the dispenser of such medical services. No such claims for
13 reimbursement shall be approved for payment by the Illinois
14 Department without such proof of receipt, unless the Illinois
15 Department shall have put into effect and shall be operating
16 a system of post-payment audit and review which shall, on a
17 sampling basis, be deemed adequate by the Illinois Department
18 to assure that such drugs, dentures, prosthetic devices and
19 eyeglasses for which payment is being made are actually being
20 received by eligible recipients. Within 90 days after the
21 effective date of this amendatory Act of 1984, the Illinois
22 Department shall establish a current list of acquisition
23 costs for all prosthetic devices and any other items
24 recognized as medical equipment and supplies reimbursable
25 under this Article and shall update such list on a quarterly
26 basis, except that the acquisition costs of all prescription
27 drugs shall be updated no less frequently than every 30 days
28 as required by Section 5-5.12.
29 The rules and regulations of the Illinois Department
30 shall require that a written statement including the required
31 opinion of a physician shall accompany any claim for
32 reimbursement for abortions, or induced miscarriages or
33 premature births. This statement shall indicate what
34 procedures were used in providing such medical services.
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1 The Illinois Department shall require that all dispensers
2 of medical services, other than an individual practitioner or
3 group of practitioners, desiring to participate in the
4 Medical Assistance program established under this Article to
5 disclose all financial, beneficial, ownership, equity, surety
6 or other interests in any and all firms, corporations,
7 partnerships, associations, business enterprises, joint
8 ventures, agencies, institutions or other legal entities
9 providing any form of health care services in this State
10 under this Article.
11 The Illinois Department may require that all dispensers
12 of medical services desiring to participate in the medical
13 assistance program established under this Article disclose,
14 under such terms and conditions as the Illinois Department
15 may by rule establish, all inquiries from clients and
16 attorneys regarding medical bills paid by the Illinois
17 Department, which inquiries could indicate potential
18 existence of claims or liens for the Illinois Department.
19 The Illinois Department shall establish policies,
20 procedures, standards and criteria by rule for the
21 acquisition, repair and replacement of orthotic and
22 prosthetic devices and durable medical equipment. Such rules
23 shall provide, but not be limited to, the following services:
24 (1) immediate repair or replacement of such devices by
25 recipients without medical authorization; and (2) rental,
26 lease, purchase or lease-purchase of durable medical
27 equipment in a cost-effective manner, taking into
28 consideration the recipient's medical prognosis, the extent
29 of the recipient's needs, and the requirements and costs for
30 maintaining such equipment. Such rules shall enable a
31 recipient to temporarily acquire and use alternative or
32 substitute devices or equipment pending repairs or
33 replacements of any device or equipment previously authorized
34 for such recipient by the Department. Rules under clause (2)
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1 above shall not provide for purchase or lease-purchase of
2 durable medical equipment or supplies used for the purpose of
3 oxygen delivery and respiratory care.
4 The Department shall execute, relative to the nursing
5 home prescreening project, written inter-agency agreements
6 with the Department of Rehabilitation Services and the
7 Department on Aging, to effect the following: (i) intake
8 procedures and common eligibility criteria for those persons
9 who are receiving non-institutional services; and (ii) the
10 establishment and development of non-institutional services
11 in areas of the State where they are not currently available
12 or are undeveloped.
13 The Illinois Department shall develop and operate, in
14 cooperation with other State Departments and agencies and in
15 compliance with applicable federal laws and regulations,
16 appropriate and effective systems of health care evaluation
17 and programs for monitoring of utilization of health care
18 services and facilities, as it affects persons eligible for
19 medical assistance under this Code. The Illinois Department
20 shall report regularly the results of the operation of such
21 systems and programs to the Citizens Assembly/Council on
22 Public Aid to enable the Committee to ensure, from time to
23 time, that these programs are effective and meaningful.
24 The Illinois Department shall report annually to the
25 General Assembly, no later than the second Friday in April of
26 1979 and each year thereafter, in regard to:
27 (a) actual statistics and trends in utilization of
28 medical services by public aid recipients;
29 (b) actual statistics and trends in the provision
30 of the various medical services by medical vendors;
31 (c) current rate structures and proposed changes in
32 those rate structures for the various medical vendors;
33 and
34 (d) efforts at utilization review and control by
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1 the Illinois Department.
2 The period covered by each report shall be the 3 years
3 ending on the June 30 prior to the report. The report shall
4 include suggested legislation for consideration by the
5 General Assembly. The filing of one copy of the report with
6 the Speaker, one copy with the Minority Leader and one copy
7 with the Clerk of the House of Representatives, one copy with
8 the President, one copy with the Minority Leader and one copy
9 with the Secretary of the Senate, one copy with the
10 Legislative Research Unit, such additional copies with the
11 State Government Report Distribution Center for the General
12 Assembly as is required under paragraph (t) of Section 7 of
13 the State Library Act and one copy with the Citizens
14 Assembly/Council on Public Aid or its successor shall be
15 deemed sufficient to comply with this Section.
16 (Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
17 89-517, eff. 1-1-97.)
18 (Text of Section after amendment by P.A. 89-507)
19 Sec. 5-5. Medical services. The Illinois Department, by
20 rule, shall determine the quantity and quality of and the
21 rate of reimbursement for the medical assistance for which
22 payment will be authorized, and the medical services to be
23 provided, which may include all or part of the following: (1)
24 inpatient hospital services; (2) outpatient hospital
25 services; (3) other laboratory and X-ray services; (4)
26 skilled nursing home services; (5) physicians' services
27 whether furnished in the office, the patient's home, a
28 hospital, a skilled nursing home, or elsewhere; (6) medical
29 care, or any other type of remedial care furnished by
30 licensed practitioners; (7) home health care services; (8)
31 private duty nursing service; (9) clinic services; (10)
32 dental services; (11) physical therapy and related services;
33 (12) prescribed drugs, dentures, and prosthetic devices; and
34 eyeglasses prescribed by a physician skilled in the diseases
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1 of the eye, or by an optometrist, whichever the person may
2 select; (13) other diagnostic, screening, preventive, and
3 rehabilitative services; (14) transportation and such other
4 expenses as may be necessary; (15) medical treatment of
5 sexual assault survivors, as defined in Section 1a of the
6 Sexual Assault Survivors Emergency Treatment Act, for
7 injuries sustained as a result of the sexual assault,
8 including examinations and laboratory tests to discover
9 evidence which may be used in criminal proceedings arising
10 from the sexual assault; (16) the diagnosis and treatment of
11 sickle cell anemia; and (17) any other medical care, and any
12 other type of remedial care recognized under the laws of this
13 State, but not including abortions, or induced miscarriages
14 or premature births, unless, in the opinion of a physician,
15 such procedures are necessary for the preservation of the
16 life of the woman seeking such treatment, or except an
17 induced premature birth intended to produce a live viable
18 child and such procedure is necessary for the health of the
19 mother or her unborn child. The Illinois Department, by rule,
20 shall prohibit any physician from providing medical
21 assistance to anyone eligible therefor under this Code where
22 such physician has been found guilty of performing an
23 abortion procedure in a wilful and wanton manner upon a woman
24 who was not pregnant at the time such abortion procedure was
25 performed. The term "any other type of remedial care" shall
26 include nursing care and nursing home service for persons who
27 rely on treatment by spiritual means alone through prayer for
28 healing.
29 The Illinois Department of Public Aid shall provide the
30 following services to persons eligible for assistance under
31 this Article who are participating in education, training or
32 employment programs operated by the Department of Human
33 Services as successor to the Department of Public Aid:
34 (1) dental services, which shall include but not be
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1 limited to prosthodontics; and
2 (2) eyeglasses prescribed by a physician skilled in
3 the diseases of the eye, or by an optometrist, whichever
4 the person may select.
5 The Illinois Department, by rule, may distinguish and
6 classify the medical services to be provided only in
7 accordance with the classes of persons designated in Section
8 5-2.
9 The Illinois Department shall authorize the provision of,
10 and shall authorize payment for, screening by low-dose
11 mammography for the presence of occult breast cancer for
12 women 35 years of age or older who are eligible for medical
13 assistance under this Article, as follows: a baseline
14 mammogram for women 35 to 39 years of age; a mammogram every
15 1 to 2 years, even if no symptoms are present, for women 40
16 to 49 years of age; and an annual mammogram for women 40 50
17 years of age or older. All screenings shall include a
18 physical breast exam, instruction on self-examination and
19 information regarding the frequency of self-examination and
20 its value as a preventative tool. As used in this Section,
21 "low-dose mammography" means the x-ray examination of the
22 breast using equipment dedicated specifically for
23 mammography, including the x-ray tube, filter, compression
24 device, image receptor, and cassettes, with an average
25 radiation exposure delivery of less than one rad mid-breast,
26 with 2 views for each breast.
27 Any medical or health care provider shall immediately
28 recommend, to any pregnant woman who is being provided
29 prenatal services and is suspected of drug abuse or is
30 addicted as defined in the Alcoholism and Other Drug Abuse
31 and Dependency Act, referral to a local substance abuse
32 treatment provider licensed by the Department of Human
33 Services or to a licensed hospital which provides substance
34 abuse treatment services. The Department of Public Aid shall
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1 assure coverage for the cost of treatment of the drug abuse
2 or addiction for pregnant recipients in accordance with the
3 Illinois Medicaid Program in conjunction with the Department
4 of Human Services.
5 All medical providers providing medical assistance to
6 pregnant women under this Code shall receive information from
7 the Department on the availability of services under the Drug
8 Free Families with a Future or any comparable program
9 providing case management services for addicted women,
10 including information on appropriate referrals for other
11 social services that may be needed by addicted women in
12 addition to treatment for addiction.
13 The Illinois Department, in cooperation with the
14 Departments of Human Services (as successor to the Department
15 of Alcoholism and Substance Abuse) and Public Health, through
16 a public awareness campaign, may provide information
17 concerning treatment for alcoholism and drug abuse and
18 addiction, prenatal health care, and other pertinent programs
19 directed at reducing the number of drug-affected infants born
20 to recipients of medical assistance.
21 Neither the Illinois Department of Public Aid nor the
22 Department of Human Services shall sanction the recipient
23 solely on the basis of her substance abuse.
24 The Illinois Department shall establish such regulations
25 governing the dispensing of health services under this
26 Article as it shall deem appropriate. In formulating these
27 regulations the Illinois Department shall consult with and
28 give substantial weight to the recommendations offered by the
29 Citizens Assembly/Council on Public Aid. The Department
30 should seek the advice of formal professional advisory
31 committees appointed by the Director of the Illinois
32 Department for the purpose of providing regular advice on
33 policy and administrative matters, information dissemination
34 and educational activities for medical and health care
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1 providers, and consistency in procedures to the Illinois
2 Department.
3 The Illinois Department may develop and contract with
4 Partnerships of medical providers to arrange medical services
5 for persons eligible under Section 5-2 of this Code.
6 Implementation of this Section may be by demonstration
7 projects in certain geographic areas. The Partnership shall
8 be represented by a sponsor organization. The Department, by
9 rule, shall develop qualifications for sponsors of
10 Partnerships. Nothing in this Section shall be construed to
11 require that the sponsor organization be a medical
12 organization.
13 The sponsor must negotiate formal written contracts with
14 medical providers for physician services, inpatient and
15 outpatient hospital care, home health services, treatment for
16 alcoholism and substance abuse, and other services determined
17 necessary by the Illinois Department by rule for delivery by
18 Partnerships. Physician services must include prenatal and
19 obstetrical care. The Illinois Department shall reimburse
20 medical services delivered by Partnership providers to
21 clients in target areas according to provisions of this
22 Article and the Illinois Health Finance Reform Act, except
23 that:
24 (1) Physicians participating in a Partnership and
25 providing certain services, which shall be determined by
26 the Illinois Department, to persons in areas covered by
27 the Partnership may receive an additional surcharge for
28 such services.
29 (2) The Department may elect to consider and
30 negotiate financial incentives to encourage the
31 development of Partnerships and the efficient delivery of
32 medical care.
33 (3) Persons receiving medical services through
34 Partnerships may receive medical and case management
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1 services above the level usually offered through the
2 medical assistance program.
3 Medical providers shall be required to meet certain
4 qualifications to participate in Partnerships to ensure the
5 delivery of high quality medical services. These
6 qualifications shall be determined by rule of the Illinois
7 Department and may be higher than qualifications for
8 participation in the medical assistance program. Partnership
9 sponsors may prescribe reasonable additional qualifications
10 for participation by medical providers, only with the prior
11 written approval of the Illinois Department.
12 Nothing in this Section shall limit the free choice of
13 practitioners, hospitals, and other providers of medical
14 services by clients.
15 The Department shall apply for a waiver from the United
16 States Health Care Financing Administration to allow for the
17 implementation of Partnerships under this Section.
18 The Illinois Department shall require health care
19 providers to maintain records that document the medical care
20 and services provided to recipients of Medical Assistance
21 under this Article. The Illinois Department shall require
22 health care providers to make available, when authorized by
23 the patient, in writing, the medical records in a timely
24 fashion to other health care providers who are treating or
25 serving persons eligible for Medical Assistance under this
26 Article. All dispensers of medical services shall be
27 required to maintain and retain business and professional
28 records sufficient to fully and accurately document the
29 nature, scope, details and receipt of the health care
30 provided to persons eligible for medical assistance under
31 this Code, in accordance with regulations promulgated by the
32 Illinois Department. The rules and regulations shall require
33 that proof of the receipt of prescription drugs, dentures,
34 prosthetic devices and eyeglasses by eligible persons under
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1 this Section accompany each claim for reimbursement submitted
2 by the dispenser of such medical services. No such claims for
3 reimbursement shall be approved for payment by the Illinois
4 Department without such proof of receipt, unless the Illinois
5 Department shall have put into effect and shall be operating
6 a system of post-payment audit and review which shall, on a
7 sampling basis, be deemed adequate by the Illinois Department
8 to assure that such drugs, dentures, prosthetic devices and
9 eyeglasses for which payment is being made are actually being
10 received by eligible recipients. Within 90 days after the
11 effective date of this amendatory Act of 1984, the Illinois
12 Department shall establish a current list of acquisition
13 costs for all prosthetic devices and any other items
14 recognized as medical equipment and supplies reimbursable
15 under this Article and shall update such list on a quarterly
16 basis, except that the acquisition costs of all prescription
17 drugs shall be updated no less frequently than every 30 days
18 as required by Section 5-5.12.
19 The rules and regulations of the Illinois Department
20 shall require that a written statement including the required
21 opinion of a physician shall accompany any claim for
22 reimbursement for abortions, or induced miscarriages or
23 premature births. This statement shall indicate what
24 procedures were used in providing such medical services.
25 The Illinois Department shall require that all dispensers
26 of medical services, other than an individual practitioner or
27 group of practitioners, desiring to participate in the
28 Medical Assistance program established under this Article to
29 disclose all financial, beneficial, ownership, equity, surety
30 or other interests in any and all firms, corporations,
31 partnerships, associations, business enterprises, joint
32 ventures, agencies, institutions or other legal entities
33 providing any form of health care services in this State
34 under this Article.
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1 The Illinois Department may require that all dispensers
2 of medical services desiring to participate in the medical
3 assistance program established under this Article disclose,
4 under such terms and conditions as the Illinois Department
5 may by rule establish, all inquiries from clients and
6 attorneys regarding medical bills paid by the Illinois
7 Department, which inquiries could indicate potential
8 existence of claims or liens for the Illinois Department.
9 The Illinois Department shall establish policies,
10 procedures, standards and criteria by rule for the
11 acquisition, repair and replacement of orthotic and
12 prosthetic devices and durable medical equipment. Such rules
13 shall provide, but not be limited to, the following services:
14 (1) immediate repair or replacement of such devices by
15 recipients without medical authorization; and (2) rental,
16 lease, purchase or lease-purchase of durable medical
17 equipment in a cost-effective manner, taking into
18 consideration the recipient's medical prognosis, the extent
19 of the recipient's needs, and the requirements and costs for
20 maintaining such equipment. Such rules shall enable a
21 recipient to temporarily acquire and use alternative or
22 substitute devices or equipment pending repairs or
23 replacements of any device or equipment previously authorized
24 for such recipient by the Department. Rules under clause (2)
25 above shall not provide for purchase or lease-purchase of
26 durable medical equipment or supplies used for the purpose of
27 oxygen delivery and respiratory care.
28 The Department shall execute, relative to the nursing
29 home prescreening project, written inter-agency agreements
30 with the Department of Human Services and the Department on
31 Aging, to effect the following: (i) intake procedures and
32 common eligibility criteria for those persons who are
33 receiving non-institutional services; and (ii) the
34 establishment and development of non-institutional services
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1 in areas of the State where they are not currently available
2 or are undeveloped.
3 The Illinois Department shall develop and operate, in
4 cooperation with other State Departments and agencies and in
5 compliance with applicable federal laws and regulations,
6 appropriate and effective systems of health care evaluation
7 and programs for monitoring of utilization of health care
8 services and facilities, as it affects persons eligible for
9 medical assistance under this Code. The Illinois Department
10 shall report regularly the results of the operation of such
11 systems and programs to the Citizens Assembly/Council on
12 Public Aid to enable the Committee to ensure, from time to
13 time, that these programs are effective and meaningful.
14 The Illinois Department shall report annually to the
15 General Assembly, no later than the second Friday in April of
16 1979 and each year thereafter, in regard to:
17 (a) actual statistics and trends in utilization of
18 medical services by public aid recipients;
19 (b) actual statistics and trends in the provision
20 of the various medical services by medical vendors;
21 (c) current rate structures and proposed changes in
22 those rate structures for the various medical vendors;
23 and
24 (d) efforts at utilization review and control by
25 the Illinois Department.
26 The period covered by each report shall be the 3 years
27 ending on the June 30 prior to the report. The report shall
28 include suggested legislation for consideration by the
29 General Assembly. The filing of one copy of the report with
30 the Speaker, one copy with the Minority Leader and one copy
31 with the Clerk of the House of Representatives, one copy with
32 the President, one copy with the Minority Leader and one copy
33 with the Secretary of the Senate, one copy with the
34 Legislative Research Unit, such additional copies with the
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1 State Government Report Distribution Center for the General
2 Assembly as is required under paragraph (t) of Section 7 of
3 the State Library Act and one copy with the Citizens
4 Assembly/Council on Public Aid or its successor shall be
5 deemed sufficient to comply with this Section.
6 (Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
7 89-507, eff. 7-1-97; 89-517, eff. 1-1-97; revised 8-26-96.)
8 (305 ILCS 5/5-16.8 new)
9 Sec. 5-16.8. Required health benefits. The medical
10 assistance program shall provide the post-mastectomy care
11 benefits required to be covered by a policy of accident and
12 health insurance under Section 356t of the Illinois Insurance
13 Code.
14 Section 95. No acceleration or delay. Where this Act
15 makes changes in a statute that is represented in this Act by
16 text that is not yet or no longer in effect (for example, a
17 Section represented by multiple versions), the use of that
18 text does not accelerate or delay the taking effect of (i)
19 the changes made by this Act or (ii) provisions derived from
20 any other Public Act.
21 Section 99. Effective date. This Act takes effect upon
22 becoming law.".