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90_SB0317enr
305 ILCS 5/4-0.5
Amends the Aid to Families with Dependent Children
Article of the Illinois Public Aid Code. Makes a technical
change in provisions regarding the termination of the AFDC
program on December 31, 1998.
LRB9001503SMdv
SB317 Enrolled LRB9001503SMdv
1 AN ACT regarding health services, amending named Acts.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5 changing Sections 4-19, 5-16.3, and 8A-6, and by adding
6 Sections 5-16.10, 5-16.11, 8A-13, 8A-14, 8A-15, 8A-16, and
7 8A-17 as follows:
8 (305 ILCS 5/4-19)
9 Sec. 4-19. Demonstration project; treatment; AFDC. The
10 Department, in cooperation with the Department of Alcoholism
11 and Substance Abuse, is authorized to conduct a demonstration
12 project in which clients who are identified as having an
13 alcohol or substance abuse problem must, as a condition of
14 eligibility for assistance under this Article, participate in
15 an alcohol or substance abuse treatment program. The
16 Department shall, by rule, establish (i) the sites for the
17 demonstration program, (ii) the methods for determining
18 whether a client has an alcohol or substance abuse problem,
19 and (iii) the sanctions for failure to cooperate. The
20 demonstration program shall terminate on January 1, 2000. At
21 the end of the demonstration program, the program may be
22 extended expended, by rule, to other areas of the State or
23 the entire State. The Department shall apply for all
24 appropriate waivers of federal requirements necessary to
25 implement this Section.
26 (305 ILCS 5/5-16.3)
27 (Text of Section before amendment by P.A. 89-507)
28 Sec. 5-16.3. System for integrated health care services.
29 (a) It shall be the public policy of the State to adopt,
30 to the extent practicable, a health care program that
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1 encourages the integration of health care services and
2 manages the health care of program enrollees while preserving
3 reasonable choice within a competitive and cost-efficient
4 environment. In furtherance of this public policy, the
5 Illinois Department shall develop and implement an integrated
6 health care program consistent with the provisions of this
7 Section. The provisions of this Section apply only to the
8 integrated health care program created under this Section.
9 Persons enrolled in the integrated health care program, as
10 determined by the Illinois Department by rule, shall be
11 afforded a choice among health care delivery systems, which
12 shall include, but are not limited to, (i) fee for service
13 care managed by a primary care physician licensed to practice
14 medicine in all its branches, (ii) managed health care
15 entities, and (iii) federally qualified health centers
16 (reimbursed according to a prospective cost-reimbursement
17 methodology) and rural health clinics (reimbursed according
18 to the Medicare methodology), where available. Persons
19 enrolled in the integrated health care program also may be
20 offered indemnity insurance plans, subject to availability.
21 For purposes of this Section, a "managed health care
22 entity" means a health maintenance organization or a managed
23 care community network as defined in this Section. A "health
24 maintenance organization" means a health maintenance
25 organization as defined in the Health Maintenance
26 Organization Act. A "managed care community network" means
27 an entity, other than a health maintenance organization, that
28 is owned, operated, or governed by providers of health care
29 services within this State and that provides or arranges
30 primary, secondary, and tertiary managed health care services
31 under contract with the Illinois Department exclusively to
32 enrollees of the integrated health care program. A managed
33 care community network may contract with the Illinois
34 Department to provide only pediatric health care services. A
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1 county provider as defined in Section 15-1 of this Code may
2 contract with the Illinois Department to provide services to
3 enrollees of the integrated health care program as a managed
4 care community network without the need to establish a
5 separate entity that provides services exclusively to
6 enrollees of the integrated health care program and shall be
7 deemed a managed care community network for purposes of this
8 Code only to the extent of the provision of services to those
9 enrollees in conjunction with the integrated health care
10 program. A county provider shall be entitled to contract
11 with the Illinois Department with respect to any contracting
12 region located in whole or in part within the county. A
13 county provider shall not be required to accept enrollees who
14 do not reside within the county.
15 Each managed care community network must demonstrate its
16 ability to bear the financial risk of serving enrollees under
17 this program. The Illinois Department shall by rule adopt
18 criteria for assessing the financial soundness of each
19 managed care community network. These rules shall consider
20 the extent to which a managed care community network is
21 comprised of providers who directly render health care and
22 are located within the community in which they seek to
23 contract rather than solely arrange or finance the delivery
24 of health care. These rules shall further consider a variety
25 of risk-bearing and management techniques, including the
26 sufficiency of quality assurance and utilization management
27 programs and whether a managed care community network has
28 sufficiently demonstrated its financial solvency and net
29 worth. The Illinois Department's criteria must be based on
30 sound actuarial, financial, and accounting principles. In
31 adopting these rules, the Illinois Department shall consult
32 with the Illinois Department of Insurance. The Illinois
33 Department is responsible for monitoring compliance with
34 these rules.
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1 This Section may not be implemented before the effective
2 date of these rules, the approval of any necessary federal
3 waivers, and the completion of the review of an application
4 submitted, at least 60 days before the effective date of
5 rules adopted under this Section, to the Illinois Department
6 by a managed care community network.
7 All health care delivery systems that contract with the
8 Illinois Department under the integrated health care program
9 shall clearly recognize a health care provider's right of
10 conscience under the Right of Conscience Act. In addition to
11 the provisions of that Act, no health care delivery system
12 that contracts with the Illinois Department under the
13 integrated health care program shall be required to provide,
14 arrange for, or pay for any health care or medical service,
15 procedure, or product if that health care delivery system is
16 owned, controlled, or sponsored by or affiliated with a
17 religious institution or religious organization that finds
18 that health care or medical service, procedure, or product to
19 violate its religious and moral teachings and beliefs.
20 (b) The Illinois Department may, by rule, provide for
21 different benefit packages for different categories of
22 persons enrolled in the program. Mental health services,
23 alcohol and substance abuse services, services related to
24 children with chronic or acute conditions requiring
25 longer-term treatment and follow-up, and rehabilitation care
26 provided by a free-standing rehabilitation hospital or a
27 hospital rehabilitation unit may be excluded from a benefit
28 package if the State ensures that those services are made
29 available through a separate delivery system. An exclusion
30 does not prohibit the Illinois Department from developing and
31 implementing demonstration projects for categories of persons
32 or services. Benefit packages for persons eligible for
33 medical assistance under Articles V, VI, and XII shall be
34 based on the requirements of those Articles and shall be
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1 consistent with the Title XIX of the Social Security Act.
2 Nothing in this Act shall be construed to apply to services
3 purchased by the Department of Children and Family Services
4 and the Department of Mental Health and Developmental
5 Disabilities under the provisions of Title 59 of the Illinois
6 Administrative Code, Part 132 ("Medicaid Community Mental
7 Health Services Program").
8 (c) The program established by this Section may be
9 implemented by the Illinois Department in various contracting
10 areas at various times. The health care delivery systems and
11 providers available under the program may vary throughout the
12 State. For purposes of contracting with managed health care
13 entities and providers, the Illinois Department shall
14 establish contracting areas similar to the geographic areas
15 designated by the Illinois Department for contracting
16 purposes under the Illinois Competitive Access and
17 Reimbursement Equity Program (ICARE) under the authority of
18 Section 3-4 of the Illinois Health Finance Reform Act or
19 similarly-sized or smaller geographic areas established by
20 the Illinois Department by rule. A managed health care entity
21 shall be permitted to contract in any geographic areas for
22 which it has a sufficient provider network and otherwise
23 meets the contracting terms of the State. The Illinois
24 Department is not prohibited from entering into a contract
25 with a managed health care entity at any time.
26 (c-5) A managed health care entity may not engage in
27 door-to-door marketing activities or marketing activities at
28 an office of the Illinois Department or a county department
29 in order to enroll in the entity's health care delivery
30 system persons who are enrolled in the integrated health care
31 program established under this Section. The Illinois
32 Department shall adopt rules defining "marketing activities"
33 prohibited by this subsection (c-5).
34 Before a managed health care entity may market its health
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1 care delivery system to persons enrolled in the integrated
2 health care program established under this Section, the
3 Illinois Department must approve a marketing plan submitted
4 by the entity to the Illinois Department. The Illinois
5 Department shall adopt guidelines for approving marketing
6 plans submitted by managed health care entities under this
7 subsection. Besides prohibiting door-to-door marketing
8 activities and marketing activities at public aid offices,
9 the guidelines shall include at least the following:
10 (1) A managed health care entity may not offer or
11 provide any gift, favor, or other inducement in marketing
12 its health care delivery system to integrated health care
13 program enrollees. A managed health care entity may
14 provide health care related items that are of nominal
15 value and pre-approved by the Illinois Department to
16 prospective enrollees. A managed health care entity may
17 also provide to enrollees health care related items that
18 have been pre-approved by the Illinois Department as an
19 incentive to manage their health care appropriately.
20 (2) All persons employed or otherwise engaged by a
21 managed health care entity to market the entity's health
22 care delivery system to integrated health care program
23 enrollees or to supervise that marketing shall register
24 with the Illinois Department.
25 The Inspector General appointed under Section 12-13.1 may
26 conduct investigations to determine whether the marketing
27 practices of managed health care entities participating in
28 the integrated health care program comply with the
29 guidelines.
30 (d) A managed health care entity that contracts with the
31 Illinois Department for the provision of services under the
32 program shall do all of the following, solely for purposes of
33 the integrated health care program:
34 (1) Provide that any individual physician licensed
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1 under the Medical Practice Act of 1987 to practice
2 medicine in all its branches, any pharmacy, any federally
3 qualified health center, and any podiatrist, that
4 consistently meets the reasonable terms and conditions
5 established by the managed health care entity, including
6 but not limited to credentialing standards, quality
7 assurance program requirements, utilization management
8 requirements, financial responsibility standards,
9 contracting process requirements, and provider network
10 size and accessibility requirements, must be accepted by
11 the managed health care entity for purposes of the
12 Illinois integrated health care program. Any individual
13 who is either terminated from or denied inclusion in the
14 panel of physicians of the managed health care entity
15 shall be given, within 10 business days after that
16 determination, a written explanation of the reasons for
17 his or her exclusion or termination from the panel. This
18 paragraph (1) does not apply to the following:
19 (A) A managed health care entity that
20 certifies to the Illinois Department that:
21 (i) it employs on a full-time basis 125
22 or more Illinois physicians licensed to
23 practice medicine in all of its branches; and
24 (ii) it will provide medical services
25 through its employees to more than 80% of the
26 recipients enrolled with the entity in the
27 integrated health care program; or
28 (B) A domestic stock insurance company
29 licensed under clause (b) of class 1 of Section 4 of
30 the Illinois Insurance Code if (i) at least 66% of
31 the stock of the insurance company is owned by a
32 professional corporation organized under the
33 Professional Service Corporation Act that has 125 or
34 more shareholders who are Illinois physicians
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1 licensed to practice medicine in all of its branches
2 and (ii) the insurance company certifies to the
3 Illinois Department that at least 80% of those
4 physician shareholders will provide services to
5 recipients enrolled with the company in the
6 integrated health care program.
7 (2) Provide for reimbursement for providers for
8 emergency care, as defined by the Illinois Department by
9 rule, that must be provided to its enrollees, including
10 an emergency room screening fee, and urgent care that it
11 authorizes for its enrollees, regardless of the
12 provider's affiliation with the managed health care
13 entity. Providers shall be reimbursed for emergency care
14 at an amount equal to the Illinois Department's
15 fee-for-service rates for those medical services rendered
16 by providers not under contract with the managed health
17 care entity to enrollees of the entity.
18 (3) Provide that any provider affiliated with a
19 managed health care entity may also provide services on a
20 fee-for-service basis to Illinois Department clients not
21 enrolled in a managed health care entity.
22 (4) Provide client education services as determined
23 and approved by the Illinois Department, including but
24 not limited to (i) education regarding appropriate
25 utilization of health care services in a managed care
26 system, (ii) written disclosure of treatment policies and
27 any restrictions or limitations on health services,
28 including, but not limited to, physical services,
29 clinical laboratory tests, hospital and surgical
30 procedures, prescription drugs and biologics, and
31 radiological examinations, and (iii) written notice that
32 the enrollee may receive from another provider those
33 services covered under this program that are not provided
34 by the managed health care entity.
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1 (5) Provide that enrollees within its system may
2 choose the site for provision of services and the panel
3 of health care providers.
4 (6) Not discriminate in its enrollment or
5 disenrollment practices among recipients of medical
6 services or program enrollees based on health status.
7 (7) Provide a quality assurance and utilization
8 review program that (i) for health maintenance
9 organizations meets the requirements of the Health
10 Maintenance Organization Act and (ii) for managed care
11 community networks meets the requirements established by
12 the Illinois Department in rules that incorporate those
13 standards set forth in the Health Maintenance
14 Organization Act.
15 (8) Issue a managed health care entity
16 identification card to each enrollee upon enrollment.
17 The card must contain all of the following:
18 (A) The enrollee's signature.
19 (B) The enrollee's health plan.
20 (C) The name and telephone number of the
21 enrollee's primary care physician.
22 (D) A telephone number to be used for
23 emergency service 24 hours per day, 7 days per week.
24 The telephone number required to be maintained
25 pursuant to this subparagraph by each managed health
26 care entity shall, at minimum, be staffed by
27 medically trained personnel and be provided
28 directly, or under arrangement, at an office or
29 offices in locations maintained solely within the
30 State of Illinois. For purposes of this
31 subparagraph, "medically trained personnel" means
32 licensed practical nurses or registered nurses
33 located in the State of Illinois who are licensed
34 pursuant to the Illinois Nursing Act of 1987.
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1 (9) Ensure that every primary care physician and
2 pharmacy in the managed health care entity meets the
3 standards established by the Illinois Department for
4 accessibility and quality of care. The Illinois
5 Department shall arrange for and oversee an evaluation of
6 the standards established under this paragraph (9) and
7 may recommend any necessary changes to these standards.
8 The Illinois Department shall submit an annual report to
9 the Governor and the General Assembly by April 1 of each
10 year regarding the effect of the standards on ensuring
11 access and quality of care to enrollees.
12 (10) Provide a procedure for handling complaints
13 that (i) for health maintenance organizations meets the
14 requirements of the Health Maintenance Organization Act
15 and (ii) for managed care community networks meets the
16 requirements established by the Illinois Department in
17 rules that incorporate those standards set forth in the
18 Health Maintenance Organization Act.
19 (11) Maintain, retain, and make available to the
20 Illinois Department records, data, and information, in a
21 uniform manner determined by the Illinois Department,
22 sufficient for the Illinois Department to monitor
23 utilization, accessibility, and quality of care.
24 (12) Except for providers who are prepaid, pay all
25 approved claims for covered services that are completed
26 and submitted to the managed health care entity within 30
27 days after receipt of the claim or receipt of the
28 appropriate capitation payment or payments by the managed
29 health care entity from the State for the month in which
30 the services included on the claim were rendered,
31 whichever is later. If payment is not made or mailed to
32 the provider by the managed health care entity by the due
33 date under this subsection, an interest penalty of 1% of
34 any amount unpaid shall be added for each month or
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1 fraction of a month after the due date, until final
2 payment is made. Nothing in this Section shall prohibit
3 managed health care entities and providers from mutually
4 agreeing to terms that require more timely payment.
5 (13) Provide integration with community-based
6 programs provided by certified local health departments
7 such as Women, Infants, and Children Supplemental Food
8 Program (WIC), childhood immunization programs, health
9 education programs, case management programs, and health
10 screening programs.
11 (14) Provide that the pharmacy formulary used by a
12 managed health care entity and its contract providers be
13 no more restrictive than the Illinois Department's
14 pharmaceutical program on the effective date of this
15 amendatory Act of 1994 and as amended after that date.
16 (15) Provide integration with community-based
17 organizations, including, but not limited to, any
18 organization that has operated within a Medicaid
19 Partnership as defined by this Code or by rule of the
20 Illinois Department, that may continue to operate under a
21 contract with the Illinois Department or a managed health
22 care entity under this Section to provide case management
23 services to Medicaid clients in designated high-need
24 areas.
25 The Illinois Department may, by rule, determine
26 methodologies to limit financial liability for managed health
27 care entities resulting from payment for services to
28 enrollees provided under the Illinois Department's integrated
29 health care program. Any methodology so determined may be
30 considered or implemented by the Illinois Department through
31 a contract with a managed health care entity under this
32 integrated health care program.
33 The Illinois Department shall contract with an entity or
34 entities to provide external peer-based quality assurance
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1 review for the integrated health care program. The entity
2 shall be representative of Illinois physicians licensed to
3 practice medicine in all its branches and have statewide
4 geographic representation in all specialties of medical care
5 that are provided within the integrated health care program.
6 The entity may not be a third party payer and shall maintain
7 offices in locations around the State in order to provide
8 service and continuing medical education to physician
9 participants within the integrated health care program. The
10 review process shall be developed and conducted by Illinois
11 physicians licensed to practice medicine in all its branches.
12 In consultation with the entity, the Illinois Department may
13 contract with other entities for professional peer-based
14 quality assurance review of individual categories of services
15 other than services provided, supervised, or coordinated by
16 physicians licensed to practice medicine in all its branches.
17 The Illinois Department shall establish, by rule, criteria to
18 avoid conflicts of interest in the conduct of quality
19 assurance activities consistent with professional peer-review
20 standards. All quality assurance activities shall be
21 coordinated by the Illinois Department.
22 (e) All persons enrolled in the program shall be
23 provided with a full written explanation of all
24 fee-for-service and managed health care plan options and a
25 reasonable opportunity to choose among the options as
26 provided by rule. The Illinois Department shall provide to
27 enrollees, upon enrollment in the integrated health care
28 program and at least annually thereafter, notice of the
29 process for requesting an appeal under the Illinois
30 Department's administrative appeal procedures.
31 Notwithstanding any other Section of this Code, the Illinois
32 Department may provide by rule for the Illinois Department to
33 assign a person enrolled in the program to a specific
34 provider of medical services or to a specific health care
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1 delivery system if an enrollee has failed to exercise choice
2 in a timely manner. An enrollee assigned by the Illinois
3 Department shall be afforded the opportunity to disenroll and
4 to select a specific provider of medical services or a
5 specific health care delivery system within the first 30 days
6 after the assignment. An enrollee who has failed to exercise
7 choice in a timely manner may be assigned only if there are 3
8 or more managed health care entities contracting with the
9 Illinois Department within the contracting area, except that,
10 outside the City of Chicago, this requirement may be waived
11 for an area by rules adopted by the Illinois Department after
12 consultation with all hospitals within the contracting area.
13 The Illinois Department shall establish by rule the procedure
14 for random assignment of enrollees who fail to exercise
15 choice in a timely manner to a specific managed health care
16 entity in proportion to the available capacity of that
17 managed health care entity. Assignment to a specific provider
18 of medical services or to a specific managed health care
19 entity may not exceed that provider's or entity's capacity as
20 determined by the Illinois Department. Any person who has
21 chosen a specific provider of medical services or a specific
22 managed health care entity, or any person who has been
23 assigned under this subsection, shall be given the
24 opportunity to change that choice or assignment at least once
25 every 12 months, as determined by the Illinois Department by
26 rule. The Illinois Department shall maintain a toll-free
27 telephone number for program enrollees' use in reporting
28 problems with managed health care entities.
29 (f) If a person becomes eligible for participation in
30 the integrated health care program while he or she is
31 hospitalized, the Illinois Department may not enroll that
32 person in the program until after he or she has been
33 discharged from the hospital. This subsection does not apply
34 to newborn infants whose mothers are enrolled in the
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1 integrated health care program.
2 (g) The Illinois Department shall, by rule, establish
3 for managed health care entities rates that (i) are certified
4 to be actuarially sound, as determined by an actuary who is
5 an associate or a fellow of the Society of Actuaries or a
6 member of the American Academy of Actuaries and who has
7 expertise and experience in medical insurance and benefit
8 programs, in accordance with the Illinois Department's
9 current fee-for-service payment system, and (ii) take into
10 account any difference of cost to provide health care to
11 different populations based on gender, age, location, and
12 eligibility category. The rates for managed health care
13 entities shall be determined on a capitated basis.
14 The Illinois Department by rule shall establish a method
15 to adjust its payments to managed health care entities in a
16 manner intended to avoid providing any financial incentive to
17 a managed health care entity to refer patients to a county
18 provider, in an Illinois county having a population greater
19 than 3,000,000, that is paid directly by the Illinois
20 Department. The Illinois Department shall by April 1, 1997,
21 and annually thereafter, review the method to adjust
22 payments. Payments by the Illinois Department to the county
23 provider, for persons not enrolled in a managed care
24 community network owned or operated by a county provider,
25 shall be paid on a fee-for-service basis under Article XV of
26 this Code.
27 The Illinois Department by rule shall establish a method
28 to reduce its payments to managed health care entities to
29 take into consideration (i) any adjustment payments paid to
30 hospitals under subsection (h) of this Section to the extent
31 those payments, or any part of those payments, have been
32 taken into account in establishing capitated rates under this
33 subsection (g) and (ii) the implementation of methodologies
34 to limit financial liability for managed health care entities
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1 under subsection (d) of this Section.
2 (h) For hospital services provided by a hospital that
3 contracts with a managed health care entity, adjustment
4 payments shall be paid directly to the hospital by the
5 Illinois Department. Adjustment payments may include but
6 need not be limited to adjustment payments to:
7 disproportionate share hospitals under Section 5-5.02 of this
8 Code; primary care access health care education payments (89
9 Ill. Adm. Code 149.140); payments for capital, direct medical
10 education, indirect medical education, certified registered
11 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
12 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
13 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
14 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
15 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
16 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
17 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
18 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
19 148.290(h)); and outpatient indigent volume adjustments (89
20 Ill. Adm. Code 148.140(b)(5)).
21 (i) For any hospital eligible for the adjustment
22 payments described in subsection (h), the Illinois Department
23 shall maintain, through the period ending June 30, 1995,
24 reimbursement levels in accordance with statutes and rules in
25 effect on April 1, 1994.
26 (j) Nothing contained in this Code in any way limits or
27 otherwise impairs the authority or power of the Illinois
28 Department to enter into a negotiated contract pursuant to
29 this Section with a managed health care entity, including,
30 but not limited to, a health maintenance organization, that
31 provides for termination or nonrenewal of the contract
32 without cause upon notice as provided in the contract and
33 without a hearing.
34 (k) Section 5-5.15 does not apply to the program
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1 developed and implemented pursuant to this Section.
2 (l) The Illinois Department shall, by rule, define those
3 chronic or acute medical conditions of childhood that require
4 longer-term treatment and follow-up care. The Illinois
5 Department shall ensure that services required to treat these
6 conditions are available through a separate delivery system.
7 A managed health care entity that contracts with the
8 Illinois Department may refer a child with medical conditions
9 described in the rules adopted under this subsection directly
10 to a children's hospital or to a hospital, other than a
11 children's hospital, that is qualified to provide inpatient
12 and outpatient services to treat those conditions. The
13 Illinois Department shall provide fee-for-service
14 reimbursement directly to a children's hospital for those
15 services pursuant to Title 89 of the Illinois Administrative
16 Code, Section 148.280(a), at a rate at least equal to the
17 rate in effect on March 31, 1994. For hospitals, other than
18 children's hospitals, that are qualified to provide inpatient
19 and outpatient services to treat those conditions, the
20 Illinois Department shall provide reimbursement for those
21 services on a fee-for-service basis, at a rate at least equal
22 to the rate in effect for those other hospitals on March 31,
23 1994.
24 A children's hospital shall be directly reimbursed for
25 all services provided at the children's hospital on a
26 fee-for-service basis pursuant to Title 89 of the Illinois
27 Administrative Code, Section 148.280(a), at a rate at least
28 equal to the rate in effect on March 31, 1994, until the
29 later of (i) implementation of the integrated health care
30 program under this Section and development of actuarially
31 sound capitation rates for services other than those chronic
32 or acute medical conditions of childhood that require
33 longer-term treatment and follow-up care as defined by the
34 Illinois Department in the rules adopted under this
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1 subsection or (ii) March 31, 1996.
2 Notwithstanding anything in this subsection to the
3 contrary, a managed health care entity shall not consider
4 sources or methods of payment in determining the referral of
5 a child. The Illinois Department shall adopt rules to
6 establish criteria for those referrals. The Illinois
7 Department by rule shall establish a method to adjust its
8 payments to managed health care entities in a manner intended
9 to avoid providing any financial incentive to a managed
10 health care entity to refer patients to a provider who is
11 paid directly by the Illinois Department.
12 (m) Behavioral health services provided or funded by the
13 Department of Mental Health and Developmental Disabilities,
14 the Department of Alcoholism and Substance Abuse, the
15 Department of Children and Family Services, and the Illinois
16 Department shall be excluded from a benefit package.
17 Conditions of an organic or physical origin or nature,
18 including medical detoxification, however, may not be
19 excluded. In this subsection, "behavioral health services"
20 means mental health services and subacute alcohol and
21 substance abuse treatment services, as defined in the
22 Illinois Alcoholism and Other Drug Dependency Act. In this
23 subsection, "mental health services" includes, at a minimum,
24 the following services funded by the Illinois Department, the
25 Department of Mental Health and Developmental Disabilities,
26 or the Department of Children and Family Services: (i)
27 inpatient hospital services, including related physician
28 services, related psychiatric interventions, and
29 pharmaceutical services provided to an eligible recipient
30 hospitalized with a primary diagnosis of psychiatric
31 disorder; (ii) outpatient mental health services as defined
32 and specified in Title 59 of the Illinois Administrative
33 Code, Part 132; (iii) any other outpatient mental health
34 services funded by the Illinois Department pursuant to the
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1 State of Illinois Medicaid Plan; (iv) partial
2 hospitalization; and (v) follow-up stabilization related to
3 any of those services. Additional behavioral health services
4 may be excluded under this subsection as mutually agreed in
5 writing by the Illinois Department and the affected State
6 agency or agencies. The exclusion of any service does not
7 prohibit the Illinois Department from developing and
8 implementing demonstration projects for categories of persons
9 or services. The Department of Mental Health and
10 Developmental Disabilities, the Department of Children and
11 Family Services, and the Department of Alcoholism and
12 Substance Abuse shall each adopt rules governing the
13 integration of managed care in the provision of behavioral
14 health services. The State shall integrate managed care
15 community networks and affiliated providers, to the extent
16 practicable, in any separate delivery system for mental
17 health services.
18 (n) The Illinois Department shall adopt rules to
19 establish reserve requirements for managed care community
20 networks, as required by subsection (a), and health
21 maintenance organizations to protect against liabilities in
22 the event that a managed health care entity is declared
23 insolvent or bankrupt. If a managed health care entity other
24 than a county provider is declared insolvent or bankrupt,
25 after liquidation and application of any available assets,
26 resources, and reserves, the Illinois Department shall pay a
27 portion of the amounts owed by the managed health care entity
28 to providers for services rendered to enrollees under the
29 integrated health care program under this Section based on
30 the following schedule: (i) from April 1, 1995 through June
31 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
32 through June 30, 2001, 80% of the amounts owed; and (iii)
33 from July 1, 2001 through June 30, 2005, 75% of the amounts
34 owed. The amounts paid under this subsection shall be
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1 calculated based on the total amount owed by the managed
2 health care entity to providers before application of any
3 available assets, resources, and reserves. After June 30,
4 2005, the Illinois Department may not pay any amounts owed to
5 providers as a result of an insolvency or bankruptcy of a
6 managed health care entity occurring after that date. The
7 Illinois Department is not obligated, however, to pay amounts
8 owed to a provider that has an ownership or other governing
9 interest in the managed health care entity. This subsection
10 applies only to managed health care entities and the services
11 they provide under the integrated health care program under
12 this Section.
13 (o) Notwithstanding any other provision of law or
14 contractual agreement to the contrary, providers shall not be
15 required to accept from any other third party payer the rates
16 determined or paid under this Code by the Illinois
17 Department, managed health care entity, or other health care
18 delivery system for services provided to recipients.
19 (p) The Illinois Department may seek and obtain any
20 necessary authorization provided under federal law to
21 implement the program, including the waiver of any federal
22 statutes or regulations. The Illinois Department may seek a
23 waiver of the federal requirement that the combined
24 membership of Medicare and Medicaid enrollees in a managed
25 care community network may not exceed 75% of the managed care
26 community network's total enrollment. The Illinois
27 Department shall not seek a waiver of this requirement for
28 any other category of managed health care entity. The
29 Illinois Department shall not seek a waiver of the inpatient
30 hospital reimbursement methodology in Section 1902(a)(13)(A)
31 of Title XIX of the Social Security Act even if the federal
32 agency responsible for administering Title XIX determines
33 that Section 1902(a)(13)(A) applies to managed health care
34 systems.
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1 Notwithstanding any other provisions of this Code to the
2 contrary, the Illinois Department shall seek a waiver of
3 applicable federal law in order to impose a co-payment system
4 consistent with this subsection on recipients of medical
5 services under Title XIX of the Social Security Act who are
6 not enrolled in a managed health care entity. The waiver
7 request submitted by the Illinois Department shall provide
8 for co-payments of up to $0.50 for prescribed drugs and up to
9 $0.50 for x-ray services and shall provide for co-payments of
10 up to $10 for non-emergency services provided in a hospital
11 emergency room and up to $10 for non-emergency ambulance
12 services. The purpose of the co-payments shall be to deter
13 those recipients from seeking unnecessary medical care.
14 Co-payments may not be used to deter recipients from seeking
15 necessary medical care. No recipient shall be required to
16 pay more than a total of $150 per year in co-payments under
17 the waiver request required by this subsection. A recipient
18 may not be required to pay more than $15 of any amount due
19 under this subsection in any one month.
20 Co-payments authorized under this subsection may not be
21 imposed when the care was necessitated by a true medical
22 emergency. Co-payments may not be imposed for any of the
23 following classifications of services:
24 (1) Services furnished to person under 18 years of
25 age.
26 (2) Services furnished to pregnant women.
27 (3) Services furnished to any individual who is an
28 inpatient in a hospital, nursing facility, intermediate
29 care facility, or other medical institution, if that
30 person is required to spend for costs of medical care all
31 but a minimal amount of his or her income required for
32 personal needs.
33 (4) Services furnished to a person who is receiving
34 hospice care.
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1 Co-payments authorized under this subsection shall not be
2 deducted from or reduce in any way payments for medical
3 services from the Illinois Department to providers. No
4 provider may deny those services to an individual eligible
5 for services based on the individual's inability to pay the
6 co-payment.
7 Recipients who are subject to co-payments shall be
8 provided notice, in plain and clear language, of the amount
9 of the co-payments, the circumstances under which co-payments
10 are exempted, the circumstances under which co-payments may
11 be assessed, and their manner of collection.
12 The Illinois Department shall establish a Medicaid
13 Co-Payment Council to assist in the development of co-payment
14 policies for the medical assistance program. The Medicaid
15 Co-Payment Council shall also have jurisdiction to develop a
16 program to provide financial or non-financial incentives to
17 Medicaid recipients in order to encourage recipients to seek
18 necessary health care. The Council shall be chaired by the
19 Director of the Illinois Department, and shall have 6
20 additional members. Two of the 6 additional members shall be
21 appointed by the Governor, and one each shall be appointed by
22 the President of the Senate, the Minority Leader of the
23 Senate, the Speaker of the House of Representatives, and the
24 Minority Leader of the House of Representatives. The Council
25 may be convened and make recommendations upon the appointment
26 of a majority of its members. The Council shall be appointed
27 and convened no later than September 1, 1994 and shall report
28 its recommendations to the Director of the Illinois
29 Department and the General Assembly no later than October 1,
30 1994. The chairperson of the Council shall be allowed to
31 vote only in the case of a tie vote among the appointed
32 members of the Council.
33 The Council shall be guided by the following principles
34 as it considers recommendations to be developed to implement
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1 any approved waivers that the Illinois Department must seek
2 pursuant to this subsection:
3 (1) Co-payments should not be used to deter access
4 to adequate medical care.
5 (2) Co-payments should be used to reduce fraud.
6 (3) Co-payment policies should be examined in
7 consideration of other states' experience, and the
8 ability of successful co-payment plans to control
9 unnecessary or inappropriate utilization of services
10 should be promoted.
11 (4) All participants, both recipients and
12 providers, in the medical assistance program have
13 responsibilities to both the State and the program.
14 (5) Co-payments are primarily a tool to educate the
15 participants in the responsible use of health care
16 resources.
17 (6) Co-payments should not be used to penalize
18 providers.
19 (7) A successful medical program requires the
20 elimination of improper utilization of medical resources.
21 The integrated health care program, or any part of that
22 program, established under this Section may not be
23 implemented if matching federal funds under Title XIX of the
24 Social Security Act are not available for administering the
25 program.
26 The Illinois Department shall submit for publication in
27 the Illinois Register the name, address, and telephone number
28 of the individual to whom a request may be directed for a
29 copy of the request for a waiver of provisions of Title XIX
30 of the Social Security Act that the Illinois Department
31 intends to submit to the Health Care Financing Administration
32 in order to implement this Section. The Illinois Department
33 shall mail a copy of that request for waiver to all
34 requestors at least 16 days before filing that request for
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1 waiver with the Health Care Financing Administration.
2 (q) After the effective date of this Section, the
3 Illinois Department may take all planning and preparatory
4 action necessary to implement this Section, including, but
5 not limited to, seeking requests for proposals relating to
6 the integrated health care program created under this
7 Section.
8 (r) In order to (i) accelerate and facilitate the
9 development of integrated health care in contracting areas
10 outside counties with populations in excess of 3,000,000 and
11 counties adjacent to those counties and (ii) maintain and
12 sustain the high quality of education and residency programs
13 coordinated and associated with local area hospitals, the
14 Illinois Department may develop and implement a demonstration
15 program for managed care community networks owned, operated,
16 or governed by State-funded medical schools. The Illinois
17 Department shall prescribe by rule the criteria, standards,
18 and procedures for effecting this demonstration program.
19 (s) (Blank).
20 (t) On April 1, 1995 and every 6 months thereafter, the
21 Illinois Department shall report to the Governor and General
22 Assembly on the progress of the integrated health care
23 program in enrolling clients into managed health care
24 entities. The report shall indicate the capacities of the
25 managed health care entities with which the State contracts,
26 the number of clients enrolled by each contractor, the areas
27 of the State in which managed care options do not exist, and
28 the progress toward meeting the enrollment goals of the
29 integrated health care program.
30 (u) The Illinois Department may implement this Section
31 through the use of emergency rules in accordance with Section
32 5-45 of the Illinois Administrative Procedure Act. For
33 purposes of that Act, the adoption of rules to implement this
34 Section is deemed an emergency and necessary for the public
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1 interest, safety, and welfare.
2 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
3 89-673, eff. 8-14-96; revised 8-26-96.)
4 (Text of Section after amendment by P.A. 89-507)
5 Sec. 5-16.3. System for integrated health care services.
6 (a) It shall be the public policy of the State to adopt,
7 to the extent practicable, a health care program that
8 encourages the integration of health care services and
9 manages the health care of program enrollees while preserving
10 reasonable choice within a competitive and cost-efficient
11 environment. In furtherance of this public policy, the
12 Illinois Department shall develop and implement an integrated
13 health care program consistent with the provisions of this
14 Section. The provisions of this Section apply only to the
15 integrated health care program created under this Section.
16 Persons enrolled in the integrated health care program, as
17 determined by the Illinois Department by rule, shall be
18 afforded a choice among health care delivery systems, which
19 shall include, but are not limited to, (i) fee for service
20 care managed by a primary care physician licensed to practice
21 medicine in all its branches, (ii) managed health care
22 entities, and (iii) federally qualified health centers
23 (reimbursed according to a prospective cost-reimbursement
24 methodology) and rural health clinics (reimbursed according
25 to the Medicare methodology), where available. Persons
26 enrolled in the integrated health care program also may be
27 offered indemnity insurance plans, subject to availability.
28 For purposes of this Section, a "managed health care
29 entity" means a health maintenance organization or a managed
30 care community network as defined in this Section. A "health
31 maintenance organization" means a health maintenance
32 organization as defined in the Health Maintenance
33 Organization Act. A "managed care community network" means
34 an entity, other than a health maintenance organization, that
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1 is owned, operated, or governed by providers of health care
2 services within this State and that provides or arranges
3 primary, secondary, and tertiary managed health care services
4 under contract with the Illinois Department exclusively to
5 enrollees of the integrated health care program. A managed
6 care community network may contract with the Illinois
7 Department to provide only pediatric health care services. A
8 county provider as defined in Section 15-1 of this Code may
9 contract with the Illinois Department to provide services to
10 enrollees of the integrated health care program as a managed
11 care community network without the need to establish a
12 separate entity that provides services exclusively to
13 enrollees of the integrated health care program and shall be
14 deemed a managed care community network for purposes of this
15 Code only to the extent of the provision of services to those
16 enrollees in conjunction with the integrated health care
17 program. A county provider shall be entitled to contract
18 with the Illinois Department with respect to any contracting
19 region located in whole or in part within the county. A
20 county provider shall not be required to accept enrollees who
21 do not reside within the county.
22 Each managed care community network must demonstrate its
23 ability to bear the financial risk of serving enrollees under
24 this program. The Illinois Department shall by rule adopt
25 criteria for assessing the financial soundness of each
26 managed care community network. These rules shall consider
27 the extent to which a managed care community network is
28 comprised of providers who directly render health care and
29 are located within the community in which they seek to
30 contract rather than solely arrange or finance the delivery
31 of health care. These rules shall further consider a variety
32 of risk-bearing and management techniques, including the
33 sufficiency of quality assurance and utilization management
34 programs and whether a managed care community network has
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1 sufficiently demonstrated its financial solvency and net
2 worth. The Illinois Department's criteria must be based on
3 sound actuarial, financial, and accounting principles. In
4 adopting these rules, the Illinois Department shall consult
5 with the Illinois Department of Insurance. The Illinois
6 Department is responsible for monitoring compliance with
7 these rules.
8 This Section may not be implemented before the effective
9 date of these rules, the approval of any necessary federal
10 waivers, and the completion of the review of an application
11 submitted, at least 60 days before the effective date of
12 rules adopted under this Section, to the Illinois Department
13 by a managed care community network.
14 All health care delivery systems that contract with the
15 Illinois Department under the integrated health care program
16 shall clearly recognize a health care provider's right of
17 conscience under the Right of Conscience Act. In addition to
18 the provisions of that Act, no health care delivery system
19 that contracts with the Illinois Department under the
20 integrated health care program shall be required to provide,
21 arrange for, or pay for any health care or medical service,
22 procedure, or product if that health care delivery system is
23 owned, controlled, or sponsored by or affiliated with a
24 religious institution or religious organization that finds
25 that health care or medical service, procedure, or product to
26 violate its religious and moral teachings and beliefs.
27 (b) The Illinois Department may, by rule, provide for
28 different benefit packages for different categories of
29 persons enrolled in the program. Mental health services,
30 alcohol and substance abuse services, services related to
31 children with chronic or acute conditions requiring
32 longer-term treatment and follow-up, and rehabilitation care
33 provided by a free-standing rehabilitation hospital or a
34 hospital rehabilitation unit may be excluded from a benefit
SB317 Enrolled -27- LRB9001503SMdv
1 package if the State ensures that those services are made
2 available through a separate delivery system. An exclusion
3 does not prohibit the Illinois Department from developing and
4 implementing demonstration projects for categories of persons
5 or services. Benefit packages for persons eligible for
6 medical assistance under Articles V, VI, and XII shall be
7 based on the requirements of those Articles and shall be
8 consistent with the Title XIX of the Social Security Act.
9 Nothing in this Act shall be construed to apply to services
10 purchased by the Department of Children and Family Services
11 and the Department of Human Services (as successor to the
12 Department of Mental Health and Developmental Disabilities)
13 under the provisions of Title 59 of the Illinois
14 Administrative Code, Part 132 ("Medicaid Community Mental
15 Health Services Program").
16 (c) The program established by this Section may be
17 implemented by the Illinois Department in various contracting
18 areas at various times. The health care delivery systems and
19 providers available under the program may vary throughout the
20 State. For purposes of contracting with managed health care
21 entities and providers, the Illinois Department shall
22 establish contracting areas similar to the geographic areas
23 designated by the Illinois Department for contracting
24 purposes under the Illinois Competitive Access and
25 Reimbursement Equity Program (ICARE) under the authority of
26 Section 3-4 of the Illinois Health Finance Reform Act or
27 similarly-sized or smaller geographic areas established by
28 the Illinois Department by rule. A managed health care entity
29 shall be permitted to contract in any geographic areas for
30 which it has a sufficient provider network and otherwise
31 meets the contracting terms of the State. The Illinois
32 Department is not prohibited from entering into a contract
33 with a managed health care entity at any time.
34 (c-5) A managed health care entity may not engage in
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1 door-to-door marketing activities or marketing activities at
2 an office of the Illinois Department or a county department
3 in order to enroll in the entity's health care delivery
4 system persons who are enrolled in the integrated health care
5 program established under this Section. The Illinois
6 Department shall adopt rules defining "marketing activities"
7 prohibited by this subsection (c-5).
8 Before a managed health care entity may market its health
9 care delivery system to persons enrolled in the integrated
10 health care program established under this Section, the
11 Illinois Department must approve a marketing plan submitted
12 by the entity to the Illinois Department. The Illinois
13 Department shall adopt guidelines for approving marketing
14 plans submitted by managed health care entities under this
15 subsection. Besides prohibiting door-to-door marketing
16 activities and marketing activities at public aid offices,
17 the guidelines shall include at least the following:
18 (1) A managed health care entity may not offer or
19 provide any gift, favor, or other inducement in marketing
20 its health care delivery system to integrated health care
21 program enrollees. A managed health care entity may
22 provide health care related items that are of nominal
23 value and pre-approved by the Illinois Department to
24 prospective enrollees. A managed health care entity may
25 also provide to enrollees health care related items that
26 have been pre-approved by the Illinois Department as an
27 incentive to manage their health care appropriately.
28 (2) All persons employed or otherwise engaged by a
29 managed health care entity to market the entity's health
30 care delivery system to integrated health care program
31 enrollees or to supervise that marketing shall register
32 with the Illinois Department.
33 The Inspector General appointed under Section 12-13.1 may
34 conduct investigations to determine whether the marketing
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1 practices of managed health care entities participating in
2 the integrated health care program comply with the
3 guidelines.
4 (d) A managed health care entity that contracts with the
5 Illinois Department for the provision of services under the
6 program shall do all of the following, solely for purposes of
7 the integrated health care program:
8 (1) Provide that any individual physician licensed
9 under the Medical Practice Act of 1987 to practice
10 medicine in all its branches, any pharmacy, any federally
11 qualified health center, and any podiatrist, that
12 consistently meets the reasonable terms and conditions
13 established by the managed health care entity, including
14 but not limited to credentialing standards, quality
15 assurance program requirements, utilization management
16 requirements, financial responsibility standards,
17 contracting process requirements, and provider network
18 size and accessibility requirements, must be accepted by
19 the managed health care entity for purposes of the
20 Illinois integrated health care program. Any individual
21 who is either terminated from or denied inclusion in the
22 panel of physicians of the managed health care entity
23 shall be given, within 10 business days after that
24 determination, a written explanation of the reasons for
25 his or her exclusion or termination from the panel. This
26 paragraph (1) does not apply to the following:
27 (A) A managed health care entity that
28 certifies to the Illinois Department that:
29 (i) it employs on a full-time basis 125
30 or more Illinois physicians licensed to
31 practice medicine in all of its branches; and
32 (ii) it will provide medical services
33 through its employees to more than 80% of the
34 recipients enrolled with the entity in the
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1 integrated health care program; or
2 (B) A domestic stock insurance company
3 licensed under clause (b) of class 1 of Section 4 of
4 the Illinois Insurance Code if (i) at least 66% of
5 the stock of the insurance company is owned by a
6 professional corporation organized under the
7 Professional Service Corporation Act that has 125 or
8 more shareholders who are Illinois physicians
9 licensed to practice medicine in all of its branches
10 and (ii) the insurance company certifies to the
11 Illinois Department that at least 80% of those
12 physician shareholders will provide services to
13 recipients enrolled with the company in the
14 integrated health care program.
15 (2) Provide for reimbursement for providers for
16 emergency care, as defined by the Illinois Department by
17 rule, that must be provided to its enrollees, including
18 an emergency room screening fee, and urgent care that it
19 authorizes for its enrollees, regardless of the
20 provider's affiliation with the managed health care
21 entity. Providers shall be reimbursed for emergency care
22 at an amount equal to the Illinois Department's
23 fee-for-service rates for those medical services rendered
24 by providers not under contract with the managed health
25 care entity to enrollees of the entity.
26 (3) Provide that any provider affiliated with a
27 managed health care entity may also provide services on a
28 fee-for-service basis to Illinois Department clients not
29 enrolled in a managed health care entity.
30 (4) Provide client education services as determined
31 and approved by the Illinois Department, including but
32 not limited to (i) education regarding appropriate
33 utilization of health care services in a managed care
34 system, (ii) written disclosure of treatment policies and
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1 any restrictions or limitations on health services,
2 including, but not limited to, physical services,
3 clinical laboratory tests, hospital and surgical
4 procedures, prescription drugs and biologics, and
5 radiological examinations, and (iii) written notice that
6 the enrollee may receive from another provider those
7 services covered under this program that are not provided
8 by the managed health care entity.
9 (5) Provide that enrollees within its system may
10 choose the site for provision of services and the panel
11 of health care providers.
12 (6) Not discriminate in its enrollment or
13 disenrollment practices among recipients of medical
14 services or program enrollees based on health status.
15 (7) Provide a quality assurance and utilization
16 review program that (i) for health maintenance
17 organizations meets the requirements of the Health
18 Maintenance Organization Act and (ii) for managed care
19 community networks meets the requirements established by
20 the Illinois Department in rules that incorporate those
21 standards set forth in the Health Maintenance
22 Organization Act.
23 (8) Issue a managed health care entity
24 identification card to each enrollee upon enrollment.
25 The card must contain all of the following:
26 (A) The enrollee's signature.
27 (B) The enrollee's health plan.
28 (C) The name and telephone number of the
29 enrollee's primary care physician.
30 (D) A telephone number to be used for
31 emergency service 24 hours per day, 7 days per week.
32 The telephone number required to be maintained
33 pursuant to this subparagraph by each managed health
34 care entity shall, at minimum, be staffed by
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1 medically trained personnel and be provided
2 directly, or under arrangement, at an office or
3 offices in locations maintained solely within the
4 State of Illinois. For purposes of this
5 subparagraph, "medically trained personnel" means
6 licensed practical nurses or registered nurses
7 located in the State of Illinois who are licensed
8 pursuant to the Illinois Nursing Act of 1987.
9 (9) Ensure that every primary care physician and
10 pharmacy in the managed health care entity meets the
11 standards established by the Illinois Department for
12 accessibility and quality of care. The Illinois
13 Department shall arrange for and oversee an evaluation of
14 the standards established under this paragraph (9) and
15 may recommend any necessary changes to these standards.
16 The Illinois Department shall submit an annual report to
17 the Governor and the General Assembly by April 1 of each
18 year regarding the effect of the standards on ensuring
19 access and quality of care to enrollees.
20 (10) Provide a procedure for handling complaints
21 that (i) for health maintenance organizations meets the
22 requirements of the Health Maintenance Organization Act
23 and (ii) for managed care community networks meets the
24 requirements established by the Illinois Department in
25 rules that incorporate those standards set forth in the
26 Health Maintenance Organization Act.
27 (11) Maintain, retain, and make available to the
28 Illinois Department records, data, and information, in a
29 uniform manner determined by the Illinois Department,
30 sufficient for the Illinois Department to monitor
31 utilization, accessibility, and quality of care.
32 (12) Except for providers who are prepaid, pay all
33 approved claims for covered services that are completed
34 and submitted to the managed health care entity within 30
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1 days after receipt of the claim or receipt of the
2 appropriate capitation payment or payments by the managed
3 health care entity from the State for the month in which
4 the services included on the claim were rendered,
5 whichever is later. If payment is not made or mailed to
6 the provider by the managed health care entity by the due
7 date under this subsection, an interest penalty of 1% of
8 any amount unpaid shall be added for each month or
9 fraction of a month after the due date, until final
10 payment is made. Nothing in this Section shall prohibit
11 managed health care entities and providers from mutually
12 agreeing to terms that require more timely payment.
13 (13) Provide integration with community-based
14 programs provided by certified local health departments
15 such as Women, Infants, and Children Supplemental Food
16 Program (WIC), childhood immunization programs, health
17 education programs, case management programs, and health
18 screening programs.
19 (14) Provide that the pharmacy formulary used by a
20 managed health care entity and its contract providers be
21 no more restrictive than the Illinois Department's
22 pharmaceutical program on the effective date of this
23 amendatory Act of 1994 and as amended after that date.
24 (15) Provide integration with community-based
25 organizations, including, but not limited to, any
26 organization that has operated within a Medicaid
27 Partnership as defined by this Code or by rule of the
28 Illinois Department, that may continue to operate under a
29 contract with the Illinois Department or a managed health
30 care entity under this Section to provide case management
31 services to Medicaid clients in designated high-need
32 areas.
33 The Illinois Department may, by rule, determine
34 methodologies to limit financial liability for managed health
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1 care entities resulting from payment for services to
2 enrollees provided under the Illinois Department's integrated
3 health care program. Any methodology so determined may be
4 considered or implemented by the Illinois Department through
5 a contract with a managed health care entity under this
6 integrated health care program.
7 The Illinois Department shall contract with an entity or
8 entities to provide external peer-based quality assurance
9 review for the integrated health care program. The entity
10 shall be representative of Illinois physicians licensed to
11 practice medicine in all its branches and have statewide
12 geographic representation in all specialties of medical care
13 that are provided within the integrated health care program.
14 The entity may not be a third party payer and shall maintain
15 offices in locations around the State in order to provide
16 service and continuing medical education to physician
17 participants within the integrated health care program. The
18 review process shall be developed and conducted by Illinois
19 physicians licensed to practice medicine in all its branches.
20 In consultation with the entity, the Illinois Department may
21 contract with other entities for professional peer-based
22 quality assurance review of individual categories of services
23 other than services provided, supervised, or coordinated by
24 physicians licensed to practice medicine in all its branches.
25 The Illinois Department shall establish, by rule, criteria to
26 avoid conflicts of interest in the conduct of quality
27 assurance activities consistent with professional peer-review
28 standards. All quality assurance activities shall be
29 coordinated by the Illinois Department.
30 (e) All persons enrolled in the program shall be
31 provided with a full written explanation of all
32 fee-for-service and managed health care plan options and a
33 reasonable opportunity to choose among the options as
34 provided by rule. The Illinois Department shall provide to
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1 enrollees, upon enrollment in the integrated health care
2 program and at least annually thereafter, notice of the
3 process for requesting an appeal under the Illinois
4 Department's administrative appeal procedures.
5 Notwithstanding any other Section of this Code, the Illinois
6 Department may provide by rule for the Illinois Department to
7 assign a person enrolled in the program to a specific
8 provider of medical services or to a specific health care
9 delivery system if an enrollee has failed to exercise choice
10 in a timely manner. An enrollee assigned by the Illinois
11 Department shall be afforded the opportunity to disenroll and
12 to select a specific provider of medical services or a
13 specific health care delivery system within the first 30 days
14 after the assignment. An enrollee who has failed to exercise
15 choice in a timely manner may be assigned only if there are 3
16 or more managed health care entities contracting with the
17 Illinois Department within the contracting area, except that,
18 outside the City of Chicago, this requirement may be waived
19 for an area by rules adopted by the Illinois Department after
20 consultation with all hospitals within the contracting area.
21 The Illinois Department shall establish by rule the procedure
22 for random assignment of enrollees who fail to exercise
23 choice in a timely manner to a specific managed health care
24 entity in proportion to the available capacity of that
25 managed health care entity. Assignment to a specific provider
26 of medical services or to a specific managed health care
27 entity may not exceed that provider's or entity's capacity as
28 determined by the Illinois Department. Any person who has
29 chosen a specific provider of medical services or a specific
30 managed health care entity, or any person who has been
31 assigned under this subsection, shall be given the
32 opportunity to change that choice or assignment at least once
33 every 12 months, as determined by the Illinois Department by
34 rule. The Illinois Department shall maintain a toll-free
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1 telephone number for program enrollees' use in reporting
2 problems with managed health care entities.
3 (f) If a person becomes eligible for participation in
4 the integrated health care program while he or she is
5 hospitalized, the Illinois Department may not enroll that
6 person in the program until after he or she has been
7 discharged from the hospital. This subsection does not apply
8 to newborn infants whose mothers are enrolled in the
9 integrated health care program.
10 (g) The Illinois Department shall, by rule, establish
11 for managed health care entities rates that (i) are certified
12 to be actuarially sound, as determined by an actuary who is
13 an associate or a fellow of the Society of Actuaries or a
14 member of the American Academy of Actuaries and who has
15 expertise and experience in medical insurance and benefit
16 programs, in accordance with the Illinois Department's
17 current fee-for-service payment system, and (ii) take into
18 account any difference of cost to provide health care to
19 different populations based on gender, age, location, and
20 eligibility category. The rates for managed health care
21 entities shall be determined on a capitated basis.
22 The Illinois Department by rule shall establish a method
23 to adjust its payments to managed health care entities in a
24 manner intended to avoid providing any financial incentive to
25 a managed health care entity to refer patients to a county
26 provider, in an Illinois county having a population greater
27 than 3,000,000, that is paid directly by the Illinois
28 Department. The Illinois Department shall by April 1, 1997,
29 and annually thereafter, review the method to adjust
30 payments. Payments by the Illinois Department to the county
31 provider, for persons not enrolled in a managed care
32 community network owned or operated by a county provider,
33 shall be paid on a fee-for-service basis under Article XV of
34 this Code.
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1 The Illinois Department by rule shall establish a method
2 to reduce its payments to managed health care entities to
3 take into consideration (i) any adjustment payments paid to
4 hospitals under subsection (h) of this Section to the extent
5 those payments, or any part of those payments, have been
6 taken into account in establishing capitated rates under this
7 subsection (g) and (ii) the implementation of methodologies
8 to limit financial liability for managed health care entities
9 under subsection (d) of this Section.
10 (h) For hospital services provided by a hospital that
11 contracts with a managed health care entity, adjustment
12 payments shall be paid directly to the hospital by the
13 Illinois Department. Adjustment payments may include but
14 need not be limited to adjustment payments to:
15 disproportionate share hospitals under Section 5-5.02 of this
16 Code; primary care access health care education payments (89
17 Ill. Adm. Code 149.140); payments for capital, direct medical
18 education, indirect medical education, certified registered
19 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
20 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
21 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
22 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
23 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
24 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
25 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
26 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
27 148.290(h)); and outpatient indigent volume adjustments (89
28 Ill. Adm. Code 148.140(b)(5)).
29 (i) For any hospital eligible for the adjustment
30 payments described in subsection (h), the Illinois Department
31 shall maintain, through the period ending June 30, 1995,
32 reimbursement levels in accordance with statutes and rules in
33 effect on April 1, 1994.
34 (j) Nothing contained in this Code in any way limits or
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1 otherwise impairs the authority or power of the Illinois
2 Department to enter into a negotiated contract pursuant to
3 this Section with a managed health care entity, including,
4 but not limited to, a health maintenance organization, that
5 provides for termination or nonrenewal of the contract
6 without cause upon notice as provided in the contract and
7 without a hearing.
8 (k) Section 5-5.15 does not apply to the program
9 developed and implemented pursuant to this Section.
10 (l) The Illinois Department shall, by rule, define those
11 chronic or acute medical conditions of childhood that require
12 longer-term treatment and follow-up care. The Illinois
13 Department shall ensure that services required to treat these
14 conditions are available through a separate delivery system.
15 A managed health care entity that contracts with the
16 Illinois Department may refer a child with medical conditions
17 described in the rules adopted under this subsection directly
18 to a children's hospital or to a hospital, other than a
19 children's hospital, that is qualified to provide inpatient
20 and outpatient services to treat those conditions. The
21 Illinois Department shall provide fee-for-service
22 reimbursement directly to a children's hospital for those
23 services pursuant to Title 89 of the Illinois Administrative
24 Code, Section 148.280(a), at a rate at least equal to the
25 rate in effect on March 31, 1994. For hospitals, other than
26 children's hospitals, that are qualified to provide inpatient
27 and outpatient services to treat those conditions, the
28 Illinois Department shall provide reimbursement for those
29 services on a fee-for-service basis, at a rate at least equal
30 to the rate in effect for those other hospitals on March 31,
31 1994.
32 A children's hospital shall be directly reimbursed for
33 all services provided at the children's hospital on a
34 fee-for-service basis pursuant to Title 89 of the Illinois
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1 Administrative Code, Section 148.280(a), at a rate at least
2 equal to the rate in effect on March 31, 1994, until the
3 later of (i) implementation of the integrated health care
4 program under this Section and development of actuarially
5 sound capitation rates for services other than those chronic
6 or acute medical conditions of childhood that require
7 longer-term treatment and follow-up care as defined by the
8 Illinois Department in the rules adopted under this
9 subsection or (ii) March 31, 1996.
10 Notwithstanding anything in this subsection to the
11 contrary, a managed health care entity shall not consider
12 sources or methods of payment in determining the referral of
13 a child. The Illinois Department shall adopt rules to
14 establish criteria for those referrals. The Illinois
15 Department by rule shall establish a method to adjust its
16 payments to managed health care entities in a manner intended
17 to avoid providing any financial incentive to a managed
18 health care entity to refer patients to a provider who is
19 paid directly by the Illinois Department.
20 (m) Behavioral health services provided or funded by the
21 Department of Human Services, the Department of Children and
22 Family Services, and the Illinois Department shall be
23 excluded from a benefit package. Conditions of an organic or
24 physical origin or nature, including medical detoxification,
25 however, may not be excluded. In this subsection,
26 "behavioral health services" means mental health services and
27 subacute alcohol and substance abuse treatment services, as
28 defined in the Illinois Alcoholism and Other Drug Dependency
29 Act. In this subsection, "mental health services" includes,
30 at a minimum, the following services funded by the Illinois
31 Department, the Department of Human Services (as successor to
32 the Department of Mental Health and Developmental
33 Disabilities), or the Department of Children and Family
34 Services: (i) inpatient hospital services, including related
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1 physician services, related psychiatric interventions, and
2 pharmaceutical services provided to an eligible recipient
3 hospitalized with a primary diagnosis of psychiatric
4 disorder; (ii) outpatient mental health services as defined
5 and specified in Title 59 of the Illinois Administrative
6 Code, Part 132; (iii) any other outpatient mental health
7 services funded by the Illinois Department pursuant to the
8 State of Illinois Medicaid Plan; (iv) partial
9 hospitalization; and (v) follow-up stabilization related to
10 any of those services. Additional behavioral health services
11 may be excluded under this subsection as mutually agreed in
12 writing by the Illinois Department and the affected State
13 agency or agencies. The exclusion of any service does not
14 prohibit the Illinois Department from developing and
15 implementing demonstration projects for categories of persons
16 or services. The Department of Children and Family Services
17 and the Department of Human Services shall each adopt rules
18 governing the integration of managed care in the provision of
19 behavioral health services. The State shall integrate managed
20 care community networks and affiliated providers, to the
21 extent practicable, in any separate delivery system for
22 mental health services.
23 (n) The Illinois Department shall adopt rules to
24 establish reserve requirements for managed care community
25 networks, as required by subsection (a), and health
26 maintenance organizations to protect against liabilities in
27 the event that a managed health care entity is declared
28 insolvent or bankrupt. If a managed health care entity other
29 than a county provider is declared insolvent or bankrupt,
30 after liquidation and application of any available assets,
31 resources, and reserves, the Illinois Department shall pay a
32 portion of the amounts owed by the managed health care entity
33 to providers for services rendered to enrollees under the
34 integrated health care program under this Section based on
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1 the following schedule: (i) from April 1, 1995 through June
2 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
3 through June 30, 2001, 80% of the amounts owed; and (iii)
4 from July 1, 2001 through June 30, 2005, 75% of the amounts
5 owed. The amounts paid under this subsection shall be
6 calculated based on the total amount owed by the managed
7 health care entity to providers before application of any
8 available assets, resources, and reserves. After June 30,
9 2005, the Illinois Department may not pay any amounts owed to
10 providers as a result of an insolvency or bankruptcy of a
11 managed health care entity occurring after that date. The
12 Illinois Department is not obligated, however, to pay amounts
13 owed to a provider that has an ownership or other governing
14 interest in the managed health care entity. This subsection
15 applies only to managed health care entities and the services
16 they provide under the integrated health care program under
17 this Section.
18 (o) Notwithstanding any other provision of law or
19 contractual agreement to the contrary, providers shall not be
20 required to accept from any other third party payer the rates
21 determined or paid under this Code by the Illinois
22 Department, managed health care entity, or other health care
23 delivery system for services provided to recipients.
24 (p) The Illinois Department may seek and obtain any
25 necessary authorization provided under federal law to
26 implement the program, including the waiver of any federal
27 statutes or regulations. The Illinois Department may seek a
28 waiver of the federal requirement that the combined
29 membership of Medicare and Medicaid enrollees in a managed
30 care community network may not exceed 75% of the managed care
31 community network's total enrollment. The Illinois
32 Department shall not seek a waiver of this requirement for
33 any other category of managed health care entity. The
34 Illinois Department shall not seek a waiver of the inpatient
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1 hospital reimbursement methodology in Section 1902(a)(13)(A)
2 of Title XIX of the Social Security Act even if the federal
3 agency responsible for administering Title XIX determines
4 that Section 1902(a)(13)(A) applies to managed health care
5 systems.
6 Notwithstanding any other provisions of this Code to the
7 contrary, the Illinois Department shall seek a waiver of
8 applicable federal law in order to impose a co-payment system
9 consistent with this subsection on recipients of medical
10 services under Title XIX of the Social Security Act who are
11 not enrolled in a managed health care entity. The waiver
12 request submitted by the Illinois Department shall provide
13 for co-payments of up to $0.50 for prescribed drugs and up to
14 $0.50 for x-ray services and shall provide for co-payments of
15 up to $10 for non-emergency services provided in a hospital
16 emergency room and up to $10 for non-emergency ambulance
17 services. The purpose of the co-payments shall be to deter
18 those recipients from seeking unnecessary medical care.
19 Co-payments may not be used to deter recipients from seeking
20 necessary medical care. No recipient shall be required to
21 pay more than a total of $150 per year in co-payments under
22 the waiver request required by this subsection. A recipient
23 may not be required to pay more than $15 of any amount due
24 under this subsection in any one month.
25 Co-payments authorized under this subsection may not be
26 imposed when the care was necessitated by a true medical
27 emergency. Co-payments may not be imposed for any of the
28 following classifications of services:
29 (1) Services furnished to person under 18 years of
30 age.
31 (2) Services furnished to pregnant women.
32 (3) Services furnished to any individual who is an
33 inpatient in a hospital, nursing facility, intermediate
34 care facility, or other medical institution, if that
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1 person is required to spend for costs of medical care all
2 but a minimal amount of his or her income required for
3 personal needs.
4 (4) Services furnished to a person who is receiving
5 hospice care.
6 Co-payments authorized under this subsection shall not be
7 deducted from or reduce in any way payments for medical
8 services from the Illinois Department to providers. No
9 provider may deny those services to an individual eligible
10 for services based on the individual's inability to pay the
11 co-payment.
12 Recipients who are subject to co-payments shall be
13 provided notice, in plain and clear language, of the amount
14 of the co-payments, the circumstances under which co-payments
15 are exempted, the circumstances under which co-payments may
16 be assessed, and their manner of collection.
17 The Illinois Department shall establish a Medicaid
18 Co-Payment Council to assist in the development of co-payment
19 policies for the medical assistance program. The Medicaid
20 Co-Payment Council shall also have jurisdiction to develop a
21 program to provide financial or non-financial incentives to
22 Medicaid recipients in order to encourage recipients to seek
23 necessary health care. The Council shall be chaired by the
24 Director of the Illinois Department, and shall have 6
25 additional members. Two of the 6 additional members shall be
26 appointed by the Governor, and one each shall be appointed by
27 the President of the Senate, the Minority Leader of the
28 Senate, the Speaker of the House of Representatives, and the
29 Minority Leader of the House of Representatives. The Council
30 may be convened and make recommendations upon the appointment
31 of a majority of its members. The Council shall be appointed
32 and convened no later than September 1, 1994 and shall report
33 its recommendations to the Director of the Illinois
34 Department and the General Assembly no later than October 1,
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1 1994. The chairperson of the Council shall be allowed to
2 vote only in the case of a tie vote among the appointed
3 members of the Council.
4 The Council shall be guided by the following principles
5 as it considers recommendations to be developed to implement
6 any approved waivers that the Illinois Department must seek
7 pursuant to this subsection:
8 (1) Co-payments should not be used to deter access
9 to adequate medical care.
10 (2) Co-payments should be used to reduce fraud.
11 (3) Co-payment policies should be examined in
12 consideration of other states' experience, and the
13 ability of successful co-payment plans to control
14 unnecessary or inappropriate utilization of services
15 should be promoted.
16 (4) All participants, both recipients and
17 providers, in the medical assistance program have
18 responsibilities to both the State and the program.
19 (5) Co-payments are primarily a tool to educate the
20 participants in the responsible use of health care
21 resources.
22 (6) Co-payments should not be used to penalize
23 providers.
24 (7) A successful medical program requires the
25 elimination of improper utilization of medical resources.
26 The integrated health care program, or any part of that
27 program, established under this Section may not be
28 implemented if matching federal funds under Title XIX of the
29 Social Security Act are not available for administering the
30 program.
31 The Illinois Department shall submit for publication in
32 the Illinois Register the name, address, and telephone number
33 of the individual to whom a request may be directed for a
34 copy of the request for a waiver of provisions of Title XIX
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1 of the Social Security Act that the Illinois Department
2 intends to submit to the Health Care Financing Administration
3 in order to implement this Section. The Illinois Department
4 shall mail a copy of that request for waiver to all
5 requestors at least 16 days before filing that request for
6 waiver with the Health Care Financing Administration.
7 (q) After the effective date of this Section, the
8 Illinois Department may take all planning and preparatory
9 action necessary to implement this Section, including, but
10 not limited to, seeking requests for proposals relating to
11 the integrated health care program created under this
12 Section.
13 (r) In order to (i) accelerate and facilitate the
14 development of integrated health care in contracting areas
15 outside counties with populations in excess of 3,000,000 and
16 counties adjacent to those counties and (ii) maintain and
17 sustain the high quality of education and residency programs
18 coordinated and associated with local area hospitals, the
19 Illinois Department may develop and implement a demonstration
20 program for managed care community networks owned, operated,
21 or governed by State-funded medical schools. The Illinois
22 Department shall prescribe by rule the criteria, standards,
23 and procedures for effecting this demonstration program.
24 (s) (Blank).
25 (t) On April 1, 1995 and every 6 months thereafter, the
26 Illinois Department shall report to the Governor and General
27 Assembly on the progress of the integrated health care
28 program in enrolling clients into managed health care
29 entities. The report shall indicate the capacities of the
30 managed health care entities with which the State contracts,
31 the number of clients enrolled by each contractor, the areas
32 of the State in which managed care options do not exist, and
33 the progress toward meeting the enrollment goals of the
34 integrated health care program.
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1 (u) The Illinois Department may implement this Section
2 through the use of emergency rules in accordance with Section
3 5-45 of the Illinois Administrative Procedure Act. For
4 purposes of that Act, the adoption of rules to implement this
5 Section is deemed an emergency and necessary for the public
6 interest, safety, and welfare.
7 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
8 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
9 (305 ILCS 5/5-16.10 new)
10 Sec. 5-16.10. Managed care entities; marketing. A
11 managed health care entity providing services under this
12 Article V may not engage in door-to-door marketing activities
13 or marketing activities at an office of the Illinois
14 Department or a county department in order to enroll
15 recipients in the entity's health care delivery system. The
16 Department shall adopt rules defining "marketing activities"
17 prohibited by this Section.
18 Before a managed health care entity providing services
19 under this Article V may market its health care delivery
20 system to recipients, the Illinois Department must approve a
21 marketing plan submitted by the entity to the Illinois
22 Department. The Illinois Department shall adopt guidelines
23 for approving marketing plans submitted by managed health
24 care entities under this Section. Besides prohibiting
25 door-to-door marketing activities and marketing activities at
26 public aid offices, the guidelines shall include at least the
27 following:
28 (1) A managed health care entity may not offer or
29 provide any gift, favor, or other inducement in marketing
30 its health care delivery system to integrated health care
31 program enrollees. A managed health care entity may
32 provide health care related items that are of nominal
33 value and pre-approved by the Department to prospective
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1 enrollees. A managed health care entity may also
2 provide to enrollees health care related items that have
3 been pre-approved by the Department as an incentive to
4 manage their health care appropriately.
5 (2) All persons employed or otherwise engaged by a
6 managed health care entity to market the entity's health
7 care delivery system to recipients or to supervise that
8 marketing shall register with the Illinois Department.
9 The Inspector General appointed under Section 12-13.1 may
10 conduct investigations to determine whether the marketing
11 practices of managed health care entities providing services
12 under this Article V comply with the guidelines.
13 (305 ILCS 5/5-16.11 new)
14 Sec. 5-16.11. Uniform standards applied to managed care
15 entities. Any managed care entity providing services under
16 this Code shall comply with the criteria, standards, and
17 procedures imposed on managed care entities under paragraph
18 (14) of subsection (d) of Section 5-16.3 of this Code.
19 (305 ILCS 5/8A-6) (from Ch. 23, par. 8A-6)
20 Sec. 8A-6. Classification of violations.
21 (a) Any person, firm, corporation, association, agency,
22 institution or other legal entity that has been found by a
23 court to have engaged in an act, practice or course of
24 conduct declared unlawful under Sections 8A-2 through 8A-5 or
25 Section 8A-13 or 8A-14 where:
26 (1) the total amount of money involved in the violation,
27 including the monetary value of federal food stamps and the
28 value of commodities, is less than $150, shall be guilty of a
29 Class A misdemeanor;
30 (2) the total amount of money involved in the violation,
31 including the monetary value of federal food stamps and the
32 value of commodities, is $150 or more but less than $1,000,
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1 shall be guilty of a Class 4 felony;
2 (3) the total amount of money involved in the violation,
3 including the monetary value of federal food stamps and the
4 value of commodities, is $1,000 or more but less than $5,000,
5 shall be guilty of a Class 3 felony;
6 (4) the total amount of money involved in the violation,
7 including the monetary value of federal food stamps and the
8 value of commodities, is $5,000 or more but less than
9 $10,000, shall be guilty of a Class 2 felony; or
10 (5) the total amount of money involved in the violation,
11 including the monetary value of federal food stamps and the
12 value of commodities, is $10,000 or more, shall be guilty of
13 a Class 1 felony and, notwithstanding the provisions of
14 Section 8A-8 except for Subsection (c) of Section 8A-8, shall
15 be ineligible for financial aid under this Article for a
16 period of two years following conviction or until the total
17 amount of money, including the value of federal food stamps,
18 is repaid, whichever first occurs.
19 (b) Any person, firm, corporation, association, agency,
20 institution or other legal entity that commits a subsequent
21 violation of any of the provisions of Sections 8A-2 through
22 8A-5 and:
23 (1) the total amount of money involved in the subsequent
24 violation, including the monetary value of federal food
25 stamps and the value of commodities, is less than $150, shall
26 be guilty of a Class 4 felony;
27 (2) the total amount of money involved in the subsequent
28 violation, including the monetary value of federal food
29 stamps and the value of commodities, is $150 or more but less
30 than $1,000, shall be guilty of a Class 3 felony;
31 (3) the total amount of money involved in the subsequent
32 violation, including the monetary value of federal food
33 stamps and the value of commodities, is $1,000 or more but
34 less than $5,000, shall be guilty of a Class 2 felony;
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1 (4) the total amount of money involved in the subsequent
2 violation, including the monetary value of federal food
3 stamps and the value of commodities, is $5,000 or more but
4 less than $10,000, shall be guilty of a Class 1 felony.
5 (c) For purposes of determining the classification of
6 offense under this Section, all of the money received as a
7 result of the unlawful act, practice or course of conduct can
8 be accumulated.
9 (Source: P.A. 85-1209.)
10 (305 ILCS 5/8A-13 new)
11 Sec. 8A-13. Managed health care fraud.
12 (a) As used in this Section, "health plan" means any of
13 the following:
14 (1) Any health care reimbursement plan sponsored
15 wholly or partially by the State.
16 (2) Any private insurance carrier, health care
17 cooperative or alliance, health maintenance organization,
18 insurer, organization, entity, association, affiliation,
19 or person that contracts to provide or provides goods or
20 services that are reimbursed by or are a required benefit
21 of a health benefits program funded wholly or partially
22 by the State.
23 (3) Anyone who provides or contracts to provide
24 goods and services to an entity described in paragraph
25 (1) or (2) of this subsection.
26 For purposes of item (2) in subsection (b),
27 "representation" and "statement" include, but are not limited
28 to, reports, claims, certifications, acknowledgments and
29 ratifications of financial information, enrollment claims,
30 demographic statistics, encounter data, health services
31 available or rendered, and the qualifications of person
32 rendering health care and ancillary services.
33 (b) Any person, firm, corporation, association, agency,
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1 institution, or other legal entity that, with the intent to
2 obtain benefits or payments under this Code to which the
3 person or entity is not entitled or in a greater amount than
4 that to which the person or entity is entitled, knowingly
5 executes or conspires to execute a scheme or artifice
6 (1) to defraud any State or federally funded or
7 mandated health plan in connection with the delivery of
8 or payment for health care benefits, items, or services,
9 or
10 (2) to obtain by means of false or fraudulent
11 pretense, representation, statement, or promise money or
12 anything of value in connection with the delivery of or
13 payment for health care benefits, items, or services that
14 are in whole or in part paid for, reimbursed, or
15 subsidized by, or are a required benefit of, a State or
16 federally funded or mandated health plan
17 is guilty of a violation of this Article and shall be
18 punished as provided in Section 8A-6.
19 (305 ILCS 5/8A-14 new)
20 Sec. 8A-14. Bribery and graft in connection with health
21 care.
22 (a) As used in this Section:
23 "Health care official" means any of the following:
24 (1) An administrator, officer, trustee, fiduciary,
25 custodian, counsel, agent, or employee of any health
26 plan.
27 (2) An officer, counsel, agent, or employee of an
28 organization that provides, proposes to provide, or
29 contracts to provide services to any health plan.
30 (3) An official, employee, or agent of a State or
31 federal agency having regulatory or administrative
32 authority over any health plan.
33 "Health plan" has the meaning attributed to that term in
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1 Section 8A-13.
2 (b) Any person, firm, corporation, association, agency,
3 institution, or other legal entity that
4 (1) directly or indirectly gives, offers, or
5 promises anything of value to a health care official, or
6 offers or promises to a health care official to give
7 anything of value to another person, with the intent
8 (A) to influence or reward any act or decision
9 of any health care official exercising any authority
10 in any State or federally funded or mandated health
11 plan other than as specifically allowed by law, or
12 (B) to influence the official to commit, aid
13 in the commission of, or conspire to allow any fraud
14 in a State or federally funded or mandated health
15 plan, or
16 (C) to induce the official to engage in any
17 conduct in violation of the official's lawful duty,
18 or
19 (2) being a health care official, directly or
20 indirectly demands, solicits, receives, accepts, or
21 agrees to accept anything of value personally or for any
22 other person or entity, the giving of which would violate
23 paragraph (1) of this subsection,
24 is guilty of a violation of this Article and shall be
25 punished as provided in Section 8A-6.
26 (305 ILCS 5/8A-15 new)
27 Sec. 8A-15. False statements relating to health care
28 delivery. Any person, firm, corporation, association,
29 agency, institution, or other legal entity that, in any
30 matter related to a State or federally funded or mandated
31 health plan, knowingly and wilfully falsifies, conceals, or
32 omits by any trick, scheme, artifice, or device a material
33 fact, or makes any false, fictitious, or fraudulent statement
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1 or representation, or makes or uses any false writing or
2 document, knowing the same to contain any false, fictitious,
3 or fraudulent statement or entry in connection with the
4 provision of health care or related services, is guilty of a
5 Class A misdemeanor.
6 (305 ILCS 5/8A-16 new)
7 Sec. 8A-16. Unfair or deceptive marketing practices.
8 (a) As used in this Section, "health plan" has the
9 meaning attributed to that term in Section 8A-13.
10 (b) It is unlawful to knowingly and willfully engage in
11 any unfair or deceptive marketing practice in connection with
12 proposing, offering, selling, soliciting, or providing any
13 health care service or any health plan. Unfair or deceptive
14 marketing practices include the following:
15 (1) Making a false and misleading oral or written
16 statement, visual description, advertisement, or other
17 representation of any kind that has the capacity,
18 tendency, or effect of deceiving or misleading health
19 care consumers with respect to any health care service,
20 health plan, or health care provider.
21 (2) Making a representation that a health care plan
22 or a health care provider offers any service, benefit,
23 access to care, or choice that it does not in fact offer.
24 (3) Making a representation that a health plan or
25 health care provider has any status, certification,
26 qualification, sponsorship, affiliation, or licensure
27 that it does not have.
28 (4) A failure to state a material fact if the
29 failure deceives or tends to deceive.
30 (5) Offering any kickback, bribe, reward, or
31 benefit to any person as an inducement to select or to
32 refrain from selecting any health care service, health
33 plan, or health care provider, unless the benefit offered
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1 is medically necessary health care or is permitted by the
2 Illinois Department.
3 (6) The use of health care consumer or other
4 information that is confidential or privileged or that
5 cannot be disclosed to or obtained by the user without
6 violating a State or federal confidentiality law,
7 including:
8 (A) medical records information; and
9 (B) information that identifies the health
10 care consumer or any member of his or her group as a
11 recipient of any government sponsored or mandated
12 welfare program.
13 (7) The use of any device or artifice in
14 advertising a health plan or soliciting a health care
15 consumer that misrepresents the solicitor's profession,
16 status, affiliation, or mission.
17 (c) Any person who commits a first violation of this
18 Section is guilty of a Class A misdemeanor and is subject to
19 a fine of not more than $5,000. Any person who commits a
20 second or subsequent violation of this Section is guilty of a
21 Class 4 felony and is subject to a fine of not more than
22 $25,000.
23 (305 ILCS 5/8A-17 new)
24 Sec. 8A-17. Penalties enhanced for persons other than
25 individuals. If a person who violates Section 8A-13, 8A-14,
26 8A-15, or 8A-16 is any person other than an individual, then
27 that person is subject to a fine of not more than $50,000 if
28 the violation is a misdemeanor and a fine of not more than
29 $250,000 if the violation is a felony.
30 Section 10. The Mental Health and Developmental
31 Disabilities Code is amended by changing Sections 2-102,
32 2-107, 2-107.1, 2-107.2, 2-110, and 3-800 and by adding
SB317 Enrolled -54- LRB9001503SMdv
1 Sections 1-121.5, 2-110.1, and 3-601.2 as follows:
2 (405 ILCS 5/1-121.5 new)
3 Sec. 1-121.5. Authorized involuntary treatment.
4 "Authorized involuntary treatment" means psychotropic
5 medication or electro-convulsive therapy, including those
6 tests and related procedures that are essential for the safe
7 and effective administration of the treatment.
8 (405 ILCS 5/2-102) (from Ch. 91 1/2, par. 2-102)
9 Sec. 2-102. (a) A recipient of services shall be
10 provided with adequate and humane care and services in the
11 least restrictive environment, pursuant to an individual
12 services plan, which shall be formulated and periodically
13 reviewed with the participation of the recipient to the
14 extent feasible and, where appropriate, such recipient's
15 nearest of kin or guardian.
16 (a-5) If the services include the administration of
17 authorized involuntary treatment psychotropic medication, the
18 physician shall advise the recipient, in writing, of the side
19 effects and risks of the treatment and alternatives to the
20 proposed treatment, and the risks and benefits thereof,
21 medication to the extent such advice is consistent with the
22 nature and frequency of the side effects and the recipient's
23 ability to understand the information communicated. The
24 physician shall determine in writing whether the recipient
25 has the capacity to make a reasoned decision about the
26 treatment. If the recipient lacks the capacity to make a
27 reasoned decision about the treatment, the treatment may be
28 administered only (i) pursuant to the provisions of Section
29 2-107 or 2-107.1 or (ii) pursuant to a power of attorney for
30 health care under the Powers of Attorney for Health Care Law
31 or a declaration for mental health treatment under the Mental
32 Health Treatment Preference Declaration Act. A surrogate
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1 decision maker, other than a court appointed guardian, under
2 the Health Care Surrogate Act may not consent to the
3 administration of authorized involuntary treatment. A
4 surrogate may, however, petition for administration of
5 authorized involuntary treatment pursuant to this Act. If
6 the recipient is under guardianship and the guardian is
7 authorized to consent to the administration of authorized
8 involuntary treatment pursuant to subsection (c) of Section
9 2-107.1 of this Code, the physician shall advise the guardian
10 in writing of the side effects and risks of the treatment,
11 alternatives to the proposed treatment, and the risks and
12 benefits of the treatment. Any recipient who is a resident of
13 a mental health or developmental disabilities facility shall
14 be advised in writing of his right to refuse such services
15 pursuant to Section 2-107 of this Code. A qualified
16 professional shall be responsible for overseeing the
17 implementation of such plan. Such care and treatment shall
18 include the regular use of sign language for any hearing
19 impaired individual for whom sign language is a primary mode
20 of communication.
21 (b) A recipient of services who is an adherent or a
22 member of any well-recognized religious denomination, the
23 principles and tenets of which teach reliance upon services
24 by spiritual means through prayer alone for healing by a duly
25 accredited practitioner thereof, shall have the right to
26 choose such services. The parent or guardian of a recipient
27 of services who is a minor, or a guardian of a recipient of
28 services who is not a minor, shall have the right to choose
29 services by spiritual means through prayer for the recipient
30 of services.
31 (Source: P.A. 86-1402.)
32 (405 ILCS 5/2-107) (from Ch. 91 1/2, par. 2-107)
33 Sec. 2-107. Refusal of services; informing of risks.
SB317 Enrolled -56- LRB9001503SMdv
1 (a) An adult recipient of services, or, if the recipient
2 is under guardianship, the recipient's guardian, shall be
3 given the opportunity to refuse generally accepted mental
4 health or developmental disability services, including but
5 not limited to medication. If such services are refused,
6 they shall not be given unless such services are necessary to
7 prevent the recipient from causing serious and imminent
8 physical harm to himself or others. The facility director
9 shall inform a recipient or guardian who refuses such
10 services of alternate services available and the risks of
11 such alternate services, as well as the possible consequences
12 to the recipient of refusal of such services.
13 (b) Authorized involuntary treatment Psychotropic
14 medication may be given under this Section for up to 24 hours
15 only if the circumstances leading up to the need for
16 emergency treatment medication are set forth in writing in
17 the recipient's record.
18 (c) Authorized involuntary treatment Psychotropic
19 medication may not be continued unless the need for such
20 treatment medication is redetermined at least every 24 hours
21 based upon a personal examination of the recipient by a
22 physician or a nurse under the supervision of a physician and
23 the circumstances demonstrating that need are set forth in
24 writing in the recipient's record.
25 (d) Authorized involuntary treatment Psychotropic
26 medications may not be administered under this Section for a
27 period in excess of 3 consecutive days, excluding Saturdays,
28 Sundays, and holidays, unless the facility files a petition
29 under Section 2-107.1 and the treatment medication continues
30 to be necessary in order to prevent the recipient from
31 causing serious and imminent physical harm to himself or
32 herself or others.
33 (e) The Department shall issue rules designed to insure
34 that in State-operated mental health facilities authorized
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1 involuntary treatment psychotropic medication is administered
2 in accordance with this Section and only when appropriately
3 authorized and monitored by a physician or a nurse under the
4 supervision of a physician in accordance with accepted
5 medical practice. The facility director of each mental
6 health facility not operated by the State shall issue rules
7 designed to insure that in that facility authorized
8 involuntary treatment psychotropic medication is administered
9 in accordance with this Section and only when appropriately
10 authorized and monitored by a physician or a nurse under the
11 supervision of a physician in accordance with accepted
12 medical practice. Such rules shall be available for public
13 inspection and copying during normal business hours.
14 (f) The provisions of this Section with respect to the
15 emergency administration of authorized involuntary treatment
16 psychotropic medication do not apply to facilities licensed
17 under the Nursing Home Care Act.
18 (Source: P.A. 89-427, eff. 6-1-96; 89-439, eff. 6-1-96.)
19 (405 ILCS 5/2-107.1) (from Ch. 91 1/2, par. 2-107.1)
20 Sec. 2-107.1. Administration of authorized involuntary
21 treatment psychotropic medication upon application to a
22 court.
23 (a) Notwithstanding the provisions of Section 2-107 of
24 this Code Act, authorized involuntary treatment psychotropic
25 medication may be administered to an adult recipient of
26 services without the informed consent of the recipient
27 against his will under the following standards:
28 (1) Any person 18 years of age or older, including
29 any guardian, may petition the circuit court for an order
30 authorizing the administration of authorized involuntary
31 treatment psychotropic medication to a recipient of
32 services. The petition shall state that the petitioner
33 has made a good faith attempt to determine whether the
SB317 Enrolled -58- LRB9001503SMdv
1 recipient has executed a power of attorney for health
2 care under the Powers of Attorney for Health Care Law or
3 a declaration for mental health treatment under the
4 Mental Health Treatment Preference Declaration Act and to
5 obtain copies of these instruments if they exist. If
6 either of the above-named instruments is available to the
7 petitioner, the instrument shall be attached to the
8 petition as an exhibit. The petitioner shall deliver a
9 copy of the petition, and notice of the time and place of
10 the hearing, to the respondent, his or her attorney, any
11 known agent or attorney-in-fact, if any, and the
12 guardian, if any, no later than 10 days prior to the date
13 of the hearing. The petition may include a request that
14 the court authorize such testing and procedures as may be
15 essential for the safe and effective administration of
16 the authorized involuntary treatment psychotropic
17 medication sought to be administered, but only where the
18 petition sets forth the specific testing and procedures
19 sought to be administered.
20 (2) The court shall hold a hearing within 14 days
21 of the filing of the petition. Continuances totaling not
22 more than 14 days may be granted to the recipient upon a
23 showing that the continuances are needed in order to
24 prepare adequately for a hearing under this Section. The
25 court may, in its discretion, grant additional
26 continuances if agreed to by all parties. The hearing
27 shall be separate from a judicial proceeding held to
28 determine whether a person is subject to involuntary
29 admission.
30 (3) Unless otherwise provided herein, the
31 procedures set forth in Article VIII of Chapter 3 of this
32 Act, including the provisions regarding appointment of
33 counsel, shall govern hearings held under this subsection
34 (a).
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1 (4) Authorized involuntary treatment Psychotropic
2 medication shall not be administered to the recipient
3 unless it has been determined by clear and convincing
4 evidence that all of the following factors are present:
5 (A) That the recipient has a serious mental
6 illness or developmental disability.
7 (B) That because of said mental illness or
8 developmental disability, the recipient exhibits any
9 one of the following: (i) deterioration of his
10 ability to function, (ii) suffering, (iii) or
11 threatening behavior, or (iv) disruptive behavior.
12 (C) That the illness or disability has existed
13 for a period marked by the continuing presence of
14 the symptoms set forth in item (B) of this
15 subdivision (4) or the repeated episodic occurrence
16 of these symptoms.
17 (D) That the benefits of the treatment
18 psychotropic medication will outweigh the harm.
19 (E) That the recipient lacks the capacity to
20 make a reasoned decision about the treatment
21 medication.
22 (F) That other less restrictive services have
23 been explored and found inappropriate.
24 (G) If the petition seeks authorization for
25 testing and other procedures, that such testing and
26 procedures are essential for the safe and effective
27 administration of the treatment psychotropic
28 medication.
29 (5) In no event shall an order issued under this
30 Section be effective for more than 90 days. However,
31 authorized involuntary treatment psychotropic medication
32 may be administered for additional 90-day periods without
33 limitation under hearings that comply with the above
34 standards and procedures of this subsection (a). If a new
SB317 Enrolled -60- LRB9001503SMdv
1 petition to authorize the administration of authorized
2 involuntary treatment psychotropic medication is filed at
3 least 15 days prior to the expiration of the prior order,
4 and if any continuance of the hearing is agreed to by the
5 recipient, the administration of the treatment medication
6 may continue in accordance with the prior order pending
7 the completion of a hearing under this Section.
8 (6) An order issued under this subsection (a) shall
9 designate the persons authorized to administer the
10 authorized involuntary treatment psychotropic medication
11 under the standards and procedures of this subsection
12 (a). Those persons shall have complete discretion not to
13 administer any treatment medication authorized under this
14 Section. The order shall also specify the medications and
15 the anticipated range of dosages that have been
16 authorized.
17 (b) A guardian may be authorized to consent to the
18 administration of authorized involuntary treatment
19 psychotropic medication to an objecting recipient only under
20 the standards and procedures of subsection (a).
21 (c) Notwithstanding any other provision of this Section,
22 a guardian may consent to the administration of authorized
23 involuntary treatment psychotropic medication to a
24 non-objecting recipient under Article XIa of the Probate Act
25 of 1975.
26 (d) Nothing in this Section shall prevent the
27 administration of authorized involuntary treatment
28 psychotropic medication to recipients in an emergency under
29 Section 2-107 of this Act.
30 (e) Notwithstanding any of the provisions of this
31 Section, authorized involuntary treatment may be administered
32 pursuant to a power of attorney for health care under the
33 Powers of Attorney for Health Care Law or a declaration for
34 mental health treatment under the Mental Health Treatment
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1 Preference Declaration Act.
2 (Source: P.A. 89-11, eff. 3-31-95; 89-439, eff. 6-1-96.)
3 (405 ILCS 5/2-107.2) (from Ch. 91 1/2, par. 2-107.2)
4 Sec. 2-107.2. Review; notice.
5 (a) Whenever any recipient, who is receiving treatment
6 in a residential mental health facility, has been receiving
7 authorized involuntary treatment psychotropic medication in
8 that facility continuously or on a regular basis for a period
9 of 3 months, and, if the treatment medication is continued
10 while the recipient is a resident in that facility, every 6
11 months thereafter, for so long as the treatment medication
12 shall continue, the facility director shall convene a
13 treatment review panel to review the medication treatment.
14 (b) At least 7 days prior to the date of the meeting,
15 the recipient, his or her guardian, if any, and the person
16 designated under subsection (b) of Section 2-200 shall be
17 given written notification of the time and place of the
18 treatment review meeting. The notice shall also advise the
19 recipient of his or her right to designate some person to
20 attend the meeting and assist the recipient.
21 (c) If, during the course of the review, the recipient
22 or guardian, if any, advises the committee that he no longer
23 agrees to continue receiving the treatment medication, the
24 treatment medication must be discontinued except that the
25 treatment medication may be administered under either Section
26 2-107 or 2-107.1. If the recipient and guardian, if any,
27 continues to agree to the treatment medication, the treatment
28 medication shall be continued if the committee determines
29 that the recipient is receiving appropriate treatment
30 medication and that the benefit to the recipient outweighs
31 any risk of harm to the recipient.
32 (d) The Department shall issue rules to implement the
33 requirements of this Section.
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1 (Source: P.A. 89-439, eff. 6-1-96.)
2 (405 ILCS 5/2-110) (from Ch. 91 1/2, par. 2-110)
3 Sec. 2-110. No recipient of services shall be subjected
4 to electro-convulsive therapy, or to any unusual, hazardous,
5 or experimental services or psychosurgery, without his
6 written and informed consent.
7 If the recipient is a minor or is under guardianship,
8 such recipient's parent or guardian is authorized, only with
9 the approval of the court, to provide informed consent for
10 participation of the ward in any such services which the
11 guardian deems to be in the best interests of the ward.
12 (Source: P.A. 80-1414.)
13 (405 ILCS 5/2-110.1 new)
14 Sec. 2-110.1. Reports.
15 (a) A mental hospital or facility at which
16 electro-convulsive therapy is administered shall submit to
17 the Department quarterly reports relating to the
18 administration of the therapy for the purposes of reducing
19 morbidity or mortality and improving patient care.
20 (b) A report shall state the following for each quarter:
21 (1) The number of persons who received the therapy,
22 including:
23 (A) the number of persons who gave informed
24 consent to the therapy;
25 (B) the number of persons confined as subject
26 to involuntary admission who gave informed consent
27 to the therapy;
28 (C) the number of persons who received the
29 therapy without informed consent pursuant to Section
30 2-107.1; and
31 (D) the number of persons who received the
32 therapy on an emergency basis pursuant to
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1 subsection (d) of Section 2-107.1.
2 (2) The age, sex, and race of the recipients of the
3 therapy.
4 (3) The source of the treatment payment.
5 (4) The average number of electro-convulsive
6 treatments administered for each complete series of
7 treatments, but not including maintenance treatments.
8 (5) The average number of maintenance
9 electro-convulsive treatments administered per month.
10 (6) Any significant adverse reactions to the
11 treatment as defined by rule.
12 (7) Autopsy findings if death followed within 14
13 days after the date of the administration of the therapy.
14 (8) Any other information required by the
15 Department by rule.
16 (c) The Department shall prepare and publish an annual
17 written report summarizing the information received under
18 this Section. The report shall not contain any information
19 that identifies or tends to identify any facility,
20 physician, health care provider, or patient.
21 (405 ILCS 5/3-601.2 new)
22 Sec. 3-601.2. Consent to admission by healthcare
23 surrogate. A surrogate decision maker under the Health Care
24 Surrogate Act may not consent to the admission to a mental
25 health facility of a person who lacks decision making
26 capacity. A surrogate may, however, petition for involuntary
27 admission pursuant to this Code. This Section does not
28 affect the authority of a court appointed guardian.
29 (405 ILCS 5/3-800) (from Ch. 91 1/2, par. 3-800)
30 Sec. 3-800. (a) Unless otherwise indicated, court
31 hearings under this Chapter shall be held pursuant to this
32 Article. Hearings shall be held in such quarters as the
SB317 Enrolled -64- LRB9001503SMdv
1 court directs. To the extent practical, hearings shall be
2 held in the mental health facility where the respondent is
3 hospitalized. Any party may request a change of venue or
4 transfer to any other county because of the convenience of
5 parties or witnesses or the condition of the respondent. The
6 respondent may request to have the proceedings transferred to
7 the county of his residence.
8 (b) If the court grants a continuance on its own motion
9 or upon the motion of one of the parties, the respondent may
10 continue to be detained pending further order of the court.
11 Such continuance shall not extend beyond 15 days except to
12 the extent that continuances are requested by the respondent.
13 (c) Court hearings under this Chapter, including
14 hearings under Section 2-107.1, shall be open to the press
15 and public unless the respondent or some other party requests
16 that they be closed. The court may also indicate its
17 intention to close a hearing, including when it determines
18 that the respondent may be unable to make a reasoned decision
19 to request that the hearing be closed. A request that a
20 hearing be closed shall be granted unless there is an
21 objection to closing the hearing by a party or any other
22 person. If an objection is made, the court shall not close
23 the hearing unless, following a hearing, it determines that
24 the patient's interest in having the hearing closed is
25 compelling. The court shall support its determination with
26 written findings of fact and conclusions of law. The court
27 shall not close the hearing if the respondent objects to its
28 closure. Whenever a court determines that a hearing shall be
29 closed, access to the records of the hearing, including but
30 not limited to transcripts and pleadings, shall be limited
31 to the parties involved in the hearing, court personnel, and
32 any person or agency providing mental health services that
33 are the subject of the hearing. Access may also be granted,
34 however, pursuant to the provisions of the Mental Health and
SB317 Enrolled -65- LRB9001503SMdv
1 Developmental Disabilities Confidentiality Act.
2 (Source: P.A. 85-971.)
3 Section 15. The Mental Health and Developmental
4 Disabilities Confidentiality Act is amended by changing
5 Sections 2 and 11 as follows:
6 (740 ILCS 110/2) (from Ch. 91 1/2, par. 802)
7 Sec. 2. The terms used in this Act, unless the context
8 requires otherwise, have the meanings ascribed to them in
9 this Section.
10 "Agent" means a person who has been legally appointed as
11 an individual's agent under a power of attorney for health
12 care or for property.
13 "Confidential communication" or "communication" means any
14 communication made by a recipient or other person to a
15 therapist or to or in the presence of other persons during or
16 in connection with providing mental health or developmental
17 disability services to a recipient. Communication includes
18 information which indicates that a person is a recipient.
19 "Guardian" means a legally appointed guardian or
20 conservator of the person.
21 "Mental health or developmental disabilities services" or
22 "services" includes but is not limited to examination,
23 diagnosis, evaluation, treatment, training, pharmaceuticals,
24 aftercare, habilitation or rehabilitation.
25 "Personal notes" means:
26 (i) information disclosed to the therapist in
27 confidence by other persons on condition that such
28 information would never be disclosed to the recipient or
29 other persons;
30 (ii) information disclosed to the therapist by the
31 recipient which would be injurious to the recipient's
32 relationships to other persons, and
SB317 Enrolled -66- LRB9001503SMdv
1 (iii) the therapist's speculations, impressions,
2 hunches, and reminders.
3 "Parent" means a parent or, in the absence of a parent or
4 guardian, a person in loco parentis.
5 "Recipient" means a person who is receiving or has
6 received mental health or developmental disabilities
7 services.
8 "Record" means any record kept by a therapist or by an
9 agency in the course of providing mental health or
10 developmental disabilities service to a recipient concerning
11 the recipient and the services provided. "Records" includes
12 all records maintained by a court that have been created in
13 connection with, in preparation for, or as a result of the
14 filing of any petition or certificate under Chapter II,
15 Article VI or VII of Chapter III, or under Article IV or V of
16 Chapter IV of the Mental Health and Developmental
17 Disabilities Code and includes the petitions, certificates,
18 dispositional reports, treatment plans, and reports of
19 diagnostic evaluations and of hearings to determine if a
20 person is subject to involuntary admission under Article VIII
21 of Chapter III or subject to judicial admission under Article
22 V of Chapter IV of that Code. Record does not include the
23 therapist's personal notes, if such notes are kept in the
24 therapist's sole possession for his own personal use and are
25 not disclosed to any other person, except the therapist's
26 supervisor, consulting therapist or attorney. If at any time
27 such notes are disclosed, they shall be considered part of
28 the recipient's record for purposes of this Act.
29 "Record custodian" means a person responsible for
30 maintaining a recipient's record.
31 "Therapist" means a psychiatrist, physician,
32 psychologist, social worker, or nurse providing mental health
33 or developmental disabilities services or any other person
34 not prohibited by law from providing such services or from
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1 holding himself out as a therapist if the recipient
2 reasonably believes that such person is permitted to do so.
3 Therapist includes any successor of the therapist.
4 (Source: P.A. 88-484; 89-58, eff. 1-1-96.)
5 (740 ILCS 110/11) (from Ch. 91 1/2, par. 811)
6 (Text of Section before amendment by P.A. 89-507)
7 Sec. 11. Disclosure of records and communications.
8 Records and communications may be disclosed, (i) in
9 accordance with the provisions of the Abused and Neglected
10 Child Reporting Act; (ii) when, and to the extent, a
11 therapist, in his or her sole discretion, determines that
12 disclosure is necessary to initiate or continue civil
13 commitment proceedings under the laws of this State or to
14 otherwise protect the recipient or other person against a
15 clear, imminent risk of serious physical or mental injury or
16 disease or death being inflicted upon the recipient or by the
17 recipient on himself or another; (iii) when, and to the
18 extent disclosure is, in the sole discretion of the
19 therapist, necessary to the provision of emergency medical
20 care to a recipient who is unable to assert or waive his or
21 her rights hereunder; (iv) when disclosure is necessary to
22 collect sums or receive third party payment representing
23 charges for mental health or developmental disabilities
24 services provided by a therapist or agency to a recipient
25 under Chapter V of the Mental Health and Developmental
26 Disabilities Code or to transfer debts under the Uncollected
27 States Claims Act; however, disclosure shall be limited to
28 information needed to pursue collection, and the information
29 so disclosed shall not be used for any other purposes nor
30 shall it be redisclosed except in connection with collection
31 activities; (v) when requested by a family member, the
32 Department of Mental Health and Developmental Disabilities
33 may assist in the location of the interment site of a
SB317 Enrolled -68- LRB9001503SMdv
1 deceased recipient who is interred in a cemetery established
2 under Section 100-26 of the Department of Mental Health and
3 Developmental Disabilities Act; (vi) in judicial commitment
4 proceedings and involuntary medication hearings under Article
5 VIII of Chapter III and Article V of Chapter IV of the Mental
6 Health and Developmental Disabilities Code and proceedings
7 and investigations preliminary thereto, to the State's
8 Attorney for the county or residence of a person who is the
9 subject of such proceedings for whom involuntary or judicial
10 admission or involuntary medication is sought, or in which
11 the person is found, or in which the facility is located, and
12 to the attorney representing the recipient in the judicial
13 commitment proceedings or medication hearing, to any person
14 or agency providing mental health services that are the
15 subject of the proceedings and to that person's or agency's
16 attorney, to any court personnel, including but not limited
17 to judges and circuit court clerks, and to a guardian ad
18 litem if one has been appointed by the court, provided that
19 the information so disclosed shall not be utilized for any
20 other purpose nor be redisclosed except in connection with
21 the proceedings or investigations; (vii) when, and to the
22 extent disclosure is necessary to comply with the
23 requirements of the Census Bureau in taking the federal
24 Decennial Census; and (viii) when, and to the extent, in the
25 therapist's sole discretion, disclosure is necessary to warn
26 or protect a specific individual against whom a recipient has
27 made a specific threat of violence where there exists a
28 therapist-recipient relationship or a special
29 recipient-individual relationship. Any person, institution,
30 or agency, under this Act, participating in good faith in the
31 making of a report under the Abused and Neglected Child
32 Reporting Act or in the disclosure of records and
33 communications under this Section, shall have immunity from
34 any liability, civil, criminal or otherwise, that might
SB317 Enrolled -69- LRB9001503SMdv
1 result by reason of such action. For the purpose of any
2 proceeding, civil or criminal, arising out of a report or
3 disclosure under this Section, the good faith of any person,
4 institution, or agency so reporting or disclosing shall be
5 presumed.
6 (Source: P.A. 88-484; 89-439, eff. 6-1-96.)
7 (Text of Section after amendment by P.A. 89-507)
8 Sec. 11. Disclosure of records and communications.
9 Records and communications may be disclosed, (i) in
10 accordance with the provisions of the Abused and Neglected
11 Child Reporting Act; (ii) when, and to the extent, a
12 therapist, in his or her sole discretion, determines that
13 disclosure is necessary to initiate or continue civil
14 commitment proceedings under the laws of this State or to
15 otherwise protect the recipient or other person against a
16 clear, imminent risk of serious physical or mental injury or
17 disease or death being inflicted upon the recipient or by the
18 recipient on himself or another; (iii) when, and to the
19 extent disclosure is, in the sole discretion of the
20 therapist, necessary to the provision of emergency medical
21 care to a recipient who is unable to assert or waive his or
22 her rights hereunder; (iv) when disclosure is necessary to
23 collect sums or receive third party payment representing
24 charges for mental health or developmental disabilities
25 services provided by a therapist or agency to a recipient
26 under Chapter V of the Mental Health and Developmental
27 Disabilities Code or to transfer debts under the Uncollected
28 State Claims Act; however, disclosure shall be limited to
29 information needed to pursue collection, and the information
30 so disclosed shall not be used for any other purposes nor
31 shall it be redisclosed except in connection with collection
32 activities; (v) when requested by a family member, the
33 Department of Human Services may assist in the location of
34 the interment site of a deceased recipient who is interred in
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1 a cemetery established under Section 100-26 of the Mental
2 Health and Developmental Disabilities Administrative Act;
3 (vi) in judicial commitment proceedings and involuntary
4 medication hearings under Article VIII of Chapter III and
5 Article V of Chapter IV of the Mental Health and
6 Developmental Disabilities Code and proceedings and
7 investigations preliminary thereto, to the State's Attorney
8 for the county or residence of a person who is the subject of
9 such proceedings for whom involuntary or judicial admission
10 or involuntary medication is sought, or in which the person
11 is found, or in which the facility is located, and to the
12 attorney representing the recipient in the judicial
13 commitment proceedings or medication hearing, to any person
14 or agency providing mental health services that are the
15 subject of the proceedings and to that person's or agency's
16 attorney, to any court personnel, including but not limited
17 to judges and circuit court clerks, and to a guardian ad
18 litem if one has been appointed by the court, provided that
19 the information so disclosed shall not be utilized for any
20 other purpose nor be redisclosed except in connection with
21 the proceedings or investigations; (vii) when, and to the
22 extent disclosure is necessary to comply with the
23 requirements of the Census Bureau in taking the federal
24 Decennial Census; and (viii) when, and to the extent, in the
25 therapist's sole discretion, disclosure is necessary to warn
26 or protect a specific individual against whom a recipient has
27 made a specific threat of violence where there exists a
28 therapist-recipient relationship or a special
29 recipient-individual relationship. Any person, institution,
30 or agency, under this Act, participating in good faith in the
31 making of a report under the Abused and Neglected Child
32 Reporting Act or in the disclosure of records and
33 communications under this Section, shall have immunity from
34 any liability, civil, criminal or otherwise, that might
SB317 Enrolled -71- LRB9001503SMdv
1 result by reason of such action. For the purpose of any
2 proceeding, civil or criminal, arising out of a report or
3 disclosure under this Section, the good faith of any person,
4 institution, or agency so reporting or disclosing shall be
5 presumed.
6 (Source: P.A. 88-484; 89-439, eff. 6-1-96; 89-507, eff.
7 7-1-97.)
8 Section 20. The Sexual Exploitation in Psychotherapy Act
9 is amended by changing the title of the Act and Sections
10 0.01, 1, 2, and 3 as follows:
11 (740 ILCS 140/Act title)
12 An Act concerning sexual exploitation by
13 psychotherapists, unlicensed health professionals, or
14 unlicensed mental health professionals.
15 (Source: P.A. 85-1254.)
16 (740 ILCS 140/0.01) (from Ch. 70, par. 800)
17 Sec. 0.01. Short title. This Act may be cited as the
18 Sexual Exploitation in Psychotherapy, Professional Health
19 Services, and Professional Mental Health Services Act.
20 (Source: P.A. 86-1324.)
21 (740 ILCS 140/1) (from Ch. 70, par. 801)
22 Sec. 1. Definitions. In this Act:
23 (a) "Emotionally dependent" means that the nature of the
24 patient's or former patient's emotional condition and the
25 nature of the treatment provided by the psychotherapist,
26 unlicensed health professional, or unlicensed mental health
27 professional are such that the psychotherapist, unlicensed
28 health professional, or unlicensed mental health professional
29 knows or has reason to believe that the patient or former
30 patient is unable to withhold consent to sexual contact by
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1 the psychotherapist, unlicensed health professional, or
2 unlicensed mental health professional.
3 (b) "Former patient" means a person who was given
4 psychotherapy within 1 year prior to sexual contact with the
5 psychotherapist or who obtained a professional consultation
6 or diagnostic or therapeutic service from an unlicensed
7 health professional or unlicensed mental health professional
8 within one year prior to sexual contact with the unlicensed
9 health professional or unlicensed mental health professional.
10 (c) "Patient" means a person who seeks or obtains
11 psychotherapy or who obtains a professional consultation or
12 diagnostic or therapeutic service from an unlicensed health
13 professional or unlicensed mental health professional.
14 (d) "Psychotherapist" means a physician, psychologist,
15 nurse, chemical dependency counselor, social worker, or other
16 person, whether or not licensed by the State, who performs or
17 purports to perform psychotherapy.
18 (e) "Psychotherapy" means the professional treatment,
19 assessment, or counseling of a mental or emotional illness,
20 symptom, or condition. "Psychotherapy" does not include
21 counseling of a spiritual or religious nature, social work,
22 or casual advice given by a friend or family member.
23 (f) "Sexual contact" means any of the following, whether
24 or not occurring with the consent of a patient or former
25 patient:
26 (1) sexual intercourse, cunnilingus, fellatio, anal
27 intercourse or any intrusion, however slight, into the
28 genital or anal openings of the patient's or former patient's
29 body by any part of the psychotherapist's, unlicensed health
30 professional's, or unlicensed mental health professional's
31 body or by any object used by the psychotherapist, unlicensed
32 health professional, or unlicensed mental health professional
33 for that purpose, or any intrusion, however slight, into the
34 genital or anal openings of the psychotherapist's, unlicensed
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1 health professional's, or unlicensed mental health
2 professional's body by any part of the patient's or former
3 patient's body or by any object used by the patient or former
4 patient for that purpose, if agreed to by the
5 psychotherapist, unlicensed health professional, or
6 unlicensed mental health professional;
7 (2) kissing or intentional touching by the
8 psychotherapist, unlicensed health professional, or
9 unlicensed mental health professional of the patient's or
10 former patient's genital area, groin, inner thigh, buttocks,
11 or breast or the clothing covering any of these body parts;
12 (3) kissing or intentional touching by the patient or
13 former patient of the psychotherapist's, unlicensed health
14 professional's, or unlicensed mental health professional's
15 genital area, groin, inner thigh, buttocks, or breast or the
16 clothing covering any of these body parts if the
17 psychotherapist, unlicensed health professional, or
18 unlicensed mental health professional agrees to the kissing
19 or intentional touching.
20 "Sexual contact" includes a request by the
21 psychotherapist, unlicensed health professional, or
22 unlicensed mental health professional for conduct described
23 in paragraphs (1) through (3).
24 "Sexual contact" does not include conduct described in
25 paragraph (1) or (2) that is a part of standard medical
26 treatment of a patient, casual social contact not intended to
27 be sexual in character, or inadvertent touching.
28 (g) "Therapeutic deception" means a representation by a
29 psychotherapist, unlicensed health professional, or
30 unlicensed mental health professional that sexual contact
31 with the psychotherapist, unlicensed health professional, or
32 unlicensed mental health professional is consistent with or
33 part of the patient's or former patient's treatment.
34 (h) "Unlicensed health professional" means a person who
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1 is not licensed or registered to provide health services by
2 the Department of Professional Regulation or a board of
3 registration duly authorized to grant licenses or
4 registration to persons engaged in the practice of providing
5 health services or whose license or registration to provide
6 health services has been returned or revoked by the
7 Department or that board.
8 (i) "Unlicensed mental health professional" means a
9 person who is not licensed or registered to provide mental
10 health services by the Department of Professional Regulation
11 or a board of registration duly authorized to grant licenses
12 or registration to persons engaged in the practice of
13 providing mental health services or whose license or
14 registration to provide mental health services has been
15 returned or revoked by the Department or that board.
16 (Source: P.A. 85-1254.)
17 (740 ILCS 140/2) (from Ch. 70, par. 802)
18 Sec. 2. Cause of action for sexual exploitation. (a) A
19 cause of action against a psychotherapist, unlicensed health
20 professional, or unlicensed mental health professional for
21 sexual exploitation exists for a patient or former patient
22 for injury caused by sexual contact with the psychotherapist,
23 unlicensed health professional, or unlicensed mental health
24 professional, if the sexual contact occurred:
25 (1) during the period the patient was receiving
26 psychotherapy from the psychotherapist, or health services
27 from the unlicensed health professional, or mental health
28 services from the unlicensed mental health professional; or
29 (2) after the period the patient received psychotherapy
30 from the psychotherapist, or health services from the
31 unlicensed health professional, or mental health services
32 from the unlicensed mental health professional if (i) the
33 former patient was emotionally dependent on the
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1 psychotherapist, unlicensed health professional, or
2 unlicensed mental health professional or (ii) the sexual
3 contact occurred by means of therapeutic deception.
4 (b) The patient or former patient may recover damages
5 from a psychotherapist, unlicensed health professional, or
6 unlicensed mental health professional who is found liable for
7 sexual exploitation. It is not a defense to the action that
8 sexual contact with a patient occurred outside a therapy or
9 treatment session or that it occurred off the premises
10 regularly used by the psychotherapist, unlicensed health
11 professional, or unlicensed mental health professional for
12 therapy or treatment sessions.
13 (c) Whenever the Attorney General has probable cause to
14 believe (i) that a psychotherapist, unlicensed health
15 professional, or unlicensed mental health professional is
16 having or has had sexual contact with one or more patients or
17 clients or former patients or former clients while the
18 psychotherapist, unlicensed health professional, or
19 unlicensed mental health professional was licensed or
20 unlicensed and (ii) that the psychotherapist, unlicensed
21 health professional, or unlicensed mental health professional
22 poses a threat to the health, safety, or welfare of members
23 of the public who are or may be patients or clients of the
24 psychotherapist, unlicensed health professional, or
25 unlicensed mental health professional, the Attorney General
26 may bring an action in the name of the State against the
27 psychotherapist, unlicensed health professional, or
28 unlicensed mental health professional to restrain by
29 temporary restraining order or preliminary or permanent
30 injunction the psychotherapist, unlicensed health
31 professional, or unlicensed mental health professional from
32 providing, offering to provide, or representing himself or
33 herself as being able to provide psychotherapy, health
34 services, or mental health services.
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1 At least 5 days prior to the commencement of any action
2 brought under this Section, except when a temporary
3 restraining order is sought, the Attorney General shall
4 notify the psychotherapist, unlicensed health professional,
5 or unlicensed mental health professional of the Attorney
6 General's intended action and shall give the psychotherapist,
7 unlicensed health professional, or unlicensed mental health
8 professional an opportunity to confer with the Attorney
9 General or his or her representative in person or by counsel
10 or other representative as to the proposed action.
11 The notice shall be given by first-class mail, postage
12 prepaid, to the psychotherapist's, unlicensed health
13 professional's, or unlicensed mental health professional's
14 usual place of business or, if that person has no usual place
15 of business, to that person's last known address.
16 (d) The action may be brought either in the circuit
17 court of the county in which the conduct complained of
18 occurred or in the circuit court of the county in which the
19 psychotherapist, unlicensed health professional, or
20 unlicensed mental health professional resides or has his or
21 her principal place of business.
22 The court may issue temporary restraining orders or
23 preliminary or permanent injunctions and make other orders or
24 judgments it deems appropriate.
25 (e) No injunction shall be issued under this Section
26 unless the court finds that the defendant has had an
27 opportunity for an evidentiary hearing as to all contested
28 material issues of fact. Issues decided in a prior
29 evidentiary hearing in a court or in an administrative
30 proceeding may be applied to a proceeding under this Section
31 in compliance with the Code of Civil Procedure.
32 If the court issues an injunction against a
33 psychotherapist, unlicensed health professional, or
34 unlicensed mental health professional under this Section, the
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1 court shall retain jurisdiction of the matter and the cause
2 shall be continued. Any psychotherapist, unlicensed health
3 professional, or unlicensed mental health professional who is
4 ordered to refrain from certain conduct or activities in an
5 action brought under this Section may petition the court for
6 a modification or termination of the injunction upon 10 days
7 notice to the Attorney General.
8 (f) Any State's Attorney or other law enforcement office
9 receiving notice of any alleged violation of this Section or
10 violation of an injunction or order issued in an action
11 brought under this Section shall immediately forward written
12 notice of the alleged violation together with any information
13 that the State's Attorney or other law enforcement office may
14 have to the office of the Attorney General.
15 (g) In an action brought under this Section, whenever
16 the court issues a temporary restraining order or a
17 preliminary or permanent injunction ordering a defendant to
18 refrain from certain conduct or activities, the order shall
19 contain the following statement:
20 VIOLATION OF THIS ORDER IS A CRIMINAL OFFENSE.
21 The clerk shall transmit 2 certified copies of each such
22 order issued under this Section to each appropriate law
23 enforcement agency having jurisdiction over locations where
24 the defendant is alleged to have committed the act giving
25 rise to the action, and the law enforcement agency shall
26 serve one copy of the order on the defendant. Unless
27 otherwise ordered by the court, service shall be by
28 delivering a copy in hand to the defendant.
29 After any such order has been served on the defendant,
30 any violation of the order by the defendant is a Class 4
31 felony punishable by a fine of not more than $25,000.
32 Law enforcement agencies shall establish procedures
33 adequate to ensure that all officers responsible for the
34 enforcement of an order entered under this Section are
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1 informed of the existence and terms of the order. Whenever
2 any law enforcement officer has probable cause to believe
3 that a defendant has violated the provisions of this Section,
4 the officer has the authority to arrest the defendant.
5 Whenever the court vacates a temporary restraining order
6 or a preliminary or permanent injunction issued under this
7 Section, the clerk shall promptly notify in writing each
8 appropriate law enforcement agency that has been notified of
9 the issuance of the order and shall direct each such agency
10 to destroy all records of the vacated order. The law
11 enforcement agency shall comply with that directive.
12 (h) Nothing contained in this Section shall prohibit the
13 Attorney General in his or her discretion from bringing an
14 action for civil contempt against the defendant rather than
15 bringing criminal charges for an alleged violation of an
16 order issued under this Section as provided in subsection
17 (g). If the court finds that a psychotherapist, unlicensed
18 health professional, or unlicensed mental health professional
19 is in civil contempt by reason of an alleged violation of an
20 injunction or the order entered under this Section, the court
21 shall assess a civil penalty of not more than $10,000 for
22 each such violation found.
23 (Source: P.A. 85-1254.)
24 (740 ILCS 140/3) (from Ch. 70, par. 803)
25 Sec. 3. Liability of employer. An employer of a
26 psychotherapist, unlicensed health professional, or
27 unlicensed mental health professional may be liable under
28 Section 2 if the employer fails or refuses to take reasonable
29 action when the employer knows or has reason to know that the
30 psychotherapist, unlicensed health professional, or
31 unlicensed mental health professional engaged in sexual
32 contact with the plaintiff or any other patient or former
33 patient of the psychotherapist, unlicensed health
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1 professional, or unlicensed mental health professional.
2 (Source: P.A. 85-1254.)
3 Section 25. The Health Care Surrogate Act is amended by
4 changing Section 10 as follows:
5 (755 ILCS 40/10) (from Ch. 110 1/2, par. 851-10)
6 Sec. 10. Definitions.
7 "Adult" means a person who is (i) 18 years of age or
8 older or (ii) an emancipated minor under the Emancipation of
9 Mature Minors Act.
10 "Artificial nutrition and hydration" means supplying food
11 and water through a conduit, such as a tube or intravenous
12 line, where the recipient is not required to chew or swallow
13 voluntarily, including, but not limited to, nasogastric
14 tubes, gastrostomies, jejunostomies, and intravenous
15 infusions. Artificial nutrition and hydration does not
16 include assisted feeding, such as spoon or bottle feeding.
17 "Available" means that a person is not "unavailable". A
18 person is unavailable if (i) the person's existence is not
19 known, (ii) the person has not been able to be contacted by
20 telephone or mail, or (iii) the person lacks decisional
21 capacity, refuses to accept the office of surrogate, or is
22 unwilling to respond in a manner that indicates a choice
23 among the life-sustaining treatment matters at issue.
24 "Attending physician" means the physician selected by or
25 assigned to the patient who has primary responsibility for
26 treatment and care of the patient and who is a licensed
27 physician in Illinois. If more than one physician shares
28 that responsibility, any of those physicians may act as the
29 attending physician under this Act.
30 "Close friend" means any person 18 years of age or older
31 who has exhibited special care and concern for the patient
32 and who presents an affidavit to the attending physician
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1 stating that he or she (i) is a close friend of the patient,
2 (ii) is willing and able to become involved in the patient's
3 health care, and (iii) has maintained such regular contact
4 with the patient as to be familiar with the patient's
5 activities, health, and religious and moral beliefs. The
6 affidavit must also state facts and circumstances that
7 demonstrate that familiarity.
8 "Death" means when, according to accepted medical
9 standards, there is (i) an irreversible cessation of
10 circulatory and respiratory functions or (ii) an irreversible
11 cessation of all functions of the entire brain, including the
12 brain stem.
13 "Decisional capacity" means the ability to understand and
14 appreciate the nature and consequences of a decision
15 regarding forgoing life-sustaining treatment and the ability
16 to reach and communicate an informed decision in the matter
17 as determined by the attending physician.
18 "Forgo life-sustaining treatment" means to withhold,
19 withdraw, or terminate all or any portion of life-sustaining
20 treatment with knowledge that the patient's death is likely
21 to result.
22 "Guardian" means a court appointed guardian of the person
23 who serves as a representative of a minor or as a
24 representative of a person under legal disability.
25 "Health care facility" means a type of health care
26 provider commonly known by a wide variety of titles,
27 including but not limited to, hospitals, medical centers,
28 nursing homes, rehabilitation centers, long term or tertiary
29 care facilities, and other facilities established to
30 administer health care and provide overnight stays in their
31 ordinary course of business or practice.
32 "Health care provider" means a person that is licensed,
33 certified, or otherwise authorized or permitted by the law of
34 this State to administer health care in the ordinary course
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1 of business or practice of a profession, including, but not
2 limited to, physicians, nurses, health care facilities, and
3 any employee, officer, director, agent, or person under
4 contract with such a person.
5 "Imminent" (as in "death is imminent") means a
6 determination made by the attending physician according to
7 accepted medical standards that death will occur in a
8 relatively short period of time, even if life-sustaining
9 treatment is initiated or continued.
10 "Life-sustaining treatment" means any medical treatment,
11 procedure, or intervention that, in the judgment of the
12 attending physician, when applied to a patient with a
13 qualifying condition, would not be effective to remove the
14 qualifying condition or would serve only to prolong the dying
15 process. Those procedures can include, but are not limited
16 to, assisted ventilation, renal dialysis, surgical
17 procedures, blood transfusions, and the administration of
18 drugs, antibiotics, and artificial nutrition and hydration.
19 "Minor" means an individual who is not an adult as
20 defined in this Act.
21 "Parent" means a person who is the natural or adoptive
22 mother or father of the child and whose parental rights have
23 not been terminated by a court of law.
24 "Patient" means an adult or minor individual, unless
25 otherwise specified, under the care or treatment of a
26 licensed physician or other health care provider.
27 "Person" means an individual, a corporation, a business
28 trust, a trust, a partnership, an association, a government,
29 a governmental subdivision or agency, or any other legal
30 entity.
31 "Qualifying condition" means the existence of one or more
32 of the following conditions in a patient certified in writing
33 in the patient's medical record by the attending physician
34 and by at least one other qualified physician:
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1 (1) "Terminal condition" means an illness or injury
2 for which there is no reasonable prospect of cure or
3 recovery, death is imminent, and the application of
4 life-sustaining treatment would only prolong the dying
5 process.
6 (2) "Permanent unconsciousness" means a condition
7 that, to a high degree of medical certainty, (i) will
8 last permanently, without improvement, (ii) in which
9 thought, sensation, purposeful action, social
10 interaction, and awareness of self and environment are
11 absent, and (iii) for which initiating or continuing
12 life-sustaining treatment, in light of the patient's
13 medical condition, provides only minimal medical benefit.
14 (3) "Incurable or irreversible condition" means an
15 illness or injury (i) for which there is no reasonable
16 prospect of cure or recovery, (ii) that ultimately will
17 cause the patient's death even if life-sustaining
18 treatment is initiated or continued, (iii) that imposes
19 severe pain or otherwise imposes an inhumane burden on
20 the patient, and (iv) for which initiating or continuing
21 life-sustaining treatment, in light of the patient's
22 medical condition, provides only minimal medical benefit.
23 The determination that a patient has a qualifying
24 condition creates no presumption regarding the application or
25 non-application of life-sustaining treatment. It is only
26 after a determination by the attending physician that the
27 patient has a qualifying condition that the surrogate
28 decision maker may consider whether or not to forgo
29 life-sustaining treatment. In making this decision, the
30 surrogate shall weigh the burdens on the patient of
31 initiating or continuing life-sustaining treatment against
32 the benefits of that treatment.
33 "Qualified physician" means a physician licensed to
34 practice medicine in all of its branches in Illinois who has
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1 personally examined the patient.
2 "Surrogate decision maker" means an adult individual or
3 individuals who (i) have decisional capacity, (ii) are
4 available upon reasonable inquiry, (iii) are willing to make
5 decisions regarding the forgoing of life-sustaining treatment
6 on behalf of a patient who lacks decisional capacity and is
7 diagnosed as suffering from a qualifying condition, and (iv)
8 are identified by the attending physician in accordance with
9 the provisions of this Act as the person or persons who are
10 to make those decisions in accordance with the provisions of
11 this Act.
12 (Source: P.A. 87-749; 88-670, eff. 12-2-94.)
13 Section 95. No acceleration or delay. Where this Act
14 makes changes in a statute that is represented in this Act by
15 text that is not yet or no longer in effect (for example, a
16 Section represented by multiple versions), the use of that
17 text does not accelerate or delay the taking effect of (i)
18 the changes made by this Act or (ii) provisions derived from
19 any other Public Act.
20 Section 99. Effective date. This Act takes effect upon
21 becoming law.