Sen. John M. Sullivan
Filed: 5/15/2009
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1 | AMENDMENT TO HOUSE BILL 542
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2 | AMENDMENT NO. ______. Amend House Bill 542 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Illinois Public Aid Code is amended by | ||||||
5 | changing Sections 5-4.2 and 5-5 as follows:
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6 | (305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)
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7 | Sec. 5-4.2. Ground ambulance Ambulance services payments. | ||||||
8 | (a) For purposes of this Section, the following terms have | ||||||
9 | the following meanings: | ||||||
10 | "Department" means the Illinois Department of Healthcare | ||||||
11 | and Family Services. | ||||||
12 | "Ground ambulance services" means medical transportation | ||||||
13 | services that are described as ground ambulance services by the | ||||||
14 | Centers for Medicare and Medicaid Services and provided in a | ||||||
15 | vehicle that is licensed as an ambulance by the Illinois | ||||||
16 | Department of Public Health pursuant to the Emergency Medical |
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1 | Services (EMS) Systems Act. | ||||||
2 | "Ground ambulance services provider" means a vehicle | ||||||
3 | service provider as described in the Emergency Medical Services | ||||||
4 | (EMS) Systems Act that operates licensed ambulances for the | ||||||
5 | purpose of providing emergency ambulance services, or | ||||||
6 | non-emergency ambulance services, or both. For purposes of this | ||||||
7 | Section, this includes both ambulance providers and ambulance | ||||||
8 | suppliers as described by the Centers for Medicare and Medicaid | ||||||
9 | Services. | ||||||
10 | "Rural county" means: any county not located in a U.S. | ||||||
11 | Bureau of the Census Metropolitan Statistical Area (MSA); or | ||||||
12 | any county located within a U.S. Bureau of the Census | ||||||
13 | Metropolitan Statistical Area but having a population of 60,000 | ||||||
14 | or less. | ||||||
15 | (b) It is the intent of the General Assembly to provide for | ||||||
16 | the payment for ground ambulance services as part of the State | ||||||
17 | Medicaid plan and to provide adequate payment for ground | ||||||
18 | ambulance services under the State Medicaid plan so as to | ||||||
19 | ensure adequate access to ground ambulance services for both | ||||||
20 | recipients of aid under this Article and for the general | ||||||
21 | population of Illinois. Unless otherwise indicated in this | ||||||
22 | Section, the practices of the Department concerning payments | ||||||
23 | for ground ambulance services provided to recipients of aid | ||||||
24 | under this Article shall be consistent with the payment | ||||||
25 | principles of Medicare, including the statutes, regulations, | ||||||
26 | policies, procedures, principles, definitions, guidelines, |
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1 | coding systems, including the ambulance condition coding | ||||||
2 | system, and manuals used by the Centers for Medicare and | ||||||
3 | Medicaid Services and the Medicare Part B Carrier or the | ||||||
4 | Medicare Administrative Contractor for the State of Illinois to | ||||||
5 | determine the payment system to ground ambulance services | ||||||
6 | providers under Title XVIII of the Social Security Act. | ||||||
7 | (c) For ground ambulance services provided to a recipient | ||||||
8 | of aid under this Article on or after July 1, 2009, the | ||||||
9 | Department shall provide payment to ground ambulance services | ||||||
10 | providers for base charges and mileage charges based upon the | ||||||
11 | lesser of the provider's charge, as reflected on the provider's | ||||||
12 | claim form, or the Illinois Medicaid Ambulance Fee Schedule | ||||||
13 | rates calculated in accordance with this Section. | ||||||
14 | Effective July 1, 2009, the Illinois Medicaid Ambulance Fee | ||||||
15 | Schedule shall be established and shall include only the ground | ||||||
16 | ambulance services rates outlined in the Medicare Ambulance Fee | ||||||
17 | Schedule as promulgated by the Centers for Medicare and | ||||||
18 | Medicaid Services and adjusted for the 4 Medicare Localities in | ||||||
19 | Illinois, with an adjustment of 100% of the Medicare Ambulance | ||||||
20 | Fee Schedule rates, by Medicare Locality, for both base rates | ||||||
21 | and mileage for rural counties, and an adjustment of 80% of the | ||||||
22 | Medicare Ambulance Fee Schedule rates, by Medicare Locality, | ||||||
23 | for both base rates and mileage for all other counties. | ||||||
24 | Effective for dates of service on or after July 1, 2010, | ||||||
25 | the Department shall update the Illinois Medicaid Ambulance Fee | ||||||
26 | Schedule rates so that they comply with the Medicare Ambulance |
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1 | Fee Schedule rates for ground ambulance services in effect at | ||||||
2 | the time of the update, in the manner prescribed in the second | ||||||
3 | paragraph of this subsection (c). | ||||||
4 | (d) Payment for mileage shall be per loaded mile with no | ||||||
5 | loaded mileage included in the base rate. If a natural | ||||||
6 | disaster, weather, road repairs, traffic congestion, or other | ||||||
7 | conditions necessitate a route other than the most direct | ||||||
8 | route, payment shall be based upon the actual distance | ||||||
9 | traveled. Notwithstanding the payment principles in subsection | ||||||
10 | (b) of this Section, the Department shall develop the Illinois | ||||||
11 | Medicaid Ambulance Fee Schedule using the ground mileage rate, | ||||||
12 | as defined by the Centers for Medicare and Medicaid Services, | ||||||
13 | and no other mileage rates which act as enhancements to the | ||||||
14 | ground mileage rate, whether permanent or temporary, shall be | ||||||
15 | recognized by the Department. When a ground ambulance services | ||||||
16 | provider provides transport pursuant to an emergency call as | ||||||
17 | defined by the Centers for Medicare and Medicaid Services, no | ||||||
18 | reduction in the mileage payment shall be made based upon the | ||||||
19 | fact that a closer facility may have been available, so long as | ||||||
20 | the ground ambulance services provider provided transport to | ||||||
21 | the recipient's facility of choice within the scope of the | ||||||
22 | Illinois Emergency Medical Services (EMS) Systems Act and | ||||||
23 | associated rules and the policies and procedures of the EMS | ||||||
24 | System of which the provider is a member. | ||||||
25 | (e) The Department shall provide payment for emergency | ||||||
26 | ground ambulance services provided to a recipient of aid under |
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1 | this Article according to the requirements provided in | ||||||
2 | subsection (b) of this Section when those services are provided | ||||||
3 | pursuant to a request made through a 9-1-1 or equivalent | ||||||
4 | emergency telephone number for evaluation, treatment, and | ||||||
5 | transport from or on behalf of an individual with a condition | ||||||
6 | of such a nature that a prudent layperson would have reasonably | ||||||
7 | expected that a delay in seeking immediate medical attention | ||||||
8 | would have been hazardous to life or health. This standard is | ||||||
9 | deemed to be met if there is an emergency medical condition | ||||||
10 | manifesting itself by acute symptoms of sufficient severity, | ||||||
11 | including but not limited to severe pain, such that a prudent | ||||||
12 | layperson who possesses an average knowledge of medicine and | ||||||
13 | health can reasonably expect that the absence of immediate | ||||||
14 | medical attention could result in placing the health of the | ||||||
15 | individual or, with respect to a pregnant woman, the health of | ||||||
16 | the woman or her unborn child, in serious jeopardy, cause | ||||||
17 | serious impairment to bodily functions, or cause serious | ||||||
18 | dysfunction of any bodily organ or part. | ||||||
19 | (f) For ground ambulance services provided to a recipient | ||||||
20 | enrolled in a Medicaid managed care plan by a ground ambulance | ||||||
21 | services provider that is not a contracted provider to the | ||||||
22 | Medicaid managed care plan in question, the amount of the | ||||||
23 | payment for ground ambulance services by the Medicaid managed | ||||||
24 | care plan shall be the lesser of the provider's charge, as | ||||||
25 | reflected on the provider's claim form, or the Illinois | ||||||
26 | Medicaid Ambulance Fee Schedule rates calculated in accordance |
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1 | with this Section. | ||||||
2 | (g) Nothing in this Section prohibits the Department from | ||||||
3 | setting payment rates for out-of-State ground ambulance | ||||||
4 | services providers by administrative rule. | ||||||
5 | (h) Effective for dates of service on or after July 1, | ||||||
6 | 2009, payments for stretcher van services provided by ground | ||||||
7 | ambulance services providers shall be as follows: | ||||||
8 | (1) For each individual base rate, the amount of the | ||||||
9 | payment shall be the lesser of the provider's charge, as | ||||||
10 | reflected on the provider's claim form, or 80% of the | ||||||
11 | Illinois Medicaid Ambulance Fee Schedule rate for the basic | ||||||
12 | life support non-emergency base rate. | ||||||
13 | (2) For each loaded mile, the amount of the payment | ||||||
14 | shall be the lesser of the provider's charge, as reflected | ||||||
15 | on the provider's claim form, or 80% of the Illinois | ||||||
16 | Medicaid Ambulance Fee Schedule rate for mileage. | ||||||
17 | For
ambulance
services provided to a recipient of aid under | ||||||
18 | this Article on or after
January 1, 1993, the Illinois | ||||||
19 | Department shall reimburse ambulance service
providers at | ||||||
20 | rates calculated in accordance with this Section. It is the | ||||||
21 | intent
of the General Assembly to provide adequate | ||||||
22 | reimbursement for ambulance
services so as to ensure adequate | ||||||
23 | access to services for recipients of aid
under this Article and | ||||||
24 | to provide appropriate incentives to ambulance service
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25 | providers to provide services in an efficient and | ||||||
26 | cost-effective manner. Thus,
it is the intent of the General |
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1 | Assembly that the Illinois Department implement
a | ||||||
2 | reimbursement system for ambulance services that, to the extent | ||||||
3 | practicable
and subject to the availability of funds | ||||||
4 | appropriated by the General Assembly
for this purpose, is | ||||||
5 | consistent with the payment principles of Medicare. To
ensure | ||||||
6 | uniformity between the payment principles of Medicare and | ||||||
7 | Medicaid, the
Illinois Department shall follow, to the extent | ||||||
8 | necessary and practicable and
subject to the availability of | ||||||
9 | funds appropriated by the General Assembly for
this purpose, | ||||||
10 | the statutes, laws, regulations, policies, procedures,
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11 | principles, definitions, guidelines, and manuals used to | ||||||
12 | determine the amounts
paid to ambulance service providers under | ||||||
13 | Title XVIII of the Social Security
Act (Medicare).
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14 | For ambulance services provided to a recipient of aid under | ||||||
15 | this Article
on or after January 1, 1996, the Illinois | ||||||
16 | Department shall reimburse ambulance
service providers based | ||||||
17 | upon the actual distance traveled if a natural
disaster, | ||||||
18 | weather conditions, road repairs, or traffic congestion | ||||||
19 | necessitates
the use of a
route other than the most direct | ||||||
20 | route.
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21 | For purposes of this Section, "ambulance services" | ||||||
22 | includes medical
transportation services provided by means of | ||||||
23 | an ambulance, medi-car, service
car, or
taxi.
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24 | This Section does not prohibit separate billing by | ||||||
25 | ambulance service
providers for oxygen furnished while | ||||||
26 | providing advanced life support
services.
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1 | (i) Beginning with services rendered on or after July 1, | ||||||
2 | 2008, all providers of non-emergency medi-car and service car | ||||||
3 | transportation must certify that the driver and employee | ||||||
4 | attendant, as applicable, have completed a safety program | ||||||
5 | approved by the Department to protect both the patient and the | ||||||
6 | driver, prior to transporting a patient.
The provider must | ||||||
7 | maintain this certification in its records. The provider shall | ||||||
8 | produce such documentation upon demand by the Department or its | ||||||
9 | representative. Failure to produce documentation of such | ||||||
10 | training shall result in recovery of any payments made by the | ||||||
11 | Department for services rendered by a non-certified driver or | ||||||
12 | employee attendant. Medi-car and service car providers must | ||||||
13 | maintain legible documentation in their records of the driver | ||||||
14 | and, as applicable, employee attendant that actually | ||||||
15 | transported the patient. Providers must recertify all drivers | ||||||
16 | and employee attendants every 3 years.
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17 | Notwithstanding the requirements above, any public | ||||||
18 | transportation provider of medi-car and service car | ||||||
19 | transportation that receives federal funding under 49 U.S.C. | ||||||
20 | 5307 and 5311 need not certify its drivers and employee | ||||||
21 | attendants under this Section, since safety training is already | ||||||
22 | federally mandated.
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23 | (Source: P.A. 95-501, eff. 8-28-07.)
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24 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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25 | Sec. 5-5. Medical services. The Illinois Department, by |
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1 | rule, shall
determine the quantity and quality of and the rate | ||||||
2 | of reimbursement for the
medical assistance for which
payment | ||||||
3 | will be authorized, and the medical services to be provided,
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4 | which may include all or part of the following: (1) inpatient | ||||||
5 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
6 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
7 | services; (5) physicians'
services whether furnished in the | ||||||
8 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
9 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
10 | care furnished by licensed practitioners; (7)
home health care | ||||||
11 | services; (8) private duty nursing service; (9) clinic
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12 | services; (10) dental services, including prevention and | ||||||
13 | treatment of periodontal disease and dental caries disease for | ||||||
14 | pregnant women; (11) physical therapy and related
services; | ||||||
15 | (12) prescribed drugs, dentures, and prosthetic devices; and
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16 | eyeglasses prescribed by a physician skilled in the diseases of | ||||||
17 | the eye,
or by an optometrist, whichever the person may select; | ||||||
18 | (13) other
diagnostic, screening, preventive, and | ||||||
19 | rehabilitative services; (14)
transportation and such other | ||||||
20 | expenses as may be necessary , provided that payment for ground | ||||||
21 | ambulance services shall be as provided in Section 5-4.2 ; (15) | ||||||
22 | medical
treatment of sexual assault survivors, as defined in
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23 | Section 1a of the Sexual Assault Survivors Emergency Treatment | ||||||
24 | Act, for
injuries sustained as a result of the sexual assault, | ||||||
25 | including
examinations and laboratory tests to discover | ||||||
26 | evidence which may be used in
criminal proceedings arising from |
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1 | the sexual assault; (16) the
diagnosis and treatment of sickle | ||||||
2 | cell anemia; and (17)
any other medical care, and any other | ||||||
3 | type of remedial care recognized
under the laws of this State, | ||||||
4 | but not including abortions, or induced
miscarriages or | ||||||
5 | premature births, unless, in the opinion of a physician,
such | ||||||
6 | procedures are necessary for the preservation of the life of | ||||||
7 | the
woman seeking such treatment, or except an induced | ||||||
8 | premature birth
intended to produce a live viable child and | ||||||
9 | such procedure is necessary
for the health of the mother or her | ||||||
10 | unborn child. The Illinois Department,
by rule, shall prohibit | ||||||
11 | any physician from providing medical assistance
to anyone | ||||||
12 | eligible therefor under this Code where such physician has been
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13 | found guilty of performing an abortion procedure in a wilful | ||||||
14 | and wanton
manner upon a woman who was not pregnant at the time | ||||||
15 | such abortion
procedure was performed. The term "any other type | ||||||
16 | of remedial care" shall
include nursing care and nursing home | ||||||
17 | service for persons who rely on
treatment by spiritual means | ||||||
18 | alone through prayer for healing.
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19 | Notwithstanding any other provision of this Section, a | ||||||
20 | comprehensive
tobacco use cessation program that includes | ||||||
21 | purchasing prescription drugs or
prescription medical devices | ||||||
22 | approved by the Food and Drug administration shall
be covered | ||||||
23 | under the medical assistance
program under this Article for | ||||||
24 | persons who are otherwise eligible for
assistance under this | ||||||
25 | Article.
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26 | Notwithstanding any other provision of this Code, the |
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1 | Illinois
Department may not require, as a condition of payment | ||||||
2 | for any laboratory
test authorized under this Article, that a | ||||||
3 | physician's handwritten signature
appear on the laboratory | ||||||
4 | test order form. The Illinois Department may,
however, impose | ||||||
5 | other appropriate requirements regarding laboratory test
order | ||||||
6 | documentation.
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7 | The Department of Healthcare and Family Services shall | ||||||
8 | provide the following services to
persons
eligible for | ||||||
9 | assistance under this Article who are participating in
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10 | education, training or employment programs operated by the | ||||||
11 | Department of Human
Services as successor to the Department of | ||||||
12 | Public Aid:
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13 | (1) dental services, which shall include but not be | ||||||
14 | limited to
prosthodontics; and
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15 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
16 | diseases of the
eye, or by an optometrist, whichever the | ||||||
17 | person may select.
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18 | The Illinois Department, by rule, may distinguish and | ||||||
19 | classify the
medical services to be provided only in accordance | ||||||
20 | with the classes of
persons designated in Section 5-2.
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21 | The Department of Healthcare and Family Services must | ||||||
22 | provide coverage and reimbursement for amino acid-based | ||||||
23 | elemental formulas, regardless of delivery method, for the | ||||||
24 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
25 | short bowel syndrome when the prescribing physician has issued | ||||||
26 | a written order stating that the amino acid-based elemental |
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1 | formula is medically necessary.
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2 | The Illinois Department shall authorize the provision of, | ||||||
3 | and shall
authorize payment for, screening by low-dose | ||||||
4 | mammography for the presence of
occult breast cancer for women | ||||||
5 | 35 years of age or older who are eligible
for medical | ||||||
6 | assistance under this Article, as follows: | ||||||
7 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
8 | age.
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9 | (B) An annual mammogram for women 40 years of age or | ||||||
10 | older. | ||||||
11 | (C) A mammogram at the age and intervals considered | ||||||
12 | medically necessary by the woman's health care provider for | ||||||
13 | women under 40 years of age and having a family history of | ||||||
14 | breast cancer, prior personal history of breast cancer, | ||||||
15 | positive genetic testing, or other risk factors. | ||||||
16 | (D) A comprehensive ultrasound screening of an entire | ||||||
17 | breast or breasts if a mammogram demonstrates | ||||||
18 | heterogeneous or dense breast tissue, when medically | ||||||
19 | necessary as determined by a physician licensed to practice | ||||||
20 | medicine in all of its branches. | ||||||
21 | All screenings
shall
include a physical breast exam, | ||||||
22 | instruction on self-examination and
information regarding the | ||||||
23 | frequency of self-examination and its value as a
preventative | ||||||
24 | tool. For purposes of this Section, "low-dose mammography" | ||||||
25 | means
the x-ray examination of the breast using equipment | ||||||
26 | dedicated specifically
for mammography, including the x-ray |
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1 | tube, filter, compression device,
and image receptor, with an | ||||||
2 | average radiation exposure delivery
of less than one rad per | ||||||
3 | breast for 2 views of an average size breast. The term also | ||||||
4 | includes digital mammography.
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5 | On and after July 1, 2008, screening and diagnostic | ||||||
6 | mammography shall be reimbursed at the same rate as the | ||||||
7 | Medicare program's rates, including the increased | ||||||
8 | reimbursement for digital mammography. | ||||||
9 | The Department shall convene an expert panel including | ||||||
10 | representatives of hospitals, free-standing mammography | ||||||
11 | facilities, and doctors, including radiologists, to establish | ||||||
12 | quality standards. Based on these quality standards, the | ||||||
13 | Department shall provide for bonus payments to mammography | ||||||
14 | facilities meeting the standards for screening and diagnosis. | ||||||
15 | The bonus payments shall be at least 15% higher than the | ||||||
16 | Medicare rates for mammography. | ||||||
17 | Subject to federal approval, the Department shall | ||||||
18 | establish a rate methodology for mammography at federally | ||||||
19 | qualified health centers and other encounter-rate clinics. | ||||||
20 | These clinics or centers may also collaborate with other | ||||||
21 | hospital-based mammography facilities. | ||||||
22 | The Department shall establish a methodology to remind | ||||||
23 | women who are age-appropriate for screening mammography, but | ||||||
24 | who have not received a mammogram within the previous 18 | ||||||
25 | months, of the importance and benefit of screening mammography. | ||||||
26 | The Department shall establish a performance goal for |
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1 | primary care providers with respect to their female patients | ||||||
2 | over age 40 receiving an annual mammogram. This performance | ||||||
3 | goal shall be used to provide additional reimbursement in the | ||||||
4 | form of a quality performance bonus to primary care providers | ||||||
5 | who meet that goal. | ||||||
6 | The Department shall devise a means of case-managing or | ||||||
7 | patient navigation for beneficiaries diagnosed with breast | ||||||
8 | cancer. This program shall initially operate as a pilot program | ||||||
9 | in areas of the State with the highest incidence of mortality | ||||||
10 | related to breast cancer. At least one pilot program site shall | ||||||
11 | be in the metropolitan Chicago area and at least one site shall | ||||||
12 | be outside the metropolitan Chicago area. An evaluation of the | ||||||
13 | pilot program shall be carried out measuring health outcomes | ||||||
14 | and cost of care for those served by the pilot program compared | ||||||
15 | to similarly situated patients who are not served by the pilot | ||||||
16 | program. | ||||||
17 | Any medical or health care provider shall immediately | ||||||
18 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
19 | services and is suspected
of drug abuse or is addicted as | ||||||
20 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
21 | Act, referral to a local substance abuse treatment provider
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22 | licensed by the Department of Human Services or to a licensed
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23 | hospital which provides substance abuse treatment services. | ||||||
24 | The Department of Healthcare and Family Services
shall assure | ||||||
25 | coverage for the cost of treatment of the drug abuse or
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26 | addiction for pregnant recipients in accordance with the |
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1 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
2 | Human Services.
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3 | All medical providers providing medical assistance to | ||||||
4 | pregnant women
under this Code shall receive information from | ||||||
5 | the Department on the
availability of services under the Drug | ||||||
6 | Free Families with a Future or any
comparable program providing | ||||||
7 | case management services for addicted women,
including | ||||||
8 | information on appropriate referrals for other social services
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9 | that may be needed by addicted women in addition to treatment | ||||||
10 | for addiction.
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11 | The Illinois Department, in cooperation with the | ||||||
12 | Departments of Human
Services (as successor to the Department | ||||||
13 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
14 | public awareness campaign, may
provide information concerning | ||||||
15 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
16 | health care, and other pertinent programs directed at
reducing | ||||||
17 | the number of drug-affected infants born to recipients of | ||||||
18 | medical
assistance.
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19 | Neither the Department of Healthcare and Family Services | ||||||
20 | nor the Department of Human
Services shall sanction the | ||||||
21 | recipient solely on the basis of
her substance abuse.
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22 | The Illinois Department shall establish such regulations | ||||||
23 | governing
the dispensing of health services under this Article | ||||||
24 | as it shall deem
appropriate. The Department
should
seek the | ||||||
25 | advice of formal professional advisory committees appointed by
| ||||||
26 | the Director of the Illinois Department for the purpose of |
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1 | providing regular
advice on policy and administrative matters, | ||||||
2 | information dissemination and
educational activities for | ||||||
3 | medical and health care providers, and
consistency in | ||||||
4 | procedures to the Illinois Department.
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5 | The Illinois Department may develop and contract with | ||||||
6 | Partnerships of
medical providers to arrange medical services | ||||||
7 | for persons eligible under
Section 5-2 of this Code. | ||||||
8 | Implementation of this Section may be by
demonstration projects | ||||||
9 | in certain geographic areas. The Partnership shall
be | ||||||
10 | represented by a sponsor organization. The Department, by rule, | ||||||
11 | shall
develop qualifications for sponsors of Partnerships. | ||||||
12 | Nothing in this
Section shall be construed to require that the | ||||||
13 | sponsor organization be a
medical organization.
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14 | The sponsor must negotiate formal written contracts with | ||||||
15 | medical
providers for physician services, inpatient and | ||||||
16 | outpatient hospital care,
home health services, treatment for | ||||||
17 | alcoholism and substance abuse, and
other services determined | ||||||
18 | necessary by the Illinois Department by rule for
delivery by | ||||||
19 | Partnerships. Physician services must include prenatal and
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20 | obstetrical care. The Illinois Department shall reimburse | ||||||
21 | medical services
delivered by Partnership providers to clients | ||||||
22 | in target areas according to
provisions of this Article and the | ||||||
23 | Illinois Health Finance Reform Act,
except that:
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24 | (1) Physicians participating in a Partnership and | ||||||
25 | providing certain
services, which shall be determined by | ||||||
26 | the Illinois Department, to persons
in areas covered by the |
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1 | Partnership may receive an additional surcharge
for such | ||||||
2 | services.
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3 | (2) The Department may elect to consider and negotiate | ||||||
4 | financial
incentives to encourage the development of | ||||||
5 | Partnerships and the efficient
delivery of medical care.
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6 | (3) Persons receiving medical services through | ||||||
7 | Partnerships may receive
medical and case management | ||||||
8 | services above the level usually offered
through the | ||||||
9 | medical assistance program.
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10 | Medical providers shall be required to meet certain | ||||||
11 | qualifications to
participate in Partnerships to ensure the | ||||||
12 | delivery of high quality medical
services. These | ||||||
13 | qualifications shall be determined by rule of the Illinois
| ||||||
14 | Department and may be higher than qualifications for | ||||||
15 | participation in the
medical assistance program. Partnership | ||||||
16 | sponsors may prescribe reasonable
additional qualifications | ||||||
17 | for participation by medical providers, only with
the prior | ||||||
18 | written approval of the Illinois Department.
| ||||||
19 | Nothing in this Section shall limit the free choice of | ||||||
20 | practitioners,
hospitals, and other providers of medical | ||||||
21 | services by clients.
In order to ensure patient freedom of | ||||||
22 | choice, the Illinois Department shall
immediately promulgate | ||||||
23 | all rules and take all other necessary actions so that
provided | ||||||
24 | services may be accessed from therapeutically certified | ||||||
25 | optometrists
to the full extent of the Illinois Optometric | ||||||
26 | Practice Act of 1987 without
discriminating between service |
| |||||||
| |||||||
1 | providers.
| ||||||
2 | The Department shall apply for a waiver from the United | ||||||
3 | States Health
Care Financing Administration to allow for the | ||||||
4 | implementation of
Partnerships under this Section.
| ||||||
5 | The Illinois Department shall require health care | ||||||
6 | providers to maintain
records that document the medical care | ||||||
7 | and services provided to recipients
of Medical Assistance under | ||||||
8 | this Article. The Illinois Department shall
require health care | ||||||
9 | providers to make available, when authorized by the
patient, in | ||||||
10 | writing, the medical records in a timely fashion to other
| ||||||
11 | health care providers who are treating or serving persons | ||||||
12 | eligible for
Medical Assistance under this Article. All | ||||||
13 | dispensers of medical services
shall be required to maintain | ||||||
14 | and retain business and professional records
sufficient to | ||||||
15 | fully and accurately document the nature, scope, details and
| ||||||
16 | receipt of the health care provided to persons eligible for | ||||||
17 | medical
assistance under this Code, in accordance with | ||||||
18 | regulations promulgated by
the Illinois Department. The rules | ||||||
19 | and regulations shall require that proof
of the receipt of | ||||||
20 | prescription drugs, dentures, prosthetic devices and
| ||||||
21 | eyeglasses by eligible persons under this Section accompany | ||||||
22 | each claim
for reimbursement submitted by the dispenser of such | ||||||
23 | medical services.
No such claims for reimbursement shall be | ||||||
24 | approved for payment by the Illinois
Department without such | ||||||
25 | proof of receipt, unless the Illinois Department
shall have put | ||||||
26 | into effect and shall be operating a system of post-payment
|
| |||||||
| |||||||
1 | audit and review which shall, on a sampling basis, be deemed | ||||||
2 | adequate by
the Illinois Department to assure that such drugs, | ||||||
3 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
4 | is being made are actually being
received by eligible | ||||||
5 | recipients. Within 90 days after the effective date of
this | ||||||
6 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
7 | a
current list of acquisition costs for all prosthetic devices | ||||||
8 | and any
other items recognized as medical equipment and | ||||||
9 | supplies reimbursable under
this Article and shall update such | ||||||
10 | list on a quarterly basis, except that
the acquisition costs of | ||||||
11 | all prescription drugs shall be updated no
less frequently than | ||||||
12 | every 30 days as required by Section 5-5.12.
| ||||||
13 | The rules and regulations of the Illinois Department shall | ||||||
14 | require
that a written statement including the required opinion | ||||||
15 | of a physician
shall accompany any claim for reimbursement for | ||||||
16 | abortions, or induced
miscarriages or premature births. This | ||||||
17 | statement shall indicate what
procedures were used in providing | ||||||
18 | such medical services.
| ||||||
19 | The Illinois Department shall require all dispensers of | ||||||
20 | medical
services, other than an individual practitioner or | ||||||
21 | group of practitioners,
desiring to participate in the Medical | ||||||
22 | Assistance program
established under this Article to disclose | ||||||
23 | all financial, beneficial,
ownership, equity, surety or other | ||||||
24 | interests in any and all firms,
corporations, partnerships, | ||||||
25 | associations, business enterprises, joint
ventures, agencies, | ||||||
26 | institutions or other legal entities providing any
form of |
| |||||||
| |||||||
1 | health care services in this State under this Article.
| ||||||
2 | The Illinois Department may require that all dispensers of | ||||||
3 | medical
services desiring to participate in the medical | ||||||
4 | assistance program
established under this Article disclose, | ||||||
5 | under such terms and conditions as
the Illinois Department may | ||||||
6 | by rule establish, all inquiries from clients
and attorneys | ||||||
7 | regarding medical bills paid by the Illinois Department, which
| ||||||
8 | inquiries could indicate potential existence of claims or liens | ||||||
9 | for the
Illinois Department.
| ||||||
10 | Enrollment of a vendor that provides non-emergency medical | ||||||
11 | transportation,
defined by the Department by rule,
shall be
| ||||||
12 | conditional for 180 days. During that time, the Department of | ||||||
13 | Healthcare and Family Services may
terminate the vendor's | ||||||
14 | eligibility to participate in the medical assistance
program | ||||||
15 | without cause. That termination of eligibility is not subject | ||||||
16 | to the
Department's hearing process.
| ||||||
17 | The Illinois Department shall establish policies, | ||||||
18 | procedures,
standards and criteria by rule for the acquisition, | ||||||
19 | repair and replacement
of orthotic and prosthetic devices and | ||||||
20 | durable medical equipment. Such
rules shall provide, but not be | ||||||
21 | limited to, the following services: (1)
immediate repair or | ||||||
22 | replacement of such devices by recipients without
medical | ||||||
23 | authorization; and (2) rental, lease, purchase or | ||||||
24 | lease-purchase of
durable medical equipment in a | ||||||
25 | cost-effective manner, taking into
consideration the | ||||||
26 | recipient's medical prognosis, the extent of the
recipient's |
| |||||||
| |||||||
1 | needs, and the requirements and costs for maintaining such
| ||||||
2 | equipment. Such rules shall enable a recipient to temporarily | ||||||
3 | acquire and
use alternative or substitute devices or equipment | ||||||
4 | pending repairs or
replacements of any device or equipment | ||||||
5 | previously authorized for such
recipient by the Department.
| ||||||
6 | The Department shall execute, relative to the nursing home | ||||||
7 | prescreening
project, written inter-agency agreements with the | ||||||
8 | Department of Human
Services and the Department on Aging, to | ||||||
9 | effect the following: (i) intake
procedures and common | ||||||
10 | eligibility criteria for those persons who are receiving
| ||||||
11 | non-institutional services; and (ii) the establishment and | ||||||
12 | development of
non-institutional services in areas of the State | ||||||
13 | where they are not currently
available or are undeveloped.
| ||||||
14 | The Illinois Department shall develop and operate, in | ||||||
15 | cooperation
with other State Departments and agencies and in | ||||||
16 | compliance with
applicable federal laws and regulations, | ||||||
17 | appropriate and effective
systems of health care evaluation and | ||||||
18 | programs for monitoring of
utilization of health care services | ||||||
19 | and facilities, as it affects
persons eligible for medical | ||||||
20 | assistance under this Code.
| ||||||
21 | The Illinois Department shall report annually to the | ||||||
22 | General Assembly,
no later than the second Friday in April of | ||||||
23 | 1979 and each year
thereafter, in regard to:
| ||||||
24 | (a) actual statistics and trends in utilization of | ||||||
25 | medical services by
public aid recipients;
| ||||||
26 | (b) actual statistics and trends in the provision of |
| |||||||
| |||||||
1 | the various medical
services by medical vendors;
| ||||||
2 | (c) current rate structures and proposed changes in | ||||||
3 | those rate structures
for the various medical vendors; and
| ||||||
4 | (d) efforts at utilization review and control by the | ||||||
5 | Illinois Department.
| ||||||
6 | The period covered by each report shall be the 3 years | ||||||
7 | ending on the June
30 prior to the report. The report shall | ||||||
8 | include suggested legislation
for consideration by the General | ||||||
9 | Assembly. The filing of one copy of the
report with the | ||||||
10 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
11 | the Clerk of the House of Representatives, one copy with the | ||||||
12 | President,
one copy with the Minority Leader and one copy with | ||||||
13 | the Secretary of the
Senate, one copy with the Legislative | ||||||
14 | Research Unit, and such additional
copies
with the State | ||||||
15 | Government Report Distribution Center for the General
Assembly | ||||||
16 | as is required under paragraph (t) of Section 7 of the State
| ||||||
17 | Library Act shall be deemed sufficient to comply with this | ||||||
18 | Section.
| ||||||
19 | Rulemaking authority to implement this amendatory Act of | ||||||
20 | the 95th General Assembly, if any, is conditioned on the rules | ||||||
21 | being adopted in accordance with all provisions of the Illinois | ||||||
22 | Administrative Procedure Act and all rules and procedures of | ||||||
23 | the Joint Committee on Administrative Rules; any purported rule | ||||||
24 | not so adopted, for whatever reason, is unauthorized. | ||||||
25 | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | ||||||
26 | 95-1045, eff. 3-27-09.)
|
| |||||||
| |||||||
1 | Section 99. Effective date. This Act takes effect upon | ||||||
2 | becoming law.".
|