Sen. William Delgado
Filed: 4/27/2009
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1 | AMENDMENT TO HOUSE BILL 917
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2 | AMENDMENT NO. ______. Amend House Bill 917 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 Section 5-5 as follows: | ||||||
6 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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7 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
8 | rule, shall
determine the quantity and quality of and the rate | ||||||
9 | of reimbursement for the
medical assistance for which
payment | ||||||
10 | will be authorized, and the medical services to be provided,
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11 | which may include all or part of the following: (1) inpatient | ||||||
12 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
13 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
14 | services; (5) physicians'
services whether furnished in the | ||||||
15 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
16 | or elsewhere; (6) medical care, or any
other type of remedial |
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1 | care furnished by licensed practitioners; (7)
home health care | ||||||
2 | services; (8) private duty nursing service; (9) clinic
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3 | services; (10) dental services, including prevention and | ||||||
4 | treatment of periodontal disease and dental caries disease for | ||||||
5 | pregnant women; (11) physical therapy and related
services; | ||||||
6 | (12) prescribed drugs, dentures, and prosthetic devices; and
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7 | eyeglasses prescribed by a physician skilled in the diseases of | ||||||
8 | the eye,
or by an optometrist, whichever the person may select; | ||||||
9 | (13) other
diagnostic, screening, preventive, and | ||||||
10 | rehabilitative services; (14)
transportation and such other | ||||||
11 | expenses as may be necessary; (15) medical
treatment of sexual | ||||||
12 | assault survivors, as defined in
Section 1a of the Sexual | ||||||
13 | Assault Survivors Emergency Treatment Act, for
injuries | ||||||
14 | sustained as a result of the sexual assault, including
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15 | examinations and laboratory tests to discover evidence which | ||||||
16 | may be used in
criminal proceedings arising from the sexual | ||||||
17 | assault; (16) the
diagnosis and treatment of sickle cell | ||||||
18 | anemia; and (17)
any other medical care, and any other type of | ||||||
19 | remedial care recognized
under the laws of this State, but not | ||||||
20 | including abortions, or induced
miscarriages or premature | ||||||
21 | births, unless, in the opinion of a physician,
such procedures | ||||||
22 | are necessary for the preservation of the life of the
woman | ||||||
23 | seeking such treatment, or except an induced premature birth
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24 | intended to produce a live viable child and such procedure is | ||||||
25 | necessary
for the health of the mother or her unborn child. The | ||||||
26 | Illinois Department,
by rule, shall prohibit any physician from |
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1 | providing medical assistance
to anyone eligible therefor under | ||||||
2 | this Code where such physician has been
found guilty of | ||||||
3 | performing an abortion procedure in a wilful and wanton
manner | ||||||
4 | upon a woman who was not pregnant at the time such abortion
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5 | procedure was performed. The term "any other type of remedial | ||||||
6 | care" shall
include nursing care and nursing home service for | ||||||
7 | persons who rely on
treatment by spiritual means alone through | ||||||
8 | prayer for healing.
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9 | Notwithstanding any other provision of this Section, a | ||||||
10 | comprehensive
tobacco use cessation program that includes | ||||||
11 | purchasing prescription drugs or
prescription medical devices | ||||||
12 | approved by the Food and Drug administration shall
be covered | ||||||
13 | under the medical assistance
program under this Article for | ||||||
14 | persons who are otherwise eligible for
assistance under this | ||||||
15 | Article.
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16 | Notwithstanding any other provision of this Code, the | ||||||
17 | Illinois
Department may not require, as a condition of payment | ||||||
18 | for any laboratory
test authorized under this Article, that a | ||||||
19 | physician's handwritten signature
appear on the laboratory | ||||||
20 | test order form. The Illinois Department may,
however, impose | ||||||
21 | other appropriate requirements regarding laboratory test
order | ||||||
22 | documentation.
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23 | The Department of Healthcare and Family Services shall | ||||||
24 | provide the following services to
persons
eligible for | ||||||
25 | assistance under this Article who are participating in
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26 | education, training or employment programs operated by the |
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1 | Department of Human
Services as successor to the Department of | ||||||
2 | Public Aid:
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3 | (1) dental services, which shall include but not be | ||||||
4 | limited to
prosthodontics; and
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5 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
6 | diseases of the
eye, or by an optometrist, whichever the | ||||||
7 | person may select.
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8 | Notwithstanding any other provisions of this Code, the | ||||||
9 | Department of Healthcare and Family Services shall adopt rules | ||||||
10 | for payment of claims for reimbursement for covered dental | ||||||
11 | services that allow a qualified provider of such services to | ||||||
12 | designate an alternate payee. Such an alternate payee may be a | ||||||
13 | public health clinic or Federally Qualified Health Center where | ||||||
14 | dental services covered under this Section are performed. If a | ||||||
15 | qualified provider of covered dental services designates an | ||||||
16 | alternate payee, the provider shall not be required to | ||||||
17 | individually enroll as a participating vendor in the medical | ||||||
18 | assistance program and the Department shall establish a process | ||||||
19 | for making reimbursement payments to the alternate payee. | ||||||
20 | The Illinois Department, by rule, may distinguish and | ||||||
21 | classify the
medical services to be provided only in accordance | ||||||
22 | with the classes of
persons designated in Section 5-2.
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23 | The Department of Healthcare and Family Services must | ||||||
24 | provide coverage and reimbursement for amino acid-based | ||||||
25 | elemental formulas, regardless of delivery method, for the | ||||||
26 | diagnosis and treatment of (i) eosinophilic disorders and (ii) |
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1 | short bowel syndrome when the prescribing physician has issued | ||||||
2 | a written order stating that the amino acid-based elemental | ||||||
3 | formula is medically necessary.
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4 | The Illinois Department shall authorize the provision of, | ||||||
5 | and shall
authorize payment for, screening by low-dose | ||||||
6 | mammography for the presence of
occult breast cancer for women | ||||||
7 | 35 years of age or older who are eligible
for medical | ||||||
8 | assistance under this Article, as follows: | ||||||
9 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
10 | age.
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11 | (B) An annual mammogram for women 40 years of age or | ||||||
12 | older. | ||||||
13 | (C) A mammogram at the age and intervals considered | ||||||
14 | medically necessary by the woman's health care provider for | ||||||
15 | women under 40 years of age and having a family history of | ||||||
16 | breast cancer, prior personal history of breast cancer, | ||||||
17 | positive genetic testing, or other risk factors. | ||||||
18 | (D) A comprehensive ultrasound screening of an entire | ||||||
19 | breast or breasts if a mammogram demonstrates | ||||||
20 | heterogeneous or dense breast tissue, when medically | ||||||
21 | necessary as determined by a physician licensed to practice | ||||||
22 | medicine in all of its branches. | ||||||
23 | All screenings
shall
include a physical breast exam, | ||||||
24 | instruction on self-examination and
information regarding the | ||||||
25 | frequency of self-examination and its value as a
preventative | ||||||
26 | tool. For purposes of this Section, "low-dose mammography" |
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1 | means
the x-ray examination of the breast using equipment | ||||||
2 | dedicated specifically
for mammography, including the x-ray | ||||||
3 | tube, filter, compression device,
and image receptor, with an | ||||||
4 | average radiation exposure delivery
of less than one rad per | ||||||
5 | breast for 2 views of an average size breast. The term also | ||||||
6 | includes digital mammography.
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7 | On and after July 1, 2008, screening and diagnostic | ||||||
8 | mammography shall be reimbursed at the same rate as the | ||||||
9 | Medicare program's rates, including the increased | ||||||
10 | reimbursement for digital mammography. | ||||||
11 | The Department shall convene an expert panel including | ||||||
12 | representatives of hospitals, free-standing mammography | ||||||
13 | facilities, and doctors, including radiologists, to establish | ||||||
14 | quality standards. Based on these quality standards, the | ||||||
15 | Department shall provide for bonus payments to mammography | ||||||
16 | facilities meeting the standards for screening and diagnosis. | ||||||
17 | The bonus payments shall be at least 15% higher than the | ||||||
18 | Medicare rates for mammography. | ||||||
19 | Subject to federal approval, the Department shall | ||||||
20 | establish a rate methodology for mammography at federally | ||||||
21 | qualified health centers and other encounter-rate clinics. | ||||||
22 | These clinics or centers may also collaborate with other | ||||||
23 | hospital-based mammography facilities. | ||||||
24 | The Department shall establish a methodology to remind | ||||||
25 | women who are age-appropriate for screening mammography, but | ||||||
26 | who have not received a mammogram within the previous 18 |
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1 | months, of the importance and benefit of screening mammography. | ||||||
2 | The Department shall establish a performance goal for | ||||||
3 | primary care providers with respect to their female patients | ||||||
4 | over age 40 receiving an annual mammogram. This performance | ||||||
5 | goal shall be used to provide additional reimbursement in the | ||||||
6 | form of a quality performance bonus to primary care providers | ||||||
7 | who meet that goal. | ||||||
8 | The Department shall devise a means of case-managing or | ||||||
9 | patient navigation for beneficiaries diagnosed with breast | ||||||
10 | cancer. This program shall initially operate as a pilot program | ||||||
11 | in areas of the State with the highest incidence of mortality | ||||||
12 | related to breast cancer. At least one pilot program site shall | ||||||
13 | be in the metropolitan Chicago area and at least one site shall | ||||||
14 | be outside the metropolitan Chicago area. An evaluation of the | ||||||
15 | pilot program shall be carried out measuring health outcomes | ||||||
16 | and cost of care for those served by the pilot program compared | ||||||
17 | to similarly situated patients who are not served by the pilot | ||||||
18 | program. | ||||||
19 | Any medical or health care provider shall immediately | ||||||
20 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
21 | services and is suspected
of drug abuse or is addicted as | ||||||
22 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
23 | Act, referral to a local substance abuse treatment provider
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24 | licensed by the Department of Human Services or to a licensed
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25 | hospital which provides substance abuse treatment services. | ||||||
26 | The Department of Healthcare and Family Services
shall assure |
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1 | coverage for the cost of treatment of the drug abuse or
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2 | addiction for pregnant recipients in accordance with the | ||||||
3 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
4 | Human Services.
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5 | All medical providers providing medical assistance to | ||||||
6 | pregnant women
under this Code shall receive information from | ||||||
7 | the Department on the
availability of services under the Drug | ||||||
8 | Free Families with a Future or any
comparable program providing | ||||||
9 | case management services for addicted women,
including | ||||||
10 | information on appropriate referrals for other social services
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11 | that may be needed by addicted women in addition to treatment | ||||||
12 | for addiction.
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13 | The Illinois Department, in cooperation with the | ||||||
14 | Departments of Human
Services (as successor to the Department | ||||||
15 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
16 | public awareness campaign, may
provide information concerning | ||||||
17 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
18 | health care, and other pertinent programs directed at
reducing | ||||||
19 | the number of drug-affected infants born to recipients of | ||||||
20 | medical
assistance.
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21 | Neither the Department of Healthcare and Family Services | ||||||
22 | nor the Department of Human
Services shall sanction the | ||||||
23 | recipient solely on the basis of
her substance abuse.
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24 | The Illinois Department shall establish such regulations | ||||||
25 | governing
the dispensing of health services under this Article | ||||||
26 | as it shall deem
appropriate. The Department
should
seek the |
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1 | advice of formal professional advisory committees appointed by
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2 | the Director of the Illinois Department for the purpose of | ||||||
3 | providing regular
advice on policy and administrative matters, | ||||||
4 | information dissemination and
educational activities for | ||||||
5 | medical and health care providers, and
consistency in | ||||||
6 | procedures to the Illinois Department.
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7 | The Illinois Department may develop and contract with | ||||||
8 | Partnerships of
medical providers to arrange medical services | ||||||
9 | for persons eligible under
Section 5-2 of this Code. | ||||||
10 | Implementation of this Section may be by
demonstration projects | ||||||
11 | in certain geographic areas. The Partnership shall
be | ||||||
12 | represented by a sponsor organization. The Department, by rule, | ||||||
13 | shall
develop qualifications for sponsors of Partnerships. | ||||||
14 | Nothing in this
Section shall be construed to require that the | ||||||
15 | sponsor organization be a
medical organization.
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16 | The sponsor must negotiate formal written contracts with | ||||||
17 | medical
providers for physician services, inpatient and | ||||||
18 | outpatient hospital care,
home health services, treatment for | ||||||
19 | alcoholism and substance abuse, and
other services determined | ||||||
20 | necessary by the Illinois Department by rule for
delivery by | ||||||
21 | Partnerships. Physician services must include prenatal and
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22 | obstetrical care. The Illinois Department shall reimburse | ||||||
23 | medical services
delivered by Partnership providers to clients | ||||||
24 | in target areas according to
provisions of this Article and the | ||||||
25 | Illinois Health Finance Reform Act,
except that:
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26 | (1) Physicians participating in a Partnership and |
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1 | providing certain
services, which shall be determined by | ||||||
2 | the Illinois Department, to persons
in areas covered by the | ||||||
3 | Partnership may receive an additional surcharge
for such | ||||||
4 | services.
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5 | (2) The Department may elect to consider and negotiate | ||||||
6 | financial
incentives to encourage the development of | ||||||
7 | Partnerships and the efficient
delivery of medical care.
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8 | (3) Persons receiving medical services through | ||||||
9 | Partnerships may receive
medical and case management | ||||||
10 | services above the level usually offered
through the | ||||||
11 | medical assistance program.
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12 | Medical providers shall be required to meet certain | ||||||
13 | qualifications to
participate in Partnerships to ensure the | ||||||
14 | delivery of high quality medical
services. These | ||||||
15 | qualifications shall be determined by rule of the Illinois
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16 | Department and may be higher than qualifications for | ||||||
17 | participation in the
medical assistance program. Partnership | ||||||
18 | sponsors may prescribe reasonable
additional qualifications | ||||||
19 | for participation by medical providers, only with
the prior | ||||||
20 | written approval of the Illinois Department.
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21 | Nothing in this Section shall limit the free choice of | ||||||
22 | practitioners,
hospitals, and other providers of medical | ||||||
23 | services by clients.
In order to ensure patient freedom of | ||||||
24 | choice, the Illinois Department shall
immediately promulgate | ||||||
25 | all rules and take all other necessary actions so that
provided | ||||||
26 | services may be accessed from therapeutically certified |
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1 | optometrists
to the full extent of the Illinois Optometric | ||||||
2 | Practice Act of 1987 without
discriminating between service | ||||||
3 | providers.
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4 | The Department shall apply for a waiver from the United | ||||||
5 | States Health
Care Financing Administration to allow for the | ||||||
6 | implementation of
Partnerships under this Section.
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7 | The Illinois Department shall require health care | ||||||
8 | providers to maintain
records that document the medical care | ||||||
9 | and services provided to recipients
of Medical Assistance under | ||||||
10 | this Article. The Illinois Department shall
require health care | ||||||
11 | providers to make available, when authorized by the
patient, in | ||||||
12 | writing, the medical records in a timely fashion to other
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13 | health care providers who are treating or serving persons | ||||||
14 | eligible for
Medical Assistance under this Article. All | ||||||
15 | dispensers of medical services
shall be required to maintain | ||||||
16 | and retain business and professional records
sufficient to | ||||||
17 | fully and accurately document the nature, scope, details and
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18 | receipt of the health care provided to persons eligible for | ||||||
19 | medical
assistance under this Code, in accordance with | ||||||
20 | regulations promulgated by
the Illinois Department. The rules | ||||||
21 | and regulations shall require that proof
of the receipt of | ||||||
22 | prescription drugs, dentures, prosthetic devices and
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23 | eyeglasses by eligible persons under this Section accompany | ||||||
24 | each claim
for reimbursement submitted by the dispenser of such | ||||||
25 | medical services.
No such claims for reimbursement shall be | ||||||
26 | approved for payment by the Illinois
Department without such |
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1 | proof of receipt, unless the Illinois Department
shall have put | ||||||
2 | into effect and shall be operating a system of post-payment
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3 | audit and review which shall, on a sampling basis, be deemed | ||||||
4 | adequate by
the Illinois Department to assure that such drugs, | ||||||
5 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
6 | is being made are actually being
received by eligible | ||||||
7 | recipients. Within 90 days after the effective date of
this | ||||||
8 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
9 | a
current list of acquisition costs for all prosthetic devices | ||||||
10 | and any
other items recognized as medical equipment and | ||||||
11 | supplies reimbursable under
this Article and shall update such | ||||||
12 | list on a quarterly basis, except that
the acquisition costs of | ||||||
13 | all prescription drugs shall be updated no
less frequently than | ||||||
14 | every 30 days as required by Section 5-5.12.
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15 | The rules and regulations of the Illinois Department shall | ||||||
16 | require
that a written statement including the required opinion | ||||||
17 | of a physician
shall accompany any claim for reimbursement for | ||||||
18 | abortions, or induced
miscarriages or premature births. This | ||||||
19 | statement shall indicate what
procedures were used in providing | ||||||
20 | such medical services.
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21 | The Illinois Department shall require all dispensers of | ||||||
22 | medical
services, other than an individual practitioner or | ||||||
23 | group of practitioners,
desiring to participate in the Medical | ||||||
24 | Assistance program
established under this Article to disclose | ||||||
25 | all financial, beneficial,
ownership, equity, surety or other | ||||||
26 | interests in any and all firms,
corporations, partnerships, |
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1 | associations, business enterprises, joint
ventures, agencies, | ||||||
2 | institutions or other legal entities providing any
form of | ||||||
3 | health care services in this State under this Article.
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4 | The Illinois Department may require that all dispensers of | ||||||
5 | medical
services desiring to participate in the medical | ||||||
6 | assistance program
established under this Article disclose, | ||||||
7 | under such terms and conditions as
the Illinois Department may | ||||||
8 | by rule establish, all inquiries from clients
and attorneys | ||||||
9 | regarding medical bills paid by the Illinois Department, which
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10 | inquiries could indicate potential existence of claims or liens | ||||||
11 | for the
Illinois Department.
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12 | Enrollment of a vendor that provides non-emergency medical | ||||||
13 | transportation,
defined by the Department by rule,
shall be
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14 | conditional for 180 days. During that time, the Department of | ||||||
15 | Healthcare and Family Services may
terminate the vendor's | ||||||
16 | eligibility to participate in the medical assistance
program | ||||||
17 | without cause. That termination of eligibility is not subject | ||||||
18 | to the
Department's hearing process.
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19 | The Illinois Department shall establish policies, | ||||||
20 | procedures,
standards and criteria by rule for the acquisition, | ||||||
21 | repair and replacement
of orthotic and prosthetic devices and | ||||||
22 | durable medical equipment. Such
rules shall provide, but not be | ||||||
23 | limited to, the following services: (1)
immediate repair or | ||||||
24 | replacement of such devices by recipients without
medical | ||||||
25 | authorization; and (2) rental, lease, purchase or | ||||||
26 | lease-purchase of
durable medical equipment in a |
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1 | cost-effective manner, taking into
consideration the | ||||||
2 | recipient's medical prognosis, the extent of the
recipient's | ||||||
3 | needs, and the requirements and costs for maintaining such
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4 | equipment. Such rules shall enable a recipient to temporarily | ||||||
5 | acquire and
use alternative or substitute devices or equipment | ||||||
6 | pending repairs or
replacements of any device or equipment | ||||||
7 | previously authorized for such
recipient by the Department.
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8 | The Department shall execute, relative to the nursing home | ||||||
9 | prescreening
project, written inter-agency agreements with the | ||||||
10 | Department of Human
Services and the Department on Aging, to | ||||||
11 | effect the following: (i) intake
procedures and common | ||||||
12 | eligibility criteria for those persons who are receiving
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13 | non-institutional services; and (ii) the establishment and | ||||||
14 | development of
non-institutional services in areas of the State | ||||||
15 | where they are not currently
available or are undeveloped.
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16 | The Illinois Department shall develop and operate, in | ||||||
17 | cooperation
with other State Departments and agencies and in | ||||||
18 | compliance with
applicable federal laws and regulations, | ||||||
19 | appropriate and effective
systems of health care evaluation and | ||||||
20 | programs for monitoring of
utilization of health care services | ||||||
21 | and facilities, as it affects
persons eligible for medical | ||||||
22 | assistance under this Code.
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23 | The Illinois Department shall report annually to the | ||||||
24 | General Assembly,
no later than the second Friday in April of | ||||||
25 | 1979 and each year
thereafter, in regard to:
| ||||||
26 | (a) actual statistics and trends in utilization of |
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1 | medical services by
public aid recipients;
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2 | (b) actual statistics and trends in the provision of | ||||||
3 | the various medical
services by medical vendors;
| ||||||
4 | (c) current rate structures and proposed changes in | ||||||
5 | those rate structures
for the various medical vendors; and
| ||||||
6 | (d) efforts at utilization review and control by the | ||||||
7 | Illinois Department.
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8 | The period covered by each report shall be the 3 years | ||||||
9 | ending on the June
30 prior to the report. The report shall | ||||||
10 | include suggested legislation
for consideration by the General | ||||||
11 | Assembly. The filing of one copy of the
report with the | ||||||
12 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
13 | the Clerk of the House of Representatives, one copy with the | ||||||
14 | President,
one copy with the Minority Leader and one copy with | ||||||
15 | the Secretary of the
Senate, one copy with the Legislative | ||||||
16 | Research Unit, and such additional
copies
with the State | ||||||
17 | Government Report Distribution Center for the General
Assembly | ||||||
18 | as is required under paragraph (t) of Section 7 of the State
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19 | Library Act shall be deemed sufficient to comply with this | ||||||
20 | Section.
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21 | Rulemaking authority to implement this amendatory Act of | ||||||
22 | the 95th General Assembly, if any, is conditioned on the rules | ||||||
23 | being adopted in accordance with all provisions of the Illinois | ||||||
24 | Administrative Procedure Act and all rules and procedures of | ||||||
25 | the Joint Committee on Administrative Rules; any purported rule | ||||||
26 | not so adopted, for whatever reason, is unauthorized. |
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1 | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | ||||||
2 | 95-1045, eff. 3-27-09.)".
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