Human Services Committee
Filed: 2/24/2010
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1 | AMENDMENT TO HOUSE BILL 5331
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2 | AMENDMENT NO. ______. Amend House Bill 5331 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, 2010, 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 | payment rates calculated in accordance with this Section. | ||||||
14 | Effective July 1, 2010, the Illinois Medicaid Ambulance Fee | ||||||
15 | Schedule shall be established and shall include only the ground | ||||||
16 | ambulance services payment rates outlined in the Medicare | ||||||
17 | Ambulance Fee Schedule as promulgated by the Centers for | ||||||
18 | Medicare and Medicaid Services in effect as of July 1, 2010 and | ||||||
19 | adjusted for the 4 Medicare Localities in Illinois, with an | ||||||
20 | adjustment of 100% of the Medicare Ambulance Fee Schedule | ||||||
21 | payment rates, by Medicare Locality, for both base rates and | ||||||
22 | mileage for rural counties, and an adjustment of 80% of the | ||||||
23 | Medicare Ambulance Fee Schedule payment rates, by Medicare | ||||||
24 | Locality, for both base rates and mileage for all other | ||||||
25 | counties. The transition from the current payment system to the | ||||||
26 | Illinois Medicaid Ambulance Fee Schedule shall be by a 2-year |
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1 | phase-in as follows: | ||||||
2 | (1) Effective for dates of service from July 1, 2010 | ||||||
3 | through June 30, 2011, for each individual base rate and | ||||||
4 | mileage rate, the payment rate for ground ambulance | ||||||
5 | services shall be based on 50% of the Medicaid payment rate | ||||||
6 | in effect as of January 1, 2010 and 50% of the Illinois | ||||||
7 | Medicaid Ambulance Fee Schedule amount in effect on July 1, | ||||||
8 | 2010 for the designated Medicare Locality, except that any | ||||||
9 | payment rate that was previously approved by the Department | ||||||
10 | that exceeds this amount shall remain in force. | ||||||
11 | (2) Effective for dates of service on or after July 1, | ||||||
12 | 2011, for each individual base rate and mileage rate, the | ||||||
13 | payment rate for ground ambulance services shall be based | ||||||
14 | on 100% of the Illinois Medicaid Ambulance Fee Schedule | ||||||
15 | amount in effect on July 1, 2011 for the designated | ||||||
16 | Medicare Locality, except that any payment rate that was | ||||||
17 | previously approved by the Department that exceeds this | ||||||
18 | amount shall remain in force. | ||||||
19 | Effective for dates of service on or after July 1, 2011, | ||||||
20 | the Department shall update the Illinois Medicaid Ambulance Fee | ||||||
21 | Schedule payment rates so that they comply with the Medicare | ||||||
22 | Ambulance Fee Schedule payment rates for ground ambulance | ||||||
23 | services in effect at the time of the update, in the manner | ||||||
24 | prescribed in the second paragraph of this subsection (c). | ||||||
25 | (d) Payment for mileage shall be per loaded mile with no | ||||||
26 | loaded mileage included in the base rate. If a natural |
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1 | disaster, weather, road repairs, traffic congestion, or other | ||||||
2 | conditions necessitate a route other than the most direct | ||||||
3 | route, payment shall be based upon the actual distance | ||||||
4 | traveled. Notwithstanding the payment principles in subsection | ||||||
5 | (b) of this Section, the Department shall develop the Illinois | ||||||
6 | Medicaid Ambulance Fee Schedule using the ground mileage | ||||||
7 | payment rate, as defined by the Centers for Medicare and | ||||||
8 | Medicaid Services, and no other mileage rates which act as | ||||||
9 | enhancements to the ground mileage rate, whether permanent or | ||||||
10 | temporary, shall be recognized by the Department. When a ground | ||||||
11 | ambulance services provider provides transport pursuant to an | ||||||
12 | emergency call as defined by the Centers for Medicare and | ||||||
13 | Medicaid Services, no reduction in the mileage payment shall be | ||||||
14 | made based upon the fact that a closer facility may have been | ||||||
15 | available, so long as the ground ambulance services provider | ||||||
16 | provided transport to the recipient's facility of choice within | ||||||
17 | the scope of the Illinois Emergency Medical Services (EMS) | ||||||
18 | Systems Act and associated rules and the policies and | ||||||
19 | procedures of the EMS System of which the provider is a member. | ||||||
20 | (e) The Department shall provide payment for emergency | ||||||
21 | ground ambulance services provided to a recipient of aid under | ||||||
22 | this Article according to the requirements provided in | ||||||
23 | subsection (b) of this Section when those services are provided | ||||||
24 | pursuant to a request made through a 9-1-1 or equivalent | ||||||
25 | emergency telephone number for evaluation, treatment, and | ||||||
26 | transport from or on behalf of an individual with a condition |
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1 | of such a nature that a prudent layperson would have reasonably | ||||||
2 | expected that a delay in seeking immediate medical attention | ||||||
3 | would have been hazardous to life or health. This standard is | ||||||
4 | deemed to be met if there is an emergency medical condition | ||||||
5 | manifesting itself by acute symptoms of sufficient severity, | ||||||
6 | including but not limited to severe pain, such that a prudent | ||||||
7 | layperson who possesses an average knowledge of medicine and | ||||||
8 | health can reasonably expect that the absence of immediate | ||||||
9 | medical attention could result in placing the health of the | ||||||
10 | individual or, with respect to a pregnant woman, the health of | ||||||
11 | the woman or her unborn child, in serious jeopardy, cause | ||||||
12 | serious impairment to bodily functions, or cause serious | ||||||
13 | dysfunction of any bodily organ or part. | ||||||
14 | (f) For ground ambulance services provided to a recipient | ||||||
15 | enrolled in a Medicaid managed care plan by a ground ambulance | ||||||
16 | services provider that is not a contracted provider to the | ||||||
17 | Medicaid managed care plan in question, the amount of the | ||||||
18 | payment for ground ambulance services by the Medicaid managed | ||||||
19 | care plan shall be the lesser of the provider's charge, as | ||||||
20 | reflected on the provider's claim form, or the Illinois | ||||||
21 | Medicaid Ambulance Fee Schedule payment rates calculated in | ||||||
22 | accordance with this Section. | ||||||
23 | (g) Nothing in this Section prohibits the Department from | ||||||
24 | setting payment rates for out-of-State ground ambulance | ||||||
25 | services providers by administrative rule. | ||||||
26 | (h) Effective for dates of service on or after July 1, |
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1 | 2010, payments for stretcher van services provided by ground | ||||||
2 | ambulance services providers shall be as follows: | ||||||
3 | (1) For each individual base rate, the amount of the | ||||||
4 | payment shall be the lesser of the provider's charge, as | ||||||
5 | reflected on the provider's claim form, or 80% of the | ||||||
6 | Illinois Medicaid Ambulance Fee Schedule payment rate for | ||||||
7 | the basic life support non-emergency base rate. | ||||||
8 | (2) For each loaded mile, the amount of the payment | ||||||
9 | shall be the lesser of the provider's charge, as reflected | ||||||
10 | on the provider's claim form, or 80% of the Illinois | ||||||
11 | Medicaid Ambulance Fee Schedule payment rate for mileage. | ||||||
12 | For
ambulance
services provided to a recipient of aid under | ||||||
13 | this Article on or after
January 1, 1993, the Illinois | ||||||
14 | Department shall reimburse ambulance service
providers at | ||||||
15 | rates calculated in accordance with this Section. It is the | ||||||
16 | intent
of the General Assembly to provide adequate | ||||||
17 | reimbursement for ambulance
services so as to ensure adequate | ||||||
18 | access to services for recipients of aid
under this Article and | ||||||
19 | to provide appropriate incentives to ambulance service
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20 | providers to provide services in an efficient and | ||||||
21 | cost-effective manner. Thus,
it is the intent of the General | ||||||
22 | Assembly that the Illinois Department implement
a | ||||||
23 | reimbursement system for ambulance services that, to the extent | ||||||
24 | practicable
and subject to the availability of funds | ||||||
25 | appropriated by the General Assembly
for this purpose, is | ||||||
26 | consistent with the payment principles of Medicare. To
ensure |
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1 | uniformity between the payment principles of Medicare and | ||||||
2 | Medicaid, the
Illinois Department shall follow, to the extent | ||||||
3 | necessary and practicable and
subject to the availability of | ||||||
4 | funds appropriated by the General Assembly for
this purpose, | ||||||
5 | the statutes, laws, regulations, policies, procedures,
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6 | principles, definitions, guidelines, and manuals used to | ||||||
7 | determine the amounts
paid to ambulance service providers under | ||||||
8 | Title XVIII of the Social Security
Act (Medicare).
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9 | For ambulance services provided to a recipient of aid under | ||||||
10 | this Article
on or after January 1, 1996, the Illinois | ||||||
11 | Department shall reimburse ambulance
service providers based | ||||||
12 | upon the actual distance traveled if a natural
disaster, | ||||||
13 | weather conditions, road repairs, or traffic congestion | ||||||
14 | necessitates
the use of a
route other than the most direct | ||||||
15 | route.
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16 | For purposes of this Section, "ambulance services" | ||||||
17 | includes medical
transportation services provided by means of | ||||||
18 | an ambulance, medi-car, service
car, or
taxi.
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19 | This Section does not prohibit separate billing by | ||||||
20 | ambulance service
providers for oxygen furnished while | ||||||
21 | providing advanced life support
services.
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22 | (i) Beginning with services rendered on or after July 1, | ||||||
23 | 2008, all providers of non-emergency medi-car and service car | ||||||
24 | transportation must certify that the driver and employee | ||||||
25 | attendant, as applicable, have completed a safety program | ||||||
26 | approved by the Department to protect both the patient and the |
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1 | driver, prior to transporting a patient.
The provider must | ||||||
2 | maintain this certification in its records. The provider shall | ||||||
3 | produce such documentation upon demand by the Department or its | ||||||
4 | representative. Failure to produce documentation of such | ||||||
5 | training shall result in recovery of any payments made by the | ||||||
6 | Department for services rendered by a non-certified driver or | ||||||
7 | employee attendant. Medi-car and service car providers must | ||||||
8 | maintain legible documentation in their records of the driver | ||||||
9 | and, as applicable, employee attendant that actually | ||||||
10 | transported the patient. Providers must recertify all drivers | ||||||
11 | and employee attendants every 3 years.
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12 | Notwithstanding the requirements above, any public | ||||||
13 | transportation provider of medi-car and service car | ||||||
14 | transportation that receives federal funding under 49 U.S.C. | ||||||
15 | 5307 and 5311 need not certify its drivers and employee | ||||||
16 | attendants under this Section, since safety training is already | ||||||
17 | federally mandated.
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18 | (Source: P.A. 95-501, eff. 8-28-07.)
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19 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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20 | (Text of Section before amendment by P.A. 96-806 ) | ||||||
21 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
22 | rule, shall
determine the quantity and quality of and the rate | ||||||
23 | of reimbursement for the
medical assistance for which
payment | ||||||
24 | will be authorized, and the medical services to be provided,
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25 | which may include all or part of the following: (1) inpatient |
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1 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
2 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
3 | services; (5) physicians'
services whether furnished in the | ||||||
4 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
5 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
6 | care furnished by licensed practitioners; (7)
home health care | ||||||
7 | services; (8) private duty nursing service; (9) clinic
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8 | services; (10) dental services, including prevention and | ||||||
9 | treatment of periodontal disease and dental caries disease for | ||||||
10 | pregnant women, provided by an individual licensed to practice | ||||||
11 | dentistry or dental surgery; for purposes of this item (10), | ||||||
12 | "dental services" means diagnostic, preventive, or corrective | ||||||
13 | procedures provided by or under the supervision of a dentist in | ||||||
14 | the practice of his or her profession; (11) physical therapy | ||||||
15 | and related
services; (12) prescribed drugs, dentures, and | ||||||
16 | prosthetic devices; and
eyeglasses prescribed by a physician | ||||||
17 | skilled in the diseases of the eye,
or by an optometrist, | ||||||
18 | whichever the person may select; (13) other
diagnostic, | ||||||
19 | screening, preventive, and rehabilitative services; (14)
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20 | transportation and such other expenses as may be necessary , | ||||||
21 | provided that payment for ground ambulance services shall be as | ||||||
22 | provided in Section 5-4.2 ; (15) medical
treatment of sexual | ||||||
23 | assault survivors, as defined in
Section 1a of the Sexual | ||||||
24 | Assault Survivors Emergency Treatment Act, for
injuries | ||||||
25 | sustained as a result of the sexual assault, including
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26 | examinations and laboratory tests to discover evidence which |
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1 | may be used in
criminal proceedings arising from the sexual | ||||||
2 | assault; (16) the
diagnosis and treatment of sickle cell | ||||||
3 | anemia; and (17)
any other medical care, and any other type of | ||||||
4 | remedial care recognized
under the laws of this State, but not | ||||||
5 | including abortions, or induced
miscarriages or premature | ||||||
6 | births, unless, in the opinion of a physician,
such procedures | ||||||
7 | are necessary for the preservation of the life of the
woman | ||||||
8 | seeking such treatment, or except an induced premature birth
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9 | intended to produce a live viable child and such procedure is | ||||||
10 | necessary
for the health of the mother or her unborn child. The | ||||||
11 | Illinois Department,
by rule, shall prohibit any physician from | ||||||
12 | providing medical assistance
to anyone eligible therefor under | ||||||
13 | this Code where such physician has been
found guilty of | ||||||
14 | performing an abortion procedure in a wilful and wanton
manner | ||||||
15 | upon a woman who was not pregnant at the time such abortion
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16 | procedure was performed. The term "any other type of remedial | ||||||
17 | care" shall
include nursing care and nursing home service for | ||||||
18 | persons who rely on
treatment by spiritual means alone through | ||||||
19 | prayer for healing.
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20 | Notwithstanding any other provision of this Section, a | ||||||
21 | comprehensive
tobacco use cessation program that includes | ||||||
22 | purchasing prescription drugs or
prescription medical devices | ||||||
23 | approved by the Food and Drug administration shall
be covered | ||||||
24 | under the medical assistance
program under this Article for | ||||||
25 | persons who are otherwise eligible for
assistance under this | ||||||
26 | Article.
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1 | Notwithstanding any other provision of this Code, the | ||||||
2 | Illinois
Department may not require, as a condition of payment | ||||||
3 | for any laboratory
test authorized under this Article, that a | ||||||
4 | physician's handwritten signature
appear on the laboratory | ||||||
5 | test order form. The Illinois Department may,
however, impose | ||||||
6 | other appropriate requirements regarding laboratory test
order | ||||||
7 | documentation.
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8 | The Department of Healthcare and Family Services shall | ||||||
9 | provide the following services to
persons
eligible for | ||||||
10 | assistance under this Article who are participating in
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11 | education, training or employment programs operated by the | ||||||
12 | Department of Human
Services as successor to the Department of | ||||||
13 | Public Aid:
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14 | (1) dental services provided by or under the | ||||||
15 | supervision of a dentist; and
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16 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
17 | diseases of the
eye, or by an optometrist, whichever the | ||||||
18 | person may select.
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19 | The Illinois Department, by rule, may distinguish and | ||||||
20 | classify the
medical services to be provided only in accordance | ||||||
21 | with the classes of
persons designated in Section 5-2.
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22 | The Department of Healthcare and Family Services must | ||||||
23 | provide coverage and reimbursement for amino acid-based | ||||||
24 | elemental formulas, regardless of delivery method, for the | ||||||
25 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
26 | short bowel syndrome when the prescribing physician has issued |
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1 | a written order stating that the amino acid-based elemental | ||||||
2 | formula is medically necessary.
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3 | The Illinois Department shall authorize the provision of, | ||||||
4 | and shall
authorize payment for, screening by low-dose | ||||||
5 | mammography for the presence of
occult breast cancer for women | ||||||
6 | 35 years of age or older who are eligible
for medical | ||||||
7 | assistance under this Article, as follows: | ||||||
8 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
9 | age.
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10 | (B) An annual mammogram for women 40 years of age or | ||||||
11 | older. | ||||||
12 | (C) A mammogram at the age and intervals considered | ||||||
13 | medically necessary by the woman's health care provider for | ||||||
14 | women under 40 years of age and having a family history of | ||||||
15 | breast cancer, prior personal history of breast cancer, | ||||||
16 | positive genetic testing, or other risk factors. | ||||||
17 | (D) A comprehensive ultrasound screening of an entire | ||||||
18 | breast or breasts if a mammogram demonstrates | ||||||
19 | heterogeneous or dense breast tissue, when medically | ||||||
20 | necessary as determined by a physician licensed to practice | ||||||
21 | medicine in all of its branches. | ||||||
22 | All screenings
shall
include a physical breast exam, | ||||||
23 | instruction on self-examination and
information regarding the | ||||||
24 | frequency of self-examination and its value as a
preventative | ||||||
25 | tool. For purposes of this Section, "low-dose mammography" | ||||||
26 | means
the x-ray examination of the breast using equipment |
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1 | dedicated specifically
for mammography, including the x-ray | ||||||
2 | tube, filter, compression device,
and image receptor, with an | ||||||
3 | average radiation exposure delivery
of less than one rad per | ||||||
4 | breast for 2 views of an average size breast.
The term also | ||||||
5 | includes digital mammography.
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6 | On and after July 1, 2008, screening and diagnostic | ||||||
7 | mammography shall be reimbursed at the same rate as the | ||||||
8 | Medicare program's rates, including the increased | ||||||
9 | reimbursement for digital mammography. | ||||||
10 | The Department shall convene an expert panel including | ||||||
11 | representatives of hospitals, free-standing mammography | ||||||
12 | facilities, and doctors, including radiologists, to establish | ||||||
13 | quality standards. Based on these quality standards, the | ||||||
14 | Department shall provide for bonus payments to mammography | ||||||
15 | facilities meeting the standards for screening and diagnosis. | ||||||
16 | The bonus payments shall be at least 15% higher than the | ||||||
17 | Medicare rates for mammography. | ||||||
18 | Subject to federal approval, the Department shall | ||||||
19 | establish a rate methodology for mammography at federally | ||||||
20 | qualified health centers and other encounter-rate clinics. | ||||||
21 | These clinics or centers may also collaborate with other | ||||||
22 | hospital-based mammography facilities. | ||||||
23 | The Department shall establish a methodology to remind | ||||||
24 | women who are age-appropriate for screening mammography, but | ||||||
25 | who have not received a mammogram within the previous 18 | ||||||
26 | months, of the importance and benefit of screening mammography. |
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1 | The Department shall establish a performance goal for | ||||||
2 | primary care providers with respect to their female patients | ||||||
3 | over age 40 receiving an annual mammogram. This performance | ||||||
4 | goal shall be used to provide additional reimbursement in the | ||||||
5 | form of a quality performance bonus to primary care providers | ||||||
6 | who meet that goal. | ||||||
7 | The Department shall devise a means of case-managing or | ||||||
8 | patient navigation for beneficiaries diagnosed with breast | ||||||
9 | cancer. This program shall initially operate as a pilot program | ||||||
10 | in areas of the State with the highest incidence of mortality | ||||||
11 | related to breast cancer. At least one pilot program site shall | ||||||
12 | be in the metropolitan Chicago area and at least one site shall | ||||||
13 | be outside the metropolitan Chicago area. An evaluation of the | ||||||
14 | pilot program shall be carried out measuring health outcomes | ||||||
15 | and cost of care for those served by the pilot program compared | ||||||
16 | to similarly situated patients who are not served by the pilot | ||||||
17 | program. | ||||||
18 | Any medical or health care provider shall immediately | ||||||
19 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
20 | services and is suspected
of drug abuse or is addicted as | ||||||
21 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
22 | Act, referral to a local substance abuse treatment provider
| ||||||
23 | licensed by the Department of Human Services or to a licensed
| ||||||
24 | hospital which provides substance abuse treatment services. | ||||||
25 | The Department of Healthcare and Family Services
shall assure | ||||||
26 | coverage for the cost of treatment of the drug abuse or
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1 | addiction for pregnant recipients in accordance with the | ||||||
2 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
3 | Human Services.
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4 | All medical providers providing medical assistance to | ||||||
5 | pregnant women
under this Code shall receive information from | ||||||
6 | the Department on the
availability of services under the Drug | ||||||
7 | Free Families with a Future or any
comparable program providing | ||||||
8 | case management services for addicted women,
including | ||||||
9 | information on appropriate referrals for other social services
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10 | that may be needed by addicted women in addition to treatment | ||||||
11 | for addiction.
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12 | The Illinois Department, in cooperation with the | ||||||
13 | Departments of Human
Services (as successor to the Department | ||||||
14 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
15 | public awareness campaign, may
provide information concerning | ||||||
16 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
17 | health care, and other pertinent programs directed at
reducing | ||||||
18 | the number of drug-affected infants born to recipients of | ||||||
19 | medical
assistance.
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20 | Neither the Department of Healthcare and Family Services | ||||||
21 | nor the Department of Human
Services shall sanction the | ||||||
22 | recipient solely on the basis of
her substance abuse.
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23 | The Illinois Department shall establish such regulations | ||||||
24 | governing
the dispensing of health services under this Article | ||||||
25 | as it shall deem
appropriate. The Department
should
seek the | ||||||
26 | advice of formal professional advisory committees appointed by
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| |||||||
1 | the Director of the Illinois Department for the purpose of | ||||||
2 | providing regular
advice on policy and administrative matters, | ||||||
3 | information dissemination and
educational activities for | ||||||
4 | medical and health care providers, and
consistency in | ||||||
5 | procedures to the Illinois Department.
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6 | The Illinois Department may develop and contract with | ||||||
7 | Partnerships of
medical providers to arrange medical services | ||||||
8 | for persons eligible under
Section 5-2 of this Code. | ||||||
9 | Implementation of this Section may be by
demonstration projects | ||||||
10 | in certain geographic areas. The Partnership shall
be | ||||||
11 | represented by a sponsor organization. The Department, by rule, | ||||||
12 | shall
develop qualifications for sponsors of Partnerships. | ||||||
13 | Nothing in this
Section shall be construed to require that the | ||||||
14 | sponsor organization be a
medical organization.
| ||||||
15 | The sponsor must negotiate formal written contracts with | ||||||
16 | medical
providers for physician services, inpatient and | ||||||
17 | outpatient hospital care,
home health services, treatment for | ||||||
18 | alcoholism and substance abuse, and
other services determined | ||||||
19 | necessary by the Illinois Department by rule for
delivery by | ||||||
20 | Partnerships. Physician services must include prenatal and
| ||||||
21 | obstetrical care. The Illinois Department shall reimburse | ||||||
22 | medical services
delivered by Partnership providers to clients | ||||||
23 | in target areas according to
provisions of this Article and the | ||||||
24 | Illinois Health Finance Reform Act,
except that:
| ||||||
25 | (1) Physicians participating in a Partnership and | ||||||
26 | providing certain
services, which shall be determined by |
| |||||||
| |||||||
1 | the Illinois Department, to persons
in areas covered by the | ||||||
2 | Partnership may receive an additional surcharge
for such | ||||||
3 | services.
| ||||||
4 | (2) The Department may elect to consider and negotiate | ||||||
5 | financial
incentives to encourage the development of | ||||||
6 | Partnerships and the efficient
delivery of medical care.
| ||||||
7 | (3) Persons receiving medical services through | ||||||
8 | Partnerships may receive
medical and case management | ||||||
9 | services above the level usually offered
through the | ||||||
10 | medical assistance program.
| ||||||
11 | Medical providers shall be required to meet certain | ||||||
12 | qualifications to
participate in Partnerships to ensure the | ||||||
13 | delivery of high quality medical
services. These | ||||||
14 | qualifications shall be determined by rule of the Illinois
| ||||||
15 | Department and may be higher than qualifications for | ||||||
16 | participation in the
medical assistance program. Partnership | ||||||
17 | sponsors may prescribe reasonable
additional qualifications | ||||||
18 | for participation by medical providers, only with
the prior | ||||||
19 | written approval of the Illinois Department.
| ||||||
20 | Nothing in this Section shall limit the free choice of | ||||||
21 | practitioners,
hospitals, and other providers of medical | ||||||
22 | services by clients.
In order to ensure patient freedom of | ||||||
23 | choice, the Illinois Department shall
immediately promulgate | ||||||
24 | all rules and take all other necessary actions so that
provided | ||||||
25 | services may be accessed from therapeutically certified | ||||||
26 | optometrists
to the full extent of the Illinois Optometric |
| |||||||
| |||||||
1 | Practice Act of 1987 without
discriminating between service | ||||||
2 | providers.
| ||||||
3 | The Department shall apply for a waiver from the United | ||||||
4 | States Health
Care Financing Administration to allow for the | ||||||
5 | implementation of
Partnerships under this Section.
| ||||||
6 | The Illinois Department shall require health care | ||||||
7 | providers to maintain
records that document the medical care | ||||||
8 | and services provided to recipients
of Medical Assistance under | ||||||
9 | this Article. The Illinois Department shall
require health care | ||||||
10 | providers to make available, when authorized by the
patient, in | ||||||
11 | writing, the medical records in a timely fashion to other
| ||||||
12 | health care providers who are treating or serving persons | ||||||
13 | eligible for
Medical Assistance under this Article. All | ||||||
14 | dispensers of medical services
shall be required to maintain | ||||||
15 | and retain business and professional records
sufficient to | ||||||
16 | fully and accurately document the nature, scope, details and
| ||||||
17 | receipt of the health care provided to persons eligible for | ||||||
18 | medical
assistance under this Code, in accordance with | ||||||
19 | regulations promulgated by
the Illinois Department. The rules | ||||||
20 | and regulations shall require that proof
of the receipt of | ||||||
21 | prescription drugs, dentures, prosthetic devices and
| ||||||
22 | eyeglasses by eligible persons under this Section accompany | ||||||
23 | each claim
for reimbursement submitted by the dispenser of such | ||||||
24 | medical services.
No such claims for reimbursement shall be | ||||||
25 | approved for payment by the Illinois
Department without such | ||||||
26 | proof of receipt, unless the Illinois Department
shall have put |
| |||||||
| |||||||
1 | into effect and shall be operating a system of post-payment
| ||||||
2 | audit and review which shall, on a sampling basis, be deemed | ||||||
3 | adequate by
the Illinois Department to assure that such drugs, | ||||||
4 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
5 | is being made are actually being
received by eligible | ||||||
6 | recipients. Within 90 days after the effective date of
this | ||||||
7 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
8 | a
current list of acquisition costs for all prosthetic devices | ||||||
9 | and any
other items recognized as medical equipment and | ||||||
10 | supplies reimbursable under
this Article and shall update such | ||||||
11 | list on a quarterly basis, except that
the acquisition costs of | ||||||
12 | all prescription drugs shall be updated no
less frequently than | ||||||
13 | every 30 days as required by Section 5-5.12.
| ||||||
14 | The rules and regulations of the Illinois Department shall | ||||||
15 | require
that a written statement including the required opinion | ||||||
16 | of a physician
shall accompany any claim for reimbursement for | ||||||
17 | abortions, or induced
miscarriages or premature births. This | ||||||
18 | statement shall indicate what
procedures were used in providing | ||||||
19 | such medical services.
| ||||||
20 | The Illinois Department shall require all dispensers of | ||||||
21 | medical
services, other than an individual practitioner or | ||||||
22 | group of practitioners,
desiring to participate in the Medical | ||||||
23 | Assistance program
established under this Article to disclose | ||||||
24 | all financial, beneficial,
ownership, equity, surety or other | ||||||
25 | interests in any and all firms,
corporations, partnerships, | ||||||
26 | associations, business enterprises, joint
ventures, agencies, |
| |||||||
| |||||||
1 | institutions or other legal entities providing any
form of | ||||||
2 | health care services in this State under this Article.
| ||||||
3 | The Illinois Department may require that all dispensers of | ||||||
4 | medical
services desiring to participate in the medical | ||||||
5 | assistance program
established under this Article disclose, | ||||||
6 | under such terms and conditions as
the Illinois Department may | ||||||
7 | by rule establish, all inquiries from clients
and attorneys | ||||||
8 | regarding medical bills paid by the Illinois Department, which
| ||||||
9 | inquiries could indicate potential existence of claims or liens | ||||||
10 | for the
Illinois Department.
| ||||||
11 | Enrollment of a vendor that provides non-emergency medical | ||||||
12 | transportation,
defined by the Department by rule,
shall be
| ||||||
13 | conditional for 180 days. During that time, the Department of | ||||||
14 | Healthcare and Family Services may
terminate the vendor's | ||||||
15 | eligibility to participate in the medical assistance
program | ||||||
16 | without cause. That termination of eligibility is not subject | ||||||
17 | to the
Department's hearing process.
| ||||||
18 | The Illinois Department shall establish policies, | ||||||
19 | procedures,
standards and criteria by rule for the acquisition, | ||||||
20 | repair and replacement
of orthotic and prosthetic devices and | ||||||
21 | durable medical equipment. Such
rules shall provide, but not be | ||||||
22 | limited to, the following services: (1)
immediate repair or | ||||||
23 | replacement of such devices by recipients without
medical | ||||||
24 | authorization; and (2) rental, lease, purchase or | ||||||
25 | lease-purchase of
durable medical equipment in a | ||||||
26 | cost-effective manner, taking into
consideration the |
| |||||||
| |||||||
1 | recipient's medical prognosis, the extent of the
recipient's | ||||||
2 | needs, and the requirements and costs for maintaining such
| ||||||
3 | equipment. Such rules shall enable a recipient to temporarily | ||||||
4 | acquire and
use alternative or substitute devices or equipment | ||||||
5 | pending repairs or
replacements of any device or equipment | ||||||
6 | previously authorized for such
recipient by the Department.
| ||||||
7 | The Department shall execute, relative to the nursing home | ||||||
8 | prescreening
project, written inter-agency agreements with the | ||||||
9 | Department of Human
Services and the Department on Aging, to | ||||||
10 | effect the following: (i) intake
procedures and common | ||||||
11 | eligibility criteria for those persons who are receiving
| ||||||
12 | non-institutional services; and (ii) the establishment and | ||||||
13 | development of
non-institutional services in areas of the State | ||||||
14 | where they are not currently
available or are undeveloped.
| ||||||
15 | The Illinois Department shall develop and operate, in | ||||||
16 | cooperation
with other State Departments and agencies and in | ||||||
17 | compliance with
applicable federal laws and regulations, | ||||||
18 | appropriate and effective
systems of health care evaluation and | ||||||
19 | programs for monitoring of
utilization of health care services | ||||||
20 | and facilities, as it affects
persons eligible for medical | ||||||
21 | assistance under this Code.
| ||||||
22 | The Illinois Department shall report annually to the | ||||||
23 | General Assembly,
no later than the second Friday in April of | ||||||
24 | 1979 and each year
thereafter, in regard to:
| ||||||
25 | (a) actual statistics and trends in utilization of | ||||||
26 | medical services by
public aid recipients;
|
| |||||||
| |||||||
1 | (b) actual statistics and trends in the provision of | ||||||
2 | the various medical
services by medical vendors;
| ||||||
3 | (c) current rate structures and proposed changes in | ||||||
4 | those rate structures
for the various medical vendors; and
| ||||||
5 | (d) efforts at utilization review and control by the | ||||||
6 | Illinois Department.
| ||||||
7 | The period covered by each report shall be the 3 years | ||||||
8 | ending on the June
30 prior to the report. The report shall | ||||||
9 | include suggested legislation
for consideration by the General | ||||||
10 | Assembly. The filing of one copy of the
report with the | ||||||
11 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
12 | the Clerk of the House of Representatives, one copy with the | ||||||
13 | President,
one copy with the Minority Leader and one copy with | ||||||
14 | the Secretary of the
Senate, one copy with the Legislative | ||||||
15 | Research Unit, and such additional
copies
with the State | ||||||
16 | Government Report Distribution Center for the General
Assembly | ||||||
17 | as is required under paragraph (t) of Section 7 of the State
| ||||||
18 | Library Act shall be deemed sufficient to comply with this | ||||||
19 | Section.
| ||||||
20 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
21 | amendatory Act of the 95th General Assembly , if any, is | ||||||
22 | conditioned on the rules being adopted in accordance with all | ||||||
23 | provisions of the Illinois Administrative Procedure Act and all | ||||||
24 | rules and procedures of the Joint Committee on Administrative | ||||||
25 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
26 | is unauthorized. |
| |||||||
| |||||||
1 | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | ||||||
2 | 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; revised 11-4-09.)
| ||||||
3 | (Text of Section after amendment by P.A. 96-806 ) | ||||||
4 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
5 | rule, shall
determine the quantity and quality of and the rate | ||||||
6 | of reimbursement for the
medical assistance for which
payment | ||||||
7 | will be authorized, and the medical services to be provided,
| ||||||
8 | which may include all or part of the following: (1) inpatient | ||||||
9 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
10 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
11 | services; (5) physicians'
services whether furnished in the | ||||||
12 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
13 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
14 | care furnished by licensed practitioners; (7)
home health care | ||||||
15 | services; (8) private duty nursing service; (9) clinic
| ||||||
16 | services; (10) dental services, including prevention and | ||||||
17 | treatment of periodontal disease and dental caries disease for | ||||||
18 | pregnant women, provided by an individual licensed to practice | ||||||
19 | dentistry or dental surgery; for purposes of this item (10), | ||||||
20 | "dental services" means diagnostic, preventive, or corrective | ||||||
21 | procedures provided by or under the supervision of a dentist in | ||||||
22 | the practice of his or her profession; (11) physical therapy | ||||||
23 | and related
services; (12) prescribed drugs, dentures, and | ||||||
24 | prosthetic devices; and
eyeglasses prescribed by a physician | ||||||
25 | skilled in the diseases of the eye,
or by an optometrist, |
| |||||||
| |||||||
1 | whichever the person may select; (13) other
diagnostic, | ||||||
2 | screening, preventive, and rehabilitative services; (14)
| ||||||
3 | transportation and such other expenses as may be necessary , | ||||||
4 | provided that payment for ground ambulance services shall be as | ||||||
5 | provided in Section 5-4.2 ; (15) medical
treatment of sexual | ||||||
6 | assault survivors, as defined in
Section 1a of the Sexual | ||||||
7 | Assault Survivors Emergency Treatment Act, for
injuries | ||||||
8 | sustained as a result of the sexual assault, including
| ||||||
9 | examinations and laboratory tests to discover evidence which | ||||||
10 | may be used in
criminal proceedings arising from the sexual | ||||||
11 | assault; (16) the
diagnosis and treatment of sickle cell | ||||||
12 | anemia; and (17)
any other medical care, and any other type of | ||||||
13 | remedial care recognized
under the laws of this State, but not | ||||||
14 | including abortions, or induced
miscarriages or premature | ||||||
15 | births, unless, in the opinion of a physician,
such procedures | ||||||
16 | are necessary for the preservation of the life of the
woman | ||||||
17 | seeking such treatment, or except an induced premature birth
| ||||||
18 | intended to produce a live viable child and such procedure is | ||||||
19 | necessary
for the health of the mother or her unborn child. The | ||||||
20 | Illinois Department,
by rule, shall prohibit any physician from | ||||||
21 | providing medical assistance
to anyone eligible therefor under | ||||||
22 | this Code where such physician has been
found guilty of | ||||||
23 | performing an abortion procedure in a wilful and wanton
manner | ||||||
24 | upon a woman who was not pregnant at the time such abortion
| ||||||
25 | procedure was performed. The term "any other type of remedial | ||||||
26 | care" shall
include nursing care and nursing home service for |
| |||||||
| |||||||
1 | persons who rely on
treatment by spiritual means alone through | ||||||
2 | prayer for healing.
| ||||||
3 | Notwithstanding any other provision of this Section, a | ||||||
4 | comprehensive
tobacco use cessation program that includes | ||||||
5 | purchasing prescription drugs or
prescription medical devices | ||||||
6 | approved by the Food and Drug administration shall
be covered | ||||||
7 | under the medical assistance
program under this Article for | ||||||
8 | persons who are otherwise eligible for
assistance under this | ||||||
9 | Article.
| ||||||
10 | Notwithstanding any other provision of this Code, the | ||||||
11 | Illinois
Department may not require, as a condition of payment | ||||||
12 | for any laboratory
test authorized under this Article, that a | ||||||
13 | physician's handwritten signature
appear on the laboratory | ||||||
14 | test order form. The Illinois Department may,
however, impose | ||||||
15 | other appropriate requirements regarding laboratory test
order | ||||||
16 | documentation.
| ||||||
17 | The Department of Healthcare and Family Services shall | ||||||
18 | provide the following services to
persons
eligible for | ||||||
19 | assistance under this Article who are participating in
| ||||||
20 | education, training or employment programs operated by the | ||||||
21 | Department of Human
Services as successor to the Department of | ||||||
22 | Public Aid:
| ||||||
23 | (1) dental services provided by or under the | ||||||
24 | supervision of a dentist; and
| ||||||
25 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
26 | diseases of the
eye, or by an optometrist, whichever the |
| |||||||
| |||||||
1 | person may select.
| ||||||
2 | The Illinois Department, by rule, may distinguish and | ||||||
3 | classify the
medical services to be provided only in accordance | ||||||
4 | with the classes of
persons designated in Section 5-2.
| ||||||
5 | The Department of Healthcare and Family Services must | ||||||
6 | provide coverage and reimbursement for amino acid-based | ||||||
7 | elemental formulas, regardless of delivery method, for the | ||||||
8 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
9 | short bowel syndrome when the prescribing physician has issued | ||||||
10 | a written order stating that the amino acid-based elemental | ||||||
11 | formula is medically necessary.
| ||||||
12 | The Illinois Department shall authorize the provision of, | ||||||
13 | and shall
authorize payment for, screening by low-dose | ||||||
14 | mammography for the presence of
occult breast cancer for women | ||||||
15 | 35 years of age or older who are eligible
for medical | ||||||
16 | assistance under this Article, as follows: | ||||||
17 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
18 | age.
| ||||||
19 | (B) An annual mammogram for women 40 years of age or | ||||||
20 | older. | ||||||
21 | (C) A mammogram at the age and intervals considered | ||||||
22 | medically necessary by the woman's health care provider for | ||||||
23 | women under 40 years of age and having a family history of | ||||||
24 | breast cancer, prior personal history of breast cancer, | ||||||
25 | positive genetic testing, or other risk factors. | ||||||
26 | (D) A comprehensive ultrasound screening of an entire |
| |||||||
| |||||||
1 | breast or breasts if a mammogram demonstrates | ||||||
2 | heterogeneous or dense breast tissue, when medically | ||||||
3 | necessary as determined by a physician licensed to practice | ||||||
4 | medicine in all of its branches. | ||||||
5 | All screenings
shall
include a physical breast exam, | ||||||
6 | instruction on self-examination and
information regarding the | ||||||
7 | frequency of self-examination and its value as a
preventative | ||||||
8 | tool. For purposes of this Section, "low-dose mammography" | ||||||
9 | means
the x-ray examination of the breast using equipment | ||||||
10 | dedicated specifically
for mammography, including the x-ray | ||||||
11 | tube, filter, compression device,
and image receptor, with an | ||||||
12 | average radiation exposure delivery
of less than one rad per | ||||||
13 | breast for 2 views of an average size breast.
The term also | ||||||
14 | includes digital mammography.
| ||||||
15 | On and after July 1, 2008, screening and diagnostic | ||||||
16 | mammography shall be reimbursed at the same rate as the | ||||||
17 | Medicare program's rates, including the increased | ||||||
18 | reimbursement for digital mammography. | ||||||
19 | The Department shall convene an expert panel including | ||||||
20 | representatives of hospitals, free-standing mammography | ||||||
21 | facilities, and doctors, including radiologists, to establish | ||||||
22 | quality standards. Based on these quality standards, the | ||||||
23 | Department shall provide for bonus payments to mammography | ||||||
24 | facilities meeting the standards for screening and diagnosis. | ||||||
25 | The bonus payments shall be at least 15% higher than the | ||||||
26 | Medicare rates for mammography. |
| |||||||
| |||||||
1 | Subject to federal approval, the Department shall | ||||||
2 | establish a rate methodology for mammography at federally | ||||||
3 | qualified health centers and other encounter-rate clinics. | ||||||
4 | These clinics or centers may also collaborate with other | ||||||
5 | hospital-based mammography facilities. | ||||||
6 | The Department shall establish a methodology to remind | ||||||
7 | women who are age-appropriate for screening mammography, but | ||||||
8 | who have not received a mammogram within the previous 18 | ||||||
9 | months, of the importance and benefit of screening mammography. | ||||||
10 | The Department shall establish a performance goal for | ||||||
11 | primary care providers with respect to their female patients | ||||||
12 | over age 40 receiving an annual mammogram. This performance | ||||||
13 | goal shall be used to provide additional reimbursement in the | ||||||
14 | form of a quality performance bonus to primary care providers | ||||||
15 | who meet that goal. | ||||||
16 | The Department shall devise a means of case-managing or | ||||||
17 | patient navigation for beneficiaries diagnosed with breast | ||||||
18 | cancer. This program shall initially operate as a pilot program | ||||||
19 | in areas of the State with the highest incidence of mortality | ||||||
20 | related to breast cancer. At least one pilot program site shall | ||||||
21 | be in the metropolitan Chicago area and at least one site shall | ||||||
22 | be outside the metropolitan Chicago area. An evaluation of the | ||||||
23 | pilot program shall be carried out measuring health outcomes | ||||||
24 | and cost of care for those served by the pilot program compared | ||||||
25 | to similarly situated patients who are not served by the pilot | ||||||
26 | program. |
| |||||||
| |||||||
1 | Any medical or health care provider shall immediately | ||||||
2 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
3 | services and is suspected
of drug abuse or is addicted as | ||||||
4 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
5 | Act, referral to a local substance abuse treatment provider
| ||||||
6 | licensed by the Department of Human Services or to a licensed
| ||||||
7 | hospital which provides substance abuse treatment services. | ||||||
8 | The Department of Healthcare and Family Services
shall assure | ||||||
9 | coverage for the cost of treatment of the drug abuse or
| ||||||
10 | addiction for pregnant recipients in accordance with the | ||||||
11 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
12 | Human Services.
| ||||||
13 | All medical providers providing medical assistance to | ||||||
14 | pregnant women
under this Code shall receive information from | ||||||
15 | the Department on the
availability of services under the Drug | ||||||
16 | Free Families with a Future or any
comparable program providing | ||||||
17 | case management services for addicted women,
including | ||||||
18 | information on appropriate referrals for other social services
| ||||||
19 | that may be needed by addicted women in addition to treatment | ||||||
20 | for addiction.
| ||||||
21 | The Illinois Department, in cooperation with the | ||||||
22 | Departments of Human
Services (as successor to the Department | ||||||
23 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
24 | public awareness campaign, may
provide information concerning | ||||||
25 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
26 | health care, and other pertinent programs directed at
reducing |
| |||||||
| |||||||
1 | the number of drug-affected infants born to recipients of | ||||||
2 | medical
assistance.
| ||||||
3 | Neither the Department of Healthcare and Family Services | ||||||
4 | nor the Department of Human
Services shall sanction the | ||||||
5 | recipient solely on the basis of
her substance abuse.
| ||||||
6 | The Illinois Department shall establish such regulations | ||||||
7 | governing
the dispensing of health services under this Article | ||||||
8 | as it shall deem
appropriate. The Department
should
seek the | ||||||
9 | advice of formal professional advisory committees appointed by
| ||||||
10 | the Director of the Illinois Department for the purpose of | ||||||
11 | providing regular
advice on policy and administrative matters, | ||||||
12 | information dissemination and
educational activities for | ||||||
13 | medical and health care providers, and
consistency in | ||||||
14 | procedures to the Illinois Department.
| ||||||
15 | Notwithstanding any other provision of law, a health care | ||||||
16 | provider under the medical assistance program may elect, in | ||||||
17 | lieu of receiving direct payment for services provided under | ||||||
18 | that program, to participate in the State Employees Deferred | ||||||
19 | Compensation Plan adopted under Article 24 of the Illinois | ||||||
20 | Pension Code. A health care provider who elects to participate | ||||||
21 | in the plan does not have a cause of action against the State | ||||||
22 | for any damages allegedly suffered by the provider as a result | ||||||
23 | of any delay by the State in crediting the amount of any | ||||||
24 | contribution to the provider's plan account. | ||||||
25 | The Illinois Department may develop and contract with | ||||||
26 | Partnerships of
medical providers to arrange medical services |
| |||||||
| |||||||
1 | for persons eligible under
Section 5-2 of this Code. | ||||||
2 | Implementation of this Section may be by
demonstration projects | ||||||
3 | in certain geographic areas. The Partnership shall
be | ||||||
4 | represented by a sponsor organization. The Department, by rule, | ||||||
5 | shall
develop qualifications for sponsors of Partnerships. | ||||||
6 | Nothing in this
Section shall be construed to require that the | ||||||
7 | sponsor organization be a
medical organization.
| ||||||
8 | The sponsor must negotiate formal written contracts with | ||||||
9 | medical
providers for physician services, inpatient and | ||||||
10 | outpatient hospital care,
home health services, treatment for | ||||||
11 | alcoholism and substance abuse, and
other services determined | ||||||
12 | necessary by the Illinois Department by rule for
delivery by | ||||||
13 | Partnerships. Physician services must include prenatal and
| ||||||
14 | obstetrical care. The Illinois Department shall reimburse | ||||||
15 | medical services
delivered by Partnership providers to clients | ||||||
16 | in target areas according to
provisions of this Article and the | ||||||
17 | Illinois Health Finance Reform Act,
except that:
| ||||||
18 | (1) Physicians participating in a Partnership and | ||||||
19 | providing certain
services, which shall be determined by | ||||||
20 | the Illinois Department, to persons
in areas covered by the | ||||||
21 | Partnership may receive an additional surcharge
for such | ||||||
22 | services.
| ||||||
23 | (2) The Department may elect to consider and negotiate | ||||||
24 | financial
incentives to encourage the development of | ||||||
25 | Partnerships and the efficient
delivery of medical care.
| ||||||
26 | (3) Persons receiving medical services through |
| |||||||
| |||||||
1 | Partnerships may receive
medical and case management | ||||||
2 | services above the level usually offered
through the | ||||||
3 | medical assistance program.
| ||||||
4 | Medical providers shall be required to meet certain | ||||||
5 | qualifications to
participate in Partnerships to ensure the | ||||||
6 | delivery of high quality medical
services. These | ||||||
7 | qualifications shall be determined by rule of the Illinois
| ||||||
8 | Department and may be higher than qualifications for | ||||||
9 | participation in the
medical assistance program. Partnership | ||||||
10 | sponsors may prescribe reasonable
additional qualifications | ||||||
11 | for participation by medical providers, only with
the prior | ||||||
12 | written approval of the Illinois Department.
| ||||||
13 | Nothing in this Section shall limit the free choice of | ||||||
14 | practitioners,
hospitals, and other providers of medical | ||||||
15 | services by clients.
In order to ensure patient freedom of | ||||||
16 | choice, the Illinois Department shall
immediately promulgate | ||||||
17 | all rules and take all other necessary actions so that
provided | ||||||
18 | services may be accessed from therapeutically certified | ||||||
19 | optometrists
to the full extent of the Illinois Optometric | ||||||
20 | Practice Act of 1987 without
discriminating between service | ||||||
21 | providers.
| ||||||
22 | The Department shall apply for a waiver from the United | ||||||
23 | States Health
Care Financing Administration to allow for the | ||||||
24 | implementation of
Partnerships under this Section.
| ||||||
25 | The Illinois Department shall require health care | ||||||
26 | providers to maintain
records that document the medical care |
| |||||||
| |||||||
1 | and services provided to recipients
of Medical Assistance under | ||||||
2 | this Article. The Illinois Department shall
require health care | ||||||
3 | providers to make available, when authorized by the
patient, in | ||||||
4 | writing, the medical records in a timely fashion to other
| ||||||
5 | health care providers who are treating or serving persons | ||||||
6 | eligible for
Medical Assistance under this Article. All | ||||||
7 | dispensers of medical services
shall be required to maintain | ||||||
8 | and retain business and professional records
sufficient to | ||||||
9 | fully and accurately document the nature, scope, details and
| ||||||
10 | receipt of the health care provided to persons eligible for | ||||||
11 | medical
assistance under this Code, in accordance with | ||||||
12 | regulations promulgated by
the Illinois Department. The rules | ||||||
13 | and regulations shall require that proof
of the receipt of | ||||||
14 | prescription drugs, dentures, prosthetic devices and
| ||||||
15 | eyeglasses by eligible persons under this Section accompany | ||||||
16 | each claim
for reimbursement submitted by the dispenser of such | ||||||
17 | medical services.
No such claims for reimbursement shall be | ||||||
18 | approved for payment by the Illinois
Department without such | ||||||
19 | proof of receipt, unless the Illinois Department
shall have put | ||||||
20 | into effect and shall be operating a system of post-payment
| ||||||
21 | audit and review which shall, on a sampling basis, be deemed | ||||||
22 | adequate by
the Illinois Department to assure that such drugs, | ||||||
23 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
24 | is being made are actually being
received by eligible | ||||||
25 | recipients. Within 90 days after the effective date of
this | ||||||
26 | amendatory Act of 1984, the Illinois Department shall establish |
| |||||||
| |||||||
1 | a
current list of acquisition costs for all prosthetic devices | ||||||
2 | and any
other items recognized as medical equipment and | ||||||
3 | supplies reimbursable under
this Article and shall update such | ||||||
4 | list on a quarterly basis, except that
the acquisition costs of | ||||||
5 | all prescription drugs shall be updated no
less frequently than | ||||||
6 | every 30 days as required by Section 5-5.12.
| ||||||
7 | The rules and regulations of the Illinois Department shall | ||||||
8 | require
that a written statement including the required opinion | ||||||
9 | of a physician
shall accompany any claim for reimbursement for | ||||||
10 | abortions, or induced
miscarriages or premature births. This | ||||||
11 | statement shall indicate what
procedures were used in providing | ||||||
12 | such medical services.
| ||||||
13 | The Illinois Department shall require all dispensers of | ||||||
14 | medical
services, other than an individual practitioner or | ||||||
15 | group of practitioners,
desiring to participate in the Medical | ||||||
16 | Assistance program
established under this Article to disclose | ||||||
17 | all financial, beneficial,
ownership, equity, surety or other | ||||||
18 | interests in any and all firms,
corporations, partnerships, | ||||||
19 | associations, business enterprises, joint
ventures, agencies, | ||||||
20 | institutions or other legal entities providing any
form of | ||||||
21 | health care services in this State under this Article.
| ||||||
22 | The Illinois Department may require that all dispensers of | ||||||
23 | medical
services desiring to participate in the medical | ||||||
24 | assistance program
established under this Article disclose, | ||||||
25 | under such terms and conditions as
the Illinois Department may | ||||||
26 | by rule establish, all inquiries from clients
and attorneys |
| |||||||
| |||||||
1 | regarding medical bills paid by the Illinois Department, which
| ||||||
2 | inquiries could indicate potential existence of claims or liens | ||||||
3 | for the
Illinois Department.
| ||||||
4 | Enrollment of a vendor that provides non-emergency medical | ||||||
5 | transportation,
defined by the Department by rule,
shall be
| ||||||
6 | conditional for 180 days. During that time, the Department of | ||||||
7 | Healthcare and Family Services may
terminate the vendor's | ||||||
8 | eligibility to participate in the medical assistance
program | ||||||
9 | without cause. That termination of eligibility is not subject | ||||||
10 | to the
Department's hearing process.
| ||||||
11 | The Illinois Department shall establish policies, | ||||||
12 | procedures,
standards and criteria by rule for the acquisition, | ||||||
13 | repair and replacement
of orthotic and prosthetic devices and | ||||||
14 | durable medical equipment. Such
rules shall provide, but not be | ||||||
15 | limited to, the following services: (1)
immediate repair or | ||||||
16 | replacement of such devices by recipients without
medical | ||||||
17 | authorization; and (2) rental, lease, purchase or | ||||||
18 | lease-purchase of
durable medical equipment in a | ||||||
19 | cost-effective manner, taking into
consideration the | ||||||
20 | recipient's medical prognosis, the extent of the
recipient's | ||||||
21 | needs, and the requirements and costs for maintaining such
| ||||||
22 | equipment. Such rules shall enable a recipient to temporarily | ||||||
23 | acquire and
use alternative or substitute devices or equipment | ||||||
24 | pending repairs or
replacements of any device or equipment | ||||||
25 | previously authorized for such
recipient by the Department.
| ||||||
26 | The Department shall execute, relative to the nursing home |
| |||||||
| |||||||
1 | prescreening
project, written inter-agency agreements with the | ||||||
2 | Department of Human
Services and the Department on Aging, to | ||||||
3 | effect the following: (i) intake
procedures and common | ||||||
4 | eligibility criteria for those persons who are receiving
| ||||||
5 | non-institutional services; and (ii) the establishment and | ||||||
6 | development of
non-institutional services in areas of the State | ||||||
7 | where they are not currently
available or are undeveloped.
| ||||||
8 | The Illinois Department shall develop and operate, in | ||||||
9 | cooperation
with other State Departments and agencies and in | ||||||
10 | compliance with
applicable federal laws and regulations, | ||||||
11 | appropriate and effective
systems of health care evaluation and | ||||||
12 | programs for monitoring of
utilization of health care services | ||||||
13 | and facilities, as it affects
persons eligible for medical | ||||||
14 | assistance under this Code.
| ||||||
15 | The Illinois Department shall report annually to the | ||||||
16 | General Assembly,
no later than the second Friday in April of | ||||||
17 | 1979 and each year
thereafter, in regard to:
| ||||||
18 | (a) actual statistics and trends in utilization of | ||||||
19 | medical services by
public aid recipients;
| ||||||
20 | (b) actual statistics and trends in the provision of | ||||||
21 | the various medical
services by medical vendors;
| ||||||
22 | (c) current rate structures and proposed changes in | ||||||
23 | those rate structures
for the various medical vendors; and
| ||||||
24 | (d) efforts at utilization review and control by the | ||||||
25 | Illinois Department.
| ||||||
26 | The period covered by each report shall be the 3 years |
| |||||||
| |||||||
1 | ending on the June
30 prior to the report. The report shall | ||||||
2 | include suggested legislation
for consideration by the General | ||||||
3 | Assembly. The filing of one copy of the
report with the | ||||||
4 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
5 | the Clerk of the House of Representatives, one copy with the | ||||||
6 | President,
one copy with the Minority Leader and one copy with | ||||||
7 | the Secretary of the
Senate, one copy with the Legislative | ||||||
8 | Research Unit, and such additional
copies
with the State | ||||||
9 | Government Report Distribution Center for the General
Assembly | ||||||
10 | as is required under paragraph (t) of Section 7 of the State
| ||||||
11 | Library Act shall be deemed sufficient to comply with this | ||||||
12 | Section.
| ||||||
13 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
14 | amendatory Act of the 95th General Assembly , if any, is | ||||||
15 | conditioned on the rules being adopted in accordance with all | ||||||
16 | provisions of the Illinois Administrative Procedure Act and all | ||||||
17 | rules and procedures of the Joint Committee on Administrative | ||||||
18 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
19 | is unauthorized. | ||||||
20 | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | ||||||
21 | 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; 96-806, eff. | ||||||
22 | 7-1-10; revised 11-4-09.) | ||||||
23 | Section 95. No acceleration or delay. Where this Act makes | ||||||
24 | changes in a statute that is represented in this Act by text | ||||||
25 | that is not yet or no longer in effect (for example, a Section |
| |||||||
| |||||||
1 | represented by multiple versions), the use of that text does | ||||||
2 | not accelerate or delay the taking effect of (i) the changes | ||||||
3 | made by this Act or (ii) provisions derived from any other | ||||||
4 | Public Act.
| ||||||
5 | Section 99. Effective date. This Act takes effect upon | ||||||
6 | becoming law.".
|