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