93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB4999

 

Introduced 02/05/04, by Deborah L. Graham

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.5
305 ILCS 5/5-5   from Ch. 23, par. 5-5

    Amends provisions of the Illinois Insurance Code setting forth coverage requirements that apply to group or individual policies of accident and health insurance and managed care plans, health maintenance organizations, and health services plan corporations. Requires coverage for a minimum of 2 spacers and peak flow meters per year. Amends the Illinois Public Aid Code. Adds to the list of medical services to be provided prescription inhalents and at least 2 spacers and peak flow meters to be provided each year.


LRB093 18428 SAS 44136 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB4999 LRB093 18428 SAS 44136 b

1     AN ACT concerning health care coverage.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by
5 changing Section 356z.4, as added by Public Act 93-529, as
6 follows:
 
7     (215 ILCS 5/356z.5)
8     Sec. 356z.5 356z.4. Prescription inhalants, spacers, and
9 peak flow meters. A group or individual policy of accident and
10 health insurance or managed care plan amended, delivered,
11 issued, or renewed after the effective date of this amendatory
12 Act of the 93rd General Assembly that provides coverage for
13 prescription drugs may not deny or limit coverage for
14 prescription inhalants and at least 2 spacers and peak flow
15 meters per year to enable persons to breathe when suffering
16 from asthma or other life-threatening bronchial ailments based
17 upon any restriction on the number of days before an inhaler
18 refill may be obtained if, contrary to those restrictions, the
19 inhalants have been ordered or prescribed by the treating
20 physician and are medically appropriate.
21 (Source: P.A. 93-529, eff. 8-14-03; revised 9-25-03.)
 
22     Section 10. The Illinois Public Aid Code is amended by
23 changing Section 5-5 as follows:
 
24     (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
25     Sec. 5-5. Medical services. The Illinois Department, by
26 rule, shall determine the quantity and quality of and the rate
27 of reimbursement for the medical assistance for which payment
28 will be authorized, and the medical services to be provided,
29 which may include all or part of the following: (1) inpatient
30 hospital services; (2) outpatient hospital services; (3) other

 

 

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1 laboratory and X-ray services; (4) skilled nursing home
2 services; (5) physicians' services whether furnished in the
3 office, the patient's home, a hospital, a skilled nursing home,
4 or elsewhere; (6) medical care, or any other type of remedial
5 care furnished by licensed practitioners; (7) home health care
6 services; (8) private duty nursing service; (9) clinic
7 services; (10) dental services; (11) physical therapy and
8 related services; (12) prescribed drugs, dentures, and
9 prosthetic devices; and eyeglasses prescribed by a physician
10 skilled in the diseases of the eye, or by an optometrist,
11 whichever the person may select; (13) other diagnostic,
12 screening, preventive, and rehabilitative services; (14)
13 transportation and such other expenses as may be necessary;
14 (15) medical treatment of sexual assault survivors, as defined
15 in Section 1a of the Sexual Assault Survivors Emergency
16 Treatment Act, for injuries sustained as a result of the sexual
17 assault, including examinations and laboratory tests to
18 discover evidence which may be used in criminal proceedings
19 arising from the sexual assault; (16) the diagnosis and
20 treatment of sickle cell anemia; and (17) any other medical
21 care, and any other type of remedial care recognized under the
22 laws of this State, but not including abortions, or induced
23 miscarriages or premature births, unless, in the opinion of a
24 physician, such procedures are necessary for the preservation
25 of the life of the woman seeking such treatment, or except an
26 induced premature birth intended to produce a live viable child
27 and such procedure is necessary for the health of the mother or
28 her unborn child. The Illinois Department, by rule, shall
29 prohibit any physician from providing medical assistance to
30 anyone eligible therefor under this Code where such physician
31 has been found guilty of performing an abortion procedure in a
32 wilful and wanton manner upon a woman who was not pregnant at
33 the time such abortion procedure was performed. The term "any
34 other type of remedial care" shall include nursing care and
35 nursing home service for persons who rely on treatment by
36 spiritual means alone through prayer for healing; and (18)

 

 

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1 coverage for prescription inhalants and and at least 2 spacers
2 and peak flow meters per year to enable persons to breathe when
3 suffering from asthma or other life-threatening bronchial
4 ailments based upon any restriction on the number of days
5 before an inhaler refill may be obtained if, contrary to those
6 restrictions, the inhalants have been ordered or prescribed by
7 the treating physician and are medically appropriate.
8     Notwithstanding any other provision of this Section, a
9 comprehensive tobacco use cessation program that includes
10 purchasing prescription drugs or prescription medical devices
11 approved by the Food and Drug administration shall be covered
12 under the medical assistance program under this Article for
13 persons who are otherwise eligible for assistance under this
14 Article.
15     Notwithstanding any other provision of this Code, the
16 Illinois Department may not require, as a condition of payment
17 for any laboratory test authorized under this Article, that a
18 physician's handwritten signature appear on the laboratory
19 test order form. The Illinois Department may, however, impose
20 other appropriate requirements regarding laboratory test order
21 documentation.
22     The Illinois Department of Public Aid shall provide the
23 following services to persons eligible for assistance under
24 this Article who are participating in education, training or
25 employment programs operated by the Department of Human
26 Services as successor to the Department of Public Aid:
27         (1) dental services, which shall include but not be
28     limited to prosthodontics; and
29         (2) eyeglasses prescribed by a physician skilled in the
30     diseases of the eye, or by an optometrist, whichever the
31     person may select.
32     The Illinois Department, by rule, may distinguish and
33 classify the medical services to be provided only in accordance
34 with the classes of persons designated in Section 5-2.
35     The Illinois Department shall authorize the provision of,
36 and shall authorize payment for, screening by low-dose

 

 

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1 mammography for the presence of occult breast cancer for women
2 35 years of age or older who are eligible for medical
3 assistance under this Article, as follows: a baseline mammogram
4 for women 35 to 39 years of age and an annual mammogram for
5 women 40 years of age or older. All screenings shall include a
6 physical breast exam, instruction on self-examination and
7 information regarding the frequency of self-examination and
8 its value as a preventative tool. As used in this Section,
9 "low-dose mammography" means the x-ray examination of the
10 breast using equipment dedicated specifically for mammography,
11 including the x-ray tube, filter, compression device, image
12 receptor, and cassettes, with an average radiation exposure
13 delivery of less than one rad mid-breast, with 2 views for each
14 breast.
15     Any medical or health care provider shall immediately
16 recommend, to any pregnant woman who is being provided prenatal
17 services and is suspected of drug abuse or is addicted as
18 defined in the Alcoholism and Other Drug Abuse and Dependency
19 Act, referral to a local substance abuse treatment provider
20 licensed by the Department of Human Services or to a licensed
21 hospital which provides substance abuse treatment services.
22 The Department of Public Aid shall assure coverage for the cost
23 of treatment of the drug abuse or addiction for pregnant
24 recipients in accordance with the Illinois Medicaid Program in
25 conjunction with the Department of Human Services.
26     All medical providers providing medical assistance to
27 pregnant women under this Code shall receive information from
28 the Department on the availability of services under the Drug
29 Free Families with a Future or any comparable program providing
30 case management services for addicted women, including
31 information on appropriate referrals for other social services
32 that may be needed by addicted women in addition to treatment
33 for addiction.
34     The Illinois Department, in cooperation with the
35 Departments of Human Services (as successor to the Department
36 of Alcoholism and Substance Abuse) and Public Health, through a

 

 

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1 public awareness campaign, may provide information concerning
2 treatment for alcoholism and drug abuse and addiction, prenatal
3 health care, and other pertinent programs directed at reducing
4 the number of drug-affected infants born to recipients of
5 medical assistance.
6     Neither the Illinois Department of Public Aid nor the
7 Department of Human Services shall sanction the recipient
8 solely on the basis of her substance abuse.
9     The Illinois Department shall establish such regulations
10 governing the dispensing of health services under this Article
11 as it shall deem appropriate. The Department should seek the
12 advice of formal professional advisory committees appointed by
13 the Director of the Illinois Department for the purpose of
14 providing regular advice on policy and administrative matters,
15 information dissemination and educational activities for
16 medical and health care providers, and consistency in
17 procedures to the Illinois Department.
18     The Illinois Department may develop and contract with
19 Partnerships of medical providers to arrange medical services
20 for persons eligible under Section 5-2 of this Code.
21 Implementation of this Section may be by demonstration projects
22 in certain geographic areas. The Partnership shall be
23 represented by a sponsor organization. The Department, by rule,
24 shall develop qualifications for sponsors of Partnerships.
25 Nothing in this Section shall be construed to require that the
26 sponsor organization be a medical organization.
27     The sponsor must negotiate formal written contracts with
28 medical providers for physician services, inpatient and
29 outpatient hospital care, home health services, treatment for
30 alcoholism and substance abuse, and other services determined
31 necessary by the Illinois Department by rule for delivery by
32 Partnerships. Physician services must include prenatal and
33 obstetrical care. The Illinois Department shall reimburse
34 medical services delivered by Partnership providers to clients
35 in target areas according to provisions of this Article and the
36 Illinois Health Finance Reform Act, except that:

 

 

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1         (1) Physicians participating in a Partnership and
2     providing certain services, which shall be determined by
3     the Illinois Department, to persons in areas covered by the
4     Partnership may receive an additional surcharge for such
5     services.
6         (2) The Department may elect to consider and negotiate
7     financial incentives to encourage the development of
8     Partnerships and the efficient delivery of medical care.
9         (3) Persons receiving medical services through
10     Partnerships may receive medical and case management
11     services above the level usually offered through the
12     medical assistance program.
13     Medical providers shall be required to meet certain
14 qualifications to participate in Partnerships to ensure the
15 delivery of high quality medical services. These
16 qualifications shall be determined by rule of the Illinois
17 Department and may be higher than qualifications for
18 participation in the medical assistance program. Partnership
19 sponsors may prescribe reasonable additional qualifications
20 for participation by medical providers, only with the prior
21 written approval of the Illinois Department.
22     Nothing in this Section shall limit the free choice of
23 practitioners, hospitals, and other providers of medical
24 services by clients. In order to ensure patient freedom of
25 choice, the Illinois Department shall immediately promulgate
26 all rules and take all other necessary actions so that provided
27 services may be accessed from therapeutically certified
28 optometrists to the full extent of the Illinois Optometric
29 Practice Act of 1987 without discriminating between service
30 providers.
31     The Department shall apply for a waiver from the United
32 States Health Care Financing Administration to allow for the
33 implementation of Partnerships under this Section.
34     The Illinois Department shall require health care
35 providers to maintain records that document the medical care
36 and services provided to recipients of Medical Assistance under

 

 

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1 this Article. The Illinois Department shall require health care
2 providers to make available, when authorized by the patient, in
3 writing, the medical records in a timely fashion to other
4 health care providers who are treating or serving persons
5 eligible for Medical Assistance under this Article. All
6 dispensers of medical services shall be required to maintain
7 and retain business and professional records sufficient to
8 fully and accurately document the nature, scope, details and
9 receipt of the health care provided to persons eligible for
10 medical assistance under this Code, in accordance with
11 regulations promulgated by the Illinois Department. The rules
12 and regulations shall require that proof of the receipt of
13 prescription drugs, dentures, prosthetic devices and
14 eyeglasses by eligible persons under this Section accompany
15 each claim for reimbursement submitted by the dispenser of such
16 medical services. No such claims for reimbursement shall be
17 approved for payment by the Illinois Department without such
18 proof of receipt, unless the Illinois Department shall have put
19 into effect and shall be operating a system of post-payment
20 audit and review which shall, on a sampling basis, be deemed
21 adequate by the Illinois Department to assure that such drugs,
22 dentures, prosthetic devices and eyeglasses for which payment
23 is being made are actually being received by eligible
24 recipients. Within 90 days after the effective date of this
25 amendatory Act of 1984, the Illinois Department shall establish
26 a current list of acquisition costs for all prosthetic devices
27 and any other items recognized as medical equipment and
28 supplies reimbursable under this Article and shall update such
29 list on a quarterly basis, except that the acquisition costs of
30 all prescription drugs shall be updated no less frequently than
31 every 30 days as required by Section 5-5.12.
32     The rules and regulations of the Illinois Department shall
33 require that a written statement including the required opinion
34 of a physician shall accompany any claim for reimbursement for
35 abortions, or induced miscarriages or premature births. This
36 statement shall indicate what procedures were used in providing

 

 

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1 such medical services.
2     The Illinois Department shall require all dispensers of
3 medical services, other than an individual practitioner or
4 group of practitioners, desiring to participate in the Medical
5 Assistance program established under this Article to disclose
6 all financial, beneficial, ownership, equity, surety or other
7 interests in any and all firms, corporations, partnerships,
8 associations, business enterprises, joint ventures, agencies,
9 institutions or other legal entities providing any form of
10 health care services in this State under this Article.
11     The Illinois Department may require that all dispensers of
12 medical services desiring to participate in the medical
13 assistance program established under this Article disclose,
14 under such terms and conditions as the Illinois Department may
15 by rule establish, all inquiries from clients and attorneys
16 regarding medical bills paid by the Illinois Department, which
17 inquiries could indicate potential existence of claims or liens
18 for the Illinois Department.
19     Enrollment of a vendor that provides non-emergency medical
20 transportation, defined by the Department by rule, shall be
21 conditional for 180 days. During that time, the Department of
22 Public Aid may terminate the vendor's eligibility to
23 participate in the medical assistance program without cause.
24 That termination of eligibility is not subject to the
25 Department's hearing process.
26     The Illinois Department shall establish policies,
27 procedures, standards and criteria by rule for the acquisition,
28 repair and replacement of orthotic and prosthetic devices and
29 durable medical equipment. Such rules shall provide, but not be
30 limited to, the following services: (1) immediate repair or
31 replacement of such devices by recipients without medical
32 authorization; and (2) rental, lease, purchase or
33 lease-purchase of durable medical equipment in a
34 cost-effective manner, taking into consideration the
35 recipient's medical prognosis, the extent of the recipient's
36 needs, and the requirements and costs for maintaining such

 

 

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1 equipment. Such rules shall enable a recipient to temporarily
2 acquire and use alternative or substitute devices or equipment
3 pending repairs or replacements of any device or equipment
4 previously authorized for such recipient by the Department.
5 Rules under clause (2) above shall not provide for purchase or
6 lease-purchase of durable medical equipment or supplies used
7 for the purpose of oxygen delivery and respiratory care.
8     The Department shall execute, relative to the nursing home
9 prescreening project, written inter-agency agreements with the
10 Department of Human Services and the Department on Aging, to
11 effect the following: (i) intake procedures and common
12 eligibility criteria for those persons who are receiving
13 non-institutional services; and (ii) the establishment and
14 development of non-institutional services in areas of the State
15 where they are not currently available or are undeveloped.
16     The Illinois Department shall develop and operate, in
17 cooperation with other State Departments and agencies and in
18 compliance with applicable federal laws and regulations,
19 appropriate and effective systems of health care evaluation and
20 programs for monitoring of utilization of health care services
21 and facilities, as it affects persons eligible for medical
22 assistance under this Code.
23     The Illinois Department shall report annually to the
24 General Assembly, no later than the second Friday in April of
25 1979 and each year thereafter, in regard to:
26         (a) actual statistics and trends in utilization of
27     medical services by public aid recipients;
28         (b) actual statistics and trends in the provision of
29     the various medical services by medical vendors;
30         (c) current rate structures and proposed changes in
31     those rate structures for the various medical vendors; and
32         (d) efforts at utilization review and control by the
33     Illinois Department.
34     The period covered by each report shall be the 3 years
35 ending on the June 30 prior to the report. The report shall
36 include suggested legislation for consideration by the General

 

 

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1 Assembly. The filing of one copy of the report with the
2 Speaker, one copy with the Minority Leader and one copy with
3 the Clerk of the House of Representatives, one copy with the
4 President, one copy with the Minority Leader and one copy with
5 the Secretary of the Senate, one copy with the Legislative
6 Research Unit, and such additional copies with the State
7 Government Report Distribution Center for the General Assembly
8 as is required under paragraph (t) of Section 7 of the State
9 Library Act shall be deemed sufficient to comply with this
10 Section.
11 (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02;
12 92-789, eff. 8-6-02; 93-632, eff. 2-1-04.)