Rep. Greg Harris

Filed: 3/3/2011

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 1191

2    AMENDMENT NO. ______. Amend House Bill 1191 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, and 356z.17, 356z.19, and 364.01 of the
16Illinois Insurance Code. The program of health benefits must

 

 

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1comply with Section 155.37 of the Illinois Insurance Code.
2    Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
995-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
106-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044,
11eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
1296-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10;
1396-1000, eff. 7-2-10.)
 
14    Section 10. The Counties Code is amended by changing
15Section 5-1069.3 as follows:
 
16    (55 ILCS 5/5-1069.3)
17    Sec. 5-1069.3. Required health benefits. If a county,
18including a home rule county, is a self-insurer for purposes of
19providing health insurance coverage for its employees, the
20coverage shall include coverage for the post-mastectomy care
21benefits required to be covered by a policy of accident and
22health insurance under Section 356t and the coverage required
23under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
24356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,

 

 

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1356z.14, and 356z.15, 356z.19, and 364.01 of the Illinois
2Insurance Code. The requirement that health benefits be covered
3as provided in this Section is an exclusive power and function
4of the State and is a denial and limitation under Article VII,
5Section 6, subsection (h) of the Illinois Constitution. A home
6rule county to which this Section applies must comply with
7every provision of this Section.
8    Rulemaking authority to implement Public Act 95-1045, if
9any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
14(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
1595-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
166-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045,
17eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10;
1896-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
 
19    Section 15. The Illinois Municipal Code is amended by
20changing Section 10-4-2.3 as follows:
 
21    (65 ILCS 5/10-4-2.3)
22    Sec. 10-4-2.3. Required health benefits. If a
23municipality, including a home rule municipality, is a
24self-insurer for purposes of providing health insurance

 

 

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1coverage for its employees, the coverage shall include coverage
2for the post-mastectomy care benefits required to be covered by
3a policy of accident and health insurance under Section 356t
4and the coverage required under Sections 356g, 356g.5,
5356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
6356z.11, 356z.12, 356z.13, 356z.14, and 356z.15, 356z.19, and
7364.01 of the Illinois Insurance Code. The requirement that
8health benefits be covered as provided in this is an exclusive
9power and function of the State and is a denial and limitation
10under Article VII, Section 6, subsection (h) of the Illinois
11Constitution. A home rule municipality to which this Section
12applies must comply with every provision of this Section.
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
2095-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
216-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045,
22eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10;
2396-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
 
24    Section 20. The School Code is amended by changing Section
2510-22.3f as follows:
 

 

 

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1    (105 ILCS 5/10-22.3f)
2    Sec. 10-22.3f. Required health benefits. Insurance
3protection and benefits for employees shall provide the
4post-mastectomy care benefits required to be covered by a
5policy of accident and health insurance under Section 356t and
6the coverage required under Sections 356g, 356g.5, 356g.5-1,
7356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
8356z.13, 356z.14, and 356z.15, 356z.19, and 364.01 of the
9Illinois Insurance Code.
10    Rulemaking authority to implement Public Act 95-1045, if
11any, is conditioned on the rules being adopted in accordance
12with all provisions of the Illinois Administrative Procedure
13Act and all rules and procedures of the Joint Committee on
14Administrative Rules; any purported rule not so adopted, for
15whatever reason, is unauthorized.
16(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
1795-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
1895-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
191-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-1000,
20eff. 7-2-10.)
 
21    Section 25. The Illinois Insurance Code is amended by
22changing Section 364.01 and by adding Section 356z.19 as
23follows:
 

 

 

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1    (215 ILCS 5/356z.19 new)
2    Sec. 356z.19. Routine patient care.
3    (a) For the purposes of this Section, the term "qualified
4individual" means an individual who is a participant or
5beneficiary in a health plan or with coverage described in
6paragraph (1) of subsection (c) and who meets the following
7conditions:
8        (1) the individual is eligible to participate in an
9    approved clinical trial according to the trial protocol
10    with respect to treatment of cancer or other
11    life-threatening disease or condition; and
12        (2) either:
13            (A) the referring health care professional is a
14        participating health care provider and has concluded
15        that the individual's participation in such trial
16        would be appropriate based upon the individual meeting
17        the conditions described in paragraph (1) of this
18        subsection; or
19            (B) the participant or beneficiary provides
20        medical and scientific information establishing that
21        the individual's participation in such trial would be
22        appropriate based upon the individual meeting the
23        conditions described in paragraph (1) of this
24        subsection.
25    (b) For the purposes of this Section, the term
26"life-threatening condition" or "life-threatening disease"

 

 

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1means any condition or disease from which the likelihood of
2death is probable unless the course of the disease or condition
3is interrupted.
4    (c) Coverage for routine patient care must comply with the
5following provisions:
6        (1) If a group health plan or a health insurance issuer
7    offering group or individual health insurance coverage
8    provides coverage to a qualified individual, then such plan
9    or issuer:
10            (A) may not deny the individual participation in
11        the clinical trial referred to in subsection (a) of
12        this Section;
13            (B) subject to subsection (d) of this Section, may
14        not deny or limit or impose additional conditions on
15        the coverage of routine patient care costs for items
16        and services furnished in connection with
17        participation in the trial; and
18            (C) may not discriminate against the individual on
19        the basis of the individual's participation in the
20        trial.
21        (2) The following provisions concerning routine
22    patient costs shall apply:
23            (A) For purposes of and, subject to subparagraph
24        (B) of paragraph (1) of this subsection, routine
25        patient care costs include all items and services
26        consistent with the coverage provided in the plan or

 

 

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1        coverage that is typically provided for a qualified
2        individual who is not enrolled in a clinical trial.
3            (B) For purposes of subparagraph (B) of paragraph
4        (1) of this subsection, routine patient care costs do
5        not include the following:
6                (i) the investigational item, device, or
7            service itself;
8                (ii) items and services that are provided
9            solely to satisfy data collection and analysis
10            needs and that are not used in the direct clinical
11            management of the patient; or
12                (iii) a service that is clearly inconsistent
13            with widely accepted and established standards of
14            care for a particular diagnosis.
15        (3) If one or more participating providers are
16    participating in a clinical trial, then nothing in
17    paragraph (1) of this subsection shall be construed as
18    preventing a plan or issuer from requiring that a qualified
19    individual participate in the trial through a
20    participating provider if the provider will accept the
21    individual as a participant in the trial.
22        (4) Notwithstanding paragraph (3) of this subsection,
23    paragraph (1) shall apply to a qualified individual
24    participating in an approved clinical trial that is
25    conducted outside the state in which the qualified
26    individual resides.

 

 

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1    (d) This Section shall not be construed to require a group
2health plan or a health insurance issuer offering group or
3individual health insurance coverage to provide benefits for
4routine patient care services provided outside of the plan's or
5coverage's health care provider network unless out-of-network
6benefits are otherwise provided under the plan or coverage.
7    (e) The following provisions concerning approved clinical
8trials shall apply:
9        (1) In this Section, the term "approved clinical trial"
10    means a phase I, phase II, phase III, or phase IV clinical
11    trial that is conducted in relation to the prevention,
12    detection, or treatment of cancer or other
13    life-threatening disease or condition and is described in
14    any of the following provisions:
15            (A) The study or investigation is approved or
16        funded (which may include funding through in-kind
17        contributions) by one or more of the following:
18                (i) The National Institutes of Health.
19                (ii) The Centers for Disease Control and
20            Prevention.
21                (iii) The Agency for Health Care Research and
22            Quality.
23                (iv) The Centers for Medicare and Medicaid
24            Services.
25                (v) A cooperative group or center of any of the
26            entities described in items (i) through (iv) of

 

 

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1            this subparagraph or the U.S. Department of
2            Defense or Department of Veterans Affairs.
3                (vi) A qualified non-governmental research
4            entity identified in the guidelines issued by the
5            National Institutes of Health for center support
6            grants.
7                (vii) Any of the following if the conditions
8            described in paragraph (2) of this subsection are
9            met:
10                    (I) The U.S. Department of Veterans
11                Affairs.
12                    (II) The U.S. Department of Defense.
13                    (III) The U.S. Department of Energy.
14            (B) The study or investigation is conducted under
15        an investigational new drug application reviewed by
16        the U.S. Food and Drug Administration.
17            (C) The study or investigation is a drug trial that
18        is exempt from having such an investigational new drug
19        application.
20        (2) A study or investigation under item (1)(A)(vii) of
21    this subsection is subject to the condition that it must be
22    reviewed and approved through a system of peer review that:
23            (A) is comparable to the system of peer review of
24        studies and investigations used by the National
25        Institutes of Health; and
26            (B) ensures unbiased review of the highest

 

 

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1        scientific standard by qualified individuals who have
2        no interest in the outcome of the review.
3    (f) Nothing in this Section shall be construed to limit a
4plan's or issuer's coverage with respect to clinical trials.
 
5    (215 ILCS 5/364.01)
6    Sec. 364.01. Qualified clinical cancer trials.
7    (a) No individual or group policy of accident and health
8insurance issued or renewed in this State may be cancelled or
9non-renewed for any individual based on that individual's
10participation in a qualified clinical cancer trial.
11    (b) Qualified clinical cancer trials must meet the
12following criteria:
13        (1) the effectiveness of the treatment has not been
14    determined relative to established therapies;
15        (2) the trial is under clinical investigation as part
16    of an approved cancer research trial in Phase II, Phase
17    III, or Phase IV of investigation;
18        (3) the trial is:
19            (A) approved by the Food and Drug Administration;
20        or
21            (B) approved and funded by the National Institutes
22        of Health, the Centers for Disease Control and
23        Prevention, the Agency for Healthcare Research and
24        Quality, the United States Department of Defense, the
25        United States Department of Veterans Affairs, or the

 

 

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1        United States Department of Energy in the form of an
2        investigational new drug application, or a cooperative
3        group or center of any entity described in this
4        subdivision (B); and
5        (4) the patient's primary care physician, if any, is
6    involved in the coordination of care.
7    (c) No group policy of accident and health insurance shall
8exclude coverage for any routine patient care administered to
9an insured who is a qualified individual participating in a
10qualified clinical cancer trial if the policy covers that same
11routine patient care of insureds not enrolled in a qualified
12clinical cancer trial.
13    (d) The coverage that may not be excluded under subsection
14(c) of this Section is subject to all terms, conditions,
15restrictions, exclusions, and limitations that apply to the
16same routine patient care received by an insured not enrolled
17in a qualified clinical cancer trial, including the application
18of any authorization requirement, utilization review, or
19medical management practices. The insured or enrollee shall
20incur no greater out-of-pocket liability than had the insured
21or enrollee not enrolled in a qualified clinical cancer trial.
22    (e) If the group policy of accident and health insurance
23uses a preferred provider program and a preferred provider
24provides routine patient care in connection with a qualified
25clinical cancer trial, then the insurer may require the insured
26to use the preferred provider if the preferred provider agrees

 

 

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1to provide to the insured that routine patient care.
2    (f) A qualified clinical cancer trial may not pay or refuse
3to pay for routine patient care of a individual participating
4in the trial, based in whole or in part on the person's having
5or not having coverage for routine patient care under a group
6policy of accident and health insurance.
7    (g) Nothing in this Section shall be construed to limit an
8insurer's coverage with respect to clinical trials.
9    (h) Nothing in this Section shall require coverage for
10out-of-network services where the underlying health benefit
11plan does not provide coverage for out-of-network services.
12    (i) As used in this Section, "routine patient care" means
13all health care services provided in the qualified clinical
14cancer trial that are otherwise generally covered under the
15policy if those items or services were not provided in
16connection with a qualified clinical cancer trial consistent
17with the standard of care for the treatment of cancer,
18including the type and frequency of any diagnostic modality,
19that a provider typically provides to a cancer patient who is
20not enrolled in a qualified clinical cancer trial. "Routine
21patient care" does not include, and a group policy of accident
22and health insurance may exclude, coverage for:
23        (1) a health care service, item, or drug that is the
24    subject of the cancer clinical trial;
25        (2) a health care service, item, or drug provided
26    solely to satisfy data collection and analysis needs for

 

 

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1    the qualified clinical cancer trial that is not used in the
2    direct clinical management of the patient;
3        (3) an investigational drug or device that has not been
4    approved for market by the United States Food and Drug
5    Administration;
6        (4) transportation, lodging, food, or other expenses
7    for the patient or a family member or companion of the
8    patient that are associated with the travel to or from a
9    facility providing the qualified clinical cancer trial,
10    unless the policy covers these expenses for a cancer
11    patient who is not enrolled in a qualified clinical cancer
12    trial;
13        (5) a health care service, item, or drug customarily
14    provided by the qualified clinical cancer trial sponsors
15    free of charge for any patient;
16        (6) a health care service or item that, except for the
17    fact that it is being provided in a qualified clinical
18    cancer trial, is otherwise specifically excluded from
19    coverage under the insured's policy, including:
20            (A) costs of extra treatments, services,
21        procedures, tests, or drugs that would not be performed
22        or administered except for the fact that the insured is
23        participating in the cancer clinical trial; and
24            (B) costs of nonhealth care services that the
25        patient is required to receive as a result of
26        participation in the approved cancer clinical trial;

 

 

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1        (7) costs for services, items, or drugs that are
2    eligible for reimbursement from a source other than a
3    patient's contract or policy providing for third-party
4    payment or prepayment of health or medical expenses,
5    including the sponsor of the approved cancer clinical
6    trial; or
7        (8) costs associated with approved cancer clinical
8    trials designed exclusively to test toxicity or disease
9    pathophysiology, unless the policy covers these expenses
10    for a cancer patient who is not enrolled in a qualified
11    clinical cancer trial; or
12        (9) a health care service or item that is eligible for
13    reimbursement by a source other than the insured's policy,
14    including the sponsor of the qualified clinical cancer
15    trial.
16    The definitions of the terms "health care services",
17"Non-Preferred Provider", "Preferred Provider", and "Preferred
18Provider Program", stated in 50 IL Adm. Code Part 2051
19Preferred Provider Programs apply to these terms in this
20Section.
21    (j) The external review procedures established under the
22Health Carrier External Review Act shall apply to the
23provisions under this Section.
24(Source: P.A. 93-1000, eff. 1-1-05.)
 
25    Section 30. The Health Maintenance Organization Act is

 

 

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1amended by changing Section 5-3 as follows:
 
2    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
3    Sec. 5-3. Insurance Code provisions.
4    (a) Health Maintenance Organizations shall be subject to
5the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
6141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
7154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
8356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
9356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
10356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
11368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2,
12409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
13Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
14XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
15    (b) For purposes of the Illinois Insurance Code, except for
16Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
17Maintenance Organizations in the following categories are
18deemed to be "domestic companies":
19        (1) a corporation authorized under the Dental Service
20    Plan Act or the Voluntary Health Services Plans Act;
21        (2) a corporation organized under the laws of this
22    State; or
23        (3) a corporation organized under the laws of another
24    state, 30% or more of the enrollees of which are residents
25    of this State, except a corporation subject to

 

 

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1    substantially the same requirements in its state of
2    organization as is a "domestic company" under Article VIII
3    1/2 of the Illinois Insurance Code.
4    (c) In considering the merger, consolidation, or other
5acquisition of control of a Health Maintenance Organization
6pursuant to Article VIII 1/2 of the Illinois Insurance Code,
7        (1) the Director shall give primary consideration to
8    the continuation of benefits to enrollees and the financial
9    conditions of the acquired Health Maintenance Organization
10    after the merger, consolidation, or other acquisition of
11    control takes effect;
12        (2)(i) the criteria specified in subsection (1)(b) of
13    Section 131.8 of the Illinois Insurance Code shall not
14    apply and (ii) the Director, in making his determination
15    with respect to the merger, consolidation, or other
16    acquisition of control, need not take into account the
17    effect on competition of the merger, consolidation, or
18    other acquisition of control;
19        (3) the Director shall have the power to require the
20    following information:
21            (A) certification by an independent actuary of the
22        adequacy of the reserves of the Health Maintenance
23        Organization sought to be acquired;
24            (B) pro forma financial statements reflecting the
25        combined balance sheets of the acquiring company and
26        the Health Maintenance Organization sought to be

 

 

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1        acquired as of the end of the preceding year and as of
2        a date 90 days prior to the acquisition, as well as pro
3        forma financial statements reflecting projected
4        combined operation for a period of 2 years;
5            (C) a pro forma business plan detailing an
6        acquiring party's plans with respect to the operation
7        of the Health Maintenance Organization sought to be
8        acquired for a period of not less than 3 years; and
9            (D) such other information as the Director shall
10        require.
11    (d) The provisions of Article VIII 1/2 of the Illinois
12Insurance Code and this Section 5-3 shall apply to the sale by
13any health maintenance organization of greater than 10% of its
14enrollee population (including without limitation the health
15maintenance organization's right, title, and interest in and to
16its health care certificates).
17    (e) In considering any management contract or service
18agreement subject to Section 141.1 of the Illinois Insurance
19Code, the Director (i) shall, in addition to the criteria
20specified in Section 141.2 of the Illinois Insurance Code, take
21into account the effect of the management contract or service
22agreement on the continuation of benefits to enrollees and the
23financial condition of the health maintenance organization to
24be managed or serviced, and (ii) need not take into account the
25effect of the management contract or service agreement on
26competition.

 

 

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1    (f) Except for small employer groups as defined in the
2Small Employer Rating, Renewability and Portability Health
3Insurance Act and except for medicare supplement policies as
4defined in Section 363 of the Illinois Insurance Code, a Health
5Maintenance Organization may by contract agree with a group or
6other enrollment unit to effect refunds or charge additional
7premiums under the following terms and conditions:
8        (i) the amount of, and other terms and conditions with
9    respect to, the refund or additional premium are set forth
10    in the group or enrollment unit contract agreed in advance
11    of the period for which a refund is to be paid or
12    additional premium is to be charged (which period shall not
13    be less than one year); and
14        (ii) the amount of the refund or additional premium
15    shall not exceed 20% of the Health Maintenance
16    Organization's profitable or unprofitable experience with
17    respect to the group or other enrollment unit for the
18    period (and, for purposes of a refund or additional
19    premium, the profitable or unprofitable experience shall
20    be calculated taking into account a pro rata share of the
21    Health Maintenance Organization's administrative and
22    marketing expenses, but shall not include any refund to be
23    made or additional premium to be paid pursuant to this
24    subsection (f)). The Health Maintenance Organization and
25    the group or enrollment unit may agree that the profitable
26    or unprofitable experience may be calculated taking into

 

 

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1    account the refund period and the immediately preceding 2
2    plan years.
3    The Health Maintenance Organization shall include a
4statement in the evidence of coverage issued to each enrollee
5describing the possibility of a refund or additional premium,
6and upon request of any group or enrollment unit, provide to
7the group or enrollment unit a description of the method used
8to calculate (1) the Health Maintenance Organization's
9profitable experience with respect to the group or enrollment
10unit and the resulting refund to the group or enrollment unit
11or (2) the Health Maintenance Organization's unprofitable
12experience with respect to the group or enrollment unit and the
13resulting additional premium to be paid by the group or
14enrollment unit.
15    In no event shall the Illinois Health Maintenance
16Organization Guaranty Association be liable to pay any
17contractual obligation of an insolvent organization to pay any
18refund authorized under this Section.
19    (g) Rulemaking authority to implement Public Act 95-1045,
20if any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for
24whatever reason, is unauthorized.
25(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
2695-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;

 

 

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195-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
21-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff.
36-1-10; 96-1000, eff. 7-2-10.)
 
4    Section 35. The Voluntary Health Services Plans Act is
5amended by changing Section 10 as follows:
 
6    (215 ILCS 165/10)  (from Ch. 32, par. 604)
7    Sec. 10. Application of Insurance Code provisions. Health
8services plan corporations and all persons interested therein
9or dealing therewith shall be subject to the provisions of
10Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
11149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
12356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
13356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
14356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401,
15401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
16and (15) of Section 367 of the Illinois Insurance Code.
17    Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
2495-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.

 

 

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18-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
2eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
396-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff.
47-2-10.)
 
5    Section 40. The Illinois Public Aid Code is amended by
6changing Section 5-5 as follows:
 
7    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
8    Sec. 5-5. Medical services. The Illinois Department, by
9rule, shall determine the quantity and quality of and the rate
10of reimbursement for the medical assistance for which payment
11will be authorized, and the medical services to be provided,
12which may include all or part of the following: (1) inpatient
13hospital services; (2) outpatient hospital services; (3) other
14laboratory and X-ray services; (4) skilled nursing home
15services; (5) physicians' services whether furnished in the
16office, the patient's home, a hospital, a skilled nursing home,
17or elsewhere; (6) medical care, or any other type of remedial
18care furnished by licensed practitioners; (7) home health care
19services; (8) private duty nursing service; (9) clinic
20services; (10) dental services, including prevention and
21treatment of periodontal disease and dental caries disease for
22pregnant women, provided by an individual licensed to practice
23dentistry or dental surgery; for purposes of this item (10),
24"dental services" means diagnostic, preventive, or corrective

 

 

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1procedures provided by or under the supervision of a dentist in
2the practice of his or her profession; (11) physical therapy
3and related services; (12) prescribed drugs, dentures, and
4prosthetic devices; and eyeglasses prescribed by a physician
5skilled in the diseases of the eye, or by an optometrist,
6whichever the person may select; (13) other diagnostic,
7screening, preventive, and rehabilitative services; (14)
8transportation and such other expenses as may be necessary;
9(15) medical treatment of sexual assault survivors, as defined
10in Section 1a of the Sexual Assault Survivors Emergency
11Treatment Act, for injuries sustained as a result of the sexual
12assault, including examinations and laboratory tests to
13discover evidence which may be used in criminal proceedings
14arising from the sexual assault; (16) the diagnosis and
15treatment of sickle cell anemia; and (17) any other medical
16care, and any other type of remedial care recognized under the
17laws of this State, but not including abortions, or induced
18miscarriages or premature births, unless, in the opinion of a
19physician, such procedures are necessary for the preservation
20of the life of the woman seeking such treatment, or except an
21induced premature birth intended to produce a live viable child
22and such procedure is necessary for the health of the mother or
23her unborn child. The Illinois Department, by rule, shall
24prohibit any physician from providing medical assistance to
25anyone eligible therefor under this Code where such physician
26has been found guilty of performing an abortion procedure in a

 

 

09700HB1191ham001- 24 -LRB097 06572 RPM 51436 a

1wilful and wanton manner upon a woman who was not pregnant at
2the time such abortion procedure was performed. The term "any
3other type of remedial care" shall include nursing care and
4nursing home service for persons who rely on treatment by
5spiritual means alone through prayer for healing.
6    Notwithstanding any other provision of this Section, a
7comprehensive tobacco use cessation program that includes
8purchasing prescription drugs or prescription medical devices
9approved by the Food and Drug Administration shall be covered
10under the medical assistance program under this Article for
11persons who are otherwise eligible for assistance under this
12Article.
13    Notwithstanding any other provision of this Code, the
14Illinois Department may not require, as a condition of payment
15for any laboratory test authorized under this Article, that a
16physician's handwritten signature appear on the laboratory
17test order form. The Illinois Department may, however, impose
18other appropriate requirements regarding laboratory test order
19documentation.
20    The Department of Healthcare and Family Services shall
21provide the following services to persons eligible for
22assistance under this Article who are participating in
23education, training or employment programs operated by the
24Department of Human Services as successor to the Department of
25Public Aid:
26        (1) dental services provided by or under the

 

 

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1    supervision of a dentist; and
2        (2) eyeglasses prescribed by a physician skilled in the
3    diseases of the eye, or by an optometrist, whichever the
4    person may select.
5    Notwithstanding any other provision of this Code and
6subject to federal approval, the Department may adopt rules to
7allow a dentist who is volunteering his or her service at no
8cost to render dental services through an enrolled
9not-for-profit health clinic without the dentist personally
10enrolling as a participating provider in the medical assistance
11program. A not-for-profit health clinic shall include a public
12health clinic or Federally Qualified Health Center or other
13enrolled provider, as determined by the Department, through
14which dental services covered under this Section are performed.
15The Department shall establish a process for payment of claims
16for reimbursement for covered dental services rendered under
17this provision.
18    Notwithstanding any other provision of this Code, the
19Illinois Department shall ensure that cancer patients in need
20of dental treatment prior to the administration of chemotherapy
21have access to such dental services and shall ensure that
22treatment is not delayed due to an inability to locate a
23provider willing to accept the Department's rates. The
24Department shall ensure that healthcare providers treating
25such patients, including medical oncologists, cancer centers,
26and cancer advocacy organizations, are aware of the mechanisms

 

 

09700HB1191ham001- 26 -LRB097 06572 RPM 51436 a

1available to the Department to ensure such access.
2    The Illinois Department shall develop a mechanism whereby
3mammography providers may download a standing order via the
4Internet for screening mammography for any woman eligible for
5mammography coverage who has not had a screening mammogram
6within the last 12 months. This mechanism shall be available
7for all women covered by any program administered by this State
8that includes mammography coverage.
9    The Illinois Department, by rule, may distinguish and
10classify the medical services to be provided only in accordance
11with the classes of persons designated in Section 5-2.
12    The Department of Healthcare and Family Services must
13provide coverage and reimbursement for amino acid-based
14elemental formulas, regardless of delivery method, for the
15diagnosis and treatment of (i) eosinophilic disorders and (ii)
16short bowel syndrome when the prescribing physician has issued
17a written order stating that the amino acid-based elemental
18formula is medically necessary.
19    The Illinois Department shall authorize the provision of,
20and shall authorize payment for, screening by low-dose
21mammography for the presence of occult breast cancer for women
2235 years of age or older who are eligible for medical
23assistance under this Article, as follows:
24        (A) A baseline mammogram for women 35 to 39 years of
25    age.
26        (B) An annual mammogram for women 40 years of age or

 

 

09700HB1191ham001- 27 -LRB097 06572 RPM 51436 a

1    older.
2        (C) A mammogram at the age and intervals considered
3    medically necessary by the woman's health care provider for
4    women under 40 years of age and having a family history of
5    breast cancer, prior personal history of breast cancer,
6    positive genetic testing, or other risk factors.
7        (D) A comprehensive ultrasound screening of an entire
8    breast or breasts if a mammogram demonstrates
9    heterogeneous or dense breast tissue, when medically
10    necessary as determined by a physician licensed to practice
11    medicine in all of its branches.
12    All screenings shall include a physical breast exam,
13instruction on self-examination and information regarding the
14frequency of self-examination and its value as a preventative
15tool. For purposes of this Section, "low-dose mammography"
16means the x-ray examination of the breast using equipment
17dedicated specifically for mammography, including the x-ray
18tube, filter, compression device, and image receptor, with an
19average radiation exposure delivery of less than one rad per
20breast for 2 views of an average size breast. The term also
21includes digital mammography.
22    On and after July 1, 2008, screening and diagnostic
23mammography shall be reimbursed at the same rate as the
24Medicare program's rates, including the increased
25reimbursement for digital mammography.
26    The Department shall convene an expert panel including

 

 

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1representatives of hospitals, free-standing mammography
2facilities, and doctors, including radiologists, to establish
3quality standards. Based on these quality standards, the
4Department shall provide for bonus payments to mammography
5facilities meeting the standards for screening and diagnosis.
6The bonus payments shall be at least 15% higher than the
7Medicare rates for mammography.
8    Subject to federal approval, the Department shall
9establish a rate methodology for mammography at federally
10qualified health centers and other encounter-rate clinics.
11These clinics or centers may also collaborate with other
12hospital-based mammography facilities.
13    The Department shall establish a methodology to remind
14women who are age-appropriate for screening mammography, but
15who have not received a mammogram within the previous 18
16months, of the importance and benefit of screening mammography.
17    The Department shall establish a performance goal for
18primary care providers with respect to their female patients
19over age 40 receiving an annual mammogram. This performance
20goal shall be used to provide additional reimbursement in the
21form of a quality performance bonus to primary care providers
22who meet that goal.
23    The Department shall devise a means of case-managing or
24patient navigation for beneficiaries diagnosed with breast
25cancer. This program shall initially operate as a pilot program
26in areas of the State with the highest incidence of mortality

 

 

09700HB1191ham001- 29 -LRB097 06572 RPM 51436 a

1related to breast cancer. At least one pilot program site shall
2be in the metropolitan Chicago area and at least one site shall
3be outside the metropolitan Chicago area. An evaluation of the
4pilot program shall be carried out measuring health outcomes
5and cost of care for those served by the pilot program compared
6to similarly situated patients who are not served by the pilot
7program.
8    Any medical or health care provider shall immediately
9recommend, to any pregnant woman who is being provided prenatal
10services and is suspected of drug abuse or is addicted as
11defined in the Alcoholism and Other Drug Abuse and Dependency
12Act, referral to a local substance abuse treatment provider
13licensed by the Department of Human Services or to a licensed
14hospital which provides substance abuse treatment services.
15The Department of Healthcare and Family Services shall assure
16coverage for the cost of treatment of the drug abuse or
17addiction for pregnant recipients in accordance with the
18Illinois Medicaid Program in conjunction with the Department of
19Human Services.
20    All medical providers providing medical assistance to
21pregnant women under this Code shall receive information from
22the Department on the availability of services under the Drug
23Free Families with a Future or any comparable program providing
24case management services for addicted women, including
25information on appropriate referrals for other social services
26that may be needed by addicted women in addition to treatment

 

 

09700HB1191ham001- 30 -LRB097 06572 RPM 51436 a

1for addiction.
2    The Illinois Department, in cooperation with the
3Departments of Human Services (as successor to the Department
4of Alcoholism and Substance Abuse) and Public Health, through a
5public awareness campaign, may provide information concerning
6treatment for alcoholism and drug abuse and addiction, prenatal
7health care, and other pertinent programs directed at reducing
8the number of drug-affected infants born to recipients of
9medical assistance.
10    Neither the Department of Healthcare and Family Services
11nor the Department of Human Services shall sanction the
12recipient solely on the basis of her substance abuse.
13    The Illinois Department shall establish such regulations
14governing the dispensing of health services under this Article
15as it shall deem appropriate. The Department should seek the
16advice of formal professional advisory committees appointed by
17the Director of the Illinois Department for the purpose of
18providing regular advice on policy and administrative matters,
19information dissemination and educational activities for
20medical and health care providers, and consistency in
21procedures to the Illinois Department.
22    Notwithstanding any other provision of law, a health care
23provider under the medical assistance program may elect, in
24lieu of receiving direct payment for services provided under
25that program, to participate in the State Employees Deferred
26Compensation Plan adopted under Article 24 of the Illinois

 

 

09700HB1191ham001- 31 -LRB097 06572 RPM 51436 a

1Pension Code. A health care provider who elects to participate
2in the plan does not have a cause of action against the State
3for any damages allegedly suffered by the provider as a result
4of any delay by the State in crediting the amount of any
5contribution to the provider's plan account.
6    The Illinois Department may develop and contract with
7Partnerships of medical providers to arrange medical services
8for persons eligible under Section 5-2 of this Code.
9Implementation of this Section may be by demonstration projects
10in certain geographic areas. The Partnership shall be
11represented by a sponsor organization. The Department, by rule,
12shall develop qualifications for sponsors of Partnerships.
13Nothing in this Section shall be construed to require that the
14sponsor organization be a medical organization.
15    The sponsor must negotiate formal written contracts with
16medical providers for physician services, inpatient and
17outpatient hospital care, home health services, treatment for
18alcoholism and substance abuse, and other services determined
19necessary by the Illinois Department by rule for delivery by
20Partnerships. Physician services must include prenatal and
21obstetrical care. The Illinois Department shall reimburse
22medical services delivered by Partnership providers to clients
23in target areas according to provisions of this Article and the
24Illinois 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
12qualifications to participate in Partnerships to ensure the
13delivery of high quality medical services. These
14qualifications shall be determined by rule of the Illinois
15Department and may be higher than qualifications for
16participation in the medical assistance program. Partnership
17sponsors may prescribe reasonable additional qualifications
18for participation by medical providers, only with the prior
19written approval of the Illinois Department.
20    Nothing in this Section shall limit the free choice of
21practitioners, hospitals, and other providers of medical
22services by clients. In order to ensure patient freedom of
23choice, the Illinois Department shall immediately promulgate
24all rules and take all other necessary actions so that provided
25services may be accessed from therapeutically certified
26optometrists to the full extent of the Illinois Optometric

 

 

09700HB1191ham001- 33 -LRB097 06572 RPM 51436 a

1Practice Act of 1987 without discriminating between service
2providers.
3    The Department shall apply for a waiver from the United
4States Health Care Financing Administration to allow for the
5implementation of Partnerships under this Section.
6    The Illinois Department shall require health care
7providers to maintain records that document the medical care
8and services provided to recipients of Medical Assistance under
9this Article. The Illinois Department shall require health care
10providers to make available, when authorized by the patient, in
11writing, the medical records in a timely fashion to other
12health care providers who are treating or serving persons
13eligible for Medical Assistance under this Article. All
14dispensers of medical services shall be required to maintain
15and retain business and professional records sufficient to
16fully and accurately document the nature, scope, details and
17receipt of the health care provided to persons eligible for
18medical assistance under this Code, in accordance with
19regulations promulgated by the Illinois Department. The rules
20and regulations shall require that proof of the receipt of
21prescription drugs, dentures, prosthetic devices and
22eyeglasses by eligible persons under this Section accompany
23each claim for reimbursement submitted by the dispenser of such
24medical services. No such claims for reimbursement shall be
25approved for payment by the Illinois Department without such
26proof of receipt, unless the Illinois Department shall have put

 

 

09700HB1191ham001- 34 -LRB097 06572 RPM 51436 a

1into effect and shall be operating a system of post-payment
2audit and review which shall, on a sampling basis, be deemed
3adequate by the Illinois Department to assure that such drugs,
4dentures, prosthetic devices and eyeglasses for which payment
5is being made are actually being received by eligible
6recipients. Within 90 days after the effective date of this
7amendatory Act of 1984, the Illinois Department shall establish
8a current list of acquisition costs for all prosthetic devices
9and any other items recognized as medical equipment and
10supplies reimbursable under this Article and shall update such
11list on a quarterly basis, except that the acquisition costs of
12all prescription drugs shall be updated no less frequently than
13every 30 days as required by Section 5-5.12.
14    The rules and regulations of the Illinois Department shall
15require that a written statement including the required opinion
16of a physician shall accompany any claim for reimbursement for
17abortions, or induced miscarriages or premature births. This
18statement shall indicate what procedures were used in providing
19such medical services.
20    The Illinois Department shall require all dispensers of
21medical services, other than an individual practitioner or
22group of practitioners, desiring to participate in the Medical
23Assistance program established under this Article to disclose
24all financial, beneficial, ownership, equity, surety or other
25interests in any and all firms, corporations, partnerships,
26associations, business enterprises, joint ventures, agencies,

 

 

09700HB1191ham001- 35 -LRB097 06572 RPM 51436 a

1institutions or other legal entities providing any form of
2health care services in this State under this Article.
3    The Illinois Department may require that all dispensers of
4medical services desiring to participate in the medical
5assistance program established under this Article disclose,
6under such terms and conditions as the Illinois Department may
7by rule establish, all inquiries from clients and attorneys
8regarding medical bills paid by the Illinois Department, which
9inquiries could indicate potential existence of claims or liens
10for the Illinois Department.
11    Enrollment of a vendor that provides non-emergency medical
12transportation, defined by the Department by rule, shall be
13conditional for 180 days. During that time, the Department of
14Healthcare and Family Services may terminate the vendor's
15eligibility to participate in the medical assistance program
16without cause. That termination of eligibility is not subject
17to the Department's hearing process.
18    The Illinois Department shall establish policies,
19procedures, standards and criteria by rule for the acquisition,
20repair and replacement of orthotic and prosthetic devices and
21durable medical equipment. Such rules shall provide, but not be
22limited to, the following services: (1) immediate repair or
23replacement of such devices by recipients without medical
24authorization; and (2) rental, lease, purchase or
25lease-purchase of durable medical equipment in a
26cost-effective manner, taking into consideration the

 

 

09700HB1191ham001- 36 -LRB097 06572 RPM 51436 a

1recipient's medical prognosis, the extent of the recipient's
2needs, and the requirements and costs for maintaining such
3equipment. Such rules shall enable a recipient to temporarily
4acquire and use alternative or substitute devices or equipment
5pending repairs or replacements of any device or equipment
6previously authorized for such recipient by the Department.
7    The Department shall execute, relative to the nursing home
8prescreening project, written inter-agency agreements with the
9Department of Human Services and the Department on Aging, to
10effect the following: (i) intake procedures and common
11eligibility criteria for those persons who are receiving
12non-institutional services; and (ii) the establishment and
13development of non-institutional services in areas of the State
14where they are not currently available or are undeveloped.
15    The Illinois Department shall develop and operate, in
16cooperation with other State Departments and agencies and in
17compliance with applicable federal laws and regulations,
18appropriate and effective systems of health care evaluation and
19programs for monitoring of utilization of health care services
20and facilities, as it affects persons eligible for medical
21assistance under this Code.
22    The Illinois Department shall report annually to the
23General Assembly, no later than the second Friday in April of
241979 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
8ending on the June 30 prior to the report. The report shall
9include suggested legislation for consideration by the General
10Assembly. The filing of one copy of the report with the
11Speaker, one copy with the Minority Leader and one copy with
12the Clerk of the House of Representatives, one copy with the
13President, one copy with the Minority Leader and one copy with
14the Secretary of the Senate, one copy with the Legislative
15Research Unit, and such additional copies with the State
16Government Report Distribution Center for the General Assembly
17as is required under paragraph (t) of Section 7 of the State
18Library Act shall be deemed sufficient to comply with this
19Section.
20    Rulemaking authority to implement Public Act 95-1045, if
21any, is conditioned on the rules being adopted in accordance
22with all provisions of the Illinois Administrative Procedure
23Act and all rules and procedures of the Joint Committee on
24Administrative Rules; any purported rule not so adopted, for
25whatever reason, is unauthorized.
26(Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07;

 

 

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195-1045, eff. 3-27-09; 96-156, eff. 1-1-10; 96-806, eff.
27-1-10; 96-926, eff. 1-1-11; 96-1000, eff. 7-2-10.)
 
3    Section 45. The Radiation Protection Act of 1990 is amended
4by changing Section 5 as follows:
 
5    (420 ILCS 40/5)  (from Ch. 111 1/2, par. 210-5)
6    (Section scheduled to be repealed on January 1, 2021)
7    Sec. 5. Limitations on application of radiation to human
8beings and requirements for radiation installation operators
9providing mammography services.
10    (a) No person shall intentionally administer radiation to a
11human being unless such person is licensed to practice a
12treatment of human ailments by virtue of the Illinois Medical,
13Dental or Podiatric Medical Practice Acts, or, as physician
14assistant, advanced practice nurse, technician, nurse, or
15other assistant, is acting under the supervision, prescription
16or direction of such licensed person. However, no such
17physician assistant, advanced practice nurse, technician,
18nurse, or other assistant acting under the supervision of a
19person licensed under the Medical Practice Act of 1987, shall
20administer radiation to human beings unless accredited by the
21Agency, except that persons enrolled in a course of education
22approved by the Agency may apply ionizing radiation to human
23beings as required by their course of study when under the
24direct supervision of a person licensed under the Medical

 

 

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1Practice Act of 1987. No person authorized by this Section to
2apply ionizing radiation shall apply such radiation except to
3those parts of the human body specified in the Act under which
4such person or his supervisor is licensed. No person may
5operate a radiation installation where ionizing radiation is
6administered to human beings unless all persons who administer
7ionizing radiation in that radiation installation are
8licensed, accredited, or exempted in accordance with this
9Section. Nothing in this Section shall be deemed to relieve a
10person from complying with the provisions of Section 10.
11    (b) In addition, no person shall provide mammography
12services unless all of the following requirements are met:
13        (1) the mammography procedures are performed using a
14    radiation machine that is specifically designed for
15    mammography;
16        (2) the mammography procedures are performed using a
17    radiation machine that is used solely for performing
18    mammography procedures;
19        (3) the mammography procedures are performed using
20    equipment that has been subjected to a quality assurance
21    program that satisfies quality assurance requirements
22    which the Agency shall establish by rule;
23        (4) beginning one year after the effective date of this
24    amendatory Act of 1991, if the mammography procedure is
25    performed by a radiologic technologist, that technologist,
26    in addition to being accredited by the Agency to perform

 

 

09700HB1191ham001- 40 -LRB097 06572 RPM 51436 a

1    radiography, has satisfied training requirements specific
2    to mammography, which the Agency shall establish by rule.
3    (c) Every operator of a radiation installation at which
4mammography services are provided shall ensure and have
5confirmed by each mammography patient that the patient is
6provided with a pamphlet which is orally reviewed with the
7patient and which contains the following:
8        (1) how to perform breast self-examination;
9        (2) that early detection of breast cancer is maximized
10    through a combined approach, using monthly breast
11    self-examination, a thorough physical examination
12    performed by a physician, and mammography performed at
13    recommended intervals;
14        (3) that mammography is the most accurate method for
15    making an early detection of breast cancer, however, no
16    diagnostic tool is 100% effective;
17        (4) that if the patient is self-referred and does not
18    have a primary care physician, or if the patient is
19    unfamiliar with the breast examination procedures, that
20    the patient has received information regarding public
21    health services where she can obtain a breast examination
22    and instructions.
23    (d) Each facility that performs mammograms shall upon
24request by or on behalf of the patient permanently or
25temporarily transfer the original mammograms and copies of the
26patient's reports to a medical institution or to a physician or

 

 

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1health care provider of the patient or to the patient directly
2without charge to the patient. Such a transfer must be done
3within 2 weeks after the request or within one week if the
4patient has already had a mammogram that shows potential
5abnormality. Transfer may not be delayed as a means of debt
6collection.
7(Source: P.A. 93-149, eff. 7-10-03; 94-104, eff. 7-1-05.)".