Illinois General Assembly - Full Text of HB0755
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Full Text of HB0755  95th General Assembly



State of Illinois
2007 and 2008


Introduced 2/7/2007, by Rep. Constance A. Howard


305 ILCS 5/5-5   from Ch. 23, par. 5-5

    Amends the Illinois Public Aid Code. Requires the Department of Public Aid to provide coverage of comprehensive and appropriate substance abuse treatment services to persons who are eligible for Medicaid. Provides that a person who is eligible for Medicaid is entitled to receive comprehensive and appropriate substance abuse treatment services on demand, without being placed on a waiting list other than as required by the schedule of the provider of the services. Provides that the services may be provided by a local substance abuse treatment provider licensed by the Department of Human Services or by a licensed hospital that provides substance abuse treatment services. Effective January 1, 2008.

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1     AN ACT concerning public aid.
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
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)
7     Sec. 5-5. Medical services. The Illinois Department, by
8 rule, shall determine the quantity and quality of and the rate
9 of reimbursement for the medical assistance for which payment
10 will be authorized, and the medical services to be provided,
11 which may include all or part of the following: (1) inpatient
12 hospital services; (2) outpatient hospital services; (3) other
13 laboratory and X-ray services; (4) skilled nursing home
14 services; (5) physicians' services whether furnished in the
15 office, the patient's home, a hospital, a skilled nursing home,
16 or elsewhere; (6) medical care, or any other type of remedial
17 care furnished by licensed practitioners; (7) home health care
18 services; (8) private duty nursing service; (9) clinic
19 services; (10) dental services, including prevention and
20 treatment of periodontal disease and dental caries disease for
21 pregnant women; (11) physical therapy and related services;
22 (12) prescribed drugs, dentures, and prosthetic devices; and
23 eyeglasses prescribed by a physician skilled in the diseases of



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



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1 prayer for healing.
2     Notwithstanding any other provision of this Section, a
3 comprehensive tobacco use cessation program that includes
4 purchasing prescription drugs or prescription medical devices
5 approved by the Food and Drug administration shall be covered
6 under the medical assistance program under this Article for
7 persons who are otherwise eligible for assistance under this
8 Article.
9     Notwithstanding any other provision of this Code, the
10 Illinois Department may not require, as a condition of payment
11 for any laboratory test authorized under this Article, that a
12 physician's handwritten signature appear on the laboratory
13 test order form. The Illinois Department may, however, impose
14 other appropriate requirements regarding laboratory test order
15 documentation.
16     The Illinois Department of Healthcare and Family Services
17 Public Aid shall provide the following services to persons
18 eligible for assistance under this Article who are
19 participating in education, training or employment programs
20 operated by the Department of Human Services as successor to
21 the Department of Public Aid:
22         (1) dental services, which shall include but not be
23     limited to prosthodontics; and
24         (2) eyeglasses prescribed by a physician skilled in the
25     diseases of the eye, or by an optometrist, whichever the
26     person may select.



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1     The Illinois Department, by rule, may distinguish and
2 classify the medical services to be provided only in accordance
3 with the classes of persons designated in Section 5-2.
4     The Illinois Department shall authorize the provision of,
5 and shall authorize payment for, screening by low-dose
6 mammography for the presence of occult breast cancer for women
7 35 years of age or older who are eligible for medical
8 assistance under this Article, as follows: a baseline mammogram
9 for women 35 to 39 years of age and an annual mammogram for
10 women 40 years of age or older. All screenings shall include a
11 physical breast exam, instruction on self-examination and
12 information regarding the frequency of self-examination and
13 its value as a preventative tool. As used in this Section,
14 "low-dose mammography" means the x-ray examination of the
15 breast using equipment dedicated specifically for mammography,
16 including the x-ray tube, filter, compression device, image
17 receptor, and cassettes, with an average radiation exposure
18 delivery of less than one rad mid-breast, with 2 views for each
19 breast.
20     The Department of Public Aid shall provide coverage of
21 comprehensive and appropriate substance abuse treatment
22 services to persons who are eligible for medical assistance
23 under this Article. A person who is eligible for medical
24 assistance under this Article is entitled to receive
25 comprehensive and appropriate substance abuse treatment
26 services on demand, without being placed on a waiting list



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1 other than as required by the schedule of the provider of the
2 services. The services may be provided by a local substance
3 abuse treatment provider licensed by the Department of Human
4 Services or by a licensed hospital that provides substance
5 abuse treatment services.
6     Any medical or health care provider shall immediately
7 recommend, to any pregnant woman who is being provided prenatal
8 services and is suspected of drug abuse or is addicted as
9 defined in the Alcoholism and Other Drug Abuse and Dependency
10 Act, referral to a local substance abuse treatment provider
11 licensed by the Department of Human Services or to a licensed
12 hospital which provides substance abuse treatment services.
13 The Department of Healthcare and Family Services Public Aid
14 shall assure coverage for the cost of treatment of the drug
15 abuse or addiction for pregnant recipients in accordance with
16 the Illinois Medicaid Program in conjunction with the
17 Department of Human Services.
18     All medical providers providing medical assistance to
19 pregnant women under this Code shall receive information from
20 the Department on the availability of services under the Drug
21 Free Families with a Future or any comparable program providing
22 case management services for addicted women, including
23 information on appropriate referrals for other social services
24 that may be needed by addicted women in addition to treatment
25 for addiction.
26     The Illinois Department, in cooperation with the



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1 Departments of Human Services (as successor to the Department
2 of Alcoholism and Substance Abuse) and Public Health, through a
3 public awareness campaign, may provide information concerning
4 treatment for alcoholism and drug abuse and addiction, prenatal
5 health care, and other pertinent programs directed at reducing
6 the number of drug-affected infants born to recipients of
7 medical assistance.
8     Neither the Illinois Department of Healthcare and Family
9 Services Public Aid nor the Department of Human Services shall
10 sanction the recipient solely on the basis of her substance
11 abuse.
12     The Illinois Department shall establish such regulations
13 governing the dispensing of health services under this Article
14 as it shall deem appropriate. The Department should seek the
15 advice of formal professional advisory committees appointed by
16 the Director of the Illinois Department for the purpose of
17 providing regular advice on policy and administrative matters,
18 information dissemination and educational activities for
19 medical and health care providers, and consistency in
20 procedures to the Illinois Department.
21     The Illinois Department may develop and contract with
22 Partnerships of medical providers to arrange medical services
23 for persons eligible under Section 5-2 of this Code.
24 Implementation of this Section may be by demonstration projects
25 in certain geographic areas. The Partnership shall be
26 represented by a sponsor organization. The Department, by rule,



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1 shall develop qualifications for sponsors of Partnerships.
2 Nothing in this Section shall be construed to require that the
3 sponsor organization be a medical organization.
4     The sponsor must negotiate formal written contracts with
5 medical providers for physician services, inpatient and
6 outpatient hospital care, home health services, treatment for
7 alcoholism and substance abuse, and other services determined
8 necessary by the Illinois Department by rule for delivery by
9 Partnerships. Physician services must include prenatal and
10 obstetrical care. The Illinois Department shall reimburse
11 medical services delivered by Partnership providers to clients
12 in target areas according to provisions of this Article and the
13 Illinois Health Finance Reform Act, except that:
14         (1) Physicians participating in a Partnership and
15     providing certain services, which shall be determined by
16     the Illinois Department, to persons in areas covered by the
17     Partnership may receive an additional surcharge for such
18     services.
19         (2) The Department may elect to consider and negotiate
20     financial incentives to encourage the development of
21     Partnerships and the efficient delivery of medical care.
22         (3) Persons receiving medical services through
23     Partnerships may receive medical and case management
24     services above the level usually offered through the
25     medical assistance program.
26     Medical providers shall be required to meet certain



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1 qualifications to participate in Partnerships to ensure the
2 delivery of high quality medical services. These
3 qualifications shall be determined by rule of the Illinois
4 Department and may be higher than qualifications for
5 participation in the medical assistance program. Partnership
6 sponsors may prescribe reasonable additional qualifications
7 for participation by medical providers, only with the prior
8 written approval of the Illinois Department.
9     Nothing in this Section shall limit the free choice of
10 practitioners, hospitals, and other providers of medical
11 services by clients. In order to ensure patient freedom of
12 choice, the Illinois Department shall immediately promulgate
13 all rules and take all other necessary actions so that provided
14 services may be accessed from therapeutically certified
15 optometrists to the full extent of the Illinois Optometric
16 Practice Act of 1987 without discriminating between service
17 providers.
18     The Department shall apply for a waiver from the United
19 States Health Care Financing Administration to allow for the
20 implementation of Partnerships under this Section.
21     The Illinois Department shall require health care
22 providers to maintain records that document the medical care
23 and services provided to recipients of Medical Assistance under
24 this Article. The Illinois Department shall require health care
25 providers to make available, when authorized by the patient, in
26 writing, the medical records in a timely fashion to other



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1 health care providers who are treating or serving persons
2 eligible for Medical Assistance under this Article. All
3 dispensers of medical services shall be required to maintain
4 and retain business and professional records sufficient to
5 fully and accurately document the nature, scope, details and
6 receipt of the health care provided to persons eligible for
7 medical assistance under this Code, in accordance with
8 regulations promulgated by the Illinois Department. The rules
9 and regulations shall require that proof of the receipt of
10 prescription drugs, dentures, prosthetic devices and
11 eyeglasses by eligible persons under this Section accompany
12 each claim for reimbursement submitted by the dispenser of such
13 medical services. No such claims for reimbursement shall be
14 approved for payment by the Illinois Department without such
15 proof of receipt, unless the Illinois Department shall have put
16 into effect and shall be operating a system of post-payment
17 audit and review which shall, on a sampling basis, be deemed
18 adequate by the Illinois Department to assure that such drugs,
19 dentures, prosthetic devices and eyeglasses for which payment
20 is being made are actually being received by eligible
21 recipients. Within 90 days after the effective date of this
22 amendatory Act of 1984, the Illinois Department shall establish
23 a current list of acquisition costs for all prosthetic devices
24 and any other items recognized as medical equipment and
25 supplies reimbursable under this Article and shall update such
26 list on a quarterly basis, except that the acquisition costs of



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1 all prescription drugs shall be updated no less frequently than
2 every 30 days as required by Section 5-5.12.
3     The rules and regulations of the Illinois Department shall
4 require that a written statement including the required opinion
5 of a physician shall accompany any claim for reimbursement for
6 abortions, or induced miscarriages or premature births. This
7 statement shall indicate what procedures were used in providing
8 such medical services.
9     The Illinois Department shall require all dispensers of
10 medical services, other than an individual practitioner or
11 group of practitioners, desiring to participate in the Medical
12 Assistance program established under this Article to disclose
13 all financial, beneficial, ownership, equity, surety or other
14 interests in any and all firms, corporations, partnerships,
15 associations, business enterprises, joint ventures, agencies,
16 institutions or other legal entities providing any form of
17 health care services in this State under this Article.
18     The Illinois Department may require that all dispensers of
19 medical services desiring to participate in the medical
20 assistance program established under this Article disclose,
21 under such terms and conditions as the Illinois Department may
22 by rule establish, all inquiries from clients and attorneys
23 regarding medical bills paid by the Illinois Department, which
24 inquiries could indicate potential existence of claims or liens
25 for the Illinois Department.
26     Enrollment of a vendor that provides non-emergency medical



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1 transportation, defined by the Department by rule, shall be
2 conditional for 180 days. During that time, the Department of
3 Healthcare and Family Services Public Aid may terminate the
4 vendor's eligibility to participate in the medical assistance
5 program without cause. That termination of eligibility is not
6 subject to the Department's hearing process.
7     The Illinois Department shall establish policies,
8 procedures, standards and criteria by rule for the acquisition,
9 repair and replacement of orthotic and prosthetic devices and
10 durable medical equipment. Such rules shall provide, but not be
11 limited to, the following services: (1) immediate repair or
12 replacement of such devices by recipients without medical
13 authorization; and (2) rental, lease, purchase or
14 lease-purchase of durable medical equipment in a
15 cost-effective manner, taking into consideration the
16 recipient's medical prognosis, the extent of the recipient's
17 needs, and the requirements and costs for maintaining such
18 equipment. Such rules shall enable a recipient to temporarily
19 acquire and use alternative or substitute devices or equipment
20 pending repairs or replacements of any device or equipment
21 previously authorized for such recipient by the Department.
22     The Department shall execute, relative to the nursing home
23 prescreening project, written inter-agency agreements with the
24 Department of Human Services and the Department on Aging, to
25 effect the following: (i) intake procedures and common
26 eligibility criteria for those persons who are receiving



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1 non-institutional services; and (ii) the establishment and
2 development of non-institutional services in areas of the State
3 where they are not currently available or are undeveloped.
4     The Illinois Department shall develop and operate, in
5 cooperation with other State Departments and agencies and in
6 compliance with applicable federal laws and regulations,
7 appropriate and effective systems of health care evaluation and
8 programs for monitoring of utilization of health care services
9 and facilities, as it affects persons eligible for medical
10 assistance under this Code.
11     The Illinois Department shall report annually to the
12 General Assembly, no later than the second Friday in April of
13 1979 and each year thereafter, in regard to:
14         (a) actual statistics and trends in utilization of
15     medical services by public aid recipients;
16         (b) actual statistics and trends in the provision of
17     the various medical services by medical vendors;
18         (c) current rate structures and proposed changes in
19     those rate structures for the various medical vendors; and
20         (d) efforts at utilization review and control by the
21     Illinois Department.
22     The period covered by each report shall be the 3 years
23 ending on the June 30 prior to the report. The report shall
24 include suggested legislation for consideration by the General
25 Assembly. The filing of one copy of the report with the
26 Speaker, one copy with the Minority Leader and one copy with



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1 the Clerk of the House of Representatives, one copy with the
2 President, one copy with the Minority Leader and one copy with
3 the Secretary of the Senate, one copy with the Legislative
4 Research Unit, and such additional copies with the State
5 Government Report Distribution Center for the General Assembly
6 as is required under paragraph (t) of Section 7 of the State
7 Library Act shall be deemed sufficient to comply with this
8 Section.
9 (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02;
10 92-789, eff. 8-6-02; 93-632, eff. 2-1-04; 93-841, eff. 7-30-04;
11 93-981, eff. 8-23-04; revised 12-15-05.)
12     Section 99. Effective date. This Act takes effect January
13 1, 2008.