Illinois General Assembly - Full Text of SB2367
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Full Text of SB2367  93rd General Assembly


Sen. Donne E. Trotter

Filed: 3/23/2004





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2     AMENDMENT NO. ______. Amend Senate Bill 2367 by replacing
3 the title with the following:
4     "AN ACT in relation to health."; and
6 by replacing everything after the enacting clause with the
7 following:
8     "Section 5. The Children's Health Insurance Program Act is
9 amended by changing Section 40 as follows:
10     (215 ILCS 106/40)
11     Sec. 40. Waivers.
12     (a) The Department shall request any necessary waivers of
13 federal requirements in order to allow receipt of federal
14 funding for:
15         (1) the coverage of families with eligible children
16 under this Act; and
17         (2) for the coverage of children who would otherwise be
18 eligible under this Act, but who have health insurance.
19     (b) The failure of the responsible federal agency to
20 approve a waiver for children who would otherwise be eligible
21 under this Act but who have health insurance shall not prevent
22 the implementation of any Section of this Act provided that
23 there are sufficient appropriated funds.
24     (c) Eligibility of a person under an approved waiver due to



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1 the relationship with a child pursuant to Article V of the
2 Illinois Public Aid Code or this Act shall be limited to such a
3 person whose countable income is determined by the Department
4 to be at or below such income eligibility standard as the
5 Department by rule shall establish. The income level
6 established by the Department shall not be below 90% of the
7 federal poverty level. Such persons who are determined to be
8 eligible must reapply, or otherwise establish eligibility, at
9 least annually. An eligible person shall be required, as
10 determined by the Department by rule, to report promptly those
11 changes in income and other circumstances that affect
12 eligibility. The eligibility of a person may be redetermined
13 based on the information reported or may be terminated based on
14 the failure to report or failure to report accurately. A person
15 may also be held liable to the Department for any payments made
16 by the Department on such person's behalf that were
17 inappropriate. An applicant shall be provided with notice of
18 these obligations.
19     (d) Subject to specific appropriation, the Department
20 shall provide outreach grants to community organizations to
21 enroll families in the program under this Section.
22 (Source: P.A. 92-597, eff. 6-28-02; 93-63, eff. 6-30-03.)
23     Section 10. The Illinois Public Aid Code is amended by
24 changing Section 5-5 as follows:
25     (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
26     Sec. 5-5. Medical services. The Illinois Department, by
27 rule, shall determine the quantity and quality of and the rate
28 of reimbursement for the medical assistance for which payment
29 will be authorized, and the medical services to be provided,
30 which may include all or part of the following: (1) inpatient
31 hospital services; (2) outpatient hospital services; (3) other
32 laboratory and X-ray services; (4) skilled nursing home



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



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1 care" shall include nursing care and nursing home service for
2 persons who rely on treatment by spiritual means alone through
3 prayer for healing.
4     Notwithstanding any other provision of this Section, a
5 comprehensive tobacco use cessation program that includes
6 purchasing prescription drugs or prescription medical devices
7 approved by the Food and Drug administration shall be covered
8 under the medical assistance program under this Article for
9 persons who are otherwise eligible for assistance under this
10 Article.
11     Notwithstanding any other provision of this Code, the
12 Illinois Department may not require, as a condition of payment
13 for any laboratory test authorized under this Article, that a
14 physician's handwritten signature appear on the laboratory
15 test order form. The Illinois Department may, however, impose
16 other appropriate requirements regarding laboratory test order
17 documentation.
18     The Illinois Department of Public Aid shall provide the
19 following services to persons eligible for assistance under
20 this Article who are participating in education, training or
21 employment programs operated by the Department of Human
22 Services as successor to the Department of Public Aid:
23         (1) dental services, which shall include but not be
24 limited to prosthodontics; and
25         (2) eyeglasses prescribed by a physician skilled in the
26 diseases of the eye, or by an optometrist, whichever the
27 person may select.
28     The Illinois Department, by rule, may distinguish and
29 classify the medical services to be provided only in accordance
30 with the classes of persons designated in Section 5-2.
31     The Illinois Department shall authorize the provision of,
32 and shall authorize payment for, screening by low-dose
33 mammography for the presence of occult breast cancer for women
34 35 years of age or older who are eligible for medical



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



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



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



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1 every 30 days as required by Section 5-5.12.
2     The rules and regulations of the Illinois Department shall
3 require that a written statement including the required opinion
4 of a physician shall accompany any claim for reimbursement for
5 abortions, or induced miscarriages or premature births. This
6 statement shall indicate what procedures were used in providing
7 such medical services.
8     The Illinois Department shall require all dispensers of
9 medical services, other than an individual practitioner or
10 group of practitioners, desiring to participate in the Medical
11 Assistance program established under this Article to disclose
12 all financial, beneficial, ownership, equity, surety or other
13 interests in any and all firms, corporations, partnerships,
14 associations, business enterprises, joint ventures, agencies,
15 institutions or other legal entities providing any form of
16 health care services in this State under this Article.
17     The Illinois Department may require that all dispensers of
18 medical services desiring to participate in the medical
19 assistance program established under this Article disclose,
20 under such terms and conditions as the Illinois Department may
21 by rule establish, all inquiries from clients and attorneys
22 regarding medical bills paid by the Illinois Department, which
23 inquiries could indicate potential existence of claims or liens
24 for the Illinois Department.
25     Enrollment of a vendor that provides non-emergency medical
26 transportation, defined by the Department by rule, shall be
27 conditional for 180 days. During that time, the Department of
28 Public Aid may terminate the vendor's eligibility to
29 participate in the medical assistance program without cause.
30 That termination of eligibility is not subject to the
31 Department's hearing process.
32     The Illinois Department shall establish policies,
33 procedures, standards and criteria by rule for the acquisition,
34 repair and replacement of orthotic and prosthetic devices and



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1 durable medical equipment. Such rules shall provide, but not be
2 limited to, the following services: (1) immediate repair or
3 replacement of such devices by recipients without medical
4 authorization; and (2) rental, lease, purchase or
5 lease-purchase of durable medical equipment in a
6 cost-effective manner, taking into consideration the
7 recipient's medical prognosis, the extent of the recipient's
8 needs, and the requirements and costs for maintaining such
9 equipment. Such rules shall enable a recipient to temporarily
10 acquire and use alternative or substitute devices or equipment
11 pending repairs or replacements of any device or equipment
12 previously authorized for such recipient by the Department.
13 Rules under clause (2) above shall not provide for purchase or
14 lease-purchase of durable medical equipment or supplies used
15 for the purpose of oxygen delivery and respiratory care.
16     The Department shall execute, relative to the nursing home
17 prescreening project, written inter-agency agreements with the
18 Department of Human Services and the Department on Aging, to
19 effect the following: (i) intake procedures and common
20 eligibility criteria for those persons who are receiving
21 non-institutional services; and (ii) the establishment and
22 development of non-institutional services in areas of the State
23 where they are not currently available or are undeveloped.
24     The Illinois Department shall develop and operate, in
25 cooperation with other State Departments and agencies and in
26 compliance with applicable federal laws and regulations,
27 appropriate and effective systems of health care evaluation and
28 programs for monitoring of utilization of health care services
29 and facilities, as it affects persons eligible for medical
30 assistance under this Code.
31     The Illinois Department shall report annually to the
32 General Assembly, no later than the second Friday in April of
33 1979 and each year thereafter, in regard to:
34         (a) actual statistics and trends in utilization of



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1 medical services by public aid recipients;
2         (b) actual statistics and trends in the provision of
3 the various medical services by medical vendors;
4         (c) current rate structures and proposed changes in
5 those rate structures for the various medical vendors; and
6         (d) efforts at utilization review and control by the
7 Illinois Department.
8     The period covered by each report shall be the 3 years
9 ending on the June 30 prior to the report. The report shall
10 include suggested legislation for consideration by the General
11 Assembly. The filing of one copy of the report with the
12 Speaker, one copy with the Minority Leader and one copy with
13 the Clerk of the House of Representatives, one copy with the
14 President, one copy with the Minority Leader and one copy with
15 the Secretary of the Senate, one copy with the Legislative
16 Research Unit, and such additional copies with the State
17 Government Report Distribution Center for the General Assembly
18 as is required under paragraph (t) of Section 7 of the State
19 Library Act shall be deemed sufficient to comply with this
20 Section.
21 (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02;
22 92-789, eff. 8-6-02; 93-632, eff. 2-1-04.)".