Illinois General Assembly - Full Text of SB2348
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Full Text of SB2348  95th General Assembly


Sen. James F. Clayborne Jr.

Filed: 3/10/2008





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2     AMENDMENT NO. ______. Amend Senate Bill 2348 by replacing
3 everything after the enacting clause with the following:
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



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1 care furnished by licensed practitioners; (7) home health care
2 services; (8) private duty nursing service; (9) clinic
3 services; (10) dental services, including prevention and
4 treatment of periodontal disease and dental caries disease for
5 pregnant women, provided by an individual licensed to practice
6 dentistry or dental surgery; for purposes of this item (10),
7 "dental services" means diagnostic, preventive, or corrective
8 procedures provided by or under the supervision of a dentist in
9 the practice of his or her profession; (11) physical therapy
10 and related services; (12) prescribed drugs, dentures, and
11 prosthetic devices; and eyeglasses prescribed by a physician
12 skilled in the diseases of the eye, or by an optometrist,
13 whichever the person may select; (13) other diagnostic,
14 screening, preventive, and rehabilitative services; (14)
15 transportation and such other expenses as may be necessary;
16 (15) medical treatment of sexual assault survivors, as defined
17 in Section 1a of the Sexual Assault Survivors Emergency
18 Treatment Act, for injuries sustained as a result of the sexual
19 assault, including examinations and laboratory tests to
20 discover evidence which may be used in criminal proceedings
21 arising from the sexual assault; (16) the diagnosis and
22 treatment of sickle cell anemia; and (17) any other medical
23 care, and any other type of remedial care recognized under the
24 laws of this State, but not including abortions, or induced
25 miscarriages or premature births, unless, in the opinion of a
26 physician, such procedures are necessary for the preservation



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1 of the life of the woman seeking such treatment, or except an
2 induced premature birth intended to produce a live viable child
3 and such procedure is necessary for the health of the mother or
4 her unborn child. The Illinois Department, by rule, shall
5 prohibit any physician from providing medical assistance to
6 anyone eligible therefor under this Code where such physician
7 has been found guilty of performing an abortion procedure in a
8 wilful and wanton manner upon a woman who was not pregnant at
9 the time such abortion procedure was performed. The term "any
10 other type of remedial care" shall include nursing care and
11 nursing home service for persons who rely on treatment by
12 spiritual means alone through prayer for healing.
13     Notwithstanding any other provision of this Section, a
14 comprehensive tobacco use cessation program that includes
15 purchasing prescription drugs or prescription medical devices
16 approved by the Food and Drug administration shall be covered
17 under the medical assistance program under this Article for
18 persons who are otherwise eligible for assistance under this
19 Article.
20     Notwithstanding any other provision of this Code, the
21 Illinois Department may not require, as a condition of payment
22 for any laboratory test authorized under this Article, that a
23 physician's handwritten signature appear on the laboratory
24 test order form. The Illinois Department may, however, impose
25 other appropriate requirements regarding laboratory test order
26 documentation.



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1     The Department of Healthcare and Family Services shall
2 provide the following services to persons eligible for
3 assistance under this Article who are participating in
4 education, training or employment programs operated by the
5 Department of Human Services as successor to the Department of
6 Public Aid:
7         (1) dental services provided by or under the
8     supervision of a dentist , which shall include but not be
9     limited to prosthodontics; and
10         (2) eyeglasses prescribed by a physician skilled in the
11     diseases of the eye, or by an optometrist, whichever the
12     person may select.
13     The Illinois Department, by rule, may distinguish and
14 classify the medical services to be provided only in accordance
15 with the classes of persons designated in Section 5-2.
16     The Department of Healthcare and Family Services must
17 provide coverage and reimbursement for amino acid-based
18 elemental formulas, regardless of delivery method, for the
19 diagnosis and treatment of (i) eosinophilic disorders and (ii)
20 short bowel syndrome when the prescribing physician has issued
21 a written order stating that the amino acid-based elemental
22 formula is medically necessary.
23     The Illinois Department shall authorize the provision of,
24 and shall authorize payment for, screening by low-dose
25 mammography for the presence of occult breast cancer for women
26 35 years of age or older who are eligible for medical



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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 Healthcare and Family Services shall assure
21 coverage for the cost of treatment of the drug abuse or
22 addiction for pregnant recipients in accordance with the
23 Illinois Medicaid Program in conjunction with the Department of
24 Human Services.
25     All medical providers providing medical assistance to
26 pregnant women under this Code shall receive information from



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1 the Department on the availability of services under the Drug
2 Free Families with a Future or any comparable program providing
3 case management services for addicted women, including
4 information on appropriate referrals for other social services
5 that may be needed by addicted women in addition to treatment
6 for addiction.
7     The Illinois Department, in cooperation with the
8 Departments of Human Services (as successor to the Department
9 of Alcoholism and Substance Abuse) and Public Health, through a
10 public awareness campaign, may provide information concerning
11 treatment for alcoholism and drug abuse and addiction, prenatal
12 health care, and other pertinent programs directed at reducing
13 the number of drug-affected infants born to recipients of
14 medical assistance.
15     Neither the Department of Healthcare and Family Services
16 nor the Department of Human Services shall sanction the
17 recipient solely on the basis of her substance abuse.
18     The Illinois Department shall establish such regulations
19 governing the dispensing of health services under this Article
20 as it shall deem appropriate. The Department should seek the
21 advice of formal professional advisory committees appointed by
22 the Director of the Illinois Department for the purpose of
23 providing regular advice on policy and administrative matters,
24 information dissemination and educational activities for
25 medical and health care providers, and consistency in
26 procedures to the Illinois Department.



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



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



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1     The Illinois Department shall require health care
2 providers to maintain records that document the medical care
3 and services provided to recipients of Medical Assistance under
4 this Article. The Illinois Department shall require health care
5 providers to make available, when authorized by the patient, in
6 writing, the medical records in a timely fashion to other
7 health care providers who are treating or serving persons
8 eligible for Medical Assistance under this Article. All
9 dispensers of medical services shall be required to maintain
10 and retain business and professional records sufficient to
11 fully and accurately document the nature, scope, details and
12 receipt of the health care provided to persons eligible for
13 medical assistance under this Code, in accordance with
14 regulations promulgated by the Illinois Department. The rules
15 and regulations shall require that proof of the receipt of
16 prescription drugs, dentures, prosthetic devices and
17 eyeglasses by eligible persons under this Section accompany
18 each claim for reimbursement submitted by the dispenser of such
19 medical services. No such claims for reimbursement shall be
20 approved for payment by the Illinois Department without such
21 proof of receipt, unless the Illinois Department shall have put
22 into effect and shall be operating a system of post-payment
23 audit and review which shall, on a sampling basis, be deemed
24 adequate by the Illinois Department to assure that such drugs,
25 dentures, prosthetic devices and eyeglasses for which payment
26 is being made are actually being received by eligible



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



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



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1 previously authorized for such recipient by the Department.
2     The Department shall execute, relative to the nursing home
3 prescreening project, written inter-agency agreements with the
4 Department of Human Services and the Department on Aging, to
5 effect the following: (i) intake procedures and common
6 eligibility criteria for those persons who are receiving
7 non-institutional services; and (ii) the establishment and
8 development of non-institutional services in areas of the State
9 where they are not currently available or are undeveloped.
10     The Illinois Department shall develop and operate, in
11 cooperation with other State Departments and agencies and in
12 compliance with applicable federal laws and regulations,
13 appropriate and effective systems of health care evaluation and
14 programs for monitoring of utilization of health care services
15 and facilities, as it affects persons eligible for medical
16 assistance under this Code.
17     The Illinois Department shall report annually to the
18 General Assembly, no later than the second Friday in April of
19 1979 and each year thereafter, in regard to:
20         (a) actual statistics and trends in utilization of
21     medical services by public aid recipients;
22         (b) actual statistics and trends in the provision of
23     the various medical services by medical vendors;
24         (c) current rate structures and proposed changes in
25     those rate structures for the various medical vendors; and
26         (d) efforts at utilization review and control by the



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1     Illinois Department.
2     The period covered by each report shall be the 3 years
3 ending on the June 30 prior to the report. The report shall
4 include suggested legislation for consideration by the General
5 Assembly. The filing of one copy of the report with the
6 Speaker, one copy with the Minority Leader and one copy with
7 the Clerk of the House of Representatives, one copy with the
8 President, one copy with the Minority Leader and one copy with
9 the Secretary of the Senate, one copy with the Legislative
10 Research Unit, and such additional copies with the State
11 Government Report Distribution Center for the General Assembly
12 as is required under paragraph (t) of Section 7 of the State
13 Library Act shall be deemed sufficient to comply with this
14 Section.
15 (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)".