Full Text of SB0770 97th General Assembly
SB0770eng 97TH GENERAL ASSEMBLY |
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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 Sections 5-4.2 and 5-5 as follows:
| 6 | | (305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)
| 7 | | Sec. 5-4.2. Ground ambulance Ambulance services payments. | 8 | | (a) For purposes of this Section, the following terms have | 9 | | the following meanings: | 10 | | "Department" means the Illinois Department of Healthcare | 11 | | and Family Services. | 12 | | "Ground ambulance services" means medical transportation | 13 | | services that are described as ground ambulance services by the | 14 | | Centers for Medicare and Medicaid Services and provided in a | 15 | | vehicle that is licensed as an ambulance by the Illinois | 16 | | Department of Public Health pursuant to the Emergency Medical | 17 | | Services (EMS) Systems Act. | 18 | | "Ground ambulance services provider" means a vehicle | 19 | | service provider as described in the Emergency Medical Services | 20 | | (EMS) Systems Act that operates licensed ambulances for the | 21 | | purpose of providing emergency ambulance services, or | 22 | | non-emergency ambulance services, or both. For purposes of this | 23 | | Section, this includes both ambulance providers and ambulance |
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| 1 | | suppliers as described by the Centers for Medicare and Medicaid | 2 | | Services. | 3 | | "Payment principles of Medicare" means: the accepted | 4 | | method propounded by the Centers for Medicare and Medicaid | 5 | | Services and used to determine the payment system for ground | 6 | | ambulance services providers and suppliers under Title XVIII of | 7 | | the Social Security Act. These principles are outlined in the | 8 | | United States Code, the Code of Federal Regulations, and the | 9 | | CMS Online Manual System, including, but not limited to, the | 10 | | Medicare Benefit Policy Manual and the Medicare Claims | 11 | | Processing Manual, and include the statutes, regulations, | 12 | | policies, procedures, definitions, guidelines, and coding | 13 | | systems, including the Health Care Common Procedure Coding | 14 | | System (HCPCS) and ambulance condition coding system, as well | 15 | | as other resources which have been or will be developed and | 16 | | recognized by the Centers for Medicare and Medicaid Services. | 17 | | "Rural county" means: any county not located in a U.S. | 18 | | Bureau of the Census Metropolitan Statistical Area (MSA); or | 19 | | any county located within a U.S. Bureau of the Census | 20 | | Metropolitan Statistical Area but having a population of 60,000 | 21 | | or less. | 22 | | (b) It is the intent of the General Assembly to provide for | 23 | | the payment for ground ambulance services as part of the State | 24 | | Medicaid plan and to provide adequate payment for ground | 25 | | ambulance services under the State Medicaid plan so as to | 26 | | ensure adequate access to ground ambulance services for both |
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| 1 | | recipients of aid under this Article and for the general | 2 | | population of Illinois. Unless otherwise indicated in this | 3 | | Section, the practices of the Department concerning payments | 4 | | for ground ambulance services provided to recipients of aid | 5 | | under this Article shall be consistent with the payment | 6 | | principles of Medicare. | 7 | | (c) For ground ambulance services provided to a recipient | 8 | | of aid under this Article on or after July 1, 2011, the | 9 | | Department shall provide payment to ground ambulance services | 10 | | providers for base charges and mileage charges based upon the | 11 | | lesser of the provider's charge, as reflected on the provider's | 12 | | claim form, or the Illinois Medicaid Ambulance Fee Schedule | 13 | | payment rates calculated in accordance with this Section. | 14 | | Effective July 1, 2011, the Illinois Medicaid Ambulance Fee | 15 | | Schedule shall be established and shall include only the ground | 16 | | ambulance services payment rates outlined in the Medicare | 17 | | Ambulance Fee Schedule as promulgated by the Centers for | 18 | | Medicare and Medicaid Services in effect as of July 1, 2011 and | 19 | | adjusted for the 4 Medicare Localities in Illinois, with an | 20 | | adjustment of 100% of the Medicare Ambulance Fee Schedule | 21 | | payment rates, by Medicare Locality, for both base rates and | 22 | | mileage for rural counties, and an adjustment of 80% of the | 23 | | Medicare Ambulance Fee Schedule payment rates, by Medicare | 24 | | Locality, for both base rates and mileage for all other | 25 | | counties. The transition from the current payment system to the | 26 | | Illinois Medicaid Ambulance Fee Schedule shall be as follows: |
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| 1 | | Effective for dates of service on or after July 1, 2011, for | 2 | | each individual base rate and mileage rate, the payment rate | 3 | | for ground ambulance services shall be based on the Illinois | 4 | | Medicaid Ambulance Fee Schedule amount in effect on July 1, | 5 | | 2011 for the designated Medicare Locality, except that any | 6 | | payment rate that was previously approved by the Department | 7 | | that exceeds this amount shall remain in force. | 8 | | Notwithstanding the payment principles in subsection (b) | 9 | | of this Section, the Department shall develop the Illinois | 10 | | Medicaid Ambulance Fee Schedule using the ground mileage | 11 | | payment rate, as defined by the Centers for Medicare and | 12 | | Medicaid Services, and no other mileage rates which act as | 13 | | enhancements to the ground mileage rate, whether permanent or | 14 | | temporary, shall be recognized by the Department. | 15 | | (d) Payment for mileage shall be per loaded mile with no | 16 | | loaded mileage included in the base rate. If a natural | 17 | | disaster, weather, road repairs, traffic congestion, or other | 18 | | conditions necessitate a route other than the most direct | 19 | | route, payment shall be based upon the actual distance | 20 | | traveled. When a ground ambulance services provider provides | 21 | | transport pursuant to an emergency call as defined by the | 22 | | Centers for Medicare and Medicaid Services, no reduction in the | 23 | | mileage payment shall be made based upon the fact that a closer | 24 | | facility may have been available, so long as the ground | 25 | | ambulance services provider provided transport to the | 26 | | recipient's facility of choice or other appropriate facility |
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| 1 | | described within the scope of the Illinois Emergency Medical | 2 | | Services (EMS) Systems Act and associated rules or the policies | 3 | | and procedures of the EMS System of which the provider is a | 4 | | member. | 5 | | (e) The Department shall provide payment for emergency | 6 | | ground ambulance services provided to a recipient of aid under | 7 | | this Article according to the requirements provided in | 8 | | subsection (b) of this Section when those services are provided | 9 | | pursuant to a request made through a 9-1-1 or equivalent | 10 | | emergency telephone number for evaluation, treatment, and | 11 | | transport from or on behalf of an individual with a condition | 12 | | of such a nature that a prudent layperson would have reasonably | 13 | | expected that a delay in seeking immediate medical attention | 14 | | would have been hazardous to life or health. This standard is | 15 | | deemed to be met if there is an emergency medical condition | 16 | | manifesting itself by acute symptoms of sufficient severity, | 17 | | including but not limited to severe pain, such that a prudent | 18 | | layperson who possesses an average knowledge of medicine and | 19 | | health can reasonably expect that the absence of immediate | 20 | | medical attention could result in placing the health of the | 21 | | individual or, with respect to a pregnant woman, the health of | 22 | | the woman or her unborn child, in serious jeopardy, cause | 23 | | serious impairment to bodily functions, or cause serious | 24 | | dysfunction of any bodily organ or part. | 25 | | (f) For ground ambulance services provided to a recipient | 26 | | enrolled in a Medicaid managed care plan by a ground ambulance |
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| 1 | | services provider that is not a contracted provider to the | 2 | | Medicaid managed care plan in question, the amount of the | 3 | | payment for ground ambulance services by the Medicaid managed | 4 | | care plan shall be the lesser of the provider's charge, as | 5 | | reflected on the provider's claim form, or the Illinois | 6 | | Medicaid Ambulance Fee Schedule payment rates calculated in | 7 | | accordance with this Section. | 8 | | (g) Nothing in this Section prohibits the Department from | 9 | | setting payment rates for out-of-State ground ambulance | 10 | | services providers by administrative rule. | 11 | | (g-5) Nothing in this Section prohibits the Department from | 12 | | setting payment rates for State ground ambulance services | 13 | | providers by administrative rule pending the availability of | 14 | | appropriations dedicated to rate increases provided under | 15 | | subsections (c) and (h) of this Section. | 16 | | (h) Effective for dates of service on or after July 1, | 17 | | 2011, payments for stretcher van services provided by ground | 18 | | ambulance services providers shall be as follows: | 19 | | (1) For each individual base rate, the amount of the | 20 | | payment shall be the lesser of the provider's charge, as | 21 | | reflected on the provider's claim form, or 80% of the | 22 | | Illinois Medicaid Ambulance Fee Schedule payment rate for | 23 | | the basic life support non-emergency base rate. | 24 | | (2) For each loaded mile, the amount of the payment | 25 | | shall be the lesser of the provider's charge, as reflected | 26 | | on the provider's claim form, or 80% of the Illinois |
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| 1 | | Medicaid Ambulance Fee Schedule payment rate for mileage. | 2 | | (i) All payments under subsections (c) and (h) of this | 3 | | Section are subject to the availability of appropriations for | 4 | | those purposes. | 5 | | For
ambulance
services provided to a recipient of aid under | 6 | | this Article on or after
January 1, 1993, the Illinois | 7 | | Department shall reimburse ambulance service
providers at | 8 | | rates calculated in accordance with this Section. It is the | 9 | | intent
of the General Assembly to provide adequate | 10 | | reimbursement for ambulance
services so as to ensure adequate | 11 | | access to services for recipients of aid
under this Article and | 12 | | to provide appropriate incentives to ambulance service
| 13 | | providers to provide services in an efficient and | 14 | | cost-effective manner. Thus,
it is the intent of the General | 15 | | Assembly that the Illinois Department implement
a | 16 | | reimbursement system for ambulance services that, to the extent | 17 | | practicable
and subject to the availability of funds | 18 | | appropriated by the General Assembly
for this purpose, is | 19 | | consistent with the payment principles of Medicare. To
ensure | 20 | | uniformity between the payment principles of Medicare and | 21 | | Medicaid, the
Illinois Department shall follow, to the extent | 22 | | necessary and practicable and
subject to the availability of | 23 | | funds appropriated by the General Assembly for
this purpose, | 24 | | the statutes, laws, regulations, policies, procedures,
| 25 | | principles, definitions, guidelines, and manuals used to | 26 | | determine the amounts
paid to ambulance service providers under |
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| 1 | | Title XVIII of the Social Security
Act (Medicare).
| 2 | | For ambulance services provided to a recipient of aid under | 3 | | this Article
on or after January 1, 1996, the Illinois | 4 | | Department shall reimburse ambulance
service providers based | 5 | | upon the actual distance traveled if a natural
disaster, | 6 | | weather conditions, road repairs, or traffic congestion | 7 | | necessitates
the use of a
route other than the most direct | 8 | | route.
| 9 | | For purposes of this Section, "ambulance services" | 10 | | includes medical
transportation services provided by means of | 11 | | an ambulance, medi-car, service
car, or
taxi.
| 12 | | This Section does not prohibit separate billing by | 13 | | ambulance service
providers for oxygen furnished while | 14 | | providing advanced life support
services.
| 15 | | (j) Beginning with services rendered on or after July 1, | 16 | | 2008, all providers of non-emergency medi-car and service car | 17 | | transportation must certify that the driver and employee | 18 | | attendant, as applicable, have completed a safety program | 19 | | approved by the Department to protect both the patient and the | 20 | | driver, prior to transporting a patient.
The provider must | 21 | | maintain this certification in its records. The provider shall | 22 | | produce such documentation upon demand by the Department or its | 23 | | representative. Failure to produce documentation of such | 24 | | training shall result in recovery of any payments made by the | 25 | | Department for services rendered by a non-certified driver or | 26 | | employee attendant. Medi-car and service car providers must |
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| 1 | | maintain legible documentation in their records of the driver | 2 | | and, as applicable, employee attendant that actually | 3 | | transported the patient. Providers must recertify all drivers | 4 | | and employee attendants every 3 years.
| 5 | | Notwithstanding the requirements above, any public | 6 | | transportation provider of medi-car and service car | 7 | | transportation that receives federal funding under 49 U.S.C. | 8 | | 5307 and 5311 need not certify its drivers and employee | 9 | | attendants under this Section, since safety training is already | 10 | | federally mandated.
| 11 | | (Source: P.A. 95-501, eff. 8-28-07.)
| 12 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 13 | | Sec. 5-5. Medical services. The Illinois Department, by | 14 | | rule, shall
determine the quantity and quality of and the rate | 15 | | of reimbursement for the
medical assistance for which
payment | 16 | | will be authorized, and the medical services to be provided,
| 17 | | which may include all or part of the following: (1) inpatient | 18 | | hospital
services; (2) outpatient hospital services; (3) other | 19 | | laboratory and
X-ray services; (4) skilled nursing home | 20 | | services; (5) physicians'
services whether furnished in the | 21 | | office, the patient's home, a
hospital, a skilled nursing home, | 22 | | or elsewhere; (6) medical care, or any
other type of remedial | 23 | | care furnished by licensed practitioners; (7)
home health care | 24 | | services; (8) private duty nursing service; (9) clinic
| 25 | | services; (10) dental services, including prevention and |
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| 1 | | treatment of periodontal disease and dental caries disease for | 2 | | pregnant women, provided by an individual licensed to practice | 3 | | dentistry or dental surgery; for purposes of this item (10), | 4 | | "dental services" means diagnostic, preventive, or corrective | 5 | | procedures provided by or under the supervision of a dentist in | 6 | | the practice of his or her profession; (11) physical therapy | 7 | | and related
services; (12) prescribed drugs, dentures, and | 8 | | prosthetic devices; and
eyeglasses prescribed by a physician | 9 | | skilled in the diseases of the eye,
or by an optometrist, | 10 | | whichever the person may select; (13) other
diagnostic, | 11 | | screening, preventive, and rehabilitative services; (14)
| 12 | | transportation and such other expenses as may be necessary , | 13 | | provided that payment for ground ambulance services shall be as | 14 | | provided in Section 5-4.2 ; (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
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| 1 | | intended to produce a live viable child and such procedure is | 2 | | necessary
for the health of the mother or her unborn child. The | 3 | | Illinois Department,
by rule, shall prohibit any physician from | 4 | | providing medical assistance
to anyone eligible therefor under | 5 | | this Code where such physician has been
found guilty of | 6 | | performing an abortion procedure in a wilful and wanton
manner | 7 | | upon a woman who was not pregnant at the time such abortion
| 8 | | procedure was performed. The term "any other type of remedial | 9 | | care" shall
include nursing care and nursing home service for | 10 | | persons who rely on
treatment by spiritual means alone through | 11 | | prayer for healing.
| 12 | | Notwithstanding any other provision of this Section, a | 13 | | comprehensive
tobacco use cessation program that includes | 14 | | purchasing prescription drugs or
prescription medical devices | 15 | | approved by the Food and Drug Administration shall
be covered | 16 | | under the medical assistance
program under this Article for | 17 | | persons who are otherwise eligible for
assistance under this | 18 | | Article.
| 19 | | Notwithstanding any other provision of this Code, the | 20 | | Illinois
Department may not require, as a condition of payment | 21 | | for any laboratory
test authorized under this Article, that a | 22 | | physician's handwritten signature
appear on the laboratory | 23 | | test order form. The Illinois Department may,
however, impose | 24 | | other appropriate requirements regarding laboratory test
order | 25 | | documentation.
| 26 | | The Department of Healthcare and Family Services shall |
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| 1 | | provide the following services to
persons
eligible for | 2 | | assistance under this Article who are participating in
| 3 | | education, training or employment programs operated by the | 4 | | Department of Human
Services as successor to the Department of | 5 | | Public Aid:
| 6 | | (1) dental services provided by or under the | 7 | | supervision of a dentist; and
| 8 | | (2) eyeglasses prescribed by a physician skilled in the | 9 | | diseases of the
eye, or by an optometrist, whichever the | 10 | | person may select.
| 11 | | Notwithstanding any other provision of this Code and | 12 | | subject to federal approval, the Department may adopt rules to | 13 | | allow a dentist who is volunteering his or her service at no | 14 | | cost to render dental services through an enrolled | 15 | | not-for-profit health clinic without the dentist personally | 16 | | enrolling as a participating provider in the medical assistance | 17 | | program. A not-for-profit health clinic shall include a public | 18 | | health clinic or Federally Qualified Health Center or other | 19 | | enrolled provider, as determined by the Department, through | 20 | | which dental services covered under this Section are performed. | 21 | | The Department shall establish a process for payment of claims | 22 | | for reimbursement for covered dental services rendered under | 23 | | this provision. | 24 | | The Illinois Department, by rule, may distinguish and | 25 | | classify the
medical services to be provided only in accordance | 26 | | with the classes of
persons designated in Section 5-2.
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| 1 | | The Department of Healthcare and Family Services must | 2 | | provide coverage and reimbursement for amino acid-based | 3 | | elemental formulas, regardless of delivery method, for the | 4 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 5 | | short bowel syndrome when the prescribing physician has issued | 6 | | a written order stating that the amino acid-based elemental | 7 | | formula is medically necessary.
| 8 | | The Illinois Department shall authorize the provision of, | 9 | | and shall
authorize payment for, screening by low-dose | 10 | | mammography for the presence of
occult breast cancer for women | 11 | | 35 years of age or older who are eligible
for medical | 12 | | assistance under this Article, as follows: | 13 | | (A) A baseline
mammogram for women 35 to 39 years of | 14 | | age.
| 15 | | (B) An annual mammogram for women 40 years of age or | 16 | | older. | 17 | | (C) A mammogram at the age and intervals considered | 18 | | medically necessary by the woman's health care provider for | 19 | | women under 40 years of age and having a family history of | 20 | | breast cancer, prior personal history of breast cancer, | 21 | | positive genetic testing, or other risk factors. | 22 | | (D) A comprehensive ultrasound screening of an entire | 23 | | breast or breasts if a mammogram demonstrates | 24 | | heterogeneous or dense breast tissue, when medically | 25 | | necessary as determined by a physician licensed to practice | 26 | | medicine in all of its branches. |
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| 1 | | All screenings
shall
include a physical breast exam, | 2 | | instruction on self-examination and
information regarding the | 3 | | frequency of self-examination and its value as a
preventative | 4 | | tool. For purposes of this Section, "low-dose mammography" | 5 | | means
the x-ray examination of the breast using equipment | 6 | | dedicated specifically
for mammography, including the x-ray | 7 | | tube, filter, compression device,
and image receptor, with an | 8 | | average radiation exposure delivery
of less than one rad per | 9 | | breast for 2 views of an average size breast.
The term also | 10 | | includes digital mammography.
| 11 | | On and after July 1, 2008, screening and diagnostic | 12 | | mammography shall be reimbursed at the same rate as the | 13 | | Medicare program's rates, including the increased | 14 | | reimbursement for digital mammography. | 15 | | The Department shall convene an expert panel including | 16 | | representatives of hospitals, free-standing mammography | 17 | | facilities, and doctors, including radiologists, to establish | 18 | | quality standards. Based on these quality standards, the | 19 | | Department shall provide for bonus payments to mammography | 20 | | facilities meeting the standards for screening and diagnosis. | 21 | | The bonus payments shall be at least 15% higher than the | 22 | | Medicare rates for mammography. | 23 | | Subject to federal approval, the Department shall | 24 | | establish a rate methodology for mammography at federally | 25 | | qualified health centers and other encounter-rate clinics. | 26 | | These clinics or centers may also collaborate with other |
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| 1 | | hospital-based mammography facilities. | 2 | | The Department shall establish a methodology to remind | 3 | | women who are age-appropriate for screening mammography, but | 4 | | who have not received a mammogram within the previous 18 | 5 | | months, of the importance and benefit of screening mammography. | 6 | | The Department shall establish a performance goal for | 7 | | primary care providers with respect to their female patients | 8 | | over age 40 receiving an annual mammogram. This performance | 9 | | goal shall be used to provide additional reimbursement in the | 10 | | form of a quality performance bonus to primary care providers | 11 | | who meet that goal. | 12 | | The Department shall devise a means of case-managing or | 13 | | patient navigation for beneficiaries diagnosed with breast | 14 | | cancer. This program shall initially operate as a pilot program | 15 | | in areas of the State with the highest incidence of mortality | 16 | | related to breast cancer. At least one pilot program site shall | 17 | | be in the metropolitan Chicago area and at least one site shall | 18 | | be outside the metropolitan Chicago area. An evaluation of the | 19 | | pilot program shall be carried out measuring health outcomes | 20 | | and cost of care for those served by the pilot program compared | 21 | | to similarly situated patients who are not served by the pilot | 22 | | program. | 23 | | Any medical or health care provider shall immediately | 24 | | recommend, to
any pregnant woman who is being provided prenatal | 25 | | services and is suspected
of drug abuse or is addicted as | 26 | | defined in the Alcoholism and Other Drug Abuse
and Dependency |
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| 1 | | Act, referral to a local substance abuse treatment provider
| 2 | | licensed by the Department of Human Services or to a licensed
| 3 | | hospital which provides substance abuse treatment services. | 4 | | The Department of Healthcare and Family Services
shall assure | 5 | | coverage for the cost of treatment of the drug abuse or
| 6 | | addiction for pregnant recipients in accordance with the | 7 | | Illinois Medicaid
Program in conjunction with the Department of | 8 | | Human Services.
| 9 | | All medical providers providing medical assistance to | 10 | | pregnant women
under this Code shall receive information from | 11 | | the Department on the
availability of services under the Drug | 12 | | Free Families with a Future or any
comparable program providing | 13 | | case management services for addicted women,
including | 14 | | information on appropriate referrals for other social services
| 15 | | that may be needed by addicted women in addition to treatment | 16 | | for addiction.
| 17 | | The Illinois Department, in cooperation with the | 18 | | Departments of Human
Services (as successor to the Department | 19 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 20 | | public awareness campaign, may
provide information concerning | 21 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 22 | | health care, and other pertinent programs directed at
reducing | 23 | | the number of drug-affected infants born to recipients of | 24 | | medical
assistance.
| 25 | | Neither the Department of Healthcare and Family Services | 26 | | nor the Department of Human
Services shall sanction the |
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| 1 | | recipient solely on the basis of
her substance abuse.
| 2 | | The Illinois Department shall establish such regulations | 3 | | governing
the dispensing of health services under this Article | 4 | | as it shall deem
appropriate. The Department
should
seek the | 5 | | advice of formal professional advisory committees appointed by
| 6 | | the Director of the Illinois Department for the purpose of | 7 | | providing regular
advice on policy and administrative matters, | 8 | | information dissemination and
educational activities for | 9 | | medical and health care providers, and
consistency in | 10 | | procedures to the Illinois Department.
| 11 | | Notwithstanding any other provision of law, a health care | 12 | | provider under the medical assistance program may elect, in | 13 | | lieu of receiving direct payment for services provided under | 14 | | that program, to participate in the State Employees Deferred | 15 | | Compensation Plan adopted under Article 24 of the Illinois | 16 | | Pension Code. A health care provider who elects to participate | 17 | | in the plan does not have a cause of action against the State | 18 | | for any damages allegedly suffered by the provider as a result | 19 | | of any delay by the State in crediting the amount of any | 20 | | contribution to the provider's plan account. | 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 may
terminate the vendor's | 4 | | eligibility to participate in the medical assistance
program | 5 | | without cause. That termination of eligibility is not subject | 6 | | 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 | | Rulemaking authority to implement Public Act 95-1045, if | 10 | | any, is conditioned on the rules being adopted in accordance | 11 | | with all provisions of the Illinois Administrative Procedure | 12 | | Act and all rules and procedures of the Joint Committee on | 13 | | Administrative Rules; any purported rule not so adopted, for | 14 | | whatever reason, is unauthorized. | 15 | | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | 16 | | 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; 96-806, eff. | 17 | | 7-1-10; 96-926, eff. 1-1-11; 96-1000, eff. 7-2-10 .)
| 18 | | Section 99. Effective date. This Act takes effect July 1, | 19 | | 2011.
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