Full Text of SB2502 97th General Assembly
SB2502sam001 97TH GENERAL ASSEMBLY | Sen. Mattie Hunter Filed: 10/27/2011
| | 09700SB2502sam001 | | LRB097 13774 KTG 58713 a |
|
| 1 | | AMENDMENT TO SENATE BILL 2502
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 2502 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 |
| | | 09700SB2502sam001 | - 2 - | LRB097 13774 KTG 58713 a |
|
| 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, for | 15 | | children and adults; (14)
transportation and such other | 16 | | expenses as may be necessary; (15) medical
treatment of sexual | 17 | | assault survivors, as defined in
Section 1a of the Sexual | 18 | | Assault Survivors Emergency Treatment Act, for
injuries | 19 | | sustained as a result of the sexual assault, including
| 20 | | examinations and laboratory tests to discover evidence which | 21 | | may be used in
criminal proceedings arising from the sexual | 22 | | assault; (16) the
diagnosis and treatment of sickle cell | 23 | | anemia; and (17)
any other medical care, and any other type of | 24 | | remedial care recognized
under the laws of this State, but not | 25 | | including abortions, or induced
miscarriages or premature | 26 | | births, unless, in the opinion of a physician,
such procedures |
| | | 09700SB2502sam001 | - 3 - | LRB097 13774 KTG 58713 a |
|
| 1 | | are necessary for the preservation of the life of the
woman | 2 | | seeking such treatment, or except an induced premature birth
| 3 | | intended to produce a live viable child and such procedure is | 4 | | necessary
for the health of the mother or her unborn child. The | 5 | | Illinois Department,
by rule, shall prohibit any physician from | 6 | | providing medical assistance
to anyone eligible therefor under | 7 | | this Code where such physician has been
found guilty of | 8 | | performing an abortion procedure in a wilful and wanton
manner | 9 | | upon a woman who was not pregnant at the time such abortion
| 10 | | procedure was performed. The term "any other type of remedial | 11 | | care" shall
include nursing care and nursing home service for | 12 | | persons who rely on
treatment by spiritual means alone through | 13 | | prayer for healing.
| 14 | | Notwithstanding any other provision of this Section, a | 15 | | comprehensive
tobacco use cessation program that includes | 16 | | purchasing prescription drugs or
prescription medical devices | 17 | | approved by the Food and Drug Administration shall
be covered | 18 | | under the medical assistance
program under this Article for | 19 | | persons who are otherwise eligible for
assistance under this | 20 | | Article.
| 21 | | Notwithstanding any other provision of this Code, the | 22 | | Illinois
Department may not require, as a condition of payment | 23 | | for any laboratory
test authorized under this Article, that a | 24 | | physician's handwritten signature
appear on the laboratory | 25 | | test order form. The Illinois Department may,
however, impose | 26 | | other appropriate requirements regarding laboratory test
order |
| | | 09700SB2502sam001 | - 4 - | LRB097 13774 KTG 58713 a |
|
| 1 | | documentation.
| 2 | | The Department of Healthcare and Family Services shall | 3 | | provide the following services to
persons
eligible for | 4 | | assistance under this Article who are participating in
| 5 | | education, training or employment programs operated by the | 6 | | Department of Human
Services as successor to the Department of | 7 | | Public Aid:
| 8 | | (1) dental services provided by or under the | 9 | | supervision of a dentist; 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 | | Notwithstanding any other provision of this Code and | 14 | | subject to federal approval, the Department may adopt rules to | 15 | | allow a dentist who is volunteering his or her service at no | 16 | | cost to render dental services through an enrolled | 17 | | not-for-profit health clinic without the dentist personally | 18 | | enrolling as a participating provider in the medical assistance | 19 | | program. A not-for-profit health clinic shall include a public | 20 | | health clinic or Federally Qualified Health Center or other | 21 | | enrolled provider, as determined by the Department, through | 22 | | which dental services covered under this Section are performed. | 23 | | The Department shall establish a process for payment of claims | 24 | | for reimbursement for covered dental services rendered under | 25 | | this provision. | 26 | | The Illinois Department, by rule, may distinguish and |
| | | 09700SB2502sam001 | - 5 - | LRB097 13774 KTG 58713 a |
|
| 1 | | classify the
medical services to be provided only in accordance | 2 | | with the classes of
persons designated in Section 5-2.
| 3 | | The Department of Healthcare and Family Services must | 4 | | provide coverage and reimbursement for amino acid-based | 5 | | elemental formulas, regardless of delivery method, for the | 6 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 7 | | short bowel syndrome when the prescribing physician has issued | 8 | | a written order stating that the amino acid-based elemental | 9 | | formula is medically necessary.
| 10 | | The Illinois Department shall authorize the provision of, | 11 | | and shall
authorize payment for, screening by low-dose | 12 | | mammography for the presence of
occult breast cancer for women | 13 | | 35 years of age or older who are eligible
for medical | 14 | | assistance under this Article, as follows: | 15 | | (A) A baseline
mammogram for women 35 to 39 years of | 16 | | age.
| 17 | | (B) An annual mammogram for women 40 years of age or | 18 | | older. | 19 | | (C) A mammogram at the age and intervals considered | 20 | | medically necessary by the woman's health care provider for | 21 | | women under 40 years of age and having a family history of | 22 | | breast cancer, prior personal history of breast cancer, | 23 | | positive genetic testing, or other risk factors. | 24 | | (D) A comprehensive ultrasound screening of an entire | 25 | | breast or breasts if a mammogram demonstrates | 26 | | heterogeneous or dense breast tissue, when medically |
| | | 09700SB2502sam001 | - 6 - | LRB097 13774 KTG 58713 a |
|
| 1 | | necessary as determined by a physician licensed to practice | 2 | | medicine in all of its branches. | 3 | | All screenings
shall
include a physical breast exam, | 4 | | instruction on self-examination and
information regarding the | 5 | | frequency of self-examination and its value as a
preventative | 6 | | tool. For purposes of this Section, "low-dose mammography" | 7 | | means
the x-ray examination of the breast using equipment | 8 | | dedicated specifically
for mammography, including the x-ray | 9 | | tube, filter, compression device,
and image receptor, with an | 10 | | average radiation exposure delivery
of less than one rad per | 11 | | breast for 2 views of an average size breast.
The term also | 12 | | includes digital mammography.
| 13 | | On and after January 1, 2012, providers participating in a | 14 | | quality improvement program approved by the Department shall be | 15 | | reimbursed for screening and diagnostic mammography at the same | 16 | | rate as the Medicare program's rates, including the increased | 17 | | reimbursement for digital mammography. On and after July 1, | 18 | | 2008, screening and diagnostic mammography shall be reimbursed | 19 | | at the same rate as the Medicare program's rates, including the | 20 | | increased reimbursement for digital mammography. | 21 | | The Department shall convene an expert panel including | 22 | | representatives of hospitals, free-standing mammography | 23 | | facilities, and doctors, including radiologists, to establish | 24 | | quality standards. Based on these quality standards, the | 25 | | Department shall provide for bonus payments to mammography | 26 | | facilities meeting the standards for screening and diagnosis. |
| | | 09700SB2502sam001 | - 7 - | LRB097 13774 KTG 58713 a |
|
| 1 | | The bonus payments shall be at least 15% higher than the | 2 | | Medicare rates for mammography. | 3 | | Subject to federal approval, the Department shall | 4 | | establish a rate methodology for mammography at federally | 5 | | qualified health centers and other encounter-rate clinics. | 6 | | These clinics or centers may also collaborate with other | 7 | | hospital-based mammography facilities. | 8 | | The Department shall establish a methodology to remind | 9 | | women who are age-appropriate for screening mammography, but | 10 | | who have not received a mammogram within the previous 18 | 11 | | months, of the importance and benefit of screening mammography. | 12 | | The Department shall establish a performance goal for | 13 | | primary care providers with respect to their female patients | 14 | | over age 40 receiving an annual mammogram. This performance | 15 | | goal shall be used to provide additional reimbursement in the | 16 | | form of a quality performance bonus to primary care providers | 17 | | who meet that goal. | 18 | | The Department shall devise a means of case-managing or | 19 | | patient navigation for beneficiaries diagnosed with breast | 20 | | cancer. This program shall initially operate as a pilot program | 21 | | in areas of the State with the highest incidence of mortality | 22 | | related to breast cancer. At least one pilot program site shall | 23 | | be in the metropolitan Chicago area and at least one site shall | 24 | | be outside the metropolitan Chicago area. An evaluation of the | 25 | | pilot program shall be carried out measuring health outcomes | 26 | | and cost of care for those served by the pilot program compared |
| | | 09700SB2502sam001 | - 8 - | LRB097 13774 KTG 58713 a |
|
| 1 | | to similarly situated patients who are not served by the pilot | 2 | | program. | 3 | | Any medical or health care provider shall immediately | 4 | | recommend, to
any pregnant woman who is being provided prenatal | 5 | | services and is suspected
of drug abuse or is addicted as | 6 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 7 | | Act, referral to a local substance abuse treatment provider
| 8 | | licensed by the Department of Human Services or to a licensed
| 9 | | hospital which provides substance abuse treatment services. | 10 | | The Department of Healthcare and Family Services
shall assure | 11 | | coverage for the cost of treatment of the drug abuse or
| 12 | | addiction for pregnant recipients in accordance with the | 13 | | Illinois Medicaid
Program in conjunction with the Department of | 14 | | Human Services.
| 15 | | All medical providers providing medical assistance to | 16 | | pregnant women
under this Code shall receive information from | 17 | | the Department on the
availability of services under the Drug | 18 | | Free Families with a Future or any
comparable program providing | 19 | | case management services for addicted women,
including | 20 | | information on appropriate referrals for other social services
| 21 | | that may be needed by addicted women in addition to treatment | 22 | | for addiction.
| 23 | | The Illinois Department, in cooperation with the | 24 | | Departments of Human
Services (as successor to the Department | 25 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 26 | | public awareness campaign, may
provide information concerning |
| | | 09700SB2502sam001 | - 9 - | LRB097 13774 KTG 58713 a |
|
| 1 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 2 | | health care, and other pertinent programs directed at
reducing | 3 | | the number of drug-affected infants born to recipients of | 4 | | medical
assistance.
| 5 | | Neither the Department of Healthcare and Family Services | 6 | | nor the Department of Human
Services shall sanction the | 7 | | recipient solely on the basis of
her substance abuse.
| 8 | | The Illinois Department shall establish such regulations | 9 | | governing
the dispensing of health services under this Article | 10 | | as it shall deem
appropriate. The Department
should
seek the | 11 | | advice of formal professional advisory committees appointed by
| 12 | | the Director of the Illinois Department for the purpose of | 13 | | providing regular
advice on policy and administrative matters, | 14 | | information dissemination and
educational activities for | 15 | | medical and health care providers, and
consistency in | 16 | | procedures to the Illinois Department.
| 17 | | Notwithstanding any other provision of law, a health care | 18 | | provider under the medical assistance program may elect, in | 19 | | lieu of receiving direct payment for services provided under | 20 | | that program, to participate in the State Employees Deferred | 21 | | Compensation Plan adopted under Article 24 of the Illinois | 22 | | Pension Code. A health care provider who elects to participate | 23 | | in the plan does not have a cause of action against the State | 24 | | for any damages allegedly suffered by the provider as a result | 25 | | of any delay by the State in crediting the amount of any | 26 | | contribution to the provider's plan account. |
| | | 09700SB2502sam001 | - 10 - | LRB097 13774 KTG 58713 a |
|
| 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 |
| | | 09700SB2502sam001 | - 11 - | LRB097 13774 KTG 58713 a |
|
| 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.
|
| | | 09700SB2502sam001 | - 12 - | LRB097 13774 KTG 58713 a |
|
| 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. Such records must be retained for a period of not | 5 | | less than 6 years from the date of service or as provided by | 6 | | applicable State law, whichever period is longer, except that | 7 | | if an audit is initiated within the required retention period | 8 | | then the records must be retained until the audit is completed | 9 | | and every exception is resolved. The Illinois Department shall
| 10 | | require health care providers to make available, when | 11 | | authorized by the
patient, in writing, the medical records in a | 12 | | timely fashion to other
health care providers who are treating | 13 | | or serving persons eligible for
Medical Assistance under this | 14 | | Article. All dispensers of medical services
shall be required | 15 | | to maintain and retain business and professional records
| 16 | | sufficient to fully and accurately document the nature, scope, | 17 | | details and
receipt of the health care provided to persons | 18 | | eligible for medical
assistance under this Code, in accordance | 19 | | with regulations promulgated by
the Illinois Department. The | 20 | | rules and regulations shall require that proof
of the receipt | 21 | | of prescription drugs, dentures, prosthetic devices and
| 22 | | eyeglasses by eligible persons under this Section accompany | 23 | | each claim
for reimbursement submitted by the dispenser of such | 24 | | medical services.
No such claims for reimbursement shall be | 25 | | approved for payment by the Illinois
Department without such | 26 | | proof of receipt, unless the Illinois Department
shall have put |
| | | 09700SB2502sam001 | - 13 - | LRB097 13774 KTG 58713 a |
|
| 1 | | into effect and shall be operating a system of post-payment
| 2 | | audit and review which shall, on a sampling basis, be deemed | 3 | | adequate by
the Illinois Department to assure that such drugs, | 4 | | dentures, prosthetic
devices and eyeglasses for which payment | 5 | | is being made are actually being
received by eligible | 6 | | recipients. Within 90 days after the effective date of
this | 7 | | amendatory Act of 1984, the Illinois Department shall establish | 8 | | a
current list of acquisition costs for all prosthetic devices | 9 | | and any
other items recognized as medical equipment and | 10 | | supplies reimbursable under
this Article and shall update such | 11 | | list on a quarterly basis, except that
the acquisition costs of | 12 | | all prescription drugs shall be updated no
less frequently than | 13 | | every 30 days as required by Section 5-5.12.
| 14 | | The rules and regulations of the Illinois Department shall | 15 | | require
that a written statement including the required opinion | 16 | | of a physician
shall accompany any claim for reimbursement for | 17 | | abortions, or induced
miscarriages or premature births. This | 18 | | statement shall indicate what
procedures were used in providing | 19 | | such medical services.
| 20 | | The Illinois Department shall require all dispensers of | 21 | | medical
services, other than an individual practitioner or | 22 | | group of practitioners,
desiring to participate in the Medical | 23 | | Assistance program
established under this Article to disclose | 24 | | all financial, beneficial,
ownership, equity, surety or other | 25 | | interests in any and all firms,
corporations, partnerships, | 26 | | associations, business enterprises, joint
ventures, agencies, |
| | | 09700SB2502sam001 | - 14 - | LRB097 13774 KTG 58713 a |
|
| 1 | | institutions or other legal entities providing any
form of | 2 | | health care services in this State under this Article.
| 3 | | The Illinois Department may require that all dispensers of | 4 | | medical
services desiring to participate in the medical | 5 | | assistance program
established under this Article disclose, | 6 | | under such terms and conditions as
the Illinois Department may | 7 | | by rule establish, all inquiries from clients
and attorneys | 8 | | regarding medical bills paid by the Illinois Department, which
| 9 | | inquiries could indicate potential existence of claims or liens | 10 | | for the
Illinois Department.
| 11 | | Enrollment of a vendor that provides non-emergency medical | 12 | | transportation,
defined by the Department by rule,
shall be
| 13 | | conditional for 180 days. During that time, the Department of | 14 | | Healthcare and Family Services may
terminate the vendor's | 15 | | eligibility to participate in the medical assistance
program | 16 | | without cause. That termination of eligibility is not subject | 17 | | to the
Department's hearing process.
| 18 | | The Illinois Department shall establish policies, | 19 | | procedures,
standards and criteria by rule for the acquisition, | 20 | | repair and replacement
of orthotic and prosthetic devices and | 21 | | durable medical equipment. Such
rules shall provide, but not be | 22 | | limited to, the following services: (1)
immediate repair or | 23 | | replacement of such devices by recipients without
medical | 24 | | authorization; and (2) rental, lease, purchase or | 25 | | lease-purchase of
durable medical equipment in a | 26 | | cost-effective manner, taking into
consideration the |
| | | 09700SB2502sam001 | - 15 - | LRB097 13774 KTG 58713 a |
|
| 1 | | recipient's medical prognosis, the extent of the
recipient's | 2 | | needs, and the requirements and costs for maintaining such
| 3 | | equipment. Such rules shall enable a recipient to temporarily | 4 | | acquire and
use alternative or substitute devices or equipment | 5 | | pending repairs or
replacements of any device or equipment | 6 | | previously authorized for such
recipient by the Department.
| 7 | | The Department shall execute, relative to the nursing home | 8 | | prescreening
project, written inter-agency agreements with the | 9 | | Department of Human
Services and the Department on Aging, to | 10 | | effect the following: (i) intake
procedures and common | 11 | | eligibility criteria for those persons who are receiving
| 12 | | non-institutional services; and (ii) the establishment and | 13 | | development of
non-institutional services in areas of the State | 14 | | where they are not currently
available or are undeveloped.
| 15 | | The Illinois Department shall develop and operate, in | 16 | | cooperation
with other State Departments and agencies and in | 17 | | compliance with
applicable federal laws and regulations, | 18 | | appropriate and effective
systems of health care evaluation and | 19 | | programs for monitoring of
utilization of health care services | 20 | | and facilities, as it affects
persons eligible for medical | 21 | | assistance under this Code.
| 22 | | The Illinois Department shall report annually to the | 23 | | General Assembly,
no later than the second Friday in April of | 24 | | 1979 and each year
thereafter, in regard to:
| 25 | | (a) actual statistics and trends in utilization of | 26 | | medical services by
public aid recipients;
|
| | | 09700SB2502sam001 | - 16 - | LRB097 13774 KTG 58713 a |
|
| 1 | | (b) actual statistics and trends in the provision of | 2 | | the various medical
services by medical vendors;
| 3 | | (c) current rate structures and proposed changes in | 4 | | those rate structures
for the various medical vendors; and
| 5 | | (d) efforts at utilization review and control by the | 6 | | Illinois Department.
| 7 | | The period covered by each report shall be the 3 years | 8 | | ending on the June
30 prior to the report. The report shall | 9 | | include suggested legislation
for consideration by the General | 10 | | Assembly. The filing of one copy of the
report with the | 11 | | Speaker, one copy with the Minority Leader and one copy
with | 12 | | the Clerk of the House of Representatives, one copy with the | 13 | | President,
one copy with the Minority Leader and one copy with | 14 | | the Secretary of the
Senate, one copy with the Legislative | 15 | | Research Unit, and such additional
copies
with the State | 16 | | Government Report Distribution Center for the General
Assembly | 17 | | as is required under paragraph (t) of Section 7 of the State
| 18 | | Library Act shall be deemed sufficient to comply with this | 19 | | Section.
| 20 | | Rulemaking authority to implement Public Act 95-1045, if | 21 | | any, is conditioned on the rules being adopted in accordance | 22 | | with all provisions of the Illinois Administrative Procedure | 23 | | Act and all rules and procedures of the Joint Committee on | 24 | | Administrative Rules; any purported rule not so adopted, for | 25 | | whatever reason, is unauthorized. | 26 | | (Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926, |
| | | 09700SB2502sam001 | - 17 - | LRB097 13774 KTG 58713 a |
|
| 1 | | eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11.)
| 2 | | Section 99. Effective date. This Act takes effect January | 3 | | 1, 2012.".
|
|