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90_HB0333eng
New Act
30 ILCS 105/5.449 new
Creates the Illinois Patient Communication Act. Bars an
entity offering a health plan from interfering with certain
communications between a health care provider and a patient
through contractual provisions, policies, or retaliatory
actions taken against the health care provider. Provides for
civil penalties and private enforcement actions. Amends the
State Finance Act to create the Patient Communication
Administration Fund.
LRB9000208DPccA
HB0333 Engrossed LRB9000208DPccA
1 AN ACT concerning mammograms, amending named Acts.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Counties Code is amended by changing
5 Section 5-1069 as follows:
6 (55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
7 Sec. 5-1069. Group life, health, accident, hospital, and
8 medical insurance.
9 (a) The county board of any county may arrange to
10 provide, for the benefit of employees of the county, group
11 life, health, accident, hospital, and medical insurance, or
12 any one or any combination of those types of insurance, or
13 the county board may self-insure, for the benefit of its
14 employees, all or a portion of the employees' group life,
15 health, accident, hospital, and medical insurance, or any one
16 or any combination of those types of insurance, including a
17 combination of self-insurance and other types of insurance
18 authorized by this Section, provided that the county board
19 complies with all other requirements of this Section. The
20 insurance may include provision for employees who rely on
21 treatment by prayer or spiritual means alone for healing in
22 accordance with the tenets and practice of a well recognized
23 religious denomination. The county board may provide for
24 payment by the county of a portion or all of the premium or
25 charge for the insurance with the employee paying the balance
26 of the premium or charge, if any. If the county board
27 undertakes a plan under which the county pays only a portion
28 of the premium or charge, the county board shall provide for
29 withholding and deducting from the compensation of those
30 employees who consent to join the plan the balance of the
31 premium or charge for the insurance.
HB0333 Engrossed -2- LRB9000208DPccA
1 (b) If the county board does not provide for
2 self-insurance or for a plan under which the county pays a
3 portion or all of the premium or charge for a group insurance
4 plan, the county board may provide for withholding and
5 deducting from the compensation of those employees who
6 consent thereto the total premium or charge for any group
7 life, health, accident, hospital, and medical insurance.
8 (c) The county board may exercise the powers granted in
9 this Section only if it provides for self-insurance or, where
10 it makes arrangements to provide group insurance through an
11 insurance carrier, if the kinds of group insurance are
12 obtained from an insurance company authorized to do business
13 in the State of Illinois. The county board may enact an
14 ordinance prescribing the method of operation of the
15 insurance program.
16 (d) If a county, including a home rule county, is a
17 self-insurer for purposes of providing health insurance
18 coverage for its employees, the insurance coverage shall
19 include screening by low-dose mammography for all women 35
20 years of age or older for the presence of occult breast
21 cancer unless the county elects to provide mammograms itself
22 under Section 5-1069.1. The coverage shall be as follows:
23 (1) A baseline mammogram for women 35 to 39 years
24 of age.
25 (2) A mammogram every one to 2 years, even if no
26 symptoms are present, for women 40 to 49 years of age.
27 (3) An annual mammogram for women 40 50 years of
28 age or older.
29 Those benefits shall be at least as favorable as for
30 other radiological examinations and subject to the same
31 dollar limits, deductibles, and co-insurance factors. For
32 purposes of this subsection, "low-dose mammography" means the
33 x-ray examination of the breast using equipment dedicated
34 specifically for mammography, including the x-ray tube,
HB0333 Engrossed -3- LRB9000208DPccA
1 filter, compression device, screens, and image receptors,
2 with an average radiation exposure delivery of less than one
3 rad mid-breast, with 2 views for each breast. The requirement
4 that mammograms be included in health insurance coverage as
5 provided in this subsection (d) is an exclusive power and
6 function of the State and is a denial and limitation under
7 Article VII, Section 6, subsection (h) of the Illinois
8 Constitution of home rule county powers. A home rule county
9 to which this subsection applies must comply with every
10 provision of this subsection.
11 (e) The term "employees" as used in this Section
12 includes elected or appointed officials but does not include
13 temporary employees.
14 (Source: P.A. 86-962; 87-780.)
15 Section 10. The Illinois Municipal Code is amended by
16 changing Section 10-4-2 as follows:
17 (65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
18 Sec. 10-4-2. Group insurance.
19 (a) The corporate authorities of any municipality may
20 arrange to provide, for the benefit of employees of the
21 municipality, group life, health, accident, hospital, and
22 medical insurance, or any one or any combination of those
23 types of insurance, and may arrange to provide that insurance
24 for the benefit of the spouses or dependents of those
25 employees. The insurance may include provision for employees
26 or other insured persons who rely on treatment by prayer or
27 spiritual means alone for healing in accordance with the
28 tenets and practice of a well recognized religious
29 denomination. The corporate authorities may provide for
30 payment by the municipality of a portion of the premium or
31 charge for the insurance with the employee paying the balance
32 of the premium or charge. If the corporate authorities
HB0333 Engrossed -4- LRB9000208DPccA
1 undertake a plan under which the municipality pays a portion
2 of the premium or charge, the corporate authorities shall
3 provide for withholding and deducting from the compensation
4 of those municipal employees who consent to join the plan the
5 balance of the premium or charge for the insurance.
6 (b) If the corporate authorities do not provide for a
7 plan under which the municipality pays a portion of the
8 premium or charge for a group insurance plan, the corporate
9 authorities may provide for withholding and deducting from
10 the compensation of those employees who consent thereto the
11 premium or charge for any group life, health, accident,
12 hospital, and medical insurance.
13 (c) The corporate authorities may exercise the powers
14 granted in this Section only if the kinds of group insurance
15 are obtained from an insurance company authorized to do
16 business in the State of Illinois. The corporate authorities
17 may enact an ordinance prescribing the method of operation of
18 the insurance program.
19 (d) If a municipality, including a home rule
20 municipality, is a self-insurer for purposes of providing
21 health insurance coverage for its employees, the insurance
22 coverage shall include screening by low-dose mammography for
23 all women 35 years of age or older for the presence of occult
24 breast cancer unless the municipality elects to provide
25 mammograms itself under Section 10-4-2.1. The coverage shall
26 be as follows:
27 (1) A baseline mammogram for women 35 to 39 years
28 of age.
29 (2) A mammogram every one to 2 years, even if no
30 symptoms are present, for women 40 to 49 years of age.
31 (3) An annual mammogram for women 40 50 years of
32 age or older.
33 Those benefits shall be at least as favorable as for
34 other radiological examinations and subject to the same
HB0333 Engrossed -5- LRB9000208DPccA
1 dollar limits, deductibles, and co-insurance factors. For
2 purposes of this subsection, "low-dose mammography" means the
3 x-ray examination of the breast using equipment dedicated
4 specifically for mammography, including the x-ray tube,
5 filter, compression device, screens, and image receptors,
6 with an average radiation exposure delivery of less than one
7 rad mid-breast, with 2 views for each breast. The requirement
8 that mammograms be included in health insurance coverage as
9 provided in this subsection (d) is an exclusive power and
10 function of the State and is a denial and limitation under
11 Article VII, Section 6, subsection (h) of the Illinois
12 Constitution of home rule municipality powers. A home rule
13 municipality to which this subsection applies must comply
14 with every provision of this subsection.
15 (Source: P.A. 86-1475; 87-780.)
16 Section 15. The Illinois Insurance Code is amended by
17 changing Section 356g as follows:
18 (215 ILCS 5/356g) (from Ch. 73, par. 968g)
19 Sec. 356g. (a) Every insurer shall provide in each group
20 or individual policy, contract, or certificate of insurance
21 issued or renewed for persons who are residents of this
22 State, coverage for screening by low-dose mammography for all
23 women 35 years of age or older for the presence of occult
24 breast cancer within the provisions of the policy, contract,
25 or certificate. The coverage shall be as follows:
26 (1) A baseline mammogram for women 35 to 39 years
27 of age.
28 (2) An mammogram every 1 to 2 years, even if no
29 symptoms are present, for women 40 to 49 years of age.
30 (3) An annual mammogram for women 40 50 years of
31 age or older.
32 These benefits shall be at least as favorable as for
HB0333 Engrossed -6- LRB9000208DPccA
1 other radiological examinations and subject to the same
2 dollar limits, deductibles, and co-insurance factors. For
3 purposes of this Section, "low-dose mammography" means the
4 x-ray examination of the breast using equipment dedicated
5 specifically for mammography, including the x-ray tube,
6 filter, compression device, and image receptor, with
7 radiation exposure delivery of less than 1 rad per breast for
8 2 views of an average size breast.
9 (b) No policy of accident or health insurance that
10 provides for the surgical procedure known as a mastectomy
11 shall be issued, amended, delivered or renewed in this State
12 on or after July 1, 1981, unless coverage is also offered for
13 prosthetic devices or reconstructive surgery incident to the
14 mastectomy, providing that the mastectomy is performed after
15 July 1, 1981. The offered coverage for prosthetic devices and
16 reconstructive surgery shall be subject to the deductible and
17 coinsurance conditions applied to the mastectomy, and all
18 other terms and conditions applicable to other benefits.
19 When a mastectomy is performed and there is no evidence of
20 malignancy then the offered coverage may be limited to the
21 provision of prosthetic devices and reconstructive surgery to
22 within 2 years after the date of the mastectomy. As used in
23 this Section, "mastectomy" means the removal of all or part
24 of the breast for medically necessary reasons, as determined
25 by a licensed physician.
26 (Source: P.A. 86-899; 87-518.)
27 Section 20. The Health Maintenance Organization Act is
28 amended by changing Section 4-6.1 as follows:
29 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
30 Sec. 4-6.1. (a) Every contract or evidence of coverage
31 issued by a Health Maintenance Organization for persons who
32 are residents of this State shall contain coverage for
HB0333 Engrossed -7- LRB9000208DPccA
1 screening by low-dose mammography for all women 35 years of
2 age or older for the presence of occult breast cancer. The
3 coverage shall be as follows:
4 (1) A baseline mammogram for women 35 to 39 years
5 of age.
6 (2) A mammogram every 1 to 2 years, even if no
7 symptoms are present, for women 40 to 49 years of age.
8 (3) An annual mammogram for women 40 50 years of
9 age or older.
10 These benefits shall be at least as favorable as for
11 other radiological examinations and subject to the same
12 dollar limits, deductibles, and co-insurance factors. For
13 purposes of this Section, "low-dose mammography" means the
14 x-ray examination of the breast using equipment dedicated
15 specifically for mammography, including the x-ray tube,
16 filter, compression device, and image receptor, with
17 radiation exposure delivery of less than 1 rad per breast for
18 2 views of an average size breast.
19 (Source: P.A. 86-899; 86-1028; 87-518.)
20 Section 25. The Illinois Public Aid Code is amended by
21 changing Section 5-5 as follows:
22 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
23 (Text of Section before amendment by P.A. 89-507)
24 Sec. 5-5. Medical services. The Illinois Department, by
25 rule, shall determine the quantity and quality of and the
26 rate of reimbursement for the medical assistance for which
27 payment will be authorized, and the medical services to be
28 provided, which may include all or part of the following: (1)
29 inpatient hospital services; (2) outpatient hospital
30 services; (3) other laboratory and X-ray services; (4)
31 skilled nursing home services; (5) physicians' services
32 whether furnished in the office, the patient's home, a
HB0333 Engrossed -8- LRB9000208DPccA
1 hospital, a skilled nursing home, or elsewhere; (6) medical
2 care, or any other type of remedial care furnished by
3 licensed practitioners; (7) home health care services; (8)
4 private duty nursing service; (9) clinic services; (10)
5 dental services; (11) physical therapy and related services;
6 (12) prescribed drugs, dentures, and prosthetic devices; and
7 eyeglasses prescribed by a physician skilled in the diseases
8 of the eye, or by an optometrist, whichever the person may
9 select; (13) other diagnostic, screening, preventive, and
10 rehabilitative services; (14) transportation and such other
11 expenses as may be necessary; (15) medical treatment of
12 sexual assault survivors, as defined in Section 1a of the
13 Sexual Assault Survivors Emergency Treatment Act, for
14 injuries sustained as a result of the sexual assault,
15 including examinations and laboratory tests to discover
16 evidence which may be used in criminal proceedings arising
17 from the sexual assault; (16) the diagnosis and treatment of
18 sickle cell anemia; and (17) any other medical care, and any
19 other type of remedial care recognized under the laws of this
20 State, but not including abortions, or induced miscarriages
21 or premature births, unless, in the opinion of a physician,
22 such procedures are necessary for the preservation of the
23 life of the woman seeking such treatment, or except an
24 induced premature birth intended to produce a live viable
25 child and such procedure is necessary for the health of the
26 mother or her unborn child. The Illinois Department, by rule,
27 shall prohibit any physician from providing medical
28 assistance to anyone eligible therefor under this Code where
29 such physician has been found guilty of performing an
30 abortion procedure in a wilful and wanton manner upon a woman
31 who was not pregnant at the time such abortion procedure was
32 performed. The term "any other type of remedial care" shall
33 include nursing care and nursing home service for persons who
34 rely on treatment by spiritual means alone through prayer for
HB0333 Engrossed -9- LRB9000208DPccA
1 healing.
2 The Illinois Department shall provide the following
3 services to persons eligible for assistance under this
4 Article who are participating in education, training or
5 employment programs:
6 (1) dental services, which shall include but not be
7 limited to prosthodontics; and
8 (2) eyeglasses prescribed by a physician skilled in
9 the diseases of the eye, or by an optometrist, whichever
10 the person may select.
11 The Illinois Department, by rule, may distinguish and
12 classify the medical services to be provided only in
13 accordance with the classes of persons designated in Section
14 5-2.
15 The Illinois Department shall authorize the provision of,
16 and shall authorize payment for, screening by low-dose
17 mammography for the presence of occult breast cancer for
18 women 35 years of age or older who are eligible for medical
19 assistance under this Article, as follows: a baseline
20 mammogram for women 35 to 39 years of age; a mammogram every
21 1 to 2 years, even if no symptoms are present, for women 40
22 to 49 years of age; and an annual mammogram for women 40 50
23 years of age or older. All screenings shall include a
24 physical breast exam, instruction on self-examination and
25 information regarding the frequency of self-examination and
26 its value as a preventative tool. As used in this Section,
27 "low-dose mammography" means the x-ray examination of the
28 breast using equipment dedicated specifically for
29 mammography, including the x-ray tube, filter, compression
30 device, image receptor, and cassettes, with an average
31 radiation exposure delivery of less than one rad mid-breast,
32 with 2 views for each breast.
33 Any medical or health care provider shall immediately
34 recommend, to any pregnant woman who is being provided
HB0333 Engrossed -10- LRB9000208DPccA
1 prenatal services and is suspected of drug abuse or is
2 addicted as defined in the Alcoholism and Other Drug Abuse
3 and Dependency Act, referral to a local substance abuse
4 treatment provider licensed by the Department of Alcoholism
5 and Substance Abuse or to a licensed hospital which provides
6 substance abuse treatment services. The Department of Public
7 Aid shall assure coverage for the cost of treatment of the
8 drug abuse or addiction for pregnant recipients in accordance
9 with the Illinois Medicaid Program in conjunction with the
10 Department of Alcoholism and Substance Abuse.
11 All medical providers providing medical assistance to
12 pregnant women under this Code shall receive information from
13 the Department on the availability of services under the Drug
14 Free Families with a Future or any comparable program
15 providing case management services for addicted women,
16 including information on appropriate referrals for other
17 social services that may be needed by addicted women in
18 addition to treatment for addiction.
19 The Illinois Department, in cooperation with the
20 Departments of Alcoholism and Substance Abuse and Public
21 Health, through a public awareness campaign, may provide
22 information concerning treatment for alcoholism and drug
23 abuse and addiction, prenatal health care, and other
24 pertinent programs directed at reducing the number of
25 drug-affected infants born to recipients of medical
26 assistance.
27 The Department shall not sanction the recipient solely on
28 the basis of her substance abuse.
29 The Illinois Department shall establish such regulations
30 governing the dispensing of health services under this
31 Article as it shall deem appropriate. In formulating these
32 regulations the Illinois Department shall consult with and
33 give substantial weight to the recommendations offered by the
34 Citizens Assembly/Council on Public Aid. The Department
HB0333 Engrossed -11- LRB9000208DPccA
1 should seek the advice of formal professional advisory
2 committees appointed by the Director of the Illinois
3 Department for the purpose of providing regular advice on
4 policy and administrative matters, information dissemination
5 and educational activities for medical and health care
6 providers, and consistency in procedures to the Illinois
7 Department.
8 The Illinois Department may develop and contract with
9 Partnerships of medical providers to arrange medical services
10 for persons eligible under Section 5-2 of this Code.
11 Implementation of this Section may be by demonstration
12 projects in certain geographic areas. The Partnership shall
13 be represented by a sponsor organization. The Department, by
14 rule, shall develop qualifications for sponsors of
15 Partnerships. Nothing in this Section shall be construed to
16 require that the sponsor organization be a medical
17 organization.
18 The sponsor must negotiate formal written contracts with
19 medical providers for physician services, inpatient and
20 outpatient hospital care, home health services, treatment for
21 alcoholism and substance abuse, and other services determined
22 necessary by the Illinois Department by rule for delivery by
23 Partnerships. Physician services must include prenatal and
24 obstetrical care. The Illinois Department shall reimburse
25 medical services delivered by Partnership providers to
26 clients in target areas according to provisions of this
27 Article and the Illinois Health Finance Reform Act, except
28 that:
29 (1) Physicians participating in a Partnership and
30 providing certain services, which shall be determined by
31 the Illinois Department, to persons in areas covered by
32 the Partnership may receive an additional surcharge for
33 such services.
34 (2) The Department may elect to consider and
HB0333 Engrossed -12- LRB9000208DPccA
1 negotiate financial incentives to encourage the
2 development of Partnerships and the efficient delivery of
3 medical care.
4 (3) Persons receiving medical services through
5 Partnerships may receive medical and case management
6 services above the level usually offered through the
7 medical assistance program.
8 Medical providers shall be required to meet certain
9 qualifications to participate in Partnerships to ensure the
10 delivery of high quality medical services. These
11 qualifications shall be determined by rule of the Illinois
12 Department and may be higher than qualifications for
13 participation in the medical assistance program. Partnership
14 sponsors may prescribe reasonable additional qualifications
15 for participation by medical providers, only with the prior
16 written approval of the Illinois Department.
17 Nothing in this Section shall limit the free choice of
18 practitioners, hospitals, and other providers of medical
19 services by clients.
20 The Department shall apply for a waiver from the United
21 States Health Care Financing Administration to allow for the
22 implementation of Partnerships under this Section.
23 The Illinois Department shall require health care
24 providers to maintain records that document the medical care
25 and services provided to recipients of Medical Assistance
26 under this Article. The Illinois Department shall require
27 health care providers to make available, when authorized by
28 the patient, in writing, the medical records in a timely
29 fashion to other health care providers who are treating or
30 serving persons eligible for Medical Assistance under this
31 Article. All dispensers of medical services shall be
32 required to maintain and retain business and professional
33 records sufficient to fully and accurately document the
34 nature, scope, details and receipt of the health care
HB0333 Engrossed -13- LRB9000208DPccA
1 provided to persons eligible for medical assistance under
2 this Code, in accordance with regulations promulgated by the
3 Illinois Department. The rules and regulations shall require
4 that proof of the receipt of prescription drugs, dentures,
5 prosthetic devices and eyeglasses by eligible persons under
6 this Section accompany each claim for reimbursement submitted
7 by the dispenser of such medical services. No such claims for
8 reimbursement shall be approved for payment by the Illinois
9 Department without such proof of receipt, unless the Illinois
10 Department shall have put into effect and shall be operating
11 a system of post-payment audit and review which shall, on a
12 sampling basis, be deemed adequate by the Illinois Department
13 to assure that such drugs, dentures, prosthetic devices and
14 eyeglasses for which payment is being made are actually being
15 received by eligible recipients. Within 90 days after the
16 effective date of this amendatory Act of 1984, the Illinois
17 Department shall establish a current list of acquisition
18 costs for all prosthetic devices and any other items
19 recognized as medical equipment and supplies reimbursable
20 under this Article and shall update such list on a quarterly
21 basis, except that the acquisition costs of all prescription
22 drugs shall be updated no less frequently than every 30 days
23 as required by Section 5-5.12.
24 The rules and regulations of the Illinois Department
25 shall require that a written statement including the required
26 opinion of a physician shall accompany any claim for
27 reimbursement for abortions, or induced miscarriages or
28 premature births. This statement shall indicate what
29 procedures were used in providing such medical services.
30 The Illinois Department shall require that all dispensers
31 of medical services, other than an individual practitioner or
32 group of practitioners, desiring to participate in the
33 Medical Assistance program established under this Article to
34 disclose all financial, beneficial, ownership, equity, surety
HB0333 Engrossed -14- LRB9000208DPccA
1 or other interests in any and all firms, corporations,
2 partnerships, associations, business enterprises, joint
3 ventures, agencies, institutions or other legal entities
4 providing any form of health care services in this State
5 under this Article.
6 The Illinois Department may require that all dispensers
7 of medical services desiring to participate in the medical
8 assistance program established under this Article disclose,
9 under such terms and conditions as the Illinois Department
10 may by rule establish, all inquiries from clients and
11 attorneys regarding medical bills paid by the Illinois
12 Department, which inquiries could indicate potential
13 existence of claims or liens for the Illinois Department.
14 The Illinois Department shall establish policies,
15 procedures, standards and criteria by rule for the
16 acquisition, repair and replacement of orthotic and
17 prosthetic devices and durable medical equipment. Such rules
18 shall provide, but not be limited to, the following services:
19 (1) immediate repair or replacement of such devices by
20 recipients without medical authorization; and (2) rental,
21 lease, purchase or lease-purchase of durable medical
22 equipment in a cost-effective manner, taking into
23 consideration the recipient's medical prognosis, the extent
24 of the recipient's needs, and the requirements and costs for
25 maintaining such equipment. Such rules shall enable a
26 recipient to temporarily acquire and use alternative or
27 substitute devices or equipment pending repairs or
28 replacements of any device or equipment previously authorized
29 for such recipient by the Department. Rules under clause (2)
30 above shall not provide for purchase or lease-purchase of
31 durable medical equipment or supplies used for the purpose of
32 oxygen delivery and respiratory care.
33 The Department shall execute, relative to the nursing
34 home prescreening project, written inter-agency agreements
HB0333 Engrossed -15- LRB9000208DPccA
1 with the Department of Rehabilitation Services and the
2 Department on Aging, to effect the following: (i) intake
3 procedures and common eligibility criteria for those persons
4 who are receiving non-institutional services; and (ii) the
5 establishment and development of non-institutional services
6 in areas of the State where they are not currently available
7 or are undeveloped.
8 The Illinois Department shall develop and operate, in
9 cooperation with other State Departments and agencies and in
10 compliance with applicable federal laws and regulations,
11 appropriate and effective systems of health care evaluation
12 and programs for monitoring of utilization of health care
13 services and facilities, as it affects persons eligible for
14 medical assistance under this Code. The Illinois Department
15 shall report regularly the results of the operation of such
16 systems and programs to the Citizens Assembly/Council on
17 Public Aid to enable the Committee to ensure, from time to
18 time, that these programs are effective and meaningful.
19 The Illinois Department shall report annually to the
20 General Assembly, no later than the second Friday in April of
21 1979 and each year thereafter, in regard to:
22 (a) actual statistics and trends in utilization of
23 medical services by public aid recipients;
24 (b) actual statistics and trends in the provision
25 of the various medical services by medical vendors;
26 (c) current rate structures and proposed changes in
27 those rate structures for the various medical vendors;
28 and
29 (d) efforts at utilization review and control by
30 the Illinois Department.
31 The period covered by each report shall be the 3 years
32 ending on the June 30 prior to the report. The report shall
33 include suggested legislation for consideration by the
34 General Assembly. The filing of one copy of the report with
HB0333 Engrossed -16- LRB9000208DPccA
1 the Speaker, one copy with the Minority Leader and one copy
2 with the Clerk of the House of Representatives, one copy with
3 the President, one copy with the Minority Leader and one copy
4 with the Secretary of the Senate, one copy with the
5 Legislative Research Unit, such additional copies with the
6 State Government Report Distribution Center for the General
7 Assembly as is required under paragraph (t) of Section 7 of
8 the State Library Act and one copy with the Citizens
9 Assembly/Council on Public Aid or its successor shall be
10 deemed sufficient to comply with this Section.
11 (Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
12 89-517, eff. 1-1-97.)
13 (Text of Section after amendment by P.A. 89-507)
14 Sec. 5-5. Medical services. The Illinois Department, by
15 rule, shall determine the quantity and quality of and the
16 rate of reimbursement for the medical assistance for which
17 payment will be authorized, and the medical services to be
18 provided, which may include all or part of the following: (1)
19 inpatient hospital services; (2) outpatient hospital
20 services; (3) other laboratory and X-ray services; (4)
21 skilled nursing home services; (5) physicians' services
22 whether furnished in the office, the patient's home, a
23 hospital, a skilled nursing home, or elsewhere; (6) medical
24 care, or any other type of remedial care furnished by
25 licensed practitioners; (7) home health care services; (8)
26 private duty nursing service; (9) clinic services; (10)
27 dental services; (11) physical therapy and related services;
28 (12) prescribed drugs, dentures, and prosthetic devices; and
29 eyeglasses prescribed by a physician skilled in the diseases
30 of the eye, or by an optometrist, whichever the person may
31 select; (13) other diagnostic, screening, preventive, and
32 rehabilitative services; (14) transportation and such other
33 expenses as may be necessary; (15) medical treatment of
34 sexual assault survivors, as defined in Section 1a of the
HB0333 Engrossed -17- LRB9000208DPccA
1 Sexual Assault Survivors Emergency Treatment Act, for
2 injuries sustained as a result of the sexual assault,
3 including examinations and laboratory tests to discover
4 evidence which may be used in criminal proceedings arising
5 from the sexual assault; (16) the diagnosis and treatment of
6 sickle cell anemia; and (17) any other medical care, and any
7 other type of remedial care recognized under the laws of this
8 State, but not including abortions, or induced miscarriages
9 or premature births, unless, in the opinion of a physician,
10 such procedures are necessary for the preservation of the
11 life of the woman seeking such treatment, or except an
12 induced premature birth intended to produce a live viable
13 child and such procedure is necessary for the health of the
14 mother or her unborn child. The Illinois Department, by rule,
15 shall prohibit any physician from providing medical
16 assistance to anyone eligible therefor under this Code where
17 such physician has been found guilty of performing an
18 abortion procedure in a wilful and wanton manner upon a woman
19 who was not pregnant at the time such abortion procedure was
20 performed. The term "any other type of remedial care" shall
21 include nursing care and nursing home service for persons who
22 rely on treatment by spiritual means alone through prayer for
23 healing.
24 The Illinois Department of Public Aid shall provide the
25 following services to persons eligible for assistance under
26 this Article who are participating in education, training or
27 employment programs operated by the Department of Human
28 Services as successor to the Department of Public Aid:
29 (1) dental services, which shall include but not be
30 limited to prosthodontics; and
31 (2) eyeglasses prescribed by a physician skilled in
32 the diseases of the eye, or by an optometrist, whichever
33 the person may select.
34 The Illinois Department, by rule, may distinguish and
HB0333 Engrossed -18- LRB9000208DPccA
1 classify the medical services to be provided only in
2 accordance with the classes of persons designated in Section
3 5-2.
4 The Illinois Department shall authorize the provision of,
5 and shall authorize payment for, screening by low-dose
6 mammography for the presence of occult breast cancer for
7 women 35 years of age or older who are eligible for medical
8 assistance under this Article, as follows: a baseline
9 mammogram for women 35 to 39 years of age; a mammogram every
10 1 to 2 years, even if no symptoms are present, for women 40
11 to 49 years of age; and an annual mammogram for women 40 50
12 years of age or older. All screenings shall include a
13 physical breast exam, instruction on self-examination and
14 information regarding the frequency of self-examination and
15 its value as a preventative tool. As used in this Section,
16 "low-dose mammography" means the x-ray examination of the
17 breast using equipment dedicated specifically for
18 mammography, including the x-ray tube, filter, compression
19 device, image receptor, and cassettes, with an average
20 radiation exposure delivery of less than one rad mid-breast,
21 with 2 views for each breast.
22 Any medical or health care provider shall immediately
23 recommend, to any pregnant woman who is being provided
24 prenatal services and is suspected of drug abuse or is
25 addicted as defined in the Alcoholism and Other Drug Abuse
26 and Dependency Act, referral to a local substance abuse
27 treatment provider licensed by the Department of Human
28 Services or to a licensed hospital which provides substance
29 abuse treatment services. The Department of Public Aid shall
30 assure coverage for the cost of treatment of the drug abuse
31 or addiction for pregnant recipients in accordance with the
32 Illinois Medicaid Program in conjunction with the Department
33 of Human Services.
34 All medical providers providing medical assistance to
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1 pregnant women under this Code shall receive information from
2 the Department on the availability of services under the Drug
3 Free Families with a Future or any comparable program
4 providing case management services for addicted women,
5 including information on appropriate referrals for other
6 social services that may be needed by addicted women in
7 addition to treatment for addiction.
8 The Illinois Department, in cooperation with the
9 Departments of Human Services (as successor to the Department
10 of Alcoholism and Substance Abuse) and Public Health, through
11 a public awareness campaign, may provide information
12 concerning treatment for alcoholism and drug abuse and
13 addiction, prenatal health care, and other pertinent programs
14 directed at reducing the number of drug-affected infants born
15 to recipients of medical assistance.
16 Neither the Illinois Department of Public Aid nor the
17 Department of Human Services shall sanction the recipient
18 solely on the basis of her substance abuse.
19 The Illinois Department shall establish such regulations
20 governing the dispensing of health services under this
21 Article as it shall deem appropriate. In formulating these
22 regulations the Illinois Department shall consult with and
23 give substantial weight to the recommendations offered by the
24 Citizens Assembly/Council on Public Aid. The Department
25 should seek the advice of formal professional advisory
26 committees appointed by the Director of the Illinois
27 Department for the purpose of providing regular advice on
28 policy and administrative matters, information dissemination
29 and educational activities for medical and health care
30 providers, and consistency in procedures to the Illinois
31 Department.
32 The Illinois Department may develop and contract with
33 Partnerships of medical providers to arrange medical services
34 for persons eligible under Section 5-2 of this Code.
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1 Implementation of this Section may be by demonstration
2 projects in certain geographic areas. The Partnership shall
3 be represented by a sponsor organization. The Department, by
4 rule, shall develop qualifications for sponsors of
5 Partnerships. Nothing in this Section shall be construed to
6 require that the sponsor organization be a medical
7 organization.
8 The sponsor must negotiate formal written contracts with
9 medical providers for physician services, inpatient and
10 outpatient hospital care, home health services, treatment for
11 alcoholism and substance abuse, and other services determined
12 necessary by the Illinois Department by rule for delivery by
13 Partnerships. Physician services must include prenatal and
14 obstetrical care. The Illinois Department shall reimburse
15 medical services delivered by Partnership providers to
16 clients in target areas according to provisions of this
17 Article and the Illinois Health Finance Reform Act, except
18 that:
19 (1) Physicians participating in a Partnership and
20 providing certain services, which shall be determined by
21 the Illinois Department, to persons in areas covered by
22 the Partnership may receive an additional surcharge for
23 such services.
24 (2) The Department may elect to consider and
25 negotiate financial incentives to encourage the
26 development of Partnerships and the efficient delivery of
27 medical care.
28 (3) Persons receiving medical services through
29 Partnerships may receive medical and case management
30 services above the level usually offered through the
31 medical assistance program.
32 Medical providers shall be required to meet certain
33 qualifications to participate in Partnerships to ensure the
34 delivery of high quality medical services. These
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1 qualifications shall be determined by rule of the Illinois
2 Department and may be higher than qualifications for
3 participation in the medical assistance program. Partnership
4 sponsors may prescribe reasonable additional qualifications
5 for participation by medical providers, only with the prior
6 written approval of the Illinois Department.
7 Nothing in this Section shall limit the free choice of
8 practitioners, hospitals, and other providers of medical
9 services by clients.
10 The Department shall apply for a waiver from the United
11 States Health Care Financing Administration to allow for the
12 implementation of Partnerships under this Section.
13 The Illinois Department shall require health care
14 providers to maintain records that document the medical care
15 and services provided to recipients of Medical Assistance
16 under this Article. The Illinois Department shall require
17 health care providers to make available, when authorized by
18 the patient, in writing, the medical records in a timely
19 fashion to other health care providers who are treating or
20 serving persons eligible for Medical Assistance under this
21 Article. All dispensers of medical services shall be
22 required to maintain and retain business and professional
23 records sufficient to fully and accurately document the
24 nature, scope, details and receipt of the health care
25 provided to persons eligible for medical assistance under
26 this Code, in accordance with regulations promulgated by the
27 Illinois Department. The rules and regulations shall require
28 that proof of the receipt of prescription drugs, dentures,
29 prosthetic devices and eyeglasses by eligible persons under
30 this Section accompany each claim for reimbursement submitted
31 by the dispenser of such medical services. No such claims for
32 reimbursement shall be approved for payment by the Illinois
33 Department without such proof of receipt, unless the Illinois
34 Department shall have put into effect and shall be operating
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1 a system of post-payment audit and review which shall, on a
2 sampling basis, be deemed adequate by the Illinois Department
3 to assure that such drugs, dentures, prosthetic devices and
4 eyeglasses for which payment is being made are actually being
5 received by eligible recipients. Within 90 days after the
6 effective date of this amendatory Act of 1984, the Illinois
7 Department shall establish a current list of acquisition
8 costs for all prosthetic devices and any other items
9 recognized as medical equipment and supplies reimbursable
10 under this Article and shall update such list on a quarterly
11 basis, except that the acquisition costs of all prescription
12 drugs shall be updated no less frequently than every 30 days
13 as required by Section 5-5.12.
14 The rules and regulations of the Illinois Department
15 shall require that a written statement including the required
16 opinion of a physician shall accompany any claim for
17 reimbursement for abortions, or induced miscarriages or
18 premature births. This statement shall indicate what
19 procedures were used in providing such medical services.
20 The Illinois Department shall require that all dispensers
21 of medical services, other than an individual practitioner or
22 group of practitioners, desiring to participate in the
23 Medical Assistance program established under this Article to
24 disclose all financial, beneficial, ownership, equity, surety
25 or other interests in any and all firms, corporations,
26 partnerships, associations, business enterprises, joint
27 ventures, agencies, institutions or other legal entities
28 providing any form of health care services in this State
29 under this Article.
30 The Illinois Department may require that all dispensers
31 of medical services desiring to participate in the medical
32 assistance program established under this Article disclose,
33 under such terms and conditions as the Illinois Department
34 may by rule establish, all inquiries from clients and
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1 attorneys regarding medical bills paid by the Illinois
2 Department, which inquiries could indicate potential
3 existence of claims or liens for the Illinois Department.
4 The Illinois Department shall establish policies,
5 procedures, standards and criteria by rule for the
6 acquisition, repair and replacement of orthotic and
7 prosthetic devices and durable medical equipment. Such rules
8 shall provide, but not be limited to, the following services:
9 (1) immediate repair or replacement of such devices by
10 recipients without medical authorization; and (2) rental,
11 lease, purchase or lease-purchase of durable medical
12 equipment in a cost-effective manner, taking into
13 consideration the recipient's medical prognosis, the extent
14 of the recipient's needs, and the requirements and costs for
15 maintaining such equipment. Such rules shall enable a
16 recipient to temporarily acquire and use alternative or
17 substitute devices or equipment pending repairs or
18 replacements of any device or equipment previously authorized
19 for such recipient by the Department. Rules under clause (2)
20 above shall not provide for purchase or lease-purchase of
21 durable medical equipment or supplies used for the purpose of
22 oxygen delivery and respiratory care.
23 The Department shall execute, relative to the nursing
24 home prescreening project, written inter-agency agreements
25 with the Department of Human Services and the Department on
26 Aging, to effect the following: (i) intake procedures and
27 common eligibility criteria for those persons who are
28 receiving non-institutional services; and (ii) the
29 establishment and development of non-institutional services
30 in areas of the State where they are not currently available
31 or are undeveloped.
32 The Illinois Department shall develop and operate, in
33 cooperation with other State Departments and agencies and in
34 compliance with applicable federal laws and regulations,
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1 appropriate and effective systems of health care evaluation
2 and programs for monitoring of utilization of health care
3 services and facilities, as it affects persons eligible for
4 medical assistance under this Code. The Illinois Department
5 shall report regularly the results of the operation of such
6 systems and programs to the Citizens Assembly/Council on
7 Public Aid to enable the Committee to ensure, from time to
8 time, that these programs are effective and meaningful.
9 The Illinois Department shall report annually to the
10 General Assembly, no later than the second Friday in April of
11 1979 and each year thereafter, in regard to:
12 (a) actual statistics and trends in utilization of
13 medical services by public aid recipients;
14 (b) actual statistics and trends in the provision
15 of the various medical services by medical vendors;
16 (c) current rate structures and proposed changes in
17 those rate structures for the various medical vendors;
18 and
19 (d) efforts at utilization review and control by
20 the Illinois Department.
21 The period covered by each report shall be the 3 years
22 ending on the June 30 prior to the report. The report shall
23 include suggested legislation for consideration by the
24 General Assembly. The filing of one copy of the report with
25 the Speaker, one copy with the Minority Leader and one copy
26 with the Clerk of the House of Representatives, one copy with
27 the President, one copy with the Minority Leader and one copy
28 with the Secretary of the Senate, one copy with the
29 Legislative Research Unit, such additional copies with the
30 State Government Report Distribution Center for the General
31 Assembly as is required under paragraph (t) of Section 7 of
32 the State Library Act and one copy with the Citizens
33 Assembly/Council on Public Aid or its successor shall be
34 deemed sufficient to comply with this Section.
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1 (Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
2 89-507, eff. 7-1-97; 89-517, eff. 1-1-97; revised 8-26-96.)
3 Section 95. No acceleration or delay. Where this Act
4 makes changes in a statute that is represented in this Act by
5 text that is not yet or no longer in effect (for example, a
6 Section represented by multiple versions), the use of that
7 text does not accelerate or delay the taking effect of (i)
8 the changes made by this Act or (ii) provisions derived from
9 any other Public Act.
10 Section 99. Effective date. This Act takes effect upon
11 becoming law.