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90_HB0333ham001
LRB9000208JSgcam01
1 AMENDMENT TO HOUSE BILL 333
2 AMENDMENT NO. . Amend House Bill 333 by replacing
3 the title with the following:
4 "AN ACT concerning mammograms, amending named Acts."; and
5 by replacing everything after the enacting clause with the
6 following:
7 "Section 5. The Counties Code is amended by changing
8 Section 5-1069 as follows:
9 (55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
10 Sec. 5-1069. Group life, health, accident, hospital, and
11 medical insurance.
12 (a) The county board of any county may arrange to
13 provide, for the benefit of employees of the county, group
14 life, health, accident, hospital, and medical insurance, or
15 any one or any combination of those types of insurance, or
16 the county board may self-insure, for the benefit of its
17 employees, all or a portion of the employees' group life,
18 health, accident, hospital, and medical insurance, or any one
19 or any combination of those types of insurance, including a
20 combination of self-insurance and other types of insurance
21 authorized by this Section, provided that the county board
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1 complies with all other requirements of this Section. The
2 insurance may include provision for employees who rely on
3 treatment by prayer or spiritual means alone for healing in
4 accordance with the tenets and practice of a well recognized
5 religious denomination. The county board may provide for
6 payment by the county of a portion or all of the premium or
7 charge for the insurance with the employee paying the balance
8 of the premium or charge, if any. If the county board
9 undertakes a plan under which the county pays only a portion
10 of the premium or charge, the county board shall provide for
11 withholding and deducting from the compensation of those
12 employees who consent to join the plan the balance of the
13 premium or charge for the insurance.
14 (b) If the county board does not provide for
15 self-insurance or for a plan under which the county pays a
16 portion or all of the premium or charge for a group insurance
17 plan, the county board may provide for withholding and
18 deducting from the compensation of those employees who
19 consent thereto the total premium or charge for any group
20 life, health, accident, hospital, and medical insurance.
21 (c) The county board may exercise the powers granted in
22 this Section only if it provides for self-insurance or, where
23 it makes arrangements to provide group insurance through an
24 insurance carrier, if the kinds of group insurance are
25 obtained from an insurance company authorized to do business
26 in the State of Illinois. The county board may enact an
27 ordinance prescribing the method of operation of the
28 insurance program.
29 (d) If a county, including a home rule county, is a
30 self-insurer for purposes of providing health insurance
31 coverage for its employees, the insurance coverage shall
32 include screening by low-dose mammography for all women 35
33 years of age or older for the presence of occult breast
34 cancer unless the county elects to provide mammograms itself
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1 under Section 5-1069.1. The coverage shall be as follows:
2 (1) A baseline mammogram for women 35 to 39 years
3 of age.
4 (2) A mammogram every one to 2 years, even if no
5 symptoms are present, for women 40 to 49 years of age.
6 (3) An annual mammogram for women 40 50 years of
7 age or older.
8 Those benefits shall be at least as favorable as for
9 other radiological examinations and subject to the same
10 dollar limits, deductibles, and co-insurance factors. For
11 purposes of this subsection, "low-dose mammography" means the
12 x-ray examination of the breast using equipment dedicated
13 specifically for mammography, including the x-ray tube,
14 filter, compression device, screens, and image receptors,
15 with an average radiation exposure delivery of less than one
16 rad mid-breast, with 2 views for each breast. The requirement
17 that mammograms be included in health insurance coverage as
18 provided in this subsection (d) is an exclusive power and
19 function of the State and is a denial and limitation under
20 Article VII, Section 6, subsection (h) of the Illinois
21 Constitution of home rule county powers. A home rule county
22 to which this subsection applies must comply with every
23 provision of this subsection.
24 (e) The term "employees" as used in this Section
25 includes elected or appointed officials but does not include
26 temporary employees.
27 (Source: P.A. 86-962; 87-780.)
28 Section 10. The Illinois Municipal Code is amended by
29 changing Section 10-4-2 as follows:
30 (65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
31 Sec. 10-4-2. Group insurance.
32 (a) The corporate authorities of any municipality may
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1 arrange to provide, for the benefit of employees of the
2 municipality, group life, health, accident, hospital, and
3 medical insurance, or any one or any combination of those
4 types of insurance, and may arrange to provide that insurance
5 for the benefit of the spouses or dependents of those
6 employees. The insurance may include provision for employees
7 or other insured persons who rely on treatment by prayer or
8 spiritual means alone for healing in accordance with the
9 tenets and practice of a well recognized religious
10 denomination. The corporate authorities may provide for
11 payment by the municipality of a portion of the premium or
12 charge for the insurance with the employee paying the balance
13 of the premium or charge. If the corporate authorities
14 undertake a plan under which the municipality pays a portion
15 of the premium or charge, the corporate authorities shall
16 provide for withholding and deducting from the compensation
17 of those municipal employees who consent to join the plan the
18 balance of the premium or charge for the insurance.
19 (b) If the corporate authorities do not provide for a
20 plan under which the municipality pays a portion of the
21 premium or charge for a group insurance plan, the corporate
22 authorities may provide for withholding and deducting from
23 the compensation of those employees who consent thereto the
24 premium or charge for any group life, health, accident,
25 hospital, and medical insurance.
26 (c) The corporate authorities may exercise the powers
27 granted in this Section only if the kinds of group insurance
28 are obtained from an insurance company authorized to do
29 business in the State of Illinois. The corporate authorities
30 may enact an ordinance prescribing the method of operation of
31 the insurance program.
32 (d) If a municipality, including a home rule
33 municipality, is a self-insurer for purposes of providing
34 health insurance coverage for its employees, the insurance
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1 coverage shall include screening by low-dose mammography for
2 all women 35 years of age or older for the presence of occult
3 breast cancer unless the municipality elects to provide
4 mammograms itself under Section 10-4-2.1. The coverage shall
5 be as follows:
6 (1) A baseline mammogram for women 35 to 39 years
7 of age.
8 (2) A mammogram every one to 2 years, even if no
9 symptoms are present, for women 40 to 49 years of age.
10 (3) An annual mammogram for women 40 50 years of
11 age or older.
12 Those benefits shall be at least as favorable as for
13 other radiological examinations and subject to the same
14 dollar limits, deductibles, and co-insurance factors. For
15 purposes of this subsection, "low-dose mammography" means the
16 x-ray examination of the breast using equipment dedicated
17 specifically for mammography, including the x-ray tube,
18 filter, compression device, screens, and image receptors,
19 with an average radiation exposure delivery of less than one
20 rad mid-breast, with 2 views for each breast. The requirement
21 that mammograms be included in health insurance coverage as
22 provided in this subsection (d) is an exclusive power and
23 function of the State and is a denial and limitation under
24 Article VII, Section 6, subsection (h) of the Illinois
25 Constitution of home rule municipality powers. A home rule
26 municipality to which this subsection applies must comply
27 with every provision of this subsection.
28 (Source: P.A. 86-1475; 87-780.)
29 Section 15. The Illinois Insurance Code is amended by
30 changing Section 356g as follows:
31 (215 ILCS 5/356g) (from Ch. 73, par. 968g)
32 Sec. 356g. (a) Every insurer shall provide in each group
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1 or individual policy, contract, or certificate of insurance
2 issued or renewed for persons who are residents of this
3 State, coverage for screening by low-dose mammography for all
4 women 35 years of age or older for the presence of occult
5 breast cancer within the provisions of the policy, contract,
6 or certificate. The coverage shall be as follows:
7 (1) A baseline mammogram for women 35 to 39 years
8 of age.
9 (2) An mammogram every 1 to 2 years, even if no
10 symptoms are present, for women 40 to 49 years of age.
11 (3) An annual mammogram for women 40 50 years of
12 age or older.
13 These benefits shall be at least as favorable as for
14 other radiological examinations and subject to the same
15 dollar limits, deductibles, and co-insurance factors. For
16 purposes of this Section, "low-dose mammography" means the
17 x-ray examination of the breast using equipment dedicated
18 specifically for mammography, including the x-ray tube,
19 filter, compression device, and image receptor, with
20 radiation exposure delivery of less than 1 rad per breast for
21 2 views of an average size breast.
22 (b) No policy of accident or health insurance that
23 provides for the surgical procedure known as a mastectomy
24 shall be issued, amended, delivered or renewed in this State
25 on or after July 1, 1981, unless coverage is also offered for
26 prosthetic devices or reconstructive surgery incident to the
27 mastectomy, providing that the mastectomy is performed after
28 July 1, 1981. The offered coverage for prosthetic devices and
29 reconstructive surgery shall be subject to the deductible and
30 coinsurance conditions applied to the mastectomy, and all
31 other terms and conditions applicable to other benefits.
32 When a mastectomy is performed and there is no evidence of
33 malignancy then the offered coverage may be limited to the
34 provision of prosthetic devices and reconstructive surgery to
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1 within 2 years after the date of the mastectomy. As used in
2 this Section, "mastectomy" means the removal of all or part
3 of the breast for medically necessary reasons, as determined
4 by a licensed physician.
5 (Source: P.A. 86-899; 87-518.)
6 Section 20. The Health Maintenance Organization Act is
7 amended by changing Section 4-6.1 as follows:
8 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
9 Sec. 4-6.1. (a) Every contract or evidence of coverage
10 issued by a Health Maintenance Organization for persons who
11 are residents of this State shall contain coverage for
12 screening by low-dose mammography for all women 35 years of
13 age or older for the presence of occult breast cancer. The
14 coverage shall be as follows:
15 (1) A baseline mammogram for women 35 to 39 years
16 of age.
17 (2) A mammogram every 1 to 2 years, even if no
18 symptoms are present, for women 40 to 49 years of age.
19 (3) An annual mammogram for women 40 50 years of
20 age or older.
21 These benefits shall be at least as favorable as for
22 other radiological examinations and subject to the same
23 dollar limits, deductibles, and co-insurance factors. For
24 purposes of this Section, "low-dose mammography" means the
25 x-ray examination of the breast using equipment dedicated
26 specifically for mammography, including the x-ray tube,
27 filter, compression device, and image receptor, with
28 radiation exposure delivery of less than 1 rad per breast for
29 2 views of an average size breast.
30 (Source: P.A. 86-899; 86-1028; 87-518.)
31 Section 25. The Illinois Public Aid Code is amended by
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1 changing Section 5-5 as follows:
2 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
3 (Text of Section before amendment by P.A. 89-507)
4 Sec. 5-5. Medical services. The Illinois Department, by
5 rule, shall determine the quantity and quality of and the
6 rate of reimbursement for the medical assistance for which
7 payment will be authorized, and the medical services to be
8 provided, which may include all or part of the following: (1)
9 inpatient hospital services; (2) outpatient hospital
10 services; (3) other laboratory and X-ray services; (4)
11 skilled nursing home services; (5) physicians' services
12 whether furnished in the office, the patient's home, a
13 hospital, a skilled nursing home, or elsewhere; (6) medical
14 care, or any other type of remedial care furnished by
15 licensed practitioners; (7) home health care services; (8)
16 private duty nursing service; (9) clinic services; (10)
17 dental services; (11) physical therapy and related services;
18 (12) prescribed drugs, dentures, and prosthetic devices; and
19 eyeglasses prescribed by a physician skilled in the diseases
20 of the eye, or by an optometrist, whichever the person may
21 select; (13) other diagnostic, screening, preventive, and
22 rehabilitative services; (14) transportation and such other
23 expenses as may be necessary; (15) medical treatment of
24 sexual assault survivors, as defined in Section 1a of the
25 Sexual Assault Survivors Emergency Treatment Act, for
26 injuries sustained as a result of the sexual assault,
27 including examinations and laboratory tests to discover
28 evidence which may be used in criminal proceedings arising
29 from the sexual assault; (16) the diagnosis and treatment of
30 sickle cell anemia; and (17) any other medical care, and any
31 other type of remedial care recognized under the laws of this
32 State, but not including abortions, or induced miscarriages
33 or premature births, unless, in the opinion of a physician,
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1 such procedures are necessary for the preservation of the
2 life of the woman seeking such treatment, or except an
3 induced premature birth intended to produce a live viable
4 child and such procedure is necessary for the health of the
5 mother or her unborn child. The Illinois Department, by rule,
6 shall prohibit any physician from providing medical
7 assistance to anyone eligible therefor under this Code where
8 such physician has been found guilty of performing an
9 abortion procedure in a wilful and wanton manner upon a woman
10 who was not pregnant at the time such abortion procedure was
11 performed. The term "any other type of remedial care" shall
12 include nursing care and nursing home service for persons who
13 rely on treatment by spiritual means alone through prayer for
14 healing.
15 The Illinois Department shall provide the following
16 services to persons eligible for assistance under this
17 Article who are participating in education, training or
18 employment programs:
19 (1) dental services, which shall include but not be
20 limited to prosthodontics; and
21 (2) eyeglasses prescribed by a physician skilled in
22 the diseases of the eye, or by an optometrist, whichever
23 the person may select.
24 The Illinois Department, by rule, may distinguish and
25 classify the medical services to be provided only in
26 accordance with the classes of persons designated in Section
27 5-2.
28 The Illinois Department shall authorize the provision of,
29 and shall authorize payment for, screening by low-dose
30 mammography for the presence of occult breast cancer for
31 women 35 years of age or older who are eligible for medical
32 assistance under this Article, as follows: a baseline
33 mammogram for women 35 to 39 years of age; a mammogram every
34 1 to 2 years, even if no symptoms are present, for women 40
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1 to 49 years of age; and an annual mammogram for women 40 50
2 years of age or older. All screenings shall include a
3 physical breast exam, instruction on self-examination and
4 information regarding the frequency of self-examination and
5 its value as a preventative tool. As used in this Section,
6 "low-dose mammography" means the x-ray examination of the
7 breast using equipment dedicated specifically for
8 mammography, including the x-ray tube, filter, compression
9 device, image receptor, and cassettes, with an average
10 radiation exposure delivery of less than one rad mid-breast,
11 with 2 views for each breast.
12 Any medical or health care provider shall immediately
13 recommend, to any pregnant woman who is being provided
14 prenatal services and is suspected of drug abuse or is
15 addicted as defined in the Alcoholism and Other Drug Abuse
16 and Dependency Act, referral to a local substance abuse
17 treatment provider licensed by the Department of Alcoholism
18 and Substance Abuse or to a licensed hospital which provides
19 substance abuse treatment services. The Department of Public
20 Aid shall assure coverage for the cost of treatment of the
21 drug abuse or addiction for pregnant recipients in accordance
22 with the Illinois Medicaid Program in conjunction with the
23 Department of Alcoholism and Substance Abuse.
24 All medical providers providing medical assistance to
25 pregnant women under this Code shall receive information from
26 the Department on the availability of services under the Drug
27 Free Families with a Future or any comparable program
28 providing case management services for addicted women,
29 including information on appropriate referrals for other
30 social services that may be needed by addicted women in
31 addition to treatment for addiction.
32 The Illinois Department, in cooperation with the
33 Departments of Alcoholism and Substance Abuse and Public
34 Health, through a public awareness campaign, may provide
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1 information concerning treatment for alcoholism and drug
2 abuse and addiction, prenatal health care, and other
3 pertinent programs directed at reducing the number of
4 drug-affected infants born to recipients of medical
5 assistance.
6 The Department shall not sanction the recipient solely on
7 the basis of her substance abuse.
8 The Illinois Department shall establish such regulations
9 governing the dispensing of health services under this
10 Article as it shall deem appropriate. In formulating these
11 regulations the Illinois Department shall consult with and
12 give substantial weight to the recommendations offered by the
13 Citizens Assembly/Council on Public Aid. The Department
14 should seek the advice of formal professional advisory
15 committees appointed by the Director of the Illinois
16 Department for the purpose of providing regular advice on
17 policy and administrative matters, information dissemination
18 and educational activities for medical and health care
19 providers, and consistency in procedures to the Illinois
20 Department.
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
25 projects in certain geographic areas. The Partnership shall
26 be represented by a sponsor organization. The Department, by
27 rule, shall develop qualifications for sponsors of
28 Partnerships. Nothing in this Section shall be construed to
29 require that the sponsor organization be a medical
30 organization.
31 The sponsor must negotiate formal written contracts with
32 medical providers for physician services, inpatient and
33 outpatient hospital care, home health services, treatment for
34 alcoholism and substance abuse, and other services determined
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1 necessary by the Illinois Department by rule for delivery by
2 Partnerships. Physician services must include prenatal and
3 obstetrical care. The Illinois Department shall reimburse
4 medical services delivered by Partnership providers to
5 clients in target areas according to provisions of this
6 Article and the Illinois Health Finance Reform Act, except
7 that:
8 (1) Physicians participating in a Partnership and
9 providing certain services, which shall be determined by
10 the Illinois Department, to persons in areas covered by
11 the Partnership may receive an additional surcharge for
12 such services.
13 (2) The Department may elect to consider and
14 negotiate financial incentives to encourage the
15 development of Partnerships and the efficient delivery of
16 medical care.
17 (3) Persons receiving medical services through
18 Partnerships may receive medical and case management
19 services above the level usually offered through the
20 medical assistance program.
21 Medical providers shall be required to meet certain
22 qualifications to participate in Partnerships to ensure the
23 delivery of high quality medical services. These
24 qualifications shall be determined by rule of the Illinois
25 Department and may be higher than qualifications for
26 participation in the medical assistance program. Partnership
27 sponsors may prescribe reasonable additional qualifications
28 for participation by medical providers, only with the prior
29 written approval of the Illinois Department.
30 Nothing in this Section shall limit the free choice of
31 practitioners, hospitals, and other providers of medical
32 services by clients.
33 The Department shall apply for a waiver from the United
34 States Health Care Financing Administration to allow for the
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1 implementation of Partnerships under this Section.
2 The Illinois Department shall require health care
3 providers to maintain records that document the medical care
4 and services provided to recipients of Medical Assistance
5 under this Article. The Illinois Department shall require
6 health care providers to make available, when authorized by
7 the patient, in writing, the medical records in a timely
8 fashion to other health care providers who are treating or
9 serving persons eligible for Medical Assistance under this
10 Article. All dispensers of medical services shall be
11 required to maintain and retain business and professional
12 records sufficient to fully and accurately document the
13 nature, scope, details and receipt of the health care
14 provided to persons eligible for medical assistance under
15 this Code, in accordance with regulations promulgated by the
16 Illinois Department. The rules and regulations shall require
17 that proof of the receipt of prescription drugs, dentures,
18 prosthetic devices and eyeglasses by eligible persons under
19 this Section accompany each claim for reimbursement submitted
20 by the dispenser of such medical services. No such claims for
21 reimbursement shall be approved for payment by the Illinois
22 Department without such proof of receipt, unless the Illinois
23 Department shall have put into effect and shall be operating
24 a system of post-payment audit and review which shall, on a
25 sampling basis, be deemed adequate by the Illinois Department
26 to assure that such drugs, dentures, prosthetic devices and
27 eyeglasses for which payment is being made are actually being
28 received by eligible recipients. Within 90 days after the
29 effective date of this amendatory Act of 1984, the Illinois
30 Department shall establish a current list of acquisition
31 costs for all prosthetic devices and any other items
32 recognized as medical equipment and supplies reimbursable
33 under this Article and shall update such list on a quarterly
34 basis, except that the acquisition costs of all prescription
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1 drugs shall be updated no less frequently than every 30 days
2 as required by Section 5-5.12.
3 The rules and regulations of the Illinois Department
4 shall require that a written statement including the required
5 opinion of a physician shall accompany any claim for
6 reimbursement for abortions, or induced miscarriages or
7 premature births. This statement shall indicate what
8 procedures were used in providing such medical services.
9 The Illinois Department shall require that all dispensers
10 of medical services, other than an individual practitioner or
11 group of practitioners, desiring to participate in the
12 Medical Assistance program established under this Article to
13 disclose all financial, beneficial, ownership, equity, surety
14 or other interests in any and all firms, corporations,
15 partnerships, associations, business enterprises, joint
16 ventures, agencies, institutions or other legal entities
17 providing any form of health care services in this State
18 under this Article.
19 The Illinois Department may require that all dispensers
20 of medical services desiring to participate in the medical
21 assistance program established under this Article disclose,
22 under such terms and conditions as the Illinois Department
23 may by rule establish, all inquiries from clients and
24 attorneys regarding medical bills paid by the Illinois
25 Department, which inquiries could indicate potential
26 existence of claims or liens for the Illinois Department.
27 The Illinois Department shall establish policies,
28 procedures, standards and criteria by rule for the
29 acquisition, repair and replacement of orthotic and
30 prosthetic devices and durable medical equipment. Such rules
31 shall provide, but not be limited to, the following services:
32 (1) immediate repair or replacement of such devices by
33 recipients without medical authorization; and (2) rental,
34 lease, purchase or lease-purchase of durable medical
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1 equipment in a cost-effective manner, taking into
2 consideration the recipient's medical prognosis, the extent
3 of the recipient's needs, and the requirements and costs for
4 maintaining such equipment. Such rules shall enable a
5 recipient to temporarily acquire and use alternative or
6 substitute devices or equipment pending repairs or
7 replacements of any device or equipment previously authorized
8 for such recipient by the Department. Rules under clause (2)
9 above shall not provide for purchase or lease-purchase of
10 durable medical equipment or supplies used for the purpose of
11 oxygen delivery and respiratory care.
12 The Department shall execute, relative to the nursing
13 home prescreening project, written inter-agency agreements
14 with the Department of Rehabilitation Services and the
15 Department on Aging, to effect the following: (i) intake
16 procedures and common eligibility criteria for those persons
17 who are receiving non-institutional services; and (ii) the
18 establishment and development of non-institutional services
19 in areas of the State where they are not currently available
20 or are undeveloped.
21 The Illinois Department shall develop and operate, in
22 cooperation with other State Departments and agencies and in
23 compliance with applicable federal laws and regulations,
24 appropriate and effective systems of health care evaluation
25 and programs for monitoring of utilization of health care
26 services and facilities, as it affects persons eligible for
27 medical assistance under this Code. The Illinois Department
28 shall report regularly the results of the operation of such
29 systems and programs to the Citizens Assembly/Council on
30 Public Aid to enable the Committee to ensure, from time to
31 time, that these programs are effective and meaningful.
32 The Illinois Department shall report annually to the
33 General Assembly, no later than the second Friday in April of
34 1979 and each year thereafter, in regard to:
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1 (a) actual statistics and trends in utilization of
2 medical services by public aid recipients;
3 (b) actual statistics and trends in the provision
4 of the various medical services by medical vendors;
5 (c) current rate structures and proposed changes in
6 those rate structures for the various medical vendors;
7 and
8 (d) efforts at utilization review and control by
9 the Illinois Department.
10 The period covered by each report shall be the 3 years
11 ending on the June 30 prior to the report. The report shall
12 include suggested legislation for consideration by the
13 General Assembly. The filing of one copy of the report with
14 the Speaker, one copy with the Minority Leader and one copy
15 with the Clerk of the House of Representatives, one copy with
16 the President, one copy with the Minority Leader and one copy
17 with the Secretary of the Senate, one copy with the
18 Legislative Research Unit, such additional copies with the
19 State Government Report Distribution Center for the General
20 Assembly as is required under paragraph (t) of Section 7 of
21 the State Library Act and one copy with the Citizens
22 Assembly/Council on Public Aid or its successor shall be
23 deemed sufficient to comply with this Section.
24 (Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
25 89-517, eff. 1-1-97.)
26 (Text of Section after amendment by P.A. 89-507)
27 Sec. 5-5. Medical services. The Illinois Department, by
28 rule, shall determine the quantity and quality of and the
29 rate of reimbursement for the medical assistance for which
30 payment will be authorized, and the medical services to be
31 provided, which may include all or part of the following: (1)
32 inpatient hospital services; (2) outpatient hospital
33 services; (3) other laboratory and X-ray services; (4)
34 skilled nursing home services; (5) physicians' services
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1 whether furnished in the office, the patient's home, a
2 hospital, a skilled nursing home, or elsewhere; (6) medical
3 care, or any other type of remedial care furnished by
4 licensed practitioners; (7) home health care services; (8)
5 private duty nursing service; (9) clinic services; (10)
6 dental services; (11) physical therapy and related services;
7 (12) prescribed drugs, dentures, and prosthetic devices; and
8 eyeglasses prescribed by a physician skilled in the diseases
9 of the eye, or by an optometrist, whichever the person may
10 select; (13) other diagnostic, screening, preventive, and
11 rehabilitative services; (14) transportation and such other
12 expenses as may be necessary; (15) medical treatment of
13 sexual assault survivors, as defined in Section 1a of the
14 Sexual Assault Survivors Emergency Treatment Act, for
15 injuries sustained as a result of the sexual assault,
16 including examinations and laboratory tests to discover
17 evidence which may be used in criminal proceedings arising
18 from the sexual assault; (16) the diagnosis and treatment of
19 sickle cell anemia; and (17) any other medical care, and any
20 other type of remedial care recognized under the laws of this
21 State, but not including abortions, or induced miscarriages
22 or premature births, unless, in the opinion of a physician,
23 such procedures are necessary for the preservation of the
24 life of the woman seeking such treatment, or except an
25 induced premature birth intended to produce a live viable
26 child and such procedure is necessary for the health of the
27 mother or her unborn child. The Illinois Department, by rule,
28 shall prohibit any physician from providing medical
29 assistance to anyone eligible therefor under this Code where
30 such physician has been found guilty of performing an
31 abortion procedure in a wilful and wanton manner upon a woman
32 who was not pregnant at the time such abortion procedure was
33 performed. The term "any other type of remedial care" shall
34 include nursing care and nursing home service for persons who
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1 rely on treatment by spiritual means alone through prayer for
2 healing.
3 The Illinois Department of Public Aid shall provide the
4 following services to persons eligible for assistance under
5 this Article who are participating in education, training or
6 employment programs operated by the Department of Human
7 Services as successor to the Department of Public Aid:
8 (1) dental services, which shall include but not be
9 limited to prosthodontics; and
10 (2) eyeglasses prescribed by a physician skilled in
11 the diseases of the eye, or by an optometrist, whichever
12 the person may select.
13 The Illinois Department, by rule, may distinguish and
14 classify the medical services to be provided only in
15 accordance with the classes of persons designated in Section
16 5-2.
17 The Illinois Department shall authorize the provision of,
18 and shall authorize payment for, screening by low-dose
19 mammography for the presence of occult breast cancer for
20 women 35 years of age or older who are eligible for medical
21 assistance under this Article, as follows: a baseline
22 mammogram for women 35 to 39 years of age; a mammogram every
23 1 to 2 years, even if no symptoms are present, for women 40
24 to 49 years of age; and an annual mammogram for women 40 50
25 years of age or older. All screenings shall include a
26 physical breast exam, instruction on self-examination and
27 information regarding the frequency of self-examination and
28 its value as a preventative tool. As used in this Section,
29 "low-dose mammography" means the x-ray examination of the
30 breast using equipment dedicated specifically for
31 mammography, including the x-ray tube, filter, compression
32 device, image receptor, and cassettes, with an average
33 radiation exposure delivery of less than one rad mid-breast,
34 with 2 views for each breast.
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1 Any medical or health care provider shall immediately
2 recommend, to any pregnant woman who is being provided
3 prenatal services and is suspected of drug abuse or is
4 addicted as defined in the Alcoholism and Other Drug Abuse
5 and Dependency Act, referral to a local substance abuse
6 treatment provider licensed by the Department of Human
7 Services or to a licensed hospital which provides substance
8 abuse treatment services. The Department of Public Aid shall
9 assure coverage for the cost of treatment of the drug abuse
10 or addiction for pregnant recipients in accordance with the
11 Illinois Medicaid Program in conjunction with the Department
12 of Human Services.
13 All medical providers providing medical assistance to
14 pregnant women under this Code shall receive information from
15 the Department on the availability of services under the Drug
16 Free Families with a Future or any comparable program
17 providing case management services for addicted women,
18 including information on appropriate referrals for other
19 social services that may be needed by addicted women in
20 addition to treatment for addiction.
21 The Illinois Department, in cooperation with the
22 Departments of Human Services (as successor to the Department
23 of Alcoholism and Substance Abuse) and Public Health, through
24 a public awareness campaign, may provide information
25 concerning treatment for alcoholism and drug abuse and
26 addiction, prenatal health care, and other pertinent programs
27 directed at reducing the number of drug-affected infants born
28 to recipients of medical assistance.
29 Neither the Illinois Department of Public Aid nor the
30 Department of Human Services shall sanction the recipient
31 solely on the basis of her substance abuse.
32 The Illinois Department shall establish such regulations
33 governing the dispensing of health services under this
34 Article as it shall deem appropriate. In formulating these
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1 regulations the Illinois Department shall consult with and
2 give substantial weight to the recommendations offered by the
3 Citizens Assembly/Council on Public Aid. The Department
4 should seek the advice of formal professional advisory
5 committees appointed by the Director of the Illinois
6 Department for the purpose of providing regular advice on
7 policy and administrative matters, information dissemination
8 and educational activities for medical and health care
9 providers, and consistency in procedures to the Illinois
10 Department.
11 The Illinois Department may develop and contract with
12 Partnerships of medical providers to arrange medical services
13 for persons eligible under Section 5-2 of this Code.
14 Implementation of this Section may be by demonstration
15 projects in certain geographic areas. The Partnership shall
16 be represented by a sponsor organization. The Department, by
17 rule, shall develop qualifications for sponsors of
18 Partnerships. Nothing in this Section shall be construed to
19 require that the sponsor organization be a medical
20 organization.
21 The sponsor must negotiate formal written contracts with
22 medical providers for physician services, inpatient and
23 outpatient hospital care, home health services, treatment for
24 alcoholism and substance abuse, and other services determined
25 necessary by the Illinois Department by rule for delivery by
26 Partnerships. Physician services must include prenatal and
27 obstetrical care. The Illinois Department shall reimburse
28 medical services delivered by Partnership providers to
29 clients in target areas according to provisions of this
30 Article and the Illinois Health Finance Reform Act, except
31 that:
32 (1) Physicians participating in a Partnership and
33 providing certain services, which shall be determined by
34 the Illinois Department, to persons in areas covered by
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1 the Partnership may receive an additional surcharge for
2 such services.
3 (2) The Department may elect to consider and
4 negotiate financial incentives to encourage the
5 development of Partnerships and the efficient delivery of
6 medical care.
7 (3) Persons receiving medical services through
8 Partnerships may receive medical and case management
9 services above the level usually offered through the
10 medical assistance program.
11 Medical providers shall be required to meet certain
12 qualifications to participate in Partnerships to ensure the
13 delivery of high quality medical services. These
14 qualifications shall be determined by rule of the Illinois
15 Department and may be higher than qualifications for
16 participation in the medical assistance program. Partnership
17 sponsors may prescribe reasonable additional qualifications
18 for participation by medical providers, only with the prior
19 written approval of the Illinois Department.
20 Nothing in this Section shall limit the free choice of
21 practitioners, hospitals, and other providers of medical
22 services by clients.
23 The Department shall apply for a waiver from the United
24 States Health Care Financing Administration to allow for the
25 implementation of Partnerships under this Section.
26 The Illinois Department shall require health care
27 providers to maintain records that document the medical care
28 and services provided to recipients of Medical Assistance
29 under this Article. The Illinois Department shall require
30 health care providers to make available, when authorized by
31 the patient, in writing, the medical records in a timely
32 fashion to other health care providers who are treating or
33 serving persons eligible for Medical Assistance under this
34 Article. All dispensers of medical services shall be
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1 required to maintain and retain business and professional
2 records sufficient to fully and accurately document the
3 nature, scope, details and receipt of the health care
4 provided to persons eligible for medical assistance under
5 this Code, in accordance with regulations promulgated by the
6 Illinois Department. The rules and regulations shall require
7 that proof of the receipt of prescription drugs, dentures,
8 prosthetic devices and eyeglasses by eligible persons under
9 this Section accompany each claim for reimbursement submitted
10 by the dispenser of such medical services. No such claims for
11 reimbursement shall be approved for payment by the Illinois
12 Department without such proof of receipt, unless the Illinois
13 Department shall have put into effect and shall be operating
14 a system of post-payment audit and review which shall, on a
15 sampling basis, be deemed adequate by the Illinois Department
16 to assure that such drugs, dentures, prosthetic devices and
17 eyeglasses for which payment is being made are actually being
18 received by eligible recipients. Within 90 days after the
19 effective date of this amendatory Act of 1984, the Illinois
20 Department shall establish a current list of acquisition
21 costs for all prosthetic devices and any other items
22 recognized as medical equipment and supplies reimbursable
23 under this Article and shall update such list on a quarterly
24 basis, except that the acquisition costs of all prescription
25 drugs shall be updated no less frequently than every 30 days
26 as required by Section 5-5.12.
27 The rules and regulations of the Illinois Department
28 shall require that a written statement including the required
29 opinion of a physician shall accompany any claim for
30 reimbursement for abortions, or induced miscarriages or
31 premature births. This statement shall indicate what
32 procedures were used in providing such medical services.
33 The Illinois Department shall require that all dispensers
34 of medical services, other than an individual practitioner or
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1 group of practitioners, desiring to participate in the
2 Medical Assistance program established under this Article to
3 disclose all financial, beneficial, ownership, equity, surety
4 or other interests in any and all firms, corporations,
5 partnerships, associations, business enterprises, joint
6 ventures, agencies, institutions or other legal entities
7 providing any form of health care services in this State
8 under this Article.
9 The Illinois Department may require that all dispensers
10 of medical services desiring to participate in the medical
11 assistance program established under this Article disclose,
12 under such terms and conditions as the Illinois Department
13 may by rule establish, all inquiries from clients and
14 attorneys regarding medical bills paid by the Illinois
15 Department, which inquiries could indicate potential
16 existence of claims or liens for the Illinois Department.
17 The Illinois Department shall establish policies,
18 procedures, standards and criteria by rule for the
19 acquisition, repair and replacement of orthotic and
20 prosthetic devices and durable medical equipment. Such rules
21 shall provide, but not be limited to, the following services:
22 (1) immediate repair or replacement of such devices by
23 recipients without medical authorization; and (2) rental,
24 lease, purchase or lease-purchase of durable medical
25 equipment in a cost-effective manner, taking into
26 consideration the recipient's medical prognosis, the extent
27 of the recipient's needs, and the requirements and costs for
28 maintaining such equipment. Such rules shall enable a
29 recipient to temporarily acquire and use alternative or
30 substitute devices or equipment pending repairs or
31 replacements of any device or equipment previously authorized
32 for such recipient by the Department. Rules under clause (2)
33 above shall not provide for purchase or lease-purchase of
34 durable medical equipment or supplies used for the purpose of
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1 oxygen delivery and respiratory care.
2 The Department shall execute, relative to the nursing
3 home prescreening project, written inter-agency agreements
4 with the Department of Human Services and the Department on
5 Aging, to effect the following: (i) intake procedures and
6 common eligibility criteria for those persons who are
7 receiving non-institutional services; and (ii) the
8 establishment and development of non-institutional services
9 in areas of the State where they are not currently available
10 or are undeveloped.
11 The Illinois Department shall develop and operate, in
12 cooperation with other State Departments and agencies and in
13 compliance with applicable federal laws and regulations,
14 appropriate and effective systems of health care evaluation
15 and programs for monitoring of utilization of health care
16 services and facilities, as it affects persons eligible for
17 medical assistance under this Code. The Illinois Department
18 shall report regularly the results of the operation of such
19 systems and programs to the Citizens Assembly/Council on
20 Public Aid to enable the Committee to ensure, from time to
21 time, that these programs are effective and meaningful.
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;
27 (b) actual statistics and trends in the provision
28 of the various medical services by medical vendors;
29 (c) current rate structures and proposed changes in
30 those rate structures for the various medical vendors;
31 and
32 (d) efforts at utilization review and control by
33 the Illinois Department.
34 The period covered by each report shall be the 3 years
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1 ending on the June 30 prior to the report. The report shall
2 include suggested legislation for consideration by the
3 General Assembly. The filing of one copy of the report with
4 the Speaker, one copy with the Minority Leader and one copy
5 with the Clerk of the House of Representatives, one copy with
6 the President, one copy with the Minority Leader and one copy
7 with the Secretary of the Senate, one copy with the
8 Legislative Research Unit, such additional copies with the
9 State Government Report Distribution Center for the General
10 Assembly as is required under paragraph (t) of Section 7 of
11 the State Library Act and one copy with the Citizens
12 Assembly/Council on Public Aid or its successor shall be
13 deemed sufficient to comply with this Section.
14 (Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
15 89-507, eff. 7-1-97; 89-517, eff. 1-1-97; revised 8-26-96.)
16 Section 95. No acceleration or delay. Where this Act
17 makes changes in a statute that is represented in this Act by
18 text that is not yet or no longer in effect (for example, a
19 Section represented by multiple versions), the use of that
20 text does not accelerate or delay the taking effect of (i)
21 the changes made by this Act or (ii) provisions derived from
22 any other Public Act.
23 Section 99. Effective date. This Act takes effect upon
24 becoming law.".