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90_HB1881enr
215 ILCS 5/107.05 from Ch. 73, par. 719.05
215 ILCS 5/107.07 from Ch. 73, par. 719.07
215 ILCS 5/107.12 from Ch. 73, par. 719.12
215 ILCS 5/107.13 from Ch. 73, par. 719.13
215 ILCS 5/107.13a from Ch. 73, par. 719.13a
215 ILCS 5/107.27 from Ch. 73, par. 719.27
215 ILCS 5/107.23 rep.
Amends the Insurance Exchange Article of the Illinois
Insurance Code. Authorizes the exchange to establish annual
fees for the admission of syndicates and limited syndicates.
Provides that the Director of Insurance shall, rather than
may, be responsible for examining the financial records of
the Exchange and related parties. Requires the Exchange to
file an annual financial statement with the Department of
Insurance. Requires syndicates to file quarterly statements,
actuarial opinions, and audited financial reports with the
Department. Provides that liquidation expenses of the
Illinois Insurance Exchange Immediate Access Association and
any liquidator shall be paid from the insolvent syndicate's
trust or custodial account. Effective immediately.
LRB9000419JSgc
HB1881 Enrolled LRB9000419JSgc
1 AN ACT relating to medical services, 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 State Employees Group Insurance Act of
5 1971 is amended by adding Section 6.9 as follows:
6 (5 ILCS 375/6.9 new)
7 Sec. 6.9. Required health benefits. The program of
8 health benefits shall provide the post-mastectomy care
9 benefits required to be covered by a policy of accident and
10 health insurance under Section 356t of the Illinois Insurance
11 Code. The program of health benefits shall provide the
12 coverage required under Section 356u of the Illinois
13 Insurance Code.
14 Section 10. The State Mandates Act is amended by adding
15 Section 8.21 as follows:
16 (30 ILCS 805/8.21 new)
17 Sec. 8.21. Exempt mandate. Notwithstanding Sections 6
18 and 8 of this Act, no reimbursement by the State is required
19 for the implementation of any mandate created by this
20 amendatory Act of 1997.
21 Section 15. The Counties Code is amended by changing
22 Section 5-1069 and adding Section 5-1069.3 as follows:
23 (55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
24 Sec. 5-1069. Group life, health, accident, hospital, and
25 medical insurance.
26 (a) The county board of any county may arrange to
27 provide, for the benefit of employees of the county, group
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1 life, health, accident, hospital, and medical insurance, or
2 any one or any combination of those types of insurance, or
3 the county board may self-insure, for the benefit of its
4 employees, all or a portion of the employees' group life,
5 health, accident, hospital, and medical insurance, or any one
6 or any combination of those types of insurance, including a
7 combination of self-insurance and other types of insurance
8 authorized by this Section, provided that the county board
9 complies with all other requirements of this Section. The
10 insurance may include provision for employees who rely on
11 treatment by prayer or spiritual means alone for healing in
12 accordance with the tenets and practice of a well recognized
13 religious denomination. The county board may provide for
14 payment by the county of a portion or all of the premium or
15 charge for the insurance with the employee paying the balance
16 of the premium or charge, if any. If the county board
17 undertakes a plan under which the county pays only a portion
18 of the premium or charge, the county board shall provide for
19 withholding and deducting from the compensation of those
20 employees who consent to join the plan the balance of the
21 premium or charge for the insurance.
22 (b) If the county board does not provide for
23 self-insurance or for a plan under which the county pays a
24 portion or all of the premium or charge for a group insurance
25 plan, the county board may provide for withholding and
26 deducting from the compensation of those employees who
27 consent thereto the total premium or charge for any group
28 life, health, accident, hospital, and medical insurance.
29 (c) The county board may exercise the powers granted in
30 this Section only if it provides for self-insurance or, where
31 it makes arrangements to provide group insurance through an
32 insurance carrier, if the kinds of group insurance are
33 obtained from an insurance company authorized to do business
34 in the State of Illinois. The county board may enact an
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1 ordinance prescribing the method of operation of the
2 insurance program.
3 (d) If a county, including a home rule county, is a
4 self-insurer for purposes of providing health insurance
5 coverage for its employees, the insurance coverage shall
6 include screening by low-dose mammography for all women 35
7 years of age or older for the presence of occult breast
8 cancer unless the county elects to provide mammograms itself
9 under Section 5-1069.1. The coverage shall be as follows:
10 (1) A baseline mammogram for women 35 to 39 years
11 of age.
12 (2) A mammogram every one to 2 years, even if no
13 symptoms are present, for women 40 to 49 years of age.
14 (3) An annual mammogram for women 40 50 years of
15 age or older.
16 Those benefits shall be at least as favorable as for
17 other radiological examinations and subject to the same
18 dollar limits, deductibles, and co-insurance factors. For
19 purposes of this subsection, "low-dose mammography" means the
20 x-ray examination of the breast using equipment dedicated
21 specifically for mammography, including the x-ray tube,
22 filter, compression device, screens, and image receptors,
23 with an average radiation exposure delivery of less than one
24 rad mid-breast, with 2 views for each breast. The requirement
25 that mammograms be included in health insurance coverage as
26 provided in this subsection (d) is an exclusive power and
27 function of the State and is a denial and limitation under
28 Article VII, Section 6, subsection (h) of the Illinois
29 Constitution of home rule county powers. A home rule county
30 to which this subsection applies must comply with every
31 provision of this subsection.
32 (e) The term "employees" as used in this Section
33 includes elected or appointed officials but does not include
34 temporary employees.
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1 (Source: P.A. 86-962; 87-780.)
2 (55 ILCS 5/5-1069.3 new)
3 Sec. 5-1069.3. Required health benefits. If a county,
4 including a home rule county, is a self-insurer for purposes
5 of providing health insurance coverage for its employees, the
6 coverage shall include coverage for the post-mastectomy care
7 benefits required to be covered by a policy of accident and
8 health insurance under Section 356t and the coverage required
9 under Section 356u of the Illinois Insurance Code. The
10 requirement that health benefits be covered as provided in
11 this Section is an exclusive power and function of the State
12 and is a denial and limitation under Article VII, Section 6,
13 subsection (h) of the Illinois Constitution. A home rule
14 county to which this Section applies must comply with every
15 provision of this Section.
16 Section 20. The Illinois Municipal Code is amended by
17 changing Section 10-4-2 and adding Section 10-4-2.3 as
18 follows:
19 (65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
20 Sec. 10-4-2. Group insurance.
21 (a) The corporate authorities of any municipality may
22 arrange to provide, for the benefit of employees of the
23 municipality, group life, health, accident, hospital, and
24 medical insurance, or any one or any combination of those
25 types of insurance, and may arrange to provide that insurance
26 for the benefit of the spouses or dependents of those
27 employees. The insurance may include provision for employees
28 or other insured persons who rely on treatment by prayer or
29 spiritual means alone for healing in accordance with the
30 tenets and practice of a well recognized religious
31 denomination. The corporate authorities may provide for
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1 payment by the municipality of a portion of the premium or
2 charge for the insurance with the employee paying the balance
3 of the premium or charge. If the corporate authorities
4 undertake a plan under which the municipality pays a portion
5 of the premium or charge, the corporate authorities shall
6 provide for withholding and deducting from the compensation
7 of those municipal employees who consent to join the plan the
8 balance of the premium or charge for the insurance.
9 (b) If the corporate authorities do not provide for a
10 plan under which the municipality pays a portion of the
11 premium or charge for a group insurance plan, the corporate
12 authorities may provide for withholding and deducting from
13 the compensation of those employees who consent thereto the
14 premium or charge for any group life, health, accident,
15 hospital, and medical insurance.
16 (c) The corporate authorities may exercise the powers
17 granted in this Section only if the kinds of group insurance
18 are obtained from an insurance company authorized to do
19 business in the State of Illinois. The corporate authorities
20 may enact an ordinance prescribing the method of operation of
21 the insurance program.
22 (d) If a municipality, including a home rule
23 municipality, is a self-insurer for purposes of providing
24 health insurance coverage for its employees, the insurance
25 coverage shall include screening by low-dose mammography for
26 all women 35 years of age or older for the presence of occult
27 breast cancer unless the municipality elects to provide
28 mammograms itself under Section 10-4-2.1. The coverage shall
29 be as follows:
30 (1) A baseline mammogram for women 35 to 39 years
31 of age.
32 (2) A mammogram every one to 2 years, even if no
33 symptoms are present, for women 40 to 49 years of age.
34 (3) An annual mammogram for women 40 50 years of
HB1881 Enrolled -6- LRB9000419JSgc
1 age or older.
2 Those benefits shall be at least as favorable as for
3 other radiological examinations and subject to the same
4 dollar limits, deductibles, and co-insurance factors. For
5 purposes of this subsection, "low-dose mammography" means the
6 x-ray examination of the breast using equipment dedicated
7 specifically for mammography, including the x-ray tube,
8 filter, compression device, screens, and image receptors,
9 with an average radiation exposure delivery of less than one
10 rad mid-breast, with 2 views for each breast. The requirement
11 that mammograms be included in health insurance coverage as
12 provided in this subsection (d) is an exclusive power and
13 function of the State and is a denial and limitation under
14 Article VII, Section 6, subsection (h) of the Illinois
15 Constitution of home rule municipality powers. A home rule
16 municipality to which this subsection applies must comply
17 with every provision of this subsection.
18 (Source: P.A. 86-1475; 87-780.)
19 (65 ILCS 5/10-4-2.3 new)
20 Sec. 10-4-2.3. Required health benefits. If a
21 municipality, including a home rule municipality, is a
22 self-insurer for purposes of providing health insurance
23 coverage for its employees, the coverage shall include
24 coverage for the post-mastectomy care benefits required to be
25 covered by a policy of accident and health insurance under
26 Section 356t and the coverage required under Section 356u of
27 the Illinois Insurance Code. The requirement that health
28 benefits be covered as provided in this is an exclusive power
29 and function of the State and is a denial and limitation
30 under Article VII, Section 6, subsection (h) of the Illinois
31 Constitution. A home rule municipality to which this Section
32 applies must comply with every provision of this Section.
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1 Section 25. The School Code is amended by adding Section
2 10-22.3f as follows:
3 (105 ILCS 5/10-22.3f new)
4 Sec. 10-22.3f. Required health benefits. Insurance
5 protection and benefits for employees shall provide the
6 post-mastectomy care benefits required to be covered by a
7 policy of accident and health insurance under Section 356t
8 and the coverage required under Section 356u of the Illinois
9 Insurance Code.
10 Section 30. The Illinois Insurance Code is amended by
11 changing Sections 122-1, 356g, and 1003 and adding Sections
12 356t and 356u as follows:
13 (215 ILCS 5/122-1) (from Ch. 73, par. 734-1)
14 Sec. 122-1. The authority and jurisdiction of Insurance
15 Department. Notwithstanding any other provision of law, and
16 except as provided herein, any person or other entity which
17 provides coverage in this State for medical, surgical,
18 chiropractic, naprapathic, physical therapy, speech
19 pathology, audiology, professional mental health, dental,
20 hospital, ophthalmologic, or optometric expenses, whether
21 such coverage is by direct-payment, reimbursement, or
22 otherwise, shall be presumed to be subject to the
23 jurisdiction of the Department unless the person or other
24 entity shows that while providing such coverage it is subject
25 to the jurisdiction of another agency of this state, any
26 subdivision of this state, or the Federal Government, or is a
27 plan of self-insurance or other employee welfare benefit
28 program of an individual employer or labor union established
29 or maintained under or pursuant to a collective bargaining
30 agreement or other arrangement which provides for health care
31 services solely for its employees or members and their
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1 dependents.
2 (Source: P.A. 86-753.)
3 (215 ILCS 5/356g) (from Ch. 73, par. 968g)
4 Sec. 356g. (a) Every insurer shall provide in each group
5 or individual policy, contract, or certificate of insurance
6 issued or renewed for persons who are residents of this
7 State, coverage for screening by low-dose mammography for all
8 women 35 years of age or older for the presence of occult
9 breast cancer within the provisions of the policy, contract,
10 or certificate. The coverage shall be as follows:
11 (1) A baseline mammogram for women 35 to 39 years
12 of age.
13 (2) An mammogram every 1 to 2 years, even if no
14 symptoms are present, for women 40 to 49 years of age.
15 (3) An annual mammogram for women 40 50 years of
16 age or older.
17 These benefits shall be at least as favorable as for
18 other radiological examinations and subject to the same
19 dollar limits, deductibles, and co-insurance factors. For
20 purposes of this Section, "low-dose mammography" means the
21 x-ray examination of the breast using equipment dedicated
22 specifically for mammography, including the x-ray tube,
23 filter, compression device, and image receptor, with
24 radiation exposure delivery of less than 1 rad per breast for
25 2 views of an average size breast.
26 (b) No policy of accident or health insurance that
27 provides for the surgical procedure known as a mastectomy
28 shall be issued, amended, delivered or renewed in this State
29 on or after July 1, 1981, unless coverage is also offered for
30 prosthetic devices or reconstructive surgery incident to the
31 mastectomy, providing that the mastectomy is performed after
32 July 1, 1981. The offered coverage for prosthetic devices and
33 reconstructive surgery shall be subject to the deductible and
HB1881 Enrolled -9- LRB9000419JSgc
1 coinsurance conditions applied to the mastectomy, and all
2 other terms and conditions applicable to other benefits.
3 When a mastectomy is performed and there is no evidence of
4 malignancy then the offered coverage may be limited to the
5 provision of prosthetic devices and reconstructive surgery to
6 within 2 years after the date of the mastectomy. As used in
7 this Section, "mastectomy" means the removal of all or part
8 of the breast for medically necessary reasons, as determined
9 by a licensed physician.
10 (Source: P.A. 86-899; 87-518.)
11 (215 ILCS 5/356t new)
12 Sec. 356t. Post-mastectomy care. An individual or group
13 policy of accident and health insurance or managed care plan
14 that provides surgical coverage and is amended, delivered,
15 issued, or renewed after the effective date of this
16 amendatory Act of 1997 shall provide inpatient coverage
17 following a mastectomy for a length of time determined by the
18 attending physician to be medically necessary and in
19 accordance with protocols and guidelines based on sound
20 scientific evidence and upon evaluation of the patient and
21 the coverage for and availability of a post-discharge
22 physician office visit or in-home nurse visit to verify the
23 condition of the patient in the first 48 hours after
24 discharge.
25 (215 ILCS 5/356u new)
26 Sec. 356u. Pap tests and prostate-specific antigen
27 tests.
28 (a) A group policy of accident and health insurance that
29 provides coverage for hospital or medical treatment or
30 services for illness on an expense-incurred basis and is
31 amended, delivered, issued, or renewed after the effective
32 date of this amendatory Act of 1997 shall provide coverage
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1 for all of the following:
2 (1) An annual cervical smear or Pap smear test for
3 female insureds.
4 (2) An annual digital rectal examination and a
5 prostate-specific antigen test, for male insureds upon
6 the recommendation of a physician licensed to practice
7 medicine in all its branches for:
8 (A) asymptomatic men age 50 and over;
9 (B) African-American men age 40 and over; and
10 (C) men age 40 and over with a family history
11 of prostate cancer.
12 (b) This Section shall not apply to agreements,
13 contracts, or policies that provide coverage for a specified
14 disease or other limited benefit coverage.
15 (215 ILCS 5/1003) (from Ch. 73, par. 1065.703)
16 Sec. 1003. Definitions. As used in this Article: (A)
17 "Adverse underwriting decision" means:
18 (1) any of the following actions with respect to
19 insurance transactions involving insurance coverage which is
20 individually underwritten:
21 (a) a declination of insurance coverage,
22 (b) a termination of insurance coverage,
23 (c) failure of an agent to apply for insurance coverage
24 with a specific insurance institution which the agent
25 represents and which is requested by an applicant,
26 (d) in the case of a property or casualty insurance
27 coverage:
28 (i) placement by an insurance institution or agent of a
29 risk with a residual market mechanism, an unauthorized
30 insurer or an insurance institution which specializes in
31 substandard risks, or
32 (ii) the charging of a higher rate on the basis of
33 information which differs from that which the applicant or
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1 policyholder furnished, or
2 (e) in the case of life, health or disability insurance
3 coverage, an offer to insure at higher than standard rates.
4 (2) Notwithstanding paragraph (1) above, the following
5 actions shall not be considered adverse underwriting
6 decisions but the insurance institution or agent responsible
7 for their occurrence shall nevertheless provide the applicant
8 or policyholder with the specific reason or reasons for their
9 occurrence:
10 (a) the termination of an individual policy form on a
11 class or statewide basis,
12 (b) a declination of insurance coverage solely because
13 such coverage is not available on a class or statewide basis,
14 or
15 (c) the rescission of a policy.
16 (B) "Affiliate" or "affiliated" means a person that
17 directly, or indirectly through one or more intermediaries,
18 controls, is controlled by or is under common control with
19 another person.
20 (C) "Agent" means an individual, firm, partnership,
21 association or corporation who is involved in the
22 solicitation, negotiation or binding of coverages for or on
23 applications or policies of insurance, covering property or
24 risks located in this State. For the purposes of this
25 Article, both "Insurance Agent" and "Insurance Broker", as
26 defined in Section 490, shall be considered an agent.
27 (D) "Applicant" means any person who seeks to contract
28 for insurance coverage other than a person seeking group
29 insurance that is not individually underwritten.
30 (E) "Director" means the Director of Insurance.
31 (F) "Consumer report" means any written, oral or other
32 communication of information bearing on a natural person's
33 credit worthiness, credit standing, credit capacity,
34 character, general reputation, personal characteristics or
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1 mode of living which is used or expected to be used in
2 connection with an insurance transaction.
3 (G) "Consumer reporting agency" means any person who:
4 (1) regularly engages, in whole or in part, in the
5 practice of assembling or preparing consumer reports for a
6 monetary fee,
7 (2) obtains information primarily from sources other than
8 insurance institutions, and
9 (3) furnishes consumer reports to other persons.
10 (H) "Control", including the terms "controlled by" or
11 "under common control with", means the possession, direct or
12 indirect, of the power to direct or cause the direction of
13 the management and policies of a person, whether through the
14 ownership of voting securities, by contract other than a
15 commercial contract for goods or nonmanagement services, or
16 otherwise, unless the power is the result of an official
17 position with or corporate office held by the person.
18 (I) "Declination of insurance coverage" means a denial,
19 in whole or in part, by an insurance institution or agent of
20 requested insurance coverage.
21 (J) "Individual" means any natural person who:
22 (1) in the case of property or casualty insurance, is a
23 past, present or proposed named insured or certificateholder;
24 (2) in the case of life, health or disability insurance,
25 is a past, present or proposed principal insured or
26 certificateholder;
27 (3) is a past, present or proposed policyowner;
28 (4) is a past or present applicant;
29 (5) is a past or present claimant; or
30 (6) derived, derives or is proposed to derive insurance
31 coverage under an insurance policy or certificate subject to
32 this Article.
33 (K) "Institutional source" means any person or
34 governmental entity that provides information about an
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1 individual to an agent, insurance institution or
2 insurance-support organization, other than:
3 (1) an agent,
4 (2) the individual who is the subject of the
5 information, or
6 (3) a natural person acting in a personal capacity
7 rather than in a business or professional capacity.
8 (L) "Insurance institution" means any corporation,
9 association, partnership, reciprocal exchange, inter-insurer,
10 Lloyd's insurer, fraternal benefit society or other person
11 engaged in the business of insurance, health maintenance
12 organizations as defined in Section 2 of the "Health
13 Maintenance Organization Act", medical service plans as
14 defined in Section 2 of "The Medical Service Plan Act",
15 hospital service corporation under "The Nonprofit Health Care
16 Service Plan Act", voluntary health services plans as defined
17 in Section 2 of "The Voluntary Health Services Plans Act",
18 vision service plans as defined in Section 2 of "The Vision
19 Service Plan Act", dental service plans as defined in Section
20 4 of "The Dental Service Plan Act", and pharmaceutical
21 service plans as defined in Section 4 of "The Pharmaceutical
22 Service Plan Act". "Insurance institution" shall not include
23 agents or insurance-support organizations.
24 (M) "Insurance-support organization" means: (1) any
25 person who regularly engages, in whole or in part, in the
26 practice of assembling or collecting information about
27 natural persons for the primary purpose of providing the
28 information to an insurance institution or agent for
29 insurance transactions, including:
30 (a) the furnishing of consumer reports or investigative
31 consumer reports to an insurance institution or agent for use
32 in connection with an insurance transaction, or
33 (b) the collection of personal information from
34 insurance institutions, agents or other insurance-support
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1 organizations for the purpose of detecting or preventing
2 fraud, material misrepresentation or material nondisclosure
3 in connection with insurance underwriting or insurance claim
4 activity.
5 (2) Notwithstanding paragraph (1) above, the following
6 persons shall not be considered "insurance-support
7 organizations" for purposes of this Article: agents,
8 government institutions, insurance institutions, medical care
9 institutions and medical professionals.
10 (N) "Insurance transaction" means any transaction
11 involving insurance primarily for personal, family or
12 household needs rather than business or professional needs
13 which entails:
14 (1) the determination of an individual's eligibility for
15 an insurance coverage, benefit or payment, or
16 (2) the servicing of an insurance application, policy,
17 contract or certificate.
18 (O) "Investigative consumer report" means a consumer
19 report or portion thereof in which information about a
20 natural person's character, general reputation, personal
21 characteristics or mode of living is obtained through
22 personal interviews with the person's neighbors, friends,
23 associates, acquaintances or others who may have knowledge
24 concerning such items of information.
25 (P) "Medical-care institution" means any facility or
26 institution that is licensed to provide health care services
27 to natural persons, including but not limited to: hospitals,
28 skilled nursing facilities, home-health agencies, medical
29 clinics, rehabilitation agencies and public-health agencies
30 and health-maintenance organizations.
31 (Q) "Medical professional" means any person licensed or
32 certified to provide health care services to natural
33 persons, including but not limited to, a physician, dentist,
34 nurse, optometrist, chiropractor, naprapath, pharmacist,
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1 physical or occupational therapist, psychiatric social
2 worker, speech therapist, clinical dietitian or clinical
3 psychologist.
4 (R) "Medical-record information" means personal
5 information which:
6 (1) relates to an individual's physical or mental
7 condition, medical history or medical treatment, and
8 (2) is obtained from a medical professional or
9 medical-care institution, from the individual, or from the
10 individual's spouse, parent or legal guardian.
11 (S) "Person" means any natural person, corporation,
12 association, partnership or other legal entity.
13 (T) "Personal information" means any individually
14 identifiable information gathered in connection with an
15 insurance transaction from which judgments can be made about
16 an individual's character, habits, avocations, finances,
17 occupation, general reputation, credit, health or any other
18 personal characteristics. "Personal information" includes an
19 individual's name and address and "medical-record
20 information" but does not include "privileged information".
21 (U) "Policyholder" means any person who:
22 (1) in the case of individual property or casualty
23 insurance, is a present named insured;
24 (2) in the case of individual life, health or disability
25 insurance, is a present policyowner; or
26 (3) in the case of group insurance which is individually
27 underwritten, is a present group certificateholder.
28 (V) "Pretext interview" means an interview whereby a
29 person, in an attempt to obtain information about a natural
30 person, performs one or more of the following acts:
31 (1) pretends to be someone he or she is not,
32 (2) pretends to represent a person he or she is not in
33 fact representing,
34 (3) misrepresents the true purpose of the interview, or
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1 (4) refuses to identify himself or herself upon request.
2 (W) "Privileged information" means any individually
3 identifiable information that: (1) relates to a claim for
4 insurance benefits or a civil or criminal proceeding
5 involving an individual, and (2) is collected in connection
6 with or in reasonable anticipation of a claim for insurance
7 benefits or civil or criminal proceeding involving an
8 individual; provided, however, information otherwise meeting
9 the requirements of this subsection shall nevertheless be
10 considered "personal information" under this Article if it is
11 disclosed in violation of Section 1014 of this Article.
12 (X) "Residual market mechanism" means an association,
13 organization or other entity described in Article XXXIII of
14 this Act, or Section 7-501 of "The Illinois Vehicle Code".
15 (Y) "Termination of insurance coverage" or "termination
16 of an insurance policy" means either a cancellation or
17 nonrenewal of an insurance policy, in whole or in part, for
18 any reason other than the failure to pay a premium as
19 required by the policy.
20 (Z) "Unauthorized insurer" means an insurance institution
21 that has not been granted a certificate of authority by the
22 Director to transact the business of insurance in this State.
23 (Source: P.A. 82-108.)
24 Section 32. The Comprehensive Health Insurance Plan Act
25 is amended by changing Section 8 as follows:
26 (215 ILCS 105/8) (from Ch. 73, par. 1308)
27 Sec. 8. Minimum benefits.
28 a. Availability. The Plan shall offer in an annually
29 renewable policy major medical expense coverage to every
30 eligible person who is not eligible for Medicare. Major
31 medical expense coverage offered by the Plan shall pay an
32 eligible person's covered expenses, subject to limit on the
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1 deductible and coinsurance payments authorized under
2 paragraph (4) of subsection d of this Section, up to a
3 lifetime benefit limit of $500,000 per covered individual.
4 The maximum limit under this subsection shall not be altered
5 by the Board, and no actuarial equivalent benefit may be
6 substituted by the Board. Any person who otherwise would
7 qualify for coverage under the Plan, but is excluded because
8 he or she is eligible for Medicare, shall be eligible for any
9 separate Medicare supplement policy which the Board may
10 offer.
11 b. Covered expenses. Covered expenses shall be limited
12 to the reasonable and customary charge, including negotiated
13 fees, in the locality for the following services and articles
14 when medically necessary and prescribed by a person licensed
15 and practicing within the scope of his or her profession as
16 authorized by State law:
17 (1) Hospital room and board and any other hospital
18 services, except that inpatient hospitalization for the
19 treatment of mental and emotional disorders shall only be
20 covered for a maximum of 45 days in a calendar year.
21 (2) Professional services for the diagnosis or
22 treatment of injuries, illnesses or conditions, other
23 than dental, or outpatient mental as described in
24 paragraph (17), which are rendered by a physician or
25 chiropractor, or by other licensed professionals at the
26 physician's or chiropractor's direction.
27 (3) If surgery has been recommended, a second
28 opinion may be required. The charge for a second opinion
29 as to whether the surgery is required will be paid in
30 full without regard to deductible or co-payment
31 requirements. If the second opinion differs from the
32 first, the charge for a third opinion, if desired, will
33 also be paid in full without regard to deductible or
34 co-payment requirements. Regardless of whether the
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1 second opinion or third opinion confirms the original
2 recommendation, it is the patient's decision whether to
3 undergo surgery.
4 (4) Drugs requiring a physician's or other legally
5 authorized prescription.
6 (5) Skilled nursing care provided in a skilled
7 nursing facility for not more than 120 days in a calendar
8 year, provided the service commences within 14 days
9 following a confinement of at least 3 consecutive days in
10 a hospital for the same condition.
11 (6) Services of a home health agency in accord with
12 a home health care plan, up to a maximum of 270 visits
13 per year.
14 (7) Services of a licensed hospice for not more
15 than 180 days during a policy year.
16 (8) Use of radium or other radioactive materials.
17 (9) Oxygen.
18 (10) Anesthetics.
19 (11) Orthoses and prostheses other than dental.
20 (12) Rental or purchase in accordance with Board
21 policies or procedures of durable medical equipment,
22 other than eyeglasses or hearing aids, for which there is
23 no personal use in the absence of the condition for which
24 it is prescribed.
25 (13) Diagnostic x-rays and laboratory tests.
26 (14) Oral surgery for excision of partially or
27 completely unerupted impacted teeth or the gums and
28 tissues of the mouth, when not performed in connection
29 with the routine extraction or repair of teeth, and oral
30 surgery and procedures, including orthodontics and
31 prosthetics necessary for craniofacial or maxillofacial
32 conditions and to correct congenital defects or injuries
33 due to accident.
34 (15) Physical, speech, and functional occupational
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1 therapy as medically necessary and provided by
2 appropriate licensed professionals.
3 (16) Transportation provided by a licensed
4 ambulance service to the nearest health care facility
5 qualified to treat the illness, injury or condition,
6 subject to the provisions of the Emergency Medical
7 Systems (EMS) Act.
8 (17) The first 50 professional outpatient visits
9 for diagnosis and treatment of mental and emotional
10 disorders rendered during the year, up to a maximum of
11 $80 per visit.
12 (18) Human organ or tissue transplants specified by
13 the Board that are performed at a hospital designated by
14 the Board as a participating transplant center for that
15 specific organ or tissue transplant.
16 (19) Naprapathic services, as appropriate, provided
17 by a licensed naprapathic practitioner.
18 c. Exclusion. Covered expenses of the Plan shall not
19 include the following:
20 (1) Any charge for treatment for cosmetic purposes
21 other than for reconstructive surgery when the service is
22 incidental to or follows surgery resulting from injury,
23 sickness or other diseases of the involved part or
24 surgery for the repair or treatment of a congenital
25 bodily defect to restore normal bodily functions.
26 (2) Any charge for care that is primarily for rest,
27 custodial, educational, or domiciliary purposes.
28 (3) Any charge for services in a private room to
29 the extent it is in excess of the institution's charge
30 for its most common semiprivate room, unless a private
31 room is prescribed as medically necessary by a physician.
32 (4) That part of any charge for room and board or
33 for services rendered or articles prescribed by a
34 physician, dentist, or other health care personnel that
HB1881 Enrolled -20- LRB9000419JSgc
1 exceeds the reasonable and customary charge in the
2 locality or for any services or supplies not medically
3 necessary for the diagnosed injury or illness.
4 (5) Any charge for services or articles the
5 provision of which is not within the scope of licensure
6 of the institution or individual providing the services
7 or articles.
8 (6) Any expense incurred prior to the effective
9 date of coverage by the Plan for the person on whose
10 behalf the expense is incurred.
11 (7) Dental care, dental surgery, dental treatment
12 or dental appliances, except as provided in paragraph
13 (14) of subsection b of this Section.
14 (8) Eyeglasses, contact lenses, hearing aids or
15 their fitting.
16 (9) Illness or injury due to (A) war or any acts of
17 war; (B) commission of, or attempt to commit, a felony;
18 or (C) aviation activities, except when traveling as a
19 fare-paying passenger on a commercial airline.
20 (10) Services of blood donors and any fee for
21 failure to replace blood provided to an eligible person
22 each policy year.
23 (11) Personal supplies or services provided by a
24 hospital or nursing home, or any other nonmedical or
25 nonprescribed supply or service.
26 (12) Routine maternity charges for a pregnancy,
27 except where added as optional coverage with payment of
28 an additional premium for pregnancy resulting from
29 conception occurring after the effective date of the
30 optional coverage.
31 (13) Expenses of obtaining an abortion, induced
32 miscarriage or induced premature birth unless, in the
33 opinion of a physician, those procedures are necessary
34 for the preservation of life of the woman seeking such
HB1881 Enrolled -21- LRB9000419JSgc
1 treatment, or except an induced premature birth intended
2 to produce a live viable child and the procedure is
3 necessary for the health of the mother or unborn child.
4 (14) Any expense or charge for services, drugs, or
5 supplies that are: (i) not provided in accord with
6 generally accepted standards of current medical practice;
7 (ii) for procedures, treatments, equipment, transplants,
8 or implants, any of which are investigational,
9 experimental, or for research purposes; (iii)
10 investigative and not proven safe and effective; or (iv)
11 for, or resulting from, a gender transformation
12 operation.
13 (15) Any expense or charge for routine physical
14 examinations or tests.
15 (16) Any expense for which a charge is not made in
16 the absence of insurance or for which there is no legal
17 obligation on the part of the patient to pay.
18 (17) Any expense incurred for benefits provided
19 under the laws of the United States and this State,
20 including Medicare and Medicaid and other medical
21 assistance, military service-connected disability
22 payments, medical services provided for members of the
23 armed forces and their dependents or employees of the
24 armed forces of the United States, and medical services
25 financed on behalf of all citizens by the United States.
26 (18) Any expense or charge for in vitro
27 fertilization, artificial insemination, or any other
28 artificial means used to cause pregnancy.
29 (19) Any expense or charge for oral contraceptives
30 used for birth control or any other temporary birth
31 control measures.
32 (20) Any expense or charge for sterilization or
33 sterilization reversals.
34 (21) Any expense or charge for weight loss
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1 programs, exercise equipment, or treatment of obesity,
2 except when certified by a physician as morbid obesity
3 (at least 2 times normal body weight).
4 (22) Any expense or charge for acupuncture
5 treatment unless used as an anesthetic agent for a
6 covered surgery.
7 (23) Any expense or charge for or related to organ
8 or tissue transplants other than those performed at a
9 hospital with a Board approved organ transplant program
10 that has been designated by the Board as a preferred or
11 exclusive provider organization for that specific organ
12 or tissue.
13 (24) Any expense or charge for procedures,
14 treatments, equipment, or services that are provided in
15 special settings for research purposes or in a controlled
16 environment, are being studied for safety, efficiency,
17 and effectiveness, and are awaiting endorsement by the
18 appropriate national medical speciality college for
19 general use within the medical community.
20 d. Premiums, deductibles, and coinsurance.
21 (1) Premiums charged for coverage issued by the
22 Plan may not be unreasonable in relation to the benefits
23 provided, the risk experience and the reasonable expenses
24 of providing the coverage.
25 (2) Separate schedules of premium rates based on
26 sex, age and geographical location shall apply for
27 individual risks.
28 (3) The Plan may provide for separate premium rates
29 for optional family coverage for the spouse or one or
30 more dependents of any person eligible to be insured
31 under the Plan who is also the oldest adult member of the
32 family and remains continuously enrolled in the Plan as
33 the primary enrollee. The rates shall be such percentage
34 of the applicable individual Plan rate as the Board, in
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1 accordance with appropriate actuarial principles, shall
2 establish for each spouse or dependent.
3 (4) The Board shall determine, in accordance with
4 appropriate actuarial principles, the average rates that
5 individual standard risks in this State are charged by at
6 least 5 of the largest insurers providing coverage to
7 residents of Illinois that is substantially similar to
8 the Plan coverage. In the event at least 5 insurers do
9 not offer substantially similar coverage, the rates shall
10 be established using reasonable actuarial techniques and
11 shall reflect anticipated claims experience, expenses,
12 and other appropriate risk factors relating to the Plan.
13 Rates for Plan coverage shall be 135% of rates so
14 established as applicable for individual standard risks;
15 provided, however, if after determining that the
16 appropriations made pursuant to Section 12 of this Act
17 are insufficient to ensure that total income from all
18 sources will equal or exceed the total incurred costs and
19 expenses for the current number of enrollees, the board
20 shall raise premium rates above this 135% standard to the
21 level it deems necessary to ensure the financial solvency
22 of the Plan for enrollees already in the Plan. All rates
23 and rate schedules shall be submitted to the board for
24 approval.
25 (5) The Plan coverage defined in Section 6 shall
26 provide for a choice of deductibles as authorized by the
27 Board per individual per annum. If 2 individual members
28 of a family satisfy the same applicable deductibles, no
29 other member of that family who is eligible for coverage
30 under the Plan shall be required to meet any deductibles
31 for the balance of that calendar year. The deductibles
32 must be applied first to the authorized amount of covered
33 expenses incurred by the covered person. A mandatory
34 coinsurance requirement shall be imposed at the rate
HB1881 Enrolled -24- LRB9000419JSgc
1 authorized by the Board in excess of the mandatory
2 deductible, the coinsurance in the aggregate not to
3 exceed such amounts as are authorized by the Board per
4 annum. At its discretion the Board may, however, offer
5 catastrophic coverages or other policies that provide for
6 larger deductibles with or without coinsurance
7 requirements. The deductibles and coinsurance factors
8 may be adjusted annually according to the Medical
9 Component of the Consumer Price Index.
10 (6) The Plan may provide for and employ cost
11 containment measures and requirements including, but not
12 limited to, preadmission certification, second surgical
13 opinion, concurrent utilization review programs,
14 individual case management, preferred provider
15 organizations, and other cost effective arrangements for
16 paying for covered expenses.
17 e. Scope of coverage. Except as provided in subsection
18 c of this Section, if the covered expenses incurred by the
19 eligible person exceed the deductible for major medical
20 expense coverage in a calendar year, the Plan shall pay at
21 least 80% of any additional covered expenses incurred by the
22 person during the calendar year.
23 f. Preexisting conditions.
24 (1) Six months: Plan coverage shall exclude charges
25 or expenses incurred during the first 6 months following
26 the effective date of coverage as to any condition if:
27 (a) the condition had manifested itself within the 6
28 month period immediately preceding the effective date of
29 coverage in such a manner as would cause an ordinarily
30 prudent person to seek diagnosis, care or treatment; or
31 (b) medical advice, care or treatment was recommended or
32 received within the 6 month period immediately preceding
33 the effective date of coverage.
34 (2) (Blank).
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1 (3) Waiver: The preexisting condition exclusions as
2 set forth in paragraph (1) of this subsection shall be
3 waived to the extent to which the eligible person: (a)
4 has satisfied similar exclusions under any prior health
5 insurance policy or plan that was involuntarily
6 terminated; (b) is ineligible for any continuation or
7 conversion rights that would continue or provide
8 substantially similar coverage following that
9 termination; and (c) has applied for Plan coverage not
10 later than 30 days following the involuntary termination.
11 No policy or plan shall be deemed to have been
12 involuntarily terminated if the master policyholder or
13 other controlling party elected to change insurance
14 coverage from one company or plan to another even if that
15 decision resulted in a discontinuation of coverage for
16 any individual under the plan, either totally or for any
17 medical condition. For each eligible person who qualifies
18 for and elects this waiver, there shall be added to each
19 payment of premium, on a prorated basis, a surcharge of
20 up to 10% of the otherwise applicable annual premium for
21 as long as that individual's coverage under the Plan
22 remains in effect or 60 months, whichever is less.
23 g. Other sources primary; nonduplication of benefits.
24 (1) The Plan shall be the last payor of benefits
25 whenever any other benefit or source of third party
26 payment is available. Subject to the provisions of
27 subsection e of Section 7, benefits otherwise payable
28 under Plan coverage shall be reduced by all amounts paid
29 or payable by Medicare or any other government program or
30 through any health insurance or other health benefit
31 plan, whether insured or otherwise, or through any third
32 party liability, settlement, judgment, or award,
33 regardless of the date of the settlement, judgment, or
34 award, whether the settlement, judgment, or award is in
HB1881 Enrolled -26- LRB9000419JSgc
1 the form of a contract, agreement, or trust on behalf of
2 a minor or otherwise and whether the settlement,
3 judgment, or award is payable to the covered person, his
4 or her dependent, estate, personal representative, or
5 guardian in a lump sum or over time, and by all hospital
6 or medical expense benefits paid or payable under any
7 worker's compensation coverage, automobile medical
8 payment, or liability insurance, whether provided on the
9 basis of fault or nonfault, and by any hospital or
10 medical benefits paid or payable under or provided
11 pursuant to any State or federal law or program.
12 (2) The Plan shall have a cause of action against
13 any covered person or any other person or entity for the
14 recovery of any amount paid to the extent the amount was
15 for treatment, services, or supplies not covered in this
16 Section or in excess of benefits as set forth in this
17 Section.
18 (3) Whenever benefits are due from the Plan because
19 of sickness or an injury to a covered person resulting
20 from a third party's wrongful act or negligence and the
21 covered person has recovered or may recover damages from
22 a third party or its insurer, the Plan shall have the
23 right to reduce benefits or to refuse to pay benefits
24 that otherwise may be payable by the amount of damages
25 that the covered person has recovered or may recover
26 regardless of the date of the sickness or injury or the
27 date of any settlement, judgment, or award resulting from
28 that sickness or injury.
29 During the pendency of any action or claim that is
30 brought by or on behalf of a covered person against a
31 third party or its insurer, any benefits that would
32 otherwise be payable except for the provisions of this
33 paragraph (3) shall be paid if payment by or for the
34 third party has not yet been made and the covered person
HB1881 Enrolled -27- LRB9000419JSgc
1 or, if incapable, that person's legal representative
2 agrees in writing to pay back promptly the benefits paid
3 as a result of the sickness or injury to the extent of
4 any future payments made by or for the third party for
5 the sickness or injury. This agreement is to apply
6 whether or not liability for the payments is established
7 or admitted by the third party or whether those payments
8 are itemized.
9 Any amounts due the plan to repay benefits may be
10 deducted from other benefits payable by the Plan after
11 payments by or for the third party are made.
12 (4) Benefits due from the Plan may be reduced or
13 refused as an offset against any amount otherwise
14 recoverable under this Section.
15 h. Right of subrogation; recoveries.
16 (1) Whenever the Plan has paid benefits because of
17 sickness or an injury to any covered person resulting
18 from a third party's wrongful act or negligence, or for
19 which an insurer is liable in accordance with the
20 provisions of any policy of insurance, and the covered
21 person has recovered or may recover damages from a third
22 party that is liable for the damages, the Plan shall have
23 the right to recover the benefits it paid from any
24 amounts that the covered person has received or may
25 receive regardless of the date of the sickness or injury
26 or the date of any settlement, judgment, or award
27 resulting from that sickness or injury. The Plan shall
28 be subrogated to any right of recovery the covered person
29 may have under the terms of any private or public health
30 care coverage or liability coverage, including coverage
31 under the Workers' Compensation Act or the Workers'
32 Occupational Diseases Act, without the necessity of
33 assignment of claim or other authorization to secure the
34 right of recovery. To enforce its subrogation right, the
HB1881 Enrolled -28- LRB9000419JSgc
1 Plan may (i) intervene or join in an action or proceeding
2 brought by the covered person or his personal
3 representative, including his guardian, conservator,
4 estate, dependents, or survivors, against any third party
5 or the third party's insurer that may be liable or (ii)
6 institute and prosecute legal proceedings against any
7 third party or the third party's insurer that may be
8 liable for the sickness or injury in an appropriate court
9 either in the name of the Plan or in the name of the
10 covered person or his personal representative, including
11 his guardian, conservator, estate, dependents, or
12 survivors.
13 (2) If any action or claim is brought by or on
14 behalf of a covered person against a third party or the
15 third party's insurer, the covered person or his personal
16 representative, including his guardian, conservator,
17 estate, dependents, or survivors, shall notify the Plan
18 by personal service or registered mail of the action or
19 claim and of the name of the court in which the action or
20 claim is brought, filing proof thereof in the action or
21 claim. The Plan may, at any time thereafter, join in the
22 action or claim upon its motion so that all orders of
23 court after hearing and judgment shall be made for its
24 protection. No release or settlement of a claim for
25 damages and no satisfaction of judgment in the action
26 shall be valid without the written consent of the Plan to
27 the extent of its interest in the settlement or judgment
28 and of the covered person or his personal representative.
29 (3) In the event that the covered person or his
30 personal representative fails to institute a proceeding
31 against any appropriate third party before the fifth
32 month before the action would be barred, the Plan may, in
33 its own name or in the name of the covered person or
34 personal representative, commence a proceeding against
HB1881 Enrolled -29- LRB9000419JSgc
1 any appropriate third party for the recovery of damages
2 on account of any sickness, injury, or death to the
3 covered person. The covered person shall cooperate in
4 doing what is reasonably necessary to assist the Plan in
5 any recovery and shall not take any action that would
6 prejudice the Plan's right to recovery. The Plan shall
7 pay to the covered person or his personal representative
8 all sums collected from any third party by judgment or
9 otherwise in excess of amounts paid in benefits under the
10 Plan and amounts paid or to be paid as costs, attorneys
11 fees, and reasonable expenses incurred by the Plan in
12 making the collection or enforcing the judgment.
13 (4) In the event that a covered person or his
14 personal representative, including his guardian,
15 conservator, estate, dependents, or survivors, recovers
16 damages from a third party for sickness or injury caused
17 to the covered person, the covered person or the personal
18 representative shall pay to the Plan from the damages
19 recovered the amount of benefits paid or to be paid on
20 behalf of the covered person.
21 (5) When the action or claim is brought by the
22 covered person alone and the covered person incurs a
23 personal liability to pay attorney's fees and costs of
24 litigation, the Plan's claim for reimbursement of the
25 benefits provided to the covered person shall be the full
26 amount of benefits paid to or on behalf of the covered
27 person under this Act less a pro rata share that
28 represents the Plan's reasonable share of attorney's fees
29 paid by the covered person and that portion of the cost
30 of litigation expenses determined by multiplying by the
31 ratio of the full amount of the expenditures to the full
32 amount of the judgement, award, or settlement.
33 (6) In the event of judgment or award in a suit or
34 claim against a third party or insurer, the court shall
HB1881 Enrolled -30- LRB9000419JSgc
1 first order paid from any judgement or award the
2 reasonable litigation expenses incurred in preparation
3 and prosecution of the action or claim, together with
4 reasonable attorney's fees. After payment of those
5 expenses and attorney's fees, the court shall apply out
6 of the balance of the judgment or award an amount
7 sufficient to reimburse the Plan the full amount of
8 benefits paid on behalf of the covered person under this
9 Act, provided the court may reduce and apportion the
10 Plan's portion of the judgement proportionate to the
11 recovery of the covered person. The burden of producing
12 evidence sufficient to support the exercise by the court
13 of its discretion to reduce the amount of a proven charge
14 sought to be enforced against the recovery shall rest
15 with the party seeking the reduction. The court may
16 consider the nature and extent of the injury, economic
17 and non-economic loss, settlement offers, comparative
18 negligence as it applies to the case at hand, hospital
19 costs, physician costs, and all other appropriate costs.
20 The Plan shall pay its pro rata share of the attorney
21 fees based on the Plan's recovery as it compares to the
22 total judgment. Any reimbursement rights of the Plan
23 shall take priority over all other liens and charges
24 existing under the laws of this State with the exception
25 of any attorney liens filed under the Attorneys Lien Act.
26 (7) The Plan may compromise or settle and release
27 any claim for benefits provided under this Act or waive
28 any claims for benefits, in whole or in part, for the
29 convenience of the Plan or if the Plan determines that
30 collection would result in undue hardship upon the
31 covered person.
32 (Source: P.A. 89-486, eff. 6-21-96.)
33 Section 35. The Health Maintenance Organization Act is
HB1881 Enrolled -31- LRB9000419JSgc
1 amended by changing Section 4-6.1 and adding Section 4-6.5 as
2 follows:
3 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
4 Sec. 4-6.1. (a) Every contract or evidence of coverage
5 issued by a Health Maintenance Organization for persons who
6 are residents of this State shall contain coverage for
7 screening by low-dose mammography for all women 35 years of
8 age or older for the presence of occult breast cancer. The
9 coverage shall be as follows:
10 (1) A baseline mammogram for women 35 to 39 years
11 of age.
12 (2) A mammogram every 1 to 2 years, even if no
13 symptoms are present, for women 40 to 49 years of age.
14 (3) An annual mammogram for women 40 50 years of
15 age or older.
16 These benefits shall be at least as favorable as for
17 other radiological examinations and subject to the same
18 dollar limits, deductibles, and co-insurance factors. For
19 purposes of this Section, "low-dose mammography" means the
20 x-ray examination of the breast using equipment dedicated
21 specifically for mammography, including the x-ray tube,
22 filter, compression device, and image receptor, with
23 radiation exposure delivery of less than 1 rad per breast for
24 2 views of an average size breast.
25 (Source: P.A. 86-899; 86-1028; 87-518.)
26 (215 ILCS 125/4-6.5 new)
27 Sec. 4-6.5. Required health benefits. A health
28 maintenance organization is subject to the provisions of
29 Sections 356t and 356u of the Illinois Insurance Code.
30 Section 40. The Voluntary Health Services Plans Act is
31 amended by changing Section 10 as follows:
HB1881 Enrolled -32- LRB9000419JSgc
1 (215 ILCS 165/10) (from Ch. 32, par. 604)
2 Sec. 10. Application of Insurance Code provisions.
3 Health services plan corporations and all persons interested
4 therein or dealing therewith shall be subject to the
5 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
6 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 367.2, 401,
7 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs
8 (7) and (15) of Section 367 of the Illinois Insurance Code.
9 (Source: P.A. 89-514, eff. 7-17-96.)
10 Section 45. The Illinois Public Aid Code is amended by
11 changing Section 5-5 and adding Section 5-16.8 as follows:
12 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
13 (Text of Section before 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
HB1881 Enrolled -33- LRB9000419JSgc
1 expenses as may be necessary; (15) medical treatment of
2 sexual assault survivors, as defined in Section 1a of the
3 Sexual Assault Survivors Emergency Treatment Act, for
4 injuries sustained as a result of the sexual assault,
5 including examinations and laboratory tests to discover
6 evidence which may be used in criminal proceedings arising
7 from the sexual assault; (16) the diagnosis and treatment of
8 sickle cell anemia; and (17) any other medical care, and any
9 other type of remedial care recognized under the laws of this
10 State, but not including abortions, or induced miscarriages
11 or premature births, unless, in the opinion of a physician,
12 such procedures are necessary for the preservation of the
13 life of the woman seeking such treatment, or except an
14 induced premature birth intended to produce a live viable
15 child and such procedure is necessary for the health of the
16 mother or her unborn child. The Illinois Department, by rule,
17 shall prohibit any physician from providing medical
18 assistance to anyone eligible therefor under this Code where
19 such physician has been found guilty of performing an
20 abortion procedure in a wilful and wanton manner upon a woman
21 who was not pregnant at the time such abortion procedure was
22 performed. The term "any other type of remedial care" shall
23 include nursing care and nursing home service for persons who
24 rely on treatment by spiritual means alone through prayer for
25 healing.
26 The Illinois Department shall provide the following
27 services to persons eligible for assistance under this
28 Article who are participating in education, training or
29 employment programs:
30 (1) dental services, which shall include but not be
31 limited to prosthodontics; and
32 (2) eyeglasses prescribed by a physician skilled in
33 the diseases of the eye, or by an optometrist, whichever
34 the person may select.
HB1881 Enrolled -34- LRB9000419JSgc
1 The Illinois Department, by rule, may distinguish and
2 classify the medical services to be provided only in
3 accordance with the classes of persons designated in Section
4 5-2.
5 The Illinois Department shall authorize the provision of,
6 and shall authorize payment for, screening by low-dose
7 mammography for the presence of occult breast cancer for
8 women 35 years of age or older who are eligible for medical
9 assistance under this Article, as follows: a baseline
10 mammogram for women 35 to 39 years of age; a mammogram every
11 1 to 2 years, even if no symptoms are present, for women 40
12 to 49 years of age; and an annual mammogram for women 40 50
13 years of age or older. All screenings shall include a
14 physical breast exam, instruction on self-examination and
15 information regarding the frequency of self-examination and
16 its value as a preventative tool. As used in this Section,
17 "low-dose mammography" means the x-ray examination of the
18 breast using equipment dedicated specifically for
19 mammography, including the x-ray tube, filter, compression
20 device, image receptor, and cassettes, with an average
21 radiation exposure delivery of less than one rad mid-breast,
22 with 2 views for each breast.
23 Any medical or health care provider shall immediately
24 recommend, to any pregnant woman who is being provided
25 prenatal services and is suspected of drug abuse or is
26 addicted as defined in the Alcoholism and Other Drug Abuse
27 and Dependency Act, referral to a local substance abuse
28 treatment provider licensed by the Department of Alcoholism
29 and Substance Abuse or to a licensed hospital which provides
30 substance abuse treatment services. The Department of Public
31 Aid shall assure coverage for the cost of treatment of the
32 drug abuse or addiction for pregnant recipients in accordance
33 with the Illinois Medicaid Program in conjunction with the
34 Department of Alcoholism and Substance Abuse.
HB1881 Enrolled -35- LRB9000419JSgc
1 All medical providers providing medical assistance to
2 pregnant women under this Code shall receive information from
3 the Department on the availability of services under the Drug
4 Free Families with a Future or any comparable program
5 providing case management services for addicted women,
6 including information on appropriate referrals for other
7 social services that may be needed by addicted women in
8 addition to treatment for addiction.
9 The Illinois Department, in cooperation with the
10 Departments of Alcoholism and Substance Abuse and Public
11 Health, through a public awareness campaign, may provide
12 information concerning treatment for alcoholism and drug
13 abuse and addiction, prenatal health care, and other
14 pertinent programs directed at reducing the number of
15 drug-affected infants born to recipients of medical
16 assistance.
17 The Department shall not sanction the recipient solely on
18 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.
HB1881 Enrolled -36- LRB9000419JSgc
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
HB1881 Enrolled -37- LRB9000419JSgc
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
HB1881 Enrolled -38- LRB9000419JSgc
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
HB1881 Enrolled -39- LRB9000419JSgc
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 Rehabilitation Services and the
26 Department on Aging, to effect the following: (i) intake
27 procedures and common eligibility criteria for those persons
28 who are 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,
HB1881 Enrolled -40- LRB9000419JSgc
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.
HB1881 Enrolled -41- LRB9000419JSgc
1 (Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
2 89-517, eff. 1-1-97.)
3 (Text of Section after 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,
34 such procedures are necessary for the preservation of the
HB1881 Enrolled -42- LRB9000419JSgc
1 life of the woman seeking such treatment, or except an
2 induced premature birth intended to produce a live viable
3 child and such procedure is necessary for the health of the
4 mother or her unborn child. The Illinois Department, by rule,
5 shall prohibit any physician from providing medical
6 assistance to anyone eligible therefor under this Code where
7 such physician has been found guilty of performing an
8 abortion procedure in a wilful and wanton manner upon a woman
9 who was not pregnant at the time such abortion procedure was
10 performed. The term "any other type of remedial care" shall
11 include nursing care and nursing home service for persons who
12 rely on treatment by spiritual means alone through prayer for
13 healing.
14 The Illinois Department of Public Aid shall provide the
15 following services to persons eligible for assistance under
16 this Article who are participating in education, training or
17 employment programs operated by the Department of Human
18 Services as successor to the Department of Public Aid:
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
HB1881 Enrolled -43- LRB9000419JSgc
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 Human
18 Services or to a licensed hospital which provides substance
19 abuse treatment services. The Department of Public Aid shall
20 assure coverage for the cost of treatment of the drug abuse
21 or addiction for pregnant recipients in accordance with the
22 Illinois Medicaid Program in conjunction with the Department
23 of Human Services.
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 Human Services (as successor to the Department
34 of Alcoholism and Substance Abuse) and Public Health, through
HB1881 Enrolled -44- LRB9000419JSgc
1 a public awareness campaign, may provide information
2 concerning treatment for alcoholism and drug abuse and
3 addiction, prenatal health care, and other pertinent programs
4 directed at reducing the number of drug-affected infants born
5 to recipients of medical assistance.
6 Neither the Illinois Department of Public Aid nor the
7 Department of Human Services shall sanction the recipient
8 solely on the basis of her substance abuse.
9 The Illinois Department shall establish such regulations
10 governing the dispensing of health services under this
11 Article as it shall deem appropriate. In formulating these
12 regulations the Illinois Department shall consult with and
13 give substantial weight to the recommendations offered by the
14 Citizens Assembly/Council on Public Aid. The Department
15 should seek the advice of formal professional advisory
16 committees appointed by the Director of the Illinois
17 Department for the purpose of providing regular advice on
18 policy and administrative matters, information dissemination
19 and educational activities for medical and health care
20 providers, and consistency in procedures to the Illinois
21 Department.
22 The Illinois Department may develop and contract with
23 Partnerships of medical providers to arrange medical services
24 for persons eligible under Section 5-2 of this Code.
25 Implementation of this Section may be by demonstration
26 projects in certain geographic areas. The Partnership shall
27 be represented by a sponsor organization. The Department, by
28 rule, shall develop qualifications for sponsors of
29 Partnerships. Nothing in this Section shall be construed to
30 require that the sponsor organization be a medical
31 organization.
32 The sponsor must negotiate formal written contracts with
33 medical providers for physician services, inpatient and
34 outpatient hospital care, home health services, treatment for
HB1881 Enrolled -45- LRB9000419JSgc
1 alcoholism and substance abuse, and other services determined
2 necessary by the Illinois Department by rule for delivery by
3 Partnerships. Physician services must include prenatal and
4 obstetrical care. The Illinois Department shall reimburse
5 medical services delivered by Partnership providers to
6 clients in target areas according to provisions of this
7 Article and the Illinois Health Finance Reform Act, except
8 that:
9 (1) Physicians participating in a Partnership and
10 providing certain services, which shall be determined by
11 the Illinois Department, to persons in areas covered by
12 the Partnership may receive an additional surcharge for
13 such services.
14 (2) The Department may elect to consider and
15 negotiate financial incentives to encourage the
16 development of Partnerships and the efficient delivery of
17 medical care.
18 (3) Persons receiving medical services through
19 Partnerships may receive medical and case management
20 services above the level usually offered through the
21 medical assistance program.
22 Medical providers shall be required to meet certain
23 qualifications to participate in Partnerships to ensure the
24 delivery of high quality medical services. These
25 qualifications shall be determined by rule of the Illinois
26 Department and may be higher than qualifications for
27 participation in the medical assistance program. Partnership
28 sponsors may prescribe reasonable additional qualifications
29 for participation by medical providers, only with the prior
30 written approval of the Illinois Department.
31 Nothing in this Section shall limit the free choice of
32 practitioners, hospitals, and other providers of medical
33 services by clients.
34 The Department shall apply for a waiver from the United
HB1881 Enrolled -46- LRB9000419JSgc
1 States Health Care Financing Administration to allow for the
2 implementation of Partnerships under this Section.
3 The Illinois Department shall require health care
4 providers to maintain records that document the medical care
5 and services provided to recipients of Medical Assistance
6 under this Article. The Illinois Department shall require
7 health care providers to make available, when authorized by
8 the patient, in writing, the medical records in a timely
9 fashion to other health care providers who are treating or
10 serving persons eligible for Medical Assistance under this
11 Article. All dispensers of medical services shall be
12 required to maintain and retain business and professional
13 records sufficient to fully and accurately document the
14 nature, scope, details and receipt of the health care
15 provided to persons eligible for medical assistance under
16 this Code, in accordance with regulations promulgated by the
17 Illinois Department. The rules and regulations shall require
18 that proof of the receipt of prescription drugs, dentures,
19 prosthetic devices and eyeglasses by eligible persons under
20 this Section accompany each claim for reimbursement submitted
21 by the dispenser of such medical services. No such claims for
22 reimbursement shall be approved for payment by the Illinois
23 Department without such proof of receipt, unless the Illinois
24 Department shall have put into effect and shall be operating
25 a system of post-payment audit and review which shall, on a
26 sampling basis, be deemed adequate by the Illinois Department
27 to assure that such drugs, dentures, prosthetic devices and
28 eyeglasses for which payment is being made are actually being
29 received by eligible recipients. Within 90 days after the
30 effective date of this amendatory Act of 1984, the Illinois
31 Department shall establish a current list of acquisition
32 costs for all prosthetic devices and any other items
33 recognized as medical equipment and supplies reimbursable
34 under this Article and shall update such list on a quarterly
HB1881 Enrolled -47- LRB9000419JSgc
1 basis, except that the acquisition costs of all prescription
2 drugs shall be updated no less frequently than every 30 days
3 as required by Section 5-5.12.
4 The rules and regulations of the Illinois Department
5 shall require that a written statement including the required
6 opinion of a physician shall accompany any claim for
7 reimbursement for abortions, or induced miscarriages or
8 premature births. This statement shall indicate what
9 procedures were used in providing such medical services.
10 The Illinois Department shall require that all dispensers
11 of medical services, other than an individual practitioner or
12 group of practitioners, desiring to participate in the
13 Medical Assistance program established under this Article to
14 disclose all financial, beneficial, ownership, equity, surety
15 or other interests in any and all firms, corporations,
16 partnerships, associations, business enterprises, joint
17 ventures, agencies, institutions or other legal entities
18 providing any form of health care services in this State
19 under this Article.
20 The Illinois Department may require that all dispensers
21 of medical services desiring to participate in the medical
22 assistance program established under this Article disclose,
23 under such terms and conditions as the Illinois Department
24 may by rule establish, all inquiries from clients and
25 attorneys regarding medical bills paid by the Illinois
26 Department, which inquiries could indicate potential
27 existence of claims or liens for the Illinois Department.
28 The Illinois Department shall establish policies,
29 procedures, standards and criteria by rule for the
30 acquisition, repair and replacement of orthotic and
31 prosthetic devices and durable medical equipment. Such rules
32 shall provide, but not be limited to, the following services:
33 (1) immediate repair or replacement of such devices by
34 recipients without medical authorization; and (2) rental,
HB1881 Enrolled -48- LRB9000419JSgc
1 lease, purchase or lease-purchase of durable medical
2 equipment in a cost-effective manner, taking into
3 consideration the recipient's medical prognosis, the extent
4 of the recipient's needs, and the requirements and costs for
5 maintaining such equipment. Such rules shall enable a
6 recipient to temporarily acquire and use alternative or
7 substitute devices or equipment pending repairs or
8 replacements of any device or equipment previously authorized
9 for such recipient by the Department. Rules under clause (2)
10 above shall not provide for purchase or lease-purchase of
11 durable medical equipment or supplies used for the purpose of
12 oxygen delivery and respiratory care.
13 The Department shall execute, relative to the nursing
14 home prescreening project, written inter-agency agreements
15 with the Department of Human Services and the Department on
16 Aging, to effect the following: (i) intake procedures and
17 common eligibility criteria for those persons who are
18 receiving non-institutional services; and (ii) the
19 establishment and development of non-institutional services
20 in areas of the State where they are not currently available
21 or are undeveloped.
22 The Illinois Department shall develop and operate, in
23 cooperation with other State Departments and agencies and in
24 compliance with applicable federal laws and regulations,
25 appropriate and effective systems of health care evaluation
26 and programs for monitoring of utilization of health care
27 services and facilities, as it affects persons eligible for
28 medical assistance under this Code. The Illinois Department
29 shall report regularly the results of the operation of such
30 systems and programs to the Citizens Assembly/Council on
31 Public Aid to enable the Committee to ensure, from time to
32 time, that these programs are effective and meaningful.
33 The Illinois Department shall report annually to the
34 General Assembly, no later than the second Friday in April of
HB1881 Enrolled -49- LRB9000419JSgc
1 1979 and each year thereafter, in regard to:
2 (a) actual statistics and trends in utilization of
3 medical services by public aid recipients;
4 (b) actual statistics and trends in the provision
5 of the various medical services by medical vendors;
6 (c) current rate structures and proposed changes in
7 those rate structures for the various medical vendors;
8 and
9 (d) efforts at utilization review and control by
10 the Illinois Department.
11 The period covered by each report shall be the 3 years
12 ending on the June 30 prior to the report. The report shall
13 include suggested legislation for consideration by the
14 General Assembly. The filing of one copy of the report with
15 the Speaker, one copy with the Minority Leader and one copy
16 with the Clerk of the House of Representatives, one copy with
17 the President, one copy with the Minority Leader and one copy
18 with the Secretary of the Senate, one copy with the
19 Legislative Research Unit, such additional copies with the
20 State Government Report Distribution Center for the General
21 Assembly as is required under paragraph (t) of Section 7 of
22 the State Library Act and one copy with the Citizens
23 Assembly/Council on Public Aid or its successor shall be
24 deemed sufficient to comply with this Section.
25 (Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
26 89-507, eff. 7-1-97; 89-517, eff. 1-1-97; revised 8-26-96.)
27 (305 ILCS 5/5-16.8 new)
28 Sec. 5-16.8. Required health benefits. The medical
29 assistance program shall provide the post-mastectomy care
30 benefits required to be covered by a policy of accident and
31 health insurance under Section 356t and the coverage required
32 under Section 356u of the Illinois Insurance Code.
HB1881 Enrolled -50- LRB9000419JSgc
1 Section 95. No acceleration or delay. Where this Act
2 makes changes in a statute that is represented in this Act by
3 text that is not yet or no longer in effect (for example, a
4 Section represented by multiple versions), the use of that
5 text does not accelerate or delay the taking effect of (i)
6 the changes made by this Act or (ii) provisions derived from
7 any other Public Act.
8 Section 99. Effective date. This Act takes effect upon
9 becoming law.