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90_SB0317ccr001
LRB9001503DJpcccr
1 90TH GENERAL ASSEMBLY
2 CONFERENCE COMMITTEE REPORT
3 ON SENATE BILL 317
4 -------------------------------------------------------------
5 -------------------------------------------------------------
6 To the President of the Senate and the Speaker of the
7 House of Representatives:
8 We, the conference committee appointed to consider the
9 differences between the houses in relation to House Amendment
10 No. 1 to Senate Bill 317, recommend the following:
11 (1) that the Senate concur in House Amendment No. 1; and
12 (2) that Senate Bill 317, AS AMENDED, be further amended
13 as follows:
14 by replacing the title with the following:
15 "AN ACT regarding health services, amending named Acts.";
16 and
17 by replacing the introductory clause of Section 5 with the
18 following:
19 "Section 5. The Illinois Public Aid Code is amended by
20 changing Sections 4-19, 5-16.3, and 8A-6, and by adding
21 Sections 5-16.10, 5-16.11, 8A-13, 8A-14, 8A-15, 8A-16, and
22 8A-17 as follows:"; and
23 in Section 5, by replacing Sec. 5-16.3 with the following:
24 "(305 ILCS 5/5-16.3)
25 (Text of Section before amendment by P.A. 89-507)
26 Sec. 5-16.3. System for integrated health care services.
27 (a) It shall be the public policy of the State to adopt,
28 to the extent practicable, a health care program that
29 encourages the integration of health care services and
30 manages the health care of program enrollees while preserving
31 reasonable choice within a competitive and cost-efficient
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1 environment. In furtherance of this public policy, the
2 Illinois Department shall develop and implement an integrated
3 health care program consistent with the provisions of this
4 Section. The provisions of this Section apply only to the
5 integrated health care program created under this Section.
6 Persons enrolled in the integrated health care program, as
7 determined by the Illinois Department by rule, shall be
8 afforded a choice among health care delivery systems, which
9 shall include, but are not limited to, (i) fee for service
10 care managed by a primary care physician licensed to practice
11 medicine in all its branches, (ii) managed health care
12 entities, and (iii) federally qualified health centers
13 (reimbursed according to a prospective cost-reimbursement
14 methodology) and rural health clinics (reimbursed according
15 to the Medicare methodology), where available. Persons
16 enrolled in the integrated health care program also may be
17 offered indemnity insurance plans, subject to availability.
18 For purposes of this Section, a "managed health care
19 entity" means a health maintenance organization or a managed
20 care community network as defined in this Section. A "health
21 maintenance organization" means a health maintenance
22 organization as defined in the Health Maintenance
23 Organization Act. A "managed care community network" means
24 an entity, other than a health maintenance organization, that
25 is owned, operated, or governed by providers of health care
26 services within this State and that provides or arranges
27 primary, secondary, and tertiary managed health care services
28 under contract with the Illinois Department exclusively to
29 enrollees of the integrated health care program. A managed
30 care community network may contract with the Illinois
31 Department to provide only pediatric health care services. A
32 county provider as defined in Section 15-1 of this Code may
33 contract with the Illinois Department to provide services to
34 enrollees of the integrated health care program as a managed
35 care community network without the need to establish a
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1 separate entity that provides services exclusively to
2 enrollees of the integrated health care program and shall be
3 deemed a managed care community network for purposes of this
4 Code only to the extent of the provision of services to those
5 enrollees in conjunction with the integrated health care
6 program. A county provider shall be entitled to contract
7 with the Illinois Department with respect to any contracting
8 region located in whole or in part within the county. A
9 county provider shall not be required to accept enrollees who
10 do not reside within the county.
11 Each managed care community network must demonstrate its
12 ability to bear the financial risk of serving enrollees under
13 this program. The Illinois Department shall by rule adopt
14 criteria for assessing the financial soundness of each
15 managed care community network. These rules shall consider
16 the extent to which a managed care community network is
17 comprised of providers who directly render health care and
18 are located within the community in which they seek to
19 contract rather than solely arrange or finance the delivery
20 of health care. These rules shall further consider a variety
21 of risk-bearing and management techniques, including the
22 sufficiency of quality assurance and utilization management
23 programs and whether a managed care community network has
24 sufficiently demonstrated its financial solvency and net
25 worth. The Illinois Department's criteria must be based on
26 sound actuarial, financial, and accounting principles. In
27 adopting these rules, the Illinois Department shall consult
28 with the Illinois Department of Insurance. The Illinois
29 Department is responsible for monitoring compliance with
30 these rules.
31 This Section may not be implemented before the effective
32 date of these rules, the approval of any necessary federal
33 waivers, and the completion of the review of an application
34 submitted, at least 60 days before the effective date of
35 rules adopted under this Section, to the Illinois Department
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1 by a managed care community network.
2 All health care delivery systems that contract with the
3 Illinois Department under the integrated health care program
4 shall clearly recognize a health care provider's right of
5 conscience under the Right of Conscience Act. In addition to
6 the provisions of that Act, no health care delivery system
7 that contracts with the Illinois Department under the
8 integrated health care program shall be required to provide,
9 arrange for, or pay for any health care or medical service,
10 procedure, or product if that health care delivery system is
11 owned, controlled, or sponsored by or affiliated with a
12 religious institution or religious organization that finds
13 that health care or medical service, procedure, or product to
14 violate its religious and moral teachings and beliefs.
15 (b) The Illinois Department may, by rule, provide for
16 different benefit packages for different categories of
17 persons enrolled in the program. Mental health services,
18 alcohol and substance abuse services, services related to
19 children with chronic or acute conditions requiring
20 longer-term treatment and follow-up, and rehabilitation care
21 provided by a free-standing rehabilitation hospital or a
22 hospital rehabilitation unit may be excluded from a benefit
23 package if the State ensures that those services are made
24 available through a separate delivery system. An exclusion
25 does not prohibit the Illinois Department from developing and
26 implementing demonstration projects for categories of persons
27 or services. Benefit packages for persons eligible for
28 medical assistance under Articles V, VI, and XII shall be
29 based on the requirements of those Articles and shall be
30 consistent with the Title XIX of the Social Security Act.
31 Nothing in this Act shall be construed to apply to services
32 purchased by the Department of Children and Family Services
33 and the Department of Mental Health and Developmental
34 Disabilities under the provisions of Title 59 of the Illinois
35 Administrative Code, Part 132 ("Medicaid Community Mental
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1 Health Services Program").
2 (c) The program established by this Section may be
3 implemented by the Illinois Department in various contracting
4 areas at various times. The health care delivery systems and
5 providers available under the program may vary throughout the
6 State. For purposes of contracting with managed health care
7 entities and providers, the Illinois Department shall
8 establish contracting areas similar to the geographic areas
9 designated by the Illinois Department for contracting
10 purposes under the Illinois Competitive Access and
11 Reimbursement Equity Program (ICARE) under the authority of
12 Section 3-4 of the Illinois Health Finance Reform Act or
13 similarly-sized or smaller geographic areas established by
14 the Illinois Department by rule. A managed health care entity
15 shall be permitted to contract in any geographic areas for
16 which it has a sufficient provider network and otherwise
17 meets the contracting terms of the State. The Illinois
18 Department is not prohibited from entering into a contract
19 with a managed health care entity at any time.
20 (c-5) A managed health care entity may not engage in
21 door-to-door marketing activities or marketing activities at
22 an office of the Illinois Department or a county department
23 in order to enroll in the entity's health care delivery
24 system persons who are enrolled in the integrated health care
25 program established under this Section. The Illinois
26 Department shall adopt rules defining "marketing activities"
27 prohibited by this subsection (c-5).
28 Before a managed health care entity may market its health
29 care delivery system to persons enrolled in the integrated
30 health care program established under this Section, the
31 Illinois Department must approve a marketing plan submitted
32 by the entity to the Illinois Department. The Illinois
33 Department shall adopt guidelines for approving marketing
34 plans submitted by managed health care entities under this
35 subsection. Besides prohibiting door-to-door marketing
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1 activities and marketing activities at public aid offices,
2 the guidelines shall include at least the following:
3 (1) A managed health care entity may not offer or
4 provide any gift, favor, or other inducement in marketing
5 its health care delivery system to integrated health care
6 program enrollees. A managed health care entity may
7 provide health care related items that are of nominal
8 value and pre-approved by the Illinois Department to
9 prospective enrollees. A managed health care entity may
10 also provide to enrollees health care related items that
11 have been pre-approved by the Illinois Department as an
12 incentive to manage their health care appropriately.
13 (2) All persons employed or otherwise engaged by a
14 managed health care entity to market the entity's health
15 care delivery system to integrated health care program
16 enrollees or to supervise that marketing shall register
17 with the Illinois Department.
18 The Inspector General appointed under Section 12-13.1 may
19 conduct investigations to determine whether the marketing
20 practices of managed health care entities participating in
21 the integrated health care program comply with the
22 guidelines.
23 (d) A managed health care entity that contracts with the
24 Illinois Department for the provision of services under the
25 program shall do all of the following, solely for purposes of
26 the integrated health care program:
27 (1) Provide that any individual physician licensed
28 under the Medical Practice Act of 1987 to practice
29 medicine in all its branches, any pharmacy, any federally
30 qualified health center, and any podiatrist, that
31 consistently meets the reasonable terms and conditions
32 established by the managed health care entity, including
33 but not limited to credentialing standards, quality
34 assurance program requirements, utilization management
35 requirements, financial responsibility standards,
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1 contracting process requirements, and provider network
2 size and accessibility requirements, must be accepted by
3 the managed health care entity for purposes of the
4 Illinois integrated health care program. Any individual
5 who is either terminated from or denied inclusion in the
6 panel of physicians of the managed health care entity
7 shall be given, within 10 business days after that
8 determination, a written explanation of the reasons for
9 his or her exclusion or termination from the panel. This
10 paragraph (1) does not apply to the following:
11 (A) A managed health care entity that
12 certifies to the Illinois Department that:
13 (i) it employs on a full-time basis 125
14 or more Illinois physicians licensed to
15 practice medicine in all of its branches; and
16 (ii) it will provide medical services
17 through its employees to more than 80% of the
18 recipients enrolled with the entity in the
19 integrated health care program; or
20 (B) A domestic stock insurance company
21 licensed under clause (b) of class 1 of Section 4 of
22 the Illinois Insurance Code if (i) at least 66% of
23 the stock of the insurance company is owned by a
24 professional corporation organized under the
25 Professional Service Corporation Act that has 125 or
26 more shareholders who are Illinois physicians
27 licensed to practice medicine in all of its branches
28 and (ii) the insurance company certifies to the
29 Illinois Department that at least 80% of those
30 physician shareholders will provide services to
31 recipients enrolled with the company in the
32 integrated health care program.
33 (2) Provide for reimbursement for providers for
34 emergency care, as defined by the Illinois Department by
35 rule, that must be provided to its enrollees, including
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1 an emergency room screening fee, and urgent care that it
2 authorizes for its enrollees, regardless of the
3 provider's affiliation with the managed health care
4 entity. Providers shall be reimbursed for emergency care
5 at an amount equal to the Illinois Department's
6 fee-for-service rates for those medical services rendered
7 by providers not under contract with the managed health
8 care entity to enrollees of the entity.
9 (3) Provide that any provider affiliated with a
10 managed health care entity may also provide services on a
11 fee-for-service basis to Illinois Department clients not
12 enrolled in a managed health care entity.
13 (4) Provide client education services as determined
14 and approved by the Illinois Department, including but
15 not limited to (i) education regarding appropriate
16 utilization of health care services in a managed care
17 system, (ii) written disclosure of treatment policies and
18 any restrictions or limitations on health services,
19 including, but not limited to, physical services,
20 clinical laboratory tests, hospital and surgical
21 procedures, prescription drugs and biologics, and
22 radiological examinations, and (iii) written notice that
23 the enrollee may receive from another provider those
24 services covered under this program that are not provided
25 by the managed health care entity.
26 (5) Provide that enrollees within its system may
27 choose the site for provision of services and the panel
28 of health care providers.
29 (6) Not discriminate in its enrollment or
30 disenrollment practices among recipients of medical
31 services or program enrollees based on health status.
32 (7) Provide a quality assurance and utilization
33 review program that (i) for health maintenance
34 organizations meets the requirements of the Health
35 Maintenance Organization Act and (ii) for managed care
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1 community networks meets the requirements established by
2 the Illinois Department in rules that incorporate those
3 standards set forth in the Health Maintenance
4 Organization Act.
5 (8) Issue a managed health care entity
6 identification card to each enrollee upon enrollment.
7 The card must contain all of the following:
8 (A) The enrollee's signature.
9 (B) The enrollee's health plan.
10 (C) The name and telephone number of the
11 enrollee's primary care physician.
12 (D) A telephone number to be used for
13 emergency service 24 hours per day, 7 days per week.
14 The telephone number required to be maintained
15 pursuant to this subparagraph by each managed health
16 care entity shall, at minimum, be staffed by
17 medically trained personnel and be provided
18 directly, or under arrangement, at an office or
19 offices in locations maintained solely within the
20 State of Illinois. For purposes of this
21 subparagraph, "medically trained personnel" means
22 licensed practical nurses or registered nurses
23 located in the State of Illinois who are licensed
24 pursuant to the Illinois Nursing Act of 1987.
25 (9) Ensure that every primary care physician and
26 pharmacy in the managed health care entity meets the
27 standards established by the Illinois Department for
28 accessibility and quality of care. The Illinois
29 Department shall arrange for and oversee an evaluation of
30 the standards established under this paragraph (9) and
31 may recommend any necessary changes to these standards.
32 The Illinois Department shall submit an annual report to
33 the Governor and the General Assembly by April 1 of each
34 year regarding the effect of the standards on ensuring
35 access and quality of care to enrollees.
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1 (10) Provide a procedure for handling complaints
2 that (i) for health maintenance organizations meets the
3 requirements of the Health Maintenance Organization Act
4 and (ii) for managed care community networks meets the
5 requirements established by the Illinois Department in
6 rules that incorporate those standards set forth in the
7 Health Maintenance Organization Act.
8 (11) Maintain, retain, and make available to the
9 Illinois Department records, data, and information, in a
10 uniform manner determined by the Illinois Department,
11 sufficient for the Illinois Department to monitor
12 utilization, accessibility, and quality of care.
13 (12) Except for providers who are prepaid, pay all
14 approved claims for covered services that are completed
15 and submitted to the managed health care entity within 30
16 days after receipt of the claim or receipt of the
17 appropriate capitation payment or payments by the managed
18 health care entity from the State for the month in which
19 the services included on the claim were rendered,
20 whichever is later. If payment is not made or mailed to
21 the provider by the managed health care entity by the due
22 date under this subsection, an interest penalty of 1% of
23 any amount unpaid shall be added for each month or
24 fraction of a month after the due date, until final
25 payment is made. Nothing in this Section shall prohibit
26 managed health care entities and providers from mutually
27 agreeing to terms that require more timely payment.
28 (13) Provide integration with community-based
29 programs provided by certified local health departments
30 such as Women, Infants, and Children Supplemental Food
31 Program (WIC), childhood immunization programs, health
32 education programs, case management programs, and health
33 screening programs.
34 (14) Provide that the pharmacy formulary used by a
35 managed health care entity and its contract providers be
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1 no more restrictive than the Illinois Department's
2 pharmaceutical program on the effective date of this
3 amendatory Act of 1994 and as amended after that date.
4 (15) Provide integration with community-based
5 organizations, including, but not limited to, any
6 organization that has operated within a Medicaid
7 Partnership as defined by this Code or by rule of the
8 Illinois Department, that may continue to operate under a
9 contract with the Illinois Department or a managed health
10 care entity under this Section to provide case management
11 services to Medicaid clients in designated high-need
12 areas.
13 The Illinois Department may, by rule, determine
14 methodologies to limit financial liability for managed health
15 care entities resulting from payment for services to
16 enrollees provided under the Illinois Department's integrated
17 health care program. Any methodology so determined may be
18 considered or implemented by the Illinois Department through
19 a contract with a managed health care entity under this
20 integrated health care program.
21 The Illinois Department shall contract with an entity or
22 entities to provide external peer-based quality assurance
23 review for the integrated health care program. The entity
24 shall be representative of Illinois physicians licensed to
25 practice medicine in all its branches and have statewide
26 geographic representation in all specialties of medical care
27 that are provided within the integrated health care program.
28 The entity may not be a third party payer and shall maintain
29 offices in locations around the State in order to provide
30 service and continuing medical education to physician
31 participants within the integrated health care program. The
32 review process shall be developed and conducted by Illinois
33 physicians licensed to practice medicine in all its branches.
34 In consultation with the entity, the Illinois Department may
35 contract with other entities for professional peer-based
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1 quality assurance review of individual categories of services
2 other than services provided, supervised, or coordinated by
3 physicians licensed to practice medicine in all its branches.
4 The Illinois Department shall establish, by rule, criteria to
5 avoid conflicts of interest in the conduct of quality
6 assurance activities consistent with professional peer-review
7 standards. All quality assurance activities shall be
8 coordinated by the Illinois Department.
9 (e) All persons enrolled in the program shall be
10 provided with a full written explanation of all
11 fee-for-service and managed health care plan options and a
12 reasonable opportunity to choose among the options as
13 provided by rule. The Illinois Department shall provide to
14 enrollees, upon enrollment in the integrated health care
15 program and at least annually thereafter, notice of the
16 process for requesting an appeal under the Illinois
17 Department's administrative appeal procedures.
18 Notwithstanding any other Section of this Code, the Illinois
19 Department may provide by rule for the Illinois Department to
20 assign a person enrolled in the program to a specific
21 provider of medical services or to a specific health care
22 delivery system if an enrollee has failed to exercise choice
23 in a timely manner. An enrollee assigned by the Illinois
24 Department shall be afforded the opportunity to disenroll and
25 to select a specific provider of medical services or a
26 specific health care delivery system within the first 30 days
27 after the assignment. An enrollee who has failed to exercise
28 choice in a timely manner may be assigned only if there are 3
29 or more managed health care entities contracting with the
30 Illinois Department within the contracting area, except that,
31 outside the City of Chicago, this requirement may be waived
32 for an area by rules adopted by the Illinois Department after
33 consultation with all hospitals within the contracting area.
34 The Illinois Department shall establish by rule the procedure
35 for random assignment of enrollees who fail to exercise
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1 choice in a timely manner to a specific managed health care
2 entity in proportion to the available capacity of that
3 managed health care entity. Assignment to a specific provider
4 of medical services or to a specific managed health care
5 entity may not exceed that provider's or entity's capacity as
6 determined by the Illinois Department. Any person who has
7 chosen a specific provider of medical services or a specific
8 managed health care entity, or any person who has been
9 assigned under this subsection, shall be given the
10 opportunity to change that choice or assignment at least once
11 every 12 months, as determined by the Illinois Department by
12 rule. The Illinois Department shall maintain a toll-free
13 telephone number for program enrollees' use in reporting
14 problems with managed health care entities.
15 (f) If a person becomes eligible for participation in
16 the integrated health care program while he or she is
17 hospitalized, the Illinois Department may not enroll that
18 person in the program until after he or she has been
19 discharged from the hospital. This subsection does not apply
20 to newborn infants whose mothers are enrolled in the
21 integrated health care program.
22 (g) The Illinois Department shall, by rule, establish
23 for managed health care entities rates that (i) are certified
24 to be actuarially sound, as determined by an actuary who is
25 an associate or a fellow of the Society of Actuaries or a
26 member of the American Academy of Actuaries and who has
27 expertise and experience in medical insurance and benefit
28 programs, in accordance with the Illinois Department's
29 current fee-for-service payment system, and (ii) take into
30 account any difference of cost to provide health care to
31 different populations based on gender, age, location, and
32 eligibility category. The rates for managed health care
33 entities shall be determined on a capitated basis.
34 The Illinois Department by rule shall establish a method
35 to adjust its payments to managed health care entities in a
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1 manner intended to avoid providing any financial incentive to
2 a managed health care entity to refer patients to a county
3 provider, in an Illinois county having a population greater
4 than 3,000,000, that is paid directly by the Illinois
5 Department. The Illinois Department shall by April 1, 1997,
6 and annually thereafter, review the method to adjust
7 payments. Payments by the Illinois Department to the county
8 provider, for persons not enrolled in a managed care
9 community network owned or operated by a county provider,
10 shall be paid on a fee-for-service basis under Article XV of
11 this Code.
12 The Illinois Department by rule shall establish a method
13 to reduce its payments to managed health care entities to
14 take into consideration (i) any adjustment payments paid to
15 hospitals under subsection (h) of this Section to the extent
16 those payments, or any part of those payments, have been
17 taken into account in establishing capitated rates under this
18 subsection (g) and (ii) the implementation of methodologies
19 to limit financial liability for managed health care entities
20 under subsection (d) of this Section.
21 (h) For hospital services provided by a hospital that
22 contracts with a managed health care entity, adjustment
23 payments shall be paid directly to the hospital by the
24 Illinois Department. Adjustment payments may include but
25 need not be limited to adjustment payments to:
26 disproportionate share hospitals under Section 5-5.02 of this
27 Code; primary care access health care education payments (89
28 Ill. Adm. Code 149.140); payments for capital, direct medical
29 education, indirect medical education, certified registered
30 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
31 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
32 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
33 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
34 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
35 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
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1 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
2 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
3 148.290(h)); and outpatient indigent volume adjustments (89
4 Ill. Adm. Code 148.140(b)(5)).
5 (i) For any hospital eligible for the adjustment
6 payments described in subsection (h), the Illinois Department
7 shall maintain, through the period ending June 30, 1995,
8 reimbursement levels in accordance with statutes and rules in
9 effect on April 1, 1994.
10 (j) Nothing contained in this Code in any way limits or
11 otherwise impairs the authority or power of the Illinois
12 Department to enter into a negotiated contract pursuant to
13 this Section with a managed health care entity, including,
14 but not limited to, a health maintenance organization, that
15 provides for termination or nonrenewal of the contract
16 without cause upon notice as provided in the contract and
17 without a hearing.
18 (k) Section 5-5.15 does not apply to the program
19 developed and implemented pursuant to this Section.
20 (l) The Illinois Department shall, by rule, define those
21 chronic or acute medical conditions of childhood that require
22 longer-term treatment and follow-up care. The Illinois
23 Department shall ensure that services required to treat these
24 conditions are available through a separate delivery system.
25 A managed health care entity that contracts with the
26 Illinois Department may refer a child with medical conditions
27 described in the rules adopted under this subsection directly
28 to a children's hospital or to a hospital, other than a
29 children's hospital, that is qualified to provide inpatient
30 and outpatient services to treat those conditions. The
31 Illinois Department shall provide fee-for-service
32 reimbursement directly to a children's hospital for those
33 services pursuant to Title 89 of the Illinois Administrative
34 Code, Section 148.280(a), at a rate at least equal to the
35 rate in effect on March 31, 1994. For hospitals, other than
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1 children's hospitals, that are qualified to provide inpatient
2 and outpatient services to treat those conditions, the
3 Illinois Department shall provide reimbursement for those
4 services on a fee-for-service basis, at a rate at least equal
5 to the rate in effect for those other hospitals on March 31,
6 1994.
7 A children's hospital shall be directly reimbursed for
8 all services provided at the children's hospital on a
9 fee-for-service basis pursuant to Title 89 of the Illinois
10 Administrative Code, Section 148.280(a), at a rate at least
11 equal to the rate in effect on March 31, 1994, until the
12 later of (i) implementation of the integrated health care
13 program under this Section and development of actuarially
14 sound capitation rates for services other than those chronic
15 or acute medical conditions of childhood that require
16 longer-term treatment and follow-up care as defined by the
17 Illinois Department in the rules adopted under this
18 subsection or (ii) March 31, 1996.
19 Notwithstanding anything in this subsection to the
20 contrary, a managed health care entity shall not consider
21 sources or methods of payment in determining the referral of
22 a child. The Illinois Department shall adopt rules to
23 establish criteria for those referrals. The Illinois
24 Department by rule shall establish a method to adjust its
25 payments to managed health care entities in a manner intended
26 to avoid providing any financial incentive to a managed
27 health care entity to refer patients to a provider who is
28 paid directly by the Illinois Department.
29 (m) Behavioral health services provided or funded by the
30 Department of Mental Health and Developmental Disabilities,
31 the Department of Alcoholism and Substance Abuse, the
32 Department of Children and Family Services, and the Illinois
33 Department shall be excluded from a benefit package.
34 Conditions of an organic or physical origin or nature,
35 including medical detoxification, however, may not be
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1 excluded. In this subsection, "behavioral health services"
2 means mental health services and subacute alcohol and
3 substance abuse treatment services, as defined in the
4 Illinois Alcoholism and Other Drug Dependency Act. In this
5 subsection, "mental health services" includes, at a minimum,
6 the following services funded by the Illinois Department, the
7 Department of Mental Health and Developmental Disabilities,
8 or the Department of Children and Family Services: (i)
9 inpatient hospital services, including related physician
10 services, related psychiatric interventions, and
11 pharmaceutical services provided to an eligible recipient
12 hospitalized with a primary diagnosis of psychiatric
13 disorder; (ii) outpatient mental health services as defined
14 and specified in Title 59 of the Illinois Administrative
15 Code, Part 132; (iii) any other outpatient mental health
16 services funded by the Illinois Department pursuant to the
17 State of Illinois Medicaid Plan; (iv) partial
18 hospitalization; and (v) follow-up stabilization related to
19 any of those services. Additional behavioral health services
20 may be excluded under this subsection as mutually agreed in
21 writing by the Illinois Department and the affected State
22 agency or agencies. The exclusion of any service does not
23 prohibit the Illinois Department from developing and
24 implementing demonstration projects for categories of persons
25 or services. The Department of Mental Health and
26 Developmental Disabilities, the Department of Children and
27 Family Services, and the Department of Alcoholism and
28 Substance Abuse shall each adopt rules governing the
29 integration of managed care in the provision of behavioral
30 health services. The State shall integrate managed care
31 community networks and affiliated providers, to the extent
32 practicable, in any separate delivery system for mental
33 health services.
34 (n) The Illinois Department shall adopt rules to
35 establish reserve requirements for managed care community
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1 networks, as required by subsection (a), and health
2 maintenance organizations to protect against liabilities in
3 the event that a managed health care entity is declared
4 insolvent or bankrupt. If a managed health care entity other
5 than a county provider is declared insolvent or bankrupt,
6 after liquidation and application of any available assets,
7 resources, and reserves, the Illinois Department shall pay a
8 portion of the amounts owed by the managed health care entity
9 to providers for services rendered to enrollees under the
10 integrated health care program under this Section based on
11 the following schedule: (i) from April 1, 1995 through June
12 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
13 through June 30, 2001, 80% of the amounts owed; and (iii)
14 from July 1, 2001 through June 30, 2005, 75% of the amounts
15 owed. The amounts paid under this subsection shall be
16 calculated based on the total amount owed by the managed
17 health care entity to providers before application of any
18 available assets, resources, and reserves. After June 30,
19 2005, the Illinois Department may not pay any amounts owed to
20 providers as a result of an insolvency or bankruptcy of a
21 managed health care entity occurring after that date. The
22 Illinois Department is not obligated, however, to pay amounts
23 owed to a provider that has an ownership or other governing
24 interest in the managed health care entity. This subsection
25 applies only to managed health care entities and the services
26 they provide under the integrated health care program under
27 this Section.
28 (o) Notwithstanding any other provision of law or
29 contractual agreement to the contrary, providers shall not be
30 required to accept from any other third party payer the rates
31 determined or paid under this Code by the Illinois
32 Department, managed health care entity, or other health care
33 delivery system for services provided to recipients.
34 (p) The Illinois Department may seek and obtain any
35 necessary authorization provided under federal law to
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1 implement the program, including the waiver of any federal
2 statutes or regulations. The Illinois Department may seek a
3 waiver of the federal requirement that the combined
4 membership of Medicare and Medicaid enrollees in a managed
5 care community network may not exceed 75% of the managed care
6 community network's total enrollment. The Illinois
7 Department shall not seek a waiver of this requirement for
8 any other category of managed health care entity. The
9 Illinois Department shall not seek a waiver of the inpatient
10 hospital reimbursement methodology in Section 1902(a)(13)(A)
11 of Title XIX of the Social Security Act even if the federal
12 agency responsible for administering Title XIX determines
13 that Section 1902(a)(13)(A) applies to managed health care
14 systems.
15 Notwithstanding any other provisions of this Code to the
16 contrary, the Illinois Department shall seek a waiver of
17 applicable federal law in order to impose a co-payment system
18 consistent with this subsection on recipients of medical
19 services under Title XIX of the Social Security Act who are
20 not enrolled in a managed health care entity. The waiver
21 request submitted by the Illinois Department shall provide
22 for co-payments of up to $0.50 for prescribed drugs and up to
23 $0.50 for x-ray services and shall provide for co-payments of
24 up to $10 for non-emergency services provided in a hospital
25 emergency room and up to $10 for non-emergency ambulance
26 services. The purpose of the co-payments shall be to deter
27 those recipients from seeking unnecessary medical care.
28 Co-payments may not be used to deter recipients from seeking
29 necessary medical care. No recipient shall be required to
30 pay more than a total of $150 per year in co-payments under
31 the waiver request required by this subsection. A recipient
32 may not be required to pay more than $15 of any amount due
33 under this subsection in any one month.
34 Co-payments authorized under this subsection may not be
35 imposed when the care was necessitated by a true medical
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1 emergency. Co-payments may not be imposed for any of the
2 following classifications of services:
3 (1) Services furnished to person under 18 years of
4 age.
5 (2) Services furnished to pregnant women.
6 (3) Services furnished to any individual who is an
7 inpatient in a hospital, nursing facility, intermediate
8 care facility, or other medical institution, if that
9 person is required to spend for costs of medical care all
10 but a minimal amount of his or her income required for
11 personal needs.
12 (4) Services furnished to a person who is receiving
13 hospice care.
14 Co-payments authorized under this subsection shall not be
15 deducted from or reduce in any way payments for medical
16 services from the Illinois Department to providers. No
17 provider may deny those services to an individual eligible
18 for services based on the individual's inability to pay the
19 co-payment.
20 Recipients who are subject to co-payments shall be
21 provided notice, in plain and clear language, of the amount
22 of the co-payments, the circumstances under which co-payments
23 are exempted, the circumstances under which co-payments may
24 be assessed, and their manner of collection.
25 The Illinois Department shall establish a Medicaid
26 Co-Payment Council to assist in the development of co-payment
27 policies for the medical assistance program. The Medicaid
28 Co-Payment Council shall also have jurisdiction to develop a
29 program to provide financial or non-financial incentives to
30 Medicaid recipients in order to encourage recipients to seek
31 necessary health care. The Council shall be chaired by the
32 Director of the Illinois Department, and shall have 6
33 additional members. Two of the 6 additional members shall be
34 appointed by the Governor, and one each shall be appointed by
35 the President of the Senate, the Minority Leader of the
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1 Senate, the Speaker of the House of Representatives, and the
2 Minority Leader of the House of Representatives. The Council
3 may be convened and make recommendations upon the appointment
4 of a majority of its members. The Council shall be appointed
5 and convened no later than September 1, 1994 and shall report
6 its recommendations to the Director of the Illinois
7 Department and the General Assembly no later than October 1,
8 1994. The chairperson of the Council shall be allowed to
9 vote only in the case of a tie vote among the appointed
10 members of the Council.
11 The Council shall be guided by the following principles
12 as it considers recommendations to be developed to implement
13 any approved waivers that the Illinois Department must seek
14 pursuant to this subsection:
15 (1) Co-payments should not be used to deter access
16 to adequate medical care.
17 (2) Co-payments should be used to reduce fraud.
18 (3) Co-payment policies should be examined in
19 consideration of other states' experience, and the
20 ability of successful co-payment plans to control
21 unnecessary or inappropriate utilization of services
22 should be promoted.
23 (4) All participants, both recipients and
24 providers, in the medical assistance program have
25 responsibilities to both the State and the program.
26 (5) Co-payments are primarily a tool to educate the
27 participants in the responsible use of health care
28 resources.
29 (6) Co-payments should not be used to penalize
30 providers.
31 (7) A successful medical program requires the
32 elimination of improper utilization of medical resources.
33 The integrated health care program, or any part of that
34 program, established under this Section may not be
35 implemented if matching federal funds under Title XIX of the
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1 Social Security Act are not available for administering the
2 program.
3 The Illinois Department shall submit for publication in
4 the Illinois Register the name, address, and telephone number
5 of the individual to whom a request may be directed for a
6 copy of the request for a waiver of provisions of Title XIX
7 of the Social Security Act that the Illinois Department
8 intends to submit to the Health Care Financing Administration
9 in order to implement this Section. The Illinois Department
10 shall mail a copy of that request for waiver to all
11 requestors at least 16 days before filing that request for
12 waiver with the Health Care Financing Administration.
13 (q) After the effective date of this Section, the
14 Illinois Department may take all planning and preparatory
15 action necessary to implement this Section, including, but
16 not limited to, seeking requests for proposals relating to
17 the integrated health care program created under this
18 Section.
19 (r) In order to (i) accelerate and facilitate the
20 development of integrated health care in contracting areas
21 outside counties with populations in excess of 3,000,000 and
22 counties adjacent to those counties and (ii) maintain and
23 sustain the high quality of education and residency programs
24 coordinated and associated with local area hospitals, the
25 Illinois Department may develop and implement a demonstration
26 program for managed care community networks owned, operated,
27 or governed by State-funded medical schools. The Illinois
28 Department shall prescribe by rule the criteria, standards,
29 and procedures for effecting this demonstration program.
30 (s) (Blank).
31 (t) On April 1, 1995 and every 6 months thereafter, the
32 Illinois Department shall report to the Governor and General
33 Assembly on the progress of the integrated health care
34 program in enrolling clients into managed health care
35 entities. The report shall indicate the capacities of the
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1 managed health care entities with which the State contracts,
2 the number of clients enrolled by each contractor, the areas
3 of the State in which managed care options do not exist, and
4 the progress toward meeting the enrollment goals of the
5 integrated health care program.
6 (u) The Illinois Department may implement this Section
7 through the use of emergency rules in accordance with Section
8 5-45 of the Illinois Administrative Procedure Act. For
9 purposes of that Act, the adoption of rules to implement this
10 Section is deemed an emergency and necessary for the public
11 interest, safety, and welfare.
12 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
13 89-673, eff. 8-14-96; revised 8-26-96.)
14 (Text of Section after amendment by P.A. 89-507)
15 Sec. 5-16.3. System for integrated health care services.
16 (a) It shall be the public policy of the State to adopt,
17 to the extent practicable, a health care program that
18 encourages the integration of health care services and
19 manages the health care of program enrollees while preserving
20 reasonable choice within a competitive and cost-efficient
21 environment. In furtherance of this public policy, the
22 Illinois Department shall develop and implement an integrated
23 health care program consistent with the provisions of this
24 Section. The provisions of this Section apply only to the
25 integrated health care program created under this Section.
26 Persons enrolled in the integrated health care program, as
27 determined by the Illinois Department by rule, shall be
28 afforded a choice among health care delivery systems, which
29 shall include, but are not limited to, (i) fee for service
30 care managed by a primary care physician licensed to practice
31 medicine in all its branches, (ii) managed health care
32 entities, and (iii) federally qualified health centers
33 (reimbursed according to a prospective cost-reimbursement
34 methodology) and rural health clinics (reimbursed according
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1 to the Medicare methodology), where available. Persons
2 enrolled in the integrated health care program also may be
3 offered indemnity insurance plans, subject to availability.
4 For purposes of this Section, a "managed health care
5 entity" means a health maintenance organization or a managed
6 care community network as defined in this Section. A "health
7 maintenance organization" means a health maintenance
8 organization as defined in the Health Maintenance
9 Organization Act. A "managed care community network" means
10 an entity, other than a health maintenance organization, that
11 is owned, operated, or governed by providers of health care
12 services within this State and that provides or arranges
13 primary, secondary, and tertiary managed health care services
14 under contract with the Illinois Department exclusively to
15 enrollees of the integrated health care program. A managed
16 care community network may contract with the Illinois
17 Department to provide only pediatric health care services. A
18 county provider as defined in Section 15-1 of this Code may
19 contract with the Illinois Department to provide services to
20 enrollees of the integrated health care program as a managed
21 care community network without the need to establish a
22 separate entity that provides services exclusively to
23 enrollees of the integrated health care program and shall be
24 deemed a managed care community network for purposes of this
25 Code only to the extent of the provision of services to those
26 enrollees in conjunction with the integrated health care
27 program. A county provider shall be entitled to contract
28 with the Illinois Department with respect to any contracting
29 region located in whole or in part within the county. A
30 county provider shall not be required to accept enrollees who
31 do not reside within the county.
32 Each managed care community network must demonstrate its
33 ability to bear the financial risk of serving enrollees under
34 this program. The Illinois Department shall by rule adopt
35 criteria for assessing the financial soundness of each
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1 managed care community network. These rules shall consider
2 the extent to which a managed care community network is
3 comprised of providers who directly render health care and
4 are located within the community in which they seek to
5 contract rather than solely arrange or finance the delivery
6 of health care. These rules shall further consider a variety
7 of risk-bearing and management techniques, including the
8 sufficiency of quality assurance and utilization management
9 programs and whether a managed care community network has
10 sufficiently demonstrated its financial solvency and net
11 worth. The Illinois Department's criteria must be based on
12 sound actuarial, financial, and accounting principles. In
13 adopting these rules, the Illinois Department shall consult
14 with the Illinois Department of Insurance. The Illinois
15 Department is responsible for monitoring compliance with
16 these rules.
17 This Section may not be implemented before the effective
18 date of these rules, the approval of any necessary federal
19 waivers, and the completion of the review of an application
20 submitted, at least 60 days before the effective date of
21 rules adopted under this Section, to the Illinois Department
22 by a managed care community network.
23 All health care delivery systems that contract with the
24 Illinois Department under the integrated health care program
25 shall clearly recognize a health care provider's right of
26 conscience under the Right of Conscience Act. In addition to
27 the provisions of that Act, no health care delivery system
28 that contracts with the Illinois Department under the
29 integrated health care program shall be required to provide,
30 arrange for, or pay for any health care or medical service,
31 procedure, or product if that health care delivery system is
32 owned, controlled, or sponsored by or affiliated with a
33 religious institution or religious organization that finds
34 that health care or medical service, procedure, or product to
35 violate its religious and moral teachings and beliefs.
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1 (b) The Illinois Department may, by rule, provide for
2 different benefit packages for different categories of
3 persons enrolled in the program. Mental health services,
4 alcohol and substance abuse services, services related to
5 children with chronic or acute conditions requiring
6 longer-term treatment and follow-up, and rehabilitation care
7 provided by a free-standing rehabilitation hospital or a
8 hospital rehabilitation unit may be excluded from a benefit
9 package if the State ensures that those services are made
10 available through a separate delivery system. An exclusion
11 does not prohibit the Illinois Department from developing and
12 implementing demonstration projects for categories of persons
13 or services. Benefit packages for persons eligible for
14 medical assistance under Articles V, VI, and XII shall be
15 based on the requirements of those Articles and shall be
16 consistent with the Title XIX of the Social Security Act.
17 Nothing in this Act shall be construed to apply to services
18 purchased by the Department of Children and Family Services
19 and the Department of Human Services (as successor to the
20 Department of Mental Health and Developmental Disabilities)
21 under the provisions of Title 59 of the Illinois
22 Administrative Code, Part 132 ("Medicaid Community Mental
23 Health Services Program").
24 (c) The program established by this Section may be
25 implemented by the Illinois Department in various contracting
26 areas at various times. The health care delivery systems and
27 providers available under the program may vary throughout the
28 State. For purposes of contracting with managed health care
29 entities and providers, the Illinois Department shall
30 establish contracting areas similar to the geographic areas
31 designated by the Illinois Department for contracting
32 purposes under the Illinois Competitive Access and
33 Reimbursement Equity Program (ICARE) under the authority of
34 Section 3-4 of the Illinois Health Finance Reform Act or
35 similarly-sized or smaller geographic areas established by
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1 the Illinois Department by rule. A managed health care entity
2 shall be permitted to contract in any geographic areas for
3 which it has a sufficient provider network and otherwise
4 meets the contracting terms of the State. The Illinois
5 Department is not prohibited from entering into a contract
6 with a managed health care entity at any time.
7 (c-5) A managed health care entity may not engage in
8 door-to-door marketing activities or marketing activities at
9 an office of the Illinois Department or a county department
10 in order to enroll in the entity's health care delivery
11 system persons who are enrolled in the integrated health care
12 program established under this Section. The Illinois
13 Department shall adopt rules defining "marketing activities"
14 prohibited by this subsection (c-5).
15 Before a managed health care entity may market its health
16 care delivery system to persons enrolled in the integrated
17 health care program established under this Section, the
18 Illinois Department must approve a marketing plan submitted
19 by the entity to the Illinois Department. The Illinois
20 Department shall adopt guidelines for approving marketing
21 plans submitted by managed health care entities under this
22 subsection. Besides prohibiting door-to-door marketing
23 activities and marketing activities at public aid offices,
24 the guidelines shall include at least the following:
25 (1) A managed health care entity may not offer or
26 provide any gift, favor, or other inducement in marketing
27 its health care delivery system to integrated health care
28 program enrollees. A managed health care entity may
29 provide health care related items that are of nominal
30 value and pre-approved by the Illinois Department to
31 prospective enrollees. A managed health care entity may
32 also provide to enrollees health care related items that
33 have been pre-approved by the Illinois Department as an
34 incentive to manage their health care appropriately.
35 (2) All persons employed or otherwise engaged by a
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1 managed health care entity to market the entity's health
2 care delivery system to integrated health care program
3 enrollees or to supervise that marketing shall register
4 with the Illinois Department.
5 The Inspector General appointed under Section 12-13.1 may
6 conduct investigations to determine whether the marketing
7 practices of managed health care entities participating in
8 the integrated health care program comply with the
9 guidelines.
10 (d) A managed health care entity that contracts with the
11 Illinois Department for the provision of services under the
12 program shall do all of the following, solely for purposes of
13 the integrated health care program:
14 (1) Provide that any individual physician licensed
15 under the Medical Practice Act of 1987 to practice
16 medicine in all its branches, any pharmacy, any federally
17 qualified health center, and any podiatrist, that
18 consistently meets the reasonable terms and conditions
19 established by the managed health care entity, including
20 but not limited to credentialing standards, quality
21 assurance program requirements, utilization management
22 requirements, financial responsibility standards,
23 contracting process requirements, and provider network
24 size and accessibility requirements, must be accepted by
25 the managed health care entity for purposes of the
26 Illinois integrated health care program. Any individual
27 who is either terminated from or denied inclusion in the
28 panel of physicians of the managed health care entity
29 shall be given, within 10 business days after that
30 determination, a written explanation of the reasons for
31 his or her exclusion or termination from the panel. This
32 paragraph (1) does not apply to the following:
33 (A) A managed health care entity that
34 certifies to the Illinois Department that:
35 (i) it employs on a full-time basis 125
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1 or more Illinois physicians licensed to
2 practice medicine in all of its branches; and
3 (ii) it will provide medical services
4 through its employees to more than 80% of the
5 recipients enrolled with the entity in the
6 integrated health care program; or
7 (B) A domestic stock insurance company
8 licensed under clause (b) of class 1 of Section 4 of
9 the Illinois Insurance Code if (i) at least 66% of
10 the stock of the insurance company is owned by a
11 professional corporation organized under the
12 Professional Service Corporation Act that has 125 or
13 more shareholders who are Illinois physicians
14 licensed to practice medicine in all of its branches
15 and (ii) the insurance company certifies to the
16 Illinois Department that at least 80% of those
17 physician shareholders will provide services to
18 recipients enrolled with the company in the
19 integrated health care program.
20 (2) Provide for reimbursement for providers for
21 emergency care, as defined by the Illinois Department by
22 rule, that must be provided to its enrollees, including
23 an emergency room screening fee, and urgent care that it
24 authorizes for its enrollees, regardless of the
25 provider's affiliation with the managed health care
26 entity. Providers shall be reimbursed for emergency care
27 at an amount equal to the Illinois Department's
28 fee-for-service rates for those medical services rendered
29 by providers not under contract with the managed health
30 care entity to enrollees of the entity.
31 (3) Provide that any provider affiliated with a
32 managed health care entity may also provide services on a
33 fee-for-service basis to Illinois Department clients not
34 enrolled in a managed health care entity.
35 (4) Provide client education services as determined
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1 and approved by the Illinois Department, including but
2 not limited to (i) education regarding appropriate
3 utilization of health care services in a managed care
4 system, (ii) written disclosure of treatment policies and
5 any restrictions or limitations on health services,
6 including, but not limited to, physical services,
7 clinical laboratory tests, hospital and surgical
8 procedures, prescription drugs and biologics, and
9 radiological examinations, and (iii) written notice that
10 the enrollee may receive from another provider those
11 services covered under this program that are not provided
12 by the managed health care entity.
13 (5) Provide that enrollees within its system may
14 choose the site for provision of services and the panel
15 of health care providers.
16 (6) Not discriminate in its enrollment or
17 disenrollment practices among recipients of medical
18 services or program enrollees based on health status.
19 (7) Provide a quality assurance and utilization
20 review program that (i) for health maintenance
21 organizations meets the requirements of the Health
22 Maintenance Organization Act and (ii) for managed care
23 community networks meets the requirements established by
24 the Illinois Department in rules that incorporate those
25 standards set forth in the Health Maintenance
26 Organization Act.
27 (8) Issue a managed health care entity
28 identification card to each enrollee upon enrollment.
29 The card must contain all of the following:
30 (A) The enrollee's signature.
31 (B) The enrollee's health plan.
32 (C) The name and telephone number of the
33 enrollee's primary care physician.
34 (D) A telephone number to be used for
35 emergency service 24 hours per day, 7 days per week.
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1 The telephone number required to be maintained
2 pursuant to this subparagraph by each managed health
3 care entity shall, at minimum, be staffed by
4 medically trained personnel and be provided
5 directly, or under arrangement, at an office or
6 offices in locations maintained solely within the
7 State of Illinois. For purposes of this
8 subparagraph, "medically trained personnel" means
9 licensed practical nurses or registered nurses
10 located in the State of Illinois who are licensed
11 pursuant to the Illinois Nursing Act of 1987.
12 (9) Ensure that every primary care physician and
13 pharmacy in the managed health care entity meets the
14 standards established by the Illinois Department for
15 accessibility and quality of care. The Illinois
16 Department shall arrange for and oversee an evaluation of
17 the standards established under this paragraph (9) and
18 may recommend any necessary changes to these standards.
19 The Illinois Department shall submit an annual report to
20 the Governor and the General Assembly by April 1 of each
21 year regarding the effect of the standards on ensuring
22 access and quality of care to enrollees.
23 (10) Provide a procedure for handling complaints
24 that (i) for health maintenance organizations meets the
25 requirements of the Health Maintenance Organization Act
26 and (ii) for managed care community networks meets the
27 requirements established by the Illinois Department in
28 rules that incorporate those standards set forth in the
29 Health Maintenance Organization Act.
30 (11) Maintain, retain, and make available to the
31 Illinois Department records, data, and information, in a
32 uniform manner determined by the Illinois Department,
33 sufficient for the Illinois Department to monitor
34 utilization, accessibility, and quality of care.
35 (12) Except for providers who are prepaid, pay all
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1 approved claims for covered services that are completed
2 and submitted to the managed health care entity within 30
3 days after receipt of the claim or receipt of the
4 appropriate capitation payment or payments by the managed
5 health care entity from the State for the month in which
6 the services included on the claim were rendered,
7 whichever is later. If payment is not made or mailed to
8 the provider by the managed health care entity by the due
9 date under this subsection, an interest penalty of 1% of
10 any amount unpaid shall be added for each month or
11 fraction of a month after the due date, until final
12 payment is made. Nothing in this Section shall prohibit
13 managed health care entities and providers from mutually
14 agreeing to terms that require more timely payment.
15 (13) Provide integration with community-based
16 programs provided by certified local health departments
17 such as Women, Infants, and Children Supplemental Food
18 Program (WIC), childhood immunization programs, health
19 education programs, case management programs, and health
20 screening programs.
21 (14) Provide that the pharmacy formulary used by a
22 managed health care entity and its contract providers be
23 no more restrictive than the Illinois Department's
24 pharmaceutical program on the effective date of this
25 amendatory Act of 1994 and as amended after that date.
26 (15) Provide integration with community-based
27 organizations, including, but not limited to, any
28 organization that has operated within a Medicaid
29 Partnership as defined by this Code or by rule of the
30 Illinois Department, that may continue to operate under a
31 contract with the Illinois Department or a managed health
32 care entity under this Section to provide case management
33 services to Medicaid clients in designated high-need
34 areas.
35 The Illinois Department may, by rule, determine
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1 methodologies to limit financial liability for managed health
2 care entities resulting from payment for services to
3 enrollees provided under the Illinois Department's integrated
4 health care program. Any methodology so determined may be
5 considered or implemented by the Illinois Department through
6 a contract with a managed health care entity under this
7 integrated health care program.
8 The Illinois Department shall contract with an entity or
9 entities to provide external peer-based quality assurance
10 review for the integrated health care program. The entity
11 shall be representative of Illinois physicians licensed to
12 practice medicine in all its branches and have statewide
13 geographic representation in all specialties of medical care
14 that are provided within the integrated health care program.
15 The entity may not be a third party payer and shall maintain
16 offices in locations around the State in order to provide
17 service and continuing medical education to physician
18 participants within the integrated health care program. The
19 review process shall be developed and conducted by Illinois
20 physicians licensed to practice medicine in all its branches.
21 In consultation with the entity, the Illinois Department may
22 contract with other entities for professional peer-based
23 quality assurance review of individual categories of services
24 other than services provided, supervised, or coordinated by
25 physicians licensed to practice medicine in all its branches.
26 The Illinois Department shall establish, by rule, criteria to
27 avoid conflicts of interest in the conduct of quality
28 assurance activities consistent with professional peer-review
29 standards. All quality assurance activities shall be
30 coordinated by the Illinois Department.
31 (e) All persons enrolled in the program shall be
32 provided with a full written explanation of all
33 fee-for-service and managed health care plan options and a
34 reasonable opportunity to choose among the options as
35 provided by rule. The Illinois Department shall provide to
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1 enrollees, upon enrollment in the integrated health care
2 program and at least annually thereafter, notice of the
3 process for requesting an appeal under the Illinois
4 Department's administrative appeal procedures.
5 Notwithstanding any other Section of this Code, the Illinois
6 Department may provide by rule for the Illinois Department to
7 assign a person enrolled in the program to a specific
8 provider of medical services or to a specific health care
9 delivery system if an enrollee has failed to exercise choice
10 in a timely manner. An enrollee assigned by the Illinois
11 Department shall be afforded the opportunity to disenroll and
12 to select a specific provider of medical services or a
13 specific health care delivery system within the first 30 days
14 after the assignment. An enrollee who has failed to exercise
15 choice in a timely manner may be assigned only if there are 3
16 or more managed health care entities contracting with the
17 Illinois Department within the contracting area, except that,
18 outside the City of Chicago, this requirement may be waived
19 for an area by rules adopted by the Illinois Department after
20 consultation with all hospitals within the contracting area.
21 The Illinois Department shall establish by rule the procedure
22 for random assignment of enrollees who fail to exercise
23 choice in a timely manner to a specific managed health care
24 entity in proportion to the available capacity of that
25 managed health care entity. Assignment to a specific provider
26 of medical services or to a specific managed health care
27 entity may not exceed that provider's or entity's capacity as
28 determined by the Illinois Department. Any person who has
29 chosen a specific provider of medical services or a specific
30 managed health care entity, or any person who has been
31 assigned under this subsection, shall be given the
32 opportunity to change that choice or assignment at least once
33 every 12 months, as determined by the Illinois Department by
34 rule. The Illinois Department shall maintain a toll-free
35 telephone number for program enrollees' use in reporting
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1 problems with managed health care entities.
2 (f) If a person becomes eligible for participation in
3 the integrated health care program while he or she is
4 hospitalized, the Illinois Department may not enroll that
5 person in the program until after he or she has been
6 discharged from the hospital. This subsection does not apply
7 to newborn infants whose mothers are enrolled in the
8 integrated health care program.
9 (g) The Illinois Department shall, by rule, establish
10 for managed health care entities rates that (i) are certified
11 to be actuarially sound, as determined by an actuary who is
12 an associate or a fellow of the Society of Actuaries or a
13 member of the American Academy of Actuaries and who has
14 expertise and experience in medical insurance and benefit
15 programs, in accordance with the Illinois Department's
16 current fee-for-service payment system, and (ii) take into
17 account any difference of cost to provide health care to
18 different populations based on gender, age, location, and
19 eligibility category. The rates for managed health care
20 entities shall be determined on a capitated basis.
21 The Illinois Department by rule shall establish a method
22 to adjust its payments to managed health care entities in a
23 manner intended to avoid providing any financial incentive to
24 a managed health care entity to refer patients to a county
25 provider, in an Illinois county having a population greater
26 than 3,000,000, that is paid directly by the Illinois
27 Department. The Illinois Department shall by April 1, 1997,
28 and annually thereafter, review the method to adjust
29 payments. Payments by the Illinois Department to the county
30 provider, for persons not enrolled in a managed care
31 community network owned or operated by a county provider,
32 shall be paid on a fee-for-service basis under Article XV of
33 this Code.
34 The Illinois Department by rule shall establish a method
35 to reduce its payments to managed health care entities to
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1 take into consideration (i) any adjustment payments paid to
2 hospitals under subsection (h) of this Section to the extent
3 those payments, or any part of those payments, have been
4 taken into account in establishing capitated rates under this
5 subsection (g) and (ii) the implementation of methodologies
6 to limit financial liability for managed health care entities
7 under subsection (d) of this Section.
8 (h) For hospital services provided by a hospital that
9 contracts with a managed health care entity, adjustment
10 payments shall be paid directly to the hospital by the
11 Illinois Department. Adjustment payments may include but
12 need not be limited to adjustment payments to:
13 disproportionate share hospitals under Section 5-5.02 of this
14 Code; primary care access health care education payments (89
15 Ill. Adm. Code 149.140); payments for capital, direct medical
16 education, indirect medical education, certified registered
17 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
18 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
19 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
20 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
21 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
22 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
23 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
24 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
25 148.290(h)); and outpatient indigent volume adjustments (89
26 Ill. Adm. Code 148.140(b)(5)).
27 (i) For any hospital eligible for the adjustment
28 payments described in subsection (h), the Illinois Department
29 shall maintain, through the period ending June 30, 1995,
30 reimbursement levels in accordance with statutes and rules in
31 effect on April 1, 1994.
32 (j) Nothing contained in this Code in any way limits or
33 otherwise impairs the authority or power of the Illinois
34 Department to enter into a negotiated contract pursuant to
35 this Section with a managed health care entity, including,
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1 but not limited to, a health maintenance organization, that
2 provides for termination or nonrenewal of the contract
3 without cause upon notice as provided in the contract and
4 without a hearing.
5 (k) Section 5-5.15 does not apply to the program
6 developed and implemented pursuant to this Section.
7 (l) The Illinois Department shall, by rule, define those
8 chronic or acute medical conditions of childhood that require
9 longer-term treatment and follow-up care. The Illinois
10 Department shall ensure that services required to treat these
11 conditions are available through a separate delivery system.
12 A managed health care entity that contracts with the
13 Illinois Department may refer a child with medical conditions
14 described in the rules adopted under this subsection directly
15 to a children's hospital or to a hospital, other than a
16 children's hospital, that is qualified to provide inpatient
17 and outpatient services to treat those conditions. The
18 Illinois Department shall provide fee-for-service
19 reimbursement directly to a children's hospital for those
20 services pursuant to Title 89 of the Illinois Administrative
21 Code, Section 148.280(a), at a rate at least equal to the
22 rate in effect on March 31, 1994. For hospitals, other than
23 children's hospitals, that are qualified to provide inpatient
24 and outpatient services to treat those conditions, the
25 Illinois Department shall provide reimbursement for those
26 services on a fee-for-service basis, at a rate at least equal
27 to the rate in effect for those other hospitals on March 31,
28 1994.
29 A children's hospital shall be directly reimbursed for
30 all services provided at the children's hospital on a
31 fee-for-service basis pursuant to Title 89 of the Illinois
32 Administrative Code, Section 148.280(a), at a rate at least
33 equal to the rate in effect on March 31, 1994, until the
34 later of (i) implementation of the integrated health care
35 program under this Section and development of actuarially
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1 sound capitation rates for services other than those chronic
2 or acute medical conditions of childhood that require
3 longer-term treatment and follow-up care as defined by the
4 Illinois Department in the rules adopted under this
5 subsection or (ii) March 31, 1996.
6 Notwithstanding anything in this subsection to the
7 contrary, a managed health care entity shall not consider
8 sources or methods of payment in determining the referral of
9 a child. The Illinois Department shall adopt rules to
10 establish criteria for those referrals. The Illinois
11 Department by rule shall establish a method to adjust its
12 payments to managed health care entities in a manner intended
13 to avoid providing any financial incentive to a managed
14 health care entity to refer patients to a provider who is
15 paid directly by the Illinois Department.
16 (m) Behavioral health services provided or funded by the
17 Department of Human Services, the Department of Children and
18 Family Services, and the Illinois Department shall be
19 excluded from a benefit package. Conditions of an organic or
20 physical origin or nature, including medical detoxification,
21 however, may not be excluded. In this subsection,
22 "behavioral health services" means mental health services and
23 subacute alcohol and substance abuse treatment services, as
24 defined in the Illinois Alcoholism and Other Drug Dependency
25 Act. In this subsection, "mental health services" includes,
26 at a minimum, the following services funded by the Illinois
27 Department, the Department of Human Services (as successor to
28 the Department of Mental Health and Developmental
29 Disabilities), or the Department of Children and Family
30 Services: (i) inpatient hospital services, including related
31 physician services, related psychiatric interventions, and
32 pharmaceutical services provided to an eligible recipient
33 hospitalized with a primary diagnosis of psychiatric
34 disorder; (ii) outpatient mental health services as defined
35 and specified in Title 59 of the Illinois Administrative
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1 Code, Part 132; (iii) any other outpatient mental health
2 services funded by the Illinois Department pursuant to the
3 State of Illinois Medicaid Plan; (iv) partial
4 hospitalization; and (v) follow-up stabilization related to
5 any of those services. Additional behavioral health services
6 may be excluded under this subsection as mutually agreed in
7 writing by the Illinois Department and the affected State
8 agency or agencies. The exclusion of any service does not
9 prohibit the Illinois Department from developing and
10 implementing demonstration projects for categories of persons
11 or services. The Department of Children and Family Services
12 and the Department of Human Services shall each adopt rules
13 governing the integration of managed care in the provision of
14 behavioral health services. The State shall integrate managed
15 care community networks and affiliated providers, to the
16 extent practicable, in any separate delivery system for
17 mental health services.
18 (n) The Illinois Department shall adopt rules to
19 establish reserve requirements for managed care community
20 networks, as required by subsection (a), and health
21 maintenance organizations to protect against liabilities in
22 the event that a managed health care entity is declared
23 insolvent or bankrupt. If a managed health care entity other
24 than a county provider is declared insolvent or bankrupt,
25 after liquidation and application of any available assets,
26 resources, and reserves, the Illinois Department shall pay a
27 portion of the amounts owed by the managed health care entity
28 to providers for services rendered to enrollees under the
29 integrated health care program under this Section based on
30 the following schedule: (i) from April 1, 1995 through June
31 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
32 through June 30, 2001, 80% of the amounts owed; and (iii)
33 from July 1, 2001 through June 30, 2005, 75% of the amounts
34 owed. The amounts paid under this subsection shall be
35 calculated based on the total amount owed by the managed
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1 health care entity to providers before application of any
2 available assets, resources, and reserves. After June 30,
3 2005, the Illinois Department may not pay any amounts owed to
4 providers as a result of an insolvency or bankruptcy of a
5 managed health care entity occurring after that date. The
6 Illinois Department is not obligated, however, to pay amounts
7 owed to a provider that has an ownership or other governing
8 interest in the managed health care entity. This subsection
9 applies only to managed health care entities and the services
10 they provide under the integrated health care program under
11 this Section.
12 (o) Notwithstanding any other provision of law or
13 contractual agreement to the contrary, providers shall not be
14 required to accept from any other third party payer the rates
15 determined or paid under this Code by the Illinois
16 Department, managed health care entity, or other health care
17 delivery system for services provided to recipients.
18 (p) The Illinois Department may seek and obtain any
19 necessary authorization provided under federal law to
20 implement the program, including the waiver of any federal
21 statutes or regulations. The Illinois Department may seek a
22 waiver of the federal requirement that the combined
23 membership of Medicare and Medicaid enrollees in a managed
24 care community network may not exceed 75% of the managed care
25 community network's total enrollment. The Illinois
26 Department shall not seek a waiver of this requirement for
27 any other category of managed health care entity. The
28 Illinois Department shall not seek a waiver of the inpatient
29 hospital reimbursement methodology in Section 1902(a)(13)(A)
30 of Title XIX of the Social Security Act even if the federal
31 agency responsible for administering Title XIX determines
32 that Section 1902(a)(13)(A) applies to managed health care
33 systems.
34 Notwithstanding any other provisions of this Code to the
35 contrary, the Illinois Department shall seek a waiver of
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1 applicable federal law in order to impose a co-payment system
2 consistent with this subsection on recipients of medical
3 services under Title XIX of the Social Security Act who are
4 not enrolled in a managed health care entity. The waiver
5 request submitted by the Illinois Department shall provide
6 for co-payments of up to $0.50 for prescribed drugs and up to
7 $0.50 for x-ray services and shall provide for co-payments of
8 up to $10 for non-emergency services provided in a hospital
9 emergency room and up to $10 for non-emergency ambulance
10 services. The purpose of the co-payments shall be to deter
11 those recipients from seeking unnecessary medical care.
12 Co-payments may not be used to deter recipients from seeking
13 necessary medical care. No recipient shall be required to
14 pay more than a total of $150 per year in co-payments under
15 the waiver request required by this subsection. A recipient
16 may not be required to pay more than $15 of any amount due
17 under this subsection in any one month.
18 Co-payments authorized under this subsection may not be
19 imposed when the care was necessitated by a true medical
20 emergency. Co-payments may not be imposed for any of the
21 following classifications of services:
22 (1) Services furnished to person under 18 years of
23 age.
24 (2) Services furnished to pregnant women.
25 (3) Services furnished to any individual who is an
26 inpatient in a hospital, nursing facility, intermediate
27 care facility, or other medical institution, if that
28 person is required to spend for costs of medical care all
29 but a minimal amount of his or her income required for
30 personal needs.
31 (4) Services furnished to a person who is receiving
32 hospice care.
33 Co-payments authorized under this subsection shall not be
34 deducted from or reduce in any way payments for medical
35 services from the Illinois Department to providers. No
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1 provider may deny those services to an individual eligible
2 for services based on the individual's inability to pay the
3 co-payment.
4 Recipients who are subject to co-payments shall be
5 provided notice, in plain and clear language, of the amount
6 of the co-payments, the circumstances under which co-payments
7 are exempted, the circumstances under which co-payments may
8 be assessed, and their manner of collection.
9 The Illinois Department shall establish a Medicaid
10 Co-Payment Council to assist in the development of co-payment
11 policies for the medical assistance program. The Medicaid
12 Co-Payment Council shall also have jurisdiction to develop a
13 program to provide financial or non-financial incentives to
14 Medicaid recipients in order to encourage recipients to seek
15 necessary health care. The Council shall be chaired by the
16 Director of the Illinois Department, and shall have 6
17 additional members. Two of the 6 additional members shall be
18 appointed by the Governor, and one each shall be appointed by
19 the President of the Senate, the Minority Leader of the
20 Senate, the Speaker of the House of Representatives, and the
21 Minority Leader of the House of Representatives. The Council
22 may be convened and make recommendations upon the appointment
23 of a majority of its members. The Council shall be appointed
24 and convened no later than September 1, 1994 and shall report
25 its recommendations to the Director of the Illinois
26 Department and the General Assembly no later than October 1,
27 1994. The chairperson of the Council shall be allowed to
28 vote only in the case of a tie vote among the appointed
29 members of the Council.
30 The Council shall be guided by the following principles
31 as it considers recommendations to be developed to implement
32 any approved waivers that the Illinois Department must seek
33 pursuant to this subsection:
34 (1) Co-payments should not be used to deter access
35 to adequate medical care.
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1 (2) Co-payments should be used to reduce fraud.
2 (3) Co-payment policies should be examined in
3 consideration of other states' experience, and the
4 ability of successful co-payment plans to control
5 unnecessary or inappropriate utilization of services
6 should be promoted.
7 (4) All participants, both recipients and
8 providers, in the medical assistance program have
9 responsibilities to both the State and the program.
10 (5) Co-payments are primarily a tool to educate the
11 participants in the responsible use of health care
12 resources.
13 (6) Co-payments should not be used to penalize
14 providers.
15 (7) A successful medical program requires the
16 elimination of improper utilization of medical resources.
17 The integrated health care program, or any part of that
18 program, established under this Section may not be
19 implemented if matching federal funds under Title XIX of the
20 Social Security Act are not available for administering the
21 program.
22 The Illinois Department shall submit for publication in
23 the Illinois Register the name, address, and telephone number
24 of the individual to whom a request may be directed for a
25 copy of the request for a waiver of provisions of Title XIX
26 of the Social Security Act that the Illinois Department
27 intends to submit to the Health Care Financing Administration
28 in order to implement this Section. The Illinois Department
29 shall mail a copy of that request for waiver to all
30 requestors at least 16 days before filing that request for
31 waiver with the Health Care Financing Administration.
32 (q) After the effective date of this Section, the
33 Illinois Department may take all planning and preparatory
34 action necessary to implement this Section, including, but
35 not limited to, seeking requests for proposals relating to
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1 the integrated health care program created under this
2 Section.
3 (r) In order to (i) accelerate and facilitate the
4 development of integrated health care in contracting areas
5 outside counties with populations in excess of 3,000,000 and
6 counties adjacent to those counties and (ii) maintain and
7 sustain the high quality of education and residency programs
8 coordinated and associated with local area hospitals, the
9 Illinois Department may develop and implement a demonstration
10 program for managed care community networks owned, operated,
11 or governed by State-funded medical schools. The Illinois
12 Department shall prescribe by rule the criteria, standards,
13 and procedures for effecting this demonstration program.
14 (s) (Blank).
15 (t) On April 1, 1995 and every 6 months thereafter, the
16 Illinois Department shall report to the Governor and General
17 Assembly on the progress of the integrated health care
18 program in enrolling clients into managed health care
19 entities. The report shall indicate the capacities of the
20 managed health care entities with which the State contracts,
21 the number of clients enrolled by each contractor, the areas
22 of the State in which managed care options do not exist, and
23 the progress toward meeting the enrollment goals of the
24 integrated health care program.
25 (u) The Illinois Department may implement this Section
26 through the use of emergency rules in accordance with Section
27 5-45 of the Illinois Administrative Procedure Act. For
28 purposes of that Act, the adoption of rules to implement this
29 Section is deemed an emergency and necessary for the public
30 interest, safety, and welfare.
31 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
32 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
33 (305 ILCS 5/5-16.10 new)
34 Sec. 5-16.10. Managed care entities; marketing. A
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1 managed health care entity providing services under this
2 Article V may not engage in door-to-door marketing activities
3 or marketing activities at an office of the Illinois
4 Department or a county department in order to enroll
5 recipients in the entity's health care delivery system. The
6 Department shall adopt rules defining "marketing activities"
7 prohibited by this Section.
8 Before a managed health care entity providing services
9 under this Article V may market its health care delivery
10 system to recipients, the Illinois Department must approve a
11 marketing plan submitted by the entity to the Illinois
12 Department. The Illinois Department shall adopt guidelines
13 for approving marketing plans submitted by managed health
14 care entities under this Section. Besides prohibiting
15 door-to-door marketing activities and marketing activities at
16 public aid offices, the guidelines shall include at least the
17 following:
18 (1) A managed health care entity may not offer or
19 provide any gift, favor, or other inducement in marketing
20 its health care delivery system to integrated health care
21 program enrollees. A managed health care entity may
22 provide health care related items that are of nominal
23 value and pre-approved by the Department to prospective
24 enrollees. A managed health care entity may also
25 provide to enrollees health care related items that have
26 been pre-approved by the Department as an incentive to
27 manage their health care appropriately.
28 (2) All persons employed or otherwise engaged by a
29 managed health care entity to market the entity's health
30 care delivery system to recipients or to supervise that
31 marketing shall register with the Illinois Department.
32 The Inspector General appointed under Section 12-13.1 may
33 conduct investigations to determine whether the marketing
34 practices of managed health care entities providing services
35 under this Article V comply with the guidelines.
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1 (305 ILCS 5/5-16.11 new)
2 Sec. 5-16.11. Uniform standards applied to managed care
3 entities. Any managed care entity providing services under
4 this Code shall comply with the criteria, standards, and
5 procedures imposed on managed care entities under paragraph
6 (14) of subsection (d) of Section 5-16.3 of this Code.
7 (305 ILCS 5/8A-6) (from Ch. 23, par. 8A-6)
8 Sec. 8A-6. Classification of violations.
9 (a) Any person, firm, corporation, association, agency,
10 institution or other legal entity that has been found by a
11 court to have engaged in an act, practice or course of
12 conduct declared unlawful under Sections 8A-2 through 8A-5 or
13 Section 8A-13 or 8A-14 where:
14 (1) the total amount of money involved in the violation,
15 including the monetary value of federal food stamps and the
16 value of commodities, is less than $150, shall be guilty of a
17 Class A misdemeanor;
18 (2) the total amount of money involved in the violation,
19 including the monetary value of federal food stamps and the
20 value of commodities, is $150 or more but less than $1,000,
21 shall be guilty of a Class 4 felony;
22 (3) the total amount of money involved in the violation,
23 including the monetary value of federal food stamps and the
24 value of commodities, is $1,000 or more but less than $5,000,
25 shall be guilty of a Class 3 felony;
26 (4) the total amount of money involved in the violation,
27 including the monetary value of federal food stamps and the
28 value of commodities, is $5,000 or more but less than
29 $10,000, shall be guilty of a Class 2 felony; or
30 (5) the total amount of money involved in the violation,
31 including the monetary value of federal food stamps and the
32 value of commodities, is $10,000 or more, shall be guilty of
33 a Class 1 felony and, notwithstanding the provisions of
34 Section 8A-8 except for Subsection (c) of Section 8A-8, shall
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1 be ineligible for financial aid under this Article for a
2 period of two years following conviction or until the total
3 amount of money, including the value of federal food stamps,
4 is repaid, whichever first occurs.
5 (b) Any person, firm, corporation, association, agency,
6 institution or other legal entity that commits a subsequent
7 violation of any of the provisions of Sections 8A-2 through
8 8A-5 and:
9 (1) the total amount of money involved in the subsequent
10 violation, including the monetary value of federal food
11 stamps and the value of commodities, is less than $150, shall
12 be guilty of a Class 4 felony;
13 (2) the total amount of money involved in the subsequent
14 violation, including the monetary value of federal food
15 stamps and the value of commodities, is $150 or more but less
16 than $1,000, shall be guilty of a Class 3 felony;
17 (3) the total amount of money involved in the subsequent
18 violation, including the monetary value of federal food
19 stamps and the value of commodities, is $1,000 or more but
20 less than $5,000, shall be guilty of a Class 2 felony;
21 (4) the total amount of money involved in the subsequent
22 violation, including the monetary value of federal food
23 stamps and the value of commodities, is $5,000 or more but
24 less than $10,000, shall be guilty of a Class 1 felony.
25 (c) For purposes of determining the classification of
26 offense under this Section, all of the money received as a
27 result of the unlawful act, practice or course of conduct can
28 be accumulated.
29 (Source: P.A. 85-1209.)
30 (305 ILCS 5/8A-13 new)
31 Sec. 8A-13. Managed health care fraud.
32 (a) As used in this Section, "health plan" means any of
33 the following:
34 (1) Any health care reimbursement plan sponsored
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1 wholly or partially by the State.
2 (2) Any private insurance carrier, health care
3 cooperative or alliance, health maintenance organization,
4 insurer, organization, entity, association, affiliation,
5 or person that contracts to provide or provides goods or
6 services that are reimbursed by or are a required benefit
7 of a health benefits program funded wholly or partially
8 by the State.
9 (3) Anyone who provides or contracts to provide
10 goods and services to an entity described in paragraph
11 (1) or (2) of this subsection.
12 For purposes of item (2) in subsection (b),
13 "representation" and "statement" include, but are not limited
14 to, reports, claims, certifications, acknowledgments and
15 ratifications of financial information, enrollment claims,
16 demographic statistics, encounter data, health services
17 available or rendered, and the qualifications of person
18 rendering health care and ancillary services.
19 (b) Any person, firm, corporation, association, agency,
20 institution, or other legal entity that, with the intent to
21 obtain benefits or payments under this Code to which the
22 person or entity is not entitled or in a greater amount than
23 that to which the person or entity is entitled, knowingly
24 executes or conspires to execute a scheme or artifice
25 (1) to defraud any State or federally funded or
26 mandated health plan in connection with the delivery of
27 or payment for health care benefits, items, or services,
28 or
29 (2) to obtain by means of false or fraudulent
30 pretense, representation, statement, or promise money or
31 anything of value in connection with the delivery of or
32 payment for health care benefits, items, or services that
33 are in whole or in part paid for, reimbursed, or
34 subsidized by, or are a required benefit of, a State or
35 federally funded or mandated health plan
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1 is guilty of a violation of this Article and shall be
2 punished as provided in Section 8A-6.
3 (305 ILCS 5/8A-14 new)
4 Sec. 8A-14. Bribery and graft in connection with health
5 care.
6 (a) As used in this Section:
7 "Health care official" means any of the following:
8 (1) An administrator, officer, trustee, fiduciary,
9 custodian, counsel, agent, or employee of any health
10 plan.
11 (2) An officer, counsel, agent, or employee of an
12 organization that provides, proposes to provide, or
13 contracts to provide services to any health plan.
14 (3) An official, employee, or agent of a State or
15 federal agency having regulatory or administrative
16 authority over any health plan.
17 "Health plan" has the meaning attributed to that term in
18 Section 8A-13.
19 (b) Any person, firm, corporation, association, agency,
20 institution, or other legal entity that
21 (1) directly or indirectly gives, offers, or
22 promises anything of value to a health care official, or
23 offers or promises to a health care official to give
24 anything of value to another person, with the intent
25 (A) to influence or reward any act or decision
26 of any health care official exercising any authority
27 in any State or federally funded or mandated health
28 plan other than as specifically allowed by law, or
29 (B) to influence the official to commit, aid
30 in the commission of, or conspire to allow any fraud
31 in a State or federally funded or mandated health
32 plan, or
33 (C) to induce the official to engage in any
34 conduct in violation of the official's lawful duty,
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1 or
2 (2) being a health care official, directly or
3 indirectly demands, solicits, receives, accepts, or
4 agrees to accept anything of value personally or for any
5 other person or entity, the giving of which would violate
6 paragraph (1) of this subsection,
7 is guilty of a violation of this Article and shall be
8 punished as provided in Section 8A-6.
9 (305 ILCS 5/8A-15 new)
10 Sec. 8A-15. False statements relating to health care
11 delivery. Any person, firm, corporation, association,
12 agency, institution, or other legal entity that, in any
13 matter related to a State or federally funded or mandated
14 health plan, knowingly and wilfully falsifies, conceals, or
15 omits by any trick, scheme, artifice, or device a material
16 fact, or makes any false, fictitious, or fraudulent statement
17 or representation, or makes or uses any false writing or
18 document, knowing the same to contain any false, fictitious,
19 or fraudulent statement or entry in connection with the
20 provision of health care or related services, is guilty of a
21 Class A misdemeanor.
22 (305 ILCS 5/8A-16 new)
23 Sec. 8A-16. Unfair or deceptive marketing practices.
24 (a) As used in this Section, "health plan" has the
25 meaning attributed to that term in Section 8A-13.
26 (b) It is unlawful to knowingly and willfully engage in
27 any unfair or deceptive marketing practice in connection with
28 proposing, offering, selling, soliciting, or providing any
29 health care service or any health plan. Unfair or deceptive
30 marketing practices include the following:
31 (1) Making a false and misleading oral or written
32 statement, visual description, advertisement, or other
33 representation of any kind that has the capacity,
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1 tendency, or effect of deceiving or misleading health
2 care consumers with respect to any health care service,
3 health plan, or health care provider.
4 (2) Making a representation that a health care plan
5 or a health care provider offers any service, benefit,
6 access to care, or choice that it does not in fact offer.
7 (3) Making a representation that a health plan or
8 health care provider has any status, certification,
9 qualification, sponsorship, affiliation, or licensure
10 that it does not have.
11 (4) A failure to state a material fact if the
12 failure deceives or tends to deceive.
13 (5) Offering any kickback, bribe, reward, or
14 benefit to any person as an inducement to select or to
15 refrain from selecting any health care service, health
16 plan, or health care provider, unless the benefit offered
17 is medically necessary health care or is permitted by the
18 Illinois Department.
19 (6) The use of health care consumer or other
20 information that is confidential or privileged or that
21 cannot be disclosed to or obtained by the user without
22 violating a State or federal confidentiality law,
23 including:
24 (A) medical records information; and
25 (B) information that identifies the health
26 care consumer or any member of his or her group as a
27 recipient of any government sponsored or mandated
28 welfare program.
29 (7) The use of any device or artifice in
30 advertising a health plan or soliciting a health care
31 consumer that misrepresents the solicitor's profession,
32 status, affiliation, or mission.
33 (c) Any person who commits a first violation of this
34 Section is guilty of a Class A misdemeanor and is subject to
35 a fine of not more than $5,000. Any person who commits a
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1 second or subsequent violation of this Section is guilty of a
2 Class 4 felony and is subject to a fine of not more than
3 $25,000.
4 (305 ILCS 5/8A-17 new)
5 Sec. 8A-17. Penalties enhanced for persons other than
6 individuals. If a person who violates Section 8A-13, 8A-14,
7 8A-15, or 8A-16 is any person other than an individual, then
8 that person is subject to a fine of not more than $50,000 if
9 the violation is a misdemeanor and a fine of not more than
10 $250,000 if the violation is a felony.
11 Section 10. The Mental Health and Developmental
12 Disabilities Code is amended by changing Sections 2-102,
13 2-107, 2-107.1, 2-107.2, 2-110, and 3-800 and by adding
14 Sections 1-121.5, 2-110.1, and 3-601.2 as follows:
15 (405 ILCS 5/1-121.5 new)
16 Sec. 1-121.5. Authorized involuntary treatment.
17 "Authorized involuntary treatment" means psychotropic
18 medication or electro-convulsive therapy, including those
19 tests and related procedures that are essential for the safe
20 and effective administration of the treatment.
21 (405 ILCS 5/2-102) (from Ch. 91 1/2, par. 2-102)
22 Sec. 2-102. (a) A recipient of services shall be
23 provided with adequate and humane care and services in the
24 least restrictive environment, pursuant to an individual
25 services plan, which shall be formulated and periodically
26 reviewed with the participation of the recipient to the
27 extent feasible and, where appropriate, such recipient's
28 nearest of kin or guardian.
29 (a-5) If the services include the administration of
30 authorized involuntary treatment psychotropic medication, the
31 physician shall advise the recipient, in writing, of the side
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1 effects and risks of the treatment and alternatives to the
2 proposed treatment, and the risks and benefits thereof,
3 medication to the extent such advice is consistent with the
4 nature and frequency of the side effects and the recipient's
5 ability to understand the information communicated. The
6 physician shall determine in writing whether the recipient
7 has the capacity to make a reasoned decision about the
8 treatment. If the recipient lacks the capacity to make a
9 reasoned decision about the treatment, the treatment may be
10 administered only (i) pursuant to the provisions of Section
11 2-107 or 2-107.1 or (ii) pursuant to a power of attorney for
12 health care under the Powers of Attorney for Health Care Law
13 or a declaration for mental health treatment under the Mental
14 Health Treatment Preference Declaration Act. A surrogate
15 decision maker, other than a court appointed guardian, under
16 the Health Care Surrogate Act may not consent to the
17 administration of authorized involuntary treatment. A
18 surrogate may, however, petition for administration of
19 authorized involuntary treatment pursuant to this Act. If
20 the recipient is under guardianship and the guardian is
21 authorized to consent to the administration of authorized
22 involuntary treatment pursuant to subsection (c) of Section
23 2-107.1 of this Code, the physician shall advise the guardian
24 in writing of the side effects and risks of the treatment,
25 alternatives to the proposed treatment, and the risks and
26 benefits of the treatment. Any recipient who is a resident of
27 a mental health or developmental disabilities facility shall
28 be advised in writing of his right to refuse such services
29 pursuant to Section 2-107 of this Code. A qualified
30 professional shall be responsible for overseeing the
31 implementation of such plan. Such care and treatment shall
32 include the regular use of sign language for any hearing
33 impaired individual for whom sign language is a primary mode
34 of communication.
35 (b) A recipient of services who is an adherent or a
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1 member of any well-recognized religious denomination, the
2 principles and tenets of which teach reliance upon services
3 by spiritual means through prayer alone for healing by a duly
4 accredited practitioner thereof, shall have the right to
5 choose such services. The parent or guardian of a recipient
6 of services who is a minor, or a guardian of a recipient of
7 services who is not a minor, shall have the right to choose
8 services by spiritual means through prayer for the recipient
9 of services.
10 (Source: P.A. 86-1402.)
11 (405 ILCS 5/2-107) (from Ch. 91 1/2, par. 2-107)
12 Sec. 2-107. Refusal of services; informing of risks.
13 (a) An adult recipient of services, or, if the recipient
14 is under guardianship, the recipient's guardian, shall be
15 given the opportunity to refuse generally accepted mental
16 health or developmental disability services, including but
17 not limited to medication. If such services are refused,
18 they shall not be given unless such services are necessary to
19 prevent the recipient from causing serious and imminent
20 physical harm to himself or others. The facility director
21 shall inform a recipient or guardian who refuses such
22 services of alternate services available and the risks of
23 such alternate services, as well as the possible consequences
24 to the recipient of refusal of such services.
25 (b) Authorized involuntary treatment Psychotropic
26 medication may be given under this Section for up to 24 hours
27 only if the circumstances leading up to the need for
28 emergency treatment medication are set forth in writing in
29 the recipient's record.
30 (c) Authorized involuntary treatment Psychotropic
31 medication may not be continued unless the need for such
32 treatment medication is redetermined at least every 24 hours
33 based upon a personal examination of the recipient by a
34 physician or a nurse under the supervision of a physician and
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1 the circumstances demonstrating that need are set forth in
2 writing in the recipient's record.
3 (d) Authorized involuntary treatment Psychotropic
4 medications may not be administered under this Section for a
5 period in excess of 3 consecutive days, excluding Saturdays,
6 Sundays, and holidays, unless the facility files a petition
7 under Section 2-107.1 and the treatment medication continues
8 to be necessary in order to prevent the recipient from
9 causing serious and imminent physical harm to himself or
10 herself or others.
11 (e) The Department shall issue rules designed to insure
12 that in State-operated mental health facilities authorized
13 involuntary treatment psychotropic medication is administered
14 in accordance with this Section and only when appropriately
15 authorized and monitored by a physician or a nurse under the
16 supervision of a physician in accordance with accepted
17 medical practice. The facility director of each mental
18 health facility not operated by the State shall issue rules
19 designed to insure that in that facility authorized
20 involuntary treatment psychotropic medication is administered
21 in accordance with this Section and only when appropriately
22 authorized and monitored by a physician or a nurse under the
23 supervision of a physician in accordance with accepted
24 medical practice. Such rules shall be available for public
25 inspection and copying during normal business hours.
26 (f) The provisions of this Section with respect to the
27 emergency administration of authorized involuntary treatment
28 psychotropic medication do not apply to facilities licensed
29 under the Nursing Home Care Act.
30 (Source: P.A. 89-427, eff. 6-1-96; 89-439, eff. 6-1-96.)
31 (405 ILCS 5/2-107.1) (from Ch. 91 1/2, par. 2-107.1)
32 Sec. 2-107.1. Administration of authorized involuntary
33 treatment psychotropic medication upon application to a
34 court.
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1 (a) Notwithstanding the provisions of Section 2-107 of
2 this Code Act, authorized involuntary treatment psychotropic
3 medication may be administered to an adult recipient of
4 services without the informed consent of the recipient
5 against his will under the following standards:
6 (1) Any person 18 years of age or older, including
7 any guardian, may petition the circuit court for an order
8 authorizing the administration of authorized involuntary
9 treatment psychotropic medication to a recipient of
10 services. The petition shall state that the petitioner
11 has made a good faith attempt to determine whether the
12 recipient has executed a power of attorney for health
13 care under the Powers of Attorney for Health Care Law or
14 a declaration for mental health treatment under the
15 Mental Health Treatment Preference Declaration Act and to
16 obtain copies of these instruments if they exist. If
17 either of the above-named instruments is available to the
18 petitioner, the instrument shall be attached to the
19 petition as an exhibit. The petitioner shall deliver a
20 copy of the petition, and notice of the time and place of
21 the hearing, to the respondent, his or her attorney, any
22 known agent or attorney-in-fact, if any, and the
23 guardian, if any, no later than 10 days prior to the date
24 of the hearing. The petition may include a request that
25 the court authorize such testing and procedures as may be
26 essential for the safe and effective administration of
27 the authorized involuntary treatment psychotropic
28 medication sought to be administered, but only where the
29 petition sets forth the specific testing and procedures
30 sought to be administered.
31 (2) The court shall hold a hearing within 14 days
32 of the filing of the petition. Continuances totaling not
33 more than 14 days may be granted to the recipient upon a
34 showing that the continuances are needed in order to
35 prepare adequately for a hearing under this Section. The
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1 court may, in its discretion, grant additional
2 continuances if agreed to by all parties. The hearing
3 shall be separate from a judicial proceeding held to
4 determine whether a person is subject to involuntary
5 admission.
6 (3) Unless otherwise provided herein, the
7 procedures set forth in Article VIII of Chapter 3 of this
8 Act, including the provisions regarding appointment of
9 counsel, shall govern hearings held under this subsection
10 (a).
11 (4) Authorized involuntary treatment Psychotropic
12 medication shall not be administered to the recipient
13 unless it has been determined by clear and convincing
14 evidence that all of the following factors are present:
15 (A) That the recipient has a serious mental
16 illness or developmental disability.
17 (B) That because of said mental illness or
18 developmental disability, the recipient exhibits any
19 one of the following: (i) deterioration of his
20 ability to function, (ii) suffering, (iii) or
21 threatening behavior, or (iv) disruptive behavior.
22 (C) That the illness or disability has existed
23 for a period marked by the continuing presence of
24 the symptoms set forth in item (B) of this
25 subdivision (4) or the repeated episodic occurrence
26 of these symptoms.
27 (D) That the benefits of the treatment
28 psychotropic medication will outweigh the harm.
29 (E) That the recipient lacks the capacity to
30 make a reasoned decision about the treatment
31 medication.
32 (F) That other less restrictive services have
33 been explored and found inappropriate.
34 (G) If the petition seeks authorization for
35 testing and other procedures, that such testing and
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1 procedures are essential for the safe and effective
2 administration of the treatment psychotropic
3 medication.
4 (5) In no event shall an order issued under this
5 Section be effective for more than 90 days. However,
6 authorized involuntary treatment psychotropic medication
7 may be administered for additional 90-day periods without
8 limitation under hearings that comply with the above
9 standards and procedures of this subsection (a). If a new
10 petition to authorize the administration of authorized
11 involuntary treatment psychotropic medication is filed at
12 least 15 days prior to the expiration of the prior order,
13 and if any continuance of the hearing is agreed to by the
14 recipient, the administration of the treatment medication
15 may continue in accordance with the prior order pending
16 the completion of a hearing under this Section.
17 (6) An order issued under this subsection (a) shall
18 designate the persons authorized to administer the
19 authorized involuntary treatment psychotropic medication
20 under the standards and procedures of this subsection
21 (a). Those persons shall have complete discretion not to
22 administer any treatment medication authorized under this
23 Section. The order shall also specify the medications and
24 the anticipated range of dosages that have been
25 authorized.
26 (b) A guardian may be authorized to consent to the
27 administration of authorized involuntary treatment
28 psychotropic medication to an objecting recipient only under
29 the standards and procedures of subsection (a).
30 (c) Notwithstanding any other provision of this Section,
31 a guardian may consent to the administration of authorized
32 involuntary treatment psychotropic medication to a
33 non-objecting recipient under Article XIa of the Probate Act
34 of 1975.
35 (d) Nothing in this Section shall prevent the
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1 administration of authorized involuntary treatment
2 psychotropic medication to recipients in an emergency under
3 Section 2-107 of this Act.
4 (e) Notwithstanding any of the provisions of this
5 Section, authorized involuntary treatment may be administered
6 pursuant to a power of attorney for health care under the
7 Powers of Attorney for Health Care Law or a declaration for
8 mental health treatment under the Mental Health Treatment
9 Preference Declaration Act.
10 (Source: P.A. 89-11, eff. 3-31-95; 89-439, eff. 6-1-96.)
11 (405 ILCS 5/2-107.2) (from Ch. 91 1/2, par. 2-107.2)
12 Sec. 2-107.2. Review; notice.
13 (a) Whenever any recipient, who is receiving treatment
14 in a residential mental health facility, has been receiving
15 authorized involuntary treatment psychotropic medication in
16 that facility continuously or on a regular basis for a period
17 of 3 months, and, if the treatment medication is continued
18 while the recipient is a resident in that facility, every 6
19 months thereafter, for so long as the treatment medication
20 shall continue, the facility director shall convene a
21 treatment review panel to review the medication treatment.
22 (b) At least 7 days prior to the date of the meeting,
23 the recipient, his or her guardian, if any, and the person
24 designated under subsection (b) of Section 2-200 shall be
25 given written notification of the time and place of the
26 treatment review meeting. The notice shall also advise the
27 recipient of his or her right to designate some person to
28 attend the meeting and assist the recipient.
29 (c) If, during the course of the review, the recipient
30 or guardian, if any, advises the committee that he no longer
31 agrees to continue receiving the treatment medication, the
32 treatment medication must be discontinued except that the
33 treatment medication may be administered under either Section
34 2-107 or 2-107.1. If the recipient and guardian, if any,
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1 continues to agree to the treatment medication, the treatment
2 medication shall be continued if the committee determines
3 that the recipient is receiving appropriate treatment
4 medication and that the benefit to the recipient outweighs
5 any risk of harm to the recipient.
6 (d) The Department shall issue rules to implement the
7 requirements of this Section.
8 (Source: P.A. 89-439, eff. 6-1-96.)
9 (405 ILCS 5/2-110) (from Ch. 91 1/2, par. 2-110)
10 Sec. 2-110. No recipient of services shall be subjected
11 to electro-convulsive therapy, or to any unusual, hazardous,
12 or experimental services or psychosurgery, without his
13 written and informed consent.
14 If the recipient is a minor or is under guardianship,
15 such recipient's parent or guardian is authorized, only with
16 the approval of the court, to provide informed consent for
17 participation of the ward in any such services which the
18 guardian deems to be in the best interests of the ward.
19 (Source: P.A. 80-1414.)
20 (405 ILCS 5/2-110.1 new)
21 Sec. 2-110.1. Reports.
22 (a) A mental hospital or facility at which
23 electro-convulsive therapy is administered shall submit to
24 the Department quarterly reports relating to the
25 administration of the therapy for the purposes of reducing
26 morbidity or mortality and improving patient care.
27 (b) A report shall state the following for each quarter:
28 (1) The number of persons who received the therapy,
29 including:
30 (A) the number of persons who gave informed
31 consent to the therapy;
32 (B) the number of persons confined as subject
33 to involuntary admission who gave informed consent
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1 to the therapy;
2 (C) the number of persons who received the
3 therapy without informed consent pursuant to Section
4 2-107.1; and
5 (D) the number of persons who received the
6 therapy on an emergency basis pursuant to
7 subsection (d) of Section 2-107.1.
8 (2) The age, sex, and race of the recipients of the
9 therapy.
10 (3) The source of the treatment payment.
11 (4) The average number of electro-convulsive
12 treatments administered for each complete series of
13 treatments, but not including maintenance treatments.
14 (5) The average number of maintenance
15 electro-convulsive treatments administered per month.
16 (6) Any significant adverse reactions to the
17 treatment as defined by rule.
18 (7) Autopsy findings if death followed within 14
19 days after the date of the administration of the therapy.
20 (8) Any other information required by the
21 Department by rule.
22 (c) The Department shall prepare and publish an annual
23 written report summarizing the information received under
24 this Section. The report shall not contain any information
25 that identifies or tends to identify any facility,
26 physician, health care provider, or patient.
27 (405 ILCS 5/3-601.2 new)
28 Sec. 3-601.2. Consent to admission by healthcare
29 surrogate. A surrogate decision maker under the Health Care
30 Surrogate Act may not consent to the admission to a mental
31 health facility of a person who lacks decision making
32 capacity. A surrogate may, however, petition for involuntary
33 admission pursuant to this Code. This Section does not
34 affect the authority of a court appointed guardian.
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1 (405 ILCS 5/3-800) (from Ch. 91 1/2, par. 3-800)
2 Sec. 3-800. (a) Unless otherwise indicated, court
3 hearings under this Chapter shall be held pursuant to this
4 Article. Hearings shall be held in such quarters as the
5 court directs. To the extent practical, hearings shall be
6 held in the mental health facility where the respondent is
7 hospitalized. Any party may request a change of venue or
8 transfer to any other county because of the convenience of
9 parties or witnesses or the condition of the respondent. The
10 respondent may request to have the proceedings transferred to
11 the county of his residence.
12 (b) If the court grants a continuance on its own motion
13 or upon the motion of one of the parties, the respondent may
14 continue to be detained pending further order of the court.
15 Such continuance shall not extend beyond 15 days except to
16 the extent that continuances are requested by the respondent.
17 (c) Court hearings under this Chapter, including
18 hearings under Section 2-107.1, shall be open to the press
19 and public unless the respondent or some other party requests
20 that they be closed. The court may also indicate its
21 intention to close a hearing, including when it determines
22 that the respondent may be unable to make a reasoned decision
23 to request that the hearing be closed. A request that a
24 hearing be closed shall be granted unless there is an
25 objection to closing the hearing by a party or any other
26 person. If an objection is made, the court shall not close
27 the hearing unless, following a hearing, it determines that
28 the patient's interest in having the hearing closed is
29 compelling. The court shall support its determination with
30 written findings of fact and conclusions of law. The court
31 shall not close the hearing if the respondent objects to its
32 closure. Whenever a court determines that a hearing shall be
33 closed, access to the records of the hearing, including but
34 not limited to transcripts and pleadings, shall be limited
35 to the parties involved in the hearing, court personnel, and
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1 any person or agency providing mental health services that
2 are the subject of the hearing. Access may also be granted,
3 however, pursuant to the provisions of the Mental Health and
4 Developmental Disabilities Confidentiality Act.
5 (Source: P.A. 85-971.)
6 Section 15. The Mental Health and Developmental
7 Disabilities Confidentiality Act is amended by changing
8 Sections 2 and 11 as follows:
9 (740 ILCS 110/2) (from Ch. 91 1/2, par. 802)
10 Sec. 2. The terms used in this Act, unless the context
11 requires otherwise, have the meanings ascribed to them in
12 this Section.
13 "Agent" means a person who has been legally appointed as
14 an individual's agent under a power of attorney for health
15 care or for property.
16 "Confidential communication" or "communication" means any
17 communication made by a recipient or other person to a
18 therapist or to or in the presence of other persons during or
19 in connection with providing mental health or developmental
20 disability services to a recipient. Communication includes
21 information which indicates that a person is a recipient.
22 "Guardian" means a legally appointed guardian or
23 conservator of the person.
24 "Mental health or developmental disabilities services" or
25 "services" includes but is not limited to examination,
26 diagnosis, evaluation, treatment, training, pharmaceuticals,
27 aftercare, habilitation or rehabilitation.
28 "Personal notes" means:
29 (i) information disclosed to the therapist in
30 confidence by other persons on condition that such
31 information would never be disclosed to the recipient or
32 other persons;
33 (ii) information disclosed to the therapist by the
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1 recipient which would be injurious to the recipient's
2 relationships to other persons, and
3 (iii) the therapist's speculations, impressions,
4 hunches, and reminders.
5 "Parent" means a parent or, in the absence of a parent or
6 guardian, a person in loco parentis.
7 "Recipient" means a person who is receiving or has
8 received mental health or developmental disabilities
9 services.
10 "Record" means any record kept by a therapist or by an
11 agency in the course of providing mental health or
12 developmental disabilities service to a recipient concerning
13 the recipient and the services provided. "Records" includes
14 all records maintained by a court that have been created in
15 connection with, in preparation for, or as a result of the
16 filing of any petition or certificate under Chapter II,
17 Article VI or VII of Chapter III, or under Article IV or V of
18 Chapter IV of the Mental Health and Developmental
19 Disabilities Code and includes the petitions, certificates,
20 dispositional reports, treatment plans, and reports of
21 diagnostic evaluations and of hearings to determine if a
22 person is subject to involuntary admission under Article VIII
23 of Chapter III or subject to judicial admission under Article
24 V of Chapter IV of that Code. Record does not include the
25 therapist's personal notes, if such notes are kept in the
26 therapist's sole possession for his own personal use and are
27 not disclosed to any other person, except the therapist's
28 supervisor, consulting therapist or attorney. If at any time
29 such notes are disclosed, they shall be considered part of
30 the recipient's record for purposes of this Act.
31 "Record custodian" means a person responsible for
32 maintaining a recipient's record.
33 "Therapist" means a psychiatrist, physician,
34 psychologist, social worker, or nurse providing mental health
35 or developmental disabilities services or any other person
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1 not prohibited by law from providing such services or from
2 holding himself out as a therapist if the recipient
3 reasonably believes that such person is permitted to do so.
4 Therapist includes any successor of the therapist.
5 (Source: P.A. 88-484; 89-58, eff. 1-1-96.)
6 (740 ILCS 110/11) (from Ch. 91 1/2, par. 811)
7 (Text of Section before amendment by P.A. 89-507)
8 Sec. 11. Disclosure of records and communications.
9 Records and communications may be disclosed, (i) in
10 accordance with the provisions of the Abused and Neglected
11 Child Reporting Act; (ii) when, and to the extent, a
12 therapist, in his or her sole discretion, determines that
13 disclosure is necessary to initiate or continue civil
14 commitment proceedings under the laws of this State or to
15 otherwise protect the recipient or other person against a
16 clear, imminent risk of serious physical or mental injury or
17 disease or death being inflicted upon the recipient or by the
18 recipient on himself or another; (iii) when, and to the
19 extent disclosure is, in the sole discretion of the
20 therapist, necessary to the provision of emergency medical
21 care to a recipient who is unable to assert or waive his or
22 her rights hereunder; (iv) when disclosure is necessary to
23 collect sums or receive third party payment representing
24 charges for mental health or developmental disabilities
25 services provided by a therapist or agency to a recipient
26 under Chapter V of the Mental Health and Developmental
27 Disabilities Code or to transfer debts under the Uncollected
28 States Claims Act; however, disclosure shall be limited to
29 information needed to pursue collection, and the information
30 so disclosed shall not be used for any other purposes nor
31 shall it be redisclosed except in connection with collection
32 activities; (v) when requested by a family member, the
33 Department of Mental Health and Developmental Disabilities
34 may assist in the location of the interment site of a
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1 deceased recipient who is interred in a cemetery established
2 under Section 100-26 of the Department of Mental Health and
3 Developmental Disabilities Act; (vi) in judicial commitment
4 proceedings and involuntary medication hearings under Article
5 VIII of Chapter III and Article V of Chapter IV of the Mental
6 Health and Developmental Disabilities Code and proceedings
7 and investigations preliminary thereto, to the State's
8 Attorney for the county or residence of a person who is the
9 subject of such proceedings for whom involuntary or judicial
10 admission or involuntary medication is sought, or in which
11 the person is found, or in which the facility is located, and
12 to the attorney representing the recipient in the judicial
13 commitment proceedings or medication hearing, to any person
14 or agency providing mental health services that are the
15 subject of the proceedings and to that person's or agency's
16 attorney, to any court personnel, including but not limited
17 to judges and circuit court clerks, and to a guardian ad
18 litem if one has been appointed by the court, provided that
19 the information so disclosed shall not be utilized for any
20 other purpose nor be redisclosed except in connection with
21 the proceedings or investigations; (vii) when, and to the
22 extent disclosure is necessary to comply with the
23 requirements of the Census Bureau in taking the federal
24 Decennial Census; and (viii) when, and to the extent, in the
25 therapist's sole discretion, disclosure is necessary to warn
26 or protect a specific individual against whom a recipient has
27 made a specific threat of violence where there exists a
28 therapist-recipient relationship or a special
29 recipient-individual relationship. Any person, institution,
30 or agency, under this Act, participating in good faith in the
31 making of a report under the Abused and Neglected Child
32 Reporting Act or in the disclosure of records and
33 communications under this Section, shall have immunity from
34 any liability, civil, criminal or otherwise, that might
35 result by reason of such action. For the purpose of any
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1 proceeding, civil or criminal, arising out of a report or
2 disclosure under this Section, the good faith of any person,
3 institution, or agency so reporting or disclosing shall be
4 presumed.
5 (Source: P.A. 88-484; 89-439, eff. 6-1-96.)
6 (Text of Section after amendment by P.A. 89-507)
7 Sec. 11. Disclosure of records and communications.
8 Records and communications may be disclosed, (i) in
9 accordance with the provisions of the Abused and Neglected
10 Child Reporting Act; (ii) when, and to the extent, a
11 therapist, in his or her sole discretion, determines that
12 disclosure is necessary to initiate or continue civil
13 commitment proceedings under the laws of this State or to
14 otherwise protect the recipient or other person against a
15 clear, imminent risk of serious physical or mental injury or
16 disease or death being inflicted upon the recipient or by the
17 recipient on himself or another; (iii) when, and to the
18 extent disclosure is, in the sole discretion of the
19 therapist, necessary to the provision of emergency medical
20 care to a recipient who is unable to assert or waive his or
21 her rights hereunder; (iv) when disclosure is necessary to
22 collect sums or receive third party payment representing
23 charges for mental health or developmental disabilities
24 services provided by a therapist or agency to a recipient
25 under Chapter V of the Mental Health and Developmental
26 Disabilities Code or to transfer debts under the Uncollected
27 State Claims Act; however, disclosure shall be limited to
28 information needed to pursue collection, and the information
29 so disclosed shall not be used for any other purposes nor
30 shall it be redisclosed except in connection with collection
31 activities; (v) when requested by a family member, the
32 Department of Human Services may assist in the location of
33 the interment site of a deceased recipient who is interred in
34 a cemetery established under Section 100-26 of the Mental
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1 Health and Developmental Disabilities Administrative Act;
2 (vi) in judicial commitment proceedings and involuntary
3 medication hearings under Article VIII of Chapter III and
4 Article V of Chapter IV of the Mental Health and
5 Developmental Disabilities Code and proceedings and
6 investigations preliminary thereto, to the State's Attorney
7 for the county or residence of a person who is the subject of
8 such proceedings for whom involuntary or judicial admission
9 or involuntary medication is sought, or in which the person
10 is found, or in which the facility is located, and to the
11 attorney representing the recipient in the judicial
12 commitment proceedings or medication hearing, to any person
13 or agency providing mental health services that are the
14 subject of the proceedings and to that person's or agency's
15 attorney, to any court personnel, including but not limited
16 to judges and circuit court clerks, and to a guardian ad
17 litem if one has been appointed by the court, provided that
18 the information so disclosed shall not be utilized for any
19 other purpose nor be redisclosed except in connection with
20 the proceedings or investigations; (vii) when, and to the
21 extent disclosure is necessary to comply with the
22 requirements of the Census Bureau in taking the federal
23 Decennial Census; and (viii) when, and to the extent, in the
24 therapist's sole discretion, disclosure is necessary to warn
25 or protect a specific individual against whom a recipient has
26 made a specific threat of violence where there exists a
27 therapist-recipient relationship or a special
28 recipient-individual relationship. Any person, institution,
29 or agency, under this Act, participating in good faith in the
30 making of a report under the Abused and Neglected Child
31 Reporting Act or in the disclosure of records and
32 communications under this Section, shall have immunity from
33 any liability, civil, criminal or otherwise, that might
34 result by reason of such action. For the purpose of any
35 proceeding, civil or criminal, arising out of a report or
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1 disclosure under this Section, the good faith of any person,
2 institution, or agency so reporting or disclosing shall be
3 presumed.
4 (Source: P.A. 88-484; 89-439, eff. 6-1-96; 89-507, eff.
5 7-1-97.)
6 Section 20. The Sexual Exploitation in Psychotherapy Act
7 is amended by changing the title of the Act and Sections
8 0.01, 1, 2, and 3 as follows:
9 (740 ILCS 140/Act title)
10 An Act concerning sexual exploitation by
11 psychotherapists, unlicensed health professionals, or
12 unlicensed mental health professionals.
13 (Source: P.A. 85-1254.)
14 (740 ILCS 140/0.01) (from Ch. 70, par. 800)
15 Sec. 0.01. Short title. This Act may be cited as the
16 Sexual Exploitation in Psychotherapy, Professional Health
17 Services, and Professional Mental Health Services Act.
18 (Source: P.A. 86-1324.)
19 (740 ILCS 140/1) (from Ch. 70, par. 801)
20 Sec. 1. Definitions. In this Act:
21 (a) "Emotionally dependent" means that the nature of the
22 patient's or former patient's emotional condition and the
23 nature of the treatment provided by the psychotherapist,
24 unlicensed health professional, or unlicensed mental health
25 professional are such that the psychotherapist, unlicensed
26 health professional, or unlicensed mental health professional
27 knows or has reason to believe that the patient or former
28 patient is unable to withhold consent to sexual contact by
29 the psychotherapist, unlicensed health professional, or
30 unlicensed mental health professional.
31 (b) "Former patient" means a person who was given
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1 psychotherapy within 1 year prior to sexual contact with the
2 psychotherapist or who obtained a professional consultation
3 or diagnostic or therapeutic service from an unlicensed
4 health professional or unlicensed mental health professional
5 within one year prior to sexual contact with the unlicensed
6 health professional or unlicensed mental health professional.
7 (c) "Patient" means a person who seeks or obtains
8 psychotherapy or who obtains a professional consultation or
9 diagnostic or therapeutic service from an unlicensed health
10 professional or unlicensed mental health professional.
11 (d) "Psychotherapist" means a physician, psychologist,
12 nurse, chemical dependency counselor, social worker, or other
13 person, whether or not licensed by the State, who performs or
14 purports to perform psychotherapy.
15 (e) "Psychotherapy" means the professional treatment,
16 assessment, or counseling of a mental or emotional illness,
17 symptom, or condition. "Psychotherapy" does not include
18 counseling of a spiritual or religious nature, social work,
19 or casual advice given by a friend or family member.
20 (f) "Sexual contact" means any of the following, whether
21 or not occurring with the consent of a patient or former
22 patient:
23 (1) sexual intercourse, cunnilingus, fellatio, anal
24 intercourse or any intrusion, however slight, into the
25 genital or anal openings of the patient's or former patient's
26 body by any part of the psychotherapist's, unlicensed health
27 professional's, or unlicensed mental health professional's
28 body or by any object used by the psychotherapist, unlicensed
29 health professional, or unlicensed mental health professional
30 for that purpose, or any intrusion, however slight, into the
31 genital or anal openings of the psychotherapist's, unlicensed
32 health professional's, or unlicensed mental health
33 professional's body by any part of the patient's or former
34 patient's body or by any object used by the patient or former
35 patient for that purpose, if agreed to by the
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1 psychotherapist, unlicensed health professional, or
2 unlicensed mental health professional;
3 (2) kissing or intentional touching by the
4 psychotherapist, unlicensed health professional, or
5 unlicensed mental health professional of the patient's or
6 former patient's genital area, groin, inner thigh, buttocks,
7 or breast or the clothing covering any of these body parts;
8 (3) kissing or intentional touching by the patient or
9 former patient of the psychotherapist's, unlicensed health
10 professional's, or unlicensed mental health professional's
11 genital area, groin, inner thigh, buttocks, or breast or the
12 clothing covering any of these body parts if the
13 psychotherapist, unlicensed health professional, or
14 unlicensed mental health professional agrees to the kissing
15 or intentional touching.
16 "Sexual contact" includes a request by the
17 psychotherapist, unlicensed health professional, or
18 unlicensed mental health professional for conduct described
19 in paragraphs (1) through (3).
20 "Sexual contact" does not include conduct described in
21 paragraph (1) or (2) that is a part of standard medical
22 treatment of a patient, casual social contact not intended to
23 be sexual in character, or inadvertent touching.
24 (g) "Therapeutic deception" means a representation by a
25 psychotherapist, unlicensed health professional, or
26 unlicensed mental health professional that sexual contact
27 with the psychotherapist, unlicensed health professional, or
28 unlicensed mental health professional is consistent with or
29 part of the patient's or former patient's treatment.
30 (h) "Unlicensed health professional" means a person who
31 is not licensed or registered to provide health services by
32 the Department of Professional Regulation or a board of
33 registration duly authorized to grant licenses or
34 registration to persons engaged in the practice of providing
35 health services or whose license or registration to provide
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1 health services has been returned or revoked by the
2 Department or that board.
3 (i) "Unlicensed mental health professional" means a
4 person who is not licensed or registered to provide mental
5 health services by the Department of Professional Regulation
6 or a board of registration duly authorized to grant licenses
7 or registration to persons engaged in the practice of
8 providing mental health services or whose license or
9 registration to provide mental health services has been
10 returned or revoked by the Department or that board.
11 (Source: P.A. 85-1254.)
12 (740 ILCS 140/2) (from Ch. 70, par. 802)
13 Sec. 2. Cause of action for sexual exploitation. (a) A
14 cause of action against a psychotherapist, unlicensed health
15 professional, or unlicensed mental health professional for
16 sexual exploitation exists for a patient or former patient
17 for injury caused by sexual contact with the psychotherapist,
18 unlicensed health professional, or unlicensed mental health
19 professional, if the sexual contact occurred:
20 (1) during the period the patient was receiving
21 psychotherapy from the psychotherapist, or health services
22 from the unlicensed health professional, or mental health
23 services from the unlicensed mental health professional; or
24 (2) after the period the patient received psychotherapy
25 from the psychotherapist, or health services from the
26 unlicensed health professional, or mental health services
27 from the unlicensed mental health professional if (i) the
28 former patient was emotionally dependent on the
29 psychotherapist, unlicensed health professional, or
30 unlicensed mental health professional or (ii) the sexual
31 contact occurred by means of therapeutic deception.
32 (b) The patient or former patient may recover damages
33 from a psychotherapist, unlicensed health professional, or
34 unlicensed mental health professional who is found liable for
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1 sexual exploitation. It is not a defense to the action that
2 sexual contact with a patient occurred outside a therapy or
3 treatment session or that it occurred off the premises
4 regularly used by the psychotherapist, unlicensed health
5 professional, or unlicensed mental health professional for
6 therapy or treatment sessions.
7 (c) Whenever the Attorney General has probable cause to
8 believe (i) that a psychotherapist, unlicensed health
9 professional, or unlicensed mental health professional is
10 having or has had sexual contact with one or more patients or
11 clients or former patients or former clients while the
12 psychotherapist, unlicensed health professional, or
13 unlicensed mental health professional was licensed or
14 unlicensed and (ii) that the psychotherapist, unlicensed
15 health professional, or unlicensed mental health professional
16 poses a threat to the health, safety, or welfare of members
17 of the public who are or may be patients or clients of the
18 psychotherapist, unlicensed health professional, or
19 unlicensed mental health professional, the Attorney General
20 may bring an action in the name of the State against the
21 psychotherapist, unlicensed health professional, or
22 unlicensed mental health professional to restrain by
23 temporary restraining order or preliminary or permanent
24 injunction the psychotherapist, unlicensed health
25 professional, or unlicensed mental health professional from
26 providing, offering to provide, or representing himself or
27 herself as being able to provide psychotherapy, health
28 services, or mental health services.
29 At least 5 days prior to the commencement of any action
30 brought under this Section, except when a temporary
31 restraining order is sought, the Attorney General shall
32 notify the psychotherapist, unlicensed health professional,
33 or unlicensed mental health professional of the Attorney
34 General's intended action and shall give the psychotherapist,
35 unlicensed health professional, or unlicensed mental health
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1 professional an opportunity to confer with the Attorney
2 General or his or her representative in person or by counsel
3 or other representative as to the proposed action.
4 The notice shall be given by first-class mail, postage
5 prepaid, to the psychotherapist's, unlicensed health
6 professional's, or unlicensed mental health professional's
7 usual place of business or, if that person has no usual place
8 of business, to that person's last known address.
9 (d) The action may be brought either in the circuit
10 court of the county in which the conduct complained of
11 occurred or in the circuit court of the county in which the
12 psychotherapist, unlicensed health professional, or
13 unlicensed mental health professional resides or has his or
14 her principal place of business.
15 The court may issue temporary restraining orders or
16 preliminary or permanent injunctions and make other orders or
17 judgments it deems appropriate.
18 (e) No injunction shall be issued under this Section
19 unless the court finds that the defendant has had an
20 opportunity for an evidentiary hearing as to all contested
21 material issues of fact. Issues decided in a prior
22 evidentiary hearing in a court or in an administrative
23 proceeding may be applied to a proceeding under this Section
24 in compliance with the Code of Civil Procedure.
25 If the court issues an injunction against a
26 psychotherapist, unlicensed health professional, or
27 unlicensed mental health professional under this Section, the
28 court shall retain jurisdiction of the matter and the cause
29 shall be continued. Any psychotherapist, unlicensed health
30 professional, or unlicensed mental health professional who is
31 ordered to refrain from certain conduct or activities in an
32 action brought under this Section may petition the court for
33 a modification or termination of the injunction upon 10 days
34 notice to the Attorney General.
35 (f) Any State's Attorney or other law enforcement office
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1 receiving notice of any alleged violation of this Section or
2 violation of an injunction or order issued in an action
3 brought under this Section shall immediately forward written
4 notice of the alleged violation together with any information
5 that the State's Attorney or other law enforcement office may
6 have to the office of the Attorney General.
7 (g) In an action brought under this Section, whenever
8 the court issues a temporary restraining order or a
9 preliminary or permanent injunction ordering a defendant to
10 refrain from certain conduct or activities, the order shall
11 contain the following statement:
12 VIOLATION OF THIS ORDER IS A CRIMINAL OFFENSE.
13 The clerk shall transmit 2 certified copies of each such
14 order issued under this Section to each appropriate law
15 enforcement agency having jurisdiction over locations where
16 the defendant is alleged to have committed the act giving
17 rise to the action, and the law enforcement agency shall
18 serve one copy of the order on the defendant. Unless
19 otherwise ordered by the court, service shall be by
20 delivering a copy in hand to the defendant.
21 After any such order has been served on the defendant,
22 any violation of the order by the defendant is a Class 4
23 felony punishable by a fine of not more than $25,000.
24 Law enforcement agencies shall establish procedures
25 adequate to ensure that all officers responsible for the
26 enforcement of an order entered under this Section are
27 informed of the existence and terms of the order. Whenever
28 any law enforcement officer has probable cause to believe
29 that a defendant has violated the provisions of this Section,
30 the officer has the authority to arrest the defendant.
31 Whenever the court vacates a temporary restraining order
32 or a preliminary or permanent injunction issued under this
33 Section, the clerk shall promptly notify in writing each
34 appropriate law enforcement agency that has been notified of
35 the issuance of the order and shall direct each such agency
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1 to destroy all records of the vacated order. The law
2 enforcement agency shall comply with that directive.
3 (h) Nothing contained in this Section shall prohibit the
4 Attorney General in his or her discretion from bringing an
5 action for civil contempt against the defendant rather than
6 bringing criminal charges for an alleged violation of an
7 order issued under this Section as provided in subsection
8 (g). If the court finds that a psychotherapist, unlicensed
9 health professional, or unlicensed mental health professional
10 is in civil contempt by reason of an alleged violation of an
11 injunction or the order entered under this Section, the court
12 shall assess a civil penalty of not more than $10,000 for
13 each such violation found.
14 (Source: P.A. 85-1254.)
15 (740 ILCS 140/3) (from Ch. 70, par. 803)
16 Sec. 3. Liability of employer. An employer of a
17 psychotherapist, unlicensed health professional, or
18 unlicensed mental health professional may be liable under
19 Section 2 if the employer fails or refuses to take reasonable
20 action when the employer knows or has reason to know that the
21 psychotherapist, unlicensed health professional, or
22 unlicensed mental health professional engaged in sexual
23 contact with the plaintiff or any other patient or former
24 patient of the psychotherapist, unlicensed health
25 professional, or unlicensed mental health professional.
26 (Source: P.A. 85-1254.)
27 Section 25. The Health Care Surrogate Act is amended by
28 changing Section 10 as follows:
29 (755 ILCS 40/10) (from Ch. 110 1/2, par. 851-10)
30 Sec. 10. Definitions.
31 "Adult" means a person who is (i) 18 years of age or
32 older or (ii) an emancipated minor under the Emancipation of
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1 Mature Minors Act.
2 "Artificial nutrition and hydration" means supplying food
3 and water through a conduit, such as a tube or intravenous
4 line, where the recipient is not required to chew or swallow
5 voluntarily, including, but not limited to, nasogastric
6 tubes, gastrostomies, jejunostomies, and intravenous
7 infusions. Artificial nutrition and hydration does not
8 include assisted feeding, such as spoon or bottle feeding.
9 "Available" means that a person is not "unavailable". A
10 person is unavailable if (i) the person's existence is not
11 known, (ii) the person has not been able to be contacted by
12 telephone or mail, or (iii) the person lacks decisional
13 capacity, refuses to accept the office of surrogate, or is
14 unwilling to respond in a manner that indicates a choice
15 among the life-sustaining treatment matters at issue.
16 "Attending physician" means the physician selected by or
17 assigned to the patient who has primary responsibility for
18 treatment and care of the patient and who is a licensed
19 physician in Illinois. If more than one physician shares
20 that responsibility, any of those physicians may act as the
21 attending physician under this Act.
22 "Close friend" means any person 18 years of age or older
23 who has exhibited special care and concern for the patient
24 and who presents an affidavit to the attending physician
25 stating that he or she (i) is a close friend of the patient,
26 (ii) is willing and able to become involved in the patient's
27 health care, and (iii) has maintained such regular contact
28 with the patient as to be familiar with the patient's
29 activities, health, and religious and moral beliefs. The
30 affidavit must also state facts and circumstances that
31 demonstrate that familiarity.
32 "Death" means when, according to accepted medical
33 standards, there is (i) an irreversible cessation of
34 circulatory and respiratory functions or (ii) an irreversible
35 cessation of all functions of the entire brain, including the
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1 brain stem.
2 "Decisional capacity" means the ability to understand and
3 appreciate the nature and consequences of a decision
4 regarding forgoing life-sustaining treatment and the ability
5 to reach and communicate an informed decision in the matter
6 as determined by the attending physician.
7 "Forgo life-sustaining treatment" means to withhold,
8 withdraw, or terminate all or any portion of life-sustaining
9 treatment with knowledge that the patient's death is likely
10 to result.
11 "Guardian" means a court appointed guardian of the person
12 who serves as a representative of a minor or as a
13 representative of a person under legal disability.
14 "Health care facility" means a type of health care
15 provider commonly known by a wide variety of titles,
16 including but not limited to, hospitals, medical centers,
17 nursing homes, rehabilitation centers, long term or tertiary
18 care facilities, and other facilities established to
19 administer health care and provide overnight stays in their
20 ordinary course of business or practice.
21 "Health care provider" means a person that is licensed,
22 certified, or otherwise authorized or permitted by the law of
23 this State to administer health care in the ordinary course
24 of business or practice of a profession, including, but not
25 limited to, physicians, nurses, health care facilities, and
26 any employee, officer, director, agent, or person under
27 contract with such a person.
28 "Imminent" (as in "death is imminent") means a
29 determination made by the attending physician according to
30 accepted medical standards that death will occur in a
31 relatively short period of time, even if life-sustaining
32 treatment is initiated or continued.
33 "Life-sustaining treatment" means any medical treatment,
34 procedure, or intervention that, in the judgment of the
35 attending physician, when applied to a patient with a
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1 qualifying condition, would not be effective to remove the
2 qualifying condition or would serve only to prolong the dying
3 process. Those procedures can include, but are not limited
4 to, assisted ventilation, renal dialysis, surgical
5 procedures, blood transfusions, and the administration of
6 drugs, antibiotics, and artificial nutrition and hydration.
7 "Minor" means an individual who is not an adult as
8 defined in this Act.
9 "Parent" means a person who is the natural or adoptive
10 mother or father of the child and whose parental rights have
11 not been terminated by a court of law.
12 "Patient" means an adult or minor individual, unless
13 otherwise specified, under the care or treatment of a
14 licensed physician or other health care provider.
15 "Person" means an individual, a corporation, a business
16 trust, a trust, a partnership, an association, a government,
17 a governmental subdivision or agency, or any other legal
18 entity.
19 "Qualifying condition" means the existence of one or more
20 of the following conditions in a patient certified in writing
21 in the patient's medical record by the attending physician
22 and by at least one other qualified physician:
23 (1) "Terminal condition" means an illness or injury
24 for which there is no reasonable prospect of cure or
25 recovery, death is imminent, and the application of
26 life-sustaining treatment would only prolong the dying
27 process.
28 (2) "Permanent unconsciousness" means a condition
29 that, to a high degree of medical certainty, (i) will
30 last permanently, without improvement, (ii) in which
31 thought, sensation, purposeful action, social
32 interaction, and awareness of self and environment are
33 absent, and (iii) for which initiating or continuing
34 life-sustaining treatment, in light of the patient's
35 medical condition, provides only minimal medical benefit.
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1 (3) "Incurable or irreversible condition" means an
2 illness or injury (i) for which there is no reasonable
3 prospect of cure or recovery, (ii) that ultimately will
4 cause the patient's death even if life-sustaining
5 treatment is initiated or continued, (iii) that imposes
6 severe pain or otherwise imposes an inhumane burden on
7 the patient, and (iv) for which initiating or continuing
8 life-sustaining treatment, in light of the patient's
9 medical condition, provides only minimal medical benefit.
10 The determination that a patient has a qualifying
11 condition creates no presumption regarding the application or
12 non-application of life-sustaining treatment. It is only
13 after a determination by the attending physician that the
14 patient has a qualifying condition that the surrogate
15 decision maker may consider whether or not to forgo
16 life-sustaining treatment. In making this decision, the
17 surrogate shall weigh the burdens on the patient of
18 initiating or continuing life-sustaining treatment against
19 the benefits of that treatment.
20 "Qualified physician" means a physician licensed to
21 practice medicine in all of its branches in Illinois who has
22 personally examined the patient.
23 "Surrogate decision maker" means an adult individual or
24 individuals who (i) have decisional capacity, (ii) are
25 available upon reasonable inquiry, (iii) are willing to make
26 decisions regarding the forgoing of life-sustaining treatment
27 on behalf of a patient who lacks decisional capacity and is
28 diagnosed as suffering from a qualifying condition, and (iv)
29 are identified by the attending physician in accordance with
30 the provisions of this Act as the person or persons who are
31 to make those decisions in accordance with the provisions of
32 this Act.
33 (Source: P.A. 87-749; 88-670, eff. 12-2-94.)
34 Section 95. No acceleration or delay. Where this Act
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1 makes changes in a statute that is represented in this Act by
2 text that is not yet or no longer in effect (for example, a
3 Section represented by multiple versions), the use of that
4 text does not accelerate or delay the taking effect of (i)
5 the changes made by this Act or (ii) provisions derived from
6 any other Public Act.".
7 Submitted on , 1997.
8 ______________________________ _____________________________
9 Senator Syverson Representative Currie
10 ______________________________ _____________________________
11 Senator Parker Representative Pugh
12 ______________________________ _____________________________
13 Senator Cronin Representative Hannig
14 ______________________________ _____________________________
15 Senator Smith Representative Zickus
16 ______________________________ _____________________________
17 Senator Garcia Representative Churchill
18 Committee for the Senate Committee for the House