State of Illinois
90th General Assembly
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90_SB0882

      305 ILCS 5/5-5            from Ch. 23, par. 5-5
          Amends the Medicaid  Article  of  the  Public  Aid  Code.
      Makes  stylistic  changes in a Section concerning requirement
      that the Department of Public  Aid  provide  certain  medical
      services for persons participating in education, training, or
      employment programs.
                                                     LRB9003202DJmg
                                               LRB9003202DJmg
 1        AN  ACT to amend the Illinois Public Aid Code by changing
 2    Section 5-5.
 3        Be it enacted by the People of  the  State  of  Illinois,
 4    represented in the General Assembly:
 5        Section  5.   The  Illinois Public Aid Code is amended by
 6    changing Section 5-5 as follows:
 7        (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
 8        (Text of Section before amendment by P.A. 89-507)
 9        Sec. 5-5.  Medical services. The Illinois Department,  by
10    rule,  shall  determine  the  quantity and quality of and the
11    rate of reimbursement for the medical  assistance  for  which
12    payment  will  be  authorized, and the medical services to be
13    provided, which may include all or part of the following: (1)
14    inpatient  hospital   services;   (2)   outpatient   hospital
15    services;  (3)  other  laboratory  and  X-ray  services;  (4)
16    skilled  nursing  home  services;  (5)  physicians'  services
17    whether  furnished  in  the  office,  the  patient's  home, a
18    hospital, a skilled nursing home, or elsewhere;  (6)  medical
19    care,  or  any  other  type  of  remedial  care  furnished by
20    licensed practitioners; (7) home health  care  services;  (8)
21    private  duty  nursing  service;  (9)  clinic  services; (10)
22    dental services; (11) physical therapy and related  services;
23    (12)  prescribed drugs, dentures, and prosthetic devices; and
24    eyeglasses prescribed by a physician skilled in the  diseases
25    of  the  eye,  or by an optometrist, whichever the person may
26    select; (13) other  diagnostic,  screening,  preventive,  and
27    rehabilitative  services;  (14) transportation and such other
28    expenses as may  be  necessary;  (15)  medical  treatment  of
29    sexual  assault  survivors,  as  defined in Section 1a of the
30    Sexual  Assault  Survivors  Emergency  Treatment   Act,   for
31    injuries  sustained  as  a  result  of  the  sexual  assault,
                            -2-                LRB9003202DJmg
 1    including  examinations  and  laboratory  tests  to  discover
 2    evidence  which  may  be used in criminal proceedings arising
 3    from the sexual assault; (16) the diagnosis and treatment  of
 4    sickle  cell anemia; and (17) any other medical care, and any
 5    other type of remedial care recognized under the laws of this
 6    State, but not including abortions, or  induced  miscarriages
 7    or  premature  births, unless, in the opinion of a physician,
 8    such procedures are necessary for  the  preservation  of  the
 9    life  of  the  woman  seeking  such  treatment,  or except an
10    induced premature birth intended to  produce  a  live  viable
11    child  and  such procedure is necessary for the health of the
12    mother or her unborn child. The Illinois Department, by rule,
13    shall  prohibit  any   physician   from   providing   medical
14    assistance  to anyone eligible therefor under this Code where
15    such  physician  has  been  found  guilty  of  performing  an
16    abortion procedure in a wilful and wanton manner upon a woman
17    who was not pregnant at the time such abortion procedure  was
18    performed.  The  term "any other type of remedial care" shall
19    include nursing care and nursing home service for persons who
20    rely on treatment by spiritual means alone through prayer for
21    healing.
22        The  Illinois  Department  shall  provide  the  following
23    services to persons who are  eligible  for  assistance  under
24    this Article and who are participating in education, training
25    or employment programs:
26             (1)  dental services, which shall include but not be
27        limited to prosthodontics; and
28             (2)  eyeglasses prescribed by a physician skilled in
29        the  diseases of the eye, or by an optometrist, whichever
30        the person may select.
31        The Illinois Department, by  rule,  may  distinguish  and
32    classify   the  medical  services  to  be  provided  only  in
33    accordance with the classes of persons designated in  Section
34    5-2.
                            -3-                LRB9003202DJmg
 1        The Illinois Department shall authorize the provision of,
 2    and  shall  authorize  payment  for,  screening  by  low-dose
 3    mammography  for  the  presence  of  occult breast cancer for
 4    women 35 years of age or older who are eligible  for  medical
 5    assistance  under  this  Article,  as  follows:   a  baseline
 6    mammogram  for women 35 to 39 years of age; a mammogram every
 7    1 to 2 years, even if no symptoms are present, for  women  40
 8    to  49  years  of  age;  and an annual mammogram for women 50
 9    years of age  or  older.   All  screenings  shall  include  a
10    physical  breast  exam,  instruction  on self-examination and
11    information regarding the frequency of  self-examination  and
12    its  value  as a preventative tool.  As used in this Section,
13    "low-dose mammography" means the  x-ray  examination  of  the
14    breast    using    equipment   dedicated   specifically   for
15    mammography, including the x-ray  tube,  filter,  compression
16    device,  image  receptor,  and  cassettes,  with  an  average
17    radiation  exposure delivery of less than one rad mid-breast,
18    with 2 views for each breast.
19        Any medical or health  care  provider  shall  immediately
20    recommend,  to  any  pregnant  woman  who  is  being provided
21    prenatal services and  is  suspected  of  drug  abuse  or  is
22    addicted  as  defined  in the Alcoholism and Other Drug Abuse
23    and Dependency Act,  referral  to  a  local  substance  abuse
24    treatment  provider  licensed by the Department of Alcoholism
25    and Substance Abuse or to a licensed hospital which  provides
26    substance abuse treatment services.  The Department of Public
27    Aid  shall  assure  coverage for the cost of treatment of the
28    drug abuse or addiction for pregnant recipients in accordance
29    with the Illinois Medicaid Program in  conjunction  with  the
30    Department of Alcoholism and Substance Abuse.
31        All  medical  providers  providing  medical assistance to
32    pregnant women under this Code shall receive information from
33    the Department on the availability of services under the Drug
34    Free  Families  with  a  Future  or  any  comparable  program
                            -4-                LRB9003202DJmg
 1    providing  case  management  services  for  addicted   women,
 2    including  information  on  appropriate  referrals  for other
 3    social services that may  be  needed  by  addicted  women  in
 4    addition to treatment for addiction.
 5        The   Illinois   Department,   in  cooperation  with  the
 6    Departments of Alcoholism  and  Substance  Abuse  and  Public
 7    Health,  through  a  public  awareness  campaign, may provide
 8    information concerning  treatment  for  alcoholism  and  drug
 9    abuse   and   addiction,  prenatal  health  care,  and  other
10    pertinent  programs  directed  at  reducing  the  number   of
11    drug-affected   infants   born   to   recipients  of  medical
12    assistance.
13        The Department shall not sanction the recipient solely on
14    the basis of her substance abuse.
15        The Illinois Department shall establish such  regulations
16    governing  the  dispensing  of  health  services  under  this
17    Article  as  it shall deem appropriate.  In formulating these
18    regulations the Illinois Department shall  consult  with  and
19    give substantial weight to the recommendations offered by the
20    Citizens  Assembly/Council  on  Public  Aid.  The  Department
21    should  seek  the  advice  of  formal  professional  advisory
22    committees   appointed   by  the  Director  of  the  Illinois
23    Department for the purpose of  providing  regular  advice  on
24    policy  and administrative matters, information dissemination
25    and  educational  activities  for  medical  and  health  care
26    providers, and consistency  in  procedures  to  the  Illinois
27    Department.
28        The  Illinois  Department  may  develop and contract with
29    Partnerships of medical providers to arrange medical services
30    for  persons  eligible  under  Section  5-2  of  this   Code.
31    Implementation  of  this  Section  may  be  by  demonstration
32    projects  in certain geographic areas.  The Partnership shall
33    be represented by a sponsor organization.  The Department, by
34    rule,  shall   develop   qualifications   for   sponsors   of
                            -5-                LRB9003202DJmg
 1    Partnerships.   Nothing in this Section shall be construed to
 2    require  that  the  sponsor   organization   be   a   medical
 3    organization.
 4        The  sponsor must negotiate formal written contracts with
 5    medical  providers  for  physician  services,  inpatient  and
 6    outpatient hospital care, home health services, treatment for
 7    alcoholism and substance abuse, and other services determined
 8    necessary by the Illinois Department by rule for delivery  by
 9    Partnerships.   Physician  services must include prenatal and
10    obstetrical care.  The Illinois  Department  shall  reimburse
11    medical   services  delivered  by  Partnership  providers  to
12    clients in target  areas  according  to  provisions  of  this
13    Article  and  the  Illinois Health Finance Reform Act, except
14    that:
15             (1)  Physicians participating in a  Partnership  and
16        providing  certain services, which shall be determined by
17        the Illinois Department, to persons in areas  covered  by
18        the  Partnership  may receive an additional surcharge for
19        such services.
20             (2)  The  Department  may  elect  to  consider   and
21        negotiate   financial   incentives   to   encourage   the
22        development of Partnerships and the efficient delivery of
23        medical care.
24             (3)  Persons   receiving  medical  services  through
25        Partnerships may  receive  medical  and  case  management
26        services  above  the  level  usually  offered through the
27        medical assistance program.
28        Medical providers  shall  be  required  to  meet  certain
29    qualifications  to  participate in Partnerships to ensure the
30    delivery   of   high   quality   medical   services.    These
31    qualifications shall be determined by rule  of  the  Illinois
32    Department   and   may  be  higher  than  qualifications  for
33    participation in the medical assistance program.  Partnership
34    sponsors may prescribe reasonable  additional  qualifications
                            -6-                LRB9003202DJmg
 1    for  participation  by medical providers, only with the prior
 2    written approval of the Illinois Department.
 3        Nothing in this Section shall limit the  free  choice  of
 4    practitioners,  hospitals,  and  other  providers  of medical
 5    services by clients.
 6        The Department shall apply for a waiver from  the  United
 7    States  Health Care Financing Administration to allow for the
 8    implementation of Partnerships under this Section.
 9        The  Illinois  Department  shall  require   health   care
10    providers  to maintain records that document the medical care
11    and services provided to  recipients  of  Medical  Assistance
12    under  this  Article.   The Illinois Department shall require
13    health care providers to make available, when  authorized  by
14    the  patient,  in  writing,  the  medical records in a timely
15    fashion to other health care providers who  are  treating  or
16    serving  persons  eligible  for Medical Assistance under this
17    Article.   All  dispensers  of  medical  services  shall   be
18    required  to  maintain  and  retain business and professional
19    records sufficient  to  fully  and  accurately  document  the
20    nature,  scope,  details  and  receipt  of  the  health  care
21    provided  to  persons  eligible  for medical assistance under
22    this Code, in accordance with regulations promulgated by  the
23    Illinois  Department. The rules and regulations shall require
24    that proof of the receipt of  prescription  drugs,  dentures,
25    prosthetic  devices  and eyeglasses by eligible persons under
26    this Section accompany each claim for reimbursement submitted
27    by the dispenser of such medical services. No such claims for
28    reimbursement shall be approved for payment by  the  Illinois
29    Department without such proof of receipt, unless the Illinois
30    Department  shall have put into effect and shall be operating
31    a system of post-payment audit and review which shall,  on  a
32    sampling basis, be deemed adequate by the Illinois Department
33    to  assure  that such drugs, dentures, prosthetic devices and
34    eyeglasses for which payment is being made are actually being
                            -7-                LRB9003202DJmg
 1    received by eligible recipients. Within  90  days  after  the
 2    effective  date  of this amendatory Act of 1984, the Illinois
 3    Department shall establish  a  current  list  of  acquisition
 4    costs   for  all  prosthetic  devices  and  any  other  items
 5    recognized as medical  equipment  and  supplies  reimbursable
 6    under  this Article and shall update such list on a quarterly
 7    basis, except that the acquisition costs of all  prescription
 8    drugs  shall be updated no less frequently than every 30 days
 9    as required by Section 5-5.12.
10        The rules and  regulations  of  the  Illinois  Department
11    shall require that a written statement including the required
12    opinion   of  a  physician  shall  accompany  any  claim  for
13    reimbursement  for  abortions,  or  induced  miscarriages  or
14    premature  births.   This  statement  shall   indicate   what
15    procedures were used in providing such medical services.
16        The Illinois Department shall require that all dispensers
17    of medical services, other than an individual practitioner or
18    group  of  practitioners,  desiring  to  participate  in  the
19    Medical  Assistance program established under this Article to
20    disclose all financial, beneficial, ownership, equity, surety
21    or other  interests  in  any  and  all  firms,  corporations,
22    partnerships,   associations,   business  enterprises,  joint
23    ventures, agencies,  institutions  or  other  legal  entities
24    providing  any  form  of  health  care services in this State
25    under this Article.
26        The Illinois Department may require that  all  dispensers
27    of  medical  services  desiring to participate in the medical
28    assistance program established under this  Article  disclose,
29    under  such  terms  and conditions as the Illinois Department
30    may  by  rule  establish,  all  inquiries  from  clients  and
31    attorneys  regarding  medical  bills  paid  by  the  Illinois
32    Department,  which   inquiries   could   indicate   potential
33    existence of claims or liens for the Illinois Department.
34        The   Illinois   Department   shall  establish  policies,
                            -8-                LRB9003202DJmg
 1    procedures,  standards  and  criteria   by   rule   for   the
 2    acquisition,   repair   and   replacement   of  orthotic  and
 3    prosthetic devices and durable medical equipment.  Such rules
 4    shall provide, but not be limited to, the following services:
 5    (1) immediate  repair  or  replacement  of  such  devices  by
 6    recipients  without  medical  authorization;  and (2) rental,
 7    lease,  purchase  or  lease-purchase   of   durable   medical
 8    equipment   in   a   cost-effective   manner,   taking   into
 9    consideration  the  recipient's medical prognosis, the extent
10    of the recipient's needs, and the requirements and costs  for
11    maintaining  such  equipment.   Such  rules  shall  enable  a
12    recipient  to  temporarily  acquire  and  use  alternative or
13    substitute  devices   or   equipment   pending   repairs   or
14    replacements of any device or equipment previously authorized
15    for  such recipient by the Department. Rules under clause (2)
16    above shall not provide for  purchase  or  lease-purchase  of
17    durable medical equipment or supplies used for the purpose of
18    oxygen delivery and respiratory care.
19        The  Department  shall  execute,  relative to the nursing
20    home prescreening project,  written  inter-agency  agreements
21    with  the  Department  of  Rehabilitation  Services  and  the
22    Department  on  Aging,  to  effect  the following: (i) intake
23    procedures and common eligibility criteria for those  persons
24    who  are  receiving  non-institutional services; and (ii) the
25    establishment and development of  non-institutional  services
26    in  areas of the State where they are not currently available
27    or are undeveloped.
28        The Illinois Department shall  develop  and  operate,  in
29    cooperation  with other State Departments and agencies and in
30    compliance with  applicable  federal  laws  and  regulations,
31    appropriate  and  effective systems of health care evaluation
32    and programs for monitoring of  utilization  of  health  care
33    services  and  facilities, as it affects persons eligible for
34    medical assistance under this Code. The  Illinois  Department
                            -9-                LRB9003202DJmg
 1    shall  report  regularly the results of the operation of such
 2    systems and programs  to  the  Citizens  Assembly/Council  on
 3    Public  Aid  to  enable the Committee to ensure, from time to
 4    time, that these programs are effective and meaningful.
 5        The Illinois Department  shall  report  annually  to  the
 6    General Assembly, no later than the second Friday in April of
 7    1979 and each year thereafter, in regard to:
 8             (a)  actual  statistics and trends in utilization of
 9        medical services by public aid recipients;
10             (b)  actual statistics and trends in  the  provision
11        of the various medical services by medical vendors;
12             (c)  current rate structures and proposed changes in
13        those  rate  structures  for the various medical vendors;
14        and
15             (d)  efforts at utilization review  and  control  by
16        the Illinois Department.
17        The  period  covered  by each report shall be the 3 years
18    ending on the June 30 prior to the report.  The report  shall
19    include   suggested  legislation  for  consideration  by  the
20    General Assembly.  The filing of one copy of the report  with
21    the  Speaker,  one copy with the Minority Leader and one copy
22    with the Clerk of the House of Representatives, one copy with
23    the President, one copy with the Minority Leader and one copy
24    with  the  Secretary  of  the  Senate,  one  copy  with   the
25    Legislative  Research  Unit,  such additional copies with the
26    State Government Report Distribution Center for  the  General
27    Assembly  as  is required under paragraph (t) of Section 7 of
28    the  State  Library  Act  and  one  copy  with  the  Citizens
29    Assembly/Council on Public Aid  or  its  successor  shall  be
30    deemed sufficient to comply with this Section.
31    (Source:  P.A.  88-670,  eff.  12-2-94;  89-21,  eff. 7-1-95;
32    89-517, eff. 1-1-97.)
33        (Text of Section after amendment by P.A. 89-507)
34        Sec. 5-5.  Medical services. The Illinois Department,  by
                            -10-               LRB9003202DJmg
 1    rule,  shall  determine  the  quantity and quality of and the
 2    rate of reimbursement for the medical  assistance  for  which
 3    payment  will  be  authorized, and the medical services to be
 4    provided, which may include all or part of the following: (1)
 5    inpatient  hospital   services;   (2)   outpatient   hospital
 6    services;  (3)  other  laboratory  and  X-ray  services;  (4)
 7    skilled  nursing  home  services;  (5)  physicians'  services
 8    whether  furnished  in  the  office,  the  patient's  home, a
 9    hospital, a skilled nursing home, or elsewhere;  (6)  medical
10    care,  or  any  other  type  of  remedial  care  furnished by
11    licensed practitioners; (7) home health  care  services;  (8)
12    private  duty  nursing  service;  (9)  clinic  services; (10)
13    dental services; (11) physical therapy and related  services;
14    (12)  prescribed drugs, dentures, and prosthetic devices; and
15    eyeglasses prescribed by a physician skilled in the  diseases
16    of  the  eye,  or by an optometrist, whichever the person may
17    select; (13) other  diagnostic,  screening,  preventive,  and
18    rehabilitative  services;  (14) transportation and such other
19    expenses as may  be  necessary;  (15)  medical  treatment  of
20    sexual  assault  survivors,  as  defined in Section 1a of the
21    Sexual  Assault  Survivors  Emergency  Treatment   Act,   for
22    injuries  sustained  as  a  result  of  the  sexual  assault,
23    including  examinations  and  laboratory  tests  to  discover
24    evidence  which  may  be used in criminal proceedings arising
25    from the sexual assault; (16) the diagnosis and treatment  of
26    sickle  cell anemia; and (17) any other medical care, and any
27    other type of remedial care recognized under the laws of this
28    State, but not including abortions, or  induced  miscarriages
29    or  premature  births, unless, in the opinion of a physician,
30    such procedures are necessary for  the  preservation  of  the
31    life  of  the  woman  seeking  such  treatment,  or except an
32    induced premature birth intended to  produce  a  live  viable
33    child  and  such procedure is necessary for the health of the
34    mother or her unborn child. The Illinois Department, by rule,
                            -11-               LRB9003202DJmg
 1    shall  prohibit  any   physician   from   providing   medical
 2    assistance  to anyone eligible therefor under this Code where
 3    such  physician  has  been  found  guilty  of  performing  an
 4    abortion procedure in a wilful and wanton manner upon a woman
 5    who was not pregnant at the time such abortion procedure  was
 6    performed.  The  term "any other type of remedial care" shall
 7    include nursing care and nursing home service for persons who
 8    rely on treatment by spiritual means alone through prayer for
 9    healing.
10        The Illinois Department of Public Aid shall  provide  the
11    following services to persons who are eligible for assistance
12    under  this  Article  and who are participating in education,
13    training or employment programs operated by the Department of
14    Human Services as successor to the Department of Public Aid:
15             (1)  dental services, which shall include but not be
16        limited to prosthodontics; and
17             (2)  eyeglasses prescribed by a physician skilled in
18        the diseases of the eye, or by an optometrist,  whichever
19        the person may select.
20        The  Illinois  Department,  by  rule, may distinguish and
21    classify  the  medical  services  to  be  provided  only   in
22    accordance  with the classes of persons designated in Section
23    5-2.
24        The Illinois Department shall authorize the provision of,
25    and  shall  authorize  payment  for,  screening  by  low-dose
26    mammography for the presence  of  occult  breast  cancer  for
27    women  35  years of age or older who are eligible for medical
28    assistance  under  this  Article,  as  follows:   a  baseline
29    mammogram for women 35 to 39 years of age; a mammogram  every
30    1  to  2 years, even if no symptoms are present, for women 40
31    to 49 years of age; and an  annual  mammogram  for  women  50
32    years  of  age  or  older.   All  screenings  shall include a
33    physical breast exam,  instruction  on  self-examination  and
34    information  regarding  the frequency of self-examination and
                            -12-               LRB9003202DJmg
 1    its value as a preventative tool.  As used in  this  Section,
 2    "low-dose  mammography"  means  the  x-ray examination of the
 3    breast   using   equipment   dedicated    specifically    for
 4    mammography,  including  the  x-ray tube, filter, compression
 5    device,  image  receptor,  and  cassettes,  with  an  average
 6    radiation exposure delivery of less than one rad  mid-breast,
 7    with 2 views for each breast.
 8        Any  medical  or  health  care provider shall immediately
 9    recommend, to  any  pregnant  woman  who  is  being  provided
10    prenatal  services  and  is  suspected  of  drug  abuse or is
11    addicted as defined in the Alcoholism and  Other  Drug  Abuse
12    and  Dependency  Act,  referral  to  a  local substance abuse
13    treatment  provider  licensed  by  the  Department  of  Human
14    Services or to a licensed hospital which  provides  substance
15    abuse treatment services.  The Department of Public Aid shall
16    assure  coverage  for the cost of treatment of the drug abuse
17    or addiction for pregnant recipients in accordance  with  the
18    Illinois  Medicaid Program in conjunction with the Department
19    of Human Services.
20        All medical providers  providing  medical  assistance  to
21    pregnant women under this Code shall receive information from
22    the Department on the availability of services under the Drug
23    Free  Families  with  a  Future  or  any  comparable  program
24    providing   case  management  services  for  addicted  women,
25    including information  on  appropriate  referrals  for  other
26    social  services  that  may  be  needed  by addicted women in
27    addition to treatment for addiction.
28        The  Illinois  Department,  in   cooperation   with   the
29    Departments of Human Services (as successor to the Department
30    of Alcoholism and Substance Abuse) and Public Health, through
31    a   public   awareness   campaign,  may  provide  information
32    concerning  treatment  for  alcoholism  and  drug  abuse  and
33    addiction, prenatal health care, and other pertinent programs
34    directed at reducing the number of drug-affected infants born
                            -13-               LRB9003202DJmg
 1    to recipients of medical assistance.
 2        Neither the Illinois Department of  Public  Aid  nor  the
 3    Department  of  Human  Services  shall sanction the recipient
 4    solely on the basis of her substance abuse.
 5        The Illinois Department shall establish such  regulations
 6    governing  the  dispensing  of  health  services  under  this
 7    Article  as  it shall deem appropriate.  In formulating these
 8    regulations the Illinois Department shall  consult  with  and
 9    give substantial weight to the recommendations offered by the
10    Citizens  Assembly/Council  on  Public  Aid.  The  Department
11    should  seek  the  advice  of  formal  professional  advisory
12    committees   appointed   by  the  Director  of  the  Illinois
13    Department for the purpose of  providing  regular  advice  on
14    policy  and administrative matters, information dissemination
15    and  educational  activities  for  medical  and  health  care
16    providers, and consistency  in  procedures  to  the  Illinois
17    Department.
18        The  Illinois  Department  may  develop and contract with
19    Partnerships of medical providers to arrange medical services
20    for  persons  eligible  under  Section  5-2  of  this   Code.
21    Implementation  of  this  Section  may  be  by  demonstration
22    projects  in certain geographic areas.  The Partnership shall
23    be represented by a sponsor organization.  The Department, by
24    rule,  shall   develop   qualifications   for   sponsors   of
25    Partnerships.   Nothing in this Section shall be construed to
26    require  that  the  sponsor   organization   be   a   medical
27    organization.
28        The  sponsor must negotiate formal written contracts with
29    medical  providers  for  physician  services,  inpatient  and
30    outpatient hospital care, home health services, treatment for
31    alcoholism and substance abuse, and other services determined
32    necessary by the Illinois Department by rule for delivery  by
33    Partnerships.   Physician  services must include prenatal and
34    obstetrical care.  The Illinois  Department  shall  reimburse
                            -14-               LRB9003202DJmg
 1    medical   services  delivered  by  Partnership  providers  to
 2    clients in target  areas  according  to  provisions  of  this
 3    Article  and  the  Illinois Health Finance Reform Act, except
 4    that:
 5             (1)  Physicians participating in a  Partnership  and
 6        providing  certain services, which shall be determined by
 7        the Illinois Department, to persons in areas  covered  by
 8        the  Partnership  may receive an additional surcharge for
 9        such services.
10             (2)  The  Department  may  elect  to  consider   and
11        negotiate   financial   incentives   to   encourage   the
12        development of Partnerships and the efficient delivery of
13        medical care.
14             (3)  Persons   receiving  medical  services  through
15        Partnerships may  receive  medical  and  case  management
16        services  above  the  level  usually  offered through the
17        medical assistance program.
18        Medical providers  shall  be  required  to  meet  certain
19    qualifications  to  participate in Partnerships to ensure the
20    delivery   of   high   quality   medical   services.    These
21    qualifications shall be determined by rule  of  the  Illinois
22    Department   and   may  be  higher  than  qualifications  for
23    participation in the medical assistance program.  Partnership
24    sponsors may prescribe reasonable  additional  qualifications
25    for  participation  by medical providers, only with the prior
26    written approval of the Illinois Department.
27        Nothing in this Section shall limit the  free  choice  of
28    practitioners,  hospitals,  and  other  providers  of medical
29    services by clients.
30        The Department shall apply for a waiver from  the  United
31    States  Health Care Financing Administration to allow for the
32    implementation of Partnerships under this Section.
33        The  Illinois  Department  shall  require   health   care
34    providers  to maintain records that document the medical care
                            -15-               LRB9003202DJmg
 1    and services provided to  recipients  of  Medical  Assistance
 2    under  this  Article.   The Illinois Department shall require
 3    health care providers to make available, when  authorized  by
 4    the  patient,  in  writing,  the  medical records in a timely
 5    fashion to other health care providers who  are  treating  or
 6    serving  persons  eligible  for Medical Assistance under this
 7    Article.   All  dispensers  of  medical  services  shall   be
 8    required  to  maintain  and  retain business and professional
 9    records sufficient  to  fully  and  accurately  document  the
10    nature,  scope,  details  and  receipt  of  the  health  care
11    provided  to  persons  eligible  for medical assistance under
12    this Code, in accordance with regulations promulgated by  the
13    Illinois  Department. The rules and regulations shall require
14    that proof of the receipt of  prescription  drugs,  dentures,
15    prosthetic  devices  and eyeglasses by eligible persons under
16    this Section accompany each claim for reimbursement submitted
17    by the dispenser of such medical services. No such claims for
18    reimbursement shall be approved for payment by  the  Illinois
19    Department without such proof of receipt, unless the Illinois
20    Department  shall have put into effect and shall be operating
21    a system of post-payment audit and review which shall,  on  a
22    sampling basis, be deemed adequate by the Illinois Department
23    to  assure  that such drugs, dentures, prosthetic devices and
24    eyeglasses for which payment is being made are actually being
25    received by eligible recipients. Within  90  days  after  the
26    effective  date  of this amendatory Act of 1984, the Illinois
27    Department shall establish  a  current  list  of  acquisition
28    costs   for  all  prosthetic  devices  and  any  other  items
29    recognized as medical  equipment  and  supplies  reimbursable
30    under  this Article and shall update such list on a quarterly
31    basis, except that the acquisition costs of all  prescription
32    drugs  shall be updated no less frequently than every 30 days
33    as required by Section 5-5.12.
34        The rules and  regulations  of  the  Illinois  Department
                            -16-               LRB9003202DJmg
 1    shall require that a written statement including the required
 2    opinion   of  a  physician  shall  accompany  any  claim  for
 3    reimbursement  for  abortions,  or  induced  miscarriages  or
 4    premature  births.   This  statement  shall   indicate   what
 5    procedures were used in providing such medical services.
 6        The Illinois Department shall require that all dispensers
 7    of medical services, other than an individual practitioner or
 8    group  of  practitioners,  desiring  to  participate  in  the
 9    Medical  Assistance program established under this Article to
10    disclose all financial, beneficial, ownership, equity, surety
11    or other  interests  in  any  and  all  firms,  corporations,
12    partnerships,   associations,   business  enterprises,  joint
13    ventures, agencies,  institutions  or  other  legal  entities
14    providing  any  form  of  health  care services in this State
15    under this Article.
16        The Illinois Department may require that  all  dispensers
17    of  medical  services  desiring to participate in the medical
18    assistance program established under this  Article  disclose,
19    under  such  terms  and conditions as the Illinois Department
20    may  by  rule  establish,  all  inquiries  from  clients  and
21    attorneys  regarding  medical  bills  paid  by  the  Illinois
22    Department,  which   inquiries   could   indicate   potential
23    existence of claims or liens for the Illinois Department.
24        The   Illinois   Department   shall  establish  policies,
25    procedures,  standards  and  criteria   by   rule   for   the
26    acquisition,   repair   and   replacement   of  orthotic  and
27    prosthetic devices and durable medical equipment.  Such rules
28    shall provide, but not be limited to, the following services:
29    (1) immediate  repair  or  replacement  of  such  devices  by
30    recipients  without  medical  authorization;  and (2) rental,
31    lease,  purchase  or  lease-purchase   of   durable   medical
32    equipment   in   a   cost-effective   manner,   taking   into
33    consideration  the  recipient's medical prognosis, the extent
34    of the recipient's needs, and the requirements and costs  for
                            -17-               LRB9003202DJmg
 1    maintaining  such  equipment.   Such  rules  shall  enable  a
 2    recipient  to  temporarily  acquire  and  use  alternative or
 3    substitute  devices   or   equipment   pending   repairs   or
 4    replacements of any device or equipment previously authorized
 5    for  such recipient by the Department. Rules under clause (2)
 6    above shall not provide for  purchase  or  lease-purchase  of
 7    durable medical equipment or supplies used for the purpose of
 8    oxygen delivery and respiratory care.
 9        The  Department  shall  execute,  relative to the nursing
10    home prescreening project,  written  inter-agency  agreements
11    with  the  Department of Human Services and the Department on
12    Aging, to effect the following:  (i)  intake  procedures  and
13    common   eligibility  criteria  for  those  persons  who  are
14    receiving   non-institutional   services;   and   (ii)    the
15    establishment  and  development of non-institutional services
16    in areas of the State where they are not currently  available
17    or are undeveloped.
18        The  Illinois  Department  shall  develop and operate, in
19    cooperation with other State Departments and agencies and  in
20    compliance  with  applicable  federal  laws  and regulations,
21    appropriate and effective systems of health  care  evaluation
22    and  programs  for  monitoring  of utilization of health care
23    services and facilities, as it affects persons  eligible  for
24    medical  assistance  under this Code. The Illinois Department
25    shall report regularly the results of the operation  of  such
26    systems  and  programs  to  the  Citizens Assembly/Council on
27    Public Aid to enable the Committee to ensure,  from  time  to
28    time, that these programs are effective and meaningful.
29        The  Illinois  Department  shall  report  annually to the
30    General Assembly, no later than the second Friday in April of
31    1979 and each year thereafter, in regard to:
32             (a)  actual statistics and trends in utilization  of
33        medical services by public aid recipients;
34             (b)  actual  statistics  and trends in the provision
                            -18-               LRB9003202DJmg
 1        of the various medical services by medical vendors;
 2             (c)  current rate structures and proposed changes in
 3        those rate structures for the  various  medical  vendors;
 4        and
 5             (d)  efforts  at  utilization  review and control by
 6        the Illinois Department.
 7        The period covered by each report shall be  the  3  years
 8    ending  on the June 30 prior to the report.  The report shall
 9    include  suggested  legislation  for  consideration  by   the
10    General  Assembly.  The filing of one copy of the report with
11    the Speaker, one copy with the Minority Leader and  one  copy
12    with the Clerk of the House of Representatives, one copy with
13    the President, one copy with the Minority Leader and one copy
14    with   the  Secretary  of  the  Senate,  one  copy  with  the
15    Legislative Research Unit, such additional  copies  with  the
16    State  Government  Report Distribution Center for the General
17    Assembly as is required under paragraph (t) of Section  7  of
18    the  State  Library  Act  and  one  copy  with  the  Citizens
19    Assembly/Council  on  Public  Aid  or  its successor shall be
20    deemed sufficient to comply with this Section.
21    (Source: P.A.  88-670,  eff.  12-2-94;  89-21,  eff.  7-1-95;
22    89-507, eff. 7-1-97; 89-517, eff. 1-1-97; revised 8-26-96.)
23        Section  95.   No  acceleration or delay.  Where this Act
24    makes changes in a statute that is represented in this Act by
25    text that is not yet or no longer in effect (for  example,  a
26    Section  represented  by  multiple versions), the use of that
27    text does not accelerate or delay the taking  effect  of  (i)
28    the  changes made by this Act or (ii) provisions derived from
29    any other Public Act.

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