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| [ Introduced ] | [ Enrolled ] | [ Senate Amendment 001 ] |
91_SB0498eng SB498 Engrossed LRB9101554SMdv 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 Sec. 5-5. Medical services. The Illinois Department, by 9 rule, shall determine the quantity and quality of and the 10 rate of reimbursement for the medical assistance for which 11 payment will be authorized, and the medical services to be 12 provided, which may include all or part of the following: (1) 13 inpatient hospital services; (2) outpatient hospital 14 services; (3) other laboratory and X-ray services; (4) 15 skilled nursing home services; (5) physicians' services 16 whether furnished in the office, the patient's home, a 17 hospital, a skilled nursing home, or elsewhere; (6) medical 18 care, or any other type of remedial care furnished by 19 licensed practitioners; (7) home health care services; (8) 20 private duty nursing service; (9) clinic services; (10) 21 dental services; (11) physical therapy and related services; 22 (12) prescribed drugs, dentures, and prosthetic devices; and 23 eyeglasses prescribed by a physician skilled in the diseases 24 of the eye, or by an optometrist, whichever the person may 25 select; (13) other diagnostic, screening, preventive, and 26 rehabilitative services; (14) transportation and such other 27 expenses as may be necessary; (15) medical treatment of 28 sexual assault survivors, as defined in Section 1a of the 29 Sexual Assault Survivors Emergency Treatment Act, for 30 injuries sustained as a result of the sexual assault, SB498 Engrossed -2- LRB9101554SMdv 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 of Public Aid shall provide the 23 following services to persons eligible for assistance under 24 this Article who are participating in education, training or 25 employment programs operated by the Department of Human 26 Services as successor to the Department of Public Aid: 27 (1) dental services, which shall include but not be 28 limited to prosthodontics; and 29 (2) eyeglasses prescribed by a physician skilled in 30 the diseases of the eye, or by an optometrist, whichever 31 the person may select. 32 The Illinois Department, by rule, may distinguish and 33 classify the medical services to be provided only in 34 accordance with the classes of persons designated in Section SB498 Engrossed -3- LRB9101554SMdv 1 5-2. 2 The Illinois Department shall authorize the provision of, 3 and shall authorize payment for, screening by low-dose 4 mammography for the presence of occult breast cancer for 5 women 35 years of age or older who are eligible for medical 6 assistance under this Article, as follows: a baseline 7 mammogram for women 35 to 39 years of age and an annual 8 mammogram for women 40 years of age or older. All screenings 9 shall include a physical breast exam, instruction on 10 self-examination and information regarding the frequency of 11 self-examination and its value as a preventative tool. As 12 used in this Section, "low-dose mammography" means the x-ray 13 examination of the breast using equipment dedicated 14 specifically for mammography, including the x-ray tube, 15 filter, compression device, image receptor, and cassettes, 16 with an average radiation exposure delivery of less than one 17 rad mid-breast, with 2 views for each breast. 18 Any medical or health care provider shall immediately 19 recommend, to any pregnant woman who is being provided 20 prenatal services and is suspected of drug abuse or is 21 addicted as defined in the Alcoholism and Other Drug Abuse 22 and Dependency Act, referral to a local substance abuse 23 treatment provider licensed by the Department of Human 24 Services or to a licensed hospital which provides substance 25 abuse treatment services. The Department of Public Aid shall 26 assure coverage for the cost of treatment of the drug abuse 27 or addiction for pregnant recipients in accordance with the 28 Illinois Medicaid Program in conjunction with the Department 29 of Human Services. 30 All medical providers providing medical assistance to 31 pregnant women under this Code shall receive information from 32 the Department on the availability of services under the Drug 33 Free Families with a Future or any comparable program 34 providing case management services for addicted women, SB498 Engrossed -4- LRB9101554SMdv 1 including information on appropriate referrals for other 2 social services that may be needed by addicted women in 3 addition to treatment for addiction. 4 The Illinois Department, in cooperation with the 5 Departments of Human Services (as successor to the Department 6 of Alcoholism and Substance Abuse) and Public Health, through 7 a public awareness campaign, may provide information 8 concerning treatment for alcoholism and drug abuse and 9 addiction, prenatal health care, and other pertinent programs 10 directed at reducing the number of drug-affected infants born 11 to recipients of medical assistance. 12 Neither the Illinois Department of Public Aid nor the 13 Department of Human Services shall sanction the recipient 14 solely on 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 SB498 Engrossed -5- LRB9101554SMdv 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 SB498 Engrossed -6- LRB9101554SMdv 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. In order to ensure patient freedom of 6 choice, the Illinois Department shall immediately promulgate 7 all rules and take all other necessary actions so that 8 provided services may be accessed from therapeutically 9 certified optometrists to the full extent of the Illinois 10 Optometric Practice Act of 1987 without discriminating 11 between service providers. 12 The Department shall apply for a waiver from the United 13 States Health Care Financing Administration to allow for the 14 implementation of Partnerships under this Section. 15 The Illinois Department shall require health care 16 providers to maintain records that document the medical care 17 and services provided to recipients of Medical Assistance 18 under this Article. The Illinois Department shall require 19 health care providers to make available, when authorized by 20 the patient, in writing, the medical records in a timely 21 fashion to other health care providers who are treating or 22 serving persons eligible for Medical Assistance under this 23 Article. All dispensers of medical services shall be 24 required to maintain and retain business and professional 25 records sufficient to fully and accurately document the 26 nature, scope, details and receipt of the health care 27 provided to persons eligible for medical assistance under 28 this Code, in accordance with regulations promulgated by the 29 Illinois Department. The rules and regulations shall require 30 that proof of the receipt of prescription drugs, dentures, 31 prosthetic devices and eyeglasses by eligible persons under 32 this Section accompany each claim for reimbursement submitted 33 by the dispenser of such medical services. No such claims for 34 reimbursement shall be approved for payment by the Illinois SB498 Engrossed -7- LRB9101554SMdv 1 Department without such proof of receipt, unless the Illinois 2 Department shall have put into effect and shall be operating 3 a system of post-payment audit and review which shall, on a 4 sampling basis, be deemed adequate by the Illinois Department 5 to assure that such drugs, dentures, prosthetic devices and 6 eyeglasses for which payment is being made are actually being 7 received by eligible recipients. Within 90 days after the 8 effective date of this amendatory Act of 1984, the Illinois 9 Department shall establish a current list of acquisition 10 costs for all prosthetic devices and any other items 11 recognized as medical equipment and supplies reimbursable 12 under this Article and shall update such list on a quarterly 13 basis, except that the acquisition costs of all prescription 14 drugs shall be updated no less frequently than every 30 days 15 as required by Section 5-5.12. 16 The rules and regulations of the Illinois Department 17 shall require that a written statement including the required 18 opinion of a physician shall accompany any claim for 19 reimbursement for abortions, or induced miscarriages or 20 premature births. This statement shall indicate what 21 procedures were used in providing such medical services. 22 The Illinois Department shall require that all dispensers 23 of medical services, other than an individual practitioner or 24 group of practitioners, desiring to participate in the 25 Medical Assistance program established under this Article to 26 disclose all financial, beneficial, ownership, equity, surety 27 or other interests in any and all firms, corporations, 28 partnerships, associations, business enterprises, joint 29 ventures, agencies, institutions or other legal entities 30 providing any form of health care services in this State 31 under this Article. 32 The Illinois Department may require that all dispensers 33 of medical services desiring to participate in the medical 34 assistance program established under this Article disclose, SB498 Engrossed -8- LRB9101554SMdv 1 under such terms and conditions as the Illinois Department 2 may by rule establish, all inquiries from clients and 3 attorneys regarding medical bills paid by the Illinois 4 Department, which inquiries could indicate potential 5 existence of claims or liens for the Illinois Department. 6 The Illinois Department shall establish policies, 7 procedures, standards and criteria by rule for the 8 acquisition, repair and replacement of orthotic and 9 prosthetic devices and durable medical equipment. Such rules 10 shall provide, but not be limited to, the following services: 11 (1) immediate repair or replacement of such devices by 12 recipients without medical authorization; and (2) rental, 13 lease, purchase or lease-purchase of durable medical 14 equipment in a cost-effective manner, taking into 15 consideration the recipient's medical prognosis, the extent 16 of the recipient's needs, and the requirements and costs for 17 maintaining such equipment. Such rules shall enable a 18 recipient to temporarily acquire and use alternative or 19 substitute devices or equipment pending repairs or 20 replacements of any device or equipment previously authorized 21 for such recipient by the Department. Rules under clause (2) 22 above shall not provide for purchase or lease-purchase of 23 durable medical equipment or supplies used for the purpose of 24 oxygen delivery and respiratory care. 25 The Department shall execute, relative to the nursing 26 home prescreening project, written inter-agency agreements 27 with the Department of Human Services and the Department on 28 Aging, to effect the following: (i) intake procedures and 29 common eligibility criteria for those persons who are 30 receiving non-institutional services; and (ii) the 31 establishment and development of non-institutional services 32 in areas of the State where they are not currently available 33 or are undeveloped. 34 The Illinois Department shall develop and operate, in SB498 Engrossed -9- LRB9101554SMdv 1 cooperation with other State Departments and agencies and in 2 compliance with applicable federal laws and regulations, 3 appropriate and effective systems of health care evaluation 4 and programs for monitoring of utilization of health care 5 services and facilities, as it affects persons eligible for 6 medical assistance under this Code. The Illinois Department 7 shall report regularly the results of the operation of such 8 systems and programs to the Citizens Assembly/Council on 9 Public Aid to enable the Committee to ensure, from time to 10 time, that these programs are effective and meaningful. 11 The Illinois Department shall report annually to the 12 General Assembly, no later than the second Friday in April of 13 1979 and each year thereafter, in regard to: 14 (a) actual statistics and trends in utilization of 15 medical services by public aid recipients; 16 (b) actual statistics and trends in the provision 17 of the various medical services by medical vendors; 18 (c) current rate structures and proposed changes in 19 those rate structures for the various medical vendors; 20 and 21 (d) efforts at utilization review and control by 22 the Illinois Department. 23 The period covered by each report shall be the 3 years 24 ending on the June 30 prior to the report. The report shall 25 include suggested legislation for consideration by the 26 General Assembly. The filing of one copy of the report with 27 the Speaker, one copy with the Minority Leader and one copy 28 with the Clerk of the House of Representatives, one copy with 29 the President, one copy with the Minority Leader and one copy 30 with the Secretary of the Senate, one copy with the 31 Legislative Research Unit, such additional copies with the 32 State Government Report Distribution Center for the General 33 Assembly as is required under paragraph (t) of Section 7 of 34 the State Library Act and one copy with the Citizens SB498 Engrossed -10- LRB9101554SMdv 1 Assembly/Council on Public Aid or its successor shall be 2 deemed sufficient to comply with this Section. 3 (Source: P.A. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97; 4 89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.) 5 Section 99. Effective date. This Act takes effect upon 6 becoming law.