Illinois General Assembly - Full Text of Public Act 096-0156
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Public Act 096-0156




Public Act 096-0156
SB1497 Enrolled LRB096 04200 DRJ 14244 b

    AN ACT concerning public aid.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The Illinois Public Aid Code is amended by
changing Section 5-5 as follows:
    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
    Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing home,
or elsewhere; (6) medical care, or any other type of remedial
care furnished by licensed practitioners; (7) home health care
services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and
treatment of periodontal disease and dental caries disease for
pregnant women, provided by an individual licensed to practice
dentistry or dental surgery; for purposes of this item (10),
"dental services" means diagnostic, preventive, or corrective
procedures provided by or under the supervision of a dentist in
the practice of his or her profession; (11) physical therapy
and related services; (12) prescribed drugs, dentures, and
prosthetic devices; and eyeglasses prescribed by a physician
skilled in the diseases of the eye, or by an optometrist,
whichever the person may select; (13) other diagnostic,
screening, preventive, and rehabilitative services; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the sexual
assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; and (17) any other medical
care, and any other type of remedial care recognized under the
laws of this State, but not including abortions, or induced
miscarriages or premature births, unless, in the opinion of a
physician, such procedures are necessary for the preservation
of the life of the woman seeking such treatment, or except an
induced premature birth intended to produce a live viable child
and such procedure is necessary for the health of the mother or
her unborn child. The Illinois Department, by rule, shall
prohibit any physician from providing medical assistance to
anyone eligible therefor under this Code where such physician
has been found guilty of performing an abortion procedure in a
wilful and wanton manner upon a woman who was not pregnant at
the time such abortion procedure was performed. The term "any
other type of remedial care" shall include nursing care and
nursing home service for persons who rely on treatment by
spiritual means alone through prayer for healing.
    Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
    Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
    The Department of Healthcare and Family Services shall
provide the following services to persons eligible for
assistance under this Article who are participating in
education, training or employment programs operated by the
Department of Human Services as successor to the Department of
Public Aid:
        (1) dental services provided by or under the
    supervision of a dentist , which shall include but not be
    limited to prosthodontics; and
        (2) eyeglasses prescribed by a physician skilled in the
    diseases of the eye, or by an optometrist, whichever the
    person may select.
    The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in accordance
with the classes of persons designated in Section 5-2.
    The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
    The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for women
35 years of age or older who are eligible for medical
assistance under this Article, as follows: a baseline mammogram
for women 35 to 39 years of age and an annual mammogram for
women 40 years of age or older. All screenings shall include a
physical breast exam, instruction on self-examination and
information regarding the frequency of self-examination and
its value as a preventative tool. As used in this Section,
"low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, image
receptor, and cassettes, with an average radiation exposure
delivery of less than one rad mid-breast, with 2 views for each
    Any medical or health care provider shall immediately
recommend, to any pregnant woman who is being provided prenatal
services and is suspected of drug abuse or is addicted as
defined in the Alcoholism and Other Drug Abuse and Dependency
Act, referral to a local substance abuse treatment provider
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department of
Human Services.
    All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under the Drug
Free Families with a Future or any comparable program providing
case management services for addicted women, including
information on appropriate referrals for other social services
that may be needed by addicted women in addition to treatment
for addiction.
    The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through a
public awareness campaign, may provide information concerning
treatment for alcoholism and drug abuse and addiction, prenatal
health care, and other pertinent programs directed at reducing
the number of drug-affected infants born to recipients of
medical assistance.
    Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of her substance abuse.
    The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
    The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration projects
in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by rule,
shall develop qualifications for sponsors of Partnerships.
Nothing in this Section shall be construed to require that the
sponsor organization be a medical organization.
    The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and the
Illinois Health Finance Reform Act, except that:
        (1) Physicians participating in a Partnership and
    providing certain services, which shall be determined by
    the Illinois Department, to persons in areas covered by the
    Partnership may receive an additional surcharge for such
        (2) The Department may elect to consider and negotiate
    financial incentives to encourage the development of
    Partnerships and the efficient delivery of medical care.
        (3) Persons receiving medical services through
    Partnerships may receive medical and case management
    services above the level usually offered through the
    medical assistance program.
    Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
    Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that provided
services may be accessed from therapeutically certified
optometrists to the full extent of the Illinois Optometric
Practice Act of 1987 without discriminating between service
    The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
    The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance under
this Article. The Illinois Department shall require health care
providers to make available, when authorized by the patient, in
writing, the medical records in a timely fashion to other
health care providers who are treating or serving persons
eligible for Medical Assistance under this Article. All
dispensers of medical services shall be required to maintain
and retain business and professional records sufficient to
fully and accurately document the nature, scope, details and
receipt of the health care provided to persons eligible for
medical assistance under this Code, in accordance with
regulations promulgated by the Illinois Department. The rules
and regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of such
medical services. No such claims for reimbursement shall be
approved for payment by the Illinois Department without such
proof of receipt, unless the Illinois Department shall have put
into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed
adequate by the Illinois Department to assure that such drugs,
dentures, prosthetic devices and eyeglasses for which payment
is being made are actually being received by eligible
recipients. Within 90 days after the effective date of this
amendatory Act of 1984, the Illinois Department shall establish
a current list of acquisition costs for all prosthetic devices
and any other items recognized as medical equipment and
supplies reimbursable under this Article and shall update such
list on a quarterly basis, except that the acquisition costs of
all prescription drugs shall be updated no less frequently than
every 30 days as required by Section 5-5.12.
    The rules and regulations of the Illinois Department shall
require that a written statement including the required opinion
of a physician shall accompany any claim for reimbursement for
abortions, or induced miscarriages or premature births. This
statement shall indicate what procedures were used in providing
such medical services.
    The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
    The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens
for the Illinois Department.
    Enrollment of a vendor that provides non-emergency medical
transportation, defined by the Department by rule, shall be
conditional for 180 days. During that time, the Department of
Healthcare and Family Services may terminate the vendor's
eligibility to participate in the medical assistance program
without cause. That termination of eligibility is not subject
to the Department's hearing process.
    The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the acquisition,
repair and replacement of orthotic and prosthetic devices and
durable medical equipment. Such rules shall provide, but not be
limited to, the following services: (1) immediate repair or
replacement of such devices by recipients without medical
authorization; and (2) rental, lease, purchase or
lease-purchase of durable medical equipment in a
cost-effective manner, taking into consideration the
recipient's medical prognosis, the extent of the recipient's
needs, and the requirements and costs for maintaining such
equipment. Such rules shall enable a recipient to temporarily
acquire and use alternative or substitute devices or equipment
pending repairs or replacements of any device or equipment
previously authorized for such recipient by the Department.
    The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the State
where they are not currently available or are undeveloped.
    The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation and
programs for monitoring of utilization of health care services
and facilities, as it affects persons eligible for medical
assistance under this Code.
    The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
        (a) actual statistics and trends in utilization of
    medical services by public aid recipients;
        (b) actual statistics and trends in the provision of
    the various medical services by medical vendors;
        (c) current rate structures and proposed changes in
    those rate structures for the various medical vendors; and
        (d) efforts at utilization review and control by the
    Illinois Department.
    The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The filing of one copy of the report with the
Speaker, one copy with the Minority Leader and one copy with
the Clerk of the House of Representatives, one copy with the
President, one copy with the Minority Leader and one copy with
the Secretary of the Senate, one copy with the Legislative
Research Unit, and such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act shall be deemed sufficient to comply with this
(Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)

Effective Date: 1/1/2010