Public Act 90-0007 of the 90th General Assembly
Public Act 90-0007
HB1881 Enrolled LRB9000419JSgc
AN ACT relating to medical services, amending named Acts.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The State Employees Group Insurance Act of
1971 is amended by adding Section 6.9 as follows:
(5 ILCS 375/6.9 new)
Sec. 6.9. Required health benefits. The program of
health benefits shall provide the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t of the Illinois Insurance
Code. The program of health benefits shall provide the
coverage required under Section 356u of the Illinois
Insurance Code.
Section 10. The State Mandates Act is amended by adding
Section 8.21 as follows:
(30 ILCS 805/8.21 new)
Sec. 8.21. Exempt mandate. Notwithstanding Sections 6
and 8 of this Act, no reimbursement by the State is required
for the implementation of any mandate created by this
amendatory Act of 1997.
Section 15. The Counties Code is amended by changing
Section 5-1069 and adding Section 5-1069.3 as follows:
(55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
Sec. 5-1069. Group life, health, accident, hospital, and
medical insurance.
(a) The county board of any county may arrange to
provide, for the benefit of employees of the county, group
life, health, accident, hospital, and medical insurance, or
any one or any combination of those types of insurance, or
the county board may self-insure, for the benefit of its
employees, all or a portion of the employees' group life,
health, accident, hospital, and medical insurance, or any one
or any combination of those types of insurance, including a
combination of self-insurance and other types of insurance
authorized by this Section, provided that the county board
complies with all other requirements of this Section. The
insurance may include provision for employees who rely on
treatment by prayer or spiritual means alone for healing in
accordance with the tenets and practice of a well recognized
religious denomination. The county board may provide for
payment by the county of a portion or all of the premium or
charge for the insurance with the employee paying the balance
of the premium or charge, if any. If the county board
undertakes a plan under which the county pays only a portion
of the premium or charge, the county board shall provide for
withholding and deducting from the compensation of those
employees who consent to join the plan the balance of the
premium or charge for the insurance.
(b) If the county board does not provide for
self-insurance or for a plan under which the county pays a
portion or all of the premium or charge for a group insurance
plan, the county board may provide for withholding and
deducting from the compensation of those employees who
consent thereto the total premium or charge for any group
life, health, accident, hospital, and medical insurance.
(c) The county board may exercise the powers granted in
this Section only if it provides for self-insurance or, where
it makes arrangements to provide group insurance through an
insurance carrier, if the kinds of group insurance are
obtained from an insurance company authorized to do business
in the State of Illinois. The county board may enact an
ordinance prescribing the method of operation of the
insurance program.
(d) If a county, including a home rule county, is a
self-insurer for purposes of providing health insurance
coverage for its employees, the insurance coverage shall
include screening by low-dose mammography for all women 35
years of age or older for the presence of occult breast
cancer unless the county elects to provide mammograms itself
under Section 5-1069.1. The coverage shall be as follows:
(1) A baseline mammogram for women 35 to 39 years
of age.
(2) A mammogram every one to 2 years, even if no
symptoms are present, for women 40 to 49 years of age.
(3) An annual mammogram for women 40 50 years of
age or older.
Those benefits shall be at least as favorable as for
other radiological examinations and subject to the same
dollar limits, deductibles, and co-insurance factors. For
purposes of this subsection, "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, screens, and image receptors,
with an average radiation exposure delivery of less than one
rad mid-breast, with 2 views for each breast. The requirement
that mammograms be included in health insurance coverage as
provided in this subsection (d) is an exclusive power and
function of the State and is a denial and limitation under
Article VII, Section 6, subsection (h) of the Illinois
Constitution of home rule county powers. A home rule county
to which this subsection applies must comply with every
provision of this subsection.
(e) The term "employees" as used in this Section
includes elected or appointed officials but does not include
temporary employees.
(Source: P.A. 86-962; 87-780.)
(55 ILCS 5/5-1069.3 new)
Sec. 5-1069.3. Required health benefits. If a county,
including a home rule county, is a self-insurer for purposes
of providing health insurance coverage for its employees, the
coverage shall include coverage for the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t and the coverage required
under Section 356u of the Illinois Insurance Code. The
requirement that health benefits be covered as provided in
this Section is an exclusive power and function of the State
and is a denial and limitation under Article VII, Section 6,
subsection (h) of the Illinois Constitution. A home rule
county to which this Section applies must comply with every
provision of this Section.
Section 20. The Illinois Municipal Code is amended by
changing Section 10-4-2 and adding Section 10-4-2.3 as
follows:
(65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
Sec. 10-4-2. Group insurance.
(a) The corporate authorities of any municipality may
arrange to provide, for the benefit of employees of the
municipality, group life, health, accident, hospital, and
medical insurance, or any one or any combination of those
types of insurance, and may arrange to provide that insurance
for the benefit of the spouses or dependents of those
employees. The insurance may include provision for employees
or other insured persons who rely on treatment by prayer or
spiritual means alone for healing in accordance with the
tenets and practice of a well recognized religious
denomination. The corporate authorities may provide for
payment by the municipality of a portion of the premium or
charge for the insurance with the employee paying the balance
of the premium or charge. If the corporate authorities
undertake a plan under which the municipality pays a portion
of the premium or charge, the corporate authorities shall
provide for withholding and deducting from the compensation
of those municipal employees who consent to join the plan the
balance of the premium or charge for the insurance.
(b) If the corporate authorities do not provide for a
plan under which the municipality pays a portion of the
premium or charge for a group insurance plan, the corporate
authorities may provide for withholding and deducting from
the compensation of those employees who consent thereto the
premium or charge for any group life, health, accident,
hospital, and medical insurance.
(c) The corporate authorities may exercise the powers
granted in this Section only if the kinds of group insurance
are obtained from an insurance company authorized to do
business in the State of Illinois. The corporate authorities
may enact an ordinance prescribing the method of operation of
the insurance program.
(d) If a municipality, including a home rule
municipality, is a self-insurer for purposes of providing
health insurance coverage for its employees, the insurance
coverage shall include screening by low-dose mammography for
all women 35 years of age or older for the presence of occult
breast cancer unless the municipality elects to provide
mammograms itself under Section 10-4-2.1. The coverage shall
be as follows:
(1) A baseline mammogram for women 35 to 39 years
of age.
(2) A mammogram every one to 2 years, even if no
symptoms are present, for women 40 to 49 years of age.
(3) An annual mammogram for women 40 50 years of
age or older.
Those benefits shall be at least as favorable as for
other radiological examinations and subject to the same
dollar limits, deductibles, and co-insurance factors. For
purposes of this subsection, "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, screens, and image receptors,
with an average radiation exposure delivery of less than one
rad mid-breast, with 2 views for each breast. The requirement
that mammograms be included in health insurance coverage as
provided in this subsection (d) is an exclusive power and
function of the State and is a denial and limitation under
Article VII, Section 6, subsection (h) of the Illinois
Constitution of home rule municipality powers. A home rule
municipality to which this subsection applies must comply
with every provision of this subsection.
(Source: P.A. 86-1475; 87-780.)
(65 ILCS 5/10-4-2.3 new)
Sec. 10-4-2.3. Required health benefits. If a
municipality, including a home rule municipality, is a
self-insurer for purposes of providing health insurance
coverage for its employees, the coverage shall include
coverage for the post-mastectomy care benefits required to be
covered by a policy of accident and health insurance under
Section 356t and the coverage required under Section 356u of
the Illinois Insurance Code. The requirement that health
benefits be covered as provided in this is an exclusive power
and function of the State and is a denial and limitation
under Article VII, Section 6, subsection (h) of the Illinois
Constitution. A home rule municipality to which this Section
applies must comply with every provision of this Section.
Section 25. The School Code is amended by adding Section
10-22.3f as follows:
(105 ILCS 5/10-22.3f new)
Sec. 10-22.3f. Required health benefits. Insurance
protection and benefits for employees shall provide the
post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t
and the coverage required under Section 356u of the Illinois
Insurance Code.
Section 30. The Illinois Insurance Code is amended by
changing Sections 122-1, 356g, and 1003 and adding Sections
356t and 356u as follows:
(215 ILCS 5/122-1) (from Ch. 73, par. 734-1)
Sec. 122-1. The authority and jurisdiction of Insurance
Department. Notwithstanding any other provision of law, and
except as provided herein, any person or other entity which
provides coverage in this State for medical, surgical,
chiropractic, naprapathic, physical therapy, speech
pathology, audiology, professional mental health, dental,
hospital, ophthalmologic, or optometric expenses, whether
such coverage is by direct-payment, reimbursement, or
otherwise, shall be presumed to be subject to the
jurisdiction of the Department unless the person or other
entity shows that while providing such coverage it is subject
to the jurisdiction of another agency of this state, any
subdivision of this state, or the Federal Government, or is a
plan of self-insurance or other employee welfare benefit
program of an individual employer or labor union established
or maintained under or pursuant to a collective bargaining
agreement or other arrangement which provides for health care
services solely for its employees or members and their
dependents.
(Source: P.A. 86-753.)
(215 ILCS 5/356g) (from Ch. 73, par. 968g)
Sec. 356g. (a) Every insurer shall provide in each group
or individual policy, contract, or certificate of insurance
issued or renewed for persons who are residents of this
State, coverage for screening by low-dose mammography for all
women 35 years of age or older for the presence of occult
breast cancer within the provisions of the policy, contract,
or certificate. The coverage shall be as follows:
(1) A baseline mammogram for women 35 to 39 years
of age.
(2) An mammogram every 1 to 2 years, even if no
symptoms are present, for women 40 to 49 years of age.
(3) An annual mammogram for women 40 50 years of
age or older.
These benefits shall be at least as favorable as for
other radiological examinations and subject to the same
dollar limits, deductibles, and co-insurance factors. For
purposes of 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, and image receptor, with
radiation exposure delivery of less than 1 rad per breast for
2 views of an average size breast.
(b) No policy of accident or health insurance that
provides for the surgical procedure known as a mastectomy
shall be issued, amended, delivered or renewed in this State
on or after July 1, 1981, unless coverage is also offered for
prosthetic devices or reconstructive surgery incident to the
mastectomy, providing that the mastectomy is performed after
July 1, 1981. The offered coverage for prosthetic devices and
reconstructive surgery shall be subject to the deductible and
coinsurance conditions applied to the mastectomy, and all
other terms and conditions applicable to other benefits.
When a mastectomy is performed and there is no evidence of
malignancy then the offered coverage may be limited to the
provision of prosthetic devices and reconstructive surgery to
within 2 years after the date of the mastectomy. As used in
this Section, "mastectomy" means the removal of all or part
of the breast for medically necessary reasons, as determined
by a licensed physician.
(Source: P.A. 86-899; 87-518.)
(215 ILCS 5/356t new)
Sec. 356t. Post-mastectomy care. An individual or group
policy of accident and health insurance or managed care plan
that provides surgical coverage and is amended, delivered,
issued, or renewed after the effective date of this
amendatory Act of 1997 shall provide inpatient coverage
following a mastectomy for a length of time determined by the
attending physician to be medically necessary and in
accordance with protocols and guidelines based on sound
scientific evidence and upon evaluation of the patient and
the coverage for and availability of a post-discharge
physician office visit or in-home nurse visit to verify the
condition of the patient in the first 48 hours after
discharge.
(215 ILCS 5/356u new)
Sec. 356u. Pap tests and prostate-specific antigen
tests.
(a) A group policy of accident and health insurance that
provides coverage for hospital or medical treatment or
services for illness on an expense-incurred basis and is
amended, delivered, issued, or renewed after the effective
date of this amendatory Act of 1997 shall provide coverage
for all of the following:
(1) An annual cervical smear or Pap smear test for
female insureds.
(2) An annual digital rectal examination and a
prostate-specific antigen test, for male insureds upon
the recommendation of a physician licensed to practice
medicine in all its branches for:
(A) asymptomatic men age 50 and over;
(B) African-American men age 40 and over; and
(C) men age 40 and over with a family history
of prostate cancer.
(b) This Section shall not apply to agreements,
contracts, or policies that provide coverage for a specified
disease or other limited benefit coverage.
(215 ILCS 5/1003) (from Ch. 73, par. 1065.703)
Sec. 1003. Definitions. As used in this Article: (A)
"Adverse underwriting decision" means:
(1) any of the following actions with respect to
insurance transactions involving insurance coverage which is
individually underwritten:
(a) a declination of insurance coverage,
(b) a termination of insurance coverage,
(c) failure of an agent to apply for insurance coverage
with a specific insurance institution which the agent
represents and which is requested by an applicant,
(d) in the case of a property or casualty insurance
coverage:
(i) placement by an insurance institution or agent of a
risk with a residual market mechanism, an unauthorized
insurer or an insurance institution which specializes in
substandard risks, or
(ii) the charging of a higher rate on the basis of
information which differs from that which the applicant or
policyholder furnished, or
(e) in the case of life, health or disability insurance
coverage, an offer to insure at higher than standard rates.
(2) Notwithstanding paragraph (1) above, the following
actions shall not be considered adverse underwriting
decisions but the insurance institution or agent responsible
for their occurrence shall nevertheless provide the applicant
or policyholder with the specific reason or reasons for their
occurrence:
(a) the termination of an individual policy form on a
class or statewide basis,
(b) a declination of insurance coverage solely because
such coverage is not available on a class or statewide basis,
or
(c) the rescission of a policy.
(B) "Affiliate" or "affiliated" means a person that
directly, or indirectly through one or more intermediaries,
controls, is controlled by or is under common control with
another person.
(C) "Agent" means an individual, firm, partnership,
association or corporation who is involved in the
solicitation, negotiation or binding of coverages for or on
applications or policies of insurance, covering property or
risks located in this State. For the purposes of this
Article, both "Insurance Agent" and "Insurance Broker", as
defined in Section 490, shall be considered an agent.
(D) "Applicant" means any person who seeks to contract
for insurance coverage other than a person seeking group
insurance that is not individually underwritten.
(E) "Director" means the Director of Insurance.
(F) "Consumer report" means any written, oral or other
communication of information bearing on a natural person's
credit worthiness, credit standing, credit capacity,
character, general reputation, personal characteristics or
mode of living which is used or expected to be used in
connection with an insurance transaction.
(G) "Consumer reporting agency" means any person who:
(1) regularly engages, in whole or in part, in the
practice of assembling or preparing consumer reports for a
monetary fee,
(2) obtains information primarily from sources other than
insurance institutions, and
(3) furnishes consumer reports to other persons.
(H) "Control", including the terms "controlled by" or
"under common control with", means the possession, direct or
indirect, of the power to direct or cause the direction of
the management and policies of a person, whether through the
ownership of voting securities, by contract other than a
commercial contract for goods or nonmanagement services, or
otherwise, unless the power is the result of an official
position with or corporate office held by the person.
(I) "Declination of insurance coverage" means a denial,
in whole or in part, by an insurance institution or agent of
requested insurance coverage.
(J) "Individual" means any natural person who:
(1) in the case of property or casualty insurance, is a
past, present or proposed named insured or certificateholder;
(2) in the case of life, health or disability insurance,
is a past, present or proposed principal insured or
certificateholder;
(3) is a past, present or proposed policyowner;
(4) is a past or present applicant;
(5) is a past or present claimant; or
(6) derived, derives or is proposed to derive insurance
coverage under an insurance policy or certificate subject to
this Article.
(K) "Institutional source" means any person or
governmental entity that provides information about an
individual to an agent, insurance institution or
insurance-support organization, other than:
(1) an agent,
(2) the individual who is the subject of the
information, or
(3) a natural person acting in a personal capacity
rather than in a business or professional capacity.
(L) "Insurance institution" means any corporation,
association, partnership, reciprocal exchange, inter-insurer,
Lloyd's insurer, fraternal benefit society or other person
engaged in the business of insurance, health maintenance
organizations as defined in Section 2 of the "Health
Maintenance Organization Act", medical service plans as
defined in Section 2 of "The Medical Service Plan Act",
hospital service corporation under "The Nonprofit Health Care
Service Plan Act", voluntary health services plans as defined
in Section 2 of "The Voluntary Health Services Plans Act",
vision service plans as defined in Section 2 of "The Vision
Service Plan Act", dental service plans as defined in Section
4 of "The Dental Service Plan Act", and pharmaceutical
service plans as defined in Section 4 of "The Pharmaceutical
Service Plan Act". "Insurance institution" shall not include
agents or insurance-support organizations.
(M) "Insurance-support organization" means: (1) any
person who regularly engages, in whole or in part, in the
practice of assembling or collecting information about
natural persons for the primary purpose of providing the
information to an insurance institution or agent for
insurance transactions, including:
(a) the furnishing of consumer reports or investigative
consumer reports to an insurance institution or agent for use
in connection with an insurance transaction, or
(b) the collection of personal information from
insurance institutions, agents or other insurance-support
organizations for the purpose of detecting or preventing
fraud, material misrepresentation or material nondisclosure
in connection with insurance underwriting or insurance claim
activity.
(2) Notwithstanding paragraph (1) above, the following
persons shall not be considered "insurance-support
organizations" for purposes of this Article: agents,
government institutions, insurance institutions, medical care
institutions and medical professionals.
(N) "Insurance transaction" means any transaction
involving insurance primarily for personal, family or
household needs rather than business or professional needs
which entails:
(1) the determination of an individual's eligibility for
an insurance coverage, benefit or payment, or
(2) the servicing of an insurance application, policy,
contract or certificate.
(O) "Investigative consumer report" means a consumer
report or portion thereof in which information about a
natural person's character, general reputation, personal
characteristics or mode of living is obtained through
personal interviews with the person's neighbors, friends,
associates, acquaintances or others who may have knowledge
concerning such items of information.
(P) "Medical-care institution" means any facility or
institution that is licensed to provide health care services
to natural persons, including but not limited to: hospitals,
skilled nursing facilities, home-health agencies, medical
clinics, rehabilitation agencies and public-health agencies
and health-maintenance organizations.
(Q) "Medical professional" means any person licensed or
certified to provide health care services to natural
persons, including but not limited to, a physician, dentist,
nurse, optometrist, chiropractor, naprapath, pharmacist,
physical or occupational therapist, psychiatric social
worker, speech therapist, clinical dietitian or clinical
psychologist.
(R) "Medical-record information" means personal
information which:
(1) relates to an individual's physical or mental
condition, medical history or medical treatment, and
(2) is obtained from a medical professional or
medical-care institution, from the individual, or from the
individual's spouse, parent or legal guardian.
(S) "Person" means any natural person, corporation,
association, partnership or other legal entity.
(T) "Personal information" means any individually
identifiable information gathered in connection with an
insurance transaction from which judgments can be made about
an individual's character, habits, avocations, finances,
occupation, general reputation, credit, health or any other
personal characteristics. "Personal information" includes an
individual's name and address and "medical-record
information" but does not include "privileged information".
(U) "Policyholder" means any person who:
(1) in the case of individual property or casualty
insurance, is a present named insured;
(2) in the case of individual life, health or disability
insurance, is a present policyowner; or
(3) in the case of group insurance which is individually
underwritten, is a present group certificateholder.
(V) "Pretext interview" means an interview whereby a
person, in an attempt to obtain information about a natural
person, performs one or more of the following acts:
(1) pretends to be someone he or she is not,
(2) pretends to represent a person he or she is not in
fact representing,
(3) misrepresents the true purpose of the interview, or
(4) refuses to identify himself or herself upon request.
(W) "Privileged information" means any individually
identifiable information that: (1) relates to a claim for
insurance benefits or a civil or criminal proceeding
involving an individual, and (2) is collected in connection
with or in reasonable anticipation of a claim for insurance
benefits or civil or criminal proceeding involving an
individual; provided, however, information otherwise meeting
the requirements of this subsection shall nevertheless be
considered "personal information" under this Article if it is
disclosed in violation of Section 1014 of this Article.
(X) "Residual market mechanism" means an association,
organization or other entity described in Article XXXIII of
this Act, or Section 7-501 of "The Illinois Vehicle Code".
(Y) "Termination of insurance coverage" or "termination
of an insurance policy" means either a cancellation or
nonrenewal of an insurance policy, in whole or in part, for
any reason other than the failure to pay a premium as
required by the policy.
(Z) "Unauthorized insurer" means an insurance institution
that has not been granted a certificate of authority by the
Director to transact the business of insurance in this State.
(Source: P.A. 82-108.)
Section 32. The Comprehensive Health Insurance Plan Act
is amended by changing Section 8 as follows:
(215 ILCS 105/8) (from Ch. 73, par. 1308)
Sec. 8. Minimum benefits.
a. Availability. The Plan shall offer in an annually
renewable policy major medical expense coverage to every
eligible person who is not eligible for Medicare. Major
medical expense coverage offered by the Plan shall pay an
eligible person's covered expenses, subject to limit on the
deductible and coinsurance payments authorized under
paragraph (4) of subsection d of this Section, up to a
lifetime benefit limit of $500,000 per covered individual.
The maximum limit under this subsection shall not be altered
by the Board, and no actuarial equivalent benefit may be
substituted by the Board. Any person who otherwise would
qualify for coverage under the Plan, but is excluded because
he or she is eligible for Medicare, shall be eligible for any
separate Medicare supplement policy which the Board may
offer.
b. Covered expenses. Covered expenses shall be limited
to the reasonable and customary charge, including negotiated
fees, in the locality for the following services and articles
when medically necessary and prescribed by a person licensed
and practicing within the scope of his or her profession as
authorized by State law:
(1) Hospital room and board and any other hospital
services, except that inpatient hospitalization for the
treatment of mental and emotional disorders shall only be
covered for a maximum of 45 days in a calendar year.
(2) Professional services for the diagnosis or
treatment of injuries, illnesses or conditions, other
than dental, or outpatient mental as described in
paragraph (17), which are rendered by a physician or
chiropractor, or by other licensed professionals at the
physician's or chiropractor's direction.
(3) If surgery has been recommended, a second
opinion may be required. The charge for a second opinion
as to whether the surgery is required will be paid in
full without regard to deductible or co-payment
requirements. If the second opinion differs from the
first, the charge for a third opinion, if desired, will
also be paid in full without regard to deductible or
co-payment requirements. Regardless of whether the
second opinion or third opinion confirms the original
recommendation, it is the patient's decision whether to
undergo surgery.
(4) Drugs requiring a physician's or other legally
authorized prescription.
(5) Skilled nursing care provided in a skilled
nursing facility for not more than 120 days in a calendar
year, provided the service commences within 14 days
following a confinement of at least 3 consecutive days in
a hospital for the same condition.
(6) Services of a home health agency in accord with
a home health care plan, up to a maximum of 270 visits
per year.
(7) Services of a licensed hospice for not more
than 180 days during a policy year.
(8) Use of radium or other radioactive materials.
(9) Oxygen.
(10) Anesthetics.
(11) Orthoses and prostheses other than dental.
(12) Rental or purchase in accordance with Board
policies or procedures of durable medical equipment,
other than eyeglasses or hearing aids, for which there is
no personal use in the absence of the condition for which
it is prescribed.
(13) Diagnostic x-rays and laboratory tests.
(14) Oral surgery for excision of partially or
completely unerupted impacted teeth or the gums and
tissues of the mouth, when not performed in connection
with the routine extraction or repair of teeth, and oral
surgery and procedures, including orthodontics and
prosthetics necessary for craniofacial or maxillofacial
conditions and to correct congenital defects or injuries
due to accident.
(15) Physical, speech, and functional occupational
therapy as medically necessary and provided by
appropriate licensed professionals.
(16) Transportation provided by a licensed
ambulance service to the nearest health care facility
qualified to treat the illness, injury or condition,
subject to the provisions of the Emergency Medical
Systems (EMS) Act.
(17) The first 50 professional outpatient visits
for diagnosis and treatment of mental and emotional
disorders rendered during the year, up to a maximum of
$80 per visit.
(18) Human organ or tissue transplants specified by
the Board that are performed at a hospital designated by
the Board as a participating transplant center for that
specific organ or tissue transplant.
(19) Naprapathic services, as appropriate, provided
by a licensed naprapathic practitioner.
c. Exclusion. Covered expenses of the Plan shall not
include the following:
(1) Any charge for treatment for cosmetic purposes
other than for reconstructive surgery when the service is
incidental to or follows surgery resulting from injury,
sickness or other diseases of the involved part or
surgery for the repair or treatment of a congenital
bodily defect to restore normal bodily functions.
(2) Any charge for care that is primarily for rest,
custodial, educational, or domiciliary purposes.
(3) Any charge for services in a private room to
the extent it is in excess of the institution's charge
for its most common semiprivate room, unless a private
room is prescribed as medically necessary by a physician.
(4) That part of any charge for room and board or
for services rendered or articles prescribed by a
physician, dentist, or other health care personnel that
exceeds the reasonable and customary charge in the
locality or for any services or supplies not medically
necessary for the diagnosed injury or illness.
(5) Any charge for services or articles the
provision of which is not within the scope of licensure
of the institution or individual providing the services
or articles.
(6) Any expense incurred prior to the effective
date of coverage by the Plan for the person on whose
behalf the expense is incurred.
(7) Dental care, dental surgery, dental treatment
or dental appliances, except as provided in paragraph
(14) of subsection b of this Section.
(8) Eyeglasses, contact lenses, hearing aids or
their fitting.
(9) Illness or injury due to (A) war or any acts of
war; (B) commission of, or attempt to commit, a felony;
or (C) aviation activities, except when traveling as a
fare-paying passenger on a commercial airline.
(10) Services of blood donors and any fee for
failure to replace blood provided to an eligible person
each policy year.
(11) Personal supplies or services provided by a
hospital or nursing home, or any other nonmedical or
nonprescribed supply or service.
(12) Routine maternity charges for a pregnancy,
except where added as optional coverage with payment of
an additional premium for pregnancy resulting from
conception occurring after the effective date of the
optional coverage.
(13) Expenses of obtaining an abortion, induced
miscarriage or induced premature birth unless, in the
opinion of a physician, those procedures are necessary
for the preservation of life of the woman seeking such
treatment, or except an induced premature birth intended
to produce a live viable child and the procedure is
necessary for the health of the mother or unborn child.
(14) Any expense or charge for services, drugs, or
supplies that are: (i) not provided in accord with
generally accepted standards of current medical practice;
(ii) for procedures, treatments, equipment, transplants,
or implants, any of which are investigational,
experimental, or for research purposes; (iii)
investigative and not proven safe and effective; or (iv)
for, or resulting from, a gender transformation
operation.
(15) Any expense or charge for routine physical
examinations or tests.
(16) Any expense for which a charge is not made in
the absence of insurance or for which there is no legal
obligation on the part of the patient to pay.
(17) Any expense incurred for benefits provided
under the laws of the United States and this State,
including Medicare and Medicaid and other medical
assistance, military service-connected disability
payments, medical services provided for members of the
armed forces and their dependents or employees of the
armed forces of the United States, and medical services
financed on behalf of all citizens by the United States.
(18) Any expense or charge for in vitro
fertilization, artificial insemination, or any other
artificial means used to cause pregnancy.
(19) Any expense or charge for oral contraceptives
used for birth control or any other temporary birth
control measures.
(20) Any expense or charge for sterilization or
sterilization reversals.
(21) Any expense or charge for weight loss
programs, exercise equipment, or treatment of obesity,
except when certified by a physician as morbid obesity
(at least 2 times normal body weight).
(22) Any expense or charge for acupuncture
treatment unless used as an anesthetic agent for a
covered surgery.
(23) Any expense or charge for or related to organ
or tissue transplants other than those performed at a
hospital with a Board approved organ transplant program
that has been designated by the Board as a preferred or
exclusive provider organization for that specific organ
or tissue.
(24) Any expense or charge for procedures,
treatments, equipment, or services that are provided in
special settings for research purposes or in a controlled
environment, are being studied for safety, efficiency,
and effectiveness, and are awaiting endorsement by the
appropriate national medical speciality college for
general use within the medical community.
d. Premiums, deductibles, and coinsurance.
(1) Premiums charged for coverage issued by the
Plan may not be unreasonable in relation to the benefits
provided, the risk experience and the reasonable expenses
of providing the coverage.
(2) Separate schedules of premium rates based on
sex, age and geographical location shall apply for
individual risks.
(3) The Plan may provide for separate premium rates
for optional family coverage for the spouse or one or
more dependents of any person eligible to be insured
under the Plan who is also the oldest adult member of the
family and remains continuously enrolled in the Plan as
the primary enrollee. The rates shall be such percentage
of the applicable individual Plan rate as the Board, in
accordance with appropriate actuarial principles, shall
establish for each spouse or dependent.
(4) The Board shall determine, in accordance with
appropriate actuarial principles, the average rates that
individual standard risks in this State are charged by at
least 5 of the largest insurers providing coverage to
residents of Illinois that is substantially similar to
the Plan coverage. In the event at least 5 insurers do
not offer substantially similar coverage, the rates shall
be established using reasonable actuarial techniques and
shall reflect anticipated claims experience, expenses,
and other appropriate risk factors relating to the Plan.
Rates for Plan coverage shall be 135% of rates so
established as applicable for individual standard risks;
provided, however, if after determining that the
appropriations made pursuant to Section 12 of this Act
are insufficient to ensure that total income from all
sources will equal or exceed the total incurred costs and
expenses for the current number of enrollees, the board
shall raise premium rates above this 135% standard to the
level it deems necessary to ensure the financial solvency
of the Plan for enrollees already in the Plan. All rates
and rate schedules shall be submitted to the board for
approval.
(5) The Plan coverage defined in Section 6 shall
provide for a choice of deductibles as authorized by the
Board per individual per annum. If 2 individual members
of a family satisfy the same applicable deductibles, no
other member of that family who is eligible for coverage
under the Plan shall be required to meet any deductibles
for the balance of that calendar year. The deductibles
must be applied first to the authorized amount of covered
expenses incurred by the covered person. A mandatory
coinsurance requirement shall be imposed at the rate
authorized by the Board in excess of the mandatory
deductible, the coinsurance in the aggregate not to
exceed such amounts as are authorized by the Board per
annum. At its discretion the Board may, however, offer
catastrophic coverages or other policies that provide for
larger deductibles with or without coinsurance
requirements. The deductibles and coinsurance factors
may be adjusted annually according to the Medical
Component of the Consumer Price Index.
(6) The Plan may provide for and employ cost
containment measures and requirements including, but not
limited to, preadmission certification, second surgical
opinion, concurrent utilization review programs,
individual case management, preferred provider
organizations, and other cost effective arrangements for
paying for covered expenses.
e. Scope of coverage. Except as provided in subsection
c of this Section, if the covered expenses incurred by the
eligible person exceed the deductible for major medical
expense coverage in a calendar year, the Plan shall pay at
least 80% of any additional covered expenses incurred by the
person during the calendar year.
f. Preexisting conditions.
(1) Six months: Plan coverage shall exclude charges
or expenses incurred during the first 6 months following
the effective date of coverage as to any condition if:
(a) the condition had manifested itself within the 6
month period immediately preceding the effective date of
coverage in such a manner as would cause an ordinarily
prudent person to seek diagnosis, care or treatment; or
(b) medical advice, care or treatment was recommended or
received within the 6 month period immediately preceding
the effective date of coverage.
(2) (Blank).
(3) Waiver: The preexisting condition exclusions as
set forth in paragraph (1) of this subsection shall be
waived to the extent to which the eligible person: (a)
has satisfied similar exclusions under any prior health
insurance policy or plan that was involuntarily
terminated; (b) is ineligible for any continuation or
conversion rights that would continue or provide
substantially similar coverage following that
termination; and (c) has applied for Plan coverage not
later than 30 days following the involuntary termination.
No policy or plan shall be deemed to have been
involuntarily terminated if the master policyholder or
other controlling party elected to change insurance
coverage from one company or plan to another even if that
decision resulted in a discontinuation of coverage for
any individual under the plan, either totally or for any
medical condition. For each eligible person who qualifies
for and elects this waiver, there shall be added to each
payment of premium, on a prorated basis, a surcharge of
up to 10% of the otherwise applicable annual premium for
as long as that individual's coverage under the Plan
remains in effect or 60 months, whichever is less.
g. Other sources primary; nonduplication of benefits.
(1) The Plan shall be the last payor of benefits
whenever any other benefit or source of third party
payment is available. Subject to the provisions of
subsection e of Section 7, benefits otherwise payable
under Plan coverage shall be reduced by all amounts paid
or payable by Medicare or any other government program or
through any health insurance or other health benefit
plan, whether insured or otherwise, or through any third
party liability, settlement, judgment, or award,
regardless of the date of the settlement, judgment, or
award, whether the settlement, judgment, or award is in
the form of a contract, agreement, or trust on behalf of
a minor or otherwise and whether the settlement,
judgment, or award is payable to the covered person, his
or her dependent, estate, personal representative, or
guardian in a lump sum or over time, and by all hospital
or medical expense benefits paid or payable under any
worker's compensation coverage, automobile medical
payment, or liability insurance, whether provided on the
basis of fault or nonfault, and by any hospital or
medical benefits paid or payable under or provided
pursuant to any State or federal law or program.
(2) The Plan shall have a cause of action against
any covered person or any other person or entity for the
recovery of any amount paid to the extent the amount was
for treatment, services, or supplies not covered in this
Section or in excess of benefits as set forth in this
Section.
(3) Whenever benefits are due from the Plan because
of sickness or an injury to a covered person resulting
from a third party's wrongful act or negligence and the
covered person has recovered or may recover damages from
a third party or its insurer, the Plan shall have the
right to reduce benefits or to refuse to pay benefits
that otherwise may be payable by the amount of damages
that the covered person has recovered or may recover
regardless of the date of the sickness or injury or the
date of any settlement, judgment, or award resulting from
that sickness or injury.
During the pendency of any action or claim that is
brought by or on behalf of a covered person against a
third party or its insurer, any benefits that would
otherwise be payable except for the provisions of this
paragraph (3) shall be paid if payment by or for the
third party has not yet been made and the covered person
or, if incapable, that person's legal representative
agrees in writing to pay back promptly the benefits paid
as a result of the sickness or injury to the extent of
any future payments made by or for the third party for
the sickness or injury. This agreement is to apply
whether or not liability for the payments is established
or admitted by the third party or whether those payments
are itemized.
Any amounts due the plan to repay benefits may be
deducted from other benefits payable by the Plan after
payments by or for the third party are made.
(4) Benefits due from the Plan may be reduced or
refused as an offset against any amount otherwise
recoverable under this Section.
h. Right of subrogation; recoveries.
(1) Whenever the Plan has paid benefits because of
sickness or an injury to any covered person resulting
from a third party's wrongful act or negligence, or for
which an insurer is liable in accordance with the
provisions of any policy of insurance, and the covered
person has recovered or may recover damages from a third
party that is liable for the damages, the Plan shall have
the right to recover the benefits it paid from any
amounts that the covered person has received or may
receive regardless of the date of the sickness or injury
or the date of any settlement, judgment, or award
resulting from that sickness or injury. The Plan shall
be subrogated to any right of recovery the covered person
may have under the terms of any private or public health
care coverage or liability coverage, including coverage
under the Workers' Compensation Act or the Workers'
Occupational Diseases Act, without the necessity of
assignment of claim or other authorization to secure the
right of recovery. To enforce its subrogation right, the
Plan may (i) intervene or join in an action or proceeding
brought by the covered person or his personal
representative, including his guardian, conservator,
estate, dependents, or survivors, against any third party
or the third party's insurer that may be liable or (ii)
institute and prosecute legal proceedings against any
third party or the third party's insurer that may be
liable for the sickness or injury in an appropriate court
either in the name of the Plan or in the name of the
covered person or his personal representative, including
his guardian, conservator, estate, dependents, or
survivors.
(2) If any action or claim is brought by or on
behalf of a covered person against a third party or the
third party's insurer, the covered person or his personal
representative, including his guardian, conservator,
estate, dependents, or survivors, shall notify the Plan
by personal service or registered mail of the action or
claim and of the name of the court in which the action or
claim is brought, filing proof thereof in the action or
claim. The Plan may, at any time thereafter, join in the
action or claim upon its motion so that all orders of
court after hearing and judgment shall be made for its
protection. No release or settlement of a claim for
damages and no satisfaction of judgment in the action
shall be valid without the written consent of the Plan to
the extent of its interest in the settlement or judgment
and of the covered person or his personal representative.
(3) In the event that the covered person or his
personal representative fails to institute a proceeding
against any appropriate third party before the fifth
month before the action would be barred, the Plan may, in
its own name or in the name of the covered person or
personal representative, commence a proceeding against
any appropriate third party for the recovery of damages
on account of any sickness, injury, or death to the
covered person. The covered person shall cooperate in
doing what is reasonably necessary to assist the Plan in
any recovery and shall not take any action that would
prejudice the Plan's right to recovery. The Plan shall
pay to the covered person or his personal representative
all sums collected from any third party by judgment or
otherwise in excess of amounts paid in benefits under the
Plan and amounts paid or to be paid as costs, attorneys
fees, and reasonable expenses incurred by the Plan in
making the collection or enforcing the judgment.
(4) In the event that a covered person or his
personal representative, including his guardian,
conservator, estate, dependents, or survivors, recovers
damages from a third party for sickness or injury caused
to the covered person, the covered person or the personal
representative shall pay to the Plan from the damages
recovered the amount of benefits paid or to be paid on
behalf of the covered person.
(5) When the action or claim is brought by the
covered person alone and the covered person incurs a
personal liability to pay attorney's fees and costs of
litigation, the Plan's claim for reimbursement of the
benefits provided to the covered person shall be the full
amount of benefits paid to or on behalf of the covered
person under this Act less a pro rata share that
represents the Plan's reasonable share of attorney's fees
paid by the covered person and that portion of the cost
of litigation expenses determined by multiplying by the
ratio of the full amount of the expenditures to the full
amount of the judgement, award, or settlement.
(6) In the event of judgment or award in a suit or
claim against a third party or insurer, the court shall
first order paid from any judgement or award the
reasonable litigation expenses incurred in preparation
and prosecution of the action or claim, together with
reasonable attorney's fees. After payment of those
expenses and attorney's fees, the court shall apply out
of the balance of the judgment or award an amount
sufficient to reimburse the Plan the full amount of
benefits paid on behalf of the covered person under this
Act, provided the court may reduce and apportion the
Plan's portion of the judgement proportionate to the
recovery of the covered person. The burden of producing
evidence sufficient to support the exercise by the court
of its discretion to reduce the amount of a proven charge
sought to be enforced against the recovery shall rest
with the party seeking the reduction. The court may
consider the nature and extent of the injury, economic
and non-economic loss, settlement offers, comparative
negligence as it applies to the case at hand, hospital
costs, physician costs, and all other appropriate costs.
The Plan shall pay its pro rata share of the attorney
fees based on the Plan's recovery as it compares to the
total judgment. Any reimbursement rights of the Plan
shall take priority over all other liens and charges
existing under the laws of this State with the exception
of any attorney liens filed under the Attorneys Lien Act.
(7) The Plan may compromise or settle and release
any claim for benefits provided under this Act or waive
any claims for benefits, in whole or in part, for the
convenience of the Plan or if the Plan determines that
collection would result in undue hardship upon the
covered person.
(Source: P.A. 89-486, eff. 6-21-96.)
Section 35. The Health Maintenance Organization Act is
amended by changing Section 4-6.1 and adding Section 4-6.5 as
follows:
(215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
Sec. 4-6.1. (a) Every contract or evidence of coverage
issued by a Health Maintenance Organization for persons who
are residents of this State shall contain coverage for
screening by low-dose mammography for all women 35 years of
age or older for the presence of occult breast cancer. The
coverage shall be as follows:
(1) A baseline mammogram for women 35 to 39 years
of age.
(2) A mammogram every 1 to 2 years, even if no
symptoms are present, for women 40 to 49 years of age.
(3) An annual mammogram for women 40 50 years of
age or older.
These benefits shall be at least as favorable as for
other radiological examinations and subject to the same
dollar limits, deductibles, and co-insurance factors. For
purposes of 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, and image receptor, with
radiation exposure delivery of less than 1 rad per breast for
2 views of an average size breast.
(Source: P.A. 86-899; 86-1028; 87-518.)
(215 ILCS 125/4-6.5 new)
Sec. 4-6.5. Required health benefits. A health
maintenance organization is subject to the provisions of
Sections 356t and 356u of the Illinois Insurance Code.
Section 40. The Voluntary Health Services Plans Act is
amended by changing Section 10 as follows:
(215 ILCS 165/10) (from Ch. 32, par. 604)
Sec. 10. Application of Insurance Code provisions.
Health services plan corporations and all persons interested
therein or dealing therewith shall be subject to the
provisions of Article XII 1/2 and Sections 3.1, 133, 140,
143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 367.2, 401,
401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs
(7) and (15) of Section 367 of the Illinois Insurance Code.
(Source: P.A. 89-514, eff. 7-17-96.)
Section 45. The Illinois Public Aid Code is amended by
changing Section 5-5 and adding Section 5-16.8 as follows:
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
(Text of Section before amendment by P.A. 89-507)
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; (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.
The Illinois Department shall provide the following
services to persons eligible for assistance under this
Article who are participating in education, training or
employment programs:
(1) dental services, 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 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; a mammogram every
1 to 2 years, even if no symptoms are present, for women 40
to 49 years of age; and an annual mammogram for women 40 50
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 breast.
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 Alcoholism
and Substance Abuse or to a licensed hospital which provides
substance abuse treatment services. The Department of Public
Aid 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 Alcoholism and Substance Abuse.
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 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.
The Department shall not 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. In formulating these
regulations the Illinois Department shall consult with and
give substantial weight to the recommendations offered by the
Citizens Assembly/Council on Public Aid. 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 services.
(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.
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 that 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.
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. Rules under clause (2)
above shall not provide for purchase or lease-purchase of
durable medical equipment or supplies used for the purpose of
oxygen delivery and respiratory care.
The Department shall execute, relative to the nursing
home prescreening project, written inter-agency agreements
with the Department of Rehabilitation 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 regularly the results of the operation of such
systems and programs to the Citizens Assembly/Council on
Public Aid to enable the Committee to ensure, from time to
time, that these programs are effective and meaningful.
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, 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 and one copy with the Citizens
Assembly/Council on Public Aid or its successor shall be
deemed sufficient to comply with this Section.
(Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
89-517, eff. 1-1-97.)
(Text of Section after amendment by P.A. 89-507)
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; (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.
The Illinois Department of Public Aid 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, 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 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; a mammogram every
1 to 2 years, even if no symptoms are present, for women 40
to 49 years of age; and an annual mammogram for women 40 50
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 breast.
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 Public Aid 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 Illinois Department of Public Aid 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. In formulating these
regulations the Illinois Department shall consult with and
give substantial weight to the recommendations offered by the
Citizens Assembly/Council on Public Aid. 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 services.
(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.
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 that 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.
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. Rules under clause (2)
above shall not provide for purchase or lease-purchase of
durable medical equipment or supplies used for the purpose of
oxygen delivery and respiratory care.
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 regularly the results of the operation of such
systems and programs to the Citizens Assembly/Council on
Public Aid to enable the Committee to ensure, from time to
time, that these programs are effective and meaningful.
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, 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 and one copy with the Citizens
Assembly/Council on Public Aid or its successor shall be
deemed sufficient to comply with this Section.
(Source: P.A. 88-670, eff. 12-2-94; 89-21, eff. 7-1-95;
89-507, eff. 7-1-97; 89-517, eff. 1-1-97; revised 8-26-96.)
(305 ILCS 5/5-16.8 new)
Sec. 5-16.8. Required health benefits. The medical
assistance program shall provide the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t and the coverage required
under Section 356u of the Illinois Insurance Code.
Section 95. No acceleration or delay. Where this Act
makes changes in a statute that is represented in this Act by
text that is not yet or no longer in effect (for example, a
Section represented by multiple versions), the use of that
text does not accelerate or delay the taking effect of (i)
the changes made by this Act or (ii) provisions derived from
any other Public Act.
Section 99. Effective date. This Act takes effect upon
becoming law.