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Public Act 91-0462
SB498 Enrolled LRB9101554SMdv
AN ACT to amend the Illinois Public Aid Code by changing
Section 5-5.
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; (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 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 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. 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 providers.
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. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97;
89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.)
Section 99. Effective date. This Act takes effect upon
becoming law.
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