|
|||||||||||||||||||||||||
|
|||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
1 | AN ACT concerning public aid.
| ||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| ||||||||||||||||||||||||
3 | represented in the General Assembly:
| ||||||||||||||||||||||||
4 | Section 5. The Illinois Public Aid Code is amended by | ||||||||||||||||||||||||
5 | changing Section 5-5 as follows:
| ||||||||||||||||||||||||
6 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| ||||||||||||||||||||||||
7 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||||||||||||||||||||
8 | rule, shall
determine the quantity and quality of and the rate | ||||||||||||||||||||||||
9 | of reimbursement for the
medical assistance for which
payment | ||||||||||||||||||||||||
10 | will be authorized, and the medical services to be provided,
| ||||||||||||||||||||||||
11 | which may include all or part of the following: (1) inpatient | ||||||||||||||||||||||||
12 | hospital
services; (2) outpatient hospital services; (3) other | ||||||||||||||||||||||||
13 | laboratory and
X-ray services; (4) skilled nursing home | ||||||||||||||||||||||||
14 | services; (5) physicians'
services whether furnished in the | ||||||||||||||||||||||||
15 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||||||||||||||||||||
16 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||||||||||||||||||||
17 | care furnished by licensed practitioners; (7)
home health care | ||||||||||||||||||||||||
18 | services; (8) private duty nursing service; (9) clinic
| ||||||||||||||||||||||||
19 | services; (10) dental services, including prevention and | ||||||||||||||||||||||||
20 | treatment of periodontal disease and dental caries disease for | ||||||||||||||||||||||||
21 | pregnant women , provided by an individual licensed to practice | ||||||||||||||||||||||||
22 | dentistry or dental surgery; for purposes of this item (10), | ||||||||||||||||||||||||
23 | "dental services" means diagnostic, preventive, or corrective |
| |||||||
| |||||||
1 | procedures provided by or under the supervision of a dentist in | ||||||
2 | the practice of his or her profession ; (11) physical therapy | ||||||
3 | and related
services; (12) prescribed drugs, dentures, and | ||||||
4 | prosthetic devices; and
eyeglasses prescribed by a physician | ||||||
5 | skilled in the diseases of the eye,
or by an optometrist, | ||||||
6 | whichever the person may select; (13) other
diagnostic, | ||||||
7 | screening, preventive, and rehabilitative services; (14)
| ||||||
8 | transportation and such other expenses as may be necessary; | ||||||
9 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
10 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
11 | Treatment Act, for
injuries sustained as a result of the sexual | ||||||
12 | assault, including
examinations and laboratory tests to | ||||||
13 | discover evidence which may be used in
criminal proceedings | ||||||
14 | arising from the sexual assault; (16) the
diagnosis and | ||||||
15 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
16 | care, and any other type of remedial care recognized
under the | ||||||
17 | laws of this State, but not including abortions, or induced
| ||||||
18 | miscarriages or premature births, unless, in the opinion of a | ||||||
19 | physician,
such procedures are necessary for the preservation | ||||||
20 | of the life of the
woman seeking such treatment, or except an | ||||||
21 | induced premature birth
intended to produce a live viable child | ||||||
22 | and such procedure is necessary
for the health of the mother or | ||||||
23 | her unborn child. The Illinois Department,
by rule, shall | ||||||
24 | prohibit any physician from providing medical assistance
to | ||||||
25 | anyone eligible therefor under this Code where such physician | ||||||
26 | has been
found guilty of performing an abortion procedure in a |
| |||||||
| |||||||
1 | wilful and wanton
manner upon a woman who was not pregnant at | ||||||
2 | the time such abortion
procedure was performed. The term "any | ||||||
3 | other type of remedial care" shall
include nursing care and | ||||||
4 | nursing home service for persons who rely on
treatment by | ||||||
5 | spiritual means alone through prayer for healing.
| ||||||
6 | Notwithstanding any other provision of this Section, a | ||||||
7 | comprehensive
tobacco use cessation program that includes | ||||||
8 | purchasing prescription drugs or
prescription medical devices | ||||||
9 | approved by the Food and Drug administration shall
be covered | ||||||
10 | under the medical assistance
program under this Article for | ||||||
11 | persons who are otherwise eligible for
assistance under this | ||||||
12 | Article.
| ||||||
13 | Notwithstanding any other provision of this Code, the | ||||||
14 | Illinois
Department may not require, as a condition of payment | ||||||
15 | for any laboratory
test authorized under this Article, that a | ||||||
16 | physician's handwritten signature
appear on the laboratory | ||||||
17 | test order form. The Illinois Department may,
however, impose | ||||||
18 | other appropriate requirements regarding laboratory test
order | ||||||
19 | documentation.
| ||||||
20 | The Department of Healthcare and Family Services shall | ||||||
21 | provide the following services to
persons
eligible for | ||||||
22 | assistance under this Article who are participating in
| ||||||
23 | education, training or employment programs operated by the | ||||||
24 | Department of Human
Services as successor to the Department of | ||||||
25 | Public Aid:
| ||||||
26 | (1) dental services provided by or under the |
| |||||||
| |||||||
1 | supervision of a dentist , which shall include but not be | ||||||
2 | limited to
prosthodontics ; and
| ||||||
3 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
4 | diseases of the
eye, or by an optometrist, whichever the | ||||||
5 | person may select.
| ||||||
6 | The Illinois Department, by rule, may distinguish and | ||||||
7 | classify the
medical services to be provided only in accordance | ||||||
8 | with the classes of
persons designated in Section 5-2.
| ||||||
9 | The Department of Healthcare and Family Services must | ||||||
10 | provide coverage and reimbursement for amino acid-based | ||||||
11 | elemental formulas, regardless of delivery method, for the | ||||||
12 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
13 | short bowel syndrome when the prescribing physician has issued | ||||||
14 | a written order stating that the amino acid-based elemental | ||||||
15 | formula is medically necessary.
| ||||||
16 | The Illinois Department shall authorize the provision of, | ||||||
17 | and shall
authorize payment for, screening by low-dose | ||||||
18 | mammography for the presence of
occult breast cancer for women | ||||||
19 | 35 years of age or older who are eligible
for medical | ||||||
20 | assistance under this Article, as follows: a baseline
mammogram | ||||||
21 | for women 35 to 39 years of age and an
annual mammogram for | ||||||
22 | women 40 years of age or older. All screenings
shall
include a | ||||||
23 | physical breast exam, instruction on self-examination and
| ||||||
24 | information regarding the frequency of self-examination and | ||||||
25 | its value as a
preventative tool. As used in this Section, | ||||||
26 | "low-dose mammography" means
the x-ray examination of the |
| |||||||
| |||||||
1 | breast using equipment dedicated specifically
for mammography, | ||||||
2 | including the x-ray tube, filter, compression device,
image | ||||||
3 | receptor, and cassettes, with an average radiation exposure | ||||||
4 | delivery
of less than one rad mid-breast, with 2 views for each | ||||||
5 | breast.
| ||||||
6 | Any medical or health care provider shall immediately | ||||||
7 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
8 | services and is suspected
of drug abuse or is addicted as | ||||||
9 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
10 | Act, referral to a local substance abuse treatment provider
| ||||||
11 | licensed by the Department of Human Services or to a licensed
| ||||||
12 | hospital which provides substance abuse treatment services. | ||||||
13 | The Department of Healthcare and Family Services
shall assure | ||||||
14 | coverage for the cost of treatment of the drug abuse or
| ||||||
15 | addiction for pregnant recipients in accordance with the | ||||||
16 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
17 | Human Services.
| ||||||
18 | All medical providers providing medical assistance to | ||||||
19 | pregnant women
under this Code shall receive information from | ||||||
20 | the Department on the
availability of services under the Drug | ||||||
21 | Free Families with a Future or any
comparable program providing | ||||||
22 | case management services for addicted women,
including | ||||||
23 | information on appropriate referrals for other social services
| ||||||
24 | that may be needed by addicted women in addition to treatment | ||||||
25 | for addiction.
| ||||||
26 | The Illinois Department, in cooperation with the |
| |||||||
| |||||||
1 | Departments of Human
Services (as successor to the Department | ||||||
2 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
3 | public awareness campaign, may
provide information concerning | ||||||
4 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
5 | health care, and other pertinent programs directed at
reducing | ||||||
6 | the number of drug-affected infants born to recipients of | ||||||
7 | medical
assistance.
| ||||||
8 | Neither the Department of Healthcare and Family Services | ||||||
9 | nor the Department of Human
Services shall sanction the | ||||||
10 | recipient solely on the basis of
her substance abuse.
| ||||||
11 | The Illinois Department shall establish such regulations | ||||||
12 | governing
the dispensing of health services under this Article | ||||||
13 | as it shall deem
appropriate. The Department
should
seek the | ||||||
14 | advice of formal professional advisory committees appointed by
| ||||||
15 | the Director of the Illinois Department for the purpose of | ||||||
16 | providing regular
advice on policy and administrative matters, | ||||||
17 | information dissemination and
educational activities for | ||||||
18 | medical and health care providers, and
consistency in | ||||||
19 | procedures to the Illinois Department.
| ||||||
20 | The Illinois Department may develop and contract with | ||||||
21 | Partnerships of
medical providers to arrange medical services | ||||||
22 | for persons eligible under
Section 5-2 of this Code. | ||||||
23 | Implementation of this Section may be by
demonstration projects | ||||||
24 | in certain geographic areas. The Partnership shall
be | ||||||
25 | represented by a sponsor organization. The Department, by rule, | ||||||
26 | shall
develop qualifications for sponsors of Partnerships. |
| |||||||
| |||||||
1 | Nothing in this
Section shall be construed to require that the | ||||||
2 | sponsor organization be a
medical organization.
| ||||||
3 | The sponsor must negotiate formal written contracts with | ||||||
4 | medical
providers for physician services, inpatient and | ||||||
5 | outpatient hospital care,
home health services, treatment for | ||||||
6 | alcoholism and substance abuse, and
other services determined | ||||||
7 | necessary by the Illinois Department by rule for
delivery by | ||||||
8 | Partnerships. Physician services must include prenatal and
| ||||||
9 | obstetrical care. The Illinois Department shall reimburse | ||||||
10 | medical services
delivered by Partnership providers to clients | ||||||
11 | in target areas according to
provisions of this Article and the | ||||||
12 | Illinois Health Finance Reform Act,
except that:
| ||||||
13 | (1) Physicians participating in a Partnership and | ||||||
14 | providing certain
services, which shall be determined by | ||||||
15 | the Illinois Department, to persons
in areas covered by the | ||||||
16 | Partnership may receive an additional surcharge
for such | ||||||
17 | services.
| ||||||
18 | (2) The Department may elect to consider and negotiate | ||||||
19 | financial
incentives to encourage the development of | ||||||
20 | Partnerships and the efficient
delivery of medical care.
| ||||||
21 | (3) Persons receiving medical services through | ||||||
22 | Partnerships may receive
medical and case management | ||||||
23 | services above the level usually offered
through the | ||||||
24 | medical assistance program.
| ||||||
25 | Medical providers shall be required to meet certain | ||||||
26 | qualifications to
participate in Partnerships to ensure the |
| |||||||
| |||||||
1 | delivery of high quality medical
services. These | ||||||
2 | qualifications shall be determined by rule of the Illinois
| ||||||
3 | Department and may be higher than qualifications for | ||||||
4 | participation in the
medical assistance program. Partnership | ||||||
5 | sponsors may prescribe reasonable
additional qualifications | ||||||
6 | for participation by medical providers, only with
the prior | ||||||
7 | written approval of the Illinois Department.
| ||||||
8 | Nothing in this Section shall limit the free choice of | ||||||
9 | practitioners,
hospitals, and other providers of medical | ||||||
10 | services by clients.
In order to ensure patient freedom of | ||||||
11 | choice, the Illinois Department shall
immediately promulgate | ||||||
12 | all rules and take all other necessary actions so that
provided | ||||||
13 | services may be accessed from therapeutically certified | ||||||
14 | optometrists
to the full extent of the Illinois Optometric | ||||||
15 | Practice Act of 1987 without
discriminating between service | ||||||
16 | providers.
| ||||||
17 | The Department shall apply for a waiver from the United | ||||||
18 | States Health
Care Financing Administration to allow for the | ||||||
19 | implementation of
Partnerships under this Section.
| ||||||
20 | The Illinois Department shall require health care | ||||||
21 | providers to maintain
records that document the medical care | ||||||
22 | and services provided to recipients
of Medical Assistance under | ||||||
23 | this Article. The Illinois Department shall
require health care | ||||||
24 | providers to make available, when authorized by the
patient, in | ||||||
25 | writing, the medical records in a timely fashion to other
| ||||||
26 | health care providers who are treating or serving persons |
| |||||||
| |||||||
1 | eligible for
Medical Assistance under this Article. All | ||||||
2 | dispensers of medical services
shall be required to maintain | ||||||
3 | and retain business and professional records
sufficient to | ||||||
4 | fully and accurately document the nature, scope, details and
| ||||||
5 | receipt of the health care provided to persons eligible for | ||||||
6 | medical
assistance under this Code, in accordance with | ||||||
7 | regulations promulgated by
the Illinois Department. The rules | ||||||
8 | and regulations shall require that proof
of the receipt of | ||||||
9 | prescription drugs, dentures, prosthetic devices and
| ||||||
10 | eyeglasses by eligible persons under this Section accompany | ||||||
11 | each claim
for reimbursement submitted by the dispenser of such | ||||||
12 | medical services.
No such claims for reimbursement shall be | ||||||
13 | approved for payment by the Illinois
Department without such | ||||||
14 | proof of receipt, unless the Illinois Department
shall have put | ||||||
15 | into effect and shall be operating a system of post-payment
| ||||||
16 | audit and review which shall, on a sampling basis, be deemed | ||||||
17 | adequate by
the Illinois Department to assure that such drugs, | ||||||
18 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
19 | is being made are actually being
received by eligible | ||||||
20 | recipients. Within 90 days after the effective date of
this | ||||||
21 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
22 | a
current list of acquisition costs for all prosthetic devices | ||||||
23 | and any
other items recognized as medical equipment and | ||||||
24 | supplies reimbursable under
this Article and shall update such | ||||||
25 | list on a quarterly basis, except that
the acquisition costs of | ||||||
26 | all prescription drugs shall be updated no
less frequently than |
| |||||||
| |||||||
1 | every 30 days as required by Section 5-5.12.
| ||||||
2 | The rules and regulations of the Illinois Department shall | ||||||
3 | require
that a written statement including the required opinion | ||||||
4 | of a physician
shall accompany any claim for reimbursement for | ||||||
5 | abortions, or induced
miscarriages or premature births. This | ||||||
6 | statement shall indicate what
procedures were used in providing | ||||||
7 | such medical services.
| ||||||
8 | The Illinois Department shall require all dispensers of | ||||||
9 | medical
services, other than an individual practitioner or | ||||||
10 | group of practitioners,
desiring to participate in the Medical | ||||||
11 | Assistance program
established under this Article to disclose | ||||||
12 | all financial, beneficial,
ownership, equity, surety or other | ||||||
13 | interests in any and all firms,
corporations, partnerships, | ||||||
14 | associations, business enterprises, joint
ventures, agencies, | ||||||
15 | institutions or other legal entities providing any
form of | ||||||
16 | health care services in this State under this Article.
| ||||||
17 | The Illinois Department may require that all dispensers of | ||||||
18 | medical
services desiring to participate in the medical | ||||||
19 | assistance program
established under this Article disclose, | ||||||
20 | under such terms and conditions as
the Illinois Department may | ||||||
21 | by rule establish, all inquiries from clients
and attorneys | ||||||
22 | regarding medical bills paid by the Illinois Department, which
| ||||||
23 | inquiries could indicate potential existence of claims or liens | ||||||
24 | for the
Illinois Department.
| ||||||
25 | Enrollment of a vendor that provides non-emergency medical | ||||||
26 | transportation,
defined by the Department by rule,
shall be
|
| |||||||
| |||||||
1 | conditional for 180 days. During that time, the Department of | ||||||
2 | Healthcare and Family Services may
terminate the vendor's | ||||||
3 | eligibility to participate in the medical assistance
program | ||||||
4 | without cause. That termination of eligibility is not subject | ||||||
5 | to the
Department's hearing process.
| ||||||
6 | The Illinois Department shall establish policies, | ||||||
7 | procedures,
standards and criteria by rule for the acquisition, | ||||||
8 | repair and replacement
of orthotic and prosthetic devices and | ||||||
9 | durable medical equipment. Such
rules shall provide, but not be | ||||||
10 | limited to, the following services: (1)
immediate repair or | ||||||
11 | replacement of such devices by recipients without
medical | ||||||
12 | authorization; and (2) rental, lease, purchase or | ||||||
13 | lease-purchase of
durable medical equipment in a | ||||||
14 | cost-effective manner, taking into
consideration the | ||||||
15 | recipient's medical prognosis, the extent of the
recipient's | ||||||
16 | needs, and the requirements and costs for maintaining such
| ||||||
17 | equipment. Such rules shall enable a recipient to temporarily | ||||||
18 | acquire and
use alternative or substitute devices or equipment | ||||||
19 | pending repairs or
replacements of any device or equipment | ||||||
20 | previously authorized for such
recipient by the Department.
| ||||||
21 | The Department shall execute, relative to the nursing home | ||||||
22 | prescreening
project, written inter-agency agreements with the | ||||||
23 | Department of Human
Services and the Department on Aging, to | ||||||
24 | effect the following: (i) intake
procedures and common | ||||||
25 | eligibility criteria for those persons who are receiving
| ||||||
26 | non-institutional services; and (ii) the establishment and |
| |||||||
| |||||||
1 | development of
non-institutional services in areas of the State | ||||||
2 | where they are not currently
available or are undeveloped.
| ||||||
3 | The Illinois Department shall develop and operate, in | ||||||
4 | cooperation
with other State Departments and agencies and in | ||||||
5 | compliance with
applicable federal laws and regulations, | ||||||
6 | appropriate and effective
systems of health care evaluation and | ||||||
7 | programs for monitoring of
utilization of health care services | ||||||
8 | and facilities, as it affects
persons eligible for medical | ||||||
9 | assistance under this Code.
| ||||||
10 | The Illinois Department shall report annually to the | ||||||
11 | General Assembly,
no later than the second Friday in April of | ||||||
12 | 1979 and each year
thereafter, in regard to:
| ||||||
13 | (a) actual statistics and trends in utilization of | ||||||
14 | medical services by
public aid recipients;
| ||||||
15 | (b) actual statistics and trends in the provision of | ||||||
16 | the various medical
services by medical vendors;
| ||||||
17 | (c) current rate structures and proposed changes in | ||||||
18 | those rate structures
for the various medical vendors; and
| ||||||
19 | (d) efforts at utilization review and control by the | ||||||
20 | Illinois Department.
| ||||||
21 | The period covered by each report shall be the 3 years | ||||||
22 | ending on the June
30 prior to the report. The report shall | ||||||
23 | include suggested legislation
for consideration by the General | ||||||
24 | Assembly. The filing of one copy of the
report with the | ||||||
25 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
26 | the Clerk of the House of Representatives, one copy with the |
| |||||||
| |||||||
1 | President,
one copy with the Minority Leader and one copy with | ||||||
2 | the Secretary of the
Senate, one copy with the Legislative | ||||||
3 | Research Unit, and such additional
copies
with the State | ||||||
4 | Government Report Distribution Center for the General
Assembly | ||||||
5 | as is required under paragraph (t) of Section 7 of the State
| ||||||
6 | Library Act shall be deemed sufficient to comply with this | ||||||
7 | Section.
| ||||||
8 | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)
|