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Paying for Health Care
For some, the most important health care issue is paying for health care. Several government-sponsored health care programs, administered primarily by the Illinois Department of Public Aid, provide payments to health care providers. In most cases, medical professionals have a right to payment within 30 days.
The federal government's role in Medicaid is quite limited. It pays a percentage of the cost of each state's health care program for indigent people and ensures that every state's program complies with various federal requirements. The amount of money a state receives from the federal government is called the Federal Financial Participation (FFP). Each state's FFP is determined by a formula based on the state's per capita income and the amount of medical services the state chooses to provide to needy people within the state.
To receive Medicaid, a person must have assets with a low value and very low income as determined by a complex formula. In Illinois, a person generally can have no more than $3,000 in assets and $591 income per month, although there is a complex formula applied which considers the applicant's unique situation. There are several assets the formula does not count, including:
As long as transfers are compensated, it is legal to restructure one's assets and income with the intent of qualifying for Medicaid. A person whose income is above Medicaid limits might be able to qualify for Medicaid under a spend-down provision. The spend-down is equal to the amount a person's income is over Medicaid limits. Medicaid occasionally agrees to cover the amount that a person's medical bills exceed a patient's spend-down. Many senior citizens find restructuring assets to qualify for Medicaid to be an especially attractive option, because Medicaid coverage pays for a wider variety of nursing care services and for a longer period of time than Medicare.
Medicare Part B, commonly known as Medical Insurance, is a voluntary health insurance program designed to cover some of the costs not covered by Medicare Part A, such as outpatient hospital services, outpatient physical therapy, speech pathology services, necessary ambulance service, and medical equipment. Unlike Part A, which is paid for out of Social Security taxes and is free to anyone who qualifies, Part B is an optional program that carries a small monthly premium.
People qualify for Hospital Insurance when they turn 65 years old or if they are covered by Social Security or Railroad Retirement benefits. The person need not actually be receiving financial benefits through either of these two programs in order to receive Medicare benefits. Anyone age 65 or older not eligible for Social Security or Railroad Retirement benefits still may receive Medicare Part A coverage by paying a monthly premium. Medicare Part B coverage is available automatically to anyone who qualifies for Medicare Part A benefits. In fact, all applicants for Medicare Part A benefits are enrolled automatically in Medicare Part B unless they opt out of Part B coverage. The federal government contracts with private insurance companies to handle routine claims processing, payment, and other functions under Parts A and B.
Another popular option in Illinois is coverage under the Illinois Comprehensive Health Insurance Plan. This program was intended as an alternative to traditional health insurance. It benefits Illinois residents who are refused health insurance by private health insurance companies, or who can obtain insurance but only at an excessive rate. The Comprehensive Health Insurance Plan provides coverage for medically necessary treatment such as hospital services.
In Illinois, two additional programs help older people and people with disabilities pay for their Medicare coverage. In order to be eligible for these programs, an individual must have assets of no more than $4,000 and must live in Illinois. The Qualified Medicare Beneficiary Program (QMB) assists those who have Part A Hospital Insurance and whose income is at 100 percent or less than the federal poverty level. The Specified Low-Income Medicare Beneficiary Program (SLMB) covers Part B Medical Insurance for individuals with incomes between 100 percent and 110 percent of the poverty level. These programs are run by the Illinois Department of Public Aid.
Access to Facilities
Hospitals rarely refuse to treat a patient if the patient has health care insurance, but sometimes hospitals do refuse to admit patients. Federal and state laws governing the medical industry clearly forbid health care providers from discriminating in deciding whom to treat. The Internal Revenue Service requires hospitals to admit all paying members of their communities in order to enjoy tax exempt status. The Hill-Burton Act, which provides construction grants for many hospital projects, requires hospitals receiving grants under its programs to admit all paying patients. Medicare and Medicaid require all participating hospitals to provide care to all covered patients.
Fortunately, most of these laws guaranteeing access to health care facilities are invoked infrequently. Most hospitals are eager to admit patients. Sometimes, however, because of prejudices or a hospital's concern about being reimbursed, Medicare or Medicaid recipients have more difficulty accessing hospitals. The AIDS epidemic has made accessibility an issue in some recent cases in which hospital decision makers were concerned with the potentially enormous costs of fighting the disease, worried about spreading the disease, or objected to the lifestyles they assumed AIDS sufferers led. Hospitals and other providers of health care should be aware of the laws in this area, and should know that refusing a person health care based on personal bias is illegal.
Consent to Care
In general, a doctor may not diagnose or treat a patient without obtaining that person's informed consent first. Informed consent means the person has given consent after receiving all relevant information about the treatment, including the risks. Failure to get informed consent for treatment can subject the doctor to charges of battery, invasion of privacy, or malpractice.
Under some circumstances, the patient's consent is not required. If the person cannot consent for himself or herself, a guardian or close relative may give permission for medical treatment. In an emergency, the head of a health care facility will consent to treatment if a patient's close relatives cannot be reached. A patient's consent to treatment will be implied if the patient is unable to give consent and an emergency exists or if the patient can give consent but the doctor does not have sufficient time to properly inform the patient of all risks and alternatives. A doctor need not obtain a client's consent to treat mental illness, mental retardation, or chemical dependency.
Minors generally need the approval of a parent or guardian to undergo a medical or surgical procedure. Exceptions to this rule are emergencies, certain reproductive matters, and testing and treatment for certain sexually-transmitted diseases.
Most doctors know they should not treat a patient without any permission, so disputes in this area rarely center on whether a doctor had permission. More often, disputes turn on whether the doctor disclosed sufficient information for the patient's consent to be informed or whether the doctor went beyond the consented actions.
To give informed consent in Illinois, a patient must be given information about the foreseeable results and risks of a particular procedure and the reasonable alternatives. The physician does not have to disclose every possible risk. It is up to the doctor to decide what to tell the patient, based on the patient's best interests. All of these must be communicated in language the patient is likely to understand.
Experimental procedures or research may not be performed on a patient without the patient's consent prior to the procedure or research. A patient's consent or refusal to participate in experimental procedures or research must be recorded in the patient's permanent record.
Right to Refuse Treatment
Illinois law also gives patients the right to refuse treatment or medication. Patients who refuse recommended treatments must be informed of the likely medical and psychological results of such refusal, and documentation must be placed in their records. The right of parents to refuse medical treatment for their children is more limited.
Written Information
Illinois law provides that patients have the right certain information in writing. Every patient has a right to a written bill for services. If the bill is not understandable, the patient has a right to an explanation. Any patient admitted to a hospital must receive a copy of the Medical Patient Rights Act, or a written statement summarizing the rights described in the law. If the patient is a minor, or cannot read the statement, the hospital must give the written information to the patient's parent, guardian, or representative.
HIV Testing
Clinics and hospitals in Illinois test patients for HIV, the virus that causes AIDS. Because of the discrimination many HIV-positive people face, there is concern for confidentiality and anonymity of the test. While all health care providers are required to respect a patient's confidentiality, some clinics are committed to anonymous testing. At these sites, fictitious names or code numbers are used to hide the patient's identity.
Anyone interested in providing HIV testing should understand the important distinction between anonymous testing and confidential testing. A test can be confidential yet still be recorded on a patient's permanent record. Anyone with access to that record, including doctors, insurance companies, and health departments can learn that the person was tested. If the testing is anonymous, no one at the testing site knows the person's true identity so the test never becomes part of the person's permanent medical record.
Confidentiality
Illinois law provides that health care providers must keep confidential patients' medical records and any information patients provide them. For example, Illinois Rules of Evidence prohibit the introduction in court of confidential communications between a patient and a health care provider. The public policy behind this rule is the promotion of complete communication between doctors and their patients. Under other Illinois laws, a health care provider must have the patient's consent to release records to a third person. This general law does not prevent a doctor from releasing records to another doctor in an emergency for the purpose of treating the patient. It also does not prevent the release of records to the Illinois Department of Public Health.
Both of these protections will be set aside if they conflict with other public policies. For example, a doctor who is told by a patient that the patient plans to kill a particular person has a legal obligation to warn that person. Also, doctors have an obligation to report to the police anyone who comes for treatment of a suspicious wound, such as a stab or gunshot wound. Confidentiality also may be relinquished by people who are HIV-positive. The State of Illinois requires that a diagnosis of HIV-positive status be reported to the State Department of Public Health.
Anatomical Gifts
Many people want to donate their bodies to science when they die. Many human organs can be transplanted into another person, giving the recipient a chance at a longer or more productive life. A wide variety of institutions also need bodies and organs for scientific, medical, and educational purposes. Unfortunately, many potential transplant recipients and many scientific and educational institutions are unable to get sufficient donations because too few people are willing to donate or do not know how to make their wishes known. To solve this problem, Illinois adopted the Uniform Anatomical Gift Act to govern the donation of bodies and body parts for transplant, medical, and scientific purposes.
Under this law, a person of sound mind, who is at least 18 years of age, may donate all or part of his or her own body. There are several ways for a donor to record his or her wish to make a donation. The donor may make the donation a provision in a will. If it is part of a will, the provision becomes effective immediately upon death, unlike other provisions of the will, which need to go through probate before they become effective. A will is not the best place for a donation, however, because its terms may not be known immediately upon death. A more common form of recording one's wish to make a donation is through use of a donor card often carried in a wallet.
A written donation statement must be signed by the donor and witnessed by at least two other people. A donation also may be made orally. Oral donations are effective if witnessed by at least two other people. A dying patient may communicate his or wish to make a donation to an attending physician who will act as one of the required witnesses. The attending physician must not be the physician who removes or transplants the organ. An intent to make a gift can be revoked orally or in writing.
If a dying person is unable to communicate and has not made his or her wishes known, a family member or guardian can make a gift of all or part of another person's body. There are statutorily prescribed categories of people who are authorized to make the gift, including the spouse, an adult child, a parent, an adult sibling, or a guardian. The law provides the exact method of authorization, as well as how people may object to making a donation.
The law forbids the sale of body parts. The recipient may not pay for an anatomical gift but may pay for the actual cost of transportation and transplant.
Reporting Abuse
By law, certain members of society, by virtue of their professions and positions, are required to report child abuse. Persons required to report abuse--known as mandatory reporters--include health care professionals, teachers, law enforcement officials, child care providers and social workers. Virtually anyone who works directly with children to provide care, protection, and supervision is required to report instances, actual or suspected, of child abuse.
Mandatory reporters are obligated to report any abuse or neglect immediately to the Illinois Department of Children and Family Services (DCFS). Failure of a mandatory reporter to report suspected child abuse is a class A misdemeanor, unless the reporter is a physician, in which case the physician will be reported to the Illinois State Medical Disciplinary Board.
Persons who report abuse or neglect in good faith are immune from civil or criminal liability. This means that if an investigation shows there was no abuse, the reporter cannot be sued as long as he or she reported the alleged child abuse with an honest belief and without knowledge of any facts or events contradicting the abuse or neglect.
Child protective service workers must request information from a person reporting child abuse. To expedite the attention given to a child in an abusive or neglected situation, the reporter should have the following items ready for report:
Health care providers also are required, under the Illinois Domestic Violence Act of 1986, to assist suspected victims of abuse by offering immediate information about services available in Illinois. Victims covered under the Act include battered women and abused high-risk adults with disabilities. A high-risk adult with a disability is someone over the age of 18 who has a physical or mental disability that prevents the adult from being able to protect himself or herself. The definition includes elderly people with disabilities. Persons who may be liable for abusing high-risk adults with disabilities, include family or household members covered under the Act as well as other persons who have responsibility for these adults, including workers in hospitals, nursing homes, and similar care facilities. Abuse of high-risk adults with disabilities includes physical abuse, sexual abuse, neglect, and exploitation, including financial exploitation. Neglect includes failure to provide food, shelter, clothing, personal hygiene, and medical care, unreasonable confinement, and failure to protect the high-risk adult from abuse or from other hazards to health or safety. People who know of or suspect abuse or neglect may make a report of any known or suspected incidence of abuse or neglect to the Illinois Department on Aging.
Patient Care Decision-Making: A Legal Guide for Providers, Clare C. Obade, Clark Boardman Callaghan, Deerfield, IL, 1994.
Consumer Fraud Bureau, Office of the Illinois Attorney General, Consumer Protection Bureau, 500 South Second Street, Springfield, IL 62706, phone: (217) 782-9011, TDD: (217) 785-2771; 100 West Randolph Street, Chicago, IL 60601, phone: (312) 814-3000, TDD: (312) 814-3374; toll-free consumer line: 1-800-252-8666. Call or write for information on the Medical Patient Rights Act or to order the free publication, Medical Bills, July 1995.
Illinois Department of Children and Family Services, Division of Child Protection, 406 East Monroe Street, Springfield, IL 62701, phone: (217) 785-2513; Chicago phone: (312) 814-6864 or toll-free: 1-800-252-2873. Call the DCFS for information, to report child abuse and neglect, or to order the free brochure, Care Enough to Call.
Illinois Department of Public Aid, Division of Medical Programs, Prescott E. Bloom Building, 201 South Grand Avenue East, Springfield, IL 62763, phone: (217) 782-0963 or toll-free: 1-800-252-8635. Contact this department for information about Medicaid and Medicare.
Illinois Department of Public Health, 535 Jefferson Street West, Springfield, IL 62761, phone: (217) 782-4977.
Illinois State Bar Association, Illinois Bar Center, Springfield, IL 62701-1778, phone: (217) 525-1760. Call the ISBA to obtain a copy of the free brochure, Your Health Care: Who Decides?
Health Care Law: A Practical Guide, Michael G. Macdonald, et al., Matthew Bender, 1993.
The free pamphlet, Understanding Social Security, may be obtained from the Social Security Administration by calling the toll-free number: 1-800-772-1213.
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