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90_SB0722
215 ILCS 5/370g from Ch. 73, par. 982g
215 ILCS 5/370i from Ch. 73, par. 982i
215 ILCS 5/370o from Ch. 73, par. 982o
215 ILCS 105/2 from Ch. 73, par. 1302
215 ILCS 105/3 from Ch. 73, par. 1303
215 ILCS 105/5 from Ch. 73, par. 1305
215 ILCS 105/8 from Ch. 73, par. 1308
215 ILCS 125/1-2 from Ch. 111 1/2, par. 1402
215 ILCS 125/4-10 from Ch. 111 1/2, par. 1409.3
215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8
215 ILCS 125/5-7.2 new
305 ILCS 5/5-5.04 new
305 ILCS 5/5-16.3
Creates the Access to Emergency Services Act. Provides
that health insurance plans, as defined, must provide
coverage for emergency services obtained by a covered
individual. Provides for administration by the Department of
Insurance. Amends the Illinois Insurance Code, Comprehensive
Health Insurance Plan Act, Health Maintenance Organization
Act, and Illinois Public Aid Code to require coverage under
those Acts for emergency service. Effective immediately.
LRB9003216JSgc
LRB9003216JSgc
1 AN ACT concerning access to emergency medical services,
2 amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 1. Short title. This Act may be cited as the
6 Access to Emergency Services Act.
7 Section 5. Legislative findings and purposes.
8 (a) The legislature recognizes that all persons need
9 access to emergency medical care, and that State and federal
10 laws require hospital emergency departments to provide that
11 care. Federal law specifically prohibits emergency
12 physicians and hospital emergency departments from delaying
13 any treatment needed to evaluate or stabilize an individual
14 in order to determine the health insurance status of the
15 individual.
16 However, health insurance plans may impede access to
17 emergency care by denying coverage or payment for failure to
18 obtain prior authorization or approval from the plan, failure
19 to seek emergency care from a preferred or contractual
20 provider, or an after-the-fact determination that the medical
21 condition did not require the use of emergency facilities or
22 services, including the 911 emergency telephone number.
23 These denials impose significant financial burdens on
24 patients who prudently seek care for symptoms of a medical
25 emergency through the 911 system and in a hospital emergency
26 department, as well as the providers of such care. This
27 serves to discourage patients from seeking appropriate
28 emergency care, and threatens the financial livelihood of
29 hospital emergency departments and trauma centers which
30 provide such necessary services to our entire population.
31 (b) This Act intended to promote access to emergency
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1 medical care by establishing a uniform definition of
2 emergency medical condition that is based on the average
3 knowledge of the prudent layperson, and requiring insurance
4 plans to cover and pay for such services without restrictions
5 that may impede or discourage access to such care.
6 Section 10. Definitions. As used in this Act:
7 "Department" means the Illinois Department of Insurance.
8 "Emergency medical screening examination" means a medical
9 screening examination and evaluation by a physician or, to
10 the extent permitted by applicable laws, by other appropriate
11 personnel under the supervision of a physician to determine
12 whether the need for emergency services exists.
13 "Emergency services" means those health care services
14 provided to evaluate and treat medical conditions of recent
15 onset and severity that would lead a prudent layperson,
16 possessing an average knowledge of medicine and health, to
17 believe that urgent and unscheduled medical care is required.
18 "Health insurance plan" means any policy, contract, plan,
19 or other arrangement that pays for or furnishes medical
20 services pursuant to the Illinois Insurance Code, the
21 Comprehensive Health Insurance Plan Act, the Health
22 Maintenance Organization Act, or the Illinois Public Aid
23 Code.
24 "Insured" means any person enrolled in or covered by a
25 health insurance plan.
26 "Post-stabilization services" means those health care
27 services determined by a treating provider to be promptly and
28 medically necessary following stabilization of an emergency
29 condition.
30 "Provider" means any physician, hospital facility, or
31 other person that is licensed or otherwise authorized to
32 furnish or arrange for the delivery or furnishing of health
33 care services.
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1 Section 15. Emergency services.
2 (a) Any health insurance plan subject to this Act shall
3 provide the insured emergency services coverage such that
4 payment for this coverage is not dependent upon whether such
5 services are performed by a preferred or nonpreferred
6 provider, and such coverage shall be at the same benefit
7 level as if the service or treatment had been rendered by a
8 plan provider.
9 (b) Prior authorization or approval by the plan shall
10 not be required.
11 (c) Coverage and payment shall not be retrospectively
12 denied, with the following exceptions:
13 (1) upon reasonable determination that the
14 emergency services claimed were never performed; or
15 (2) upon reasonable determination that an emergency
16 medical screening examination was performed on a patient
17 who personally sought emergency services knowing that he
18 or she did not have an emergency condition or necessity,
19 and who did not in fact require emergency services.
20 (d) When an enrollee presents to a hospital seeking
21 emergency services, as defined in Section 10, the
22 determination as to whether the need for those services
23 exists shall be made for purposes of treatment by a physician
24 of the hospital or, to the extent permitted by applicable
25 law, by other appropriate licensed personnel under the
26 supervision of a physician. The physician or other
27 appropriate personnel shall indicate in the patient's chart
28 the results of the emergency medical screening examination.
29 The plan shall compensate the provider for an emergency
30 medical screening examination that is reasonably calculated
31 to assist the health care provider in determining whether the
32 patient's condition requires emergency services. The plan
33 shall compensate the provider for an emergency medical
34 screening examination as defined in Section 10.
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1 (e) The appropriate use of the 911 emergency telephone
2 number shall not be discouraged or penalized, and coverage or
3 payment shall not be denied solely on the basis that the
4 insured used the 911 emergency telephone number to summon
5 emergency services.
6 Section 20. Post-stabilization services.
7 (a) If prior authorization for post-stabilization
8 services is required, the health insurance plan shall provide
9 access 24 hours a day, 7 days a week to persons designated by
10 plan to make such determinations. If a provider has
11 attempted to contact such person for prior authorization and
12 no designated persons were accessible or the authorization
13 was not denied within 30 minutes of the request, the health
14 insurance plan is deemed to have approved the request for
15 prior authorization.
16 (b) Coverage and payment for post-stabilization services
17 which received prior authorization or deemed approval shall
18 not be retrospectively denied.
19 Section 25. Enforcement.
20 (a) The Department shall enforce the provisions of this
21 Act. It shall promptly investigate complaints which it
22 receives alleging violation of the Act. If the complaint is
23 found to be valid, the Department shall immediately seek
24 appropriate corrective action by the health insurance plan
25 including, but not limited to, ceasing the noncompliant
26 activity, restoring coverage, paying or reimbursing claims,
27 and other appropriate restitution.
28 (b) Subject to the provisions of the Illinois
29 Administrative Procedure Act, the Department shall impose an
30 administrative fine on a health insurance plan found to have
31 violated any provision of this Act.
32 (1) Failure to comply with requested corrective
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1 action shall result in a fine of $5,000 per violation.
2 (2) A repeated violation shall result in a fine of
3 $10,000 per violation.
4 (3) A pattern of repeated violations shall result
5 in a fine of $25,000.
6 (c) Notwithstanding the existence or pursuit of any
7 other remedy, the Department may, through the Attorney
8 General, seek an injunction to restrain or prevent any health
9 insurance plan from violation or continuing to violate any
10 provisions of this Act.
11 Section 30. Rules. The Department shall adopt emergency
12 rules to implement the provisions of this Act, in accordance
13 with Section 5-45 of the Illinois Administrative Procedure
14 Act.
15 Section 90. The Illinois Insurance Code is amended by
16 changing Sections 370g, 370i, and 370o as follows:
17 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
18 Sec. 370g. Definitions. As used in this Article, the
19 following definitions apply:
20 (a) "Health care services" means health care services or
21 products rendered or sold by a provider within the scope of
22 the provider's license or legal authorization. The term
23 includes, but is not limited to, hospital, medical, surgical,
24 dental, vision and pharmaceutical services or products.
25 (b) "Insurer" means an insurance company or a health
26 service corporation authorized in this State to issue
27 policies or subscriber contracts which reimburse for expenses
28 of health care services.
29 (c) "Insured" means an individual entitled to
30 reimbursement for expenses of health care services under a
31 policy or subscriber contract issued or administered by an
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1 insurer.
2 (d) "Provider" means an individual or entity duly
3 licensed or legally authorized to provide health care
4 services.
5 (e) "Noninstitutional provider" means any person
6 licensed under the Medical Practice Act of 1987, as now or
7 hereafter amended.
8 (f) "Beneficiary" means an individual entitled to
9 reimbursement for expenses of or the discount of provider
10 fees for health care services under a program where the
11 beneficiary has an incentive to utilize the services of a
12 provider which has entered into an agreement or arrangement
13 with an administrator.
14 (g) "Administrator" means any person, partnership or
15 corporation, other than an insurer or health maintenance
16 organization holding a certificate of authority under the
17 "Health Maintenance Organization Act", as now or hereafter
18 amended, that arranges, contracts with, or administers
19 contracts with a provider whereby beneficiaries are provided
20 an incentive to use the services of such provider.
21 (h) "Emergency services" means those health care
22 services provided to evaluate and treat medical conditions of
23 recent onset and severity that would lead a prudent
24 layperson, possessing an average knowledge of medicine and
25 health, to believe that urgent or unscheduled medical care is
26 required an accidental bodily injury or emergency medical
27 condition which reasonably requires the beneficiary or
28 insured to seek immediate medical care under circumstances or
29 at locations which reasonably preclude the beneficiary or
30 insured from obtaining needed medical care from a preferred
31 provider.
32 (i) "Post-stabilization services" means those health
33 care services determined by a treating provider to be
34 promptly and medically necessary following stabilization of
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1 an emergency condition.
2 (j) "Emergency medical screening examination" means a
3 medical screening examination and evaluation by a physician
4 or, to the extent permitted by applicable laws, by other
5 appropriate personnel under the supervision of a physician to
6 determine whether the need for emergency services exists.
7 (Source: P.A. 88-400.)
8 (215 ILCS 5/370i) (from Ch. 73, par. 982i)
9 Sec. 370i. Policies, agreements or arrangements with
10 incentives or limits on reimbursement authorized.
11 (a) Policies, agreements or arrangements issued under
12 this Article may not contain terms or conditions that would
13 operate unreasonably to restrict the access and availability
14 of health care services for the insured.
15 (1) If prior authorization for post-stabilization
16 services is required, the insurer or administrator shall
17 provide access 24 hours a day, 7 days a week to persons
18 designated by the insurer or administrator to make such
19 determinations. If a provider has attempted to contact
20 such person for prior authorization and no designated
21 persons were accessible or the authorization was not
22 denied within 30 minutes of the request, the insurer or
23 administrator is deemed to have approved the request for
24 prior authorization.
25 Coverage and payment for post-stabilization services
26 which received prior authorization or deemed approval
27 shall not be retrospectively denied.
28 (2) The appropriate use of the 911 emergency
29 telephone number shall not be discouraged or penalized,
30 and coverage or payment shall not be denied solely on the
31 basis that the insured or beneficiary used the 911
32 emergency telephone number to summon emergency services.
33 (3) When an enrollee presents to a hospital seeking
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1 emergency services, as defined in Section 370(g), the
2 determination as to whether the need for those services
3 exists shall be made for purposes of treatment by a
4 physician of the hospital or, to the extent permitted by
5 applicable law, by other appropriate licensed personnel
6 under the supervision of a physician. The physician or
7 other appropriate personnel shall indicate in the
8 patient's chart the results of the emergency medical
9 screening examination. The plan shall compensate the
10 provider for an emergency medical screening examination
11 that is reasonably calculated to assist the health care
12 provider in determining whether the patient's condition
13 requires emergency services. The plan shall compensate
14 the provider for an emergency medical screening
15 examination as defined in Section 370(g).
16 (b) Subject to the provisions of subsection (a), an
17 insurer or administrator may:
18 (1) enter into agreements with certain providers of its
19 choice relating to health care services which may be rendered
20 to insureds or beneficiaries of the insurer or administrator,
21 including agreements relating to the amounts to be charged
22 the insureds or beneficiaries for services rendered;
23 (2) issue or administer programs, policies or subscriber
24 contracts in this State that include incentives for the
25 insured or beneficiary to utilize the services of a provider
26 which has entered into an agreement with the insurer or
27 administrator pursuant to paragraph (1) above.
28 (Source: P.A. 84-618.)
29 (215 ILCS 5/370o) (from Ch. 73, par. 982o)
30 Sec. 370o. Emergency services Care.
31 (a) Any referred provider contract, subject to this
32 Article shall provide the beneficiary or insured emergency
33 services care coverage such that payment for this coverage is
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1 not dependent upon whether such services are performed by a
2 preferred or nonpreferred provider and such coverage shall be
3 at the same benefit level as if the service or treatment had
4 been rendered by a plan provider.
5 (b) Prior authorization or approval by the plan shall
6 not be required.
7 (c) Coverage and payment shall not be retrospectively
8 denied, with the following exceptions:
9 (1) upon reasonable determination that the
10 emergency services claimed were never performed; or
11 (2) upon reasonable determination that an emergency
12 medical screening examination was performed on a patient
13 who personally sought emergency services knowing that he
14 or she did not have an emergency condition or necessity,
15 and who did not in fact require emergency services.
16 (3) When an enrollee presents to a hospital seeking
17 emergency services, as defined in Section 370(g), the
18 determination as to whether the need for those services
19 exists shall be made for purposes of treatment by a
20 physician of the hospital or, to the extent permitted by
21 applicable law, by other appropriate licensed personnel
22 under the supervision of a physician. The physician or
23 other appropriate personnel shall indicate in the
24 patient's chart the results of the emergency medical
25 screening examination. The plan shall compensate the
26 provider for an emergency medical screening examination
27 that is reasonably calculated to assist the health care
28 provider in determining whether the patient's condition
29 requires emergency services. The plan shall compensate
30 the provider for an emergency medical screening
31 examination as defined in Section 370(g).
32 (Source: P.A. 85-476.)
33 Section 92. The Comprehensive Health Insurance Plan Act
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1 is amended by changing Sections 2, 3, 5, and 8 as follows:
2 (215 ILCS 105/2) (from Ch. 73, par. 1302)
3 Sec. 2. Definitions. As used in this Act, unless the
4 context otherwise requires:
5 "Administering carrier" means the insurer or third party
6 administrator designated under Section 5 of this Act.
7 "Benefits plan" means the coverage to be offered by the
8 Plan to eligible persons pursuant to this Act.
9 "Board" means the Illinois Comprehensive Health Insurance
10 Board.
11 "Department" means the Illinois Department of Insurance.
12 "Director" means the Director of the Illinois Department
13 of Insurance.
14 "Eligible person" means a resident of this State who
15 qualifies under Section 7.
16 "Emergency medical screening examination" means a medical
17 screening examination and evaluation by a physician or, to
18 the extent permitted by applicable laws, by other appropriate
19 personnel under the supervision of a physician to determine
20 whether the need for emergency services exists.
21 "Emergency services" means those health care services
22 provided to evaluate and treat medical conditions of recent
23 onset and severity that would lead a prudent layperson,
24 possessing an average knowledge of medicine and health, to
25 believe that urgent or unscheduled medical care is required.
26 "Employee" means a resident of this State who has entered
27 into the employment of or works under contract or service of
28 an employer including the officers, managers and employees of
29 subsidiary or affiliated corporations and the individual
30 proprietors, partners and employees of affiliated individuals
31 and firms when the business of the subsidiary or affiliated
32 corporations, firms or individuals is controlled by a common
33 employer through stock ownership, contract, or otherwise.
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1 "Family" means the eligible person and his or her legal
2 spouse, the eligible person's dependent children under the
3 age of 19, the eligible person's dependent children under the
4 age of 23 who are full-time students, the eligible person's
5 dependent disabled children of any age, or any other member
6 of the eligible person's family who is claimed as a dependent
7 for purposes of filing federal income tax returns and resides
8 in the eligible person's household.
9 "Health insurance" means any hospital, surgical, or
10 medical coverage provided under an expense-incurred policy or
11 contract, minimum premium plan, stop loss coverage,
12 non-profit health care service plan contract, health
13 maintenance organization or other subscriber contract, or any
14 other health care plan or arrangement that pays for or
15 furnishes medical or health care services by a provider of
16 these services, whether by insurance or otherwise. Health
17 insurance shall not include accident only, disability income,
18 hospital confinement indemnity, dental, or credit insurance,
19 coverage issued as a supplement to liability insurance,
20 insurance arising out of a workers' compensation or similar
21 law, automobile medical-payment insurance, or insurance under
22 which benefits are payable with or without regard to fault
23 and which is statutorily required to be contained in any
24 liability insurance policy or equivalent self-insurance.
25 "Health Maintenance Organization" means an organization
26 as defined in the Health Maintenance Organization Act.
27 "Hospice" means a program as defined in and licensed
28 under the Hospice Program Licensing Act.
29 "Hospital" means an institution as defined in the
30 Hospital Licensing Act, an institution that meets all
31 comparable conditions and requirements in effect in the state
32 in which it is located, or the University of Illinois
33 Hospital as defined in the University of Illinois Hospital
34 Act.
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1 "Insured" means any individual resident of this State who
2 is eligible to receive benefits from any insurer or insurance
3 arrangement as defined in this Section.
4 "Insurer" means any insurance company authorized to
5 transact health insurance business in this State and any
6 corporation that provides medical services and is organized
7 under the Voluntary Health Services Plans Act or the Health
8 Maintenance Organization Act.
9 "Medical assistance" means health care benefits provided
10 under Articles V (Medical Assistance) and VI (General
11 Assistance) of the Illinois Public Aid Code or under any
12 similar program of health care benefits in a state other than
13 Illinois.
14 "Medically necessary" means that a service, drug, or
15 supply is necessary and appropriate for the diagnosis or
16 treatment of an illness or injury in accord with generally
17 accepted standards of medical practice at the time the
18 service, drug, or supply is provided. When specifically
19 applied to a confinement it further means that the diagnosis
20 or treatment of the insured person's medical symptoms or
21 condition cannot be safely provided to that person as an
22 outpatient. A service, drug, or supply shall not be medically
23 necessary if it: (i) is investigational, experimental, or for
24 research purposes; or (ii) is provided solely for the
25 convenience of the patient, the patient's family, physician,
26 hospital, or any other provider; or (iii) exceeds in scope,
27 duration, or intensity that level of care that is needed to
28 provide safe, adequate, and appropriate diagnosis or
29 treatment; or (iv) could have been omitted without adversely
30 affecting the insured person's condition or the quality of
31 medical care; or (v) involves the use of a medical device,
32 drug, or substance not formally approved by the United States
33 Food and Drug Administration.
34 "Medicare" means coverage under Title XVIII of the Social
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1 Security Act, 42 U.S.C. Sec. 1395, et seq..
2 "Minimum premium plan" means an arrangement whereby a
3 specified amount of health care claims is self-funded, but
4 the insurance company assumes the risk that claims will
5 exceed that amount.
6 "Participating transplant center" means a hospital
7 designated by the Board as a preferred or exclusive provider
8 of services for one or more specified human organ or tissue
9 transplants for which the hospital has signed an agreement
10 with the Board to accept a transplant payment allowance for
11 all expenses related to the transplant during a transplant
12 benefit period.
13 "Physician" means a person licensed to practice medicine
14 pursuant to the Medical Practice Act of 1987.
15 "Plan" means the comprehensive health insurance plan
16 established by this Act.
17 "Plan of operation" means the plan of operation of the
18 Plan, including articles, bylaws and operating rules, adopted
19 by the board pursuant to this Act.
20 "Post-stabilization services" means those health care
21 services determined by a treating provider to be promptly and
22 medically necessary following stabilization of an emergency
23 condition.
24 "Resident" means a person who has been legally domiciled
25 in this State for a period of at least 180 days and continues
26 to be domiciled in this State.
27 "Skilled nursing facility" means a facility or that
28 portion of a facility that is licensed by the Illinois
29 Department of Public Health under the Nursing Home Care Act
30 or a comparable licensing authority in another state to
31 provide skilled nursing care.
32 "Stop-loss coverage" means an arrangement whereby an
33 insurer insures against the risk that any one claim will
34 exceed a specific dollar amount or that the entire loss of a
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1 self-insurance plan will exceed a specific amount.
2 "Third party administrator" means an administrator as
3 defined in Section 511.101 of the Illinois Insurance Code who
4 is licensed under Article XXXI 1/4 of that Code.
5 (Source: P.A. 87-560; 88-364.)
6 (215 ILCS 105/3) (from Ch. 73, par. 1303)
7 Sec. 3. Operation of the Plan.
8 a. There is hereby created an Illinois Comprehensive
9 Health Insurance Plan.
10 b. The Plan shall operate subject to the supervision and
11 control of the board. The board is created as a political
12 subdivision and body politic and corporate and, as such, is
13 not a State agency. The board shall consist of 10 public
14 members, appointed by the Governor with the advice and
15 consent of the Senate.
16 Initial members shall be appointed to the Board by the
17 Governor as follows: 2 members to serve until July 1, 1988,
18 and until their successors are appointed and qualified; 2
19 members to serve until July 1, 1989, and until their
20 successors are appointed and qualified; 3 members to serve
21 until July 1, 1990, and until their successors are appointed
22 and qualified; and 3 members to serve until July 1, 1991, and
23 until their successors are appointed and qualified. As terms
24 of initial members expire, their successors shall be
25 appointed for terms to expire the first day in July 3 years
26 thereafter, and until their successors are appointed and
27 qualified.
28 Any vacancy in the Board occurring for any reason other
29 than the expiration of a term shall be filled for the
30 unexpired term in the same manner as the original
31 appointment.
32 Any member of the Board may be removed by the Governor
33 for neglect of duty, misfeasance, malfeasance, or nonfeasance
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1 in office.
2 In addition, a representative of the Illinois Health Care
3 Cost Containment Council, a representative of the Office of
4 the Attorney General and the Director or the Director's
5 designated representative shall be members of the board.
6 Four members of the General Assembly, one each appointed by
7 the President and Minority Leader of the Senate and by the
8 Speaker and Minority Leader of the House of Representatives,
9 shall serve as nonvoting members of the board. At least 2 of
10 the public members shall be individuals reasonably expected
11 to qualify for coverage under the Plan, the parent or spouse
12 of such an individual, or a surviving family member of an
13 individual who could have qualified for the plan during his
14 lifetime. The Director or Director's representative shall be
15 the chairperson of the board. Members of the board shall
16 receive no compensation, but shall be reimbursed for
17 reasonable expenses incurred in the necessary performance of
18 their duties.
19 c. The board shall make an annual report in September
20 and shall file the report with the Secretary of the Senate
21 and the Clerk of the House of Representatives. The report
22 shall summarize the activities of the Plan in the preceding
23 calendar year, including net written and earned premiums, the
24 expense of administration, the paid and incurred losses for
25 the year and other information as may be requested by the
26 General Assembly. The report shall also include analysis and
27 recommendations regarding utilization review, quality
28 assurance and access to cost effective quality health care.
29 d. In its plan of operation the board shall:
30 (1) Establish procedures for selecting an
31 administering carrier in accordance with Section 5 of
32 this Act.
33 (2) Establish procedures for the operation of the
34 board.
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1 (3) Create a Plan fund, under management of the
2 board, to fund administrative expenses.
3 (4) Establish procedures for the handling and
4 accounting of assets and monies of the Plan.
5 (5) Develop and implement a program to publicize
6 the existence of the Plan, the eligibility requirements
7 and procedures for enrollment and to maintain public
8 awareness of the Plan.
9 (6) Establish procedures under which applicants and
10 participants may have grievances reviewed by a grievance
11 committee appointed by the board. The grievances shall
12 be reported to the board immediately after completion of
13 the review. The Department and the board shall retain
14 all written complaints regarding the Plan for at least 3
15 years. Oral complaints shall be reduced to written form
16 and maintained for at least 3 years.
17 (7) Provide for other matters as may be necessary
18 and proper for the execution of its powers, duties and
19 obligations under the Plan.
20 e. No later than 5 years after the Plan is operative the
21 board and the Department shall conduct cooperatively a study
22 of the Plan and the persons insured by the Plan to determine:
23 (1) claims experience including a breakdown of medical
24 conditions for which claims were paid; (2) whether
25 availability of the Plan affected employment opportunities
26 for participants; (3) whether availability of the Plan
27 affected the receipt of medical assistance benefits by Plan
28 participants; (4) whether a change occurred in the number of
29 personal bankruptcies due to medical or other health related
30 costs; (5) data regarding all complaints received about the
31 Plan including its operation and services; (6) and any other
32 significant observations regarding utilization of the Plan.
33 The study shall culminate in a written report to be presented
34 to the Governor, the President of the Senate, the Speaker of
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1 the House and the chairpersons of the House and Senate
2 Insurance Committees. The report shall be filed with the
3 Secretary of the Senate and the Clerk of the House of
4 Representatives. The report shall also be available to
5 members of the general public upon request.
6 f. The board may:
7 (1) Prepare and distribute certificate of
8 eligibility forms and enrollment instruction forms to
9 insurance producers and to the general public in this
10 State.
11 (2) Provide for reinsurance of risks incurred by
12 the Plan and enter into reinsurance agreements with
13 insurers to establish a reinsurance plan for risks of
14 coverage described in the Plan, or obtain commercial
15 reinsurance to reduce the risk of loss through the Plan.
16 (3) Issue additional types of health insurance
17 policies to provide optional coverages as are otherwise
18 permitted by this Act including a Medicare supplement
19 policy designed to supplement Medicare.
20 (4) Provide for and employ cost containment
21 measures and requirements including, but not limited to,
22 preadmission certification, second surgical opinion,
23 concurrent utilization review programs, and individual
24 case management for the purpose of making the pool more
25 cost effective. Prior authorization for emergency
26 services shall not be required. If prior authorization
27 for post-stabilization services is required, the Plan or
28 administering carrier shall provide access 24 hours a
29 day, 7 days a week to persons designated by the Plan or
30 administering carrier to make such determinations. If a
31 health care provider has attempted to contact such person
32 for prior authorization and no designated persons were
33 accessible or the authorization was not denied within 30
34 minutes of the request, the Plan or administering carrier
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1 is deemed to have approved the request for prior
2 authorization. When an enrollee presents to a hospital
3 seeking emergency services, as defined in Section 2, the
4 determination as to whether the need for those services
5 exists shall be made for purposes of treatment by a
6 physician of the hospital or, to the extent permitted by
7 applicable law, by other appropriate licensed personnel
8 under the supervision of a physician. The physician or
9 other appropriate personnel shall indicate in the
10 patient's chart the results of the emergency medical
11 screening examination. The plan shall compensate the
12 provider for an emergency medical screening examination
13 that is reasonably calculated to assist the health care
14 provider in determining whether the patient's condition
15 requires emergency services. The plan shall compensate
16 the provider for emergency medical screening examination
17 as defined in Section 2.
18 (5) Design, utilize, or contract with preferred
19 provider organizations and health maintenance
20 organizations and otherwise arrange for the delivery of
21 cost effective health care services. Any such contract or
22 arrangement subject to this Act shall provide the insured
23 emergency services coverage such that payment for this
24 coverage is not dependent upon whether such services are
25 performed by a preferred or nonpreferred provider, and
26 such coverage shall be a the same benefit level as if the
27 service or treatment had been rendered by a plan
28 provider.
29 (6) Adopt bylaws, rules, regulations, policies and
30 procedures as may be necessary or convenient for the
31 implementation of the Act and the operation of the Plan.
32 g. The Director may, by rule, establish additional
33 powers and duties of the board and may adopt rules for any
34 other purposes, including the operation of the Plan, as are
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1 necessary or proper to implement this Act.
2 h. The board is not liable for any obligation of the
3 Plan. There is no liability on the part of any member or
4 employee of the board or the Department, and no cause of
5 action of any nature may arise against them, for any action
6 taken or omission made by them in the performance of their
7 powers and duties under this Act, unless the action or
8 omission constitutes willful or wanton misconduct. The board
9 may provide in its bylaws or rules for indemnification of,
10 and legal representation for, its members and employees.
11 i. There is no liability on the part of any insurance
12 producer for the failure of any applicant to be accepted by
13 the Plan unless the failure of the applicant to be accepted
14 by the Plan is due to an act or omission by the insurance
15 producer which constitutes willful or wanton misconduct.
16 (Source: P.A. 86-547; 86-1322; 87-560.)
17 (215 ILCS 105/5) (from Ch. 73, par. 1305)
18 Sec. 5. Administering carrier.
19 a. The board shall select an administering carrier
20 through a competitive bidding process to administer the plan.
21 The board shall evaluate bids submitted under this Section
22 based on criteria established by the board which shall
23 include:
24 (1) The carrier's proven ability to handle other
25 large group accident and health benefit plans.
26 (2) The efficiency of the carrier's claim paying
27 procedures.
28 (3) An estimate of total charges for administering
29 the plan.
30 (4) The ability of the carrier to administer the
31 plan in a cost-efficient manner.
32 (5) The financial condition and stability of the
33 carrier.
-20- LRB9003216JSgc
1 b. The administering carrier shall serve for a period of
2 5 years subject to removal for cause and subject to the
3 terms, conditions and limitations of the contract between the
4 board and the administering carrier. At least one year prior
5 to the expiration of each 5 year period of service by an
6 administering carrier, the board shall advertise for and
7 accept bids to serve as the administering carrier for the
8 succeeding 5 year period. Selection of the administering
9 carrier for the succeeding period shall be made at least 6
10 months prior to the end of the current 5 year period.
11 c. The administering carrier shall perform such
12 eligibility and administrative claims payment functions
13 relating to the plan as may be assigned to it including:
14 (1) The administering carrier shall establish a
15 premium billing procedure for collection of premiums from
16 plan participants. Billings shall be made on a periodic
17 basis as determined by the board.
18 (2) The administering carrier shall perform all
19 necessary functions to assure timely payment of benefits
20 to participants under the plan, including:
21 (a) Making available information relating to the proper
22 manner of submitting a claim for benefits under the plan and
23 distributing forms upon which submissions shall be made.
24 (b) Evaluating the eligibility of each claim for payment
25 under the plan. Coverage and payment for emergency services
26 shall not be retrospectively denied, except upon reasonable
27 determination that (1) the emergency services claimed were
28 never performed or (2) an emergency medical screening
29 examination was performed on a patient who personally sought
30 emergency services knowing that he or she did not have an
31 emergency condition or necessity, and who did not in fact
32 require emergency services.
33 Coverage and payment for post-stabilization services that
34 received prior authorization or deemed approval shall not be
-21- LRB9003216JSgc
1 retrospectively denied.
2 When an enrollee presents to a hospital seeking emergency
3 services, as defined in Section 2, the determination as to
4 whether the need for those services exists shall be made for
5 purposes of treatment by a physician of the hospital or, to
6 the extent permitted by applicable law, by other appropriate
7 licensed personnel under the supervision of a physician. The
8 physician or other appropriate personnel shall indicate in
9 the patient's chart the results of the emergency medical
10 screening examination. The plan shall compensate the
11 provider for an emergency medical screening examination that
12 is reasonably calculated to assist the health care provider
13 in determining whether the patient's condition requires
14 emergency services. The plan shall compensate the provider
15 for emergency medical screening examination as defined in
16 Section 2.
17 (c) The administering carrier shall be governed by the
18 requirements of Part 919 of Title 50 of the Illinois
19 Administrative Code, promulgated by the Department of
20 Insurance, regarding the handling of claims under this Act.
21 d. The administering carrier shall submit regular
22 reports to the board regarding the operation of the plan.
23 The frequency, content and form of the report shall be as
24 determined by the board.
25 e. The administering carrier shall pay claims expenses
26 from the premium payments received from or on behalf of plan
27 participants. If the administering carrier's payments for
28 claims expenses exceed the portion of premiums allocated by
29 the board for payment of claims expenses, the board shall
30 provide to the administering carrier additional funds for
31 payment of claims expenses.
32 f. The administering carrier shall be paid as provided
33 in the board's contract with the administering carrier for
34 expenses incurred in the performance of its services.
-22- LRB9003216JSgc
1 (Source: P.A. 85-1013.)
2 (215 ILCS 105/8) (from Ch. 73, par. 1308)
3 Sec. 8. Minimum benefits.
4 a. Availability. The Plan shall offer in an annually
5 renewable policy major medical expense coverage to every
6 eligible person who is not eligible for Medicare. Major
7 medical expense coverage offered by the Plan shall pay an
8 eligible person's covered expenses, subject to limit on the
9 deductible and coinsurance payments authorized under
10 paragraph (4) of subsection d of this Section, up to a
11 lifetime benefit limit of $500,000 per covered individual.
12 The maximum limit under this subsection shall not be altered
13 by the Board, and no actuarial equivalent benefit may be
14 substituted by the Board. Any person who otherwise would
15 qualify for coverage under the Plan, but is excluded because
16 he or she is eligible for Medicare, shall be eligible for any
17 separate Medicare supplement policy which the Board may
18 offer.
19 b. Covered expenses. Covered expenses shall be limited
20 to the reasonable and customary charge, including negotiated
21 fees, in the locality for the following services and articles
22 when medically necessary and prescribed by a person licensed
23 and practicing within the scope of his or her profession as
24 authorized by State law:
25 (1) Hospital room and board and any other hospital
26 services including emergency and post-stabilization
27 services, except that inpatient hospitalization for the
28 treatment of mental and emotional disorders shall only be
29 covered for a maximum of 45 days in a calendar year.
30 (2) Professional services for the diagnosis or
31 treatment of injuries, illnesses or conditions, other
32 than dental, or outpatient mental as described in
33 paragraph (17), which are rendered by a physician or
-23- LRB9003216JSgc
1 chiropractor, or by other licensed professionals at the
2 physician's or chiropractor's direction.
3 (3) If surgery has been recommended, a second
4 opinion may be required. The charge for a second opinion
5 as to whether the surgery is required will be paid in
6 full without regard to deductible or co-payment
7 requirements. If the second opinion differs from the
8 first, the charge for a third opinion, if desired, will
9 also be paid in full without regard to deductible or
10 co-payment requirements. Regardless of whether the
11 second opinion or third opinion confirms the original
12 recommendation, it is the patient's decision whether to
13 undergo surgery.
14 (4) Drugs requiring a physician's or other legally
15 authorized prescription.
16 (5) Skilled nursing care provided in a skilled
17 nursing facility for not more than 120 days in a calendar
18 year, provided the service commences within 14 days
19 following a confinement of at least 3 consecutive days in
20 a hospital for the same condition.
21 (6) Services of a home health agency in accord with
22 a home health care plan, up to a maximum of 270 visits
23 per year.
24 (7) Services of a licensed hospice for not more
25 than 180 days during a policy year.
26 (8) Use of radium or other radioactive materials.
27 (9) Oxygen.
28 (10) Anesthetics.
29 (11) Orthoses and prostheses other than dental.
30 (12) Rental or purchase in accordance with Board
31 policies or procedures of durable medical equipment,
32 other than eyeglasses or hearing aids, for which there is
33 no personal use in the absence of the condition for which
34 it is prescribed.
-24- LRB9003216JSgc
1 (13) Diagnostic x-rays and laboratory tests.
2 (14) Oral surgery for excision of partially or
3 completely unerupted impacted teeth or the gums and
4 tissues of the mouth, when not performed in connection
5 with the routine extraction or repair of teeth, and oral
6 surgery and procedures, including orthodontics and
7 prosthetics necessary for craniofacial or maxillofacial
8 conditions and to correct congenital defects or injuries
9 due to accident.
10 (15) Physical, speech, and functional occupational
11 therapy as medically necessary and provided by
12 appropriate licensed professionals.
13 (16) Transportation summoned by use of the 911
14 emergency telephone number or other means provided by a
15 licensed ambulance service to the nearest health care
16 facility qualified to treat the illness, injury or
17 condition, subject to the provisions of the Emergency
18 Medical Services (EMS) Systems (EMS) Act.
19 (17) The first 50 professional outpatient visits
20 for diagnosis and treatment of mental and emotional
21 disorders rendered during the year, up to a maximum of
22 $80 per visit.
23 (18) Human organ or tissue transplants specified by
24 the Board that are performed at a hospital designated by
25 the Board as a participating transplant center for that
26 specific organ or tissue transplant.
27 c. Exclusion. Covered expenses of the Plan shall not
28 include the following:
29 (1) Any charge for treatment for cosmetic purposes
30 other than for reconstructive surgery when the service is
31 incidental to or follows surgery resulting from injury,
32 sickness or other diseases of the involved part or
33 surgery for the repair or treatment of a congenital
34 bodily defect to restore normal bodily functions.
-25- LRB9003216JSgc
1 (2) Any charge for care that is primarily for rest,
2 custodial, educational, or domiciliary purposes.
3 (3) Any charge for services in a private room to
4 the extent it is in excess of the institution's charge
5 for its most common semiprivate room, unless a private
6 room is prescribed as medically necessary by a physician.
7 (4) That part of any charge for room and board or
8 for services rendered or articles prescribed by a
9 physician, dentist, or other health care personnel that
10 exceeds the reasonable and customary charge in the
11 locality or for any services or supplies not medically
12 necessary for the diagnosed injury or illness.
13 (5) Any charge for services or articles the
14 provision of which is not within the scope of licensure
15 of the institution or individual providing the services
16 or articles.
17 (6) Any expense incurred prior to the effective
18 date of coverage by the Plan for the person on whose
19 behalf the expense is incurred.
20 (7) Dental care, dental surgery, dental treatment
21 or dental appliances, except as provided in paragraph
22 (14) of subsection b of this Section.
23 (8) Eyeglasses, contact lenses, hearing aids or
24 their fitting.
25 (9) Illness or injury due to (A) war or any acts of
26 war; (B) commission of, or attempt to commit, a felony;
27 or (C) aviation activities, except when traveling as a
28 fare-paying passenger on a commercial airline.
29 (10) Services of blood donors and any fee for
30 failure to replace blood provided to an eligible person
31 each policy year.
32 (11) Personal supplies or services provided by a
33 hospital or nursing home, or any other nonmedical or
34 nonprescribed supply or service.
-26- LRB9003216JSgc
1 (12) Routine maternity charges for a pregnancy,
2 except where added as optional coverage with payment of
3 an additional premium for pregnancy resulting from
4 conception occurring after the effective date of the
5 optional coverage.
6 (13) Expenses of obtaining an abortion, induced
7 miscarriage or induced premature birth unless, in the
8 opinion of a physician, those procedures are necessary
9 for the preservation of life of the woman seeking such
10 treatment, or except an induced premature birth intended
11 to produce a live viable child and the procedure is
12 necessary for the health of the mother or unborn child.
13 (14) Any expense or charge for services, drugs, or
14 supplies that are: (i) not provided in accord with
15 generally accepted standards of current medical practice;
16 (ii) for procedures, treatments, equipment, transplants,
17 or implants, any of which are investigational,
18 experimental, or for research purposes; (iii)
19 investigative and not proven safe and effective; or (iv)
20 for, or resulting from, a gender transformation
21 operation.
22 (15) Any expense or charge for routine physical
23 examinations or tests.
24 (16) Any expense for which a charge is not made in
25 the absence of insurance or for which there is no legal
26 obligation on the part of the patient to pay.
27 (17) Any expense incurred for benefits provided
28 under the laws of the United States and this State,
29 including Medicare and Medicaid and other medical
30 assistance, military service-connected disability
31 payments, medical services provided for members of the
32 armed forces and their dependents or employees of the
33 armed forces of the United States, and medical services
34 financed on behalf of all citizens by the United States.
-27- LRB9003216JSgc
1 (18) Any expense or charge for in vitro
2 fertilization, artificial insemination, or any other
3 artificial means used to cause pregnancy.
4 (19) Any expense or charge for oral contraceptives
5 used for birth control or any other temporary birth
6 control measures.
7 (20) Any expense or charge for sterilization or
8 sterilization reversals.
9 (21) Any expense or charge for weight loss
10 programs, exercise equipment, or treatment of obesity,
11 except when certified by a physician as morbid obesity
12 (at least 2 times normal body weight).
13 (22) Any expense or charge for acupuncture
14 treatment unless used as an anesthetic agent for a
15 covered surgery.
16 (23) Any expense or charge for or related to organ
17 or tissue transplants other than those performed at a
18 hospital with a Board approved organ transplant program
19 that has been designated by the Board as a preferred or
20 exclusive provider organization for that specific organ
21 or tissue.
22 (24) Any expense or charge for procedures,
23 treatments, equipment, or services that are provided in
24 special settings for research purposes or in a controlled
25 environment, are being studied for safety, efficiency,
26 and effectiveness, and are awaiting endorsement by the
27 appropriate national medical speciality college for
28 general use within the medical community.
29 d. Premiums, deductibles, and coinsurance.
30 (1) Premiums charged for coverage issued by the
31 Plan may not be unreasonable in relation to the benefits
32 provided, the risk experience and the reasonable expenses
33 of providing the coverage.
34 (2) Separate schedules of premium rates based on
-28- LRB9003216JSgc
1 sex, age and geographical location shall apply for
2 individual risks.
3 (3) The Plan may provide for separate premium rates
4 for optional family coverage for the spouse or one or
5 more dependents of any person eligible to be insured
6 under the Plan who is also the oldest adult member of the
7 family and remains continuously enrolled in the Plan as
8 the primary enrollee. The rates shall be such percentage
9 of the applicable individual Plan rate as the Board, in
10 accordance with appropriate actuarial principles, shall
11 establish for each spouse or dependent.
12 (4) The Board shall determine, in accordance with
13 appropriate actuarial principles, the average rates that
14 individual standard risks in this State are charged by at
15 least 5 of the largest insurers providing coverage to
16 residents of Illinois that is substantially similar to
17 the Plan coverage. In the event at least 5 insurers do
18 not offer substantially similar coverage, the rates shall
19 be established using reasonable actuarial techniques and
20 shall reflect anticipated claims experience, expenses,
21 and other appropriate risk factors relating to the Plan.
22 Rates for Plan coverage shall be 135% of rates so
23 established as applicable for individual standard risks;
24 provided, however, if after determining that the
25 appropriations made pursuant to Section 12 of this Act
26 are insufficient to ensure that total income from all
27 sources will equal or exceed the total incurred costs and
28 expenses for the current number of enrollees, the board
29 shall raise premium rates above this 135% standard to the
30 level it deems necessary to ensure the financial solvency
31 of the Plan for enrollees already in the Plan. All rates
32 and rate schedules shall be submitted to the board for
33 approval.
34 (5) The Plan coverage defined in Section 6 shall
-29- LRB9003216JSgc
1 provide for a choice of deductibles as authorized by the
2 Board per individual per annum. If 2 individual members
3 of a family satisfy the same applicable deductibles, no
4 other member of that family who is eligible for coverage
5 under the Plan shall be required to meet any deductibles
6 for the balance of that calendar year. The deductibles
7 must be applied first to the authorized amount of covered
8 expenses incurred by the covered person. A mandatory
9 coinsurance requirement shall be imposed at the rate
10 authorized by the Board in excess of the mandatory
11 deductible, the coinsurance in the aggregate not to
12 exceed such amounts as are authorized by the Board per
13 annum. At its discretion the Board may, however, offer
14 catastrophic coverages or other policies that provide for
15 larger deductibles with or without coinsurance
16 requirements. The deductibles and coinsurance factors
17 may be adjusted annually according to the Medical
18 Component of the Consumer Price Index.
19 (6) The Plan may provide for and employ cost
20 containment measures and requirements including, but not
21 limited to, preadmission certification, second surgical
22 opinion, concurrent utilization review programs,
23 individual case management, preferred provider
24 organizations, and other cost effective arrangements for
25 paying for covered expenses.
26 e. Scope of coverage. Except as provided in subsection
27 c of this Section, if the covered expenses incurred by the
28 eligible person exceed the deductible for major medical
29 expense coverage in a calendar year, the Plan shall pay at
30 least 80% of any additional covered expenses incurred by the
31 person during the calendar year.
32 f. Preexisting conditions.
33 (1) Six months: Plan coverage shall exclude charges
34 or expenses incurred during the first 6 months following
-30- LRB9003216JSgc
1 the effective date of coverage as to any condition if:
2 (a) the condition had manifested itself within the 6
3 month period immediately preceding the effective date of
4 coverage in such a manner as would cause an ordinarily
5 prudent person to seek diagnosis, care or treatment; or
6 (b) medical advice, care or treatment was recommended or
7 received within the 6 month period immediately preceding
8 the effective date of coverage.
9 (2) (Blank).
10 (3) Waiver: The preexisting condition exclusions as
11 set forth in paragraph (1) of this subsection shall be
12 waived to the extent to which the eligible person: (a)
13 has satisfied similar exclusions under any prior health
14 insurance policy or plan that was involuntarily
15 terminated; (b) is ineligible for any continuation or
16 conversion rights that would continue or provide
17 substantially similar coverage following that
18 termination; and (c) has applied for Plan coverage not
19 later than 30 days following the involuntary termination.
20 No policy or plan shall be deemed to have been
21 involuntarily terminated if the master policyholder or
22 other controlling party elected to change insurance
23 coverage from one company or plan to another even if that
24 decision resulted in a discontinuation of coverage for
25 any individual under the plan, either totally or for any
26 medical condition. For each eligible person who qualifies
27 for and elects this waiver, there shall be added to each
28 payment of premium, on a prorated basis, a surcharge of
29 up to 10% of the otherwise applicable annual premium for
30 as long as that individual's coverage under the Plan
31 remains in effect or 60 months, whichever is less.
32 g. Other sources primary; nonduplication of benefits.
33 (1) The Plan shall be the last payor of benefits
34 whenever any other benefit or source of third party
-31- LRB9003216JSgc
1 payment is available. Subject to the provisions of
2 subsection e of Section 7, benefits otherwise payable
3 under Plan coverage shall be reduced by all amounts paid
4 or payable by Medicare or any other government program or
5 through any health insurance or other health benefit
6 plan, whether insured or otherwise, or through any third
7 party liability, settlement, judgment, or award,
8 regardless of the date of the settlement, judgment, or
9 award, whether the settlement, judgment, or award is in
10 the form of a contract, agreement, or trust on behalf of
11 a minor or otherwise and whether the settlement,
12 judgment, or award is payable to the covered person, his
13 or her dependent, estate, personal representative, or
14 guardian in a lump sum or over time, and by all hospital
15 or medical expense benefits paid or payable under any
16 worker's compensation coverage, automobile medical
17 payment, or liability insurance, whether provided on the
18 basis of fault or nonfault, and by any hospital or
19 medical benefits paid or payable under or provided
20 pursuant to any State or federal law or program.
21 (2) The Plan shall have a cause of action against
22 any covered person or any other person or entity for the
23 recovery of any amount paid to the extent the amount was
24 for treatment, services, or supplies not covered in this
25 Section or in excess of benefits as set forth in this
26 Section.
27 (3) Whenever benefits are due from the Plan because
28 of sickness or an injury to a covered person resulting
29 from a third party's wrongful act or negligence and the
30 covered person has recovered or may recover damages from
31 a third party or its insurer, the Plan shall have the
32 right to reduce benefits or to refuse to pay benefits
33 that otherwise may be payable by the amount of damages
34 that the covered person has recovered or may recover
-32- LRB9003216JSgc
1 regardless of the date of the sickness or injury or the
2 date of any settlement, judgment, or award resulting from
3 that sickness or injury.
4 During the pendency of any action or claim that is
5 brought by or on behalf of a covered person against a
6 third party or its insurer, any benefits that would
7 otherwise be payable except for the provisions of this
8 paragraph (3) shall be paid if payment by or for the
9 third party has not yet been made and the covered person
10 or, if incapable, that person's legal representative
11 agrees in writing to pay back promptly the benefits paid
12 as a result of the sickness or injury to the extent of
13 any future payments made by or for the third party for
14 the sickness or injury. This agreement is to apply
15 whether or not liability for the payments is established
16 or admitted by the third party or whether those payments
17 are itemized.
18 Any amounts due the plan to repay benefits may be
19 deducted from other benefits payable by the Plan after
20 payments by or for the third party are made.
21 (4) Benefits due from the Plan may be reduced or
22 refused as an offset against any amount otherwise
23 recoverable under this Section.
24 h. Right of subrogation; recoveries.
25 (1) Whenever the Plan has paid benefits because of
26 sickness or an injury to any covered person resulting
27 from a third party's wrongful act or negligence, or for
28 which an insurer is liable in accordance with the
29 provisions of any policy of insurance, and the covered
30 person has recovered or may recover damages from a third
31 party that is liable for the damages, the Plan shall have
32 the right to recover the benefits it paid from any
33 amounts that the covered person has received or may
34 receive regardless of the date of the sickness or injury
-33- LRB9003216JSgc
1 or the date of any settlement, judgment, or award
2 resulting from that sickness or injury. The Plan shall
3 be subrogated to any right of recovery the covered person
4 may have under the terms of any private or public health
5 care coverage or liability coverage, including coverage
6 under the Workers' Compensation Act or the Workers'
7 Occupational Diseases Act, without the necessity of
8 assignment of claim or other authorization to secure the
9 right of recovery. To enforce its subrogation right, the
10 Plan may (i) intervene or join in an action or proceeding
11 brought by the covered person or his personal
12 representative, including his guardian, conservator,
13 estate, dependents, or survivors, against any third party
14 or the third party's insurer that may be liable or (ii)
15 institute and prosecute legal proceedings against any
16 third party or the third party's insurer that may be
17 liable for the sickness or injury in an appropriate court
18 either in the name of the Plan or in the name of the
19 covered person or his personal representative, including
20 his guardian, conservator, estate, dependents, or
21 survivors.
22 (2) If any action or claim is brought by or on
23 behalf of a covered person against a third party or the
24 third party's insurer, the covered person or his personal
25 representative, including his guardian, conservator,
26 estate, dependents, or survivors, shall notify the Plan
27 by personal service or registered mail of the action or
28 claim and of the name of the court in which the action or
29 claim is brought, filing proof thereof in the action or
30 claim. The Plan may, at any time thereafter, join in the
31 action or claim upon its motion so that all orders of
32 court after hearing and judgment shall be made for its
33 protection. No release or settlement of a claim for
34 damages and no satisfaction of judgment in the action
-34- LRB9003216JSgc
1 shall be valid without the written consent of the Plan to
2 the extent of its interest in the settlement or judgment
3 and of the covered person or his personal representative.
4 (3) In the event that the covered person or his
5 personal representative fails to institute a proceeding
6 against any appropriate third party before the fifth
7 month before the action would be barred, the Plan may, in
8 its own name or in the name of the covered person or
9 personal representative, commence a proceeding against
10 any appropriate third party for the recovery of damages
11 on account of any sickness, injury, or death to the
12 covered person. The covered person shall cooperate in
13 doing what is reasonably necessary to assist the Plan in
14 any recovery and shall not take any action that would
15 prejudice the Plan's right to recovery. The Plan shall
16 pay to the covered person or his personal representative
17 all sums collected from any third party by judgment or
18 otherwise in excess of amounts paid in benefits under the
19 Plan and amounts paid or to be paid as costs, attorneys
20 fees, and reasonable expenses incurred by the Plan in
21 making the collection or enforcing the judgment.
22 (4) In the event that a covered person or his
23 personal representative, including his guardian,
24 conservator, estate, dependents, or survivors, recovers
25 damages from a third party for sickness or injury caused
26 to the covered person, the covered person or the personal
27 representative shall pay to the Plan from the damages
28 recovered the amount of benefits paid or to be paid on
29 behalf of the covered person.
30 (5) When the action or claim is brought by the
31 covered person alone and the covered person incurs a
32 personal liability to pay attorney's fees and costs of
33 litigation, the Plan's claim for reimbursement of the
34 benefits provided to the covered person shall be the full
-35- LRB9003216JSgc
1 amount of benefits paid to or on behalf of the covered
2 person under this Act less a pro rata share that
3 represents the Plan's reasonable share of attorney's fees
4 paid by the covered person and that portion of the cost
5 of litigation expenses determined by multiplying by the
6 ratio of the full amount of the expenditures to the full
7 amount of the judgement, award, or settlement.
8 (6) In the event of judgment or award in a suit or
9 claim against a third party or insurer, the court shall
10 first order paid from any judgement or award the
11 reasonable litigation expenses incurred in preparation
12 and prosecution of the action or claim, together with
13 reasonable attorney's fees. After payment of those
14 expenses and attorney's fees, the court shall apply out
15 of the balance of the judgment or award an amount
16 sufficient to reimburse the Plan the full amount of
17 benefits paid on behalf of the covered person under this
18 Act, provided the court may reduce and apportion the
19 Plan's portion of the judgement proportionate to the
20 recovery of the covered person. The burden of producing
21 evidence sufficient to support the exercise by the court
22 of its discretion to reduce the amount of a proven charge
23 sought to be enforced against the recovery shall rest
24 with the party seeking the reduction. The court may
25 consider the nature and extent of the injury, economic
26 and non-economic loss, settlement offers, comparative
27 negligence as it applies to the case at hand, hospital
28 costs, physician costs, and all other appropriate costs.
29 The Plan shall pay its pro rata share of the attorney
30 fees based on the Plan's recovery as it compares to the
31 total judgment. Any reimbursement rights of the Plan
32 shall take priority over all other liens and charges
33 existing under the laws of this State with the exception
34 of any attorney liens filed under the Attorneys Lien Act.
-36- LRB9003216JSgc
1 (7) The Plan may compromise or settle and release
2 any claim for benefits provided under this Act or waive
3 any claims for benefits, in whole or in part, for the
4 convenience of the Plan or if the Plan determines that
5 collection would result in undue hardship upon the
6 covered person.
7 (Source: P.A. 89-486, eff. 6-21-96.)
8 Section 93. The Health Maintenance Organization Act is
9 amended by changing Sections 1-2, 4-10, and 4-15 and adding
10 Section 5-7.2 as follows:
11 (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
12 Sec. 1-2. Definitions. As used in this Act, unless the
13 context otherwise requires, the following terms shall have
14 the meanings ascribed to them:
15 (1) "Advertisement" means any printed or published
16 material, audiovisual material and descriptive literature of
17 the health care plan used in direct mail, newspapers,
18 magazines, radio scripts, television scripts, billboards and
19 similar displays; and any descriptive literature or sales
20 aids of all kinds disseminated by a representative of the
21 health care plan for presentation to the public including,
22 but not limited to, circulars, leaflets, booklets,
23 depictions, illustrations, form letters and prepared sales
24 presentations.
25 (2) "Director" means the Director of Insurance.
26 (3) "Basic Health Care Services" means emergency care,
27 and inpatient hospital and physician care, outpatient medical
28 services, mental health services and care for alcohol and
29 drug abuse, including any reasonable deductibles and
30 co-payments, all of which are subject to such limitations as
31 are determined by the Director pursuant to rule.
32 (4) "Enrollee" means an individual who has been enrolled
-37- LRB9003216JSgc
1 in a health care plan.
2 (5) "Evidence of Coverage" means any certificate,
3 agreement, or contract issued to an enrollee setting out the
4 coverage to which he is entitled in exchange for a per capita
5 prepaid sum.
6 (6) "Group Contract" means a contract for health care
7 services which by its terms limits eligibility to members of
8 a specified group.
9 (7) "Health Care Plan" means any arrangement whereby any
10 organization undertakes to provide or arrange for and pay for
11 or reimburse the cost of basic health care services from
12 providers selected by the Health Maintenance Organization and
13 such arrangement consists of arranging for or the provision
14 of such health care services, as distinguished from mere
15 indemnification against the cost of such services, except as
16 otherwise authorized by Section 2-3 of this Act, on a per
17 capita prepaid basis, through insurance or otherwise. A
18 "health care plan" also includes any arrangement whereby an
19 organization undertakes to provide or arrange for or pay for
20 or reimburse the cost of any health care service for persons
21 who are enrolled in the integrated health care program
22 established under Section 5-16.3 of the Illinois Public Aid
23 Code through providers selected by the organization and the
24 arrangement consists of making provision for the delivery of
25 health care services, as distinguished from mere
26 indemnification. Nothing in this definition, however,
27 affects the total medical services available to persons
28 eligible for medical assistance under the Illinois Public Aid
29 Code.
30 (8) "Health Care Services" means any services included
31 in the furnishing to any individual of medical or dental
32 care, or the hospitalization or incident to the furnishing of
33 such care or hospitalization as well as the furnishing to any
34 person of any and all other services for the purpose of
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1 preventing, alleviating, curing or healing human illness or
2 injury.
3 (9) "Health Maintenance Organization" means any
4 organization formed under the laws of this or another state
5 to provide or arrange for one or more health care plans under
6 a system which causes any part of the risk of health care
7 delivery to be borne by the organization or its providers.
8 (10) "Net Worth" means admitted assets, as defined in
9 Section 1-3 of this Act, minus liabilities.
10 (11) "Organization" means any insurance company, or a
11 nonprofit corporation authorized under the Medical Service
12 Plan Act, the Dental Service Plan Act, the Vision Service
13 Plan Act, the Pharmaceutical Service Plan Act, the Voluntary
14 Health Services Plans Act or the Non-profit Health Care
15 Service Plan Act, or a corporation organized under the laws
16 of this or another state for the purpose of operating one or
17 more health care plans and doing no business other than that
18 of a Health Maintenance Organization or an insurance company.
19 Organization shall also mean the University of Illinois
20 Hospital as defined in the University of Illinois Hospital
21 Act.
22 (12) "Provider" means any physician, hospital facility,
23 or other person which is licensed or otherwise authorized to
24 furnish health care services and also includes any other
25 entity that arranges for the delivery or furnishing of health
26 care service.
27 (13) "Producer" means a person directly or indirectly
28 associated with a health care plan who engages in
29 solicitation or enrollment.
30 (14) "Per capita prepaid" means a basis of prepayment by
31 which a fixed amount of money is prepaid per individual or
32 any other enrollment unit to the Health Maintenance
33 Organization or for health care services which are provided
34 during a definite time period regardless of the frequency or
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1 extent of the services rendered by the Health Maintenance
2 Organization, except for copayments and deductibles and
3 except as provided in subsection (f) of Section 5-3 of this
4 Act.
5 (15) "Subscriber" means a person who has entered into a
6 contractual relationship with the Health Maintenance
7 Organization for the provision of or arrangement of at least
8 basic health care services to the beneficiaries of such
9 contract.
10 (16) "Emergency medical screening examination" means a
11 medical screening examination and evaluation by a physician
12 or, to the extent permitted by applicable laws, by other
13 appropriate personnel under the supervision of a physician to
14 determine whether the need for emergency services exists.
15 (17) "Emergency services" means those health care
16 services provided to evaluate and treat medical conditions of
17 recent onset and severity that would lead a prudent
18 layperson, possessing an average knowledge of medicine and
19 health, to believe that urgent or unscheduled medical care is
20 required.
21 (18) Post-stabilization services" means those health
22 care services determined by a treating provider to be
23 promptly and medically necessary following stabilization of
24 an emergency condition.
25 (Source: P.A. 88-554, eff. 7-26-94; 89-90, eff. 6-30-95.)
26 (215 ILCS 125/4-10) (from Ch. 111 1/2, par. 1409.3)
27 Sec. 4-10. (a) Medical necessity; dispute resolution;
28 independent; second opinion; post-stabilization service.
29 (a) Each Health Maintenance Organization shall provide a
30 mechanism for the timely review by a physician holding the
31 same class of license as the primary care physician, who is
32 unaffiliated with the Health Maintenance Organization,
33 jointly selected by the patient (or the patient's next of kin
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1 or legal representative if the patient is unable to act for
2 himself), primary care physician and the Health Maintenance
3 Organization in the event of a dispute between the primary
4 care physician and the Health Maintenance Organization
5 regarding the medical necessity of a covered service proposed
6 by a primary care physician. In the event that the reviewing
7 physician determines the covered service to be medically
8 necessary, the Health Maintenance Organization shall provide
9 the covered service. Future contractual or employment action
10 by the Health Maintenance Organization regarding the primary
11 care physician shall not be based solely on the physician's
12 participation in this procedure.
13 (b) If prior authorization for post-stabilization
14 services is required, the health care plan shall provide
15 access 24 hours a day, 7 days a week to persons designated by
16 the plan to make such determinations. If a health care
17 provider has attempted to contact such person for prior
18 authorization and no designated persons were accessible or
19 the authorization was not denied within 30 minutes of the
20 request, the health care plan is deemed to have approved the
21 request for prior authorization.
22 (Source: P.A. 85-20; 85-850.)
23 (215 ILCS 125/4-15) (from Ch. 111 1/2, par. 1409.8)
24 Sec. 4-15. Emergency transportation.
25 (a) No contract or evidence of coverage for basic health
26 care services delivered, issued for delivery, renewed or
27 amended by a Health Maintenance Organization shall discourage
28 or penalize use of the 911 emergency telephone number or
29 exclude coverage or require prior authorization for emergency
30 transportation by ambulance or emergency services rendered by
31 any provider. Payment for emergency services shall not
32 depend upon whether such services are performed by a
33 preferred or nonpreferred provider and such coverage shall be
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1 at the same level as if the service or treatment had been
2 rendered by a plan provider. For the purposes of this
3 Section, the term "emergency" means a need for immediate
4 medical attention resulting from a life threatening condition
5 or situation or a need for immediate medical attention as
6 otherwise reasonably determined by a physician, public safety
7 official or other emergency medical personnel.
8 (b) Upon reasonable demand by a provider of emergency
9 transportation by ambulance, a Health Maintenance
10 Organization shall promptly pay to the provider, subject to
11 coverage limitations stated in the contract or evidence of
12 coverage, the charges for emergency transportation by
13 ambulance provided to an enrollee in a health care plan
14 arranged for by the Health Maintenance Organization. By
15 accepting any such payment from the Health Maintenance
16 Organization, the provider of emergency transportation by
17 ambulance agrees not to seek any payment from the enrollee
18 for services provided to the enrollee.
19 (Source: P.A. 86-833; 86-1028.)
20 (215 ILCS 125/5-7.2 new)
21 Sec. 5-7.2. Retrospective denials.
22 (a) No health care plan shall retrospectively deny
23 coverage and payment for emergency services except upon
24 reasonable determination that:
25 (1) the emergency services claimed were never
26 performed; or
27 (2) an emergency medical screening examination was
28 performed on a patient who personally sought emergency
29 services knowing that he or she did not have an emergency
30 condition or necessity, and who did not in fact require
31 emergency services.
32 (b) No health care plan shall retrospectively deny
33 coverage and payment for post-stabilization services which
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1 received prior authorization or deemed approval.
2 (c) No health care plan shall retrospectively deny
3 payment for emergency medical screening examinations.
4 Section 96. The Illinois Public Aid Code is amended by
5 changing Section 5-16.3 and adding Section 5-5.04 as follows:
6 (305 ILCS 5/5-5.04 new)
7 Sec. 5-5.04. Emergency services.
8 (a) As used in this Act, "emergency medical screening
9 examination" means a medical screening examination and
10 evaluation by a physician or, to the extent permitted by
11 applicable laws, by other appropriate personnel under the
12 supervision of a physician to determine whether the need for
13 emergency services exists and "emergency services" means
14 those health care services provided to evaluate and treat
15 medical conditions of recent onset and severity that would
16 lead a prudent layperson, possessing an average knowledge of
17 medicine and health, to believe that urgent or unscheduled
18 medical care is required. No prior authorization or approval
19 shall be required in order to seek and receive emergency
20 services.
21 (b) Coverage and payment for emergency services shall
22 not be retrospectively denied except upon reasonable
23 determination by the Illinois Department that:
24 (1) the emergency medical services claimed were
25 never performed; or
26 (2) an emergency medical screening examination was
27 performed on a patient who personally sought emergency
28 services knowing that he or she did not have an emergency
29 condition or necessity, and who did not in fact require
30 emergency services.
31 (305 ILCS 5/5-16.3)
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1 (Text of Section before amendment by P.A. 89-507)
2 Sec. 5-16.3. System for integrated health care services.
3 (a) It shall be the public policy of the State to adopt,
4 to the extent practicable, a health care program that
5 encourages the integration of health care services and
6 manages the health care of program enrollees while preserving
7 reasonable choice within a competitive and cost-efficient
8 environment. In furtherance of this public policy, the
9 Illinois Department shall develop and implement an integrated
10 health care program consistent with the provisions of this
11 Section. The provisions of this Section apply only to the
12 integrated health care program created under this Section.
13 Persons enrolled in the integrated health care program, as
14 determined by the Illinois Department by rule, shall be
15 afforded a choice among health care delivery systems, which
16 shall include, but are not limited to, (i) fee for service
17 care managed by a primary care physician licensed to practice
18 medicine in all its branches, (ii) managed health care
19 entities, and (iii) federally qualified health centers
20 (reimbursed according to a prospective cost-reimbursement
21 methodology) and rural health clinics (reimbursed according
22 to the Medicare methodology), where available. Persons
23 enrolled in the integrated health care program also may be
24 offered indemnity insurance plans, subject to availability.
25 For purposes of this Section, a "managed health care
26 entity" means a health maintenance organization or a managed
27 care community network as defined in this Section. A "health
28 maintenance organization" means a health maintenance
29 organization as defined in the Health Maintenance
30 Organization Act. A "managed care community network" means
31 an entity, other than a health maintenance organization, that
32 is owned, operated, or governed by providers of health care
33 services within this State and that provides or arranges
34 primary, secondary, and tertiary managed health care services
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1 under contract with the Illinois Department exclusively to
2 enrollees of the integrated health care program. A managed
3 care community network may contract with the Illinois
4 Department to provide only pediatric health care services. A
5 county provider as defined in Section 15-1 of this Code may
6 contract with the Illinois Department to provide services to
7 enrollees of the integrated health care program as a managed
8 care community network without the need to establish a
9 separate entity that provides services exclusively to
10 enrollees of the integrated health care program and shall be
11 deemed a managed care community network for purposes of this
12 Code only to the extent of the provision of services to those
13 enrollees in conjunction with the integrated health care
14 program. A county provider shall be entitled to contract
15 with the Illinois Department with respect to any contracting
16 region located in whole or in part within the county. A
17 county provider shall not be required to accept enrollees who
18 do not reside within the county.
19 Each managed care community network must demonstrate its
20 ability to bear the financial risk of serving enrollees under
21 this program. The Illinois Department shall by rule adopt
22 criteria for assessing the financial soundness of each
23 managed care community network. These rules shall consider
24 the extent to which a managed care community network is
25 comprised of providers who directly render health care and
26 are located within the community in which they seek to
27 contract rather than solely arrange or finance the delivery
28 of health care. These rules shall further consider a variety
29 of risk-bearing and management techniques, including the
30 sufficiency of quality assurance and utilization management
31 programs and whether a managed care community network has
32 sufficiently demonstrated its financial solvency and net
33 worth. The Illinois Department's criteria must be based on
34 sound actuarial, financial, and accounting principles. In
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1 adopting these rules, the Illinois Department shall consult
2 with the Illinois Department of Insurance. The Illinois
3 Department is responsible for monitoring compliance with
4 these rules.
5 This Section may not be implemented before the effective
6 date of these rules, the approval of any necessary federal
7 waivers, and the completion of the review of an application
8 submitted, at least 60 days before the effective date of
9 rules adopted under this Section, to the Illinois Department
10 by a managed care community network.
11 All health care delivery systems that contract with the
12 Illinois Department under the integrated health care program
13 shall clearly recognize a health care provider's right of
14 conscience under the Right of Conscience Act. In addition to
15 the provisions of that Act, no health care delivery system
16 that contracts with the Illinois Department under the
17 integrated health care program shall be required to provide,
18 arrange for, or pay for any health care or medical service,
19 procedure, or product if that health care delivery system is
20 owned, controlled, or sponsored by or affiliated with a
21 religious institution or religious organization that finds
22 that health care or medical service, procedure, or product to
23 violate its religious and moral teachings and beliefs.
24 (b) The Illinois Department may, by rule, provide for
25 different benefit packages for different categories of
26 persons enrolled in the program. Mental health services,
27 alcohol and substance abuse services, services related to
28 children with chronic or acute conditions requiring
29 longer-term treatment and follow-up, and rehabilitation care
30 provided by a free-standing rehabilitation hospital or a
31 hospital rehabilitation unit may be excluded from a benefit
32 package if the State ensures that those services are made
33 available through a separate delivery system. An exclusion
34 does not prohibit the Illinois Department from developing and
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1 implementing demonstration projects for categories of persons
2 or services. Benefit packages for persons eligible for
3 medical assistance under Articles V, VI, and XII shall be
4 based on the requirements of those Articles and shall be
5 consistent with the Title XIX of the Social Security Act.
6 Nothing in this Act shall be construed to apply to services
7 purchased by the Department of Children and Family Services
8 and the Department of Mental Health and Developmental
9 Disabilities under the provisions of Title 59 of the Illinois
10 Administrative Code, Part 132 ("Medicaid Community Mental
11 Health Services Program").
12 (c) The program established by this Section may be
13 implemented by the Illinois Department in various contracting
14 areas at various times. The health care delivery systems and
15 providers available under the program may vary throughout the
16 State. For purposes of contracting with managed health care
17 entities and providers, the Illinois Department shall
18 establish contracting areas similar to the geographic areas
19 designated by the Illinois Department for contracting
20 purposes under the Illinois Competitive Access and
21 Reimbursement Equity Program (ICARE) under the authority of
22 Section 3-4 of the Illinois Health Finance Reform Act or
23 similarly-sized or smaller geographic areas established by
24 the Illinois Department by rule. A managed health care entity
25 shall be permitted to contract in any geographic areas for
26 which it has a sufficient provider network and otherwise
27 meets the contracting terms of the State. The Illinois
28 Department is not prohibited from entering into a contract
29 with a managed health care entity at any time.
30 (d) A managed health care entity that contracts with the
31 Illinois Department for the provision of services under the
32 program shall do all of the following, solely for purposes of
33 the integrated health care program:
34 (1) Provide that any individual physician licensed
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1 to practice medicine in all its branches, any pharmacy,
2 any federally qualified health center, and any
3 podiatrist, that consistently meets the reasonable terms
4 and conditions established by the managed health care
5 entity, including but not limited to credentialing
6 standards, quality assurance program requirements,
7 utilization management requirements, financial
8 responsibility standards, contracting process
9 requirements, and provider network size and accessibility
10 requirements, must be accepted by the managed health care
11 entity for purposes of the Illinois integrated health
12 care program. Any individual who is either terminated
13 from or denied inclusion in the panel of physicians of
14 the managed health care entity shall be given, within 10
15 business days after that determination, a written
16 explanation of the reasons for his or her exclusion or
17 termination from the panel. This paragraph (1) does not
18 apply to the following:
19 (A) A managed health care entity that
20 certifies to the Illinois Department that:
21 (i) it employs on a full-time basis 125
22 or more Illinois physicians licensed to
23 practice medicine in all of its branches; and
24 (ii) it will provide medical services
25 through its employees to more than 80% of the
26 recipients enrolled with the entity in the
27 integrated health care program; or
28 (B) A domestic stock insurance company
29 licensed under clause (b) of class 1 of Section 4 of
30 the Illinois Insurance Code if (i) at least 66% of
31 the stock of the insurance company is owned by a
32 professional corporation organized under the
33 Professional Service Corporation Act that has 125 or
34 more shareholders who are Illinois physicians
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1 licensed to practice medicine in all of its branches
2 and (ii) the insurance company certifies to the
3 Illinois Department that at least 80% of those
4 physician shareholders will provide services to
5 recipients enrolled with the company in the
6 integrated health care program.
7 (2) Provide for reimbursement for providers for
8 emergency services care, as defined by subsection (a) of
9 Section 5-5.04 of this Code the Illinois Department by
10 rule, that must be provided to its enrollees, including
11 an emergency department room screening fee, and urgent
12 care that it authorizes for its enrollees, regardless of
13 the provider's affiliation with the managed health care
14 entity. Providers shall be reimbursed for emergency
15 services care at an amount equal to the Illinois
16 Department's fee-for-service rates for those medical
17 services rendered by providers not under contract with
18 the managed health care entity to enrollees of the
19 entity.
20 (A) Coverage and payment for emergency
21 services shall not be retrospectively denied except
22 upon reasonable determination by the Illinois
23 Department that (1) the emergency services claimed
24 were never performed or (2) an emergency medical
25 screening examination was performed on a patient who
26 personally sought emergency services knowing that he
27 or she did not have an emergency condition or
28 necessity, and who did not in fact require emergency
29 services.
30 (B) The appropriate use of the 911 emergency
31 telephone number shall not be discouraged or
32 penalized, and coverage or payment shall not be
33 denied solely on the basis that the enrollee used
34 the 911 emergency telephone number to summon
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1 emergency services. Coverage and payment for
2 emergency medical screening examinations shall not
3 be retrospectively denied.
4 (2.5) Provide for reimbursement for
5 post-stabilization services, which are those health care
6 services determined by a treating provider to be promptly
7 and medically necessary following stabilization of an
8 emergency condition.
9 (A) If prior authorization for
10 post-stabilization services is required, the managed
11 health care entity shall provide access 24 hours a
12 day, 7 days a week to persons designated by the
13 entity to make such determinations. If a health
14 care provider has attempted to contact such person
15 for prior authorization and no designated persons
16 were accessible or the authorization was not denied
17 within 30 minutes of the request, the managed health
18 care entity is deemed to have approved the request
19 for prior authorization.
20 (B) Coverage and payment for
21 post-stabilization services which received prior
22 authorization or deemed approval shall not be
23 retrospectively denied.
24 (3) Provide that any provider affiliated with a
25 managed health care entity may also provide services on a
26 fee-for-service basis to Illinois Department clients not
27 enrolled in a managed health care entity.
28 (4) Provide client education services as determined
29 and approved by the Illinois Department, including but
30 not limited to (i) education regarding appropriate
31 utilization of health care services in a managed care
32 system, (ii) written disclosure of treatment policies and
33 any restrictions or limitations on health services,
34 including, but not limited to, physical services,
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1 clinical laboratory tests, hospital and surgical
2 procedures, prescription drugs and biologics, and
3 radiological examinations, and (iii) written notice that
4 the enrollee may receive from another provider those
5 services covered under this program that are not provided
6 by the managed health care entity.
7 (5) Provide that enrollees within its system may
8 choose the site for provision of services and the panel
9 of health care providers.
10 (6) Not discriminate in its enrollment or
11 disenrollment practices among recipients of medical
12 services or program enrollees based on health status.
13 (7) Provide a quality assurance and utilization
14 review program that (i) for health maintenance
15 organizations meets the requirements of the Health
16 Maintenance Organization Act and (ii) for managed care
17 community networks meets the requirements established by
18 the Illinois Department in rules that incorporate those
19 standards set forth in the Health Maintenance
20 Organization Act.
21 (8) Issue a managed health care entity
22 identification card to each enrollee upon enrollment.
23 The card must contain all of the following:
24 (A) The enrollee's signature.
25 (B) The enrollee's health plan.
26 (C) The name and telephone number of the
27 enrollee's primary care physician.
28 (D) A telephone number to be used for
29 emergency service 24 hours per day, 7 days per week.
30 The telephone number required to be maintained
31 pursuant to this subparagraph by each managed health
32 care entity shall, at minimum, be staffed by
33 medically trained personnel and be provided
34 directly, or under arrangement, at an office or
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1 offices in locations maintained solely within the
2 State of Illinois. For purposes of this
3 subparagraph, "medically trained personnel" means
4 licensed practical nurses or registered nurses
5 located in the State of Illinois who are licensed
6 pursuant to the Illinois Nursing Act of 1987.
7 (9) Ensure that every primary care physician and
8 pharmacy in the managed health care entity meets the
9 standards established by the Illinois Department for
10 accessibility and quality of care. The Illinois
11 Department shall arrange for and oversee an evaluation of
12 the standards established under this paragraph (9) and
13 may recommend any necessary changes to these standards.
14 The Illinois Department shall submit an annual report to
15 the Governor and the General Assembly by April 1 of each
16 year regarding the effect of the standards on ensuring
17 access and quality of care to enrollees.
18 (10) Provide a procedure for handling complaints
19 that (i) for health maintenance organizations meets the
20 requirements of the Health Maintenance Organization Act
21 and (ii) for managed care community networks meets the
22 requirements established by the Illinois Department in
23 rules that incorporate those standards set forth in the
24 Health Maintenance Organization Act.
25 (11) Maintain, retain, and make available to the
26 Illinois Department records, data, and information, in a
27 uniform manner determined by the Illinois Department,
28 sufficient for the Illinois Department to monitor
29 utilization, accessibility, and quality of care.
30 (12) Except for providers who are prepaid, pay all
31 approved claims for covered services that are completed
32 and submitted to the managed health care entity within 30
33 days after receipt of the claim or receipt of the
34 appropriate capitation payment or payments by the managed
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1 health care entity from the State for the month in which
2 the services included on the claim were rendered,
3 whichever is later. If payment is not made or mailed to
4 the provider by the managed health care entity by the due
5 date under this subsection, an interest penalty of 1% of
6 any amount unpaid shall be added for each month or
7 fraction of a month after the due date, until final
8 payment is made. Nothing in this Section shall prohibit
9 managed health care entities and providers from mutually
10 agreeing to terms that require more timely payment.
11 (13) Provide integration with community-based
12 programs provided by certified local health departments
13 such as Women, Infants, and Children Supplemental Food
14 Program (WIC), childhood immunization programs, health
15 education programs, case management programs, and health
16 screening programs.
17 (14) Provide that the pharmacy formulary used by a
18 managed health care entity and its contract providers be
19 no more restrictive than the Illinois Department's
20 pharmaceutical program on the effective date of this
21 amendatory Act of 1994 and as amended after that date.
22 (15) Provide integration with community-based
23 organizations, including, but not limited to, any
24 organization that has operated within a Medicaid
25 Partnership as defined by this Code or by rule of the
26 Illinois Department, that may continue to operate under a
27 contract with the Illinois Department or a managed health
28 care entity under this Section to provide case management
29 services to Medicaid clients in designated high-need
30 areas.
31 The Illinois Department may, by rule, determine
32 methodologies to limit financial liability for managed health
33 care entities resulting from payment for services to
34 enrollees provided under the Illinois Department's integrated
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1 health care program. Any methodology so determined may be
2 considered or implemented by the Illinois Department through
3 a contract with a managed health care entity under this
4 integrated health care program.
5 The Illinois Department shall contract with an entity or
6 entities to provide external peer-based quality assurance
7 review for the integrated health care program. The entity
8 shall be representative of Illinois physicians licensed to
9 practice medicine in all its branches and have statewide
10 geographic representation in all specialties of medical care
11 that are provided within the integrated health care program.
12 The entity may not be a third party payer and shall maintain
13 offices in locations around the State in order to provide
14 service and continuing medical education to physician
15 participants within the integrated health care program. The
16 review process shall be developed and conducted by Illinois
17 physicians licensed to practice medicine in all its branches.
18 In consultation with the entity, the Illinois Department may
19 contract with other entities for professional peer-based
20 quality assurance review of individual categories of services
21 other than services provided, supervised, or coordinated by
22 physicians licensed to practice medicine in all its branches.
23 The Illinois Department shall establish, by rule, criteria to
24 avoid conflicts of interest in the conduct of quality
25 assurance activities consistent with professional peer-review
26 standards. All quality assurance activities shall be
27 coordinated by the Illinois Department.
28 (e) All persons enrolled in the program shall be
29 provided with a full written explanation of all
30 fee-for-service and managed health care plan options and a
31 reasonable opportunity to choose among the options as
32 provided by rule. The Illinois Department shall provide to
33 enrollees, upon enrollment in the integrated health care
34 program and at least annually thereafter, notice of the
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1 process for requesting an appeal under the Illinois
2 Department's administrative appeal procedures.
3 Notwithstanding any other Section of this Code, the Illinois
4 Department may provide by rule for the Illinois Department to
5 assign a person enrolled in the program to a specific
6 provider of medical services or to a specific health care
7 delivery system if an enrollee has failed to exercise choice
8 in a timely manner. An enrollee assigned by the Illinois
9 Department shall be afforded the opportunity to disenroll and
10 to select a specific provider of medical services or a
11 specific health care delivery system within the first 30 days
12 after the assignment. An enrollee who has failed to exercise
13 choice in a timely manner may be assigned only if there are 3
14 or more managed health care entities contracting with the
15 Illinois Department within the contracting area, except that,
16 outside the City of Chicago, this requirement may be waived
17 for an area by rules adopted by the Illinois Department after
18 consultation with all hospitals within the contracting area.
19 The Illinois Department shall establish by rule the procedure
20 for random assignment of enrollees who fail to exercise
21 choice in a timely manner to a specific managed health care
22 entity in proportion to the available capacity of that
23 managed health care entity. Assignment to a specific provider
24 of medical services or to a specific managed health care
25 entity may not exceed that provider's or entity's capacity as
26 determined by the Illinois Department. Any person who has
27 chosen a specific provider of medical services or a specific
28 managed health care entity, or any person who has been
29 assigned under this subsection, shall be given the
30 opportunity to change that choice or assignment at least once
31 every 12 months, as determined by the Illinois Department by
32 rule. The Illinois Department shall maintain a toll-free
33 telephone number for program enrollees' use in reporting
34 problems with managed health care entities.
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1 (f) If a person becomes eligible for participation in
2 the integrated health care program while he or she is
3 hospitalized, the Illinois Department may not enroll that
4 person in the program until after he or she has been
5 discharged from the hospital. This subsection does not apply
6 to newborn infants whose mothers are enrolled in the
7 integrated health care program.
8 (g) The Illinois Department shall, by rule, establish
9 for managed health care entities rates that (i) are certified
10 to be actuarially sound, as determined by an actuary who is
11 an associate or a fellow of the Society of Actuaries or a
12 member of the American Academy of Actuaries and who has
13 expertise and experience in medical insurance and benefit
14 programs, in accordance with the Illinois Department's
15 current fee-for-service payment system, and (ii) take into
16 account any difference of cost to provide health care to
17 different populations based on gender, age, location, and
18 eligibility category. The rates for managed health care
19 entities shall be determined on a capitated basis.
20 The Illinois Department by rule shall establish a method
21 to adjust its payments to managed health care entities in a
22 manner intended to avoid providing any financial incentive to
23 a managed health care entity to refer patients to a county
24 provider, in an Illinois county having a population greater
25 than 3,000,000, that is paid directly by the Illinois
26 Department. The Illinois Department shall by April 1, 1997,
27 and annually thereafter, review the method to adjust
28 payments. Payments by the Illinois Department to the county
29 provider, for persons not enrolled in a managed care
30 community network owned or operated by a county provider,
31 shall be paid on a fee-for-service basis under Article XV of
32 this Code.
33 The Illinois Department by rule shall establish a method
34 to reduce its payments to managed health care entities to
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1 take into consideration (i) any adjustment payments paid to
2 hospitals under subsection (h) of this Section to the extent
3 those payments, or any part of those payments, have been
4 taken into account in establishing capitated rates under this
5 subsection (g) and (ii) the implementation of methodologies
6 to limit financial liability for managed health care entities
7 under subsection (d) of this Section.
8 (h) For hospital services provided by a hospital that
9 contracts with a managed health care entity, adjustment
10 payments shall be paid directly to the hospital by the
11 Illinois Department. Adjustment payments may include but
12 need not be limited to adjustment payments to:
13 disproportionate share hospitals under Section 5-5.02 of this
14 Code; primary care access health care education payments (89
15 Ill. Adm. Code 149.140); payments for capital, direct medical
16 education, indirect medical education, certified registered
17 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
18 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
19 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
20 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
21 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
22 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
23 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
24 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
25 148.290(h)); and outpatient indigent volume adjustments (89
26 Ill. Adm. Code 148.140(b)(5)).
27 (i) For any hospital eligible for the adjustment
28 payments described in subsection (h), the Illinois Department
29 shall maintain, through the period ending June 30, 1995,
30 reimbursement levels in accordance with statutes and rules in
31 effect on April 1, 1994.
32 (j) Nothing contained in this Code in any way limits or
33 otherwise impairs the authority or power of the Illinois
34 Department to enter into a negotiated contract pursuant to
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1 this Section with a managed health care entity, including,
2 but not limited to, a health maintenance organization, that
3 provides for termination or nonrenewal of the contract
4 without cause upon notice as provided in the contract and
5 without a hearing.
6 (k) Section 5-5.15 does not apply to the program
7 developed and implemented pursuant to this Section.
8 (l) The Illinois Department shall, by rule, define those
9 chronic or acute medical conditions of childhood that require
10 longer-term treatment and follow-up care. The Illinois
11 Department shall ensure that services required to treat these
12 conditions are available through a separate delivery system.
13 A managed health care entity that contracts with the
14 Illinois Department may refer a child with medical conditions
15 described in the rules adopted under this subsection directly
16 to a children's hospital or to a hospital, other than a
17 children's hospital, that is qualified to provide inpatient
18 and outpatient services to treat those conditions. The
19 Illinois Department shall provide fee-for-service
20 reimbursement directly to a children's hospital for those
21 services pursuant to Title 89 of the Illinois Administrative
22 Code, Section 148.280(a), at a rate at least equal to the
23 rate in effect on March 31, 1994. For hospitals, other than
24 children's hospitals, that are qualified to provide inpatient
25 and outpatient services to treat those conditions, the
26 Illinois Department shall provide reimbursement for those
27 services on a fee-for-service basis, at a rate at least equal
28 to the rate in effect for those other hospitals on March 31,
29 1994.
30 A children's hospital shall be directly reimbursed for
31 all services provided at the children's hospital on a
32 fee-for-service basis pursuant to Title 89 of the Illinois
33 Administrative Code, Section 148.280(a), at a rate at least
34 equal to the rate in effect on March 31, 1994, until the
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1 later of (i) implementation of the integrated health care
2 program under this Section and development of actuarially
3 sound capitation rates for services other than those chronic
4 or acute medical conditions of childhood that require
5 longer-term treatment and follow-up care as defined by the
6 Illinois Department in the rules adopted under this
7 subsection or (ii) March 31, 1996.
8 Notwithstanding anything in this subsection to the
9 contrary, a managed health care entity shall not consider
10 sources or methods of payment in determining the referral of
11 a child. The Illinois Department shall adopt rules to
12 establish criteria for those referrals. The Illinois
13 Department by rule shall establish a method to adjust its
14 payments to managed health care entities in a manner intended
15 to avoid providing any financial incentive to a managed
16 health care entity to refer patients to a provider who is
17 paid directly by the Illinois Department.
18 (m) Behavioral health services provided or funded by the
19 Department of Mental Health and Developmental Disabilities,
20 the Department of Alcoholism and Substance Abuse, the
21 Department of Children and Family Services, and the Illinois
22 Department shall be excluded from a benefit package.
23 Conditions of an organic or physical origin or nature,
24 including medical detoxification, however, may not be
25 excluded. In this subsection, "behavioral health services"
26 means mental health services and subacute alcohol and
27 substance abuse treatment services, as defined in the
28 Illinois Alcoholism and Other Drug Dependency Act. In this
29 subsection, "mental health services" includes, at a minimum,
30 the following services funded by the Illinois Department, the
31 Department of Mental Health and Developmental Disabilities,
32 or the Department of Children and Family Services: (i)
33 inpatient hospital services, including related physician
34 services, related psychiatric interventions, and
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1 pharmaceutical services provided to an eligible recipient
2 hospitalized with a primary diagnosis of psychiatric
3 disorder; (ii) outpatient mental health services as defined
4 and specified in Title 59 of the Illinois Administrative
5 Code, Part 132; (iii) any other outpatient mental health
6 services funded by the Illinois Department pursuant to the
7 State of Illinois Medicaid Plan; (iv) partial
8 hospitalization; and (v) follow-up stabilization related to
9 any of those services. Additional behavioral health services
10 may be excluded under this subsection as mutually agreed in
11 writing by the Illinois Department and the affected State
12 agency or agencies. The exclusion of any service does not
13 prohibit the Illinois Department from developing and
14 implementing demonstration projects for categories of persons
15 or services. The Department of Mental Health and
16 Developmental Disabilities, the Department of Children and
17 Family Services, and the Department of Alcoholism and
18 Substance Abuse shall each adopt rules governing the
19 integration of managed care in the provision of behavioral
20 health services. The State shall integrate managed care
21 community networks and affiliated providers, to the extent
22 practicable, in any separate delivery system for mental
23 health services.
24 (n) The Illinois Department shall adopt rules to
25 establish reserve requirements for managed care community
26 networks, as required by subsection (a), and health
27 maintenance organizations to protect against liabilities in
28 the event that a managed health care entity is declared
29 insolvent or bankrupt. If a managed health care entity other
30 than a county provider is declared insolvent or bankrupt,
31 after liquidation and application of any available assets,
32 resources, and reserves, the Illinois Department shall pay a
33 portion of the amounts owed by the managed health care entity
34 to providers for services rendered to enrollees under the
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1 integrated health care program under this Section based on
2 the following schedule: (i) from April 1, 1995 through June
3 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
4 through June 30, 2001, 80% of the amounts owed; and (iii)
5 from July 1, 2001 through June 30, 2005, 75% of the amounts
6 owed. The amounts paid under this subsection shall be
7 calculated based on the total amount owed by the managed
8 health care entity to providers before application of any
9 available assets, resources, and reserves. After June 30,
10 2005, the Illinois Department may not pay any amounts owed to
11 providers as a result of an insolvency or bankruptcy of a
12 managed health care entity occurring after that date. The
13 Illinois Department is not obligated, however, to pay amounts
14 owed to a provider that has an ownership or other governing
15 interest in the managed health care entity. This subsection
16 applies only to managed health care entities and the services
17 they provide under the integrated health care program under
18 this Section.
19 (o) Notwithstanding any other provision of law or
20 contractual agreement to the contrary, providers shall not be
21 required to accept from any other third party payer the rates
22 determined or paid under this Code by the Illinois
23 Department, managed health care entity, or other health care
24 delivery system for services provided to recipients.
25 (p) The Illinois Department may seek and obtain any
26 necessary authorization provided under federal law to
27 implement the program, including the waiver of any federal
28 statutes or regulations. The Illinois Department may seek a
29 waiver of the federal requirement that the combined
30 membership of Medicare and Medicaid enrollees in a managed
31 care community network may not exceed 75% of the managed care
32 community network's total enrollment. The Illinois
33 Department shall not seek a waiver of this requirement for
34 any other category of managed health care entity. The
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1 Illinois Department shall not seek a waiver of the inpatient
2 hospital reimbursement methodology in Section 1902(a)(13)(A)
3 of Title XIX of the Social Security Act even if the federal
4 agency responsible for administering Title XIX determines
5 that Section 1902(a)(13)(A) applies to managed health care
6 systems.
7 Notwithstanding any other provisions of this Code to the
8 contrary, the Illinois Department shall seek a waiver of
9 applicable federal law in order to impose a co-payment system
10 consistent with this subsection on recipients of medical
11 services under Title XIX of the Social Security Act who are
12 not enrolled in a managed health care entity. The waiver
13 request submitted by the Illinois Department shall provide
14 for co-payments of up to $0.50 for prescribed drugs and up to
15 $0.50 for x-ray services and shall provide for co-payments of
16 up to $10 for non-emergency services provided in a hospital
17 emergency department room and up to $10 for non-emergency
18 ambulance services. The purpose of the co-payments shall be
19 to deter those recipients from seeking unnecessary medical
20 care. Co-payments may not be used to deter recipients from
21 seeking or accessing emergency services and other necessary
22 medical care. No recipient shall be required to pay more
23 than a total of $150 per year in co-payments under the waiver
24 request required by this subsection. A recipient may not be
25 required to pay more than $15 of any amount due under this
26 subsection in any one month.
27 Co-payments authorized under this subsection may not be
28 imposed when the care was necessitated by a true medical
29 condition as described in the definition of "emergency
30 services under subsection (a) of Section 5-5.04 emergency.
31 Copayments for non-emergency services in a hospital emergency
32 department shall not be imposed retrospectively except upon
33 reasonable determination by the Illinois Department that (1)
34 the emergency services claimed were never performed or (2) an
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1 emergency medical screening examination was performed on a
2 patient who personally sought emergency services knowing that
3 he or she did not have an emergency condition or necessity,
4 and who did not in fact require emergency services.
5 Co-payments may not be imposed for any of the following
6 classifications of services:
7 (1) Services furnished to person under 18 years of
8 age.
9 (2) Services furnished to pregnant women.
10 (3) Services furnished to any individual who is an
11 inpatient in a hospital, nursing facility, intermediate
12 care facility, or other medical institution, if that
13 person is required to spend for costs of medical care all
14 but a minimal amount of his or her income required for
15 personal needs.
16 (4) Services furnished to a person who is receiving
17 hospice care.
18 Co-payments authorized under this subsection shall not be
19 deducted from or reduce in any way payments for medical
20 services from the Illinois Department to providers. No
21 provider may deny those services to an individual eligible
22 for services based on the individual's inability to pay the
23 co-payment.
24 Recipients who are subject to co-payments shall be
25 provided notice, in plain and clear language, of the amount
26 of the co-payments, the circumstances under which co-payments
27 are exempted, the circumstances under which co-payments may
28 be assessed, and their manner of collection.
29 The Illinois Department shall establish a Medicaid
30 Co-Payment Council to assist in the development of co-payment
31 policies for the medical assistance program. The Medicaid
32 Co-Payment Council shall also have jurisdiction to develop a
33 program to provide financial or non-financial incentives to
34 Medicaid recipients in order to encourage recipients to seek
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1 necessary health care. The Council shall be chaired by the
2 Director of the Illinois Department, and shall have 6
3 additional members. Two of the 6 additional members shall be
4 appointed by the Governor, and one each shall be appointed by
5 the President of the Senate, the Minority Leader of the
6 Senate, the Speaker of the House of Representatives, and the
7 Minority Leader of the House of Representatives. The Council
8 may be convened and make recommendations upon the appointment
9 of a majority of its members. The Council shall be appointed
10 and convened no later than September 1, 1994 and shall report
11 its recommendations to the Director of the Illinois
12 Department and the General Assembly no later than October 1,
13 1994. The chairperson of the Council shall be allowed to
14 vote only in the case of a tie vote among the appointed
15 members of the Council.
16 The Council shall be guided by the following principles
17 as it considers recommendations to be developed to implement
18 any approved waivers that the Illinois Department must seek
19 pursuant to this subsection:
20 (1) Co-payments should not be used to deter access
21 to adequate medical care.
22 (2) Co-payments should be used to reduce fraud.
23 (3) Co-payment policies should be examined in
24 consideration of other states' experience, and the
25 ability of successful co-payment plans to control
26 unnecessary or inappropriate utilization of services
27 should be promoted.
28 (4) All participants, both recipients and
29 providers, in the medical assistance program have
30 responsibilities to both the State and the program.
31 (5) Co-payments are primarily a tool to educate the
32 participants in the responsible use of health care
33 resources.
34 (6) Co-payments should not be used to penalize
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1 providers.
2 (7) A successful medical program requires the
3 elimination of improper utilization of medical resources.
4 The integrated health care program, or any part of that
5 program, established under this Section may not be
6 implemented if matching federal funds under Title XIX of the
7 Social Security Act are not available for administering the
8 program.
9 The Illinois Department shall submit for publication in
10 the Illinois Register the name, address, and telephone number
11 of the individual to whom a request may be directed for a
12 copy of the request for a waiver of provisions of Title XIX
13 of the Social Security Act that the Illinois Department
14 intends to submit to the Health Care Financing Administration
15 in order to implement this Section. The Illinois Department
16 shall mail a copy of that request for waiver to all
17 requestors at least 16 days before filing that request for
18 waiver with the Health Care Financing Administration.
19 (q) After the effective date of this Section, the
20 Illinois Department may take all planning and preparatory
21 action necessary to implement this Section, including, but
22 not limited to, seeking requests for proposals relating to
23 the integrated health care program created under this
24 Section.
25 (r) In order to (i) accelerate and facilitate the
26 development of integrated health care in contracting areas
27 outside counties with populations in excess of 3,000,000 and
28 counties adjacent to those counties and (ii) maintain and
29 sustain the high quality of education and residency programs
30 coordinated and associated with local area hospitals, the
31 Illinois Department may develop and implement a demonstration
32 program for managed care community networks owned, operated,
33 or governed by State-funded medical schools. The Illinois
34 Department shall prescribe by rule the criteria, standards,
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1 and procedures for effecting this demonstration program.
2 (s) (Blank).
3 (t) On April 1, 1995 and every 6 months thereafter, the
4 Illinois Department shall report to the Governor and General
5 Assembly on the progress of the integrated health care
6 program in enrolling clients into managed health care
7 entities. The report shall indicate the capacities of the
8 managed health care entities with which the State contracts,
9 the number of clients enrolled by each contractor, the areas
10 of the State in which managed care options do not exist, and
11 the progress toward meeting the enrollment goals of the
12 integrated health care program.
13 (u) The Illinois Department may implement this Section
14 through the use of emergency rules in accordance with Section
15 5-45 of the Illinois Administrative Procedure Act. For
16 purposes of that Act, the adoption of rules to implement this
17 Section is deemed an emergency and necessary for the public
18 interest, safety, and welfare.
19 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
20 89-673, eff. 8-14-96; revised 8-26-96.)
21 (Text of Section after amendment by P.A. 89-507)
22 Sec. 5-16.3. System for integrated health care services.
23 (a) It shall be the public policy of the State to adopt,
24 to the extent practicable, a health care program that
25 encourages the integration of health care services and
26 manages the health care of program enrollees while preserving
27 reasonable choice within a competitive and cost-efficient
28 environment. In furtherance of this public policy, the
29 Illinois Department shall develop and implement an integrated
30 health care program consistent with the provisions of this
31 Section. The provisions of this Section apply only to the
32 integrated health care program created under this Section.
33 Persons enrolled in the integrated health care program, as
34 determined by the Illinois Department by rule, shall be
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1 afforded a choice among health care delivery systems, which
2 shall include, but are not limited to, (i) fee for service
3 care managed by a primary care physician licensed to practice
4 medicine in all its branches, (ii) managed health care
5 entities, and (iii) federally qualified health centers
6 (reimbursed according to a prospective cost-reimbursement
7 methodology) and rural health clinics (reimbursed according
8 to the Medicare methodology), where available. Persons
9 enrolled in the integrated health care program also may be
10 offered indemnity insurance plans, subject to availability.
11 For purposes of this Section, a "managed health care
12 entity" means a health maintenance organization or a managed
13 care community network as defined in this Section. A "health
14 maintenance organization" means a health maintenance
15 organization as defined in the Health Maintenance
16 Organization Act. A "managed care community network" means
17 an entity, other than a health maintenance organization, that
18 is owned, operated, or governed by providers of health care
19 services within this State and that provides or arranges
20 primary, secondary, and tertiary managed health care services
21 under contract with the Illinois Department exclusively to
22 enrollees of the integrated health care program. A managed
23 care community network may contract with the Illinois
24 Department to provide only pediatric health care services. A
25 county provider as defined in Section 15-1 of this Code may
26 contract with the Illinois Department to provide services to
27 enrollees of the integrated health care program as a managed
28 care community network without the need to establish a
29 separate entity that provides services exclusively to
30 enrollees of the integrated health care program and shall be
31 deemed a managed care community network for purposes of this
32 Code only to the extent of the provision of services to those
33 enrollees in conjunction with the integrated health care
34 program. A county provider shall be entitled to contract
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1 with the Illinois Department with respect to any contracting
2 region located in whole or in part within the county. A
3 county provider shall not be required to accept enrollees who
4 do not reside within the county.
5 Each managed care community network must demonstrate its
6 ability to bear the financial risk of serving enrollees under
7 this program. The Illinois Department shall by rule adopt
8 criteria for assessing the financial soundness of each
9 managed care community network. These rules shall consider
10 the extent to which a managed care community network is
11 comprised of providers who directly render health care and
12 are located within the community in which they seek to
13 contract rather than solely arrange or finance the delivery
14 of health care. These rules shall further consider a variety
15 of risk-bearing and management techniques, including the
16 sufficiency of quality assurance and utilization management
17 programs and whether a managed care community network has
18 sufficiently demonstrated its financial solvency and net
19 worth. The Illinois Department's criteria must be based on
20 sound actuarial, financial, and accounting principles. In
21 adopting these rules, the Illinois Department shall consult
22 with the Illinois Department of Insurance. The Illinois
23 Department is responsible for monitoring compliance with
24 these rules.
25 This Section may not be implemented before the effective
26 date of these rules, the approval of any necessary federal
27 waivers, and the completion of the review of an application
28 submitted, at least 60 days before the effective date of
29 rules adopted under this Section, to the Illinois Department
30 by a managed care community network.
31 All health care delivery systems that contract with the
32 Illinois Department under the integrated health care program
33 shall clearly recognize a health care provider's right of
34 conscience under the Right of Conscience Act. In addition to
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1 the provisions of that Act, no health care delivery system
2 that contracts with the Illinois Department under the
3 integrated health care program shall be required to provide,
4 arrange for, or pay for any health care or medical service,
5 procedure, or product if that health care delivery system is
6 owned, controlled, or sponsored by or affiliated with a
7 religious institution or religious organization that finds
8 that health care or medical service, procedure, or product to
9 violate its religious and moral teachings and beliefs.
10 (b) The Illinois Department may, by rule, provide for
11 different benefit packages for different categories of
12 persons enrolled in the program. Mental health services,
13 alcohol and substance abuse services, services related to
14 children with chronic or acute conditions requiring
15 longer-term treatment and follow-up, and rehabilitation care
16 provided by a free-standing rehabilitation hospital or a
17 hospital rehabilitation unit may be excluded from a benefit
18 package if the State ensures that those services are made
19 available through a separate delivery system. An exclusion
20 does not prohibit the Illinois Department from developing and
21 implementing demonstration projects for categories of persons
22 or services. Benefit packages for persons eligible for
23 medical assistance under Articles V, VI, and XII shall be
24 based on the requirements of those Articles and shall be
25 consistent with the Title XIX of the Social Security Act.
26 Nothing in this Act shall be construed to apply to services
27 purchased by the Department of Children and Family Services
28 and the Department of Human Services (as successor to the
29 Department of Mental Health and Developmental Disabilities)
30 under the provisions of Title 59 of the Illinois
31 Administrative Code, Part 132 ("Medicaid Community Mental
32 Health Services Program").
33 (c) The program established by this Section may be
34 implemented by the Illinois Department in various contracting
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1 areas at various times. The health care delivery systems and
2 providers available under the program may vary throughout the
3 State. For purposes of contracting with managed health care
4 entities and providers, the Illinois Department shall
5 establish contracting areas similar to the geographic areas
6 designated by the Illinois Department for contracting
7 purposes under the Illinois Competitive Access and
8 Reimbursement Equity Program (ICARE) under the authority of
9 Section 3-4 of the Illinois Health Finance Reform Act or
10 similarly-sized or smaller geographic areas established by
11 the Illinois Department by rule. A managed health care entity
12 shall be permitted to contract in any geographic areas for
13 which it has a sufficient provider network and otherwise
14 meets the contracting terms of the State. The Illinois
15 Department is not prohibited from entering into a contract
16 with a managed health care entity at any time.
17 (d) A managed health care entity that contracts with the
18 Illinois Department for the provision of services under the
19 program shall do all of the following, solely for purposes of
20 the integrated health care program:
21 (1) Provide that any individual physician licensed
22 to practice medicine in all its branches, any pharmacy,
23 any federally qualified health center, and any
24 podiatrist, that consistently meets the reasonable terms
25 and conditions established by the managed health care
26 entity, including but not limited to credentialing
27 standards, quality assurance program requirements,
28 utilization management requirements, financial
29 responsibility standards, contracting process
30 requirements, and provider network size and accessibility
31 requirements, must be accepted by the managed health care
32 entity for purposes of the Illinois integrated health
33 care program. Any individual who is either terminated
34 from or denied inclusion in the panel of physicians of
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1 the managed health care entity shall be given, within 10
2 business days after that determination, a written
3 explanation of the reasons for his or her exclusion or
4 termination from the panel. This paragraph (1) does not
5 apply to the following:
6 (A) A managed health care entity that
7 certifies to the Illinois Department that:
8 (i) it employs on a full-time basis 125
9 or more Illinois physicians licensed to
10 practice medicine in all of its branches; and
11 (ii) it will provide medical services
12 through its employees to more than 80% of the
13 recipients enrolled with the entity in the
14 integrated health care program; or
15 (B) A domestic stock insurance company
16 licensed under clause (b) of class 1 of Section 4 of
17 the Illinois Insurance Code if (i) at least 66% of
18 the stock of the insurance company is owned by a
19 professional corporation organized under the
20 Professional Service Corporation Act that has 125 or
21 more shareholders who are Illinois physicians
22 licensed to practice medicine in all of its branches
23 and (ii) the insurance company certifies to the
24 Illinois Department that at least 80% of those
25 physician shareholders will provide services to
26 recipients enrolled with the company in the
27 integrated health care program.
28 (2) Provide for reimbursement for providers for
29 emergency services care, as defined by subsection (a) of
30 Section 5-5.04 of this Code the Illinois Department by
31 rule, that must be provided to its enrollees, including
32 an emergency department room screening fee, and urgent
33 care that it authorizes for its enrollees, regardless of
34 the provider's affiliation with the managed health care
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1 entity. Providers shall be reimbursed for emergency
2 services care at an amount equal to the Illinois
3 Department's fee-for-service rates for those medical
4 services rendered by providers not under contract with
5 the managed health care entity to enrollees of the
6 entity.
7 (A) Coverage and payment for emergency
8 services shall not be retrospectively denied except
9 upon reasonable determination by the Illinois
10 Department that (1) the emergency services claimed
11 were never performed or (2) an emergency medical
12 screening examination was performed on a patient who
13 personally sought emergency services knowing that he
14 or she did not have an emergency condition or
15 necessity, and who did not in fact require emergency
16 services.
17 (B) The appropriate use of the 911 emergency
18 telephone number shall not be discouraged or
19 penalized, and coverage or payment shall not be
20 denied solely on the basis that the enrollee used
21 the 911 emergency telephone number to summon
22 emergency services. Coverage and payment for
23 emergency medical screening examinations shall not
24 be retrospectively denied.
25 (2.5) Provide for reimbursement for
26 post-stabilization services, which are those health care
27 services determined by a treating provider to be promptly
28 and medically necessary following stabilization of an
29 emergency condition.
30 (A) If prior authorization for
31 post-stabilization services is required, the managed
32 health care entity shall provide access 24 hours a
33 day, 7 days a week to persons designated by the
34 entity to make such determinations. If a health
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1 care provider has attempted to contact such person
2 for prior authorization and no designated persons
3 were accessible or the authorization was not denied
4 within 30 minutes of the request, the managed health
5 care entity is deemed to have approved the request
6 for prior authorization.
7 (B) Coverage and payment for
8 post-stabilization services which received prior
9 authorization or deemed approval shall not be
10 retrospectively denied.
11 (3) Provide that any provider affiliated with a
12 managed health care entity may also provide services on a
13 fee-for-service basis to Illinois Department clients not
14 enrolled in a managed health care entity.
15 (4) Provide client education services as determined
16 and approved by the Illinois Department, including but
17 not limited to (i) education regarding appropriate
18 utilization of health care services in a managed care
19 system, (ii) written disclosure of treatment policies and
20 any restrictions or limitations on health services,
21 including, but not limited to, physical services,
22 clinical laboratory tests, hospital and surgical
23 procedures, prescription drugs and biologics, and
24 radiological examinations, and (iii) written notice that
25 the enrollee may receive from another provider those
26 services covered under this program that are not provided
27 by the managed health care entity.
28 (5) Provide that enrollees within its system may
29 choose the site for provision of services and the panel
30 of health care providers.
31 (6) Not discriminate in its enrollment or
32 disenrollment practices among recipients of medical
33 services or program enrollees based on health status.
34 (7) Provide a quality assurance and utilization
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1 review program that (i) for health maintenance
2 organizations meets the requirements of the Health
3 Maintenance Organization Act and (ii) for managed care
4 community networks meets the requirements established by
5 the Illinois Department in rules that incorporate those
6 standards set forth in the Health Maintenance
7 Organization Act.
8 (8) Issue a managed health care entity
9 identification card to each enrollee upon enrollment.
10 The card must contain all of the following:
11 (A) The enrollee's signature.
12 (B) The enrollee's health plan.
13 (C) The name and telephone number of the
14 enrollee's primary care physician.
15 (D) A telephone number to be used for
16 emergency service 24 hours per day, 7 days per week.
17 The telephone number required to be maintained
18 pursuant to this subparagraph by each managed health
19 care entity shall, at minimum, be staffed by
20 medically trained personnel and be provided
21 directly, or under arrangement, at an office or
22 offices in locations maintained solely within the
23 State of Illinois. For purposes of this
24 subparagraph, "medically trained personnel" means
25 licensed practical nurses or registered nurses
26 located in the State of Illinois who are licensed
27 pursuant to the Illinois Nursing Act of 1987.
28 (9) Ensure that every primary care physician and
29 pharmacy in the managed health care entity meets the
30 standards established by the Illinois Department for
31 accessibility and quality of care. The Illinois
32 Department shall arrange for and oversee an evaluation of
33 the standards established under this paragraph (9) and
34 may recommend any necessary changes to these standards.
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1 The Illinois Department shall submit an annual report to
2 the Governor and the General Assembly by April 1 of each
3 year regarding the effect of the standards on ensuring
4 access and quality of care to enrollees.
5 (10) Provide a procedure for handling complaints
6 that (i) for health maintenance organizations meets the
7 requirements of the Health Maintenance Organization Act
8 and (ii) for managed care community networks meets the
9 requirements established by the Illinois Department in
10 rules that incorporate those standards set forth in the
11 Health Maintenance Organization Act.
12 (11) Maintain, retain, and make available to the
13 Illinois Department records, data, and information, in a
14 uniform manner determined by the Illinois Department,
15 sufficient for the Illinois Department to monitor
16 utilization, accessibility, and quality of care.
17 (12) Except for providers who are prepaid, pay all
18 approved claims for covered services that are completed
19 and submitted to the managed health care entity within 30
20 days after receipt of the claim or receipt of the
21 appropriate capitation payment or payments by the managed
22 health care entity from the State for the month in which
23 the services included on the claim were rendered,
24 whichever is later. If payment is not made or mailed to
25 the provider by the managed health care entity by the due
26 date under this subsection, an interest penalty of 1% of
27 any amount unpaid shall be added for each month or
28 fraction of a month after the due date, until final
29 payment is made. Nothing in this Section shall prohibit
30 managed health care entities and providers from mutually
31 agreeing to terms that require more timely payment.
32 (13) Provide integration with community-based
33 programs provided by certified local health departments
34 such as Women, Infants, and Children Supplemental Food
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1 Program (WIC), childhood immunization programs, health
2 education programs, case management programs, and health
3 screening programs.
4 (14) Provide that the pharmacy formulary used by a
5 managed health care entity and its contract providers be
6 no more restrictive than the Illinois Department's
7 pharmaceutical program on the effective date of this
8 amendatory Act of 1994 and as amended after that date.
9 (15) Provide integration with community-based
10 organizations, including, but not limited to, any
11 organization that has operated within a Medicaid
12 Partnership as defined by this Code or by rule of the
13 Illinois Department, that may continue to operate under a
14 contract with the Illinois Department or a managed health
15 care entity under this Section to provide case management
16 services to Medicaid clients in designated high-need
17 areas.
18 The Illinois Department may, by rule, determine
19 methodologies to limit financial liability for managed health
20 care entities resulting from payment for services to
21 enrollees provided under the Illinois Department's integrated
22 health care program. Any methodology so determined may be
23 considered or implemented by the Illinois Department through
24 a contract with a managed health care entity under this
25 integrated health care program.
26 The Illinois Department shall contract with an entity or
27 entities to provide external peer-based quality assurance
28 review for the integrated health care program. The entity
29 shall be representative of Illinois physicians licensed to
30 practice medicine in all its branches and have statewide
31 geographic representation in all specialties of medical care
32 that are provided within the integrated health care program.
33 The entity may not be a third party payer and shall maintain
34 offices in locations around the State in order to provide
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1 service and continuing medical education to physician
2 participants within the integrated health care program. The
3 review process shall be developed and conducted by Illinois
4 physicians licensed to practice medicine in all its branches.
5 In consultation with the entity, the Illinois Department may
6 contract with other entities for professional peer-based
7 quality assurance review of individual categories of services
8 other than services provided, supervised, or coordinated by
9 physicians licensed to practice medicine in all its branches.
10 The Illinois Department shall establish, by rule, criteria to
11 avoid conflicts of interest in the conduct of quality
12 assurance activities consistent with professional peer-review
13 standards. All quality assurance activities shall be
14 coordinated by the Illinois Department.
15 (e) All persons enrolled in the program shall be
16 provided with a full written explanation of all
17 fee-for-service and managed health care plan options and a
18 reasonable opportunity to choose among the options as
19 provided by rule. The Illinois Department shall provide to
20 enrollees, upon enrollment in the integrated health care
21 program and at least annually thereafter, notice of the
22 process for requesting an appeal under the Illinois
23 Department's administrative appeal procedures.
24 Notwithstanding any other Section of this Code, the Illinois
25 Department may provide by rule for the Illinois Department to
26 assign a person enrolled in the program to a specific
27 provider of medical services or to a specific health care
28 delivery system if an enrollee has failed to exercise choice
29 in a timely manner. An enrollee assigned by the Illinois
30 Department shall be afforded the opportunity to disenroll and
31 to select a specific provider of medical services or a
32 specific health care delivery system within the first 30 days
33 after the assignment. An enrollee who has failed to exercise
34 choice in a timely manner may be assigned only if there are 3
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1 or more managed health care entities contracting with the
2 Illinois Department within the contracting area, except that,
3 outside the City of Chicago, this requirement may be waived
4 for an area by rules adopted by the Illinois Department after
5 consultation with all hospitals within the contracting area.
6 The Illinois Department shall establish by rule the procedure
7 for random assignment of enrollees who fail to exercise
8 choice in a timely manner to a specific managed health care
9 entity in proportion to the available capacity of that
10 managed health care entity. Assignment to a specific provider
11 of medical services or to a specific managed health care
12 entity may not exceed that provider's or entity's capacity as
13 determined by the Illinois Department. Any person who has
14 chosen a specific provider of medical services or a specific
15 managed health care entity, or any person who has been
16 assigned under this subsection, shall be given the
17 opportunity to change that choice or assignment at least once
18 every 12 months, as determined by the Illinois Department by
19 rule. The Illinois Department shall maintain a toll-free
20 telephone number for program enrollees' use in reporting
21 problems with managed health care entities.
22 (f) If a person becomes eligible for participation in
23 the integrated health care program while he or she is
24 hospitalized, the Illinois Department may not enroll that
25 person in the program until after he or she has been
26 discharged from the hospital. This subsection does not apply
27 to newborn infants whose mothers are enrolled in the
28 integrated health care program.
29 (g) The Illinois Department shall, by rule, establish
30 for managed health care entities rates that (i) are certified
31 to be actuarially sound, as determined by an actuary who is
32 an associate or a fellow of the Society of Actuaries or a
33 member of the American Academy of Actuaries and who has
34 expertise and experience in medical insurance and benefit
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1 programs, in accordance with the Illinois Department's
2 current fee-for-service payment system, and (ii) take into
3 account any difference of cost to provide health care to
4 different populations based on gender, age, location, and
5 eligibility category. The rates for managed health care
6 entities shall be determined on a capitated basis.
7 The Illinois Department by rule shall establish a method
8 to adjust its payments to managed health care entities in a
9 manner intended to avoid providing any financial incentive to
10 a managed health care entity to refer patients to a county
11 provider, in an Illinois county having a population greater
12 than 3,000,000, that is paid directly by the Illinois
13 Department. The Illinois Department shall by April 1, 1997,
14 and annually thereafter, review the method to adjust
15 payments. Payments by the Illinois Department to the county
16 provider, for persons not enrolled in a managed care
17 community network owned or operated by a county provider,
18 shall be paid on a fee-for-service basis under Article XV of
19 this Code.
20 The Illinois Department by rule shall establish a method
21 to reduce its payments to managed health care entities to
22 take into consideration (i) any adjustment payments paid to
23 hospitals under subsection (h) of this Section to the extent
24 those payments, or any part of those payments, have been
25 taken into account in establishing capitated rates under this
26 subsection (g) and (ii) the implementation of methodologies
27 to limit financial liability for managed health care entities
28 under subsection (d) of this Section.
29 (h) For hospital services provided by a hospital that
30 contracts with a managed health care entity, adjustment
31 payments shall be paid directly to the hospital by the
32 Illinois Department. Adjustment payments may include but
33 need not be limited to adjustment payments to:
34 disproportionate share hospitals under Section 5-5.02 of this
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1 Code; primary care access health care education payments (89
2 Ill. Adm. Code 149.140); payments for capital, direct medical
3 education, indirect medical education, certified registered
4 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
5 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
6 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
7 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
8 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
9 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
10 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
11 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
12 148.290(h)); and outpatient indigent volume adjustments (89
13 Ill. Adm. Code 148.140(b)(5)).
14 (i) For any hospital eligible for the adjustment
15 payments described in subsection (h), the Illinois Department
16 shall maintain, through the period ending June 30, 1995,
17 reimbursement levels in accordance with statutes and rules in
18 effect on April 1, 1994.
19 (j) Nothing contained in this Code in any way limits or
20 otherwise impairs the authority or power of the Illinois
21 Department to enter into a negotiated contract pursuant to
22 this Section with a managed health care entity, including,
23 but not limited to, a health maintenance organization, that
24 provides for termination or nonrenewal of the contract
25 without cause upon notice as provided in the contract and
26 without a hearing.
27 (k) Section 5-5.15 does not apply to the program
28 developed and implemented pursuant to this Section.
29 (l) The Illinois Department shall, by rule, define those
30 chronic or acute medical conditions of childhood that require
31 longer-term treatment and follow-up care. The Illinois
32 Department shall ensure that services required to treat these
33 conditions are available through a separate delivery system.
34 A managed health care entity that contracts with the
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1 Illinois Department may refer a child with medical conditions
2 described in the rules adopted under this subsection directly
3 to a children's hospital or to a hospital, other than a
4 children's hospital, that is qualified to provide inpatient
5 and outpatient services to treat those conditions. The
6 Illinois Department shall provide fee-for-service
7 reimbursement directly to a children's hospital for those
8 services pursuant to Title 89 of the Illinois Administrative
9 Code, Section 148.280(a), at a rate at least equal to the
10 rate in effect on March 31, 1994. For hospitals, other than
11 children's hospitals, that are qualified to provide inpatient
12 and outpatient services to treat those conditions, the
13 Illinois Department shall provide reimbursement for those
14 services on a fee-for-service basis, at a rate at least equal
15 to the rate in effect for those other hospitals on March 31,
16 1994.
17 A children's hospital shall be directly reimbursed for
18 all services provided at the children's hospital on a
19 fee-for-service basis pursuant to Title 89 of the Illinois
20 Administrative Code, Section 148.280(a), at a rate at least
21 equal to the rate in effect on March 31, 1994, until the
22 later of (i) implementation of the integrated health care
23 program under this Section and development of actuarially
24 sound capitation rates for services other than those chronic
25 or acute medical conditions of childhood that require
26 longer-term treatment and follow-up care as defined by the
27 Illinois Department in the rules adopted under this
28 subsection or (ii) March 31, 1996.
29 Notwithstanding anything in this subsection to the
30 contrary, a managed health care entity shall not consider
31 sources or methods of payment in determining the referral of
32 a child. The Illinois Department shall adopt rules to
33 establish criteria for those referrals. The Illinois
34 Department by rule shall establish a method to adjust its
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1 payments to managed health care entities in a manner intended
2 to avoid providing any financial incentive to a managed
3 health care entity to refer patients to a provider who is
4 paid directly by the Illinois Department.
5 (m) Behavioral health services provided or funded by the
6 Department of Human Services, the Department of Children and
7 Family Services, and the Illinois Department shall be
8 excluded from a benefit package. Conditions of an organic or
9 physical origin or nature, including medical detoxification,
10 however, may not be excluded. In this subsection,
11 "behavioral health services" means mental health services and
12 subacute alcohol and substance abuse treatment services, as
13 defined in the Illinois Alcoholism and Other Drug Dependency
14 Act. In this subsection, "mental health services" includes,
15 at a minimum, the following services funded by the Illinois
16 Department, the Department of Human Services (as successor to
17 the Department of Mental Health and Developmental
18 Disabilities), or the Department of Children and Family
19 Services: (i) inpatient hospital services, including related
20 physician services, related psychiatric interventions, and
21 pharmaceutical services provided to an eligible recipient
22 hospitalized with a primary diagnosis of psychiatric
23 disorder; (ii) outpatient mental health services as defined
24 and specified in Title 59 of the Illinois Administrative
25 Code, Part 132; (iii) any other outpatient mental health
26 services funded by the Illinois Department pursuant to the
27 State of Illinois Medicaid Plan; (iv) partial
28 hospitalization; and (v) follow-up stabilization related to
29 any of those services. Additional behavioral health services
30 may be excluded under this subsection as mutually agreed in
31 writing by the Illinois Department and the affected State
32 agency or agencies. The exclusion of any service does not
33 prohibit the Illinois Department from developing and
34 implementing demonstration projects for categories of persons
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1 or services. The Department of Children and Family Services
2 and the Department of Human Services shall each adopt rules
3 governing the integration of managed care in the provision of
4 behavioral health services. The State shall integrate managed
5 care community networks and affiliated providers, to the
6 extent practicable, in any separate delivery system for
7 mental health services.
8 (n) The Illinois Department shall adopt rules to
9 establish reserve requirements for managed care community
10 networks, as required by subsection (a), and health
11 maintenance organizations to protect against liabilities in
12 the event that a managed health care entity is declared
13 insolvent or bankrupt. If a managed health care entity other
14 than a county provider is declared insolvent or bankrupt,
15 after liquidation and application of any available assets,
16 resources, and reserves, the Illinois Department shall pay a
17 portion of the amounts owed by the managed health care entity
18 to providers for services rendered to enrollees under the
19 integrated health care program under this Section based on
20 the following schedule: (i) from April 1, 1995 through June
21 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
22 through June 30, 2001, 80% of the amounts owed; and (iii)
23 from July 1, 2001 through June 30, 2005, 75% of the amounts
24 owed. The amounts paid under this subsection shall be
25 calculated based on the total amount owed by the managed
26 health care entity to providers before application of any
27 available assets, resources, and reserves. After June 30,
28 2005, the Illinois Department may not pay any amounts owed to
29 providers as a result of an insolvency or bankruptcy of a
30 managed health care entity occurring after that date. The
31 Illinois Department is not obligated, however, to pay amounts
32 owed to a provider that has an ownership or other governing
33 interest in the managed health care entity. This subsection
34 applies only to managed health care entities and the services
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1 they provide under the integrated health care program under
2 this Section.
3 (o) Notwithstanding any other provision of law or
4 contractual agreement to the contrary, providers shall not be
5 required to accept from any other third party payer the rates
6 determined or paid under this Code by the Illinois
7 Department, managed health care entity, or other health care
8 delivery system for services provided to recipients.
9 (p) The Illinois Department may seek and obtain any
10 necessary authorization provided under federal law to
11 implement the program, including the waiver of any federal
12 statutes or regulations. The Illinois Department may seek a
13 waiver of the federal requirement that the combined
14 membership of Medicare and Medicaid enrollees in a managed
15 care community network may not exceed 75% of the managed care
16 community network's total enrollment. The Illinois
17 Department shall not seek a waiver of this requirement for
18 any other category of managed health care entity. The
19 Illinois Department shall not seek a waiver of the inpatient
20 hospital reimbursement methodology in Section 1902(a)(13)(A)
21 of Title XIX of the Social Security Act even if the federal
22 agency responsible for administering Title XIX determines
23 that Section 1902(a)(13)(A) applies to managed health care
24 systems.
25 Notwithstanding any other provisions of this Code to the
26 contrary, the Illinois Department shall seek a waiver of
27 applicable federal law in order to impose a co-payment system
28 consistent with this subsection on recipients of medical
29 services under Title XIX of the Social Security Act who are
30 not enrolled in a managed health care entity. The waiver
31 request submitted by the Illinois Department shall provide
32 for co-payments of up to $0.50 for prescribed drugs and up to
33 $0.50 for x-ray services and shall provide for co-payments of
34 up to $10 for non-emergency services provided in a hospital
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1 emergency department room and up to $10 for non-emergency
2 ambulance services. The purpose of the co-payments shall be
3 to deter those recipients from seeking unnecessary medical
4 care. Co-payments may not be used to deter recipients from
5 seeking or accessing emergency services or other necessary
6 medical care. No recipient shall be required to pay more
7 than a total of $150 per year in co-payments under the waiver
8 request required by this subsection. A recipient may not be
9 required to pay more than $15 of any amount due under this
10 subsection in any one month.
11 Co-payments authorized under this subsection may not be
12 imposed when the care was necessitated by a medical condition
13 as described in the definition of "emergency services" under
14 subsection (a) of Section 5-5.04 true medical emergency.
15 Copayments for non-emergency services in a hospital emergency
16 department shall not be imposed retrospectively except upon
17 reasonable determination by the Illinois Department that (1)
18 the emergency services claimed were never performed or (2) an
19 emergency medical screening examination was performed on a
20 patient who personally sought emergency services knowing that
21 he or she did not have an emergency condition or necessity,
22 and who did not in fact require emergency services.
23 Co-payments may not be imposed for any of the following
24 classifications of services:
25 (1) Services furnished to person under 18 years of
26 age.
27 (2) Services furnished to pregnant women.
28 (3) Services furnished to any individual who is an
29 inpatient in a hospital, nursing facility, intermediate
30 care facility, or other medical institution, if that
31 person is required to spend for costs of medical care all
32 but a minimal amount of his or her income required for
33 personal needs.
34 (4) Services furnished to a person who is receiving
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1 hospice care.
2 Co-payments authorized under this subsection shall not be
3 deducted from or reduce in any way payments for medical
4 services from the Illinois Department to providers. No
5 provider may deny those services to an individual eligible
6 for services based on the individual's inability to pay the
7 co-payment.
8 Recipients who are subject to co-payments shall be
9 provided notice, in plain and clear language, of the amount
10 of the co-payments, the circumstances under which co-payments
11 are exempted, the circumstances under which co-payments may
12 be assessed, and their manner of collection.
13 The Illinois Department shall establish a Medicaid
14 Co-Payment Council to assist in the development of co-payment
15 policies for the medical assistance program. The Medicaid
16 Co-Payment Council shall also have jurisdiction to develop a
17 program to provide financial or non-financial incentives to
18 Medicaid recipients in order to encourage recipients to seek
19 necessary health care. The Council shall be chaired by the
20 Director of the Illinois Department, and shall have 6
21 additional members. Two of the 6 additional members shall be
22 appointed by the Governor, and one each shall be appointed by
23 the President of the Senate, the Minority Leader of the
24 Senate, the Speaker of the House of Representatives, and the
25 Minority Leader of the House of Representatives. The Council
26 may be convened and make recommendations upon the appointment
27 of a majority of its members. The Council shall be appointed
28 and convened no later than September 1, 1994 and shall report
29 its recommendations to the Director of the Illinois
30 Department and the General Assembly no later than October 1,
31 1994. The chairperson of the Council shall be allowed to
32 vote only in the case of a tie vote among the appointed
33 members of the Council.
34 The Council shall be guided by the following principles
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1 as it considers recommendations to be developed to implement
2 any approved waivers that the Illinois Department must seek
3 pursuant to this subsection:
4 (1) Co-payments should not be used to deter access
5 to adequate medical care.
6 (2) Co-payments should be used to reduce fraud.
7 (3) Co-payment policies should be examined in
8 consideration of other states' experience, and the
9 ability of successful co-payment plans to control
10 unnecessary or inappropriate utilization of services
11 should be promoted.
12 (4) All participants, both recipients and
13 providers, in the medical assistance program have
14 responsibilities to both the State and the program.
15 (5) Co-payments are primarily a tool to educate the
16 participants in the responsible use of health care
17 resources.
18 (6) Co-payments should not be used to penalize
19 providers.
20 (7) A successful medical program requires the
21 elimination of improper utilization of medical resources.
22 The integrated health care program, or any part of that
23 program, established under this Section may not be
24 implemented if matching federal funds under Title XIX of the
25 Social Security Act are not available for administering the
26 program.
27 The Illinois Department shall submit for publication in
28 the Illinois Register the name, address, and telephone number
29 of the individual to whom a request may be directed for a
30 copy of the request for a waiver of provisions of Title XIX
31 of the Social Security Act that the Illinois Department
32 intends to submit to the Health Care Financing Administration
33 in order to implement this Section. The Illinois Department
34 shall mail a copy of that request for waiver to all
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1 requestors at least 16 days before filing that request for
2 waiver with the Health Care Financing Administration.
3 (q) After the effective date of this Section, the
4 Illinois Department may take all planning and preparatory
5 action necessary to implement this Section, including, but
6 not limited to, seeking requests for proposals relating to
7 the integrated health care program created under this
8 Section.
9 (r) In order to (i) accelerate and facilitate the
10 development of integrated health care in contracting areas
11 outside counties with populations in excess of 3,000,000 and
12 counties adjacent to those counties and (ii) maintain and
13 sustain the high quality of education and residency programs
14 coordinated and associated with local area hospitals, the
15 Illinois Department may develop and implement a demonstration
16 program for managed care community networks owned, operated,
17 or governed by State-funded medical schools. The Illinois
18 Department shall prescribe by rule the criteria, standards,
19 and procedures for effecting this demonstration program.
20 (s) (Blank).
21 (t) On April 1, 1995 and every 6 months thereafter, the
22 Illinois Department shall report to the Governor and General
23 Assembly on the progress of the integrated health care
24 program in enrolling clients into managed health care
25 entities. The report shall indicate the capacities of the
26 managed health care entities with which the State contracts,
27 the number of clients enrolled by each contractor, the areas
28 of the State in which managed care options do not exist, and
29 the progress toward meeting the enrollment goals of the
30 integrated health care program.
31 (u) The Illinois Department may implement this Section
32 through the use of emergency rules in accordance with Section
33 5-45 of the Illinois Administrative Procedure Act. For
34 purposes of that Act, the adoption of rules to implement this
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1 Section is deemed an emergency and necessary for the public
2 interest, safety, and welfare.
3 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
4 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
5 Section 95. No acceleration or delay. Where this Act
6 makes changes in a statute that is represented in this Act by
7 text that is not yet or no longer in effect (for example, a
8 Section represented by multiple versions), the use of that
9 text does not accelerate or delay the taking effect of (i)
10 the changes made by this Act or (ii) provisions derived from
11 any other Public Act.
12 Section 99. Effective date. This Act takes effect upon
13 becoming law.