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Public Act 103-0104 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Health Maintenance Organization Act is | ||||
amended by changing Sections 1-2 and 2-3 as follows:
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(215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
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Sec. 1-2. Definitions. As used in this Act, unless the | ||||
context otherwise
requires, the following terms shall have the | ||||
meanings ascribed to them:
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(1) "Advertisement" means any printed or published | ||||
material,
audiovisual material and descriptive literature of | ||||
the health care plan
used in direct mail, newspapers, | ||||
magazines, radio scripts, television
scripts, billboards and | ||||
similar displays; and any descriptive literature or
sales aids | ||||
of all kinds disseminated by a representative of the health | ||||
care
plan for presentation to the public including, but not | ||||
limited to, circulars,
leaflets, booklets, depictions, | ||||
illustrations, form letters and prepared
sales presentations.
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(2) "Director" means the Director of Insurance.
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(3) "Basic health care services" means emergency care, and | ||||
inpatient
hospital and physician care, outpatient medical | ||||
services, mental
health services and care for alcohol and drug | ||||
abuse, including any
reasonable deductibles and co-payments, |
all of which are subject to the
limitations described in | ||
Section 4-20 of this Act and as determined by the Director | ||
pursuant to rule.
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(4) "Enrollee" means an individual who has been enrolled | ||
in a health
care plan.
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(5) "Evidence of coverage" means any certificate, | ||
agreement,
or contract issued to an enrollee setting out the | ||
coverage to which he is
entitled in exchange for a per capita | ||
prepaid sum.
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(6) "Group contract" means a contract for health care | ||
services which
by its terms limits eligibility to members of a | ||
specified group.
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(7) "Health care plan" means any arrangement in which an | ||
whereby any organization
provides, arranges undertakes to | ||
provide or arrange for , pays and pay for , or reimburses | ||
reimburse the
cost of basic health care services, excluding | ||
any reasonable deductibles and copayments , from providers | ||
selected by
the Health Maintenance Organization ; and the such | ||
arrangement
consists of providing for the arranging for or the | ||
provision of basic such health care services that is , as
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distinguished from mere indemnification against the cost of | ||
such services ,
on a per capita prepaid basis, through | ||
insurance or otherwise, except as otherwise authorized by | ||
Section 2-3 of this Act ,
on a per capita prepaid basis, through | ||
insurance or otherwise . A "health
care plan" also includes any | ||
arrangement in which whereby an organization provides, |
arranges undertakes to
provide or arrange for , pays or pay | ||
for , or reimburses reimburse the cost of any health care
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service for persons who are enrolled under Article V of the | ||
Illinois Public Aid
Code or under the Children's Health | ||
Insurance Program Act through
providers selected by the | ||
organization ; and the arrangement consists of making
a | ||
provision for the delivery of health care services that is , as | ||
distinguished from mere
indemnification. A "health care plan" | ||
also includes any arrangement pursuant
to Section 4-17. | ||
Nothing in this definition, however, affects the total
medical | ||
services available to persons eligible for medical assistance | ||
under the
Illinois Public Aid Code. Nothing in this definition | ||
shall be construed as requiring a health care plan or health | ||
maintenance organization to utilize a referral system that | ||
enrollees must use to access basic health care services and | ||
other health care services from providers that are under | ||
contract with or employed by the health maintenance | ||
organization. The Director may prescribe by rule the language | ||
that must be included in the plan name, marketing, | ||
advertising, or other consumer disclosure requirements to | ||
differentiate a health care plan that does not use a referral | ||
system for such providers from a health care plan that does use | ||
a referral system for such providers.
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(8) "Health care services" means any services included in | ||
the furnishing
to any individual of medical or dental care, or | ||
the hospitalization or
incident to the furnishing of such care |
or hospitalization as well as the
furnishing to any person of | ||
any and all other services for the purpose of
preventing, | ||
alleviating, curing or healing human illness or injury.
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(9) "Health Maintenance Organization" means any | ||
organization formed
under the laws of this or another state to | ||
provide or arrange for one or
more health care plans under a | ||
system which causes any part of the risk of
health care | ||
delivery to be borne by the organization or its providers.
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(10) "Net worth" means admitted assets, as defined in | ||
Section 1-3 of
this Act, minus liabilities.
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(11) "Organization" means any insurance company, a | ||
nonprofit
corporation authorized under the Dental
Service Plan | ||
Act or the Voluntary
Health Services Plans Act,
or a | ||
corporation organized under the laws of this or another state | ||
for the
purpose of operating one or more health care plans and | ||
doing no business other
than that of a Health Maintenance | ||
Organization or an insurance company.
"Organization" shall | ||
also mean the University of Illinois Hospital as
defined in | ||
the University of Illinois Hospital Act or a unit of local | ||
government health system operating within a county with a | ||
population of 3,000,000 or more.
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(12) "Provider" means any physician, hospital facility,
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facility licensed under the Nursing Home Care Act, or facility | ||
or long-term care facility as those terms are defined in the | ||
Nursing Home Care Act or other person which is licensed or | ||
otherwise authorized
to furnish health care services and also |
includes any other entity that
arranges for the delivery or | ||
furnishing of health care service.
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(13) "Producer" means a person directly or indirectly | ||
associated with a
health care plan who engages in solicitation | ||
or enrollment.
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(14) "Per capita prepaid" means a basis of prepayment by | ||
which a fixed
amount of money is prepaid per individual or any | ||
other enrollment unit to
the Health Maintenance Organization | ||
or for health care services which are
provided during a | ||
definite time period regardless of the frequency or
extent of | ||
the services rendered
by the Health Maintenance Organization, | ||
except for copayments and deductibles
and except as provided | ||
in subsection (f) of Section 5-3 of this Act.
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(15) "Referral system" means any arrangement in a health | ||
care plan in which a primary care provider coordinates or | ||
manages the care of a health maintenance organization's | ||
enrollee by referring the enrollee to other providers or | ||
specialists. | ||
(16) (15) "Subscriber" means a person who has entered into | ||
a contractual
relationship with the Health Maintenance | ||
Organization for the provision of
or arrangement of at least | ||
basic health care services to the beneficiaries
of such | ||
contract.
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(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; | ||
99-78, eff. 7-20-15.)
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(215 ILCS 125/2-3) (from Ch. 111 1/2, par. 1405)
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Sec. 2-3. Powers of health maintenance organizations. The | ||
powers of a health maintenance organization include, but are | ||
not
limited to the following:
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(a) The purchase, lease, construction, renovation, | ||
operation, or
maintenance of hospitals, medical facilities or | ||
both, and their ancillary
equipment, and such property as may | ||
reasonably be required for its
principal office or for such | ||
other purposes as may be necessary in the
transaction of the | ||
business of the organization.
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(b) The making of loans to a medical group under contract | ||
with it and in
furtherance of its program or the making of | ||
loans to a corporation or
corporations under its control for | ||
the purpose of acquiring or constructing
medical facilities at | ||
hospitals or in furtherance of a program providing
health care | ||
services for enrollees.
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(c) The furnishing of health care services through | ||
providers which are
under contract with or employed by the | ||
health maintenance
organization.
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(d) The contracting with any person for the performance on | ||
its behalf of
certain functions such as marketing, enrollment | ||
and administration. | ||
(d-5) The voluntary use of a referral system for enrollees | ||
to access providers under contract with or employed by the | ||
health maintenance organization. Nothing in this subsection | ||
(d-5) shall be construed as requiring the use of a referral |
system with the health maintenance organization's contracted | ||
or employed providers to obtain a certificate of authority as | ||
set forth in Section 2-1.
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(e) The contracting with an insurance company licensed in | ||
this State, or
with a hospital, medical, dental, vision or | ||
pharmaceutical service
corporation authorized to do business | ||
in this State, for the provision of
insurance, indemnity, or | ||
reimbursement against the cost of health care
service provided | ||
by the health maintenance organization.
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(f) The offering, in addition to basic health care | ||
services, of (1)
health care services, (2) indemnity benefits | ||
covering out of area or
emergency services, (3) indemnity | ||
benefits provided through insurers or
hospital, medical, | ||
dental, vision, or pharmaceutical service
corporations, and | ||
(4) health maintenance organization point-of-service
benefits | ||
as authorized under Article 4.5.
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(g) Rendering services related to the functions involved | ||
in the
operating of its health maintenance organization | ||
business including but not
limited to providing health | ||
services, data processing, accounting, or
claims.
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(g-5) Indemnification for services provided to a child as | ||
required under
subdivision (e)(3) of Section 4-2.
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(h) Any other business activity reasonably complementary | ||
or
supplementary to its health maintenance organization | ||
business to the extent
approved by the Director.
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(Source: P.A. 92-135, eff. 1-1-02.)
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Section 99. Effective date. This Act takes effect January | ||
1, 2024.
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