093_HB0107ham002
LRB093 03403 JLS 12651 a
1 AMENDMENT TO HOUSE BILL 107
2 AMENDMENT NO. . Amend House Bill 107, AS AMENDED, by
3 replacing the title with the following:
4 "AN ACT relating to managed care."; and
5 by replacing everything after the enacting clause with the
6 following:
7 "Section 5. The Managed Care Reform and Patient Rights
8 Act is amended by changing Section 65 as follows:
9 (215 ILCS 134/65)
10 Sec. 65. Emergency services prior to stabilization.
11 (a) A health care plan that provides or that is required
12 under by law to provide coverage for emergency services shall
13 provide coverage such that payment under this coverage is not
14 dependent upon whether the services are performed by a plan
15 or non-plan health care provider and without regard to prior
16 authorization. This coverage shall be at the same benefit
17 level as if the services or treatment had been rendered by
18 the health care plan physician licensed to practice medicine
19 in all its branches or health care provider.
20 (b) Prior authorization or approval by the plan shall
21 not be required for emergency services.
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1 (c) Coverage and payment shall only be retrospectively
2 denied under the following circumstances:
3 (1) upon reasonable determination that the
4 emergency services claimed were never performed;
5 (2) upon timely determination that the emergency
6 evaluation and treatment were rendered to an enrollee who
7 sought emergency services and whose circumstance did not
8 meet the definition of emergency medical condition;
9 (3) upon determination that the patient receiving
10 such services was not an enrollee of the health care
11 plan; or
12 (4) upon material misrepresentation by the enrollee
13 or health care provider; "material" means a fact or
14 situation that is not merely technical in nature and
15 results or could result in a substantial change in the
16 situation.
17 (d) When an enrollee presents to a hospital seeking
18 emergency services, the determination as to whether the need
19 for those services exists shall be made for purposes of
20 treatment by a physician licensed to practice medicine in
21 all its branches or, to the extent permitted by applicable
22 law, by other appropriately licensed personnel under the
23 supervision of or in collaboration with a physician licensed
24 to practice medicine in all its branches. The physician or
25 other appropriate personnel shall indicate in the patient's
26 chart the results of the emergency medical screening
27 examination.
28 (e) The appropriate use of the 911 emergency telephone
29 system or its local equivalent shall not be discouraged or
30 penalized by the health care plan when an emergency medical
31 condition exists. This provision shall not imply that the use
32 of 911 or its local equivalent is a factor in determining the
33 existence of an emergency medical condition.
34 (f) The medical director's or his or her designee's
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1 determination of whether the enrollee meets the standard of
2 an emergency medical condition shall be based solely upon the
3 presenting symptoms documented in the medical record at the
4 time care was sought. Only a clinical peer may make an
5 adverse determination.
6 (g) Nothing in this Section shall prohibit the
7 imposition of deductibles, copayments, and co-insurance.
8 Nothing in this Section alters the prohibition on billing
9 enrollees contained in the Health Maintenance Organization
10 Act.
11 (Source: P.A. 91-617, eff. 1-1-00.)".