93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB5924


 
Introduced 2/6/2004, by Frank J. Mautino
 
SYNOPSIS AS INTRODUCED:
 		













215 ILCS 134/65









    Amends the Managed Care Reform and Patient Rights Act.  Makes a technical
change in a Section concerning emergency services.
















LRB093 19177 SAS 44912 b

















 


 


A BILL FOR









 











HB5924

LRB093 19177 SAS 44912 b






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    AN ACT concerning managed care. 

 
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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 Managed Care Reform and Patient Rights Act 
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is amended by
changing Section 65 as follows:


 
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    (215 ILCS 134/65)

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    Sec. 65. Emergency services prior to stabilization.


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    (a) A health care plan
that provides or that is required 
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under
by law to provide coverage for
emergency
services shall 
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provide coverage such that payment under this coverage is not

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dependent upon whether the services are performed by a plan or 
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non-plan health
care provider and without regard to prior 
13
authorization. This coverage shall be
at the same benefit level 
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as if the services or treatment had been rendered by
the health 
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care plan physician licensed to practice medicine in all
its 
16
branches or health care provider.


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    (b) Prior authorization or approval by the plan shall not 
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be required for
emergency services.


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    (c) Coverage and payment shall only be retrospectively 
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denied under the
following circumstances:


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        (1) upon reasonable determination that the emergency 
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    services claimed were
never performed;


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        (2) upon timely determination that the emergency 
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    evaluation and treatment
were
rendered to an enrollee who 
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    sought emergency services and whose circumstance
did not 
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    meet the definition of emergency medical condition;


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        (3) upon determination that the patient receiving such 
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    services was not an
enrollee of the health care plan; or


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        (4) upon material misrepresentation by the enrollee or 
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    health care
provider; "material" means a fact or situation 
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    that is not merely technical in
nature and results or could 
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    result in a substantial change in the situation.


 


 






HB5924
- 2 -
LRB093 19177 SAS 44912 b




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    (d) When an enrollee presents to a hospital seeking 
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emergency services,
the determination as to whether the need 
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for those
services exists shall be made for purposes of 
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treatment by a
physician licensed to practice medicine in all 
5
its branches  or, to the extent
permitted by applicable law, by 
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other appropriately licensed
personnel under the supervision 
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of
or in collaboration with a physician licensed to practice 
8
medicine in all its
branches.
 The physician or other

9
appropriate personnel shall indicate in the patient's chart the 
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results of the
emergency medical screening examination.


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    (e) The appropriate use of the 911 emergency telephone 
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system or its local
equivalent shall not be discouraged or 
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penalized by the health care plan when
an emergency medical 
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condition exists.
This provision shall not imply that the use 
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of 911 or its local equivalent is a
factor in determining the 
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existence of an emergency medical condition.


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    (f) The medical director's or his or her designee's

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determination of whether the enrollee meets the standard of an 
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emergency
medical condition shall be based solely upon the 
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presenting symptoms documented
in the medical record at the 
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time care was
sought.
Only a clinical peer may make an adverse 
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determination.


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    (g) Nothing in this Section shall prohibit the imposition 
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of deductibles,
copayments, and co-insurance.
Nothing in this 
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Section alters the prohibition on billing enrollees contained

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in the Health Maintenance Organization Act.


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(Source: P.A. 91-617, eff. 1-1-00.)