102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB5793

 

Introduced 11/16/2022, by Rep. Margaret Croke - Kelly M. Cassidy

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 125/1-2  from Ch. 111 1/2, par. 1402
215 ILCS 125/2-3  from Ch. 111 1/2, par. 1405

    Amends the Health Maintenance Organization Act. Provides that the powers of a health maintenance organization include the voluntary use of a referral system for enrollees to access providers under contract with or employed by the health maintenance organization. Provides that the provisions shall not be construed as requiring the use of a referral system to obtain a certificate of authority. Changes the definition of "health care plan". Defines "referral system". Effective January 1, 2023.


LRB102 28598 BMS 40478 b

 

 

A BILL FOR

 

HB5793LRB102 28598 BMS 40478 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Health Maintenance Organization Act is
5amended by changing Sections 1-2 and 2-3 as follows:
 
6    (215 ILCS 125/1-2)  (from Ch. 111 1/2, par. 1402)
7    Sec. 1-2. Definitions. As used in this Act, unless the
8context otherwise requires, the following terms shall have the
9meanings ascribed to them:
10    (1) "Advertisement" means any printed or published
11material, audiovisual material and descriptive literature of
12the health care plan used in direct mail, newspapers,
13magazines, radio scripts, television scripts, billboards and
14similar displays; and any descriptive literature or sales aids
15of all kinds disseminated by a representative of the health
16care plan for presentation to the public including, but not
17limited to, circulars, leaflets, booklets, depictions,
18illustrations, form letters and prepared sales presentations.
19    (2) "Director" means the Director of Insurance.
20    (3) "Basic health care services" means emergency care, and
21inpatient hospital and physician care, outpatient medical
22services, mental health services and care for alcohol and drug
23abuse, including any reasonable deductibles and co-payments,

 

 

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1all of which are subject to the limitations described in
2Section 4-20 of this Act and as determined by the Director
3pursuant to rule.
4    (4) "Enrollee" means an individual who has been enrolled
5in a health care plan.
6    (5) "Evidence of coverage" means any certificate,
7agreement, or contract issued to an enrollee setting out the
8coverage to which he is entitled in exchange for a per capita
9prepaid sum.
10    (6) "Group contract" means a contract for health care
11services which by its terms limits eligibility to members of a
12specified group.
13    (7) "Health care plan" means any arrangement in which an
14whereby any organization provides, arranges undertakes to
15provide or arrange for, pays and pay for, or reimburses
16reimburse the cost of basic health care services, excluding
17any reasonable deductibles and copayments, from providers
18selected by the Health Maintenance Organization; and the such
19arrangement consists of providing for the arranging for or the
20provision of basic such health care services that is , as
21distinguished from mere indemnification against the cost of
22such services, on a per capita prepaid basis, through
23insurance or otherwise, except as otherwise authorized by
24Section 2-3 of this Act, on a per capita prepaid basis, through
25insurance or otherwise. A "health care plan" also includes any
26arrangement in which whereby an organization provides,

 

 

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1arranges undertakes to provide or arrange for, pays or pay
2for, or reimburses reimburse the cost of any health care
3service for persons who are enrolled under Article V of the
4Illinois Public Aid Code or under the Children's Health
5Insurance Program Act through providers selected by the
6organization; and the arrangement consists of making a
7provision for the delivery of health care services that is , as
8distinguished from mere indemnification. A "health care plan"
9also includes any arrangement pursuant to Section 4-17.
10Nothing in this definition, however, affects the total medical
11services available to persons eligible for medical assistance
12under the Illinois Public Aid Code. Nothing in this definition
13shall be construed as requiring a health care plan or health
14maintenance organization to utilize a referral system that
15enrollees must use to access basic health care services and
16other health care services from providers that are under
17contract with or employed by the health maintenance
18organization.
19    (8) "Health care services" means any services included in
20the furnishing to any individual of medical or dental care, or
21the hospitalization or incident to the furnishing of such care
22or hospitalization as well as the furnishing to any person of
23any and all other services for the purpose of preventing,
24alleviating, curing or healing human illness or injury.
25    (9) "Health Maintenance Organization" means any
26organization formed under the laws of this or another state to

 

 

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1provide or arrange for one or more health care plans under a
2system which causes any part of the risk of health care
3delivery to be borne by the organization or its providers.
4    (10) "Net worth" means admitted assets, as defined in
5Section 1-3 of this Act, minus liabilities.
6    (11) "Organization" means any insurance company, a
7nonprofit corporation authorized under the Dental Service Plan
8Act or the Voluntary Health Services Plans Act, or a
9corporation organized under the laws of this or another state
10for the purpose of operating one or more health care plans and
11doing no business other than that of a Health Maintenance
12Organization or an insurance company. "Organization" shall
13also mean the University of Illinois Hospital as defined in
14the University of Illinois Hospital Act or a unit of local
15government health system operating within a county with a
16population of 3,000,000 or more.
17    (12) "Provider" means any physician, hospital facility,
18facility licensed under the Nursing Home Care Act, or facility
19or long-term care facility as those terms are defined in the
20Nursing Home Care Act or other person which is licensed or
21otherwise authorized to furnish health care services and also
22includes any other entity that arranges for the delivery or
23furnishing of health care service.
24    (13) "Producer" means a person directly or indirectly
25associated with a health care plan who engages in solicitation
26or enrollment.

 

 

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1    (14) "Per capita prepaid" means a basis of prepayment by
2which a fixed amount of money is prepaid per individual or any
3other enrollment unit to the Health Maintenance Organization
4or for health care services which are provided during a
5definite time period regardless of the frequency or extent of
6the services rendered by the Health Maintenance Organization,
7except for copayments and deductibles and except as provided
8in subsection (f) of Section 5-3 of this Act.
9    (15) "Referral system" means any arrangement in a health
10care plan in which a primary care provider coordinates or
11manages the care of a health maintenance organization's
12enrollee by referring the enrollee to other providers or
13specialists.
14    (16) (15) "Subscriber" means a person who has entered into
15a contractual relationship with the Health Maintenance
16Organization for the provision of or arrangement of at least
17basic health care services to the beneficiaries of such
18contract.
19(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14;
2099-78, eff. 7-20-15.)
 
21    (215 ILCS 125/2-3)  (from Ch. 111 1/2, par. 1405)
22    Sec. 2-3. Powers of health maintenance organizations. The
23powers of a health maintenance organization include, but are
24not limited to the following:
25    (a) The purchase, lease, construction, renovation,

 

 

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1operation, or maintenance of hospitals, medical facilities or
2both, and their ancillary equipment, and such property as may
3reasonably be required for its principal office or for such
4other purposes as may be necessary in the transaction of the
5business of the organization.
6    (b) The making of loans to a medical group under contract
7with it and in furtherance of its program or the making of
8loans to a corporation or corporations under its control for
9the purpose of acquiring or constructing medical facilities at
10hospitals or in furtherance of a program providing health care
11services for enrollees.
12    (c) The furnishing of health care services through
13providers which are under contract with or employed by the
14health maintenance organization.
15    (d) The contracting with any person for the performance on
16its behalf of certain functions such as marketing, enrollment
17and administration.
18    (d-5) The voluntary use of a referral system for enrollees
19to access providers under contract with or employed by the
20health maintenance organization. Nothing in this subsection
21(d-5) shall be construed as requiring the use of a referral
22system to obtain a certificate of authority as set forth in
23Section 2-1.
24    (e) The contracting with an insurance company licensed in
25this State, or with a hospital, medical, dental, vision or
26pharmaceutical service corporation authorized to do business

 

 

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1in this State, for the provision of insurance, indemnity, or
2reimbursement against the cost of health care service provided
3by the health maintenance organization.
4    (f) The offering, in addition to basic health care
5services, of (1) health care services, (2) indemnity benefits
6covering out of area or emergency services, (3) indemnity
7benefits provided through insurers or hospital, medical,
8dental, vision, or pharmaceutical service corporations, and
9(4) health maintenance organization point-of-service benefits
10as authorized under Article 4.5.
11    (g) Rendering services related to the functions involved
12in the operating of its health maintenance organization
13business including but not limited to providing health
14services, data processing, accounting, or claims.
15    (g-5) Indemnification for services provided to a child as
16required under subdivision (e)(3) of Section 4-2.
17    (h) Any other business activity reasonably complementary
18or supplementary to its health maintenance organization
19business to the extent approved by the Director.
20(Source: P.A. 92-135, eff. 1-1-02.)
 
21    Section 99. Effective date. This Act takes effect January
221, 2023.