Full Text of HB4667 94th General Assembly
HB4667 94TH GENERAL ASSEMBLY
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94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006 HB4667
Introduced 1/12/2006, by Rep. Frank J. Mautino SYNOPSIS AS INTRODUCED: |
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215 ILCS 125/1-2 |
from Ch. 111 1/2, par. 1402 |
215 ILCS 125/4-14 |
from Ch. 111 1/2, par. 1409.7 |
215 ILCS 125/4-20 new |
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215 ILCS 125/5-7 |
from Ch. 111 1/2, par. 1415 |
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Amends the Health Maintenance Organization Act. Requires evidences of coverage to contain a clear and complete statement of deductibles. Provides that HMOs may establish annual deductibles not to exceed certain amounts. Provides that co-payments may not exceed 50% of the usual and customary fee charged to the HMO for the service and provides that deductibles are not subject to this limitation. Makes other changes. Effective immediately.
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A BILL FOR
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HB4667 |
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LRB094 17959 LJB 53262 b |
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| AN ACT concerning insurance.
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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 | 5 |
| amended by changing Sections 1-2, 4-14, and 5-7 and by adding | 6 |
| Section 4-20 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 | 9 |
| context otherwise
requires, the following terms shall have the | 10 |
| meanings ascribed to them:
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| (1) "Advertisement" means any printed or published | 12 |
| material,
audiovisual material and descriptive literature of | 13 |
| the health care plan
used in direct mail, newspapers, | 14 |
| magazines, radio scripts, television
scripts, billboards and | 15 |
| similar displays; and any descriptive literature or
sales aids | 16 |
| of all kinds disseminated by a representative of the health | 17 |
| care
plan for presentation to the public including, but not | 18 |
| limited to, circulars,
leaflets, booklets, depictions, | 19 |
| 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 | 22 |
| inpatient
hospital and physician care, outpatient medical | 23 |
| services, mental
health services and care for alcohol and drug | 24 |
| abuse, including any
reasonable deductibles and co-payments, | 25 |
| all of which are subject to limitations in Section 4-20 of this | 26 |
| Act and to such
limitations as are determined by the Director | 27 |
| pursuant to rule.
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| (4) "Enrollee" means an individual who has been enrolled in | 29 |
| a health
care plan.
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| (5) "Evidence of coverage" means any certificate, | 31 |
| agreement,
or contract issued to an enrollee setting out the | 32 |
| coverage to which he is
entitled in exchange for a per capita |
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LRB094 17959 LJB 53262 b |
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| prepaid sum.
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| (6) "Group contract" means a contract for health care | 3 |
| services which
by its terms limits eligibility to members of a | 4 |
| specified group.
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| (7) "Health care plan" means any arrangement whereby any | 6 |
| organization
undertakes to provide or arrange for and pay for | 7 |
| or reimburse the
cost of basic health care services from | 8 |
| providers selected by
the Health Maintenance Organization and | 9 |
| such arrangement
consists of arranging for or the provision of | 10 |
| such health care services, as
distinguished from mere | 11 |
| indemnification against the cost of such services,
except as | 12 |
| otherwise authorized by Section 2-3 of this Act,
on a per | 13 |
| capita prepaid basis, through insurance or otherwise. A "health
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| care plan" also includes any arrangement whereby an | 15 |
| organization undertakes to
provide or arrange for or pay for or | 16 |
| reimburse the cost of any health care
service for persons who | 17 |
| are enrolled under Article V of the Illinois Public Aid
Code or | 18 |
| under the Children's Health Insurance Program Act through
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| providers selected by the organization and the arrangement | 20 |
| consists of making
provision for the delivery of health care | 21 |
| services, as distinguished from mere
indemnification. A | 22 |
| "health care plan" also includes any arrangement pursuant
to | 23 |
| Section 4-17. Nothing in this definition, however, affects the | 24 |
| total
medical services available to persons eligible for | 25 |
| medical assistance under the
Illinois Public Aid Code.
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| (8) "Health care services" means any services included in | 27 |
| the furnishing
to any individual of medical or dental care, or | 28 |
| the hospitalization or
incident to the furnishing of such care | 29 |
| or hospitalization as well as the
furnishing to any person of | 30 |
| any and all other services for the purpose of
preventing, | 31 |
| alleviating, curing or healing human illness or injury.
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| (9) "Health Maintenance Organization" means any | 33 |
| organization formed
under the laws of this or another state to | 34 |
| provide or arrange for one or
more health care plans under a | 35 |
| system which causes any part of the risk of
health care | 36 |
| delivery to be borne by the organization or its providers.
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| (10) "Net worth" means admitted assets, as defined in | 2 |
| Section 1-3 of
this Act, minus liabilities.
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| (11) "Organization" means any insurance company, a | 4 |
| nonprofit
corporation authorized under the Dental
Service Plan | 5 |
| Act or the Voluntary
Health Services Plans Act,
or a | 6 |
| corporation organized under the laws of this or another state | 7 |
| for the
purpose of operating one or more health care plans and | 8 |
| doing no business other
than that of a Health Maintenance | 9 |
| Organization or an insurance company.
"Organization" shall | 10 |
| also mean the University of Illinois Hospital as
defined in the | 11 |
| University of Illinois Hospital Act.
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| (12) "Provider" means any physician, hospital facility,
or | 13 |
| other person which is licensed or otherwise authorized
to | 14 |
| furnish health care services and also includes any other entity | 15 |
| that
arranges for the delivery or furnishing of health care | 16 |
| service.
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| (13) "Producer" means a person directly or indirectly | 18 |
| associated with a
health care plan who engages in solicitation | 19 |
| or enrollment.
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| (14) "Per capita prepaid" means a basis of prepayment by | 21 |
| which a fixed
amount of money is prepaid per individual or any | 22 |
| other enrollment unit to
the Health Maintenance Organization or | 23 |
| for health care services which are
provided during a definite | 24 |
| time period regardless of the frequency or
extent of the | 25 |
| services rendered
by the Health Maintenance Organization, | 26 |
| except for copayments and deductibles
and except as provided in | 27 |
| subsection (f) of Section 5-3 of this Act.
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| (15) "Subscriber" means a person who has entered into a | 29 |
| contractual
relationship with the Health Maintenance | 30 |
| Organization for the provision of
or arrangement of at least | 31 |
| basic health care services to the beneficiaries
of such | 32 |
| contract.
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| (Source: P.A. 92-370, eff. 8-15-01.)
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| (215 ILCS 125/4-14) (from Ch. 111 1/2, par. 1409.7)
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| Sec. 4-14. Evidence of Coverage. (a) Every subscriber shall |
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| be issued an evidence of coverage, which
shall contain a clear | 2 |
| and complete statement of:
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| (1) The health services to which each enrollee is entitled;
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| (2) Eligibility requirements indicating the conditions | 5 |
| which must be met
to enroll in a Health Care Plan;
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| (3) Any limitation of the services, kinds of services or | 7 |
| benefits to be
provided, and exclusions, including any | 8 |
| co-payment, or other charges , including deductibles ;
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| (4) The terms or conditions upon which coverage may be | 10 |
| cancelled or
otherwise terminated;
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| (5) Where and in what manner information is available as to | 12 |
| where and
how services may be obtained; and
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| (6) The method for resolving complaints.
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| (b) Any amendment to the evidence of coverage may be | 15 |
| provided to the
subscriber in a separate document.
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| (Source: P.A. 86-620.)
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| (215 ILCS 125/4-20 new)
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| Sec. 4-20. Deductibles and co-payments. | 19 |
| (a) Annual deductibles established by HMOs shall not exceed | 20 |
| $1,000 for a single enrollee or $2,000 for a family. | 21 |
| (b) No co-payment for basic health care services may exceed | 22 |
| 50% of the usual and customary fee charged to the HMO for that | 23 |
| service. | 24 |
| (c) Deductibles are not subject to the limitation contained | 25 |
| in subsection (b) of this Section.
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| (215 ILCS 125/5-7) (from Ch. 111 1/2, par. 1415)
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| Sec. 5-7. Rules and regulations to carry out provisions of | 28 |
| Act. The Director may, after notice and hearing, promulgate | 29 |
| reasonable rules
and regulations as are necessary and proper | 30 |
| to:
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| (1) Establish minimum coverage standards for basic health | 32 |
| care services,
the application of which standards discriminate | 33 |
| against no class of physician;
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| (2) Establish specific standards, including standards for |
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| the full and
fair disclosure of health care services provided | 2 |
| by group contracts or
evidences of coverage which may cover but | 3 |
| shall not be limited to:
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| (a) Coordination of benefits ;
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| (b) Conversion ;
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| (c) Cancellation and termination ;
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| (d) Co-payments;
Deductibles and co-payments
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| (e) Pre-existing conditions; and
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| (3) Otherwise carry out the provisions of this Act.
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| (Source: P.A. 86-620.)
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| Section 99. Effective date. This Act takes effect upon | 12 |
| becoming law.
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