Full Text of SB3048 98th General Assembly
SB3048 98TH GENERAL ASSEMBLY |
| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014 SB3048 Introduced 2/7/2014, by Sen. Linda Holmes SYNOPSIS AS INTRODUCED: |
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215 ILCS 125/1-2 | from Ch. 111 1/2, par. 1402 |
215 ILCS 134/10 |
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Amends the Health Maintenance Organization Act to include in the definition of "provider" facilities and long-term care facilities as those terms are defined in the Nursing Home Care Act. Amends the Managed Care Reform and Patient Rights Act to include in the definition of "health care provider" long-term care facilities as defined in the Nursing Home Care Act. Effective immediately.
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Health Maintenance Organization Act is | 5 | | amended by changing Section 1-2 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 | 8 | | context otherwise
requires, the following terms shall have the | 9 | | meanings ascribed to them:
| 10 | | (1) "Advertisement" means any printed or published | 11 | | material,
audiovisual material and descriptive literature of | 12 | | the health care plan
used in direct mail, newspapers, | 13 | | magazines, radio scripts, television
scripts, billboards and | 14 | | similar displays; and any descriptive literature or
sales aids | 15 | | of all kinds disseminated by a representative of the health | 16 | | care
plan for presentation to the public including, but not | 17 | | limited to, circulars,
leaflets, booklets, depictions, | 18 | | illustrations, form letters and prepared
sales presentations.
| 19 | | (2) "Director" means the Director of Insurance.
| 20 | | (3) "Basic health care services" means emergency care, and | 21 | | inpatient
hospital and physician care, outpatient medical | 22 | | services, mental
health services and care for alcohol and drug | 23 | | abuse, including any
reasonable deductibles and co-payments, |
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| 1 | | all of which are subject to the
limitations described in | 2 | | Section 4-20 of this Act and as determined by the Director | 3 | | pursuant to rule.
| 4 | | (4) "Enrollee" means an individual who has been enrolled in | 5 | | a health
care plan.
| 6 | | (5) "Evidence of coverage" means any certificate, | 7 | | agreement,
or contract issued to an enrollee setting out the | 8 | | coverage to which he is
entitled in exchange for a per capita | 9 | | prepaid sum.
| 10 | | (6) "Group contract" means a contract for health care | 11 | | services which
by its terms limits eligibility to members of a | 12 | | specified group.
| 13 | | (7) "Health care plan" means any arrangement whereby any | 14 | | organization
undertakes to provide or arrange for and pay for | 15 | | or reimburse the
cost of basic health care services, excluding | 16 | | any reasonable deductibles and copayments, from providers | 17 | | selected by
the Health Maintenance Organization and such | 18 | | arrangement
consists of arranging for or the provision of such | 19 | | health care services, as
distinguished from mere | 20 | | indemnification against the cost of such services,
except as | 21 | | otherwise authorized by Section 2-3 of this Act,
on a per | 22 | | capita prepaid basis, through insurance or otherwise. A "health
| 23 | | care plan" also includes any arrangement whereby an | 24 | | organization undertakes to
provide or arrange for or pay for or | 25 | | reimburse the cost of any health care
service for persons who | 26 | | are enrolled under Article V of the Illinois Public Aid
Code or |
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| 1 | | under the Children's Health Insurance Program Act through
| 2 | | providers selected by the organization and the arrangement | 3 | | consists of making
provision for the delivery of health care | 4 | | services, as distinguished from mere
indemnification. A | 5 | | "health care plan" also includes any arrangement pursuant
to | 6 | | Section 4-17. Nothing in this definition, however, affects the | 7 | | total
medical services available to persons eligible for | 8 | | medical assistance under the
Illinois Public Aid Code.
| 9 | | (8) "Health care services" means any services included in | 10 | | the furnishing
to any individual of medical or dental care, or | 11 | | the hospitalization or
incident to the furnishing of such care | 12 | | or hospitalization as well as the
furnishing to any person of | 13 | | any and all other services for the purpose of
preventing, | 14 | | alleviating, curing or healing human illness or injury.
| 15 | | (9) "Health Maintenance Organization" means any | 16 | | organization formed
under the laws of this or another state to | 17 | | provide or arrange for one or
more health care plans under a | 18 | | system which causes any part of the risk of
health care | 19 | | delivery to be borne by the organization or its providers.
| 20 | | (10) "Net worth" means admitted assets, as defined in | 21 | | Section 1-3 of
this Act, minus liabilities.
| 22 | | (11) "Organization" means any insurance company, a | 23 | | nonprofit
corporation authorized under the Dental
Service Plan | 24 | | Act or the Voluntary
Health Services Plans Act,
or a | 25 | | corporation organized under the laws of this or another state | 26 | | for the
purpose of operating one or more health care plans and |
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| 1 | | doing no business other
than that of a Health Maintenance | 2 | | Organization or an insurance company.
"Organization" shall | 3 | | also mean the University of Illinois Hospital as
defined in the | 4 | | University of Illinois Hospital Act.
| 5 | | (12) "Provider" means any physician, hospital facility, or | 6 | | facility or long-term care facility as those terms are defined | 7 | | in the Nursing Home Care Act
or other person which is licensed | 8 | | or otherwise authorized
to furnish health care services and | 9 | | also includes any other entity that
arranges for the delivery | 10 | | or furnishing of health care service.
| 11 | | (13) "Producer" means a person directly or indirectly | 12 | | associated with a
health care plan who engages in solicitation | 13 | | or enrollment.
| 14 | | (14) "Per capita prepaid" means a basis of prepayment by | 15 | | which a fixed
amount of money is prepaid per individual or any | 16 | | other enrollment unit to
the Health Maintenance Organization or | 17 | | for health care services which are
provided during a definite | 18 | | time period regardless of the frequency or
extent of the | 19 | | services rendered
by the Health Maintenance Organization, | 20 | | except for copayments and deductibles
and except as provided in | 21 | | subsection (f) of Section 5-3 of this Act.
| 22 | | (15) "Subscriber" means a person who has entered into a | 23 | | contractual
relationship with the Health Maintenance | 24 | | Organization for the provision of
or arrangement of at least | 25 | | basic health care services to the beneficiaries
of such | 26 | | contract.
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| 1 | | (Source: P.A. 97-1148, eff. 1-24-13.)
| 2 | | Section 10. The Managed Care Reform and Patient Rights Act | 3 | | is amended by changing Section 10 as follows:
| 4 | | (215 ILCS 134/10)
| 5 | | Sec. 10. Definitions:
| 6 | | "Adverse determination" means a determination by a health | 7 | | care plan under
Section 45 or by a utilization review program | 8 | | under Section
85 that
a health care service is not medically | 9 | | necessary.
| 10 | | "Clinical peer" means a health care professional who is in | 11 | | the same
profession and the same or similar specialty as the | 12 | | health care provider who
typically manages the medical | 13 | | condition, procedures, or treatment under
review.
| 14 | | "Department" means the Department of Insurance.
| 15 | | "Emergency medical condition" means a medical condition | 16 | | manifesting itself by
acute symptoms of sufficient severity | 17 | | (including, but not limited to, severe
pain) such that a | 18 | | prudent
layperson, who possesses an average knowledge of health | 19 | | and medicine, could
reasonably expect the absence of immediate | 20 | | medical attention to result in:
| 21 | | (1) placing the health of the individual (or, with | 22 | | respect to a pregnant
woman, the
health of the woman or her | 23 | | unborn child) in serious jeopardy;
| 24 | | (2) serious
impairment to bodily functions; or
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| 1 | | (3) serious dysfunction of any bodily organ
or part.
| 2 | | "Emergency medical screening examination" means a medical | 3 | | screening
examination and
evaluation by a physician licensed to | 4 | | practice medicine in all its branches, or
to the extent | 5 | | permitted
by applicable laws, by other appropriately licensed | 6 | | personnel under the
supervision of or in
collaboration with a | 7 | | physician licensed to practice medicine in all its
branches to | 8 | | determine whether
the need for emergency services exists.
| 9 | | "Emergency services" means, with respect to an enrollee of | 10 | | a health care
plan,
transportation services, including but not | 11 | | limited to ambulance services, and
covered inpatient and | 12 | | outpatient hospital services
furnished by a provider
qualified | 13 | | to furnish those services that are needed to evaluate or | 14 | | stabilize an
emergency medical condition. "Emergency services" | 15 | | does not
refer to post-stabilization medical services.
| 16 | | "Enrollee" means any person and his or her dependents | 17 | | enrolled in or covered
by a health care plan.
| 18 | | "Health care plan" means a plan that establishes, operates, | 19 | | or maintains a
network of health care providers that has | 20 | | entered into an agreement with the
plan to provide health care | 21 | | services to enrollees to whom the plan has the
ultimate | 22 | | obligation to arrange for the provision of or payment for | 23 | | services
through organizational arrangements for ongoing | 24 | | quality assurance,
utilization review programs, or dispute | 25 | | resolution.
Nothing in this definition shall be construed to | 26 | | mean that an independent
practice association or a physician |
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| 1 | | hospital organization that subcontracts
with
a health care plan | 2 | | is, for purposes of that subcontract, a health care plan.
| 3 | | For purposes of this definition, "health care plan" shall | 4 | | not include the
following:
| 5 | | (1) indemnity health insurance policies including | 6 | | those using a contracted
provider network;
| 7 | | (2) health care plans that offer only dental or only | 8 | | vision coverage;
| 9 | | (3) preferred provider administrators, as defined in | 10 | | Section 370g(g) of
the
Illinois Insurance Code;
| 11 | | (4) employee or employer self-insured health benefit | 12 | | plans under the
federal Employee Retirement Income | 13 | | Security Act of 1974;
| 14 | | (5) health care provided pursuant to the Workers' | 15 | | Compensation Act or the
Workers' Occupational Diseases | 16 | | Act; and
| 17 | | (6) not-for-profit voluntary health services plans | 18 | | with health maintenance
organization
authority in | 19 | | existence as of January 1, 1999 that are affiliated with a | 20 | | union
and that
only extend coverage to union members and | 21 | | their dependents.
| 22 | | "Health care professional" means a physician, a registered | 23 | | professional
nurse,
or other individual appropriately licensed | 24 | | or registered
to provide health care services.
| 25 | | "Health care provider" means any physician, hospital | 26 | | facility, long-term care facility as defined in Section 1-113 |
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| 1 | | of the Nursing Home Care Act, or other
person that is licensed | 2 | | or otherwise authorized to deliver health care
services. | 3 | | Nothing in this
Act shall be construed to define Independent | 4 | | Practice Associations or
Physician-Hospital Organizations as | 5 | | health care providers.
| 6 | | "Health care services" means any services included in the | 7 | | furnishing to any
individual of medical care, or the
| 8 | | hospitalization incident to the furnishing of such care, as | 9 | | well as the
furnishing to any person of
any and all other | 10 | | services for the purpose of preventing,
alleviating, curing, or | 11 | | healing human illness or injury including home health
and | 12 | | pharmaceutical services and products.
| 13 | | "Medical director" means a physician licensed in any state | 14 | | to practice
medicine in all its
branches appointed by a health | 15 | | care plan.
| 16 | | "Person" means a corporation, association, partnership,
| 17 | | limited liability company, sole proprietorship, or any other | 18 | | legal entity.
| 19 | | "Physician" means a person licensed under the Medical
| 20 | | Practice Act of 1987.
| 21 | | "Post-stabilization medical services" means health care | 22 | | services
provided to an enrollee that are furnished in a | 23 | | licensed hospital by a provider
that is qualified to furnish | 24 | | such services, and determined to be medically
necessary and | 25 | | directly related to the emergency medical condition following
| 26 | | stabilization.
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| 1 | | "Stabilization" means, with respect to an emergency | 2 | | medical condition, to
provide such medical treatment of the | 3 | | condition as may be necessary to assure,
within reasonable | 4 | | medical probability, that no material deterioration
of the | 5 | | condition is likely to result.
| 6 | | "Utilization review" means the evaluation of the medical | 7 | | necessity,
appropriateness, and efficiency of the use of health | 8 | | care services, procedures,
and facilities.
| 9 | | "Utilization review program" means a program established | 10 | | by a person to
perform utilization review.
| 11 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 12 | | Section 99. Effective date. This Act takes effect upon | 13 | | becoming law.
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