Full Text of SB3048 98th General Assembly
SB3048eng 98TH GENERAL ASSEMBLY |
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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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