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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 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
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 in
5a 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 whereby any
14organization undertakes to provide or arrange for and pay for
15or reimburse the cost of basic health care services, excluding
16any reasonable deductibles and copayments, from providers
17selected by the Health Maintenance Organization and such
18arrangement consists of arranging for or the provision of such
19health care services, as distinguished from mere
20indemnification against the cost of such services, except as
21otherwise authorized by Section 2-3 of this Act, on a per
22capita prepaid basis, through insurance or otherwise. A "health
23care plan" also includes any arrangement whereby an
24organization undertakes to provide or arrange for or pay for or
25reimburse the cost of any health care service for persons who
26are enrolled under Article V of the Illinois Public Aid Code or



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1under the Children's Health Insurance Program Act through
2providers selected by the organization and the arrangement
3consists of making provision for the delivery of health care
4services, as distinguished from mere indemnification. A
5"health care plan" also includes any arrangement pursuant to
6Section 4-17. Nothing in this definition, however, affects the
7total medical services available to persons eligible for
8medical assistance under the Illinois Public Aid Code.
9    (8) "Health care services" means any services included in
10the furnishing to any individual of medical or dental care, or
11the hospitalization or incident to the furnishing of such care
12or hospitalization as well as the furnishing to any person of
13any and all other services for the purpose of preventing,
14alleviating, curing or healing human illness or injury.
15    (9) "Health Maintenance Organization" means any
16organization formed under the laws of this or another state to
17provide or arrange for one or more health care plans under a
18system which causes any part of the risk of health care
19delivery to be borne by the organization or its providers.
20    (10) "Net worth" means admitted assets, as defined in
21Section 1-3 of this Act, minus liabilities.
22    (11) "Organization" means any insurance company, a
23nonprofit corporation authorized under the Dental Service Plan
24Act or the Voluntary Health Services Plans Act, or a
25corporation organized under the laws of this or another state
26for the purpose of operating one or more health care plans and



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1doing no business other than that of a Health Maintenance
2Organization or an insurance company. "Organization" shall
3also mean the University of Illinois Hospital as defined in the
4University of Illinois Hospital Act.
5    (12) "Provider" means any physician, hospital facility, or
6facility or long-term care facility as those terms are defined
7in the Nursing Home Care Act or other person which is licensed
8or otherwise authorized to furnish health care services and
9also includes any other entity that arranges for the delivery
10or furnishing of health care service.
11    (13) "Producer" means a person directly or indirectly
12associated with a health care plan who engages in solicitation
13or enrollment.
14    (14) "Per capita prepaid" means a basis of prepayment by
15which a fixed amount of money is prepaid per individual or any
16other enrollment unit to the Health Maintenance Organization or
17for health care services which are provided during a definite
18time period regardless of the frequency or extent of the
19services rendered by the Health Maintenance Organization,
20except for copayments and deductibles and except as provided in
21subsection (f) of Section 5-3 of this Act.
22    (15) "Subscriber" means a person who has entered into a
23contractual relationship with the Health Maintenance
24Organization for the provision of or arrangement of at least
25basic health care services to the beneficiaries of such



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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
3is 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
7care plan under Section 45 or by a utilization review program
8under Section 85 that a health care service is not medically
10    "Clinical peer" means a health care professional who is in
11the same profession and the same or similar specialty as the
12health care provider who typically manages the medical
13condition, procedures, or treatment under review.
14    "Department" means the Department of Insurance.
15    "Emergency medical condition" means a medical condition
16manifesting itself by acute symptoms of sufficient severity
17(including, but not limited to, severe pain) such that a
18prudent layperson, who possesses an average knowledge of health
19and medicine, could reasonably expect the absence of immediate
20medical 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
3screening examination and evaluation by a physician licensed to
4practice medicine in all its branches, or to the extent
5permitted by applicable laws, by other appropriately licensed
6personnel under the supervision of or in collaboration with a
7physician licensed to practice medicine in all its branches to
8determine whether the need for emergency services exists.
9    "Emergency services" means, with respect to an enrollee of
10a health care plan, transportation services, including but not
11limited to ambulance services, and covered inpatient and
12outpatient hospital services furnished by a provider qualified
13to furnish those services that are needed to evaluate or
14stabilize an emergency medical condition. "Emergency services"
15does not refer to post-stabilization medical services.
16    "Enrollee" means any person and his or her dependents
17enrolled in or covered by a health care plan.
18    "Health care plan" means a plan that establishes, operates,
19or maintains a network of health care providers that has
20entered into an agreement with the plan to provide health care
21services to enrollees to whom the plan has the ultimate
22obligation to arrange for the provision of or payment for
23services through organizational arrangements for ongoing
24quality assurance, utilization review programs, or dispute
25resolution. Nothing in this definition shall be construed to
26mean that an independent practice association or a physician



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1hospital organization that subcontracts with a health care plan
2is, for purposes of that subcontract, a health care plan.
3    For purposes of this definition, "health care plan" shall
4not 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
23professional nurse, or other individual appropriately licensed
24or registered to provide health care services.
25    "Health care provider" means any physician, hospital
26facility, long-term care facility as defined in Section 1-113



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1of the Nursing Home Care Act, or other person that is licensed
2or otherwise authorized to deliver health care services.
3Nothing in this Act shall be construed to define Independent
4Practice Associations or Physician-Hospital Organizations as
5health care providers.
6    "Health care services" means any services included in the
7furnishing to any individual of medical care, or the
8hospitalization incident to the furnishing of such care, as
9well as the furnishing to any person of any and all other
10services for the purpose of preventing, alleviating, curing, or
11healing human illness or injury including home health and
12pharmaceutical services and products.
13    "Medical director" means a physician licensed in any state
14to practice medicine in all its branches appointed by a health
15care plan.
16    "Person" means a corporation, association, partnership,
17limited liability company, sole proprietorship, or any other
18legal entity.
19    "Physician" means a person licensed under the Medical
20Practice Act of 1987.
21    "Post-stabilization medical services" means health care
22services provided to an enrollee that are furnished in a
23licensed hospital by a provider that is qualified to furnish
24such services, and determined to be medically necessary and
25directly related to the emergency medical condition following



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1    "Stabilization" means, with respect to an emergency
2medical condition, to provide such medical treatment of the
3condition as may be necessary to assure, within reasonable
4medical probability, that no material deterioration of the
5condition is likely to result.
6    "Utilization review" means the evaluation of the medical
7necessity, appropriateness, and efficiency of the use of health
8care services, procedures, and facilities.
9    "Utilization review program" means a program established
10by 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
13becoming law.