State of Illinois
2021 and 2022


Introduced 2/25/2021, by Sen. Don Harmon


215 ILCS 134/65

    Amends the Managed Care Reform and Patient Rights Act. Makes a technical change in a Section concerning emergency services.

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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 Managed Care Reform and Patient Rights Act
5is amended by changing Section 65 as follows:
6    (215 ILCS 134/65)
7    Sec. 65. Emergency services prior to stabilization.
8    (a) A health care plan that that provides or that is
9required by law to provide coverage for emergency services
10shall provide coverage such that payment under this coverage
11is not dependent upon whether the services are performed by a
12plan or non-plan health care provider and without regard to
13prior authorization. This coverage shall be at the same
14benefit level as if the services or treatment had been
15rendered by the health care plan physician licensed to
16practice medicine in all its branches or health care provider.
17    (b) Prior authorization or approval by the plan shall not
18be required for emergency services.
19    (c) Coverage and payment shall only be retrospectively
20denied under the following circumstances:
21        (1) upon reasonable determination that the emergency
22    services claimed were never performed;
23        (2) upon timely determination that the emergency



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1    evaluation and treatment were rendered to an enrollee who
2    sought emergency services and whose circumstance did not
3    meet the definition of emergency medical condition;
4        (3) upon determination that the patient receiving such
5    services was not an enrollee of the health care plan; or
6        (4) upon material misrepresentation by the enrollee or
7    health care provider; "material" means a fact or situation
8    that is not merely technical in nature and results or
9    could result in a substantial change in the situation.
10    (d) When an enrollee presents to a hospital seeking
11emergency services, the determination as to whether the need
12for those services exists shall be made for purposes of
13treatment by a physician licensed to practice medicine in all
14its branches or, to the extent permitted by applicable law, by
15other appropriately licensed personnel under the supervision
16of or in collaboration with a physician licensed to practice
17medicine in all its branches. The physician or other
18appropriate personnel shall indicate in the patient's chart
19the results of the emergency medical screening examination.
20    (e) The appropriate use of the 911 emergency telephone
21system or its local equivalent shall not be discouraged or
22penalized by the health care plan when an emergency medical
23condition exists. This provision shall not imply that the use
24of 911 or its local equivalent is a factor in determining the
25existence of an emergency medical condition.
26    (f) The medical director's or his or her designee's



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1determination of whether the enrollee meets the standard of an
2emergency medical condition shall be based solely upon the
3presenting symptoms documented in the medical record at the
4time care was sought. Only a clinical peer may make an adverse
6    (g) Nothing in this Section shall prohibit the imposition
7of deductibles, copayments, and co-insurance. Nothing in this
8Section alters the prohibition on billing enrollees contained
9in the Health Maintenance Organization Act.
10(Source: P.A. 91-617, eff. 1-1-00.)