Full Text of HB5793 102nd General Assembly
HB5793 102ND GENERAL ASSEMBLY |
| | 102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022 HB5793 Introduced 11/16/2022, by Rep. Margaret Croke - Kelly M. Cassidy SYNOPSIS AS INTRODUCED: |
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215 ILCS 125/1-2 | from Ch. 111 1/2, par. 1402 |
215 ILCS 125/2-3 | from Ch. 111 1/2, par. 1405 |
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Amends the Health Maintenance Organization Act. Provides that the powers of a health maintenance organization include the voluntary use of a referral system for enrollees to access providers under contract with or employed by the health maintenance organization. Provides that the provisions shall not be construed as requiring the use of a referral system to obtain a certificate of authority. Changes the definition of "health care plan". Defines "referral system". Effective January 1, 2023.
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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 Sections 1-2 and 2-3 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 | 5 | | in 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 in which an | 14 | | whereby any organization
provides, arranges undertakes to | 15 | | provide or arrange for , pays and pay for , or reimburses | 16 | | reimburse the
cost of basic health care services, excluding | 17 | | any reasonable deductibles and copayments , from providers | 18 | | selected by
the Health Maintenance Organization ; and the such | 19 | | arrangement
consists of providing for the arranging for or the | 20 | | provision of basic such health care services that is , as
| 21 | | distinguished from mere indemnification against the cost of | 22 | | such services ,
on a per capita prepaid basis, through | 23 | | insurance or otherwise, except as otherwise authorized by | 24 | | Section 2-3 of this Act ,
on a per capita prepaid basis, through | 25 | | insurance or otherwise . A "health
care plan" also includes any | 26 | | arrangement in which whereby an organization provides, |
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| 1 | | arranges undertakes to
provide or arrange for , pays or pay | 2 | | for , or reimburses reimburse the cost of any health care
| 3 | | service for persons who are enrolled under Article V of the | 4 | | Illinois Public Aid
Code or under the Children's Health | 5 | | Insurance Program Act through
providers selected by the | 6 | | organization ; and the arrangement consists of making
a | 7 | | provision for the delivery of health care services that is , as | 8 | | distinguished from mere
indemnification. A "health care plan" | 9 | | also includes any arrangement pursuant
to Section 4-17. | 10 | | Nothing in this definition, however, affects the total
medical | 11 | | services available to persons eligible for medical assistance | 12 | | under the
Illinois Public Aid Code. Nothing in this definition | 13 | | shall be construed as requiring a health care plan or health | 14 | | maintenance organization to utilize a referral system that | 15 | | enrollees must use to access basic health care services and | 16 | | other health care services from providers that are under | 17 | | contract with or employed by the health maintenance | 18 | | organization.
| 19 | | (8) "Health care services" means any services included in | 20 | | the furnishing
to any individual of medical or dental care, or | 21 | | the hospitalization or
incident to the furnishing of such care | 22 | | or hospitalization as well as the
furnishing to any person of | 23 | | any and all other services for the purpose of
preventing, | 24 | | alleviating, curing or healing human illness or injury.
| 25 | | (9) "Health Maintenance Organization" means any | 26 | | organization formed
under the laws of this or another state to |
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| 1 | | provide or arrange for one or
more health care plans under a | 2 | | system which causes any part of the risk of
health care | 3 | | delivery to be borne by the organization or its providers.
| 4 | | (10) "Net worth" means admitted assets, as defined in | 5 | | Section 1-3 of
this Act, minus liabilities.
| 6 | | (11) "Organization" means any insurance company, a | 7 | | nonprofit
corporation authorized under the Dental
Service Plan | 8 | | Act or the Voluntary
Health Services Plans Act,
or a | 9 | | corporation organized under the laws of this or another state | 10 | | for the
purpose of operating one or more health care plans and | 11 | | doing no business other
than that of a Health Maintenance | 12 | | Organization or an insurance company.
"Organization" shall | 13 | | also mean the University of Illinois Hospital as
defined in | 14 | | the University of Illinois Hospital Act or a unit of local | 15 | | government health system operating within a county with a | 16 | | population of 3,000,000 or more.
| 17 | | (12) "Provider" means any physician, hospital facility,
| 18 | | facility licensed under the Nursing Home Care Act, or facility | 19 | | or long-term care facility as those terms are defined in the | 20 | | Nursing Home Care Act or other person which is licensed or | 21 | | otherwise authorized
to furnish health care services and also | 22 | | includes any other entity that
arranges for the delivery or | 23 | | furnishing of health care service.
| 24 | | (13) "Producer" means a person directly or indirectly | 25 | | associated with a
health care plan who engages in solicitation | 26 | | or enrollment.
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| 1 | | (14) "Per capita prepaid" means a basis of prepayment by | 2 | | which a fixed
amount of money is prepaid per individual or any | 3 | | other enrollment unit to
the Health Maintenance Organization | 4 | | or for health care services which are
provided during a | 5 | | definite time period regardless of the frequency or
extent of | 6 | | the services rendered
by the Health Maintenance Organization, | 7 | | except for copayments and deductibles
and except as provided | 8 | | in subsection (f) of Section 5-3 of this Act.
| 9 | | (15) "Referral system" means any arrangement in a health | 10 | | care plan in which a primary care provider coordinates or | 11 | | manages the care of a health maintenance organization's | 12 | | enrollee by referring the enrollee to other providers or | 13 | | specialists. | 14 | | (16) (15) "Subscriber" means a person who has entered into | 15 | | a contractual
relationship with the Health Maintenance | 16 | | Organization for the provision of
or arrangement of at least | 17 | | basic health care services to the beneficiaries
of such | 18 | | contract.
| 19 | | (Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; | 20 | | 99-78, eff. 7-20-15.)
| 21 | | (215 ILCS 125/2-3) (from Ch. 111 1/2, par. 1405)
| 22 | | Sec. 2-3. Powers of health maintenance organizations. The | 23 | | powers of a health maintenance organization include, but are | 24 | | not
limited to the following:
| 25 | | (a) The purchase, lease, construction, renovation, |
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| 1 | | operation, or
maintenance of hospitals, medical facilities or | 2 | | both, and their ancillary
equipment, and such property as may | 3 | | reasonably be required for its
principal office or for such | 4 | | other purposes as may be necessary in the
transaction of the | 5 | | business of the organization.
| 6 | | (b) The making of loans to a medical group under contract | 7 | | with it and in
furtherance of its program or the making of | 8 | | loans to a corporation or
corporations under its control for | 9 | | the purpose of acquiring or constructing
medical facilities at | 10 | | hospitals or in furtherance of a program providing
health care | 11 | | services for enrollees.
| 12 | | (c) The furnishing of health care services through | 13 | | providers which are
under contract with or employed by the | 14 | | health maintenance
organization.
| 15 | | (d) The contracting with any person for the performance on | 16 | | its behalf of
certain functions such as marketing, enrollment | 17 | | and administration. | 18 | | (d-5) The voluntary use of a referral system for enrollees | 19 | | to access providers under contract with or employed by the | 20 | | health maintenance organization. Nothing in this subsection | 21 | | (d-5) shall be construed as requiring the use of a referral | 22 | | system to obtain a certificate of authority as set forth in | 23 | | Section 2-1.
| 24 | | (e) The contracting with an insurance company licensed in | 25 | | this State, or
with a hospital, medical, dental, vision or | 26 | | pharmaceutical service
corporation authorized to do business |
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| 1 | | in this State, for the provision of
insurance, indemnity, or | 2 | | reimbursement against the cost of health care
service provided | 3 | | by the health maintenance organization.
| 4 | | (f) The offering, in addition to basic health care | 5 | | services, of (1)
health care services, (2) indemnity benefits | 6 | | covering out of area or
emergency services, (3) indemnity | 7 | | benefits provided through insurers or
hospital, medical, | 8 | | dental, vision, or pharmaceutical service
corporations, and | 9 | | (4) health maintenance organization point-of-service
benefits | 10 | | as authorized under Article 4.5.
| 11 | | (g) Rendering services related to the functions involved | 12 | | in the
operating of its health maintenance organization | 13 | | business including but not
limited to providing health | 14 | | services, data processing, accounting, or
claims.
| 15 | | (g-5) Indemnification for services provided to a child as | 16 | | required under
subdivision (e)(3) of Section 4-2.
| 17 | | (h) Any other business activity reasonably complementary | 18 | | or
supplementary to its health maintenance organization | 19 | | business to the extent
approved by the Director.
| 20 | | (Source: P.A. 92-135, eff. 1-1-02.)
| 21 | | Section 99. Effective date. This Act takes effect January | 22 | | 1, 2023.
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