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|[ Introduced ]||[ Engrossed ]||[ House Amendment 001 ]|
|[ Senate Amendment 001 ]|
90_HB1565enr 215 ILCS 125/1-1 from Ch. 111 1/2, par. 1401 Amends the Health Maintenance Organization Act. Makes a stylistic change concerning the short title of the Act. LRB9003794JSgc HB1565 Enrolled LRB9003794JSgc 1 AN ACT to amend the Health Maintenance Organization Act 2 by changing Section 1-2 and adding Section 4-17. 3 Be it enacted by the People of the State of Illinois, 4 represented in the General Assembly: 5 Section 5. The Health Maintenance Organization Act is 6 amended by changing Section 1-2 and adding Section 4-17 as 7 follows: 8 (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402) 9 Sec. 1-2. Definitions. As used in this Act, unless the 10 context otherwise requires, the following terms shall have 11 the meanings ascribed to them: 12 (1) "Advertisement" means any printed or published 13 material, audiovisual material and descriptive literature of 14 the health care plan used in direct mail, newspapers, 15 magazines, radio scripts, television scripts, billboards and 16 similar displays; and any descriptive literature or sales 17 aids of all kinds disseminated by a representative of the 18 health care plan for presentation to the public including, 19 but not limited to, circulars, leaflets, booklets, 20 depictions, illustrations, form letters and prepared sales 21 presentations. 22 (2) "Director" means the Director of Insurance. 23 (3) "Basic Health Care Services" means emergency care, 24 and inpatient hospital and physician care, outpatient medical 25 services, mental health services and care for alcohol and 26 drug abuse, including any reasonable deductibles and 27 co-payments, all of which are subject to such limitations as 28 are determined by the Director pursuant to rule. 29 (4) "Enrollee" means an individual who has been enrolled 30 in a health care plan. 31 (5) "Evidence of Coverage" means any certificate, HB1565 Enrolled -2- LRB9003794JSgc 1 agreement, or contract issued to an enrollee setting out the 2 coverage to which he is entitled in exchange for a per capita 3 prepaid sum. 4 (6) "Group Contract" means a contract for health care 5 services which by its terms limits eligibility to members of 6 a specified group. 7 (7) "Health Care Plan" means any arrangement whereby any 8 organization undertakes to provide or arrange for and pay for 9 or reimburse the cost of basic health care services from 10 providers selected by the Health Maintenance Organization and 11 such arrangement consists of arranging for or the provision 12 of such health care services, as distinguished from mere 13 indemnification against the cost of such services, except as 14 otherwise authorized by Section 2-3 of this Act, on a per 15 capita prepaid basis, through insurance or otherwise. A 16 "health care plan" also includes any arrangement whereby an 17 organization undertakes to provide or arrange for or pay for 18 or reimburse the cost of any health care service for persons 19 who are enrolled in the integrated health care program 20 established under Section 5-16.3 of the Illinois Public Aid 21 Code through providers selected by the organization and the 22 arrangement consists of making provision for the delivery of 23 health care services, as distinguished from mere 24 indemnification. A "health care plan" also includes any 25 arrangement pursuant to Section 4-17. Nothing in this 26 definition, however, affects the total medical services 27 available to persons eligible for medical assistance under 28 the Illinois Public Aid Code. 29 (8) "Health Care Services" means any services included 30 in the furnishing to any individual of medical or dental 31 care, or the hospitalization or incident to the furnishing of 32 such care or hospitalization as well as the furnishing to any 33 person of any and all other services for the purpose of 34 preventing, alleviating, curing or healing human illness or HB1565 Enrolled -3- LRB9003794JSgc 1 injury. 2 (9) "Health Maintenance Organization" means any 3 organization formed under the laws of this or another state 4 to provide or arrange for one or more health care plans under 5 a system which causes any part of the risk of health care 6 delivery to be borne by the organization or its providers. 7 (10) "Net Worth" means admitted assets, as defined in 8 Section 1-3 of this Act, minus liabilities. 9 (11) "Organization" means any insurance company, or a 10 nonprofit corporation authorized under the Medical Service 11 Plan Act, the Dental Service Plan Act, the Vision Service 12 Plan Act, the Pharmaceutical Service Plan Act, the Voluntary 13 Health Services Plans Act or the Non-profit Health Care 14 Service Plan Act, or a corporation organized under the laws 15 of this or another state for the purpose of operating one or 16 more health care plans and doing no business other than that 17 of a Health Maintenance Organization or an insurance company. 18 Organization shall also mean the University of Illinois 19 Hospital as defined in the University of Illinois Hospital 20 Act. 21 (12) "Provider" means any physician, hospital facility, 22 or other person which is licensed or otherwise authorized to 23 furnish health care services and also includes any other 24 entity that arranges for the delivery or furnishing of health 25 care service. 26 (13) "Producer" means a person directly or indirectly 27 associated with a health care plan who engages in 28 solicitation or enrollment. 29 (14) "Per capita prepaid" means a basis of prepayment by 30 which a fixed amount of money is prepaid per individual or 31 any other enrollment unit to the Health Maintenance 32 Organization or for health care services which are provided 33 during a definite time period regardless of the frequency or 34 extent of the services rendered by the Health Maintenance HB1565 Enrolled -4- LRB9003794JSgc 1 Organization, except for copayments and deductibles and 2 except as provided in subsection (f) of Section 5-3 of this 3 Act. 4 (15) "Subscriber" means a person who has entered into a 5 contractual relationship with the Health Maintenance 6 Organization for the provision of or arrangement of at least 7 basic health care services to the beneficiaries of such 8 contract. 9 (Source: P.A. 88-554, eff. 7-26-94; 89-90, eff. 6-30-95.) 10 (215 ILCS 125/4-17 new) 11 Sec. 4-17. Basic outpatient preventive and primary 12 health care services for children. In order to attempt to 13 address the needs of children in Illinois (i) without health 14 care coverage, either through a parent's employment, through 15 medical assistance under the Illinois Public Aid Code, or any 16 other health plan or (ii) who lose medical assistance if and 17 when their parents move from welfare to work and do not find 18 employment that offers health care coverage, a health 19 maintenance organization may undertake to provide or arrange 20 for and to pay for or reimburse the cost of basic outpatient 21 preventive and primary health care services. The Department 22 shall promulgate rules to establish minimum coverage and 23 disclosure requirements. These requirements at a minimum 24 shall include routine physical examinations and 25 immunizations, sick visits, diagnostic x-rays and laboratory 26 services, and emergency outpatient services. Coverage may 27 also include preventive dental services, vision screening and 28 one pair of eyeglasses, prescription drugs, and mental health 29 services. The coverage may include any reasonable 30 co-payments, deductibles, and benefit maximums subject to 31 limitations established by the Director by rule. Coverage 32 shall be limited to children who are 18 years of age or 33 under, who have resided in the State of Illinois for at least HB1565 Enrolled -5- LRB9003794JSgc 1 30 days, and who do not qualify for medical assistance under 2 the Illinois Public Aid Code. Any such coverage shall be 3 made available to an adult on behalf of such children and 4 shall not be funded through State appropriations. In 5 counties with populations in excess of 3,000,000, the 6 Director shall not approve any arrangement under this Section 7 unless and until an arrangement for at least one health 8 maintenance organization under contract with the Illinois 9 Department of Public Aid for furnishing health services 10 pursuant to Section 5-11 of the Illinois Public Aid Code and 11 for which the requirements of 42 CFR 434.26(a) have been 12 waived is approved. 13 Section 99. Effective date. This Act takes effect upon 14 becoming law.
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