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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,
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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
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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
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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
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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.