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| [ Senate Amendment 001 ] |
90_HB1565ham001
LRB9003794JSsbam
1 AMENDMENT TO HOUSE BILL 1565
2 AMENDMENT NO. . Amend House Bill 1565 by replacing
3 the title with the following:
4 "AN ACT to amend the Health Maintenance Organization Act
5 by changing Section 1-2 and adding Section 4-17."; and
6 by replacing everything after the enacting clause with the
7 following:
8 "Section 5. The Health Maintenance Organization Act is
9 amended by changing Section 1-2 and adding Section 4-17 as
10 follows:
11 (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
12 Sec. 1-2. Definitions. As used in this Act, unless the
13 context otherwise requires, the following terms shall have
14 the meanings ascribed to them:
15 (1) "Advertisement" means any printed or published
16 material, audiovisual material and descriptive literature of
17 the health care plan used in direct mail, newspapers,
18 magazines, radio scripts, television scripts, billboards and
19 similar displays; and any descriptive literature or sales
20 aids of all kinds disseminated by a representative of the
21 health care plan for presentation to the public including,
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1 but not limited to, circulars, leaflets, booklets,
2 depictions, illustrations, form letters and prepared sales
3 presentations.
4 (2) "Director" means the Director of Insurance.
5 (3) "Basic Health Care Services" means emergency care,
6 and inpatient hospital and physician care, outpatient medical
7 services, mental health services and care for alcohol and
8 drug abuse, including any reasonable deductibles and
9 co-payments, all of which are subject to such limitations as
10 are determined by the Director pursuant to rule.
11 (4) "Enrollee" means an individual who has been enrolled
12 in a health care plan.
13 (5) "Evidence of Coverage" means any certificate,
14 agreement, or contract issued to an enrollee setting out the
15 coverage to which he is entitled in exchange for a per capita
16 prepaid sum.
17 (6) "Group Contract" means a contract for health care
18 services which by its terms limits eligibility to members of
19 a specified group.
20 (7) "Health Care Plan" means any arrangement whereby any
21 organization undertakes to provide or arrange for and pay for
22 or reimburse the cost of basic health care services from
23 providers selected by the Health Maintenance Organization and
24 such arrangement consists of arranging for or the provision
25 of such health care services, as distinguished from mere
26 indemnification against the cost of such services, except as
27 otherwise authorized by Section 2-3 of this Act, on a per
28 capita prepaid basis, through insurance or otherwise. A
29 "health care plan" also includes any arrangement whereby an
30 organization undertakes to provide or arrange for or pay for
31 or reimburse the cost of any health care service for persons
32 who are enrolled in the integrated health care program
33 established under Section 5-16.3 of the Illinois Public Aid
34 Code through providers selected by the organization and the
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1 arrangement consists of making provision for the delivery of
2 health care services, as distinguished from mere
3 indemnification. A "health care plan" also includes any
4 arrangement pursuant to Section 4-17. Nothing in this
5 definition, however, affects the total medical services
6 available to persons eligible for medical assistance under
7 the Illinois Public Aid Code.
8 (8) "Health Care Services" means any services included
9 in the furnishing to any individual of medical or dental
10 care, or the hospitalization or incident to the furnishing of
11 such care or hospitalization as well as the furnishing to any
12 person of any and all other services for the purpose of
13 preventing, alleviating, curing or healing human illness or
14 injury.
15 (9) "Health Maintenance Organization" means any
16 organization formed under the laws of this or another state
17 to provide or arrange for one or more health care plans under
18 a system which causes any part of the risk of health care
19 delivery to be borne by the organization or its providers.
20 (10) "Net Worth" means admitted assets, as defined in
21 Section 1-3 of this Act, minus liabilities.
22 (11) "Organization" means any insurance company, or a
23 nonprofit corporation authorized under the Medical Service
24 Plan Act, the Dental Service Plan Act, the Vision Service
25 Plan Act, the Pharmaceutical Service Plan Act, the Voluntary
26 Health Services Plans Act or the Non-profit Health Care
27 Service Plan Act, or a corporation organized under the laws
28 of this or another state for the purpose of operating one or
29 more health care plans and doing no business other than that
30 of a Health Maintenance Organization or an insurance company.
31 Organization shall also mean the University of Illinois
32 Hospital as defined in the University of Illinois Hospital
33 Act.
34 (12) "Provider" means any physician, hospital facility,
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1 or other person which is licensed or otherwise authorized to
2 furnish health care services and also includes any other
3 entity that arranges for the delivery or furnishing of health
4 care service.
5 (13) "Producer" means a person directly or indirectly
6 associated with a health care plan who engages in
7 solicitation or enrollment.
8 (14) "Per capita prepaid" means a basis of prepayment by
9 which a fixed amount of money is prepaid per individual or
10 any other enrollment unit to the Health Maintenance
11 Organization or for health care services which are provided
12 during a definite time period regardless of the frequency or
13 extent of the services rendered by the Health Maintenance
14 Organization, except for copayments and deductibles and
15 except as provided in subsection (f) of Section 5-3 of this
16 Act.
17 (15) "Subscriber" means a person who has entered into a
18 contractual relationship with the Health Maintenance
19 Organization for the provision of or arrangement of at least
20 basic health care services to the beneficiaries of such
21 contract.
22 (Source: P.A. 88-554, eff. 7-26-94; 89-90, eff. 6-30-95.)
23 (215 ILCS 125/4-17 new)
24 Sec. 4-17. Basic outpatient preventive and primary
25 health care services for children. In order to attempt to
26 address the needs of children in Illinois (i) without health
27 care coverage, either through a parent's employment, through
28 medical assistance under the Illinois Public Aid Code, or any
29 other health plan or (ii) who lose medical assistance if and
30 when their parents move from welfare to work and do not find
31 employment that offers health care coverage, a health
32 maintenance organization, within reasonable limits proposed
33 by the health maintenance organization and approved by the
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1 Director, including reasonable copayments, deductibles, and
2 benefit maximums, may undertake to provide or arrange for
3 basic outpatient preventive and primary health care services,
4 which may include routine physical examinations and
5 immunizations, sick visits, diagnostic x-rays and laboratory
6 services, emergency outpatient services, preventive dental
7 services, vision screening and one pair of eyeglasses,
8 prescription drugs, and mental health services. Coverage
9 shall be limited to children who are 18 years of age or
10 under, who have resided in the State of Illinois for at least
11 30 days, and who do not qualify for medical assistance under
12 the Illinois Public Aid Code. In counties with populations
13 in excess of 3,000,000, the Director shall not approve any
14 arrangement under this Section unless and until an
15 arrangement for at least one health maintenance organization
16 under contract with the Illinois Department of Public Aid for
17 furnishing health services pursuant to Section 5-11 of the
18 Illinois Public Aid Code and for which the requirements of 42
19 CFR 434.26(a) have been waived is approved.".