State of Illinois
90th General Assembly
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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,
                            -2-              LRB9003794JSsbam
 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
                            -3-              LRB9003794JSsbam
 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,
                            -4-              LRB9003794JSsbam
 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
                            -5-              LRB9003794JSsbam
 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.".

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