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90_HB3268
New Act
Creates the Managed Care Emergency Services Act.
Provides that a managed care plan shall provide emergency
services coverage that is not dependent upon whether the
services are performed by a participating or nonparticipating
provider. Requires the benefits to be at the level that
exists with respect to care provided by a participating
provider. Prohibits retrospective denial of benefits.
LRB9011498JSks
LRB9011498JSks
1 AN ACT relating to the delivery of health care services.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Managed Care Emergency Services Act.
6 Section 5. Definitions. For purposes of this Act, the
7 following words shall have the meanings provided in this
8 Section, unless otherwise indicated:
9 "Emergency medical screening examination" means a medical
10 screening examination and evaluation by a physician or, to
11 the extent permitted by applicable laws, by other appropriate
12 personnel under the supervision of a physician to determine
13 whether the need for emergency services exists.
14 "Emergency services" means the provision of health care
15 services for sudden and, at the time, unexpected onset of a
16 health condition that would lead a prudent layperson to
17 believe that failure to receive immediate medical attention
18 would result in serious impairment to bodily function or
19 serious dysfunction of any body organ or part or would place
20 the person's health in serious jeopardy.
21 "Enrollee" means a person enrolled in a managed care
22 plan.
23 "Managed care plan" means a plan that establishes,
24 operates, or maintains a network of health care providers
25 that have entered into agreements with the plan to provide
26 health care services to enrollees where the plan has the
27 obligation to the enrollee to arrange for the provision of or
28 pay for services through:
29 (1) organizational arrangements for ongoing quality
30 assurance, utilization review programs, or dispute
31 resolution; or
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1 (2) financial incentives for persons enrolled in
2 the plan to use the participating providers and
3 procedures covered by the plan.
4 A managed care plan may be established or operated by any
5 entity including, but not necessarily limited to, a licensed
6 insurance company, hospital or medical service plan, health
7 maintenance organization, limited health service
8 organization, preferred provider organization, third party
9 administrator, independent practice association, or employer
10 or employee organization.
11 For purposes of this definition, "managed care plan"
12 shall not include the following:
13 (1) strict indemnity health insurance policies or
14 plans issued by an insurer that does not require approval
15 of a primary care provider or other similar coordinator
16 to access health care services; and
17 (2) managed care plans that offer only dental or
18 vision coverage.
19 "Post-stabilization services" means those health care
20 services determined by a treating provider to be promptly and
21 medically necessary following stabilization of an emergency
22 condition.
23 Section 10. Emergency services.
24 (a) Any managed care plan subject to this Act shall
25 provide the enrollee emergency services coverage such that
26 payment for this coverage is not dependent upon whether such
27 services are performed by a participating or nonparticipating
28 provider, and such coverage shall be at the same benefit
29 level as if the service or treatment had been rendered by a
30 plan provider. Nothing in this Act is intended to prohibit a
31 plan from imposing its customary and normal co-payments,
32 deductibles, co-insurance, and other like charges for
33 emergency services.
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1 (b) Prior authorization or approval by the plan shall
2 not be required for emergency services rendered under this
3 Section.
4 (c) Coverage and payment shall not be retrospectively
5 denied, with the following exceptions:
6 (1) upon reasonable determination that the
7 emergency services claimed were never performed; or
8 (2) upon reasonable determination that an emergency
9 medical screening examination was performed on a patient
10 who personally sought emergency services knowing that he
11 or she did not have an emergency condition or necessity,
12 and who did not in fact require emergency services.
13 (d) When an enrollee presents to a hospital seeking
14 emergency services, as defined in this Act, the determination
15 as to whether the need for those services exists shall be
16 made for purposes of treatment by a physician or, to the
17 extent permitted by applicable law, by other appropriate
18 licensed personnel under the supervision of a physician. The
19 physician or other appropriate personnel shall indicate in
20 the patient's chart the results of the emergency medical
21 screening examination. The plan shall compensate the
22 provider for an emergency medical screening examination that
23 is reasonably calculated to assist the health care provider
24 in determining whether the patient's condition requires
25 emergency services. A plan shall have no duty to pay for
26 services rendered after an emergency medical screening
27 examination determines the lack of a need for emergency
28 services.
29 (e) The appropriate use of the 911 emergency telephone
30 number shall not be discouraged or penalized, and coverage or
31 payment shall not be denied solely on the basis that the
32 insured used the 911 emergency telephone number to summon
33 emergency services.
34 (f) If prior authorization for post-stabilization
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1 services, as defined in this Act, is required, the managed
2 care plan shall provide access 24 hours a day, 7 days a week
3 to persons designated by plan to make such determinations.
4 If a provider has attempted to contact such person for prior
5 authorization and no designated persons were accessible or
6 the authorization was not denied within one hour of the
7 request, the plan is deemed to have approved the request for
8 prior authorization.
9 (g) Coverage and payment for post-stabilization services
10 which received prior authorization or deemed approval shall
11 not be retrospectively denied. Nothing in this Act is
12 intended to prohibit a plan from imposing its customary and
13 normal co-payments, deductibles, co-insurance, and other like
14 changes for post-stabilization services.