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90_HB3725
215 ILCS 125/4-19 new
Amends the Health Maintenance Organization Act. Requires
a health maintenance organization to provide reimbursement
for emergency services provided by a participating or
nonparticipating provider.
LRB9011011JSgc
LRB9011011JSgc
1 AN ACT to amend the Health Maintenance Organization Act
2 by adding Section 4-19.
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 adding Section 4-19 as follows:
7 (215 ILCS 125/4-19 new)
8 Sec. 4-19. Emergency services.
9 (a) A health maintenance organization shall provide
10 reimbursement for covered emergency services provided at a
11 participating or nonparticipating emergency department up to
12 the point of stabilization of an enrollee.
13 (b) Once the enrollee is stabilized, the emergency
14 department shall contact the primary care physician or health
15 care plan as specified on the identification card to seek
16 prior authorization for any additional nonemergency services
17 beyond stabilization.
18 (c) With any claim for reimbursement, the emergency
19 department shall provide the health maintenance organization
20 with the medical record documenting the presenting symptoms
21 of the enrollee at the time care was sought and the objective
22 findings of the medical examination.
23 (d) The health maintenance organization's medical
24 director's determination of whether the enrollee meets the
25 standard of emergency shall take into account the presenting
26 symptoms at the time care was sought.
27 (e) Health maintenance organizations may require an
28 enrollee to pay a copayment for emergency services.
29 (f) Health maintenance organizations shall provide
30 enrollees with information on procedures for the coverage of
31 emergency services both inside and out of the plan service
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1 area.