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90_SB0237ham003
LRB9001529JSmgam02
1 AMENDMENT TO SENATE BILL 237
2 AMENDMENT NO. . Amend Senate Bill 237, AS AMENDED,
3 by replacing the title with the following:
4 "AN ACT relating to children, amending named Acts."; and
5 by inserting immediately below the last line of Section 15
6 the following:
7 "Section 20. The Health Maintenance Organization Act is
8 amended by changing Section 1-2 and adding Section 4-17 as
9 follows:
10 (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
11 Sec. 1-2. Definitions. As used in this Act, unless the
12 context otherwise requires, the following terms shall have
13 the meanings ascribed to them:
14 (1) "Advertisement" means any printed or published
15 material, audiovisual material and descriptive literature of
16 the health care plan used in direct mail, newspapers,
17 magazines, radio scripts, television scripts, billboards and
18 similar displays; and any descriptive literature or sales
19 aids of all kinds disseminated by a representative of the
20 health care plan for presentation to the public including,
21 but not limited to, circulars, leaflets, booklets,
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1 depictions, illustrations, form letters and prepared sales
2 presentations.
3 (2) "Director" means the Director of Insurance.
4 (3) "Basic Health Care Services" means emergency care,
5 and inpatient hospital and physician care, outpatient medical
6 services, mental health services and care for alcohol and
7 drug abuse, including any reasonable deductibles and
8 co-payments, all of which are subject to such limitations as
9 are determined by the Director pursuant to rule.
10 (4) "Enrollee" means an individual who has been enrolled
11 in a health care plan.
12 (5) "Evidence of Coverage" means any certificate,
13 agreement, or contract issued to an enrollee setting out the
14 coverage to which he is entitled in exchange for a per capita
15 prepaid sum.
16 (6) "Group Contract" means a contract for health care
17 services which by its terms limits eligibility to members of
18 a specified group.
19 (7) "Health Care Plan" means any arrangement whereby any
20 organization undertakes to provide or arrange for and pay for
21 or reimburse the cost of basic health care services from
22 providers selected by the Health Maintenance Organization and
23 such arrangement consists of arranging for or the provision
24 of such health care services, as distinguished from mere
25 indemnification against the cost of such services, except as
26 otherwise authorized by Section 2-3 of this Act, on a per
27 capita prepaid basis, through insurance or otherwise. A
28 "health care plan" also includes any arrangement whereby an
29 organization undertakes to provide or arrange for or pay for
30 or reimburse the cost of any health care service for persons
31 who are enrolled in the integrated health care program
32 established under Section 5-16.3 of the Illinois Public Aid
33 Code through providers selected by the organization and the
34 arrangement consists of making provision for the delivery of
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1 health care services, as distinguished from mere
2 indemnification. A "health care plan" also includes any
3 arrangement pursuant to Section 4-17. Nothing in this
4 definition, however, affects the total medical services
5 available to persons eligible for medical assistance under
6 the Illinois Public Aid Code.
7 (8) "Health Care Services" means any services included
8 in the furnishing to any individual of medical or dental
9 care, or the hospitalization or incident to the furnishing of
10 such care or hospitalization as well as the furnishing to any
11 person of any and all other services for the purpose of
12 preventing, alleviating, curing or healing human illness or
13 injury.
14 (9) "Health Maintenance Organization" means any
15 organization formed under the laws of this or another state
16 to provide or arrange for one or more health care plans under
17 a system which causes any part of the risk of health care
18 delivery to be borne by the organization or its providers.
19 (10) "Net Worth" means admitted assets, as defined in
20 Section 1-3 of this Act, minus liabilities.
21 (11) "Organization" means any insurance company, or a
22 nonprofit corporation authorized under the Medical Service
23 Plan Act, the Dental Service Plan Act, the Vision Service
24 Plan Act, the Pharmaceutical Service Plan Act, the Voluntary
25 Health Services Plans Act or the Non-profit Health Care
26 Service Plan Act, or a corporation organized under the laws
27 of this or another state for the purpose of operating one or
28 more health care plans and doing no business other than that
29 of a Health Maintenance Organization or an insurance company.
30 Organization shall also mean the University of Illinois
31 Hospital as defined in the University of Illinois Hospital
32 Act.
33 (12) "Provider" means any physician, hospital facility,
34 or other person which is licensed or otherwise authorized to
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1 furnish health care services and also includes any other
2 entity that arranges for the delivery or furnishing of health
3 care service.
4 (13) "Producer" means a person directly or indirectly
5 associated with a health care plan who engages in
6 solicitation or enrollment.
7 (14) "Per capita prepaid" means a basis of prepayment by
8 which a fixed amount of money is prepaid per individual or
9 any other enrollment unit to the Health Maintenance
10 Organization or for health care services which are provided
11 during a definite time period regardless of the frequency or
12 extent of the services rendered by the Health Maintenance
13 Organization, except for copayments and deductibles and
14 except as provided in subsection (f) of Section 5-3 of this
15 Act.
16 (15) "Subscriber" means a person who has entered into a
17 contractual relationship with the Health Maintenance
18 Organization for the provision of or arrangement of at least
19 basic health care services to the beneficiaries of such
20 contract.
21 (Source: P.A. 88-554, eff. 7-26-94; 89-90, eff. 6-30-95.)
22 (215 ILCS 125/4-17 new)
23 Sec. 4-17. Basic outpatient preventive and primary
24 health care services for children. In order to attempt to
25 address the needs of children in Illinois (i) without health
26 care coverage, either through a parent's employment, through
27 medical assistance under the Illinois Public Aid Code, or any
28 other health plan or (ii) who lose medical assistance if and
29 when their parents move from welfare to work and do not find
30 employment that offers health care coverage, a health
31 maintenance organization may undertake to provide or arrange
32 for and to pay for or reimburse the cost of basic outpatient
33 preventive and primary health care services. The Department
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1 shall promulgate rules to establish minimum coverage and
2 disclosure requirements. These requirements at a minimum
3 shall include routine physical examinations and
4 immunizations, sick visits, diagnostic x-rays and laboratory
5 services, and emergency outpatient services. Coverage may
6 also include preventive dental services, vision screening and
7 one pair of eyeglasses, prescription drugs, and mental health
8 services. The coverage may include any reasonable copayments,
9 deductibles, and benefit maximums subject to limitations
10 established by the Director by rule. Coverage shall be
11 limited to children who are 18 years of age or under, who
12 have resided in the State of Illinois for at least 30 days,
13 and who do not qualify for medical assistance under the
14 Illinois Public Aid Code. Any such coverage shall be made
15 available to an adult on behalf of such children and shall
16 not be funded through State appropriations. In counties with
17 populations in excess of 3,000,000, the Director shall not
18 approve any arrangement under this Section unless and until
19 an arrangement for at least one health maintenance
20 organization under contract with the Illinois Department of
21 Public Aid for furnishing health services pursuant to Section
22 5-11 of the Illinois Public Aid Code and for which the
23 requirements of 42 CFR 434.26(a) have been waived is
24 approved."; and
25 by replacing Section 99 of the bill with the following:
26 "Section 99. Effective date. This Section and Section 20
27 of this Act take effect upon becoming law; Sections 5, 10,
28 and 15 of this Act take effect July 1, 1997.".