State of Illinois
90th General Assembly
Legislation

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[ Engrossed ][ Enrolled ][ House Amendment 001 ]

90_SB0457

      215 ILCS 125/4-17 new
          Amends the Health Maintenance Organization Act.  Provides
      that enrollees who are residents  of  a  retirement  facility
      consisting  of  a  long-term  care  facility  and residential
      apartments may be referred to that facility's long-term  care
      facility  even  though the facility is not part of the health
      maintenance organization network.  Specifies conditions  that
      must be met.
                                                     LRB9000384JSgc
                                               LRB9000384JSgc
 1        AN  ACT  to amend the Health Maintenance Organization Act
 2    by adding Section 4-17.
 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 4-17 as follows:
 7        (215 ILCS 125/4-17 new)
 8        Sec. 4-17.  Retirement facility residents.  With  respect
 9    to  an  enrollee  who  is a resident of a retirement facility
10    consisting of a long-term care facility, as  defined  in  the
11    Nursing Home Care Act, and residential apartments, a contract
12    or  evidence  of  coverage  issued,  amended,  delivered,  or
13    renewed  after  the  effective date of this amendatory Act of
14    1997 shall provide that the enrollee's primary care physician
15    must  refer  the  enrollee  to  the   retirement   facility's
16    long-term  care  facility if the primary care physician finds
17    that:
18        (1)  it is in the best interest of the patient;
19        (2)  the facility agrees to be reimbursed at  the  health
20    maintenance  organization's  contract  rate  negotiated  with
21    similar providers for the same services and supplies; and
22        (3)  the facility meets all guidelines established by the
23    health  maintenance  organization related to quality of care,
24    utilization referral authorization, risk assumption,  use  of
25    the  health  maintenance  organization's  network,  and other
26    criteria applicable under contract for the same services  and
27    supplies.

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