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| Public Act 098-0841 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Health Maintenance Organization Act is | ||||
amended by changing Section 1-2 as follows:
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(215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
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Sec. 1-2. Definitions. As used in this Act, unless the | ||||
context otherwise
requires, the following terms shall have the | ||||
meanings ascribed to them:
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(1) "Advertisement" means any printed or published | ||||
material,
audiovisual material and descriptive literature of | ||||
the health care plan
used in direct mail, newspapers, | ||||
magazines, radio scripts, television
scripts, billboards and | ||||
similar displays; and any descriptive literature or
sales aids | ||||
of all kinds disseminated by a representative of the health | ||||
care
plan for presentation to the public including, but not | ||||
limited to, circulars,
leaflets, booklets, depictions, | ||||
illustrations, form letters and prepared
sales presentations.
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(2) "Director" means the Director of Insurance.
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(3) "Basic health care services" means emergency care, and | ||||
inpatient
hospital and physician care, outpatient medical | ||||
services, mental
health services and care for alcohol and drug | ||||
abuse, including any
reasonable deductibles and co-payments, | ||||
all of which are subject to the
limitations described in | ||
Section 4-20 of this Act and as determined by the Director | ||
pursuant to rule.
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(4) "Enrollee" means an individual who has been enrolled in | ||
a health
care plan.
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(5) "Evidence of coverage" means any certificate, | ||
agreement,
or contract issued to an enrollee setting out the | ||
coverage to which he is
entitled in exchange for a per capita | ||
prepaid sum.
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(6) "Group contract" means a contract for health care | ||
services which
by its terms limits eligibility to members of a | ||
specified group.
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(7) "Health care plan" means any arrangement whereby any | ||
organization
undertakes to provide or arrange for and pay for | ||
or reimburse the
cost of basic health care services, excluding | ||
any reasonable deductibles and copayments, from providers | ||
selected by
the Health Maintenance Organization and such | ||
arrangement
consists of arranging for or the provision of such | ||
health care services, as
distinguished from mere | ||
indemnification against the cost of such services,
except as | ||
otherwise authorized by Section 2-3 of this Act,
on a per | ||
capita prepaid basis, through insurance or otherwise. A "health
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care plan" also includes any arrangement whereby an | ||
organization undertakes to
provide or arrange for or pay for or | ||
reimburse the cost of any health care
service for persons who | ||
are enrolled under Article V of the Illinois Public Aid
Code or | ||
under the Children's Health Insurance Program Act through
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providers selected by the organization and the arrangement | ||
consists of making
provision for the delivery of health care | ||
services, as distinguished from mere
indemnification. A | ||
"health care plan" also includes any arrangement pursuant
to | ||
Section 4-17. Nothing in this definition, however, affects the | ||
total
medical services available to persons eligible for | ||
medical assistance under the
Illinois Public Aid Code.
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(8) "Health care services" means any services included in | ||
the furnishing
to any individual of medical or dental care, or | ||
the hospitalization or
incident to the furnishing of such care | ||
or hospitalization as well as the
furnishing to any person of | ||
any and all other services for the purpose of
preventing, | ||
alleviating, curing or healing human illness or injury.
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(9) "Health Maintenance Organization" means any | ||
organization formed
under the laws of this or another state to | ||
provide or arrange for one or
more health care plans under a | ||
system which causes any part of the risk of
health care | ||
delivery to be borne by the organization or its providers.
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(10) "Net worth" means admitted assets, as defined in | ||
Section 1-3 of
this Act, minus liabilities.
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(11) "Organization" means any insurance company, a | ||
nonprofit
corporation authorized under the Dental
Service Plan | ||
Act or the Voluntary
Health Services Plans Act,
or a | ||
corporation organized under the laws of this or another state | ||
for the
purpose of operating one or more health care plans and | ||
doing no business other
than that of a Health Maintenance | ||
Organization or an insurance company.
"Organization" shall | ||
also mean the University of Illinois Hospital as
defined in the | ||
University of Illinois Hospital Act.
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(12) "Provider" means any physician, hospital facility, or | ||
facility or long-term care facility as those terms are defined | ||
in the Nursing Home Care Act
or other person which is licensed | ||
or otherwise authorized
to furnish health care services and | ||
also includes any other entity that
arranges for the delivery | ||
or furnishing of health care service.
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(13) "Producer" means a person directly or indirectly | ||
associated with a
health care plan who engages in solicitation | ||
or enrollment.
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(14) "Per capita prepaid" means a basis of prepayment by | ||
which a fixed
amount of money is prepaid per individual or any | ||
other enrollment unit to
the Health Maintenance Organization or | ||
for health care services which are
provided during a definite | ||
time period regardless of the frequency or
extent of the | ||
services rendered
by the Health Maintenance Organization, | ||
except for copayments and deductibles
and except as provided in | ||
subsection (f) of Section 5-3 of this Act.
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(15) "Subscriber" means a person who has entered into a | ||
contractual
relationship with the Health Maintenance | ||
Organization for the provision of
or arrangement of at least | ||
basic health care services to the beneficiaries
of such | ||
contract.
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(Source: P.A. 97-1148, eff. 1-24-13.)
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Section 10. The Managed Care Reform and Patient Rights Act | ||
is amended by changing Section 10 as follows:
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(215 ILCS 134/10)
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Sec. 10. Definitions:
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"Adverse determination" means a determination by a health | ||
care plan under
Section 45 or by a utilization review program | ||
under Section
85 that
a health care service is not medically | ||
necessary.
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"Clinical peer" means a health care professional who is in | ||
the same
profession and the same or similar specialty as the | ||
health care provider who
typically manages the medical | ||
condition, procedures, or treatment under
review.
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"Department" means the Department of Insurance.
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"Emergency medical condition" means a medical condition | ||
manifesting itself by
acute symptoms of sufficient severity | ||
(including, but not limited to, severe
pain) such that a | ||
prudent
layperson, who possesses an average knowledge of health | ||
and medicine, could
reasonably expect the absence of immediate | ||
medical attention to result in:
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(1) placing the health of the individual (or, with | ||
respect to a pregnant
woman, the
health of the woman or her | ||
unborn child) in serious jeopardy;
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(2) serious
impairment to bodily functions; or
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(3) serious dysfunction of any bodily organ
or part.
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"Emergency medical screening examination" means a medical | ||
screening
examination and
evaluation by a physician licensed to | ||
practice medicine in all its branches, or
to the extent | ||
permitted
by applicable laws, by other appropriately licensed | ||
personnel under the
supervision of or in
collaboration with a | ||
physician licensed to practice medicine in all its
branches to | ||
determine whether
the need for emergency services exists.
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"Emergency services" means, with respect to an enrollee of | ||
a health care
plan,
transportation services, including but not | ||
limited to ambulance services, and
covered inpatient and | ||
outpatient hospital services
furnished by a provider
qualified | ||
to furnish those services that are needed to evaluate or | ||
stabilize an
emergency medical condition. "Emergency services" | ||
does not
refer to post-stabilization medical services.
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"Enrollee" means any person and his or her dependents | ||
enrolled in or covered
by a health care plan.
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"Health care plan" means a plan that establishes, operates, | ||
or maintains a
network of health care providers that has | ||
entered into an agreement with the
plan to provide health care | ||
services to enrollees to whom the plan has the
ultimate | ||
obligation to arrange for the provision of or payment for | ||
services
through organizational arrangements for ongoing | ||
quality assurance,
utilization review programs, or dispute | ||
resolution.
Nothing in this definition shall be construed to | ||
mean that an independent
practice association or a physician | ||
hospital organization that subcontracts
with
a health care plan | ||
is, for purposes of that subcontract, a health care plan.
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For purposes of this definition, "health care plan" shall | ||
not include the
following:
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(1) indemnity health insurance policies including | ||
those using a contracted
provider network;
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(2) health care plans that offer only dental or only | ||
vision coverage;
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(3) preferred provider administrators, as defined in | ||
Section 370g(g) of
the
Illinois Insurance Code;
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(4) employee or employer self-insured health benefit | ||
plans under the
federal Employee Retirement Income | ||
Security Act of 1974;
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(5) health care provided pursuant to the Workers' | ||
Compensation Act or the
Workers' Occupational Diseases | ||
Act; and
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(6) not-for-profit voluntary health services plans | ||
with health maintenance
organization
authority in | ||
existence as of January 1, 1999 that are affiliated with a | ||
union
and that
only extend coverage to union members and | ||
their dependents.
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"Health care professional" means a physician, a registered | ||
professional
nurse,
or other individual appropriately licensed | ||
or registered
to provide health care services.
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"Health care provider" means any physician, hospital | ||
facility, long-term care facility as defined in Section 1-113 | ||
of the Nursing Home Care Act, or other
person that is licensed | ||
or otherwise authorized to deliver health care
services. | ||
Nothing in this
Act shall be construed to define Independent | ||
Practice Associations or
Physician-Hospital Organizations as | ||
health care providers.
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"Health care services" means any services included in the | ||
furnishing to any
individual of medical care, or the
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hospitalization incident to the furnishing of such care, as | ||
well as the
furnishing to any person of
any and all other | ||
services for the purpose of preventing,
alleviating, curing, or | ||
healing human illness or injury including home health
and | ||
pharmaceutical services and products.
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"Medical director" means a physician licensed in any state | ||
to practice
medicine in all its
branches appointed by a health | ||
care plan.
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"Person" means a corporation, association, partnership,
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limited liability company, sole proprietorship, or any other | ||
legal entity.
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"Physician" means a person licensed under the Medical
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Practice Act of 1987.
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"Post-stabilization medical services" means health care | ||
services
provided to an enrollee that are furnished in a | ||
licensed hospital by a provider
that is qualified to furnish | ||
such services, and determined to be medically
necessary and | ||
directly related to the emergency medical condition following
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stabilization.
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"Stabilization" means, with respect to an emergency | ||
medical condition, to
provide such medical treatment of the | ||
condition as may be necessary to assure,
within reasonable | ||
medical probability, that no material deterioration
of the | ||
condition is likely to result.
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"Utilization review" means the evaluation of the medical | ||
necessity,
appropriateness, and efficiency of the use of health | ||
care services, procedures,
and facilities.
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"Utilization review program" means a program established | ||
by a person to
perform utilization review.
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(Source: P.A. 91-617, eff. 1-1-00.)
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Section 99. Effective date. This Act takes effect upon | ||
becoming law.
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