Public Act 90-0376 of the 90th General Assembly
Public Act 90-0376
HB1565 Enrolled LRB9003794JSgc
AN ACT to amend the Health Maintenance Organization Act
by changing Section 1-2 and adding Section 4-17.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Health Maintenance Organization Act is
amended by changing Section 1-2 and adding Section 4-17 as
follows:
(215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
Sec. 1-2. Definitions. As used in this Act, unless the
context otherwise requires, the following terms shall have
the meanings ascribed to them:
(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.
(2) "Director" means the Director of Insurance.
(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 such limitations as
are determined by the Director pursuant to rule.
(4) "Enrollee" means an individual who has been enrolled
in a health care plan.
(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.
(6) "Group Contract" means a contract for health care
services which by its terms limits eligibility to members of
a specified group.
(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 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 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 in the integrated health care program
established under Section 5-16.3 of the Illinois Public Aid
Code through 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.
(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.
(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.
(10) "Net Worth" means admitted assets, as defined in
Section 1-3 of this Act, minus liabilities.
(11) "Organization" means any insurance company, or a
nonprofit corporation authorized under the Medical Service
Plan Act, the Dental Service Plan Act, the Vision Service
Plan Act, the Pharmaceutical Service Plan Act, the Voluntary
Health Services Plans Act or the Non-profit Health Care
Service Plan 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.
(12) "Provider" means any physician, hospital facility,
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.
(13) "Producer" means a person directly or indirectly
associated with a health care plan who engages in
solicitation or enrollment.
(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.
(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.
(Source: P.A. 88-554, eff. 7-26-94; 89-90, eff. 6-30-95.)
(215 ILCS 125/4-17 new)
Sec. 4-17. Basic outpatient preventive and primary
health care services for children. In order to attempt to
address the needs of children in Illinois (i) without health
care coverage, either through a parent's employment, through
medical assistance under the Illinois Public Aid Code, or any
other health plan or (ii) who lose medical assistance if and
when their parents move from welfare to work and do not find
employment that offers health care coverage, a health
maintenance organization may undertake to provide or arrange
for and to pay for or reimburse the cost of basic outpatient
preventive and primary health care services. The Department
shall promulgate rules to establish minimum coverage and
disclosure requirements. These requirements at a minimum
shall include routine physical examinations and
immunizations, sick visits, diagnostic x-rays and laboratory
services, and emergency outpatient services. Coverage may
also include preventive dental services, vision screening and
one pair of eyeglasses, prescription drugs, and mental health
services. The coverage may include any reasonable
co-payments, deductibles, and benefit maximums subject to
limitations established by the Director by rule. Coverage
shall be limited to children who are 18 years of age or
under, who have resided in the State of Illinois for at least
30 days, and who do not qualify for medical assistance under
the Illinois Public Aid Code. Any such coverage shall be
made available to an adult on behalf of such children and
shall not be funded through State appropriations. In
counties with populations in excess of 3,000,000, the
Director shall not approve any arrangement under this Section
unless and until an arrangement for at least one health
maintenance organization under contract with the Illinois
Department of Public Aid for furnishing health services
pursuant to Section 5-11 of the Illinois Public Aid Code and
for which the requirements of 42 CFR 434.26(a) have been
waived is approved.
Section 99. Effective date. This Act takes effect upon
becoming law.