Public Act 90-0408 of the 90th General Assembly

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Public Act 90-0408

SB457 Enrolled                                 LRB9000384JSgc

    AN ACT to amend the Health Maintenance  Organization  Act
by 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 adding Section 4-17 as follows:

    (215 ILCS 125/4-17 new)
    Sec.  4-17.  Retirement facility residents.  With respect
to an enrollee who is a resident  of  a  retirement  facility
consisting  of  a  long-term care facility, as defined in the
Nursing Home Care Act, and residential apartments, a contract
or  evidence  of  coverage  issued,  amended,  delivered,  or
renewed after the effective date of this  amendatory  Act  of
1997 shall provide that the enrollee's primary care physician
must   refer   the  enrollee  to  the  retirement  facility's
long-term care facility for Medicare covered skilled  nursing
services if the primary care physician finds that:
         (1)  it is in the best interests of the patient;
         (2)  the  facility,  if not a participating provider
    in the specific health maintenance  organization,  agrees
    during  the  preauthorization period to a negotiated rate
    for   skilled   nursing   services   covered   in    that
    organization's health care plan; and
         (3)  the  facility  meets  all the requirements of a
    participating provider for skilled  nursing  services  as
    defined   and   covered   under  the  health  maintenance
    organization's health care plan.
    Both the facility and the health maintenance organization
must fully disclose all pertinent information to consumers to
assure that their decisions are based upon full knowledge  of
the implications of their decision making.

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