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