Public Act 103-0104
 
HB1186 EnrolledLRB103 05082 BMS 50096 b


  
    AN ACT concerning regulation.
  
 
    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 Sections 1-2 and 2-3 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 the
limitations described in 
Section 4-20 of this Act and as 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 in which an 
whereby any organization
provides, arranges undertakes to 
provide or arrange for, pays and pay for, or reimburses 
reimburse the
cost of basic health care services, excluding 
any reasonable deductibles and copayments, from providers 
selected by
the Health Maintenance Organization; and the such 
arrangement
consists of providing for the arranging for or the 
provision of basic such health care services that is , as

distinguished from mere indemnification against the cost of 
such services,
on a per capita prepaid basis, through 
insurance or otherwise, 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 in which whereby an organization provides, 
arranges undertakes to
provide or arrange for, pays or pay 
for, or reimburses 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
providers selected by the 
organization; and the arrangement consists of making
a 
provision for the delivery of health care services that is , 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. Nothing in this definition 
shall be construed as requiring a health care plan or health 
maintenance organization to utilize a referral system that 
enrollees must use to access basic health care services and 
other health care services from providers that are under 
contract with or employed by the health maintenance 
organization. The Director may prescribe by rule the language 
that must be included in the plan name, marketing, 
advertising, or other consumer disclosure requirements to 
differentiate a health care plan that does not use a referral 
system for such providers from a health care plan that does use 
a referral system for such providers. 

    (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, 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 or a unit of local 
government health system operating within a county with a 
population of 3,000,000 or more.

    (12) "Provider" means any physician, hospital facility,

facility licensed under the Nursing Home Care Act, 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.

    (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) "Referral system" means any arrangement in a health 
care plan in which  a primary care provider coordinates or 
manages the care of a health maintenance organization's 
enrollee by referring the enrollee to other providers or 
specialists. 
    (16) (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. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 
99-78, eff. 7-20-15.)

 



    (215 ILCS 125/2-3)  (from Ch. 111 1/2, par. 1405)



    Sec. 2-3. Powers of health maintenance organizations. The 
powers of a health maintenance organization include, but are 
not
limited to the following:

    (a) The purchase, lease, construction, renovation, 
operation, or
maintenance of hospitals, medical facilities or 
both, and their ancillary
equipment, and such property as may 
reasonably be required for its
principal office or for such 
other purposes as may be necessary in the
transaction of the 
business of the organization.

    (b) The making of loans to a medical group under contract 
with it and in
furtherance of its program or the making of 
loans to a corporation or
corporations under its control for 
the purpose of acquiring or constructing
medical facilities at 
hospitals or in furtherance of a program providing
health care 
services for enrollees.

    (c) The furnishing of health care services through 
providers which are
under contract with or employed by the 
health maintenance
organization.

    (d) The contracting with any person for the performance on 
its behalf of
certain functions such as marketing, enrollment 
and administration.
    (d-5) The voluntary use of a referral system for enrollees 
to access providers under contract with or employed by the 
health maintenance organization. Nothing in this subsection 
(d-5) shall be construed as requiring the use of a referral 
system  with the health maintenance organization's contracted 
or employed providers to obtain a certificate of authority as 
set forth in Section 2-1. 

    (e) The contracting with an insurance company licensed in 
this State, or
with a hospital, medical, dental, vision or 
pharmaceutical service
corporation authorized to do business 
in this State, for the provision of
insurance, indemnity, or 
reimbursement against the cost of health care
service provided 
by the health maintenance organization.

    (f) The offering, in addition to basic health care 
services, of (1)
health care services, (2) indemnity benefits 
covering out of area or
emergency services, (3) indemnity 
benefits provided through insurers or
hospital, medical, 
dental, vision, or pharmaceutical service
corporations, and 
(4) health maintenance organization point-of-service
benefits 
as authorized under Article 4.5.

    (g) Rendering services related to the functions involved 
in the
operating of its health maintenance organization 
business including but not
limited to providing health 
services, data processing, accounting, or
claims.

    (g-5) Indemnification for services provided to a child as 
required under
subdivision (e)(3) of Section 4-2.

    (h) Any other business activity reasonably complementary 
or
supplementary to its health maintenance organization 
business to the extent
approved by the Director.

(Source: P.A. 92-135, eff. 1-1-02.)

 
 
    Section 99. Effective date. This Act takes effect January 
1, 2024.