Public Act 097-1148
 
SB3233 EnrolledLRB097 19652 RPM 64906 b


  
    AN ACT concerning insurance.
  
 
    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 4-14 and  by adding Section 
4-20 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 such
limitations described in 
Section 4-20 of this Act and 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, 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

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

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, 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.

    (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. 92-370, eff. 8-15-01.)

 



    (215 ILCS 125/4-14)  (from Ch. 111 1/2, par. 1409.7)



    Sec. 4-14. Evidence of Coverage. 
    (a) Every subscriber shall be issued an evidence of 
coverage, which
shall contain a clear and complete statement 
of:

        (1) The health services to which each enrollee is 
    entitled;

        (2) Eligibility requirements indicating the conditions 
    which must be met
to enroll in a Health Care Plan;

        (3) Any limitation of the services, kinds of services 
    or benefits to be
provided, and exclusions, including any 
    reasonable deductibles, copayments, co-payment, or other 
    charges;

        (4) The terms or conditions upon which coverage may be 
    cancelled or
otherwise terminated;

        (5) Where and in what manner information is available 
    as to where and
how services may be obtained; and

        (6) The method for resolving complaints.

    (b) Any amendment to the evidence of coverage may be 
provided to the
subscriber in a separate document.

(Source: P.A. 86-620.)

 
    (215 ILCS 125/4-20 new)
    Sec. 4-20. Deductibles and copayments.
    (a) A Health Maintenance Organization may require 
deductibles and copayments of enrollees as a
condition for the 
receipt of specific health care services, including basic

health care services. Deductibles and copayments shall be the 
only
allowable charges, other than premiums, assessed 
enrollees. Nothing within
this subsection (a) shall preclude 
the provider from charging reasonable
administrative fees, 
such as service fees for checks returned for non-sufficient

funds and missed appointments.
    (b) Deductibles and copayments shall be for specific dollar 
amounts or for
specific percentages of the cost of the health 
care services.
    (c) No combination of deductibles and copayments paid for 
the receipt of basic health care services may exceed the annual 
maximum out-of-pocket expenses of a high deductible health plan 
as defined in 26 U.S.C. 223. 
    (d) Deductibles and copayments applicable to supplemental 
health care
services, catastrophic-only plans as defined under 
the federal Affordable Care Act, or pre-existing conditions are 
not subject to the annual limitations described in this 
Section.
    (e) This Section applies to enrollees and does not limit 
the health care plan payment for services provided by 
non-participating providers. 
    (f) This Section applies to enrollees and does not limit 
the health care plan payment for services provided by 
non-participating providers. 
 
 
    Section 99. Effective date. This Act takes effect upon 
becoming law.