Public Act 098-0841
 
SB3048 EnrolledLRB098 17860 RPM 52984 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 Section 1-2 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 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
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) "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. 97-1148, eff. 1-24-13.)
 
    Section 10. The Managed Care Reform and Patient Rights Act
is amended by changing Section 10 as follows:
 
    (215 ILCS 134/10)
    Sec. 10. Definitions:
    "Adverse determination" means a determination by a health
care plan under Section 45 or by a utilization review program
under Section 85 that a health care service is not medically
necessary.
    "Clinical peer" means a health care professional who is in
the same profession and the same or similar specialty as the
health care provider who typically manages the medical
condition, procedures, or treatment under review.
    "Department" means the Department of Insurance.
    "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including, but not limited to, severe pain) such that a
prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate
medical attention to result in:
        (1) placing the health of the individual (or, with
    respect to a pregnant woman, the health of the woman or her
    unborn child) in serious jeopardy;
        (2) serious impairment to bodily functions; or
        (3) serious dysfunction of any bodily organ or part.
    "Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed to
practice medicine in all its branches, or to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
    "Emergency services" means, with respect to an enrollee of
a health care plan, transportation services, including but not
limited to ambulance services, and covered inpatient and
outpatient hospital services furnished by a provider qualified
to furnish those services that are needed to evaluate or
stabilize an emergency medical condition. "Emergency services"
does not refer to post-stabilization medical services.
    "Enrollee" means any person and his or her dependents
enrolled in or covered by a health care plan.
    "Health care plan" means a plan that establishes, operates,
or maintains a network of health care providers that has
entered into an agreement with the plan to provide health care
services to enrollees to whom the plan has the ultimate
obligation to arrange for the provision of or payment for
services through organizational arrangements for ongoing
quality assurance, utilization review programs, or dispute
resolution. Nothing in this definition shall be construed to
mean that an independent practice association or a physician
hospital organization that subcontracts with a health care plan
is, for purposes of that subcontract, a health care plan.
    For purposes of this definition, "health care plan" shall
not include the following:
        (1) indemnity health insurance policies including
    those using a contracted provider network;
        (2) health care plans that offer only dental or only
    vision coverage;
        (3) preferred provider administrators, as defined in
    Section 370g(g) of the Illinois Insurance Code;
        (4) employee or employer self-insured health benefit
    plans under the federal Employee Retirement Income
    Security Act of 1974;
        (5) health care provided pursuant to the Workers'
    Compensation Act or the Workers' Occupational Diseases
    Act; and
        (6) not-for-profit voluntary health services plans
    with health maintenance organization authority in
    existence as of January 1, 1999 that are affiliated with a
    union and that only extend coverage to union members and
    their dependents.
    "Health care professional" means a physician, a registered
professional nurse, or other individual appropriately licensed
or registered to provide health care services.
    "Health care provider" means any physician, hospital
facility, long-term care facility as defined in Section 1-113
of the Nursing Home Care Act, or other person that is licensed
or otherwise authorized to deliver health care services.
Nothing in this Act shall be construed to define Independent
Practice Associations or Physician-Hospital Organizations as
health care providers.
    "Health care services" means any services included in the
furnishing to any individual of medical care, or the
hospitalization incident to the furnishing of such care, 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 including home health and
pharmaceutical services and products.
    "Medical director" means a physician licensed in any state
to practice medicine in all its branches appointed by a health
care plan.
    "Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
    "Physician" means a person licensed under the Medical
Practice Act of 1987.
    "Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
licensed hospital by a provider that is qualified to furnish
such services, and determined to be medically necessary and
directly related to the emergency medical condition following
stabilization.
    "Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to assure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
    "Utilization review" means the evaluation of the medical
necessity, appropriateness, and efficiency of the use of health
care services, procedures, and facilities.
    "Utilization review program" means a program established
by a person to perform utilization review.
(Source: P.A. 91-617, eff. 1-1-00.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.