101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB3673

 

Introduced , by Rep. Sonya M. Harper

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 134/10

    Amends the Managed Care Reform and Patient Rights Act. Provides that specified medical conditions are included in the definition of "emergency medical condition" regardless of the final diagnosis that is given.


LRB101 10456 SMS 55562 b

 

 

A BILL FOR

 

HB3673LRB101 10456 SMS 55562 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Managed Care Reform and Patient Rights Act
5is amended by changing Section 10 as follows:
 
6    (215 ILCS 134/10)
7    Sec. 10. Definitions.
8    "Adverse determination" means a determination by a health
9care plan under Section 45 or by a utilization review program
10under Section 85 that a health care service is not medically
11necessary.
12    "Clinical peer" means a health care professional who is in
13the same profession and the same or similar specialty as the
14health care provider who typically manages the medical
15condition, procedures, or treatment under review.
16    "Department" means the Department of Insurance.
17    "Emergency medical condition" means a medical condition
18manifesting itself by acute symptoms of sufficient severity
19(including, but not limited to, severe pain), regardless of the
20final diagnosis that is given, such that a prudent layperson,
21who possesses an average knowledge of health and medicine,
22could reasonably expect the absence of immediate medical
23attention to result in:

 

 

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1        (1) placing the health of the individual (or, with
2    respect to a pregnant woman, the health of the woman or her
3    unborn child) in serious jeopardy;
4        (2) serious impairment to bodily functions; or
5        (3) serious dysfunction of any bodily organ or part.
6    "Emergency medical screening examination" means a medical
7screening examination and evaluation by a physician licensed to
8practice medicine in all its branches, or to the extent
9permitted by applicable laws, by other appropriately licensed
10personnel under the supervision of or in collaboration with a
11physician licensed to practice medicine in all its branches to
12determine whether the need for emergency services exists.
13    "Emergency services" means, with respect to an enrollee of
14a health care plan, transportation services, including but not
15limited to ambulance services, and covered inpatient and
16outpatient hospital services furnished by a provider qualified
17to furnish those services that are needed to evaluate or
18stabilize an emergency medical condition. "Emergency services"
19does not refer to post-stabilization medical services.
20    "Enrollee" means any person and his or her dependents
21enrolled in or covered by a health care plan.
22    "Health care plan" means a plan, including, but not limited
23to, a health maintenance organization, a managed care community
24network as defined in the Illinois Public Aid Code, or an
25accountable care entity as defined in the Illinois Public Aid
26Code that receives capitated payments to cover medical services

 

 

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1from the Department of Healthcare and Family Services, that
2establishes, operates, or maintains a network of health care
3providers that has entered into an agreement with the plan to
4provide health care services to enrollees to whom the plan has
5the ultimate obligation to arrange for the provision of or
6payment for services through organizational arrangements for
7ongoing quality assurance, utilization review programs, or
8dispute resolution. Nothing in this definition shall be
9construed to mean that an independent practice association or a
10physician hospital organization that subcontracts with a
11health care plan is, for purposes of that subcontract, a health
12care plan.
13    For purposes of this definition, "health care plan" shall
14not include the following:
15        (1) indemnity health insurance policies including
16    those using a contracted provider network;
17        (2) health care plans that offer only dental or only
18    vision coverage;
19        (3) preferred provider administrators, as defined in
20    Section 370g(g) of the Illinois Insurance Code;
21        (4) employee or employer self-insured health benefit
22    plans under the federal Employee Retirement Income
23    Security Act of 1974;
24        (5) health care provided pursuant to the Workers'
25    Compensation Act or the Workers' Occupational Diseases
26    Act; and

 

 

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1        (6) not-for-profit voluntary health services plans
2    with health maintenance organization authority in
3    existence as of January 1, 1999 that are affiliated with a
4    union and that only extend coverage to union members and
5    their dependents.
6    "Health care professional" means a physician, a registered
7professional nurse, or other individual appropriately licensed
8or registered to provide health care services.
9    "Health care provider" means any physician, hospital
10facility, facility licensed under the Nursing Home Care Act,
11long-term care facility as defined in Section 1-113 of the
12Nursing Home Care Act, or other person that is licensed or
13otherwise authorized to deliver health care services. Nothing
14in this Act shall be construed to define Independent Practice
15Associations or Physician-Hospital Organizations as health
16care providers.
17    "Health care services" means any services included in the
18furnishing to any individual of medical care, or the
19hospitalization incident to the furnishing of such care, as
20well as the furnishing to any person of any and all other
21services for the purpose of preventing, alleviating, curing, or
22healing human illness or injury including home health and
23pharmaceutical services and products.
24    "Medical director" means a physician licensed in any state
25to practice medicine in all its branches appointed by a health
26care plan.

 

 

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1    "Person" means a corporation, association, partnership,
2limited liability company, sole proprietorship, or any other
3legal entity.
4    "Physician" means a person licensed under the Medical
5Practice Act of 1987.
6    "Post-stabilization medical services" means health care
7services provided to an enrollee that are furnished in a
8licensed hospital by a provider that is qualified to furnish
9such services, and determined to be medically necessary and
10directly related to the emergency medical condition following
11stabilization.
12    "Stabilization" means, with respect to an emergency
13medical condition, to provide such medical treatment of the
14condition as may be necessary to assure, within reasonable
15medical probability, that no material deterioration of the
16condition is likely to result.
17    "Utilization review" means the evaluation of the medical
18necessity, appropriateness, and efficiency of the use of health
19care services, procedures, and facilities.
20    "Utilization review program" means a program established
21by a person to perform utilization review.
22(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 99-78,
23eff. 7-20-15.)