93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB5924

 

Introduced 2/6/2004, by Frank J. Mautino

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 134/65

    Amends the Managed Care Reform and Patient Rights Act. Makes a technical change in a Section concerning emergency services.


LRB093 19177 SAS 44912 b

 

 

A BILL FOR

 

HB5924 LRB093 19177 SAS 44912 b

1     AN ACT concerning managed care.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Managed Care Reform and Patient Rights Act
5 is amended by changing Section 65 as follows:
 
6     (215 ILCS 134/65)
7     Sec. 65. Emergency services prior to stabilization.
8     (a) A health care plan that provides or that is required
9 under by law to provide coverage for emergency services shall
10 provide coverage such that payment under this coverage is not
11 dependent upon whether the services are performed by a plan or
12 non-plan health care provider and without regard to prior
13 authorization. This coverage shall be at the same benefit level
14 as if the services or treatment had been rendered by the health
15 care plan physician licensed to practice medicine in all its
16 branches or health care provider.
17     (b) Prior authorization or approval by the plan shall not
18 be required for emergency services.
19     (c) Coverage and payment shall only be retrospectively
20 denied under the following circumstances:
21         (1) upon reasonable determination that the emergency
22     services claimed were never performed;
23         (2) upon timely determination that the emergency
24     evaluation and treatment were rendered to an enrollee who
25     sought emergency services and whose circumstance did not
26     meet the definition of emergency medical condition;
27         (3) upon determination that the patient receiving such
28     services was not an enrollee of the health care plan; or
29         (4) upon material misrepresentation by the enrollee or
30     health care provider; "material" means a fact or situation
31     that is not merely technical in nature and results or could
32     result in a substantial change in the situation.

 

 

HB5924 - 2 - LRB093 19177 SAS 44912 b

1     (d) When an enrollee presents to a hospital seeking
2 emergency services, the determination as to whether the need
3 for those services exists shall be made for purposes of
4 treatment by a physician licensed to practice medicine in all
5 its branches or, to the extent permitted by applicable law, by
6 other appropriately licensed personnel under the supervision
7 of or in collaboration with a physician licensed to practice
8 medicine in all its branches. The physician or other
9 appropriate personnel shall indicate in the patient's chart the
10 results of the emergency medical screening examination.
11     (e) The appropriate use of the 911 emergency telephone
12 system or its local equivalent shall not be discouraged or
13 penalized by the health care plan when an emergency medical
14 condition exists. This provision shall not imply that the use
15 of 911 or its local equivalent is a factor in determining the
16 existence of an emergency medical condition.
17     (f) The medical director's or his or her designee's
18 determination of whether the enrollee meets the standard of an
19 emergency medical condition shall be based solely upon the
20 presenting symptoms documented in the medical record at the
21 time care was sought. Only a clinical peer may make an adverse
22 determination.
23     (g) Nothing in this Section shall prohibit the imposition
24 of deductibles, copayments, and co-insurance. Nothing in this
25 Section alters the prohibition on billing enrollees contained
26 in the Health Maintenance Organization Act.
27 (Source: P.A. 91-617, eff. 1-1-00.)