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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 Health Maintenance Organization Act is
5amended by changing Sections 1-2 and 2-3 as follows:
 
6    (215 ILCS 125/1-2)  (from Ch. 111 1/2, par. 1402)
7    Sec. 1-2. Definitions. As used in this Act, unless the
8context otherwise requires, the following terms shall have the
9meanings ascribed to them:
10    (1) "Advertisement" means any printed or published
11material, audiovisual material and descriptive literature of
12the health care plan used in direct mail, newspapers,
13magazines, radio scripts, television scripts, billboards and
14similar displays; and any descriptive literature or sales aids
15of all kinds disseminated by a representative of the health
16care plan for presentation to the public including, but not
17limited to, circulars, leaflets, booklets, depictions,
18illustrations, form letters and prepared sales presentations.
19    (2) "Director" means the Director of Insurance.
20    (3) "Basic health care services" means emergency care, and
21inpatient hospital and physician care, outpatient medical
22services, mental health services and care for alcohol and drug
23abuse, including any reasonable deductibles and co-payments,

 

 

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1all of which are subject to the limitations described in
2Section 4-20 of this Act and as determined by the Director
3pursuant to rule.
4    (4) "Enrollee" means an individual who has been enrolled
5in a health care plan.
6    (5) "Evidence of coverage" means any certificate,
7agreement, or contract issued to an enrollee setting out the
8coverage to which he is entitled in exchange for a per capita
9prepaid sum.
10    (6) "Group contract" means a contract for health care
11services which by its terms limits eligibility to members of a
12specified group.
13    (7) "Health care plan" means any arrangement in which an
14whereby any organization provides, arranges undertakes to
15provide or arrange for, pays and pay for, or reimburses
16reimburse the cost of basic health care services, excluding
17any reasonable deductibles and copayments, from providers
18selected by the Health Maintenance Organization; and the such
19arrangement consists of providing for the arranging for or the
20provision of basic such health care services that is , as
21distinguished from mere indemnification against the cost of
22such services, on a per capita prepaid basis, through
23insurance or otherwise, except as otherwise authorized by
24Section 2-3 of this Act, on a per capita prepaid basis, through
25insurance or otherwise. A "health care plan" also includes any
26arrangement in which whereby an organization provides,

 

 

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1arranges undertakes to provide or arrange for, pays or pay
2for, or reimburses reimburse the cost of any health care
3service for persons who are enrolled under Article V of the
4Illinois Public Aid Code or under the Children's Health
5Insurance Program Act through providers selected by the
6organization; and the arrangement consists of making a
7provision for the delivery of health care services that is , as
8distinguished from mere indemnification. A "health care plan"
9also includes any arrangement pursuant to Section 4-17.
10Nothing in this definition, however, affects the total medical
11services available to persons eligible for medical assistance
12under the Illinois Public Aid Code. Nothing in this definition
13shall be construed as requiring a health care plan or health
14maintenance organization to utilize a referral system that
15enrollees must use to access basic health care services and
16other health care services from providers that are under
17contract with or employed by the health maintenance
18organization. The Director may prescribe by rule the language
19that must be included in the plan name, marketing,
20advertising, or other consumer disclosure requirements to
21differentiate a health care plan that does not use a referral
22system for such providers from a health care plan that does use
23a referral system for such providers.
24    (8) "Health care services" means any services included in
25the furnishing to any individual of medical or dental care, or
26the hospitalization or incident to the furnishing of such care

 

 

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1or hospitalization as well as the furnishing to any person of
2any and all other services for the purpose of preventing,
3alleviating, curing or healing human illness or injury.
4    (9) "Health Maintenance Organization" means any
5organization formed under the laws of this or another state to
6provide or arrange for one or more health care plans under a
7system which causes any part of the risk of health care
8delivery to be borne by the organization or its providers.
9    (10) "Net worth" means admitted assets, as defined in
10Section 1-3 of this Act, minus liabilities.
11    (11) "Organization" means any insurance company, a
12nonprofit corporation authorized under the Dental Service Plan
13Act or the Voluntary Health Services Plans Act, or a
14corporation organized under the laws of this or another state
15for the purpose of operating one or more health care plans and
16doing no business other than that of a Health Maintenance
17Organization or an insurance company. "Organization" shall
18also mean the University of Illinois Hospital as defined in
19the University of Illinois Hospital Act or a unit of local
20government health system operating within a county with a
21population of 3,000,000 or more.
22    (12) "Provider" means any physician, hospital facility,
23facility licensed under the Nursing Home Care Act, or facility
24or long-term care facility as those terms are defined in the
25Nursing Home Care Act or other person which is licensed or
26otherwise authorized to furnish health care services and also

 

 

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1includes any other entity that arranges for the delivery or
2furnishing of health care service.
3    (13) "Producer" means a person directly or indirectly
4associated with a health care plan who engages in solicitation
5or enrollment.
6    (14) "Per capita prepaid" means a basis of prepayment by
7which a fixed amount of money is prepaid per individual or any
8other enrollment unit to the Health Maintenance Organization
9or for health care services which are provided during a
10definite time period regardless of the frequency or extent of
11the services rendered by the Health Maintenance Organization,
12except for copayments and deductibles and except as provided
13in subsection (f) of Section 5-3 of this Act.
14    (15) "Referral system" means any arrangement in a health
15care plan in which a primary care provider coordinates or
16manages the care of a health maintenance organization's
17enrollee by referring the enrollee to other providers or
18specialists.
19    (16) (15) "Subscriber" means a person who has entered into
20a contractual relationship with the Health Maintenance
21Organization for the provision of or arrangement of at least
22basic health care services to the beneficiaries of such
23contract.
24(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14;
2599-78, eff. 7-20-15.)
 

 

 

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1    (215 ILCS 125/2-3)  (from Ch. 111 1/2, par. 1405)
2    Sec. 2-3. Powers of health maintenance organizations. The
3powers of a health maintenance organization include, but are
4not limited to the following:
5    (a) The purchase, lease, construction, renovation,
6operation, or maintenance of hospitals, medical facilities or
7both, and their ancillary equipment, and such property as may
8reasonably be required for its principal office or for such
9other purposes as may be necessary in the transaction of the
10business of the organization.
11    (b) The making of loans to a medical group under contract
12with it and in furtherance of its program or the making of
13loans to a corporation or corporations under its control for
14the purpose of acquiring or constructing medical facilities at
15hospitals or in furtherance of a program providing health care
16services for enrollees.
17    (c) The furnishing of health care services through
18providers which are under contract with or employed by the
19health maintenance organization.
20    (d) The contracting with any person for the performance on
21its behalf of certain functions such as marketing, enrollment
22and administration.
23    (d-5) The voluntary use of a referral system for enrollees
24to access providers under contract with or employed by the
25health maintenance organization. Nothing in this subsection
26(d-5) shall be construed as requiring the use of a referral

 

 

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1system with the health maintenance organization's contracted
2or employed providers to obtain a certificate of authority as
3set forth in Section 2-1.
4    (e) The contracting with an insurance company licensed in
5this State, or with a hospital, medical, dental, vision or
6pharmaceutical service corporation authorized to do business
7in this State, for the provision of insurance, indemnity, or
8reimbursement against the cost of health care service provided
9by the health maintenance organization.
10    (f) The offering, in addition to basic health care
11services, of (1) health care services, (2) indemnity benefits
12covering out of area or emergency services, (3) indemnity
13benefits provided through insurers or hospital, medical,
14dental, vision, or pharmaceutical service corporations, and
15(4) health maintenance organization point-of-service benefits
16as authorized under Article 4.5.
17    (g) Rendering services related to the functions involved
18in the operating of its health maintenance organization
19business including but not limited to providing health
20services, data processing, accounting, or claims.
21    (g-5) Indemnification for services provided to a child as
22required under subdivision (e)(3) of Section 4-2.
23    (h) Any other business activity reasonably complementary
24or supplementary to its health maintenance organization
25business to the extent approved by the Director.
26(Source: P.A. 92-135, eff. 1-1-02.)
 

 

 

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1    Section 99. Effective date. This Act takes effect January
21, 2024.