Illinois General Assembly - Full Text of HB3833
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Full Text of HB3833  100th General Assembly

HB3833 100TH GENERAL ASSEMBLY

  
  

 


 
100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB3833

 

Introduced , by Rep. Dan Brady

 

SYNOPSIS AS INTRODUCED:
 
105 ILCS 145/10
215 ILCS 5/512-7  from Ch. 73, par. 1065.59-7
215 ILCS 125/1-2  from Ch. 111 1/2, par. 1402
215 ILCS 130/1002  from Ch. 73, par. 1501-2
215 ILCS 134/10
215 ILCS 165/2  from Ch. 32, par. 596
770 ILCS 23/5

    Amends the Care of Students with Diabetes Act, the Illinois Insurance Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, the Managed Care Reform and Patient Rights Act, the Voluntary Health Services Plans Act, and the Health Care Services Lien Act to add pharmacy or pharmacist-provided services to the types of health services under the Acts and to add pharmacists as health care providers or health care professionals under the Acts. Effective January 1, 2018.


LRB100 09858 SMS 20028 b

 

 

A BILL FOR

 

HB3833LRB100 09858 SMS 20028 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 Care of Students with Diabetes Act is
5amended by changing Section 10 as follows:
 
6    (105 ILCS 145/10)
7    Sec. 10. Definitions. As used in this Act:
8    "Delegated care aide" means a school employee who has
9agreed to receive training in diabetes care and to assist
10students in implementing their diabetes care plan and has
11entered into an agreement with a parent or guardian and the
12school district or private school.
13    "Diabetes care plan" means a document that specifies the
14diabetes-related services needed by a student at school and at
15school-sponsored activities and identifies the appropriate
16staff to provide and supervise these services.
17    "Health care provider" means a physician licensed to
18practice medicine in all of its branches, advanced practice
19nurse who has a written agreement with a collaborating
20physician who authorizes the provision of diabetes care, or a
21physician assistant who has a written supervision agreement
22with a supervising physician who authorizes the provision of
23diabetes care, or pharmacist licensed to practice pharmacy.

 

 

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1    "Principal" means the principal of the school.
2    "School" means any primary or secondary public, charter, or
3private school located in this State.
4    "School employee" means a person who is employed by a
5public school district or private school, a person who is
6employed by a local health department and assigned to a school,
7or a person who contracts with a school or school district to
8perform services in connection with a student's diabetes care
9plan. This definition must not be interpreted as requiring a
10school district or private school to hire additional personnel
11for the sole purpose of serving as a designated care aide.
12(Source: P.A. 96-1485, eff. 12-1-10.)
 
13    Section 10. The Illinois Insurance Code is amended by
14changing Section 512-7 as follows:
 
15    (215 ILCS 5/512-7)  (from Ch. 73, par. 1065.59-7)
16    Sec. 512-7. Contractual provisions.
17    (a) Any agreement or contract entered into in this State
18between the entity administrator of a program and a pharmacy or
19pharmacist shall include a statement of the method and amount
20of reimbursement to the pharmacy or pharmacist for services
21rendered to persons enrolled in the program, the frequency of
22payment by the program administrator to the pharmacy or
23pharmacist for those services, and a method for the
24adjudication of complaints and the settlement of disputes

 

 

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1between the contracting parties.
2    (b)(1) A program shall provide an annual period of at least
3    30 days during which any pharmacy or pharmacist licensed
4    under the Pharmacy Practice Act may elect to participate in
5    the program under the program terms for at least one year.
6        (2) If compliance with the requirements of this
7    subsection (b) would impair any provision of a contract
8    between a program and any other person, and if the contract
9    provision was in existence before January 1, 1990, then
10    immediately after the expiration of those contract
11    provisions the program shall comply with the requirements
12    of this subsection (b).
13        (3) This subsection (b) does not apply if:
14            (A) the program administrator is a licensed health
15        maintenance organization that owns or controls a
16        pharmacy and that enters into an agreement or contract
17        with that pharmacy in accordance with subsection (a);
18        or
19            (B) the program administrator is a licensed health
20        maintenance organization that is owned or controlled
21        by another entity that also owns or controls a
22        pharmacy, and the administrator enters into an
23        agreement or contract with that pharmacy in accordance
24        with subsection (a).
25            (4) This subsection (b) shall be inoperative after
26        October 31, 1992.

 

 

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1    (c) The entity program administrator shall cause to be
2issued an identification card to each person enrolled in the
3program. The identification card shall include:
4        (1) the name of the individual enrolled in the program;
5    and
6        (2) an expiration date if required under the
7    contractual arrangement or agreement between a provider of
8    pharmaceutical services and prescription drug products and
9    the entity third party prescription program administrator.
10(Source: P.A. 95-689, eff. 10-29-07.)
 
11    Section 15. The Health Maintenance Organization Act is
12amended by changing Section 1-2 as follows:
 
13    (215 ILCS 125/1-2)  (from Ch. 111 1/2, par. 1402)
14    Sec. 1-2. Definitions. As used in this Act, unless the
15context otherwise requires, the following terms shall have the
16meanings ascribed to them:
17    (1) "Advertisement" means any printed or published
18material, audiovisual material and descriptive literature of
19the health care plan used in direct mail, newspapers,
20magazines, radio scripts, television scripts, billboards and
21similar displays; and any descriptive literature or sales aids
22of all kinds disseminated by a representative of the health
23care plan for presentation to the public including, but not
24limited to, circulars, leaflets, booklets, depictions,

 

 

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1illustrations, form letters and prepared sales presentations.
2    (2) "Director" means the Director of Insurance.
3    (3) "Basic health care services" means emergency care, and
4inpatient hospital and physician care, outpatient medical
5services, mental health services and care for alcohol and drug
6abuse, including any reasonable deductibles and co-payments,
7all of which are subject to the limitations described in
8Section 4-20 of this Act and as determined by the Director
9pursuant to rule.
10    (4) "Enrollee" means an individual who has been enrolled in
11a health care plan.
12    (5) "Evidence of coverage" means any certificate,
13agreement, or contract issued to an enrollee setting out the
14coverage to which he is entitled in exchange for a per capita
15prepaid sum.
16    (6) "Group contract" means a contract for health care
17services which by its terms limits eligibility to members of a
18specified group.
19    (7) "Health care plan" means any arrangement whereby any
20organization undertakes to provide or arrange for and pay for
21or reimburse the cost of basic health care services, excluding
22any reasonable deductibles and copayments, from providers
23selected by the Health Maintenance Organization and such
24arrangement consists of arranging for or the provision of such
25health care services, as distinguished from mere
26indemnification against the cost of such services, except as

 

 

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1otherwise authorized by Section 2-3 of this Act, on a per
2capita prepaid basis, through insurance or otherwise. A "health
3care plan" also includes any arrangement whereby an
4organization undertakes to provide or arrange for or pay for or
5reimburse the cost of any health care service for persons who
6are enrolled under Article V of the Illinois Public Aid Code or
7under the Children's Health Insurance Program Act through
8providers selected by the organization and the arrangement
9consists of making provision for the delivery of health care
10services, as distinguished from mere indemnification. A
11"health care plan" also includes any arrangement pursuant to
12Section 4-17. Nothing in this definition, however, affects the
13total medical services available to persons eligible for
14medical assistance under the Illinois Public Aid Code.
15    (8) "Health care services" means any services included in
16the furnishing to any individual of medical care, or dental
17care, pharmacist-provided services or the hospitalization or
18incident to the furnishing of such care or hospitalization as
19well as the furnishing to any person of any and all other
20services for the purpose of preventing, alleviating, curing or
21healing human illness or injury.
22    (9) "Health Maintenance Organization" means any
23organization formed under the laws of this or another state to
24provide or arrange for one or more health care plans under a
25system which causes any part of the risk of health care
26delivery to be borne by the organization or its providers.

 

 

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1    (10) "Net worth" means admitted assets, as defined in
2Section 1-3 of this Act, minus liabilities.
3    (11) "Organization" means any insurance company, a
4nonprofit corporation authorized under the Dental Service Plan
5Act or the Voluntary Health Services Plans Act, or a
6corporation organized under the laws of this or another state
7for the purpose of operating one or more health care plans and
8doing no business other than that of a Health Maintenance
9Organization or an insurance company. "Organization" shall
10also mean the University of Illinois Hospital as defined in the
11University of Illinois Hospital Act or a unit of local
12government health system operating within a county with a
13population of 3,000,000 or more.
14    (12) "Provider" means any physician, pharmacist, hospital
15facility, facility licensed under the Nursing Home Care Act, or
16facility or long-term care facility as those terms are defined
17in the Nursing Home Care Act or other person which is licensed
18or otherwise authorized to furnish health care services and
19also includes any other entity that arranges for the delivery
20or furnishing of health care service.
21    (13) "Producer" means a person directly or indirectly
22associated with a health care plan who engages in solicitation
23or enrollment.
24    (14) "Per capita prepaid" means a basis of prepayment by
25which a fixed amount of money is prepaid per individual or any
26other enrollment unit to the Health Maintenance Organization or

 

 

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1for health care services which are provided during a definite
2time period regardless of the frequency or extent of the
3services rendered by the Health Maintenance Organization,
4except for copayments and deductibles and except as provided in
5subsection (f) of Section 5-3 of this Act.
6    (15) "Subscriber" means a person who has entered into a
7contractual relationship with the Health Maintenance
8Organization for the provision of or arrangement of at least
9basic health care services to the beneficiaries of such
10contract.
11(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 99-78,
12eff. 7-20-15.)
 
13    Section 20. The Limited Health Service Organization Act is
14amended by changing Section 1002 as follows:
 
15    (215 ILCS 130/1002)  (from Ch. 73, par. 1501-2)
16    Sec. 1002. Definitions. As used in this Act, unless the
17context otherwise requires, the following terms shall have the
18meanings ascribed to them:
19    "Advertisement" means any printed or published material,
20audiovisual material and descriptive literature of the limited
21health care plan used in direct mail, newspapers, magazines,
22radio scripts, television scripts, billboards and similar
23displays; and any descriptive literature or sales aids of all
24kinds disseminated by a representative of the limited health

 

 

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1care plan for presentation to the public including, but not
2limited to, circulars, leaflets, booklets, depictions,
3illustrations, form letters and prepared sales presentations.
4    "Copayment" means the amount that an enrollee must pay in
5order to receive a specific service that is not fully prepaid.
6    "Director" means the Director of Insurance.
7    "Enrollee" means an individual who has been enrolled in a
8limited health care plan.
9    "Evidence of coverage" means any certificate, agreement or
10contract issued to an enrollee setting out the coverage to
11which that enrollee is entitled in exchange for a per capita
12prepaid sum.
13    "Group contract" means a contract for limited health
14services which by its terms limits eligibility to members of a
15specified group.
16    "In-plan covered services" means covered limited health
17services obtained from providers who are employed by, under
18contract with, referred by, or otherwise affiliated with the
19LHSO and emergency services.
20    "Limited health care plan" means any arrangement whereby an
21organization undertakes to provide or arrange for and, pay for
22or reimburse the cost of any limited health services from
23providers selected by the limited health service organization
24and such arrangement consists of arranging for or the provision
25of such limited health services on a per capita prepaid basis,
26as distinguished from mere indemnification against the cost of

 

 

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1such limited services on a per capita prepaid basis through
2insurance except as otherwise provided under Section 3009.
3    "Limited health service" means ambulance care services,
4dental care services, vision care services, pharmaceutical
5services, pharmacist-provided services, clinical laboratory
6services, and podiatric care services. Limited health service
7shall not include hospital, medical, surgical or emergency
8services except when those services are essential to the
9delivery of the limited health service. Essential hospital,
10medical, surgical, or emergency services shall be covered
11unless specifically excluded.
12    "Limited health service organization" (LHSO) means any
13organization formed under the laws of this or another state to
14provide or arrange for one or more limited health care plans
15under a system which causes any part of the risk of limited
16health care delivery to be borne by the organization or its
17providers.
18    "Net worth" means admitted assets, as defined in Section
191003 of this Act, minus liabilities.
20    "Organization" means any insurance company or other
21corporation organized under the laws of this or another state
22for the purpose of operating one or more limited health care
23plans and doing no business other than that of a health
24maintenance organization or a limited health service
25organization or an insurance company. Organization does not
26include (1) any entity otherwise authorized on the effective

 

 

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1date of this Act pursuant to the laws of this State either to
2provide any limited health service on a prepayment basis or to
3indemnity for any limited health service; nor does it include
4(2) any provider or other entity when providing or arranging
5for the provision of limited health services pursuant to a
6contract with a limited health service organization or with any
7entity described in (1) of this definition.
8    "Out-of-plan covered services" means non-emergency,
9self-referred covered limited health services obtained from
10providers who are not otherwise employed by, under contract
11with, or otherwise affiliated with the LHSO or services
12obtained without a referral from providers who have contracted
13to provide limited health services to the enrollee on behalf of
14the limited health care plan.
15    "Point-of-service product" (POS) means a group contract
16that includes both in-plan covered services and out-of-plan
17covered services as well as a POS contract in which the risk
18for out-of-plan covered services is borne through reinsurance.
19This term does not apply to indemnity benefits offered through
20an LHSO that are underwritten in whole by a licensed insurance
21carrier and offered in conjunction with the LHSO benefit
22package.
23    "Provider" means any physician, dentist, pharmacist,
24health facility, or other person or institution which is duly
25licensed or otherwise authorized to deliver or furnish limited
26health services and also includes any other entity that

 

 

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1arranges for the delivery or furnishing of limited health
2service.
3    "Per capita prepaid" means a basis of payment by which a
4fixed amount of money is prepaid per individual or any other
5enrollment unit to the limited health service organization or
6for limited health services which are provided during a
7definite time period regardless of the frequency or extent of
8the services rendered, except for copayments of a fixed amount
9by the limited health service organization.
10    "Subscriber" means the person whose employment or other
11status, except for family dependency, is the basis for
12entitlement to limited health services pursuant to a contract
13with an organization authorized to provide or arrange for such
14services under this Act.
15    "Uncovered expense" means the cost of limited health
16services that are the obligation of a limited health service
17organization for which an enrollee may be liable in the event
18of the insolvency of the organization. Costs incurred by a
19provider who has agreed in writing not to bill enrollees,
20except for permissible supplemental charges, shall be
21considered covered expenses.
22(Source: P.A. 87-1079; 88-568, eff. 8-5-94; 88-667, eff.
239-16-94.)
 
24    Section 25. The Managed Care Reform and Patient Rights Act
25is amended by changing Section 10 as follows:
 

 

 

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1    (215 ILCS 134/10)
2    Sec. 10. Definitions.
3    "Adverse determination" means a determination by a health
4care plan under Section 45 or by a utilization review program
5under Section 85 that a health care service is not medically
6necessary.
7    "Clinical peer" means a health care professional who is in
8the same profession and the same or similar specialty as the
9health care provider who typically manages the medical
10condition, procedures, or treatment under review.
11    "Department" means the Department of Insurance.
12    "Emergency medical condition" means a medical condition
13manifesting itself by acute symptoms of sufficient severity
14(including, but not limited to, severe pain) such that a
15prudent layperson, who possesses an average knowledge of health
16and medicine, could reasonably expect the absence of immediate
17medical attention to result in:
18        (1) placing the health of the individual (or, with
19    respect to a pregnant woman, the health of the woman or her
20    unborn child) in serious jeopardy;
21        (2) serious impairment to bodily functions; or
22        (3) serious dysfunction of any bodily organ or part.
23    "Emergency medical screening examination" means a medical
24screening examination and evaluation by a physician licensed to
25practice medicine in all its branches, or to the extent

 

 

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1permitted by applicable laws, by other appropriately licensed
2personnel under the supervision of or in collaboration with a
3physician licensed to practice medicine in all its branches to
4determine whether the need for emergency services exists.
5    "Emergency services" means, with respect to an enrollee of
6a health care plan, transportation services, including but not
7limited to ambulance services, and covered inpatient and
8outpatient hospital services furnished by a provider qualified
9to furnish those services that are needed to evaluate or
10stabilize an emergency medical condition. "Emergency services"
11does not refer to post-stabilization medical services.
12    "Enrollee" means any person and his or her dependents
13enrolled in or covered by a health care plan.
14    "Health care plan" means a plan, including, but not limited
15to, a health maintenance organization, a managed care community
16network as defined in the Illinois Public Aid Code, or an
17accountable care entity as defined in the Illinois Public Aid
18Code that receives capitated payments to cover medical services
19from the Department of Healthcare and Family Services, that
20establishes, operates, or maintains a network of health care
21providers that has entered into an agreement with the plan to
22provide health care services to enrollees to whom the plan has
23the ultimate obligation to arrange for the provision of or
24payment for services through organizational arrangements for
25ongoing quality assurance, utilization review programs, or
26dispute resolution. Nothing in this definition shall be

 

 

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1construed to mean that an independent practice association or a
2physician hospital organization that subcontracts with a
3health care plan is, for purposes of that subcontract, a health
4care plan.
5    For purposes of this definition, "health care plan" shall
6not include the following:
7        (1) indemnity health insurance policies including
8    those using a contracted provider network;
9        (2) health care plans that offer only dental or only
10    vision coverage;
11        (3) preferred provider administrators, as defined in
12    Section 370g(g) of the Illinois Insurance Code;
13        (4) employee or employer self-insured health benefit
14    plans under the federal Employee Retirement Income
15    Security Act of 1974;
16        (5) health care provided pursuant to the Workers'
17    Compensation Act or the Workers' Occupational Diseases
18    Act; and
19        (6) not-for-profit voluntary health services plans
20    with health maintenance organization authority in
21    existence as of January 1, 1999 that are affiliated with a
22    union and that only extend coverage to union members and
23    their dependents.
24    "Health care professional" means a physician, a
25pharmacist, a registered professional nurse, or other
26individual appropriately licensed or registered to provide

 

 

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1health care services.
2    "Health care provider" means any physician, pharmacist,
3hospital facility, facility licensed under the Nursing Home
4Care Act, long-term care facility as defined in Section 1-113
5of the Nursing Home Care Act, or other person that is licensed
6or otherwise authorized to deliver health care services.
7Nothing in this Act shall be construed to define Independent
8Practice Associations or Physician-Hospital Organizations as
9health care providers.
10    "Health care services" means any services included in the
11furnishing to any individual of medical or pharmacist care, or
12the hospitalization incident to the furnishing of such care, as
13well as the furnishing to any person of any and all other
14services for the purpose of preventing, alleviating, curing, or
15healing human illness or injury including home health and
16pharmaceutical services and products.
17    "Medical director" means a physician licensed in any state
18to practice medicine in all its branches appointed by a health
19care plan.
20    "Person" means a corporation, association, partnership,
21limited liability company, sole proprietorship, or any other
22legal entity.
23    "Pharmacist" has the meaning given to that term in the
24Pharmacy Practice Act.
25    "Physician" means a person licensed under the Medical
26Practice Act of 1987.

 

 

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1    "Post-stabilization medical services" means health care
2services provided to an enrollee that are furnished in a
3licensed hospital by a provider that is qualified to furnish
4such services, and determined to be medically necessary and
5directly related to the emergency medical condition following
6stabilization.
7    "Stabilization" means, with respect to an emergency
8medical condition, to provide such medical treatment of the
9condition as may be necessary to assure, within reasonable
10medical probability, that no material deterioration of the
11condition is likely to result.
12    "Utilization review" means the evaluation of the medical
13necessity, appropriateness, and efficiency of the use of health
14care services, procedures, and facilities.
15    "Utilization review program" means a program established
16by a person to perform utilization review.
17(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 99-78,
18eff. 7-20-15.)
 
19    Section 30. The Voluntary Health Services Plans Act is
20amended by changing Sections 2 and 7 as follows:
 
21    (215 ILCS 165/2)  (from Ch. 32, par. 596)
22    Sec. 2. For the purposes of this Act, the following terms
23have the respective meanings set forth in this section, unless
24different meanings are plainly indicated by the context:

 

 

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1    (a) "Health Services Plan Corporation" means a corporation
2organized under the terms of this Act for the purpose of
3establishing and operating a voluntary health services plan and
4providing other medically related services.
5    (b) "Voluntary health services plan" means either a plan or
6system under which medical, hospital, nursing and relating
7health services may be rendered to a subscriber or beneficiary
8at the expense of a health services plan corporation, or any
9contractual arrangement to provide, either directly or through
10arrangements with others, dental care services to subscribers
11and beneficiaries.
12    (c) "Subscriber" means a natural person to whom a
13subscription certificate has been issued by a health services
14plan corporation. Persons eligible under Section 5-2 of the
15Illinois Public Aid Code may be subscribers if a written
16agreement exists, as specified in Section 25 of this Act,
17between the Health Services Plan Corporation and the Department
18of Healthcare and Family Services. A subscription certificate
19may be issued to such persons at no cost.
20    (d) "Beneficiary" means a person designated in a
21subscription certificate as one entitled to receive health
22services.
23    (e) "Health services" means those services ordinarily
24rendered by physicians licensed in Illinois to practice
25medicine in all of its branches, by podiatric physicians
26licensed in Illinois to practice podiatric medicine, by

 

 

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1dentists and dental surgeons licensed to practice in Illinois,
2by nurses registered in Illinois, by dental hygienists licensed
3to practice in Illinois, by pharmacists licensed in Illinois to
4practice pharmacy, and by assistants and technicians acting
5under professional supervision; it likewise means hospital
6services as usually and customarily rendered in Illinois, and
7the compounding and dispensing of drugs and medicines by
8pharmacists and assistant pharmacists registered in Illinois.
9    (f) "Subscription certificate" means a certificate issued
10to a subscriber by a health services plan corporation, setting
11forth the terms and conditions upon which health services shall
12be rendered to a subscriber or a beneficiary.
13    (g) "Physician rendering service for a plan" means a
14physician licensed in Illinois to practice medicine in all of
15its branches who has undertaken or agreed, upon terms and
16conditions acceptable both to himself and to the health
17services plan corporation involved, to furnish medical service
18to the plan's subscribers and beneficiaries.
19    (h) "Dentist or dental surgeon rendering service for a
20plan" means a dentist or dental surgeon licensed in Illinois to
21practice dentistry or dental surgery who has undertaken or
22agreed, upon terms and conditions acceptable both to himself
23and to the health services plan corporation involved, to
24furnish dental or dental surgical services to the plan's
25subscribers and beneficiaries.
26    (i) "Director" means the Director of Insurance of the State

 

 

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1of Illinois.
2    (j) "Person" means any of the following: a natural person,
3corporation, partnership or unincorporated association.
4    (k) "Podiatric physician or podiatric surgeon rendering
5service for a plan" means any podiatric physician or podiatric
6surgeon licensed in Illinois to practice podiatry, who has
7undertaken or agreed, upon terms and conditions acceptable both
8to himself and to the health services plan corporation
9involved, to furnish podiatric or podiatric surgical services
10to the plan's subscribers and beneficiaries.
11    (l) "Pharmacist rendering service for a plan" means a
12pharmacist licensed in Illinois to practice pharmacy who has
13undertaken or agreed, upon terms and conditions acceptable both
14to the pharmacist and to the health services plan corporation
15involved, to furnish pharmacy and pharmacist-provided service
16to the plan's subscribers and beneficiaries.
17(Source: P.A. 98-214, eff. 8-9-13.)
 
18    Section 35. The Health Care Services Lien Act is amended by
19changing Section 5 as follows:
 
20    (770 ILCS 23/5)
21    Sec. 5. Definitions. In this Act:
22    "Health care professional" means any individual in any of
23the following license categories: licensed physician, licensed
24dentist, licensed optometrist, licensed naprapath, licensed

 

 

HB3833- 21 -LRB100 09858 SMS 20028 b

1clinical psychologist, or licensed physical therapist, or
2licensed pharmacist.
3    "Health care provider" means any entity in any of the
4following license categories: licensed hospital, licensed home
5health agency, licensed ambulatory surgical treatment center,
6licensed long-term care facilities, or licensed emergency
7medical services personnel, or licensed pharmacy.
8    This amendatory Act of the 94th General Assembly applies to
9causes of action accruing on or after its effective date.
10(Source: P.A. 93-51, eff. 7-1-03; 94-403, eff. 1-1-06.)
 
11    Section 99. Effective date. This Act takes effect January
121, 2018.