Illinois Compiled Statutes
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215 ILCS 130/1002
(215 ILCS 130/1002)
(from Ch. 73, par. 1501-2)
As used in this Act, unless the context
otherwise requires, the following terms shall have the meanings ascribed
"Advertisement" means any printed or published material,
audiovisual material and descriptive literature of the limited 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 limited
health care plan for presentation to the public including, but not limited
to, circulars, leaflets, booklets, depictions, illustrations, form letters
and prepared sales presentations.
"Copayment" means the amount that an enrollee must pay in order to
receive a specific service that is not fully prepaid.
"Director" means the Director of Insurance.
"Enrollee" means an individual who has been enrolled in a limited health care plan.
"Evidence of coverage" means any certificate, agreement or
contract issued to an enrollee setting out the coverage to which that
enrollee is entitled in exchange for a per capita prepaid sum.
"Group contract" means a contract for limited health services
which by its terms limits eligibility to members of a specified group.
"In-plan covered services" means covered limited health services
obtained from providers who are employed by, under contract with, referred
by, or otherwise affiliated with the LHSO and emergency services.
"Limited health care plan" means any arrangement whereby an
organization undertakes to provide or arrange for and, pay for or reimburse
the cost of any limited health services from providers selected by the
limited health service organization and such arrangement consists of
arranging for or the provision of such limited health services on a per
capita prepaid basis, as distinguished from mere indemnification against
the cost of such limited services on a per capita prepaid basis through
insurance except as otherwise provided under Section 3009.
"Limited health service" means ambulance care services, dental care
services, vision care services, pharmaceutical services, clinical laboratory
services, and podiatric care services. Limited health service shall not
include hospital, medical, surgical or emergency services except when those
services are essential to the delivery of the limited health service.
Essential hospital, medical, surgical, or emergency services shall be covered
unless specifically excluded.
"Limited health service organization" (LHSO) means any organization
formed under the laws of this or another state to provide or arrange for
one or more limited health care plans under a system which causes any part
of the risk of limited health care delivery to be borne by the organization
or its providers.
"Net worth" means admitted assets, as defined in Section 1003 of
this Act, minus liabilities.
"Organization" means any insurance company or other corporation
organized under the laws of this or another state for the purpose of
operating one or more limited health care plans and doing no business other
than that of a health maintenance organization or a limited health service
organization or an insurance company. Organization does not include (1)
any entity otherwise authorized on the effective date of this Act pursuant
to the laws of this State either to provide any limited health service on a
prepayment basis or to indemnity for any limited health service; nor does
it include (2) any provider or other entity when providing or arranging for
the provision of limited health services pursuant to a contract with a
limited health service organization or with any entity described in (1) of
"Out-of-plan covered services" means non-emergency, self-referred
covered limited health services obtained from providers who are not
otherwise employed by, under contract with, or otherwise affiliated with
the LHSO or services obtained without a referral from providers who have
contracted to provide limited health services to the enrollee on behalf of
the limited health care plan.
"Point-of-service product" (POS) means a group contract that includes
both in-plan covered services and out-of-plan covered services as well as a
POS contract in which the risk for out-of-plan covered services is borne
through reinsurance. This term does not apply to indemnity benefits
offered through an LHSO that are underwritten in whole by a licensed
insurance carrier and offered in conjunction with the LHSO benefit package.
"Provider" means any physician, dentist, health facility, or
other person or institution which is duly licensed or otherwise authorized
to deliver or furnish limited health services and also includes any other
entity that arranges for the delivery or furnishing of limited health service.
"Per capita prepaid" means a basis of payment by which a fixed
amount of money is prepaid per individual or any other enrollment unit to
the limited health service organization or for limited health services
which are provided during a definite time period regardless of the
frequency or extent of the services rendered, except for copayments of a
fixed amount by the limited health service organization.
"Subscriber" means the person whose employment or other status,
except for family dependency, is the basis for entitlement to limited
health services pursuant to a contract with an organization authorized to
provide or arrange for such services under this Act.
"Uncovered expense" means the cost of limited health services that
are the obligation of a limited health service organization for which an
enrollee may be liable in the event of the insolvency of the organization.
Costs incurred by a provider who has agreed in writing not to bill
enrollees, except for permissible supplemental charges, shall be considered
(Source: P.A. 87-1079; 88-568, eff. 8-5-94; 88-667, eff. 9-16-94.)