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90_HB0390
215 ILCS 5/370g from Ch. 73, par. 982g
215 ILCS 5/370i from Ch. 73, par. 982i
215 ILCS 5/370o from Ch. 73, par. 982o
215 ILCS 105/2 from Ch. 73, par. 1302
215 ILCS 105/3 from Ch. 73, par. 1303
215 ILCS 105/5 from Ch. 73, par. 1305
215 ILCS 105/8 from Ch. 73, par. 1308
215 ILCS 125/1-2 from Ch. 111 1/2, par. 1402
215 ILCS 125/4-10 from Ch. 111 1/2, par. 1409.3
215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8
215 ILCS 125/5-7.2 new
305 ILCS 5/5-5.04 new
305 ILCS 5/5-16.3
Creates the Access to Emergency Services Act. Provides
that health insurance plans, as defined, must provide
coverage for emergency services obtained by a covered
individual. Provides for administration by the Department of
Insurance. Amends the Illinois Insurance Code, Comprehensive
Health Insurance Plan Act, Health Maintenance Organization
Act, and Illinois Public Aid Code to require coverage under
those Acts for emergency service. Effective immediately.
LRB9001344JSgc
LRB9001344JSgc
1 AN ACT concerning access to emergency medical services,
2 amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 1. Short title. This Act may be cited as the
6 Access to Emergency Services Act.
7 Section 5. Legislative findings and purposes.
8 (a) The legislature recognizes that all persons need
9 access to emergency medical care, and that State and federal
10 laws require hospital emergency departments to provide that
11 care. Federal law specifically prohibits emergency
12 physicians and hospital emergency departments from delaying
13 any treatment needed to evaluate or stabilize an individual
14 in order to determine the health insurance status of the
15 individual.
16 However, health insurance plans may impede access to
17 emergency care by denying coverage or payment for failure to
18 obtain prior authorization or approval from the plan, failure
19 to seek emergency care from a preferred or contractual
20 provider, or an after-the-fact determination that the medical
21 condition did not require the use of emergency facilities or
22 services, including the 911 emergency telephone number.
23 These denials impose significant financial burdens on
24 patients who prudently seek care for symptoms of a medical
25 emergency through the 911 system and in a hospital emergency
26 department, as well as the providers of such care. This
27 serves to discourage patients from seeking appropriate
28 emergency care, and threatens the financial livelihood of
29 hospital emergency departments and trauma centers which
30 provide such necessary services to our entire population.
31 (b) This Act intended to promote access to emergency
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1 medical care by establishing a uniform definition of
2 emergency medical condition that is based on the average
3 knowledge of the prudent layperson, and requiring insurance
4 plans to cover and pay for such services without restrictions
5 that may impede or discourage access to such care.
6 Section 10. Definitions. As used in this Act:
7 "Department" means the Illinois Department of Insurance.
8 "Emergency services" means those health care services
9 provided to evaluate and treat medical conditions of recent
10 onset and severity that would lead a prudent layperson,
11 possessing an average knowledge of medicine and health, to
12 believe that urgent and unscheduled medical care is required.
13 "Health insurance plan" means any policy, contract, plan,
14 or other arrangement that pays for or furnishes medical
15 services pursuant to the Illinois Insurance Code, the
16 Comprehensive Health Insurance Plan Act, the Health
17 Maintenance Organization Act, or the Illinois Public Aid
18 Code.
19 "Insured" means any person enrolled in or covered by a
20 health insurance plan.
21 "Post-emergency services" means those health care
22 services determined by a treating provider to be promptly and
23 medically necessary following stabilization of an emergency
24 condition.
25 "Provider" means any physician, hospital facility, or
26 other person that is licensed or otherwise authorized to
27 furnish or arrange for the delivery or furnishing of health
28 care services.
29 Section 15. Emergency services.
30 (a) Any health insurance plan subject to this Act shall
31 provide the insured emergency services coverage such that
32 payment for this coverage is not dependent upon whether such
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1 services are performed by a preferred or nonpreferred
2 provider, and such coverage shall be at the same benefit
3 level as if the service or treatment had been rendered by a
4 plan provider.
5 (b) Prior authorization or approval by the plan shall
6 not be required.
7 (c) Coverage and payment shall not be retrospectively
8 denied, with the following exceptions:
9 (1) upon reasonable determination that the
10 emergency services claimed were never performed; or
11 (2) upon reasonable determination that an emergency
12 medical screening examination was performed on a patient
13 who personally sought emergency services knowing that he
14 or she did not have an emergency condition or necessity,
15 and who did not in fact require emergency services.
16 (d) The appropriate use of the 911 emergency telephone
17 number shall not be discouraged or penalized, and coverage or
18 payment shall not be denied solely on the basis that the
19 insured used the 911 emergency telephone number to summon
20 emergency services.
21 Section 20. Post-emergency services.
22 (a) If prior authorization for post-emergency services
23 is required, the health insurance plan shall provide access
24 24 hours a day, 7 days a week to persons designated by plan
25 to make such determinations. If a provider has attempted to
26 contact such person for prior authorization and no designated
27 persons were accessible or the authorization was not denied
28 within 30 minutes of the request, the health insurance plan
29 is deemed to have approved the request for prior
30 authorization.
31 (b) Coverage and payment for post-emergency services
32 which received prior authorization or deemed approval shall
33 not be retrospectively denied.
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1 Section 25. Enforcement.
2 (a) The Department shall enforce the provisions of this
3 Act. It shall promptly investigate complaints which it
4 receives alleging violation of the Act. If the complaint is
5 found to be valid, the Department shall immediately seek
6 appropriate corrective action by the health insurance plan
7 including, but not limited to, ceasing the noncompliant
8 activity, restoring coverage, paying or reimbursing claims,
9 and other appropriate restitution.
10 (b) Subject to the provisions of the Illinois
11 Administrative Procedure Act, the Department shall impose an
12 administrative fine on a health insurance plan found to have
13 violated any provision of this Act.
14 (1) Failure to comply with requested corrective
15 action shall result in a fine of $5,000 per violation.
16 (2) A repeated violation shall result in a fine of
17 $10,000 per violation.
18 (3) A pattern of repeated violations shall result
19 in a fine of $25,000.
20 (c) Notwithstanding the existence or pursuit of any
21 other remedy, the Department may, through the Attorney
22 General, seek an injunction to restrain or prevent any health
23 insurance plan from violation or continuing to violate any
24 provisions of this Act.
25 Section 30. Rules. The Department shall adopt emergency
26 rules to implement the provisions of this Act, in accordance
27 with Section 5-45 of the Illinois Administrative Procedure
28 Act.
29 Section 90. The Illinois Insurance Code is amended by
30 changing Sections 370g, 370i, and 370o as follows:
31 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
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1 Sec. 370g. Definitions. As used in this Article, the
2 following definitions apply:
3 (a) "Health care services" means health care services or
4 products rendered or sold by a provider within the scope of
5 the provider's license or legal authorization. The term
6 includes, but is not limited to, hospital, medical, surgical,
7 dental, vision and pharmaceutical services or products.
8 (b) "Insurer" means an insurance company or a health
9 service corporation authorized in this State to issue
10 policies or subscriber contracts which reimburse for expenses
11 of health care services.
12 (c) "Insured" means an individual entitled to
13 reimbursement for expenses of health care services under a
14 policy or subscriber contract issued or administered by an
15 insurer.
16 (d) "Provider" means an individual or entity duly
17 licensed or legally authorized to provide health care
18 services.
19 (e) "Noninstitutional provider" means any person
20 licensed under the Medical Practice Act of 1987, as now or
21 hereafter amended.
22 (f) "Beneficiary" means an individual entitled to
23 reimbursement for expenses of or the discount of provider
24 fees for health care services under a program where the
25 beneficiary has an incentive to utilize the services of a
26 provider which has entered into an agreement or arrangement
27 with an administrator.
28 (g) "Administrator" means any person, partnership or
29 corporation, other than an insurer or health maintenance
30 organization holding a certificate of authority under the
31 "Health Maintenance Organization Act", as now or hereafter
32 amended, that arranges, contracts with, or administers
33 contracts with a provider whereby beneficiaries are provided
34 an incentive to use the services of such provider.
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1 (h) "Emergency services" means those health care
2 services provided to evaluate and treat medical conditions of
3 recent onset and severity that would lead a prudent
4 layperson, possessing an average knowledge of medicine and
5 health, to believe that urgent or unscheduled medical care is
6 required an accidental bodily injury or emergency medical
7 condition which reasonably requires the beneficiary or
8 insured to seek immediate medical care under circumstances or
9 at locations which reasonably preclude the beneficiary or
10 insured from obtaining needed medical care from a preferred
11 provider.
12 (i) "Post-emergency services" means those health care
13 services determined by a treating provider to be promptly and
14 medically necessary following stabilization of an emergency
15 condition.
16 (Source: P.A. 88-400.)
17 (215 ILCS 5/370i) (from Ch. 73, par. 982i)
18 Sec. 370i. Policies, agreements or arrangements with
19 incentives or limits on reimbursement authorized.
20 (a) Policies, agreements or arrangements issued under
21 this Article may not contain terms or conditions that would
22 operate unreasonably to restrict the access and availability
23 of health care services for the insured.
24 (1) If prior authorization for post-emergency
25 services is required, the insurer or administrator shall
26 provide access 24 hours a day, 7 days a week to persons
27 designated by the insurer or administrator to make such
28 determinations. If a provider has attempted to contact
29 such person for prior authorization and no designated
30 persons were accessible or the authorization was not
31 denied within 30 minutes of the request, the insurer or
32 administrator is deemed to have approved the request for
33 prior authorization.
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1 Coverage and payment for post-emergency services
2 which received prior authorization or deemed approval
3 shall not be retrospectively denied.
4 (2) The appropriate use of the 911 emergency
5 telephone number shall not be discouraged or penalized,
6 and coverage or payment shall not be denied solely on the
7 basis that the insured or beneficiary used the 911
8 emergency telephone number to summon emergency services.
9 (b) Subject to the provisions of subsection (a), an
10 insurer or administrator may:
11 (1) enter into agreements with certain providers of its
12 choice relating to health care services which may be rendered
13 to insureds or beneficiaries of the insurer or administrator,
14 including agreements relating to the amounts to be charged
15 the insureds or beneficiaries for services rendered;
16 (2) issue or administer programs, policies or subscriber
17 contracts in this State that include incentives for the
18 insured or beneficiary to utilize the services of a provider
19 which has entered into an agreement with the insurer or
20 administrator pursuant to paragraph (1) above.
21 (Source: P.A. 84-618.)
22 (215 ILCS 5/370o) (from Ch. 73, par. 982o)
23 Sec. 370o. Emergency services Care.
24 (a) Any referred provider contract, subject to this
25 Article shall provide the beneficiary or insured emergency
26 services care coverage such that payment for this coverage is
27 not dependent upon whether such services are performed by a
28 preferred or nonpreferred provider and such coverage shall be
29 at the same benefit level as if the service or treatment had
30 been rendered by a plan provider.
31 (b) Prior authorization or approval by the plan shall
32 not be required.
33 (c) Coverage and payment shall not be retrospectively
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1 denied, with the following exceptions:
2 (1) upon reasonable determination that the
3 emergency services claimed were never performed; or
4 (2) upon reasonable determination that an emergency
5 medical screening examination was performed on a patient
6 who personally sought emergency services knowing that he
7 or she did not have an emergency condition or necessity,
8 and who did not in fact require emergency services.
9 (Source: P.A. 85-476.)
10 Section 92. The Comprehensive Health Insurance Plan Act
11 is amended by changing Sections 2, 3, 5, and 8 as follows:
12 (215 ILCS 105/2) (from Ch. 73, par. 1302)
13 Sec. 2. Definitions. As used in this Act, unless the
14 context otherwise requires:
15 "Administering carrier" means the insurer or third party
16 administrator designated under Section 5 of this Act.
17 "Benefits plan" means the coverage to be offered by the
18 Plan to eligible persons pursuant to this Act.
19 "Board" means the Illinois Comprehensive Health Insurance
20 Board.
21 "Department" means the Illinois Department of Insurance.
22 "Director" means the Director of the Illinois Department
23 of Insurance.
24 "Eligible person" means a resident of this State who
25 qualifies under Section 7.
26 "Emergency services" means those health care services
27 provided to evaluate and treat medical conditions of recent
28 onset and severity that would lead a prudent layperson,
29 possessing an average knowledge of medicine and health, to
30 believe that urgent or unscheduled medical care is required.
31 "Employee" means a resident of this State who has entered
32 into the employment of or works under contract or service of
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1 an employer including the officers, managers and employees of
2 subsidiary or affiliated corporations and the individual
3 proprietors, partners and employees of affiliated individuals
4 and firms when the business of the subsidiary or affiliated
5 corporations, firms or individuals is controlled by a common
6 employer through stock ownership, contract, or otherwise.
7 "Family" means the eligible person and his or her legal
8 spouse, the eligible person's dependent children under the
9 age of 19, the eligible person's dependent children under the
10 age of 23 who are full-time students, the eligible person's
11 dependent disabled children of any age, or any other member
12 of the eligible person's family who is claimed as a dependent
13 for purposes of filing federal income tax returns and resides
14 in the eligible person's household.
15 "Health insurance" means any hospital, surgical, or
16 medical coverage provided under an expense-incurred policy or
17 contract, minimum premium plan, stop loss coverage,
18 non-profit health care service plan contract, health
19 maintenance organization or other subscriber contract, or any
20 other health care plan or arrangement that pays for or
21 furnishes medical or health care services by a provider of
22 these services, whether by insurance or otherwise. Health
23 insurance shall not include accident only, disability income,
24 hospital confinement indemnity, dental, or credit insurance,
25 coverage issued as a supplement to liability insurance,
26 insurance arising out of a workers' compensation or similar
27 law, automobile medical-payment insurance, or insurance under
28 which benefits are payable with or without regard to fault
29 and which is statutorily required to be contained in any
30 liability insurance policy or equivalent self-insurance.
31 "Health Maintenance Organization" means an organization
32 as defined in the Health Maintenance Organization Act.
33 "Hospice" means a program as defined in and licensed
34 under the Hospice Program Licensing Act.
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1 "Hospital" means an institution as defined in the
2 Hospital Licensing Act, an institution that meets all
3 comparable conditions and requirements in effect in the state
4 in which it is located, or the University of Illinois
5 Hospital as defined in the University of Illinois Hospital
6 Act.
7 "Insured" means any individual resident of this State who
8 is eligible to receive benefits from any insurer or insurance
9 arrangement as defined in this Section.
10 "Insurer" means any insurance company authorized to
11 transact health insurance business in this State and any
12 corporation that provides medical services and is organized
13 under the Voluntary Health Services Plans Act or the Health
14 Maintenance Organization Act.
15 "Medical assistance" means health care benefits provided
16 under Articles V (Medical Assistance) and VI (General
17 Assistance) of the Illinois Public Aid Code or under any
18 similar program of health care benefits in a state other than
19 Illinois.
20 "Medically necessary" means that a service, drug, or
21 supply is necessary and appropriate for the diagnosis or
22 treatment of an illness or injury in accord with generally
23 accepted standards of medical practice at the time the
24 service, drug, or supply is provided. When specifically
25 applied to a confinement it further means that the diagnosis
26 or treatment of the insured person's medical symptoms or
27 condition cannot be safely provided to that person as an
28 outpatient. A service, drug, or supply shall not be medically
29 necessary if it: (i) is investigational, experimental, or for
30 research purposes; or (ii) is provided solely for the
31 convenience of the patient, the patient's family, physician,
32 hospital, or any other provider; or (iii) exceeds in scope,
33 duration, or intensity that level of care that is needed to
34 provide safe, adequate, and appropriate diagnosis or
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1 treatment; or (iv) could have been omitted without adversely
2 affecting the insured person's condition or the quality of
3 medical care; or (v) involves the use of a medical device,
4 drug, or substance not formally approved by the United States
5 Food and Drug Administration.
6 "Medicare" means coverage under Title XVIII of the Social
7 Security Act, 42 U.S.C. Sec. 1395, et seq..
8 "Minimum premium plan" means an arrangement whereby a
9 specified amount of health care claims is self-funded, but
10 the insurance company assumes the risk that claims will
11 exceed that amount.
12 "Participating transplant center" means a hospital
13 designated by the Board as a preferred or exclusive provider
14 of services for one or more specified human organ or tissue
15 transplants for which the hospital has signed an agreement
16 with the Board to accept a transplant payment allowance for
17 all expenses related to the transplant during a transplant
18 benefit period.
19 "Physician" means a person licensed to practice medicine
20 pursuant to the Medical Practice Act of 1987.
21 "Plan" means the comprehensive health insurance plan
22 established by this Act.
23 "Plan of operation" means the plan of operation of the
24 Plan, including articles, bylaws and operating rules, adopted
25 by the board pursuant to this Act.
26 "Post-emergency services" means those health care
27 services determined by a treating provider to be promptly and
28 medically necessary following stabilization of an emergency
29 condition.
30 "Resident" means a person who has been legally domiciled
31 in this State for a period of at least 180 days and continues
32 to be domiciled in this State.
33 "Skilled nursing facility" means a facility or that
34 portion of a facility that is licensed by the Illinois
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1 Department of Public Health under the Nursing Home Care Act
2 or a comparable licensing authority in another state to
3 provide skilled nursing care.
4 "Stop-loss coverage" means an arrangement whereby an
5 insurer insures against the risk that any one claim will
6 exceed a specific dollar amount or that the entire loss of a
7 self-insurance plan will exceed a specific amount.
8 "Third party administrator" means an administrator as
9 defined in Section 511.101 of the Illinois Insurance Code who
10 is licensed under Article XXXI 1/4 of that Code.
11 (Source: P.A. 87-560; 88-364.)
12 (215 ILCS 105/3) (from Ch. 73, par. 1303)
13 Sec. 3. Operation of the Plan.
14 a. There is hereby created an Illinois Comprehensive
15 Health Insurance Plan.
16 b. The Plan shall operate subject to the supervision and
17 control of the board. The board is created as a political
18 subdivision and body politic and corporate and, as such, is
19 not a State agency. The board shall consist of 10 public
20 members, appointed by the Governor with the advice and
21 consent of the Senate.
22 Initial members shall be appointed to the Board by the
23 Governor as follows: 2 members to serve until July 1, 1988,
24 and until their successors are appointed and qualified; 2
25 members to serve until July 1, 1989, and until their
26 successors are appointed and qualified; 3 members to serve
27 until July 1, 1990, and until their successors are appointed
28 and qualified; and 3 members to serve until July 1, 1991, and
29 until their successors are appointed and qualified. As terms
30 of initial members expire, their successors shall be
31 appointed for terms to expire the first day in July 3 years
32 thereafter, and until their successors are appointed and
33 qualified.
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1 Any vacancy in the Board occurring for any reason other
2 than the expiration of a term shall be filled for the
3 unexpired term in the same manner as the original
4 appointment.
5 Any member of the Board may be removed by the Governor
6 for neglect of duty, misfeasance, malfeasance, or nonfeasance
7 in office.
8 In addition, a representative of the Illinois Health Care
9 Cost Containment Council, a representative of the Office of
10 the Attorney General and the Director or the Director's
11 designated representative shall be members of the board.
12 Four members of the General Assembly, one each appointed by
13 the President and Minority Leader of the Senate and by the
14 Speaker and Minority Leader of the House of Representatives,
15 shall serve as nonvoting members of the board. At least 2 of
16 the public members shall be individuals reasonably expected
17 to qualify for coverage under the Plan, the parent or spouse
18 of such an individual, or a surviving family member of an
19 individual who could have qualified for the plan during his
20 lifetime. The Director or Director's representative shall be
21 the chairperson of the board. Members of the board shall
22 receive no compensation, but shall be reimbursed for
23 reasonable expenses incurred in the necessary performance of
24 their duties.
25 c. The board shall make an annual report in September
26 and shall file the report with the Secretary of the Senate
27 and the Clerk of the House of Representatives. The report
28 shall summarize the activities of the Plan in the preceding
29 calendar year, including net written and earned premiums, the
30 expense of administration, the paid and incurred losses for
31 the year and other information as may be requested by the
32 General Assembly. The report shall also include analysis and
33 recommendations regarding utilization review, quality
34 assurance and access to cost effective quality health care.
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1 d. In its plan of operation the board shall:
2 (1) Establish procedures for selecting an
3 administering carrier in accordance with Section 5 of
4 this Act.
5 (2) Establish procedures for the operation of the
6 board.
7 (3) Create a Plan fund, under management of the
8 board, to fund administrative expenses.
9 (4) Establish procedures for the handling and
10 accounting of assets and monies of the Plan.
11 (5) Develop and implement a program to publicize
12 the existence of the Plan, the eligibility requirements
13 and procedures for enrollment and to maintain public
14 awareness of the Plan.
15 (6) Establish procedures under which applicants and
16 participants may have grievances reviewed by a grievance
17 committee appointed by the board. The grievances shall
18 be reported to the board immediately after completion of
19 the review. The Department and the board shall retain
20 all written complaints regarding the Plan for at least 3
21 years. Oral complaints shall be reduced to written form
22 and maintained for at least 3 years.
23 (7) Provide for other matters as may be necessary
24 and proper for the execution of its powers, duties and
25 obligations under the Plan.
26 e. No later than 5 years after the Plan is operative the
27 board and the Department shall conduct cooperatively a study
28 of the Plan and the persons insured by the Plan to determine:
29 (1) claims experience including a breakdown of medical
30 conditions for which claims were paid; (2) whether
31 availability of the Plan affected employment opportunities
32 for participants; (3) whether availability of the Plan
33 affected the receipt of medical assistance benefits by Plan
34 participants; (4) whether a change occurred in the number of
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1 personal bankruptcies due to medical or other health related
2 costs; (5) data regarding all complaints received about the
3 Plan including its operation and services; (6) and any other
4 significant observations regarding utilization of the Plan.
5 The study shall culminate in a written report to be presented
6 to the Governor, the President of the Senate, the Speaker of
7 the House and the chairpersons of the House and Senate
8 Insurance Committees. The report shall be filed with the
9 Secretary of the Senate and the Clerk of the House of
10 Representatives. The report shall also be available to
11 members of the general public upon request.
12 f. The board may:
13 (1) Prepare and distribute certificate of
14 eligibility forms and enrollment instruction forms to
15 insurance producers and to the general public in this
16 State.
17 (2) Provide for reinsurance of risks incurred by
18 the Plan and enter into reinsurance agreements with
19 insurers to establish a reinsurance plan for risks of
20 coverage described in the Plan, or obtain commercial
21 reinsurance to reduce the risk of loss through the Plan.
22 (3) Issue additional types of health insurance
23 policies to provide optional coverages as are otherwise
24 permitted by this Act including a Medicare supplement
25 policy designed to supplement Medicare.
26 (4) Provide for and employ cost containment
27 measures and requirements including, but not limited to,
28 preadmission certification, second surgical opinion,
29 concurrent utilization review programs, and individual
30 case management for the purpose of making the pool more
31 cost effective. Prior authorization for emergency
32 services shall not be required. If prior authorization
33 for post-emergency services is required, the Plan or
34 administering carrier shall provide access 24 hours a
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1 day, 7 days a week to persons designated by the Plan or
2 administering carrier to make such determinations. If a
3 health care provider has attempted to contact such person
4 for prior authorization and no designated persons were
5 accessible or the authorization was not denied within 30
6 minutes of the request, the Plan or administering carrier
7 is deemed to have approved the request for prior
8 authorization.
9 (5) Design, utilize, or contract with preferred
10 provider organizations and health maintenance
11 organizations and otherwise arrange for the delivery of
12 cost effective health care services. Any such contract or
13 arrangement subject to this Act shall provide the insured
14 emergency services coverage such that payment for this
15 coverage is not dependent upon whether such services are
16 performed by a preferred or nonpreferred provider, and
17 such coverage shall be a the same benefit level as if the
18 service or treatment had been rendered by a plan
19 provider.
20 (6) Adopt bylaws, rules, regulations, policies and
21 procedures as may be necessary or convenient for the
22 implementation of the Act and the operation of the Plan.
23 g. The Director may, by rule, establish additional
24 powers and duties of the board and may adopt rules for any
25 other purposes, including the operation of the Plan, as are
26 necessary or proper to implement this Act.
27 h. The board is not liable for any obligation of the
28 Plan. There is no liability on the part of any member or
29 employee of the board or the Department, and no cause of
30 action of any nature may arise against them, for any action
31 taken or omission made by them in the performance of their
32 powers and duties under this Act, unless the action or
33 omission constitutes willful or wanton misconduct. The board
34 may provide in its bylaws or rules for indemnification of,
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1 and legal representation for, its members and employees.
2 i. There is no liability on the part of any insurance
3 producer for the failure of any applicant to be accepted by
4 the Plan unless the failure of the applicant to be accepted
5 by the Plan is due to an act or omission by the insurance
6 producer which constitutes willful or wanton misconduct.
7 (Source: P.A. 86-547; 86-1322; 87-560.)
8 (215 ILCS 105/5) (from Ch. 73, par. 1305)
9 Sec. 5. Administering carrier.
10 a. The board shall select an administering carrier
11 through a competitive bidding process to administer the plan.
12 The board shall evaluate bids submitted under this Section
13 based on criteria established by the board which shall
14 include:
15 (1) The carrier's proven ability to handle other large
16 group accident and health benefit plans.
17 (2) The efficiency of the carrier's claim paying
18 procedures.
19 (3) An estimate of total charges for administering the
20 plan.
21 (4) The ability of the carrier to administer the plan in
22 a cost-efficient manner.
23 (5) The financial condition and stability of the
24 carrier.
25 b. The administering carrier shall serve for a period of
26 5 years subject to removal for cause and subject to the
27 terms, conditions and limitations of the contract between the
28 board and the administering carrier. At least one year prior
29 to the expiration of each 5 year period of service by an
30 administering carrier, the board shall advertise for and
31 accept bids to serve as the administering carrier for the
32 succeeding 5 year period. Selection of the administering
33 carrier for the succeeding period shall be made at least 6
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1 months prior to the end of the current 5 year period.
2 c. The administering carrier shall perform such
3 eligibility and administrative claims payment functions
4 relating to the plan as may be assigned to it including:
5 (1) The administering carrier shall establish a premium
6 billing procedure for collection of premiums from plan
7 participants. Billings shall be made on a periodic basis as
8 determined by the board.
9 (2) The administering carrier shall perform all
10 necessary functions to assure timely payment of benefits to
11 participants under the plan, including:
12 (a) Making available information relating to the proper
13 manner of submitting a claim for benefits under the plan and
14 distributing forms upon which submissions shall be made.
15 (b) Evaluating the eligibility of each claim for payment
16 under the plan. Coverage and payment for emergency services
17 shall not be retrospectively denied, except upon reasonable
18 determination that (1) the emergency services claimed were
19 never performed or (2) an emergency medical screening
20 examination was performed on a patient who personally sought
21 emergency services knowing that he or she did not have an
22 emergency condition or necessity, and who did not in fact
23 require emergency services.
24 Coverage and payment for post-emergency services that
25 received prior authorization or deemed approval shall not be
26 retrospectively denied.
27 (c) The administering carrier shall be governed by the
28 requirements of Part 919 of Title 50 of the Illinois
29 Administrative Code, promulgated by the Department of
30 Insurance, regarding the handling of claims under this Act.
31 d. The administering carrier shall submit regular
32 reports to the board regarding the operation of the plan.
33 The frequency, content and form of the report shall be as
34 determined by the board.
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1 e. The administering carrier shall pay claims expenses
2 from the premium payments received from or on behalf of plan
3 participants. If the administering carrier's payments for
4 claims expenses exceed the portion of premiums allocated by
5 the board for payment of claims expenses, the board shall
6 provide to the administering carrier additional funds for
7 payment of claims expenses.
8 f. The administering carrier shall be paid as provided
9 in the board's contract with the administering carrier for
10 expenses incurred in the performance of its services.
11 (Source: P.A. 85-1013.)
12 (215 ILCS 105/8) (from Ch. 73, par. 1308)
13 Sec. 8. Minimum benefits.
14 a. Availability. The Plan shall offer in an annually
15 renewable policy major medical expense coverage to every
16 eligible person who is not eligible for Medicare. Major
17 medical expense coverage offered by the Plan shall pay an
18 eligible person's covered expenses, subject to limit on the
19 deductible and coinsurance payments authorized under
20 paragraph (4) of subsection d of this Section, up to a
21 lifetime benefit limit of $500,000 per covered individual.
22 The maximum limit under this subsection shall not be altered
23 by the Board, and no actuarial equivalent benefit may be
24 substituted by the Board. Any person who otherwise would
25 qualify for coverage under the Plan, but is excluded because
26 he or she is eligible for Medicare, shall be eligible for any
27 separate Medicare supplement policy which the Board may
28 offer.
29 b. Covered expenses. Covered expenses shall be limited
30 to the reasonable and customary charge, including negotiated
31 fees, in the locality for the following services and articles
32 when medically necessary and prescribed by a person licensed
33 and practicing within the scope of his or her profession as
-20- LRB9001344JSgc
1 authorized by State law:
2 (1) Hospital room and board and any other hospital
3 services including emergency and post-emergency services,
4 except that inpatient hospitalization for the treatment
5 of mental and emotional disorders shall only be covered
6 for a maximum of 45 days in a calendar year.
7 (2) Professional services for the diagnosis or
8 treatment of injuries, illnesses or conditions, other
9 than dental, or outpatient mental as described in
10 paragraph (17), which are rendered by a physician or
11 chiropractor, or by other licensed professionals at the
12 physician's or chiropractor's direction.
13 (3) If surgery has been recommended, a second
14 opinion may be required. The charge for a second opinion
15 as to whether the surgery is required will be paid in
16 full without regard to deductible or co-payment
17 requirements. If the second opinion differs from the
18 first, the charge for a third opinion, if desired, will
19 also be paid in full without regard to deductible or
20 co-payment requirements. Regardless of whether the
21 second opinion or third opinion confirms the original
22 recommendation, it is the patient's decision whether to
23 undergo surgery.
24 (4) Drugs requiring a physician's or other legally
25 authorized prescription.
26 (5) Skilled nursing care provided in a skilled
27 nursing facility for not more than 120 days in a calendar
28 year, provided the service commences within 14 days
29 following a confinement of at least 3 consecutive days in
30 a hospital for the same condition.
31 (6) Services of a home health agency in accord with
32 a home health care plan, up to a maximum of 270 visits
33 per year.
34 (7) Services of a licensed hospice for not more
-21- LRB9001344JSgc
1 than 180 days during a policy year.
2 (8) Use of radium or other radioactive materials.
3 (9) Oxygen.
4 (10) Anesthetics.
5 (11) Orthoses and prostheses other than dental.
6 (12) Rental or purchase in accordance with Board
7 policies or procedures of durable medical equipment,
8 other than eyeglasses or hearing aids, for which there is
9 no personal use in the absence of the condition for which
10 it is prescribed.
11 (13) Diagnostic x-rays and laboratory tests.
12 (14) Oral surgery for excision of partially or
13 completely unerupted impacted teeth or the gums and
14 tissues of the mouth, when not performed in connection
15 with the routine extraction or repair of teeth, and oral
16 surgery and procedures, including orthodontics and
17 prosthetics necessary for craniofacial or maxillofacial
18 conditions and to correct congenital defects or injuries
19 due to accident.
20 (15) Physical, speech, and functional occupational
21 therapy as medically necessary and provided by
22 appropriate licensed professionals.
23 (16) Transportation summoned by use of the 911
24 emergency telephone number or other means provided by a
25 licensed ambulance service to the nearest health care
26 facility qualified to treat the illness, injury or
27 condition, subject to the provisions of the Emergency
28 Medical Services (EMS) Systems (EMS) Act.
29 (17) The first 50 professional outpatient visits
30 for diagnosis and treatment of mental and emotional
31 disorders rendered during the year, up to a maximum of
32 $80 per visit.
33 (18) Human organ or tissue transplants specified by
34 the Board that are performed at a hospital designated by
-22- LRB9001344JSgc
1 the Board as a participating transplant center for that
2 specific organ or tissue transplant.
3 c. Exclusion. Covered expenses of the Plan shall not
4 include the following:
5 (1) Any charge for treatment for cosmetic purposes
6 other than for reconstructive surgery when the service is
7 incidental to or follows surgery resulting from injury,
8 sickness or other diseases of the involved part or
9 surgery for the repair or treatment of a congenital
10 bodily defect to restore normal bodily functions.
11 (2) Any charge for care that is primarily for rest,
12 custodial, educational, or domiciliary purposes.
13 (3) Any charge for services in a private room to
14 the extent it is in excess of the institution's charge
15 for its most common semiprivate room, unless a private
16 room is prescribed as medically necessary by a physician.
17 (4) That part of any charge for room and board or
18 for services rendered or articles prescribed by a
19 physician, dentist, or other health care personnel that
20 exceeds the reasonable and customary charge in the
21 locality or for any services or supplies not medically
22 necessary for the diagnosed injury or illness.
23 (5) Any charge for services or articles the
24 provision of which is not within the scope of licensure
25 of the institution or individual providing the services
26 or articles.
27 (6) Any expense incurred prior to the effective
28 date of coverage by the Plan for the person on whose
29 behalf the expense is incurred.
30 (7) Dental care, dental surgery, dental treatment
31 or dental appliances, except as provided in paragraph
32 (14) of subsection b of this Section.
33 (8) Eyeglasses, contact lenses, hearing aids or
34 their fitting.
-23- LRB9001344JSgc
1 (9) Illness or injury due to (A) war or any acts of
2 war; (B) commission of, or attempt to commit, a felony;
3 or (C) aviation activities, except when traveling as a
4 fare-paying passenger on a commercial airline.
5 (10) Services of blood donors and any fee for
6 failure to replace blood provided to an eligible person
7 each policy year.
8 (11) Personal supplies or services provided by a
9 hospital or nursing home, or any other nonmedical or
10 nonprescribed supply or service.
11 (12) Routine maternity charges for a pregnancy,
12 except where added as optional coverage with payment of
13 an additional premium for pregnancy resulting from
14 conception occurring after the effective date of the
15 optional coverage.
16 (13) Expenses of obtaining an abortion, induced
17 miscarriage or induced premature birth unless, in the
18 opinion of a physician, those procedures are necessary
19 for the preservation of life of the woman seeking such
20 treatment, or except an induced premature birth intended
21 to produce a live viable child and the procedure is
22 necessary for the health of the mother or unborn child.
23 (14) Any expense or charge for services, drugs, or
24 supplies that are: (i) not provided in accord with
25 generally accepted standards of current medical practice;
26 (ii) for procedures, treatments, equipment, transplants,
27 or implants, any of which are investigational,
28 experimental, or for research purposes; (iii)
29 investigative and not proven safe and effective; or (iv)
30 for, or resulting from, a gender transformation
31 operation.
32 (15) Any expense or charge for routine physical
33 examinations or tests.
34 (16) Any expense for which a charge is not made in
-24- LRB9001344JSgc
1 the absence of insurance or for which there is no legal
2 obligation on the part of the patient to pay.
3 (17) Any expense incurred for benefits provided
4 under the laws of the United States and this State,
5 including Medicare and Medicaid and other medical
6 assistance, military service-connected disability
7 payments, medical services provided for members of the
8 armed forces and their dependents or employees of the
9 armed forces of the United States, and medical services
10 financed on behalf of all citizens by the United States.
11 (18) Any expense or charge for in vitro
12 fertilization, artificial insemination, or any other
13 artificial means used to cause pregnancy.
14 (19) Any expense or charge for oral contraceptives
15 used for birth control or any other temporary birth
16 control measures.
17 (20) Any expense or charge for sterilization or
18 sterilization reversals.
19 (21) Any expense or charge for weight loss
20 programs, exercise equipment, or treatment of obesity,
21 except when certified by a physician as morbid obesity
22 (at least 2 times normal body weight).
23 (22) Any expense or charge for acupuncture
24 treatment unless used as an anesthetic agent for a
25 covered surgery.
26 (23) Any expense or charge for or related to organ
27 or tissue transplants other than those performed at a
28 hospital with a Board approved organ transplant program
29 that has been designated by the Board as a preferred or
30 exclusive provider organization for that specific organ
31 or tissue.
32 (24) Any expense or charge for procedures,
33 treatments, equipment, or services that are provided in
34 special settings for research purposes or in a controlled
-25- LRB9001344JSgc
1 environment, are being studied for safety, efficiency,
2 and effectiveness, and are awaiting endorsement by the
3 appropriate national medical speciality college for
4 general use within the medical community.
5 d. Premiums, deductibles, and coinsurance.
6 (1) Premiums charged for coverage issued by the
7 Plan may not be unreasonable in relation to the benefits
8 provided, the risk experience and the reasonable expenses
9 of providing the coverage.
10 (2) Separate schedules of premium rates based on
11 sex, age and geographical location shall apply for
12 individual risks.
13 (3) The Plan may provide for separate premium rates
14 for optional family coverage for the spouse or one or
15 more dependents of any person eligible to be insured
16 under the Plan who is also the oldest adult member of the
17 family and remains continuously enrolled in the Plan as
18 the primary enrollee. The rates shall be such percentage
19 of the applicable individual Plan rate as the Board, in
20 accordance with appropriate actuarial principles, shall
21 establish for each spouse or dependent.
22 (4) The Board shall determine, in accordance with
23 appropriate actuarial principles, the average rates that
24 individual standard risks in this State are charged by at
25 least 5 of the largest insurers providing coverage to
26 residents of Illinois that is substantially similar to
27 the Plan coverage. In the event at least 5 insurers do
28 not offer substantially similar coverage, the rates shall
29 be established using reasonable actuarial techniques and
30 shall reflect anticipated claims experience, expenses,
31 and other appropriate risk factors relating to the Plan.
32 Rates for Plan coverage shall be 135% of rates so
33 established as applicable for individual standard risks;
34 provided, however, if after determining that the
-26- LRB9001344JSgc
1 appropriations made pursuant to Section 12 of this Act
2 are insufficient to ensure that total income from all
3 sources will equal or exceed the total incurred costs and
4 expenses for the current number of enrollees, the board
5 shall raise premium rates above this 135% standard to the
6 level it deems necessary to ensure the financial solvency
7 of the Plan for enrollees already in the Plan. All rates
8 and rate schedules shall be submitted to the board for
9 approval.
10 (5) The Plan coverage defined in Section 6 shall
11 provide for a choice of deductibles as authorized by the
12 Board per individual per annum. If 2 individual members
13 of a family satisfy the same applicable deductibles, no
14 other member of that family who is eligible for coverage
15 under the Plan shall be required to meet any deductibles
16 for the balance of that calendar year. The deductibles
17 must be applied first to the authorized amount of covered
18 expenses incurred by the covered person. A mandatory
19 coinsurance requirement shall be imposed at the rate
20 authorized by the Board in excess of the mandatory
21 deductible, the coinsurance in the aggregate not to
22 exceed such amounts as are authorized by the Board per
23 annum. At its discretion the Board may, however, offer
24 catastrophic coverages or other policies that provide for
25 larger deductibles with or without coinsurance
26 requirements. The deductibles and coinsurance factors
27 may be adjusted annually according to the Medical
28 Component of the Consumer Price Index.
29 (6) The Plan may provide for and employ cost
30 containment measures and requirements including, but not
31 limited to, preadmission certification, second surgical
32 opinion, concurrent utilization review programs,
33 individual case management, preferred provider
34 organizations, and other cost effective arrangements for
-27- LRB9001344JSgc
1 paying for covered expenses.
2 e. Scope of coverage. Except as provided in subsection
3 c of this Section, if the covered expenses incurred by the
4 eligible person exceed the deductible for major medical
5 expense coverage in a calendar year, the Plan shall pay at
6 least 80% of any additional covered expenses incurred by the
7 person during the calendar year.
8 f. Preexisting conditions.
9 (1) Six months: Plan coverage shall exclude charges
10 or expenses incurred during the first 6 months following
11 the effective date of coverage as to any condition if:
12 (a) the condition had manifested itself within the 6
13 month period immediately preceding the effective date of
14 coverage in such a manner as would cause an ordinarily
15 prudent person to seek diagnosis, care or treatment; or
16 (b) medical advice, care or treatment was recommended or
17 received within the 6 month period immediately preceding
18 the effective date of coverage.
19 (2) (Blank).
20 (3) Waiver: The preexisting condition exclusions as
21 set forth in paragraph (1) of this subsection shall be
22 waived to the extent to which the eligible person: (a)
23 has satisfied similar exclusions under any prior health
24 insurance policy or plan that was involuntarily
25 terminated; (b) is ineligible for any continuation or
26 conversion rights that would continue or provide
27 substantially similar coverage following that
28 termination; and (c) has applied for Plan coverage not
29 later than 30 days following the involuntary termination.
30 No policy or plan shall be deemed to have been
31 involuntarily terminated if the master policyholder or
32 other controlling party elected to change insurance
33 coverage from one company or plan to another even if that
34 decision resulted in a discontinuation of coverage for
-28- LRB9001344JSgc
1 any individual under the plan, either totally or for any
2 medical condition. For each eligible person who qualifies
3 for and elects this waiver, there shall be added to each
4 payment of premium, on a prorated basis, a surcharge of
5 up to 10% of the otherwise applicable annual premium for
6 as long as that individual's coverage under the Plan
7 remains in effect or 60 months, whichever is less.
8 g. Other sources primary; nonduplication of benefits.
9 (1) The Plan shall be the last payor of benefits
10 whenever any other benefit or source of third party
11 payment is available. Subject to the provisions of
12 subsection e of Section 7, benefits otherwise payable
13 under Plan coverage shall be reduced by all amounts paid
14 or payable by Medicare or any other government program or
15 through any health insurance or other health benefit
16 plan, whether insured or otherwise, or through any third
17 party liability, settlement, judgment, or award,
18 regardless of the date of the settlement, judgment, or
19 award, whether the settlement, judgment, or award is in
20 the form of a contract, agreement, or trust on behalf of
21 a minor or otherwise and whether the settlement,
22 judgment, or award is payable to the covered person, his
23 or her dependent, estate, personal representative, or
24 guardian in a lump sum or over time, and by all hospital
25 or medical expense benefits paid or payable under any
26 worker's compensation coverage, automobile medical
27 payment, or liability insurance, whether provided on the
28 basis of fault or nonfault, and by any hospital or
29 medical benefits paid or payable under or provided
30 pursuant to any State or federal law or program.
31 (2) The Plan shall have a cause of action against
32 any covered person or any other person or entity for the
33 recovery of any amount paid to the extent the amount was
34 for treatment, services, or supplies not covered in this
-29- LRB9001344JSgc
1 Section or in excess of benefits as set forth in this
2 Section.
3 (3) Whenever benefits are due from the Plan because
4 of sickness or an injury to a covered person resulting
5 from a third party's wrongful act or negligence and the
6 covered person has recovered or may recover damages from
7 a third party or its insurer, the Plan shall have the
8 right to reduce benefits or to refuse to pay benefits
9 that otherwise may be payable by the amount of damages
10 that the covered person has recovered or may recover
11 regardless of the date of the sickness or injury or the
12 date of any settlement, judgment, or award resulting from
13 that sickness or injury.
14 During the pendency of any action or claim that is
15 brought by or on behalf of a covered person against a
16 third party or its insurer, any benefits that would
17 otherwise be payable except for the provisions of this
18 paragraph (3) shall be paid if payment by or for the
19 third party has not yet been made and the covered person
20 or, if incapable, that person's legal representative
21 agrees in writing to pay back promptly the benefits paid
22 as a result of the sickness or injury to the extent of
23 any future payments made by or for the third party for
24 the sickness or injury. This agreement is to apply
25 whether or not liability for the payments is established
26 or admitted by the third party or whether those payments
27 are itemized.
28 Any amounts due the plan to repay benefits may be
29 deducted from other benefits payable by the Plan after
30 payments by or for the third party are made.
31 (4) Benefits due from the Plan may be reduced or
32 refused as an offset against any amount otherwise
33 recoverable under this Section.
34 h. Right of subrogation; recoveries.
-30- LRB9001344JSgc
1 (1) Whenever the Plan has paid benefits because of
2 sickness or an injury to any covered person resulting
3 from a third party's wrongful act or negligence, or for
4 which an insurer is liable in accordance with the
5 provisions of any policy of insurance, and the covered
6 person has recovered or may recover damages from a third
7 party that is liable for the damages, the Plan shall have
8 the right to recover the benefits it paid from any
9 amounts that the covered person has received or may
10 receive regardless of the date of the sickness or injury
11 or the date of any settlement, judgment, or award
12 resulting from that sickness or injury. The Plan shall
13 be subrogated to any right of recovery the covered person
14 may have under the terms of any private or public health
15 care coverage or liability coverage, including coverage
16 under the Workers' Compensation Act or the Workers'
17 Occupational Diseases Act, without the necessity of
18 assignment of claim or other authorization to secure the
19 right of recovery. To enforce its subrogation right, the
20 Plan may (i) intervene or join in an action or proceeding
21 brought by the covered person or his personal
22 representative, including his guardian, conservator,
23 estate, dependents, or survivors, against any third party
24 or the third party's insurer that may be liable or (ii)
25 institute and prosecute legal proceedings against any
26 third party or the third party's insurer that may be
27 liable for the sickness or injury in an appropriate court
28 either in the name of the Plan or in the name of the
29 covered person or his personal representative, including
30 his guardian, conservator, estate, dependents, or
31 survivors.
32 (2) If any action or claim is brought by or on
33 behalf of a covered person against a third party or the
34 third party's insurer, the covered person or his personal
-31- LRB9001344JSgc
1 representative, including his guardian, conservator,
2 estate, dependents, or survivors, shall notify the Plan
3 by personal service or registered mail of the action or
4 claim and of the name of the court in which the action or
5 claim is brought, filing proof thereof in the action or
6 claim. The Plan may, at any time thereafter, join in the
7 action or claim upon its motion so that all orders of
8 court after hearing and judgment shall be made for its
9 protection. No release or settlement of a claim for
10 damages and no satisfaction of judgment in the action
11 shall be valid without the written consent of the Plan to
12 the extent of its interest in the settlement or judgment
13 and of the covered person or his personal representative.
14 (3) In the event that the covered person or his
15 personal representative fails to institute a proceeding
16 against any appropriate third party before the fifth
17 month before the action would be barred, the Plan may, in
18 its own name or in the name of the covered person or
19 personal representative, commence a proceeding against
20 any appropriate third party for the recovery of damages
21 on account of any sickness, injury, or death to the
22 covered person. The covered person shall cooperate in
23 doing what is reasonably necessary to assist the Plan in
24 any recovery and shall not take any action that would
25 prejudice the Plan's right to recovery. The Plan shall
26 pay to the covered person or his personal representative
27 all sums collected from any third party by judgment or
28 otherwise in excess of amounts paid in benefits under the
29 Plan and amounts paid or to be paid as costs, attorneys
30 fees, and reasonable expenses incurred by the Plan in
31 making the collection or enforcing the judgment.
32 (4) In the event that a covered person or his
33 personal representative, including his guardian,
34 conservator, estate, dependents, or survivors, recovers
-32- LRB9001344JSgc
1 damages from a third party for sickness or injury caused
2 to the covered person, the covered person or the personal
3 representative shall pay to the Plan from the damages
4 recovered the amount of benefits paid or to be paid on
5 behalf of the covered person.
6 (5) When the action or claim is brought by the
7 covered person alone and the covered person incurs a
8 personal liability to pay attorney's fees and costs of
9 litigation, the Plan's claim for reimbursement of the
10 benefits provided to the covered person shall be the full
11 amount of benefits paid to or on behalf of the covered
12 person under this Act less a pro rata share that
13 represents the Plan's reasonable share of attorney's fees
14 paid by the covered person and that portion of the cost
15 of litigation expenses determined by multiplying by the
16 ratio of the full amount of the expenditures to the full
17 amount of the judgement, award, or settlement.
18 (6) In the event of judgment or award in a suit or
19 claim against a third party or insurer, the court shall
20 first order paid from any judgement or award the
21 reasonable litigation expenses incurred in preparation
22 and prosecution of the action or claim, together with
23 reasonable attorney's fees. After payment of those
24 expenses and attorney's fees, the court shall apply out
25 of the balance of the judgment or award an amount
26 sufficient to reimburse the Plan the full amount of
27 benefits paid on behalf of the covered person under this
28 Act, provided the court may reduce and apportion the
29 Plan's portion of the judgement proportionate to the
30 recovery of the covered person. The burden of producing
31 evidence sufficient to support the exercise by the court
32 of its discretion to reduce the amount of a proven charge
33 sought to be enforced against the recovery shall rest
34 with the party seeking the reduction. The court may
-33- LRB9001344JSgc
1 consider the nature and extent of the injury, economic
2 and non-economic loss, settlement offers, comparative
3 negligence as it applies to the case at hand, hospital
4 costs, physician costs, and all other appropriate costs.
5 The Plan shall pay its pro rata share of the attorney
6 fees based on the Plan's recovery as it compares to the
7 total judgment. Any reimbursement rights of the Plan
8 shall take priority over all other liens and charges
9 existing under the laws of this State with the exception
10 of any attorney liens filed under the Attorneys Lien Act.
11 (7) The Plan may compromise or settle and release
12 any claim for benefits provided under this Act or waive
13 any claims for benefits, in whole or in part, for the
14 convenience of the Plan or if the Plan determines that
15 collection would result in undue hardship upon the
16 covered person.
17 (Source: P.A. 89-486, eff. 6-21-96.)
18 Section 93. The Health Maintenance Organization Act is
19 amended by changing Sections 1-2, 4-10, and 4-15 and adding
20 Section 5-7.2 as follows:
21 (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
22 Sec. 1-2. Definitions. As used in this Act, unless the
23 context otherwise requires, the following terms shall have
24 the meanings ascribed to them:
25 (1) "Advertisement" means any printed or published
26 material, audiovisual material and descriptive literature of
27 the health care plan used in direct mail, newspapers,
28 magazines, radio scripts, television scripts, billboards and
29 similar displays; and any descriptive literature or sales
30 aids of all kinds disseminated by a representative of the
31 health care plan for presentation to the public including,
32 but not limited to, circulars, leaflets, booklets,
-34- LRB9001344JSgc
1 depictions, illustrations, form letters and prepared sales
2 presentations.
3 (2) "Director" means the Director of Insurance.
4 (3) "Basic Health Care Services" means emergency care,
5 and inpatient hospital and physician care, outpatient medical
6 services, mental health services and care for alcohol and
7 drug abuse, including any reasonable deductibles and
8 co-payments, all of which are subject to such limitations as
9 are determined by the Director pursuant to rule.
10 (4) "Enrollee" means an individual who has been enrolled
11 in a health care plan.
12 (5) "Evidence of Coverage" means any certificate,
13 agreement, or contract issued to an enrollee setting out the
14 coverage to which he is entitled in exchange for a per capita
15 prepaid sum.
16 (6) "Group Contract" means a contract for health care
17 services which by its terms limits eligibility to members of
18 a specified group.
19 (7) "Health Care Plan" means any arrangement whereby any
20 organization undertakes to provide or arrange for and pay for
21 or reimburse the cost of basic health care services from
22 providers selected by the Health Maintenance Organization and
23 such arrangement consists of arranging for or the provision
24 of such health care services, as distinguished from mere
25 indemnification against the cost of such services, except as
26 otherwise authorized by Section 2-3 of this Act, on a per
27 capita prepaid basis, through insurance or otherwise. A
28 "health care plan" also includes any arrangement whereby an
29 organization undertakes to provide or arrange for or pay for
30 or reimburse the cost of any health care service for persons
31 who are enrolled in the integrated health care program
32 established under Section 5-16.3 of the Illinois Public Aid
33 Code through providers selected by the organization and the
34 arrangement consists of making provision for the delivery of
-35- LRB9001344JSgc
1 health care services, as distinguished from mere
2 indemnification. Nothing in this definition, however,
3 affects the total medical services available to persons
4 eligible for medical assistance under the Illinois Public Aid
5 Code.
6 (8) "Health Care Services" means any services included
7 in the furnishing to any individual of medical or dental
8 care, or the hospitalization or incident to the furnishing of
9 such care or hospitalization as well as the furnishing to any
10 person of any and all other services for the purpose of
11 preventing, alleviating, curing or healing human illness or
12 injury.
13 (9) "Health Maintenance Organization" means any
14 organization formed under the laws of this or another state
15 to provide or arrange for one or more health care plans under
16 a system which causes any part of the risk of health care
17 delivery to be borne by the organization or its providers.
18 (10) "Net Worth" means admitted assets, as defined in
19 Section 1-3 of this Act, minus liabilities.
20 (11) "Organization" means any insurance company, or a
21 nonprofit corporation authorized under the Medical Service
22 Plan Act, the Dental Service Plan Act, the Vision Service
23 Plan Act, the Pharmaceutical Service Plan Act, the Voluntary
24 Health Services Plans Act or the Non-profit Health Care
25 Service Plan Act, or a corporation organized under the laws
26 of this or another state for the purpose of operating one or
27 more health care plans and doing no business other than that
28 of a Health Maintenance Organization or an insurance company.
29 Organization shall also mean the University of Illinois
30 Hospital as defined in the University of Illinois Hospital
31 Act.
32 (12) "Provider" means any physician, hospital facility,
33 or other person which is licensed or otherwise authorized to
34 furnish health care services and also includes any other
-36- LRB9001344JSgc
1 entity that arranges for the delivery or furnishing of health
2 care service.
3 (13) "Producer" means a person directly or indirectly
4 associated with a health care plan who engages in
5 solicitation or enrollment.
6 (14) "Per capita prepaid" means a basis of prepayment by
7 which a fixed amount of money is prepaid per individual or
8 any other enrollment unit to the Health Maintenance
9 Organization or for health care services which are provided
10 during a definite time period regardless of the frequency or
11 extent of the services rendered by the Health Maintenance
12 Organization, except for copayments and deductibles and
13 except as provided in subsection (f) of Section 5-3 of this
14 Act.
15 (15) "Subscriber" means a person who has entered into a
16 contractual relationship with the Health Maintenance
17 Organization for the provision of or arrangement of at least
18 basic health care services to the beneficiaries of such
19 contract.
20 (16) "Emergency services" means those health care
21 services provided to evaluate and treat medical conditions of
22 recent onset and severity that would lead a prudent
23 layperson, possessing an average knowledge of medicine and
24 health, to believe that urgent or unscheduled medical care is
25 required.
26 (17) Post-emergency services" means those health care
27 services determined by a treating provider to be promptly and
28 medically necessary following stabilization of an emergency
29 condition.
30 (Source: P.A. 88-554, eff. 7-26-94; 89-90, eff. 6-30-95.)
31 (215 ILCS 125/4-10) (from Ch. 111 1/2, par. 1409.3)
32 Sec. 4-10. (a) Medical necessity; dispute resolution;
33 independent; second opinion; post-emergency service.
-37- LRB9001344JSgc
1 (a) Each Health Maintenance Organization shall provide a
2 mechanism for the timely review by a physician holding the
3 same class of license as the primary care physician, who is
4 unaffiliated with the Health Maintenance Organization,
5 jointly selected by the patient (or the patient's next of kin
6 or legal representative if the patient is unable to act for
7 himself), primary care physician and the Health Maintenance
8 Organization in the event of a dispute between the primary
9 care physician and the Health Maintenance Organization
10 regarding the medical necessity of a covered service proposed
11 by a primary care physician. In the event that the reviewing
12 physician determines the covered service to be medically
13 necessary, the Health Maintenance Organization shall provide
14 the covered service. Future contractual or employment action
15 by the Health Maintenance Organization regarding the primary
16 care physician shall not be based solely on the physician's
17 participation in this procedure.
18 (b) If prior authorization for post-emergency services
19 is required, the health care plan shall provide access 24
20 hours a day, 7 days a week to persons designated by the plan
21 to make such determinations. If a health care provider has
22 attempted to contact such person for prior authorization and
23 no designated persons were accessible or the authorization
24 was not denied within 30 minutes of the request, the health
25 care plan is deemed to have approved the request for prior
26 authorization.
27 (Source: P.A. 85-20; 85-850.)
28 (215 ILCS 125/4-15) (from Ch. 111 1/2, par. 1409.8)
29 Sec. 4-15. Emergency transportation.
30 (a) No contract or evidence of coverage for basic health
31 care services delivered, issued for delivery, renewed or
32 amended by a Health Maintenance Organization shall discourage
33 or penalize use of the 911 emergency telephone number or
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1 exclude coverage or require prior authorization for emergency
2 transportation by ambulance or emergency services rendered by
3 any provider. Payment for emergency services shall not
4 depend upon whether such services are performed by a
5 preferred or nonpreferred provider and such coverage shall be
6 at the same level as if the service or treatment had been
7 rendered by a plan provider. For the purposes of this
8 Section, the term "emergency" means a need for immediate
9 medical attention resulting from a life threatening condition
10 or situation or a need for immediate medical attention as
11 otherwise reasonably determined by a physician, public safety
12 official or other emergency medical personnel.
13 (b) Upon reasonable demand by a provider of emergency
14 transportation by ambulance, a Health Maintenance
15 Organization shall promptly pay to the provider, subject to
16 coverage limitations stated in the contract or evidence of
17 coverage, the charges for emergency transportation by
18 ambulance provided to an enrollee in a health care plan
19 arranged for by the Health Maintenance Organization. By
20 accepting any such payment from the Health Maintenance
21 Organization, the provider of emergency transportation by
22 ambulance agrees not to seek any payment from the enrollee
23 for services provided to the enrollee.
24 (Source: P.A. 86-833; 86-1028.)
25 (215 ILCS 125/5-7.2 new)
26 Sec. 5-7.2. Retrospective denials.
27 (a) No health care plan shall retrospectively deny
28 coverage and payment for emergency services except upon
29 reasonable determination that:
30 (1) the emergency services claimed were never
31 performed; or
32 (2) an emergency medical screening examination was
33 performed on a patient who personally sought emergency
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1 services knowing that he or she did not have an emergency
2 condition or necessity, and who did not in fact require
3 emergency services.
4 (b) No health care plan shall retrospectively deny
5 coverage and payment for post-emergency services which
6 received prior authorization or deemed approval.
7 Section 96. The Illinois Public Aid Code is amended by
8 changing Section 5-16.3 and adding Section 5-5.04 as follows:
9 (305 ILCS 5/5-5.04 new)
10 Sec. 5-5.04. Emergency services.
11 (a) As used in this Act, "emergency services" means
12 those health care services provided to evaluate and treat
13 medical conditions of recent onset and severity that would
14 lead a prudent layperson, possessing an average knowledge of
15 medicine and health, to believe that urgent or unscheduled
16 medical care is required. No prior authorization or approval
17 shall be required in order to seek and receive emergency
18 services.
19 (b) Coverage and payment for emergency services shall
20 not be retrospectively denied except upon reasonable
21 determination by the Illinois Department that:
22 (1) the emergency medical services claimed were
23 never performed; or
24 (2) an emergency medical screening examination was
25 performed on a patient who personally sought emergency
26 services knowing that he or she did not have an emergency
27 condition or necessity, and who did not in fact require
28 emergency services.
29 (305 ILCS 5/5-16.3)
30 (Text of Section before amendment by P.A. 89-507)
31 Sec. 5-16.3. System for integrated health care services.
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1 (a) It shall be the public policy of the State to adopt,
2 to the extent practicable, a health care program that
3 encourages the integration of health care services and
4 manages the health care of program enrollees while preserving
5 reasonable choice within a competitive and cost-efficient
6 environment. In furtherance of this public policy, the
7 Illinois Department shall develop and implement an integrated
8 health care program consistent with the provisions of this
9 Section. The provisions of this Section apply only to the
10 integrated health care program created under this Section.
11 Persons enrolled in the integrated health care program, as
12 determined by the Illinois Department by rule, shall be
13 afforded a choice among health care delivery systems, which
14 shall include, but are not limited to, (i) fee for service
15 care managed by a primary care physician licensed to practice
16 medicine in all its branches, (ii) managed health care
17 entities, and (iii) federally qualified health centers
18 (reimbursed according to a prospective cost-reimbursement
19 methodology) and rural health clinics (reimbursed according
20 to the Medicare methodology), where available. Persons
21 enrolled in the integrated health care program also may be
22 offered indemnity insurance plans, subject to availability.
23 For purposes of this Section, a "managed health care
24 entity" means a health maintenance organization or a managed
25 care community network as defined in this Section. A "health
26 maintenance organization" means a health maintenance
27 organization as defined in the Health Maintenance
28 Organization Act. A "managed care community network" means
29 an entity, other than a health maintenance organization, that
30 is owned, operated, or governed by providers of health care
31 services within this State and that provides or arranges
32 primary, secondary, and tertiary managed health care services
33 under contract with the Illinois Department exclusively to
34 enrollees of the integrated health care program. A managed
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1 care community network may contract with the Illinois
2 Department to provide only pediatric health care services. A
3 county provider as defined in Section 15-1 of this Code may
4 contract with the Illinois Department to provide services to
5 enrollees of the integrated health care program as a managed
6 care community network without the need to establish a
7 separate entity that provides services exclusively to
8 enrollees of the integrated health care program and shall be
9 deemed a managed care community network for purposes of this
10 Code only to the extent of the provision of services to those
11 enrollees in conjunction with the integrated health care
12 program. A county provider shall be entitled to contract
13 with the Illinois Department with respect to any contracting
14 region located in whole or in part within the county. A
15 county provider shall not be required to accept enrollees who
16 do not reside within the county.
17 Each managed care community network must demonstrate its
18 ability to bear the financial risk of serving enrollees under
19 this program. The Illinois Department shall by rule adopt
20 criteria for assessing the financial soundness of each
21 managed care community network. These rules shall consider
22 the extent to which a managed care community network is
23 comprised of providers who directly render health care and
24 are located within the community in which they seek to
25 contract rather than solely arrange or finance the delivery
26 of health care. These rules shall further consider a variety
27 of risk-bearing and management techniques, including the
28 sufficiency of quality assurance and utilization management
29 programs and whether a managed care community network has
30 sufficiently demonstrated its financial solvency and net
31 worth. The Illinois Department's criteria must be based on
32 sound actuarial, financial, and accounting principles. In
33 adopting these rules, the Illinois Department shall consult
34 with the Illinois Department of Insurance. The Illinois
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1 Department is responsible for monitoring compliance with
2 these rules.
3 This Section may not be implemented before the effective
4 date of these rules, the approval of any necessary federal
5 waivers, and the completion of the review of an application
6 submitted, at least 60 days before the effective date of
7 rules adopted under this Section, to the Illinois Department
8 by a managed care community network.
9 All health care delivery systems that contract with the
10 Illinois Department under the integrated health care program
11 shall clearly recognize a health care provider's right of
12 conscience under the Right of Conscience Act. In addition to
13 the provisions of that Act, no health care delivery system
14 that contracts with the Illinois Department under the
15 integrated health care program shall be required to provide,
16 arrange for, or pay for any health care or medical service,
17 procedure, or product if that health care delivery system is
18 owned, controlled, or sponsored by or affiliated with a
19 religious institution or religious organization that finds
20 that health care or medical service, procedure, or product to
21 violate its religious and moral teachings and beliefs.
22 (b) The Illinois Department may, by rule, provide for
23 different benefit packages for different categories of
24 persons enrolled in the program. Mental health services,
25 alcohol and substance abuse services, services related to
26 children with chronic or acute conditions requiring
27 longer-term treatment and follow-up, and rehabilitation care
28 provided by a free-standing rehabilitation hospital or a
29 hospital rehabilitation unit may be excluded from a benefit
30 package if the State ensures that those services are made
31 available through a separate delivery system. An exclusion
32 does not prohibit the Illinois Department from developing and
33 implementing demonstration projects for categories of persons
34 or services. Benefit packages for persons eligible for
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1 medical assistance under Articles V, VI, and XII shall be
2 based on the requirements of those Articles and shall be
3 consistent with the Title XIX of the Social Security Act.
4 Nothing in this Act shall be construed to apply to services
5 purchased by the Department of Children and Family Services
6 and the Department of Mental Health and Developmental
7 Disabilities under the provisions of Title 59 of the Illinois
8 Administrative Code, Part 132 ("Medicaid Community Mental
9 Health Services Program").
10 (c) The program established by this Section may be
11 implemented by the Illinois Department in various contracting
12 areas at various times. The health care delivery systems and
13 providers available under the program may vary throughout the
14 State. For purposes of contracting with managed health care
15 entities and providers, the Illinois Department shall
16 establish contracting areas similar to the geographic areas
17 designated by the Illinois Department for contracting
18 purposes under the Illinois Competitive Access and
19 Reimbursement Equity Program (ICARE) under the authority of
20 Section 3-4 of the Illinois Health Finance Reform Act or
21 similarly-sized or smaller geographic areas established by
22 the Illinois Department by rule. A managed health care entity
23 shall be permitted to contract in any geographic areas for
24 which it has a sufficient provider network and otherwise
25 meets the contracting terms of the State. The Illinois
26 Department is not prohibited from entering into a contract
27 with a managed health care entity at any time.
28 (d) A managed health care entity that contracts with the
29 Illinois Department for the provision of services under the
30 program shall do all of the following, solely for purposes of
31 the integrated health care program:
32 (1) Provide that any individual physician licensed
33 to practice medicine in all its branches, any pharmacy,
34 any federally qualified health center, and any
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1 podiatrist, that consistently meets the reasonable terms
2 and conditions established by the managed health care
3 entity, including but not limited to credentialing
4 standards, quality assurance program requirements,
5 utilization management requirements, financial
6 responsibility standards, contracting process
7 requirements, and provider network size and accessibility
8 requirements, must be accepted by the managed health care
9 entity for purposes of the Illinois integrated health
10 care program. Any individual who is either terminated
11 from or denied inclusion in the panel of physicians of
12 the managed health care entity shall be given, within 10
13 business days after that determination, a written
14 explanation of the reasons for his or her exclusion or
15 termination from the panel. This paragraph (1) does not
16 apply to the following:
17 (A) A managed health care entity that
18 certifies to the Illinois Department that:
19 (i) it employs on a full-time basis 125
20 or more Illinois physicians licensed to
21 practice medicine in all of its branches; and
22 (ii) it will provide medical services
23 through its employees to more than 80% of the
24 recipients enrolled with the entity in the
25 integrated health care program; or
26 (B) A domestic stock insurance company
27 licensed under clause (b) of class 1 of Section 4 of
28 the Illinois Insurance Code if (i) at least 66% of
29 the stock of the insurance company is owned by a
30 professional corporation organized under the
31 Professional Service Corporation Act that has 125 or
32 more shareholders who are Illinois physicians
33 licensed to practice medicine in all of its branches
34 and (ii) the insurance company certifies to the
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1 Illinois Department that at least 80% of those
2 physician shareholders will provide services to
3 recipients enrolled with the company in the
4 integrated health care program.
5 (2) Provide for reimbursement for providers for
6 emergency services care, as defined by subsection (a) of
7 Section 5-5.04 of this Code the Illinois Department by
8 rule, that must be provided to its enrollees, including
9 an emergency department room screening fee, and urgent
10 care that it authorizes for its enrollees, regardless of
11 the provider's affiliation with the managed health care
12 entity. Providers shall be reimbursed for emergency
13 services care at an amount equal to the Illinois
14 Department's fee-for-service rates for those medical
15 services rendered by providers not under contract with
16 the managed health care entity to enrollees of the
17 entity.
18 (A) Coverage and payment for emergency
19 services shall not be retrospectively denied except
20 upon reasonable determination by the Illinois
21 Department that (1) the emergency services claimed
22 were never performed or (2) an emergency medical
23 screening examination was performed on a patient who
24 personally sought emergency services knowing that he
25 or she did not have an emergency condition or
26 necessity, and who did not in fact require emergency
27 services.
28 (B) The appropriate use of the 911 emergency
29 telephone number shall not be discouraged or
30 penalized, and coverage or payment shall not be
31 denied solely on the basis that the enrollee used
32 the 911 emergency telephone number to summon
33 emergency services.
34 (2.5) Provide for reimbursement for post-emergency
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1 services, which are those health care services determined
2 by a treating provider to be promptly and medically
3 necessary following stabilization of an emergency
4 condition.
5 (A) If prior authorization for post-emergency
6 services is required, the managed health care entity
7 shall provide access 24 hours a day, 7 days a week
8 to persons designated by the entity to make such
9 determinations. If a health care provider has
10 attempted to contact such person for prior
11 authorization and no designated persons were
12 accessible or the authorization was not denied
13 within 30 minutes of the request, the managed health
14 care entity is deemed to have approved the request
15 for prior authorization.
16 (B) Coverage and payment for post-emergency
17 services which received prior authorization or
18 deemed approval shall not be retrospectively denied.
19 (3) Provide that any provider affiliated with a
20 managed health care entity may also provide services on a
21 fee-for-service basis to Illinois Department clients not
22 enrolled in a managed health care entity.
23 (4) Provide client education services as determined
24 and approved by the Illinois Department, including but
25 not limited to (i) education regarding appropriate
26 utilization of health care services in a managed care
27 system, (ii) written disclosure of treatment policies and
28 any restrictions or limitations on health services,
29 including, but not limited to, physical services,
30 clinical laboratory tests, hospital and surgical
31 procedures, prescription drugs and biologics, and
32 radiological examinations, and (iii) written notice that
33 the enrollee may receive from another provider those
34 services covered under this program that are not provided
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1 by the managed health care entity.
2 (5) Provide that enrollees within its system may
3 choose the site for provision of services and the panel
4 of health care providers.
5 (6) Not discriminate in its enrollment or
6 disenrollment practices among recipients of medical
7 services or program enrollees based on health status.
8 (7) Provide a quality assurance and utilization
9 review program that (i) for health maintenance
10 organizations meets the requirements of the Health
11 Maintenance Organization Act and (ii) for managed care
12 community networks meets the requirements established by
13 the Illinois Department in rules that incorporate those
14 standards set forth in the Health Maintenance
15 Organization Act.
16 (8) Issue a managed health care entity
17 identification card to each enrollee upon enrollment.
18 The card must contain all of the following:
19 (A) The enrollee's signature.
20 (B) The enrollee's health plan.
21 (C) The name and telephone number of the
22 enrollee's primary care physician.
23 (D) A telephone number to be used for
24 emergency service 24 hours per day, 7 days per week.
25 The telephone number required to be maintained
26 pursuant to this subparagraph by each managed health
27 care entity shall, at minimum, be staffed by
28 medically trained personnel and be provided
29 directly, or under arrangement, at an office or
30 offices in locations maintained solely within the
31 State of Illinois. For purposes of this
32 subparagraph, "medically trained personnel" means
33 licensed practical nurses or registered nurses
34 located in the State of Illinois who are licensed
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1 pursuant to the Illinois Nursing Act of 1987.
2 (9) Ensure that every primary care physician and
3 pharmacy in the managed health care entity meets the
4 standards established by the Illinois Department for
5 accessibility and quality of care. The Illinois
6 Department shall arrange for and oversee an evaluation of
7 the standards established under this paragraph (9) and
8 may recommend any necessary changes to these standards.
9 The Illinois Department shall submit an annual report to
10 the Governor and the General Assembly by April 1 of each
11 year regarding the effect of the standards on ensuring
12 access and quality of care to enrollees.
13 (10) Provide a procedure for handling complaints
14 that (i) for health maintenance organizations meets the
15 requirements of the Health Maintenance Organization Act
16 and (ii) for managed care community networks meets the
17 requirements established by the Illinois Department in
18 rules that incorporate those standards set forth in the
19 Health Maintenance Organization Act.
20 (11) Maintain, retain, and make available to the
21 Illinois Department records, data, and information, in a
22 uniform manner determined by the Illinois Department,
23 sufficient for the Illinois Department to monitor
24 utilization, accessibility, and quality of care.
25 (12) Except for providers who are prepaid, pay all
26 approved claims for covered services that are completed
27 and submitted to the managed health care entity within 30
28 days after receipt of the claim or receipt of the
29 appropriate capitation payment or payments by the managed
30 health care entity from the State for the month in which
31 the services included on the claim were rendered,
32 whichever is later. If payment is not made or mailed to
33 the provider by the managed health care entity by the due
34 date under this subsection, an interest penalty of 1% of
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1 any amount unpaid shall be added for each month or
2 fraction of a month after the due date, until final
3 payment is made. Nothing in this Section shall prohibit
4 managed health care entities and providers from mutually
5 agreeing to terms that require more timely payment.
6 (13) Provide integration with community-based
7 programs provided by certified local health departments
8 such as Women, Infants, and Children Supplemental Food
9 Program (WIC), childhood immunization programs, health
10 education programs, case management programs, and health
11 screening programs.
12 (14) Provide that the pharmacy formulary used by a
13 managed health care entity and its contract providers be
14 no more restrictive than the Illinois Department's
15 pharmaceutical program on the effective date of this
16 amendatory Act of 1994 and as amended after that date.
17 (15) Provide integration with community-based
18 organizations, including, but not limited to, any
19 organization that has operated within a Medicaid
20 Partnership as defined by this Code or by rule of the
21 Illinois Department, that may continue to operate under a
22 contract with the Illinois Department or a managed health
23 care entity under this Section to provide case management
24 services to Medicaid clients in designated high-need
25 areas.
26 The Illinois Department may, by rule, determine
27 methodologies to limit financial liability for managed health
28 care entities resulting from payment for services to
29 enrollees provided under the Illinois Department's integrated
30 health care program. Any methodology so determined may be
31 considered or implemented by the Illinois Department through
32 a contract with a managed health care entity under this
33 integrated health care program.
34 The Illinois Department shall contract with an entity or
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1 entities to provide external peer-based quality assurance
2 review for the integrated health care program. The entity
3 shall be representative of Illinois physicians licensed to
4 practice medicine in all its branches and have statewide
5 geographic representation in all specialties of medical care
6 that are provided within the integrated health care program.
7 The entity may not be a third party payer and shall maintain
8 offices in locations around the State in order to provide
9 service and continuing medical education to physician
10 participants within the integrated health care program. The
11 review process shall be developed and conducted by Illinois
12 physicians licensed to practice medicine in all its branches.
13 In consultation with the entity, the Illinois Department may
14 contract with other entities for professional peer-based
15 quality assurance review of individual categories of services
16 other than services provided, supervised, or coordinated by
17 physicians licensed to practice medicine in all its branches.
18 The Illinois Department shall establish, by rule, criteria to
19 avoid conflicts of interest in the conduct of quality
20 assurance activities consistent with professional peer-review
21 standards. All quality assurance activities shall be
22 coordinated by the Illinois Department.
23 (e) All persons enrolled in the program shall be
24 provided with a full written explanation of all
25 fee-for-service and managed health care plan options and a
26 reasonable opportunity to choose among the options as
27 provided by rule. The Illinois Department shall provide to
28 enrollees, upon enrollment in the integrated health care
29 program and at least annually thereafter, notice of the
30 process for requesting an appeal under the Illinois
31 Department's administrative appeal procedures.
32 Notwithstanding any other Section of this Code, the Illinois
33 Department may provide by rule for the Illinois Department to
34 assign a person enrolled in the program to a specific
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1 provider of medical services or to a specific health care
2 delivery system if an enrollee has failed to exercise choice
3 in a timely manner. An enrollee assigned by the Illinois
4 Department shall be afforded the opportunity to disenroll and
5 to select a specific provider of medical services or a
6 specific health care delivery system within the first 30 days
7 after the assignment. An enrollee who has failed to exercise
8 choice in a timely manner may be assigned only if there are 3
9 or more managed health care entities contracting with the
10 Illinois Department within the contracting area, except that,
11 outside the City of Chicago, this requirement may be waived
12 for an area by rules adopted by the Illinois Department after
13 consultation with all hospitals within the contracting area.
14 The Illinois Department shall establish by rule the procedure
15 for random assignment of enrollees who fail to exercise
16 choice in a timely manner to a specific managed health care
17 entity in proportion to the available capacity of that
18 managed health care entity. Assignment to a specific provider
19 of medical services or to a specific managed health care
20 entity may not exceed that provider's or entity's capacity as
21 determined by the Illinois Department. Any person who has
22 chosen a specific provider of medical services or a specific
23 managed health care entity, or any person who has been
24 assigned under this subsection, shall be given the
25 opportunity to change that choice or assignment at least once
26 every 12 months, as determined by the Illinois Department by
27 rule. The Illinois Department shall maintain a toll-free
28 telephone number for program enrollees' use in reporting
29 problems with managed health care entities.
30 (f) If a person becomes eligible for participation in
31 the integrated health care program while he or she is
32 hospitalized, the Illinois Department may not enroll that
33 person in the program until after he or she has been
34 discharged from the hospital. This subsection does not apply
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1 to newborn infants whose mothers are enrolled in the
2 integrated health care program.
3 (g) The Illinois Department shall, by rule, establish
4 for managed health care entities rates that (i) are certified
5 to be actuarially sound, as determined by an actuary who is
6 an associate or a fellow of the Society of Actuaries or a
7 member of the American Academy of Actuaries and who has
8 expertise and experience in medical insurance and benefit
9 programs, in accordance with the Illinois Department's
10 current fee-for-service payment system, and (ii) take into
11 account any difference of cost to provide health care to
12 different populations based on gender, age, location, and
13 eligibility category. The rates for managed health care
14 entities shall be determined on a capitated basis.
15 The Illinois Department by rule shall establish a method
16 to adjust its payments to managed health care entities in a
17 manner intended to avoid providing any financial incentive to
18 a managed health care entity to refer patients to a county
19 provider, in an Illinois county having a population greater
20 than 3,000,000, that is paid directly by the Illinois
21 Department. The Illinois Department shall by April 1, 1997,
22 and annually thereafter, review the method to adjust
23 payments. Payments by the Illinois Department to the county
24 provider, for persons not enrolled in a managed care
25 community network owned or operated by a county provider,
26 shall be paid on a fee-for-service basis under Article XV of
27 this Code.
28 The Illinois Department by rule shall establish a method
29 to reduce its payments to managed health care entities to
30 take into consideration (i) any adjustment payments paid to
31 hospitals under subsection (h) of this Section to the extent
32 those payments, or any part of those payments, have been
33 taken into account in establishing capitated rates under this
34 subsection (g) and (ii) the implementation of methodologies
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1 to limit financial liability for managed health care entities
2 under subsection (d) of this Section.
3 (h) For hospital services provided by a hospital that
4 contracts with a managed health care entity, adjustment
5 payments shall be paid directly to the hospital by the
6 Illinois Department. Adjustment payments may include but
7 need not be limited to adjustment payments to:
8 disproportionate share hospitals under Section 5-5.02 of this
9 Code; primary care access health care education payments (89
10 Ill. Adm. Code 149.140); payments for capital, direct medical
11 education, indirect medical education, certified registered
12 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
13 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
14 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
15 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
16 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
17 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
18 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
19 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
20 148.290(h)); and outpatient indigent volume adjustments (89
21 Ill. Adm. Code 148.140(b)(5)).
22 (i) For any hospital eligible for the adjustment
23 payments described in subsection (h), the Illinois Department
24 shall maintain, through the period ending June 30, 1995,
25 reimbursement levels in accordance with statutes and rules in
26 effect on April 1, 1994.
27 (j) Nothing contained in this Code in any way limits or
28 otherwise impairs the authority or power of the Illinois
29 Department to enter into a negotiated contract pursuant to
30 this Section with a managed health care entity, including,
31 but not limited to, a health maintenance organization, that
32 provides for termination or nonrenewal of the contract
33 without cause upon notice as provided in the contract and
34 without a hearing.
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1 (k) Section 5-5.15 does not apply to the program
2 developed and implemented pursuant to this Section.
3 (l) The Illinois Department shall, by rule, define those
4 chronic or acute medical conditions of childhood that require
5 longer-term treatment and follow-up care. The Illinois
6 Department shall ensure that services required to treat these
7 conditions are available through a separate delivery system.
8 A managed health care entity that contracts with the
9 Illinois Department may refer a child with medical conditions
10 described in the rules adopted under this subsection directly
11 to a children's hospital or to a hospital, other than a
12 children's hospital, that is qualified to provide inpatient
13 and outpatient services to treat those conditions. The
14 Illinois Department shall provide fee-for-service
15 reimbursement directly to a children's hospital for those
16 services pursuant to Title 89 of the Illinois Administrative
17 Code, Section 148.280(a), at a rate at least equal to the
18 rate in effect on March 31, 1994. For hospitals, other than
19 children's hospitals, that are qualified to provide inpatient
20 and outpatient services to treat those conditions, the
21 Illinois Department shall provide reimbursement for those
22 services on a fee-for-service basis, at a rate at least equal
23 to the rate in effect for those other hospitals on March 31,
24 1994.
25 A children's hospital shall be directly reimbursed for
26 all services provided at the children's hospital on a
27 fee-for-service basis pursuant to Title 89 of the Illinois
28 Administrative Code, Section 148.280(a), at a rate at least
29 equal to the rate in effect on March 31, 1994, until the
30 later of (i) implementation of the integrated health care
31 program under this Section and development of actuarially
32 sound capitation rates for services other than those chronic
33 or acute medical conditions of childhood that require
34 longer-term treatment and follow-up care as defined by the
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1 Illinois Department in the rules adopted under this
2 subsection or (ii) March 31, 1996.
3 Notwithstanding anything in this subsection to the
4 contrary, a managed health care entity shall not consider
5 sources or methods of payment in determining the referral of
6 a child. The Illinois Department shall adopt rules to
7 establish criteria for those referrals. The Illinois
8 Department by rule shall establish a method to adjust its
9 payments to managed health care entities in a manner intended
10 to avoid providing any financial incentive to a managed
11 health care entity to refer patients to a provider who is
12 paid directly by the Illinois Department.
13 (m) Behavioral health services provided or funded by the
14 Department of Mental Health and Developmental Disabilities,
15 the Department of Alcoholism and Substance Abuse, the
16 Department of Children and Family Services, and the Illinois
17 Department shall be excluded from a benefit package.
18 Conditions of an organic or physical origin or nature,
19 including medical detoxification, however, may not be
20 excluded. In this subsection, "behavioral health services"
21 means mental health services and subacute alcohol and
22 substance abuse treatment services, as defined in the
23 Illinois Alcoholism and Other Drug Dependency Act. In this
24 subsection, "mental health services" includes, at a minimum,
25 the following services funded by the Illinois Department, the
26 Department of Mental Health and Developmental Disabilities,
27 or the Department of Children and Family Services: (i)
28 inpatient hospital services, including related physician
29 services, related psychiatric interventions, and
30 pharmaceutical services provided to an eligible recipient
31 hospitalized with a primary diagnosis of psychiatric
32 disorder; (ii) outpatient mental health services as defined
33 and specified in Title 59 of the Illinois Administrative
34 Code, Part 132; (iii) any other outpatient mental health
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1 services funded by the Illinois Department pursuant to the
2 State of Illinois Medicaid Plan; (iv) partial
3 hospitalization; and (v) follow-up stabilization related to
4 any of those services. Additional behavioral health services
5 may be excluded under this subsection as mutually agreed in
6 writing by the Illinois Department and the affected State
7 agency or agencies. The exclusion of any service does not
8 prohibit the Illinois Department from developing and
9 implementing demonstration projects for categories of persons
10 or services. The Department of Mental Health and
11 Developmental Disabilities, the Department of Children and
12 Family Services, and the Department of Alcoholism and
13 Substance Abuse shall each adopt rules governing the
14 integration of managed care in the provision of behavioral
15 health services. The State shall integrate managed care
16 community networks and affiliated providers, to the extent
17 practicable, in any separate delivery system for mental
18 health services.
19 (n) The Illinois Department shall adopt rules to
20 establish reserve requirements for managed care community
21 networks, as required by subsection (a), and health
22 maintenance organizations to protect against liabilities in
23 the event that a managed health care entity is declared
24 insolvent or bankrupt. If a managed health care entity other
25 than a county provider is declared insolvent or bankrupt,
26 after liquidation and application of any available assets,
27 resources, and reserves, the Illinois Department shall pay a
28 portion of the amounts owed by the managed health care entity
29 to providers for services rendered to enrollees under the
30 integrated health care program under this Section based on
31 the following schedule: (i) from April 1, 1995 through June
32 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
33 through June 30, 2001, 80% of the amounts owed; and (iii)
34 from July 1, 2001 through June 30, 2005, 75% of the amounts
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1 owed. The amounts paid under this subsection shall be
2 calculated based on the total amount owed by the managed
3 health care entity to providers before application of any
4 available assets, resources, and reserves. After June 30,
5 2005, the Illinois Department may not pay any amounts owed to
6 providers as a result of an insolvency or bankruptcy of a
7 managed health care entity occurring after that date. The
8 Illinois Department is not obligated, however, to pay amounts
9 owed to a provider that has an ownership or other governing
10 interest in the managed health care entity. This subsection
11 applies only to managed health care entities and the services
12 they provide under the integrated health care program under
13 this Section.
14 (o) Notwithstanding any other provision of law or
15 contractual agreement to the contrary, providers shall not be
16 required to accept from any other third party payer the rates
17 determined or paid under this Code by the Illinois
18 Department, managed health care entity, or other health care
19 delivery system for services provided to recipients.
20 (p) The Illinois Department may seek and obtain any
21 necessary authorization provided under federal law to
22 implement the program, including the waiver of any federal
23 statutes or regulations. The Illinois Department may seek a
24 waiver of the federal requirement that the combined
25 membership of Medicare and Medicaid enrollees in a managed
26 care community network may not exceed 75% of the managed care
27 community network's total enrollment. The Illinois
28 Department shall not seek a waiver of this requirement for
29 any other category of managed health care entity. The
30 Illinois Department shall not seek a waiver of the inpatient
31 hospital reimbursement methodology in Section 1902(a)(13)(A)
32 of Title XIX of the Social Security Act even if the federal
33 agency responsible for administering Title XIX determines
34 that Section 1902(a)(13)(A) applies to managed health care
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1 systems.
2 Notwithstanding any other provisions of this Code to the
3 contrary, the Illinois Department shall seek a waiver of
4 applicable federal law in order to impose a co-payment system
5 consistent with this subsection on recipients of medical
6 services under Title XIX of the Social Security Act who are
7 not enrolled in a managed health care entity. The waiver
8 request submitted by the Illinois Department shall provide
9 for co-payments of up to $0.50 for prescribed drugs and up to
10 $0.50 for x-ray services and shall provide for co-payments of
11 up to $10 for non-emergency services provided in a hospital
12 emergency department room and up to $10 for non-emergency
13 ambulance services. The purpose of the co-payments shall be
14 to deter those recipients from seeking unnecessary medical
15 care. Co-payments may not be used to deter recipients from
16 seeking or accessing emergency services and other necessary
17 medical care. No recipient shall be required to pay more
18 than a total of $150 per year in co-payments under the waiver
19 request required by this subsection. A recipient may not be
20 required to pay more than $15 of any amount due under this
21 subsection in any one month.
22 Co-payments authorized under this subsection may not be
23 imposed when the care was necessitated by a true medical
24 condition as described in the definition of "emergency
25 services under subsection (a) of Section 5-5.04 emergency.
26 Copayments for non-emergency services in a hospital emergency
27 department shall not be imposed retrospectively except upon
28 reasonable determination by the Illinois Department that (1)
29 the emergency services claimed were never performed or (2) an
30 emergency medical screening examination was performed on a
31 patient who personally sought emergency services knowing that
32 he or she did not have an emergency condition or necessity,
33 and who did not in fact require emergency services.
34 Co-payments may not be imposed for any of the following
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1 classifications of services:
2 (1) Services furnished to person under 18 years of
3 age.
4 (2) Services furnished to pregnant women.
5 (3) Services furnished to any individual who is an
6 inpatient in a hospital, nursing facility, intermediate
7 care facility, or other medical institution, if that
8 person is required to spend for costs of medical care all
9 but a minimal amount of his or her income required for
10 personal needs.
11 (4) Services furnished to a person who is receiving
12 hospice care.
13 Co-payments authorized under this subsection shall not be
14 deducted from or reduce in any way payments for medical
15 services from the Illinois Department to providers. No
16 provider may deny those services to an individual eligible
17 for services based on the individual's inability to pay the
18 co-payment.
19 Recipients who are subject to co-payments shall be
20 provided notice, in plain and clear language, of the amount
21 of the co-payments, the circumstances under which co-payments
22 are exempted, the circumstances under which co-payments may
23 be assessed, and their manner of collection.
24 The Illinois Department shall establish a Medicaid
25 Co-Payment Council to assist in the development of co-payment
26 policies for the medical assistance program. The Medicaid
27 Co-Payment Council shall also have jurisdiction to develop a
28 program to provide financial or non-financial incentives to
29 Medicaid recipients in order to encourage recipients to seek
30 necessary health care. The Council shall be chaired by the
31 Director of the Illinois Department, and shall have 6
32 additional members. Two of the 6 additional members shall be
33 appointed by the Governor, and one each shall be appointed by
34 the President of the Senate, the Minority Leader of the
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1 Senate, the Speaker of the House of Representatives, and the
2 Minority Leader of the House of Representatives. The Council
3 may be convened and make recommendations upon the appointment
4 of a majority of its members. The Council shall be appointed
5 and convened no later than September 1, 1994 and shall report
6 its recommendations to the Director of the Illinois
7 Department and the General Assembly no later than October 1,
8 1994. The chairperson of the Council shall be allowed to
9 vote only in the case of a tie vote among the appointed
10 members of the Council.
11 The Council shall be guided by the following principles
12 as it considers recommendations to be developed to implement
13 any approved waivers that the Illinois Department must seek
14 pursuant to this subsection:
15 (1) Co-payments should not be used to deter access
16 to adequate medical care.
17 (2) Co-payments should be used to reduce fraud.
18 (3) Co-payment policies should be examined in
19 consideration of other states' experience, and the
20 ability of successful co-payment plans to control
21 unnecessary or inappropriate utilization of services
22 should be promoted.
23 (4) All participants, both recipients and
24 providers, in the medical assistance program have
25 responsibilities to both the State and the program.
26 (5) Co-payments are primarily a tool to educate the
27 participants in the responsible use of health care
28 resources.
29 (6) Co-payments should not be used to penalize
30 providers.
31 (7) A successful medical program requires the
32 elimination of improper utilization of medical resources.
33 The integrated health care program, or any part of that
34 program, established under this Section may not be
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1 implemented if matching federal funds under Title XIX of the
2 Social Security Act are not available for administering the
3 program.
4 The Illinois Department shall submit for publication in
5 the Illinois Register the name, address, and telephone number
6 of the individual to whom a request may be directed for a
7 copy of the request for a waiver of provisions of Title XIX
8 of the Social Security Act that the Illinois Department
9 intends to submit to the Health Care Financing Administration
10 in order to implement this Section. The Illinois Department
11 shall mail a copy of that request for waiver to all
12 requestors at least 16 days before filing that request for
13 waiver with the Health Care Financing Administration.
14 (q) After the effective date of this Section, the
15 Illinois Department may take all planning and preparatory
16 action necessary to implement this Section, including, but
17 not limited to, seeking requests for proposals relating to
18 the integrated health care program created under this
19 Section.
20 (r) In order to (i) accelerate and facilitate the
21 development of integrated health care in contracting areas
22 outside counties with populations in excess of 3,000,000 and
23 counties adjacent to those counties and (ii) maintain and
24 sustain the high quality of education and residency programs
25 coordinated and associated with local area hospitals, the
26 Illinois Department may develop and implement a demonstration
27 program for managed care community networks owned, operated,
28 or governed by State-funded medical schools. The Illinois
29 Department shall prescribe by rule the criteria, standards,
30 and procedures for effecting this demonstration program.
31 (s) (Blank).
32 (t) On April 1, 1995 and every 6 months thereafter, the
33 Illinois Department shall report to the Governor and General
34 Assembly on the progress of the integrated health care
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1 program in enrolling clients into managed health care
2 entities. The report shall indicate the capacities of the
3 managed health care entities with which the State contracts,
4 the number of clients enrolled by each contractor, the areas
5 of the State in which managed care options do not exist, and
6 the progress toward meeting the enrollment goals of the
7 integrated health care program.
8 (u) The Illinois Department may implement this Section
9 through the use of emergency rules in accordance with Section
10 5-45 of the Illinois Administrative Procedure Act. For
11 purposes of that Act, the adoption of rules to implement this
12 Section is deemed an emergency and necessary for the public
13 interest, safety, and welfare.
14 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
15 89-673, eff. 8-14-96; revised 8-26-96.)
16 (Text of Section after amendment by P.A. 89-507)
17 Sec. 5-16.3. System for integrated health care services.
18 (a) It shall be the public policy of the State to adopt,
19 to the extent practicable, a health care program that
20 encourages the integration of health care services and
21 manages the health care of program enrollees while preserving
22 reasonable choice within a competitive and cost-efficient
23 environment. In furtherance of this public policy, the
24 Illinois Department shall develop and implement an integrated
25 health care program consistent with the provisions of this
26 Section. The provisions of this Section apply only to the
27 integrated health care program created under this Section.
28 Persons enrolled in the integrated health care program, as
29 determined by the Illinois Department by rule, shall be
30 afforded a choice among health care delivery systems, which
31 shall include, but are not limited to, (i) fee for service
32 care managed by a primary care physician licensed to practice
33 medicine in all its branches, (ii) managed health care
34 entities, and (iii) federally qualified health centers
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1 (reimbursed according to a prospective cost-reimbursement
2 methodology) and rural health clinics (reimbursed according
3 to the Medicare methodology), where available. Persons
4 enrolled in the integrated health care program also may be
5 offered indemnity insurance plans, subject to availability.
6 For purposes of this Section, a "managed health care
7 entity" means a health maintenance organization or a managed
8 care community network as defined in this Section. A "health
9 maintenance organization" means a health maintenance
10 organization as defined in the Health Maintenance
11 Organization Act. A "managed care community network" means
12 an entity, other than a health maintenance organization, that
13 is owned, operated, or governed by providers of health care
14 services within this State and that provides or arranges
15 primary, secondary, and tertiary managed health care services
16 under contract with the Illinois Department exclusively to
17 enrollees of the integrated health care program. A managed
18 care community network may contract with the Illinois
19 Department to provide only pediatric health care services. A
20 county provider as defined in Section 15-1 of this Code may
21 contract with the Illinois Department to provide services to
22 enrollees of the integrated health care program as a managed
23 care community network without the need to establish a
24 separate entity that provides services exclusively to
25 enrollees of the integrated health care program and shall be
26 deemed a managed care community network for purposes of this
27 Code only to the extent of the provision of services to those
28 enrollees in conjunction with the integrated health care
29 program. A county provider shall be entitled to contract
30 with the Illinois Department with respect to any contracting
31 region located in whole or in part within the county. A
32 county provider shall not be required to accept enrollees who
33 do not reside within the county.
34 Each managed care community network must demonstrate its
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1 ability to bear the financial risk of serving enrollees under
2 this program. The Illinois Department shall by rule adopt
3 criteria for assessing the financial soundness of each
4 managed care community network. These rules shall consider
5 the extent to which a managed care community network is
6 comprised of providers who directly render health care and
7 are located within the community in which they seek to
8 contract rather than solely arrange or finance the delivery
9 of health care. These rules shall further consider a variety
10 of risk-bearing and management techniques, including the
11 sufficiency of quality assurance and utilization management
12 programs and whether a managed care community network has
13 sufficiently demonstrated its financial solvency and net
14 worth. The Illinois Department's criteria must be based on
15 sound actuarial, financial, and accounting principles. In
16 adopting these rules, the Illinois Department shall consult
17 with the Illinois Department of Insurance. The Illinois
18 Department is responsible for monitoring compliance with
19 these rules.
20 This Section may not be implemented before the effective
21 date of these rules, the approval of any necessary federal
22 waivers, and the completion of the review of an application
23 submitted, at least 60 days before the effective date of
24 rules adopted under this Section, to the Illinois Department
25 by a managed care community network.
26 All health care delivery systems that contract with the
27 Illinois Department under the integrated health care program
28 shall clearly recognize a health care provider's right of
29 conscience under the Right of Conscience Act. In addition to
30 the provisions of that Act, no health care delivery system
31 that contracts with the Illinois Department under the
32 integrated health care program shall be required to provide,
33 arrange for, or pay for any health care or medical service,
34 procedure, or product if that health care delivery system is
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1 owned, controlled, or sponsored by or affiliated with a
2 religious institution or religious organization that finds
3 that health care or medical service, procedure, or product to
4 violate its religious and moral teachings and beliefs.
5 (b) The Illinois Department may, by rule, provide for
6 different benefit packages for different categories of
7 persons enrolled in the program. Mental health services,
8 alcohol and substance abuse services, services related to
9 children with chronic or acute conditions requiring
10 longer-term treatment and follow-up, and rehabilitation care
11 provided by a free-standing rehabilitation hospital or a
12 hospital rehabilitation unit may be excluded from a benefit
13 package if the State ensures that those services are made
14 available through a separate delivery system. An exclusion
15 does not prohibit the Illinois Department from developing and
16 implementing demonstration projects for categories of persons
17 or services. Benefit packages for persons eligible for
18 medical assistance under Articles V, VI, and XII shall be
19 based on the requirements of those Articles and shall be
20 consistent with the Title XIX of the Social Security Act.
21 Nothing in this Act shall be construed to apply to services
22 purchased by the Department of Children and Family Services
23 and the Department of Human Services (as successor to the
24 Department of Mental Health and Developmental Disabilities)
25 under the provisions of Title 59 of the Illinois
26 Administrative Code, Part 132 ("Medicaid Community Mental
27 Health Services Program").
28 (c) The program established by this Section may be
29 implemented by the Illinois Department in various contracting
30 areas at various times. The health care delivery systems and
31 providers available under the program may vary throughout the
32 State. For purposes of contracting with managed health care
33 entities and providers, the Illinois Department shall
34 establish contracting areas similar to the geographic areas
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1 designated by the Illinois Department for contracting
2 purposes under the Illinois Competitive Access and
3 Reimbursement Equity Program (ICARE) under the authority of
4 Section 3-4 of the Illinois Health Finance Reform Act or
5 similarly-sized or smaller geographic areas established by
6 the Illinois Department by rule. A managed health care entity
7 shall be permitted to contract in any geographic areas for
8 which it has a sufficient provider network and otherwise
9 meets the contracting terms of the State. The Illinois
10 Department is not prohibited from entering into a contract
11 with a managed health care entity at any time.
12 (d) A managed health care entity that contracts with the
13 Illinois Department for the provision of services under the
14 program shall do all of the following, solely for purposes of
15 the integrated health care program:
16 (1) Provide that any individual physician licensed
17 to practice medicine in all its branches, any pharmacy,
18 any federally qualified health center, and any
19 podiatrist, that consistently meets the reasonable terms
20 and conditions established by the managed health care
21 entity, including but not limited to credentialing
22 standards, quality assurance program requirements,
23 utilization management requirements, financial
24 responsibility standards, contracting process
25 requirements, and provider network size and accessibility
26 requirements, must be accepted by the managed health care
27 entity for purposes of the Illinois integrated health
28 care program. Any individual who is either terminated
29 from or denied inclusion in the panel of physicians of
30 the managed health care entity shall be given, within 10
31 business days after that determination, a written
32 explanation of the reasons for his or her exclusion or
33 termination from the panel. This paragraph (1) does not
34 apply to the following:
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1 (A) A managed health care entity that
2 certifies to the Illinois Department that:
3 (i) it employs on a full-time basis 125
4 or more Illinois physicians licensed to
5 practice medicine in all of its branches; and
6 (ii) it will provide medical services
7 through its employees to more than 80% of the
8 recipients enrolled with the entity in the
9 integrated health care program; or
10 (B) A domestic stock insurance company
11 licensed under clause (b) of class 1 of Section 4 of
12 the Illinois Insurance Code if (i) at least 66% of
13 the stock of the insurance company is owned by a
14 professional corporation organized under the
15 Professional Service Corporation Act that has 125 or
16 more shareholders who are Illinois physicians
17 licensed to practice medicine in all of its branches
18 and (ii) the insurance company certifies to the
19 Illinois Department that at least 80% of those
20 physician shareholders will provide services to
21 recipients enrolled with the company in the
22 integrated health care program.
23 (2) Provide for reimbursement for providers for
24 emergency services care, as defined by subsection (a) of
25 Section 5-5.04 of this Code the Illinois Department by
26 rule, that must be provided to its enrollees, including
27 an emergency department room screening fee, and urgent
28 care that it authorizes for its enrollees, regardless of
29 the provider's affiliation with the managed health care
30 entity. Providers shall be reimbursed for emergency
31 services care at an amount equal to the Illinois
32 Department's fee-for-service rates for those medical
33 services rendered by providers not under contract with
34 the managed health care entity to enrollees of the
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1 entity.
2 (A) Coverage and payment for emergency
3 services shall not be retrospectively denied except
4 upon reasonable determination by the Illinois
5 Department that (1) the emergency services claimed
6 were never performed or (2) an emergency medical
7 screening examination was performed on a patient who
8 personally sought emergency services knowing that he
9 or she did not have an emergency condition or
10 necessity, and who did not in fact require emergency
11 services.
12 (B) The appropriate use of the 911 emergency
13 telephone number shall not be discouraged or
14 penalized, and coverage or payment shall not be
15 denied solely on the basis that the enrollee used
16 the 911 emergency telephone number to summon
17 emergency services.
18 (2.5) Provide for reimbursement for post-emergency
19 services, which are those health care services determined
20 by a treating provider to be promptly and medically
21 necessary following stabilization of an emergency
22 condition.
23 (A) If prior authorization for post-emergency
24 services is required, the managed health care entity
25 shall provide access 24 hours a day, 7 days a week
26 to persons designated by the entity to make such
27 determinations. If a health care provider has
28 attempted to contact such person for prior
29 authorization and no designated persons were
30 accessible or the authorization was not denied
31 within 30 minutes of the request, the managed health
32 care entity is deemed to have approved the request
33 for prior authorization.
34 (B) Coverage and payment for post-emergency
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1 services which received prior authorization or
2 deemed approval shall not be retrospectively denied.
3 (3) Provide that any provider affiliated with a
4 managed health care entity may also provide services on a
5 fee-for-service basis to Illinois Department clients not
6 enrolled in a managed health care entity.
7 (4) Provide client education services as determined
8 and approved by the Illinois Department, including but
9 not limited to (i) education regarding appropriate
10 utilization of health care services in a managed care
11 system, (ii) written disclosure of treatment policies and
12 any restrictions or limitations on health services,
13 including, but not limited to, physical services,
14 clinical laboratory tests, hospital and surgical
15 procedures, prescription drugs and biologics, and
16 radiological examinations, and (iii) written notice that
17 the enrollee may receive from another provider those
18 services covered under this program that are not provided
19 by the managed health care entity.
20 (5) Provide that enrollees within its system may
21 choose the site for provision of services and the panel
22 of health care providers.
23 (6) Not discriminate in its enrollment or
24 disenrollment practices among recipients of medical
25 services or program enrollees based on health status.
26 (7) Provide a quality assurance and utilization
27 review program that (i) for health maintenance
28 organizations meets the requirements of the Health
29 Maintenance Organization Act and (ii) for managed care
30 community networks meets the requirements established by
31 the Illinois Department in rules that incorporate those
32 standards set forth in the Health Maintenance
33 Organization Act.
34 (8) Issue a managed health care entity
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1 identification card to each enrollee upon enrollment.
2 The card must contain all of the following:
3 (A) The enrollee's signature.
4 (B) The enrollee's health plan.
5 (C) The name and telephone number of the
6 enrollee's primary care physician.
7 (D) A telephone number to be used for
8 emergency service 24 hours per day, 7 days per week.
9 The telephone number required to be maintained
10 pursuant to this subparagraph by each managed health
11 care entity shall, at minimum, be staffed by
12 medically trained personnel and be provided
13 directly, or under arrangement, at an office or
14 offices in locations maintained solely within the
15 State of Illinois. For purposes of this
16 subparagraph, "medically trained personnel" means
17 licensed practical nurses or registered nurses
18 located in the State of Illinois who are licensed
19 pursuant to the Illinois Nursing Act of 1987.
20 (9) Ensure that every primary care physician and
21 pharmacy in the managed health care entity meets the
22 standards established by the Illinois Department for
23 accessibility and quality of care. The Illinois
24 Department shall arrange for and oversee an evaluation of
25 the standards established under this paragraph (9) and
26 may recommend any necessary changes to these standards.
27 The Illinois Department shall submit an annual report to
28 the Governor and the General Assembly by April 1 of each
29 year regarding the effect of the standards on ensuring
30 access and quality of care to enrollees.
31 (10) Provide a procedure for handling complaints
32 that (i) for health maintenance organizations meets the
33 requirements of the Health Maintenance Organization Act
34 and (ii) for managed care community networks meets the
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1 requirements established by the Illinois Department in
2 rules that incorporate those standards set forth in the
3 Health Maintenance Organization Act.
4 (11) Maintain, retain, and make available to the
5 Illinois Department records, data, and information, in a
6 uniform manner determined by the Illinois Department,
7 sufficient for the Illinois Department to monitor
8 utilization, accessibility, and quality of care.
9 (12) Except for providers who are prepaid, pay all
10 approved claims for covered services that are completed
11 and submitted to the managed health care entity within 30
12 days after receipt of the claim or receipt of the
13 appropriate capitation payment or payments by the managed
14 health care entity from the State for the month in which
15 the services included on the claim were rendered,
16 whichever is later. If payment is not made or mailed to
17 the provider by the managed health care entity by the due
18 date under this subsection, an interest penalty of 1% of
19 any amount unpaid shall be added for each month or
20 fraction of a month after the due date, until final
21 payment is made. Nothing in this Section shall prohibit
22 managed health care entities and providers from mutually
23 agreeing to terms that require more timely payment.
24 (13) Provide integration with community-based
25 programs provided by certified local health departments
26 such as Women, Infants, and Children Supplemental Food
27 Program (WIC), childhood immunization programs, health
28 education programs, case management programs, and health
29 screening programs.
30 (14) Provide that the pharmacy formulary used by a
31 managed health care entity and its contract providers be
32 no more restrictive than the Illinois Department's
33 pharmaceutical program on the effective date of this
34 amendatory Act of 1994 and as amended after that date.
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1 (15) Provide integration with community-based
2 organizations, including, but not limited to, any
3 organization that has operated within a Medicaid
4 Partnership as defined by this Code or by rule of the
5 Illinois Department, that may continue to operate under a
6 contract with the Illinois Department or a managed health
7 care entity under this Section to provide case management
8 services to Medicaid clients in designated high-need
9 areas.
10 The Illinois Department may, by rule, determine
11 methodologies to limit financial liability for managed health
12 care entities resulting from payment for services to
13 enrollees provided under the Illinois Department's integrated
14 health care program. Any methodology so determined may be
15 considered or implemented by the Illinois Department through
16 a contract with a managed health care entity under this
17 integrated health care program.
18 The Illinois Department shall contract with an entity or
19 entities to provide external peer-based quality assurance
20 review for the integrated health care program. The entity
21 shall be representative of Illinois physicians licensed to
22 practice medicine in all its branches and have statewide
23 geographic representation in all specialties of medical care
24 that are provided within the integrated health care program.
25 The entity may not be a third party payer and shall maintain
26 offices in locations around the State in order to provide
27 service and continuing medical education to physician
28 participants within the integrated health care program. The
29 review process shall be developed and conducted by Illinois
30 physicians licensed to practice medicine in all its branches.
31 In consultation with the entity, the Illinois Department may
32 contract with other entities for professional peer-based
33 quality assurance review of individual categories of services
34 other than services provided, supervised, or coordinated by
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1 physicians licensed to practice medicine in all its branches.
2 The Illinois Department shall establish, by rule, criteria to
3 avoid conflicts of interest in the conduct of quality
4 assurance activities consistent with professional peer-review
5 standards. All quality assurance activities shall be
6 coordinated by the Illinois Department.
7 (e) All persons enrolled in the program shall be
8 provided with a full written explanation of all
9 fee-for-service and managed health care plan options and a
10 reasonable opportunity to choose among the options as
11 provided by rule. The Illinois Department shall provide to
12 enrollees, upon enrollment in the integrated health care
13 program and at least annually thereafter, notice of the
14 process for requesting an appeal under the Illinois
15 Department's administrative appeal procedures.
16 Notwithstanding any other Section of this Code, the Illinois
17 Department may provide by rule for the Illinois Department to
18 assign a person enrolled in the program to a specific
19 provider of medical services or to a specific health care
20 delivery system if an enrollee has failed to exercise choice
21 in a timely manner. An enrollee assigned by the Illinois
22 Department shall be afforded the opportunity to disenroll and
23 to select a specific provider of medical services or a
24 specific health care delivery system within the first 30 days
25 after the assignment. An enrollee who has failed to exercise
26 choice in a timely manner may be assigned only if there are 3
27 or more managed health care entities contracting with the
28 Illinois Department within the contracting area, except that,
29 outside the City of Chicago, this requirement may be waived
30 for an area by rules adopted by the Illinois Department after
31 consultation with all hospitals within the contracting area.
32 The Illinois Department shall establish by rule the procedure
33 for random assignment of enrollees who fail to exercise
34 choice in a timely manner to a specific managed health care
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1 entity in proportion to the available capacity of that
2 managed health care entity. Assignment to a specific provider
3 of medical services or to a specific managed health care
4 entity may not exceed that provider's or entity's capacity as
5 determined by the Illinois Department. Any person who has
6 chosen a specific provider of medical services or a specific
7 managed health care entity, or any person who has been
8 assigned under this subsection, shall be given the
9 opportunity to change that choice or assignment at least once
10 every 12 months, as determined by the Illinois Department by
11 rule. The Illinois Department shall maintain a toll-free
12 telephone number for program enrollees' use in reporting
13 problems with managed health care entities.
14 (f) If a person becomes eligible for participation in
15 the integrated health care program while he or she is
16 hospitalized, the Illinois Department may not enroll that
17 person in the program until after he or she has been
18 discharged from the hospital. This subsection does not apply
19 to newborn infants whose mothers are enrolled in the
20 integrated health care program.
21 (g) The Illinois Department shall, by rule, establish
22 for managed health care entities rates that (i) are certified
23 to be actuarially sound, as determined by an actuary who is
24 an associate or a fellow of the Society of Actuaries or a
25 member of the American Academy of Actuaries and who has
26 expertise and experience in medical insurance and benefit
27 programs, in accordance with the Illinois Department's
28 current fee-for-service payment system, and (ii) take into
29 account any difference of cost to provide health care to
30 different populations based on gender, age, location, and
31 eligibility category. The rates for managed health care
32 entities shall be determined on a capitated basis.
33 The Illinois Department by rule shall establish a method
34 to adjust its payments to managed health care entities in a
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1 manner intended to avoid providing any financial incentive to
2 a managed health care entity to refer patients to a county
3 provider, in an Illinois county having a population greater
4 than 3,000,000, that is paid directly by the Illinois
5 Department. The Illinois Department shall by April 1, 1997,
6 and annually thereafter, review the method to adjust
7 payments. Payments by the Illinois Department to the county
8 provider, for persons not enrolled in a managed care
9 community network owned or operated by a county provider,
10 shall be paid on a fee-for-service basis under Article XV of
11 this Code.
12 The Illinois Department by rule shall establish a method
13 to reduce its payments to managed health care entities to
14 take into consideration (i) any adjustment payments paid to
15 hospitals under subsection (h) of this Section to the extent
16 those payments, or any part of those payments, have been
17 taken into account in establishing capitated rates under this
18 subsection (g) and (ii) the implementation of methodologies
19 to limit financial liability for managed health care entities
20 under subsection (d) of this Section.
21 (h) For hospital services provided by a hospital that
22 contracts with a managed health care entity, adjustment
23 payments shall be paid directly to the hospital by the
24 Illinois Department. Adjustment payments may include but
25 need not be limited to adjustment payments to:
26 disproportionate share hospitals under Section 5-5.02 of this
27 Code; primary care access health care education payments (89
28 Ill. Adm. Code 149.140); payments for capital, direct medical
29 education, indirect medical education, certified registered
30 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
31 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
32 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
33 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
34 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
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1 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
2 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
3 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
4 148.290(h)); and outpatient indigent volume adjustments (89
5 Ill. Adm. Code 148.140(b)(5)).
6 (i) For any hospital eligible for the adjustment
7 payments described in subsection (h), the Illinois Department
8 shall maintain, through the period ending June 30, 1995,
9 reimbursement levels in accordance with statutes and rules in
10 effect on April 1, 1994.
11 (j) Nothing contained in this Code in any way limits or
12 otherwise impairs the authority or power of the Illinois
13 Department to enter into a negotiated contract pursuant to
14 this Section with a managed health care entity, including,
15 but not limited to, a health maintenance organization, that
16 provides for termination or nonrenewal of the contract
17 without cause upon notice as provided in the contract and
18 without a hearing.
19 (k) Section 5-5.15 does not apply to the program
20 developed and implemented pursuant to this Section.
21 (l) The Illinois Department shall, by rule, define those
22 chronic or acute medical conditions of childhood that require
23 longer-term treatment and follow-up care. The Illinois
24 Department shall ensure that services required to treat these
25 conditions are available through a separate delivery system.
26 A managed health care entity that contracts with the
27 Illinois Department may refer a child with medical conditions
28 described in the rules adopted under this subsection directly
29 to a children's hospital or to a hospital, other than a
30 children's hospital, that is qualified to provide inpatient
31 and outpatient services to treat those conditions. The
32 Illinois Department shall provide fee-for-service
33 reimbursement directly to a children's hospital for those
34 services pursuant to Title 89 of the Illinois Administrative
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1 Code, Section 148.280(a), at a rate at least equal to the
2 rate in effect on March 31, 1994. For hospitals, other than
3 children's hospitals, that are qualified to provide inpatient
4 and outpatient services to treat those conditions, the
5 Illinois Department shall provide reimbursement for those
6 services on a fee-for-service basis, at a rate at least equal
7 to the rate in effect for those other hospitals on March 31,
8 1994.
9 A children's hospital shall be directly reimbursed for
10 all services provided at the children's hospital on a
11 fee-for-service basis pursuant to Title 89 of the Illinois
12 Administrative Code, Section 148.280(a), at a rate at least
13 equal to the rate in effect on March 31, 1994, until the
14 later of (i) implementation of the integrated health care
15 program under this Section and development of actuarially
16 sound capitation rates for services other than those chronic
17 or acute medical conditions of childhood that require
18 longer-term treatment and follow-up care as defined by the
19 Illinois Department in the rules adopted under this
20 subsection or (ii) March 31, 1996.
21 Notwithstanding anything in this subsection to the
22 contrary, a managed health care entity shall not consider
23 sources or methods of payment in determining the referral of
24 a child. The Illinois Department shall adopt rules to
25 establish criteria for those referrals. The Illinois
26 Department by rule shall establish a method to adjust its
27 payments to managed health care entities in a manner intended
28 to avoid providing any financial incentive to a managed
29 health care entity to refer patients to a provider who is
30 paid directly by the Illinois Department.
31 (m) Behavioral health services provided or funded by the
32 Department of Human Services, the Department of Children and
33 Family Services, and the Illinois Department shall be
34 excluded from a benefit package. Conditions of an organic or
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1 physical origin or nature, including medical detoxification,
2 however, may not be excluded. In this subsection,
3 "behavioral health services" means mental health services and
4 subacute alcohol and substance abuse treatment services, as
5 defined in the Illinois Alcoholism and Other Drug Dependency
6 Act. In this subsection, "mental health services" includes,
7 at a minimum, the following services funded by the Illinois
8 Department, the Department of Human Services (as successor to
9 the Department of Mental Health and Developmental
10 Disabilities), or the Department of Children and Family
11 Services: (i) inpatient hospital services, including related
12 physician services, related psychiatric interventions, and
13 pharmaceutical services provided to an eligible recipient
14 hospitalized with a primary diagnosis of psychiatric
15 disorder; (ii) outpatient mental health services as defined
16 and specified in Title 59 of the Illinois Administrative
17 Code, Part 132; (iii) any other outpatient mental health
18 services funded by the Illinois Department pursuant to the
19 State of Illinois Medicaid Plan; (iv) partial
20 hospitalization; and (v) follow-up stabilization related to
21 any of those services. Additional behavioral health services
22 may be excluded under this subsection as mutually agreed in
23 writing by the Illinois Department and the affected State
24 agency or agencies. The exclusion of any service does not
25 prohibit the Illinois Department from developing and
26 implementing demonstration projects for categories of persons
27 or services. The Department of Children and Family Services
28 and the Department of Human Services shall each adopt rules
29 governing the integration of managed care in the provision of
30 behavioral health services. The State shall integrate managed
31 care community networks and affiliated providers, to the
32 extent practicable, in any separate delivery system for
33 mental health services.
34 (n) The Illinois Department shall adopt rules to
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1 establish reserve requirements for managed care community
2 networks, as required by subsection (a), and health
3 maintenance organizations to protect against liabilities in
4 the event that a managed health care entity is declared
5 insolvent or bankrupt. If a managed health care entity other
6 than a county provider is declared insolvent or bankrupt,
7 after liquidation and application of any available assets,
8 resources, and reserves, the Illinois Department shall pay a
9 portion of the amounts owed by the managed health care entity
10 to providers for services rendered to enrollees under the
11 integrated health care program under this Section based on
12 the following schedule: (i) from April 1, 1995 through June
13 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
14 through June 30, 2001, 80% of the amounts owed; and (iii)
15 from July 1, 2001 through June 30, 2005, 75% of the amounts
16 owed. The amounts paid under this subsection shall be
17 calculated based on the total amount owed by the managed
18 health care entity to providers before application of any
19 available assets, resources, and reserves. After June 30,
20 2005, the Illinois Department may not pay any amounts owed to
21 providers as a result of an insolvency or bankruptcy of a
22 managed health care entity occurring after that date. The
23 Illinois Department is not obligated, however, to pay amounts
24 owed to a provider that has an ownership or other governing
25 interest in the managed health care entity. This subsection
26 applies only to managed health care entities and the services
27 they provide under the integrated health care program under
28 this Section.
29 (o) Notwithstanding any other provision of law or
30 contractual agreement to the contrary, providers shall not be
31 required to accept from any other third party payer the rates
32 determined or paid under this Code by the Illinois
33 Department, managed health care entity, or other health care
34 delivery system for services provided to recipients.
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1 (p) The Illinois Department may seek and obtain any
2 necessary authorization provided under federal law to
3 implement the program, including the waiver of any federal
4 statutes or regulations. The Illinois Department may seek a
5 waiver of the federal requirement that the combined
6 membership of Medicare and Medicaid enrollees in a managed
7 care community network may not exceed 75% of the managed care
8 community network's total enrollment. The Illinois
9 Department shall not seek a waiver of this requirement for
10 any other category of managed health care entity. The
11 Illinois Department shall not seek a waiver of the inpatient
12 hospital reimbursement methodology in Section 1902(a)(13)(A)
13 of Title XIX of the Social Security Act even if the federal
14 agency responsible for administering Title XIX determines
15 that Section 1902(a)(13)(A) applies to managed health care
16 systems.
17 Notwithstanding any other provisions of this Code to the
18 contrary, the Illinois Department shall seek a waiver of
19 applicable federal law in order to impose a co-payment system
20 consistent with this subsection on recipients of medical
21 services under Title XIX of the Social Security Act who are
22 not enrolled in a managed health care entity. The waiver
23 request submitted by the Illinois Department shall provide
24 for co-payments of up to $0.50 for prescribed drugs and up to
25 $0.50 for x-ray services and shall provide for co-payments of
26 up to $10 for non-emergency services provided in a hospital
27 emergency department room and up to $10 for non-emergency
28 ambulance services. The purpose of the co-payments shall be
29 to deter those recipients from seeking unnecessary medical
30 care. Co-payments may not be used to deter recipients from
31 seeking or accessing emergency services or other necessary
32 medical care. No recipient shall be required to pay more
33 than a total of $150 per year in co-payments under the waiver
34 request required by this subsection. A recipient may not be
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1 required to pay more than $15 of any amount due under this
2 subsection in any one month.
3 Co-payments authorized under this subsection may not be
4 imposed when the care was necessitated by a medical condition
5 as described in the definition of "emergency services" under
6 subsection (a) of Section 5-5.04 true medical emergency.
7 Copayments for non-emergency services in a hospital emergency
8 department shall not be imposed retrospectively except upon
9 reasonable determination by the Illinois Department that (1)
10 the emergency services claimed were never performed or (2) an
11 emergency medical screening examination was performed on a
12 patient who personally sought emergency services knowing that
13 he or she did not have an emergency condition or necessity,
14 and who did not in fact require emergency services.
15 Co-payments may not be imposed for any of the following
16 classifications of services:
17 (1) Services furnished to person under 18 years of
18 age.
19 (2) Services furnished to pregnant women.
20 (3) Services furnished to any individual who is an
21 inpatient in a hospital, nursing facility, intermediate
22 care facility, or other medical institution, if that
23 person is required to spend for costs of medical care all
24 but a minimal amount of his or her income required for
25 personal needs.
26 (4) Services furnished to a person who is receiving
27 hospice care.
28 Co-payments authorized under this subsection shall not be
29 deducted from or reduce in any way payments for medical
30 services from the Illinois Department to providers. No
31 provider may deny those services to an individual eligible
32 for services based on the individual's inability to pay the
33 co-payment.
34 Recipients who are subject to co-payments shall be
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1 provided notice, in plain and clear language, of the amount
2 of the co-payments, the circumstances under which co-payments
3 are exempted, the circumstances under which co-payments may
4 be assessed, and their manner of collection.
5 The Illinois Department shall establish a Medicaid
6 Co-Payment Council to assist in the development of co-payment
7 policies for the medical assistance program. The Medicaid
8 Co-Payment Council shall also have jurisdiction to develop a
9 program to provide financial or non-financial incentives to
10 Medicaid recipients in order to encourage recipients to seek
11 necessary health care. The Council shall be chaired by the
12 Director of the Illinois Department, and shall have 6
13 additional members. Two of the 6 additional members shall be
14 appointed by the Governor, and one each shall be appointed by
15 the President of the Senate, the Minority Leader of the
16 Senate, the Speaker of the House of Representatives, and the
17 Minority Leader of the House of Representatives. The Council
18 may be convened and make recommendations upon the appointment
19 of a majority of its members. The Council shall be appointed
20 and convened no later than September 1, 1994 and shall report
21 its recommendations to the Director of the Illinois
22 Department and the General Assembly no later than October 1,
23 1994. The chairperson of the Council shall be allowed to
24 vote only in the case of a tie vote among the appointed
25 members of the Council.
26 The Council shall be guided by the following principles
27 as it considers recommendations to be developed to implement
28 any approved waivers that the Illinois Department must seek
29 pursuant to this subsection:
30 (1) Co-payments should not be used to deter access
31 to adequate medical care.
32 (2) Co-payments should be used to reduce fraud.
33 (3) Co-payment policies should be examined in
34 consideration of other states' experience, and the
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1 ability of successful co-payment plans to control
2 unnecessary or inappropriate utilization of services
3 should be promoted.
4 (4) All participants, both recipients and
5 providers, in the medical assistance program have
6 responsibilities to both the State and the program.
7 (5) Co-payments are primarily a tool to educate the
8 participants in the responsible use of health care
9 resources.
10 (6) Co-payments should not be used to penalize
11 providers.
12 (7) A successful medical program requires the
13 elimination of improper utilization of medical resources.
14 The integrated health care program, or any part of that
15 program, established under this Section may not be
16 implemented if matching federal funds under Title XIX of the
17 Social Security Act are not available for administering the
18 program.
19 The Illinois Department shall submit for publication in
20 the Illinois Register the name, address, and telephone number
21 of the individual to whom a request may be directed for a
22 copy of the request for a waiver of provisions of Title XIX
23 of the Social Security Act that the Illinois Department
24 intends to submit to the Health Care Financing Administration
25 in order to implement this Section. The Illinois Department
26 shall mail a copy of that request for waiver to all
27 requestors at least 16 days before filing that request for
28 waiver with the Health Care Financing Administration.
29 (q) After the effective date of this Section, the
30 Illinois Department may take all planning and preparatory
31 action necessary to implement this Section, including, but
32 not limited to, seeking requests for proposals relating to
33 the integrated health care program created under this
34 Section.
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1 (r) In order to (i) accelerate and facilitate the
2 development of integrated health care in contracting areas
3 outside counties with populations in excess of 3,000,000 and
4 counties adjacent to those counties and (ii) maintain and
5 sustain the high quality of education and residency programs
6 coordinated and associated with local area hospitals, the
7 Illinois Department may develop and implement a demonstration
8 program for managed care community networks owned, operated,
9 or governed by State-funded medical schools. The Illinois
10 Department shall prescribe by rule the criteria, standards,
11 and procedures for effecting this demonstration program.
12 (s) (Blank).
13 (t) On April 1, 1995 and every 6 months thereafter, the
14 Illinois Department shall report to the Governor and General
15 Assembly on the progress of the integrated health care
16 program in enrolling clients into managed health care
17 entities. The report shall indicate the capacities of the
18 managed health care entities with which the State contracts,
19 the number of clients enrolled by each contractor, the areas
20 of the State in which managed care options do not exist, and
21 the progress toward meeting the enrollment goals of the
22 integrated health care program.
23 (u) The Illinois Department may implement this Section
24 through the use of emergency rules in accordance with Section
25 5-45 of the Illinois Administrative Procedure Act. For
26 purposes of that Act, the adoption of rules to implement this
27 Section is deemed an emergency and necessary for the public
28 interest, safety, and welfare.
29 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
30 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
31 Section 95. No acceleration or delay. Where this Act
32 makes changes in a statute that is represented in this Act by
33 text that is not yet or no longer in effect (for example, a
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1 Section represented by multiple versions), the use of that
2 text does not accelerate or delay the taking effect of (i)
3 the changes made by this Act or (ii) provisions derived from
4 any other Public Act.
5 Section 99. Effective date. This Act takes effect upon
6 becoming law.