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90_HB0643eng
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.
LRB9002943JSgc
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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 medical screening examination" means a medical
9 screening examination and evaluation by a physician or, to
10 the extent permitted by applicable laws, by other appropriate
11 personnel under the supervision of a physician to determine
12 whether the need for emergency services exists.
13 "Emergency services" means those health care services
14 provided to evaluate and treat medical conditions of recent
15 onset and severity that would lead a prudent layperson,
16 possessing an average knowledge of medicine and health, to
17 believe that urgent and unscheduled medical care is required.
18 "Health insurance plan" means any policy, contract, plan,
19 or other arrangement that pays for or furnishes medical
20 services pursuant to the Illinois Insurance Code, the
21 Comprehensive Health Insurance Plan Act, the Health
22 Maintenance Organization Act, or the Illinois Public Aid
23 Code.
24 "Insured" means any person enrolled in or covered by a
25 health insurance plan.
26 "Post-stabilization 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 "Provider" means any physician, hospital facility, or
31 other person that is licensed or otherwise authorized to
32 furnish or arrange for the delivery or furnishing of health
33 care services.
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1 Section 15. Emergency services.
2 (a) Any health insurance plan subject to this Act shall
3 provide the insured emergency services coverage such that
4 payment for this coverage is not dependent upon whether such
5 services are performed by a preferred or nonpreferred
6 provider, and such coverage shall be at the same benefit
7 level as if the service or treatment had been rendered by a
8 plan provider.
9 (b) Prior authorization or approval by the plan shall
10 not be required.
11 (c) Coverage and payment shall not be retrospectively
12 denied, with the following exceptions:
13 (1) upon reasonable determination that the
14 emergency services claimed were never performed; or
15 (2) upon reasonable determination that an emergency
16 medical screening examination was performed on a patient
17 who personally sought emergency services knowing that he
18 or she did not have an emergency condition or necessity,
19 and who did not in fact require emergency services.
20 (d) When an enrollee presents to a hospital seeking
21 emergency services, as defined in Section 10, the
22 determination as to whether the need for those services
23 exists shall be made for purposes of treatment by a physician
24 or, to the extent permitted by applicable law, by other
25 appropriate licensed personnel under the supervision of a
26 physician. The physician or other appropriate personnel
27 shall indicate in the patient's chart the results of the
28 emergency medical screening examination.
29 (e) The appropriate use of the 911 emergency telephone
30 number shall not be discouraged or penalized, and coverage or
31 payment shall not be denied solely on the basis that the
32 insured used the 911 emergency telephone number to summon
33 emergency services.
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1 Section 20. Post-stabilization services.
2 (a) If prior authorization for post-stabilization
3 services is required, the health insurance plan shall provide
4 access 24 hours a day, 7 days a week to persons designated by
5 plan to make such determinations. If a provider has
6 attempted to contact such person for prior authorization and
7 no designated persons were accessible or the authorization
8 was not denied within 30 minutes of the request, the health
9 insurance plan is deemed to have approved the request for
10 prior authorization.
11 (b) Coverage and payment for post-stabilization services
12 which received prior authorization or deemed approval shall
13 not be retrospectively denied.
14 Section 25. Enforcement.
15 (a) The Department shall enforce the provisions of this
16 Act. It shall promptly investigate complaints which it
17 receives alleging violation of the Act. If the complaint is
18 found to be valid, the Department shall immediately seek
19 appropriate corrective action by the health insurance plan
20 including, but not limited to, ceasing the noncompliant
21 activity, restoring coverage, paying or reimbursing claims,
22 and other appropriate restitution.
23 (b) Subject to the provisions of the Illinois
24 Administrative Procedure Act, the Department shall impose an
25 administrative fine on a health insurance plan found to have
26 violated any provision of this Act.
27 (1) Failure to comply with requested corrective
28 action shall result in a fine of $5,000 per violation.
29 (2) A repeated violation shall result in a fine of
30 $10,000 per violation.
31 (3) A pattern of repeated violations shall result
32 in a fine of $25,000.
33 (c) Notwithstanding the existence or pursuit of any
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1 other remedy, the Department may, through the Attorney
2 General, seek an injunction to restrain or prevent any health
3 insurance plan from violation or continuing to violate any
4 provisions of this Act.
5 Section 30. Rules. The Department shall adopt emergency
6 rules to implement the provisions of this Act, in accordance
7 with Section 5-45 of the Illinois Administrative Procedure
8 Act.
9 Section 90. The Illinois Insurance Code is amended by
10 changing Sections 370g, 370i, and 370o as follows:
11 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
12 Sec. 370g. Definitions. As used in this Article, the
13 following definitions apply:
14 (a) "Health care services" means health care services or
15 products rendered or sold by a provider within the scope of
16 the provider's license or legal authorization. The term
17 includes, but is not limited to, hospital, medical, surgical,
18 dental, vision and pharmaceutical services or products.
19 (b) "Insurer" means an insurance company or a health
20 service corporation authorized in this State to issue
21 policies or subscriber contracts which reimburse for expenses
22 of health care services.
23 (c) "Insured" means an individual entitled to
24 reimbursement for expenses of health care services under a
25 policy or subscriber contract issued or administered by an
26 insurer.
27 (d) "Provider" means an individual or entity duly
28 licensed or legally authorized to provide health care
29 services.
30 (e) "Noninstitutional provider" means any person
31 licensed under the Medical Practice Act of 1987, as now or
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1 hereafter amended.
2 (f) "Beneficiary" means an individual entitled to
3 reimbursement for expenses of or the discount of provider
4 fees for health care services under a program where the
5 beneficiary has an incentive to utilize the services of a
6 provider which has entered into an agreement or arrangement
7 with an administrator.
8 (g) "Administrator" means any person, partnership or
9 corporation, other than an insurer or health maintenance
10 organization holding a certificate of authority under the
11 "Health Maintenance Organization Act", as now or hereafter
12 amended, that arranges, contracts with, or administers
13 contracts with a provider whereby beneficiaries are provided
14 an incentive to use the services of such provider.
15 (h) "Emergency services" means those health care
16 services provided to evaluate and treat medical conditions of
17 recent onset and severity that would lead a prudent
18 layperson, possessing an average knowledge of medicine and
19 health, to believe that urgent or unscheduled medical care is
20 required an accidental bodily injury or emergency medical
21 condition which reasonably requires the beneficiary or
22 insured to seek immediate medical care under circumstances or
23 at locations which reasonably preclude the beneficiary or
24 insured from obtaining needed medical care from a preferred
25 provider.
26 (i) "Post-stabilization services" means those health
27 care services determined by a treating provider to be
28 promptly and medically necessary following stabilization of
29 an emergency condition.
30 (j) "Emergency medical screening examination" means a
31 medical screening examination and evaluation by a physician
32 or, to the extent permitted by applicable laws, by other
33 appropriate personnel under the supervision of a physician to
34 determine whether the need for emergency services exists.
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1 (Source: P.A. 88-400.)
2 (215 ILCS 5/370i) (from Ch. 73, par. 982i)
3 Sec. 370i. Policies, agreements or arrangements with
4 incentives or limits on reimbursement authorized.
5 (a) Policies, agreements or arrangements issued under
6 this Article may not contain terms or conditions that would
7 operate unreasonably to restrict the access and availability
8 of health care services for the insured.
9 (1) If prior authorization for post-stabilization
10 services is required, the insurer or administrator shall
11 provide access 24 hours a day, 7 days a week to persons
12 designated by the insurer or administrator to make such
13 determinations. If a provider has attempted to contact
14 such person for prior authorization and no designated
15 persons were accessible or the authorization was not
16 denied within 30 minutes of the request, the insurer or
17 administrator is deemed to have approved the request for
18 prior authorization.
19 Coverage and payment for post-stabilization services
20 which received prior authorization or deemed approval
21 shall not be retrospectively denied.
22 (2) The appropriate use of the 911 emergency
23 telephone number shall not be discouraged or penalized,
24 and coverage or payment shall not be denied solely on the
25 basis that the insured or beneficiary used the 911
26 emergency telephone number to summon emergency services.
27 (3) When an enrollee presents to a hospital seeking
28 emergency services, as defined in Section 370(g), the
29 determination as to whether the need for those services
30 exists shall be made for purposes of treatment by a
31 physician or, to the extent permitted by applicable law,
32 by other appropriate licensed personnel under the
33 supervision of a physician. The physician or other
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1 appropriate personnel shall indicate in the patient's
2 chart the results of the emergency medical screening
3 examination.
4 (b) Subject to the provisions of subsection (a), an
5 insurer or administrator may:
6 (1) enter into agreements with certain providers of its
7 choice relating to health care services which may be rendered
8 to insureds or beneficiaries of the insurer or administrator,
9 including agreements relating to the amounts to be charged
10 the insureds or beneficiaries for services rendered;
11 (2) issue or administer programs, policies or subscriber
12 contracts in this State that include incentives for the
13 insured or beneficiary to utilize the services of a provider
14 which has entered into an agreement with the insurer or
15 administrator pursuant to paragraph (1) above.
16 (Source: P.A. 84-618.)
17 (215 ILCS 5/370o) (from Ch. 73, par. 982o)
18 Sec. 370o. Emergency services Care.
19 (a) Any referred provider contract, subject to this
20 Article shall provide the beneficiary or insured emergency
21 services care coverage such that payment for this coverage is
22 not dependent upon whether such services are performed by a
23 preferred or nonpreferred provider and such coverage shall be
24 at the same benefit level as if the service or treatment had
25 been rendered by a plan provider.
26 (b) Prior authorization or approval by the plan shall
27 not be required.
28 (c) Coverage and payment shall not be retrospectively
29 denied, with the following exceptions:
30 (1) upon reasonable determination that the
31 emergency services claimed were never performed; or
32 (2) upon reasonable determination that an emergency
33 medical screening examination was performed on a patient
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1 who personally sought emergency services knowing that he
2 or she did not have an emergency condition or necessity,
3 and who did not in fact require emergency services.
4 (3) When an enrollee presents to a hospital seeking
5 emergency services, as defined in Section 370(g), the
6 determination as to whether the need for those services
7 exists shall be made for purposes of treatment by a
8 physician or, to the extent permitted by applicable law,
9 by other appropriate licensed personnel under the
10 supervision of a physician. The physician or other
11 appropriate personnel shall indicate in the patient's
12 chart the results of the emergency medical screening
13 examination.
14 (Source: P.A. 85-476.)
15 Section 92. The Comprehensive Health Insurance Plan Act
16 is amended by changing Sections 2, 3, 5, and 8 as follows:
17 (215 ILCS 105/2) (from Ch. 73, par. 1302)
18 Sec. 2. Definitions. As used in this Act, unless the
19 context otherwise requires:
20 "Administering carrier" means the insurer or third party
21 administrator designated under Section 5 of this Act.
22 "Benefits plan" means the coverage to be offered by the
23 Plan to eligible persons pursuant to this Act.
24 "Board" means the Illinois Comprehensive Health Insurance
25 Board.
26 "Department" means the Illinois Department of Insurance.
27 "Director" means the Director of the Illinois Department
28 of Insurance.
29 "Eligible person" means a resident of this State who
30 qualifies under Section 7.
31 "Emergency medical screening examination" means a medical
32 screening examination and evaluation by a physician or, to
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1 the extent permitted by applicable laws, by other appropriate
2 personnel under the supervision of a physician to determine
3 whether the need for emergency services exists.
4 "Emergency services" means those health care services
5 provided to evaluate and treat medical conditions of recent
6 onset and severity that would lead a prudent layperson,
7 possessing an average knowledge of medicine and health, to
8 believe that urgent or unscheduled medical care is required.
9 "Employee" means a resident of this State who has entered
10 into the employment of or works under contract or service of
11 an employer including the officers, managers and employees of
12 subsidiary or affiliated corporations and the individual
13 proprietors, partners and employees of affiliated individuals
14 and firms when the business of the subsidiary or affiliated
15 corporations, firms or individuals is controlled by a common
16 employer through stock ownership, contract, or otherwise.
17 "Family" means the eligible person and his or her legal
18 spouse, the eligible person's dependent children under the
19 age of 19, the eligible person's dependent children under the
20 age of 23 who are full-time students, the eligible person's
21 dependent disabled children of any age, or any other member
22 of the eligible person's family who is claimed as a dependent
23 for purposes of filing federal income tax returns and resides
24 in the eligible person's household.
25 "Health insurance" means any hospital, surgical, or
26 medical coverage provided under an expense-incurred policy or
27 contract, minimum premium plan, stop loss coverage,
28 non-profit health care service plan contract, health
29 maintenance organization or other subscriber contract, or any
30 other health care plan or arrangement that pays for or
31 furnishes medical or health care services by a provider of
32 these services, whether by insurance or otherwise. Health
33 insurance shall not include accident only, disability income,
34 hospital confinement indemnity, dental, or credit insurance,
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1 coverage issued as a supplement to liability insurance,
2 insurance arising out of a workers' compensation or similar
3 law, automobile medical-payment insurance, or insurance under
4 which benefits are payable with or without regard to fault
5 and which is statutorily required to be contained in any
6 liability insurance policy or equivalent self-insurance.
7 "Health Maintenance Organization" means an organization
8 as defined in the Health Maintenance Organization Act.
9 "Hospice" means a program as defined in and licensed
10 under the Hospice Program Licensing Act.
11 "Hospital" means an institution as defined in the
12 Hospital Licensing Act, an institution that meets all
13 comparable conditions and requirements in effect in the state
14 in which it is located, or the University of Illinois
15 Hospital as defined in the University of Illinois Hospital
16 Act.
17 "Insured" means any individual resident of this State who
18 is eligible to receive benefits from any insurer or insurance
19 arrangement as defined in this Section.
20 "Insurer" means any insurance company authorized to
21 transact health insurance business in this State and any
22 corporation that provides medical services and is organized
23 under the Voluntary Health Services Plans Act or the Health
24 Maintenance Organization Act.
25 "Medical assistance" means health care benefits provided
26 under Articles V (Medical Assistance) and VI (General
27 Assistance) of the Illinois Public Aid Code or under any
28 similar program of health care benefits in a state other than
29 Illinois.
30 "Medically necessary" means that a service, drug, or
31 supply is necessary and appropriate for the diagnosis or
32 treatment of an illness or injury in accord with generally
33 accepted standards of medical practice at the time the
34 service, drug, or supply is provided. When specifically
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1 applied to a confinement it further means that the diagnosis
2 or treatment of the insured person's medical symptoms or
3 condition cannot be safely provided to that person as an
4 outpatient. A service, drug, or supply shall not be medically
5 necessary if it: (i) is investigational, experimental, or for
6 research purposes; or (ii) is provided solely for the
7 convenience of the patient, the patient's family, physician,
8 hospital, or any other provider; or (iii) exceeds in scope,
9 duration, or intensity that level of care that is needed to
10 provide safe, adequate, and appropriate diagnosis or
11 treatment; or (iv) could have been omitted without adversely
12 affecting the insured person's condition or the quality of
13 medical care; or (v) involves the use of a medical device,
14 drug, or substance not formally approved by the United States
15 Food and Drug Administration.
16 "Medicare" means coverage under Title XVIII of the Social
17 Security Act, 42 U.S.C. Sec. 1395, et seq..
18 "Minimum premium plan" means an arrangement whereby a
19 specified amount of health care claims is self-funded, but
20 the insurance company assumes the risk that claims will
21 exceed that amount.
22 "Participating transplant center" means a hospital
23 designated by the Board as a preferred or exclusive provider
24 of services for one or more specified human organ or tissue
25 transplants for which the hospital has signed an agreement
26 with the Board to accept a transplant payment allowance for
27 all expenses related to the transplant during a transplant
28 benefit period.
29 "Physician" means a person licensed to practice medicine
30 pursuant to the Medical Practice Act of 1987.
31 "Plan" means the comprehensive health insurance plan
32 established by this Act.
33 "Plan of operation" means the plan of operation of the
34 Plan, including articles, bylaws and operating rules, adopted
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1 by the board pursuant to this Act.
2 "Post-stabilization services" means those health care
3 services determined by a treating provider to be promptly and
4 medically necessary following stabilization of an emergency
5 condition.
6 "Resident" means a person who has been legally domiciled
7 in this State for a period of at least 180 days and continues
8 to be domiciled in this State.
9 "Skilled nursing facility" means a facility or that
10 portion of a facility that is licensed by the Illinois
11 Department of Public Health under the Nursing Home Care Act
12 or a comparable licensing authority in another state to
13 provide skilled nursing care.
14 "Stop-loss coverage" means an arrangement whereby an
15 insurer insures against the risk that any one claim will
16 exceed a specific dollar amount or that the entire loss of a
17 self-insurance plan will exceed a specific amount.
18 "Third party administrator" means an administrator as
19 defined in Section 511.101 of the Illinois Insurance Code who
20 is licensed under Article XXXI 1/4 of that Code.
21 (Source: P.A. 87-560; 88-364.)
22 (215 ILCS 105/3) (from Ch. 73, par. 1303)
23 Sec. 3. Operation of the Plan.
24 a. There is hereby created an Illinois Comprehensive
25 Health Insurance Plan.
26 b. The Plan shall operate subject to the supervision and
27 control of the board. The board is created as a political
28 subdivision and body politic and corporate and, as such, is
29 not a State agency. The board shall consist of 10 public
30 members, appointed by the Governor with the advice and
31 consent of the Senate.
32 Initial members shall be appointed to the Board by the
33 Governor as follows: 2 members to serve until July 1, 1988,
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1 and until their successors are appointed and qualified; 2
2 members to serve until July 1, 1989, and until their
3 successors are appointed and qualified; 3 members to serve
4 until July 1, 1990, and until their successors are appointed
5 and qualified; and 3 members to serve until July 1, 1991, and
6 until their successors are appointed and qualified. As terms
7 of initial members expire, their successors shall be
8 appointed for terms to expire the first day in July 3 years
9 thereafter, and until their successors are appointed and
10 qualified.
11 Any vacancy in the Board occurring for any reason other
12 than the expiration of a term shall be filled for the
13 unexpired term in the same manner as the original
14 appointment.
15 Any member of the Board may be removed by the Governor
16 for neglect of duty, misfeasance, malfeasance, or nonfeasance
17 in office.
18 In addition, a representative of the Illinois Health Care
19 Cost Containment Council, a representative of the Office of
20 the Attorney General and the Director or the Director's
21 designated representative shall be members of the board.
22 Four members of the General Assembly, one each appointed by
23 the President and Minority Leader of the Senate and by the
24 Speaker and Minority Leader of the House of Representatives,
25 shall serve as nonvoting members of the board. At least 2 of
26 the public members shall be individuals reasonably expected
27 to qualify for coverage under the Plan, the parent or spouse
28 of such an individual, or a surviving family member of an
29 individual who could have qualified for the plan during his
30 lifetime. The Director or Director's representative shall be
31 the chairperson of the board. Members of the board shall
32 receive no compensation, but shall be reimbursed for
33 reasonable expenses incurred in the necessary performance of
34 their duties.
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1 c. The board shall make an annual report in September
2 and shall file the report with the Secretary of the Senate
3 and the Clerk of the House of Representatives. The report
4 shall summarize the activities of the Plan in the preceding
5 calendar year, including net written and earned premiums, the
6 expense of administration, the paid and incurred losses for
7 the year and other information as may be requested by the
8 General Assembly. The report shall also include analysis and
9 recommendations regarding utilization review, quality
10 assurance and access to cost effective quality health care.
11 d. In its plan of operation the board shall:
12 (1) Establish procedures for selecting an
13 administering carrier in accordance with Section 5 of
14 this Act.
15 (2) Establish procedures for the operation of the
16 board.
17 (3) Create a Plan fund, under management of the
18 board, to fund administrative expenses.
19 (4) Establish procedures for the handling and
20 accounting of assets and monies of the Plan.
21 (5) Develop and implement a program to publicize
22 the existence of the Plan, the eligibility requirements
23 and procedures for enrollment and to maintain public
24 awareness of the Plan.
25 (6) Establish procedures under which applicants and
26 participants may have grievances reviewed by a grievance
27 committee appointed by the board. The grievances shall
28 be reported to the board immediately after completion of
29 the review. The Department and the board shall retain
30 all written complaints regarding the Plan for at least 3
31 years. Oral complaints shall be reduced to written form
32 and maintained for at least 3 years.
33 (7) Provide for other matters as may be necessary
34 and proper for the execution of its powers, duties and
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1 obligations under the Plan.
2 e. No later than 5 years after the Plan is operative the
3 board and the Department shall conduct cooperatively a study
4 of the Plan and the persons insured by the Plan to determine:
5 (1) claims experience including a breakdown of medical
6 conditions for which claims were paid; (2) whether
7 availability of the Plan affected employment opportunities
8 for participants; (3) whether availability of the Plan
9 affected the receipt of medical assistance benefits by Plan
10 participants; (4) whether a change occurred in the number of
11 personal bankruptcies due to medical or other health related
12 costs; (5) data regarding all complaints received about the
13 Plan including its operation and services; (6) and any other
14 significant observations regarding utilization of the Plan.
15 The study shall culminate in a written report to be presented
16 to the Governor, the President of the Senate, the Speaker of
17 the House and the chairpersons of the House and Senate
18 Insurance Committees. The report shall be filed with the
19 Secretary of the Senate and the Clerk of the House of
20 Representatives. The report shall also be available to
21 members of the general public upon request.
22 f. The board may:
23 (1) Prepare and distribute certificate of
24 eligibility forms and enrollment instruction forms to
25 insurance producers and to the general public in this
26 State.
27 (2) Provide for reinsurance of risks incurred by
28 the Plan and enter into reinsurance agreements with
29 insurers to establish a reinsurance plan for risks of
30 coverage described in the Plan, or obtain commercial
31 reinsurance to reduce the risk of loss through the Plan.
32 (3) Issue additional types of health insurance
33 policies to provide optional coverages as are otherwise
34 permitted by this Act including a Medicare supplement
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1 policy designed to supplement Medicare.
2 (4) Provide for and employ cost containment
3 measures and requirements including, but not limited to,
4 preadmission certification, second surgical opinion,
5 concurrent utilization review programs, and individual
6 case management for the purpose of making the pool more
7 cost effective. Prior authorization for emergency
8 services shall not be required. If prior authorization
9 for post-stabilization services is required, the Plan or
10 administering carrier shall provide access 24 hours a
11 day, 7 days a week to persons designated by the Plan or
12 administering carrier to make such determinations. If a
13 health care provider has attempted to contact such person
14 for prior authorization and no designated persons were
15 accessible or the authorization was not denied within 30
16 minutes of the request, the Plan or administering carrier
17 is deemed to have approved the request for prior
18 authorization. When an enrollee presents to a hospital
19 seeking emergency services, as defined in Section 2, the
20 determination as to whether the need for those services
21 exists shall be made for purposes of treatment by a
22 physician or, to the extent permitted by applicable law,
23 by other appropriate licensed personnel under the
24 supervision of a physician. The physician or other
25 appropriate personnel shall indicate in the patient's
26 chart the results of the emergency medical screening
27 examination.
28 (5) Design, utilize, or contract with preferred
29 provider organizations and health maintenance
30 organizations and otherwise arrange for the delivery of
31 cost effective health care services. Any such contract or
32 arrangement subject to this Act shall provide the insured
33 emergency services coverage such that payment for this
34 coverage is not dependent upon whether such services are
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1 performed by a preferred or nonpreferred provider, and
2 such coverage shall be at the same benefit level as if
3 the service or treatment had been rendered by a plan
4 provider.
5 (6) Adopt bylaws, rules, regulations, policies and
6 procedures as may be necessary or convenient for the
7 implementation of the Act and the operation of the Plan.
8 g. The Director may, by rule, establish additional
9 powers and duties of the board and may adopt rules for any
10 other purposes, including the operation of the Plan, as are
11 necessary or proper to implement this Act.
12 h. The board is not liable for any obligation of the
13 Plan. There is no liability on the part of any member or
14 employee of the board or the Department, and no cause of
15 action of any nature may arise against them, for any action
16 taken or omission made by them in the performance of their
17 powers and duties under this Act, unless the action or
18 omission constitutes willful or wanton misconduct. The board
19 may provide in its bylaws or rules for indemnification of,
20 and legal representation for, its members and employees.
21 i. There is no liability on the part of any insurance
22 producer for the failure of any applicant to be accepted by
23 the Plan unless the failure of the applicant to be accepted
24 by the Plan is due to an act or omission by the insurance
25 producer which constitutes willful or wanton misconduct.
26 (Source: P.A. 86-547; 86-1322; 87-560.)
27 (215 ILCS 105/5) (from Ch. 73, par. 1305)
28 Sec. 5. Administering carrier.
29 a. The board shall select an administering carrier
30 through a competitive bidding process to administer the plan.
31 The board shall evaluate bids submitted under this Section
32 based on criteria established by the board which shall
33 include:
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1 (1) The carrier's proven ability to handle other
2 large group accident and health benefit plans.
3 (2) The efficiency of the carrier's claim paying
4 procedures.
5 (3) An estimate of total charges for administering
6 the plan.
7 (4) The ability of the carrier to administer the
8 plan in a cost-efficient manner.
9 (5) The financial condition and stability of the
10 carrier.
11 b. The administering carrier shall serve for a period of
12 5 years subject to removal for cause and subject to the
13 terms, conditions and limitations of the contract between the
14 board and the administering carrier. At least one year prior
15 to the expiration of each 5 year period of service by an
16 administering carrier, the board shall advertise for and
17 accept bids to serve as the administering carrier for the
18 succeeding 5 year period. Selection of the administering
19 carrier for the succeeding period shall be made at least 6
20 months prior to the end of the current 5 year period.
21 c. The administering carrier shall perform such
22 eligibility and administrative claims payment functions
23 relating to the plan as may be assigned to it including:
24 (1) The administering carrier shall establish a
25 premium billing procedure for collection of premiums from
26 plan participants. Billings shall be made on a periodic
27 basis as determined by the board.
28 (2) The administering carrier shall perform all
29 necessary functions to assure timely payment of benefits
30 to participants under the plan, including:
31 (a) Making available information relating to the proper
32 manner of submitting a claim for benefits under the plan and
33 distributing forms upon which submissions shall be made.
34 (b) Evaluating the eligibility of each claim for payment
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1 under the plan. Coverage and payment for emergency services
2 shall not be retrospectively denied, except upon reasonable
3 determination that (1) the emergency services claimed were
4 never performed or (2) an emergency medical screening
5 examination was performed on a patient who personally sought
6 emergency services knowing that he or she did not have an
7 emergency condition or necessity, and who did not in fact
8 require emergency services.
9 Coverage and payment for post-stabilization services that
10 received prior authorization or deemed approval shall not be
11 retrospectively denied.
12 When an enrollee presents to a hospital seeking emergency
13 services, as defined in Section 2, the determination as to
14 whether the need for those services exists shall be made for
15 purposes of treatment by a physician or, to the extent
16 permitted by applicable law, by other appropriate licensed
17 personnel under the supervision of a physician. The
18 physician or other appropriate personnel shall indicate in
19 the patient's chart the results of the emergency medical
20 screening examination.
21 (c) The administering carrier shall be governed by the
22 requirements of Part 919 of Title 50 of the Illinois
23 Administrative Code, promulgated by the Department of
24 Insurance, regarding the handling of claims under this Act.
25 d. The administering carrier shall submit regular
26 reports to the board regarding the operation of the plan.
27 The frequency, content and form of the report shall be as
28 determined by the board.
29 e. The administering carrier shall pay claims expenses
30 from the premium payments received from or on behalf of plan
31 participants. If the administering carrier's payments for
32 claims expenses exceed the portion of premiums allocated by
33 the board for payment of claims expenses, the board shall
34 provide to the administering carrier additional funds for
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1 payment of claims expenses.
2 f. The administering carrier shall be paid as provided
3 in the board's contract with the administering carrier for
4 expenses incurred in the performance of its services.
5 (Source: P.A. 85-1013.)
6 (215 ILCS 105/8) (from Ch. 73, par. 1308)
7 Sec. 8. Minimum benefits.
8 a. Availability. The Plan shall offer in an annually
9 renewable policy major medical expense coverage to every
10 eligible person who is not eligible for Medicare. Major
11 medical expense coverage offered by the Plan shall pay an
12 eligible person's covered expenses, subject to limit on the
13 deductible and coinsurance payments authorized under
14 paragraph (4) of subsection d of this Section, up to a
15 lifetime benefit limit of $500,000 per covered individual.
16 The maximum limit under this subsection shall not be altered
17 by the Board, and no actuarial equivalent benefit may be
18 substituted by the Board. Any person who otherwise would
19 qualify for coverage under the Plan, but is excluded because
20 he or she is eligible for Medicare, shall be eligible for any
21 separate Medicare supplement policy which the Board may
22 offer.
23 b. Covered expenses. Covered expenses shall be limited
24 to the reasonable and customary charge, including negotiated
25 fees, in the locality for the following services and articles
26 when medically necessary and prescribed by a person licensed
27 and practicing within the scope of his or her profession as
28 authorized by State law:
29 (1) Hospital room and board and any other hospital
30 services including emergency and post-stabilization
31 services, except that inpatient hospitalization for the
32 treatment of mental and emotional disorders shall only be
33 covered for a maximum of 45 days in a calendar year.
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1 (2) Professional services for the diagnosis or
2 treatment of injuries, illnesses or conditions, other
3 than dental, or outpatient mental as described in
4 paragraph (17), which are rendered by a physician or
5 chiropractor, or by other licensed professionals at the
6 physician's or chiropractor's direction.
7 (3) If surgery has been recommended, a second
8 opinion may be required. The charge for a second opinion
9 as to whether the surgery is required will be paid in
10 full without regard to deductible or co-payment
11 requirements. If the second opinion differs from the
12 first, the charge for a third opinion, if desired, will
13 also be paid in full without regard to deductible or
14 co-payment requirements. Regardless of whether the
15 second opinion or third opinion confirms the original
16 recommendation, it is the patient's decision whether to
17 undergo surgery.
18 (4) Drugs requiring a physician's or other legally
19 authorized prescription.
20 (5) Skilled nursing care provided in a skilled
21 nursing facility for not more than 120 days in a calendar
22 year, provided the service commences within 14 days
23 following a confinement of at least 3 consecutive days in
24 a hospital for the same condition.
25 (6) Services of a home health agency in accord with
26 a home health care plan, up to a maximum of 270 visits
27 per year.
28 (7) Services of a licensed hospice for not more
29 than 180 days during a policy year.
30 (8) Use of radium or other radioactive materials.
31 (9) Oxygen.
32 (10) Anesthetics.
33 (11) Orthoses and prostheses other than dental.
34 (12) Rental or purchase in accordance with Board
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1 policies or procedures of durable medical equipment,
2 other than eyeglasses or hearing aids, for which there is
3 no personal use in the absence of the condition for which
4 it is prescribed.
5 (13) Diagnostic x-rays and laboratory tests.
6 (14) Oral surgery for excision of partially or
7 completely unerupted impacted teeth or the gums and
8 tissues of the mouth, when not performed in connection
9 with the routine extraction or repair of teeth, and oral
10 surgery and procedures, including orthodontics and
11 prosthetics necessary for craniofacial or maxillofacial
12 conditions and to correct congenital defects or injuries
13 due to accident.
14 (15) Physical, speech, and functional occupational
15 therapy as medically necessary and provided by
16 appropriate licensed professionals.
17 (16) Transportation summoned by use of the 911
18 emergency telephone number or other means provided by a
19 licensed ambulance service to the nearest health care
20 facility qualified to treat the illness, injury or
21 condition, subject to the provisions of the Emergency
22 Medical Services (EMS) Systems (EMS) Act.
23 (17) The first 50 professional outpatient visits
24 for diagnosis and treatment of mental and emotional
25 disorders rendered during the year, up to a maximum of
26 $80 per visit.
27 (18) Human organ or tissue transplants specified by
28 the Board that are performed at a hospital designated by
29 the Board as a participating transplant center for that
30 specific organ or tissue transplant.
31 c. Exclusion. Covered expenses of the Plan shall not
32 include the following:
33 (1) Any charge for treatment for cosmetic purposes
34 other than for reconstructive surgery when the service is
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1 incidental to or follows surgery resulting from injury,
2 sickness or other diseases of the involved part or
3 surgery for the repair or treatment of a congenital
4 bodily defect to restore normal bodily functions.
5 (2) Any charge for care that is primarily for rest,
6 custodial, educational, or domiciliary purposes.
7 (3) Any charge for services in a private room to
8 the extent it is in excess of the institution's charge
9 for its most common semiprivate room, unless a private
10 room is prescribed as medically necessary by a physician.
11 (4) That part of any charge for room and board or
12 for services rendered or articles prescribed by a
13 physician, dentist, or other health care personnel that
14 exceeds the reasonable and customary charge in the
15 locality or for any services or supplies not medically
16 necessary for the diagnosed injury or illness.
17 (5) Any charge for services or articles the
18 provision of which is not within the scope of licensure
19 of the institution or individual providing the services
20 or articles.
21 (6) Any expense incurred prior to the effective
22 date of coverage by the Plan for the person on whose
23 behalf the expense is incurred.
24 (7) Dental care, dental surgery, dental treatment
25 or dental appliances, except as provided in paragraph
26 (14) of subsection b of this Section.
27 (8) Eyeglasses, contact lenses, hearing aids or
28 their fitting.
29 (9) Illness or injury due to (A) war or any acts of
30 war; (B) commission of, or attempt to commit, a felony;
31 or (C) aviation activities, except when traveling as a
32 fare-paying passenger on a commercial airline.
33 (10) Services of blood donors and any fee for
34 failure to replace blood provided to an eligible person
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1 each policy year.
2 (11) Personal supplies or services provided by a
3 hospital or nursing home, or any other nonmedical or
4 nonprescribed supply or service.
5 (12) Routine maternity charges for a pregnancy,
6 except where added as optional coverage with payment of
7 an additional premium for pregnancy resulting from
8 conception occurring after the effective date of the
9 optional coverage.
10 (13) Expenses of obtaining an abortion, induced
11 miscarriage or induced premature birth unless, in the
12 opinion of a physician, those procedures are necessary
13 for the preservation of life of the woman seeking such
14 treatment, or except an induced premature birth intended
15 to produce a live viable child and the procedure is
16 necessary for the health of the mother or unborn child.
17 (14) Any expense or charge for services, drugs, or
18 supplies that are: (i) not provided in accord with
19 generally accepted standards of current medical practice;
20 (ii) for procedures, treatments, equipment, transplants,
21 or implants, any of which are investigational,
22 experimental, or for research purposes; (iii)
23 investigative and not proven safe and effective; or (iv)
24 for, or resulting from, a gender transformation
25 operation.
26 (15) Any expense or charge for routine physical
27 examinations or tests.
28 (16) Any expense for which a charge is not made in
29 the absence of insurance or for which there is no legal
30 obligation on the part of the patient to pay.
31 (17) Any expense incurred for benefits provided
32 under the laws of the United States and this State,
33 including Medicare and Medicaid and other medical
34 assistance, military service-connected disability
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1 payments, medical services provided for members of the
2 armed forces and their dependents or employees of the
3 armed forces of the United States, and medical services
4 financed on behalf of all citizens by the United States.
5 (18) Any expense or charge for in vitro
6 fertilization, artificial insemination, or any other
7 artificial means used to cause pregnancy.
8 (19) Any expense or charge for oral contraceptives
9 used for birth control or any other temporary birth
10 control measures.
11 (20) Any expense or charge for sterilization or
12 sterilization reversals.
13 (21) Any expense or charge for weight loss
14 programs, exercise equipment, or treatment of obesity,
15 except when certified by a physician as morbid obesity
16 (at least 2 times normal body weight).
17 (22) Any expense or charge for acupuncture
18 treatment unless used as an anesthetic agent for a
19 covered surgery.
20 (23) Any expense or charge for or related to organ
21 or tissue transplants other than those performed at a
22 hospital with a Board approved organ transplant program
23 that has been designated by the Board as a preferred or
24 exclusive provider organization for that specific organ
25 or tissue.
26 (24) Any expense or charge for procedures,
27 treatments, equipment, or services that are provided in
28 special settings for research purposes or in a controlled
29 environment, are being studied for safety, efficiency,
30 and effectiveness, and are awaiting endorsement by the
31 appropriate national medical speciality college for
32 general use within the medical community.
33 d. Premiums, deductibles, and coinsurance.
34 (1) Premiums charged for coverage issued by the
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1 Plan may not be unreasonable in relation to the benefits
2 provided, the risk experience and the reasonable expenses
3 of providing the coverage.
4 (2) Separate schedules of premium rates based on
5 sex, age and geographical location shall apply for
6 individual risks.
7 (3) The Plan may provide for separate premium rates
8 for optional family coverage for the spouse or one or
9 more dependents of any person eligible to be insured
10 under the Plan who is also the oldest adult member of the
11 family and remains continuously enrolled in the Plan as
12 the primary enrollee. The rates shall be such percentage
13 of the applicable individual Plan rate as the Board, in
14 accordance with appropriate actuarial principles, shall
15 establish for each spouse or dependent.
16 (4) The Board shall determine, in accordance with
17 appropriate actuarial principles, the average rates that
18 individual standard risks in this State are charged by at
19 least 5 of the largest insurers providing coverage to
20 residents of Illinois that is substantially similar to
21 the Plan coverage. In the event at least 5 insurers do
22 not offer substantially similar coverage, the rates shall
23 be established using reasonable actuarial techniques and
24 shall reflect anticipated claims experience, expenses,
25 and other appropriate risk factors relating to the Plan.
26 Rates for Plan coverage shall be 135% of rates so
27 established as applicable for individual standard risks;
28 provided, however, if after determining that the
29 appropriations made pursuant to Section 12 of this Act
30 are insufficient to ensure that total income from all
31 sources will equal or exceed the total incurred costs and
32 expenses for the current number of enrollees, the board
33 shall raise premium rates above this 135% standard to the
34 level it deems necessary to ensure the financial solvency
HB0643 Engrossed -28- LRB9002943JSgc
1 of the Plan for enrollees already in the Plan. All rates
2 and rate schedules shall be submitted to the board for
3 approval.
4 (5) The Plan coverage defined in Section 6 shall
5 provide for a choice of deductibles as authorized by the
6 Board per individual per annum. If 2 individual members
7 of a family satisfy the same applicable deductibles, no
8 other member of that family who is eligible for coverage
9 under the Plan shall be required to meet any deductibles
10 for the balance of that calendar year. The deductibles
11 must be applied first to the authorized amount of covered
12 expenses incurred by the covered person. A mandatory
13 coinsurance requirement shall be imposed at the rate
14 authorized by the Board in excess of the mandatory
15 deductible, the coinsurance in the aggregate not to
16 exceed such amounts as are authorized by the Board per
17 annum. At its discretion the Board may, however, offer
18 catastrophic coverages or other policies that provide for
19 larger deductibles with or without coinsurance
20 requirements. The deductibles and coinsurance factors
21 may be adjusted annually according to the Medical
22 Component of the Consumer Price Index.
23 (6) The Plan may provide for and employ cost
24 containment measures and requirements including, but not
25 limited to, preadmission certification, second surgical
26 opinion, concurrent utilization review programs,
27 individual case management, preferred provider
28 organizations, and other cost effective arrangements for
29 paying for covered expenses.
30 e. Scope of coverage. Except as provided in subsection
31 c of this Section, if the covered expenses incurred by the
32 eligible person exceed the deductible for major medical
33 expense coverage in a calendar year, the Plan shall pay at
34 least 80% of any additional covered expenses incurred by the
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1 person during the calendar year.
2 f. Preexisting conditions.
3 (1) Six months: Plan coverage shall exclude charges
4 or expenses incurred during the first 6 months following
5 the effective date of coverage as to any condition if:
6 (a) the condition had manifested itself within the 6
7 month period immediately preceding the effective date of
8 coverage in such a manner as would cause an ordinarily
9 prudent person to seek diagnosis, care or treatment; or
10 (b) medical advice, care or treatment was recommended or
11 received within the 6 month period immediately preceding
12 the effective date of coverage.
13 (2) (Blank).
14 (3) Waiver: The preexisting condition exclusions as
15 set forth in paragraph (1) of this subsection shall be
16 waived to the extent to which the eligible person: (a)
17 has satisfied similar exclusions under any prior health
18 insurance policy or plan that was involuntarily
19 terminated; (b) is ineligible for any continuation or
20 conversion rights that would continue or provide
21 substantially similar coverage following that
22 termination; and (c) has applied for Plan coverage not
23 later than 30 days following the involuntary termination.
24 No policy or plan shall be deemed to have been
25 involuntarily terminated if the master policyholder or
26 other controlling party elected to change insurance
27 coverage from one company or plan to another even if that
28 decision resulted in a discontinuation of coverage for
29 any individual under the plan, either totally or for any
30 medical condition. For each eligible person who qualifies
31 for and elects this waiver, there shall be added to each
32 payment of premium, on a prorated basis, a surcharge of
33 up to 10% of the otherwise applicable annual premium for
34 as long as that individual's coverage under the Plan
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1 remains in effect or 60 months, whichever is less.
2 g. Other sources primary; nonduplication of benefits.
3 (1) The Plan shall be the last payor of benefits
4 whenever any other benefit or source of third party
5 payment is available. Subject to the provisions of
6 subsection e of Section 7, benefits otherwise payable
7 under Plan coverage shall be reduced by all amounts paid
8 or payable by Medicare or any other government program or
9 through any health insurance or other health benefit
10 plan, whether insured or otherwise, or through any third
11 party liability, settlement, judgment, or award,
12 regardless of the date of the settlement, judgment, or
13 award, whether the settlement, judgment, or award is in
14 the form of a contract, agreement, or trust on behalf of
15 a minor or otherwise and whether the settlement,
16 judgment, or award is payable to the covered person, his
17 or her dependent, estate, personal representative, or
18 guardian in a lump sum or over time, and by all hospital
19 or medical expense benefits paid or payable under any
20 worker's compensation coverage, automobile medical
21 payment, or liability insurance, whether provided on the
22 basis of fault or nonfault, and by any hospital or
23 medical benefits paid or payable under or provided
24 pursuant to any State or federal law or program.
25 (2) The Plan shall have a cause of action against
26 any covered person or any other person or entity for the
27 recovery of any amount paid to the extent the amount was
28 for treatment, services, or supplies not covered in this
29 Section or in excess of benefits as set forth in this
30 Section.
31 (3) Whenever benefits are due from the Plan because
32 of sickness or an injury to a covered person resulting
33 from a third party's wrongful act or negligence and the
34 covered person has recovered or may recover damages from
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1 a third party or its insurer, the Plan shall have the
2 right to reduce benefits or to refuse to pay benefits
3 that otherwise may be payable by the amount of damages
4 that the covered person has recovered or may recover
5 regardless of the date of the sickness or injury or the
6 date of any settlement, judgment, or award resulting from
7 that sickness or injury.
8 During the pendency of any action or claim that is
9 brought by or on behalf of a covered person against a
10 third party or its insurer, any benefits that would
11 otherwise be payable except for the provisions of this
12 paragraph (3) shall be paid if payment by or for the
13 third party has not yet been made and the covered person
14 or, if incapable, that person's legal representative
15 agrees in writing to pay back promptly the benefits paid
16 as a result of the sickness or injury to the extent of
17 any future payments made by or for the third party for
18 the sickness or injury. This agreement is to apply
19 whether or not liability for the payments is established
20 or admitted by the third party or whether those payments
21 are itemized.
22 Any amounts due the plan to repay benefits may be
23 deducted from other benefits payable by the Plan after
24 payments by or for the third party are made.
25 (4) Benefits due from the Plan may be reduced or
26 refused as an offset against any amount otherwise
27 recoverable under this Section.
28 h. Right of subrogation; recoveries.
29 (1) Whenever the Plan has paid benefits because of
30 sickness or an injury to any covered person resulting
31 from a third party's wrongful act or negligence, or for
32 which an insurer is liable in accordance with the
33 provisions of any policy of insurance, and the covered
34 person has recovered or may recover damages from a third
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1 party that is liable for the damages, the Plan shall have
2 the right to recover the benefits it paid from any
3 amounts that the covered person has received or may
4 receive regardless of the date of the sickness or injury
5 or the date of any settlement, judgment, or award
6 resulting from that sickness or injury. The Plan shall
7 be subrogated to any right of recovery the covered person
8 may have under the terms of any private or public health
9 care coverage or liability coverage, including coverage
10 under the Workers' Compensation Act or the Workers'
11 Occupational Diseases Act, without the necessity of
12 assignment of claim or other authorization to secure the
13 right of recovery. To enforce its subrogation right, the
14 Plan may (i) intervene or join in an action or proceeding
15 brought by the covered person or his personal
16 representative, including his guardian, conservator,
17 estate, dependents, or survivors, against any third party
18 or the third party's insurer that may be liable or (ii)
19 institute and prosecute legal proceedings against any
20 third party or the third party's insurer that may be
21 liable for the sickness or injury in an appropriate court
22 either in the name of the Plan or in the name of the
23 covered person or his personal representative, including
24 his guardian, conservator, estate, dependents, or
25 survivors.
26 (2) If any action or claim is brought by or on
27 behalf of a covered person against a third party or the
28 third party's insurer, the covered person or his personal
29 representative, including his guardian, conservator,
30 estate, dependents, or survivors, shall notify the Plan
31 by personal service or registered mail of the action or
32 claim and of the name of the court in which the action or
33 claim is brought, filing proof thereof in the action or
34 claim. The Plan may, at any time thereafter, join in the
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1 action or claim upon its motion so that all orders of
2 court after hearing and judgment shall be made for its
3 protection. No release or settlement of a claim for
4 damages and no satisfaction of judgment in the action
5 shall be valid without the written consent of the Plan to
6 the extent of its interest in the settlement or judgment
7 and of the covered person or his personal representative.
8 (3) In the event that the covered person or his
9 personal representative fails to institute a proceeding
10 against any appropriate third party before the fifth
11 month before the action would be barred, the Plan may, in
12 its own name or in the name of the covered person or
13 personal representative, commence a proceeding against
14 any appropriate third party for the recovery of damages
15 on account of any sickness, injury, or death to the
16 covered person. The covered person shall cooperate in
17 doing what is reasonably necessary to assist the Plan in
18 any recovery and shall not take any action that would
19 prejudice the Plan's right to recovery. The Plan shall
20 pay to the covered person or his personal representative
21 all sums collected from any third party by judgment or
22 otherwise in excess of amounts paid in benefits under the
23 Plan and amounts paid or to be paid as costs, attorneys
24 fees, and reasonable expenses incurred by the Plan in
25 making the collection or enforcing the judgment.
26 (4) In the event that a covered person or his
27 personal representative, including his guardian,
28 conservator, estate, dependents, or survivors, recovers
29 damages from a third party for sickness or injury caused
30 to the covered person, the covered person or the personal
31 representative shall pay to the Plan from the damages
32 recovered the amount of benefits paid or to be paid on
33 behalf of the covered person.
34 (5) When the action or claim is brought by the
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1 covered person alone and the covered person incurs a
2 personal liability to pay attorney's fees and costs of
3 litigation, the Plan's claim for reimbursement of the
4 benefits provided to the covered person shall be the full
5 amount of benefits paid to or on behalf of the covered
6 person under this Act less a pro rata share that
7 represents the Plan's reasonable share of attorney's fees
8 paid by the covered person and that portion of the cost
9 of litigation expenses determined by multiplying by the
10 ratio of the full amount of the expenditures to the full
11 amount of the judgement, award, or settlement.
12 (6) In the event of judgment or award in a suit or
13 claim against a third party or insurer, the court shall
14 first order paid from any judgement or award the
15 reasonable litigation expenses incurred in preparation
16 and prosecution of the action or claim, together with
17 reasonable attorney's fees. After payment of those
18 expenses and attorney's fees, the court shall apply out
19 of the balance of the judgment or award an amount
20 sufficient to reimburse the Plan the full amount of
21 benefits paid on behalf of the covered person under this
22 Act, provided the court may reduce and apportion the
23 Plan's portion of the judgement proportionate to the
24 recovery of the covered person. The burden of producing
25 evidence sufficient to support the exercise by the court
26 of its discretion to reduce the amount of a proven charge
27 sought to be enforced against the recovery shall rest
28 with the party seeking the reduction. The court may
29 consider the nature and extent of the injury, economic
30 and non-economic loss, settlement offers, comparative
31 negligence as it applies to the case at hand, hospital
32 costs, physician costs, and all other appropriate costs.
33 The Plan shall pay its pro rata share of the attorney
34 fees based on the Plan's recovery as it compares to the
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1 total judgment. Any reimbursement rights of the Plan
2 shall take priority over all other liens and charges
3 existing under the laws of this State with the exception
4 of any attorney liens filed under the Attorneys Lien Act.
5 (7) The Plan may compromise or settle and release
6 any claim for benefits provided under this Act or waive
7 any claims for benefits, in whole or in part, for the
8 convenience of the Plan or if the Plan determines that
9 collection would result in undue hardship upon the
10 covered person.
11 (Source: P.A. 89-486, eff. 6-21-96.)
12 Section 93. The Health Maintenance Organization Act is
13 amended by changing Sections 1-2, 4-10, and 4-15 and adding
14 Section 5-7.2 as follows:
15 (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
16 Sec. 1-2. Definitions. As used in this Act, unless the
17 context otherwise requires, the following terms shall have
18 the meanings ascribed to them:
19 (1) "Advertisement" means any printed or published
20 material, audiovisual material and descriptive literature of
21 the health care plan used in direct mail, newspapers,
22 magazines, radio scripts, television scripts, billboards and
23 similar displays; and any descriptive literature or sales
24 aids of all kinds disseminated by a representative of the
25 health care plan for presentation to the public including,
26 but not limited to, circulars, leaflets, booklets,
27 depictions, illustrations, form letters and prepared sales
28 presentations.
29 (2) "Director" means the Director of Insurance.
30 (3) "Basic Health Care Services" means emergency care,
31 and inpatient hospital and physician care, outpatient medical
32 services, mental health services and care for alcohol and
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1 drug abuse, including any reasonable deductibles and
2 co-payments, all of which are subject to such limitations as
3 are determined by the Director pursuant to rule.
4 (4) "Enrollee" means an individual who has been enrolled
5 in a health care plan.
6 (5) "Evidence of Coverage" means any certificate,
7 agreement, or contract issued to an enrollee setting out the
8 coverage to which he is entitled in exchange for a per capita
9 prepaid sum.
10 (6) "Group Contract" means a contract for health care
11 services which by its terms limits eligibility to members of
12 a specified group.
13 (7) "Health Care Plan" means any arrangement whereby any
14 organization undertakes to provide or arrange for and pay for
15 or reimburse the cost of basic health care services from
16 providers selected by the Health Maintenance Organization and
17 such arrangement consists of arranging for or the provision
18 of such health care services, as distinguished from mere
19 indemnification against the cost of such services, except as
20 otherwise authorized by Section 2-3 of this Act, on a per
21 capita prepaid basis, through insurance or otherwise. A
22 "health care plan" also includes any arrangement whereby an
23 organization undertakes to provide or arrange for or pay for
24 or reimburse the cost of any health care service for persons
25 who are enrolled in the integrated health care program
26 established under Section 5-16.3 of the Illinois Public Aid
27 Code through providers selected by the organization and the
28 arrangement consists of making provision for the delivery of
29 health care services, as distinguished from mere
30 indemnification. Nothing in this definition, however,
31 affects the total medical services available to persons
32 eligible for medical assistance under the Illinois Public Aid
33 Code.
34 (8) "Health Care Services" means any services included
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1 in the furnishing to any individual of medical or dental
2 care, or the hospitalization or incident to the furnishing of
3 such care or hospitalization as well as the furnishing to any
4 person of any and all other services for the purpose of
5 preventing, alleviating, curing or healing human illness or
6 injury.
7 (9) "Health Maintenance Organization" means any
8 organization formed under the laws of this or another state
9 to provide or arrange for one or more health care plans under
10 a system which causes any part of the risk of health care
11 delivery to be borne by the organization or its providers.
12 (10) "Net Worth" means admitted assets, as defined in
13 Section 1-3 of this Act, minus liabilities.
14 (11) "Organization" means any insurance company, or a
15 nonprofit corporation authorized under the Medical Service
16 Plan Act, the Dental Service Plan Act, the Vision Service
17 Plan Act, the Pharmaceutical Service Plan Act, the Voluntary
18 Health Services Plans Act or the Non-profit Health Care
19 Service Plan Act, or a corporation organized under the laws
20 of this or another state for the purpose of operating one or
21 more health care plans and doing no business other than that
22 of a Health Maintenance Organization or an insurance company.
23 Organization shall also mean the University of Illinois
24 Hospital as defined in the University of Illinois Hospital
25 Act.
26 (12) "Provider" means any physician, hospital facility,
27 or other person which is licensed or otherwise authorized to
28 furnish health care services and also includes any other
29 entity that arranges for the delivery or furnishing of health
30 care service.
31 (13) "Producer" means a person directly or indirectly
32 associated with a health care plan who engages in
33 solicitation or enrollment.
34 (14) "Per capita prepaid" means a basis of prepayment by
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1 which a fixed amount of money is prepaid per individual or
2 any other enrollment unit to the Health Maintenance
3 Organization or for health care services which are provided
4 during a definite time period regardless of the frequency or
5 extent of the services rendered by the Health Maintenance
6 Organization, except for copayments and deductibles and
7 except as provided in subsection (f) of Section 5-3 of this
8 Act.
9 (15) "Subscriber" means a person who has entered into a
10 contractual relationship with the Health Maintenance
11 Organization for the provision of or arrangement of at least
12 basic health care services to the beneficiaries of such
13 contract.
14 (16) "Emergency medical screening examination" means a
15 medical screening examination and evaluation by a physician
16 or, to the extent permitted by applicable laws, by other
17 appropriate personnel under the supervision of a physician to
18 determine whether the need for emergency services exists.
19 (17) "Emergency services" means those health care
20 services provided to evaluate and treat medical conditions of
21 recent onset and severity that would lead a prudent
22 layperson, possessing an average knowledge of medicine and
23 health, to believe that urgent or unscheduled medical care is
24 required.
25 (18) "Post-stabilization services" means those health
26 care services determined by a treating provider to be
27 promptly and medically necessary following stabilization of
28 an emergency condition.
29 (Source: P.A. 88-554, eff. 7-26-94; 89-90, eff. 6-30-95.)
30 (215 ILCS 125/4-10) (from Ch. 111 1/2, par. 1409.3)
31 Sec. 4-10. (a) Medical necessity; dispute resolution;
32 independent; second opinion; post-stabilization service.
33 (a) Each Health Maintenance Organization shall provide a
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1 mechanism for the timely review by a physician holding the
2 same class of license as the primary care physician, who is
3 unaffiliated with the Health Maintenance Organization,
4 jointly selected by the patient (or the patient's next of kin
5 or legal representative if the patient is unable to act for
6 himself), primary care physician and the Health Maintenance
7 Organization in the event of a dispute between the primary
8 care physician and the Health Maintenance Organization
9 regarding the medical necessity of a covered service proposed
10 by a primary care physician. In the event that the reviewing
11 physician determines the covered service to be medically
12 necessary, the Health Maintenance Organization shall provide
13 the covered service. Future contractual or employment action
14 by the Health Maintenance Organization regarding the primary
15 care physician shall not be based solely on the physician's
16 participation in this procedure.
17 (b) If prior authorization for post-stabilization
18 services is required, the health care plan shall provide
19 access 24 hours a day, 7 days a week to persons designated by
20 the plan to make such determinations. If a health care
21 provider has attempted to contact such person for prior
22 authorization and no designated persons were accessible or
23 the authorization was not denied within 30 minutes of the
24 request, the health care plan is deemed to have approved the
25 request for prior authorization.
26 (Source: P.A. 85-20; 85-850.)
27 (215 ILCS 125/4-15) (from Ch. 111 1/2, par. 1409.8)
28 Sec. 4-15. Emergency transportation.
29 (a) No contract or evidence of coverage for basic health
30 care services delivered, issued for delivery, renewed or
31 amended by a Health Maintenance Organization shall discourage
32 or penalize use of the 911 emergency telephone number or
33 exclude coverage or require prior authorization for emergency
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1 transportation by ambulance or emergency services rendered by
2 any provider. Payment for emergency services shall not
3 depend upon whether such services are performed by a
4 preferred or nonpreferred provider and such coverage shall be
5 at the same level as if the service or treatment had been
6 rendered by a plan provider. For the purposes of this
7 Section, the term "emergency" means a need for immediate
8 medical attention resulting from a life threatening condition
9 or situation or a need for immediate medical attention as
10 otherwise reasonably determined by a physician, public safety
11 official or other emergency medical personnel.
12 (b) Upon reasonable demand by a provider of emergency
13 transportation by ambulance, a Health Maintenance
14 Organization shall promptly pay to the provider, subject to
15 coverage limitations stated in the contract or evidence of
16 coverage, the charges for emergency transportation by
17 ambulance provided to an enrollee in a health care plan
18 arranged for by the Health Maintenance Organization. By
19 accepting any such payment from the Health Maintenance
20 Organization, the provider of emergency transportation by
21 ambulance agrees not to seek any payment from the enrollee
22 for services provided to the enrollee.
23 (Source: P.A. 86-833; 86-1028.)
24 (215 ILCS 125/5-7.2 new)
25 Sec. 5-7.2. Retrospective denials.
26 (a) No health care plan shall retrospectively deny
27 coverage and payment for emergency services except upon
28 reasonable determination that:
29 (1) the emergency services claimed were never
30 performed; or
31 (2) an emergency medical screening examination was
32 performed on a patient who personally sought emergency
33 services knowing that he or she did not have an emergency
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1 condition or necessity, and who did not in fact require
2 emergency services.
3 (b) No health care plan shall retrospectively deny
4 coverage and payment for post-stabilization services which
5 received prior authorization or deemed approval.
6 Section 96. The Illinois Public Aid Code is amended by
7 changing Section 5-16.3 and adding Section 5-5.04 as follows:
8 (305 ILCS 5/5-5.04 new)
9 Sec. 5-5.04. Emergency services.
10 (a) As used in this Act, "emergency medical screening
11 examination" means a medical screening examination and
12 evaluation by a physician or, to the extent permitted by
13 applicable laws, by other appropriate personnel under the
14 supervision of a physician to determine whether the need for
15 emergency services exists and "emergency services" means
16 those health care services provided to evaluate and treat
17 medical conditions of recent onset and severity that would
18 lead a prudent layperson, possessing an average knowledge of
19 medicine and health, to believe that urgent or unscheduled
20 medical care is required. No prior authorization or approval
21 shall be required in order to seek and receive emergency
22 services.
23 (b) Coverage and payment for emergency services shall
24 not be retrospectively denied except upon reasonable
25 determination by the Illinois Department that:
26 (1) the emergency medical services claimed were
27 never performed; or
28 (2) an emergency medical screening examination was
29 performed on a patient who personally sought emergency
30 services knowing that he or she did not have an emergency
31 condition or necessity, and who did not in fact require
32 emergency services.
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1 (305 ILCS 5/5-16.3)
2 (Text of Section before amendment by P.A. 89-507)
3 Sec. 5-16.3. System for integrated health care services.
4 (a) It shall be the public policy of the State to adopt,
5 to the extent practicable, a health care program that
6 encourages the integration of health care services and
7 manages the health care of program enrollees while preserving
8 reasonable choice within a competitive and cost-efficient
9 environment. In furtherance of this public policy, the
10 Illinois Department shall develop and implement an integrated
11 health care program consistent with the provisions of this
12 Section. The provisions of this Section apply only to the
13 integrated health care program created under this Section.
14 Persons enrolled in the integrated health care program, as
15 determined by the Illinois Department by rule, shall be
16 afforded a choice among health care delivery systems, which
17 shall include, but are not limited to, (i) fee for service
18 care managed by a primary care physician licensed to practice
19 medicine in all its branches, (ii) managed health care
20 entities, and (iii) federally qualified health centers
21 (reimbursed according to a prospective cost-reimbursement
22 methodology) and rural health clinics (reimbursed according
23 to the Medicare methodology), where available. Persons
24 enrolled in the integrated health care program also may be
25 offered indemnity insurance plans, subject to availability.
26 For purposes of this Section, a "managed health care
27 entity" means a health maintenance organization or a managed
28 care community network as defined in this Section. A "health
29 maintenance organization" means a health maintenance
30 organization as defined in the Health Maintenance
31 Organization Act. A "managed care community network" means
32 an entity, other than a health maintenance organization, that
33 is owned, operated, or governed by providers of health care
34 services within this State and that provides or arranges
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1 primary, secondary, and tertiary managed health care services
2 under contract with the Illinois Department exclusively to
3 enrollees of the integrated health care program. A managed
4 care community network may contract with the Illinois
5 Department to provide only pediatric health care services. A
6 county provider as defined in Section 15-1 of this Code may
7 contract with the Illinois Department to provide services to
8 enrollees of the integrated health care program as a managed
9 care community network without the need to establish a
10 separate entity that provides services exclusively to
11 enrollees of the integrated health care program and shall be
12 deemed a managed care community network for purposes of this
13 Code only to the extent of the provision of services to those
14 enrollees in conjunction with the integrated health care
15 program. A county provider shall be entitled to contract
16 with the Illinois Department with respect to any contracting
17 region located in whole or in part within the county. A
18 county provider shall not be required to accept enrollees who
19 do not reside within the county.
20 Each managed care community network must demonstrate its
21 ability to bear the financial risk of serving enrollees under
22 this program. The Illinois Department shall by rule adopt
23 criteria for assessing the financial soundness of each
24 managed care community network. These rules shall consider
25 the extent to which a managed care community network is
26 comprised of providers who directly render health care and
27 are located within the community in which they seek to
28 contract rather than solely arrange or finance the delivery
29 of health care. These rules shall further consider a variety
30 of risk-bearing and management techniques, including the
31 sufficiency of quality assurance and utilization management
32 programs and whether a managed care community network has
33 sufficiently demonstrated its financial solvency and net
34 worth. The Illinois Department's criteria must be based on
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1 sound actuarial, financial, and accounting principles. In
2 adopting these rules, the Illinois Department shall consult
3 with the Illinois Department of Insurance. The Illinois
4 Department is responsible for monitoring compliance with
5 these rules.
6 This Section may not be implemented before the effective
7 date of these rules, the approval of any necessary federal
8 waivers, and the completion of the review of an application
9 submitted, at least 60 days before the effective date of
10 rules adopted under this Section, to the Illinois Department
11 by a managed care community network.
12 All health care delivery systems that contract with the
13 Illinois Department under the integrated health care program
14 shall clearly recognize a health care provider's right of
15 conscience under the Right of Conscience Act. In addition to
16 the provisions of that Act, no health care delivery system
17 that contracts with the Illinois Department under the
18 integrated health care program shall be required to provide,
19 arrange for, or pay for any health care or medical service,
20 procedure, or product if that health care delivery system is
21 owned, controlled, or sponsored by or affiliated with a
22 religious institution or religious organization that finds
23 that health care or medical service, procedure, or product to
24 violate its religious and moral teachings and beliefs.
25 (b) The Illinois Department may, by rule, provide for
26 different benefit packages for different categories of
27 persons enrolled in the program. Mental health services,
28 alcohol and substance abuse services, services related to
29 children with chronic or acute conditions requiring
30 longer-term treatment and follow-up, and rehabilitation care
31 provided by a free-standing rehabilitation hospital or a
32 hospital rehabilitation unit may be excluded from a benefit
33 package if the State ensures that those services are made
34 available through a separate delivery system. An exclusion
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1 does not prohibit the Illinois Department from developing and
2 implementing demonstration projects for categories of persons
3 or services. Benefit packages for persons eligible for
4 medical assistance under Articles V, VI, and XII shall be
5 based on the requirements of those Articles and shall be
6 consistent with the Title XIX of the Social Security Act.
7 Nothing in this Act shall be construed to apply to services
8 purchased by the Department of Children and Family Services
9 and the Department of Mental Health and Developmental
10 Disabilities under the provisions of Title 59 of the Illinois
11 Administrative Code, Part 132 ("Medicaid Community Mental
12 Health Services Program").
13 (c) The program established by this Section may be
14 implemented by the Illinois Department in various contracting
15 areas at various times. The health care delivery systems and
16 providers available under the program may vary throughout the
17 State. For purposes of contracting with managed health care
18 entities and providers, the Illinois Department shall
19 establish contracting areas similar to the geographic areas
20 designated by the Illinois Department for contracting
21 purposes under the Illinois Competitive Access and
22 Reimbursement Equity Program (ICARE) under the authority of
23 Section 3-4 of the Illinois Health Finance Reform Act or
24 similarly-sized or smaller geographic areas established by
25 the Illinois Department by rule. A managed health care entity
26 shall be permitted to contract in any geographic areas for
27 which it has a sufficient provider network and otherwise
28 meets the contracting terms of the State. The Illinois
29 Department is not prohibited from entering into a contract
30 with a managed health care entity at any time.
31 (d) A managed health care entity that contracts with the
32 Illinois Department for the provision of services under the
33 program shall do all of the following, solely for purposes of
34 the integrated health care program:
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1 (1) Provide that any individual physician licensed
2 to practice medicine in all its branches, any pharmacy,
3 any federally qualified health center, and any
4 podiatrist, that consistently meets the reasonable terms
5 and conditions established by the managed health care
6 entity, including but not limited to credentialing
7 standards, quality assurance program requirements,
8 utilization management requirements, financial
9 responsibility standards, contracting process
10 requirements, and provider network size and accessibility
11 requirements, must be accepted by the managed health care
12 entity for purposes of the Illinois integrated health
13 care program. Any individual who is either terminated
14 from or denied inclusion in the panel of physicians of
15 the managed health care entity shall be given, within 10
16 business days after that determination, a written
17 explanation of the reasons for his or her exclusion or
18 termination from the panel. This paragraph (1) does not
19 apply to the following:
20 (A) A managed health care entity that
21 certifies to the Illinois Department that:
22 (i) it employs on a full-time basis 125
23 or more Illinois physicians licensed to
24 practice medicine in all of its branches; and
25 (ii) it will provide medical services
26 through its employees to more than 80% of the
27 recipients enrolled with the entity in the
28 integrated health care program; or
29 (B) A domestic stock insurance company
30 licensed under clause (b) of class 1 of Section 4 of
31 the Illinois Insurance Code if (i) at least 66% of
32 the stock of the insurance company is owned by a
33 professional corporation organized under the
34 Professional Service Corporation Act that has 125 or
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1 more shareholders who are Illinois physicians
2 licensed to practice medicine in all of its branches
3 and (ii) the insurance company certifies to the
4 Illinois Department that at least 80% of those
5 physician shareholders will provide services to
6 recipients enrolled with the company in the
7 integrated health care program.
8 (2) Provide for reimbursement for providers for
9 emergency services care, as defined by subsection (a) of
10 Section 5-5.04 of this Code the Illinois Department by
11 rule, that must be provided to its enrollees, including
12 an emergency department room screening fee, and urgent
13 care that it authorizes for its enrollees, regardless of
14 the provider's affiliation with the managed health care
15 entity. Providers shall be reimbursed for emergency
16 services care at an amount equal to the Illinois
17 Department's fee-for-service rates for those medical
18 services rendered by providers not under contract with
19 the managed health care entity to enrollees of the
20 entity.
21 (A) Coverage and payment for emergency
22 services shall not be retrospectively denied except
23 upon reasonable determination by the Illinois
24 Department that (1) the emergency services claimed
25 were never performed or (2) an emergency medical
26 screening examination was performed on a patient who
27 personally sought emergency services knowing that he
28 or she did not have an emergency condition or
29 necessity, and who did not in fact require emergency
30 services.
31 (B) The appropriate use of the 911 emergency
32 telephone number shall not be discouraged or
33 penalized, and coverage or payment shall not be
34 denied solely on the basis that the enrollee used
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1 the 911 emergency telephone number to summon
2 emergency services.
3 (2.5) Provide for reimbursement for
4 post-stabilization services, which are those health care
5 services determined by a treating provider to be promptly
6 and medically necessary following stabilization of an
7 emergency condition.
8 (A) If prior authorization for
9 post-stabilization services is required, the managed
10 health care entity shall provide access 24 hours a
11 day, 7 days a week to persons designated by the
12 entity to make such determinations. If a health
13 care provider has attempted to contact such person
14 for prior authorization and no designated persons
15 were accessible or the authorization was not denied
16 within 30 minutes of the request, the managed health
17 care entity is deemed to have approved the request
18 for prior authorization.
19 (B) Coverage and payment for
20 post-stabilization services which received prior
21 authorization or deemed approval shall not be
22 retrospectively denied.
23 (3) Provide that any provider affiliated with a
24 managed health care entity may also provide services on a
25 fee-for-service basis to Illinois Department clients not
26 enrolled in a managed health care entity.
27 (4) Provide client education services as determined
28 and approved by the Illinois Department, including but
29 not limited to (i) education regarding appropriate
30 utilization of health care services in a managed care
31 system, (ii) written disclosure of treatment policies and
32 any restrictions or limitations on health services,
33 including, but not limited to, physical services,
34 clinical laboratory tests, hospital and surgical
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1 procedures, prescription drugs and biologics, and
2 radiological examinations, and (iii) written notice that
3 the enrollee may receive from another provider those
4 services covered under this program that are not provided
5 by the managed health care entity.
6 (5) Provide that enrollees within its system may
7 choose the site for provision of services and the panel
8 of health care providers.
9 (6) Not discriminate in its enrollment or
10 disenrollment practices among recipients of medical
11 services or program enrollees based on health status.
12 (7) Provide a quality assurance and utilization
13 review program that (i) for health maintenance
14 organizations meets the requirements of the Health
15 Maintenance Organization Act and (ii) for managed care
16 community networks meets the requirements established by
17 the Illinois Department in rules that incorporate those
18 standards set forth in the Health Maintenance
19 Organization Act.
20 (8) Issue a managed health care entity
21 identification card to each enrollee upon enrollment.
22 The card must contain all of the following:
23 (A) The enrollee's signature.
24 (B) The enrollee's health plan.
25 (C) The name and telephone number of the
26 enrollee's primary care physician.
27 (D) A telephone number to be used for
28 emergency service 24 hours per day, 7 days per week.
29 The telephone number required to be maintained
30 pursuant to this subparagraph by each managed health
31 care entity shall, at minimum, be staffed by
32 medically trained personnel and be provided
33 directly, or under arrangement, at an office or
34 offices in locations maintained solely within the
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1 State of Illinois. For purposes of this
2 subparagraph, "medically trained personnel" means
3 licensed practical nurses or registered nurses
4 located in the State of Illinois who are licensed
5 pursuant to the Illinois Nursing Act of 1987.
6 (9) Ensure that every primary care physician and
7 pharmacy in the managed health care entity meets the
8 standards established by the Illinois Department for
9 accessibility and quality of care. The Illinois
10 Department shall arrange for and oversee an evaluation of
11 the standards established under this paragraph (9) and
12 may recommend any necessary changes to these standards.
13 The Illinois Department shall submit an annual report to
14 the Governor and the General Assembly by April 1 of each
15 year regarding the effect of the standards on ensuring
16 access and quality of care to enrollees.
17 (10) Provide a procedure for handling complaints
18 that (i) for health maintenance organizations meets the
19 requirements of the Health Maintenance Organization Act
20 and (ii) for managed care community networks meets the
21 requirements established by the Illinois Department in
22 rules that incorporate those standards set forth in the
23 Health Maintenance Organization Act.
24 (11) Maintain, retain, and make available to the
25 Illinois Department records, data, and information, in a
26 uniform manner determined by the Illinois Department,
27 sufficient for the Illinois Department to monitor
28 utilization, accessibility, and quality of care.
29 (12) Except for providers who are prepaid, pay all
30 approved claims for covered services that are completed
31 and submitted to the managed health care entity within 30
32 days after receipt of the claim or receipt of the
33 appropriate capitation payment or payments by the managed
34 health care entity from the State for the month in which
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1 the services included on the claim were rendered,
2 whichever is later. If payment is not made or mailed to
3 the provider by the managed health care entity by the due
4 date under this subsection, an interest penalty of 1% of
5 any amount unpaid shall be added for each month or
6 fraction of a month after the due date, until final
7 payment is made. Nothing in this Section shall prohibit
8 managed health care entities and providers from mutually
9 agreeing to terms that require more timely payment.
10 (13) Provide integration with community-based
11 programs provided by certified local health departments
12 such as Women, Infants, and Children Supplemental Food
13 Program (WIC), childhood immunization programs, health
14 education programs, case management programs, and health
15 screening programs.
16 (14) Provide that the pharmacy formulary used by a
17 managed health care entity and its contract providers be
18 no more restrictive than the Illinois Department's
19 pharmaceutical program on the effective date of this
20 amendatory Act of 1994 and as amended after that date.
21 (15) Provide integration with community-based
22 organizations, including, but not limited to, any
23 organization that has operated within a Medicaid
24 Partnership as defined by this Code or by rule of the
25 Illinois Department, that may continue to operate under a
26 contract with the Illinois Department or a managed health
27 care entity under this Section to provide case management
28 services to Medicaid clients in designated high-need
29 areas.
30 The Illinois Department may, by rule, determine
31 methodologies to limit financial liability for managed health
32 care entities resulting from payment for services to
33 enrollees provided under the Illinois Department's integrated
34 health care program. Any methodology so determined may be
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1 considered or implemented by the Illinois Department through
2 a contract with a managed health care entity under this
3 integrated health care program.
4 The Illinois Department shall contract with an entity or
5 entities to provide external peer-based quality assurance
6 review for the integrated health care program. The entity
7 shall be representative of Illinois physicians licensed to
8 practice medicine in all its branches and have statewide
9 geographic representation in all specialties of medical care
10 that are provided within the integrated health care program.
11 The entity may not be a third party payer and shall maintain
12 offices in locations around the State in order to provide
13 service and continuing medical education to physician
14 participants within the integrated health care program. The
15 review process shall be developed and conducted by Illinois
16 physicians licensed to practice medicine in all its branches.
17 In consultation with the entity, the Illinois Department may
18 contract with other entities for professional peer-based
19 quality assurance review of individual categories of services
20 other than services provided, supervised, or coordinated by
21 physicians licensed to practice medicine in all its branches.
22 The Illinois Department shall establish, by rule, criteria to
23 avoid conflicts of interest in the conduct of quality
24 assurance activities consistent with professional peer-review
25 standards. All quality assurance activities shall be
26 coordinated by the Illinois Department.
27 (e) All persons enrolled in the program shall be
28 provided with a full written explanation of all
29 fee-for-service and managed health care plan options and a
30 reasonable opportunity to choose among the options as
31 provided by rule. The Illinois Department shall provide to
32 enrollees, upon enrollment in the integrated health care
33 program and at least annually thereafter, notice of the
34 process for requesting an appeal under the Illinois
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1 Department's administrative appeal procedures.
2 Notwithstanding any other Section of this Code, the Illinois
3 Department may provide by rule for the Illinois Department to
4 assign a person enrolled in the program to a specific
5 provider of medical services or to a specific health care
6 delivery system if an enrollee has failed to exercise choice
7 in a timely manner. An enrollee assigned by the Illinois
8 Department shall be afforded the opportunity to disenroll and
9 to select a specific provider of medical services or a
10 specific health care delivery system within the first 30 days
11 after the assignment. An enrollee who has failed to exercise
12 choice in a timely manner may be assigned only if there are 3
13 or more managed health care entities contracting with the
14 Illinois Department within the contracting area, except that,
15 outside the City of Chicago, this requirement may be waived
16 for an area by rules adopted by the Illinois Department after
17 consultation with all hospitals within the contracting area.
18 The Illinois Department shall establish by rule the procedure
19 for random assignment of enrollees who fail to exercise
20 choice in a timely manner to a specific managed health care
21 entity in proportion to the available capacity of that
22 managed health care entity. Assignment to a specific provider
23 of medical services or to a specific managed health care
24 entity may not exceed that provider's or entity's capacity as
25 determined by the Illinois Department. Any person who has
26 chosen a specific provider of medical services or a specific
27 managed health care entity, or any person who has been
28 assigned under this subsection, shall be given the
29 opportunity to change that choice or assignment at least once
30 every 12 months, as determined by the Illinois Department by
31 rule. The Illinois Department shall maintain a toll-free
32 telephone number for program enrollees' use in reporting
33 problems with managed health care entities.
34 (f) If a person becomes eligible for participation in
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1 the integrated health care program while he or she is
2 hospitalized, the Illinois Department may not enroll that
3 person in the program until after he or she has been
4 discharged from the hospital. This subsection does not apply
5 to newborn infants whose mothers are enrolled in the
6 integrated health care program.
7 (g) The Illinois Department shall, by rule, establish
8 for managed health care entities rates that (i) are certified
9 to be actuarially sound, as determined by an actuary who is
10 an associate or a fellow of the Society of Actuaries or a
11 member of the American Academy of Actuaries and who has
12 expertise and experience in medical insurance and benefit
13 programs, in accordance with the Illinois Department's
14 current fee-for-service payment system, and (ii) take into
15 account any difference of cost to provide health care to
16 different populations based on gender, age, location, and
17 eligibility category. The rates for managed health care
18 entities shall be determined on a capitated basis.
19 The Illinois Department by rule shall establish a method
20 to adjust its payments to managed health care entities in a
21 manner intended to avoid providing any financial incentive to
22 a managed health care entity to refer patients to a county
23 provider, in an Illinois county having a population greater
24 than 3,000,000, that is paid directly by the Illinois
25 Department. The Illinois Department shall by April 1, 1997,
26 and annually thereafter, review the method to adjust
27 payments. Payments by the Illinois Department to the county
28 provider, for persons not enrolled in a managed care
29 community network owned or operated by a county provider,
30 shall be paid on a fee-for-service basis under Article XV of
31 this Code.
32 The Illinois Department by rule shall establish a method
33 to reduce its payments to managed health care entities to
34 take into consideration (i) any adjustment payments paid to
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1 hospitals under subsection (h) of this Section to the extent
2 those payments, or any part of those payments, have been
3 taken into account in establishing capitated rates under this
4 subsection (g) and (ii) the implementation of methodologies
5 to limit financial liability for managed health care entities
6 under subsection (d) of this Section.
7 (h) For hospital services provided by a hospital that
8 contracts with a managed health care entity, adjustment
9 payments shall be paid directly to the hospital by the
10 Illinois Department. Adjustment payments may include but
11 need not be limited to adjustment payments to:
12 disproportionate share hospitals under Section 5-5.02 of this
13 Code; primary care access health care education payments (89
14 Ill. Adm. Code 149.140); payments for capital, direct medical
15 education, indirect medical education, certified registered
16 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
17 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
18 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
19 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
20 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
21 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
22 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
23 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
24 148.290(h)); and outpatient indigent volume adjustments (89
25 Ill. Adm. Code 148.140(b)(5)).
26 (i) For any hospital eligible for the adjustment
27 payments described in subsection (h), the Illinois Department
28 shall maintain, through the period ending June 30, 1995,
29 reimbursement levels in accordance with statutes and rules in
30 effect on April 1, 1994.
31 (j) Nothing contained in this Code in any way limits or
32 otherwise impairs the authority or power of the Illinois
33 Department to enter into a negotiated contract pursuant to
34 this Section with a managed health care entity, including,
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1 but not limited to, a health maintenance organization, that
2 provides for termination or nonrenewal of the contract
3 without cause upon notice as provided in the contract and
4 without a hearing.
5 (k) Section 5-5.15 does not apply to the program
6 developed and implemented pursuant to this Section.
7 (l) The Illinois Department shall, by rule, define those
8 chronic or acute medical conditions of childhood that require
9 longer-term treatment and follow-up care. The Illinois
10 Department shall ensure that services required to treat these
11 conditions are available through a separate delivery system.
12 A managed health care entity that contracts with the
13 Illinois Department may refer a child with medical conditions
14 described in the rules adopted under this subsection directly
15 to a children's hospital or to a hospital, other than a
16 children's hospital, that is qualified to provide inpatient
17 and outpatient services to treat those conditions. The
18 Illinois Department shall provide fee-for-service
19 reimbursement directly to a children's hospital for those
20 services pursuant to Title 89 of the Illinois Administrative
21 Code, Section 148.280(a), at a rate at least equal to the
22 rate in effect on March 31, 1994. For hospitals, other than
23 children's hospitals, that are qualified to provide inpatient
24 and outpatient services to treat those conditions, the
25 Illinois Department shall provide reimbursement for those
26 services on a fee-for-service basis, at a rate at least equal
27 to the rate in effect for those other hospitals on March 31,
28 1994.
29 A children's hospital shall be directly reimbursed for
30 all services provided at the children's hospital on a
31 fee-for-service basis pursuant to Title 89 of the Illinois
32 Administrative Code, Section 148.280(a), at a rate at least
33 equal to the rate in effect on March 31, 1994, until the
34 later of (i) implementation of the integrated health care
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1 program under this Section and development of actuarially
2 sound capitation rates for services other than those chronic
3 or acute medical conditions of childhood that require
4 longer-term treatment and follow-up care as defined by the
5 Illinois Department in the rules adopted under this
6 subsection or (ii) March 31, 1996.
7 Notwithstanding anything in this subsection to the
8 contrary, a managed health care entity shall not consider
9 sources or methods of payment in determining the referral of
10 a child. The Illinois Department shall adopt rules to
11 establish criteria for those referrals. The Illinois
12 Department by rule shall establish a method to adjust its
13 payments to managed health care entities in a manner intended
14 to avoid providing any financial incentive to a managed
15 health care entity to refer patients to a provider who is
16 paid directly by the Illinois Department.
17 (m) Behavioral health services provided or funded by the
18 Department of Mental Health and Developmental Disabilities,
19 the Department of Alcoholism and Substance Abuse, the
20 Department of Children and Family Services, and the Illinois
21 Department shall be excluded from a benefit package.
22 Conditions of an organic or physical origin or nature,
23 including medical detoxification, however, may not be
24 excluded. In this subsection, "behavioral health services"
25 means mental health services and subacute alcohol and
26 substance abuse treatment services, as defined in the
27 Illinois Alcoholism and Other Drug Dependency Act. In this
28 subsection, "mental health services" includes, at a minimum,
29 the following services funded by the Illinois Department, the
30 Department of Mental Health and Developmental Disabilities,
31 or the Department of Children and Family Services: (i)
32 inpatient hospital services, including related physician
33 services, related psychiatric interventions, and
34 pharmaceutical services provided to an eligible recipient
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1 hospitalized with a primary diagnosis of psychiatric
2 disorder; (ii) outpatient mental health services as defined
3 and specified in Title 59 of the Illinois Administrative
4 Code, Part 132; (iii) any other outpatient mental health
5 services funded by the Illinois Department pursuant to the
6 State of Illinois Medicaid Plan; (iv) partial
7 hospitalization; and (v) follow-up stabilization related to
8 any of those services. Additional behavioral health services
9 may be excluded under this subsection as mutually agreed in
10 writing by the Illinois Department and the affected State
11 agency or agencies. The exclusion of any service does not
12 prohibit the Illinois Department from developing and
13 implementing demonstration projects for categories of persons
14 or services. The Department of Mental Health and
15 Developmental Disabilities, the Department of Children and
16 Family Services, and the Department of Alcoholism and
17 Substance Abuse shall each adopt rules governing the
18 integration of managed care in the provision of behavioral
19 health services. The State shall integrate managed care
20 community networks and affiliated providers, to the extent
21 practicable, in any separate delivery system for mental
22 health services.
23 (n) The Illinois Department shall adopt rules to
24 establish reserve requirements for managed care community
25 networks, as required by subsection (a), and health
26 maintenance organizations to protect against liabilities in
27 the event that a managed health care entity is declared
28 insolvent or bankrupt. If a managed health care entity other
29 than a county provider is declared insolvent or bankrupt,
30 after liquidation and application of any available assets,
31 resources, and reserves, the Illinois Department shall pay a
32 portion of the amounts owed by the managed health care entity
33 to providers for services rendered to enrollees under the
34 integrated health care program under this Section based on
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1 the following schedule: (i) from April 1, 1995 through June
2 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
3 through June 30, 2001, 80% of the amounts owed; and (iii)
4 from July 1, 2001 through June 30, 2005, 75% of the amounts
5 owed. The amounts paid under this subsection shall be
6 calculated based on the total amount owed by the managed
7 health care entity to providers before application of any
8 available assets, resources, and reserves. After June 30,
9 2005, the Illinois Department may not pay any amounts owed to
10 providers as a result of an insolvency or bankruptcy of a
11 managed health care entity occurring after that date. The
12 Illinois Department is not obligated, however, to pay amounts
13 owed to a provider that has an ownership or other governing
14 interest in the managed health care entity. This subsection
15 applies only to managed health care entities and the services
16 they provide under the integrated health care program under
17 this Section.
18 (o) Notwithstanding any other provision of law or
19 contractual agreement to the contrary, providers shall not be
20 required to accept from any other third party payer the rates
21 determined or paid under this Code by the Illinois
22 Department, managed health care entity, or other health care
23 delivery system for services provided to recipients.
24 (p) The Illinois Department may seek and obtain any
25 necessary authorization provided under federal law to
26 implement the program, including the waiver of any federal
27 statutes or regulations. The Illinois Department may seek a
28 waiver of the federal requirement that the combined
29 membership of Medicare and Medicaid enrollees in a managed
30 care community network may not exceed 75% of the managed care
31 community network's total enrollment. The Illinois
32 Department shall not seek a waiver of this requirement for
33 any other category of managed health care entity. The
34 Illinois Department shall not seek a waiver of the inpatient
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1 hospital reimbursement methodology in Section 1902(a)(13)(A)
2 of Title XIX of the Social Security Act even if the federal
3 agency responsible for administering Title XIX determines
4 that Section 1902(a)(13)(A) applies to managed health care
5 systems.
6 Notwithstanding any other provisions of this Code to the
7 contrary, the Illinois Department shall seek a waiver of
8 applicable federal law in order to impose a co-payment system
9 consistent with this subsection on recipients of medical
10 services under Title XIX of the Social Security Act who are
11 not enrolled in a managed health care entity. The waiver
12 request submitted by the Illinois Department shall provide
13 for co-payments of up to $0.50 for prescribed drugs and up to
14 $0.50 for x-ray services and shall provide for co-payments of
15 up to $10 for non-emergency services provided in a hospital
16 emergency department room and up to $10 for non-emergency
17 ambulance services. The purpose of the co-payments shall be
18 to deter those recipients from seeking unnecessary medical
19 care. Co-payments may not be used to deter recipients from
20 seeking or accessing emergency services and other necessary
21 medical care. No recipient shall be required to pay more
22 than a total of $150 per year in co-payments under the waiver
23 request required by this subsection. A recipient may not be
24 required to pay more than $15 of any amount due under this
25 subsection in any one month.
26 Co-payments authorized under this subsection may not be
27 imposed when the care was necessitated by a true medical
28 condition as described in the definition of "emergency
29 services" under subsection (a) of Section 5-5.04 emergency.
30 Copayments for non-emergency services in a hospital emergency
31 department shall not be imposed retrospectively except upon
32 reasonable determination by the Illinois Department that (1)
33 the emergency services claimed were never performed or (2) an
34 emergency medical screening examination was performed on a
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1 patient who personally sought emergency services knowing that
2 he or she did not have an emergency condition or necessity,
3 and who did not in fact require emergency services.
4 Co-payments may not be imposed for any of the following
5 classifications of services:
6 (1) Services furnished to person under 18 years of
7 age.
8 (2) Services furnished to pregnant women.
9 (3) Services furnished to any individual who is an
10 inpatient in a hospital, nursing facility, intermediate
11 care facility, or other medical institution, if that
12 person is required to spend for costs of medical care all
13 but a minimal amount of his or her income required for
14 personal needs.
15 (4) Services furnished to a person who is receiving
16 hospice care.
17 Co-payments authorized under this subsection shall not be
18 deducted from or reduce in any way payments for medical
19 services from the Illinois Department to providers. No
20 provider may deny those services to an individual eligible
21 for services based on the individual's inability to pay the
22 co-payment.
23 Recipients who are subject to co-payments shall be
24 provided notice, in plain and clear language, of the amount
25 of the co-payments, the circumstances under which co-payments
26 are exempted, the circumstances under which co-payments may
27 be assessed, and their manner of collection.
28 The Illinois Department shall establish a Medicaid
29 Co-Payment Council to assist in the development of co-payment
30 policies for the medical assistance program. The Medicaid
31 Co-Payment Council shall also have jurisdiction to develop a
32 program to provide financial or non-financial incentives to
33 Medicaid recipients in order to encourage recipients to seek
34 necessary health care. The Council shall be chaired by the
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1 Director of the Illinois Department, and shall have 6
2 additional members. Two of the 6 additional members shall be
3 appointed by the Governor, and one each shall be appointed by
4 the President of the Senate, the Minority Leader of the
5 Senate, the Speaker of the House of Representatives, and the
6 Minority Leader of the House of Representatives. The Council
7 may be convened and make recommendations upon the appointment
8 of a majority of its members. The Council shall be appointed
9 and convened no later than September 1, 1994 and shall report
10 its recommendations to the Director of the Illinois
11 Department and the General Assembly no later than October 1,
12 1994. The chairperson of the Council shall be allowed to
13 vote only in the case of a tie vote among the appointed
14 members of the Council.
15 The Council shall be guided by the following principles
16 as it considers recommendations to be developed to implement
17 any approved waivers that the Illinois Department must seek
18 pursuant to this subsection:
19 (1) Co-payments should not be used to deter access
20 to adequate medical care.
21 (2) Co-payments should be used to reduce fraud.
22 (3) Co-payment policies should be examined in
23 consideration of other states' experience, and the
24 ability of successful co-payment plans to control
25 unnecessary or inappropriate utilization of services
26 should be promoted.
27 (4) All participants, both recipients and
28 providers, in the medical assistance program have
29 responsibilities to both the State and the program.
30 (5) Co-payments are primarily a tool to educate the
31 participants in the responsible use of health care
32 resources.
33 (6) Co-payments should not be used to penalize
34 providers.
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1 (7) A successful medical program requires the
2 elimination of improper utilization of medical resources.
3 The integrated health care program, or any part of that
4 program, established under this Section may not be
5 implemented if matching federal funds under Title XIX of the
6 Social Security Act are not available for administering the
7 program.
8 The Illinois Department shall submit for publication in
9 the Illinois Register the name, address, and telephone number
10 of the individual to whom a request may be directed for a
11 copy of the request for a waiver of provisions of Title XIX
12 of the Social Security Act that the Illinois Department
13 intends to submit to the Health Care Financing Administration
14 in order to implement this Section. The Illinois Department
15 shall mail a copy of that request for waiver to all
16 requestors at least 16 days before filing that request for
17 waiver with the Health Care Financing Administration.
18 (q) After the effective date of this Section, the
19 Illinois Department may take all planning and preparatory
20 action necessary to implement this Section, including, but
21 not limited to, seeking requests for proposals relating to
22 the integrated health care program created under this
23 Section.
24 (r) In order to (i) accelerate and facilitate the
25 development of integrated health care in contracting areas
26 outside counties with populations in excess of 3,000,000 and
27 counties adjacent to those counties and (ii) maintain and
28 sustain the high quality of education and residency programs
29 coordinated and associated with local area hospitals, the
30 Illinois Department may develop and implement a demonstration
31 program for managed care community networks owned, operated,
32 or governed by State-funded medical schools. The Illinois
33 Department shall prescribe by rule the criteria, standards,
34 and procedures for effecting this demonstration program.
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1 (s) (Blank).
2 (t) On April 1, 1995 and every 6 months thereafter, the
3 Illinois Department shall report to the Governor and General
4 Assembly on the progress of the integrated health care
5 program in enrolling clients into managed health care
6 entities. The report shall indicate the capacities of the
7 managed health care entities with which the State contracts,
8 the number of clients enrolled by each contractor, the areas
9 of the State in which managed care options do not exist, and
10 the progress toward meeting the enrollment goals of the
11 integrated health care program.
12 (u) The Illinois Department may implement this Section
13 through the use of emergency rules in accordance with Section
14 5-45 of the Illinois Administrative Procedure Act. For
15 purposes of that Act, the adoption of rules to implement this
16 Section is deemed an emergency and necessary for the public
17 interest, safety, and welfare.
18 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
19 89-673, eff. 8-14-96; revised 8-26-96.)
20 (Text of Section after amendment by P.A. 89-507)
21 Sec. 5-16.3. System for integrated health care services.
22 (a) It shall be the public policy of the State to adopt,
23 to the extent practicable, a health care program that
24 encourages the integration of health care services and
25 manages the health care of program enrollees while preserving
26 reasonable choice within a competitive and cost-efficient
27 environment. In furtherance of this public policy, the
28 Illinois Department shall develop and implement an integrated
29 health care program consistent with the provisions of this
30 Section. The provisions of this Section apply only to the
31 integrated health care program created under this Section.
32 Persons enrolled in the integrated health care program, as
33 determined by the Illinois Department by rule, shall be
34 afforded a choice among health care delivery systems, which
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1 shall include, but are not limited to, (i) fee for service
2 care managed by a primary care physician licensed to practice
3 medicine in all its branches, (ii) managed health care
4 entities, and (iii) federally qualified health centers
5 (reimbursed according to a prospective cost-reimbursement
6 methodology) and rural health clinics (reimbursed according
7 to the Medicare methodology), where available. Persons
8 enrolled in the integrated health care program also may be
9 offered indemnity insurance plans, subject to availability.
10 For purposes of this Section, a "managed health care
11 entity" means a health maintenance organization or a managed
12 care community network as defined in this Section. A "health
13 maintenance organization" means a health maintenance
14 organization as defined in the Health Maintenance
15 Organization Act. A "managed care community network" means
16 an entity, other than a health maintenance organization, that
17 is owned, operated, or governed by providers of health care
18 services within this State and that provides or arranges
19 primary, secondary, and tertiary managed health care services
20 under contract with the Illinois Department exclusively to
21 enrollees of the integrated health care program. A managed
22 care community network may contract with the Illinois
23 Department to provide only pediatric health care services. A
24 county provider as defined in Section 15-1 of this Code may
25 contract with the Illinois Department to provide services to
26 enrollees of the integrated health care program as a managed
27 care community network without the need to establish a
28 separate entity that provides services exclusively to
29 enrollees of the integrated health care program and shall be
30 deemed a managed care community network for purposes of this
31 Code only to the extent of the provision of services to those
32 enrollees in conjunction with the integrated health care
33 program. A county provider shall be entitled to contract
34 with the Illinois Department with respect to any contracting
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1 region located in whole or in part within the county. A
2 county provider shall not be required to accept enrollees who
3 do not reside within the county.
4 Each managed care community network must demonstrate its
5 ability to bear the financial risk of serving enrollees under
6 this program. The Illinois Department shall by rule adopt
7 criteria for assessing the financial soundness of each
8 managed care community network. These rules shall consider
9 the extent to which a managed care community network is
10 comprised of providers who directly render health care and
11 are located within the community in which they seek to
12 contract rather than solely arrange or finance the delivery
13 of health care. These rules shall further consider a variety
14 of risk-bearing and management techniques, including the
15 sufficiency of quality assurance and utilization management
16 programs and whether a managed care community network has
17 sufficiently demonstrated its financial solvency and net
18 worth. The Illinois Department's criteria must be based on
19 sound actuarial, financial, and accounting principles. In
20 adopting these rules, the Illinois Department shall consult
21 with the Illinois Department of Insurance. The Illinois
22 Department is responsible for monitoring compliance with
23 these rules.
24 This Section may not be implemented before the effective
25 date of these rules, the approval of any necessary federal
26 waivers, and the completion of the review of an application
27 submitted, at least 60 days before the effective date of
28 rules adopted under this Section, to the Illinois Department
29 by a managed care community network.
30 All health care delivery systems that contract with the
31 Illinois Department under the integrated health care program
32 shall clearly recognize a health care provider's right of
33 conscience under the Right of Conscience Act. In addition to
34 the provisions of that Act, no health care delivery system
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1 that contracts with the Illinois Department under the
2 integrated health care program shall be required to provide,
3 arrange for, or pay for any health care or medical service,
4 procedure, or product if that health care delivery system is
5 owned, controlled, or sponsored by or affiliated with a
6 religious institution or religious organization that finds
7 that health care or medical service, procedure, or product to
8 violate its religious and moral teachings and beliefs.
9 (b) The Illinois Department may, by rule, provide for
10 different benefit packages for different categories of
11 persons enrolled in the program. Mental health services,
12 alcohol and substance abuse services, services related to
13 children with chronic or acute conditions requiring
14 longer-term treatment and follow-up, and rehabilitation care
15 provided by a free-standing rehabilitation hospital or a
16 hospital rehabilitation unit may be excluded from a benefit
17 package if the State ensures that those services are made
18 available through a separate delivery system. An exclusion
19 does not prohibit the Illinois Department from developing and
20 implementing demonstration projects for categories of persons
21 or services. Benefit packages for persons eligible for
22 medical assistance under Articles V, VI, and XII shall be
23 based on the requirements of those Articles and shall be
24 consistent with the Title XIX of the Social Security Act.
25 Nothing in this Act shall be construed to apply to services
26 purchased by the Department of Children and Family Services
27 and the Department of Human Services (as successor to the
28 Department of Mental Health and Developmental Disabilities)
29 under the provisions of Title 59 of the Illinois
30 Administrative Code, Part 132 ("Medicaid Community Mental
31 Health Services Program").
32 (c) The program established by this Section may be
33 implemented by the Illinois Department in various contracting
34 areas at various times. The health care delivery systems and
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1 providers available under the program may vary throughout the
2 State. For purposes of contracting with managed health care
3 entities and providers, the Illinois Department shall
4 establish contracting areas similar to the geographic areas
5 designated by the Illinois Department for contracting
6 purposes under the Illinois Competitive Access and
7 Reimbursement Equity Program (ICARE) under the authority of
8 Section 3-4 of the Illinois Health Finance Reform Act or
9 similarly-sized or smaller geographic areas established by
10 the Illinois Department by rule. A managed health care entity
11 shall be permitted to contract in any geographic areas for
12 which it has a sufficient provider network and otherwise
13 meets the contracting terms of the State. The Illinois
14 Department is not prohibited from entering into a contract
15 with a managed health care entity at any time.
16 (d) A managed health care entity that contracts with the
17 Illinois Department for the provision of services under the
18 program shall do all of the following, solely for purposes of
19 the integrated health care program:
20 (1) Provide that any individual physician licensed
21 to practice medicine in all its branches, any pharmacy,
22 any federally qualified health center, and any
23 podiatrist, that consistently meets the reasonable terms
24 and conditions established by the managed health care
25 entity, including but not limited to credentialing
26 standards, quality assurance program requirements,
27 utilization management requirements, financial
28 responsibility standards, contracting process
29 requirements, and provider network size and accessibility
30 requirements, must be accepted by the managed health care
31 entity for purposes of the Illinois integrated health
32 care program. Any individual who is either terminated
33 from or denied inclusion in the panel of physicians of
34 the managed health care entity shall be given, within 10
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1 business days after that determination, a written
2 explanation of the reasons for his or her exclusion or
3 termination from the panel. This paragraph (1) does not
4 apply to the following:
5 (A) A managed health care entity that
6 certifies to the Illinois Department that:
7 (i) it employs on a full-time basis 125
8 or more Illinois physicians licensed to
9 practice medicine in all of its branches; and
10 (ii) it will provide medical services
11 through its employees to more than 80% of the
12 recipients enrolled with the entity in the
13 integrated health care program; or
14 (B) A domestic stock insurance company
15 licensed under clause (b) of class 1 of Section 4 of
16 the Illinois Insurance Code if (i) at least 66% of
17 the stock of the insurance company is owned by a
18 professional corporation organized under the
19 Professional Service Corporation Act that has 125 or
20 more shareholders who are Illinois physicians
21 licensed to practice medicine in all of its branches
22 and (ii) the insurance company certifies to the
23 Illinois Department that at least 80% of those
24 physician shareholders will provide services to
25 recipients enrolled with the company in the
26 integrated health care program.
27 (2) Provide for reimbursement for providers for
28 emergency services care, as defined by subsection (a) of
29 Section 5-5.04 of this Code the Illinois Department by
30 rule, that must be provided to its enrollees, including
31 an emergency department room screening fee, and urgent
32 care that it authorizes for its enrollees, regardless of
33 the provider's affiliation with the managed health care
34 entity. Providers shall be reimbursed for emergency
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1 services care at an amount equal to the Illinois
2 Department's fee-for-service rates for those medical
3 services rendered by providers not under contract with
4 the managed health care entity to enrollees of the
5 entity.
6 (A) Coverage and payment for emergency
7 services shall not be retrospectively denied except
8 upon reasonable determination by the Illinois
9 Department that (1) the emergency services claimed
10 were never performed or (2) an emergency medical
11 screening examination was performed on a patient who
12 personally sought emergency services knowing that he
13 or she did not have an emergency condition or
14 necessity, and who did not in fact require emergency
15 services.
16 (B) The appropriate use of the 911 emergency
17 telephone number shall not be discouraged or
18 penalized, and coverage or payment shall not be
19 denied solely on the basis that the enrollee used
20 the 911 emergency telephone number to summon
21 emergency services.
22 (2.5) Provide for reimbursement for
23 post-stabilization services, which are those health care
24 services determined by a treating provider to be promptly
25 and medically necessary following stabilization of an
26 emergency condition.
27 (A) If prior authorization for
28 post-stabilization services is required, the managed
29 health care entity shall provide access 24 hours a
30 day, 7 days a week to persons designated by the
31 entity to make such determinations. If a health
32 care provider has attempted to contact such person
33 for prior authorization and no designated persons
34 were accessible or the authorization was not denied
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1 within 30 minutes of the request, the managed health
2 care entity is deemed to have approved the request
3 for prior authorization.
4 (B) Coverage and payment for
5 post-stabilization services which received prior
6 authorization or deemed approval shall not be
7 retrospectively denied.
8 (3) Provide that any provider affiliated with a
9 managed health care entity may also provide services on a
10 fee-for-service basis to Illinois Department clients not
11 enrolled in a managed health care entity.
12 (4) Provide client education services as determined
13 and approved by the Illinois Department, including but
14 not limited to (i) education regarding appropriate
15 utilization of health care services in a managed care
16 system, (ii) written disclosure of treatment policies and
17 any restrictions or limitations on health services,
18 including, but not limited to, physical services,
19 clinical laboratory tests, hospital and surgical
20 procedures, prescription drugs and biologics, and
21 radiological examinations, and (iii) written notice that
22 the enrollee may receive from another provider those
23 services covered under this program that are not provided
24 by the managed health care entity.
25 (5) Provide that enrollees within its system may
26 choose the site for provision of services and the panel
27 of health care providers.
28 (6) Not discriminate in its enrollment or
29 disenrollment practices among recipients of medical
30 services or program enrollees based on health status.
31 (7) Provide a quality assurance and utilization
32 review program that (i) for health maintenance
33 organizations meets the requirements of the Health
34 Maintenance Organization Act and (ii) for managed care
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1 community networks meets the requirements established by
2 the Illinois Department in rules that incorporate those
3 standards set forth in the Health Maintenance
4 Organization Act.
5 (8) Issue a managed health care entity
6 identification card to each enrollee upon enrollment.
7 The card must contain all of the following:
8 (A) The enrollee's signature.
9 (B) The enrollee's health plan.
10 (C) The name and telephone number of the
11 enrollee's primary care physician.
12 (D) A telephone number to be used for
13 emergency service 24 hours per day, 7 days per week.
14 The telephone number required to be maintained
15 pursuant to this subparagraph by each managed health
16 care entity shall, at minimum, be staffed by
17 medically trained personnel and be provided
18 directly, or under arrangement, at an office or
19 offices in locations maintained solely within the
20 State of Illinois. For purposes of this
21 subparagraph, "medically trained personnel" means
22 licensed practical nurses or registered nurses
23 located in the State of Illinois who are licensed
24 pursuant to the Illinois Nursing Act of 1987.
25 (9) Ensure that every primary care physician and
26 pharmacy in the managed health care entity meets the
27 standards established by the Illinois Department for
28 accessibility and quality of care. The Illinois
29 Department shall arrange for and oversee an evaluation of
30 the standards established under this paragraph (9) and
31 may recommend any necessary changes to these standards.
32 The Illinois Department shall submit an annual report to
33 the Governor and the General Assembly by April 1 of each
34 year regarding the effect of the standards on ensuring
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1 access and quality of care to enrollees.
2 (10) Provide a procedure for handling complaints
3 that (i) for health maintenance organizations meets the
4 requirements of the Health Maintenance Organization Act
5 and (ii) for managed care community networks meets the
6 requirements established by the Illinois Department in
7 rules that incorporate those standards set forth in the
8 Health Maintenance Organization Act.
9 (11) Maintain, retain, and make available to the
10 Illinois Department records, data, and information, in a
11 uniform manner determined by the Illinois Department,
12 sufficient for the Illinois Department to monitor
13 utilization, accessibility, and quality of care.
14 (12) Except for providers who are prepaid, pay all
15 approved claims for covered services that are completed
16 and submitted to the managed health care entity within 30
17 days after receipt of the claim or receipt of the
18 appropriate capitation payment or payments by the managed
19 health care entity from the State for the month in which
20 the services included on the claim were rendered,
21 whichever is later. If payment is not made or mailed to
22 the provider by the managed health care entity by the due
23 date under this subsection, an interest penalty of 1% of
24 any amount unpaid shall be added for each month or
25 fraction of a month after the due date, until final
26 payment is made. Nothing in this Section shall prohibit
27 managed health care entities and providers from mutually
28 agreeing to terms that require more timely payment.
29 (13) Provide integration with community-based
30 programs provided by certified local health departments
31 such as Women, Infants, and Children Supplemental Food
32 Program (WIC), childhood immunization programs, health
33 education programs, case management programs, and health
34 screening programs.
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1 (14) Provide that the pharmacy formulary used by a
2 managed health care entity and its contract providers be
3 no more restrictive than the Illinois Department's
4 pharmaceutical program on the effective date of this
5 amendatory Act of 1994 and as amended after that date.
6 (15) Provide integration with community-based
7 organizations, including, but not limited to, any
8 organization that has operated within a Medicaid
9 Partnership as defined by this Code or by rule of the
10 Illinois Department, that may continue to operate under a
11 contract with the Illinois Department or a managed health
12 care entity under this Section to provide case management
13 services to Medicaid clients in designated high-need
14 areas.
15 The Illinois Department may, by rule, determine
16 methodologies to limit financial liability for managed health
17 care entities resulting from payment for services to
18 enrollees provided under the Illinois Department's integrated
19 health care program. Any methodology so determined may be
20 considered or implemented by the Illinois Department through
21 a contract with a managed health care entity under this
22 integrated health care program.
23 The Illinois Department shall contract with an entity or
24 entities to provide external peer-based quality assurance
25 review for the integrated health care program. The entity
26 shall be representative of Illinois physicians licensed to
27 practice medicine in all its branches and have statewide
28 geographic representation in all specialties of medical care
29 that are provided within the integrated health care program.
30 The entity may not be a third party payer and shall maintain
31 offices in locations around the State in order to provide
32 service and continuing medical education to physician
33 participants within the integrated health care program. The
34 review process shall be developed and conducted by Illinois
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1 physicians licensed to practice medicine in all its branches.
2 In consultation with the entity, the Illinois Department may
3 contract with other entities for professional peer-based
4 quality assurance review of individual categories of services
5 other than services provided, supervised, or coordinated by
6 physicians licensed to practice medicine in all its branches.
7 The Illinois Department shall establish, by rule, criteria to
8 avoid conflicts of interest in the conduct of quality
9 assurance activities consistent with professional peer-review
10 standards. All quality assurance activities shall be
11 coordinated by the Illinois Department.
12 (e) All persons enrolled in the program shall be
13 provided with a full written explanation of all
14 fee-for-service and managed health care plan options and a
15 reasonable opportunity to choose among the options as
16 provided by rule. The Illinois Department shall provide to
17 enrollees, upon enrollment in the integrated health care
18 program and at least annually thereafter, notice of the
19 process for requesting an appeal under the Illinois
20 Department's administrative appeal procedures.
21 Notwithstanding any other Section of this Code, the Illinois
22 Department may provide by rule for the Illinois Department to
23 assign a person enrolled in the program to a specific
24 provider of medical services or to a specific health care
25 delivery system if an enrollee has failed to exercise choice
26 in a timely manner. An enrollee assigned by the Illinois
27 Department shall be afforded the opportunity to disenroll and
28 to select a specific provider of medical services or a
29 specific health care delivery system within the first 30 days
30 after the assignment. An enrollee who has failed to exercise
31 choice in a timely manner may be assigned only if there are 3
32 or more managed health care entities contracting with the
33 Illinois Department within the contracting area, except that,
34 outside the City of Chicago, this requirement may be waived
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1 for an area by rules adopted by the Illinois Department after
2 consultation with all hospitals within the contracting area.
3 The Illinois Department shall establish by rule the procedure
4 for random assignment of enrollees who fail to exercise
5 choice in a timely manner to a specific managed health care
6 entity in proportion to the available capacity of that
7 managed health care entity. Assignment to a specific provider
8 of medical services or to a specific managed health care
9 entity may not exceed that provider's or entity's capacity as
10 determined by the Illinois Department. Any person who has
11 chosen a specific provider of medical services or a specific
12 managed health care entity, or any person who has been
13 assigned under this subsection, shall be given the
14 opportunity to change that choice or assignment at least once
15 every 12 months, as determined by the Illinois Department by
16 rule. The Illinois Department shall maintain a toll-free
17 telephone number for program enrollees' use in reporting
18 problems with managed health care entities.
19 (f) If a person becomes eligible for participation in
20 the integrated health care program while he or she is
21 hospitalized, the Illinois Department may not enroll that
22 person in the program until after he or she has been
23 discharged from the hospital. This subsection does not apply
24 to newborn infants whose mothers are enrolled in the
25 integrated health care program.
26 (g) The Illinois Department shall, by rule, establish
27 for managed health care entities rates that (i) are certified
28 to be actuarially sound, as determined by an actuary who is
29 an associate or a fellow of the Society of Actuaries or a
30 member of the American Academy of Actuaries and who has
31 expertise and experience in medical insurance and benefit
32 programs, in accordance with the Illinois Department's
33 current fee-for-service payment system, and (ii) take into
34 account any difference of cost to provide health care to
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1 different populations based on gender, age, location, and
2 eligibility category. The rates for managed health care
3 entities shall be determined on a capitated basis.
4 The Illinois Department by rule shall establish a method
5 to adjust its payments to managed health care entities in a
6 manner intended to avoid providing any financial incentive to
7 a managed health care entity to refer patients to a county
8 provider, in an Illinois county having a population greater
9 than 3,000,000, that is paid directly by the Illinois
10 Department. The Illinois Department shall by April 1, 1997,
11 and annually thereafter, review the method to adjust
12 payments. Payments by the Illinois Department to the county
13 provider, for persons not enrolled in a managed care
14 community network owned or operated by a county provider,
15 shall be paid on a fee-for-service basis under Article XV of
16 this Code.
17 The Illinois Department by rule shall establish a method
18 to reduce its payments to managed health care entities to
19 take into consideration (i) any adjustment payments paid to
20 hospitals under subsection (h) of this Section to the extent
21 those payments, or any part of those payments, have been
22 taken into account in establishing capitated rates under this
23 subsection (g) and (ii) the implementation of methodologies
24 to limit financial liability for managed health care entities
25 under subsection (d) of this Section.
26 (h) For hospital services provided by a hospital that
27 contracts with a managed health care entity, adjustment
28 payments shall be paid directly to the hospital by the
29 Illinois Department. Adjustment payments may include but
30 need not be limited to adjustment payments to:
31 disproportionate share hospitals under Section 5-5.02 of this
32 Code; primary care access health care education payments (89
33 Ill. Adm. Code 149.140); payments for capital, direct medical
34 education, indirect medical education, certified registered
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1 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
2 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
3 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
4 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
5 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
6 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
7 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
8 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
9 148.290(h)); and outpatient indigent volume adjustments (89
10 Ill. Adm. Code 148.140(b)(5)).
11 (i) For any hospital eligible for the adjustment
12 payments described in subsection (h), the Illinois Department
13 shall maintain, through the period ending June 30, 1995,
14 reimbursement levels in accordance with statutes and rules in
15 effect on April 1, 1994.
16 (j) Nothing contained in this Code in any way limits or
17 otherwise impairs the authority or power of the Illinois
18 Department to enter into a negotiated contract pursuant to
19 this Section with a managed health care entity, including,
20 but not limited to, a health maintenance organization, that
21 provides for termination or nonrenewal of the contract
22 without cause upon notice as provided in the contract and
23 without a hearing.
24 (k) Section 5-5.15 does not apply to the program
25 developed and implemented pursuant to this Section.
26 (l) The Illinois Department shall, by rule, define those
27 chronic or acute medical conditions of childhood that require
28 longer-term treatment and follow-up care. The Illinois
29 Department shall ensure that services required to treat these
30 conditions are available through a separate delivery system.
31 A managed health care entity that contracts with the
32 Illinois Department may refer a child with medical conditions
33 described in the rules adopted under this subsection directly
34 to a children's hospital or to a hospital, other than a
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1 children's hospital, that is qualified to provide inpatient
2 and outpatient services to treat those conditions. The
3 Illinois Department shall provide fee-for-service
4 reimbursement directly to a children's hospital for those
5 services pursuant to Title 89 of the Illinois Administrative
6 Code, Section 148.280(a), at a rate at least equal to the
7 rate in effect on March 31, 1994. For hospitals, other than
8 children's hospitals, that are qualified to provide inpatient
9 and outpatient services to treat those conditions, the
10 Illinois Department shall provide reimbursement for those
11 services on a fee-for-service basis, at a rate at least equal
12 to the rate in effect for those other hospitals on March 31,
13 1994.
14 A children's hospital shall be directly reimbursed for
15 all services provided at the children's hospital on a
16 fee-for-service basis pursuant to Title 89 of the Illinois
17 Administrative Code, Section 148.280(a), at a rate at least
18 equal to the rate in effect on March 31, 1994, until the
19 later of (i) implementation of the integrated health care
20 program under this Section and development of actuarially
21 sound capitation rates for services other than those chronic
22 or acute medical conditions of childhood that require
23 longer-term treatment and follow-up care as defined by the
24 Illinois Department in the rules adopted under this
25 subsection or (ii) March 31, 1996.
26 Notwithstanding anything in this subsection to the
27 contrary, a managed health care entity shall not consider
28 sources or methods of payment in determining the referral of
29 a child. The Illinois Department shall adopt rules to
30 establish criteria for those referrals. The Illinois
31 Department by rule shall establish a method to adjust its
32 payments to managed health care entities in a manner intended
33 to avoid providing any financial incentive to a managed
34 health care entity to refer patients to a provider who is
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1 paid directly by the Illinois Department.
2 (m) Behavioral health services provided or funded by the
3 Department of Human Services, the Department of Children and
4 Family Services, and the Illinois Department shall be
5 excluded from a benefit package. Conditions of an organic or
6 physical origin or nature, including medical detoxification,
7 however, may not be excluded. In this subsection,
8 "behavioral health services" means mental health services and
9 subacute alcohol and substance abuse treatment services, as
10 defined in the Illinois Alcoholism and Other Drug Dependency
11 Act. In this subsection, "mental health services" includes,
12 at a minimum, the following services funded by the Illinois
13 Department, the Department of Human Services (as successor to
14 the Department of Mental Health and Developmental
15 Disabilities), or the Department of Children and Family
16 Services: (i) inpatient hospital services, including related
17 physician services, related psychiatric interventions, and
18 pharmaceutical services provided to an eligible recipient
19 hospitalized with a primary diagnosis of psychiatric
20 disorder; (ii) outpatient mental health services as defined
21 and specified in Title 59 of the Illinois Administrative
22 Code, Part 132; (iii) any other outpatient mental health
23 services funded by the Illinois Department pursuant to the
24 State of Illinois Medicaid Plan; (iv) partial
25 hospitalization; and (v) follow-up stabilization related to
26 any of those services. Additional behavioral health services
27 may be excluded under this subsection as mutually agreed in
28 writing by the Illinois Department and the affected State
29 agency or agencies. The exclusion of any service does not
30 prohibit the Illinois Department from developing and
31 implementing demonstration projects for categories of persons
32 or services. The Department of Children and Family Services
33 and the Department of Human Services shall each adopt rules
34 governing the integration of managed care in the provision of
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1 behavioral health services. The State shall integrate managed
2 care community networks and affiliated providers, to the
3 extent practicable, in any separate delivery system for
4 mental health services.
5 (n) The Illinois Department shall adopt rules to
6 establish reserve requirements for managed care community
7 networks, as required by subsection (a), and health
8 maintenance organizations to protect against liabilities in
9 the event that a managed health care entity is declared
10 insolvent or bankrupt. If a managed health care entity other
11 than a county provider is declared insolvent or bankrupt,
12 after liquidation and application of any available assets,
13 resources, and reserves, the Illinois Department shall pay a
14 portion of the amounts owed by the managed health care entity
15 to providers for services rendered to enrollees under the
16 integrated health care program under this Section based on
17 the following schedule: (i) from April 1, 1995 through June
18 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
19 through June 30, 2001, 80% of the amounts owed; and (iii)
20 from July 1, 2001 through June 30, 2005, 75% of the amounts
21 owed. The amounts paid under this subsection shall be
22 calculated based on the total amount owed by the managed
23 health care entity to providers before application of any
24 available assets, resources, and reserves. After June 30,
25 2005, the Illinois Department may not pay any amounts owed to
26 providers as a result of an insolvency or bankruptcy of a
27 managed health care entity occurring after that date. The
28 Illinois Department is not obligated, however, to pay amounts
29 owed to a provider that has an ownership or other governing
30 interest in the managed health care entity. This subsection
31 applies only to managed health care entities and the services
32 they provide under the integrated health care program under
33 this Section.
34 (o) Notwithstanding any other provision of law or
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1 contractual agreement to the contrary, providers shall not be
2 required to accept from any other third party payer the rates
3 determined or paid under this Code by the Illinois
4 Department, managed health care entity, or other health care
5 delivery system for services provided to recipients.
6 (p) The Illinois Department may seek and obtain any
7 necessary authorization provided under federal law to
8 implement the program, including the waiver of any federal
9 statutes or regulations. The Illinois Department may seek a
10 waiver of the federal requirement that the combined
11 membership of Medicare and Medicaid enrollees in a managed
12 care community network may not exceed 75% of the managed care
13 community network's total enrollment. The Illinois
14 Department shall not seek a waiver of this requirement for
15 any other category of managed health care entity. The
16 Illinois Department shall not seek a waiver of the inpatient
17 hospital reimbursement methodology in Section 1902(a)(13)(A)
18 of Title XIX of the Social Security Act even if the federal
19 agency responsible for administering Title XIX determines
20 that Section 1902(a)(13)(A) applies to managed health care
21 systems.
22 Notwithstanding any other provisions of this Code to the
23 contrary, the Illinois Department shall seek a waiver of
24 applicable federal law in order to impose a co-payment system
25 consistent with this subsection on recipients of medical
26 services under Title XIX of the Social Security Act who are
27 not enrolled in a managed health care entity. The waiver
28 request submitted by the Illinois Department shall provide
29 for co-payments of up to $0.50 for prescribed drugs and up to
30 $0.50 for x-ray services and shall provide for co-payments of
31 up to $10 for non-emergency services provided in a hospital
32 emergency department room and up to $10 for non-emergency
33 ambulance services. The purpose of the co-payments shall be
34 to deter those recipients from seeking unnecessary medical
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1 care. Co-payments may not be used to deter recipients from
2 seeking or accessing emergency services or other necessary
3 medical care. No recipient shall be required to pay more
4 than a total of $150 per year in co-payments under the waiver
5 request required by this subsection. A recipient may not be
6 required to pay more than $15 of any amount due under this
7 subsection in any one month.
8 Co-payments authorized under this subsection may not be
9 imposed when the care was necessitated by a medical condition
10 as described in the definition of "emergency services" under
11 subsection (a) of Section 5-5.04 true medical emergency.
12 Copayments for non-emergency services in a hospital emergency
13 department shall not be imposed retrospectively except upon
14 reasonable determination by the Illinois Department that (1)
15 the emergency services claimed were never performed or (2) an
16 emergency medical screening examination was performed on a
17 patient who personally sought emergency services knowing that
18 he or she did not have an emergency condition or necessity,
19 and who did not in fact require emergency services.
20 Co-payments may not be imposed for any of the following
21 classifications of services:
22 (1) Services furnished to person under 18 years of
23 age.
24 (2) Services furnished to pregnant women.
25 (3) Services furnished to any individual who is an
26 inpatient in a hospital, nursing facility, intermediate
27 care facility, or other medical institution, if that
28 person is required to spend for costs of medical care all
29 but a minimal amount of his or her income required for
30 personal needs.
31 (4) Services furnished to a person who is receiving
32 hospice care.
33 Co-payments authorized under this subsection shall not be
34 deducted from or reduce in any way payments for medical
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1 services from the Illinois Department to providers. No
2 provider may deny those services to an individual eligible
3 for services based on the individual's inability to pay the
4 co-payment.
5 Recipients who are subject to co-payments shall be
6 provided notice, in plain and clear language, of the amount
7 of the co-payments, the circumstances under which co-payments
8 are exempted, the circumstances under which co-payments may
9 be assessed, and their manner of collection.
10 The Illinois Department shall establish a Medicaid
11 Co-Payment Council to assist in the development of co-payment
12 policies for the medical assistance program. The Medicaid
13 Co-Payment Council shall also have jurisdiction to develop a
14 program to provide financial or non-financial incentives to
15 Medicaid recipients in order to encourage recipients to seek
16 necessary health care. The Council shall be chaired by the
17 Director of the Illinois Department, and shall have 6
18 additional members. Two of the 6 additional members shall be
19 appointed by the Governor, and one each shall be appointed by
20 the President of the Senate, the Minority Leader of the
21 Senate, the Speaker of the House of Representatives, and the
22 Minority Leader of the House of Representatives. The Council
23 may be convened and make recommendations upon the appointment
24 of a majority of its members. The Council shall be appointed
25 and convened no later than September 1, 1994 and shall report
26 its recommendations to the Director of the Illinois
27 Department and the General Assembly no later than October 1,
28 1994. The chairperson of the Council shall be allowed to
29 vote only in the case of a tie vote among the appointed
30 members of the Council.
31 The Council shall be guided by the following principles
32 as it considers recommendations to be developed to implement
33 any approved waivers that the Illinois Department must seek
34 pursuant to this subsection:
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1 (1) Co-payments should not be used to deter access
2 to adequate medical care.
3 (2) Co-payments should be used to reduce fraud.
4 (3) Co-payment policies should be examined in
5 consideration of other states' experience, and the
6 ability of successful co-payment plans to control
7 unnecessary or inappropriate utilization of services
8 should be promoted.
9 (4) All participants, both recipients and
10 providers, in the medical assistance program have
11 responsibilities to both the State and the program.
12 (5) Co-payments are primarily a tool to educate the
13 participants in the responsible use of health care
14 resources.
15 (6) Co-payments should not be used to penalize
16 providers.
17 (7) A successful medical program requires the
18 elimination of improper utilization of medical resources.
19 The integrated health care program, or any part of that
20 program, established under this Section may not be
21 implemented if matching federal funds under Title XIX of the
22 Social Security Act are not available for administering the
23 program.
24 The Illinois Department shall submit for publication in
25 the Illinois Register the name, address, and telephone number
26 of the individual to whom a request may be directed for a
27 copy of the request for a waiver of provisions of Title XIX
28 of the Social Security Act that the Illinois Department
29 intends to submit to the Health Care Financing Administration
30 in order to implement this Section. The Illinois Department
31 shall mail a copy of that request for waiver to all
32 requestors at least 16 days before filing that request for
33 waiver with the Health Care Financing Administration.
34 (q) After the effective date of this Section, the
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1 Illinois Department may take all planning and preparatory
2 action necessary to implement this Section, including, but
3 not limited to, seeking requests for proposals relating to
4 the integrated health care program created under this
5 Section.
6 (r) In order to (i) accelerate and facilitate the
7 development of integrated health care in contracting areas
8 outside counties with populations in excess of 3,000,000 and
9 counties adjacent to those counties and (ii) maintain and
10 sustain the high quality of education and residency programs
11 coordinated and associated with local area hospitals, the
12 Illinois Department may develop and implement a demonstration
13 program for managed care community networks owned, operated,
14 or governed by State-funded medical schools. The Illinois
15 Department shall prescribe by rule the criteria, standards,
16 and procedures for effecting this demonstration program.
17 (s) (Blank).
18 (t) On April 1, 1995 and every 6 months thereafter, the
19 Illinois Department shall report to the Governor and General
20 Assembly on the progress of the integrated health care
21 program in enrolling clients into managed health care
22 entities. The report shall indicate the capacities of the
23 managed health care entities with which the State contracts,
24 the number of clients enrolled by each contractor, the areas
25 of the State in which managed care options do not exist, and
26 the progress toward meeting the enrollment goals of the
27 integrated health care program.
28 (u) The Illinois Department may implement this Section
29 through the use of emergency rules in accordance with Section
30 5-45 of the Illinois Administrative Procedure Act. For
31 purposes of that Act, the adoption of rules to implement this
32 Section is deemed an emergency and necessary for the public
33 interest, safety, and welfare.
34 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
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1 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
2 Section 95. No acceleration or delay. Where this Act
3 makes changes in a statute that is represented in this Act by
4 text that is not yet or no longer in effect (for example, a
5 Section represented by multiple versions), the use of that
6 text does not accelerate or delay the taking effect of (i)
7 the changes made by this Act or (ii) provisions derived from
8 any other Public Act.
9 Section 99. Effective date. This Act takes effect upon
10 becoming law.