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90_SB0457
215 ILCS 125/4-17 new
Amends the Health Maintenance Organization Act. Provides
that enrollees who are residents of a retirement facility
consisting of a long-term care facility and residential
apartments may be referred to that facility's long-term care
facility even though the facility is not part of the health
maintenance organization network. Specifies conditions that
must be met.
LRB9000384JSgc
LRB9000384JSgc
1 AN ACT to amend the Health Maintenance Organization Act
2 by adding Section 4-17.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Health Maintenance Organization Act is
6 amended by adding Section 4-17 as follows:
7 (215 ILCS 125/4-17 new)
8 Sec. 4-17. Retirement facility residents. With respect
9 to an enrollee who is a resident of a retirement facility
10 consisting of a long-term care facility, as defined in the
11 Nursing Home Care Act, and residential apartments, a contract
12 or evidence of coverage issued, amended, delivered, or
13 renewed after the effective date of this amendatory Act of
14 1997 shall provide that the enrollee's primary care physician
15 must refer the enrollee to the retirement facility's
16 long-term care facility if the primary care physician finds
17 that:
18 (1) it is in the best interest of the patient;
19 (2) the facility agrees to be reimbursed at the health
20 maintenance organization's contract rate negotiated with
21 similar providers for the same services and supplies; and
22 (3) the facility meets all guidelines established by the
23 health maintenance organization related to quality of care,
24 utilization referral authorization, risk assumption, use of
25 the health maintenance organization's network, and other
26 criteria applicable under contract for the same services and
27 supplies.