State of Illinois
92nd General Assembly

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 1        AN ACT concerning emergency treatment.

 2        Be it enacted by the People of  the  State  of  Illinois,
 3    represented in the General Assembly:

 4        Section  5.  The  Managed  Care Reform and Patient Rights
 5    Act is amended by changing Section 65 as follows:

 6        (215 ILCS 134/65)
 7        Sec. 65. Emergency services prior to stabilization.
 8        (a)  A health care plan that provides or that is required
 9    under by law to provide coverage for emergency services shall
10    provide coverage such that payment under this coverage is not
11    dependent upon whether the services are performed by  a  plan
12    or  non-plan health care provider and without regard to prior
13    authorization. This coverage shall be  at  the  same  benefit
14    level  as  if  the services or treatment had been rendered by
15    the health care plan physician licensed to practice  medicine
16    in all its branches or health care provider.
17        (b)  Prior  authorization  or  approval by the plan shall
18    not be required for emergency services.
19        (c)  Coverage and payment shall only  be  retrospectively
20    denied under the following circumstances:
21             (1)  upon    reasonable   determination   that   the
22        emergency services claimed were never performed;
23             (2)  upon timely determination  that  the  emergency
24        evaluation and treatment were rendered to an enrollee who
25        sought  emergency services and whose circumstance did not
26        meet the definition of emergency medical condition;
27             (3)  upon determination that the  patient  receiving
28        such  services  was  not  an  enrollee of the health care
29        plan; or
30             (4)  upon material misrepresentation by the enrollee
31        or health care  provider;  "material"  means  a  fact  or
                            -2-                LRB9207097JSpc
 1        situation  that  is  not  merely  technical in nature and
 2        results or could result in a substantial  change  in  the
 3        situation.
 4        (d)  When  an  enrollee  presents  to  a hospital seeking
 5    emergency services, the determination as to whether the  need
 6    for  those  services  exists  shall  be  made for purposes of
 7    treatment by a  physician licensed to  practice  medicine  in
 8    all  its  branches  or, to the extent permitted by applicable
 9    law, by other  appropriately  licensed  personnel  under  the
10    supervision of  or in collaboration with a physician licensed
11    to  practice  medicine in all its branches.  The physician or
12    other appropriate personnel shall indicate in  the  patient's
13    chart   the   results  of  the  emergency  medical  screening
14    examination.
15        (e)  The appropriate use of the 911  emergency  telephone
16    system  or  its  local equivalent shall not be discouraged or
17    penalized by the health care plan when an  emergency  medical
18    condition exists. This provision shall not imply that the use
19    of 911 or its local equivalent is a factor in determining the
20    existence of an emergency medical condition.
21        (f)  The  medical  director's  or  his  or her designee's
22    determination of whether the enrollee meets the  standard  of
23    an emergency medical condition shall be based solely upon the
24    presenting  symptoms  documented in the medical record at the
25    time care was sought.  Only  a  clinical  peer  may  make  an
26    adverse determination.
27        (g)  Nothing   in   this   Section   shall  prohibit  the
28    imposition  of  deductibles,  copayments,  and  co-insurance.
29    Nothing in this Section alters  the  prohibition  on  billing
30    enrollees  contained  in  the Health Maintenance Organization
31    Act.
32    (Source: P.A. 91-617, eff. 1-1-00.)

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