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92_HB3303
LRB9207097JSpc
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.)