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| Public Act 097-1148 | ||||
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Health Maintenance Organization Act is | ||||
amended by changing Sections 1-2 and 4-14 and by adding Section | ||||
4-20 as follows:
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(215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
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Sec. 1-2. Definitions. As used in this Act, unless the | ||||
context otherwise
requires, the following terms shall have the | ||||
meanings ascribed to them:
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(1) "Advertisement" means any printed or published | ||||
material,
audiovisual material and descriptive literature of | ||||
the health care plan
used in direct mail, newspapers, | ||||
magazines, radio scripts, television
scripts, billboards and | ||||
similar displays; and any descriptive literature or
sales aids | ||||
of all kinds disseminated by a representative of the health | ||||
care
plan for presentation to the public including, but not | ||||
limited to, circulars,
leaflets, booklets, depictions, | ||||
illustrations, form letters and prepared
sales presentations.
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(2) "Director" means the Director of Insurance.
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(3) "Basic health care services" means emergency care, and | ||||
inpatient
hospital and physician care, outpatient medical | ||||
services, mental
health services and care for alcohol and drug | ||||
abuse, including any
reasonable deductibles and co-payments, | ||
all of which are subject to the such
limitations described in | ||
Section 4-20 of this Act and as are determined by the Director | ||
pursuant to rule.
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(4) "Enrollee" means an individual who has been enrolled in | ||
a health
care plan.
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(5) "Evidence of coverage" means any certificate, | ||
agreement,
or contract issued to an enrollee setting out the | ||
coverage to which he is
entitled in exchange for a per capita | ||
prepaid sum.
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(6) "Group contract" means a contract for health care | ||
services which
by its terms limits eligibility to members of a | ||
specified group.
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(7) "Health care plan" means any arrangement whereby any | ||
organization
undertakes to provide or arrange for and pay for | ||
or reimburse the
cost of basic health care services, excluding | ||
any reasonable deductibles and copayments, from providers | ||
selected by
the Health Maintenance Organization and such | ||
arrangement
consists of arranging for or the provision of such | ||
health care services, as
distinguished from mere | ||
indemnification against the cost of such services,
except as | ||
otherwise authorized by Section 2-3 of this Act,
on a per | ||
capita prepaid basis, through insurance or otherwise. A "health
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care plan" also includes any arrangement whereby an | ||
organization undertakes to
provide or arrange for or pay for or | ||
reimburse the cost of any health care
service for persons who | ||
are enrolled under Article V of the Illinois Public Aid
Code or | ||
under the Children's Health Insurance Program Act through
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providers selected by the organization and the arrangement | ||
consists of making
provision for the delivery of health care | ||
services, as distinguished from mere
indemnification. A | ||
"health care plan" also includes any arrangement pursuant
to | ||
Section 4-17. Nothing in this definition, however, affects the | ||
total
medical services available to persons eligible for | ||
medical assistance under the
Illinois Public Aid Code.
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(8) "Health care services" means any services included in | ||
the furnishing
to any individual of medical or dental care, or | ||
the hospitalization or
incident to the furnishing of such care | ||
or hospitalization as well as the
furnishing to any person of | ||
any and all other services for the purpose of
preventing, | ||
alleviating, curing or healing human illness or injury.
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(9) "Health Maintenance Organization" means any | ||
organization formed
under the laws of this or another state to | ||
provide or arrange for one or
more health care plans under a | ||
system which causes any part of the risk of
health care | ||
delivery to be borne by the organization or its providers.
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(10) "Net worth" means admitted assets, as defined in | ||
Section 1-3 of
this Act, minus liabilities.
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(11) "Organization" means any insurance company, a | ||
nonprofit
corporation authorized under the Dental
Service Plan | ||
Act or the Voluntary
Health Services Plans Act,
or a | ||
corporation organized under the laws of this or another state | ||
for the
purpose of operating one or more health care plans and | ||
doing no business other
than that of a Health Maintenance | ||
Organization or an insurance company.
"Organization" shall | ||
also mean the University of Illinois Hospital as
defined in the | ||
University of Illinois Hospital Act.
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(12) "Provider" means any physician, hospital facility,
or | ||
other person which is licensed or otherwise authorized
to | ||
furnish health care services and also includes any other entity | ||
that
arranges for the delivery or furnishing of health care | ||
service.
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(13) "Producer" means a person directly or indirectly | ||
associated with a
health care plan who engages in solicitation | ||
or enrollment.
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(14) "Per capita prepaid" means a basis of prepayment by | ||
which a fixed
amount of money is prepaid per individual or any | ||
other enrollment unit to
the Health Maintenance Organization or | ||
for health care services which are
provided during a definite | ||
time period regardless of the frequency or
extent of the | ||
services rendered
by the Health Maintenance Organization, | ||
except for copayments and deductibles
and except as provided in | ||
subsection (f) of Section 5-3 of this Act.
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(15) "Subscriber" means a person who has entered into a | ||
contractual
relationship with the Health Maintenance | ||
Organization for the provision of
or arrangement of at least | ||
basic health care services to the beneficiaries
of such | ||
contract.
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(Source: P.A. 92-370, eff. 8-15-01.)
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(215 ILCS 125/4-14) (from Ch. 111 1/2, par. 1409.7)
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Sec. 4-14. Evidence of Coverage. | ||
(a) Every subscriber shall be issued an evidence of | ||
coverage, which
shall contain a clear and complete statement | ||
of:
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(1) The health services to which each enrollee is | ||
entitled;
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(2) Eligibility requirements indicating the conditions | ||
which must be met
to enroll in a Health Care Plan;
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(3) Any limitation of the services, kinds of services | ||
or benefits to be
provided, and exclusions, including any | ||
reasonable deductibles, copayments, co-payment, or other | ||
charges;
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(4) The terms or conditions upon which coverage may be | ||
cancelled or
otherwise terminated;
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(5) Where and in what manner information is available | ||
as to where and
how services may be obtained; and
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(6) The method for resolving complaints.
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(b) Any amendment to the evidence of coverage may be | ||
provided to the
subscriber in a separate document.
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(Source: P.A. 86-620.)
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(215 ILCS 125/4-20 new) | ||
Sec. 4-20. Deductibles and copayments. | ||
(a) A Health Maintenance Organization may require | ||
deductibles and copayments of enrollees as a
condition for the | ||
receipt of specific health care services, including basic
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health care services. Deductibles and copayments shall be the | ||
only
allowable charges, other than premiums, assessed | ||
enrollees. Nothing within
this subsection (a) shall preclude | ||
the provider from charging reasonable
administrative fees, | ||
such as service fees for checks returned for non-sufficient
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funds and missed appointments. | ||
(b) Deductibles and copayments shall be for specific dollar | ||
amounts or for
specific percentages of the cost of the health | ||
care services. | ||
(c) No combination of deductibles and copayments paid for | ||
the receipt of basic health care services may exceed the annual | ||
maximum out-of-pocket expenses of a high deductible health plan | ||
as defined in 26 U.S.C. 223. | ||
(d) Deductibles and copayments applicable to supplemental | ||
health care
services, catastrophic-only plans as defined under | ||
the federal Affordable Care Act, or pre-existing conditions are | ||
not subject to the annual limitations described in this | ||
Section. | ||
(e) This Section applies to enrollees and does not limit | ||
the health care plan payment for services provided by | ||
non-participating providers. | ||
(f) This Section applies to enrollees and does not limit | ||
the health care plan payment for services provided by | ||
non-participating providers.
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Section 99. Effective date. This Act takes effect upon | ||
becoming law.
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