96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
SB0683

 

Introduced 2/6/2009, by Sen. John J. Cullerton

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 125/4-10   from Ch. 111 1/2, par. 1409.3

    Amends the Health Maintenance Organization Act. Makes a technical change in a Section concerning medical necessity determinations.


LRB096 06747 RPM 16831 b

 

 

A BILL FOR

 

SB0683 LRB096 06747 RPM 16831 b

1     AN ACT concerning regulation.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Health Maintenance Organization Act is
5 amended by changing Section 4-10 as follows:
 
6     (215 ILCS 125/4-10)  (from Ch. 111 1/2, par. 1409.3)
7     Sec. 4-10. (a) Medical Necessity - Dispute
8 Resolution-Independent Second Opinion. Each Health Maintenance
9 Organization shall provide a mechanism for the the timely
10 review by a physician holding the same class of license as the
11 primary care physician, who is unaffiliated with the Health
12 Maintenance Organization, jointly selected by the patient (or
13 the patient's next of kin or legal representative if the
14 patient is unable to act for himself), primary care physician
15 and the Health Maintenance Organization in the event of a
16 dispute between the primary care physician and the Health
17 Maintenance Organization regarding the medical necessity of a
18 covered service proposed by a primary care physician. In the
19 event that the reviewing physician determines the covered
20 service to be medically necessary, the Health Maintenance
21 Organization shall provide the covered service. Future
22 contractual or employment action by the Health Maintenance
23 Organization regarding the primary care physician shall not be

 

 

SB0683 - 2 - LRB096 06747 RPM 16831 b

1 based solely on the physician's participation in this
2 procedure.
3 (Source: P.A. 85-20; 85-850.)