96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
SB0688

 

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

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 134/65

    Amends the Managed Care Reform and Patient Rights Act. Makes a technical change in a Section concerning emergency services.


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A BILL FOR

 

SB0688 LRB096 06752 RPM 16836 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 Managed Care Reform and Patient Rights Act
5 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 that provides or that is
9 required by law to provide coverage for emergency services
10 shall provide coverage such that payment under this coverage is
11 not 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 level
14 as if the services or treatment had been rendered by the health
15 care plan physician licensed to practice medicine in all its
16 branches or health care provider.
17     (b) Prior authorization or approval by the plan shall not
18 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 emergency
22     services claimed were never performed;
23         (2) upon timely determination that the emergency

 

 

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1     evaluation and treatment were rendered to an enrollee who
2     sought emergency services and whose circumstance did not
3     meet the definition of emergency medical condition;
4         (3) upon determination that the patient receiving such
5     services was not an enrollee of the health care plan; or
6         (4) upon material misrepresentation by the enrollee or
7     health care provider; "material" means a fact or situation
8     that is not merely technical in nature and results or could
9     result in a substantial change in the situation.
10     (d) When an enrollee presents to a hospital seeking
11 emergency services, the determination as to whether the need
12 for those services exists shall be made for purposes of
13 treatment by a physician licensed to practice medicine in all
14 its branches or, to the extent permitted by applicable law, by
15 other appropriately licensed personnel under the supervision
16 of or in collaboration with a physician licensed to practice
17 medicine in all its branches. The physician or other
18 appropriate personnel shall indicate in the patient's chart the
19 results of the emergency medical screening examination.
20     (e) The appropriate use of the 911 emergency telephone
21 system or its local equivalent shall not be discouraged or
22 penalized by the health care plan when an emergency medical
23 condition exists. This provision shall not imply that the use
24 of 911 or its local equivalent is a factor in determining the
25 existence of an emergency medical condition.
26     (f) The medical director's or his or her designee's

 

 

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1 determination of whether the enrollee meets the standard of an
2 emergency medical condition shall be based solely upon the
3 presenting symptoms documented in the medical record at the
4 time care was sought. Only a clinical peer may make an adverse
5 determination.
6     (g) Nothing in this Section shall prohibit the imposition
7 of deductibles, copayments, and co-insurance. Nothing in this
8 Section alters the prohibition on billing enrollees contained
9 in the Health Maintenance Organization Act.
10 (Source: P.A. 91-617, eff. 1-1-00.)