093_HB0107ham002

 










                                     LRB093 03403 JLS 12651 a

 1                     AMENDMENT TO HOUSE BILL 107

 2        AMENDMENT NO.     .  Amend House Bill 107, AS AMENDED, by
 3    replacing the title with the following:
 4        "AN ACT relating to managed care."; and

 5    by replacing everything after the enacting  clause  with  the
 6    following:

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

 9        (215 ILCS 134/65)
10        Sec. 65.  Emergency services prior to stabilization.
11        (a)  A health care plan that provides or that is required
12    under by law to provide coverage for emergency services shall
13    provide coverage such that payment under this coverage is not
14    dependent upon whether the services are performed by  a  plan
15    or  non-plan health care provider and without regard to prior
16    authorization. This coverage shall be  at  the  same  benefit
17    level  as  if  the services or treatment had been rendered by
18    the health care plan physician licensed to practice  medicine
19    in all its branches or health care provider.
20        (b)  Prior  authorization  or  approval by the plan shall
21    not be required for emergency services.
 
                            -2-      LRB093 03403 JLS 12651 a
 1        (c)  Coverage and payment shall only  be  retrospectively
 2    denied under the following circumstances:
 3             (1)  upon    reasonable   determination   that   the
 4        emergency services claimed were never performed;
 5             (2)  upon timely determination  that  the  emergency
 6        evaluation and treatment were rendered to an enrollee who
 7        sought  emergency services and whose circumstance did not
 8        meet the definition of emergency medical condition;
 9             (3)  upon determination that the  patient  receiving
10        such  services  was  not  an  enrollee of the health care
11        plan; or
12             (4)  upon material misrepresentation by the enrollee
13        or health care  provider;  "material"  means  a  fact  or
14        situation  that  is  not  merely  technical in nature and
15        results or could result in a substantial  change  in  the
16        situation.
17        (d)  When  an  enrollee  presents  to  a hospital seeking
18    emergency services, the determination as to whether the  need
19    for  those  services  exists  shall  be  made for purposes of
20    treatment by a  physician licensed to  practice  medicine  in
21    all  its  branches  or, to the extent permitted by applicable
22    law, by other  appropriately  licensed  personnel  under  the
23    supervision of  or in collaboration with a physician licensed
24    to  practice  medicine in all its branches.  The physician or
25    other appropriate personnel shall indicate in  the  patient's
26    chart   the   results  of  the  emergency  medical  screening
27    examination.
28        (e)  The appropriate use of the 911  emergency  telephone
29    system  or  its  local equivalent shall not be discouraged or
30    penalized by the health care plan when an  emergency  medical
31    condition exists. This provision shall not imply that the use
32    of 911 or its local equivalent is a factor in determining the
33    existence of an emergency medical condition.
34        (f)  The  medical  director's  or  his  or her designee's
 
                            -3-      LRB093 03403 JLS 12651 a
 1    determination of whether the enrollee meets the  standard  of
 2    an 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
 5    adverse determination.
 6        (g)  Nothing   in   this   Section   shall  prohibit  the
 7    imposition  of  deductibles,  copayments,  and  co-insurance.
 8    Nothing in this Section alters  the  prohibition  on  billing
 9    enrollees  contained  in  the Health Maintenance Organization
10    Act.
11    (Source: P.A. 91-617, eff. 1-1-00.)".