State of Illinois
91st General Assembly

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HB0161 Engrossed                               LRB9100274JSgc

 1        AN ACT concerning health care services.

 2        Be it enacted by the People of  the  State  of  Illinois,
 3    represented in the General Assembly:

 4        Section  1.   Short  Title.  This Act may be cited as the
 5    Health Services Act.

 6        Section 5.  Definitions:
 7        "Emergency medical condition" means a  medical  condition
 8    manifesting  itself  by acute symptoms of sufficient severity
 9    (including severe pain) such that a  prudent  layperson,  who
10    possesses  an average knowledge of health and medicine, could
11    reasonably expect the absence of immediate medical  attention
12    to result in:
13             (1)  placing  the health of the individual (or, with
14        respect to a pregnant woman, the health of the  woman  or
15        her unborn child) in serious jeopardy;
16             (2)  serious impairment to bodily functions; or
17             (3)  serious  dysfunction  of  any  bodily  organ or
18        part.
19        "Emergency services" means, with respect to  an  enrollee
20    of   a  health  plan,  transportation  services  and  covered
21    inpatient and outpatient hospital  services  furnished  by  a
22    provider  qualified to furnish those services that are needed
23    to evaluate or  stabilize  an  emergency  medical  condition.
24    "Emergency  services"  does  not  refer to post-stabilization
25    medical services.
26        "Enrollee" means any person and  his  or  her  dependents
27    enrolled in or covered by a health care plan.
28        "Health   care  plan"  means  a  plan  that  establishes,
29    operates, or maintains a network  of  health  care  providers
30    that  have  entered  into agreements with the plan to provide
31    health care services to enrollees to whom the  plan  has  the
HB0161 Engrossed            -2-                LRB9100274JSgc
 1    obligation  to  arrange  for  the provision of or payment for
 2    services  through  organizational  arrangements  for  ongoing
 3    quality assurance, utilization review  programs,  or  dispute
 4    resolution.
 5        For purposes of this definition, "health care plan" shall
 6    not include the following:
 7             (1)  indemnity  health  insurance policies including
 8        those using a contracted provider network;
 9             (2)  health care plans that  offer  only  dental  or
10        only vision coverage;
11             (3)  preferred  provider  administrators, as defined
12        in Section 370g(g) of the Illinois Insurance Code;
13             (4)  employee  or   employer   self-insured   health
14        benefit  plans  under  the  federal  Employee  Retirement
15        Income Security Act of 1974; and
16             (5)  health  care  provided pursuant to the Workers'
17        Compensation Act or the  Workers'  Occupational  Diseases
18        Act.
19        "Health  care  provider"  means  any  physician, hospital
20    facility, or other  person  that  is  licensed  or  otherwise
21    authorized to deliver health care services.
22        "Medical  director"  means  a  physician  licensed in any
23    state to practice medicine in all its branches appointed by a
24    health care plan.
25        "Post-stabilization medical services" means  health  care
26    services  provided  to  an  enrollee  that are furnished in a
27    licensed hospital by a provider that is qualified to  furnish
28    such  services,  and determined to be medically necessary and
29    directly related to the emergency medical condition following
30    stabilization.
31        "Stabilization"  means,  with  respect  to  an  emergency
32    medical condition, to provide such medical treatment  of  the
33    condition  as  may  be necessary to assure, within reasonable
34    medical probability, that no material  deterioration  of  the
HB0161 Engrossed            -3-                LRB9100274JSgc
 1    condition is likely to result.
 2        "Utilization  review" means the evaluation of the medical
 3    necessity, appropriateness, and  efficiency  of  the  use  of
 4    health care services, procedures, and facilities.
 5        "Utilization  review program" means a program established
 6    by a person to perform utilization review.

 7        Section 10. Emergency services prior to stabilization.
 8        (a)  A health care plan that provides or that is required
 9    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 provider.
16        (b)  Prior  authorization  or  approval by the plan shall
17    not be required for emergency services.
18        (c)  Payment shall not be  retrospectively  denied,  with
19    the following exceptions:
20             (1)  upon    reasonable   determination   that   the
21        emergency services claimed were never performed;
22             (2)  upon   determination   that    the    emergency
23        evaluation and treatment were rendered to an enrollee who
24        sought  emergency services and whose circumstance did not
25        meet the definition of emergency medical condition;
26             (3)  upon determination that the  patient  receiving
27        such  services  was  not  an  enrollee of the health care
28        plan; or
29             (4)  upon material misrepresentation by the enrollee
30        or health care  provider;  "material"  means  a  fact  or
31        situation  that  is  not  merely  technical in nature and
32        results or could result in a substantial  change  in  the
33        situation.
HB0161 Engrossed            -4-                LRB9100274JSgc
 1        (d)  When  an  enrollee  presents  to  a hospital seeking
 2    emergency services, the determination as to whether the  need
 3    for  those  services  exists  shall  be  made for purposes of
 4    treatment by a physician  or,  to  the  extent  permitted  by
 5    applicable  law,  by  other  appropriately licensed personnel
 6    under the supervision of a physician. The physician or  other
 7    appropriate  personnel  shall indicate in the patient's chart
 8    the results of the emergency medical screening examination.
 9        (e)  The appropriate use of the 911  emergency  telephone
10    system  or  its  local equivalent shall not be discouraged or
11    penalized by the health care plan when an  emergency  medical
12    condition exists. This provision shall not imply that the use
13    of 911 or its local equivalent is a factor in determining the
14    existence of an emergency medical condition.
15        (f)  The  medical  director's  or  his  or her designee's
16    determination of whether the enrollee meets the  standard  of
17    an emergency medical condition shall be based solely upon the
18    presenting  symptoms  documented in the medical record at the
19    time care was sought.
20        (g)  Nothing  in  this   Section   shall   prohibit   the
21    imposition of deductibles, co-payments, and co-insurance.

22        Section 15.  Utilization review program registration.
23        (a)  No  person  may conduct a utilization review program
24    in this State unless once every 2 years the person  registers
25    the   utilization  review  program  with  the  Department  of
26    Insurance and certifies compliance with  all  of  the  Health
27    Utilization    Management    Standards    of   the   American
28    Accreditation  Healthcare  Commission   (URAC)   or   submits
29    evidence  of  accreditation  by  the  American  Accreditation
30    Healthcare  Commission  (URAC)  for  its  Health  Utilization
31    Management Standards.
32        (b)  In  addition,  the  Director  of  the  Department of
33    Insurance,  in  consultation  with  the   Director   of   the
HB0161 Engrossed            -5-                LRB9100274JSgc
 1    Department   of   Public   Health,  may  certify  alternative
 2    utilization  review  standards  of   national   accreditation
 3    organizations  or  entities in order for plans to comply with
 4    this Section.  Any alternative utilization  review  standards
 5    shall   meet   or   exceed  those  standards  required  under
 6    subsection (a).
 7        (c)  The provisions of this Section do not apply to:
 8             (1)  persons providing  utilization  review  program
 9        services only to the federal government;
10             (2)  self-insured  health  plans  under  the federal
11        Employee Retirement Income Security Act of 1974, however,
12        this  Section  does  apply  to   persons   conducting   a
13        utilization  review  program  on  behalf  of these health
14        plans;
15             (3)  hospitals   and   medical   groups   performing
16        utilization  review  activities  for  internal   purposes
17        unless the utilization on review program is conducted for
18        another person.
19        Nothing in this Act prohibits a health care plan or other
20    entity  from  contractually requiring an entity designated in
21    item (3) of this subsection  to  adhere  to  the  utilization
22    review program requirements of this Act.
23        (d)  This registration shall include submission of all of
24    the   following   information  regarding  utilization  review
25    program activities:
26             (1)  The  name,  address,  and  telephone   of   the
27        utilization review programs.
28             (2)  The organization and governing structure of the
29        utilization review programs.
30             (3)  The  number  of  lives  for  which  utilization
31        review is conducted by each utilization review program.
32             (4)  Hours  of  operation of each utilization review
33        program.
34             (5)  Description of the grievance process  for  each
HB0161 Engrossed            -6-                LRB9100274JSgc
 1        utilization review program.
 2             (6)  Number  of  covered lives for which utilization
 3        review was conducted for the previous calendar  year  for
 4        each utilization review program.
 5             (7)  Written  policies and procedures for protecting
 6        confidential information according  to  applicable  State
 7        and federal laws for each utilization review program.
 8        (e)  If   the   Department  of  Insurance  finds  that  a
 9    utilization review program is not  in  compliance  with  this
10    Section,  the Department shall issue a corrective action plan
11    and allow a reasonable amount of time for compliance with the
12    plan.  If the utilization review program does not  come  into
13    compliance,  the  Department  may  issue  a  cease and desist
14    order.  Before issuing a cease and desist  order  under  this
15    Section,  the Department shall provide the utilization review
16    program with a written notice of the reasons  for  the  order
17    and  allow  a  reasonable amount of time to supply additional
18    information demonstrating  compliance  with  requirements  of
19    this  Section  and  to request a hearing.  The hearing notice
20    shall be sent by certified mail,  return  receipt  requested,
21    and  the  hearing  shall  be conducted in accordance with the
22    Illinois Administrative Procedure Act.
23        (f)  A utilization review program subject to a corrective
24    action  may  continue  to  conduct  business  until  a  final
25    decision has been issued by the Department.

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