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91_HB0161ham002
LRB9100274JSpcam04
1 AMENDMENT TO HOUSE BILL 161
2 AMENDMENT NO. . Amend House Bill 161, AS AMENDED, by
3 replacing the title with the following:
4 "AN ACT concerning health care services."; and
5 by replacing everything after the enacting clause with the
6 following:
7 "Section 1. Short Title. This Act may be cited as the
8 Health Services Act.
9 Section 5. Definitions:
10 "Emergency medical condition" means a medical condition
11 manifesting itself by acute symptoms of sufficient severity
12 (including severe pain) such that a prudent layperson, who
13 possesses an average knowledge of health and medicine, could
14 reasonably expect the absence of immediate medical attention
15 to result in:
16 (1) placing the health of the individual (or, with
17 respect to a pregnant woman, the health of the woman or
18 her unborn child) in serious jeopardy;
19 (2) serious impairment to bodily functions; or
20 (3) serious dysfunction of any bodily organ or
21 part.
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1 "Emergency services" means, with respect to an enrollee
2 of a health plan, transportation services and covered
3 inpatient and outpatient hospital services furnished by a
4 provider qualified to furnish those services that are needed
5 to evaluate or stabilize an emergency medical condition.
6 "Emergency services" does not refer to post-stabilization
7 medical services.
8 "Enrollee" means any person and his or her dependents
9 enrolled in or covered by a health care plan.
10 "Health care plan" means a plan that establishes,
11 operates, or maintains a network of health care providers
12 that have entered into agreements with the plan to provide
13 health care services to enrollees to whom the plan has the
14 obligation to arrange for the provision of or payment for
15 services through organizational arrangements for ongoing
16 quality assurance, utilization review programs, or dispute
17 resolution.
18 For purposes of this definition, "health care plan" shall
19 not include the following:
20 (1) indemnity health insurance policies including
21 those using a contracted provider network;
22 (2) health care plans that offer only dental or
23 only vision coverage;
24 (3) preferred provider administrators, as defined
25 in Section 370g(g) of the Illinois Insurance Code;
26 (4) employee or employer self-insured health
27 benefit plans under the federal Employee Retirement
28 Income Security Act of 1974; and
29 (5) health care provided pursuant to the Workers'
30 Compensation Act or the Workers' Occupational Diseases
31 Act.
32 "Health care provider" means any physician, hospital
33 facility, or other person that is licensed or otherwise
34 authorized to deliver health care services.
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1 "Medical director" means a physician licensed in any
2 state to practice medicine in all its branches appointed by a
3 health care plan.
4 "Post-stabilization medical services" means health care
5 services provided to an enrollee that are furnished in a
6 licensed hospital by a provider that is qualified to furnish
7 such services, and determined to be medically necessary and
8 directly related to the emergency medical condition following
9 stabilization.
10 "Stabilization" means, with respect to an emergency
11 medical condition, to provide such medical treatment of the
12 condition as may be necessary to assure, within reasonable
13 medical probability, that no material deterioration of the
14 condition is likely to result.
15 "Utilization review" means the evaluation of the medical
16 necessity, appropriateness, and efficiency of the use of
17 health care services, procedures, and facilities.
18 "Utilization review program" means a program established
19 by a person to perform utilization review.
20 Section 10. Emergency services prior to stabilization.
21 (a) A health care plan that provides or that is required
22 by law to provide coverage for emergency services shall
23 provide coverage such that payment under this coverage is not
24 dependent upon whether the services are performed by a plan
25 or non-plan health care provider and without regard to prior
26 authorization. This coverage shall be at the same benefit
27 level as if the services or treatment had been rendered by
28 the health care plan provider.
29 (b) Prior authorization or approval by the plan shall
30 not be required for emergency services.
31 (c) Payment shall not be retrospectively denied, with
32 the following exceptions:
33 (1) upon reasonable determination that the
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1 emergency services claimed were never performed;
2 (2) upon determination that the emergency
3 evaluation and treatment were rendered to an enrollee who
4 sought emergency services and whose circumstance did not
5 meet the definition of emergency medical condition;
6 (3) upon determination that the patient receiving
7 such services was not an enrollee of the health care
8 plan; or
9 (4) upon material misrepresentation by the enrollee
10 or health care provider; "material" means a fact or
11 situation that is not merely technical in nature and
12 results or could result in a substantial change in the
13 situation.
14 (d) When an enrollee presents to a hospital seeking
15 emergency services, the determination as to whether the need
16 for those services exists shall be made for purposes of
17 treatment by a physician or, to the extent permitted by
18 applicable law, by other appropriately licensed personnel
19 under the supervision of a physician. The physician or other
20 appropriate personnel shall indicate in the patient's chart
21 the results of the emergency medical screening examination.
22 (e) The appropriate use of the 911 emergency telephone
23 system or its local equivalent shall not be discouraged or
24 penalized by the health care plan when an emergency medical
25 condition exists. This provision shall not imply that the use
26 of 911 or its local equivalent is a factor in determining the
27 existence of an emergency medical condition.
28 (f) The medical director's or his or her designee's
29 determination of whether the enrollee meets the standard of
30 an emergency medical condition shall be based solely upon the
31 presenting symptoms documented in the medical record at the
32 time care was sought.
33 (g) Nothing in this Section shall prohibit the
34 imposition of deductibles, co-payments, and co-insurance.
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1 Section 15. Utilization review program registration.
2 (a) No person may conduct a utilization review program
3 in this State unless once every 2 years the person registers
4 the utilization review program with the Department of
5 Insurance and certifies compliance with all of the Health
6 Utilization Management Standards of the American
7 Accreditation Healthcare Commission (URAC) or submits
8 evidence of accreditation by the American Accreditation
9 Healthcare Commission (URAC) for its Health Utilization
10 Management Standards.
11 (b) In addition, the Director of the Department of
12 Insurance, in consultation with the Director of the
13 Department of Public Health, may certify alternative
14 utilization review standards of national accreditation
15 organizations or entities in order for plans to comply with
16 this Section. Any alternative utilization review standards
17 shall meet or exceed those standards required under
18 subsection (a).
19 (c) The provisions of this Section do not apply to:
20 (1) persons providing utilization review program
21 services only to the federal government;
22 (2) self-insured health plans under the federal
23 Employee Retirement Income Security Act of 1974, however,
24 this Section does apply to persons conducting a
25 utilization review program on behalf of these health
26 plans;
27 (3) hospitals and medical groups performing
28 utilization review activities for internal purposes
29 unless the utilization on review program is conducted for
30 another person.
31 Nothing in this Act prohibits a health care plan or other
32 entity from contractually requiring an entity designated in
33 item (3) of this subsection to adhere to the utilization
34 review program requirements of this Act.
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1 (d) This registration shall include submission of all of
2 the following information regarding utilization review
3 program activities:
4 (1) The name, address, and telephone of the
5 utilization review programs.
6 (2) The organization and governing structure of the
7 utilization review programs.
8 (3) The number of lives for which utilization
9 review is conducted by each utilization review program.
10 (4) Hours of operation of each utilization review
11 program.
12 (5) Description of the grievance process for each
13 utilization review program.
14 (6) Number of covered lives for which utilization
15 review was conducted for the previous calendar year for
16 each utilization review program.
17 (7) Written policies and procedures for protecting
18 confidential information according to applicable State
19 and federal laws for each utilization review program.
20 (e) If the Department of Insurance finds that a
21 utilization review program is not in compliance with this
22 Section, the Department shall issue a corrective action plan
23 and allow a reasonable amount of time for compliance with the
24 plan. If the utilization review program does not come into
25 compliance, the Department may issue a cease and desist
26 order. Before issuing a cease and desist order under this
27 Section, the Department shall provide the utilization review
28 program with a written notice of the reasons for the order
29 and allow a reasonable amount of time to supply additional
30 information demonstrating compliance with requirements of
31 this Section and to request a hearing. The hearing notice
32 shall be sent by certified mail, return receipt requested,
33 and the hearing shall be conducted in accordance with the
34 Illinois Administrative Procedure Act.
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1 (f) A utilization review program subject to a corrective
2 action may continue to conduct business until a final
3 decision has been issued by the Department.".