State of Illinois
91st General Assembly
Legislation

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91_SB0727

 
                                               LRB9105755JSpc

 1        AN ACT concerning emergency  medical  services,  amending
 2    named Acts.

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

 5        Section 1.  Short title.  This Act may be  cited  as  the
 6    Access to Emergency Services Act.

 7        Section 5.  Legislative findings and purposes.
 8        (a)  The  legislature  recognizes  that  all persons need
 9    access to emergency medical care and that State  and  federal
10    laws  require  hospital emergency departments to provide that
11    care.    Federal   law   specifically   prohibits   emergency
12    physicians and hospital emergency departments  from  delaying
13    any  treatment  needed to evaluate or stabilize an individual
14    in order to determine the  health  insurance  status  of  the
15    individual.
16        However,  health  insurance  plans  may  impede access to
17    emergency care by denying coverage or payment for failure  to
18    obtain prior authorization or approval from the plan, failure
19    to  seek  emergency  care  from  a  preferred  or contractual
20    provider, or an after-the-fact determination that the medical
21    condition did not require the  use  emergency  facilities  or
22    services, including the 911 emergency telephone number.
23        These  denials  impose  significant  financial burdens on
24    patients who prudently seek care for symptoms  of  a  medical
25    emergency  through the 911 system and in a hospital emergency
26    department, as well as the  providers  of  such  care.   This
27    serves   to  discourage  patients  from  seeking  appropriate
28    emergency care and  threatens  the  financial  livelihood  of
29    hospital   emergency  departments  and  trauma  centers  that
30    provide such necessary services to our entire population.
31        (b)  This Act is intended to promote access to  emergency
 
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 1    medical   care   by  establishing  a  uniform  definition  of
 2    emergency medical condition that  is  based  on  the  average
 3    knowledge  of  the  prudent  layperson  and  requiring health
 4    insurance plans to cover and pay for  such  services  without
 5    restrictions  that  may  impede  or discourage access to such
 6    care.

 7        Section 10.  Definitions:
 8        "Department" means the Department of Insurance.
 9        "Emergency medical condition" means a  medical  condition
10    manifesting  itself  by acute symptoms of sufficient severity
11    (including, but not limited to,  severe  pain)  such  that  a
12    prudent  layperson,  who  possesses  an  average knowledge of
13    health and medicine, could reasonably expect the  absence  of
14    immediate medical attention to result in:
15             (1)  placing  the health of the individual (or, with
16        respect to a pregnant woman, the health of the  woman  or
17        her unborn child) in serious jeopardy;
18             (2)  serious impairment to bodily functions; or
19             (3)  serious  dysfunction  of  any  bodily  organ or
20        part.
21        "Emergency medical screening examination" means a medical
22    screening examination and evaluation by a  physician,  or  to
23    the   extent   permitted   by   applicable   laws,  by  other
24    appropriately licensed personnel under the supervision  of  a
25    physician   to  determine  whether  the  need  for  emergency
26    services exists.
27        "Emergency services" means, with respect to  an  enrollee
28    of  a  health  insurance  plan,  transportation  services and
29    covered inpatient and outpatient hospital services  furnished
30    by  a  provider  qualified to furnish those services that are
31    needed  to  evaluate  or  stabilize  an   emergency   medical
32    condition.   "Emergency   services"   does   not   refer   to
33    post-stabilization medical services.
 
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 1        "Enrollee"  means  any  person  and his or her dependents
 2    enrolled in or covered by a health insurance plan.
 3        "Health care  provider"  means  any  physician,  hospital
 4    facility,  or  other  person  that  is  licensed or otherwise
 5    authorized to deliver health care services.
 6        "Health care services" means any services included in the
 7    furnishing  to  any  individual  of  medical  care,  or   the
 8    hospitalization or incident to the furnishing of such care or
 9    hospitalization  as  well  as the furnishing to any person of
10    any and all other services for  the  purpose  of  preventing,
11    alleviating,  curing,  or  healing  human  illness  or injury
12    including  home  health  and  pharmaceutical   services   and
13    products.
14        "Health insurance plan" means any policy, contract, plan,
15    or  other  arrangement  that  pays  for  or furnishes medical
16    services  pursuant  to  the  Illinois  Insurance  Code,   the
17    Comprehensive   Health   Insurance   Plan   Act,  the  Health
18    Maintenance Organization Act,  or  the  Illinois  Public  Aid
19    Code.
20        "Physician"  means  a  person  licensed under the Medical
21    Practice Act of 1987.
22        "Post-stabilization medical services" means  health  care
23    services  provided  to  an  enrollee  that are furnished in a
24    licensed hospital by a physician or health care provider that
25    is qualified to furnish such services, and determined  to  be
26    medically  necessary  and  directly  related to the emergency
27    medical condition following stabilization.
28        "Stabilization"  means,  with  respect  to  an  emergency
29    medical condition, to provide such medical treatment  of  the
30    condition  as  may  be necessary to assure, within reasonable
31    medical probability, that no material  deterioration  of  the
32    condition  is  likely  to  result  from  or  occur during the
33    transfer of the enrollee from a facility.
 
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 1        Section 15. Emergency services prior to stabilization.
 2        (a)  A health insurance plan subject  to  this  Act  that
 3    provides  or  that is required by law to provide coverage for
 4    emergency services shall provide coverage such  that  payment
 5    under  this  coverage  is  not  dependent  upon  whether  the
 6    services  are  performed  by  a plan or non-plan physician or
 7    health  care   provider   and   without   regard   to   prior
 8    authorization.  This  coverage  shall  be at the same benefit
 9    level as if the services or treatment had  been  rendered  by
10    the health insurance plan physician or health care provider.
11        (b)  Prior  authorization  or  approval by the plan shall
12    not be required for emergency services.
13        (c)  Coverage and payment shall  not  be  retrospectively
14    denied, with the following exceptions:
15             (1)  upon    reasonable   determination   that   the
16        emergency services claimed were never performed;
17             (2)  upon   reasonable   determination   that    the
18        emergency  evaluation  and  treatment were rendered to an
19        enrollee  who  sought  emergency   services   and   whose
20        circumstance  did  not  meet  the definition of emergency
21        medical condition;
22             (3)  upon determination that the  patient  receiving
23        such services was not an enrollee of the health insurance
24        plan; or
25             (4)  upon material misrepresentation by the enrollee
26        or  health  care  provider;  "material"  means  a fact or
27        situation that is not  merely  technical  in  nature  and
28        results  or  could  result in a substantial change in the
29        situation.
30        (d)  When an enrollee  presents  to  a  hospital  seeking
31    emergency  services, the determination as to whether the need
32    for those services exists  shall  be  made  for  purposes  of
33    treatment by a physician licensed to practice medicine in all
34    its  branches  or, to the extent permitted by applicable law,
 
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 1    by  other  appropriately   licensed   personnel   under   the
 2    supervision  of  a physician licensed to practice medicine in
 3    all  its  branches.  The  physician  or   other   appropriate
 4    personnel  shall  indicate in the patient's chart the results
 5    of the emergency medical screening examination.
 6        (e)  The appropriate use of the 911  emergency  telephone
 7    system  or  its  local equivalent shall not be discouraged or
 8    penalized by the health  insurance  plan  when  an  emergency
 9    medical condition exists. This provision shall not imply that
10    the  use  of  911  or  its  local  equivalent  is a factor in
11    determining the existence of an emergency medical condition.
12        (f)  Nothing  in  this   Section   shall   prohibit   the
13    imposition of deductibles, co-payments, and co-insurance.

14        Section 20. Post-stabilization medical services.
15        (a) If prior authorization for covered post-stabilization
16    services  is  required by the health insurance plan, the plan
17    shall provide access 24 hours a day, 7 days a week to persons
18    designated by the plan to make such determinations.
19        (b) The treating physician or health care provider  shall
20    contact  the  health insurance plan or delegated physician or
21    health care provider as designated on the  enrollee's  health
22    insurance   card   to   obtain   authorization,   denial,  or
23    arrangements for an alternate plan of treatment  or  transfer
24    of the enrollee.
25        (c)  The treating physician licensed to practice medicine
26    in all its branches or health care provider shall document in
27    the  enrollee's  medical  record  the  enrollee's  presenting
28    symptoms; emergency medical condition; and time, phone number
29    dialed,  and  result  of  the  communication  for request for
30    authorization of post  stabilization  medical  services.  The
31    health insurance plan shall provide reimbursement for covered
32    post-stabilization medical services if:
33             (1)  authorization  to  render them is received from
 
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 1        the health insurance plan or its delegated  physician  or
 2        health care provider; or
 3             (2)  after  2  documented  good  faith  efforts, the
 4        treating physician or health care provider has  attempted
 5        to  contact  the  enrollee's health insurance plan or its
 6        delegated  physician  or   health   care   provider,   as
 7        designated  on  the enrollee's health insurance card, for
 8        prior   authorization   of   post-stabilization   medical
 9        services and neither the plan nor designated persons were
10        accessible or the authorization was not denied within  60
11        minutes  of  the  request.  "Two  documented  good  faith
12        efforts"  means the physician or health care provider has
13        called the telephone  number  on  the  enrollee's  health
14        insurance  card  or other available number either 2 times
15        or one time and made an additional call to  any  referral
16        number  provided.  "Good faith" means honesty of purpose,
17        freedom from intention to defraud, and being faithful  to
18        one's  duty  or  obligation. For the purpose of this Act,
19        good faith shall be presumed.
20        (d)  After  rendering  any   post-stabilization   medical
21    services,  the  treating  physician  or  health care provider
22    shall continue to make every reasonable effort to contact the
23    health insurance plan or its delegated  physician  or  health
24    care    provider    regarding   authorization,   denial,   or
25    arrangements for an alternate plan of treatment  or  transfer
26    of  the  enrollee until the treating physician or health care
27    provider receives instructions from the health insurance plan
28    or delegated physician or health care provider for  continued
29    care  or  the  care  is  transferred  to another physician or
30    health care provider or the patient is discharged.
31        (e)  Payment for covered post-stabilization services  may
32    be denied:
33             (1)  if   the  treating  physician  or  health  care
34        provider  does  not  meet  the  conditions  outlined   in
 
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 1        subsection (c);
 2             (2)  upon  determination that the post-stabilization
 3        services claimed were not performed;
 4             (3)  upon determination that the  post-stabilization
 5        services  rendered  were  contrary to the instructions of
 6        the health insurance plan or its delegated  physician  or
 7        health  care  provider  if contact was made between those
 8        parties prior to the service being rendered;
 9             (4)  upon determination that the  patient  receiving
10        such services was not an enrollee of the health insurance
11        plan; or
12             (5)  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        (f)  Coverage and payment for post-stabilization  medical
18    services  for which prior authorization or deemed approval is
19    received shall not be retrospectively denied.
20        (g)  Nothing in this Section prohibits a health insurance
21    plan   from   delegating   tasks    associated    with    the
22    responsibilities  enumerated  in  this  Section to the health
23    insurance plan's contracted health care providers or  another
24    entity.   However,  the  ultimate responsibility for coverage
25    and payment decisions may not be delegated.
26        (h)  Nothing  in  this   Section   shall   prohibit   the
27    imposition of deductibles, co-payments, and co-insurance.

28        Section 25.  Enforcement.
29        (a)  The  Department shall enforce the provisions of this
30    Act.  It shall promptly investigate  complaints  it  receives
31    alleging  violation of the Act.  If the complaint is found to
32    be valid, the Department shall immediately  seek  appropriate
33    corrective action by the health insurance plan including, but
 
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 1    not  limited to, ceasing the noncompliant activity, restoring
 2    coverage, paying or reimbursing claims, and other appropriate
 3    restitution.
 4        (b)  Subject  to   the   provisions   of   the   Illinois
 5    Administrative  Procedure  Act,  the Department may impose an
 6    administrative fine on a health insurance plan found to  have
 7    violated any provision of this Act up to a fine of $5,000 per
 8    violation.   A  repeated  violation shall result in a fine of
 9    $10,000 per violation, per day.
10        (c)  Notwithstanding the  existence  or  pursuit  of  any
11    other  remedy,  the  Department  may,  through  the  Attorney
12    General, seek an injunction to restrain or prevent any health
13    insurance  plan  from  violation or continuing to violate any
14    provisions of this Act.

15        Section 30.  Rules.  The Department shall adopt emergency
16    rules to implement the provisions of this Act, in  accordance
17    with  Section  5-45  of the Illinois Administrative Procedure
18    Act.

19        Section 91.  The Illinois Insurance Code  is  amended  by
20    changing  Section  370g and adding Sections 155.36, 370s, and
21    511.118 as follows:

22        (215 ILCS 5/155.36 new)
23        Sec.   155.36.  Access   to   Emergency   Services   Act.
24    Insurance companies that  transact  the  kinds  of  insurance
25    authorized  under  Class  1(b)  or Class 2(a) of Section 4 of
26    this Code shall comply with the Access to Emergency  Services
27    Act.

28        (215 ILCS 5/370g) (from Ch. 73, par. 982g)
29        Sec.  370g.   Definitions.   As used in this Article, the
30    following definitions apply:
 
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 1        (a)  "Health care services" means health care services or
 2    products rendered or sold by a provider within the  scope  of
 3    the  provider's  license  or  legal  authorization.  The term
 4    includes, but is not limited to, hospital, medical, surgical,
 5    dental, vision and pharmaceutical services or products.
 6        (b)  "Insurer" means an insurance  company  or  a  health
 7    service   corporation  authorized  in  this  State  to  issue
 8    policies or subscriber contracts which reimburse for expenses
 9    of health care services.
10        (c)  "Insured"   means   an   individual   entitled    to
11    reimbursement  for  expenses  of health care services under a
12    policy or subscriber contract issued or  administered  by  an
13    insurer.
14        (d)  "Provider"   means  an  individual  or  entity  duly
15    licensed  or  legally  authorized  to  provide  health   care
16    services.
17        (e)  "Noninstitutional   provider"   means   any   person
18    licensed  under  the  Medical Practice Act of 1987, as now or
19    hereafter amended.
20        (f)  "Beneficiary"  means  an  individual   entitled   to
21    reimbursement  for  expenses  of  or the discount of provider
22    fees for health care  services  under  a  program  where  the
23    beneficiary  has  an  incentive  to utilize the services of a
24    provider which has entered into an agreement  or  arrangement
25    with an administrator.
26        (g)  "Administrator"  means  any  person,  partnership or
27    corporation, other than  an  insurer  or  health  maintenance
28    organization  holding  a  certificate  of authority under the
29    "Health Maintenance Organization Act", as  now  or  hereafter
30    amended,   that  arranges,  contracts  with,  or  administers
31    contracts with a provider whereby beneficiaries are  provided
32    an incentive to use the services of such provider.
33        (h)  "Emergency   medical   condition"  means  a  medical
34    condition manifesting itself by acute symptoms of  sufficient
 
                            -10-               LRB9105755JSpc
 1    severity (including, but limited to, severe pain) such that a
 2    prudent  layperson,  who  possesses  an  average knowledge of
 3    health and medicine, could reasonably expect the  absence  of
 4    immediate medical attention to result in:
 5             (1)  placing  the health of the individual (or, with
 6        respect to a pregnant woman, the health of the  woman  or
 7        her unborn child) in serious jeopardy;
 8             (2)  serious impairment to bodily functions; or
 9             (3)  serious  dysfunction  of  any  bodily  organ or
10        part. "Emergency" means an accidental  bodily  injury  or
11        emergency medical condition which reasonably requires the
12        beneficiary  or  insured  to  seek immediate medical care
13        under circumstances  or  at  locations  which  reasonably
14        preclude the beneficiary or insured from obtaining needed
15        medical care from a preferred provider.
16    (Source: P.A. 88-400.)

17        (215 ILCS 5/370s new)
18        Sec.   370s.  Access  to  Emergency  Services  Act.   All
19    administrators shall comply  with  the  Access  to  Emergency
20    Services Act.

21        (215 ILCS 5/511.118 new)
22        Sec.  511.118.  Access  to  Emergency  Services Act.  All
23    administrators shall comply  with  the  Access  to  Emergency
24    Services Act.

25        Section  93.  The Comprehensive Health Insurance Plan Act
26    is amended by adding Section 8.6 as follows:

27        (215 ILCS 105/8.6 new)
28        Sec. 8.6.  Access to Emergency Services Act.  The plan is
29    subject to the provisions of the Access to Emergency Services
30    Act.
 
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 1        Section 95.  The Health Maintenance Organization  Act  is
 2    amended by adding Section 5-3.6 as follows:

 3        (215 ILCS 125/5-3.6 new)
 4        Sec.  5-3.6.  Access  to  Emergency Services Act.  Health
 5    maintenance organizations are subject to  the  provisions  of
 6    the Access to Emergency Services Act.

 7        Section  97.  The  Illinois Public Aid Code is amended by
 8    adding Section 5-16.12 as follows:

 9        (305 ILCS 5/5-16.12 new)
10        Sec. 5-16.12.  Access to  Emergency  Services  Act.   The
11    medical assistance program and other programs administered by
12    the Department are subject to the provisions of the Access to
13    Emergency  Services  Act.   The Department may adopt rules to
14    implement  those  provisions.   These  rules  shall   require
15    compliance  with  that  Act in the medical assistance managed
16    care  programs  and  other  programs  administered   by   the
17    Department.

18        Section  99.   Effective  date.   This  Act  takes effect
19    January 1, 2000.

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