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Public Act 097-1148





Public Act 097-1148
SB3233 EnrolledLRB097 19652 RPM 64906 b

    AN ACT concerning insurance.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The Health Maintenance Organization Act is
amended by changing Sections 1-2 and 4-14 and by adding Section
4-20 as follows:
    (215 ILCS 125/1-2)  (from Ch. 111 1/2, par. 1402)
    Sec. 1-2. Definitions. As used in this Act, unless the
context otherwise requires, the following terms shall have the
meanings ascribed to them:
    (1) "Advertisement" means any printed or published
material, audiovisual material and descriptive literature of
the health care plan used in direct mail, newspapers,
magazines, radio scripts, television scripts, billboards and
similar displays; and any descriptive literature or sales aids
of all kinds disseminated by a representative of the health
care plan for presentation to the public including, but not
limited to, circulars, leaflets, booklets, depictions,
illustrations, form letters and prepared sales presentations.
    (2) "Director" means the Director of Insurance.
    (3) "Basic health care services" means emergency care, and
inpatient hospital and physician care, outpatient medical
services, mental health services and care for alcohol and drug
abuse, including any reasonable deductibles and co-payments,
all of which are subject to the such limitations described in
Section 4-20 of this Act and as are determined by the Director
pursuant to rule.
    (4) "Enrollee" means an individual who has been enrolled in
a health care plan.
    (5) "Evidence of coverage" means any certificate,
agreement, or contract issued to an enrollee setting out the
coverage to which he is entitled in exchange for a per capita
prepaid sum.
    (6) "Group contract" means a contract for health care
services which by its terms limits eligibility to members of a
specified group.
    (7) "Health care plan" means any arrangement whereby any
organization undertakes to provide or arrange for and pay for
or reimburse the cost of basic health care services, excluding
any reasonable deductibles and copayments, from providers
selected by the Health Maintenance Organization and such
arrangement consists of arranging for or the provision of such
health care services, as distinguished from mere
indemnification against the cost of such services, except as
otherwise authorized by Section 2-3 of this Act, on a per
capita prepaid basis, through insurance or otherwise. A "health
care plan" also includes any arrangement whereby an
organization undertakes to provide or arrange for or pay for or
reimburse the cost of any health care service for persons who
are enrolled under Article V of the Illinois Public Aid Code or
under the Children's Health Insurance Program Act through
providers selected by the organization and the arrangement
consists of making provision for the delivery of health care
services, as distinguished from mere indemnification. A
"health care plan" also includes any arrangement pursuant to
Section 4-17. Nothing in this definition, however, affects the
total medical services available to persons eligible for
medical assistance under the Illinois Public Aid Code.
    (8) "Health care services" means any services included in
the furnishing to any individual of medical or dental care, or
the hospitalization or incident to the furnishing of such care
or hospitalization as well as the furnishing to any person of
any and all other services for the purpose of preventing,
alleviating, curing or healing human illness or injury.
    (9) "Health Maintenance Organization" means any
organization formed under the laws of this or another state to
provide or arrange for one or more health care plans under a
system which causes any part of the risk of health care
delivery to be borne by the organization or its providers.
    (10) "Net worth" means admitted assets, as defined in
Section 1-3 of this Act, minus liabilities.
    (11) "Organization" means any insurance company, a
nonprofit corporation authorized under the Dental Service Plan
Act or the Voluntary Health Services Plans Act, or a
corporation organized under the laws of this or another state
for the purpose of operating one or more health care plans and
doing no business other than that of a Health Maintenance
Organization or an insurance company. "Organization" shall
also mean the University of Illinois Hospital as defined in the
University of Illinois Hospital Act.
    (12) "Provider" means any physician, hospital facility, or
other person which is licensed or otherwise authorized to
furnish health care services and also includes any other entity
that arranges for the delivery or furnishing of health care
    (13) "Producer" means a person directly or indirectly
associated with a health care plan who engages in solicitation
or enrollment.
    (14) "Per capita prepaid" means a basis of prepayment by
which a fixed amount of money is prepaid per individual or any
other enrollment unit to the Health Maintenance Organization or
for health care services which are provided during a definite
time period regardless of the frequency or extent of the
services rendered by the Health Maintenance Organization,
except for copayments and deductibles and except as provided in
subsection (f) of Section 5-3 of this Act.
    (15) "Subscriber" means a person who has entered into a
contractual relationship with the Health Maintenance
Organization for the provision of or arrangement of at least
basic health care services to the beneficiaries of such
(Source: P.A. 92-370, eff. 8-15-01.)
    (215 ILCS 125/4-14)  (from Ch. 111 1/2, par. 1409.7)
    Sec. 4-14. Evidence of Coverage.
    (a) Every subscriber shall be issued an evidence of
coverage, which shall contain a clear and complete statement
        (1) The health services to which each enrollee is
        (2) Eligibility requirements indicating the conditions
    which must be met to enroll in a Health Care Plan;
        (3) Any limitation of the services, kinds of services
    or benefits to be provided, and exclusions, including any
    reasonable deductibles, copayments, co-payment, or other
        (4) The terms or conditions upon which coverage may be
    cancelled or otherwise terminated;
        (5) Where and in what manner information is available
    as to where and how services may be obtained; and
        (6) The method for resolving complaints.
    (b) Any amendment to the evidence of coverage may be
provided to the subscriber in a separate document.
(Source: P.A. 86-620.)
    (215 ILCS 125/4-20 new)
    Sec. 4-20. Deductibles and copayments.
    (a) A Health Maintenance Organization may require
deductibles and copayments of enrollees as a condition for the
receipt of specific health care services, including basic
health care services. Deductibles and copayments shall be the
only allowable charges, other than premiums, assessed
enrollees. Nothing within this subsection (a) shall preclude
the provider from charging reasonable administrative fees,
such as service fees for checks returned for non-sufficient
funds and missed appointments.
    (b) Deductibles and copayments shall be for specific dollar
amounts or for specific percentages of the cost of the health
care services.
    (c) No combination of deductibles and copayments paid for
the receipt of basic health care services may exceed the annual
maximum out-of-pocket expenses of a high deductible health plan
as defined in 26 U.S.C. 223.
    (d) Deductibles and copayments applicable to supplemental
health care services, catastrophic-only plans as defined under
the federal Affordable Care Act, or pre-existing conditions are
not subject to the annual limitations described in this
    (e) This Section applies to enrollees and does not limit
the health care plan payment for services provided by
non-participating providers.
    (f) This Section applies to enrollees and does not limit
the health care plan payment for services provided by
non-participating providers.
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 1/24/2013