Public Act 90-0376 of the 90th General Assembly

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Public Act 90-0376

HB1565 Enrolled                                LRB9003794JSgc

    AN ACT to amend the Health Maintenance  Organization  Act
by changing Section 1-2 and adding Section 4-17.

    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  Section 1-2 and adding Section 4-17 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 such limitations 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  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  in  the  integrated  health  care program
established under Section 5-16.3 of the Illinois  Public  Aid
Code  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,  or  a
nonprofit  corporation  authorized  under the Medical Service
Plan Act, the Dental Service Plan  Act,  the  Vision  Service
Plan  Act, the Pharmaceutical Service Plan Act, the Voluntary
Health Services Plans  Act  or  the  Non-profit  Health  Care
Service  Plan  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 service.
    (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
contract.
(Source: P.A. 88-554, eff. 7-26-94; 89-90, eff. 6-30-95.)

    (215 ILCS 125/4-17 new)
    Sec.   4-17.  Basic  outpatient  preventive  and  primary
health care services for children. In  order  to  attempt  to
address  the needs of children in Illinois (i) without health
care coverage, either through a parent's employment,  through
medical assistance under the Illinois Public Aid Code, or any
other  health plan or (ii) who lose medical assistance if and
when their parents move from welfare to work and do not  find
employment   that  offers  health  care  coverage,  a  health
maintenance  organization may undertake to provide or arrange
for and to pay for or reimburse the cost of basic  outpatient
preventive  and primary health care services.  The Department
shall promulgate rules  to  establish  minimum  coverage  and
disclosure  requirements.   These  requirements  at a minimum
shall   include    routine    physical    examinations    and
immunizations,  sick visits, diagnostic x-rays and laboratory
services, and emergency outpatient services.    Coverage  may
also include preventive dental services, vision screening and
one pair of eyeglasses, prescription drugs, and mental health
services.   The   coverage   may   include   any   reasonable
co-payments,  deductibles,  and  benefit  maximums subject to
limitations established by the Director by  rule.    Coverage
shall  be  limited  to  children  who  are 18 years of age or
under, who have resided in the State of Illinois for at least
30 days, and who do not qualify for medical assistance  under
the  Illinois  Public  Aid  Code.  Any such coverage shall be
made available to an adult on behalf  of  such  children  and
shall  not  be  funded  through  State  appropriations.    In
counties   with  populations  in  excess  of  3,000,000,  the
Director shall not approve any arrangement under this Section
unless and until an  arrangement  for  at  least  one  health
maintenance  organization  under  contract  with the Illinois
Department of  Public  Aid  for  furnishing  health  services
pursuant  to Section 5-11 of the Illinois Public Aid Code and
for which the requirements of  42  CFR  434.26(a)  have  been
waived is approved.

    Section  99.  Effective date.  This Act takes effect upon
becoming law.

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