State of Illinois
90th General Assembly

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[ Introduced ][ Engrossed ][ House Amendment 001 ]
[ Senate Amendment 001 ]


      215 ILCS 125/1-1          from Ch. 111 1/2, par. 1401
          Amends the Health Maintenance Organization Act.  Makes  a
      stylistic change concerning the short title of the Act.
HB1565 Enrolled                                LRB9003794JSgc
 1        AN  ACT  to amend the Health Maintenance Organization Act
 2    by changing Section 1-2 and adding Section 4-17.
 3        Be it enacted by the People of  the  State  of  Illinois,
 4    represented in the General Assembly:
 5        Section  5.  The  Health  Maintenance Organization Act is
 6    amended by changing Section 1-2 and adding  Section  4-17  as
 7    follows:
 8        (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
 9        Sec.  1-2.   Definitions. As used in this Act, unless the
10    context otherwise requires, the following  terms  shall  have
11    the meanings ascribed to them:
12        (1)  "Advertisement"   means  any  printed  or  published
13    material, audiovisual material and descriptive literature  of
14    the  health  care  plan  used  in  direct  mail,  newspapers,
15    magazines,  radio scripts, television scripts, billboards and
16    similar displays; and any  descriptive  literature  or  sales
17    aids  of  all  kinds  disseminated by a representative of the
18    health care plan for presentation to  the  public  including,
19    but   not   limited   to,   circulars,   leaflets,  booklets,
20    depictions, illustrations, form letters  and  prepared  sales
21    presentations.
22        (2)  "Director" means the Director of Insurance.
23        (3)  "Basic  Health  Care Services" means emergency care,
24    and inpatient hospital and physician care, outpatient medical
25    services, mental health services and  care  for  alcohol  and
26    drug   abuse,   including   any  reasonable  deductibles  and
27    co-payments, all of which are subject to such limitations  as
28    are determined by the Director pursuant to rule.
29        (4)  "Enrollee" means an individual who has been enrolled
30    in a health care plan.
31        (5)  "Evidence   of   Coverage"  means  any  certificate,
HB1565 Enrolled            -2-                 LRB9003794JSgc
 1    agreement, or contract issued to an enrollee setting out  the
 2    coverage to which he is entitled in exchange for a per capita
 3    prepaid sum.
 4        (6)  "Group  Contract"  means  a contract for health care
 5    services which by its terms limits eligibility to members  of
 6    a specified group.
 7        (7)  "Health Care Plan" means any arrangement whereby any
 8    organization undertakes to provide or arrange for and pay for
 9    or  reimburse  the  cost  of  basic health care services from
10    providers selected by the Health Maintenance Organization and
11    such arrangement consists of arranging for or  the  provision
12    of  such  health  care  services,  as distinguished from mere
13    indemnification against the cost of such services, except  as
14    otherwise  authorized  by  Section  2-3 of this Act, on a per
15    capita prepaid basis,  through  insurance  or  otherwise.   A
16    "health  care  plan" also includes any arrangement whereby an
17    organization undertakes to provide or arrange for or pay  for
18    or  reimburse the cost of any health care service for persons
19    who are  enrolled  in  the  integrated  health  care  program
20    established  under  Section 5-16.3 of the Illinois Public Aid
21    Code through providers selected by the organization  and  the
22    arrangement  consists of making provision for the delivery of
23    health   care   services,   as   distinguished   from    mere
24    indemnification.   A  "health  care  plan"  also includes any
25    arrangement  pursuant  to  Section  4-17.   Nothing  in  this
26    definition,  however,  affects  the  total  medical  services
27    available to persons eligible for  medical  assistance  under
28    the Illinois Public Aid Code.
29        (8)  "Health  Care  Services" means any services included
30    in the furnishing to any  individual  of  medical  or  dental
31    care, or the hospitalization or incident to the furnishing of
32    such care or hospitalization as well as the furnishing to any
33    person  of  any  and  all  other  services for the purpose of
34    preventing, alleviating, curing or healing human  illness  or
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 1    injury.
 2        (9)  "Health    Maintenance   Organization"   means   any
 3    organization formed under the laws of this or  another  state
 4    to provide or arrange for one or more health care plans under
 5    a  system  which  causes  any part of the risk of health care
 6    delivery to be borne by the organization or its providers.
 7        (10)  "Net Worth" means admitted assets,  as  defined  in
 8    Section 1-3 of this Act, minus liabilities.
 9        (11)  "Organization"  means  any  insurance company, or a
10    nonprofit corporation authorized under  the  Medical  Service
11    Plan  Act,  the  Dental  Service Plan Act, the Vision Service
12    Plan Act, the Pharmaceutical Service Plan Act, the  Voluntary
13    Health  Services  Plans  Act  or  the  Non-profit Health Care
14    Service Plan Act, or a corporation organized under  the  laws
15    of  this or another state for the purpose of operating one or
16    more health care plans and doing no business other than  that
17    of a Health Maintenance Organization or an insurance company.
18    Organization  shall  also  mean  the  University  of Illinois
19    Hospital as defined in the University  of  Illinois  Hospital
20    Act.
21        (12)  "Provider"  means any physician, hospital facility,
22    or other person which is licensed or otherwise authorized  to
23    furnish  health  care  services  and  also includes any other
24    entity that arranges for the delivery or furnishing of health
25    care service.
26        (13)  "Producer" means a person  directly  or  indirectly
27    associated   with   a   health   care  plan  who  engages  in
28    solicitation or enrollment.
29        (14)  "Per capita prepaid" means a basis of prepayment by
30    which a fixed amount of money is prepaid  per  individual  or
31    any   other   enrollment   unit  to  the  Health  Maintenance
32    Organization or for health care services which  are  provided
33    during  a definite time period regardless of the frequency or
34    extent of the services rendered  by  the  Health  Maintenance
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 1    Organization,  except  for  copayments  and  deductibles  and
 2    except  as  provided in subsection (f) of Section 5-3 of this
 3    Act.
 4        (15)  "Subscriber" means a person who has entered into  a
 5    contractual   relationship   with   the   Health  Maintenance
 6    Organization for the provision of or arrangement of at  least
 7    basic  health  care  services  to  the  beneficiaries of such
 8    contract.
 9    (Source: P.A. 88-554, eff. 7-26-94; 89-90, eff. 6-30-95.)
10        (215 ILCS 125/4-17 new)
11        Sec.  4-17.  Basic  outpatient  preventive  and   primary
12    health  care  services  for  children. In order to attempt to
13    address the needs of children in Illinois (i) without  health
14    care  coverage, either through a parent's employment, through
15    medical assistance under the Illinois Public Aid Code, or any
16    other health plan or (ii) who lose medical assistance if  and
17    when  their parents move from welfare to work and do not find
18    employment  that  offers  health  care  coverage,  a   health
19    maintenance  organization may undertake to provide or arrange
20    for  and to pay for or reimburse the cost of basic outpatient
21    preventive and primary health care services.  The  Department
22    shall  promulgate  rules  to  establish  minimum coverage and
23    disclosure requirements.  These  requirements  at  a  minimum
24    shall    include    routine    physical    examinations   and
25    immunizations, sick visits, diagnostic x-rays and  laboratory
26    services,  and  emergency  outpatient services.  Coverage may
27    also include preventive dental services, vision screening and
28    one pair of eyeglasses, prescription drugs, and mental health
29    services.   The   coverage   may   include   any   reasonable
30    co-payments, deductibles, and  benefit  maximums  subject  to
31    limitations  established  by the Director by rule.   Coverage
32    shall be limited to children who  are  18  years  of  age  or
33    under, who have resided in the State of Illinois for at least
HB1565 Enrolled            -5-                 LRB9003794JSgc
 1    30  days, and who do not qualify for medical assistance under
 2    the Illinois Public Aid Code.  Any  such  coverage  shall  be
 3    made  available  to  an  adult on behalf of such children and
 4    shall  not  be  funded  through  State  appropriations.    In
 5    counties  with  populations  in  excess  of  3,000,000,   the
 6    Director shall not approve any arrangement under this Section
 7    unless  and  until  an  arrangement  for  at least one health
 8    maintenance organization under  contract  with  the  Illinois
 9    Department  of  Public  Aid  for  furnishing  health services
10    pursuant to Section 5-11 of the Illinois Public Aid Code  and
11    for  which  the  requirements  of  42 CFR 434.26(a) have been
12    waived is approved.
13        Section 99.  Effective date.  This Act takes effect  upon
14    becoming law.

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