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91_SB0824sam001
LRB9106020JScsam01
1 AMENDMENT TO SENATE BILL 824
2 AMENDMENT NO. . Amend Senate Bill 824 by replacing
3 the title with the following:
4 "AN ACT to create the Choice of Physician Act."; 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 Choice of Physician Act.
9 Section 5. Definitions. In this Act:
10 "Employer" means any legal entity that has more than 25
11 employees and is subject to and is required to provide
12 unemployment insurance to its employees under the
13 Unemployment Insurance Act.
14 "Managed care plan" means a plan that establishes,
15 operates or maintains a network of health care providers
16 that have entered into agreements with the plan to provide
17 health care services to enrollees where the plan has the
18 ultimate and direct contractual obligation to the enrollee to
19 arrange for the provision of or pay for services through:
20 (1) organizational arrangements for ongoing quality
21 assurance, utilization review programs, or dispute
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1 resolution; or
2 (2) financial incentives for enrollees enrolled in
3 the plan to use the participating providers and
4 procedures covered by the plan.
5 A managed care plan may be established or operated by any
6 entity including a licensed insurance company, hospital or
7 medical service plan, health maintenance organization,
8 limited health services organization, preferred provider
9 organization, third party administrator, or an employer or
10 employee organization.
11 Section 10. Choice of physician requirements for
12 employer provided health benefits.
13 (a) An employer providing, offering, or making health
14 care benefits available to employees or individuals through a
15 managed care plan or health maintenance organization shall
16 offer to all covered persons the opportunity to elect at the
17 time of enrollment and once annually thereafter to obtain
18 coverage under which the choice of physician may not be
19 restricted in any manner. This coverage shall provide
20 coverage for health care benefits regardless of which
21 physician is selected to provide service.
22 (b) An employee or individual who elects to obtain the
23 coverage offered under subsection (a) may be charged an
24 amount in addition to any charge otherwise imposed in
25 connection with health care benefits offered or provided by
26 the employer.
27 (c) Payment of reasonable amounts of coinsurance,
28 co-payments, or deductibles may be required with respect to
29 coverage offered under subsection (a). The co-insurance
30 rates may not be greater than 20 percentage points more than
31 the co-insurance rates otherwise imposed in connection with
32 health care benefits offered or provided by the employer.
33 The maximum out-of-pocket amount shall not exceed $5,000 for
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1 an individual and $7,500 for family coverage.
2 Section 90. The Health Maintenance Organization Act is
3 amended by changing Section 1-2 and adding Section 2-11 as
4 follows:
5 (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
6 Sec. 1-2. Definitions. As used in this Act, unless the
7 context otherwise requires, the following terms shall have
8 the meanings ascribed to them:
9 (1) "Advertisement" means any printed or published
10 material, audiovisual material and descriptive literature of
11 the health care plan used in direct mail, newspapers,
12 magazines, radio scripts, television scripts, billboards and
13 similar displays; and any descriptive literature or sales
14 aids of all kinds disseminated by a representative of the
15 health care plan for presentation to the public including,
16 but not limited to, circulars, leaflets, booklets,
17 depictions, illustrations, form letters and prepared sales
18 presentations.
19 (2) "Director" means the Director of Insurance.
20 (3) "Basic health care services" means emergency care,
21 and inpatient hospital and physician care, outpatient medical
22 services, mental health services and care for alcohol and
23 drug abuse, including any reasonable deductibles and
24 co-payments, all of which are subject to such limitations as
25 are determined by the Director pursuant to rule.
26 (4) "Enrollee" means an individual who has been enrolled
27 in a health care plan.
28 (5) "Evidence of coverage" means any certificate,
29 agreement, or contract issued to an enrollee setting out the
30 coverage to which he is entitled in exchange for a per capita
31 prepaid sum.
32 (6) "Group contract" means a contract for health care
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1 services which by its terms limits eligibility to members of
2 a specified group.
3 (7) "Health care plan" means any arrangement whereby any
4 organization undertakes to provide or arrange for and pay for
5 or reimburse the cost of basic health care services from
6 providers selected by the Health Maintenance Organization and
7 such arrangement consists of arranging for or the provision
8 of such health care services, as distinguished from mere
9 indemnification against the cost of such services, except as
10 otherwise authorized by Section 2-3 of this Act, on a per
11 capita prepaid basis, through insurance or otherwise. A
12 "health care plan" also includes any arrangement whereby an
13 organization undertakes to provide or arrange for or pay for
14 or reimburse the cost of any health care service for persons
15 who are enrolled in the integrated health care program
16 established under Section 5-16.3 of the Illinois Public Aid
17 Code through providers selected by the organization and the
18 arrangement consists of making provision for the delivery of
19 health care services, as distinguished from mere
20 indemnification. A "health care plan" also includes any
21 arrangement pursuant to Section 4-17. Nothing in this
22 definition, however, affects the total medical services
23 available to persons eligible for medical assistance under
24 the Illinois Public Aid Code.
25 (8) "Health care services" means any services included
26 in the furnishing to any individual of medical or dental
27 care, or the hospitalization or incident to the furnishing of
28 such care or hospitalization as well as the furnishing to any
29 person of any and all other services for the purpose of
30 preventing, alleviating, curing or healing human illness or
31 injury.
32 (9) "Health Maintenance Organization" means any
33 organization formed under the laws of this or another state
34 to provide or arrange for one or more health care plans under
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1 a system which causes any part of the risk of health care
2 delivery to be borne by the organization or its providers.
3 (10) "Net worth" means admitted assets, as defined in
4 Section 1-3 of this Act, minus liabilities.
5 (11) "Organization" means any insurance company, a
6 nonprofit corporation authorized under the Dental Service
7 Plan Act or the Voluntary Health Services Plans Act, or a
8 corporation organized under the laws of this or another state
9 for the purpose of operating one or more health care plans
10 and doing no business other than that of a Health Maintenance
11 Organization or an insurance company. "Organization" shall
12 also mean the University of Illinois Hospital as defined in
13 the University of Illinois Hospital Act.
14 "Point-of-service product" means a group contract that
15 includes both in-plan covered services and out-of-plan
16 covered services as well as a point-of-service product under
17 which the risk for out-of-plan covered services is borne
18 through reinsurance. This term does not apply to indemnity
19 benefits offered through a health maintenance organization
20 that are underwritten in whole by a licensed insurance
21 carrier and offered in conjunction with the health
22 maintenance organization benefit package.
23 (12) "Provider" means any physician, hospital facility,
24 or other person which is licensed or otherwise authorized to
25 furnish health care services and also includes any other
26 entity that arranges for the delivery or furnishing of health
27 care service.
28 (13) "Producer" means a person directly or indirectly
29 associated with a health care plan who engages in
30 solicitation or enrollment.
31 (14) "Per capita prepaid" means a basis of prepayment by
32 which a fixed amount of money is prepaid per individual or
33 any other enrollment unit to the Health Maintenance
34 Organization or for health care services which are provided
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1 during a definite time period regardless of the frequency or
2 extent of the services rendered by the Health Maintenance
3 Organization, except for copayments and deductibles and
4 except as provided in subsection (f) of Section 5-3 of this
5 Act.
6 (15) "Subscriber" means a person who has entered into a
7 contractual relationship with the Health Maintenance
8 Organization for the provision of or arrangement of at least
9 basic health care services to the beneficiaries of such
10 contract.
11 (Source: P.A. 89-90, eff. 6-30-95; 90-177, eff. 7-23-97;
12 90-372, eff. 7-1-98; 90-376, eff. 8-14-97; 90-655, eff.
13 7-30-98.)
14 (215 ILCS 125/2-11 new)
15 Sec. 2-11. Point-of-service product.
16 (a) A health maintenance organization may offer a
17 point-of-service product to its subscribers and enrollees. A
18 health maintenance organization that offers a
19 point-of-service product must comply with the rules of the
20 Department applicable to point-of-service products.
21 (b) The Department shall promulgate rules regulating the
22 provision of point-of-service products by health maintenance
23 organizations.
24 Section 99. Effective date. This Act takes effect upon
25 becoming law.".