State of Illinois
91st General Assembly
Legislation

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91_SB1698

 
                                               LRB9113161JSpc

 1        AN ACT to create the Choice of Physician Act.

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

 4        Section 1.  Short title.  This Act may be  cited  as  the
 5    Choice of Physician Act.

 6        Section 5.  Definitions.  In this Act:
 7        "Employer"  means  any legal entity that has more than 25
 8    employees and is  subject  to  and  is  required  to  provide
 9    unemployment   insurance   to   its   employees   under   the
10    Unemployment Insurance Act.
11        "Managed  care  plan"  means  a  plan  that  establishes,
12    operates  or  maintains  a   network of health care providers
13    that have entered into agreements with the  plan  to  provide
14    health  care  services  to  enrollees  where the plan has the
15    ultimate and direct contractual obligation to the enrollee to
16    arrange for the provision of or pay for services through:
17             (1) organizational arrangements for ongoing  quality
18        assurance,  utilization    review  programs,  or  dispute
19        resolution; or
20             (2)  financial  incentives for enrollees enrolled in
21        the  plan  to  use  the   participating   providers   and
22        procedures covered by the plan.
23        A managed care plan may be established or operated by any
24    entity  including  a  licensed insurance company, hospital or
25    medical  service  plan,  health   maintenance   organization,
26    limited  health  services  organization,  preferred  provider
27    organization,  third  party  administrator, or an employer or
28    employee organization.

29        Section  10.  Choice  of   physician   requirements   for
30    employer provided health benefits.
 
                            -2-                LRB9113161JSpc
 1        (a)  An  employer  providing,  offering, or making health
 2    care benefits available to employees or individuals through a
 3    managed care plan or health  maintenance  organization  shall
 4    offer to all covered persons the opportunity to elect  at the
 5    time  of  enrollment  and  once annually thereafter to obtain
 6    coverage under which the  choice  of  physician  may  not  be
 7    restricted   in  any  manner.  This  coverage  shall  provide
 8    coverage  for  health  care  benefits  regardless  of   which
 9    physician is selected to provide service.
10        (b)  An  employee  or individual who elects to obtain the
11    coverage offered under  subsection  (a)  may  be  charged  an
12    amount  in  addition  to  any  charge  otherwise  imposed  in
13    connection  with  health care benefits offered or provided by
14    the employer.
15        (c)  Payment  of  reasonable  amounts   of   coinsurance,
16    co-payments,  or  deductibles may be required with respect to
17    coverage offered  under  subsection  (a).   The  co-insurance
18    rates  may not be greater than 20 percentage points more than
19    the co-insurance rates otherwise imposed in  connection  with
20    health  care  benefits  offered  or provided by the employer.
21    The maximum out-of-pocket amount shall not exceed $5,000  for
22    an individual and $7,500 for family coverage.

23        Section  90.  The  Health Maintenance Organization Act is
24    amended by changing Section 1-2 and adding  Section  2-11  as
25    follows:

26        (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
27        Sec.  1-2.  Definitions.  As used in this Act, unless the
28    context otherwise requires, the following  terms  shall  have
29    the meanings ascribed to them:
30        (1)  "Advertisement"   means  any  printed  or  published
31    material, audiovisual material and descriptive literature  of
32    the  health  care  plan  used  in  direct  mail,  newspapers,
 
                            -3-                LRB9113161JSpc
 1    magazines,  radio scripts, television scripts, billboards and
 2    similar displays; and any  descriptive  literature  or  sales
 3    aids  of  all  kinds  disseminated by a representative of the
 4    health care plan for presentation to  the  public  including,
 5    but   not   limited   to,   circulars,   leaflets,  booklets,
 6    depictions, illustrations, form letters  and  prepared  sales
 7    presentations.
 8        (2)  "Director" means the Director of Insurance.
 9        (3)  "Basic  health  care services" means emergency care,
10    and inpatient hospital and physician care, outpatient medical
11    services, mental health services and  care  for  alcohol  and
12    drug   abuse,   including   any  reasonable  deductibles  and
13    co-payments, all of which are subject to such limitations  as
14    are determined by the Director pursuant to rule.
15        (4)  "Enrollee" means an individual who has been enrolled
16    in a health care plan.
17        (5)  "Evidence   of   coverage"  means  any  certificate,
18    agreement, or contract issued to an enrollee setting out  the
19    coverage to which he is entitled in exchange for a per capita
20    prepaid sum.
21        (6)  "Group  contract"  means  a contract for health care
22    services which by its terms limits eligibility to members  of
23    a specified group.
24        (7)  "Health care plan" means any arrangement whereby any
25    organization undertakes to provide or arrange for and pay for
26    or  reimburse  the  cost  of  basic health care services from
27    providers selected by the Health Maintenance Organization and
28    such arrangement consists of arranging for or  the  provision
29    of  such  health  care  services,  as distinguished from mere
30    indemnification against the cost of such services, except  as
31    otherwise  authorized  by  Section  2-3 of this Act, on a per
32    capita prepaid basis,  through  insurance  or  otherwise.   A
33    "health  care  plan" also includes any arrangement whereby an
34    organization undertakes to provide or arrange for or pay  for
 
                            -4-                LRB9113161JSpc
 1    or  reimburse the cost of any health care service for persons
 2    who are  enrolled  in  the  integrated  health  care  program
 3    established  under  Section 5-16.3 of the Illinois Public Aid
 4    Code through providers selected by the organization  and  the
 5    arrangement  consists of making provision for the delivery of
 6    health   care   services,   as   distinguished   from    mere
 7    indemnification.   A  "health  care  plan"  also includes any
 8    arrangement  pursuant  to  Section  4-17.   Nothing  in  this
 9    definition,  however,  affects  the  total  medical  services
10    available to persons eligible for  medical  assistance  under
11    the Illinois Public Aid Code.
12        (8)  "Health  care  services" means any services included
13    in the furnishing to any  individual  of  medical  or  dental
14    care, or the hospitalization or incident to the furnishing of
15    such care or hospitalization as well as the furnishing to any
16    person  of  any  and  all  other  services for the purpose of
17    preventing, alleviating, curing or healing human  illness  or
18    injury.
19        (9)  "Health    Maintenance   Organization"   means   any
20    organization formed under the laws of this or  another  state
21    to provide or arrange for one or more health care plans under
22    a  system  which  causes  any part of the risk of health care
23    delivery to be borne by the organization or its providers.
24        (10)  "Net worth" means admitted assets,  as  defined  in
25    Section 1-3 of this Act, minus liabilities.
26        (11)  "Organization"   means  any  insurance  company,  a
27    nonprofit corporation authorized  under  the  Dental  Service
28    Plan  Act  or  the  Voluntary Health Services Plans Act, or a
29    corporation organized under the laws of this or another state
30    for the purpose of operating one or more  health  care  plans
31    and doing no business other than that of a Health Maintenance
32    Organization  or  an insurance company.  "Organization" shall
33    also mean the University of Illinois Hospital as  defined  in
34    the University of Illinois Hospital Act.
 
                            -5-                LRB9113161JSpc
 1        "Point-of-service  product"  means  a group contract that
 2    includes  both  in-plan  covered  services  and   out-of-plan
 3    covered  services as well as a point-of-service product under
 4    which the risk for  out-of-plan  covered  services  is  borne
 5    through  reinsurance.   This term does not apply to indemnity
 6    benefits offered through a  health  maintenance  organization
 7    that  are  underwritten  in  whole  by  a  licensed insurance
 8    carrier  and  offered  in   conjunction   with   the   health
 9    maintenance organization benefit package.
10        (12)  "Provider"  means any physician, hospital facility,
11    or other person which is licensed or otherwise authorized  to
12    furnish  health  care  services  and  also includes any other
13    entity that arranges for the delivery or furnishing of health
14    care service.
15        (13)  "Producer" means a person  directly  or  indirectly
16    associated   with   a   health   care  plan  who  engages  in
17    solicitation or enrollment.
18        (14)  "Per capita prepaid" means a basis of prepayment by
19    which a fixed amount of money is prepaid  per  individual  or
20    any   other   enrollment   unit  to  the  Health  Maintenance
21    Organization or for health care services which  are  provided
22    during  a definite time period regardless of the frequency or
23    extent of the services rendered  by  the  Health  Maintenance
24    Organization,  except  for  copayments  and  deductibles  and
25    except  as  provided in subsection (f) of Section 5-3 of this
26    Act.
27        (15)  "Subscriber" means a person who has entered into  a
28    contractual   relationship   with   the   Health  Maintenance
29    Organization for the provision of or arrangement of at  least
30    basic  health  care  services  to  the  beneficiaries of such
31    contract.
32    (Source: P.A. 89-90,  eff.  6-30-95;  90-177,  eff.  7-23-97;
33    90-372,  eff.  7-1-98;  90-376,  eff.  8-14-97;  90-655, eff.
34    7-30-98.)
 
                            -6-                LRB9113161JSpc
 1        (215 ILCS 125/2-11 new)
 2        Sec. 2-11.  Point-of-service product.
 3        (a)  A  health  maintenance  organization  may  offer   a
 4    point-of-service product to its subscribers and enrollees.  A
 5    health     maintenance    organization    that    offers    a
 6    point-of-service product must comply with the  rules  of  the
 7    Department applicable to point-of-service products.
 8        (b)  The Department shall promulgate rules regulating the
 9    provision  of point-of-service products by health maintenance
10    organizations.

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

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