Illinois 2023-2024 Regular Session

Illinois House Bill HB1186 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	Public Act 103-0104
2	1		HB1186 EnrolledLRB103 05082 BMS 50096 b HB1186 Enrolled LRB103 05082 BMS 50096 b
3	2		HB1186 Enrolled LRB103 05082 BMS 50096 b
4		-	AN ACT concerning regulation.
5		-	Be it enacted by the People of the State of Illinois,
6		-	represented in the General Assembly:
7		-	Section 5. The Health Maintenance Organization Act is
8		-	amended by changing Sections 1-2 and 2-3 as follows:
9		-	(215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
10		-	Sec. 1-2. Definitions. As used in this Act, unless the
11		-	context otherwise requires, the following terms shall have the
12		-	meanings ascribed to them:
13		-	(1) "Advertisement" means any printed or published
14		-	material, audiovisual material and descriptive literature of
15		-	the health care plan used in direct mail, newspapers,
16		-	magazines, radio scripts, television scripts, billboards and
17		-	similar displays; and any descriptive literature or sales aids
18		-	of all kinds disseminated by a representative of the health
19		-	care plan for presentation to the public including, but not
20		-	limited to, circulars, leaflets, booklets, depictions,
21		-	illustrations, form letters and prepared sales presentations.
22		-	(2) "Director" means the Director of Insurance.
23		-	(3) "Basic health care services" means emergency care, and
24		-	inpatient hospital and physician care, outpatient medical
25		-	services, mental health services and care for alcohol and drug
26		-	abuse, including any reasonable deductibles and co-payments,
	3	+	1 AN ACT concerning regulation.
	4	+	2 Be it enacted by the People of the State of Illinois,
	5	+	3 represented in the General Assembly:
	6	+	4 Section 5. The Health Maintenance Organization Act is
	7	+	5 amended by changing Sections 1-2 and 2-3 as follows:
	8	+	6 (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
	9	+	7 Sec. 1-2. Definitions. As used in this Act, unless the
	10	+	8 context otherwise requires, the following terms shall have the
	11	+	9 meanings ascribed to them:
	12	+	10 (1) "Advertisement" means any printed or published
	13	+	11 material, audiovisual material and descriptive literature of
	14	+	12 the health care plan used in direct mail, newspapers,
	15	+	13 magazines, radio scripts, television scripts, billboards and
	16	+	14 similar displays; and any descriptive literature or sales aids
	17	+	15 of all kinds disseminated by a representative of the health
	18	+	16 care plan for presentation to the public including, but not
	19	+	17 limited to, circulars, leaflets, booklets, depictions,
	20	+	18 illustrations, form letters and prepared sales presentations.
	21	+	19 (2) "Director" means the Director of Insurance.
	22	+	20 (3) "Basic health care services" means emergency care, and
	23	+	21 inpatient hospital and physician care, outpatient medical
	24	+	22 services, mental health services and care for alcohol and drug
	25	+	23 abuse, including any reasonable deductibles and co-payments,
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33		-	all of which are subject to the limitations described in
34		-	Section 4-20 of this Act and as determined by the Director
35		-	pursuant to rule.
36		-	(4) "Enrollee" means an individual who has been enrolled
37		-	in a health care plan.
38		-	(5) "Evidence of coverage" means any certificate,
39		-	agreement, or contract issued to an enrollee setting out the
40		-	coverage to which he is entitled in exchange for a per capita
41		-	prepaid sum.
42		-	(6) "Group contract" means a contract for health care
43		-	services which by its terms limits eligibility to members of a
44		-	specified group.
45		-	(7) "Health care plan" means any arrangement in which an
46		-	whereby any organization provides, arranges undertakes to
47		-	provide or arrange for, pays and pay for, or reimburses
48		-	reimburse the cost of basic health care services, excluding
49		-	any reasonable deductibles and copayments, from providers
50		-	selected by the Health Maintenance Organization; and the such
51		-	arrangement consists of providing for the arranging for or the
52		-	provision of basic such health care services that is , as
53		-	distinguished from mere indemnification against the cost of
54		-	such services, on a per capita prepaid basis, through
55		-	insurance or otherwise, except as otherwise authorized by
56		-	Section 2-3 of this Act, on a per capita prepaid basis, through
57		-	insurance or otherwise. A "health care plan" also includes any
58		-	arrangement in which whereby an organization provides,
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	34	+	1 all of which are subject to the limitations described in
	35	+	2 Section 4-20 of this Act and as determined by the Director
	36	+	3 pursuant to rule.
	37	+	4 (4) "Enrollee" means an individual who has been enrolled
	38	+	5 in a health care plan.
	39	+	6 (5) "Evidence of coverage" means any certificate,
	40	+	7 agreement, or contract issued to an enrollee setting out the
	41	+	8 coverage to which he is entitled in exchange for a per capita
	42	+	9 prepaid sum.
	43	+	10 (6) "Group contract" means a contract for health care
	44	+	11 services which by its terms limits eligibility to members of a
	45	+	12 specified group.
	46	+	13 (7) "Health care plan" means any arrangement in which an
	47	+	14 whereby any organization provides, arranges undertakes to
	48	+	15 provide or arrange for, pays and pay for, or reimburses
	49	+	16 reimburse the cost of basic health care services, excluding
	50	+	17 any reasonable deductibles and copayments, from providers
	51	+	18 selected by the Health Maintenance Organization; and the such
	52	+	19 arrangement consists of providing for the arranging for or the
	53	+	20 provision of basic such health care services that is , as
	54	+	21 distinguished from mere indemnification against the cost of
	55	+	22 such services, on a per capita prepaid basis, through
	56	+	23 insurance or otherwise, except as otherwise authorized by
	57	+	24 Section 2-3 of this Act, on a per capita prepaid basis, through
	58	+	25 insurance or otherwise. A "health care plan" also includes any
	59	+	26 arrangement in which whereby an organization provides,
59	60
60	61
61		-	arranges undertakes to provide or arrange for, pays or pay
62		-	for, or reimburses reimburse the cost of any health care
63		-	service for persons who are enrolled under Article V of the
64		-	Illinois Public Aid Code or under the Children's Health
65		-	Insurance Program Act through providers selected by the
66		-	organization; and the arrangement consists of making a
67		-	provision for the delivery of health care services that is , as
68		-	distinguished from mere indemnification. A "health care plan"
69		-	also includes any arrangement pursuant to Section 4-17.
70		-	Nothing in this definition, however, affects the total medical
71		-	services available to persons eligible for medical assistance
72		-	under the Illinois Public Aid Code. Nothing in this definition
73		-	shall be construed as requiring a health care plan or health
74		-	maintenance organization to utilize a referral system that
75		-	enrollees must use to access basic health care services and
76		-	other health care services from providers that are under
77		-	contract with or employed by the health maintenance
78		-	organization. The Director may prescribe by rule the language
79		-	that must be included in the plan name, marketing,
80		-	advertising, or other consumer disclosure requirements to
81		-	differentiate a health care plan that does not use a referral
82		-	system for such providers from a health care plan that does use
83		-	a referral system for such providers.
84		-	(8) "Health care services" means any services included in
85		-	the furnishing to any individual of medical or dental care, or
86		-	the hospitalization or incident to the furnishing of such care
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88	63
89		-	or hospitalization as well as the furnishing to any person of
90		-	any and all other services for the purpose of preventing,
91		-	alleviating, curing or healing human illness or injury.
92		-	(9) "Health Maintenance Organization" means any
93		-	organization formed under the laws of this or another state to
94		-	provide or arrange for one or more health care plans under a
95		-	system which causes any part of the risk of health care
96		-	delivery to be borne by the organization or its providers.
97		-	(10) "Net worth" means admitted assets, as defined in
98		-	Section 1-3 of this Act, minus liabilities.
99		-	(11) "Organization" means any insurance company, a
100		-	nonprofit corporation authorized under the Dental Service Plan
101		-	Act or the Voluntary Health Services Plans Act, or a
102		-	corporation organized under the laws of this or another state
103		-	for the purpose of operating one or more health care plans and
104		-	doing no business other than that of a Health Maintenance
105		-	Organization or an insurance company. "Organization" shall
106		-	also mean the University of Illinois Hospital as defined in
107		-	the University of Illinois Hospital Act or a unit of local
108		-	government health system operating within a county with a
109		-	population of 3,000,000 or more.
110		-	(12) "Provider" means any physician, hospital facility,
111		-	facility licensed under the Nursing Home Care Act, or facility
112		-	or long-term care facility as those terms are defined in the
113		-	Nursing Home Care Act or other person which is licensed or
114		-	otherwise authorized to furnish health care services and also
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117		-	includes any other entity that arranges for the delivery or
118		-	furnishing of health care service.
119		-	(13) "Producer" means a person directly or indirectly
120		-	associated with a health care plan who engages in solicitation
121		-	or enrollment.
122		-	(14) "Per capita prepaid" means a basis of prepayment by
123		-	which a fixed amount of money is prepaid per individual or any
124		-	other enrollment unit to the Health Maintenance Organization
125		-	or for health care services which are provided during a
126		-	definite time period regardless of the frequency or extent of
127		-	the services rendered by the Health Maintenance Organization,
128		-	except for copayments and deductibles and except as provided
129		-	in subsection (f) of Section 5-3 of this Act.
130		-	(15) "Referral system" means any arrangement in a health
131		-	care plan in which a primary care provider coordinates or
132		-	manages the care of a health maintenance organization's
133		-	enrollee by referring the enrollee to other providers or
134		-	specialists.
135		-	(16) (15) "Subscriber" means a person who has entered into
136		-	a contractual relationship with the Health Maintenance
137		-	Organization for the provision of or arrangement of at least
138		-	basic health care services to the beneficiaries of such
139		-	contract.
140		-	(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14;
141		-	99-78, eff. 7-20-15.)
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	70	+	1 arranges undertakes to provide or arrange for, pays or pay
	71	+	2 for, or reimburses reimburse the cost of any health care
	72	+	3 service for persons who are enrolled under Article V of the
	73	+	4 Illinois Public Aid Code or under the Children's Health
	74	+	5 Insurance Program Act through providers selected by the
	75	+	6 organization; and the arrangement consists of making a
	76	+	7 provision for the delivery of health care services that is , as
	77	+	8 distinguished from mere indemnification. A "health care plan"
	78	+	9 also includes any arrangement pursuant to Section 4-17.
	79	+	10 Nothing in this definition, however, affects the total medical
	80	+	11 services available to persons eligible for medical assistance
	81	+	12 under the Illinois Public Aid Code. Nothing in this definition
	82	+	13 shall be construed as requiring a health care plan or health
	83	+	14 maintenance organization to utilize a referral system that
	84	+	15 enrollees must use to access basic health care services and
	85	+	16 other health care services from providers that are under
	86	+	17 contract with or employed by the health maintenance
	87	+	18 organization. The Director may prescribe by rule the language
	88	+	19 that must be included in the plan name, marketing,
	89	+	20 advertising, or other consumer disclosure requirements to
	90	+	21 differentiate a health care plan that does not use a referral
	91	+	22 system for such providers from a health care plan that does use
	92	+	23 a referral system for such providers.
	93	+	24 (8) "Health care services" means any services included in
	94	+	25 the furnishing to any individual of medical or dental care, or
	95	+	26 the hospitalization or incident to the furnishing of such care
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144		-	(215 ILCS 125/2-3) (from Ch. 111 1/2, par. 1405)
145		-	Sec. 2-3. Powers of health maintenance organizations. The
146		-	powers of a health maintenance organization include, but are
147		-	not limited to the following:
148		-	(a) The purchase, lease, construction, renovation,
149		-	operation, or maintenance of hospitals, medical facilities or
150		-	both, and their ancillary equipment, and such property as may
151		-	reasonably be required for its principal office or for such
152		-	other purposes as may be necessary in the transaction of the
153		-	business of the organization.
154		-	(b) The making of loans to a medical group under contract
155		-	with it and in furtherance of its program or the making of
156		-	loans to a corporation or corporations under its control for
157		-	the purpose of acquiring or constructing medical facilities at
158		-	hospitals or in furtherance of a program providing health care
159		-	services for enrollees.
160		-	(c) The furnishing of health care services through
161		-	providers which are under contract with or employed by the
162		-	health maintenance organization.
163		-	(d) The contracting with any person for the performance on
164		-	its behalf of certain functions such as marketing, enrollment
165		-	and administration.
166		-	(d-5) The voluntary use of a referral system for enrollees
167		-	to access providers under contract with or employed by the
168		-	health maintenance organization. Nothing in this subsection
169		-	(d-5) shall be construed as requiring the use of a referral
170	98
171	99
172		-	system with the health maintenance organization's contracted
173		-	or employed providers to obtain a certificate of authority as
174		-	set forth in Section 2-1.
175		-	(e) The contracting with an insurance company licensed in
176		-	this State, or with a hospital, medical, dental, vision or
177		-	pharmaceutical service corporation authorized to do business
178		-	in this State, for the provision of insurance, indemnity, or
179		-	reimbursement against the cost of health care service provided
180		-	by the health maintenance organization.
181		-	(f) The offering, in addition to basic health care
182		-	services, of (1) health care services, (2) indemnity benefits
183		-	covering out of area or emergency services, (3) indemnity
184		-	benefits provided through insurers or hospital, medical,
185		-	dental, vision, or pharmaceutical service corporations, and
186		-	(4) health maintenance organization point-of-service benefits
187		-	as authorized under Article 4.5.
188		-	(g) Rendering services related to the functions involved
189		-	in the operating of its health maintenance organization
190		-	business including but not limited to providing health
191		-	services, data processing, accounting, or claims.
192		-	(g-5) Indemnification for services provided to a child as
193		-	required under subdivision (e)(3) of Section 4-2.
194		-	(h) Any other business activity reasonably complementary
195		-	or supplementary to its health maintenance organization
196		-	business to the extent approved by the Director.
197		-	(Source: P.A. 92-135, eff. 1-1-02.)
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199	103
200		-	Section 99. Effective date. This Act takes effect January
201		-	1, 2024.
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	106	+	1 or hospitalization as well as the furnishing to any person of
	107	+	2 any and all other services for the purpose of preventing,
	108	+	3 alleviating, curing or healing human illness or injury.
	109	+	4 (9) "Health Maintenance Organization" means any
	110	+	5 organization formed under the laws of this or another state to
	111	+	6 provide or arrange for one or more health care plans under a
	112	+	7 system which causes any part of the risk of health care
	113	+	8 delivery to be borne by the organization or its providers.
	114	+	9 (10) "Net worth" means admitted assets, as defined in
	115	+	10 Section 1-3 of this Act, minus liabilities.
	116	+	11 (11) "Organization" means any insurance company, a
	117	+	12 nonprofit corporation authorized under the Dental Service Plan
	118	+	13 Act or the Voluntary Health Services Plans Act, or a
	119	+	14 corporation organized under the laws of this or another state
	120	+	15 for the purpose of operating one or more health care plans and
	121	+	16 doing no business other than that of a Health Maintenance
	122	+	17 Organization or an insurance company. "Organization" shall
	123	+	18 also mean the University of Illinois Hospital as defined in
	124	+	19 the University of Illinois Hospital Act or a unit of local
	125	+	20 government health system operating within a county with a
	126	+	21 population of 3,000,000 or more.
	127	+	22 (12) "Provider" means any physician, hospital facility,
	128	+	23 facility licensed under the Nursing Home Care Act, or facility
	129	+	24 or long-term care facility as those terms are defined in the
	130	+	25 Nursing Home Care Act or other person which is licensed or
	131	+	26 otherwise authorized to furnish health care services and also
	132	+
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	134	+
	135	+
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	142	+	1 includes any other entity that arranges for the delivery or
	143	+	2 furnishing of health care service.
	144	+	3 (13) "Producer" means a person directly or indirectly
	145	+	4 associated with a health care plan who engages in solicitation
	146	+	5 or enrollment.
	147	+	6 (14) "Per capita prepaid" means a basis of prepayment by
	148	+	7 which a fixed amount of money is prepaid per individual or any
	149	+	8 other enrollment unit to the Health Maintenance Organization
	150	+	9 or for health care services which are provided during a
	151	+	10 definite time period regardless of the frequency or extent of
	152	+	11 the services rendered by the Health Maintenance Organization,
	153	+	12 except for copayments and deductibles and except as provided
	154	+	13 in subsection (f) of Section 5-3 of this Act.
	155	+	14 (15) "Referral system" means any arrangement in a health
	156	+	15 care plan in which a primary care provider coordinates or
	157	+	16 manages the care of a health maintenance organization's
	158	+	17 enrollee by referring the enrollee to other providers or
	159	+	18 specialists.
	160	+	19 (16) (15) "Subscriber" means a person who has entered into
	161	+	20 a contractual relationship with the Health Maintenance
	162	+	21 Organization for the provision of or arrangement of at least
	163	+	22 basic health care services to the beneficiaries of such
	164	+	23 contract.
	165	+	24 (Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14;
	166	+	25 99-78, eff. 7-20-15.)
	167	+
	168	+
	169	+
	170	+
	171	+
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	177	+	1 (215 ILCS 125/2-3) (from Ch. 111 1/2, par. 1405)
	178	+	2 Sec. 2-3. Powers of health maintenance organizations. The
	179	+	3 powers of a health maintenance organization include, but are
	180	+	4 not limited to the following:
	181	+	5 (a) The purchase, lease, construction, renovation,
	182	+	6 operation, or maintenance of hospitals, medical facilities or
	183	+	7 both, and their ancillary equipment, and such property as may
	184	+	8 reasonably be required for its principal office or for such
	185	+	9 other purposes as may be necessary in the transaction of the
	186	+	10 business of the organization.
	187	+	11 (b) The making of loans to a medical group under contract
	188	+	12 with it and in furtherance of its program or the making of
	189	+	13 loans to a corporation or corporations under its control for
	190	+	14 the purpose of acquiring or constructing medical facilities at
	191	+	15 hospitals or in furtherance of a program providing health care
	192	+	16 services for enrollees.
	193	+	17 (c) The furnishing of health care services through
	194	+	18 providers which are under contract with or employed by the
	195	+	19 health maintenance organization.
	196	+	20 (d) The contracting with any person for the performance on
	197	+	21 its behalf of certain functions such as marketing, enrollment
	198	+	22 and administration.
	199	+	23 (d-5) The voluntary use of a referral system for enrollees
	200	+	24 to access providers under contract with or employed by the
	201	+	25 health maintenance organization. Nothing in this subsection
	202	+	26 (d-5) shall be construed as requiring the use of a referral
	203	+
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	207	+
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	213	+	1 system with the health maintenance organization's contracted
	214	+	2 or employed providers to obtain a certificate of authority as
	215	+	3 set forth in Section 2-1.
	216	+	4 (e) The contracting with an insurance company licensed in
	217	+	5 this State, or with a hospital, medical, dental, vision or
	218	+	6 pharmaceutical service corporation authorized to do business
	219	+	7 in this State, for the provision of insurance, indemnity, or
	220	+	8 reimbursement against the cost of health care service provided
	221	+	9 by the health maintenance organization.
	222	+	10 (f) The offering, in addition to basic health care
	223	+	11 services, of (1) health care services, (2) indemnity benefits
	224	+	12 covering out of area or emergency services, (3) indemnity
	225	+	13 benefits provided through insurers or hospital, medical,
	226	+	14 dental, vision, or pharmaceutical service corporations, and
	227	+	15 (4) health maintenance organization point-of-service benefits
	228	+	16 as authorized under Article 4.5.
	229	+	17 (g) Rendering services related to the functions involved
	230	+	18 in the operating of its health maintenance organization
	231	+	19 business including but not limited to providing health
	232	+	20 services, data processing, accounting, or claims.
	233	+	21 (g-5) Indemnification for services provided to a child as
	234	+	22 required under subdivision (e)(3) of Section 4-2.
	235	+	23 (h) Any other business activity reasonably complementary
	236	+	24 or supplementary to its health maintenance organization
	237	+	25 business to the extent approved by the Director.
	238	+	26 (Source: P.A. 92-135, eff. 1-1-02.)
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	249	+	1 Section 99. Effective date. This Act takes effect January
	250	+	2 1, 2024.
	251	+
	252	+
	253	+
	254	+
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