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91_HB0161eng HB0161 Engrossed LRB9100274JSgc 1 AN ACT concerning health care services. 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 Health Services Act. 6 Section 5. Definitions: 7 "Emergency medical condition" means a medical condition 8 manifesting itself by acute symptoms of sufficient severity 9 (including severe pain) such that a prudent layperson, who 10 possesses an average knowledge of health and medicine, could 11 reasonably expect the absence of immediate medical attention 12 to result in: 13 (1) placing the health of the individual (or, with 14 respect to a pregnant woman, the health of the woman or 15 her unborn child) in serious jeopardy; 16 (2) serious impairment to bodily functions; or 17 (3) serious dysfunction of any bodily organ or 18 part. 19 "Emergency services" means, with respect to an enrollee 20 of a health plan, transportation services and covered 21 inpatient and outpatient hospital services furnished by a 22 provider qualified to furnish those services that are needed 23 to evaluate or stabilize an emergency medical condition. 24 "Emergency services" does not refer to post-stabilization 25 medical services. 26 "Enrollee" means any person and his or her dependents 27 enrolled in or covered by a health care plan. 28 "Health care plan" means a plan that establishes, 29 operates, or maintains a network of health care providers 30 that have entered into agreements with the plan to provide 31 health care services to enrollees to whom the plan has the HB0161 Engrossed -2- LRB9100274JSgc 1 obligation to arrange for the provision of or payment for 2 services through organizational arrangements for ongoing 3 quality assurance, utilization review programs, or dispute 4 resolution. 5 For purposes of this definition, "health care plan" shall 6 not include the following: 7 (1) indemnity health insurance policies including 8 those using a contracted provider network; 9 (2) health care plans that offer only dental or 10 only vision coverage; 11 (3) preferred provider administrators, as defined 12 in Section 370g(g) of the Illinois Insurance Code; 13 (4) employee or employer self-insured health 14 benefit plans under the federal Employee Retirement 15 Income Security Act of 1974; and 16 (5) health care provided pursuant to the Workers' 17 Compensation Act or the Workers' Occupational Diseases 18 Act. 19 "Health care provider" means any physician, hospital 20 facility, or other person that is licensed or otherwise 21 authorized to deliver health care services. 22 "Medical director" means a physician licensed in any 23 state to practice medicine in all its branches appointed by a 24 health care plan. 25 "Post-stabilization medical services" means health care 26 services provided to an enrollee that are furnished in a 27 licensed hospital by a provider that is qualified to furnish 28 such services, and determined to be medically necessary and 29 directly related to the emergency medical condition following 30 stabilization. 31 "Stabilization" means, with respect to an emergency 32 medical condition, to provide such medical treatment of the 33 condition as may be necessary to assure, within reasonable 34 medical probability, that no material deterioration of the HB0161 Engrossed -3- LRB9100274JSgc 1 condition is likely to result. 2 "Utilization review" means the evaluation of the medical 3 necessity, appropriateness, and efficiency of the use of 4 health care services, procedures, and facilities. 5 "Utilization review program" means a program established 6 by a person to perform utilization review. 7 Section 10. Emergency services prior to stabilization. 8 (a) A health care plan that provides or that is required 9 by law to provide coverage for emergency services shall 10 provide coverage such that payment under this coverage is not 11 dependent upon whether the services are performed by a plan 12 or non-plan health care provider and without regard to prior 13 authorization. This coverage shall be at the same benefit 14 level as if the services or treatment had been rendered by 15 the health care plan provider. 16 (b) Prior authorization or approval by the plan shall 17 not be required for emergency services. 18 (c) Payment shall not be retrospectively denied, with 19 the following exceptions: 20 (1) upon reasonable determination that the 21 emergency services claimed were never performed; 22 (2) upon determination that the emergency 23 evaluation and treatment were rendered to an enrollee who 24 sought emergency services and whose circumstance did not 25 meet the definition of emergency medical condition; 26 (3) upon determination that the patient receiving 27 such services was not an enrollee of the health care 28 plan; or 29 (4) upon material misrepresentation by the enrollee 30 or health care provider; "material" means a fact or 31 situation that is not merely technical in nature and 32 results or could result in a substantial change in the 33 situation. HB0161 Engrossed -4- LRB9100274JSgc 1 (d) When an enrollee presents to a hospital seeking 2 emergency services, the determination as to whether the need 3 for those services exists shall be made for purposes of 4 treatment by a physician or, to the extent permitted by 5 applicable law, by other appropriately licensed personnel 6 under the supervision of a physician. The physician or other 7 appropriate personnel shall indicate in the patient's chart 8 the results of the emergency medical screening examination. 9 (e) The appropriate use of the 911 emergency telephone 10 system or its local equivalent shall not be discouraged or 11 penalized by the health care plan when an emergency medical 12 condition exists. This provision shall not imply that the use 13 of 911 or its local equivalent is a factor in determining the 14 existence of an emergency medical condition. 15 (f) The medical director's or his or her designee's 16 determination of whether the enrollee meets the standard of 17 an emergency medical condition shall be based solely upon the 18 presenting symptoms documented in the medical record at the 19 time care was sought. 20 (g) Nothing in this Section shall prohibit the 21 imposition of deductibles, co-payments, and co-insurance. 22 Section 15. Utilization review program registration. 23 (a) No person may conduct a utilization review program 24 in this State unless once every 2 years the person registers 25 the utilization review program with the Department of 26 Insurance and certifies compliance with all of the Health 27 Utilization Management Standards of the American 28 Accreditation Healthcare Commission (URAC) or submits 29 evidence of accreditation by the American Accreditation 30 Healthcare Commission (URAC) for its Health Utilization 31 Management Standards. 32 (b) In addition, the Director of the Department of 33 Insurance, in consultation with the Director of the HB0161 Engrossed -5- LRB9100274JSgc 1 Department of Public Health, may certify alternative 2 utilization review standards of national accreditation 3 organizations or entities in order for plans to comply with 4 this Section. Any alternative utilization review standards 5 shall meet or exceed those standards required under 6 subsection (a). 7 (c) The provisions of this Section do not apply to: 8 (1) persons providing utilization review program 9 services only to the federal government; 10 (2) self-insured health plans under the federal 11 Employee Retirement Income Security Act of 1974, however, 12 this Section does apply to persons conducting a 13 utilization review program on behalf of these health 14 plans; 15 (3) hospitals and medical groups performing 16 utilization review activities for internal purposes 17 unless the utilization on review program is conducted for 18 another person. 19 Nothing in this Act prohibits a health care plan or other 20 entity from contractually requiring an entity designated in 21 item (3) of this subsection to adhere to the utilization 22 review program requirements of this Act. 23 (d) This registration shall include submission of all of 24 the following information regarding utilization review 25 program activities: 26 (1) The name, address, and telephone of the 27 utilization review programs. 28 (2) The organization and governing structure of the 29 utilization review programs. 30 (3) The number of lives for which utilization 31 review is conducted by each utilization review program. 32 (4) Hours of operation of each utilization review 33 program. 34 (5) Description of the grievance process for each HB0161 Engrossed -6- LRB9100274JSgc 1 utilization review program. 2 (6) Number of covered lives for which utilization 3 review was conducted for the previous calendar year for 4 each utilization review program. 5 (7) Written policies and procedures for protecting 6 confidential information according to applicable State 7 and federal laws for each utilization review program. 8 (e) If the Department of Insurance finds that a 9 utilization review program is not in compliance with this 10 Section, the Department shall issue a corrective action plan 11 and allow a reasonable amount of time for compliance with the 12 plan. If the utilization review program does not come into 13 compliance, the Department may issue a cease and desist 14 order. Before issuing a cease and desist order under this 15 Section, the Department shall provide the utilization review 16 program with a written notice of the reasons for the order 17 and allow a reasonable amount of time to supply additional 18 information demonstrating compliance with requirements of 19 this Section and to request a hearing. The hearing notice 20 shall be sent by certified mail, return receipt requested, 21 and the hearing shall be conducted in accordance with the 22 Illinois Administrative Procedure Act. 23 (f) A utilization review program subject to a corrective 24 action may continue to conduct business until a final 25 decision has been issued by the Department.