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91_SB0472
LRB9102445JSpc
1 AN ACT concerning payment for emergency medical
2 conditions for persons enrolled in health care plans.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 1. Short title. This Act may be cited as the
6 Access to Emergency Services Act.
7 Section 5. Legislative findings and purposes.
8 (a) The legislature recognizes that all persons need
9 access to emergency medical care and that State and federal
10 laws require hospital emergency departments to provide that
11 care. Federal law specifically prohibits emergency
12 physicians and hospital emergency departments from delaying
13 any treatment needed to evaluate or stabilize an individual
14 in order to determine the health insurance status of the
15 individual.
16 (b) This Act is intended to promote access to emergency
17 medical care by establishing a uniform definition of
18 emergency medical condition that is based on the average
19 knowledge of a prudent layperson and standardize the health
20 care plans coverage process for those services.
21 Section 10. Definitions.
22 "Department" means the Department of Insurance.
23 "Delegated provider" means a partnership, association,
24 corporation, or other legal entity including, but not limited
25 to, individual practice associations (IPAs) and physician
26 hospital organizations (PHOs), that delivers or arranges for
27 the delivery of health care services through providers it has
28 contracted with or otherwise made arrangements with to
29 furnish health care services.
30 "Director" means the Director of Insurance.
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1 "Emergency medical condition" means a medical condition
2 manifesting itself by acute symptoms of sufficient severity
3 (including severe pain) such that a prudent layperson, who
4 possesses an average knowledge of health and medicine, could
5 reasonably expect the absence of immediate medical attention
6 to result in (i) placing the health of the individual (or,
7 with respect to a pregnant woman, the health of the woman or
8 her unborn child) in serious jeopardy, (ii) serious
9 impairment to bodily functions, or (iii) serious dysfunction
10 of any bodily organ or part.
11 "Emergency services" means, with respect to an individual
12 enrolled in a health care plan, covered inpatient and covered
13 outpatient services that are:
14 (1) furnished in a licensed hospital by a provider
15 that is qualified to furnish those services;
16 (2) needed to evaluate whether an emergency medical
17 condition exists; and
18 (3) needed for stabilization of an emergency
19 medical condition if one exists.
20 "Emergency services" does not refer to post-stabilization
21 medical services.
22 "Enrollee" means an individual enrolled in a health care
23 plan.
24 "Good faith" means honesty of purpose, freedom from
25 intention to defraud, and being faithful to one's duty or
26 obligation. In addition the definition afforded this term by
27 the courts of the State of Illinois shall apply.
28 "Health care plan" means any arrangement whereby an
29 organization undertakes to provide or arrange for and pay for
30 or reimburse the cost of health care services from providers
31 selected by the plan and the arrangement consists of
32 arranging for or the provision of health care services, as
33 distinguished from mere indemnification against the cost of
34 those services, on a per capita prepaid basis, through
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1 insurance or otherwise. The term "health care plan" includes,
2 but is not limited to, any entity licensed under the Health
3 Maintenance Organization Act. The requirements of this Act
4 are not applicable to self insured employers, employee
5 benefit trust funds, or other ERISA exempt organizations.
6 "Medical director" means a physician licensed to practice
7 medicine in all its branches in Illinois as appointed by a
8 health care plan who is responsible for final review when
9 questions of medical practice arise in the health care plan
10 in order to assure the quality of health care services
11 provided.
12 "Post-stabilization medical services" means covered
13 health care services provided to an enrollee that are
14 furnished in a licensed hospital by a provider that is
15 qualified to furnish those services and determined to be
16 medically necessary and directly related to an emergency
17 medical condition following stabilization.
18 "Provider" means a physician, hospital facility, or other
19 person that is licensed or otherwise authorized to furnish
20 emergency services and post-stabilization medical services.
21 "Stabilization" means, with respect to an emergency
22 medical condition, to provide such medical treatment of the
23 condition as may be necessary to assure, within reasonable
24 medical probability, that no immediate material deterioration
25 of the condition is likely to result.
26 Section 15. Applicability. This Act applies to health
27 care plans for which coverage terms are amended, delivered,
28 issued, or renewed in this State after the effective date of
29 this Act.
30 Section 20. Emergency services prior to stabilization.
31 (a) Except as provided for in subsection (c), a health
32 care plan shall cover emergency services without regard to
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1 prior authorization or the treating provider's contractual
2 relationship with the organization.
3 (b) Reimbursement shall be provided by the health care
4 plan at the same rate as if the service or treatment had been
5 rendered by similar provider contracting with a health care
6 plan.
7 (c) Payment for covered emergency services may be
8 denied:
9 (1) upon determination that the emergency services
10 claimed were not performed;
11 (2) upon determination that emergency evaluation
12 and treatment were rendered to an enrollee who sought
13 emergency services and whose circumstance did not meet
14 the definition of emergency medical condition;
15 (3) upon determination that the patient receiving
16 the services was not a covered enrollee of the health
17 care plan; or
18 (4) upon material misrepresentation by an enrollee
19 or provider.
20 (d) The appropriate use of 911 telephone systems or its
21 local equivalent shall not be discouraged or penalized when
22 an emergency medical condition exists. This provision shall
23 not imply that the use of 911 or its local equivalent is a
24 factor in determining the existence of an emergency medical
25 condition.
26 (e) For purposes of coverage, the medical director's or
27 his or her designee's determination of whether an enrollee
28 meets the standard of an emergency medical condition shall be
29 based primarily upon the presenting symptoms documented in
30 the medical record at the time care was sought and the
31 circumstances that led an enrollee to believe that he or she
32 had an emergency medical condition.
33 Section 25. Post-stabilization medical services.
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1 (a) If prior benefit authorization for
2 post-stabilization medical services is required, the treating
3 provider shall contact the health care plan or delegated
4 provider as designated on the covered enrollee's health
5 insurance card to obtain benefit authorization or denial,
6 benefit authorization for an alternate plan of treatment, or
7 transfer of the covered enrollee.
8 (b) The treating provider shall document in an
9 enrollee's medical record the enrollee's presenting symptoms,
10 emergency medical condition, the time, phone number or
11 numbers dialed, and result of the communication efforts to
12 request benefit authorization of post-stabilization medical
13 services. The health care plan shall provide reimbursement
14 as required under subsection (b) of Section 20 of this Act
15 for covered post-stabilization medical services if any of the
16 following apply:
17 (1) Benefit authorization for covered
18 post-stabilization medical services is received from the
19 health care plan or its delegated provider.
20 (2) After at least 2 documented good faith efforts
21 over the course of 60 minutes, but each effort being at
22 least 10 minutes apart, the treating health care provider
23 has attempted without success to contact an enrollee's
24 health care plan or its delegated health care provider,
25 as designated on an enrollee's health insurance card, for
26 prior benefit authorization of post-stabilization medical
27 services. A "documented good faith effort" means
28 contacting the health care plan or delegated provider and
29 any subsequent parties to whom the calls are being
30 forwarded in good faith.
31 (3) The treating health care provider has contacted
32 the plan or designated persons with a request for prior
33 benefit authorization of post-stabilization services in
34 one of its 2 documented good faith efforts as defined in
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1 item (2) and the plan or designated persons did not deny
2 the request within 60 minutes of receiving the request.
3 (c) If the provider renders post-stabilization medical
4 services pursuant to item (2) or (3) of subsection (b), the
5 treating provider shall continue to make every reasonable
6 effort to contact the health care plan or the delegated
7 provider regarding benefit authorization or denial or benefit
8 authorization for an alternate plan of treatment or transfer
9 of the covered enrollee until the treating provider receives
10 benefit authorization from the health care plan or delegated
11 provider for continued care or the care is transferred to
12 another health care provider or the patient is discharged.
13 (d) Payment for covered post-stabilization medical
14 services may be denied:
15 (1) if the treating provider does not meet the
16 conditions outlined in subsections (b) and (c);
17 (2) upon determination that the post-stabilization
18 medical services claimed were not performed;
19 (3) upon determination that the post-stabilization
20 medical services rendered were denied or were contrary to
21 the instructions of the health care plan or delegated
22 provider if contact was made between these parties prior
23 to the service being rendered;
24 (4) upon determination that the patient receiving
25 the services was not a covered enrollee of the health
26 care plan; or
27 (5) upon material misrepresentation by an enrollee
28 or provider.
29 (e) Nothing in this Section prohibits a health care plan
30 from delegating the responsibilities enumerated in this
31 Section to the health care plan's contracted medical
32 providers.
33 Section 30. Provision of medical records for review.
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1 For emergency services and post-stabilization medical
2 services claims reviewed for reimbursement, the emergency
3 department shall provide upon request of the health care
4 plan, at no charge, a copy of the medical record.
5 Section 40. Nothing in this Act prohibits a health care
6 plan from imposing deductibles or copayments in covering
7 emergency medical services or post-stabilization medical
8 services. Copayments may vary from those copayments charged
9 for other covered services.
10 Section 50. Collection rights.
11 (a) Providers and their assignees or subcontractors
12 shall not seek any type of payment from, bill, charge,
13 collect a deposit from, or have any recourse against an
14 enrollee, persons acting on an enrollee's behalf (other than
15 the health care plan), the employer, or group contract holder
16 for emergency services or post-stabilization medical services
17 provided, except for the payment of applicable copayments or
18 deductibles for services covered by the health care plan or
19 fees for services not covered under an enrollee's evidence of
20 coverage.
21 (b) Any collection or attempt to collect moneys or
22 maintain action against any subscriber or enrollee as
23 prohibited in subsection (a) may be reported to the Director
24 by any person. Any person making such a report shall be
25 immune from liability for doing so.
26 (c) The Director shall investigate such reports.
27 (d) If the Director finds that providers and their
28 assignees or subcontractors are not in compliance with this
29 Section, he or she shall provide the person attempting to
30 bill, charge, collect a deposit from, or institute recourse
31 against an enrollee with a written notice of the reasons for
32 the finding and shall allow 14 days within which to supply
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1 additional information demonstrating compliance with the
2 requirements of this Section and the opportunity to request a
3 hearing. The Director shall send a hearing notice by
4 certified mail, return receipt requested, and conduct a
5 hearing in accordance with the Illinois Administrative
6 Procedure Act.
7 (e) Within 14 days after the final decision is rendered
8 under subsection (d), the Director shall provide a written
9 notice of the report to the reported provider's licensing or
10 disciplinary board or committee and require that the provider
11 reimburse, with interest at the rate of 8% per year, the
12 subscriber or enrollee any moneys found to be collected in
13 violation of this Section.
14 (f) The Director shall maintain a record of all notices
15 to licensing or disciplinary boards or committees pursuant to
16 this Section. This record shall be provided to any person
17 within 14 days of the Director's receipt of a written request
18 for the record.
19 (g) The Department, any enrollee, subscriber, or health
20 care plan may pursue injunctive relief to ensure compliance
21 with this Section.
22 Section 60. Enforcement.
23 (a) The Department shall enforce the provisions of this
24 Act.
25 (b) The filing of a grievance with the health care plan
26 shall not preclude an enrollee from filing a complaint with
27 the Department, nor shall it preclude the Department from
28 investigating a complaint pursuant to its authority under
29 Section 4-6 of the Health Maintenance Organization Act.
30 (c) Any person or organization which engages in a
31 pattern of practice and violation of this Act shall be guilty
32 of a Class B misdemeanor.
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1 Section 99. Effective date. This Act takes effect
2 January 1, 2000.