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91_SB0727
LRB9105755JSpc
1 AN ACT concerning emergency medical services, amending
2 named Acts.
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 However, health insurance plans may impede access to
17 emergency care by denying coverage or payment for failure to
18 obtain prior authorization or approval from the plan, failure
19 to seek emergency care from a preferred or contractual
20 provider, or an after-the-fact determination that the medical
21 condition did not require the use emergency facilities or
22 services, including the 911 emergency telephone number.
23 These denials impose significant financial burdens on
24 patients who prudently seek care for symptoms of a medical
25 emergency through the 911 system and in a hospital emergency
26 department, as well as the providers of such care. This
27 serves to discourage patients from seeking appropriate
28 emergency care and threatens the financial livelihood of
29 hospital emergency departments and trauma centers that
30 provide such necessary services to our entire population.
31 (b) This Act is intended to promote access to emergency
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1 medical care by establishing a uniform definition of
2 emergency medical condition that is based on the average
3 knowledge of the prudent layperson and requiring health
4 insurance plans to cover and pay for such services without
5 restrictions that may impede or discourage access to such
6 care.
7 Section 10. Definitions:
8 "Department" means the Department of Insurance.
9 "Emergency medical condition" means a medical condition
10 manifesting itself by acute symptoms of sufficient severity
11 (including, but not limited to, severe pain) such that a
12 prudent layperson, who possesses an average knowledge of
13 health and medicine, could reasonably expect the absence of
14 immediate medical attention to result in:
15 (1) placing the health of the individual (or, with
16 respect to a pregnant woman, the health of the woman or
17 her unborn child) in serious jeopardy;
18 (2) serious impairment to bodily functions; or
19 (3) serious dysfunction of any bodily organ or
20 part.
21 "Emergency medical screening examination" means a medical
22 screening examination and evaluation by a physician, or to
23 the extent permitted by applicable laws, by other
24 appropriately licensed personnel under the supervision of a
25 physician to determine whether the need for emergency
26 services exists.
27 "Emergency services" means, with respect to an enrollee
28 of a health insurance plan, transportation services and
29 covered inpatient and outpatient hospital services furnished
30 by a provider qualified to furnish those services that are
31 needed to evaluate or stabilize an emergency medical
32 condition. "Emergency services" does not refer to
33 post-stabilization medical services.
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1 "Enrollee" means any person and his or her dependents
2 enrolled in or covered by a health insurance plan.
3 "Health care provider" means any physician, hospital
4 facility, or other person that is licensed or otherwise
5 authorized to deliver health care services.
6 "Health care services" means any services included in the
7 furnishing to any individual of medical care, or the
8 hospitalization or incident to the furnishing of such care or
9 hospitalization as well as the furnishing to any person of
10 any and all other services for the purpose of preventing,
11 alleviating, curing, or healing human illness or injury
12 including home health and pharmaceutical services and
13 products.
14 "Health insurance plan" means any policy, contract, plan,
15 or other arrangement that pays for or furnishes medical
16 services pursuant to the Illinois Insurance Code, the
17 Comprehensive Health Insurance Plan Act, the Health
18 Maintenance Organization Act, or the Illinois Public Aid
19 Code.
20 "Physician" means a person licensed under the Medical
21 Practice Act of 1987.
22 "Post-stabilization medical services" means health care
23 services provided to an enrollee that are furnished in a
24 licensed hospital by a physician or health care provider that
25 is qualified to furnish such services, and determined to be
26 medically necessary and directly related to the emergency
27 medical condition following stabilization.
28 "Stabilization" means, with respect to an emergency
29 medical condition, to provide such medical treatment of the
30 condition as may be necessary to assure, within reasonable
31 medical probability, that no material deterioration of the
32 condition is likely to result from or occur during the
33 transfer of the enrollee from a facility.
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1 Section 15. Emergency services prior to stabilization.
2 (a) A health insurance plan subject to this Act that
3 provides or that is required by law to provide coverage for
4 emergency services shall provide coverage such that payment
5 under this coverage is not dependent upon whether the
6 services are performed by a plan or non-plan physician or
7 health care provider and without regard to prior
8 authorization. This coverage shall be at the same benefit
9 level as if the services or treatment had been rendered by
10 the health insurance plan physician or health care provider.
11 (b) Prior authorization or approval by the plan shall
12 not be required for emergency services.
13 (c) Coverage and payment shall not be retrospectively
14 denied, with the following exceptions:
15 (1) upon reasonable determination that the
16 emergency services claimed were never performed;
17 (2) upon reasonable determination that the
18 emergency evaluation and treatment were rendered to an
19 enrollee who sought emergency services and whose
20 circumstance did not meet the definition of emergency
21 medical condition;
22 (3) upon determination that the patient receiving
23 such services was not an enrollee of the health insurance
24 plan; or
25 (4) upon material misrepresentation by the enrollee
26 or health care provider; "material" means a fact or
27 situation that is not merely technical in nature and
28 results or could result in a substantial change in the
29 situation.
30 (d) When an enrollee presents to a hospital seeking
31 emergency services, the determination as to whether the need
32 for those services exists shall be made for purposes of
33 treatment by a physician licensed to practice medicine in all
34 its branches or, to the extent permitted by applicable law,
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1 by other appropriately licensed personnel under the
2 supervision of a physician licensed to practice medicine in
3 all its branches. The physician or other appropriate
4 personnel shall indicate in the patient's chart the results
5 of the emergency medical screening examination.
6 (e) The appropriate use of the 911 emergency telephone
7 system or its local equivalent shall not be discouraged or
8 penalized by the health insurance plan when an emergency
9 medical condition exists. This provision shall not imply that
10 the use of 911 or its local equivalent is a factor in
11 determining the existence of an emergency medical condition.
12 (f) Nothing in this Section shall prohibit the
13 imposition of deductibles, co-payments, and co-insurance.
14 Section 20. Post-stabilization medical services.
15 (a) If prior authorization for covered post-stabilization
16 services is required by the health insurance plan, the plan
17 shall provide access 24 hours a day, 7 days a week to persons
18 designated by the plan to make such determinations.
19 (b) The treating physician or health care provider shall
20 contact the health insurance plan or delegated physician or
21 health care provider as designated on the enrollee's health
22 insurance card to obtain authorization, denial, or
23 arrangements for an alternate plan of treatment or transfer
24 of the enrollee.
25 (c) The treating physician licensed to practice medicine
26 in all its branches or health care provider shall document in
27 the enrollee's medical record the enrollee's presenting
28 symptoms; emergency medical condition; and time, phone number
29 dialed, and result of the communication for request for
30 authorization of post stabilization medical services. The
31 health insurance plan shall provide reimbursement for covered
32 post-stabilization medical services if:
33 (1) authorization to render them is received from
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1 the health insurance plan or its delegated physician or
2 health care provider; or
3 (2) after 2 documented good faith efforts, the
4 treating physician or health care provider has attempted
5 to contact the enrollee's health insurance plan or its
6 delegated physician or health care provider, as
7 designated on the enrollee's health insurance card, for
8 prior authorization of post-stabilization medical
9 services and neither the plan nor designated persons were
10 accessible or the authorization was not denied within 60
11 minutes of the request. "Two documented good faith
12 efforts" means the physician or health care provider has
13 called the telephone number on the enrollee's health
14 insurance card or other available number either 2 times
15 or one time and made an additional call to any referral
16 number provided. "Good faith" means honesty of purpose,
17 freedom from intention to defraud, and being faithful to
18 one's duty or obligation. For the purpose of this Act,
19 good faith shall be presumed.
20 (d) After rendering any post-stabilization medical
21 services, the treating physician or health care provider
22 shall continue to make every reasonable effort to contact the
23 health insurance plan or its delegated physician or health
24 care provider regarding authorization, denial, or
25 arrangements for an alternate plan of treatment or transfer
26 of the enrollee until the treating physician or health care
27 provider receives instructions from the health insurance plan
28 or delegated physician or health care provider for continued
29 care or the care is transferred to another physician or
30 health care provider or the patient is discharged.
31 (e) Payment for covered post-stabilization services may
32 be denied:
33 (1) if the treating physician or health care
34 provider does not meet the conditions outlined in
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1 subsection (c);
2 (2) upon determination that the post-stabilization
3 services claimed were not performed;
4 (3) upon determination that the post-stabilization
5 services rendered were contrary to the instructions of
6 the health insurance plan or its delegated physician or
7 health care provider if contact was made between those
8 parties prior to the service being rendered;
9 (4) upon determination that the patient receiving
10 such services was not an enrollee of the health insurance
11 plan; or
12 (5) upon material misrepresentation by the enrollee
13 or health care provider; "material" means a fact or
14 situation that is not merely technical in nature and
15 results or could result in a substantial change in the
16 situation.
17 (f) Coverage and payment for post-stabilization medical
18 services for which prior authorization or deemed approval is
19 received shall not be retrospectively denied.
20 (g) Nothing in this Section prohibits a health insurance
21 plan from delegating tasks associated with the
22 responsibilities enumerated in this Section to the health
23 insurance plan's contracted health care providers or another
24 entity. However, the ultimate responsibility for coverage
25 and payment decisions may not be delegated.
26 (h) Nothing in this Section shall prohibit the
27 imposition of deductibles, co-payments, and co-insurance.
28 Section 25. Enforcement.
29 (a) The Department shall enforce the provisions of this
30 Act. It shall promptly investigate complaints it receives
31 alleging violation of the Act. If the complaint is found to
32 be valid, the Department shall immediately seek appropriate
33 corrective action by the health insurance plan including, but
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1 not limited to, ceasing the noncompliant activity, restoring
2 coverage, paying or reimbursing claims, and other appropriate
3 restitution.
4 (b) Subject to the provisions of the Illinois
5 Administrative Procedure Act, the Department may impose an
6 administrative fine on a health insurance plan found to have
7 violated any provision of this Act up to a fine of $5,000 per
8 violation. A repeated violation shall result in a fine of
9 $10,000 per violation, per day.
10 (c) Notwithstanding the existence or pursuit of any
11 other remedy, the Department may, through the Attorney
12 General, seek an injunction to restrain or prevent any health
13 insurance plan from violation or continuing to violate any
14 provisions of this Act.
15 Section 30. Rules. The Department shall adopt emergency
16 rules to implement the provisions of this Act, in accordance
17 with Section 5-45 of the Illinois Administrative Procedure
18 Act.
19 Section 91. The Illinois Insurance Code is amended by
20 changing Section 370g and adding Sections 155.36, 370s, and
21 511.118 as follows:
22 (215 ILCS 5/155.36 new)
23 Sec. 155.36. Access to Emergency Services Act.
24 Insurance companies that transact the kinds of insurance
25 authorized under Class 1(b) or Class 2(a) of Section 4 of
26 this Code shall comply with the Access to Emergency Services
27 Act.
28 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
29 Sec. 370g. Definitions. As used in this Article, the
30 following definitions apply:
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1 (a) "Health care services" means health care services or
2 products rendered or sold by a provider within the scope of
3 the provider's license or legal authorization. The term
4 includes, but is not limited to, hospital, medical, surgical,
5 dental, vision and pharmaceutical services or products.
6 (b) "Insurer" means an insurance company or a health
7 service corporation authorized in this State to issue
8 policies or subscriber contracts which reimburse for expenses
9 of health care services.
10 (c) "Insured" means an individual entitled to
11 reimbursement for expenses of health care services under a
12 policy or subscriber contract issued or administered by an
13 insurer.
14 (d) "Provider" means an individual or entity duly
15 licensed or legally authorized to provide health care
16 services.
17 (e) "Noninstitutional provider" means any person
18 licensed under the Medical Practice Act of 1987, as now or
19 hereafter amended.
20 (f) "Beneficiary" means an individual entitled to
21 reimbursement for expenses of or the discount of provider
22 fees for health care services under a program where the
23 beneficiary has an incentive to utilize the services of a
24 provider which has entered into an agreement or arrangement
25 with an administrator.
26 (g) "Administrator" means any person, partnership or
27 corporation, other than an insurer or health maintenance
28 organization holding a certificate of authority under the
29 "Health Maintenance Organization Act", as now or hereafter
30 amended, that arranges, contracts with, or administers
31 contracts with a provider whereby beneficiaries are provided
32 an incentive to use the services of such provider.
33 (h) "Emergency medical condition" means a medical
34 condition manifesting itself by acute symptoms of sufficient
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1 severity (including, but limited to, severe pain) such that a
2 prudent layperson, who possesses an average knowledge of
3 health and medicine, could reasonably expect the absence of
4 immediate medical attention to result in:
5 (1) placing the health of the individual (or, with
6 respect to a pregnant woman, the health of the woman or
7 her unborn child) in serious jeopardy;
8 (2) serious impairment to bodily functions; or
9 (3) serious dysfunction of any bodily organ or
10 part. "Emergency" means an accidental bodily injury or
11 emergency medical condition which reasonably requires the
12 beneficiary or insured to seek immediate medical care
13 under circumstances or at locations which reasonably
14 preclude the beneficiary or insured from obtaining needed
15 medical care from a preferred provider.
16 (Source: P.A. 88-400.)
17 (215 ILCS 5/370s new)
18 Sec. 370s. Access to Emergency Services Act. All
19 administrators shall comply with the Access to Emergency
20 Services Act.
21 (215 ILCS 5/511.118 new)
22 Sec. 511.118. Access to Emergency Services Act. All
23 administrators shall comply with the Access to Emergency
24 Services Act.
25 Section 93. The Comprehensive Health Insurance Plan Act
26 is amended by adding Section 8.6 as follows:
27 (215 ILCS 105/8.6 new)
28 Sec. 8.6. Access to Emergency Services Act. The plan is
29 subject to the provisions of the Access to Emergency Services
30 Act.
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1 Section 95. The Health Maintenance Organization Act is
2 amended by adding Section 5-3.6 as follows:
3 (215 ILCS 125/5-3.6 new)
4 Sec. 5-3.6. Access to Emergency Services Act. Health
5 maintenance organizations are subject to the provisions of
6 the Access to Emergency Services Act.
7 Section 97. The Illinois Public Aid Code is amended by
8 adding Section 5-16.12 as follows:
9 (305 ILCS 5/5-16.12 new)
10 Sec. 5-16.12. Access to Emergency Services Act. The
11 medical assistance program and other programs administered by
12 the Department are subject to the provisions of the Access to
13 Emergency Services Act. The Department may adopt rules to
14 implement those provisions. These rules shall require
15 compliance with that Act in the medical assistance managed
16 care programs and other programs administered by the
17 Department.
18 Section 99. Effective date. This Act takes effect
19 January 1, 2000.