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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.
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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,
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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
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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.
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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.)
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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.