(215 ILCS 5/Art. XX.5 heading)
ARTICLE XX-1/2
HEALTH CARE REIMBURSEMENT
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(215 ILCS 5/370f) (from Ch. 73, par. 982f)
Sec. 370f.
Short Title.
This Article may be cited as the "Health Care
Reimbursement Reform Act of 1985".
(Source: P.A. 84-618.)
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(215 ILCS 5/370g) (from Ch. 73, par. 982g)
Sec. 370g.
Definitions.
As used in this Article, the following definitions
apply:
(a) "Health care services" means health care services or products
rendered or sold by a provider within the scope of the provider's license
or legal authorization. The term includes, but is not limited to, hospital,
medical, surgical, dental, vision and pharmaceutical services or products.
(b) "Insurer" means an insurance company or a health service corporation
authorized in this State to issue policies or subscriber contracts which
reimburse for expenses of health care services.
(c) "Insured" means an individual entitled to reimbursement for expenses
of health care services under a policy or subscriber contract issued or
administered by an insurer.
(d) "Provider" means an individual or entity duly licensed or legally
authorized to provide health care services.
(e) "Noninstitutional provider" means any person licensed under the Medical
Practice Act of 1987, as now or hereafter amended.
(f) "Beneficiary" means an individual entitled to reimbursement for
expenses of or the discount of provider fees for health care services under
a program where the beneficiary has an incentive to utilize the services of a
provider which has entered into an agreement or arrangement with an
administrator.
(g) "Administrator" means any person, partnership or corporation, other
than an insurer or health maintenance organization holding a certificate of
authority under the "Health Maintenance Organization Act", as now or hereafter
amended, that arranges, contracts with, or administers contracts with a
provider whereby beneficiaries are provided an incentive to use the services of
such provider.
(h) "Emergency medical condition" means a medical condition manifesting
itself
by
acute symptoms of sufficient severity (including severe
pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in:
(1) placing the health of the individual (or, with
| | respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
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(2) serious
impairment to bodily functions; or
(3) serious dysfunction of any bodily organ
or part.
(Source: P.A. 91-617, eff. 1-1-00.)
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(215 ILCS 5/370h) (from Ch. 73, par. 982h)
Sec. 370h.
Noninstitutional providers.
Before entering into any agreement
under this Article an insurer or administrator shall establish terms and
conditions that must be met by noninstitutional providers wishing to enter into
an agreement with the insurer or administrator. These terms and conditions may
not discriminate unreasonably against or among noninstitutional providers.
Neither difference in prices among noninstitutional providers produced by
a process of individual negotiation nor price differences among other
noninstitutional providers in different geographical areas or different
specialties constitutes unreasonable discrimination.
An insurer or administrator shall not refuse to contract with any
noninstitutional provider who meets the terms and conditions
established by the insurer or administrator.
(Source: P.A. 90-655, eff. 7-30-98.)
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(215 ILCS 5/370i) (from Ch. 73, par. 982i)
Sec. 370i.
Policies, agreements or arrangements with incentives or
limits on reimbursement authorized.
(a) Policies, agreements or arrangements issued under this Article may
not contain terms or conditions that would operate unreasonably to restrict
the access and availability of health care services for the insured.
(b) An insurer or administrator may:
(1) enter into agreements with certain providers of
| | its choice relating to health care services which may be rendered to insureds or beneficiaries of the insurer or administrator, including agreements relating to the amounts to be charged the insureds or beneficiaries for services rendered;
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(2) issue or administer programs, policies or
| | subscriber contracts in this State that include incentives for the insured or beneficiary to utilize the services of a provider which has entered into an agreement with the insurer or administrator pursuant to paragraph (1) above.
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(c) After the effective date of this amendatory Act of the 92nd General
Assembly, any insurer
that arranges, contracts with, or administers contracts with a provider whereby
beneficiaries are
provided an incentive to use the services of such provider must include the
following disclosure
on its contracts and evidences of coverage: "WARNING, LIMITED BENEFITS WILL
BE
PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that
when you elect to utilize the services of a non-participating provider for a
covered service in
non-emergency situations, benefit payments to such non-participating provider
are not based
upon the amount billed. The basis of your benefit payment will be determined
according to your
policy's fee schedule, usual and customary charge (which is determined by
comparing charges
for similar services adjusted to the geographical area where the services are
performed), or other
method as defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE
COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS
REQUIRED PORTION. Non-participating providers may bill members for any amount
up to
the billed charge after the plan has paid its portion of the bill.
Participating providers have
agreed to accept discounted payments for services with no additional billing to
the member other
than co-insurance and deductible amounts. You may obtain further information
about the
participating status of professional providers and information on out-of-pocket
expenses by
calling the toll free telephone number on your identification card.".
(Source: P.A. 92-579, eff. 1-1-03.)
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(215 ILCS 5/370j) (from Ch. 73, par. 982j)
Sec. 370j.
Requirements not applicable to insurers.
Except as otherwise
provided, no insurer authorized to do business in this State shall be subject to any
of the requirements of this Article that are applicable to administrators.
Requirements not applicable to self-insured
employers, employee benefit trust funds, other ERISA exempt
organizations or the State of Illinois. Such organizations are not
subject to any provisions of
this Article even though they may contract with administrators for
administration of health insurance claims subject to contractual
arrangements of the administrator's preferred provider program.
(Source: P.A. 84-1431.)
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(215 ILCS 5/370k) (from Ch. 73, par. 982k)
Sec. 370k.
Registration.
(a) All administrators of a preferred provider
program subject to this Article shall register with the Department of
Insurance, which shall by rule establish criteria for such registration
including minimum solvency requirements and an annual registration fee for
each administrator.
(b) The Department of Insurance shall compile and maintain a listing
updated
at least annually of administrators and insurers offering agreements
authorized under this Article.
(c) Preferred provider administrators are subject
to the provisions of Sections 368b, 368c, 368d, and 368e of this
Code.
(Source: P.A. 93-261, eff. 1-1-04.)
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(215 ILCS 5/370l) (from Ch. 73, par. 982l)
Sec. 370l.
Fiduciary and bonding requirements.
Each
administrator who handles money for purposes of payment for providers
services subject to this Article shall (1) establish and maintain
a fiduciary account, separate and apart from any and all other accounts,
for the receipt and disbursement of funds for reimbursement for programs
covered under this Article, or (2) post or cause to be posted, a bond of
indemnity in an amount equal to not less than 10% of the total estimated
annual reimbursements under such programs.
If a bond of indemnity is posted, it shall be held by the Director of
Insurance for the benefit and indemnification of the beneficiaries and
payors of services under the programs subject to this Article.
An administrator who operates more than one such program may establish
and maintain a separate fiduciary account or bond of indemnity for each
such program, or may operate and maintain a consolidated fiduciary account
or bond of indemnity for all such programs.
(Source: P.A. 84-618.)
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(215 ILCS 5/370m) (from Ch. 73, par. 982m)
Sec. 370m.
Program Requirements.
Each
administrator shall provide to each beneficiary of any program subject to
this Article a document which (1) sets forth those providers with which
agreements or arrangements have been made to provide health care services
to such beneficiary, a source for the beneficiary to contact regarding
changes in such providers and a clear description of any incentives for the
beneficiary to utilize such providers, (2) discloses the extent of coverage
as well as any limitations or exclusions of health care services under the
program, (3) clearly sets out the circumstances under which reimbursement
will be made to a beneficiary unable to utilize the services of a provider
with which an arrangement or agreement has been made, (4) a description of
the process for addressing a beneficiary complaint under the program, and
(5) discloses deductible and coinsurance amounts charged to any person
receiving health care services from such a provider.
(Source: P.A. 84-618.)
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(215 ILCS 5/370n) (from Ch. 73, par. 982n)
Sec. 370n.
Utilization Review Requirements:
Any preferred provider
organization providing hospital, medical or dental services must include a
program of utilization review.
This Section applies to insurers and administrators.
(Source: P.A. 84-1431.)
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(215 ILCS 5/370o) (from Ch. 73, par. 982o)
Sec. 370o.
Emergency Care.
Any preferred provider contract, subject to
this Article shall provide the beneficiary or insured emergency care
coverage such that payment for this coverage is not dependent upon whether
such services are performed by a preferred or nonpreferred provider and
such coverage shall be at the same benefit level as if the service or
treatment had been rendered by a plan provider.
(Source: P.A. 85-476.)
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(215 ILCS 5/370p) (from Ch. 73, par. 982p)
Sec. 370p.
Failure to register.
Any
administrator subject to this Article who fails to register or pay the fee
required by this Article shall be construed to be an unauthorized insurer as
defined in Article VII of the "Illinois Insurance Code", as now or
hereafter amended, and shall be subject to the penalties contained therein.
(Source: P.A. 84-618.)
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(215 ILCS 5/370q) (from Ch. 73, par. 982q)
Sec. 370q.
To the extent of any conflict between this Article and any
other statutory provision, this Article prevails over the conflicting
provision. Agreements may be entered into under this Article
notwithstanding any policy provision to the contrary.
(Source: P.A. 84-618.)
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(215 ILCS 5/370r) (from Ch. 73, par. 982r)
Sec. 370r.
(Renumbered).
(Source: Renumbered by P.A. 95-331, eff. 8-21-07.)
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(215 ILCS 5/370s)
Sec. 370s.
Managed Care Reform and Patient Rights Act.
All
administrators shall comply with Sections 55 and
85 of the Managed Care Reform and Patient
Rights Act.
(Source: P.A. 91-617, eff. 1-1-00.)
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(215 ILCS 5/370t)
Sec. 370t.
Drug formulary; notice.
All administrators must comply with
Section 155.37 of this Code.
(Source: P.A. 92-440, eff. 8-17-01.)
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