Bill Text: IL HB3673 | 2019-2020 | 101st General Assembly | Introduced

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Bill Title: Amends the Managed Care Reform and Patient Rights Act. Provides that specified medical conditions are included in the definition of "emergency medical condition" regardless of the final diagnosis that is given.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2019-04-12 - Rule 19(a) / Re-referred to Rules Committee [HB3673 Detail]

Download: Illinois-2019-HB3673-Introduced.html

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101ST GENERAL ASSEMBLY State of Illinois 2019 and 2020 HB3673 Introduced , by Rep. Sonya M. Harper SYNOPSIS AS INTRODUCED:
215 ILCS 134/10
Amends the Managed Care Reform and Patient Rights Act. Provides that specified medical conditions are included in the definition of "emergency medical condition" regardless of the final diagnosis that is given.
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A BILL FOR
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AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Managed Care Reform and Patient Rights Act
is amended by changing Section 10 as follows:
(215 ILCS 134/10)
Sec. 10. Definitions.
"Adverse determination" means a determination by a health
care plan under Section 45 or by a utilization review program
under Section 85 that a health care service is not medically
necessary.
"Clinical peer" means a health care professional who is in
the same profession and the same or similar specialty as the
health care provider who typically manages the medical
condition, procedures, or treatment under review.
"Department" means the Department of Insurance.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including, but not limited to, severe pain), regardless of the
final diagnosis that is given, 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:

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(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;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
"Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed to
practice medicine in all its branches, or to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
"Emergency services" means, with respect to an enrollee of
a health care plan, transportation services, including but not
limited to ambulance services, and covered inpatient and
outpatient hospital services furnished by a provider qualified
to furnish those services that are needed to evaluate or
stabilize an emergency medical condition. "Emergency services"
does not refer to post-stabilization medical services.
"Enrollee" means any person and his or her dependents
enrolled in or covered by a health care plan.
"Health care plan" means a plan, including, but not limited
to, a health maintenance organization, a managed care community
network as defined in the Illinois Public Aid Code, or an
accountable care entity as defined in the Illinois Public Aid
Code that receives capitated payments to cover medical services

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from the Department of Healthcare and Family Services, that
establishes, operates, or maintains a network of health care
providers that has entered into an agreement with the plan to
provide health care services to enrollees to whom the plan has
the ultimate obligation to arrange for the provision of or
payment for services through organizational arrangements for
ongoing quality assurance, utilization review programs, or
dispute resolution. Nothing in this definition shall be
construed to mean that an independent practice association or a
physician hospital organization that subcontracts with a
health care plan is, for purposes of that subcontract, a health
care plan.
For purposes of this definition, "health care plan" shall
not include the following:
(1) indemnity health insurance policies including
those using a contracted provider network;
(2) health care plans that offer only dental or only
vision coverage;
(3) preferred provider administrators, as defined in
Section 370g(g) of the Illinois Insurance Code;
(4) employee or employer self-insured health benefit
plans under the federal Employee Retirement Income
Security Act of 1974;
(5) health care provided pursuant to the Workers'
Compensation Act or the Workers' Occupational Diseases
Act; and

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(6) not-for-profit voluntary health services plans
with health maintenance organization authority in
existence as of January 1, 1999 that are affiliated with a
union and that only extend coverage to union members and
their dependents.
"Health care professional" means a physician, a registered
professional nurse, or other individual appropriately licensed
or registered to provide health care services.
"Health care provider" means any physician, hospital
facility, facility licensed under the Nursing Home Care Act,
long-term care facility as defined in Section 1-113 of the
Nursing Home Care Act, or other person that is licensed or
otherwise authorized to deliver health care services. Nothing
in this Act shall be construed to define Independent Practice
Associations or Physician-Hospital Organizations as health
care providers.
"Health care services" means any services included in the
furnishing to any individual of medical care, or the
hospitalization incident to the furnishing of such care, as
well as the furnishing to any person of any and all other
services for the purpose of preventing, alleviating, curing, or
healing human illness or injury including home health and
pharmaceutical services and products.
"Medical director" means a physician licensed in any state
to practice medicine in all its branches appointed by a health
care plan.

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"Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
"Physician" means a person licensed under the Medical
Practice Act of 1987.
"Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
licensed hospital by a provider that is qualified to furnish
such services, and determined to be medically necessary and
directly related to the emergency medical condition following
stabilization.
"Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to assure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
"Utilization review" means the evaluation of the medical
necessity, appropriateness, and efficiency of the use of health
care services, procedures, and facilities.
"Utilization review program" means a program established
by a person to perform utilization review.
(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 99-78,
eff. 7-20-15.)