Bill Text: IL HB3833 | 2017-2018 | 100th General Assembly | Introduced

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Bill Title: Amends the Care of Students with Diabetes Act, the Illinois Insurance Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, the Managed Care Reform and Patient Rights Act, the Voluntary Health Services Plans Act, and the Health Care Services Lien Act to add pharmacy or pharmacist-provided services to the types of health services under the Acts and to add pharmacists as health care providers or health care professionals under the Acts. Effective January 1, 2018.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Failed) 2019-01-08 - Session Sine Die [HB3833 Detail]

Download: Illinois-2017-HB3833-Introduced.html

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100TH GENERAL ASSEMBLY State of Illinois 2017 and 2018 HB3833 Introduced , by Rep. Dan Brady SYNOPSIS AS INTRODUCED:
105 ILCS 145/10
215 ILCS 5/512-7 from Ch. 73, par. 1065.59-7
215 ILCS 125/1-2 from Ch. 111 1/2, par. 1402
215 ILCS 130/1002 from Ch. 73, par. 1501-2
215 ILCS 134/10
215 ILCS 165/2 from Ch. 32, par. 596
770 ILCS 23/5
Amends the Care of Students with Diabetes Act, the Illinois Insurance Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, the Managed Care Reform and Patient Rights Act, the Voluntary Health Services Plans Act, and the Health Care Services Lien Act to add pharmacy or pharmacist-provided services to the types of health services under the Acts and to add pharmacists as health care providers or health care professionals under the Acts. Effective January 1, 2018.
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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 Care of Students with Diabetes Act is
amended by changing Section 10 as follows:
(105 ILCS 145/10)
Sec. 10. Definitions. As used in this Act:
"Delegated care aide" means a school employee who has
agreed to receive training in diabetes care and to assist
students in implementing their diabetes care plan and has
entered into an agreement with a parent or guardian and the
school district or private school.
"Diabetes care plan" means a document that specifies the
diabetes-related services needed by a student at school and at
school-sponsored activities and identifies the appropriate
staff to provide and supervise these services.
"Health care provider" means a physician licensed to
practice medicine in all of its branches, advanced practice
nurse who has a written agreement with a collaborating
physician who authorizes the provision of diabetes care, or a
physician assistant who has a written supervision agreement
with a supervising physician who authorizes the provision of
diabetes care, or pharmacist licensed to practice pharmacy.

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"Principal" means the principal of the school.
"School" means any primary or secondary public, charter, or
private school located in this State.
"School employee" means a person who is employed by a
public school district or private school, a person who is
employed by a local health department and assigned to a school,
or a person who contracts with a school or school district to
perform services in connection with a student's diabetes care
plan. This definition must not be interpreted as requiring a
school district or private school to hire additional personnel
for the sole purpose of serving as a designated care aide.
(Source: P.A. 96-1485, eff. 12-1-10.)
Section 10. The Illinois Insurance Code is amended by
changing Section 512-7 as follows:
(215 ILCS 5/512-7) (from Ch. 73, par. 1065.59-7)
Sec. 512-7. Contractual provisions.
(a) Any agreement or contract entered into in this State
between the entity administrator of a program and a pharmacy or
pharmacist shall include a statement of the method and amount
of reimbursement to the pharmacy or pharmacist for services
rendered to persons enrolled in the program, the frequency of
payment by the program administrator to the pharmacy or
pharmacist for those services, and a method for the
adjudication of complaints and the settlement of disputes

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between the contracting parties.
(b)(1) A program shall provide an annual period of at least
30 days during which any pharmacy or pharmacist licensed
under the Pharmacy Practice Act may elect to participate in
the program under the program terms for at least one year.
(2) If compliance with the requirements of this
subsection (b) would impair any provision of a contract
between a program and any other person, and if the contract
provision was in existence before January 1, 1990, then
immediately after the expiration of those contract
provisions the program shall comply with the requirements
of this subsection (b).
(3) This subsection (b) does not apply if:
(A) the program administrator is a licensed health
maintenance organization that owns or controls a
pharmacy and that enters into an agreement or contract
with that pharmacy in accordance with subsection (a);
or
(B) the program administrator is a licensed health
maintenance organization that is owned or controlled
by another entity that also owns or controls a
pharmacy, and the administrator enters into an
agreement or contract with that pharmacy in accordance
with subsection (a).
(4) This subsection (b) shall be inoperative after
October 31, 1992.

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(c) The entity program administrator shall cause to be
issued an identification card to each person enrolled in the
program. The identification card shall include:
(1) the name of the individual enrolled in the program;
and
(2) an expiration date if required under the
contractual arrangement or agreement between a provider of
pharmaceutical services and prescription drug products and
the entity third party prescription program administrator.
(Source: P.A. 95-689, eff. 10-29-07.)
Section 15. The Health Maintenance Organization Act is
amended by changing Section 1-2 as follows:
(215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
Sec. 1-2. Definitions. As used in this Act, unless the
context otherwise requires, the following terms shall have the
meanings ascribed to them:
(1) "Advertisement" means any printed or published
material, audiovisual material and descriptive literature of
the health care plan used in direct mail, newspapers,
magazines, radio scripts, television scripts, billboards and
similar displays; and any descriptive literature or sales aids
of all kinds disseminated by a representative of the health
care plan for presentation to the public including, but not
limited to, circulars, leaflets, booklets, depictions,

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illustrations, form letters and prepared sales presentations.
(2) "Director" means the Director of Insurance.
(3) "Basic health care services" means emergency care, and
inpatient hospital and physician care, outpatient medical
services, mental health services and care for alcohol and drug
abuse, including any reasonable deductibles and co-payments,
all of which are subject to the limitations described in
Section 4-20 of this Act and as determined by the Director
pursuant to rule.
(4) "Enrollee" means an individual who has been enrolled in
a health care plan.
(5) "Evidence of coverage" means any certificate,
agreement, or contract issued to an enrollee setting out the
coverage to which he is entitled in exchange for a per capita
prepaid sum.
(6) "Group contract" means a contract for health care
services which by its terms limits eligibility to members of a
specified group.
(7) "Health care plan" means any arrangement whereby any
organization undertakes to provide or arrange for and pay for
or reimburse the cost of basic health care services, excluding
any reasonable deductibles and copayments, from providers
selected by the Health Maintenance Organization and such
arrangement consists of arranging for or the provision of such
health care services, as distinguished from mere
indemnification against the cost of such services, except as

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otherwise authorized by Section 2-3 of this Act, on a per
capita prepaid basis, through insurance or otherwise. A "health
care plan" also includes any arrangement whereby an
organization undertakes to provide or arrange for or pay for or
reimburse the cost of any health care service for persons who
are enrolled under Article V of the Illinois Public Aid Code or
under the Children's Health Insurance Program Act through
providers selected by the organization and the arrangement
consists of making provision for the delivery of health care
services, as distinguished from mere indemnification. A
"health care plan" also includes any arrangement pursuant to
Section 4-17. Nothing in this definition, however, affects the
total medical services available to persons eligible for
medical assistance under the Illinois Public Aid Code.
(8) "Health care services" means any services included in
the furnishing to any individual of medical care, or dental
care, pharmacist-provided services or the hospitalization or
incident to the furnishing of such care or hospitalization 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.
(9) "Health Maintenance Organization" means any
organization formed under the laws of this or another state to
provide or arrange for one or more health care plans under a
system which causes any part of the risk of health care
delivery to be borne by the organization or its providers.

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(10) "Net worth" means admitted assets, as defined in
Section 1-3 of this Act, minus liabilities.
(11) "Organization" means any insurance company, a
nonprofit corporation authorized under the Dental Service Plan
Act or the Voluntary Health Services Plans Act, or a
corporation organized under the laws of this or another state
for the purpose of operating one or more health care plans and
doing no business other than that of a Health Maintenance
Organization or an insurance company. "Organization" shall
also mean the University of Illinois Hospital as defined in the
University of Illinois Hospital Act or a unit of local
government health system operating within a county with a
population of 3,000,000 or more.
(12) "Provider" means any physician, pharmacist, hospital
facility, facility licensed under the Nursing Home Care Act, or
facility or long-term care facility as those terms are defined
in the Nursing Home Care Act or other person which is licensed
or otherwise authorized to furnish health care services and
also includes any other entity that arranges for the delivery
or furnishing of health care service.
(13) "Producer" means a person directly or indirectly
associated with a health care plan who engages in solicitation
or enrollment.
(14) "Per capita prepaid" means a basis of prepayment by
which a fixed amount of money is prepaid per individual or any
other enrollment unit to the Health Maintenance Organization or

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for health care services which are provided during a definite
time period regardless of the frequency or extent of the
services rendered by the Health Maintenance Organization,
except for copayments and deductibles and except as provided in
subsection (f) of Section 5-3 of this Act.
(15) "Subscriber" means a person who has entered into a
contractual relationship with the Health Maintenance
Organization for the provision of or arrangement of at least
basic health care services to the beneficiaries of such
contract.
(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 99-78,
eff. 7-20-15.)
Section 20. The Limited Health Service Organization Act is
amended by changing Section 1002 as follows:
(215 ILCS 130/1002) (from Ch. 73, par. 1501-2)
Sec. 1002. Definitions. As used in this Act, unless the
context otherwise requires, the following terms shall have the
meanings ascribed to them:
"Advertisement" means any printed or published material,
audiovisual material and descriptive literature of the limited
health care plan used in direct mail, newspapers, magazines,
radio scripts, television scripts, billboards and similar
displays; and any descriptive literature or sales aids of all
kinds disseminated by a representative of the limited health

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care plan for presentation to the public including, but not
limited to, circulars, leaflets, booklets, depictions,
illustrations, form letters and prepared sales presentations.
"Copayment" means the amount that an enrollee must pay in
order to receive a specific service that is not fully prepaid.
"Director" means the Director of Insurance.
"Enrollee" means an individual who has been enrolled in a
limited health care plan.
"Evidence of coverage" means any certificate, agreement or
contract issued to an enrollee setting out the coverage to
which that enrollee is entitled in exchange for a per capita
prepaid sum.
"Group contract" means a contract for limited health
services which by its terms limits eligibility to members of a
specified group.
"In-plan covered services" means covered limited health
services obtained from providers who are employed by, under
contract with, referred by, or otherwise affiliated with the
LHSO and emergency services.
"Limited health care plan" means any arrangement whereby an
organization undertakes to provide or arrange for and, pay for
or reimburse the cost of any limited health services from
providers selected by the limited health service organization
and such arrangement consists of arranging for or the provision
of such limited health services on a per capita prepaid basis,
as distinguished from mere indemnification against the cost of

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such limited services on a per capita prepaid basis through
insurance except as otherwise provided under Section 3009.
"Limited health service" means ambulance care services,
dental care services, vision care services, pharmaceutical
services, pharmacist-provided services, clinical laboratory
services, and podiatric care services. Limited health service
shall not include hospital, medical, surgical or emergency
services except when those services are essential to the
delivery of the limited health service. Essential hospital,
medical, surgical, or emergency services shall be covered
unless specifically excluded.
"Limited health service organization" (LHSO) means any
organization formed under the laws of this or another state to
provide or arrange for one or more limited health care plans
under a system which causes any part of the risk of limited
health care delivery to be borne by the organization or its
providers.
"Net worth" means admitted assets, as defined in Section
1003 of this Act, minus liabilities.
"Organization" means any insurance company or other
corporation organized under the laws of this or another state
for the purpose of operating one or more limited health care
plans and doing no business other than that of a health
maintenance organization or a limited health service
organization or an insurance company. Organization does not
include (1) any entity otherwise authorized on the effective

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date of this Act pursuant to the laws of this State either to
provide any limited health service on a prepayment basis or to
indemnity for any limited health service; nor does it include
(2) any provider or other entity when providing or arranging
for the provision of limited health services pursuant to a
contract with a limited health service organization or with any
entity described in (1) of this definition.
"Out-of-plan covered services" means non-emergency,
self-referred covered limited health services obtained from
providers who are not otherwise employed by, under contract
with, or otherwise affiliated with the LHSO or services
obtained without a referral from providers who have contracted
to provide limited health services to the enrollee on behalf of
the limited health care plan.
"Point-of-service product" (POS) means a group contract
that includes both in-plan covered services and out-of-plan
covered services as well as a POS contract in which the risk
for out-of-plan covered services is borne through reinsurance.
This term does not apply to indemnity benefits offered through
an LHSO that are underwritten in whole by a licensed insurance
carrier and offered in conjunction with the LHSO benefit
package.
"Provider" means any physician, dentist, pharmacist,
health facility, or other person or institution which is duly
licensed or otherwise authorized to deliver or furnish limited
health services and also includes any other entity that

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arranges for the delivery or furnishing of limited health
service.
"Per capita prepaid" means a basis of payment by which a
fixed amount of money is prepaid per individual or any other
enrollment unit to the limited health service organization or
for limited health services which are provided during a
definite time period regardless of the frequency or extent of
the services rendered, except for copayments of a fixed amount
by the limited health service organization.
"Subscriber" means the person whose employment or other
status, except for family dependency, is the basis for
entitlement to limited health services pursuant to a contract
with an organization authorized to provide or arrange for such
services under this Act.
"Uncovered expense" means the cost of limited health
services that are the obligation of a limited health service
organization for which an enrollee may be liable in the event
of the insolvency of the organization. Costs incurred by a
provider who has agreed in writing not to bill enrollees,
except for permissible supplemental charges, shall be
considered covered expenses.
(Source: P.A. 87-1079; 88-568, eff. 8-5-94; 88-667, eff.
9-16-94.)
Section 25. The Managed Care Reform and Patient Rights Act
is amended by changing Section 10 as follows:

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(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) 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;
(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

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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
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

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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
(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
pharmacist, a registered professional nurse, or other
individual appropriately licensed or registered to provide

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health care services.
"Health care provider" means any physician, pharmacist,
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 or pharmacist 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.
"Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
"Pharmacist" has the meaning given to that term in the
Pharmacy Practice Act.
"Physician" means a person licensed under the Medical
Practice Act of 1987.

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"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.)
Section 30. The Voluntary Health Services Plans Act is
amended by changing Sections 2 and 7 as follows:
(215 ILCS 165/2) (from Ch. 32, par. 596)
Sec. 2. For the purposes of this Act, the following terms
have the respective meanings set forth in this section, unless
different meanings are plainly indicated by the context:

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(a) "Health Services Plan Corporation" means a corporation
organized under the terms of this Act for the purpose of
establishing and operating a voluntary health services plan and
providing other medically related services.
(b) "Voluntary health services plan" means either a plan or
system under which medical, hospital, nursing and relating
health services may be rendered to a subscriber or beneficiary
at the expense of a health services plan corporation, or any
contractual arrangement to provide, either directly or through
arrangements with others, dental care services to subscribers
and beneficiaries.
(c) "Subscriber" means a natural person to whom a
subscription certificate has been issued by a health services
plan corporation. Persons eligible under Section 5-2 of the
Illinois Public Aid Code may be subscribers if a written
agreement exists, as specified in Section 25 of this Act,
between the Health Services Plan Corporation and the Department
of Healthcare and Family Services. A subscription certificate
may be issued to such persons at no cost.
(d) "Beneficiary" means a person designated in a
subscription certificate as one entitled to receive health
services.
(e) "Health services" means those services ordinarily
rendered by physicians licensed in Illinois to practice
medicine in all of its branches, by podiatric physicians
licensed in Illinois to practice podiatric medicine, by

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dentists and dental surgeons licensed to practice in Illinois,
by nurses registered in Illinois, by dental hygienists licensed
to practice in Illinois, by pharmacists licensed in Illinois to
practice pharmacy, and by assistants and technicians acting
under professional supervision; it likewise means hospital
services as usually and customarily rendered in Illinois, and
the compounding and dispensing of drugs and medicines by
pharmacists and assistant pharmacists registered in Illinois.
(f) "Subscription certificate" means a certificate issued
to a subscriber by a health services plan corporation, setting
forth the terms and conditions upon which health services shall
be rendered to a subscriber or a beneficiary.
(g) "Physician rendering service for a plan" means a
physician licensed in Illinois to practice medicine in all of
its branches who has undertaken or agreed, upon terms and
conditions acceptable both to himself and to the health
services plan corporation involved, to furnish medical service
to the plan's subscribers and beneficiaries.
(h) "Dentist or dental surgeon rendering service for a
plan" means a dentist or dental surgeon licensed in Illinois to
practice dentistry or dental surgery who has undertaken or
agreed, upon terms and conditions acceptable both to himself
and to the health services plan corporation involved, to
furnish dental or dental surgical services to the plan's
subscribers and beneficiaries.
(i) "Director" means the Director of Insurance of the State

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of Illinois.
(j) "Person" means any of the following: a natural person,
corporation, partnership or unincorporated association.
(k) "Podiatric physician or podiatric surgeon rendering
service for a plan" means any podiatric physician or podiatric
surgeon licensed in Illinois to practice podiatry, who has
undertaken or agreed, upon terms and conditions acceptable both
to himself and to the health services plan corporation
involved, to furnish podiatric or podiatric surgical services
to the plan's subscribers and beneficiaries.
(l) "Pharmacist rendering service for a plan" means a
pharmacist licensed in Illinois to practice pharmacy who has
undertaken or agreed, upon terms and conditions acceptable both
to the pharmacist and to the health services plan corporation
involved, to furnish pharmacy and pharmacist-provided service
to the plan's subscribers and beneficiaries.
(Source: P.A. 98-214, eff. 8-9-13.)
Section 35. The Health Care Services Lien Act is amended by
changing Section 5 as follows:
(770 ILCS 23/5)
Sec. 5. Definitions. In this Act:
"Health care professional" means any individual in any of
the following license categories: licensed physician, licensed
dentist, licensed optometrist, licensed naprapath, licensed

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clinical psychologist, or licensed physical therapist, or
licensed pharmacist.
"Health care provider" means any entity in any of the
following license categories: licensed hospital, licensed home
health agency, licensed ambulatory surgical treatment center,
licensed long-term care facilities, or licensed emergency
medical services personnel, or licensed pharmacy.
This amendatory Act of the 94th General Assembly applies to
causes of action accruing on or after its effective date.
(Source: P.A. 93-51, eff. 7-1-03; 94-403, eff. 1-1-06.)
Section 99. Effective date. This Act takes effect January
1, 2018.