96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
SB0688


 
Introduced 2/6/2009, by Sen. John J. Cullerton
 
SYNOPSIS AS INTRODUCED:














215 ILCS 134/65









 Amends the Managed Care Reform and Patient Rights Act. Makes a technical
change in a Section concerning emergency services.
















LRB096 06752 RPM 16836 b

















 


 


A BILL FOR









 











SB0688

LRB096 06752 RPM 16836 b






1
 AN ACT concerning regulation.


2
 Be it enacted by the People of the State of Illinois, 
3
represented in the General Assembly: 


4
 Section 5. The Managed Care Reform and Patient Rights Act 
5
is amended by changing Section 65 as follows:




6
 (215 ILCS 134/65)



7
 Sec. 65. Emergency services prior to stabilization. 

8
 (a) A health care plan
that
that provides or that is 
9
required by law to provide coverage for emergency
services 
10
shall provide coverage such that payment under this coverage is 
11
not
dependent upon whether the services are performed by a plan 
12
or non-plan health
care provider and without regard to prior 
13
authorization. This coverage shall be
at the same benefit level 
14
as if the services or treatment had been rendered by
the health 
15
care plan physician licensed to practice medicine in all
its 
16
branches or health care provider.
17
 (b) Prior authorization or approval by the plan shall not 
18
be required for
emergency services.

19
 (c) Coverage and payment shall only be retrospectively 
20
denied under the
following circumstances:


21
  (1) upon reasonable determination that the emergency 
22
 services claimed were
never performed;


23
  (2) upon timely determination that the emergency 
 


 






SB0688
- 2 -
LRB096 06752 RPM 16836 b





1
 evaluation and treatment
were
rendered to an enrollee who 
2
 sought emergency services and whose circumstance
did not 
3
 meet the definition of emergency medical condition;


4
  (3) upon determination that the patient receiving such 
5
 services was not an
enrollee of the health care plan; or


6
  (4) upon material misrepresentation by the enrollee or 
7
 health care
provider; "material" means a fact or situation 
8
 that is not merely technical in
nature and results or could 
9
 result in a substantial change in the situation.

10
 (d) When an enrollee presents to a hospital seeking 
11
emergency services,
the determination as to whether the need 
12
for those
services exists shall be made for purposes of 
13
treatment by a
physician licensed to practice medicine in all 
14
its branches or, to the extent
permitted by applicable law, by 
15
other appropriately licensed
personnel under the supervision 
16
of
or in collaboration with a physician licensed to practice 
17
medicine in all its
branches.
The physician or other

18
appropriate personnel shall indicate in the patient's chart the 
19
results of the
emergency medical screening examination.

20
 (e) The appropriate use of the 911 emergency telephone 
21
system or its local
equivalent shall not be discouraged or 
22
penalized by the health care plan when
an emergency medical 
23
condition exists.
This provision shall not imply that the use 
24
of 911 or its local equivalent is a
factor in determining the 
25
existence of an emergency medical condition.

26
 (f) The medical director's or his or her designee's

 


 






SB0688
- 3 -
LRB096 06752 RPM 16836 b





1
determination of whether the enrollee meets the standard of an 
2
emergency
medical condition shall be based solely upon the 
3
presenting symptoms documented
in the medical record at the 
4
time care was
sought.
Only a clinical peer may make an adverse 
5
determination.

6
 (g) Nothing in this Section shall prohibit the imposition 
7
of deductibles,
copayments, and co-insurance.
Nothing in this 
8
Section alters the prohibition on billing enrollees contained

9
in the Health Maintenance Organization Act.

10
(Source: P.A. 91-617, eff. 1-1-00.)