215 ILCS 130/1002
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 130/ - Limited Health Service Organization Act.|Article 1 - Short Title And Definitions

 (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 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 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, 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 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, 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 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.)