215 ILCS 125/1-2
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article I - Short Title And Definitions

 (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, 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 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 or dental care, 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.(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, 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 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.)