2023 Illinois Compiled Statutes › Chapter 215 - INSURANCE › 215 ILCS 125/ - Health Maintenance Organization Act. › Article I - Short Title And Definitions

(215 ILCS 125/Art. I heading)
ARTICLE I.  
		SHORT TITLE AND DEFINITIONS
(215 ILCS 125/1-1) (from Ch. 111 1/2, par. 1401)
Sec. 1-1. 
		
		This Act shall be known and may be cited as the "Health
Maintenance Organization Act".
(Source: P.A. 85-20.)
(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, 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 in which an organization
provides, arranges for, pays for, or reimburses the
cost of basic health care services, excluding any reasonable deductibles and copayments from providers selected by
the Health Maintenance Organization; and the arrangement
consists of providing for the provision of basic health care services that is 
distinguished from mere indemnification against the cost of such services
on a per capita prepaid basis, through insurance or otherwise, except as otherwise authorized by Section 2-3 of this Act.  A "health
care plan" also includes any arrangement in which an organization provides, arranges for, pays for, or reimburses 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
a provision for the delivery of health care services that is 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. Nothing in this definition shall be construed as requiring a health care plan or health maintenance organization to utilize a referral system that enrollees must use to access basic health care services and other health care services from providers that are under contract with or employed by the health maintenance organization. The Director may prescribe by rule the language that must be included in the plan name, marketing, advertising, or other consumer disclosure requirements to differentiate a health care plan that does not use a referral system for such providers from a health care plan that does use a referral system for such providers.
(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) "Referral system" means any arrangement in a health care plan in which  a primary care provider coordinates or manages the care of a health maintenance organization's enrollee by referring the enrollee to other providers or specialists.
(16) "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. 103-104, eff. 1-1-24.)
(215 ILCS 125/1-3) (from Ch. 111 1/2, par. 1402.1)
Sec. 1-3. 
		Definitions of admitted assets. 
		"Admitted Assets" includes
the investments authorized or permitted by Section 3-1 of this Act and, in
addition thereto, only the following:
(1) Amounts due from affiliates pursuant to     management contracts or service agreements which meet the requirements of Section 141.1 of the Illinois Insurance Code to the extent that the affiliate has liquid assets with which to pay the balance and maintain its accounts on a current basis; provided that the aggregate amount due from affiliates may not exceed the lesser of 10% of the organization's admitted assets or 25% of the organization's net worth as defined in Section 3-1.  Any amount outstanding more than 3 months shall be deemed not current.  For purpose of this subsection "affiliates" are as defined in Article VIII 1/2 of the Illinois Insurance Code.
(2) Amounts advanced to providers under contract to     the organization for services to be rendered to enrollees pursuant to the contract.  Amounts advanced must be for period of not more than 3 months and must be based on historical or estimated utilization patterns with the provider and must be reconciled against actual incurred claims at least semi-annually. Amounts due in the aggregate may not exceed 50% of the organization's net worth as defined in Section 3-1.  Amounts due from a single provider may not exceed the lesser of 5% of the organization's admitted assets or 10% of the organization's net worth.
(3) Amounts permitted under Section 2-7.
(Source: P.A. 91-357, eff. 7-29-99; 91-549, eff. 8-14-99; 92-16, eff.
6-28-01.)