Illinois Administrative Code › Title 50 - INSURANCE › Part 2051 - PREFERRED PROVIDER PROGRAMS › Section 2051.220 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Act" means the Health Care Reimbursement Reform Act of 1985 [
				215 ILCS 5 /Art. XX1/2].
"Administrator", "Preferred Provider Program Administrator" or
				"PPP Administrator" means any person, partnership or corporation, other than a
				risk-bearing entity that arranges, contracts with, or administers contracts
				with a provider under which insureds or beneficiaries are provided an incentive
				to use the services of the provider. Administrator also includes any person,
				partnership or corporation, other than a risk-bearing entity, that enters into
				a contract with another administrator to enroll beneficiaries or insureds in a
				preferred provider program marketed as an independently identifiable program
				based on marketing materials or member benefit identification cards. For the
				purposes of this Part, an employer shall be considered an administrator.
"Administrator Trust Fund" or "ATF" means a special fiduciary
				account established and maintained by an administrator pursuant to Section
				370
l
of the Act in which contributions and/or premiums are
				deposited.
"Advertisement" means any printed or published material,
				audiovisual material and descriptive literature of the administrator,
				discounted health care services plan administrator, or private label marketer
				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 administrator, discounted
				health care services plan administrator, or private label marketer for
				presentation to the public, including, but not limited to, circulars, leaflets,
				booklets, depictions, illustrations, form letters and prepared sales
				presentations.
"Affiliate" means a person that directly, or indirectly through
				one or more intermediaries, controls, or is controlled by, or is under common
				control with, the persons specified.
"Beneficiary" means an individual, enrollee, insured,
				participant or any other person entitled to reimbursement for covered expenses
				of, or the discounting of provider fees for, health care services under a
				program in which the beneficiary has an incentive to utilize the services of a
				provider that has entered into an agreement or arrangement with an
				administrator pursuant to Section 370g(f) of the Act. Beneficiary, for the
				purposes of a workers' compensation preferred provider program (WC PPP), shall
				also include covered employees.
"Code" means the Illinois Insurance Code [ 215 ILCS 5 ].
"Control", "controlling", "controlled by" and "under common
				control with" means the possession, directly or indirectly, of the power to
				direct or cause the direction of the management and policies of a person,
				whether through the ownership of voting securities, the holding of
				policyholders' proxies, by contract other than a commercial contract for goods
				or non-management services, or otherwise, unless the power is solely the result
				of an official position with or corporate office held by the person. Control is
				presumed to exist if any person, directly or indirectly, owns, controls, holds
				with the power to vote, or holds shareholders' proxies representing 10% or more
				of the voting securities of any other person, or holds or controls sufficient
				policyholders' proxies to elect the majority of the board of directors of the
				domestic company. This presumption may be rebutted by a showing made to the
				Director.
"Covered Employee" means an employee or former employee whose
				employer has established or contracted for an approved WC PPP for the provision
				of health care services to injured employees in accordance with Section
				8.1 a of the Workers'
				Compensation Act.
"Department" means the Illinois Department of Insurance.
"Director" means the Director of the Illinois Department of
				Insurance.
"Discounted Health Care Services" means health care services
				provided by health care services providers under a discounted health care
				services plan when there are no other incentives, such as copayment,
				coinsurance or any other reimbursement differential, for beneficiaries to
				utilize the provider.
"Discounted Health Care Services Plan" or "DHCSP" means a
				preferred provider program by which beneficiaries, in exchange for fees, dues,
				charges or other consideration, are provided an incentive, in the form of
				discounted health care services, to use the services of the provider.
"Discounted Health Care Services Plan Administrator" or "DHCSP
				Administrator" means an administrator that arranges, contracts with, or
				administers contracts with a provider under which insureds or beneficiaries are
				provided an incentive to use health care services provided by health care
				services providers under a discounted health care services plan in which there
				are no other incentives, such as copayment, coinsurance or any other
				reimbursement differential, for beneficiaries to utilize the provider. DHCSP
				administrator also includes any person, partnership or corporation, other than
				a risk-bearing entity, that enters into a contract with another DHCSP
				administrator to enroll beneficiaries or insureds in a DHCSP marketed as an
				independently identifiable program based on marketing materials or member
				benefit identification cards.
"Doing Business As" or "DBA" means the name under which
				discounted health care services are marketed.
"Economic Evaluation" means any evaluation, as described in
				Section 8.1a(b) of the Workers' Compensation Act, of a particular physician,
				provider, medical group or individual practice association based in whole or in
				part on the economic costs or utilization of services associated with medical
				care provided or authorized by the physician, provider, medical group or
				individual practice association. Negotiated rates with a provider are not a
				form of economic evaluation.
"Employer" means an employer contracting directly with
				providers, or with multiple WC PPP administrators for the purposes of
				implementing a preferred provider program under Section 8.1a of the Workers'
				Compensation Act.
"Exclusive Provider Organization" or "EPO" means any
				arrangement, other than a health maintenance organization, limited health
				service organization, voluntary health services plans, or a DHCSP, under which
				the beneficiary receives no coverage or benefits when utilizing non-preferred
				providers, except when such an arrangement is shown to be in the best interest
				of the beneficiaries and has been expressly approved by the Director in
				writing. WC PPPs are not a form of EPO.
"Financial Institution" means a federal or State chartered bank
				or savings and loan institution.
"Gatekeeper Option" means an option offered by or through a
				preferred provider program that requires the beneficiary to preselect a
				particular primary care physician, from a list of participating primary care
				physicians, who shall coordinate all of the non-emergency primary, specialty,
				hospital and other health care services, including referrals to other
				providers, as a condition for receipt of a higher level of benefits or
				reimbursement level, or both.
"Health Care Preferred Provider Program" or "HC PPP" means a
				preferred provider program for the provision of health care services provided
				for health insurance or discounted health care services coverage.
"Health Care Preferred Provider Program Administrator" or "HC
				PPP Administrator" means an administrator of an HC PPP. HC PPP administrator
				also includes any person, partnership or corporation, other than a risk-bearing
				entity, that enters into a contract with another HC PPP administrator to enroll
				beneficiaries or insureds in an HC PPP marketed as an independently
				identifiable program based on marketing materials or member benefit
				identification cards.
"Health Care Services" means health care services or products
				rendered or sold by a provider within the scope of the provider's license or
				legal authorization. The term includes, but is not limited to, hospital,
				medical, surgical, dental, vision and pharmaceutical services or
				products.
"Health Service Corporation" means a voluntary health service
				plan and/or a dental service plan licensed under the Voluntary Health Services
				Plans Act [ 215 ILCS 165 ] or the Dental Service Plan Act [ 215 ILCS 110
				].
"HMO Act" means the Health Maintenance Organization Act [ 215
				ILCS 125 ].
"Non-preferred Provider" means any provider that does not have
				a contractual relationship, directly or indirectly, with the administrator or
				DHCSP administrator for the provision of, or discounting of, health care
				services.
"Payor" means an entity responsible for bearing the risk of
				health care services. An administrator other than a self-insured employer
				implementing a WC PPP, is prohibited from being a payor and may not bear or
				assume any underwriting risk.
"Preferred Provider" means any provider who has entered, either
				directly or indirectly, into an agreement with an administrator, employer or
				risk-bearing entity relating to health care services that may be rendered to
				beneficiaries under a preferred provider program, including providing discounts
				for health care services.
"Preferred Provider Arrangements" means policies, agreements or
				arrangements with providers relating to the amounts to be charged to
				beneficiaries or, in the case of Workers' Compensation preferred provider
				programs, employers, for health care services that include incentives for the
				beneficiary to use those services, including discounted health care
				services.
"Preferred Provider Program" or "PPP" means a system to make
				preferred provider arrangements available to beneficiaries.
"Primary Care Physician" means a provider who has contracted
				with an administrator to provide primary care services as defined by the
				contract and who is a physician licensed to practice medicine in all of its
				branches who spends a majority of clinical time engaged in general practice or
				in the practice of internal medicine, pediatrics, gynecology, obstetrics or
				family practice, or a chiropractic physician licensed to treat human ailments
				without the use of drugs or operative surgery. (See 77 Ill. Adm. Code
				240.20.)
"Primary Treating Physician" means a provider who has
				contracted with a WC PPP administrator to provide health care services and who
				is a type of physician licensed to treat the injury experienced by the covered
				employee. This physician will be responsible for managing the care of the
				covered employee, including rendering and prescribing treatment.
"Private Label Marketer" means any entity, other than a DHCSP
				administrator, that directly or indirectly contracts with an administrator
				respecting the marketing or use of a DHCSP under a name other than that of the
				administrator.
"Provider" means an individual or entity duly licensed or
				legally authorized to provide health care services.
"Risk-Bearing Entity" means an insurer, health service
				corporation, limited health service organization holding a certificate of
				authority under the Limited Health Service Organization Act [ 215 ILCS 130 ],
				or health maintenance organization holding a certificate of authority under the
				HMO Act.
"Specialty Preferred Provider Program Administrator" or "SPPP
				Administrator" means an administrator of a preferred provider program for the
				provision of workers' compensation benefits that contracts with preferred
				providers for health care services in one or a limited number of health care
				specialties, including but not limited to ambulance services, durable medical
				equipment, lab and imaging services, home health services, physical and
				occupational therapy and pharmacy benefits. SPPP administrators are subject to
				the requirements of a WC PPP administrator, unless specifically exempted, and
				must contract with a WC PPP administrator to supplement WC PPPs approved by the
				Director of Insurance.
"Workers' Compensation Preferred Provider Program" or "WC PPP"
				means a preferred provider program for the provision of workers' compensation
				benefits that meets the requirements of Section 8.1a of the Workers'
				Compensation Act.
"Workers' Compensation Preferred Provider Program
				Administrator" or "WC PPP Administrator" means an administrator of a WC
				PPP.