100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4443

 

Introduced , by Rep. Robyn Gabel

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/352  from Ch. 73, par. 964
215 ILCS 5/368a
305 ILCS 5/5-16.8

    Amends the Illinois Insurance Code. Provides that all managed care plans shall ensure that all claims and indemnities concerning health care services shall be paid within 30 days after receipt of a claim that has provided specified information on a CMS-1500 Health Insurance Claim Form or a UB-04 (CMS-1450) form. Provides that certain health care providers shall be notified of any known failure of the claim and provide detailed information on how the claim may be satisfied to receive payment within 30 days after receipt. Provides that any undisputed portions of a claim must be reimbursed by the managed care plan within 30 days after receipt. Grants the Department of Insurance specific authority to issue a cease and desist order, fine, or otherwise penalize managed care plans that violate provisions concerning timely payment for health care services. Provides that a policy issued or delivered to the Department of Healthcare and Family Services that provides coverage to certain persons is subject to the provisions concerning timely payment for health care services. Makes conforming changes in the Illinois Public Aid Code.


LRB100 16214 SMS 31872 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB4443LRB100 16214 SMS 31872 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Sections 352 and 368a as follows:
 
6    (215 ILCS 5/352)  (from Ch. 73, par. 964)
7    Sec. 352. Scope of Article.
8    (a) Except as provided in subsections (b), (c), (d), and
9(e), this Article shall apply to all companies transacting in
10this State the kinds of business enumerated in clause (b) of
11Class 1 and clause (a) of Class 2 of section 4. Nothing in this
12Article shall apply to, or in any way affect policies or
13contracts described in clause (a) of Class 1 of Section 4;
14however, this Article shall apply to policies and contracts
15which contain benefits providing reimbursement for the
16expenses of long term health care which are certified or
17ordered by a physician including but not limited to
18professional nursing care, custodial nursing care, and
19non-nursing custodial care provided in a nursing home or at a
20residence of the insured.
21    (b) (Blank).
22    (c) A policy issued and delivered in this State that
23provides coverage under that policy for certificate holders who

 

 

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1are neither residents of nor employed in this State does not
2need to provide to those nonresident certificate holders who
3are not employed in this State the coverages or services
4mandated by this Article.
5    (d) Stop-loss insurance is exempt from all Sections of this
6Article, except this Section and Sections 353a, 354, 357.30,
7and 370. For purposes of this exemption, stop-loss insurance is
8further defined as follows:
9        (1) The policy must be issued to and insure an
10    employer, trustee, or other sponsor of the plan, or the
11    plan itself, but not employees, members, or participants.
12        (2) Payments by the insurer must be made to the
13    employer, trustee, or other sponsors of the plan, or the
14    plan itself, but not to the employees, members,
15    participants, or health care providers.
16    (e) A policy issued or delivered in this State to the
17Department of Healthcare and Family Services (formerly
18Illinois Department of Public Aid) and providing coverage,
19under clause (b) of Class 1 or clause (a) of Class 2 as
20described in Section 4, to persons who are enrolled under
21Article V of the Illinois Public Aid Code or under the
22Children's Health Insurance Program Act is exempt from all
23restrictions, limitations, standards, rules, or regulations
24respecting benefits imposed by or under authority of this Code,
25except those specified by subsection (1) of Section 143,
26Section 368a, Section 370c, and Section 370c.1. Nothing in this

 

 

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1subsection, however, affects the total medical services
2available to persons eligible for medical assistance under the
3Illinois Public Aid Code.
4(Source: P.A. 99-480, eff. 9-9-15.)
 
5    (215 ILCS 5/368a)
6    Sec. 368a. Timely payment for health care services.
7    (a) This Section applies to insurers, health maintenance
8organizations, managed care plans, health care plans,
9preferred provider organizations, third party administrators,
10independent practice associations, and physician-hospital
11organizations (hereinafter referred to as "payors") that
12provide periodic payments, which are payments not requiring a
13claim, bill, capitation encounter data, or capitation
14reconciliation reports, such as prospective capitation
15payments, to health care professionals and health care
16facilities to provide medical or health care services for
17insureds or enrollees.
18        (1) A payor shall make periodic payments in accordance
19    with item (3). Failure to make periodic payments within the
20    period of time specified in item (3) shall entitle the
21    health care professional or health care facility to
22    interest at the rate of 9% per year from the date payment
23    was required to be made to the date of the late payment,
24    provided that interest amounting to less than $1 need not
25    be paid. Any required interest payments shall be made

 

 

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1    within 30 days after the payment.
2        (2) When a payor requires selection of a health care
3    professional or health care facility, the selection shall
4    be completed by the insured or enrollee no later than 30
5    days after enrollment. The payor shall provide written
6    notice of this requirement to all insureds and enrollees.
7    Nothing in this Section shall be construed to require a
8    payor to select a health care professional or health care
9    facility for an insured or enrollee.
10        (3) A payor shall provide the health care professional
11    or health care facility with notice of the selection as a
12    health care professional or health care facility by an
13    insured or enrollee and the effective date of the selection
14    within 60 calendar days after the selection. No later than
15    the 60th day following the date an insured or enrollee has
16    selected a health care professional or health care facility
17    or the date that selection becomes effective, whichever is
18    later, or in cases of retrospective enrollment only, 30
19    days after notice by an employer to the payor of the
20    selection, a payor shall begin periodic payment of the
21    required amounts to the insured's or enrollee's health care
22    professional or health care facility, or the designee of
23    either, calculated from the date of selection or the date
24    the selection becomes effective, whichever is later. All
25    subsequent payments shall be made in accordance with a
26    monthly periodic cycle.

 

 

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1    (b) Notwithstanding any other provision of this Section,
2independent practice associations and physician-hospital
3organizations shall make periodic payment of the required
4amounts in accordance with a monthly periodic schedule after an
5insured or enrollee has selected a health care professional or
6health care facility or after that selection becomes effective,
7whichever is later.
8    Notwithstanding any other provision of this Section,
9independent practice associations and physician-hospital
10organizations shall make all other payments for health services
11within 30 days after receipt of due proof of loss. Independent
12practice associations and physician-hospital organizations
13shall notify the insured, insured's assignee, health care
14professional, or health care facility of any failure to provide
15sufficient documentation for a due proof of loss within 30 days
16after receipt of the claim for health services.
17    Failure to pay within the required time period shall
18entitle the payee to interest at the rate of 9% per year from
19the date the payment is due to the date of the late payment,
20provided that interest amounting to less than $1 need not be
21paid. Any required interest payments shall be made within 30
22days after the payment.
23    (c) All insurers, health maintenance organizations,
24managed care plans, health care plans, preferred provider
25organizations, and third party administrators shall ensure
26that all claims and indemnities concerning health care services

 

 

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1other than for any periodic payment shall be paid within 30
2days after receipt of due written proof of such loss. An
3insured, insured's assignee, health care professional, or
4health care facility shall be notified of any known failure to
5provide sufficient documentation for a due proof of loss within
630 days after receipt of the claim for health care services.
7Failure to pay within such period shall entitle the payee to
8interest at the rate of 9% per year from the 30th day after
9receipt of such proof of loss to the date of late payment,
10provided that interest amounting to less than one dollar need
11not be paid. Any required interest payments shall be made
12within 30 days after the payment.
13    (c-5) All managed care plans shall ensure that all claims
14and indemnities concerning health care services other than for
15any periodic payment shall be paid within 30 days after receipt
16of a claim as defined under paragraph (1) or (2) of this
17subsection. An insured, insured's assignee, health care
18professional, or health care facility shall be notified of any
19known failure to provide sufficient documentation for a claim
20or why the claim or portion thereof is not complete or is in
21some manner deficient and specify in detail the information,
22documentation, or processes necessary for the insured,
23insured's assignee, health care professional, or health care
24facility to satisfy the requirements of this subsection and
25receive payment within 30 days after receipt of the claim for
26health care services. Any undisputed portions of a claim must

 

 

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1be reimbursed by the managed care plan within 30 days after
2receipt. Failure to pay within such period shall entitle the
3payee to interest at the rate of 9% per year from the 30th day
4after receipt of such proof of loss to the date of late
5payment, provided that interest amounting to less than one
6dollar need not be paid. Any required interest payments shall
7be made within 30 days after the payment.
8    For information submitted on a:
9        (1) CMS-1500 Health Insurance Claim Form, as
10    periodically updated and revised, the following minimum
11    requirements must be complete and received by the managed
12    care plan before the form is considered a claim for
13    purposes of this subsection (c-5):
 
           
14 Item Number Item Description
15 1a Insured's I.D. number
16 2 Patient's name
17 3Patient's birth date and sex
18 4Insured's name
19 10aPatient's condition – employment
20 10bPatient's condition – auto accident
21 10cPatient's condition – other accident
22 11Insured's policy group number (if
23 provided on I.D. card)
24 11dIs there another health benefit plan?
25 17aI.D. number of referring physician

 

 

 

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1 (if required by insurer)
2 21Diagnosis
3 24ADates of service
4 24BPlace of service
5 24DProcedures, services, or supplies
6 24EDiagnosis code
7 24FCharges
8 25Federal tax I.D. number
9 28Total charge
10 31Signature of physician or supplier
11 with date
12 33Physician's or supplier's billing name,
13 address, zip code, and phone number
14        (2) UB-04 (CMS-1450), as periodically updated and
15    revised, the following minimum requirements must be
16    complete and received by the managed care plan before the
17    form is considered a claim for purposes of this subsection
18    (c-5):
 
       
19 Item Number Item Description
20 1Provider name and address
21 5Federal tax I.D. number
22 6Statement covers period
23 12Patient name
24 14Patient's birthdate

 

 

 

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1 15Patient's sex
2 17Admission date
3 18Admission hour
4 19 Type of admission
5 21 Discharge hour
6 42 Revenue codes
7 43 Revenue description
8 44 HCPCS/CPT4 codes
9 45 Service date
10 46 Service units
11 47 Total charges by revenue code
12 50 Payer I.D.
13 51 Provider number
14 58 Insured's name
15 60 Patient's I.D. number (policy number,
16 social security number, or both)
17 62 Insurance group number (if on I.D. card)
18 67 Principal diagnosis code
19 76 Admitting diagnosis code
20 80 Principal procedure code and date
21 81 Other procedures code and date
22 82 Attending physician's I.D. number
23    (d) The Department shall enforce the provisions of this
24Section pursuant to the enforcement powers granted to it by
25law.

 

 

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1    (e) The Department is hereby granted specific authority to
2issue a cease and desist order, fine, or otherwise penalize
3managed care plans, independent practice associations, and
4physician-hospital organizations that violate this Section.
5The Department shall adopt reasonable rules to enforce
6compliance with this Section by managed care plans, independent
7practice associations, and physician-hospital organizations.
8(Source: P.A. 97-813, eff. 7-13-12.)
 
9    Section 10. The Illinois Public Aid Code is amended by
10changing Section 5-16.8 as follows:
 
11    (305 ILCS 5/5-16.8)
12    Sec. 5-16.8. Required health benefits. The medical
13assistance program shall (i) provide the post-mastectomy care
14benefits required to be covered by a policy of accident and
15health insurance under Section 356t and the coverage required
16under Sections 356g.5, 356u, 356w, 356x, 356z.6, and 356z.25 of
17the Illinois Insurance Code and (ii) be subject to the
18provisions of Sections 356z.19, 364.01, 368a, 370c, and 370c.1
19of the Illinois Insurance Code.
20    On and after July 1, 2012, the Department shall reduce any
21rate of reimbursement for services or other payments or alter
22any methodologies authorized by this Code to reduce any rate of
23reimbursement for services or other payments in accordance with
24Section 5-5e.

 

 

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1    To ensure full access to the benefits set forth in this
2Section, on and after January 1, 2016, the Department shall
3ensure that provider and hospital reimbursement for
4post-mastectomy care benefits required under this Section are
5no lower than the Medicare reimbursement rate.
6(Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15;
799-642, eff. 7-28-16; 100-138, eff. 8-18-17.)