SB2735 EnrolledLRB103 34765 RPS 64615 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
5adding Section 355.6 as follows:
 
6    (215 ILCS 5/355.6 new)
7    Sec. 355.6. Health care provider reimbursement.
8    (a) In this Section, "health care provider" has the
9meaning given to the term "provider" in Section 370g.
10    (b) Any group or individual policy of accident and health
11insurance or managed care plan amended, delivered, issued, or
12renewed on or after January 1, 2026 shall offer all reasonably
13available methods of payment from the insurer or managed care
14plan, or its contracted vendor, to the contracted health care
15provider, which shall include, but not be limited to, payment
16by check and electronic funds transfer. An insurer or managed
17care plan shall not mandate payment by credit card. For
18purposes of this subsection, "credit card" means a single-use
19or virtual credit card provided in an electronic, digital,
20facsimile, physical, or paper format.
21    (c) If one of the available payment methods has a fee
22associated with it, the insurer or managed care plan, or its
23contracted vendor, shall, prior to initiating the first

 

 

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1payment to an in-network health care provider or upon changing
2the payment methods available to a health care provider:
3        (1) notify the health care provider that there may be
4    fees associated with a particular payment method and that
5    the insurer or managed care plan, or its contracted
6    vendor, shall disclose any fees beyond what the health
7    care provider would normally pay to process a payment
8    using that payment method; and
9        (2) provide the health care provider with clear
10    instructions on the insurer's or managed care plan's, or
11    its contracted vendor's, website or through means other
12    than the contract offered to the health care provider as
13    to how to select each method.
14    (d) If a health care provider requests a change in the
15available payment method, the insurer or managed care plan, or
16its contracted vendor, shall implement the change to the
17payment method selected by the health care provider within 30
18business days, subject to federal and State verification
19measures to prevent fraud and abuse.
20    (e) An insurer or managed care plan shall not use a health
21care provider's preferred method of payment as a factor when
22deciding whether to provide credentials to a health care
23provider.
 
24    Section 10. The Health Maintenance Organization Act is
25amended by changing Section 5-3 as follows:
 

 

 

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1    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
2    Sec. 5-3. Insurance Code provisions.
3    (a) Health Maintenance Organizations shall be subject to
4the provisions of Sections 133, 134, 136, 137, 139, 140,
5141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
6154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
7355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1, 356m, 356q,
8356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
9356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
10356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
11356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,
12356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
13356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
14356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,
15356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
16356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
17356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
18368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
19408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
20subsection (2) of Section 367, and Articles IIA, VIII 1/2,
21XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
22Illinois Insurance Code.
23    (b) For purposes of the Illinois Insurance Code, except
24for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
25Health Maintenance Organizations in the following categories

 

 

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1are deemed to be "domestic companies":
2        (1) a corporation authorized under the Dental Service
3    Plan Act or the Voluntary Health Services Plans Act;
4        (2) a corporation organized under the laws of this
5    State; or
6        (3) a corporation organized under the laws of another
7    state, 30% or more of the enrollees of which are residents
8    of this State, except a corporation subject to
9    substantially the same requirements in its state of
10    organization as is a "domestic company" under Article VIII
11    1/2 of the Illinois Insurance Code.
12    (c) In considering the merger, consolidation, or other
13acquisition of control of a Health Maintenance Organization
14pursuant to Article VIII 1/2 of the Illinois Insurance Code,
15        (1) the Director shall give primary consideration to
16    the continuation of benefits to enrollees and the
17    financial conditions of the acquired Health Maintenance
18    Organization after the merger, consolidation, or other
19    acquisition of control takes effect;
20        (2)(i) the criteria specified in subsection (1)(b) of
21    Section 131.8 of the Illinois Insurance Code shall not
22    apply and (ii) the Director, in making his determination
23    with respect to the merger, consolidation, or other
24    acquisition of control, need not take into account the
25    effect on competition of the merger, consolidation, or
26    other acquisition of control;

 

 

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1        (3) the Director shall have the power to require the
2    following information:
3            (A) certification by an independent actuary of the
4        adequacy of the reserves of the Health Maintenance
5        Organization sought to be acquired;
6            (B) pro forma financial statements reflecting the
7        combined balance sheets of the acquiring company and
8        the Health Maintenance Organization sought to be
9        acquired as of the end of the preceding year and as of
10        a date 90 days prior to the acquisition, as well as pro
11        forma financial statements reflecting projected
12        combined operation for a period of 2 years;
13            (C) a pro forma business plan detailing an
14        acquiring party's plans with respect to the operation
15        of the Health Maintenance Organization sought to be
16        acquired for a period of not less than 3 years; and
17            (D) such other information as the Director shall
18        require.
19    (d) The provisions of Article VIII 1/2 of the Illinois
20Insurance Code and this Section 5-3 shall apply to the sale by
21any health maintenance organization of greater than 10% of its
22enrollee population (including, without limitation, the health
23maintenance organization's right, title, and interest in and
24to its health care certificates).
25    (e) In considering any management contract or service
26agreement subject to Section 141.1 of the Illinois Insurance

 

 

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1Code, the Director (i) shall, in addition to the criteria
2specified in Section 141.2 of the Illinois Insurance Code,
3take into account the effect of the management contract or
4service agreement on the continuation of benefits to enrollees
5and the financial condition of the health maintenance
6organization to be managed or serviced, and (ii) need not take
7into account the effect of the management contract or service
8agreement on competition.
9    (f) Except for small employer groups as defined in the
10Small Employer Rating, Renewability and Portability Health
11Insurance Act and except for medicare supplement policies as
12defined in Section 363 of the Illinois Insurance Code, a
13Health Maintenance Organization may by contract agree with a
14group or other enrollment unit to effect refunds or charge
15additional premiums under the following terms and conditions:
16        (i) the amount of, and other terms and conditions with
17    respect to, the refund or additional premium are set forth
18    in the group or enrollment unit contract agreed in advance
19    of the period for which a refund is to be paid or
20    additional premium is to be charged (which period shall
21    not be less than one year); and
22        (ii) the amount of the refund or additional premium
23    shall not exceed 20% of the Health Maintenance
24    Organization's profitable or unprofitable experience with
25    respect to the group or other enrollment unit for the
26    period (and, for purposes of a refund or additional

 

 

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1    premium, the profitable or unprofitable experience shall
2    be calculated taking into account a pro rata share of the
3    Health Maintenance Organization's administrative and
4    marketing expenses, but shall not include any refund to be
5    made or additional premium to be paid pursuant to this
6    subsection (f)). The Health Maintenance Organization and
7    the group or enrollment unit may agree that the profitable
8    or unprofitable experience may be calculated taking into
9    account the refund period and the immediately preceding 2
10    plan years.
11    The Health Maintenance Organization shall include a
12statement in the evidence of coverage issued to each enrollee
13describing the possibility of a refund or additional premium,
14and upon request of any group or enrollment unit, provide to
15the group or enrollment unit a description of the method used
16to calculate (1) the Health Maintenance Organization's
17profitable experience with respect to the group or enrollment
18unit and the resulting refund to the group or enrollment unit
19or (2) the Health Maintenance Organization's unprofitable
20experience with respect to the group or enrollment unit and
21the resulting additional premium to be paid by the group or
22enrollment unit.
23    In no event shall the Illinois Health Maintenance
24Organization Guaranty Association be liable to pay any
25contractual obligation of an insolvent organization to pay any
26refund authorized under this Section.

 

 

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1    (g) Rulemaking authority to implement Public Act 95-1045,
2if any, is conditioned on the rules being adopted in
3accordance with all provisions of the Illinois Administrative
4Procedure Act and all rules and procedures of the Joint
5Committee on Administrative Rules; any purported rule not so
6adopted, for whatever reason, is unauthorized.
7(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
8102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
91-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
10eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
11102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
121-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
13eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
14103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
156-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
16eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)