Rep. Daniel J. Burke

Filed: 3/5/2012

 

 


 

 


 
09700HB3812ham002LRB097 13098 RPM 67113 a

1
AMENDMENT TO HOUSE BILL 3812

2    AMENDMENT NO. ______. Amend House Bill 3812 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 368c as follows:
 
6    (215 ILCS 5/368c)
7    Sec. 368c. Remittance advice and procedures.
8    (a) A remittance advice shall be furnished to a health care
9professional or health care provider that identifies the
10disposition of each claim. The remittance advice shall identify
11the services billed; the patient responsibility, if any; the
12actual payment, if any, for the services billed; and the reason
13for any reduction to the amount for which the claim was
14submitted. For any reductions to the amount for which the claim
15was submitted, the remittance shall identify any withholds and
16the reason for any denial or reduction.

 

 

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1    A remittance advice for capitation or prospective payment
2arrangements shall be furnished to a health care professional
3or health care provider pursuant to a contract with an insurer,
4health maintenance organization, independent practice
5association, or physician hospital organization in accordance
6with the terms of the contract.
7    (b) When health care services are provided by a
8non-participating health care professional or health care
9provider, an insurer, health maintenance organization,
10independent practice association, or physician hospital
11organization may pay for covered services either to a patient
12directly or to the non-participating health care professional
13or health care provider.
14    (c) When a person presents a benefits information card, a
15health care professional or health care provider shall make a
16good faith effort to inform the person if the health care
17professional or health care provider is not a participating
18provider has a participation contract with the insurer, health
19maintenance organization, or other entity identified on the
20card.
21(Source: P.A. 93-261, eff. 1-1-04.)
 
22    Section 10. The Managed Care Reform and Patient Rights Act
23is amended by changing Section 15 as follows:
 
24    (215 ILCS 134/15)

 

 

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1    Sec. 15. Provision of information.
2    (a) A health care plan shall provide annually to enrollees
3and prospective enrollees, upon request, a complete list of
4participating health care providers in the health care plan's
5service area and a description of the following terms of
6coverage:
7        (1) the service area;
8        (2) the covered benefits and services with all
9    exclusions, exceptions, and limitations;
10        (3) the pre-certification and other utilization review
11    procedures and requirements;
12        (4) a description of the process for the selection of a
13    primary care physician, any limitation on access to
14    specialists, and the plan's standing referral policy for
15    participating providers and participating health care
16    professionals;
17        (5) the emergency coverage and benefits, including any
18    restrictions on emergency care services;
19        (6) the out-of-area coverage and benefits, if any;
20        (7) the enrollee's financial responsibility for
21    copayments, deductibles, premiums, and any other
22    out-of-pocket expenses;
23        (8) the provisions for continuity of treatment in the
24    event a health care provider's participation terminates
25    during the course of an enrollee's treatment by that
26    provider;

 

 

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1        (9) the appeals process, forms, and time frames for
2    health care services appeals, complaints, and external
3    independent reviews, administrative complaints, and
4    utilization review complaints, including a phone number to
5    call to receive more information from the health care plan
6    concerning the appeals process; and
7        (10) a statement of all basic health care services and
8    all specific benefits and services mandated to be provided
9    to enrollees by any State law or administrative rule.
10    In the event of an inconsistency between any separate
11written disclosure statement and the enrollee contract or
12certificate, the terms of the enrollee contract or certificate
13shall control.
14    (a-5) The required list of participating health care
15providers shall be provided via the health care plan's Internet
16website and shall be updated at least every 30 days on a
17good-faith effort based on information made available to the
18plan for credentialed providers. The health care plan shall
19regularly inform policyholders, insureds, or enrollees to
20consult the list of participating health care providers to
21allow policyholders, insureds, or enrollees to make informed
22decisions prior to making appointments. The health plan shall
23also make available the procedures for making referrals both
24within and outside the network to insureds, enrollees, and
25participating health care providers and health care
26professionals, as well as the possibility of reduced benefits

 

 

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1for services provided by a non-participating health care
2provider or a non-participating health care professional.
3Further, the health care plan shall maintain a toll-free
4telephone number for policyholders, insureds, enrollees, or
5health care providers to verify whether a health care provider
6is a participating provider.
7    (a-10) Notwithstanding any other provision of this Act or
8the Illinois Insurance Code, when a person presents a benefits
9information card, a health care provider shall make a good
10faith effort to inform the person if the health care provider
11is not a participating provider with the insurer, health
12maintenance organization, or other entity identified on the
13card.
14    (b) Upon written request, a health care plan shall provide
15to enrollees a description of the financial relationships
16between the health care plan and any health care provider and,
17if requested, the percentage of copayments, deductibles, and
18total premiums spent on healthcare related expenses and the
19percentage of copayments, deductibles, and total premiums
20spent on other expenses, including administrative expenses,
21except that no health care plan shall be required to disclose
22specific provider reimbursement.
23    (c) A participating health care provider shall provide all
24of the following, where applicable, to enrollees upon request:
25        (1) Information related to the health care provider's
26    educational background, experience, training, specialty,

 

 

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1    and board certification, if applicable.
2        (2) The names of licensed facilities on the provider
3    panel where the health care provider presently has
4    privileges for the treatment, illness, or procedure that is
5    the subject of the request.
6        (3) Information regarding the health care provider's
7    participation in continuing education programs and
8    compliance with any licensure, certification, or
9    registration requirements, if applicable.
10    (d) A health care plan shall provide the information
11required to be disclosed under this Act upon enrollment and
12annually thereafter in a legible and understandable format,
13except as provided in item (a-5). The Department shall
14promulgate rules to establish the format based, to the extent
15practical, on the standards developed for supplemental
16insurance coverage under Title XVIII of the federal Social
17Security Act as a guide, so that a person can compare the
18attributes of the various health care plans.
19    (e) The written disclosure requirements of this Section may
20be met by disclosure to one enrollee in a household.
21(Source: P.A. 91-617, eff. 1-1-00.)".