98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB5615

 

Introduced , by Rep. Jim Durkin

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 134/5
215 ILCS 134/15
215 ILCS 134/30

    Amends the Managed Care Reform and Patient Rights Act. Provides that an individual's right to purchase any health care services with that individual's own funds may not be invalidated through a contractual provision or requirement between the insurer and a participating health care provider. Requires audiological services providers to provide to enrollees, upon request, a detailed and itemized statement with information outlining the costs of audiological devices, the plan payment amounts, and the amount of out-of-pocket costs to be paid by the enrollee for the various device options available to treat the enrollee's condition. Provides that no health care plan nor its subcontractors may, by contract, written policy, procedure, or otherwise, mandate or prohibit an enrollee from purchasing audiological equipment with a value over and above the plan benefit.


LRB098 18093 RPM 53222 b

 

 

A BILL FOR

 

HB5615LRB098 18093 RPM 53222 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 Managed Care Reform and Patient Rights Act
5is amended by changing Sections 5, 15, and 30 as follows:
 
6    (215 ILCS 134/5)
7    Sec. 5. Health care patient rights.
8    (a) The General Assembly finds that:
9        (1) A patient has the right to care consistent with
10    professional standards of practice to assure quality
11    nursing and medical practices, to choose the participating
12    physician responsible for coordinating his or her care, to
13    receive information concerning his or her condition and
14    proposed treatment, to refuse any treatment to the extent
15    permitted by law, and to privacy and confidentiality of
16    records except as otherwise provided by law.
17        (2) A patient has the right, regardless of source of
18    payment, to examine and to receive a reasonable explanation
19    of his or her total bill for health care services rendered
20    by his or her physician or other health care provider,
21    including the itemized charges for specific health care
22    services received. A physician or other health care
23    provider has responsibility only for a reasonable

 

 

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1    explanation of those specific health care services
2    provided by the health care provider.
3        (3) A patient has the right to timely prior notice of
4    the termination whenever a health care plan cancels or
5    refuses to renew an enrollee's participation in the plan.
6        (4) A patient has the right to privacy and
7    confidentiality in health care. This right may be expressly
8    waived in writing by the patient or the patient's guardian.
9        (5) An individual has the right to purchase any health
10    care services with that individual's own funds, and that
11    right may not be invalidated through a contractual
12    provision or requirement between the insurer and a
13    participating health care provider.
14    (b) Nothing in this Section shall preclude the health care
15plan from sharing information for plan quality assessment and
16improvement purposes as required by Section 80.
17(Source: P.A. 91-617, eff. 1-1-00.)
 
18    (215 ILCS 134/15)
19    Sec. 15. Provision of information.
20    (a) A health care plan shall provide annually to enrollees
21and prospective enrollees, upon request, a complete list of
22participating health care providers in the health care plan's
23service area and a description of the following terms of
24coverage:
25        (1) the service area;

 

 

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1        (2) the covered benefits and services with all
2    exclusions, exceptions, and limitations;
3        (3) the pre-certification and other utilization review
4    procedures and requirements;
5        (4) a description of the process for the selection of a
6    primary care physician, any limitation on access to
7    specialists, and the plan's standing referral policy;
8        (5) the emergency coverage and benefits, including any
9    restrictions on emergency care services;
10        (6) the out-of-area coverage and benefits, if any;
11        (7) the enrollee's financial responsibility for
12    copayments, deductibles, premiums, and any other
13    out-of-pocket expenses;
14        (8) the provisions for continuity of treatment in the
15    event a health care provider's participation terminates
16    during the course of an enrollee's treatment by that
17    provider;
18        (9) the appeals process, forms, and time frames for
19    health care services appeals, complaints, and external
20    independent reviews, administrative complaints, and
21    utilization review complaints, including a phone number to
22    call to receive more information from the health care plan
23    concerning the appeals process; and
24        (10) a statement of all basic health care services and
25    all specific benefits and services mandated to be provided
26    to enrollees by any State law or administrative rule.

 

 

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1    In the event of an inconsistency between any separate
2written disclosure statement and the enrollee contract or
3certificate, the terms of the enrollee contract or certificate
4shall control.
5    (b) Upon written request, a health care plan shall provide
6to enrollees a description of the financial relationships
7between the health care plan and any health care provider and,
8if requested, the percentage of copayments, deductibles, and
9total premiums spent on healthcare related expenses and the
10percentage of copayments, deductibles, and total premiums
11spent on other expenses, including administrative expenses,
12except that no health care plan shall be required to disclose
13specific provider reimbursement.
14    (c) A participating health care provider shall provide all
15of the following, where applicable, to enrollees upon request:
16        (1) Information related to the health care provider's
17    educational background, experience, training, specialty,
18    and board certification, if applicable.
19        (2) The names of licensed facilities on the provider
20    panel where the health care provider presently has
21    privileges for the treatment, illness, or procedure that is
22    the subject of the request.
23        (3) Information regarding the health care provider's
24    participation in continuing education programs and
25    compliance with any licensure, certification, or
26    registration requirements, if applicable.

 

 

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1        (4) With regard to audiological services providers, a
2    detailed and itemized statement with information outlining
3    the costs of audiological devices, the plan payment
4    amounts, and the amount of out-of-pocket costs to be paid
5    by the enrollee for the various device options available to
6    treat the enrollee's condition.
7    (d) A health care plan shall provide the information
8required to be disclosed under this Act upon enrollment and
9annually thereafter in a legible and understandable format. The
10Department shall promulgate rules to establish the format
11based, to the extent practical, on the standards developed for
12supplemental insurance coverage under Title XVIII of the
13federal Social Security Act as a guide, so that a person can
14compare the attributes of the various health care plans.
15    (e) The written disclosure requirements of this Section may
16be met by disclosure to one enrollee in a household.
17(Source: P.A. 91-617, eff. 1-1-00.)
 
18    (215 ILCS 134/30)
19    Sec. 30. Prohibitions.
20    (a) No health care plan or its subcontractors may prohibit
21or discourage health care providers by contract or policy from
22discussing any health care services and health care providers,
23utilization review and quality assurance policies, terms and
24conditions of plans and plan policy with enrollees, prospective
25enrollees, providers, or the public.

 

 

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1    (b) No health care plan by contract, written policy, or
2procedure may permit or allow an individual or entity to
3dispense a different drug in place of the drug or brand of drug
4ordered or prescribed without the express permission of the
5person ordering or prescribing the drug, except as provided
6under Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
7    (b-5) No health care plan nor its subcontractors may, by
8contract, written policy, procedure, or otherwise, mandate or
9prohibit an enrollee from purchasing audiological equipment
10with a value over and above the plan benefit.
11    (c) No health care plan or its subcontractors may by
12contract, written policy, procedure, or otherwise mandate or
13require an enrollee to substitute his or her participating
14primary care physician under the plan during inpatient
15hospitalization, such as with a hospitalist physician licensed
16to practice medicine in all its branches, without the agreement
17of that enrollee's participating primary care physician.
18"Participating primary care physician" for health care plans
19and subcontractors that do not require coordination of care by
20a primary care physician means the participating physician
21treating the patient. All health care plans shall inform
22enrollees of any policies, recommendations, or guidelines
23concerning the substitution of the enrollee's primary care
24physician when hospitalization is necessary in the manner set
25forth in subsections (d) and (e) of Section 15.
26    (d) Any violation of this Section shall be subject to the

 

 

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1penalties under this Act.
2(Source: P.A. 94-866, eff. 6-16-06.)