Public Act 93-0261

HB1074 Enrolled                      LRB093 05507 JLS 05598 b

    AN ACT in relation to insurance.

    Be it enacted by the People of  the  State  of  Illinois,
represented in the General Assembly:

    Section  5.  The  Illinois  Insurance  Code is amended by
changing Section 370k and adding Sections 368b,  368c,  368d,
and 368e as follows:

    (215 ILCS 5/368b new)
    Sec. 368b.  Contracting procedures.
    (a)  A  health  care professional or health care provider
offered  a  contract  by  an  insurer,   health   maintenance
organization,  independent practice association, or physician
hospital organization for signature after the effective  date
of  this amendatory Act of the 93rd General Assembly shall be
provided with a proposed health care professional  or  health
care  provider  services contract including, if any, exhibits
and  attachments  that  the  contract  indicates  are  to  be
attached. Within 35 days after a written request, the  health
care  professional or health care provider offered a contract
shall be given the opportunity to review and obtain a copy of
the following: a specialty-specific fee schedule sample based
on a minimum of the 50 highest volume fee schedule codes with
the rates applicable  to  the  health  care  professional  or
health  care  provider  to  whom the contract is offered, the
network  provider  administration  manual,  and   a   summary
capitation  schedule,  if  payment  is  made  on a capitation
basis. If 50 codes do not exist for a  particular  specialty,
the  health care professional or health care provider offered
a contract shall be given the opportunity to review or obtain
a copy of a fee schedule sample with the codes applicable  to
that  particular  specialty. This information may be provided
electronically. An insurer, health maintenance  organization,
independent   practice  association,  or  physician  hospital
organization may substitute the fee schedule  sample  with  a
document  providing  reference  to  the information needed to
calculate the fee schedule that is available to the public at
no charge and the percentage or conversion  factor  at  which
the   insurer,  health  maintenance  organization,  preferred
provider organization, independent practice  association,  or
physician hospital organization sets its rates.
    (b)  The  fee  schedule, the capitation schedule, and the
network    provider    administration    manual    constitute
confidential, proprietary, and trade secret  information  and
are  subject  to the provisions of the Illinois Trade Secrets
Act. The health care professional  or  health  care  provider
receiving   such   protected  information  may  disclose  the
information on a need to know basis and only  to  individuals
and  entities  that  provide services directly related to the
health care professional's or health care provider's decision
to enter into the contract or keep the contract in force. Any
person  or  entity  receiving  or  reviewing  such  protected
information pursuant to this Section shall not  disclose  the
information  to  any  other  person, organization, or entity,
unless the disclosure is requested pursuant to a valid  court
order  or  required  by a state or federal government agency.
Individuals or entities receiving  such  information  from  a
health   care   professional   or  health  care  provider  as
delineated in this subsection are subject to  the  provisions
of the Illinois Trade Secrets Act.
    (c)  The health care professional or health care provider
shall  be  allowed at least 30 days to review the health care
professional  or  health  care  provider  services  contract,
including exhibits and attachments, if any,  before  signing.
The  30-day  review  period begins upon receipt of the health
care  professional or health care provider services contract,
unless the information available upon request  in  subsection
(a)  is  not  included. If information is not included in the
professional services contract and is requested  pursuant  to
subsection  (a),  the 30-day review period begins on the date
of receipt of the information.  Nothing  in  this  subsection
shall  prohibit  a  health  care  professional or health care
provider from signing a contract prior to the  expiration  of
the 30-day review period.
    (d)  The   insurer,   health   maintenance  organization,
independent  practice  association,  or  physician   hospital
organization   shall   provide  all  contracted  health  care
professionals or health care providers with  any  changes  to
the fee schedule provided under subsection (a) not later than
35  days after the effective date of the changes, unless such
changes are specified in the contract  and  the  health  care
professional or health care provider is able to calculate the
changed  rates  based  on  information  in  the  contract and
information available to the public at  no  charge.  For  the
purposes  of  this subsection, "changes" means an increase or
decrease in the fee schedule referred to in  subsection  (a).
This  information  may  be  made  available  by mail, e-mail,
newsletter, website listing, or other reasonable method. Upon
request, a health care professional or health  care  provider
may  request  an updated copy of the fee schedule referred to
in subsection (a) every calendar quarter.
    (e)  Upon termination of  a  contract  with  an  insurer,
health   maintenance   organization,   independent   practice
association,  or  physician  hospital organization and at the
request of the patient, a health care professional or  health
care  provider shall transfer copies of the patient's medical
records. Any other  provision  of  law  notwithstanding,  the
costs  for copying and transferring copies of medical records
shall be assigned per the arrangements agreed upon,  if  any,
in  the  health  care  professional  or  health care provider
services contract.
    (215 ILCS 5/368c new)
    Sec. 368c.  Remittance advice and procedures.
    (a)  A remittance advice shall be furnished to  a  health
care professional or health care provider that identifies the
disposition  of  each  claim.   The  remittance  advice shall
identify the services billed; the patient responsibility,  if
any; the actual payment, if any, for the services billed; and
the  reason  for  any  reduction  to the amount for which the
claim was submitted.  For any reductions to  the  amount  for
which  the claim was submitted, the remittance shall identify
any withholds and the reason for any denial or reduction.
    A remittance advice for capitation or prospective payment
arrangements shall be furnished to a health care professional
or health care  provider  pursuant  to  a  contract  with  an
insurer,   health   maintenance   organization,   independent
practice  association,  or physician hospital organization in
accordance with the terms of the contract.
    (b)  When  health  care  services  are  provided   by   a
non-participating  health  care  professional  or health care
provider,  an  insurer,  health   maintenance   organization,
independent   practice  association,  or  physician  hospital
organization may pay for covered services either to a patient
directly or to the non-participating health care professional
or health care provider.
    (c)  When a person presents a benefits information  card,
a health care professional or health care provider shall make
a  good  faith effort to inform the person if the health care
professional or health  care  provider  has  a  participation
contract  with  the insurer, health maintenance organization,
or other entity identified on the card.

    (215 ILCS 5/368d new)
    Sec. 368d.  Recoupments.
    (a)  A health care professional or health  care  provider
shall  be provided a remittance advice, which must include an
explanation of a recoupment or offset taken  by  an  insurer,
health   maintenance   organization,   independent   practice
association,  or physician hospital organization, if any. The
recoupment explanation shall, at a minimum, include the  name
of  the  patient; the date of service; the service code or if
no service code  is  available  a  service  description;  the
recoupment  amount;  and  the  reason  for  the recoupment or
offset.  In  addition,   an   insurer,   health   maintenance
organization,  independent practice association, or physician
hospital  organization  shall  provide  with  the  remittance
advice a telephone number or mailing address to  initiate  an
appeal of the recoupment or offset.
    (b)  It   is   not   a  recoupment  when  a  health  care
professional or  health  care  provider  is  paid  an  amount
prospectively  or  concurrently  under  a  contract  with  an
insurer,   health   maintenance   organization,   independent
practice association, or physician hospital organization that
requires  a  retrospective reconciliation based upon specific
conditions outlined in the contract.

    (215 ILCS 5/368e new)
    Sec. 368e.  Administration and enforcement.
    (a)  Other  than  the  duties  specifically  created   in
Sections  368b,  368c, and 368d, nothing in those Sections is
intended to  preclude,  prevent,  or  require  the  adoption,
modification,  or  termination of any utilization management,
quality management, or  claims  processing  methodologies  or
other   provisions  of  a  contract  applicable  to  services
provided  under  a  contract  between  an   insurer,   health
maintenance  organization,  independent practice association,
or  physician  hospital  organization  and  a   health   care
professional or health care provider.
    (b)  Nothing  in Sections 368b, 368c, and 368d precludes,
prevents,  or  requires  the   adoption,   modification,   or
termination  of  any  health  plan term, benefit, coverage or
eligibility provision, or payment methodology.
    (c)  The provisions of Sections 368b, 368c, and 368d  are
deemed  incorporated into health care professional and health
care provider service contracts entered into on or before the
effective date of this amendatory Act  of  the  93rd  General
Assembly  and  do  not require an insurer, health maintenance
organization, independent practice association, or  physician
hospital  organization  to renew or renegotiate the contracts
with a health care professional or health care provider.
    (d)  The Department shall enforce the provisions of  this
Section  and  Sections  368b,  368c, and 368d pursuant to the
enforcement powers granted to it by law.
    (e)  The Department is hereby granted specific  authority
to issue a cease and desist order against, fine, or otherwise
penalize     independent     practice     associations    and
physician-hospital organizations for violations.
    (f)  The  Department  shall  adopt  reasonable  rules  to
enforce compliance with this Section and Sections 368b, 368c,
and 368d.

    (215 ILCS 5/370k) (from Ch. 73, par. 982k)
    Sec. 370k. Registration.
    (a)  All administrators of a preferred  provider  program
subject to this Article shall register with the Department of
Insurance,  which  shall  by rule establish criteria for such
registration including minimum solvency requirements  and  an
annual registration fee for each administrator.
    (b)  The   Department  of  Insurance  shall  compile  and
maintain   a   listing   updated   at   least   annually   of
administrators and insurers  offering  agreements  authorized
under this Article.
    (c)  Preferred provider administrators are subject to the
provisions  of  Sections  368b,  368c, 368d, and 368e of this
Code.
(Source: P.A. 84-618.)

    Section 10.  The Health Maintenance Organization  Act  is
amended by changing Section 5-3 as follows:

    (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
    Sec. 5-3.  Insurance Code provisions.
    (a)  Health Maintenance Organizations shall be subject to
the  provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
141.3, 143, 143c, 147, 148, 149, 151, 152, 153,  154,  154.5,
154.6,  154.7,  154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
356y, 356z.2, 367i, 368a, 368b, 368c, 368d, 368e, 401, 401.1,
402, 403,  403A,  408,  408.2,  409,  412,  444,  and  444.1,
paragraph  (c) of subsection (2) of Section 367, and Articles
IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
the Illinois Insurance Code.
    (b)  For purposes of the Illinois Insurance Code,  except
for  Sections  444  and 444.1 and Articles XIII and XIII 1/2,
Health Maintenance Organizations in the following  categories
are deemed to be "domestic companies":
         (1)  a   corporation  authorized  under  the  Dental
    Service Plan Act or the Voluntary Health  Services  Plans
    Act;
         (2)  a  corporation organized under the laws of this
    State; or
         (3)  a  corporation  organized  under  the  laws  of
    another state, 30% or more of the enrollees of which  are
    residents  of this State, except a corporation subject to
    substantially the  same  requirements  in  its  state  of
    organization  as  is  a  "domestic company" under Article
    VIII 1/2 of the Illinois Insurance Code.
    (c)  In considering the merger, consolidation,  or  other
acquisition  of  control of a Health Maintenance Organization
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
         (1)  the Director shall give  primary  consideration
    to  the  continuation  of  benefits  to enrollees and the
    financial conditions of the acquired  Health  Maintenance
    Organization  after  the  merger, consolidation, or other
    acquisition of control takes effect;
         (2)(i)  the criteria specified in subsection  (1)(b)
    of Section 131.8 of the Illinois Insurance Code shall not
    apply  and (ii) the Director, in making his determination
    with respect  to  the  merger,  consolidation,  or  other
    acquisition  of  control,  need not take into account the
    effect on competition of the  merger,  consolidation,  or
    other acquisition of control;
         (3)  the  Director  shall  have the power to require
    the following information:
              (A)  certification by an independent actuary of
         the  adequacy  of  the  reserves   of   the   Health
         Maintenance Organization sought to be acquired;
              (B)  pro  forma financial statements reflecting
         the combined balance sheets of the acquiring company
         and the Health Maintenance Organization sought to be
         acquired as of the end of the preceding year and  as
         of  a date 90 days prior to the acquisition, as well
         as  pro  forma   financial   statements   reflecting
         projected  combined  operation  for  a  period  of 2
         years;
              (C)  a pro forma  business  plan  detailing  an
         acquiring   party's   plans   with  respect  to  the
         operation of  the  Health  Maintenance  Organization
         sought  to be acquired for a period of not less than
         3 years; and
              (D)  such other  information  as  the  Director
         shall require.
    (d)  The  provisions  of Article VIII 1/2 of the Illinois
Insurance Code and this Section 5-3 shall apply to  the  sale
by any health maintenance organization of greater than 10% of
its  enrollee  population  (including  without limitation the
health maintenance organization's right, title, and  interest
in and to its health care certificates).
    (e)  In  considering  any  management contract or service
agreement subject to Section 141.1 of the Illinois  Insurance
Code,  the  Director  (i)  shall, in addition to the criteria
specified in Section 141.2 of the  Illinois  Insurance  Code,
take  into  account  the effect of the management contract or
service  agreement  on  the  continuation  of   benefits   to
enrollees   and   the   financial  condition  of  the  health
maintenance organization to be managed or serviced, and  (ii)
need  not  take  into  account  the  effect of the management
contract or service agreement on competition.
    (f)  Except for small employer groups as defined  in  the
Small  Employer  Rating,  Renewability and Portability Health
Insurance Act and except for medicare supplement policies  as
defined  in  Section  363  of  the Illinois Insurance Code, a
Health Maintenance Organization may by contract agree with  a
group  or  other  enrollment unit to effect refunds or charge
additional premiums under the following terms and conditions:
         (i)  the amount of, and other terms  and  conditions
    with respect to, the refund or additional premium are set
    forth  in the group or enrollment unit contract agreed in
    advance of the period for which a refund is to be paid or
    additional premium is to be charged (which  period  shall
    not be less than one year); and
         (ii)  the amount of the refund or additional premium
    shall   not   exceed   20%   of  the  Health  Maintenance
    Organization's profitable or unprofitable experience with
    respect to the group or other  enrollment  unit  for  the
    period  (and,  for  purposes  of  a  refund or additional
    premium, the profitable or unprofitable experience  shall
    be calculated taking into account a pro rata share of the
    Health   Maintenance  Organization's  administrative  and
    marketing expenses, but shall not include any  refund  to
    be made or additional premium to be paid pursuant to this
    subsection (f)).  The Health Maintenance Organization and
    the   group   or  enrollment  unit  may  agree  that  the
    profitable or unprofitable experience may  be  calculated
    taking into account the refund period and the immediately
    preceding 2 plan years.
    The  Health  Maintenance  Organization  shall  include  a
statement in the evidence of coverage issued to each enrollee
describing the possibility of a refund or additional premium,
and  upon request of any group or enrollment unit, provide to
the group or enrollment unit a description of the method used
to  calculate  (1)  the  Health  Maintenance   Organization's
profitable experience with respect to the group or enrollment
unit and the resulting refund to the group or enrollment unit
or  (2)  the  Health  Maintenance Organization's unprofitable
experience with respect to the group or enrollment  unit  and
the  resulting  additional premium to be paid by the group or
enrollment unit.
    In  no  event  shall  the  Illinois  Health   Maintenance
Organization  Guaranty  Association  be  liable  to  pay  any
contractual  obligation  of  an insolvent organization to pay
any refund authorized under this Section.
(Source: P.A. 91-357,  eff.  7-29-99;  91-406,  eff.  1-1-00;
91-549,  eff.  8-14-99;  91-605,  eff. 12-14-99; 91-788, eff.
6-9-00; 92-764, eff. 1-1-03.)

    Section 99. Effective date. This Act takes effect January
1, 2004.

Effective Date: 01/01/04