HB2711 99TH GENERAL ASSEMBLY

LRB099 04229 MLM 24251 b

99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
HB2711

Introduced , by Rep. Dan Brady

SYNOPSIS AS INTRODUCED:

215 ILCS 5/356z.23 new

Amends the Illinois Insurance Code in relation to patient access to eye care. Provides that insurers may not set reimbursement rates in a manner that discriminates against a class of eye care providers. Provides that eye care coverage insurers may not preclude obtaining eye care directly from a licensed provider on a health care panel or promote a class of providers to the detriment of another class of providers. Requires that all providers on a provider panel be included in any publicly accessible list. Requires the inclusion of ophthalmologists and optometrists in provider panels. Imposes additional requirements.

A BILL FOR

AN ACT concerning regulation.

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 adding Section 356z.23 as follows:

(215 ILCS 5/356z.23 new)

Sec. 356z.23. Patient access to eye care.

(a) In this Section:

"Covered person" means an individual enrolled in a health benefit plan or an eligible dependent thereof.

"Covered services" means those health care services that a health care insurer is obligated to pay for or provide to a covered person under a health benefit plan.

"Eye care" means those health care services and materials related to the care of the eye and related structures and vision care services that a health care insurer is obligated to pay for or provide to covered persons under the health benefit plan.

"Health benefit plan" means any public or private health plan, program, policy, or agreement implemented in this State that provides health benefits to covered persons, including, but not limited to, payment and reimbursement for health care services.

"Health care insurer" means an entity, including, but not limited to, insurance companies, hospital service nonprofit corporations, nonprofit medical service corporations, health care corporations, health maintenance organizations, and preferred provider organizations authorized by the State to offer or provide health benefit plans, programs, policies, subscriber contracts, or any other agreements of a similar nature that compensate or indemnify health care providers for furnishing health care services.

(b) A health care insurer providing a health benefit plan that includes eye care benefits shall:

(1) not set professional fees or reimbursement for the same eye care services as defined by established current procedural terminology codes in a manner that discriminates against an individual eye care provider or a class of eye care providers;

(2) not preclude a covered person who seeks eye care from obtaining such service directly from a provider on the health benefit plan provider panel who is licensed to provide eye care;

(3) not promote or recommend any class of providers to the detriment of any other class of providers for the same eye care service;

(4) ensure that all eye care providers on a health benefit plan provider panel are included on any publicly accessible list of participating providers for the plan;

(5) allow each eye care provider on a health benefit plan provider panel, without discrimination between classes of eye care providers, to furnish covered eye care services to covered persons to the extent permitted by the provider's licensure;

(6) not require any eye care provider to hold hospital privileges or impose any other condition or restriction for initial admittance to a provider panel not necessary for the delivery of eye care upon the providers that would have the effect of excluding an individual eye care provider or class of eye care providers from participation on the health benefit plan; and

(7) include optometrists and ophthalmologists on the health benefit plan provider panel in a manner that ensures plan enrollees timely access and geographic access.

(c) Nothing in this Section shall preclude a covered person from receiving eye care or other covered services from the covered person's personal physician in accordance with the terms of the health benefit plan.

(d) A person adversely affected by a violation of this Section by a health care insurer may bring an action in a court of competent jurisdiction for injunctive relief against the insurer and, upon prevailing, in addition to any injunctive relief that may be granted, shall recover from the insurer damages of not more than $100 and attorney's fees and costs.

(e) Nothing in this Section requires a health benefit plan to include eye care benefits.

(f) The Director may adopt rules to enforce this Section.