HB5580 103RD GENERAL ASSEMBLY

LRB103 38270 RPS 68405 b

103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5580

Introduced 2/9/2024, by Rep. Hoan Huynh

SYNOPSIS AS INTRODUCED:

215 ILCS 134/20
215 ILCS 134/62 new

Amends the Managed Care Reform and Patient Rights Act. Sets forth requirements for carriers that offer a provider panel. Requires notice of the development of a provider panel to be filed with Department of Public Health prior to establishment. Provides that a carrier that uses a provider panel shall establish procedure for notifying an enrollee of the termination of a health care provider. Sets forth provisions permitting, under certain circumstances, a health care provider to continue to render health care services following termination from the carrier's provider panel. Requires a carrier to provide a list of members in the carrier's provider panel. Establishes notice requirements for benefit reductions and termination of health care providers from the carrier's provider panel. Requires any carrier requiring preauthorization for medical treatment to have personnel available to provide preauthorization at all times when the preauthorization is required. Provides that no contract between a health care provider and a carrier shall include provisions that require a health care provider to deny covered services that the provider knows to be medically necessary and appropriate that are provided with respect to a specific enrollee or group of enrollees with similar medical conditions. Sets forth prohibited provisions in a contract between a carrier and a health care provider. Defines terms. Makes other and conforming changes.

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 Managed Care Reform and Patient Rights Act is amended by changing Section 20 and by adding Section 62 as follows:

(215 ILCS 134/20)

Sec. 20. Notice of nonrenewal or termination. A health care plan must give at least 60 days' days notice of nonrenewal or termination of a health care provider from the health care plan's provider panel or termination of any other contractual relationship to the health care provider and to the enrollees served by the health care provider. The notice shall include a name and address to which an enrollee or health care provider may direct comments and concerns regarding the nonrenewal or termination. Immediate written notice may be provided without 60 days' days notice when a health care provider's license has been disciplined by a State licensing board.

(Source: P.A. 91-617, eff. 1-1-00.)

(215 ILCS 134/62 new)

Sec. 62. Provider panels.

(a) In this Section:

"Carrier" means:

(1) any insurer proposing to issue or that issues individual or group policies of accident and health insurance providing hospital, medical, surgical, or other major medical coverage on an expense-incurred basis;

(2) any corporation providing individual or group health or accident subscription contracts;

(3) any health maintenance organization providing health care plans or health care services;

(4) any corporation offering or providing prepaid dental or optometric services plans; or

(5) any other person or organization that provides health benefit plans subject to State regulation.

"Carrier" includes an entity that arranges a provider panel for compensation.

"Provider panel" means the health care providers with which a carrier contracts to provide health care services to the carrier's enrollees under the carrier's health care or health benefit plan. "Provider panel" does not include an arrangement between a carrier and providers in which any provider may participate solely on the basis of the provider's contracting with the carrier to provide services at a discounted fee-for-service rate.

(b) Any carrier that offers a provider panel shall establish and use the provider panel according to the following requirements:

(1) Notice of the development of a provider panel serving residents of the State must be filed with the Department of Public Health prior to establishment.

(2) Carriers shall provide a provider application and the relevant terms and conditions to a health care provider upon request.

(c) A carrier that uses a provider panel shall establish procedures for:

(1) notifying an enrollee of:

(A) the termination or nonrenewal from the carrier's provider panel of a health care provider who was furnishing health care services to the enrollee or furnished health care services to the enrollee in the 6 months prior to the notice; and

(B) the right of an enrollee to continue to receive health care services, as provided in subsection (e), following the health care provider's termination from a carrier's provider panel, except when a health care provider is terminated for cause. The notice required under this paragraph (1) shall be provided at least 60 days prior to the date of termination of the health care provider from a carrier's provider panel in accordance with Section 20; and

(2) notifying a health care provider at least 60 days prior to the termination of the health care provider from a carrier's provider panel in accordance with Section 20.

(d) A carrier may not deny an application for participation or terminate participation on its provider panel on the basis of gender, race, age, sexual orientation, gender identity, religion, or national origin.

(e)(1) A health care provider shall be permitted by the carrier to render health care services to any of the carrier's enrollees for a period of at least 90 days from the date of the health care provider's termination from the carrier's provider panel, except when a health care provider is terminated for cause.

(2) Notwithstanding paragraph (1) of this subsection, any health care provider shall be permitted by the carrier to continue rendering health services to any enrollee who has been medically confirmed to be pregnant at the time of a provider's termination of participation, except when a health care provider is terminated for cause. That treatment shall, at the enrollee's option, continue through the provision of postpartum care directly relating to the delivery.

(3) Notwithstanding paragraph (1) of this subsection, any health care provider shall be permitted by the carrier to continue rendering health services to any enrollee who is determined to be terminally ill, as defined under Section 1861(dd)(3)(A) of the Social Security Act, at the time of a health care provider's termination of participation, except when a health care provider is terminated for cause. The treatment shall, at the enrollee's option, continue for the remainder of the enrollee's life for care directly related to the treatment of the terminal illness.

(4) Notwithstanding paragraph (1) of this subsection, any health care provider shall be permitted by the carrier to continue rendering health services to any enrollee who has been determined by a medical professional to have a life-threatening condition at the time of a health care provider's termination of participation. The treatment shall, at the enrollee's option, continue for up to 180 days for care directly related to the life-threatening condition.

(5) Notwithstanding paragraph (1) of this subsection, any health care provider shall be permitted by the carrier to continue rendering health services to any enrollee who is admitted to and receiving treatment in any inpatient facility at the time of a health care provider's termination of participation. Such admission and treatment shall continue until the enrollee is discharged from the inpatient facility.

(f) For any health care services received by an enrollee from a provider after the date the provider has been terminated from the carrier's provider panel:

(1) the carrier shall reimburse a health care provider under this subsection in accordance with the carrier's agreement with the health care provider existing immediately before the health care provider's termination of participation;

(2) the health care provider shall accept such reimbursement from the carrier and any cost-sharing payment from the enrollee for items and services as payment in full; and

(3) the health care provider shall continue to adhere to all policies and procedures and quality standards imposed by the carrier for an enrollee that were required of the provider immediately before the provider's termination of participation.

(g) A carrier shall provide to a purchaser upon enrollment and make available to existing enrollees at least once a year a list of members in its provider panel, which list shall also indicate those providers who are not currently accepting new patients. This list shall also include all the information specified in subsection (a) of Section 15. This list may be made available in a form other than a printed document if the purchaser or existing enrollee is given the means to request and receive a printed copy of the list. If this information is provided in paper form, it shall be updated at least once a year. If this information is provided in electronic form, it shall be updated monthly.

(h) No contract between a carrier and a health care provider may require that the health care provider indemnify the carrier for the carrier's negligence, willful misconduct, or breach of contract, if any.

(i) No contract between a carrier and a health care provider shall require a provider, as a condition of participation on the panel, to waive any right to seek legal redress against the carrier.

(j) No contract between a carrier and a health care provider shall prohibit, impede, or interfere in the discussion of medical treatment options between a patient and a health care provider.

(k) Any carrier requiring preauthorization for medical treatment shall have personnel available to provide preauthorization at all times when the preauthorization is required.

(l) Carriers shall provide to their group policyholders written notice of any benefit reductions during the contract period at least 60 days before the benefit reductions take effect. Thereafter, group policyholders shall provide to their enrollees written notice of any benefit reductions during the contract period at least 30 days before the benefit reductions take effect. The notice shall be provided to the group policyholder as a separate distinct notification and may not be combined with any other notification or marketing materials.

(m) No contract between a health care provider and a carrier shall include provisions that require a health care provider to deny covered services that the provider knows to be medically necessary and appropriate that are provided with respect to a specific enrollee or group of enrollees with similar medical conditions.

(n) If a provider panel contract between a health care provider and a carrier, or other entity that provides hospital, physician, or other health care services to a carrier, includes provisions that require a provider, as a condition of participating in one of the carrier's or other entity's provider panels, to participate in any other provider panel owned or operated by that carrier or other entity, the contract shall contain a provision permitting the health care provider to refuse participation in one or more such other provider panels at the time the contract is executed. If a health care provider contracts with a carrier or other entity that subsequently contracts with one or more unaffiliated carriers to include the health care provider in the provider panels of the unaffiliated carriers, and the contract permits an unaffiliated carrier to impose participation terms with respect to the health care provider that differ materially in reimbursement rates or in managed care procedures, such as conducting economic profiling or requiring a patient to obtain primary care physician referral to a specialist, from the terms agreed to by the provider in the original contract, the provider panel contract shall contain a provision permitting the health care provider to refuse participation with any such unaffiliated carrier.

(o) A carrier that rents or leases its provider panel to unaffiliated carriers shall make available, upon request, to its health care providers a list of unaffiliated carriers that rent or lease its provider panel. If the list is provided in electronic form, the list shall be updated monthly. The health care provider shall be given the means to request and receive a printed copy of the list.