93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB4847

 

Introduced 02/04/04, by Karen May, Mary E. Flowers, Kathleen A. Ryg, Carolyn H. Krause, Sandra M. Pihos

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/368a

    Amends the Illinois Insurance Code. Requires payors to notify individual insureds or enrollees within 30 days if the chosen health care physician no longer participates in the physician network. Requires payors to notify insureds or enrollees of their right to transition services under Section 25 of the Managed Care Reform and Patient Rights Act.


LRB093 14813 SAS 40374 b

 

 

A BILL FOR

 

HB4847 LRB093 14813 SAS 40374 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by
5 changing Section 368a as follows:
 
6     (215 ILCS 5/368a)
7     Sec. 368a. Timely payment for health care services.
8     (a) This Section applies to insurers, health maintenance
9 organizations, managed care plans, health care plans,
10 preferred provider organizations, third party administrators,
11 independent practice associations, and physician-hospital
12 organizations (hereinafter referred to as "payors") that
13 provide periodic payments, which are payments not requiring a
14 claim, bill, capitation encounter data, or capitation
15 reconciliation reports, such as prospective capitation
16 payments, to health care professionals and health care
17 facilities to provide medical or health care services for
18 insureds or enrollees.
19         (1) A payor shall make periodic payments in accordance
20     with item (3). Failure to make periodic payments within the
21     period of time specified in item (3) shall entitle the
22     health care professional or health care facility to
23     interest at the rate of 9% per year from the date payment
24     was required to be made to the date of the late payment,
25     provided that interest amounting to less than $1 need not
26     be paid. Any required interest payments shall be made
27     within 30 days after the payment.
28         (2) When a payor requires selection of a health care
29     professional or health care facility, the selection shall
30     be completed by the insured or enrollee no later than 30
31     days after enrollment. The payor shall provide written
32     notice of this requirement to all insureds and enrollees.

 

 

HB4847 - 2 - LRB093 14813 SAS 40374 b

1     Nothing in this Section shall be construed to require a
2     payor to select a health care professional or health care
3     facility for an insured or enrollee.
4         (3) A payor shall provide the health care professional
5     or health care facility with notice of the selection as a
6     health care professional or health care facility by an
7     insured or enrollee and the effective date of the selection
8     within 60 calendar days after the selection. No later than
9     the 60th day following the date an insured or enrollee has
10     selected a health care professional or health care facility
11     or the date that selection becomes effective, whichever is
12     later, or in cases of retrospective enrollment only, 30
13     days after notice by an employer to the payor of the
14     selection, a payor shall begin periodic payment of the
15     required amounts to the insured's or enrollee's health care
16     professional or health care facility, or the designee of
17     either, calculated from the date of selection or the date
18     the selection becomes effective, whichever is later. All
19     subsequent payments shall be made in accordance with a
20     monthly periodic cycle. Payors are required to notify
21     individual insureds or enrollees within 30 days if the
22     insured's or enrollee's chosen health care professional no
23     longer participates in the physician network. Payors must
24     notify insureds or enrollees of their right to transition
25     services under Section 25 of the Managed Care Reform and
26     Patient Rights Act.
27     (b) Notwithstanding any other provision of this Section,
28 independent practice associations and physician-hospital
29 organizations shall make periodic payment of the required
30 amounts in accordance with a monthly periodic schedule after an
31 insured or enrollee has selected a health care professional or
32 health care facility or after that selection becomes effective,
33 whichever is later.
34     Notwithstanding any other provision of this Section,
35 independent practice associations and physician-hospital
36 organizations shall make all other payments for health services

 

 

HB4847 - 3 - LRB093 14813 SAS 40374 b

1 within 30 days after receipt of due proof of loss. Independent
2 practice associations and physician-hospital organizations
3 shall notify the insured, insured's assignee, health care
4 professional, or health care facility of any failure to provide
5 sufficient documentation for a due proof of loss within 30 days
6 after receipt of the claim for health services.
7     Failure to pay within the required time period shall
8 entitle the payee to interest at the rate of 9% per year from
9 the date the payment is due to the date of the late payment,
10 provided that interest amounting to less that $1 need not be
11 paid. Any required interest payments shall be made within 30
12 days after the payment.
13     (c) All insurers, health maintenance organizations,
14 managed care plans, health care plans, preferred provider
15 organizations, and third party administrators shall ensure
16 that all claims and indemnities concerning health care services
17 other than for any periodic payment shall be paid within 30
18 days after receipt of due written proof of such loss. An
19 insured, insured's assignee, health care professional, or
20 health care facility shall be notified of any known failure to
21 provide sufficient documentation for a due proof of loss within
22 30 days after receipt of the claim for health care services.
23 Failure to pay within such period shall entitle the payee to
24 interest at the rate of 9% per year from the 30th day after
25 receipt of such proof of loss to the date of late payment,
26 provided that interest amounting to less than one dollar need
27 not be paid. Any required interest payments shall be made
28 within 30 days after the payment.
29     (d) The Department shall enforce the provisions of this
30 Section pursuant to the enforcement powers granted to it by
31 law.
32     (e) The Department is hereby granted specific authority to
33 issue a cease and desist order, fine, or otherwise penalize
34 independent practice associations and physician-hospital
35 organizations that violate this Section. The Department shall
36 adopt reasonable rules to enforce compliance with this Section

 

 

HB4847 - 4 - LRB093 14813 SAS 40374 b

1 by independent practice associations and physician-hospital
2 organizations.
3 (Source: P.A. 91-605, eff. 12-14-99; 91-788, eff. 6-9-00;
4 92-745, eff. 1-1-03.)