97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
HB2919

 

Introduced 2/23/2011, by Rep. Angelo Saviano

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/368b
215 ILCS 5/368c
215 ILCS 5/368e
215 ILCS 5/370  from Ch. 73, par. 982
215 ILCS 5/370a  from Ch. 73, par. 982a
215 ILCS 5/370b  from Ch. 73, par. 982b

    Amends the Illinois Insurance Code. In the provision concerning contracting procedures, specifies that no contract is required to provide services to an insured, enrollee, or beneficiary. Provides that when health care services are provided by a nonparticipating health care professional or health care provider, an insurer, health maintenance organization, independent practice association, or physician hospital organization shall (now, may) pay for covered services either to a patient directly or to the nonparticipating health care professional or health care provider. Provides that the Director of Insurance may require an insurance company or agent that wilfully violates any provision of the Article of the Code concerning accident and health insurance to pay to the people of the State a penalty in a sum not exceeding $10,000 (now, $1,000). Specifies that certain provisions of the Code are deemed incorporated into health care professional and health care provider service contracts entered into on or before the effective date of the amendatory Act. Makes other changes.


LRB097 00133 RPM 40141 b

 

 

A BILL FOR

 

HB2919LRB097 00133 RPM 40141 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Sections 368b, 368c, 368e, 370, 370a, and 370b as
6follows:
 
7    (215 ILCS 5/368b)
8    Sec. 368b. Contracting procedures.
9    (a) A health care professional or health care provider
10offered a contract by an insurer, health maintenance
11organization, independent practice association, or physician
12hospital organization for signature after the effective date of
13this amendatory Act of the 93rd General Assembly shall be
14provided with a proposed health care professional or health
15care provider services contract including, if any, exhibits and
16attachments that the contract indicates are to be attached.
17Within 35 days after a written request, the health care
18professional or health care provider offered a contract shall
19be given the opportunity to review and obtain a copy of the
20following: a specialty-specific fee schedule sample based on a
21minimum of the 50 highest volume fee schedule codes with the
22rates applicable to the health care professional or health care
23provider to whom the contract is offered, the network provider

 

 

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1administration manual, and a summary capitation schedule, if
2payment is made on a capitation basis. If 50 codes do not exist
3for a particular specialty, the health care professional or
4health care provider offered a contract shall be given the
5opportunity to review or obtain a copy of a fee schedule sample
6with the codes applicable to that particular specialty. This
7information may be provided electronically. An insurer, health
8maintenance organization, independent practice association, or
9physician hospital organization may substitute the fee
10schedule sample with a document providing reference to the
11information needed to calculate the fee schedule that is
12available to the public at no charge and the percentage or
13conversion factor at which the insurer, health maintenance
14organization, preferred provider organization, independent
15practice association, or physician hospital organization sets
16its rates.
17    (b) The fee schedule, the capitation schedule, and the
18network provider administration manual constitute
19confidential, proprietary, and trade secret information and
20are subject to the provisions of the Illinois Trade Secrets
21Act. The health care professional or health care provider
22receiving such protected information may disclose the
23information on a need to know basis and only to individuals and
24entities that provide services directly related to the health
25care professional's or health care provider's decision to enter
26into the contract or keep the contract in force. Any person or

 

 

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1entity receiving or reviewing such protected information
2pursuant to this Section shall not disclose the information to
3any other person, organization, or entity, unless the
4disclosure is requested pursuant to a valid court order or
5required by a state or federal government agency. Individuals
6or entities receiving such information from a health care
7professional or health care provider as delineated in this
8subsection are subject to the provisions of the Illinois Trade
9Secrets Act.
10    (c) The health care professional or health care provider
11shall be allowed at least 30 days to review the health care
12professional or health care provider services contract,
13including exhibits and attachments, if any, before signing. The
1430-day review period begins upon receipt of the health care
15professional or health care provider services contract, unless
16the information available upon request in subsection (a) is not
17included. If information is not included in the professional
18services contract and is requested pursuant to subsection (a),
19the 30-day review period begins on the date of receipt of the
20information. Nothing in this subsection shall prohibit a health
21care professional or health care provider from signing a
22contract prior to the expiration of the 30-day review period.
23    (d) The insurer, health maintenance organization,
24independent practice association, or physician hospital
25organization shall provide all contracted health care
26professionals or health care providers with any changes to the

 

 

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1fee schedule provided under subsection (a) not later than 35
2days after the effective date of the changes, unless such
3changes are specified in the contract and the health care
4professional or health care provider is able to calculate the
5changed rates based on information in the contract and
6information available to the public at no charge. For the
7purposes of this subsection, "changes" means an increase or
8decrease in the fee schedule referred to in subsection (a).
9This information may be made available by mail, e-mail,
10newsletter, website listing, or other reasonable method. Upon
11request, a health care professional or health care provider may
12request an updated copy of the fee schedule referred to in
13subsection (a) every calendar quarter.
14    (e) Upon termination of a contract with an insurer, health
15maintenance organization, independent practice association, or
16physician hospital organization and at the request of the
17patient, a health care professional or health care provider
18shall provide transfer copies of the patient's medical records.
19Any other provision of law notwithstanding, the costs for
20copying and transferring copies of medical records shall be
21assigned per the arrangements agreed upon, if any, in the
22health care professional or health care provider services
23contract.
24    (f) No contract is required to provide services to an
25insured, enrollee, or beneficiary.
26(Source: P.A. 93-261, eff. 1-1-04.)
 

 

 

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1    (215 ILCS 5/368c)
2    Sec. 368c. Remittance advice and procedures.
3    (a) A remittance advice shall be furnished to a health care
4professional or health care provider that identifies the
5disposition of each claim. The remittance advice shall identify
6the services billed; the patient responsibility, if any; the
7actual payment, if any, for the services billed; and the reason
8for any reduction to the amount for which the claim was
9submitted. For any reductions to the amount for which the claim
10was submitted, the remittance shall identify any withholds and
11the reason for any denial or reduction.
12    A remittance advice for capitation or prospective payment
13arrangements shall be furnished to a health care professional
14or health care provider pursuant to a contract with an insurer,
15health maintenance organization, independent practice
16association, or physician hospital organization in accordance
17with the terms of the contract.
18    (b) When health care services are provided by a
19non-participating health care professional or health care
20provider, an insurer, health maintenance organization,
21independent practice association, or physician hospital
22organization shall may pay for covered services either to a
23patient directly or to the non-participating health care
24professional or health care provider.
25    (c) When a person presents a benefits information card, a

 

 

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1health care professional or health care provider shall make a
2good faith effort to inform the person if the health care
3professional or health care provider has a participation
4contract with the insurer, health maintenance organization, or
5other entity identified on the card.
6(Source: P.A. 93-261, eff. 1-1-04.)
 
7    (215 ILCS 5/368e)
8    Sec. 368e. Administration and enforcement.
9    (a) Other than the duties specifically created in Sections
10368b, 368c, and 368d, nothing in those Sections is intended to
11preclude, prevent, or require the adoption, modification, or
12termination of any utilization management, quality management,
13or claims processing methodologies or other provisions of a
14contract applicable to services provided under a contract
15between an insurer, health maintenance organization,
16independent practice association, or physician hospital
17organization and a health care professional or health care
18provider.
19    (b) Nothing in Sections 368b, 368c, and 368d precludes,
20prevents, or requires the adoption, modification, or
21termination of any health plan term, benefit, coverage or
22eligibility provision, or payment methodology.
23    (c) The provisions of Sections 368b, 368c, and 368d are
24deemed incorporated into health care professional and health
25care provider service contracts entered into on or before

 

 

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1January 1, 2004 (the effective date of Public Act 93-261) this
2amendatory Act of the 93rd General Assembly and do not require
3an insurer, health maintenance organization, independent
4practice association, or physician hospital organization to
5renew or renegotiate the contracts with a health care
6professional or health care provider.
7    (c-5) The amendatory provisions of Sections 368b, 368c,
8368d, 370a, and 370b are deemed incorporated into health care
9professional and health care provider service contracts
10entered into on or before the effective date of this amendatory
11Act of the 97th General Assembly and do not require an insurer,
12health maintenance organization, independent practice
13association, or physician hospital organization to renew or
14renegotiate the contracts with a health care professional or
15health care provider.
16    (d) The Department shall enforce the provisions of this
17Section and Sections 368b, 368c, and 368d pursuant to the
18enforcement powers granted to it by law.
19    (e) The Department is hereby granted specific authority to
20issue a cease and desist order against, fine, or otherwise
21penalize independent practice associations and
22physician-hospital organizations for violations.
23    (f) The Department shall adopt reasonable rules to enforce
24compliance with this Section and Sections 368b, 368c, and 368d.
25(Source: P.A. 93-261, eff. 1-1-04.)
 

 

 

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1    (215 ILCS 5/370)  (from Ch. 73, par. 982)
2    Sec. 370. Policies issued in violation of article-Penalty.
3    (1) Any company, or any officer or agent thereof, issuing
4or delivering to any person in this State any policy in wilful
5violation of the provision of this article shall be guilty of a
6petty offense.
7    (2) The Director may revoke the license of any foreign or
8alien company, or of the agent thereof wilfully violating any
9provision of this article or suspend such license for any
10period of time up to, but not to exceed, two years; or may by
11order require such insurance company or agent to pay to the
12people of the State of Illinois a penalty in a sum not
13exceeding $10,000 $1,000, and upon the failure of such
14insurance company or agent to pay such penalty within twenty
15days after the mailing of such order, postage prepaid,
16registered, and addressed to the last known place of business
17of such insurance company or agent, unless such order is stayed
18by an order of a court of competent jurisdiction, the Director
19of Insurance may revoke or suspend the license of such
20insurance company or agent for any period of time up to, but
21not exceeding a period of, two years.
22(Source: P.A. 93-32, eff. 7-1-03.)
 
23    (215 ILCS 5/370a)  (from Ch. 73, par. 982a)
24    Sec. 370a. Assignability of Accident and Health Insurance.
25    (a) No provision of the Illinois Insurance Code, or any

 

 

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1other law, prohibits an insured under any policy of accident
2and health insurance or any other person who may be the owner
3of any rights under such policy from making an assignment of
4all or any part of his rights and privileges under the policy
5including but not limited to the right to designate a
6beneficiary and to have an individual policy issued in
7accordance with its terms. Subject to the terms of the policy
8or any contract relating thereto, an assignment by an insured
9or by any other owner of rights under the policy, made before
10or after the effective date of this amendatory Act of 1969 is
11valid for the purpose of vesting in the assignee, in accordance
12with any provisions included therein as to the time at which it
13is effective, all rights and privileges so assigned. However,
14such assignment is without prejudice to the company on account
15of any payment it makes or individual policy it issues before
16receipt of notice of the assignment. This amendatory Act of
171969 acknowledges, declares and codifies the existing right of
18assignment of interests under accident and health insurance
19policies.
20    (b) For the purposes of payment for covered services, if If
21an enrollee or insured of an insurer, health maintenance
22organization, managed care plan, health care plan, preferred
23provider organization, or third party administrator assigns a
24claim to a health care professional or health care facility,
25then payment shall be made directly to the health care
26professional or health care facility regardless of whether the

 

 

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1professional is a participating or nonparticipating provider,
2including any interest required under Section 368a, of this
3Code for failure to pay claims within 30 days after receipt by
4the insurer of due proof of loss. Nothing in this Section shall
5be construed to prevent any parties from reconciling duplicate
6payments.
7(Source: P.A. 91-605, eff. 12-14-99; 91-788, eff. 6-9-00.)
 
8    (215 ILCS 5/370b)  (from Ch. 73, par. 982b)
9    Sec. 370b. Reimbursement on equal basis. Notwithstanding
10any provision of any individual or group policy of accident and
11health insurance, or any provision of a policy, contract, plan
12or agreement for hospital or medical service or indemnity,
13wherever such policy, contract, plan or agreement provides for
14reimbursement for any service provided by persons licensed
15under the Medical Practice Act of 1987 or the Podiatric Medical
16Practice Act of 1987, the person entitled to benefits or person
17performing services under such policy, contract, plan or
18agreement is entitled to reimbursement on an equal basis for
19such service, when the service is performed by a person
20licensed under the Medical Practice Act of 1987 or the
21Podiatric Medical Practice Act of 1987 whether the person is a
22participating or nonparticipating provider. The provisions of
23this Section do not apply to any policy, contract, plan or
24agreement in effect prior to September 19, 1969 or to preferred
25provider arrangements or benefit agreements.

 

 

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1(Source: P.A. 90-14, eff. 7-1-97.)