Illinois General Assembly - Full Text of HB4703
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Full Text of HB4703  102nd General Assembly

HB4703enr 102ND GENERAL ASSEMBLY

  
  
  

 


 
HB4703 EnrolledLRB102 24386 BMS 33620 b

1    AN ACT concerning regulation.
 
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 356z.3 and 356z.3a as follows:
 
6    (215 ILCS 5/356z.3)
7    Sec. 356z.3. Disclosure of limited benefit. An insurer
8that issues, delivers, amends, or renews an individual or
9group policy of accident and health insurance in this State
10after the effective date of this amendatory Act of the 92nd
11General Assembly and arranges, contracts with, or administers
12contracts with a provider whereby beneficiaries are provided
13an incentive to use the services of such provider must include
14the following disclosure on its contracts and evidences of
15coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
16NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that
17when you elect to utilize the services of a non-participating
18provider for a covered service in non-emergency situations,
19benefit payments to such non-participating provider are not
20based upon the amount billed. The basis of your benefit
21payment will be determined according to your policy's fee
22schedule, usual and customary charge (which is determined by
23comparing charges for similar services adjusted to the

 

 

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1geographical area where the services are performed), or other
2method as defined by the policy. YOU CAN EXPECT TO PAY MORE
3THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE
4PLAN HAS PAID ITS REQUIRED PORTION. Non-participating
5providers may bill members for any amount up to the billed
6charge after the plan has paid its portion of the bill, except
7as provided in Section 356z.3a of the Illinois Insurance Code
8for covered services received at a participating health care
9facility from a nonparticipating provider that are: (a)
10ancillary services, (b) items or services furnished as a
11result of unforeseen, urgent medical needs that arise at the
12time the item or service is furnished, or (c) items or services
13received when the facility or the non-participating provider
14fails to satisfy the notice and consent criteria specified
15under Section 356z.3a. Participating providers have agreed to
16accept discounted payments for services with no additional
17billing to the member other than co-insurance and deductible
18amounts. You may obtain further information about the
19participating status of professional providers and information
20on out-of-pocket expenses by calling the toll free telephone
21number on your identification card.".
22(Source: P.A. 96-1523, eff. 6-1-11; 97-813, eff. 7-13-12.)
 
23    (215 ILCS 5/356z.3a)
24    Sec. 356z.3a. Billing; emergency services;
25nonparticipating providers Nonparticipating facility-based

 

 

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1physicians and providers.
2    (a) As used in this Section: For purposes of this Section,
3"facility-based provider" means a physician or other provider
4who provide radiology, anesthesiology, pathology, neonatology,
5or emergency department services to insureds, beneficiaries,
6or enrollees in a participating hospital or participating
7ambulatory surgical treatment center.
8    "Ancillary services" means:
9        (1) items and services related to emergency medicine,
10    anesthesiology, pathology, radiology, and neonatology that
11    are provided by any health care provider;
12        (2) items and services provided by assistant surgeons,
13    hospitalists, and intensivists;
14        (3) diagnostic services, including radiology and
15    laboratory services, except for advanced diagnostic
16    laboratory tests identified on the most current list
17    published by the United States Secretary of Health and
18    Human Services under 42 U.S.C. 300gg-132(b)(3);
19        (4) items and services provided by other specialty
20    practitioners as the United States Secretary of Health and
21    Human Services specifies through rulemaking under 42
22    U.S.C. 300gg-132(b)(3); and
23        (5) items and services provided by a nonparticipating
24    provider if there is no participating provider who can
25    furnish the item or service at the facility.
26    "Cost sharing" means the amount an insured, beneficiary,

 

 

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1or enrollee is responsible for paying for a covered item or
2service under the terms of the policy or certificate. "Cost
3sharing" includes copayments, coinsurance, and amounts paid
4toward deductibles, but does not include amounts paid towards
5premiums, balance billing by out-of-network providers, or the
6cost of items or services that are not covered under the policy
7or certificate.
8    "Emergency department of a hospital" means any hospital
9department that provides emergency services, including a
10hospital outpatient department.
11    "Emergency medical condition" has the meaning ascribed to
12that term in Section 10 of the Managed Care Reform and Patient
13Rights Act.
14    "Emergency medical screening examination" has the meaning
15ascribed to that term in Section 10 of the Managed Care Reform
16and Patient Rights Act.
17    "Emergency services" means, with respect to an emergency
18medical condition:
19        (1) in general, an emergency medical screening
20    examination, including ancillary services routinely
21    available to the emergency department to evaluate such
22    emergency medical condition, and such further medical
23    examination and treatment as would be required to
24    stabilize the patient regardless of the department of the
25    hospital or other facility in which such further
26    examination or treatment is furnished; or

 

 

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1        (2) additional items and services for which benefits
2    are provided or covered under the coverage and that are
3    furnished by a nonparticipating provider or
4    nonparticipating emergency facility regardless of the
5    department of the hospital or other facility in which such
6    items are furnished after the insured, beneficiary, or
7    enrollee is stabilized and as part of outpatient
8    observation or an inpatient or outpatient stay with
9    respect to the visit in which the services described in
10    paragraph (1) are furnished. Services after stabilization
11    cease to be emergency services only when all the
12    conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
13    regulations thereunder are met.
14    "Freestanding Emergency Center" means a facility licensed
15under Section 32.5 of the Emergency Medical Services (EMS)
16Systems Act.
17    "Health care facility" means, in the context of
18non-emergency services, any of the following:
19        (1) a hospital as defined in 42 U.S.C. 1395x(e);
20        (2) a hospital outpatient department;
21        (3) a critical access hospital certified under 42
22    U.S.C. 1395i-4(e);
23        (4) an ambulatory surgical treatment center as defined
24    in the Ambulatory Surgical Treatment Center Act; or
25        (5) any recipient of a license under the Hospital
26    Licensing Act that is not otherwise described in this

 

 

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1    definition.
2    "Health care provider" means a provider as defined in
3subsection (d) of Section 370g. "Health care provider" does
4not include a provider of air ambulance or ground ambulance
5services.
6    "Health care services" has the meaning ascribed to that
7term in subsection (a) of Section 370g.
8    "Health insurance issuer" has the meaning ascribed to that
9term in Section 5 of the Illinois Health Insurance Portability
10and Accountability Act.
11    "Nonparticipating emergency facility" means, with respect
12to the furnishing of an item or service under a policy of group
13or individual health insurance coverage, any of the following
14facilities that does not have a contractual relationship
15directly or indirectly with a health insurance issuer in
16relation to the coverage:
17        (1) an emergency department of a hospital;
18        (2) a Freestanding Emergency Center;
19        (3) an ambulatory surgical treatment center as defined
20    in the Ambulatory Surgical Treatment Center Act; or
21        (4) with respect to emergency services described in
22    paragraph (2) of the definition of "emergency services", a
23    hospital.
24    "Nonparticipating provider" means, with respect to the
25furnishing of an item or service under a policy of group or
26individual health insurance coverage, any health care provider

 

 

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1who does not have a contractual relationship directly or
2indirectly with a health insurance issuer in relation to the
3coverage.
4    "Participating emergency facility" means any of the
5following facilities that has a contractual relationship
6directly or indirectly with a health insurance issuer offering
7group or individual health insurance coverage setting forth
8the terms and conditions on which a relevant health care
9service is provided to an insured, beneficiary, or enrollee
10under the coverage:
11        (1) an emergency department of a hospital;
12        (2) a Freestanding Emergency Center;
13        (3) an ambulatory surgical treatment center as defined
14    in the Ambulatory Surgical Treatment Center Act; or
15        (4) with respect to emergency services described in
16    paragraph (2) of the definition of "emergency services", a
17    hospital.
18For purposes of this definition, a single case agreement
19between an emergency facility and an issuer that is used to
20address unique situations in which an insured, beneficiary, or
21enrollee requires services that typically occur out-of-network
22constitutes a contractual relationship and is limited to the
23parties to the agreement.
24    "Participating health care facility" means any health care
25facility that has a contractual relationship directly or
26indirectly with a health insurance issuer offering group or

 

 

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1individual health insurance coverage setting forth the terms
2and conditions on which a relevant health care service is
3provided to an insured, beneficiary, or enrollee under the
4coverage. A single case agreement between an emergency
5facility and an issuer that is used to address unique
6situations in which an insured, beneficiary, or enrollee
7requires services that typically occur out-of-network
8constitutes a contractual relationship for purposes of this
9definition and is limited to the parties to the agreement.
10    "Participating provider" means any health care provider
11that has a contractual relationship directly or indirectly
12with a health insurance issuer offering group or individual
13health insurance coverage setting forth the terms and
14conditions on which a relevant health care service is provided
15to an insured, beneficiary, or enrollee under the coverage.
16    "Qualifying payment amount" has the meaning given to that
17term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
18promulgated thereunder.
19    "Recognized amount" means the lesser of the amount
20initially billed by the provider or the qualifying payment
21amount.
22    "Stabilize" means "stabilization" as defined in Section 10
23of the Managed Care Reform and Patient Rights Act.
24    "Treating provider" means a health care provider who has
25evaluated the individual.
26    "Visit" means, with respect to health care services

 

 

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1furnished to an individual at a health care facility, health
2care services furnished by a provider at the facility, as well
3as equipment, devices, telehealth services, imaging services,
4laboratory services, and preoperative and postoperative
5services regardless of whether the provider furnishing such
6services is at the facility.
7    (b) Emergency services. When a beneficiary, insured, or
8enrollee receives emergency services from a nonparticipating
9provider or a nonparticipating emergency facility, the health
10insurance issuer shall ensure that the beneficiary, insured,
11or enrollee shall incur no greater out-of-pocket costs than
12the beneficiary, insured, or enrollee would have incurred with
13a participating provider or a participating emergency
14facility. Any cost-sharing requirements shall be applied as
15though the emergency services had been received from a
16participating provider or a participating facility. Cost
17sharing shall be calculated based on the recognized amount for
18the emergency services. If the cost sharing for the same item
19or service furnished by a participating provider would have
20been a flat-dollar copayment, that amount shall be the
21cost-sharing amount unless the provider has billed a lesser
22total amount. In no event shall the beneficiary, insured,
23enrollee, or any group policyholder or plan sponsor be liable
24to or billed by the health insurance issuer, the
25nonparticipating provider, or the nonparticipating emergency
26facility for any amount beyond the cost sharing calculated in

 

 

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1accordance with this subsection with respect to the emergency
2services delivered. Administrative requirements or limitations
3shall be no greater than those applicable to emergency
4services received from a participating provider or a
5participating emergency facility.
6    (b-5) Non-emergency services at participating health care
7facilities.
8        (1) When a beneficiary, insured, or enrollee utilizes
9    a participating health care facility network hospital or a
10    participating network ambulatory surgery center and, due
11    to any reason, covered ancillary services in network
12    services for radiology, anesthesiology, pathology,
13    emergency physician, or neonatology are unavailable and
14    are provided by a nonparticipating facility-based
15    physician or provider during or resulting from the visit,
16    the health insurance issuer insurer or health plan shall
17    ensure that the beneficiary, insured, or enrollee shall
18    incur no greater out-of-pocket costs than the beneficiary,
19    insured, or enrollee would have incurred with a
20    participating physician or provider for the ancillary
21    covered services. Any cost-sharing requirements shall be
22    applied as though the ancillary services had been received
23    from a participating provider. Cost sharing shall be
24    calculated based on the recognized amount for the
25    ancillary services. If the cost sharing for the same item
26    or service furnished by a participating provider would

 

 

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1    have been a flat-dollar copayment, that amount shall be
2    the cost-sharing amount unless the provider has billed a
3    lesser total amount. In no event shall the beneficiary,
4    insured, enrollee, or any group policyholder or plan
5    sponsor be liable to or billed by the health insurance
6    issuer, the nonparticipating provider, or the
7    participating health care facility for any amount beyond
8    the cost sharing calculated in accordance with this
9    subsection with respect to the ancillary services
10    delivered. In addition to ancillary services, the
11    requirements of this paragraph shall also apply with
12    respect to covered items or services furnished as a result
13    of unforeseen, urgent medical needs that arise at the time
14    an item or service is furnished, regardless of whether the
15    nonparticipating provider satisfied the notice and consent
16    criteria under paragraph (2) of this subsection.
17        (2) When a beneficiary, insured, or enrollee utilizes
18    a participating health care facility and receives
19    non-emergency covered health care services other than
20    those described in paragraph (1) of this subsection from a
21    nonparticipating provider during or resulting from the
22    visit, the health insurance issuer shall ensure that the
23    beneficiary, insured, or enrollee incurs no greater
24    out-of-pocket costs than the beneficiary, insured, or
25    enrollee would have incurred with a participating provider
26    unless the nonparticipating provider, or the participating

 

 

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1    health care facility on behalf of the nonparticipating
2    provider, satisfies the notice and consent criteria
3    provided in 42 U.S.C. 300gg-132 and regulations
4    promulgated thereunder. If the notice and consent criteria
5    are not satisfied, then:
6            (A) any cost-sharing requirements shall be applied
7        as though the health care services had been received
8        from a participating provider;
9            (B) cost sharing shall be calculated based on the
10        recognized amount for the health care services; and
11            (C) in no event shall the beneficiary, insured,
12        enrollee, or any group policyholder or plan sponsor be
13        liable to or billed by the health insurance issuer,
14        the nonparticipating provider, or the participating
15        health care facility for any amount beyond the cost
16        sharing calculated in accordance with this subsection
17        with respect to the health care services delivered.
18    (c) Notwithstanding If a beneficiary, insured, or enrollee
19agrees in writing, notwithstanding any other provision of this
20Code, except when the notice and consent criteria are
21satisfied for the situation in paragraph (2) of subsection
22(b-5), any benefits a beneficiary, insured, or enrollee
23receives for services under the situations situation in
24subsections subsection (b) or (b-5) are assigned to the
25nonparticipating facility-based providers or the facility
26acting on their behalf. Upon receipt of the provider's bill or

 

 

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1facility's bill, the health insurance issuer The insurer or
2health plan shall provide the nonparticipating provider or the
3facility with a written explanation of benefits that specifies
4the proposed reimbursement and the applicable deductible,
5copayment or coinsurance amounts owed by the insured,
6beneficiary or enrollee. The health insurance issuer insurer
7or health plan shall pay any reimbursement subject to this
8Section directly to the nonparticipating facility-based
9provider or the facility. The nonparticipating facility-based
10physician or provider shall not bill the beneficiary, insured,
11or enrollee, except for applicable deductible, copayment, or
12coinsurance amounts that would apply if the beneficiary,
13insured, or enrollee utilized a participating physician or
14provider for covered services. If a beneficiary, insured, or
15enrollee specifically rejects assignment under this Section in
16writing to the nonparticipating facility-based provider, then
17the nonparticipating facility-based provider may bill the
18beneficiary, insured, or enrollee for the services rendered.
19    (d) For bills assigned under subsection (c), the
20nonparticipating facility-based provider or the facility may
21bill the health insurance issuer insurer or health plan for
22the services rendered, and the health insurance issuer insurer
23or health plan may pay the billed amount or attempt to
24negotiate reimbursement with the nonparticipating
25facility-based provider or the facility. Within 30 calendar
26days after the provider or facility transmits the bill to the

 

 

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1health insurance issuer, the issuer shall send an initial
2payment or notice of denial of payment with the written
3explanation of benefits to the provider or facility. If
4attempts to negotiate reimbursement for services provided by a
5nonparticipating facility-based provider do not result in a
6resolution of the payment dispute within 30 days after receipt
7of written explanation of benefits by the health insurance
8issuer insurer or health plan, then the health insurance
9issuer an insurer or health plan or nonparticipating
10facility-based physician or provider or the facility may
11initiate binding arbitration to determine payment for services
12provided on a per bill basis. The party requesting arbitration
13shall notify the other party arbitration has been initiated
14and state its final offer before arbitration. In response to
15this notice, the nonrequesting party shall inform the
16requesting party of its final offer before the arbitration
17occurs. Arbitration shall be initiated by filing a request
18with the Department of Insurance.
19    (e) The Department of Insurance shall publish a list of
20approved arbitrators or entities that shall provide binding
21arbitration. These arbitrators shall be American Arbitration
22Association or American Health Lawyers Association trained
23arbitrators. Both parties must agree on an arbitrator from the
24Department of Insurance's or its approved entity's list of
25arbitrators. If no agreement can be reached, then a list of 5
26arbitrators shall be provided by the Department of Insurance

 

 

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1or the approved entity. From the list of 5 arbitrators, the
2health insurance issuer insurer can veto 2 arbitrators and the
3provider or facility can veto 2 arbitrators. The remaining
4arbitrator shall be the chosen arbitrator. This arbitration
5shall consist of a review of the written submissions by both
6parties. The arbitrator shall not establish a rebuttable
7presumption that the qualifying payment amount should be the
8total amount owed to the provider or facility by the
9combination of the issuer and the insured, beneficiary, or
10enrollee. Binding arbitration shall provide for a written
11decision within 45 days after the request is filed with the
12Department of Insurance. Both parties shall be bound by the
13arbitrator's decision. The arbitrator's expenses and fees,
14together with other expenses, not including attorney's fees,
15incurred in the conduct of the arbitration, shall be paid as
16provided in the decision.
17    (f) (Blank). This Section 356z.3a does not apply to a
18beneficiary, insured, or enrollee who willfully chooses to
19access a nonparticipating facility-based physician or provider
20for health care services available through the insurer's or
21plan's network of participating physicians and providers. In
22these circumstances, the contractual requirements for
23nonparticipating facility-based provider reimbursements will
24apply.
25    (g) Section 368a of this Act shall not apply during the
26pendency of a decision under subsection (d). Upon the issuance

 

 

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1of the arbitrator's decision, Section 368a applies with
2respect to the amount, if any, by which the arbitrator's
3determination exceeds the issuer's initial payment under
4subsection (c), or the entire amount of the arbitrator's
5determination if initial payment was denied. Any any interest
6required to be paid a provider under Section 368a shall not
7accrue until after 30 days of an arbitrator's decision as
8provided in subsection (d), but in no circumstances longer
9than 150 days from date the nonparticipating facility-based
10provider billed for services rendered.
11    (h) Nothing in this Section shall be interpreted to change
12the prudent layperson provisions with respect to emergency
13services under the Managed Care Reform and Patient Rights Act.
14    (i) Nothing in this Section shall preclude a health care
15provider from billing a beneficiary, insured, or enrollee for
16reasonable administrative fees, such as service fees for
17checks returned for nonsufficient funds and missed
18appointments.
19    (j) Nothing in this Section shall preclude a beneficiary,
20insured, or enrollee from assigning benefits to a
21nonparticipating provider when the notice and consent criteria
22are satisfied under paragraph (2) of subsection (b-5) or in
23any other situation not described in subsections (b) or (b-5).
24    (k) Except when the notice and consent criteria are
25satisfied under paragraph (2) of subsection (b-5), if an
26individual receives health care services under the situations

 

 

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1described in subsections (b) or (b-5), no referral requirement
2or any other provision contained in the policy or certificate
3of coverage shall deny coverage, reduce benefits, or otherwise
4defeat the requirements of this Section for services that
5would have been covered with a participating provider.
6However, this subsection shall not be construed to preclude a
7provider contract with a health insurance issuer, or with an
8administrator or similar entity acting on the issuer's behalf,
9from imposing requirements on the participating provider,
10participating emergency facility, or participating health care
11facility relating to the referral of covered individuals to
12nonparticipating providers.
13    (l) Except if the notice and consent criteria are
14satisfied under paragraph (2) of subsection (b-5),
15cost-sharing amounts calculated in conformity with this
16Section shall count toward any deductible or out-of-pocket
17maximum applicable to in-network coverage.
18    (m) The Department has the authority to enforce the
19requirements of this Section in the situations described in
20subsections (b) and (b-5), and in any other situation for
21which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
22regulations promulgated thereunder would prohibit an
23individual from being billed or liable for emergency services
24furnished by a nonparticipating provider or nonparticipating
25emergency facility or for non-emergency health care services
26furnished by a nonparticipating provider at a participating

 

 

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1health care facility.
2    (n) This Section does not apply with respect to air
3ambulance or ground ambulance services. This Section does not
4apply to any policy of excepted benefits or to short-term,
5limited-duration health insurance coverage.
6(Source: P.A. 98-154, eff. 8-2-13.)
 
7    Section 10. The Network Adequacy and Transparency Act is
8amended by changing Section 10 as follows:
 
9    (215 ILCS 124/10)
10    Sec. 10. Network adequacy.
11    (a) An insurer providing a network plan shall file a
12description of all of the following with the Director:
13        (1) The written policies and procedures for adding
14    providers to meet patient needs based on increases in the
15    number of beneficiaries, changes in the
16    patient-to-provider ratio, changes in medical and health
17    care capabilities, and increased demand for services.
18        (2) The written policies and procedures for making
19    referrals within and outside the network.
20        (3) The written policies and procedures on how the
21    network plan will provide 24-hour, 7-day per week access
22    to network-affiliated primary care, emergency services,
23    and woman's principal health care providers.
24    An insurer shall not prohibit a preferred provider from

 

 

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1discussing any specific or all treatment options with
2beneficiaries irrespective of the insurer's position on those
3treatment options or from advocating on behalf of
4beneficiaries within the utilization review, grievance, or
5appeals processes established by the insurer in accordance
6with any rights or remedies available under applicable State
7or federal law.
8    (b) Insurers must file for review a description of the
9services to be offered through a network plan. The description
10shall include all of the following:
11        (1) A geographic map of the area proposed to be served
12    by the plan by county service area and zip code, including
13    marked locations for preferred providers.
14        (2) As deemed necessary by the Department, the names,
15    addresses, phone numbers, and specialties of the providers
16    who have entered into preferred provider agreements under
17    the network plan.
18        (3) The number of beneficiaries anticipated to be
19    covered by the network plan.
20        (4) An Internet website and toll-free telephone number
21    for beneficiaries and prospective beneficiaries to access
22    current and accurate lists of preferred providers,
23    additional information about the plan, as well as any
24    other information required by Department rule.
25        (5) A description of how health care services to be
26    rendered under the network plan are reasonably accessible

 

 

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1    and available to beneficiaries. The description shall
2    address all of the following:
3            (A) the type of health care services to be
4        provided by the network plan;
5            (B) the ratio of physicians and other providers to
6        beneficiaries, by specialty and including primary care
7        physicians and facility-based physicians when
8        applicable under the contract, necessary to meet the
9        health care needs and service demands of the currently
10        enrolled population;
11            (C) the travel and distance standards for plan
12        beneficiaries in county service areas; and
13            (D) a description of how the use of telemedicine,
14        telehealth, or mobile care services may be used to
15        partially meet the network adequacy standards, if
16        applicable.
17        (6) A provision ensuring that whenever a beneficiary
18    has made a good faith effort, as evidenced by accessing
19    the provider directory, calling the network plan, and
20    calling the provider, to utilize preferred providers for a
21    covered service and it is determined the insurer does not
22    have the appropriate preferred providers due to
23    insufficient number, type, or unreasonable travel distance
24    or delay, the insurer shall ensure, directly or
25    indirectly, by terms contained in the payer contract, that
26    the beneficiary will be provided the covered service at no

 

 

HB4703 Enrolled- 21 -LRB102 24386 BMS 33620 b

1    greater cost to the beneficiary than if the service had
2    been provided by a preferred provider. This paragraph (6)
3    does not apply to: (A) a beneficiary who willfully chooses
4    to access a non-preferred provider for health care
5    services available through the panel of preferred
6    providers, or (B) a beneficiary enrolled in a health
7    maintenance organization. In these circumstances, the
8    contractual requirements for non-preferred provider
9    reimbursements shall apply unless Section 356z.3a of the
10    Illinois Insurance Code requires otherwise. In no event
11    shall a beneficiary who receives care at a participating
12    health care facility be required to search for
13    participating providers under the circumstances described
14    in subsections (b) or (b-5) of Section 356z.3a of the
15    Illinois Insurance Code except under the circumstances
16    described in paragraph (2) of subsection (b-5).
17        (7) A provision that the beneficiary shall receive
18    emergency care coverage such that payment for this
19    coverage is not dependent upon whether the emergency
20    services are performed by a preferred or non-preferred
21    provider and the coverage shall be at the same benefit
22    level as if the service or treatment had been rendered by a
23    preferred provider. For purposes of this paragraph (7),
24    "the same benefit level" means that the beneficiary is
25    provided the covered service at no greater cost to the
26    beneficiary than if the service had been provided by a

 

 

HB4703 Enrolled- 22 -LRB102 24386 BMS 33620 b

1    preferred provider. This provision shall be consistent
2    with Section 356z.3a of the Illinois Insurance Code.
3        (8) A limitation that, if the plan provides that the
4    beneficiary will incur a penalty for failing to
5    pre-certify inpatient hospital treatment, the penalty may
6    not exceed $1,000 per occurrence in addition to the plan
7    cost sharing provisions.
8    (c) The network plan shall demonstrate to the Director a
9minimum ratio of providers to plan beneficiaries as required
10by the Department.
11        (1) The ratio of physicians or other providers to plan
12    beneficiaries shall be established annually by the
13    Department in consultation with the Department of Public
14    Health based upon the guidance from the federal Centers
15    for Medicare and Medicaid Services. The Department shall
16    not establish ratios for vision or dental providers who
17    provide services under dental-specific or vision-specific
18    benefits. The Department shall consider establishing
19    ratios for the following physicians or other providers:
20            (A) Primary Care;
21            (B) Pediatrics;
22            (C) Cardiology;
23            (D) Gastroenterology;
24            (E) General Surgery;
25            (F) Neurology;
26            (G) OB/GYN;

 

 

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1            (H) Oncology/Radiation;
2            (I) Ophthalmology;
3            (J) Urology;
4            (K) Behavioral Health;
5            (L) Allergy/Immunology;
6            (M) Chiropractic;
7            (N) Dermatology;
8            (O) Endocrinology;
9            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
10            (Q) Infectious Disease;
11            (R) Nephrology;
12            (S) Neurosurgery;
13            (T) Orthopedic Surgery;
14            (U) Physiatry/Rehabilitative;
15            (V) Plastic Surgery;
16            (W) Pulmonary;
17            (X) Rheumatology;
18            (Y) Anesthesiology;
19            (Z) Pain Medicine;
20            (AA) Pediatric Specialty Services;
21            (BB) Outpatient Dialysis; and
22            (CC) HIV.
23        (2) The Director shall establish a process for the
24    review of the adequacy of these standards, along with an
25    assessment of additional specialties to be included in the
26    list under this subsection (c).

 

 

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1    (d) The network plan shall demonstrate to the Director
2maximum travel and distance standards for plan beneficiaries,
3which shall be established annually by the Department in
4consultation with the Department of Public Health based upon
5the guidance from the federal Centers for Medicare and
6Medicaid Services. These standards shall consist of the
7maximum minutes or miles to be traveled by a plan beneficiary
8for each county type, such as large counties, metro counties,
9or rural counties as defined by Department rule.
10    The maximum travel time and distance standards must
11include standards for each physician and other provider
12category listed for which ratios have been established.
13    The Director shall establish a process for the review of
14the adequacy of these standards along with an assessment of
15additional specialties to be included in the list under this
16subsection (d).
17    (d-5)(1) Every insurer shall ensure that beneficiaries
18have timely and proximate access to treatment for mental,
19emotional, nervous, or substance use disorders or conditions
20in accordance with the provisions of paragraph (4) of
21subsection (a) of Section 370c of the Illinois Insurance Code.
22Insurers shall use a comparable process, strategy, evidentiary
23standard, and other factors in the development and application
24of the network adequacy standards for timely and proximate
25access to treatment for mental, emotional, nervous, or
26substance use disorders or conditions and those for the access

 

 

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1to treatment for medical and surgical conditions. As such, the
2network adequacy standards for timely and proximate access
3shall equally be applied to treatment facilities and providers
4for mental, emotional, nervous, or substance use disorders or
5conditions and specialists providing medical or surgical
6benefits pursuant to the parity requirements of Section 370c.1
7of the Illinois Insurance Code and the federal Paul Wellstone
8and Pete Domenici Mental Health Parity and Addiction Equity
9Act of 2008. Notwithstanding the foregoing, the network
10adequacy standards for timely and proximate access to
11treatment for mental, emotional, nervous, or substance use
12disorders or conditions shall, at a minimum, satisfy the
13following requirements:
14        (A) For beneficiaries residing in the metropolitan
15    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
16    network adequacy standards for timely and proximate access
17    to treatment for mental, emotional, nervous, or substance
18    use disorders or conditions means a beneficiary shall not
19    have to travel longer than 30 minutes or 30 miles from the
20    beneficiary's residence to receive outpatient treatment
21    for mental, emotional, nervous, or substance use disorders
22    or conditions. Beneficiaries shall not be required to wait
23    longer than 10 business days between requesting an initial
24    appointment and being seen by the facility or provider of
25    mental, emotional, nervous, or substance use disorders or
26    conditions for outpatient treatment or to wait longer than

 

 

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1    20 business days between requesting a repeat or follow-up
2    appointment and being seen by the facility or provider of
3    mental, emotional, nervous, or substance use disorders or
4    conditions for outpatient treatment; however, subject to
5    the protections of paragraph (3) of this subsection, a
6    network plan shall not be held responsible if the
7    beneficiary or provider voluntarily chooses to schedule an
8    appointment outside of these required time frames.
9        (B) For beneficiaries residing in Illinois counties
10    other than those counties listed in subparagraph (A) of
11    this paragraph, network adequacy standards for timely and
12    proximate access to treatment for mental, emotional,
13    nervous, or substance use disorders or conditions means a
14    beneficiary shall not have to travel longer than 60
15    minutes or 60 miles from the beneficiary's residence to
16    receive outpatient treatment for mental, emotional,
17    nervous, or substance use disorders or conditions.
18    Beneficiaries shall not be required to wait longer than 10
19    business days between requesting an initial appointment
20    and being seen by the facility or provider of mental,
21    emotional, nervous, or substance use disorders or
22    conditions for outpatient treatment or to wait longer than
23    20 business days between requesting a repeat or follow-up
24    appointment and being seen by the facility or provider of
25    mental, emotional, nervous, or substance use disorders or
26    conditions for outpatient treatment; however, subject to

 

 

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1    the protections of paragraph (3) of this subsection, a
2    network plan shall not be held responsible if the
3    beneficiary or provider voluntarily chooses to schedule an
4    appointment outside of these required time frames.
5    (2) For beneficiaries residing in all Illinois counties,
6network adequacy standards for timely and proximate access to
7treatment for mental, emotional, nervous, or substance use
8disorders or conditions means a beneficiary shall not have to
9travel longer than 60 minutes or 60 miles from the
10beneficiary's residence to receive inpatient or residential
11treatment for mental, emotional, nervous, or substance use
12disorders or conditions.
13    (3) If there is no in-network facility or provider
14available for a beneficiary to receive timely and proximate
15access to treatment for mental, emotional, nervous, or
16substance use disorders or conditions in accordance with the
17network adequacy standards outlined in this subsection, the
18insurer shall provide necessary exceptions to its network to
19ensure admission and treatment with a provider or at a
20treatment facility in accordance with the network adequacy
21standards in this subsection.
22    (e) Except for network plans solely offered as a group
23health plan, these ratio and time and distance standards apply
24to the lowest cost-sharing tier of any tiered network.
25    (f) The network plan may consider use of other health care
26service delivery options, such as telemedicine or telehealth,

 

 

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1mobile clinics, and centers of excellence, or other ways of
2delivering care to partially meet the requirements set under
3this Section.
4    (g) Except for the requirements set forth in subsection
5(d-5), insurers who are not able to comply with the provider
6ratios and time and distance standards established by the
7Department may request an exception to these requirements from
8the Department. The Department may grant an exception in the
9following circumstances:
10        (1) if no providers or facilities meet the specific
11    time and distance standard in a specific service area and
12    the insurer (i) discloses information on the distance and
13    travel time points that beneficiaries would have to travel
14    beyond the required criterion to reach the next closest
15    contracted provider outside of the service area and (ii)
16    provides contact information, including names, addresses,
17    and phone numbers for the next closest contracted provider
18    or facility;
19        (2) if patterns of care in the service area do not
20    support the need for the requested number of provider or
21    facility type and the insurer provides data on local
22    patterns of care, such as claims data, referral patterns,
23    or local provider interviews, indicating where the
24    beneficiaries currently seek this type of care or where
25    the physicians currently refer beneficiaries, or both; or
26        (3) other circumstances deemed appropriate by the

 

 

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1    Department consistent with the requirements of this Act.
2    (h) Insurers are required to report to the Director any
3material change to an approved network plan within 15 days
4after the change occurs and any change that would result in
5failure to meet the requirements of this Act. Upon notice from
6the insurer, the Director shall reevaluate the network plan's
7compliance with the network adequacy and transparency
8standards of this Act.
9(Source: P.A. 102-144, eff. 1-1-22.)
 
10    Section 15. The Health Maintenance Organization Act is
11amended by changing Sections 4.5-1 and 5-3 as follows:
 
12    (215 ILCS 125/4.5-1)
13    Sec. 4.5-1. Point-of-service health service contracts.
14    (a) A health maintenance organization that offers a
15point-of-service contract:
16        (1) must include as in-plan covered services all
17    services required by law to be provided by a health
18    maintenance organization;
19        (2) must provide incentives, which shall include
20    financial incentives, for enrollees to use in-plan covered
21    services;
22        (3) may not offer services out-of-plan without
23    providing those services on an in-plan basis;
24        (4) may include annual out-of-pocket limits and

 

 

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1    lifetime maximum benefits allowances for out-of-plan
2    services that are separate from any limits or allowances
3    applied to in-plan services;
4        (5) may not consider emergency services, authorized
5    referral services, or non-routine services obtained out of
6    the service area to be point-of-service services;
7        (6) may treat as out-of-plan services those services
8    that an enrollee obtains from a participating provider,
9    but for which the proper authorization was not given by
10    the health maintenance organization; and
11        (7) after the effective date of this amendatory Act of
12    the 92nd General Assembly, must include the following
13    disclosure on its point-of-service contracts and evidences
14    of coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
15    NON-PARTICIPATING PROVIDERS ARE USED. You should be aware
16    that when you elect to utilize the services of a
17    non-participating provider for a covered service in
18    non-emergency situations, benefit payments to such
19    non-participating provider are not based upon the amount
20    billed. The basis of your benefit payment will be
21    determined according to your policy's fee schedule, usual
22    and customary charge (which is determined by comparing
23    charges for similar services adjusted to the geographical
24    area where the services are performed), or other method as
25    defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE
26    COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN

 

 

HB4703 Enrolled- 31 -LRB102 24386 BMS 33620 b

1    HAS PAID ITS REQUIRED PORTION. Non-participating providers
2    may bill members for any amount up to the billed charge
3    after the plan has paid its portion of the bill, except as
4    provided in Section 356z.3a of the Illinois Insurance Code
5    for covered services received at a participating health
6    care facility from a non-participating provider that are:
7    (a) ancillary services, (b) items or services furnished as
8    a result of unforeseen, urgent medical needs that arise at
9    the time the item or service is furnished, or (c) items or
10    services received when the facility or the
11    non-participating provider fails to satisfy the notice and
12    consent criteria specified under Section 356z.3a.
13    Participating providers have agreed to accept discounted
14    payments for services with no additional billing to the
15    member other than co-insurance and deductible amounts. You
16    may obtain further information about the participating
17    status of professional providers and information on
18    out-of-pocket expenses by calling the toll free telephone
19    number on your identification card.".
20    (b) A health maintenance organization offering a
21point-of-service contract is subject to all of the following
22limitations:
23        (1) The health maintenance organization may not expend
24    in any calendar quarter more than 20% of its total
25    expenditures for all its members for out-of-plan covered
26    services.

 

 

HB4703 Enrolled- 32 -LRB102 24386 BMS 33620 b

1        (2) If the amount specified in item (1) of this
2    subsection is exceeded by 2% in a quarter, the health
3    maintenance organization must effect compliance with item
4    (1) of this subsection by the end of the following
5    quarter.
6        (3) If compliance with the amount specified in item
7    (1) of this subsection is not demonstrated in the health
8    maintenance organization's next quarterly report, the
9    health maintenance organization may not offer the
10    point-of-service contract to new groups or include the
11    point-of-service option in the renewal of an existing
12    group until compliance with the amount specified in item
13    (1) of this subsection is demonstrated or until otherwise
14    allowed by the Director.
15        (4) A health maintenance organization failing, without
16    just cause, to comply with the provisions of this
17    subsection shall be required, after notice and hearing, to
18    pay a penalty of $250 for each day out of compliance, to be
19    recovered by the Director. Any penalty recovered shall be
20    paid into the General Revenue Fund. The Director may
21    reduce the penalty if the health maintenance organization
22    demonstrates to the Director that the imposition of the
23    penalty would constitute a financial hardship to the
24    health maintenance organization.
25    (c) A health maintenance organization that offers a
26point-of-service product must do all of the following:

 

 

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1        (1) File a quarterly financial statement detailing
2    compliance with the requirements of subsection (b).
3        (2) Track out-of-plan, point-of-service utilization
4    separately from in-plan or non-point-of-service,
5    out-of-plan emergency care, referral care, and urgent care
6    out of the service area utilization.
7        (3) Record out-of-plan utilization in a manner that
8    will permit such utilization and cost reporting as the
9    Director may, by rule, require.
10        (4) Demonstrate to the Director's satisfaction that
11    the health maintenance organization has the fiscal,
12    administrative, and marketing capacity to control its
13    point-of-service enrollment, utilization, and costs so as
14    not to jeopardize the financial security of the health
15    maintenance organization.
16        (5) Maintain, in addition to any other deposit
17    required under this Act, the deposit required by Section
18    2-6.
19        (6) Maintain cash and cash equivalents of sufficient
20    amount to fully liquidate 10 days' average claim payments,
21    subject to review by the Director.
22        (7) Maintain and file with the Director, reinsurance
23    coverage protecting against catastrophic losses on out of
24    network point-of-service services. Deductibles may not
25    exceed $100,000 per covered life per year, and the portion
26    of risk retained by the health maintenance organization

 

 

HB4703 Enrolled- 34 -LRB102 24386 BMS 33620 b

1    once deductibles have been satisfied may not exceed 20%.
2    Reinsurance must be placed with licensed authorized
3    reinsurers qualified to do business in this State.
4    (d) A health maintenance organization may not issue a
5point-of-service contract until it has filed and had approved
6by the Director a plan to comply with the provisions of this
7Section. The compliance plan must, at a minimum, include
8provisions demonstrating that the health maintenance
9organization will do all of the following:
10        (1) Design the benefit levels and conditions of
11    coverage for in-plan covered services and out-of-plan
12    covered services as required by this Article.
13        (2) Provide or arrange for the provision of adequate
14    systems to:
15            (A) process and pay claims for all out-of-plan
16        covered services;
17            (B) meet the requirements for point-of-service
18        contracts set forth in this Section and any additional
19        requirements that may be set forth by the Director;
20        and
21            (C) generate accurate data and financial and
22        regulatory reports on a timely basis so that the
23        Department of Insurance can evaluate the health
24        maintenance organization's experience with the
25        point-of-service contract and monitor compliance with
26        point-of-service contract provisions.

 

 

HB4703 Enrolled- 35 -LRB102 24386 BMS 33620 b

1        (3) Comply with the requirements of subsections (b)
2    and (c).
3(Source: P.A. 92-135, eff. 1-1-02; 92-579, eff. 1-1-03.)
 
4    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
5    Sec. 5-3. Insurance Code provisions.
6    (a) Health Maintenance Organizations shall be subject to
7the provisions of Sections 133, 134, 136, 137, 139, 140,
8141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
9154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
10355.3, 355b, 356g.5-1, 356m, 356q, 356v, 356w, 356x, 356y,
11356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
12356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
13356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26,
14356z.29, 356z.30, 356z.30a, 356z.32, 356z.33, 356z.35,
15356z.36, 356z.40, 356z.41, 356z.43, 356z.46, 356z.47, 356z.48,
16356z.50, 356z.51, 364, 364.01, 367.2, 367.2-5, 367i, 368a,
17368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403,
18403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
19subsection (2) of Section 367, and Articles IIA, VIII 1/2,
20XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
21Illinois Insurance Code.
22    (b) For purposes of the Illinois Insurance Code, except
23for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
24Health Maintenance Organizations in the following categories
25are deemed to be "domestic companies":

 

 

HB4703 Enrolled- 36 -LRB102 24386 BMS 33620 b

1        (1) a corporation authorized under the Dental Service
2    Plan Act or the Voluntary Health Services Plans Act;
3        (2) a corporation organized under the laws of this
4    State; or
5        (3) a corporation organized under the laws of another
6    state, 30% or more of the enrollees of which are residents
7    of this State, except a corporation subject to
8    substantially the same requirements in its state of
9    organization as is a "domestic company" under Article VIII
10    1/2 of the Illinois Insurance Code.
11    (c) In considering the merger, consolidation, or other
12acquisition of control of a Health Maintenance Organization
13pursuant to Article VIII 1/2 of the Illinois Insurance Code,
14        (1) the Director shall give primary consideration to
15    the continuation of benefits to enrollees and the
16    financial conditions of the acquired Health Maintenance
17    Organization after the merger, consolidation, or other
18    acquisition of control takes effect;
19        (2)(i) the criteria specified in subsection (1)(b) of
20    Section 131.8 of the Illinois Insurance Code shall not
21    apply and (ii) the Director, in making his determination
22    with respect to the merger, consolidation, or other
23    acquisition of control, need not take into account the
24    effect on competition of the merger, consolidation, or
25    other acquisition of control;
26        (3) the Director shall have the power to require the

 

 

HB4703 Enrolled- 37 -LRB102 24386 BMS 33620 b

1    following information:
2            (A) certification by an independent actuary of the
3        adequacy of the reserves of the Health Maintenance
4        Organization sought to be acquired;
5            (B) pro forma financial statements reflecting the
6        combined balance sheets of the acquiring company and
7        the Health Maintenance Organization sought to be
8        acquired as of the end of the preceding year and as of
9        a date 90 days prior to the acquisition, as well as pro
10        forma financial statements reflecting projected
11        combined operation for a period of 2 years;
12            (C) a pro forma business plan detailing an
13        acquiring party's plans with respect to the operation
14        of the Health Maintenance Organization sought to be
15        acquired for a period of not less than 3 years; and
16            (D) such other information as the Director shall
17        require.
18    (d) The provisions of Article VIII 1/2 of the Illinois
19Insurance Code and this Section 5-3 shall apply to the sale by
20any health maintenance organization of greater than 10% of its
21enrollee population (including without limitation the health
22maintenance organization's right, title, and interest in and
23to its health care certificates).
24    (e) In considering any management contract or service
25agreement subject to Section 141.1 of the Illinois Insurance
26Code, the Director (i) shall, in addition to the criteria

 

 

HB4703 Enrolled- 38 -LRB102 24386 BMS 33620 b

1specified in Section 141.2 of the Illinois Insurance Code,
2take into account the effect of the management contract or
3service agreement on the continuation of benefits to enrollees
4and the financial condition of the health maintenance
5organization to be managed or serviced, and (ii) need not take
6into account the effect of the management contract or service
7agreement on competition.
8    (f) Except for small employer groups as defined in the
9Small Employer Rating, Renewability and Portability Health
10Insurance Act and except for medicare supplement policies as
11defined in Section 363 of the Illinois Insurance Code, a
12Health Maintenance Organization may by contract agree with a
13group or other enrollment unit to effect refunds or charge
14additional premiums under the following terms and conditions:
15        (i) the amount of, and other terms and conditions with
16    respect to, the refund or additional premium are set forth
17    in the group or enrollment unit contract agreed in advance
18    of the period for which a refund is to be paid or
19    additional premium is to be charged (which period shall
20    not be less than one year); and
21        (ii) the amount of the refund or additional premium
22    shall not exceed 20% of the Health Maintenance
23    Organization's profitable or unprofitable experience with
24    respect to the group or other enrollment unit for the
25    period (and, for purposes of a refund or additional
26    premium, the profitable or unprofitable experience shall

 

 

HB4703 Enrolled- 39 -LRB102 24386 BMS 33620 b

1    be calculated taking into account a pro rata share of the
2    Health Maintenance Organization's administrative and
3    marketing expenses, but shall not include any refund to be
4    made or additional premium to be paid pursuant to this
5    subsection (f)). The Health Maintenance Organization and
6    the group or enrollment unit may agree that the profitable
7    or unprofitable experience may be calculated taking into
8    account the refund period and the immediately preceding 2
9    plan years.
10    The Health Maintenance Organization shall include a
11statement in the evidence of coverage issued to each enrollee
12describing the possibility of a refund or additional premium,
13and upon request of any group or enrollment unit, provide to
14the group or enrollment unit a description of the method used
15to calculate (1) the Health Maintenance Organization's
16profitable experience with respect to the group or enrollment
17unit and the resulting refund to the group or enrollment unit
18or (2) the Health Maintenance Organization's unprofitable
19experience with respect to the group or enrollment unit and
20the resulting additional premium to be paid by the group or
21enrollment unit.
22    In no event shall the Illinois Health Maintenance
23Organization Guaranty Association be liable to pay any
24contractual obligation of an insolvent organization to pay any
25refund authorized under this Section.
26    (g) Rulemaking authority to implement Public Act 95-1045,

 

 

HB4703 Enrolled- 40 -LRB102 24386 BMS 33620 b

1if any, is conditioned on the rules being adopted in
2accordance with all provisions of the Illinois Administrative
3Procedure Act and all rules and procedures of the Joint
4Committee on Administrative Rules; any purported rule not so
5adopted, for whatever reason, is unauthorized.
6(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
7101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
81-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
9eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
10102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
111-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
12eff. 10-8-21; revised 10-27-21.)
 
13    Section 20. The Managed Care Reform and Patient Rights Act
14is amended by changing Section 70 as follows:
 
15    (215 ILCS 134/70)
16    Sec. 70. Post-stabilization medical services.
17    (a) If prior authorization for covered post-stabilization
18services is required by the health care plan, the plan shall
19provide access 24 hours a day, 7 days a week to persons
20designated by the plan to make such determinations, provided
21that any determination made under this Section must be made by
22a health care professional. The review shall be resolved in
23accordance with the provisions of Section 85 and the time
24requirements of this Section.

 

 

HB4703 Enrolled- 41 -LRB102 24386 BMS 33620 b

1    (a-5) Prior authorization or approval by the plan shall
2not be required for post-stabilization services that
3constitute emergency services under Section 356z.3a of the
4Illinois Insurance Code.
5    (b) The treating physician licensed to practice medicine
6in all its branches or health care provider shall contact the
7health care plan or delegated health care provider as
8designated on the enrollee's health insurance card to obtain
9authorization, denial, or arrangements for an alternate plan
10of treatment or transfer of the enrollee.
11    (c) The treating physician licensed to practice medicine
12in all its branches or health care provider shall document in
13the enrollee's medical record the enrollee's presenting
14symptoms; emergency medical condition; and time, phone number
15dialed, and result of the communication for request for
16authorization of post-stabilization medical services. The
17health care plan shall provide reimbursement for covered
18post-stabilization medical services if:
19        (1) authorization to render them is received from the
20    health care plan or its delegated health care provider, or
21        (2) after 2 documented good faith efforts, the
22    treating health care provider has attempted to contact the
23    enrollee's health care plan or its delegated health care
24    provider, as designated on the enrollee's health insurance
25    card, for prior authorization of post-stabilization
26    medical services and neither the plan nor designated

 

 

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1    persons were accessible or the authorization was not
2    denied within 60 minutes of the request. "Two documented
3    good faith efforts" means the health care provider has
4    called the telephone number on the enrollee's health
5    insurance card or other available number either 2 times or
6    one time and an additional call to any referral number
7    provided. "Good faith" means honesty of purpose, freedom
8    from intention to defraud, and being faithful to one's
9    duty or obligation. For the purpose of this Act, good
10    faith shall be presumed.
11    (d) After rendering any post-stabilization medical
12services, the treating physician licensed to practice medicine
13in all its branches or health care provider shall continue to
14make every reasonable effort to contact the health care plan
15or its delegated health care provider regarding authorization,
16denial, or arrangements for an alternate plan of treatment or
17transfer of the enrollee until the treating health care
18provider receives instructions from the health care plan or
19delegated health care provider for continued care or the care
20is transferred to another health care provider or the patient
21is discharged.
22    (e) Payment for covered post-stabilization services may be
23denied:
24        (1) if the treating health care provider does not meet
25    the conditions outlined in subsection (c);
26        (2) upon determination that the post-stabilization

 

 

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1    services claimed were not performed;
2        (3) upon timely determination that the
3    post-stabilization services rendered were contrary to the
4    instructions of the health care plan or its delegated
5    health care provider if contact was made between those
6    parties prior to the service being rendered;
7        (4) upon determination that the patient receiving such
8    services was not an enrollee of the health care plan; or
9        (5) upon material misrepresentation by the enrollee or
10    health care provider; "material" means a fact or situation
11    that is not merely technical in nature and results or
12    could result in a substantial change in the situation.
13    (f) Nothing in this Section prohibits a health care plan
14from delegating tasks associated with the responsibilities
15enumerated in this Section to the health care plan's
16contracted health care providers or another entity. Only a
17clinical peer may make an adverse determination. However, the
18ultimate responsibility for coverage and payment decisions may
19not be delegated.
20    (g) Coverage and payment for post-stabilization medical
21services for which prior authorization or deemed approval is
22received shall not be retrospectively denied.
23    (h) Nothing in this Section shall prohibit the imposition
24of deductibles, copayments, and co-insurance. Nothing in this
25Section alters the prohibition on billing enrollees contained
26in the Health Maintenance Organization Act.

 

 

HB4703 Enrolled- 44 -LRB102 24386 BMS 33620 b

1(Source: P.A. 91-617, eff. 1-1-00.)
 
2    Section 25. The Voluntary Health Services Plans Act is
3amended by changing Section 10 as follows:
 
4    (215 ILCS 165/10)  (from Ch. 32, par. 604)
5    Sec. 10. Application of Insurance Code provisions. Health
6services plan corporations and all persons interested therein
7or dealing therewith shall be subject to the provisions of
8Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
9143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
10356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
11356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
12356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
13356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
14356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
15356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.43, 364.01,
16367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
17and paragraphs (7) and (15) of Section 367 of the Illinois
18Insurance Code.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for
24whatever reason, is unauthorized.

 

 

HB4703 Enrolled- 45 -LRB102 24386 BMS 33620 b

1(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
2101-281, eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff.
31-1-21; 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306,
4eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21;
5revised 10-27-21.)
 
6    Section 99. Effective date. This Act takes effect July 1,
72022, except that the changes to Section 356z.3 of the
8Illinois Insurance Code and Section 4.5-1 of the Health
9Maintenance Organization Act take effect January 1, 2023.