Full Text of HB4703 102nd General Assembly
HB4703enr 102ND GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 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 Sections 356z.3 and 356z.3a as follows: | 6 | | (215 ILCS 5/356z.3)
| 7 | | Sec. 356z.3. Disclosure of limited benefit. An insurer | 8 | | that
issues,
delivers,
amends, or
renews an individual or | 9 | | group policy of accident and health insurance in this
State | 10 | | after the
effective date of this amendatory Act of the 92nd | 11 | | General Assembly and
arranges, contracts
with, or administers | 12 | | contracts with a provider whereby beneficiaries are
provided | 13 | | an incentive to
use the services of such provider must include | 14 | | the following disclosure on its
contracts and
evidences of | 15 | | coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
| 16 | | NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that | 17 | | when you elect
to
utilize the services of a non-participating | 18 | | provider for a covered service in non-emergency
situations, | 19 | | benefit payments to such non-participating provider are not | 20 | | based upon the amount
billed. The basis of your benefit | 21 | | payment will be determined according to your policy's fee
| 22 | | schedule, usual and customary charge (which is determined by | 23 | | comparing charges for similar
services adjusted to the |
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| 1 | | geographical area where the services are performed), or other | 2 | | method as
defined by the policy. YOU CAN EXPECT TO PAY MORE | 3 | | THAN THE COINSURANCE
AMOUNT DEFINED IN THE POLICY AFTER THE | 4 | | PLAN HAS PAID ITS REQUIRED
PORTION. Non-participating | 5 | | providers may bill members for any amount up to the
billed
| 6 | | charge after the plan has paid its portion of the bill , except | 7 | | as provided in Section 356z.3a of the Illinois Insurance Code | 8 | | for covered services received at a participating health care | 9 | | facility from a nonparticipating provider that are: (a) | 10 | | ancillary services, (b) items or services furnished as a | 11 | | result of unforeseen, urgent medical needs that arise at the | 12 | | time the item or service is furnished, or (c) items or services | 13 | | received when the facility or the non-participating provider | 14 | | fails to satisfy the notice and consent criteria specified | 15 | | under Section 356z.3a . Participating providers
have agreed to | 16 | | accept
discounted payments for services with no additional | 17 | | billing to the member other
than co-insurance and deductible | 18 | | amounts. You may obtain further information
about the
| 19 | | participating
status of professional providers and information | 20 | | on out-of-pocket expenses by
calling the toll
free telephone | 21 | | number 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; | 25 | | nonparticipating providers Nonparticipating facility-based |
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| 1 | | physicians and providers . | 2 | | (a) As used in this Section: For purposes of this Section, | 3 | | "facility-based provider" means a physician or other provider | 4 | | who provide radiology, anesthesiology, pathology, neonatology, | 5 | | or emergency department services to insureds, beneficiaries, | 6 | | or enrollees in a participating hospital or participating | 7 | | ambulatory 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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| 1 | | or enrollee is responsible for paying for a covered item or | 2 | | service under the terms of the policy or certificate. "Cost | 3 | | sharing" includes copayments, coinsurance, and amounts paid | 4 | | toward deductibles, but does not include amounts paid towards | 5 | | premiums, balance billing by out-of-network providers, or the | 6 | | cost of items or services that are not covered under the policy | 7 | | or certificate. | 8 | | "Emergency department of a hospital" means any hospital | 9 | | department that provides emergency services, including a | 10 | | hospital outpatient department. | 11 | | "Emergency medical condition" has the meaning ascribed to | 12 | | that term in Section 10 of the Managed Care Reform and Patient | 13 | | Rights Act. | 14 | | "Emergency medical screening examination" has the meaning | 15 | | ascribed to that term in Section 10 of the Managed Care Reform | 16 | | and Patient Rights Act. | 17 | | "Emergency services" means, with respect to an emergency | 18 | | medical 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 | 15 | | under Section 32.5 of the Emergency Medical Services (EMS) | 16 | | Systems Act. | 17 | | "Health care facility" means, in the context of | 18 | | non-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 | 3 | | subsection (d) of Section 370g. "Health care provider" does | 4 | | not include a provider of air ambulance or ground ambulance | 5 | | services. | 6 | | "Health care services" has the meaning ascribed to that | 7 | | term in subsection (a) of Section 370g. | 8 | | "Health insurance issuer" has the meaning ascribed to that | 9 | | term in Section 5 of the Illinois Health Insurance Portability | 10 | | and Accountability Act. | 11 | | "Nonparticipating emergency facility" means, with respect | 12 | | to the furnishing of an item or service under a policy of group | 13 | | or individual health insurance coverage, any of the following | 14 | | facilities that does not have a contractual relationship | 15 | | directly or indirectly with a health insurance issuer in | 16 | | relation 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 | 25 | | furnishing of an item or service under a policy of group or | 26 | | individual health insurance coverage, any health care provider |
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| 1 | | who does not have a contractual relationship directly or | 2 | | indirectly with a health insurance issuer in relation to the | 3 | | coverage. | 4 | | "Participating emergency facility" means any of the | 5 | | following facilities that has a contractual relationship | 6 | | directly or indirectly with a health insurance issuer offering | 7 | | group or individual health insurance coverage setting forth | 8 | | the terms and conditions on which a relevant health care | 9 | | service is provided to an insured, beneficiary, or enrollee | 10 | | under 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. | 18 | | For purposes of this definition, a single case agreement | 19 | | between an emergency facility and an issuer that is used to | 20 | | address unique situations in which an insured, beneficiary, or | 21 | | enrollee requires services that typically occur out-of-network | 22 | | constitutes a contractual relationship and is limited to the | 23 | | parties to the agreement. | 24 | | "Participating health care facility" means any health care | 25 | | facility that has a contractual
relationship directly or | 26 | | indirectly with a health insurance issuer offering group or |
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| 1 | | individual health insurance coverage setting forth the terms | 2 | | and conditions on which a relevant health care service is | 3 | | provided to an insured, beneficiary, or enrollee under the | 4 | | coverage. A single case agreement between an emergency | 5 | | facility and an issuer that is used to address unique | 6 | | situations in which an insured, beneficiary, or enrollee | 7 | | requires services that typically occur out-of-network | 8 | | constitutes a contractual relationship for purposes of this | 9 | | definition and is limited to the parties to the agreement. | 10 | | "Participating provider" means any health care provider | 11 | | that has a
contractual relationship directly or indirectly | 12 | | with a health insurance issuer offering group or individual | 13 | | health insurance coverage setting forth the terms and | 14 | | conditions on which a relevant health care service is provided | 15 | | to an insured, beneficiary, or enrollee under the coverage. | 16 | | "Qualifying payment amount" has the meaning given to that | 17 | | term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations | 18 | | promulgated thereunder. | 19 | | "Recognized amount" means the lesser of the amount | 20 | | initially billed by the provider or the qualifying payment | 21 | | amount. | 22 | | "Stabilize" means "stabilization" as defined in Section 10 | 23 | | of the Managed Care Reform and Patient Rights Act. | 24 | | "Treating provider" means a health care provider who has | 25 | | evaluated the individual. | 26 | | "Visit" means, with respect to health care services |
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| 1 | | furnished to an individual at a health care facility, health | 2 | | care services furnished by a provider at the facility, as well | 3 | | as equipment, devices, telehealth services, imaging services, | 4 | | laboratory services, and preoperative and postoperative | 5 | | services regardless of whether the provider furnishing such | 6 | | services is at the facility. | 7 | | (b) Emergency services. When a beneficiary, insured, or | 8 | | enrollee receives emergency services from a nonparticipating | 9 | | provider or a nonparticipating emergency facility, the health | 10 | | insurance issuer shall ensure that the beneficiary, insured, | 11 | | or enrollee shall incur no greater out-of-pocket costs than | 12 | | the beneficiary, insured, or enrollee would have incurred with | 13 | | a participating provider or a participating emergency | 14 | | facility. Any cost-sharing requirements shall be applied as | 15 | | though the emergency services had been received from a | 16 | | participating provider or a participating facility. Cost | 17 | | sharing shall be calculated based on the recognized amount for | 18 | | the emergency services. If the cost sharing for the same item | 19 | | or service furnished by a participating provider would have | 20 | | been a flat-dollar copayment, that amount shall be the | 21 | | cost-sharing amount unless the provider has billed a lesser | 22 | | total amount. In no event shall the beneficiary, insured, | 23 | | enrollee, or any group policyholder or plan sponsor be liable | 24 | | to or billed by the health insurance issuer, the | 25 | | nonparticipating provider, or the nonparticipating emergency | 26 | | facility for any amount beyond the cost sharing calculated in |
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| 1 | | accordance with this subsection with respect to the emergency | 2 | | services delivered. Administrative requirements or limitations | 3 | | shall be no greater than those applicable to emergency | 4 | | services received from a participating provider or a | 5 | | participating emergency facility. | 6 | | (b-5) Non-emergency services at participating health care | 7 | | facilities. | 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 | 19 | | agrees in writing, notwithstanding any other provision of this | 20 | | Code, except when the notice and consent criteria are | 21 | | satisfied for the situation in paragraph (2) of subsection | 22 | | (b-5), any benefits a beneficiary, insured, or enrollee | 23 | | receives for services under the situations situation in | 24 | | subsections subsection (b) or (b-5) are assigned to the | 25 | | nonparticipating facility-based providers or the facility | 26 | | acting on their behalf . Upon receipt of the provider's bill or |
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| 1 | | facility's bill, the health insurance issuer The insurer or | 2 | | health plan shall provide the nonparticipating provider or the | 3 | | facility with a written explanation of benefits that specifies | 4 | | the proposed reimbursement and the applicable deductible, | 5 | | copayment or coinsurance amounts owed by the insured, | 6 | | beneficiary or enrollee. The health insurance issuer insurer | 7 | | or health plan shall pay any reimbursement subject to this | 8 | | Section directly to the nonparticipating facility-based | 9 | | provider or the facility . The nonparticipating facility-based | 10 | | physician or provider shall not bill the beneficiary, insured, | 11 | | or enrollee, except for applicable deductible, copayment, or | 12 | | coinsurance amounts that would apply if the beneficiary, | 13 | | insured, or enrollee utilized a participating physician or | 14 | | provider for covered services. If a beneficiary, insured, or | 15 | | enrollee specifically rejects assignment under this Section in | 16 | | writing to the nonparticipating facility-based provider, then | 17 | | the nonparticipating facility-based provider may bill the | 18 | | beneficiary, insured, or enrollee for the services rendered. | 19 | | (d) For bills assigned under subsection (c), the | 20 | | nonparticipating facility-based provider or the facility may | 21 | | bill the health insurance issuer insurer or health plan for | 22 | | the services rendered, and the health insurance issuer insurer | 23 | | or health plan may pay the billed amount or attempt to | 24 | | negotiate reimbursement with the nonparticipating | 25 | | facility-based provider or the facility . Within 30 calendar | 26 | | days after the provider or facility transmits the bill to the |
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| 1 | | health insurance issuer, the issuer shall send an initial | 2 | | payment or notice of denial of payment with the written | 3 | | explanation of benefits to the provider or facility. If | 4 | | attempts to negotiate reimbursement for services provided by a | 5 | | nonparticipating facility-based provider do not result in a | 6 | | resolution of the payment dispute within 30 days after receipt | 7 | | of written explanation of benefits by the health insurance | 8 | | issuer insurer or health plan , then the health insurance | 9 | | issuer an insurer or health plan or nonparticipating | 10 | | facility-based physician or provider or the facility may | 11 | | initiate binding arbitration to determine payment for services | 12 | | provided on a per bill basis. The party requesting arbitration | 13 | | shall notify the other party arbitration has been initiated | 14 | | and state its final offer before arbitration. In response to | 15 | | this notice, the nonrequesting party shall inform the | 16 | | requesting party of its final offer before the arbitration | 17 | | occurs. Arbitration shall be initiated by filing a request | 18 | | with the Department of Insurance. | 19 | | (e) The Department of Insurance shall publish a list of | 20 | | approved arbitrators or entities that shall provide binding | 21 | | arbitration. These arbitrators shall be American Arbitration | 22 | | Association or American Health Lawyers Association trained | 23 | | arbitrators. Both parties must agree on an arbitrator from the | 24 | | Department of Insurance's or its approved entity's list of | 25 | | arbitrators. If no agreement can be reached, then a list of 5 | 26 | | arbitrators shall be provided by the Department of Insurance |
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| 1 | | or the approved entity . From the list of 5 arbitrators, the | 2 | | health insurance issuer insurer can veto 2 arbitrators and the | 3 | | provider or facility can veto 2 arbitrators. The remaining | 4 | | arbitrator shall be the chosen arbitrator. This arbitration | 5 | | shall consist of a review of the written submissions by both | 6 | | parties. The arbitrator shall not establish a rebuttable | 7 | | presumption that the qualifying payment amount should be the | 8 | | total amount owed to the provider or facility by the | 9 | | combination of the issuer and the insured, beneficiary, or | 10 | | enrollee. Binding arbitration shall provide for a written | 11 | | decision within 45 days after the request is filed with the | 12 | | Department of Insurance. Both parties shall be bound by the | 13 | | arbitrator's decision. The arbitrator's expenses and fees, | 14 | | together with other expenses, not including attorney's fees, | 15 | | incurred in the conduct of the arbitration, shall be paid as | 16 | | provided in the decision. | 17 | | (f) (Blank). This Section 356z.3a does not apply to a | 18 | | beneficiary, insured, or enrollee who willfully chooses to | 19 | | access a nonparticipating facility-based physician or provider | 20 | | for health care services available through the insurer's or | 21 | | plan's network of participating physicians and providers. In | 22 | | these circumstances, the contractual requirements for | 23 | | nonparticipating facility-based provider reimbursements will | 24 | | apply. | 25 | | (g) Section 368a of this Act shall not apply during the | 26 | | pendency of a decision under subsection (d) . Upon the issuance |
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| 1 | | of the arbitrator's decision, Section 368a applies with | 2 | | respect to the amount, if any, by which the arbitrator's | 3 | | determination exceeds the issuer's initial payment under | 4 | | subsection (c), or the entire amount of the arbitrator's | 5 | | determination if initial payment was denied. Any any interest | 6 | | required to be paid a provider under Section 368a shall not | 7 | | accrue until after 30 days of an arbitrator's decision as | 8 | | provided in subsection (d), but in no circumstances longer | 9 | | than 150 days from date the nonparticipating facility-based | 10 | | provider billed for services rendered.
| 11 | | (h) Nothing in this Section shall be interpreted to change | 12 | | the prudent layperson provisions with respect to emergency | 13 | | services under the Managed Care Reform and Patient Rights Act. | 14 | | (i) Nothing in this Section shall preclude a health care | 15 | | provider from billing a beneficiary, insured, or enrollee for | 16 | | reasonable administrative fees, such as service fees for | 17 | | checks returned for nonsufficient funds and missed | 18 | | appointments. | 19 | | (j) Nothing in this Section shall preclude a beneficiary, | 20 | | insured, or enrollee from assigning benefits to a | 21 | | nonparticipating provider when the notice and consent criteria | 22 | | are satisfied under paragraph (2) of subsection (b-5) or in | 23 | | any other situation not described in subsections (b) or (b-5). | 24 | | (k) Except when the notice and consent criteria are | 25 | | satisfied under paragraph (2) of subsection (b-5), if an | 26 | | individual receives health care services under the situations |
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| 1 | | described in subsections (b) or (b-5), no referral requirement | 2 | | or any other provision contained in the policy or certificate | 3 | | of coverage shall deny coverage, reduce benefits, or otherwise | 4 | | defeat the requirements of this Section for services that | 5 | | would have been covered with a participating provider. | 6 | | However, this subsection shall not be construed to preclude a | 7 | | provider contract with a health insurance issuer, or with an | 8 | | administrator or similar entity acting on the issuer's behalf, | 9 | | from imposing requirements on the participating provider, | 10 | | participating emergency facility, or participating health care | 11 | | facility relating to the referral of covered individuals to | 12 | | nonparticipating providers. | 13 | | (l) Except if the notice and consent criteria are | 14 | | satisfied under paragraph (2) of subsection (b-5), | 15 | | cost-sharing amounts calculated in conformity with this | 16 | | Section shall count toward any deductible or out-of-pocket | 17 | | maximum applicable to in-network coverage. | 18 | | (m) The Department has the authority to enforce the | 19 | | requirements of this Section in the situations described in | 20 | | subsections (b) and (b-5), and in any other situation for | 21 | | which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and | 22 | | regulations promulgated thereunder would prohibit an | 23 | | individual from being billed or liable for emergency services | 24 | | furnished by a nonparticipating provider or nonparticipating | 25 | | emergency facility or for non-emergency health care services | 26 | | furnished by a nonparticipating provider at a participating |
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| 1 | | health care facility. | 2 | | (n) This Section does not apply with respect to air | 3 | | ambulance or ground ambulance services. This Section does not | 4 | | apply to any policy of excepted benefits or to short-term, | 5 | | limited-duration health insurance coverage. | 6 | | (Source: P.A. 98-154, eff. 8-2-13.) | 7 | | Section 10. The Network Adequacy and Transparency Act is | 8 | | amended 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 | 12 | | description 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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| 1 | | discussing any specific or all treatment options with | 2 | | beneficiaries irrespective of the insurer's position on those | 3 | | treatment options or from advocating on behalf of | 4 | | beneficiaries within the utilization review, grievance, or | 5 | | appeals processes established by the insurer in accordance | 6 | | with any rights or remedies available under applicable State | 7 | | or federal law. | 8 | | (b) Insurers must file for review a description of the | 9 | | services to be offered through a network plan. The description | 10 | | shall 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 |
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| 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 |
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| 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 | 9 | | minimum ratio of providers to plan beneficiaries as required | 10 | | by 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 | 2 | | maximum travel and distance standards for plan beneficiaries, | 3 | | which shall be established annually by the Department in | 4 | | consultation with the Department of Public Health based upon | 5 | | the guidance from the federal Centers for Medicare and | 6 | | Medicaid Services. These standards shall consist of the | 7 | | maximum minutes or miles to be traveled by a plan beneficiary | 8 | | for each county type, such as large counties, metro counties, | 9 | | or rural counties as defined by Department rule. | 10 | | The maximum travel time and distance standards must | 11 | | include standards for each physician and other provider | 12 | | category listed for which ratios have been established. | 13 | | The Director shall establish a process for the review of | 14 | | the adequacy of these standards along with an assessment of | 15 | | additional specialties to be included in the list under this | 16 | | subsection (d). | 17 | | (d-5)(1) Every insurer shall ensure that beneficiaries | 18 | | have timely and proximate access to treatment for mental, | 19 | | emotional, nervous, or substance use disorders or conditions | 20 | | in accordance with the provisions of paragraph (4) of | 21 | | subsection (a) of Section 370c of the Illinois Insurance Code. | 22 | | Insurers shall use a comparable process, strategy, evidentiary | 23 | | standard, and other factors in the development and application | 24 | | of the network adequacy standards for timely and proximate | 25 | | access to treatment for mental, emotional, nervous, or | 26 | | substance use disorders or conditions and those for the access |
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| 1 | | to treatment for medical and surgical conditions. As such, the | 2 | | network adequacy standards for timely and proximate access | 3 | | shall equally be applied to treatment facilities and providers | 4 | | for mental, emotional, nervous, or substance use disorders or | 5 | | conditions and specialists providing medical or surgical | 6 | | benefits pursuant to the parity requirements of Section 370c.1 | 7 | | of the Illinois Insurance Code and the federal Paul Wellstone | 8 | | and Pete Domenici Mental Health Parity and Addiction Equity | 9 | | Act of 2008. Notwithstanding the foregoing, the network | 10 | | adequacy standards for timely and proximate access to | 11 | | treatment for mental, emotional, nervous, or substance use | 12 | | disorders or conditions shall, at a minimum, satisfy the | 13 | | following 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, | 6 | | network adequacy standards for timely and proximate access to | 7 | | treatment for mental, emotional, nervous, or substance use | 8 | | disorders or conditions means a beneficiary shall not have to | 9 | | travel longer than 60 minutes or 60 miles from the | 10 | | beneficiary's residence to receive inpatient or residential | 11 | | treatment for mental, emotional, nervous, or substance use | 12 | | disorders or conditions. | 13 | | (3) If there is no in-network facility or provider | 14 | | available for a beneficiary to receive timely and proximate | 15 | | access to treatment for mental, emotional, nervous, or | 16 | | substance use disorders or conditions in accordance with the | 17 | | network adequacy standards outlined in this subsection, the | 18 | | insurer shall provide necessary exceptions to its network to | 19 | | ensure admission and treatment with a provider or at a | 20 | | treatment facility in accordance with the network adequacy | 21 | | standards in this subsection. | 22 | | (e) Except for network plans solely offered as a group | 23 | | health plan, these ratio and time and distance standards apply | 24 | | to the lowest cost-sharing tier of any tiered network. | 25 | | (f) The network plan may consider use of other health care | 26 | | service delivery options, such as telemedicine or telehealth, |
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| 1 | | mobile clinics, and centers of excellence, or other ways of | 2 | | delivering care to partially meet the requirements set under | 3 | | this Section. | 4 | | (g) Except for the requirements set forth in subsection | 5 | | (d-5), insurers who are not able to comply with the provider | 6 | | ratios and time and distance standards established by the | 7 | | Department may request an exception to these requirements from | 8 | | the Department. The Department may grant an exception in the | 9 | | following 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 | 3 | | material change to an approved network plan within 15 days | 4 | | after the change occurs and any change that would result in | 5 | | failure to meet the requirements of this Act. Upon notice from | 6 | | the insurer, the Director shall reevaluate the network plan's | 7 | | compliance with the network adequacy and transparency | 8 | | standards of this Act.
| 9 | | (Source: P.A. 102-144, eff. 1-1-22 .) | 10 | | Section 15. The Health Maintenance Organization Act is | 11 | | amended 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 | 15 | | point-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 |
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| 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 | 21 | | point-of-service contract
is
subject to all of the following | 22 | | limitations:
| 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.
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| 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
| 26 | | point-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 |
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| 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 | 5 | | point-of-service
contract
until it has filed and had approved | 6 | | by the Director a plan to comply with the
provisions of
this | 7 | | Section. The compliance plan must, at a minimum, include | 8 | | provisions
demonstrating
that the health maintenance | 9 | | organization 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.
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| 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 | 7 | | the provisions of Sections 133, 134, 136, 137, 139, 140, | 8 | | 141.1,
141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, | 9 | | 154, 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, | 10 | | 355.3, 355b, 356g.5-1, 356m, 356q, 356v, 356w, 356x, 356y,
| 11 | | 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, | 12 | | 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, | 13 | | 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, | 14 | | 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33, 356z.35, | 15 | | 356z.36, 356z.40, 356z.41, 356z.43, 356z.46, 356z.47, 356z.48, | 16 | | 356z.50, 356z.51, 364, 364.01, 367.2, 367.2-5, 367i, 368a, | 17 | | 368b, 368c, 368d, 368e, 370c,
370c.1, 401, 401.1, 402, 403, | 18 | | 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of | 19 | | subsection (2) of Section 367, and Articles IIA, VIII 1/2,
| 20 | | XII,
XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | 21 | | Illinois Insurance Code.
| 22 | | (b) For purposes of the Illinois Insurance Code, except | 23 | | for Sections 444
and 444.1 and Articles XIII and XIII 1/2, | 24 | | Health Maintenance Organizations in
the following categories | 25 | | are deemed to be "domestic companies":
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| 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 | 12 | | acquisition of
control of a Health Maintenance Organization | 13 | | pursuant 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 |
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| 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 | 19 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 20 | | any health maintenance
organization of greater than 10% of its
| 21 | | enrollee population (including without limitation the health | 22 | | maintenance
organization's right, title, and interest in and | 23 | | to its health care
certificates).
| 24 | | (e) In considering any management contract or service | 25 | | agreement subject
to Section 141.1 of the Illinois Insurance | 26 | | Code, the Director (i) shall, in
addition to the criteria |
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| 1 | | specified in Section 141.2 of the Illinois
Insurance Code, | 2 | | take into account the effect of the management contract or
| 3 | | service agreement on the continuation of benefits to enrollees | 4 | | and the
financial condition of the health maintenance | 5 | | organization to be managed or
serviced, and (ii) need not take | 6 | | into account the effect of the management
contract or service | 7 | | agreement on competition.
| 8 | | (f) Except for small employer groups as defined in the | 9 | | Small Employer
Rating, Renewability and Portability Health | 10 | | Insurance Act and except for
medicare supplement policies as | 11 | | defined in Section 363 of the Illinois
Insurance Code, a | 12 | | Health Maintenance Organization may by contract agree with a
| 13 | | group or other enrollment unit to effect refunds or charge | 14 | | additional 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 |
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| 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 | 11 | | statement in the
evidence of coverage issued to each enrollee | 12 | | describing the possibility of a
refund or additional premium, | 13 | | and upon request of any group or enrollment unit,
provide to | 14 | | the group or enrollment unit a description of the method used | 15 | | to
calculate (1) the Health Maintenance Organization's | 16 | | profitable experience with
respect to the group or enrollment | 17 | | unit and the resulting refund to the group
or enrollment unit | 18 | | or (2) the Health Maintenance Organization's unprofitable
| 19 | | experience with respect to the group or enrollment unit and | 20 | | the resulting
additional premium to be paid by the group or | 21 | | enrollment unit.
| 22 | | In no event shall the Illinois Health Maintenance | 23 | | Organization
Guaranty Association be liable to pay any | 24 | | contractual obligation of an
insolvent organization to pay any | 25 | | refund authorized under this Section.
| 26 | | (g) Rulemaking authority to implement Public Act 95-1045, |
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| 1 | | if any, is conditioned on the rules being adopted in | 2 | | accordance with all provisions of the Illinois Administrative | 3 | | Procedure Act and all rules and procedures of the Joint | 4 | | Committee on Administrative Rules; any purported rule not so | 5 | | adopted, for whatever reason, is unauthorized. | 6 | | (Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19; | 7 | | 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff. | 8 | | 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, | 9 | | eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | 10 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | 11 | | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | 12 | | eff. 10-8-21; revised 10-27-21.) | 13 | | Section 20. The Managed Care Reform and Patient Rights Act | 14 | | is 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 | 18 | | services is
required by the health care
plan, the plan shall | 19 | | provide access 24 hours a day, 7 days a week to persons
| 20 | | designated by
the plan to make such determinations, provided | 21 | | that any determination made
under this Section must be made by | 22 | | a health care
professional. The review shall be resolved in | 23 | | accordance with the provisions
of Section 85 and the time | 24 | | requirements of this Section.
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| 1 | | (a-5) Prior authorization or approval by the plan shall | 2 | | not be required for post-stabilization services that | 3 | | constitute emergency services under Section 356z.3a of the | 4 | | Illinois Insurance Code. | 5 | | (b) The treating physician licensed to practice medicine | 6 | | in all its branches
or health care provider shall contact the | 7 | | health care plan or
delegated health care provider as
| 8 | | designated on the enrollee's health insurance card to obtain
| 9 | | authorization, denial, or
arrangements for an alternate plan | 10 | | of treatment or transfer of the
enrollee.
| 11 | | (c) The treating physician licensed to practice medicine | 12 | | in all its
branches or
health care provider shall document in | 13 | | the enrollee's
medical record the enrollee's
presenting | 14 | | symptoms; emergency medical condition; and time, phone number
| 15 | | dialed,
and result of the communication for request for | 16 | | authorization of
post-stabilization medical services. The | 17 | | health care plan shall provide
reimbursement for covered
| 18 | | post-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 | 12 | | services,
the treating physician licensed to practice medicine
| 13 | | in all its branches or health care
provider shall continue to | 14 | | make every reasonable effort to contact the health
care plan
| 15 | | or its delegated health care provider regarding authorization, | 16 | | denial, or
arrangements
for an
alternate plan of treatment or | 17 | | transfer of the enrollee until the
treating health care | 18 | | provider
receives instructions from the health care plan or | 19 | | delegated health care
provider for
continued care or the care | 20 | | is transferred to another health care provider or
the patient | 21 | | is discharged.
| 22 | | (e) Payment for covered post-stabilization services may be | 23 | | denied:
| 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 | 14 | | from delegating
tasks associated with the responsibilities | 15 | | enumerated in this Section to the
health care plan's | 16 | | contracted health care providers or another
entity. Only a | 17 | | clinical peer may make an adverse determination. However, the
| 18 | | ultimate responsibility for
coverage and payment decisions may | 19 | | not be delegated.
| 20 | | (g) Coverage and payment for post-stabilization medical | 21 | | services for which
prior
authorization or deemed approval is | 22 | | received shall not be retrospectively
denied.
| 23 | | (h) Nothing in this Section shall prohibit the imposition | 24 | | of deductibles,
copayments, and co-insurance.
Nothing in this | 25 | | Section alters the prohibition on billing enrollees contained
| 26 | | in the Health Maintenance Organization Act.
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| 1 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 2 | | Section 25. The Voluntary Health Services Plans Act is | 3 | | amended 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 | 6 | | services
plan corporations and all persons interested therein | 7 | | or dealing therewith
shall be subject to the provisions of | 8 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 9 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, | 10 | | 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v,
356w, | 11 | | 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | 12 | | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | 13 | | 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, | 14 | | 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33, | 15 | | 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.43, 364.01, | 16 | | 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, | 17 | | and paragraphs (7) and (15) of Section 367 of the Illinois
| 18 | | Insurance Code.
| 19 | | Rulemaking authority to implement Public Act 95-1045, if | 20 | | any, is conditioned on the rules being adopted in accordance | 21 | | with all provisions of the Illinois Administrative Procedure | 22 | | Act and all rules and procedures of the Joint Committee on | 23 | | Administrative Rules; any purported rule not so adopted, for | 24 | | whatever reason, is unauthorized. |
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| 1 | | (Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19; | 2 | | 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff. | 3 | | 1-1-21; 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, | 4 | | eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; | 5 | | revised 10-27-21.)
| 6 | | Section 99. Effective date. This Act takes effect July 1, | 7 | | 2022, except that the changes to Section 356z.3 of the
| 8 | | Illinois Insurance Code and Section 4.5-1 of the Health
| 9 | | Maintenance Organization Act take effect January 1, 2023.
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