Illinois General Assembly - Full Text of HB5539
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Full Text of HB5539  102nd General Assembly

HB5539 102ND GENERAL ASSEMBLY

  
  

 


 
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB5539

 

Introduced 1/31/2022, by Rep. Michael Kelly

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/364.4 new

    Amends the Illinois Insurance Code. Provides that each insurer shall make available on its publicly accessible website or through a toll-free telephone number an interactive mechanism where any member of the public may access specified health care cost information. Provides that the Department of Insurance shall adopt rules to define specified terms. Provides that an insurer shall provide notification on its website that the actual amount that a covered person will be responsible to pay following the receipt of a particular health care service may vary due to unforeseen costs that arise during the provision of the service. Provides that each estimate of out-of-pocket costs provided shall provide the out-of-pocket costs a covered person may owe if he or she has exceeded his or her deductible and the out-of-pocket costs a covered person may owe if he or she has not exceeded his or her deductible. Provides that an insurer may contract with a third party to satisfy part or all of the requirements. Provides that nothing in the provisions shall prohibit an insurer from charging a covered person cost sharing beyond that included in the estimate provided if the additional cost sharing resulted from unforeseen provisions of additional health care services and the cost-sharing requirements of the unforeseen health care services were disclosed in the covered person's policy or certificate of insurance. Provides that some of the provisions do not apply to a health maintenance organization.


LRB102 25169 BMS 34432 b

 

 

A BILL FOR

 

HB5539LRB102 25169 BMS 34432 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
5adding Section 364.4 as follows:
 
6    (215 ILCS 5/364.4 new)
7    Sec. 364.4. Health care cost information disclosure.
8    (a) As used in this Section:
9    "Emergency services" means health care services that are
10provided for a condition of recent onset and sufficient
11severity, including, but not limited to, severe pain that
12would lead a prudent layperson, possessing an average
13knowledge of medicine and health, to believe that his or her
14condition, sickness, or injury is of such a nature that
15failure to obtain immediate medical care could result in:
16        (1) placing the patient's health in serious jeopardy;
17        (2) serious impairment to bodily functions; or
18        (3) serious dysfunction of any bodily organ or part.
19    "Health benefit policy" or "policy" means any individual
20or group plan, policy, or contract for health care services
21amended, delivered, issued, or renewed in this State.
22    "Health care provider" means any physician, dentist,
23podiatric physician, pharmacist, optometrist, psychologist,

 

 

HB5539- 2 -LRB102 25169 BMS 34432 b

1clinical social worker, advanced practice registered nurse,
2optician, licensed professional counselor, physical therapist,
3marriage and family therapist, athletic trainer, occupational
4therapist, speech-language pathologist, audiologist,
5dietitian, or physician assistant.
6    "Health care services" means:
7        (1) physical and occupational therapy services;
8        (2) obstetrical and gynecological services;
9        (3) radiology and imaging services;
10        (4) laboratory services;
11        (5) infusion services;
12        (6) inpatient or outpatient surgical procedures;
13        (7) outpatient nonsurgical diagnostic tests or
14    procedures; and
15        (8) any services designated by the Director as
16    shoppable by health care consumers.
17    "Hierarchical Condition Category Methodology" means a
18coding system designed by the Centers for Medicare and
19Medicaid Services to estimate future health care costs for
20patients.
21    (b) Each insurer shall make available on its publicly
22accessible website or through a toll-free telephone number an
23interactive mechanism where any member of the public may:
24        (1) for each health benefit policy offered, compare
25    the payment amounts accepted by in-network providers from
26    the insurer for the provision of a particular health care

 

 

HB5539- 3 -LRB102 25169 BMS 34432 b

1    service within the previous year;
2        (2) for each health benefit policy offered, obtain an
3    estimate of the average amount accepted by in-network
4    providers from the insurer for the provision of a
5    particular health care service within the previous year;
6        (3) for each health benefit policy offered, obtain an
7    estimate of the out-of-pocket costs that the covered
8    person would owe his or her provider following the
9    provision of a particular health care service;
10        (4) compare quality metrics applicable to in-network
11    providers for major diagnostic categories with adjustments
12    by risk and severity based upon the Hierarchical Condition
13    Category Methodology or a nationally recognized health
14    care quality reporting standard designated by the
15    Director. Metrics shall be based on reasonably universal
16    and uniform databases with sufficient claim volume. If
17    applicable to the provider, quality metrics include, but
18    are not limited to:
19            (A) risk-adjusted readmission rates and absolute
20        hospital readmission rates;
21            (B) risk-adjusted hospitalization rates and
22        absolute hospitalization rates;
23            (C) admission volume;
24            (D) utilization volume;
25            (E) risk-adjusted rates of adverse events; and
26            (F) risk-adjusted total cost of care and absolute

 

 

HB5539- 4 -LRB102 25169 BMS 34432 b

1        relative total cost of care; and
2        (5) access any all-payer health claims database that
3    may be maintained by the Department.
4    The Department shall adopt rules that define the following
5terms: "risk-adjusted hospital readmission rates", "absolute
6hospital readmission rates", "risk-adjusted hospitalization
7rates", "absolute hospitalization rates", "admission volume",
8"utilization volume", "risk-adjusted rates of adverse events",
9"risk-adjusted total cost of care", and "absolute relative
10total cost of care".
11    (c) An insurer shall provide notification on its website
12that the actual amount that a covered person will be
13responsible to pay following the receipt of a particular
14health care service may vary due to unforeseen costs that
15arise during the provision of the service.
16    (d) Each estimate of out-of-pocket costs provided pursuant
17to paragraph (3) of subsection (b) shall provide:
18        (1) the out-of-pocket costs a covered person may owe
19    if he or she has exceeded his or her deductible; and
20        (2) the out-of-pocket costs a covered person may owe
21    if he or she has not exceeded his or her deductible.
22    (e) An insurer may contract with a third party to satisfy
23part or all of the requirements of this Section.
24    (f) Nothing in this Section shall prohibit an insurer from
25charging a covered person cost sharing beyond that included in
26the estimate provided pursuant to paragraph (3) of subsection

 

 

HB5539- 5 -LRB102 25169 BMS 34432 b

1(b) if the additional cost sharing resulted from unforeseen
2provisions of additional health care services and the
3cost-sharing requirements of the unforeseen health care
4services were disclosed in the covered person's policy or
5certificate of insurance.
6    (g) The requirements of this Section, with the exception
7of paragraph (4) of subsection (b), do not apply to a health
8maintenance organization, as defined in the Health Maintenance
9Organization Act.