HB4086 94TH GENERAL ASSEMBLY

LRB094 12785 LJB 47629 b

94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB4086

Introduced 6/27/2005, by Rep. Mary E. Flowers

SYNOPSIS AS INTRODUCED:

215 ILCS 134/15

Amends the Managed Care Reform and Patient Rights Act. Requires health care plans to provide certain information on participating physicians to enrollees and prospective enrollees. Requires the removal of physicians who are deceased or are no longer practicing medicine from the list. Requires health care plans to provide periodic updates of physician listings with new and corrected information in printed form and on the plan's Internet website.

A BILL FOR

AN ACT concerning insurance.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Managed Care Reform and Patient Rights Act is amended by changing Section 15 as follows:

(215 ILCS 134/15)

Sec. 15. Provision of information.

(a) A health care plan shall provide annually to enrollees and prospective enrollees, upon request, a complete list of participating health care providers in the health care plan's service area and a description of the following terms of coverage:

(1) the service area;

(2) the covered benefits and services with all exclusions, exceptions, and limitations;

(3) the pre-certification and other utilization review procedures and requirements;

(4) a description of the process for the selection of a primary care physician, any limitation on access to specialists, and the plan's standing referral policy;

(5) the emergency coverage and benefits, including any restrictions on emergency care services;

(6) the out-of-area coverage and benefits, if any;

(7) the enrollee's financial responsibility for copayments, deductibles, premiums, and any other out-of-pocket expenses;

(8) the provisions for continuity of treatment in the event a health care provider's participation terminates during the course of an enrollee's treatment by that provider;

(9) the appeals process, forms, and time frames for health care services appeals, complaints, and external independent reviews, administrative complaints, and utilization review complaints, including a phone number to call to receive more information from the health care plan concerning the appeals process; and

(10) a statement of all basic health care services and all specific benefits and services mandated to be provided to enrollees by any State law or administrative rule.

In the event of an inconsistency between any separate written disclosure statement and the enrollee contract or certificate, the terms of the enrollee contract or certificate shall control.

(b) Upon written request, a health care plan shall provide to enrollees a description of the financial relationships between the health care plan and any health care provider and, if requested, the percentage of copayments, deductibles, and total premiums spent on healthcare related expenses and the percentage of copayments, deductibles, and total premiums spent on other expenses, including administrative expenses, except that no health care plan shall be required to disclose specific provider reimbursement.

(c) A participating health care provider shall provide all of the following, where applicable, to enrollees upon request:

(1) Information related to the health care provider's educational background, experience, training, specialty, and board certification, if applicable.

(2) The names of licensed facilities on the provider panel where the health care provider presently has privileges for the treatment, illness, or procedure that is the subject of the request.

(3) Information regarding the health care provider's participation in continuing education programs and compliance with any licensure, certification, or registration requirements, if applicable.

(d) A health care plan shall provide the information required to be disclosed under this Act upon enrollment and annually thereafter in a legible and understandable format. The Department shall promulgate rules to establish the format based, to the extent practical, on the standards developed for supplemental insurance coverage under Title XVIII of the federal Social Security Act as a guide, so that a person can compare the attributes of the various health care plans.

(e) The written disclosure requirements of this Section may be met by disclosure to one enrollee in a household.

(f) As part of the list of participating health care providers required to be provided to enrollees and prospective enrollees under subsection (a) of this Section, a health care plan shall provide current and accurate information on participating physicians, which shall include, but not be limited to, the specialty practice area of each participating physician. Any participating physician who is deceased or is no longer practicing medicine shall be removed from the list.

Health care plans shall provide periodic updates of participating physician listings with new and corrected information in both printed form and on the plan's Internet website, if applicable.

(Source: P.A. 91-617, eff. 1-1-00.)