Full Text of HB3749 96th General Assembly
HB3749ham001 96TH GENERAL ASSEMBLY
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Health Care Availability and Accessibility Committee
Filed: 3/10/2009
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| AMENDMENT TO HOUSE BILL 3749
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| AMENDMENT NO. ______. Amend House Bill 3749 by replacing | 3 |
| everything after the enacting clause with the following:
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| "Section 5. The Illinois Insurance Code is amended by | 5 |
| changing Sections 357.9 357.9a, 368b, 368c, 368d, 368e, 368g, | 6 |
| 370, 370a, and 370b as follows:
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| (215 ILCS 5/357.9) (from Ch. 73, par. 969.9)
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| Sec. 357.9. "TIME OF PAYMENT OF CLAIMS: Indemnities
payable | 9 |
| under
this policy for any loss other than loss for which this | 10 |
| policy provides
any periodic payment will be paid immediately | 11 |
| upon receipt of due
written proof of such loss.
Subject
to due | 12 |
| written proof of loss, all
accrued indemnities for loss for | 13 |
| which this policy provides periodic
payment will be paid ....
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| (insert period for payment which must not be
less frequently | 15 |
| than monthly) and any balance remaining unpaid upon the
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| termination of liability, will be paid immediately upon receipt |
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| of due
written proof."
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| All claims and indemnities payable under the terms of
a | 3 |
| policy of accident and health insurance shall be paid within 30 | 4 |
| days
following receipt by the insurer of due proof of loss.
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| Failure to pay
within such period shall entitle the insured
to | 6 |
| interest at the rate of 10% 9
per cent per annum from the 30th | 7 |
| day after receipt of such proof of loss to
the date of late | 8 |
| payment, provided that interest amounting to less than one
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| dollar need not be paid.
An insured or an insured's assignee | 10 |
| shall be
notified by the insurer, health maintenance | 11 |
| organization, managed care plan,
health care plan, preferred | 12 |
| provider organization, or third party administrator
of any | 13 |
| known failure to provide sufficient documentation for a
due | 14 |
| proof of
loss within 30 days after receipt of the claim.
Any
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| required interest payments shall be made within 30 days after | 16 |
| the payment.
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| The requirements of this Section shall apply to any policy | 18 |
| of accident
and health insurance delivered, issued for | 19 |
| delivery, renewed or amended on
or after 180 days following the | 20 |
| effective date of this amendatory Act of 1985.
The requirements | 21 |
| of this Section also shall specifically apply to
any group | 22 |
| policy of dental insurance only, delivered, issued for
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| delivery, renewed or amended on or after 180 days following the | 24 |
| effective
date of this amendatory Act of 1987.
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| (Source: P.A. 91-605, eff. 12-14-99.)
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| (215 ILCS 5/357.9a) (from Ch. 73, par. 969.9a)
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| Sec. 357.9a. Delay in payment of claims. Periodic payments
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| of accrued indemnities for loss-of-time coverage under | 4 |
| accident
and health policies shall commence not later than 30 | 5 |
| days after
the receipt by the company of the required written | 6 |
| proofs of loss.
An insurer which violates this Section if | 7 |
| liable under said policy, shall
pay to the insured, in addition | 8 |
| to any other penalty provided for in this Code,
interest at the | 9 |
| rate of 10% 9% per annum from the 30th day after
receipt of | 10 |
| such proofs of loss to the date of late payment of the
accrued | 11 |
| indemnities, provided that interest amounting to less than
one | 12 |
| dollar need not be paid.
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| (Source: P.A. 92-139, eff. 7-24-01.)
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| (215 ILCS 5/368c)
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| Sec. 368c. Remittance advice and procedures.
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| (a) A remittance advice shall be furnished to a health care | 17 |
| professional or
health
care provider that identifies the | 18 |
| disposition of each claim. The remittance
advice shall identify | 19 |
| the services billed; the patient responsibility, if any;
the | 20 |
| actual payment, if any, for the services billed ; and the | 21 |
| reason for any
reduction to the amount for
which the claim was | 22 |
| submitted. For any reductions to the amount for which the
claim | 23 |
| was submitted, the remittance shall identify any withholds and | 24 |
| the reason
for any denial or reduction. An insurer, health | 25 |
| maintenance
organization,
independent practice association, or |
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| physician hospital organization may not reduce the amount for | 2 |
| which a claim is submitted other than pursuant to the terms of | 3 |
| a contract signed by the health care professional or health | 4 |
| care provider. If no contract exists, then the health care | 5 |
| professional's or health care provider's charges shall be paid | 6 |
| with the patient's responsibility being no more than 30% of the | 7 |
| charges, not including any applicable deductible.
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| A remittance advice for capitation or prospective payment | 9 |
| arrangements shall
be
furnished to a health care professional | 10 |
| or health care provider pursuant to a
contract with
an insurer, | 11 |
| health maintenance organization,
independent practice | 12 |
| association,
or
physician hospital organization in accordance | 13 |
| with the terms of the contract.
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| (b) When health care services are provided by a | 15 |
| non-participating
health care
professional or health care | 16 |
| provider, an insurer, health maintenance
organization,
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| independent practice association, or physician hospital | 18 |
| organization may pay
for covered
services either to a patient | 19 |
| directly or to the non-participating health care
professional | 20 |
| or
health care provider.
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| (c) When a person presents a
benefits information card,
a | 22 |
| health care professional or health care provider shall make a | 23 |
| good faith
effort
to inform the
person if the
health care | 24 |
| professional or health care provider has a participation | 25 |
| contract
with the
insurer,
health maintenance organization, or | 26 |
| other
entity identified on the card.
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| (Source: P.A. 93-261, eff. 1-1-04.)
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| (215 ILCS 5/368d)
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| Sec. 368d. Recoupments.
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| (a) A health care professional or health care provider | 5 |
| shall be provided a
remittance advice, which must include an | 6 |
| explanation of a
recoupment or
offset taken by an insurer, | 7 |
| health maintenance organization,
independent practice | 8 |
| association, or physician hospital
organization, if any. The | 9 |
| recoupment explanation shall, at a minimum, include
the name
of | 10 |
| the patient; the date of service; the service code or if no | 11 |
| service code is
available a service description;
the recoupment | 12 |
| amount; and the reason for the recoupment or offset. In
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| addition,
an insurer,
health maintenance organization, | 14 |
| independent
practice association, or physician
hospital | 15 |
| organization shall provide with the remittance advice a | 16 |
| telephone
number or mailing address to initiate an appeal of | 17 |
| the recoupment or offset . An insurer, health maintenance
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| organization,
independent practice association, or physician | 19 |
| hospital organization may not recoup any amount unless the | 20 |
| recoupment request is submitted within 60 days after the | 21 |
| payment of the claim. Offsets are prohibited.
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| (b) It is not a recoupment when a health care professional | 23 |
| or health care
provider
is paid an amount prospectively or | 24 |
| concurrently under a contract with an
insurer, health
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| maintenance organization, independent practice
association, or |
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| physician
hospital
organization that requires a retrospective | 2 |
| reconciliation based upon specific
conditions
outlined in the | 3 |
| contract.
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| (Source: P.A. 93-261, eff. 1-1-04.)
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| (215 ILCS 5/368g new) | 6 |
| Sec. 368g. Coverage and rates. | 7 |
| (a) No policy of accident and health or managed care plan | 8 |
| amended, delivered, issued, or renewed in this State may deny, | 9 |
| discontinue, or alter coverage of a treatment method that | 10 |
| follows a prescribed standard of care for any illness, | 11 |
| condition, injury, disease, or disability during a benefit | 12 |
| period if the illness, condition, injury, disease, or | 13 |
| disability was covered at any time during the benefit period or | 14 |
| if a claim regarding the treatment method is paid during the | 15 |
| benefit period. If a treatment method is covered by the policy | 16 |
| or plan during the benefit period or if a claim regarding the | 17 |
| treatment method is paid, then the policy or plan must continue | 18 |
| coverage of the treatment method at the payment rate set by a | 19 |
| contract signed by the health care professional or provider or | 20 |
| the health care professional's or health care provider's | 21 |
| charges for the remainder of the benefit period. | 22 |
| (b) No company that issues, delivers, amends, or renews an | 23 |
| individual or group policy of accident and health or managed | 24 |
| care plan in this State may alter its definition of "eligible | 25 |
| expense" or "maximum allowable expense" for a policy or plan |
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| after the policy's or plan's benefit period has started. | 2 |
| (c) The Director is hereby granted specific authority to | 3 |
| issue a cease and desist order against, fine, or otherwise | 4 |
| penalize any company doing business in this State that violates | 5 |
| the provisions of this Section.
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| (215 ILCS 5/370a) (from Ch. 73, par. 982a)
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| Sec. 370a. Assignability of Accident and Health Insurance.
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| (a) No provision of the Illinois Insurance Code, or any | 9 |
| other law, prohibits
an insured under any policy of accident | 10 |
| and health insurance or any other
person who may be the owner | 11 |
| of any rights under such policy from making an
assignment of | 12 |
| all or any part of his rights and privileges under the policy
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| including but not limited to the right to designate a | 14 |
| beneficiary and to
have an individual policy issued in | 15 |
| accordance with its terms. Subject to
the terms of the policy | 16 |
| or any contract relating thereto, an assignment by
an insured | 17 |
| or by any other owner of rights under the policy, made before | 18 |
| or
after the effective date of this amendatory Act of 1969 is | 19 |
| valid for the
purpose of vesting in the assignee, in accordance | 20 |
| with any provisions
included therein as to the time at which it | 21 |
| is effective, all rights and
privileges so assigned. However, | 22 |
| such assignment is without prejudice to
the company on account | 23 |
| of any payment it makes or individual policy it
issues before | 24 |
| receipt of notice of the assignment. This amendatory Act of
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| 1969 acknowledges, declares and codifies the existing right of |
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| assignment
of interests under accident and health insurance | 2 |
| policies.
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| (b) For the purposes of payment for covered services, if If | 4 |
| an enrollee or insured of an insurer, health maintenance | 5 |
| organization,
managed care plan, health care plan, preferred | 6 |
| provider organization, or third
party administrator assigns a | 7 |
| claim to a health care professional or health
care facility, | 8 |
| then payment
shall be made directly to the health care | 9 |
| professional or health care facility regardless of whether the | 10 |
| professional is a participating or non-participating provider,
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| including any interest
required under Section 368a, of this | 12 |
| Code for failure to pay
claims
within 30
days after receipt by | 13 |
| the insurer of due proof of loss. Nothing in this
Section shall | 14 |
| be construed to prevent any parties from reconciling duplicate
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| payments.
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| (Source: P.A. 91-605, eff. 12-14-99; 91-788, eff. 6-9-00.)
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| (215 ILCS 5/370b) (from Ch. 73, par. 982b)
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| Sec. 370b. Reimbursement on equal basis. Notwithstanding | 19 |
| any provision
of any individual or group
policy of accident and | 20 |
| health insurance, or any provision of a policy,
contract, plan | 21 |
| or agreement for hospital or medical service or indemnity,
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| wherever such policy, contract, plan or agreement provides for
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| reimbursement for any service provided by persons licensed | 24 |
| under the Medical Practice Act of 1987 or the Podiatric Medical
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| Practice
Act of 1987, the person entitled to benefits or person |
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| performing services
under such policy, contract, plan or | 2 |
| agreement is entitled to reimbursement
on an equal basis for | 3 |
| such service, when the service is performed by a
person | 4 |
| licensed under the Medical Practice Act of 1987 or the
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| Podiatric Medical Practice Act of 1987 whether the person is a | 6 |
| participating or non-participating provider . The provisions of | 7 |
| this Section do
not apply to any policy, contract, plan or | 8 |
| agreement in effect prior to
September 19, 1969 or to
preferred | 9 |
| provider arrangements or benefit agreements.
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| (Source: P.A. 90-14, eff. 7-1-97.)".
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