Full Text of HB3812 97th General Assembly
HB3812ham004 97TH GENERAL ASSEMBLY | Rep. Daniel J. Burke Filed: 3/8/2012
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| 1 | | AMENDMENT TO HOUSE BILL 3812
| 2 | | AMENDMENT NO. ______. Amend House Bill 3812 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 368c as follows:
| 6 | | (215 ILCS 5/368c)
| 7 | | Sec. 368c. Remittance advice and procedures.
| 8 | | (a) A remittance advice shall be furnished to a health care | 9 | | professional or
health
care provider that identifies the | 10 | | disposition of each claim. The remittance
advice shall identify | 11 | | the services billed; the patient responsibility, if any;
the | 12 | | actual payment, if any, for the services billed; and the reason | 13 | | for any
reduction to the amount for
which the claim was | 14 | | submitted. For any reductions to the amount for which the
claim | 15 | | was submitted, the remittance shall identify any withholds and | 16 | | the reason
for any denial or reduction.
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| 1 | | A remittance advice for capitation or prospective payment | 2 | | arrangements shall
be
furnished to a health care professional | 3 | | or health care provider pursuant to a
contract with
an insurer, | 4 | | health maintenance organization,
independent practice | 5 | | association,
or
physician hospital organization in accordance | 6 | | with the terms of the contract.
| 7 | | (b) When health care services are provided by a | 8 | | non-participating
health care
professional or health care | 9 | | provider, an insurer, health maintenance
organization,
| 10 | | independent practice association, or physician hospital | 11 | | organization may pay
for covered
services either to a patient | 12 | | directly or to the non-participating health care
professional | 13 | | or
health care provider.
| 14 | | (c) When a person presents a
benefits information card,
a | 15 | | health care professional or health care provider shall make a | 16 | | good faith
effort
to inform the
person if the
health care | 17 | | professional or health care provider is not a participating | 18 | | provider has a participation contract
with the
insurer,
health | 19 | | maintenance organization, or other
entity identified on the | 20 | | card.
| 21 | | (Source: P.A. 93-261, eff. 1-1-04.)
| 22 | | Section 10. The Managed Care Reform and Patient Rights Act | 23 | | is amended by changing Section 15 as follows:
| 24 | | (215 ILCS 134/15)
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| 1 | | Sec. 15. Provision of information.
| 2 | | (a) A health care plan shall provide annually to enrollees | 3 | | and prospective
enrollees, upon request, a complete list of | 4 | | participating health care providers
in the
health care plan's | 5 | | service area and a description of the following terms of
| 6 | | coverage:
| 7 | | (1) the service area;
| 8 | | (2) the covered benefits and services with all | 9 | | exclusions, exceptions, and
limitations;
| 10 | | (3) the pre-certification and other utilization review | 11 | | procedures
and requirements;
| 12 | | (4) a description of the process for the selection of a | 13 | | primary care
physician,
any limitation on access to | 14 | | specialists, and the plan's standing referral
policy for | 15 | | participating providers and participating health care | 16 | | professionals ;
| 17 | | (5) the emergency coverage and benefits, including any | 18 | | restrictions on
emergency
care services;
| 19 | | (6) the out-of-area coverage and benefits, if any;
| 20 | | (7) the enrollee's financial responsibility for | 21 | | copayments, deductibles,
premiums, and any other | 22 | | out-of-pocket expenses;
| 23 | | (8) the provisions for continuity of treatment in the | 24 | | event a health care
provider's
participation terminates | 25 | | during the course of an enrollee's treatment by that
| 26 | | provider;
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| 1 | | (9) the appeals process, forms, and time frames for | 2 | | health care services
appeals, complaints, and external | 3 | | independent reviews, administrative
complaints,
and | 4 | | utilization review complaints, including a phone
number
to | 5 | | call to receive more information from the health care plan | 6 | | concerning the
appeals process; and
| 7 | | (10) a statement of all basic health care services and | 8 | | all specific
benefits and
services mandated to be provided | 9 | | to enrollees by any State law or
administrative
rule.
| 10 | | In the event of an inconsistency between any separate | 11 | | written disclosure
statement and the enrollee contract or | 12 | | certificate, the terms of the enrollee
contract or certificate | 13 | | shall control.
| 14 | | (a-5) The required list of participating health care | 15 | | providers shall be provided via the health care plan's Internet | 16 | | website and shall be updated at least every 30 days on a | 17 | | good-faith effort based on information made available to the | 18 | | plan for credentialed providers. The health care plan shall | 19 | | regularly inform policyholders, insureds, or enrollees to | 20 | | consult the list of participating health care providers to | 21 | | allow policyholders, insureds, or enrollees to make informed | 22 | | decisions prior to making appointments. The health plan shall | 23 | | also make available the procedures for making referrals within | 24 | | the network to insureds, enrollees, and participating health | 25 | | care providers and health care professionals, as well as the | 26 | | possibility of reduced benefits for services provided by a |
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| 1 | | non-participating health care provider or a non-participating | 2 | | health care professional. Further, the health care plan shall | 3 | | maintain a toll-free telephone number for policyholders, | 4 | | insureds, enrollees, or health care providers to verify whether | 5 | | a health care provider is a participating provider. | 6 | | (a-10) Notwithstanding any other provision of this Act or | 7 | | the Illinois Insurance Code, when a person presents a benefits | 8 | | information card, a health care provider shall make a good | 9 | | faith effort to inform the person if the health care provider | 10 | | is not a participating provider with the insurer, health | 11 | | maintenance organization, or other entity identified on the | 12 | | card. | 13 | | (b) Upon written request, a health care plan shall provide | 14 | | to enrollees a
description of the financial relationships | 15 | | between the health care plan and any
health care provider
and, | 16 | | if requested, the percentage
of copayments, deductibles, and | 17 | | total premiums spent on healthcare related
expenses and the | 18 | | percentage of
copayments, deductibles, and total premiums | 19 | | spent on other expenses, including
administrative expenses,
| 20 | | except that no health care plan shall be required to disclose | 21 | | specific provider
reimbursement.
| 22 | | (c) A participating health care provider shall provide all | 23 | | of the
following, where applicable, to enrollees upon request:
| 24 | | (1) Information related to the health care provider's | 25 | | educational
background,
experience, training, specialty, | 26 | | and board certification, if applicable.
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| 1 | | (2) The names of licensed facilities on the provider | 2 | | panel where
the health
care provider presently has | 3 | | privileges for the treatment, illness, or
procedure
that is | 4 | | the subject of the request.
| 5 | | (3) Information regarding the health care provider's | 6 | | participation
in
continuing education programs and | 7 | | compliance with any licensure,
certification, or | 8 | | registration requirements, if applicable.
| 9 | | (d) A health care plan shall provide the information | 10 | | required to be
disclosed under this Act upon enrollment and | 11 | | annually thereafter in a legible
and understandable format , | 12 | | except as provided in item (a-5) . The Department
shall | 13 | | promulgate rules to establish the format based, to the extent
| 14 | | practical,
on
the standards developed for supplemental | 15 | | insurance coverage under Title XVIII
of
the federal Social | 16 | | Security Act as a guide, so that a person can compare the
| 17 | | attributes of the various health care plans.
| 18 | | (e) The written disclosure requirements of this Section may | 19 | | be met by
disclosure to one enrollee in a household.
| 20 | | (Source: P.A. 91-617, eff. 1-1-00.)".
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