State of Illinois
2013 and 2014


Introduced , by Rep. Timothy L. Schmitz


215 ILCS 5/370u new
215 ILCS 134/5
215 ILCS 134/15

    Amends the Health Care Reimbursement Article of the Illinois Insurance Code to provide that all insurers and administrators shall comply with the provision of the Managed Care Reform and Patient Rights Act that establishes a patient's right to receive timely prior verification of his or her health plan benefits before obtaining health care services and amends the Managed Care Reform and Patient Rights Act to set forth that provision. Further amends the Managed Care Reform and Patient Rights Act to provide that a health care plan shall provide enrollees or their designated health care providers with timely Internet access to verification of benefits for specific health care services prior to the enrollee obtaining such services and that the verification shall be binding on the health care plan.

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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 adding
5Section 370u as follows:
6    (215 ILCS 5/370u new)
7    Sec. 370u. Managed Care Reform and Patient Rights Act. All
8insurers and administrators shall comply with item (2.5) of
9subsection (a) of Section 5 of the Managed Care Reform and
10Patient Rights Act.
11    Section 10. The Managed Care Reform and Patient Rights Act
12is amended by changing Sections 5 and 15 as follows:
13    (215 ILCS 134/5)
14    Sec. 5. Health care patient rights.
15    (a) The General Assembly finds that:
16        (1) A patient has the right to care consistent with
17    professional standards of practice to assure quality
18    nursing and medical practices, to choose the participating
19    physician responsible for coordinating his or her care, to
20    receive information concerning his or her condition and
21    proposed treatment, to refuse any treatment to the extent



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1    permitted by law, and to privacy and confidentiality of
2    records except as otherwise provided by law.
3        (2) A patient has the right, regardless of source of
4    payment, to examine and to receive a reasonable explanation
5    of his or her total bill for health care services rendered
6    by his or her physician or other health care provider,
7    including the itemized charges for specific health care
8    services received. A physician or other health care
9    provider has responsibility only for a reasonable
10    explanation of those specific health care services
11    provided by the health care provider.
12        (2.5) A patient has the right to receive timely prior
13    verification of his or her health plan benefits before
14    obtaining health care services.
15        (3) A patient has the right to timely prior notice of
16    the termination whenever a health care plan cancels or
17    refuses to renew an enrollee's participation in the plan.
18        (4) A patient has the right to privacy and
19    confidentiality in health care. This right may be expressly
20    waived in writing by the patient or the patient's guardian.
21        (5) An individual has the right to purchase any health
22    care services with that individual's own funds.
23    (b) Nothing in this Section shall preclude the health care
24plan from sharing information for plan quality assessment and
25improvement purposes as required by Section 80.
26(Source: P.A. 91-617, eff. 1-1-00.)



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1    (215 ILCS 134/15)
2    Sec. 15. Provision of information.
3    (a) A health care plan shall provide annually to enrollees
4and prospective enrollees, upon request, a complete list of
5participating health care providers in the health care plan's
6service area and a description of the following terms of
8        (1) the service area;
9        (2) the covered benefits and services with all
10    exclusions, exceptions, and limitations;
11        (3) the pre-certification and other utilization review
12    procedures and requirements;
13        (4) a description of the process for the selection of a
14    primary care physician, any limitation on access to
15    specialists, and the plan's standing referral policy;
16        (5) the emergency coverage and benefits, including any
17    restrictions on emergency care services;
18        (6) the out-of-area coverage and benefits, if any;
19        (7) the enrollee's financial responsibility for
20    copayments, deductibles, premiums, and any other
21    out-of-pocket expenses;
22        (8) the provisions for continuity of treatment in the
23    event a health care provider's participation terminates
24    during the course of an enrollee's treatment by that
25    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
11written disclosure statement and the enrollee contract or
12certificate, the terms of the enrollee contract or certificate
13shall control.
14    (a-5) A health care plan shall provide enrollees or their
15designated health care providers with timely Internet access to
16verification of benefits for specific health care services
17prior to the enrollee obtaining such services. The verification
18shall be binding on the health care plan.
19    (b) Upon written request, a health care plan shall provide
20to enrollees a description of the financial relationships
21between the health care plan and any health care provider and,
22if requested, the percentage of copayments, deductibles, and
23total premiums spent on healthcare related expenses and the
24percentage of copayments, deductibles, and total premiums
25spent on other expenses, including administrative expenses,
26except that no health care plan shall be required to disclose



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1specific provider reimbursement.
2    (c) A participating health care provider shall provide all
3of the following, where applicable, to enrollees upon request:
4        (1) Information related to the health care provider's
5    educational background, experience, training, specialty,
6    and board certification, if applicable.
7        (2) The names of licensed facilities on the provider
8    panel where the health care provider presently has
9    privileges for the treatment, illness, or procedure that is
10    the subject of the request.
11        (3) Information regarding the health care provider's
12    participation in continuing education programs and
13    compliance with any licensure, certification, or
14    registration requirements, if applicable.
15    (d) A health care plan shall provide the information
16required to be disclosed under this Act upon enrollment and
17annually thereafter in a legible and understandable format. The
18Department shall promulgate rules to establish the format
19based, to the extent practical, on the standards developed for
20supplemental insurance coverage under Title XVIII of the
21federal Social Security Act as a guide, so that a person can
22compare the attributes of the various health care plans.
23    (e) The written disclosure requirements of this Section may
24be met by disclosure to one enrollee in a household.
25(Source: P.A. 91-617, eff. 1-1-00.)