Full Text of SB1547 98th General Assembly
SB1547ham002 98TH GENERAL ASSEMBLY | Rep. Lou Lang Filed: 3/4/2014
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| 1 | | AMENDMENT TO SENATE BILL 1547
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1547, AS AMENDED, | 3 | | by replacing everything after the enacting clause with the | 4 | | following:
| 5 | | "Section 5. The Illinois Insurance Code is amended by | 6 | | changing Sections 370g and 370h and by adding Sections 370d.1 | 7 | | and 370u as follows: | 8 | | (215 ILCS 5/370d.1 new) | 9 | | Sec. 370d.1. Exclusive provider organization plans. | 10 | | (a) For the purpose of this Section: | 11 | | "Exclusive provider organization plan" or "EPO" means | 12 | | a benefit plan that utilizes a network of contracted health | 13 | | care providers and that excludes benefits for services | 14 | | provided by non-contracted health care providers, except | 15 | | for emergency services or when services are not available | 16 | | to an insured from a contracted provider within a |
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| 1 | | designated service area. | 2 | | "Designated service area" means a geographic service | 3 | | area as specified in a health insurance policy for an EPO | 4 | | with approval from the Department. | 5 | | "Emergency services" means, with respect to an | 6 | | enrollee of a health care plan, transportation services, | 7 | | including, but not limited to, ambulance services, and | 8 | | covered inpatient and outpatient hospital services | 9 | | furnished by a provider qualified to furnish those services | 10 | | that are needed to evaluate or stabilize an emergency | 11 | | medical condition. "Emergency services" does not include | 12 | | post-stabilization medical services. | 13 | | (b) An insurer having authority under Class 1(b) or 2(a) of | 14 | | Section 4 of this Code to write accident and health insurance | 15 | | under the provisions of this Code shall be authorized to issue | 16 | | policies for exclusive provider organization plans for either | 17 | | group or individual policies, provided such policies otherwise | 18 | | conform to the terms of this Section, the Uniform Health Care | 19 | | Service Benefits Information Card Act, and the Health Carrier | 20 | | External Review Act. An insurer issuing exclusive provider | 21 | | organization plans under this Section shall not be required to | 22 | | be licensed as a health maintenance organization under the | 23 | | Health Maintenance Organization Act in order to issue a policy | 24 | | under this Section. | 25 | | (c) An insurer writing policies for an EPO shall limit | 26 | | enrollment in such a plan solely to those individuals who |
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| 1 | | either live, work, or reside in the designated service area. | 2 | | (d) Except as otherwise stated in this Section, an EPO | 3 | | shall comply with all other provisions of this Code, and | 4 | | regulations issued hereunder, relating to accident and health | 5 | | insurance policies that utilize a contracted health care | 6 | | provider network to provide the benefits under such policies. | 7 | | (e) This Section does not apply to: | 8 | | (1) the Children's Health Insurance Program issued | 9 | | under the Children's Health Insurance Program Act; | 10 | | (2) a Medicaid managed care program issued under | 11 | | Article V of the Illinois Public Aid Code; or | 12 | | (3) the State Employees' Group Insurance Act. | 13 | | (f) An insurer writing policies for an EPO shall provide | 14 | | within the contract and evidence of coverage a description of | 15 | | benefits and services available out of the EPO's designated | 16 | | service area, including any limitations and exclusions. | 17 | | (g) An insurer shall not require a health care professional | 18 | | or health care provider, as a condition of participating in the | 19 | | EPO, to sign a contract requiring the health care professional | 20 | | or health care provider to provide services under another of | 21 | | the company's networks or plans. | 22 | | (h) An insurer shall not require a health care professional | 23 | | or health care provider, as a condition of participating in any | 24 | | of the company's networks or plans, to sign a contract | 25 | | requiring the health care professional or health care provider | 26 | | to provide services under the insurer's EPO. |
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| 1 | | (i) An EPO issued or renewed in this State must prominently | 2 | | display on the cover page of the policy, evidence of coverage, | 3 | | and any marketing materials, that it is an exclusive provider | 4 | | organization benefit plan and that services, other than | 5 | | emergency services, provided by non-contracted health care | 6 | | providers may not be covered under the plan, as well as the | 7 | | components of an EPO plan, including explanations of in-network | 8 | | and out-of-network services. | 9 | | (j) An EPO must clearly state on the health care benefit | 10 | | information card that it is an EPO. | 11 | | (k) An insurer that issues, delivers, amends, or renews an | 12 | | individual or group EPO in this State after the effective date | 13 | | of this amendatory Act of the 98th General Assembly must | 14 | | include the following disclosure on its contracts and evidences | 15 | | of coverage: "WARNING, NO BENEFITS WILL BE PAID WHEN NON- | 16 | | PARTICIPATING PROVIDERS ARE USED. You should be aware that no | 17 | | benefits shall be available under this plan except for | 18 | | emergency services or when services are not available from a | 19 | | contracted provider within the designated service area. YOU | 20 | | WILL HAVE TO PAY FOR ANY SERVICE OR TREATMENT OUTSIDE OF THE | 21 | | EXCLUSIVE PROVIDER ORGANIZATION PLAN NETWORK. | 22 | | Non-participating providers may bill members for any | 23 | | treatments and services provided to the patient. Participating | 24 | | providers have agreed to accept discounted payments for | 25 | | services with no additional billing to the member other than | 26 | | copayments, co-insurance, and deductible amounts. You may |
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| 1 | | obtain further information about the participating status of | 2 | | professional providers by calling the toll-free telephone | 3 | | number on your identification card.". | 4 | | (l) Any insurer that issues, delivers, amends, or renews an | 5 | | individual or group EPO in this State after the effective date | 6 | | of this amendatory Act of the 98th General Assembly must comply | 7 | | with Sections 20, 25, 30, 35, 45, 65, 70, 85, 95, and 100 of the | 8 | | Managed Care Reform and Patient Rights Act. | 9 | | (m) Any insurer that issues, delivers, amends, or renews an | 10 | | individual or group EPO in this State after the effective date | 11 | | of this amendatory Act of the 98th General Assembly must comply | 12 | | with the following provisions: | 13 | | (1) An EPO shall provide annually to enrollees and | 14 | | prospective enrollees, upon request, a complete list of | 15 | | participating health care providers in the health care | 16 | | plan's service area and a description of the following | 17 | | terms of coverage: | 18 | | (A) the service area; | 19 | | (B) the covered benefits and services with all | 20 | | exclusions, exceptions, and limitations; | 21 | | (C) the pre-certification and other utilization | 22 | | review procedures and requirements; | 23 | | (D) the emergency coverage and benefits, including | 24 | | specifics on the differences in benefits between | 25 | | emergency care and non-emergency care, including any | 26 | | restrictions on emergency care services, so long as |
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| 1 | | such specifics and restrictions allow coverage for | 2 | | medical conditions within the meaning of an emergency | 3 | | medical condition as defined in Section 10 of the | 4 | | Managed Care Reform and Patient Rights Act; | 5 | | (E) the out-of-area coverage and benefits, if any; | 6 | | (F) the enrollee's financial responsibility for | 7 | | copayments, deductibles, premiums, and any other | 8 | | out-of-pocket expenses; | 9 | | (G) the provisions for continuity of treatment in | 10 | | the event a health care provider's participation | 11 | | terminates during the course of an enrollee's | 12 | | treatment by that provider; and | 13 | | (H) the appeals process, forms, and time frames for | 14 | | health care services appeals, complaints, and external | 15 | | independent reviews, administrative complaints, and | 16 | | utilization review complaints, including a phone | 17 | | number to call to receive more information from the | 18 | | health care plan concerning the appeals process. | 19 | | (2) An EPO shall provide the information required to be | 20 | | disclosed under this Section upon enrollment and annually | 21 | | thereafter in a legible and understandable format. | 22 | | (3) The written disclosure requirements of this | 23 | | Section may be met by disclosure to one enrollee in a | 24 | | household. | 25 | | (n) The following provisions shall apply concerning EPO | 26 | | restrictions on primary care physicians. |
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| 1 | | (1) An EPO is prohibited from requiring enrollees to | 2 | | choose a primary care physician for the coordination of | 3 | | care. | 4 | | (2) Enrollees may at any time select any physician from | 5 | | within the EPO network to provide care. | 6 | | (3) An EPO is prohibited from requiring enrollees to | 7 | | obtain prior authorization from any participating | 8 | | physician in the network before seeing an EPO network | 9 | | provider of their choice. | 10 | | (o) An insurer that issues, delivers, amends, or renews an | 11 | | individual or group EPO shall provide an internal claims and | 12 | | appeals process that incorporates the claims and appeals | 13 | | procedures set forth in Section 45 of the Managed Care Reform | 14 | | and Patient Rights Act. | 15 | | (p) The Director of Insurance shall adopt rules necessary | 16 | | to implement this Section.
| 17 | | (215 ILCS 5/370g) (from Ch. 73, par. 982g)
| 18 | | Sec. 370g. Definitions. As used in this Article, the | 19 | | following definitions
apply:
| 20 | | (a) "Health care services" means health care services or | 21 | | products
rendered or sold by a provider within the scope of the | 22 | | provider's license
or legal authorization. The term includes, | 23 | | but is not limited to, hospital,
medical, surgical, dental, | 24 | | vision and pharmaceutical services or products.
| 25 | | (b) "Insurer" means an insurance company or a health |
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| 1 | | service corporation
authorized in this State to issue policies | 2 | | or subscriber contracts which
reimburse for expenses of health | 3 | | care services.
| 4 | | (c) "Insured" means an individual entitled to | 5 | | reimbursement for expenses
of health care services under a | 6 | | policy or subscriber contract issued or
administered by an | 7 | | insurer.
| 8 | | (d) "Provider" means an individual or entity duly licensed | 9 | | or legally
authorized to provide health care services.
| 10 | | (e) "Noninstitutional provider" means any person licensed | 11 | | under the Medical
Practice Act of 1987, as now or hereafter | 12 | | amended.
| 13 | | (f) "Beneficiary" means an individual entitled to | 14 | | reimbursement for
expenses of or the discount of provider fees | 15 | | for health care services under
a program where the beneficiary | 16 | | has an incentive to utilize the services of a
provider which | 17 | | has entered into an agreement or arrangement with an
| 18 | | administrator.
| 19 | | (g) "Administrator" means any person, partnership or | 20 | | corporation, other
than an insurer or health maintenance | 21 | | organization holding a certificate of
authority under the | 22 | | "Health Maintenance Organization Act", as now or hereafter
| 23 | | amended, that arranges, contracts with, or administers | 24 | | contracts with a
provider whereby beneficiaries are provided an | 25 | | incentive to use the services of
such provider.
| 26 | | (h) "Emergency medical condition" means a medical |
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| 1 | | condition manifesting
itself
by
acute symptoms of sufficient | 2 | | severity (including severe
pain) such that a prudent
layperson, | 3 | | who possesses an average knowledge of health and medicine, | 4 | | could
reasonably expect the absence of immediate medical | 5 | | attention to result in:
| 6 | | (1) placing the health of the individual (or, with | 7 | | respect to a pregnant
woman, the
health of the woman or her | 8 | | unborn child) in serious jeopardy;
| 9 | | (2) serious
impairment to bodily functions; or
| 10 | | (3) serious dysfunction of any bodily organ
or part.
| 11 | | (i) "Exclusive provider organization plan" or "EPO" means a | 12 | | benefit plan that utilizes a network of contracted health care | 13 | | providers and that excludes benefits for services provided by | 14 | | non-contracted health care providers, except for emergency | 15 | | services and subject to the requirements of Section 356z.3a or | 16 | | when services are not available to an insured from a contracted | 17 | | provider within a designated service area. | 18 | | (j) "Designated service area" means a geographic area as | 19 | | specified in a health insurance policy for an EPO. | 20 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 21 | | (215 ILCS 5/370h) (from Ch. 73, par. 982h)
| 22 | | Sec. 370h. Noninstitutional providers. | 23 | | (a) Before entering into any agreement
under this Article | 24 | | an insurer or administrator shall establish terms and
| 25 | | conditions that must be met by noninstitutional providers |
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| 1 | | wishing to enter into
an agreement with the insurer or | 2 | | administrator. These terms and conditions may
not discriminate | 3 | | unreasonably against or among noninstitutional providers.
| 4 | | Neither difference in prices among noninstitutional providers | 5 | | produced by
a process of individual negotiation nor price | 6 | | differences among other
noninstitutional providers in | 7 | | different geographical areas or different
specialties | 8 | | constitutes unreasonable discrimination.
| 9 | | (b) An insurer or administrator shall not refuse to | 10 | | contract with any
noninstitutional provider who meets the terms | 11 | | and conditions
established by the insurer or administrator.
| 12 | | (c) Any insurer that issues, delivers, amends, or renews an | 13 | | individual or group EPO in this State after the effective date | 14 | | of this amendatory Act of the 98th General Assembly shall not | 15 | | be obligated to comply with this Section solely with respect to | 16 | | the EPO product. | 17 | | (Source: P.A. 90-655, eff. 7-30-98.)
| 18 | | (215 ILCS 5/370u new) | 19 | | Sec. 370u. Exclusive provider organization plans | 20 | | permitted. | 21 | | (a) An insurer having authority under Class 1(b) or 2(a) of | 22 | | Section 4 of this Code to write accident and health insurance | 23 | | as applicable under this Code, may offer an EPO, provided that | 24 | | the administrator meets the requirements of this Code and the | 25 | | Director determines that: |
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| 1 | | (1) the level of coverage, including deductibles, | 2 | | copayments, coinsurance, or other cost-sharing provisions | 3 | | to beneficiaries, or insured individuals does not operate | 4 | | unreasonably to restrict the access and availability of | 5 | | health care services for the insured; or | 6 | | (2) the EPO has established an exclusive network that | 7 | | is adequate to provide health care services as required. | 8 | | (b) Until the effective date of the rules adopted by the | 9 | | Director for EPO plans, insurers must file a description of the | 10 | | services to be offered through an EPO. The description shall | 11 | | include all of the following: | 12 | | (1) The method of marketing the program. | 13 | | (2) A geographic map of the area proposed to be served | 14 | | by the program by county and zip code, including marked | 15 | | locations for providers. | 16 | | (3) The names, addresses, and specialties of the | 17 | | providers who have entered into EPO contracts under the | 18 | | program. | 19 | | (4) The names of available primary care physicians and | 20 | | the encouragement of each enrollee to select such a | 21 | | physician to handle their care coordination. | 22 | | (5) The number of beneficiaries anticipated to be | 23 | | covered by the providers listed in paragraph (3) of this | 24 | | subsection (b). | 25 | | (6) An Internet website and toll-free telephone number | 26 | | for beneficiaries and prospective beneficiaries to access |
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| 1 | | regarding up-to-date lists of providers. A plan shall | 2 | | identify specific providers in a beneficiary's area, | 3 | | confirm specific provider participation, or provide a | 4 | | listing of providers by mail. Provider lists requested by | 5 | | phone must be sent within 3 working days after the request | 6 | | is made. The up-to-date provider list applies to all | 7 | | providers that have entered arrangements to provide | 8 | | services under the program either directly or indirectly | 9 | | through another administrator. Insurers' Internet website | 10 | | addresses shall be prominently displayed on all | 11 | | advertisements, marketing materials, brochures, benefit | 12 | | cards, and identification cards. | 13 | | (7) A description of how health care services to be | 14 | | rendered under the EPO provider program are reasonably | 15 | | accessible and available to beneficiaries. Standards shall | 16 | | address the following: | 17 | | (A) The ratio of providers to beneficiaries, by | 18 | | specialty applicable under the contract, necessary to | 19 | | meet the health care needs and service demands of the | 20 | | currently enrolled population such that there shall be | 21 | | at least one full-time physician for each 1,200 | 22 | | enrollees. | 23 | | (B) The greatest distance or time that the | 24 | | beneficiary may be required to travel to access: | 25 | | (i) provider hospital services when applicable | 26 | | under the contract; |
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| 1 | | (ii) primary care physician and women's | 2 | | principal health care provider services when | 3 | | applicable under the contract; and | 4 | | (iii) any applicable health care service | 5 | | providers. | 6 | | (C) A process for tracking when providers within | 7 | | the network stop accepting new EPO patients. | 8 | | (D) A process for encouraging all EPO providers to | 9 | | utilize an electronic system to ensure the timely | 10 | | exchange of health records between and among providers | 11 | | who have entered into EPO contracts listed in paragraph | 12 | | (3) of this subsection (b). | 13 | | (E) Written policies and procedures for | 14 | | determining when the program is closed to new providers | 15 | | desiring to enter into EPO arrangements. | 16 | | (F) Written policies and procedures for adding | 17 | | providers to meet patient needs based on increases in | 18 | | the number of beneficiaries, changes in the patient to | 19 | | provider ratio, changes in medical and health care | 20 | | capabilities, changes in number of providers accepting | 21 | | new patients, and increased demand for services. | 22 | | (G) The provision of 24 hour, 7 day-per-week access | 23 | | to network-affiliated primary care and women's | 24 | | principal health care providers. | 25 | | (H) The procedures for making referrals outside | 26 | | the network when procedures cannot be provided within |
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| 1 | | the network. | 2 | | (I) A provision that whenever a beneficiary has | 3 | | made a good faith effort to utilize EPO providers for a | 4 | | covered service and it is determined the insurer does | 5 | | not have the appropriate EPO providers due to | 6 | | insufficient number or type or distance, the insurer | 7 | | shall ensure, directly or indirectly, by terms | 8 | | contained in the payor contract, that the beneficiary | 9 | | will be provided the covered service at no greater cost | 10 | | to the beneficiary than if the service had been | 11 | | provided by an EPO provider. This subparagraph (G) does | 12 | | not apply to a beneficiary who willfully chooses to | 13 | | access a non-preferred provider for health care | 14 | | services reasonably available through the insurer's | 15 | | panel of participating providers. In these | 16 | | circumstances, the contractual requirements for | 17 | | non-preferred provider reimbursements shall apply. | 18 | | (J) The procedures for paying benefits when | 19 | | particular physician specialties are not represented | 20 | | within the provider network or the services of such | 21 | | providers are not available at the time care is sought. | 22 | | In any case in which a beneficiary has made a good | 23 | | faith effort to utilize network providers, by | 24 | | satisfying contractual obligations specified in the | 25 | | benefit contract or certificate, for a covered service | 26 | | and the insurer does not have the appropriate preferred |
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| 1 | | specialty providers (including, but not limited to, | 2 | | radiologists, anesthesiologists, pathologists and | 3 | | emergency room physicians) under contract due to the | 4 | | inability of the insurer to contract with the | 5 | | specialists, or due to the insufficient number or type | 6 | | of, or travel distance to, specialists, the insurer | 7 | | shall ensure that the beneficiary will be provided the | 8 | | covered service at no greater cost to the beneficiary | 9 | | than if the service had been provided by an EPO | 10 | | provider. This subparagraph (J) does not apply to a | 11 | | beneficiary who willfully chooses to access a | 12 | | non-preferred provider for health care services | 13 | | reasonably available through the insurer's panel of | 14 | | participating providers. In these circumstances, the | 15 | | contractual requirements for non-preferred provider | 16 | | reimbursements shall apply. | 17 | | (K) A provision that the beneficiary shall receive | 18 | | emergency care coverage such that payment for the | 19 | | coverage is not dependent upon whether the services are | 20 | | performed by a preferred or non-preferred provider and | 21 | | the coverage shall be at the same benefit level as if | 22 | | the service or treatment had been rendered by a | 23 | | preferred provider. For the purposes of this | 24 | | subparagraph (K), "the same benefit level" means that | 25 | | the beneficiary will be provided the covered service at | 26 | | no greater cost to the beneficiary than if the service |
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| 1 | | had been provided by a preferred provider. | 2 | | (L) A limitation that, if the plan provides that | 3 | | the beneficiary will incur a penalty for failing to | 4 | | pre-certify inpatient hospital treatment, the penalty | 5 | | may not exceed $1,000 per occurrence. | 6 | | (M) Efforts to address the needs of beneficiaries | 7 | | with limited English proficiency and literacy or | 8 | | diverse cultural and ethnic backgrounds, and to comply | 9 | | with the Americans With Disabilities Act of 1990. | 10 | | (N) A sample beneficiary identification card in | 11 | | conformity with the Uniform Health Care Service | 12 | | Benefits Information Card Act and the Uniform | 13 | | Prescription Drug Information Card Act when | 14 | | pharmaceutical services are provided as part of the | 15 | | program's health care services. | 16 | | (8) The process for encouraging EPO providers to | 17 | | utilize an electronic system to ensure the timely exchange | 18 | | of health records between and among providers who have | 19 | | entered into EPO agreements listed in paragraph (3) of this | 20 | | subsection (b). | 21 | | (9) The educational efforts the insurer will use to | 22 | | inform beneficiaries that they are purchasing an EPO | 23 | | product, including the major differences between an EPO, an | 24 | | HMO and a PPO. | 25 | | (c) The Director of Insurance shall adopt rules necessary | 26 | | to
implement this Section. ".
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