Full Text of SB0650 101st General Assembly
SB0650sam003 101ST GENERAL ASSEMBLY | Sen. Ann Gillespie Filed: 4/9/2019
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| 1 | | AMENDMENT TO SENATE BILL 650
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 650 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. Short title. This Act may be cited as the | 5 | | Outpatient Dialysis Payer Transparency Act. | 6 | | Section 5. Definitions. As used in this Act, unless the | 7 | | context requires otherwise:
| 8 | | "Financially interested outpatient dialysis provider" | 9 | | means an outpatient dialysis provider that receives a direct or | 10 | | indirect financial benefit from a third-party premium payment.
| 11 | | "Outpatient dialysis provider" means any professional | 12 | | person, organization, health facility, or other person or | 13 | | institution certified by the Centers for Medicare and Medicaid | 14 | | Services as an independent dialysis facility as described in | 15 | | Part 494 of Title 42 of the Code of Federal Regulations.
| 16 | | "Third-party premium payment" means any premium payment |
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| 1 | | for a health care plan or accident and health insurance plan | 2 | | made directly or indirectly by an outpatient dialysis provider | 3 | | or other third party, made indirectly through payments to the | 4 | | individual for the purpose of making health care plan premium | 5 | | payments or accident and health insurance premium payments, or | 6 | | provided to one or more intermediaries with the intention that | 7 | | the funds be used to make health care plan premium payments or | 8 | | accident and health insurance premium payments for the | 9 | | individuals.
| 10 | | Section 10. Third-party premium payments. | 11 | | (a) A financially interested outpatient dialysis provider | 12 | | making third-party premium payments shall comply with all of | 13 | | the following requirements:
| 14 | | (1) It shall provide assistance for the full plan year | 15 | | and notify the enrollee prior to any open enrollment | 16 | | periods, if applicable, if financial assistance will be | 17 | | discontinued. Assistance may be discontinued at the | 18 | | request of an enrollee who obtains other health coverage, | 19 | | or if the enrollee dies during the plan year.
| 20 | | (2) If the financially interested outpatient dialysis | 21 | | provider provides coverage for an enrollee with end stage | 22 | | renal disease, the financially interested outpatient | 23 | | dialysis provider shall agree not to condition financial | 24 | | assistance on eligibility for, or receipt of, any surgery, | 25 | | transplant, procedure, drug, or device.
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| 1 | | (3) It shall inform an applicant of financial | 2 | | assistance, and shall inform a recipient annually, of all | 3 | | available health coverage options, including, but not | 4 | | limited to, Medicare, Medicaid, individual market plans, | 5 | | and employer plans, if applicable.
| 6 | | (4) It shall agree not to steer, direct, or advise the | 7 | | patient into or away from a specific coverage program | 8 | | option, health care plan contract, or accident and health | 9 | | insurance plan contract.
| 10 | | (5) It shall agree that financial assistance shall not | 11 | | be conditioned on the use of a specific outpatient dialysis | 12 | | facility or other health care provider.
| 13 | | (b) A financially interested outpatient dialysis provider | 14 | | shall not make a third-party premium payment unless the | 15 | | financially interested outpatient dialysis provider:
| 16 | | (1) annually provides a statement to the health care | 17 | | plan or accident and health insurance plan that it meets | 18 | | the requirements set forth in subsection (a), as | 19 | | applicable; and
| 20 | | (2) discloses to the health care plan or accident and | 21 | | health insurance plan, before making the initial payment, | 22 | | the name of the enrollee for each health care plan contract | 23 | | or accident and health insurance plan contract on whose | 24 | | behalf a third-party premium payment described in this | 25 | | Section will be made. |
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| 1 | | Section 90. The Illinois Insurance Code is amended by | 2 | | adding Section 356z.33 as follows: | 3 | | (215 ILCS 5/356z.33 new) | 4 | | Sec. 356z.33. Third-party premium payments; determination | 5 | | of reimbursement. | 6 | | (a) As used in this Section, unless the context requires | 7 | | otherwise: | 8 | | "Financially interested outpatient dialysis provider" | 9 | | means an outpatient dialysis provider that receives a direct or | 10 | | indirect financial benefit from a third-party premium payment. | 11 | | "Outpatient dialysis provider" means any professional | 12 | | person, organization, health facility, or other person or | 13 | | institution certified by the Centers for Medicare and Medicaid | 14 | | Services as an independent dialysis facility as described in | 15 | | Part 494 of Title 42 of the Code of Federal Regulations. | 16 | | "Third-party premium payment" means any accident and | 17 | | health plan premium payment made directly or indirectly by an | 18 | | outpatient dialysis provider or other third party, made | 19 | | indirectly through payments to the individual for the purpose | 20 | | of making health care plan premium payments, or provided to one | 21 | | or more intermediaries with the intention that the funds be | 22 | | used to make health care plan premium payments for the | 23 | | individuals. | 24 | | (b) If a financially interested outpatient dialysis | 25 | | provider makes a third-party premium payment to an accident and |
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| 1 | | health insurer on behalf of an enrollee, reimbursement to a | 2 | | financially interested outpatient dialysis provider for | 3 | | covered services provided shall be determined by the following: | 4 | | (1) For a contracted financially interested outpatient | 5 | | dialysis provider that makes a third-party premium payment | 6 | | or has a financial relationship with the entity making the | 7 | | third-party premium payment, the amount of reimbursement | 8 | | for covered services that shall be paid to the financially | 9 | | interested outpatient dialysis provider on behalf of the | 10 | | enrollee shall be governed by the terms and conditions of | 11 | | the enrollee's accident and health insurance plan contract | 12 | | or the Medicare reimbursement rate, whichever is lower. | 13 | | Financially interested outpatient dialysis providers shall | 14 | | not bill the enrollee or seek reimbursement from the | 15 | | enrollee for any services provided, except for cost sharing | 16 | | pursuant to the terms and conditions of the enrollee's | 17 | | accident and health insurance plan contract. If an | 18 | | enrollee's contract imposes a coinsurance payment for a | 19 | | claim that is subject to this paragraph, the coinsurance | 20 | | payment shall be based on the amount paid by the accident | 21 | | and health insurance plan pursuant to this paragraph. | 22 | | (2) For a noncontracting financially interested | 23 | | outpatient dialysis provider that makes a third-party | 24 | | premium payment or has a financial relationship with the | 25 | | entity making the third-party premium payment, the amount | 26 | | of reimbursement for covered services that shall be paid to |
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| 1 | | the financially interested outpatient dialysis provider on | 2 | | behalf of the enrollee shall be governed by the terms and | 3 | | conditions of the enrollee's accident and health insurance | 4 | | plan contract or the Medicare reimbursement rate, | 5 | | whichever is lower. Financially interested outpatient | 6 | | dialysis providers shall not bill the enrollee or seek | 7 | | reimbursement from the enrollee for any services provided, | 8 | | except for cost sharing pursuant to the terms and | 9 | | conditions of the enrollee's accident and health insurance | 10 | | plan contract. If an enrollee's contract imposes a | 11 | | coinsurance payment for a claim that is subject to this | 12 | | paragraph, the coinsurance payment shall be based on the | 13 | | amount paid by the accident and health insurance plan | 14 | | pursuant to this paragraph. A claim submitted to an | 15 | | accident and health insurance plan by a noncontracting | 16 | | financially interested outpatient dialysis provider may be | 17 | | considered an incomplete claim and contested by the | 18 | | accident and health insurance plan if the financially | 19 | | interested outpatient dialysis provider has not provided | 20 | | the information as required in subsection (b) of Section 10 | 21 | | of the Outpatient Dialysis Payer Transparency Act. | 22 | | (c) The following shall occur if an accident and health | 23 | | insurer subsequently discovers that a financially interested | 24 | | outpatient dialysis provider fails to provide disclosure | 25 | | pursuant to subsection (b) of Section 10 of the Outpatient | 26 | | Dialysis Payer Transparency Act: |
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| 1 | | (1) The accident and health insurer shall be entitled | 2 | | to recover 120% of the difference between any payment made | 3 | | to an outpatient dialysis provider and the payment to which | 4 | | the outpatient dialysis provider would have been entitled | 5 | | pursuant to subsection (b), including interest on that | 6 | | difference. | 7 | | (2) The accident and health insurer shall notify the | 8 | | Department of Insurance of the amount by which the | 9 | | outpatient dialysis provider was overpaid and shall remit | 10 | | to the Department of Insurance any amount exceeding the | 11 | | difference between the payment made to the outpatient | 12 | | dialysis provider and the payment to which the outpatient | 13 | | dialysis provider would have been entitled pursuant to | 14 | | subsection (b), including interest on that difference that | 15 | | was recovered pursuant to paragraph (1). | 16 | | (d) This Section does not affect a contracted payment rate | 17 | | for an outpatient dialysis provider who is not a financially | 18 | | interested outpatient dialysis provider. | 19 | | (e) This Section does not give an insurer any additional | 20 | | ability to refuse to accept premium payments or to cancel or | 21 | | refuse to renew an existing enrollment or subscription, | 22 | | regardless of the source of payment. | 23 | | Section 95. The Health Maintenance Organization Act is | 24 | | amended by changing Section 1-2 and by adding Sections 4-5.1 as | 25 | | follows:
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| 1 | | (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
| 2 | | Sec. 1-2. Definitions. As used in this Act, unless the | 3 | | context otherwise
requires, the following terms shall have the | 4 | | meanings ascribed to them:
| 5 | | (1) "Advertisement" means any printed or published | 6 | | material,
audiovisual material and descriptive literature of | 7 | | the health care plan
used in direct mail, newspapers, | 8 | | magazines, radio scripts, television
scripts, billboards and | 9 | | similar displays; and any descriptive literature or
sales aids | 10 | | of all kinds disseminated by a representative of the health | 11 | | care
plan for presentation to the public including, but not | 12 | | limited to, circulars,
leaflets, booklets, depictions, | 13 | | illustrations, form letters and prepared
sales presentations.
| 14 | | (2) "Director" means the Director of Insurance.
| 15 | | (3) "Basic health care services" means emergency care, and | 16 | | inpatient
hospital and physician care, outpatient medical | 17 | | services, mental
health services and care for alcohol and drug | 18 | | abuse, including any
reasonable deductibles and co-payments, | 19 | | all of which are subject to the
limitations described in | 20 | | Section 4-20 of this Act and as determined by the Director | 21 | | pursuant to rule.
| 22 | | (4) "Enrollee" means an individual who has been enrolled in | 23 | | a health
care plan.
| 24 | | (5) "Evidence of coverage" means any certificate, | 25 | | agreement,
or contract issued to an enrollee setting out the |
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| 1 | | coverage to which he is
entitled in exchange for a per capita | 2 | | prepaid sum.
| 3 | | (5.5) "Financially interested outpatient dialysis | 4 | | provider" means an outpatient dialysis provider that receives a | 5 | | direct or indirect financial benefit from a third-party premium | 6 | | payment. | 7 | | (6) "Group contract" means a contract for health care | 8 | | services which
by its terms limits eligibility to members of a | 9 | | specified group.
| 10 | | (7) "Health care plan" means any arrangement whereby any | 11 | | organization
undertakes to provide or arrange for and pay for | 12 | | or reimburse the
cost of basic health care services, excluding | 13 | | any reasonable deductibles and copayments, from providers | 14 | | selected by
the Health Maintenance Organization and such | 15 | | arrangement
consists of arranging for or the provision of such | 16 | | health care services, as
distinguished from mere | 17 | | indemnification against the cost of such services,
except as | 18 | | otherwise authorized by Section 2-3 of this Act,
on a per | 19 | | capita prepaid basis, through insurance or otherwise. A "health
| 20 | | care plan" also includes any arrangement whereby an | 21 | | organization undertakes to
provide or arrange for or pay for or | 22 | | reimburse the cost of any health care
service for persons who | 23 | | are enrolled under Article V of the Illinois Public Aid
Code or | 24 | | under the Children's Health Insurance Program Act through
| 25 | | providers selected by the organization and the arrangement | 26 | | consists of making
provision for the delivery of health care |
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| 1 | | services, as distinguished from mere
indemnification. A | 2 | | "health care plan" also includes any arrangement pursuant
to | 3 | | Section 4-17. Nothing in this definition, however, affects the | 4 | | total
medical services available to persons eligible for | 5 | | medical assistance under the
Illinois Public Aid Code.
| 6 | | (8) "Health care services" means any services included in | 7 | | the furnishing
to any individual of medical or dental care, or | 8 | | the hospitalization or
incident to the furnishing of such care | 9 | | or hospitalization as well as the
furnishing to any person of | 10 | | any and all other services for the purpose of
preventing, | 11 | | alleviating, curing or healing human illness or injury.
| 12 | | (9) "Health Maintenance Organization" means any | 13 | | organization formed
under the laws of this or another state to | 14 | | provide or arrange for one or
more health care plans under a | 15 | | system which causes any part of the risk of
health care | 16 | | delivery to be borne by the organization or its providers.
| 17 | | (10) "Net worth" means admitted assets, as defined in | 18 | | Section 1-3 of
this Act, minus liabilities.
| 19 | | (11) "Organization" means any insurance company, a | 20 | | nonprofit
corporation authorized under the Dental
Service Plan | 21 | | Act or the Voluntary
Health Services Plans Act,
or a | 22 | | corporation organized under the laws of this or another state | 23 | | for the
purpose of operating one or more health care plans and | 24 | | doing no business other
than that of a Health Maintenance | 25 | | Organization or an insurance company.
"Organization" shall | 26 | | also mean the University of Illinois Hospital as
defined in the |
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| 1 | | University of Illinois Hospital Act or a unit of local | 2 | | government health system operating within a county with a | 3 | | population of 3,000,000 or more.
| 4 | | (11.5) "Outpatient dialysis provider" means any | 5 | | professional person, organization, health facility, or other | 6 | | person or institution certified by the Centers for Medicare and | 7 | | Medicaid Services as an independent dialysis facility as | 8 | | described in Part 494 of Title 42 of the Code of Federal | 9 | | Regulations. | 10 | | (12) "Provider" means any physician, hospital facility,
| 11 | | facility licensed under the Nursing Home Care Act, or facility | 12 | | or long-term care facility as those terms are defined in the | 13 | | Nursing Home Care Act or other person which is licensed or | 14 | | otherwise authorized
to furnish health care services and also | 15 | | includes any other entity that
arranges for the delivery or | 16 | | furnishing of health care service.
| 17 | | (13) "Producer" means a person directly or indirectly | 18 | | associated with a
health care plan who engages in solicitation | 19 | | or enrollment.
| 20 | | (14) "Per capita prepaid" means a basis of prepayment by | 21 | | which a fixed
amount of money is prepaid per individual or any | 22 | | other enrollment unit to
the Health Maintenance Organization or | 23 | | for health care services which are
provided during a definite | 24 | | time period regardless of the frequency or
extent of the | 25 | | services rendered
by the Health Maintenance Organization, | 26 | | except for copayments and deductibles
and except as provided in |
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| 1 | | subsection (f) of Section 5-3 of this Act.
| 2 | | (15) "Subscriber" means a person who has entered into a | 3 | | contractual
relationship with the Health Maintenance | 4 | | Organization for the provision of
or arrangement of at least | 5 | | basic health care services to the beneficiaries
of such | 6 | | contract. | 7 | | (16) "Third-party premium payment" means any health care | 8 | | plan premium payment made directly or indirectly by an | 9 | | outpatient dialysis provider or other third party, made | 10 | | indirectly through payments to the individual for the purpose | 11 | | of making health care plan premium payments, or provided to one | 12 | | or more intermediaries with the intention that the funds be | 13 | | used to make health care plan premium payments for the | 14 | | individuals.
| 15 | | (Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 99-78, | 16 | | eff. 7-20-15.)
| 17 | | (215 ILCS 125/4-5.1 new) | 18 | | Sec. 4-5.1. Third-party premium payments; determination of | 19 | | reimbursement. | 20 | | (a) If a financially interested outpatient dialysis | 21 | | provider makes a third-party premium payment to a Health | 22 | | Maintenance Organization on behalf of an enrollee, | 23 | | reimbursement to a financially interested outpatient dialysis | 24 | | provider for covered services provided shall be determined by | 25 | | the following: |
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| 1 | | (1) For a contracted financially interested outpatient | 2 | | dialysis provider that makes a third-party premium payment | 3 | | or has a financial relationship with the entity making the | 4 | | third-party premium payment, the amount of reimbursement | 5 | | for covered services that shall be paid to the financially | 6 | | interested outpatient dialysis provider on behalf of the | 7 | | enrollee shall be governed by the terms and conditions of | 8 | | the enrollee's health care plan contract or the Medicare | 9 | | reimbursement rate, whichever is lower. Financially | 10 | | interested outpatient dialysis providers shall not bill | 11 | | the enrollee or seek reimbursement from the enrollee for | 12 | | any services provided, except for cost sharing pursuant to | 13 | | the terms and conditions of the enrollee's health care plan | 14 | | contract. If an enrollee's contract imposes a coinsurance | 15 | | payment for a claim that is subject to this paragraph, the | 16 | | coinsurance payment shall be based on the amount paid by | 17 | | the Health Maintenance Organization pursuant to this | 18 | | paragraph. | 19 | | (2) For a noncontracting financially interested | 20 | | outpatient dialysis provider that makes a third-party | 21 | | premium payment or has a financial relationship with the | 22 | | entity making the third-party premium payment, the amount | 23 | | of reimbursement for covered services that shall be paid to | 24 | | the financially interested outpatient dialysis provider on | 25 | | behalf of the enrollee shall be governed by the terms and | 26 | | conditions of the enrollee's health care plan contract or |
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| 1 | | the Medicare reimbursement rate, whichever is lower. | 2 | | Financially interested outpatient dialysis providers shall | 3 | | not bill the enrollee or seek reimbursement from the | 4 | | enrollee for any services provided, except for cost sharing | 5 | | pursuant to the terms and conditions of the enrollee's | 6 | | health care plan contract. If an enrollee's contract | 7 | | imposes a coinsurance payment for a claim that is subject | 8 | | to this paragraph, the coinsurance payment shall be based | 9 | | on the amount paid by the Health Maintenance Organization | 10 | | pursuant to this paragraph. A claim submitted to a Health | 11 | | Maintenance Organization by a noncontracting financially | 12 | | interested outpatient dialysis provider may be considered | 13 | | an incomplete claim and contested by the Health Maintenance | 14 | | Organization if the financially interested outpatient | 15 | | dialysis provider has not provided the information as | 16 | | required in subsection (b) of Section 10 of the Outpatient | 17 | | Dialysis Payer Transparency Act. | 18 | | (b) The following shall occur if a Health Maintenance | 19 | | Organization subsequently discovers that a financially | 20 | | interested outpatient dialysis provider fails to provide | 21 | | disclosure pursuant to subsection (b) of Section 10 of the | 22 | | Outpatient Dialysis Payer Transparency Act: | 23 | | (1) The Health Maintenance Organization shall be | 24 | | entitled to recover 120% of the difference between any | 25 | | payment made to an outpatient dialysis provider and the | 26 | | payment to which the outpatient dialysis provider would |
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| 1 | | have been entitled pursuant to subsection (a), including | 2 | | interest on that difference. | 3 | | (2) The Health Maintenance Organization shall notify | 4 | | the Department of Insurance of the amount by which the | 5 | | outpatient dialysis provider was overpaid and shall remit | 6 | | to the Department of Insurance any amount exceeding the | 7 | | difference between the payment made to the outpatient | 8 | | dialysis provider and the payment to which the outpatient | 9 | | dialysis provider would have been entitled pursuant to | 10 | | subsection (a), including interest on that difference that | 11 | | was recovered pursuant to paragraph (1). | 12 | | (c) This Section does not affect a contracted payment rate | 13 | | for an outpatient dialysis provider who is not a financially | 14 | | interested outpatient dialysis provider. | 15 | | (d) This Section does not give an insurer any additional | 16 | | ability to refuse to accept premium payments or to cancel or | 17 | | refuse to renew an existing enrollment or subscription, | 18 | | regardless of the source of payment.
| 19 | | Section 99. Effective date. This Act takes effect upon | 20 | | becoming law.".
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