Illinois General Assembly - Full Text of HB4703
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Full Text of HB4703  102nd General Assembly

HB4703 102ND GENERAL ASSEMBLY

  
  

 


 
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB4703

 

Introduced 1/27/2022, by Rep. Bob Morgan

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.3
215 ILCS 5/356z.3a
215 ILCS 124/10
215 ILCS 125/4.5-1
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 134/70
215 ILCS 165/10  from Ch. 32, par. 604

    Amends the Illinois Insurance Code. Provides that when an insured receives emergency services or covered ancillary services from a nonparticipating provider or a nonparticipating facility, the health insurance issuer shall ensure that cost-sharing requirements are applied as though the services had been received from a participating provider or facility, and that the insured or any group policyholder or plan sponsor shall not be liable to or billed by the health insurance issuer, the nonparticipating provider, or the facility beyond the cost-sharing amount. Contains provisions concerning a notice and consent process for out-of-network coverage; billing for reasonable administrative fees; assignment of benefits to nonparticipating providers; and cost-sharing amounts and deductibles. Amends the Illinois Insurance Code and the Health Maintenance Organization Act to make a change in provisions concerning disclosure of nonparticipating provider benefits. Amends the Network Adequacy and Transparency Act. Provides that a beneficiary who receives care at a participating health care facility shall not be required to search for participating providers under certain circumstances. Amends the Managed Care Reform and Patient Rights Act. Provides that prior authorization or approval by the plan shall not be required for post-stabilization services that constitute emergency services. Amends the Health Maintenance Organization Act and the Voluntary Health Services Plans Act to provide that health maintenance organizations and voluntary health services plans are subject to provisions of the Illinois Insurance Code concerning billing and cost sharing. Makes other changes. Effective July 1, 2022, except that certain changes take effect January 1, 2023.


LRB102 24386 BMS 33620 b

 

 

A BILL FOR

 

HB4703LRB102 24386 BMS 33620 b

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
5changing Sections 356z.3 and 356z.3a as follows:
 
6    (215 ILCS 5/356z.3)
7    Sec. 356z.3. Disclosure of limited benefit. An insurer
8that issues, delivers, amends, or renews an individual or
9group policy of accident and health insurance in this State
10after the effective date of this amendatory Act of the 92nd
11General Assembly and arranges, contracts with, or administers
12contracts with a provider whereby beneficiaries are provided
13an incentive to use the services of such provider must include
14the following disclosure on its contracts and evidences of
15coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
16NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that
17when you elect to utilize the services of a non-participating
18provider for a covered service in non-emergency situations,
19benefit payments to such non-participating provider are not
20based upon the amount billed. The basis of your benefit
21payment will be determined according to your policy's fee
22schedule, usual and customary charge (which is determined by
23comparing charges for similar services adjusted to the

 

 

HB4703- 2 -LRB102 24386 BMS 33620 b

1geographical area where the services are performed), or other
2method as defined by the policy. YOU CAN EXPECT TO PAY MORE
3THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE
4PLAN HAS PAID ITS REQUIRED PORTION. Non-participating
5providers may bill members for any amount up to the billed
6charge after the plan has paid its portion of the bill, except
7as provided in Section 356z.3a of the Illinois Insurance Code
8for covered services received at a participating health care
9facility from a nonparticipating provider that are: (a)
10ancillary services, (b) items or services furnished as a
11result of unforeseen, urgent medical needs that arise at the
12time the item or service is furnished, or (c) items or services
13received when the facility or the non-participating provider
14fails to satisfy the notice and consent criteria specified
15under Section 356z.3a. Participating providers have agreed to
16accept discounted payments for services with no additional
17billing to the member other than co-insurance and deductible
18amounts. You may obtain further information about the
19participating status of professional providers and information
20on out-of-pocket expenses by calling the toll free telephone
21number on your identification card.".
22(Source: P.A. 96-1523, eff. 6-1-11; 97-813, eff. 7-13-12.)
 
23    (215 ILCS 5/356z.3a)
24    Sec. 356z.3a. Billing; emergency services;
25nonparticipating providers Nonparticipating facility-based

 

 

HB4703- 3 -LRB102 24386 BMS 33620 b

1physicians and providers.
2    (a) As used in this Section: For purposes of this Section,
3"facility-based provider" means a physician or other provider
4who provide radiology, anesthesiology, pathology, neonatology,
5or emergency department services to insureds, beneficiaries,
6or enrollees in a participating hospital or participating
7ambulatory surgical treatment center.
8    "Ancillary services" means:
9        (1) items and services related to emergency medicine,
10    anesthesiology, pathology, radiology, and neonatology that
11    are provided by any health care provider;
12        (2) items and services provided by assistant surgeons,
13    hospitalists, and intensivists;
14        (3) diagnostic services, including radiology and
15    laboratory services; and
16        (4) items and services provided by a nonparticipating
17    provider if there is no participating provider who can
18    furnish the item or service at the facility.
19    "Cost sharing" means the amount an insured, beneficiary,
20or enrollee is responsible for paying for a covered item or
21service under the terms of the policy or certificate. "Cost
22sharing" includes copayments, coinsurance, and amounts paid
23toward deductibles, but does not include amounts paid towards
24premiums, balance billing by out-of-network providers, or the
25cost of items or services that are not covered under the policy
26or certificate.

 

 

HB4703- 4 -LRB102 24386 BMS 33620 b

1    "Emergency department of a hospital" means any hospital
2department that provides emergency services, including a
3hospital outpatient department.
4    "Emergency medical condition" has the meaning ascribed to
5that term in Section 10 of the Managed Care Reform and Patient
6Rights Act.
7    "Emergency medical screening examination" has the meaning
8ascribed to that term in Section 10 of the Managed Care Reform
9and Patient Rights Act.
10    "Emergency services" means, with respect to an emergency
11medical condition:
12        (1) in general, an emergency medical screening
13    examination, including ancillary services routinely
14    available to the emergency department to evaluate such
15    emergency medical condition, and such further medical
16    examination and treatment as would be required to
17    stabilize the patient regardless of the department of the
18    hospital or other facility in which such further
19    examination or treatment is furnished; or
20        (2) additional items and services for which benefits
21    are provided or covered under the coverage and that are
22    furnished by a nonparticipating provider or
23    nonparticipating emergency facility regardless of the
24    department of the hospital or other facility in which such
25    items are furnished after the insured, beneficiary, or
26    enrollee is stabilized and as part of outpatient

 

 

HB4703- 5 -LRB102 24386 BMS 33620 b

1    observation or an inpatient or outpatient stay with
2    respect to the visit in which the services described in
3    paragraph (1) are furnished. Services after stabilization
4    cease to be emergency services only when all the
5    conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
6    regulations thereunder are met.
7    "Freestanding Emergency Center" means a facility licensed
8under Section 32.5 of the Emergency Medical Services (EMS)
9Systems Act.
10    "Health care facility" means, in the context of
11non-emergency services, any of the following:
12        (1) a hospital as defined in 42 U.S.C. 1395x(e);
13        (2) a hospital outpatient department;
14        (3) a critical access hospital certified under 42
15    U.S.C. 1395i-4(e);
16        (4) an ambulatory surgical treatment center as defined
17    in the Ambulatory Surgical Treatment Center Act; or
18        (5) any recipient of a license under the Hospital
19    Licensing Act that is not otherwise described in this
20    definition.
21    "Health care provider" means a provider as defined in
22subsection (d) of Section 370g. "Health care provider" does
23not include a provider of air ambulance or ground ambulance
24services.
25    "Health care services" has the meaning ascribed to that
26term in subsection (a) of Section 370g.

 

 

HB4703- 6 -LRB102 24386 BMS 33620 b

1    "Health insurance issuer" has the meaning ascribed to that
2term in Section 5 of the Illinois Health Insurance Portability
3and Accountability Act.
4    "Nonparticipating emergency facility" means, with respect
5to the furnishing of an item or service under a policy of group
6or individual health insurance coverage, any of the following
7facilities that does not have a contractual relationship
8directly or indirectly with a health insurance issuer in
9relation to the coverage:
10        (1) an emergency department of a hospital;
11        (2) a Freestanding Emergency Center;
12        (3) an ambulatory surgical treatment center as defined
13    in the Ambulatory Surgical Treatment Center Act; or
14        (4) with respect to emergency services described in
15    paragraph (2) of the definition of "emergency services", a
16    hospital.
17    "Nonparticipating provider" means, with respect to the
18furnishing of an item or service under a policy of group or
19individual health insurance coverage, any health care provider
20who does not have a contractual relationship directly or
21indirectly with a health insurance issuer in relation to the
22coverage.
23    "Participating emergency facility" means any of the
24following facilities that has a contractual relationship
25directly or indirectly with a health insurance issuer offering
26group or individual health insurance coverage setting forth

 

 

HB4703- 7 -LRB102 24386 BMS 33620 b

1the terms and conditions on which a relevant health care
2service is provided to an insured, beneficiary, or enrollee
3under the coverage:
4        (1) an emergency department of a hospital;
5        (2) a Freestanding Emergency Center;
6        (3) an ambulatory surgical treatment center as defined
7    in the Ambulatory Surgical Treatment Center Act; or
8        (4) with respect to emergency services described in
9    paragraph (2) of the definition of "emergency services", a
10    hospital.
11For purposes of this definition, a single case agreement
12between an emergency facility and an issuer that is used to
13address unique situations in which an insured, beneficiary, or
14enrollee requires services that typically occur out-of-network
15constitutes a contractual relationship and is limited to the
16parties to the agreement.
17    "Participating health care facility" means any health care
18facility that has a contractual relationship directly or
19indirectly with a health insurance issuer offering group or
20individual health insurance coverage setting forth the terms
21and conditions on which a relevant health care service is
22provided to an insured, beneficiary, or enrollee under the
23coverage. A single case agreement between an emergency
24facility and an issuer that is used to address unique
25situations in which an insured, beneficiary, or enrollee
26requires services that typically occur out-of-network

 

 

HB4703- 8 -LRB102 24386 BMS 33620 b

1constitutes a contractual relationship for purposes of this
2definition and is limited to the parties to the agreement.
3    "Participating provider" means any health care provider
4that has a contractual relationship directly or indirectly
5with a health insurance issuer offering group or individual
6health insurance coverage setting forth the terms and
7conditions on which a relevant health care service is provided
8to an insured, beneficiary, or enrollee under the coverage.
9    "Recognized amount" means the lesser of:
10        (1) the amount billed by the provider;
11        (2) the amount negotiated under subsection (d); or
12        (3) the amount determined after arbitration under
13    subsection (e).
14    "Stabilize" means "stabilization" as defined in Section 10
15of the Managed Care Reform and Patient Rights Act.
16    "Treating provider" means a health care provider who has
17evaluated the individual.
18    "Visit" means, with respect to health care services
19furnished to an individual at a health care facility, health
20care services furnished by a provider at the facility, as well
21as equipment, devices, telehealth services, imaging services,
22laboratory services, and preoperative and postoperative
23services regardless of whether the provider furnishing such
24services is at the facility.
25    (b) Emergency services. When a beneficiary, insured, or
26enrollee receives emergency services from a nonparticipating

 

 

HB4703- 9 -LRB102 24386 BMS 33620 b

1provider or a nonparticipating emergency facility, the health
2insurance issuer shall ensure that the beneficiary, insured,
3or enrollee shall incur no greater out-of-pocket costs than
4the beneficiary, insured, or enrollee would have incurred with
5a participating provider or a participating emergency
6facility. Any cost-sharing requirements shall be applied as
7though the emergency services had been received from a
8participating provider or a participating facility. Cost
9sharing shall be calculated based on the recognized amount for
10the emergency services. In no event shall the beneficiary,
11insured, enrollee, or any group policyholder or plan sponsor
12be liable to or billed by the health insurance issuer, the
13nonparticipating provider, or the nonparticipating emergency
14facility for any amount beyond the cost sharing calculated in
15accordance with this subsection with respect to the emergency
16services delivered. Administrative requirements or limitations
17shall be no greater than those applicable to emergency
18services received from a participating provider or a
19participating emergency facility.
20    (b-5) Non-emergency services at participating health care
21facilities.
22        (1) When a beneficiary, insured, or enrollee utilizes
23    a participating health care facility network hospital or a
24    participating network ambulatory surgery center and, due
25    to any reason, covered ancillary services in network
26    services for radiology, anesthesiology, pathology,

 

 

HB4703- 10 -LRB102 24386 BMS 33620 b

1    emergency physician, or neonatology are unavailable and
2    are provided by a nonparticipating facility-based
3    physician or provider during or resulting from the visit,
4    the health insurance issuer insurer or health plan shall
5    ensure that the beneficiary, insured, or enrollee shall
6    incur no greater out-of-pocket costs than the beneficiary,
7    insured, or enrollee would have incurred with a
8    participating physician or provider for the ancillary
9    covered services. Any cost-sharing requirements shall be
10    applied as though the ancillary services had been received
11    from a participating provider. Cost sharing shall be
12    calculated based on the recognized amount for the
13    ancillary services. In no event shall the beneficiary,
14    insured, enrollee, or any group policyholder or plan
15    sponsor be liable to or billed by the health insurance
16    issuer, the nonparticipating provider, or the
17    participating health care facility for any amount beyond
18    the cost sharing calculated in accordance with this
19    subsection with respect to the ancillary services
20    delivered. In addition to ancillary services, the
21    requirements of this paragraph shall also apply with
22    respect to covered items or services furnished as a result
23    of unforeseen, urgent medical needs that arise at the time
24    an item or service is furnished, regardless of whether the
25    nonparticipating provider satisfied the notice and consent
26    criteria under paragraph (2) of this subsection.

 

 

HB4703- 11 -LRB102 24386 BMS 33620 b

1        (2) When a beneficiary, insured, or enrollee utilizes
2    a participating health care facility and receives
3    non-emergency covered health care services other than
4    those described in paragraph (1) of this subsection from a
5    nonparticipating provider during or resulting from the
6    visit, the health insurance issuer shall ensure that the
7    beneficiary, insured, or enrollee incurs no greater
8    out-of-pocket costs than the beneficiary, insured, or
9    enrollee would have incurred with a participating provider
10    unless the nonparticipating provider, or the participating
11    health care facility on behalf of the nonparticipating
12    provider, satisfies the notice and consent criteria
13    provided in 42 U.S.C. 300gg-132 and regulations
14    promulgated thereunder. If the notice and consent criteria
15    are not satisfied, then:
16            (A) any cost-sharing requirements shall be applied
17        as though the health care services had been received
18        from a participating provider;
19            (B) cost sharing shall be calculated based on the
20        recognized amount for the health care services; and
21            (C) in no event shall the beneficiary, insured,
22        enrollee, or any group policyholder or plan sponsor be
23        liable to or billed by the health insurance issuer,
24        the nonparticipating provider, or the participating
25        health care facility for any amount beyond the cost
26        sharing calculated in accordance with this subsection

 

 

HB4703- 12 -LRB102 24386 BMS 33620 b

1        with respect to the health care services delivered.
2    (c) Notwithstanding If a beneficiary, insured, or enrollee
3agrees in writing, notwithstanding any other provision of this
4Code, except when the notice and consent criteria are
5satisfied for the situation in paragraph (2) of subsection
6(b-5), any benefits a beneficiary, insured, or enrollee
7receives for services under the situations situation in
8subsections subsection (b) or (b-5) are assigned to the
9nonparticipating facility-based providers or the facility
10acting on their behalf. The health insurance issuer insurer or
11health plan shall provide the nonparticipating provider or the
12facility with a written explanation of benefits that specifies
13the proposed reimbursement and the applicable deductible,
14copayment or coinsurance amounts owed by the insured,
15beneficiary or enrollee. The health insurance issuer insurer
16or health plan shall pay any reimbursement subject to this
17Section directly to the nonparticipating facility-based
18provider or the facility. The nonparticipating facility-based
19physician or provider shall not bill the beneficiary, insured,
20or enrollee, except for applicable deductible, copayment, or
21coinsurance amounts that would apply if the beneficiary,
22insured, or enrollee utilized a participating physician or
23provider for covered services. If a beneficiary, insured, or
24enrollee specifically rejects assignment under this Section in
25writing to the nonparticipating facility-based provider, then
26the nonparticipating facility-based provider may bill the

 

 

HB4703- 13 -LRB102 24386 BMS 33620 b

1beneficiary, insured, or enrollee for the services rendered.
2    (d) For bills assigned under subsection (c), the
3nonparticipating facility-based provider or the facility may
4bill the health insurance issuer insurer or health plan for
5the services rendered, and the health insurance issuer insurer
6or health plan may pay the billed amount or attempt to
7negotiate reimbursement with the nonparticipating
8facility-based provider or the facility. Within 30 calendar
9days after the provider or facility transmits the bill to the
10health insurance issuer, the issuer shall send an initial
11payment or notice of denial of payment with the written
12explanation of benefits to the provider or facility. If
13attempts to negotiate reimbursement for services provided by a
14nonparticipating facility-based provider do not result in a
15resolution of the payment dispute within 30 days after receipt
16of written explanation of benefits by the health insurance
17issuer insurer or health plan, then the health insurance
18issuer an insurer or health plan or nonparticipating
19facility-based physician or provider or the facility may
20initiate binding arbitration to determine payment for services
21provided on a per bill basis. The party requesting arbitration
22shall notify the other party arbitration has been initiated
23and state its final offer before arbitration. In response to
24this notice, the nonrequesting party shall inform the
25requesting party of its final offer before the arbitration
26occurs. Arbitration shall be initiated by filing a request

 

 

HB4703- 14 -LRB102 24386 BMS 33620 b

1with the Department of Insurance.
2    (e) The Department of Insurance shall publish a list of
3approved arbitrators or entities that shall provide binding
4arbitration. These arbitrators shall be American Arbitration
5Association or American Health Lawyers Association trained
6arbitrators. Both parties must agree on an arbitrator from the
7Department of Insurance's or its approved entity's list of
8arbitrators. If no agreement can be reached, then a list of 5
9arbitrators shall be provided by the Department of Insurance
10or the approved entity. From the list of 5 arbitrators, the
11health insurance issuer insurer can veto 2 arbitrators and the
12provider or facility can veto 2 arbitrators. The remaining
13arbitrator shall be the chosen arbitrator. This arbitration
14shall consist of a review of the written submissions by both
15parties. Binding arbitration shall provide for a written
16decision within 45 days after the request is filed with the
17Department of Insurance. Both parties shall be bound by the
18arbitrator's decision. The arbitrator's expenses and fees,
19together with other expenses, not including attorney's fees,
20incurred in the conduct of the arbitration, shall be paid as
21provided in the decision.
22    (f) (Blank). This Section 356z.3a does not apply to a
23beneficiary, insured, or enrollee who willfully chooses to
24access a nonparticipating facility-based physician or provider
25for health care services available through the insurer's or
26plan's network of participating physicians and providers. In

 

 

HB4703- 15 -LRB102 24386 BMS 33620 b

1these circumstances, the contractual requirements for
2nonparticipating facility-based provider reimbursements will
3apply.
4    (g) Section 368a of this Act shall not apply during the
5pendency of a decision under subsection (d). Upon the issuance
6of the arbitrator's decision, Section 368a applies with
7respect to the amount, if any, by which the arbitrator's
8determination exceeds the issuer's initial payment under
9subsection (c), or the entire amount of the arbitrator's
10determination if initial payment was denied. Any any interest
11required to be paid a provider under Section 368a shall not
12accrue until after 30 days of an arbitrator's decision as
13provided in subsection (d), but in no circumstances longer
14than 150 days from date the nonparticipating facility-based
15provider billed for services rendered.
16    (h) Nothing in this Section shall be interpreted to change
17the prudent layperson provisions with respect to emergency
18services under the Managed Care Reform and Patient Rights Act.
19    (i) Nothing in this Section shall preclude a health care
20provider from billing a beneficiary, insured, or enrollee for
21reasonable administrative fees, such as service fees for
22checks returned for nonsufficient funds and missed
23appointments.
24    (j) Nothing in this Section shall preclude a beneficiary,
25insured, or enrollee from assigning benefits to a
26nonparticipating provider when the notice and consent criteria

 

 

HB4703- 16 -LRB102 24386 BMS 33620 b

1are satisfied under paragraph (2) of subsection (b-5) or in
2any other situation not described in subsections (b) or (b-5).
3    (k) Except when the notice and consent criteria are
4satisfied under paragraph (2) of subsection (b-5), if an
5individual receives health care services under the situations
6described in subsections (b) or (b-5), no referral requirement
7or any other provision contained in the policy or certificate
8of coverage shall deny coverage, reduce benefits, or otherwise
9defeat the requirements of this Section for services that
10would have been covered with a participating provider.
11However, this subsection shall not be construed to preclude a
12provider contract with a health insurance issuer, or with an
13administrator or similar entity acting on the issuer's behalf,
14from imposing requirements on the participating provider,
15participating emergency facility, or participating health care
16facility relating to the referral of covered individuals to
17nonparticipating providers.
18    (l) Except if the notice and consent criteria are
19satisfied under paragraph (2) of subsection (b-5),
20cost-sharing amounts calculated in conformity with this
21Section shall count toward any deductible or out-of-pocket
22maximum applicable to in-network coverage.
23    (m) The Department has the authority to enforce the
24requirements of this Section in the situations described in
25subsections (b) and (b-5), and in any other situation for
26which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and

 

 

HB4703- 17 -LRB102 24386 BMS 33620 b

1regulations promulgated thereunder would prohibit an
2individual from being billed or liable for emergency services
3furnished by a nonparticipating provider or nonparticipating
4emergency facility or for non-emergency health care services
5furnished by a nonparticipating provider at a participating
6health care facility.
7    (n) This Section does not apply with respect to air
8ambulance or ground ambulance services. This Section does not
9apply to any policy of excepted benefits or to short-term,
10limited-duration health insurance coverage.
11(Source: P.A. 98-154, eff. 8-2-13.)
 
12    Section 10. The Network Adequacy and Transparency Act is
13amended by changing Section 10 as follows:
 
14    (215 ILCS 124/10)
15    Sec. 10. Network adequacy.
16    (a) An insurer providing a network plan shall file a
17description of all of the following with the Director:
18        (1) The written policies and procedures for adding
19    providers to meet patient needs based on increases in the
20    number of beneficiaries, changes in the
21    patient-to-provider ratio, changes in medical and health
22    care capabilities, and increased demand for services.
23        (2) The written policies and procedures for making
24    referrals within and outside the network.

 

 

HB4703- 18 -LRB102 24386 BMS 33620 b

1        (3) The written policies and procedures on how the
2    network plan will provide 24-hour, 7-day per week access
3    to network-affiliated primary care, emergency services,
4    and woman's principal health care providers.
5    An insurer shall not prohibit a preferred provider from
6discussing any specific or all treatment options with
7beneficiaries irrespective of the insurer's position on those
8treatment options or from advocating on behalf of
9beneficiaries within the utilization review, grievance, or
10appeals processes established by the insurer in accordance
11with any rights or remedies available under applicable State
12or federal law.
13    (b) Insurers must file for review a description of the
14services to be offered through a network plan. The description
15shall include all of the following:
16        (1) A geographic map of the area proposed to be served
17    by the plan by county service area and zip code, including
18    marked locations for preferred providers.
19        (2) As deemed necessary by the Department, the names,
20    addresses, phone numbers, and specialties of the providers
21    who have entered into preferred provider agreements under
22    the network plan.
23        (3) The number of beneficiaries anticipated to be
24    covered by the network plan.
25        (4) An Internet website and toll-free telephone number
26    for beneficiaries and prospective beneficiaries to access

 

 

HB4703- 19 -LRB102 24386 BMS 33620 b

1    current and accurate lists of preferred providers,
2    additional information about the plan, as well as any
3    other information required by Department rule.
4        (5) A description of how health care services to be
5    rendered under the network plan are reasonably accessible
6    and available to beneficiaries. The description shall
7    address all of the following:
8            (A) the type of health care services to be
9        provided by the network plan;
10            (B) the ratio of physicians and other providers to
11        beneficiaries, by specialty and including primary care
12        physicians and facility-based physicians when
13        applicable under the contract, necessary to meet the
14        health care needs and service demands of the currently
15        enrolled population;
16            (C) the travel and distance standards for plan
17        beneficiaries in county service areas; and
18            (D) a description of how the use of telemedicine,
19        telehealth, or mobile care services may be used to
20        partially meet the network adequacy standards, if
21        applicable.
22        (6) A provision ensuring that whenever a beneficiary
23    has made a good faith effort, as evidenced by accessing
24    the provider directory, calling the network plan, and
25    calling the provider, to utilize preferred providers for a
26    covered service and it is determined the insurer does not

 

 

HB4703- 20 -LRB102 24386 BMS 33620 b

1    have the appropriate preferred providers due to
2    insufficient number, type, or unreasonable travel distance
3    or delay, the insurer shall ensure, directly or
4    indirectly, by terms contained in the payer contract, that
5    the beneficiary will be provided the covered service at no
6    greater cost to the beneficiary than if the service had
7    been provided by a preferred provider. This paragraph (6)
8    does not apply to: (A) a beneficiary who willfully chooses
9    to access a non-preferred provider for health care
10    services available through the panel of preferred
11    providers, or (B) a beneficiary enrolled in a health
12    maintenance organization. In these circumstances, the
13    contractual requirements for non-preferred provider
14    reimbursements shall apply unless Section 356z.3a of the
15    Illinois Insurance Code requires otherwise. In no event
16    shall a beneficiary who receives care at a participating
17    health care facility be required to search for
18    participating providers under the circumstances described
19    in subsections (b) or (b-5) of Section 356z.3a of the
20    Illinois Insurance Code except under the circumstances
21    described in paragraph (2) of subsection (b-5).
22        (7) A provision that the beneficiary shall receive
23    emergency care coverage such that payment for this
24    coverage is not dependent upon whether the emergency
25    services are performed by a preferred or non-preferred
26    provider and the coverage shall be at the same benefit

 

 

HB4703- 21 -LRB102 24386 BMS 33620 b

1    level as if the service or treatment had been rendered by a
2    preferred provider. For purposes of this paragraph (7),
3    "the same benefit level" means that the beneficiary is
4    provided the covered service at no greater cost to the
5    beneficiary than if the service had been provided by a
6    preferred provider. This provision shall be consistent
7    with Section 356z.3a of the Illinois Insurance Code.
8        (8) A limitation that, if the plan provides that the
9    beneficiary will incur a penalty for failing to
10    pre-certify inpatient hospital treatment, the penalty may
11    not exceed $1,000 per occurrence in addition to the plan
12    cost sharing provisions.
13    (c) The network plan shall demonstrate to the Director a
14minimum ratio of providers to plan beneficiaries as required
15by the Department.
16        (1) The ratio of physicians or other providers to plan
17    beneficiaries shall be established annually by the
18    Department in consultation with the Department of Public
19    Health based upon the guidance from the federal Centers
20    for Medicare and Medicaid Services. The Department shall
21    not establish ratios for vision or dental providers who
22    provide services under dental-specific or vision-specific
23    benefits. The Department shall consider establishing
24    ratios for the following physicians or other providers:
25            (A) Primary Care;
26            (B) Pediatrics;

 

 

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1            (C) Cardiology;
2            (D) Gastroenterology;
3            (E) General Surgery;
4            (F) Neurology;
5            (G) OB/GYN;
6            (H) Oncology/Radiation;
7            (I) Ophthalmology;
8            (J) Urology;
9            (K) Behavioral Health;
10            (L) Allergy/Immunology;
11            (M) Chiropractic;
12            (N) Dermatology;
13            (O) Endocrinology;
14            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
15            (Q) Infectious Disease;
16            (R) Nephrology;
17            (S) Neurosurgery;
18            (T) Orthopedic Surgery;
19            (U) Physiatry/Rehabilitative;
20            (V) Plastic Surgery;
21            (W) Pulmonary;
22            (X) Rheumatology;
23            (Y) Anesthesiology;
24            (Z) Pain Medicine;
25            (AA) Pediatric Specialty Services;
26            (BB) Outpatient Dialysis; and

 

 

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1            (CC) HIV.
2        (2) The Director shall establish a process for the
3    review of the adequacy of these standards, along with an
4    assessment of additional specialties to be included in the
5    list under this subsection (c).
6    (d) The network plan shall demonstrate to the Director
7maximum travel and distance standards for plan beneficiaries,
8which shall be established annually by the Department in
9consultation with the Department of Public Health based upon
10the guidance from the federal Centers for Medicare and
11Medicaid Services. These standards shall consist of the
12maximum minutes or miles to be traveled by a plan beneficiary
13for each county type, such as large counties, metro counties,
14or rural counties as defined by Department rule.
15    The maximum travel time and distance standards must
16include standards for each physician and other provider
17category listed for which ratios have been established.
18    The Director shall establish a process for the review of
19the adequacy of these standards along with an assessment of
20additional specialties to be included in the list under this
21subsection (d).
22    (d-5)(1) Every insurer shall ensure that beneficiaries
23have timely and proximate access to treatment for mental,
24emotional, nervous, or substance use disorders or conditions
25in accordance with the provisions of paragraph (4) of
26subsection (a) of Section 370c of the Illinois Insurance Code.

 

 

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1Insurers shall use a comparable process, strategy, evidentiary
2standard, and other factors in the development and application
3of the network adequacy standards for timely and proximate
4access to treatment for mental, emotional, nervous, or
5substance use disorders or conditions and those for the access
6to treatment for medical and surgical conditions. As such, the
7network adequacy standards for timely and proximate access
8shall equally be applied to treatment facilities and providers
9for mental, emotional, nervous, or substance use disorders or
10conditions and specialists providing medical or surgical
11benefits pursuant to the parity requirements of Section 370c.1
12of the Illinois Insurance Code and the federal Paul Wellstone
13and Pete Domenici Mental Health Parity and Addiction Equity
14Act of 2008. Notwithstanding the foregoing, the network
15adequacy standards for timely and proximate access to
16treatment for mental, emotional, nervous, or substance use
17disorders or conditions shall, at a minimum, satisfy the
18following requirements:
19        (A) For beneficiaries residing in the metropolitan
20    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
21    network adequacy standards for timely and proximate access
22    to treatment for mental, emotional, nervous, or substance
23    use disorders or conditions means a beneficiary shall not
24    have to travel longer than 30 minutes or 30 miles from the
25    beneficiary's residence to receive outpatient treatment
26    for mental, emotional, nervous, or substance use disorders

 

 

HB4703- 25 -LRB102 24386 BMS 33620 b

1    or conditions. Beneficiaries shall not be required to wait
2    longer than 10 business days between requesting an initial
3    appointment and being seen by the facility or provider of
4    mental, emotional, nervous, or substance use disorders or
5    conditions for outpatient treatment or to wait longer than
6    20 business days between requesting a repeat or follow-up
7    appointment and being seen by the facility or provider of
8    mental, emotional, nervous, or substance use disorders or
9    conditions for outpatient treatment; however, subject to
10    the protections of paragraph (3) of this subsection, a
11    network plan shall not be held responsible if the
12    beneficiary or provider voluntarily chooses to schedule an
13    appointment outside of these required time frames.
14        (B) For beneficiaries residing in Illinois counties
15    other than those counties listed in subparagraph (A) of
16    this paragraph, network adequacy standards for timely and
17    proximate access to treatment for mental, emotional,
18    nervous, or substance use disorders or conditions means a
19    beneficiary shall not have to travel longer than 60
20    minutes or 60 miles from the beneficiary's residence to
21    receive outpatient treatment for mental, emotional,
22    nervous, or substance use disorders or conditions.
23    Beneficiaries shall not be required to wait longer than 10
24    business days between requesting an initial appointment
25    and being seen by the facility or provider of mental,
26    emotional, nervous, or substance use disorders or

 

 

HB4703- 26 -LRB102 24386 BMS 33620 b

1    conditions for outpatient treatment or to wait longer than
2    20 business days between requesting a repeat or follow-up
3    appointment and being seen by the facility or provider of
4    mental, emotional, nervous, or substance use disorders or
5    conditions for outpatient treatment; however, subject to
6    the protections of paragraph (3) of this subsection, a
7    network plan shall not be held responsible if the
8    beneficiary or provider voluntarily chooses to schedule an
9    appointment outside of these required time frames.
10    (2) For beneficiaries residing in all Illinois counties,
11network adequacy standards for timely and proximate access to
12treatment for mental, emotional, nervous, or substance use
13disorders or conditions means a beneficiary shall not have to
14travel longer than 60 minutes or 60 miles from the
15beneficiary's residence to receive inpatient or residential
16treatment for mental, emotional, nervous, or substance use
17disorders or conditions.
18    (3) If there is no in-network facility or provider
19available for a beneficiary to receive timely and proximate
20access to treatment for mental, emotional, nervous, or
21substance use disorders or conditions in accordance with the
22network adequacy standards outlined in this subsection, the
23insurer shall provide necessary exceptions to its network to
24ensure admission and treatment with a provider or at a
25treatment facility in accordance with the network adequacy
26standards in this subsection.

 

 

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1    (e) Except for network plans solely offered as a group
2health plan, these ratio and time and distance standards apply
3to the lowest cost-sharing tier of any tiered network.
4    (f) The network plan may consider use of other health care
5service delivery options, such as telemedicine or telehealth,
6mobile clinics, and centers of excellence, or other ways of
7delivering care to partially meet the requirements set under
8this Section.
9    (g) Except for the requirements set forth in subsection
10(d-5), insurers who are not able to comply with the provider
11ratios and time and distance standards established by the
12Department may request an exception to these requirements from
13the Department. The Department may grant an exception in the
14following circumstances:
15        (1) if no providers or facilities meet the specific
16    time and distance standard in a specific service area and
17    the insurer (i) discloses information on the distance and
18    travel time points that beneficiaries would have to travel
19    beyond the required criterion to reach the next closest
20    contracted provider outside of the service area and (ii)
21    provides contact information, including names, addresses,
22    and phone numbers for the next closest contracted provider
23    or facility;
24        (2) if patterns of care in the service area do not
25    support the need for the requested number of provider or
26    facility type and the insurer provides data on local

 

 

HB4703- 28 -LRB102 24386 BMS 33620 b

1    patterns of care, such as claims data, referral patterns,
2    or local provider interviews, indicating where the
3    beneficiaries currently seek this type of care or where
4    the physicians currently refer beneficiaries, or both; or
5        (3) other circumstances deemed appropriate by the
6    Department consistent with the requirements of this Act.
7    (h) Insurers are required to report to the Director any
8material change to an approved network plan within 15 days
9after the change occurs and any change that would result in
10failure to meet the requirements of this Act. Upon notice from
11the insurer, the Director shall reevaluate the network plan's
12compliance with the network adequacy and transparency
13standards of this Act.
14(Source: P.A. 102-144, eff. 1-1-22.)
 
15    Section 15. The Health Maintenance Organization Act is
16amended by changing Sections 4.5-1 and 5-3 as follows:
 
17    (215 ILCS 125/4.5-1)
18    Sec. 4.5-1. Point-of-service health service contracts.
19    (a) A health maintenance organization that offers a
20point-of-service contract:
21        (1) must include as in-plan covered services all
22    services required by law to be provided by a health
23    maintenance organization;
24        (2) must provide incentives, which shall include

 

 

HB4703- 29 -LRB102 24386 BMS 33620 b

1    financial incentives, for enrollees to use in-plan covered
2    services;
3        (3) may not offer services out-of-plan without
4    providing those services on an in-plan basis;
5        (4) may include annual out-of-pocket limits and
6    lifetime maximum benefits allowances for out-of-plan
7    services that are separate from any limits or allowances
8    applied to in-plan services;
9        (5) may not consider emergency services, authorized
10    referral services, or non-routine services obtained out of
11    the service area to be point-of-service services;
12        (6) may treat as out-of-plan services those services
13    that an enrollee obtains from a participating provider,
14    but for which the proper authorization was not given by
15    the health maintenance organization; and
16        (7) after the effective date of this amendatory Act of
17    the 92nd General Assembly, must include the following
18    disclosure on its point-of-service contracts and evidences
19    of coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
20    NON-PARTICIPATING PROVIDERS ARE USED. You should be aware
21    that when you elect to utilize the services of a
22    non-participating provider for a covered service in
23    non-emergency situations, benefit payments to such
24    non-participating provider are not based upon the amount
25    billed. The basis of your benefit payment will be
26    determined according to your policy's fee schedule, usual

 

 

HB4703- 30 -LRB102 24386 BMS 33620 b

1    and customary charge (which is determined by comparing
2    charges for similar services adjusted to the geographical
3    area where the services are performed), or other method as
4    defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE
5    COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN
6    HAS PAID ITS REQUIRED PORTION. Non-participating providers
7    may bill members for any amount up to the billed charge
8    after the plan has paid its portion of the bill, except as
9    provided in Section 356z.3a of the Illinois Insurance Code
10    for covered services received at a participating health
11    care facility from a non-participating provider that are:
12    (a) ancillary services, (b) items or services furnished as
13    a result of unforeseen, urgent medical needs that arise at
14    the time the item or service is furnished, or (c) items or
15    services received when the facility or the
16    non-participating provider fails to satisfy the notice and
17    consent criteria specified under Section 356z.3a.
18    Participating providers have agreed to accept discounted
19    payments for services with no additional billing to the
20    member other than co-insurance and deductible amounts. You
21    may obtain further information about the participating
22    status of professional providers and information on
23    out-of-pocket expenses by calling the toll free telephone
24    number on your identification card.".
25    (b) A health maintenance organization offering a
26point-of-service contract is subject to all of the following

 

 

HB4703- 31 -LRB102 24386 BMS 33620 b

1limitations:
2        (1) The health maintenance organization may not expend
3    in any calendar quarter more than 20% of its total
4    expenditures for all its members for out-of-plan covered
5    services.
6        (2) If the amount specified in item (1) of this
7    subsection is exceeded by 2% in a quarter, the health
8    maintenance organization must effect compliance with item
9    (1) of this subsection by the end of the following
10    quarter.
11        (3) If compliance with the amount specified in item
12    (1) of this subsection is not demonstrated in the health
13    maintenance organization's next quarterly report, the
14    health maintenance organization may not offer the
15    point-of-service contract to new groups or include the
16    point-of-service option in the renewal of an existing
17    group until compliance with the amount specified in item
18    (1) of this subsection is demonstrated or until otherwise
19    allowed by the Director.
20        (4) A health maintenance organization failing, without
21    just cause, to comply with the provisions of this
22    subsection shall be required, after notice and hearing, to
23    pay a penalty of $250 for each day out of compliance, to be
24    recovered by the Director. Any penalty recovered shall be
25    paid into the General Revenue Fund. The Director may
26    reduce the penalty if the health maintenance organization

 

 

HB4703- 32 -LRB102 24386 BMS 33620 b

1    demonstrates to the Director that the imposition of the
2    penalty would constitute a financial hardship to the
3    health maintenance organization.
4    (c) A health maintenance organization that offers a
5point-of-service product must do all of the following:
6        (1) File a quarterly financial statement detailing
7    compliance with the requirements of subsection (b).
8        (2) Track out-of-plan, point-of-service utilization
9    separately from in-plan or non-point-of-service,
10    out-of-plan emergency care, referral care, and urgent care
11    out of the service area utilization.
12        (3) Record out-of-plan utilization in a manner that
13    will permit such utilization and cost reporting as the
14    Director may, by rule, require.
15        (4) Demonstrate to the Director's satisfaction that
16    the health maintenance organization has the fiscal,
17    administrative, and marketing capacity to control its
18    point-of-service enrollment, utilization, and costs so as
19    not to jeopardize the financial security of the health
20    maintenance organization.
21        (5) Maintain, in addition to any other deposit
22    required under this Act, the deposit required by Section
23    2-6.
24        (6) Maintain cash and cash equivalents of sufficient
25    amount to fully liquidate 10 days' average claim payments,
26    subject to review by the Director.

 

 

HB4703- 33 -LRB102 24386 BMS 33620 b

1        (7) Maintain and file with the Director, reinsurance
2    coverage protecting against catastrophic losses on out of
3    network point-of-service services. Deductibles may not
4    exceed $100,000 per covered life per year, and the portion
5    of risk retained by the health maintenance organization
6    once deductibles have been satisfied may not exceed 20%.
7    Reinsurance must be placed with licensed authorized
8    reinsurers qualified to do business in this State.
9    (d) A health maintenance organization may not issue a
10point-of-service contract until it has filed and had approved
11by the Director a plan to comply with the provisions of this
12Section. The compliance plan must, at a minimum, include
13provisions demonstrating that the health maintenance
14organization will do all of the following:
15        (1) Design the benefit levels and conditions of
16    coverage for in-plan covered services and out-of-plan
17    covered services as required by this Article.
18        (2) Provide or arrange for the provision of adequate
19    systems to:
20            (A) process and pay claims for all out-of-plan
21        covered services;
22            (B) meet the requirements for point-of-service
23        contracts set forth in this Section and any additional
24        requirements that may be set forth by the Director;
25        and
26            (C) generate accurate data and financial and

 

 

HB4703- 34 -LRB102 24386 BMS 33620 b

1        regulatory reports on a timely basis so that the
2        Department of Insurance can evaluate the health
3        maintenance organization's experience with the
4        point-of-service contract and monitor compliance with
5        point-of-service contract provisions.
6        (3) Comply with the requirements of subsections (b)
7    and (c).
8(Source: P.A. 92-135, eff. 1-1-02; 92-579, eff. 1-1-03.)
 
9    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
10    Sec. 5-3. Insurance Code provisions.
11    (a) Health Maintenance Organizations shall be subject to
12the provisions of Sections 133, 134, 136, 137, 139, 140,
13141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
14154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
15355.3, 355b, 356g.5-1, 356m, 356q, 356v, 356w, 356x, 356y,
16356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
17356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
18356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26,
19356z.29, 356z.30, 356z.30a, 356z.32, 356z.33, 356z.35,
20356z.36, 356z.40, 356z.41, 356z.43, 356z.46, 356z.47, 356z.48,
21356z.50, 356z.51, 364, 364.01, 367.2, 367.2-5, 367i, 368a,
22368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403,
23403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
24subsection (2) of Section 367, and Articles IIA, VIII 1/2,
25XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the

 

 

HB4703- 35 -LRB102 24386 BMS 33620 b

1Illinois Insurance Code.
2    (b) For purposes of the Illinois Insurance Code, except
3for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
4Health Maintenance Organizations in the following categories
5are deemed to be "domestic companies":
6        (1) a corporation authorized under the Dental Service
7    Plan Act or the Voluntary Health Services Plans Act;
8        (2) a corporation organized under the laws of this
9    State; or
10        (3) a corporation organized under the laws of another
11    state, 30% or more of the enrollees of which are residents
12    of this State, except a corporation subject to
13    substantially the same requirements in its state of
14    organization as is a "domestic company" under Article VIII
15    1/2 of the Illinois Insurance Code.
16    (c) In considering the merger, consolidation, or other
17acquisition of control of a Health Maintenance Organization
18pursuant to Article VIII 1/2 of the Illinois Insurance Code,
19        (1) the Director shall give primary consideration to
20    the continuation of benefits to enrollees and the
21    financial conditions of the acquired Health Maintenance
22    Organization after the merger, consolidation, or other
23    acquisition of control takes effect;
24        (2)(i) the criteria specified in subsection (1)(b) of
25    Section 131.8 of the Illinois Insurance Code shall not
26    apply and (ii) the Director, in making his determination

 

 

HB4703- 36 -LRB102 24386 BMS 33620 b

1    with respect to the merger, consolidation, or other
2    acquisition of control, need not take into account the
3    effect on competition of the merger, consolidation, or
4    other acquisition of control;
5        (3) the Director shall have the power to require the
6    following information:
7            (A) certification by an independent actuary of the
8        adequacy of the reserves of the Health Maintenance
9        Organization sought to be acquired;
10            (B) pro forma financial statements reflecting the
11        combined balance sheets of the acquiring company and
12        the Health Maintenance Organization sought to be
13        acquired as of the end of the preceding year and as of
14        a date 90 days prior to the acquisition, as well as pro
15        forma financial statements reflecting projected
16        combined operation for a period of 2 years;
17            (C) a pro forma business plan detailing an
18        acquiring party's plans with respect to the operation
19        of the Health Maintenance Organization sought to be
20        acquired for a period of not less than 3 years; and
21            (D) such other information as the Director shall
22        require.
23    (d) The provisions of Article VIII 1/2 of the Illinois
24Insurance Code and this Section 5-3 shall apply to the sale by
25any health maintenance organization of greater than 10% of its
26enrollee population (including without limitation the health

 

 

HB4703- 37 -LRB102 24386 BMS 33620 b

1maintenance organization's right, title, and interest in and
2to its health care certificates).
3    (e) In considering any management contract or service
4agreement subject to Section 141.1 of the Illinois Insurance
5Code, the Director (i) shall, in addition to the criteria
6specified in Section 141.2 of the Illinois Insurance Code,
7take into account the effect of the management contract or
8service agreement on the continuation of benefits to enrollees
9and the financial condition of the health maintenance
10organization to be managed or serviced, and (ii) need not take
11into account the effect of the management contract or service
12agreement on competition.
13    (f) Except for small employer groups as defined in the
14Small Employer Rating, Renewability and Portability Health
15Insurance Act and except for medicare supplement policies as
16defined in Section 363 of the Illinois Insurance Code, a
17Health Maintenance Organization may by contract agree with a
18group or other enrollment unit to effect refunds or charge
19additional premiums under the following terms and conditions:
20        (i) the amount of, and other terms and conditions with
21    respect to, the refund or additional premium are set forth
22    in the group or enrollment unit contract agreed in advance
23    of the period for which a refund is to be paid or
24    additional premium is to be charged (which period shall
25    not be less than one year); and
26        (ii) the amount of the refund or additional premium

 

 

HB4703- 38 -LRB102 24386 BMS 33620 b

1    shall not exceed 20% of the Health Maintenance
2    Organization's profitable or unprofitable experience with
3    respect to the group or other enrollment unit for the
4    period (and, for purposes of a refund or additional
5    premium, the profitable or unprofitable experience shall
6    be calculated taking into account a pro rata share of the
7    Health Maintenance Organization's administrative and
8    marketing expenses, but shall not include any refund to be
9    made or additional premium to be paid pursuant to this
10    subsection (f)). The Health Maintenance Organization and
11    the group or enrollment unit may agree that the profitable
12    or unprofitable experience may be calculated taking into
13    account the refund period and the immediately preceding 2
14    plan years.
15    The Health Maintenance Organization shall include a
16statement in the evidence of coverage issued to each enrollee
17describing the possibility of a refund or additional premium,
18and upon request of any group or enrollment unit, provide to
19the group or enrollment unit a description of the method used
20to calculate (1) the Health Maintenance Organization's
21profitable experience with respect to the group or enrollment
22unit and the resulting refund to the group or enrollment unit
23or (2) the Health Maintenance Organization's unprofitable
24experience with respect to the group or enrollment unit and
25the resulting additional premium to be paid by the group or
26enrollment unit.

 

 

HB4703- 39 -LRB102 24386 BMS 33620 b

1    In no event shall the Illinois Health Maintenance
2Organization Guaranty Association be liable to pay any
3contractual obligation of an insolvent organization to pay any
4refund authorized under this Section.
5    (g) Rulemaking authority to implement Public Act 95-1045,
6if any, is conditioned on the rules being adopted in
7accordance with all provisions of the Illinois Administrative
8Procedure Act and all rules and procedures of the Joint
9Committee on Administrative Rules; any purported rule not so
10adopted, for whatever reason, is unauthorized.
11(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
12101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
131-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
14eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
15102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
161-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
17eff. 10-8-21; revised 10-27-21.)
 
18    Section 20. The Managed Care Reform and Patient Rights Act
19is amended by changing Section 70 as follows:
 
20    (215 ILCS 134/70)
21    Sec. 70. Post-stabilization medical services.
22    (a) If prior authorization for covered post-stabilization
23services is required by the health care plan, the plan shall
24provide access 24 hours a day, 7 days a week to persons

 

 

HB4703- 40 -LRB102 24386 BMS 33620 b

1designated by the plan to make such determinations, provided
2that any determination made under this Section must be made by
3a health care professional. The review shall be resolved in
4accordance with the provisions of Section 85 and the time
5requirements of this Section.
6    (a-5) Prior authorization or approval by the plan shall
7not be required for post-stabilization services that
8constitute emergency services under Section 356z.3a of the
9Illinois Insurance Code.
10    (b) The treating physician licensed to practice medicine
11in all its branches or health care provider shall contact the
12health care plan or delegated health care provider as
13designated on the enrollee's health insurance card to obtain
14authorization, denial, or arrangements for an alternate plan
15of treatment or transfer of the enrollee.
16    (c) The treating physician licensed to practice medicine
17in all its branches or health care provider shall document in
18the enrollee's medical record the enrollee's presenting
19symptoms; emergency medical condition; and time, phone number
20dialed, and result of the communication for request for
21authorization of post-stabilization medical services. The
22health care plan shall provide reimbursement for covered
23post-stabilization medical services if:
24        (1) authorization to render them is received from the
25    health care plan or its delegated health care provider, or
26        (2) after 2 documented good faith efforts, the

 

 

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1    treating health care provider has attempted to contact the
2    enrollee's health care plan or its delegated health care
3    provider, as designated on the enrollee's health insurance
4    card, for prior authorization of post-stabilization
5    medical services and neither the plan nor designated
6    persons were accessible or the authorization was not
7    denied within 60 minutes of the request. "Two documented
8    good faith efforts" means the health care provider has
9    called the telephone number on the enrollee's health
10    insurance card or other available number either 2 times or
11    one time and an additional call to any referral number
12    provided. "Good faith" means honesty of purpose, freedom
13    from intention to defraud, and being faithful to one's
14    duty or obligation. For the purpose of this Act, good
15    faith shall be presumed.
16    (d) After rendering any post-stabilization medical
17services, the treating physician licensed to practice medicine
18in all its branches or health care provider shall continue to
19make every reasonable effort to contact the health care plan
20or its delegated health care provider regarding authorization,
21denial, or arrangements for an alternate plan of treatment or
22transfer of the enrollee until the treating health care
23provider receives instructions from the health care plan or
24delegated health care provider for continued care or the care
25is transferred to another health care provider or the patient
26is discharged.

 

 

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1    (e) Payment for covered post-stabilization services may be
2denied:
3        (1) if the treating health care provider does not meet
4    the conditions outlined in subsection (c);
5        (2) upon determination that the post-stabilization
6    services claimed were not performed;
7        (3) upon timely determination that the
8    post-stabilization services rendered were contrary to the
9    instructions of the health care plan or its delegated
10    health care provider if contact was made between those
11    parties prior to the service being rendered;
12        (4) upon determination that the patient receiving such
13    services was not an enrollee of the health care plan; or
14        (5) upon material misrepresentation by the enrollee or
15    health care provider; "material" means a fact or situation
16    that is not merely technical in nature and results or
17    could result in a substantial change in the situation.
18    (f) Nothing in this Section prohibits a health care plan
19from delegating tasks associated with the responsibilities
20enumerated in this Section to the health care plan's
21contracted health care providers or another entity. Only a
22clinical peer may make an adverse determination. However, the
23ultimate responsibility for coverage and payment decisions may
24not be delegated.
25    (g) Coverage and payment for post-stabilization medical
26services for which prior authorization or deemed approval is

 

 

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1received shall not be retrospectively denied.
2    (h) Nothing in this Section shall prohibit the imposition
3of deductibles, copayments, and co-insurance. Nothing in this
4Section alters the prohibition on billing enrollees contained
5in the Health Maintenance Organization Act.
6(Source: P.A. 91-617, eff. 1-1-00.)
 
7    Section 25. The Voluntary Health Services Plans Act is
8amended by changing Section 10 as follows:
 
9    (215 ILCS 165/10)  (from Ch. 32, par. 604)
10    Sec. 10. Application of Insurance Code provisions. Health
11services plan corporations and all persons interested therein
12or dealing therewith shall be subject to the provisions of
13Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
14143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
15356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
16356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
17356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
18356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
19356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
20356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.43, 364.01,
21367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
22and paragraphs (7) and (15) of Section 367 of the Illinois
23Insurance Code.
24    Rulemaking authority to implement Public Act 95-1045, if

 

 

HB4703- 44 -LRB102 24386 BMS 33620 b

1any, is conditioned on the rules being adopted in accordance
2with all provisions of the Illinois Administrative Procedure
3Act and all rules and procedures of the Joint Committee on
4Administrative Rules; any purported rule not so adopted, for
5whatever reason, is unauthorized.
6(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
7101-281, eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff.
81-1-21; 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306,
9eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21;
10revised 10-27-21.)
 
11    Section 99. Effective date. This Act takes effect July 1,
122022, except that the changes to Section 356z.3 of the
13Illinois Insurance Code and Section 4.5-1 of the Health
14Maintenance Organization Act take effect January 1, 2023.