Full Text of SB1187 101st General Assembly
SB1187 101ST GENERAL ASSEMBLY |
| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020 SB1187 Introduced 2/5/2019, by Sen. Jim Oberweis SYNOPSIS AS INTRODUCED: |
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Creates the Right to Shop Act. Requires a carrier offering a health plan to develop and implement a program that provides incentives for enrollees in a health plan who elect to receive a comparable health care service from a provider that collects less than the average in-network allowed amount paid by that carrier to a network provider for that comparable health care service. Provides how incentives may be calculated, distributed, and offered. Requires the carrier to file a description of the health care service incentive program with the Department of Insurance. Requires a carrier to establish an interactive mechanism on its website to enable an enrollee to request the estimated amount the carrier would pay to a network provider for a comparable health care service. Requires the Director of Central Management Services to conduct an analysis on the cost effectiveness of implementing an incentive-based program for current enrollees and retirees of the State group health benefits plan. Requires a program found to be cost effective to be implemented as part of the next open enrollment. Effective immediately.
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| | | FISCAL NOTE ACT MAY APPLY | |
| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 1. Short title. This Act may be cited as the Right | 5 | | to Shop Act. | 6 | | Section 5. Applicability. This Act applies to health | 7 | | benefit plans amended, delivered, issued, or renewed in this | 8 | | State on or after January 1, 2020. | 9 | | Section 10. Definitions. In this Act: | 10 | | "Allowed amount" means the contractually agreed upon | 11 | | amount paid by a carrier
to a provider participating in the | 12 | | carrier's network. | 13 | | "Carrier" means an entity that provides a health benefit | 14 | | plan in this State and is subject to State insurance | 15 | | regulation. | 16 | | "Comparable health care service" means a covered | 17 | | non-emergency health care service or bundle of services. The | 18 | | Director may limit what is considered a comparable health care | 19 | | service if a carrier demonstrates that the allowed amount | 20 | | variation among network providers is less than $50. | 21 | | "Department" means the Department of Insurance. | 22 | | "Director" means the Director of Insurance. |
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| 1 | | "Enrollee" means an individual enrolled in a health benefit | 2 | | plan. | 3 | | "Health benefit plan" or "health plan" means a policy, | 4 | | contract, certificate, plan, or agreement offered or issued by | 5 | | a carrier to provide, deliver, arrange for, pay for, or | 6 | | reimburse any of the costs of health care services. "Health | 7 | | benefit plan" or "health plan" does not include individual, | 8 | | accident-only, credit, dental, vision, Medicare supplement, | 9 | | hospital indemnity, long term care, specific disease, | 10 | | stop-loss or disability income insurance, coverage issued as a | 11 | | supplement to liability insurance, workers' compensation or | 12 | | similar insurance, or automobile medical payment insurance. | 13 | | "Health care services" means services for the diagnosis, | 14 | | prevention, treatment, cure, or relief of a health condition, | 15 | | illness, injury, or disease. | 16 | | "Network" means the group or groups of preferred providers | 17 | | providing services to a network plan. | 18 | | "Network plan" means an individual or group policy of | 19 | | health plans that either requires a covered person to use or | 20 | | creates incentives, including financial incentives, for an | 21 | | enrollee to use providers managed, owned, under contract with, | 22 | | or employed by the carrier. | 23 | | "Program" means the comparable health care service | 24 | | incentive program established by a carrier pursuant to this | 25 | | Act. | 26 | | "Provider" means a physician, hospital facility, or other |
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| 1 | | health care practitioner licensed or otherwise authorized to | 2 | | furnish health care services consistent with State law. | 3 | | Section 15. Health care service incentive program. | 4 | | (a) Beginning January 1, 2020, a carrier offering a health | 5 | | benefit plan in this State shall develop and implement a | 6 | | program that provides incentives for enrollees in a health plan | 7 | | who elect to receive a comparable health care service that is | 8 | | covered by the health plan from a provider that collects less | 9 | | than the average in-network allowed amount paid by that carrier | 10 | | to a network provider for that comparable health care service. | 11 | | (b) Incentives may be calculated as a percentage of the | 12 | | difference in allowed amounts to the average, as a flat dollar | 13 | | amount, or by some other reasonable methodology approved by the | 14 | | Department. The carrier shall provide the incentive as a cash | 15 | | payment, gift cards, or credits toward the enrollee's annual | 16 | | in-network deductible and out-of-pocket limit or premium | 17 | | reductions. | 18 | | (c) A carrier shall make the health care service incentive | 19 | | program available as a component of all health plans offered in | 20 | | the individual and small group markets by the carrier in this | 21 | | State, but not including plans in which enrollees receive a | 22 | | premium subsidy under the federal Patient Protection and | 23 | | Affordable Care Act. Annually at enrollment or renewal, a | 24 | | carrier shall provide notice about the availability of the | 25 | | program, a description of the incentives available to an |
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| 1 | | enrollee and how to earn such incentives to an enrollee who is | 2 | | enrolled in a health plan eligible for the program. A carrier | 3 | | may contract with a third-party vendor to satisfy the | 4 | | requirements of this subsection. | 5 | | Section 20. Administrative expense; filing requirements. | 6 | | (a) A comparable health care service incentive payment made | 7 | | by a carrier in accordance with this Act is not an | 8 | | administrative expense of the carrier for rate development or | 9 | | rate filing purposes. | 10 | | (b) Prior to offering the health care service incentive | 11 | | program to an enrollee, a carrier shall file a description of | 12 | | the program with the Department in the manner determined by the | 13 | | Department. The Director may review the filing made by the | 14 | | carrier to determine whether the carrier's program complies | 15 | | with the requirements of this Act. Filings and any supporting | 16 | | documentation are confidential until the filing has been | 17 | | approved or denied by the Department. | 18 | | Section 25. Health care price transparency tools. | 19 | | (a) Beginning upon approval of the next health insurance | 20 | | rate filing after the effective date of this Act, a carrier | 21 | | offering a health plan in this State shall comply with the | 22 | | following requirements: | 23 | | (1) A carrier shall establish an interactive mechanism | 24 | | on its publicly-accessible website that enables an |
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| 1 | | enrollee to request and obtain from the carrier information | 2 | | on the payments made by the carrier to network providers | 3 | | for comparable health care services, as well as quality | 4 | | data for those providers, to the extent available. The | 5 | | interactive mechanism must allow an enrollee seeking | 6 | | information about the cost of a particular health care | 7 | | service to: | 8 | | (A) compare allowed amounts among network | 9 | | providers; | 10 | | (B) estimate out-of-pocket costs applicable to | 11 | | that enrollee's health plan; and | 12 | | (C) provide the average paid within a reasonable | 13 | | timeframe (not to exceed one year) to network providers | 14 | | for the procedure or service under the enrollee's | 15 | | health plan. | 16 | | The out-of-pocket estimate must provide a good faith | 17 | | estimate of the amount the enrollee will be responsible to | 18 | | pay out-of-pocket for a proposed non-emergency procedure | 19 | | or service that is a medically necessary covered benefit | 20 | | from a carrier's network provider, including a copayment, | 21 | | deductible, coinsurance, or other out-of-pocket amount for | 22 | | a covered benefit, based on the information available to | 23 | | the carrier at the time the request is made. A carrier may | 24 | | contract with a third-party vendor to satisfy the | 25 | | requirements of this paragraph. | 26 | | (2) A carrier shall notify an enrollee that the |
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| 1 | | information provided under paragraph (1) is an estimation | 2 | | of costs and that the actual amount the enrollee will be | 3 | | responsible to pay may vary due to unforeseen services that | 4 | | arise out of the proposed non-emergency procedure or | 5 | | service. | 6 | | (b) Nothing in this Section prohibits a carrier from | 7 | | imposing cost-sharing requirements disclosed in the enrollee's | 8 | | certificate of coverage for unforeseen health care services | 9 | | that arise out of the non-emergency procedure or service or for | 10 | | a procedure or service provided to an enrollee that was not | 11 | | included in the original estimate. | 12 | | Section 30. Patient freedom and choice; lower prices. | 13 | | (a) If an enrollee elects to receive a covered health care | 14 | | service from an out-of-network provider at a price that is the | 15 | | same or less than the average that an enrollee's carrier pays | 16 | | for that service to providers in its provider network within a | 17 | | reasonable timeframe, not to exceed one year, the carrier shall | 18 | | allow the enrollee to obtain the service from the | 19 | | out-of-network provider at the provider's price and, upon | 20 | | request by the enrollee, shall apply the payments made by the | 21 | | enrollee for that health care service toward the enrollee's | 22 | | deductible and out-of-pocket maximum as specified in the | 23 | | enrollee's health plan as if the health care services had been | 24 | | provided by a network provider. The carrier shall provide a | 25 | | downloadable or interactive online form to the enrollee for the |
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| 1 | | purpose of submitting proof of payment to an out-of-network | 2 | | provider for purposes of administering this Section. | 3 | | (b) A carrier may base the average paid to a network | 4 | | provider on what that carrier pays to providers in the network | 5 | | applicable to the enrollee's specific health plan or across all | 6 | | of its plans offered in this State. A carrier shall, at a | 7 | | minimum, inform enrollees of its ability to pay and the process | 8 | | to request the average allowed amount paid for a procedure or | 9 | | service, both on its website and in benefit plan material. | 10 | | Section 35. State group health benefits plan; analysis. The | 11 | | Director of Central Management Services shall conduct an | 12 | | analysis no later than one year from the effective date of this | 13 | | Act of the cost effectiveness of implementing an | 14 | | incentive-based program for enrollees and retirees of the State | 15 | | group health benefits plan offered under the State Employees | 16 | | Group Insurance Act of 1971. A program found to be cost | 17 | | effective shall be implemented as part of the next open | 18 | | enrollment. The Director of Central Management Services shall | 19 | | communicate the rationale for the decision to relevant General | 20 | | Assembly committees in writing. | 21 | | Section 40. Rulemaking authority. The Director may adopt | 22 | | reasonable rules as necessary to implement the purposes and | 23 | | provisions of this Act.
| 24 | | Section 99. Effective date. This Act takes effect upon |
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| 1 | | becoming law.
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