Full Text of SB1878 98th General Assembly
SB1878 98TH GENERAL ASSEMBLY |
| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014 SB1878 Introduced 2/15/2013, by Sen. Andy Manar SYNOPSIS AS INTRODUCED: |
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215 ILCS 134/5 |
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215 ILCS 134/15 |
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215 ILCS 134/30 |
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Amends the Managed Care Reform and Patient Rights Act. Provides that an individual's right to purchase any health care services with
that individual's own funds may not be invalidated through a contractual provision or requirement between the insurer and a participating health care provider. Requires audiological services providers to provide to enrollees, upon request, a detailed and itemized statement with information outlining the costs of audiological devices, the plan payment amounts, and the amount of out-of-pocket costs to be paid by the enrollee for the various device options available to treat the enrollee's condition. Provides that no health care plan nor its subcontractors may, by contract, written policy, procedure, or otherwise, mandate or prohibit an enrollee from purchasing audiological equipment with a value over and above the plan benefit.
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| | A BILL FOR |
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| 1 | | AN ACT concerning insurance.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Managed Care Reform and Patient Rights Act | 5 | | is amended by changing Sections 5, 15, and 30 as follows:
| 6 | | (215 ILCS 134/5)
| 7 | | Sec. 5. Health care patient rights.
| 8 | | (a) The General Assembly finds that:
| 9 | | (1) A patient has the right to care consistent with | 10 | | professional standards
of
practice to assure quality | 11 | | nursing and medical practices, to choose
the participating | 12 | | physician responsible for coordinating his or her
care, to | 13 | | receive information concerning his or her condition and | 14 | | proposed
treatment, to refuse any treatment to the extent | 15 | | permitted by law, and to
privacy and confidentiality of | 16 | | records except as otherwise provided by law.
| 17 | | (2) A patient has the right, regardless of source of | 18 | | payment, to examine
and
to receive a reasonable explanation | 19 | | of his or her total bill for health care
services rendered | 20 | | by his or her physician or other health care provider,
| 21 | | including the itemized charges for specific health care | 22 | | services received. A
physician or other health care | 23 | | provider has responsibility only for a
reasonable |
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| 1 | | explanation of those specific health care services | 2 | | provided by the
health care provider.
| 3 | | (3) A patient has the right to timely prior notice of | 4 | | the termination
whenever
a health care plan cancels or | 5 | | refuses to renew an enrollee's
participation in the plan.
| 6 | | (4) A patient has the right to privacy and | 7 | | confidentiality in health care.
This right may be expressly | 8 | | waived in writing by the patient or the patient's
guardian.
| 9 | | (5) An individual has the right to purchase any health | 10 | | care services with
that individual's own funds , and that | 11 | | right may not be invalidated through a contractual | 12 | | provision or requirement between the insurer and a | 13 | | participating health care provider .
| 14 | | (b) Nothing in this Section shall preclude the health care | 15 | | plan from
sharing information for
plan quality assessment and | 16 | | improvement purposes as required by Section 80.
| 17 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 18 | | (215 ILCS 134/15)
| 19 | | Sec. 15. Provision of information.
| 20 | | (a) A health care plan shall provide annually to enrollees | 21 | | and prospective
enrollees, upon request, a complete list of | 22 | | participating health care providers
in the
health care plan's | 23 | | service area and a description of the following terms of
| 24 | | coverage:
| 25 | | (1) the service area;
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| 1 | | (2) the covered benefits and services with all | 2 | | exclusions, exceptions, and
limitations;
| 3 | | (3) the pre-certification and other utilization review | 4 | | procedures
and requirements;
| 5 | | (4) a description of the process for the selection of a | 6 | | primary care
physician,
any limitation on access to | 7 | | specialists, and the plan's standing referral
policy;
| 8 | | (5) the emergency coverage and benefits, including any | 9 | | restrictions on
emergency
care services;
| 10 | | (6) the out-of-area coverage and benefits, if any;
| 11 | | (7) the enrollee's financial responsibility for | 12 | | copayments, deductibles,
premiums, and any other | 13 | | out-of-pocket expenses;
| 14 | | (8) the provisions for continuity of treatment in the | 15 | | event a health care
provider's
participation terminates | 16 | | during the course of an enrollee's treatment by that
| 17 | | provider;
| 18 | | (9) the appeals process, forms, and time frames for | 19 | | health care services
appeals, complaints, and external | 20 | | independent reviews, administrative
complaints,
and | 21 | | utilization review complaints, including a phone
number
to | 22 | | call to receive more information from the health care plan | 23 | | concerning the
appeals process; and
| 24 | | (10) a statement of all basic health care services and | 25 | | all specific
benefits and
services mandated to be provided | 26 | | to enrollees by any State law or
administrative
rule.
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| 1 | | In the event of an inconsistency between any separate | 2 | | written disclosure
statement and the enrollee contract or | 3 | | certificate, the terms of the enrollee
contract or certificate | 4 | | shall control.
| 5 | | (b) Upon written request, a health care plan shall provide | 6 | | to enrollees a
description of the financial relationships | 7 | | between the health care plan and any
health care provider
and, | 8 | | if requested, the percentage
of copayments, deductibles, and | 9 | | total premiums spent on healthcare related
expenses and the | 10 | | percentage of
copayments, deductibles, and total premiums | 11 | | spent on other expenses, including
administrative expenses,
| 12 | | except that no health care plan shall be required to disclose | 13 | | specific provider
reimbursement.
| 14 | | (c) A participating health care provider shall provide all | 15 | | of the
following, where applicable, to enrollees upon request:
| 16 | | (1) Information related to the health care provider's | 17 | | educational
background,
experience, training, specialty, | 18 | | and board certification, if applicable.
| 19 | | (2) The names of licensed facilities on the provider | 20 | | panel where
the health
care provider presently has | 21 | | privileges for the treatment, illness, or
procedure
that is | 22 | | the subject of the request.
| 23 | | (3) Information regarding the health care provider's | 24 | | participation
in
continuing education programs and | 25 | | compliance with any licensure,
certification, or | 26 | | registration requirements, if applicable.
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| 1 | | (4) With regard to audiological services providers, a | 2 | | detailed and itemized statement with information outlining | 3 | | the costs of audiological devices, the plan payment | 4 | | amounts, and the amount of out-of-pocket costs to be paid | 5 | | by the enrollee for the various device options available to | 6 | | treat the enrollee's condition. | 7 | | (d) A health care plan shall provide the information | 8 | | required to be
disclosed under this Act upon enrollment and | 9 | | annually thereafter in a legible
and understandable format. The | 10 | | Department
shall promulgate rules to establish the format | 11 | | based, to the extent
practical,
on
the standards developed for | 12 | | supplemental insurance coverage under Title XVIII
of
the | 13 | | federal Social Security Act as a guide, so that a person can | 14 | | compare the
attributes of the various health care plans.
| 15 | | (e) The written disclosure requirements of this Section may | 16 | | be met by
disclosure to one enrollee in a household.
| 17 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 18 | | (215 ILCS 134/30)
| 19 | | Sec. 30. Prohibitions.
| 20 | | (a) No health care plan or its subcontractors may prohibit | 21 | | or discourage
health care providers
by contract or policy from
| 22 | | discussing any health care services and health care providers, | 23 | | utilization
review and quality assurance policies, terms and | 24 | | conditions of plans and plan
policy with enrollees, prospective | 25 | | enrollees, providers, or the public.
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| 1 | | (b) No health care plan by contract, written policy, or | 2 | | procedure may
permit or allow an individual or entity to | 3 | | dispense a different
drug in place of the drug or brand of drug | 4 | | ordered or prescribed without the
express permission of the | 5 | | person ordering or prescribing the drug, except as
provided | 6 | | under Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
| 7 | | (b-5) No health care plan nor its subcontractors may, by | 8 | | contract, written policy, procedure, or otherwise, mandate or | 9 | | prohibit an enrollee from purchasing audiological equipment | 10 | | with a value over and above the plan benefit. | 11 | | (c) No health care plan or its subcontractors may by | 12 | | contract, written
policy, procedure, or otherwise mandate or | 13 | | require an enrollee
to substitute his or her participating | 14 | | primary care physician
under the plan during inpatient | 15 | | hospitalization, such as with a hospitalist physician licensed | 16 | | to practice medicine in all its branches,
without the agreement | 17 | | of that enrollee's
participating primary care physician. | 18 | | "Participating primary care
physician" for health care plans | 19 | | and subcontractors that do not require
coordination of care by | 20 | | a primary care physician means the participating
physician | 21 | | treating the patient. All health care plans shall inform | 22 | | enrollees
of any policies, recommendations, or guidelines | 23 | | concerning the
substitution of the enrollee's primary care | 24 | | physician when hospitalization is
necessary in the manner set | 25 | | forth in subsections (d) and (e) of Section 15.
| 26 | | (d) Any violation of this Section shall be subject to the
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| 1 | | penalties under this Act.
| 2 | | (Source: P.A. 94-866, eff. 6-16-06.)
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