Full Text of HB2919 97th General Assembly
HB2919 97TH GENERAL ASSEMBLY |
| | 97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012 HB2919 Introduced 2/23/2011, by Rep. Angelo Saviano SYNOPSIS AS INTRODUCED: |
| 215 ILCS 5/368b | | 215 ILCS 5/368c | | 215 ILCS 5/368e | | 215 ILCS 5/370 | from Ch. 73, par. 982 | 215 ILCS 5/370a | from Ch. 73, par. 982a | 215 ILCS 5/370b | from Ch. 73, par. 982b |
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Amends the Illinois Insurance Code. In the provision concerning contracting procedures, specifies that no contract is required to provide services to an insured, enrollee, or beneficiary. Provides that when health care services are provided by a nonparticipating
health care
professional or health care provider, an insurer, health maintenance
organization,
independent practice association, or physician hospital organization shall (now, may) pay
for covered
services either to a patient directly or to the nonparticipating health care
professional or
health care provider. Provides that the Director of Insurance may require an insurance company or agent that wilfully violates any provision of the Article of the Code concerning accident and health insurance to pay to
the people of the State a penalty in a sum not exceeding $10,000 (now, $1,000). Specifies that certain provisions of the Code are deemed incorporated into health care professional and health care provider service contracts entered into on or before the effective date of the amendatory Act. Makes other changes.
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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 Illinois Insurance Code is amended by | 5 | | changing Sections 368b, 368c, 368e, 370, 370a, and 370b as | 6 | | follows:
| 7 | | (215 ILCS 5/368b)
| 8 | | Sec. 368b. Contracting procedures.
| 9 | | (a) A health care professional or health care provider | 10 | | offered a contract by
an
insurer, health maintenance | 11 | | organization,
independent practice association, or physician
| 12 | | hospital organization for signature after the effective date of | 13 | | this amendatory
Act of the
93rd General Assembly shall be | 14 | | provided with a proposed health care
professional or
health | 15 | | care provider
services contract including, if any, exhibits and | 16 | | attachments that the contract
indicates are
to be attached. | 17 | | Within 35 days after a written request, the health care
| 18 | | professional or health
care provider offered a contract shall | 19 | | be given the opportunity to review and
obtain a
copy of the | 20 | | following: a specialty-specific fee schedule sample based on a
| 21 | | minimum of
the 50 highest volume fee schedule codes with the | 22 | | rates applicable to the
health care
professional or health care | 23 | | provider to whom the contract is offered, the
network
provider
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| 1 | | administration manual, and a summary capitation schedule, if | 2 | | payment is made on
a
capitation basis. If 50 codes do not exist | 3 | | for a particular specialty, the
health care
professional or | 4 | | health care provider offered a contract shall be given the
| 5 | | opportunity to
review or obtain a copy of a fee schedule sample | 6 | | with the codes applicable to
that
particular specialty. This | 7 | | information may be provided electronically. An
insurer, health
| 8 | | maintenance organization, independent practice
association, or | 9 | | physician hospital
organization may substitute the fee | 10 | | schedule sample with a document providing
reference
to the | 11 | | information needed to calculate the fee schedule that is | 12 | | available to
the public at no
charge and the percentage or | 13 | | conversion factor at which the insurer, health
maintenance
| 14 | | organization, preferred provider organization, independent | 15 | | practice
association, or physician hospital organization sets | 16 | | its rates.
| 17 | | (b) The fee schedule, the capitation schedule, and
the | 18 | | network provider
administration manual constitute | 19 | | confidential, proprietary, and trade secret
information and | 20 | | are subject to the provisions of the Illinois Trade Secrets
| 21 | | Act.
The health
care professional or health care provider | 22 | | receiving such protected information
may disclose
the | 23 | | information on a need to know basis and only to individuals and | 24 | | entities
that provide
services directly related to the health | 25 | | care professional's or health care
provider's decision
to enter | 26 | | into the contract or keep the contract in force. Any person or |
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| 1 | | entity
receiving or
reviewing such protected information | 2 | | pursuant to this Section shall not
disclose
the
information to | 3 | | any other person, organization, or entity, unless the | 4 | | disclosure
is requested
pursuant to a valid court order or | 5 | | required by a state or federal government
agency.
Individuals | 6 | | or entities receiving such information from a health care
| 7 | | professional
or health care provider as delineated in this | 8 | | subsection are subject to the
provisions of the
Illinois Trade | 9 | | Secrets Act.
| 10 | | (c) The health care professional or health care provider | 11 | | shall be allowed at
least
30 days to review the health care | 12 | | professional or health care provider services
contract, | 13 | | including
exhibits and
attachments, if any, before signing. The | 14 | | 30-day review period begins upon
receipt of the
health care
| 15 | | professional or health care provider services contract, unless | 16 | | the information
available
upon request
in subsection (a) is not | 17 | | included. If information is not included in the
professional
| 18 | | services contract and is requested pursuant to subsection (a), | 19 | | the 30-day
review period
begins on the date of receipt of the | 20 | | information. Nothing in this subsection
shall prohibit
a health | 21 | | care professional or health care provider from signing a | 22 | | contract
prior to the
expiration of the 30-day review period.
| 23 | | (d) The insurer, health maintenance organization,
| 24 | | independent practice
association, or physician hospital | 25 | | organization shall provide all contracted
health care
| 26 | | professionals or health care providers with any changes to the |
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| 1 | | fee schedule
provided
under subsection (a) not later than 35 | 2 | | days after the effective date of the
changes,
unless such
| 3 | | changes are specified in the contract and the health care | 4 | | professional or
health care
provider is able to calculate the | 5 | | changed rates based on information in the
contract and
| 6 | | information available to the public at no charge. For the | 7 | | purposes of this
subsection,
"changes" means an increase or | 8 | | decrease in the fee schedule referred to in
subsection (a).
| 9 | | This information may be made available by mail, e-mail, | 10 | | newsletter, website
listing, or
other reasonable method. Upon | 11 | | request, a health care professional or health
care provider
may | 12 | | request an updated copy of the fee schedule referred to in | 13 | | subsection (a)
every
calendar quarter.
| 14 | | (e) Upon termination of a contract with an insurer, health | 15 | | maintenance
organization, independent practice
association, or | 16 | | physician hospital
organization and at
the request of the | 17 | | patient, a health care professional or health care provider
| 18 | | shall provide transfer
copies of the patient's medical records. | 19 | | Any other provision of law
notwithstanding, the
costs for | 20 | | copying and transferring copies of medical records shall be | 21 | | assigned
per the
arrangements agreed upon, if any, in the | 22 | | health care professional or health
care provider services
| 23 | | contract.
| 24 | | (f) No contract is required to provide services to an | 25 | | insured, enrollee, or beneficiary. | 26 | | (Source: P.A. 93-261, eff. 1-1-04.)
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| 1 | | (215 ILCS 5/368c)
| 2 | | Sec. 368c. Remittance advice and procedures.
| 3 | | (a) A remittance advice shall be furnished to a health care | 4 | | professional or
health
care provider that identifies the | 5 | | disposition of each claim. The remittance
advice shall identify | 6 | | the services billed; the patient responsibility, if any;
the | 7 | | actual payment, if any, for the services billed; and the reason | 8 | | for any
reduction to the amount for
which the claim was | 9 | | submitted. For any reductions to the amount for which the
claim | 10 | | was submitted, the remittance shall identify any withholds and | 11 | | the reason
for any denial or reduction.
| 12 | | A remittance advice for capitation or prospective payment | 13 | | arrangements shall
be
furnished to a health care professional | 14 | | or health care provider pursuant to a
contract with
an insurer, | 15 | | health maintenance organization,
independent practice | 16 | | association,
or
physician hospital organization in accordance | 17 | | with the terms of the contract.
| 18 | | (b) When health care services are provided by a | 19 | | non-participating
health care
professional or health care | 20 | | provider, an insurer, health maintenance
organization,
| 21 | | independent practice association, or physician hospital | 22 | | organization shall may pay
for covered
services either to a | 23 | | patient directly or to the non-participating health care
| 24 | | professional or
health care provider.
| 25 | | (c) When a person presents a
benefits information card,
a |
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| 1 | | health care professional or health care provider shall make a | 2 | | good faith
effort
to inform the
person if the
health care | 3 | | professional or health care provider has a participation | 4 | | contract
with the
insurer,
health maintenance organization, or | 5 | | other
entity identified on the card.
| 6 | | (Source: P.A. 93-261, eff. 1-1-04.)
| 7 | | (215 ILCS 5/368e)
| 8 | | Sec. 368e. Administration and enforcement.
| 9 | | (a) Other than the duties specifically created in Sections | 10 | | 368b, 368c, and
368d,
nothing in those Sections is intended to | 11 | | preclude, prevent, or require the
adoption,
modification, or | 12 | | termination of any utilization management, quality management,
| 13 | | or
claims processing methodologies or other provisions of a | 14 | | contract applicable to
services provided under a
contract
| 15 | | between an insurer, health maintenance organization,
| 16 | | independent practice
association, or
physician hospital | 17 | | organization and a health care professional or health care
| 18 | | provider.
| 19 | | (b) Nothing in Sections 368b, 368c, and 368d precludes, | 20 | | prevents, or
requires
the
adoption, modification, or | 21 | | termination of any health plan term, benefit,
coverage or
| 22 | | eligibility provision, or payment methodology.
| 23 | | (c) The provisions of Sections 368b, 368c, and 368d are | 24 | | deemed incorporated
into health care professional and health | 25 | | care provider service contracts
entered into on or before |
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| 1 | | January 1, 2004 ( the
effective date of Public Act 93-261)
this | 2 | | amendatory Act of the 93rd General Assembly and do not require | 3 | | an insurer,
health
maintenance organization, independent | 4 | | practice
association, or physician
hospital
organization to | 5 | | renew or renegotiate the contracts with a health care
| 6 | | professional or health
care provider.
| 7 | | (c-5) The amendatory provisions of Sections 368b, 368c, | 8 | | 368d, 370a, and 370b are deemed incorporated into health care | 9 | | professional and health care provider service contracts | 10 | | entered into on or before the effective date of this amendatory | 11 | | Act of the 97th General Assembly and do not require an insurer, | 12 | | health maintenance organization, independent practice | 13 | | association, or physician hospital organization to renew or | 14 | | renegotiate the contracts with a health care professional or | 15 | | health care provider. | 16 | | (d) The Department shall enforce the provisions of this | 17 | | Section and
Sections 368b, 368c, and 368d pursuant to the | 18 | | enforcement powers granted to it
by law.
| 19 | | (e) The Department is hereby granted specific authority to | 20 | | issue a cease and
desist order against, fine, or otherwise | 21 | | penalize independent practice
associations and
| 22 | | physician-hospital organizations for violations.
| 23 | | (f) The Department shall adopt reasonable rules to enforce | 24 | | compliance with
this Section and Sections 368b, 368c, and 368d.
| 25 | | (Source: P.A. 93-261, eff. 1-1-04.)
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| 1 | | (215 ILCS 5/370) (from Ch. 73, par. 982)
| 2 | | Sec. 370.
Policies
issued in violation of article-Penalty.
| 3 | | (1) Any company, or any officer or agent thereof, issuing | 4 | | or delivering
to any person in this State any policy in wilful | 5 | | violation of the provision
of this article shall be guilty of a | 6 | | petty offense.
| 7 | | (2) The Director may revoke the license of any foreign or | 8 | | alien company,
or of the agent thereof wilfully violating any | 9 | | provision of this article or
suspend such license for any | 10 | | period of time up to, but not to exceed, two
years; or may by | 11 | | order require such insurance company or agent to pay to
the | 12 | | people of the State of Illinois a penalty in a sum not | 13 | | exceeding $10,000 $1,000 ,
and upon the failure of such | 14 | | insurance company or agent to
pay such penalty within twenty | 15 | | days after the mailing of such order,
postage prepaid, | 16 | | registered, and addressed to the last known place of
business | 17 | | of such insurance company or agent, unless such order is stayed | 18 | | by
an order of a court of competent jurisdiction, the Director | 19 | | of Insurance
may revoke or suspend the license of such | 20 | | insurance company or agent for
any period of time up to, but | 21 | | not exceeding a period of, two years.
| 22 | | (Source: P.A. 93-32, eff. 7-1-03.)
| 23 | | (215 ILCS 5/370a) (from Ch. 73, par. 982a)
| 24 | | Sec. 370a. Assignability of Accident and Health Insurance.
| 25 | | (a) No provision of the Illinois Insurance Code, or any |
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| 1 | | other law, prohibits
an insured under any policy of accident | 2 | | and health insurance or any other
person who may be the owner | 3 | | of any rights under such policy from making an
assignment of | 4 | | all or any part of his rights and privileges under the policy
| 5 | | including but not limited to the right to designate a | 6 | | beneficiary and to
have an individual policy issued in | 7 | | accordance with its terms. Subject to
the terms of the policy | 8 | | or any contract relating thereto, an assignment by
an insured | 9 | | or by any other owner of rights under the policy, made before | 10 | | or
after the effective date of this amendatory Act of 1969 is | 11 | | valid for the
purpose of vesting in the assignee, in accordance | 12 | | with any provisions
included therein as to the time at which it | 13 | | is effective, all rights and
privileges so assigned. However, | 14 | | such assignment is without prejudice to
the company on account | 15 | | of any payment it makes or individual policy it
issues before | 16 | | receipt of notice of the assignment. This amendatory Act of
| 17 | | 1969 acknowledges, declares and codifies the existing right of | 18 | | assignment
of interests under accident and health insurance | 19 | | policies. | 20 | | (b) For the purposes of payment for covered services, if
If | 21 | | an enrollee or insured of an insurer, health maintenance | 22 | | organization,
managed care plan, health care plan, preferred | 23 | | provider organization, or third
party administrator assigns a | 24 | | claim to a health care professional or health
care facility, | 25 | | then payment
shall be made directly to the health care | 26 | | professional or health care facility regardless of whether the |
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| 1 | | professional is a participating or nonparticipating provider,
| 2 | | including any interest
required under Section 368a, of this | 3 | | Code for failure to pay
claims
within 30
days after receipt by | 4 | | the insurer of due proof of loss. Nothing in this
Section shall | 5 | | be construed to prevent any parties from reconciling duplicate
| 6 | | payments.
| 7 | | (Source: P.A. 91-605, eff. 12-14-99; 91-788, eff. 6-9-00.)
| 8 | | (215 ILCS 5/370b) (from Ch. 73, par. 982b)
| 9 | | Sec. 370b. Reimbursement on equal basis. Notwithstanding | 10 | | any provision
of any individual or group
policy of accident and | 11 | | health insurance, or any provision of a policy,
contract, plan | 12 | | or agreement for hospital or medical service or indemnity,
| 13 | | wherever such policy, contract, plan or agreement provides for
| 14 | | reimbursement for any service provided by persons licensed | 15 | | under the Medical Practice Act of 1987 or the Podiatric Medical
| 16 | | Practice
Act of 1987, the person entitled to benefits or person | 17 | | performing services
under such policy, contract, plan or | 18 | | agreement is entitled to reimbursement
on an equal basis for | 19 | | such service, when the service is performed by a
person | 20 | | licensed under the Medical Practice Act of 1987 or the
| 21 | | Podiatric Medical Practice Act of 1987 whether the person is a | 22 | | participating or nonparticipating provider . The provisions of | 23 | | this Section do
not apply to any policy, contract, plan or | 24 | | agreement in effect prior to
September 19, 1969 or to
preferred | 25 | | provider arrangements or benefit agreements.
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| 1 | | (Source: P.A. 90-14, eff. 7-1-97.)
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