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| [ Engrossed ] | [ House Amendment 001 ] |
90_HB0843
New Act
Creates the Patient Access to Treatment Act. Provides
that managed care entities may not deny or limit
reimbursement to a member for dermatological services on the
grounds that the member was not referred to the provider by a
person acting on behalf of the managed care entity.
Prohibits unreasonable cost-sharing arrangements. Requires
terms and conditions of coverage to be disclosed in a
readable and understandable format consistent with standards
developed for supplemental insurance coverage under the
federal Social Security Act. Effective immediately.
LRB9001150JSgc
LRB9001150JSgc
1 AN ACT to create the Patient Access to Treatment Act.
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
5 Patient Access to Treatment Act.
6 Section 5. Definitions. In this Act:
7 "Cost-sharing requirements" means requirements in a
8 contract, agreement or other arrangement with, or that is
9 issued, underwritten, or administered by, a managed care
10 entity under which a member is required to pay for part of
11 health care services that are covered by the managed care
12 entity, and those cost-sharing requirements shall include,
13 but shall not be limited to, deductibles, copayments, and
14 coinsurance.
15 "Department" means the Department of Insurance.
16 "Enrollee" means an individual entitled to the provision
17 of or reimbursement for health care services under a group or
18 individual contract, agreement, or other arrangement with, or
19 that has been issued by, a health maintenance organization.
20 "Health care services" means health care related items,
21 treatment, and services sold or rendered by a provider within
22 the scope of the provider's license or legal authorization,
23 and includes, but is not limited to, hospital, medical,
24 surgical, dental, vision, and pharmaceutical items,
25 treatment, and services.
26 "Health maintenance organization" means an entity
27 required to be licensed under the Health Maintenance
28 Organization Act.
29 "Insured" means an individual entitled to reimbursement
30 for expenses of health care services under a group or
31 individual policy underwritten, issued, or administered by an
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1 insurer.
2 "Insurer" means any entity that is required to be
3 licensed under the Illinois Insurance Code.
4 "Managed care entity" means a health maintenance
5 organization, an insurer, a hospital, or medical service plan
6 licensed under the Health Maintenance Organization Act,
7 Illinois Insurance Code, Limited Health Service Organization
8 Act, Dental Service Plan Act, Pharmaceutical Service Plan
9 Act, Vision Service Plan Act, or Voluntary Health Services
10 Plans Act, an employer or employee organization or plan, and
11 any other entity, including a preferred provider
12 organization, that establishes, operates, or maintains a
13 network of providers, conducts or arranges for utilization
14 review activities, and contracts with a health maintenance
15 organization, an insurer, a hospital or medical service plan,
16 an employer, an employer organization, or with any other
17 entity providing coverage for health care services.
18 "Member" means an enrollee, an insured, and any other
19 person entitled to receive health care coverage for health
20 care services from a managed care entity.
21 "Person" means an individual, an agency, a political
22 subdivision, a partnership, a corporation, a limited
23 liability company, an association, or any other entity.
24 "Provider" means a person duly licensed or legally
25 authorized to provide health care services.
26 "Provider network" means, with respect to a managed care
27 entity, providers who have entered into an agreement, either
28 directly or indirectly through another person, with the
29 managed care entity under which the providers are obligated
30 to provide health care services to members of the managed
31 care entity in return for reimbursement as set forth in the
32 agreement and in accordance with any other requirements set
33 forth in the agreement.
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1 Section 10. Direct access. Managed care entities shall
2 not deny or limit reimbursement for health care services
3 provided to a member by a dermatologist, or deny the
4 provision of health care services to a member by a
5 dermatologist, on the grounds that the member was not
6 referred to the dermatologist by a provider or other person
7 acting on behalf of, pursuant to an agreement with, or under
8 the direction of, whether direct or indirect, the managed
9 care entity. As frequently as reasonably necessary to
10 facilitate direct access to providers, but no less frequently
11 than once each year, a managed care entity shall deliver to
12 members a complete listing of all providers of dermatological
13 services in any provider network selected by the managed care
14 entity.
15 Section 15. Prohibition on unreasonable cost-sharing
16 requirements. Managed care entities shall not impose
17 unreasonable cost-sharing requirements on members who receive
18 health care services from dermatologists that are covered by
19 the managed care entity and that are medically necessary. By
20 way of example, but not in limitation, a cost-sharing
21 requirement shall be deemed to be unreasonable if it requires
22 or effectively causes a member to pay the following amounts;
23 (1) more than 20% of the costs of medically
24 necessary health care services covered by the managed
25 care entity; or
26 (2) more than $1,500 per individual or $3,000 per
27 family of the costs of medically necessary health care
28 services covered by the managed care entity.
29 Section 20. Prohibited reimbursement arrangements.
30 Managed care entities may pay providers using incentive
31 payments, but only if no specific payment or withholding of
32 payment has the direct or indirect effect of reducing or
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1 limiting medically necessary health care services that a
2 provider would otherwise be responsible for providing to
3 members.
4 Section 25. Required disclosure of information.
5 Prospective members shall be provided information as to the
6 terms and conditions of the coverage that they will receive
7 from the managed care entity so that they can make informed
8 decisions about accepting the coverage. When the coverage is
9 described orally to members, then easily understood,
10 truthful, and objective terms shall be used. All written
11 descriptions shall be in readable and understandable format,
12 consistent with standards developed for supplemental
13 insurance coverage under Title XVII of the Social Security
14 Act. This format shall be standardized so that potential
15 members can compare the attributes of the various managed
16 care entities. Specific items that must be included in any
17 oral or written description of the managed care entity are:
18 (1) covered provisions, benefits, and any
19 exclusions by category of service, provider, or physician
20 and, if applicable, by specific service;
21 (2) any and all prior authorization or other review
22 requirements, including preauthorization review,
23 concurrent review, post-service review, post-payment
24 review, and any procedures that may lead the member to be
25 denied coverage or not be provided a particular service;
26 (3) financial arrangements or contractual
27 provisions with providers, utilization review companies,
28 and third party administrators that would limit the
29 services offered, restrict referral or treatment options,
30 or negatively affect any provider's fiduciary
31 responsibility to the provider's patients, including but
32 not limited to financial incentives not to provide
33 medical or other services;
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1 (4) explanation of how coverage limitations affect
2 members, including information on member financial
3 responsibility for cost-sharing requirements, for payment
4 of noncovered services, and for payment of out-of-plan
5 services;
6 (5) loss ratios of the managed care entity; and
7 (6) member satisfaction statistics, including but
8 not limited to percent of re-enrollment and reasons for
9 leaving the coverage.
10 Section 30. Enforcement and rules. This Act shall be
11 enforced by the Department. The Department is authorized to
12 issue rules clarifying the requirements of this Act. Each
13 violation of this Act by a managed care entity shall subject
14 the managed care entity to a fine of $5,000 per violation as
15 determined by the Department. The Department is also
16 authorized to take any action necessary to prevent violation
17 of this Act, including but not limited to seeking an
18 injunction against the managed care entity and revoking the
19 managed care entity's license.
20 Section 35. Limitations. Nothing in this Act shall be
21 construed as requiring or allowing any provider to provide
22 health care services that the provider is not duly licensed
23 or legally authorized to provide or to provide any health
24 care services that the provider is not qualified to provide.
25 Section 99. Effective date. This Act takes effect upon
26 becoming law.