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| [ Engrossed ] | [ House Amendment 001 ] |
91_HB0382
LRB9100759JSpc
1 AN ACT concerning health benefit notices, amending named
2 Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The State Employees Group Insurance Act of
6 1971 is amended by adding Section 6.12 as follows:
7 (5 ILCS 375/6.12 new)
8 Sec. 6.12. Benefit notices. The program of health
9 benefits shall provide the benefit payment and denial notices
10 required under Section 155.36 of the Illinois Insurance Code.
11
12 Section 10. The State Mandates Act is amended by adding
13 Section 8.23 as follows:
14 (30 ILCS 805/8.23 new)
15 Sec. 8.23. Exempt mandate. Notwithstanding Sections 6
16 and 8 of this Act, no reimbursement by the State is required
17 for the implementation of any mandate created by this
18 amendatory Act of 1999.
19 Section 15. The Counties Code is amended by adding
20 Section 5-1069.4 as follows:
21 (55 ILCS 5/5-1069.4 new)
22 Sec. 5-1069.4. Health benefit notices. If a county,
23 including a home rule county, is a self-insurer for purposes
24 of providing health insurance coverage for its employees, the
25 county must provide benefit payment and denial notices as
26 required under Section 155.36 of the Illinois Insurance Code.
27 The requirement that benefit payment and denial notices be
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1 provided in accordance with this Section is an exclusive
2 power and function of the State and is a denial and
3 limitation under Article VII, Section 6, subsection (h) of
4 the Illinois Constitution. A home rule county to which this
5 Section applies must comply with every provision of this
6 Section.
7 Section 20. The Illinois Municipal Code is amended by
8 adding Section 10-4-2.4 as follows:
9 (65 ILCS 5/10-4-2.4 new)
10 Sec. 10-4-2.4. Health benefit notices. If a
11 municipality, including a home rule municipality, is a
12 self-insurer for purposes of providing health insurance
13 coverage for its employees, the municipality must provide
14 benefit payment and denial notices as required under Section
15 155.36 of the Illinois Insurance Code. The requirement that
16 benefit payment and denial notices be provided in accordance
17 with this Section is an exclusive power and function of the
18 State and is a denial and limitation under Article VII,
19 Section 6, subsection (h) of the Illinois Constitution. A
20 home rule municipality to which this Section applies must
21 comply with every provision of this Section.
22 Section 25. The School Code is amended by adding Section
23 10-22.3g as follows:
24 (105 ILCS 5/10-22.3g new)
25 Sec. 10-22.3g. Health benefit notices. Insurance
26 protection and benefits for employees shall provide the
27 benefit payment and denial notices required under Section
28 155.36 of the Illinois Insurance Code.
29 Section 30. The Illinois Insurance Code is amended by
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1 adding Sections 155.36 and 511.114 as follows:
2 (215 ILCS 5/155.36 new)
3 Sec. 155.36. Benefit payment and denial notices.
4 (a) An insurance company or managed care plan providing
5 health care benefits shall provide its insureds and enrollees
6 with detailed notices of benefit payment and denial. A
7 notice of denial shall be signed by the individual
8 responsible for denying payment and include an address and
9 accessible telephone number for the individual responsible
10 for denying payment. In addition, a notice of denial shall
11 clearly state the procedures for appealing the denial. The
12 insured or enrollee shall be given the opportunity to respond
13 to any denial and explain any discrepancies.
14 (b) For the purposes of this Section "managed care plan"
15 means a plan that establishes, operates, or maintains a
16 network of health care providers that have entered into
17 agreements with the plan to provide health care services to
18 enrollees where the plan has the ultimate and direct
19 contractual obligation to the enrollee to arrange for the
20 provision of or pay for services through:
21 (1) organizational arrangements for ongoing quality
22 assurance, utilization review programs, or dispute
23 resolution; or
24 (2) financial incentives for persons enrolled in
25 the plan to use the participating providers and
26 procedures covered by the plan.
27 A managed care plan may be established or operated by any
28 entity including a licensed insurance company, hospital or
29 medical service plan, health maintenance organization,
30 limited health service organization, preferred provider
31 organization, third party administrator, or an employer or
32 employee organization.
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1 (215 ILCS 5/511.114 new)
2 Sec. 511.114. Benefit payment and denial notices. An
3 administrator must comply with the requirements of Section
4 155.36 of this Code.
5 Section 35. The Comprehensive Health Insurance Plan Act
6 is amended by adding Section 8.7 as follows:
7 (215 ILCS 105/8.7 new)
8 Sec. 8.7. Benefit notices. The plan is subject to the
9 provisions of Section 155.36 of the Illinois Insurance Code.
10 Section 40. The Health Maintenance Organization Act is
11 amended by adding Section 4-6.6 as follows:
12 (215 ILCS 125/4-6.6 new)
13 Sec. 4-6.6. Benefit notices. A health maintenance
14 organization is subject to the provisions of Section 155.36
15 of the Illinois Insurance Code.
16 Section 45. The Limited Health Service Organization Act
17 is amended by changing Section 4003 as follows:
18 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
19 Sec. 4003. Illinois Insurance Code provisions. Limited
20 health service organizations shall be subject to the
21 provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
22 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
23 154.6, 154.7, 154.8, 155.04, 155.36, 355.2, 356v, 401, 401.1,
24 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and
25 Articles VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and
26 XXVI of the Illinois Insurance Code. For purposes of the
27 Illinois Insurance Code, except for Sections 444 and 444.1
28 and Articles XIII and XIII 1/2, limited health service
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1 organizations in the following categories are deemed to be
2 domestic companies:
3 (1) a corporation under the laws of this State; or
4 (2) a corporation organized under the laws of
5 another state, 30% of more of the enrollees of which are
6 residents of this State, except a corporation subject to
7 substantially the same requirements in its state of
8 organization as is a domestic company under Article VIII
9 1/2 of the Illinois Insurance Code.
10 (Source: P.A. 90-25, eff. 1-1-98; 90-583, eff. 5-29-98;
11 90-655, eff. 7-30-98.)
12 Section 50. The Voluntary Health Services Plans Act is
13 amended by changing Section 10 as follows:
14 (215 ILCS 165/10) (from Ch. 32, par. 604)
15 Sec. 10. Application of Insurance Code provisions.
16 Health services plan corporations and all persons interested
17 therein or dealing therewith shall be subject to the
18 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
19 143, 143c, 149, 155.36, 354, 355.2, 356r, 356t, 356u, 356v,
20 356w, 356x, 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2,
21 and 412, and paragraphs (7) and (15) of Section 367 of the
22 Illinois Insurance Code.
23 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
24 90-25, eff. 1-1-98; 90-655, eff. 7-30-98; 90-741, eff.
25 1-1-99.)