Illinois General Assembly - Full Text of SB2807
Illinois General Assembly

Previous General Assemblies

Full Text of SB2807  100th General Assembly

SB2807sam001 100TH GENERAL ASSEMBLY

Sen. Jim Oberweis

Filed: 4/11/2018

 

 


 

 


 
10000SB2807sam001LRB100 17655 SMS 38355 a

1
AMENDMENT TO SENATE BILL 2807

2    AMENDMENT NO. ______. Amend Senate Bill 2807 by replacing
3everything after the enacting clause with the following:
 
4    "Section 1. Short title. This Act may be cited as the Right
5to Shop Act.
 
6    Section 5. Applicability. This Act applies to health
7benefit plans amended, delivered, issued, or renewed in this
8State on or after January 1, 2019.
 
9    Section 10. Definitions. In this Act:
10    "Allowed amount" means the contractually agreed upon
11amount paid by a carrier to a provider participating in the
12carrier's network.
13    "Carrier" means an entity that provides a health benefit
14plan in this State and is subject to State insurance
15regulation.

 

 

10000SB2807sam001- 2 -LRB100 17655 SMS 38355 a

1    "Comparable health care service" means a covered
2non-emergency health care service or bundle of services. The
3Director may limit what is considered a comparable health care
4service if a carrier demonstrates that the allowed amount
5variation among network providers is less than $50.
6    "Department" means the Department of Insurance.
7    "Director" means the Director of Insurance.
8    "Enrollee" means an individual enrolled in a health benefit
9plan.
10    "Health benefit plan" or "health plan" means a policy,
11contract, certificate, plan, or agreement offered or issued by
12a carrier to provide, deliver, arrange for, pay for, or
13reimburse any of the costs of health care services. "Health
14benefit plan" or "health plan" does not include individual,
15accident-only, credit, dental, vision, Medicare supplement,
16hospital indemnity, long term care, specific disease,
17stop-loss or disability income insurance, coverage issued as a
18supplement to liability insurance, workers' compensation or
19similar insurance, or automobile medical payment insurance.
20    "Health care services" means services for the diagnosis,
21prevention, treatment, cure, or relief of a health condition,
22illness, injury, or disease.
23    "Network" means the group or groups of preferred providers
24providing services to a network plan.
25    "Network plan" means an individual or group policy of
26health plans that either requires a covered person to use or

 

 

10000SB2807sam001- 3 -LRB100 17655 SMS 38355 a

1creates incentives, including financial incentives, for an
2enrollee to use providers managed, owned, under contract with,
3or employed by the carrier.
4    "Program" means the comparable health care service
5incentive program established by a carrier pursuant to this
6Act.
7    "Provider" means a physician, hospital facility, or other
8health care practitioner licensed or otherwise authorized to
9furnish health care services consistent with State law.
 
10    Section 15. Health care service incentive program.
11    (a) Beginning January 1, 2019, a carrier offering a health
12benefit plan in this State shall develop and implement a
13program that provides incentives for enrollees in a health plan
14who elect to receive a comparable health care service that is
15covered by the health plan from a provider that collects less
16than the average in-network allowed amount paid by that carrier
17to a network provider for that comparable health care service.
18    (b) Incentives may be calculated as a percentage of the
19difference in allowed amounts to the average, as a flat dollar
20amount, or by some other reasonable methodology approved by the
21Department. The carrier shall provide the incentive as a cash
22payment, gift cards, or credits toward the enrollee's annual
23in-network deductible and out-of-pocket limit or premium
24reductions.
25    (c) A carrier shall make the health care service incentive

 

 

10000SB2807sam001- 4 -LRB100 17655 SMS 38355 a

1program available as a component of all health plans offered in
2the individual and small group markets by the carrier in this
3State, but not including plans in which enrollees receive a
4premium subsidy under the federal Patient Protection and
5Affordable Care Act. Annually at enrollment or renewal, a
6carrier shall provide notice about the availability of the
7program, a description of the incentives available to an
8enrollee and how to earn such incentives to an enrollee who is
9enrolled in a health plan eligible for the program. A carrier
10may contract with a third-party vendor to satisfy the
11requirements of this subsection.
 
12    Section 20. Administrative expense; filing requirements.
13    (a) A comparable health care service incentive payment made
14by a carrier in accordance with this Act is not an
15administrative expense of the carrier for rate development or
16rate filing purposes.
17    (b) Prior to offering the health care service incentive
18program to an enrollee, a carrier shall file a description of
19the program with the Department in the manner determined by the
20Department. The Director may review the filing made by the
21carrier to determine whether the carrier's program complies
22with the requirements of this Act. Filings and any supporting
23documentation are confidential until the filing has been
24approved or denied by the Department.
 

 

 

10000SB2807sam001- 5 -LRB100 17655 SMS 38355 a

1    Section 25. Health care price transparency tools.
2    (a) Beginning upon approval of the next health insurance
3rate filing after the effective date of this Act, a carrier
4offering a health plan in this State shall comply with the
5following requirements:
6        (1) A carrier shall establish an interactive mechanism
7    on its publicly-accessible website that enables an
8    enrollee to request and obtain from the carrier information
9    on the payments made by the carrier to network providers
10    for comparable health care services, as well as quality
11    data for those providers, to the extent available. The
12    interactive mechanism must allow an enrollee seeking
13    information about the cost of a particular health care
14    service to:
15            (A) compare allowed amounts among network
16        providers;
17            (B) estimate out-of-pocket costs applicable to
18        that enrollee's health plan; and
19            (C) provide the average paid within a reasonable
20        timeframe (not to exceed one year) to network providers
21        for the procedure or service under the enrollee's
22        health plan.
23        The out-of-pocket estimate must provide a good faith
24    estimate of the amount the enrollee will be responsible to
25    pay out-of-pocket for a proposed non-emergency procedure
26    or service that is a medically necessary covered benefit

 

 

10000SB2807sam001- 6 -LRB100 17655 SMS 38355 a

1    from a carrier's network provider, including a copayment,
2    deductible, coinsurance, or other out-of-pocket amount for
3    a covered benefit, based on the information available to
4    the carrier at the time the request is made. A carrier may
5    contract with a third-party vendor to satisfy the
6    requirements of this paragraph.
7        (2) A carrier shall notify an enrollee that the
8    information provided under paragraph (1) is an estimation
9    of costs and that the actual amount the enrollee will be
10    responsible to pay may vary due to unforeseen services that
11    arise out of the proposed non-emergency procedure or
12    service.
13    (b) Nothing in this Section prohibits a carrier from
14imposing cost-sharing requirements disclosed in the enrollee's
15certificate of coverage for unforeseen health care services
16that arise out of the non-emergency procedure or service or for
17a procedure or service provided to an enrollee that was not
18included in the original estimate.
 
19    Section 30. Patient freedom and choice; lower prices.
20    (a) If an enrollee elects to receive a covered health care
21service from an out-of-network provider at a price that is the
22same or less than the average that an enrollee's carrier pays
23for that service to providers in its provider network within a
24reasonable timeframe, not to exceed one year, the carrier shall
25allow the enrollee to obtain the service from the

 

 

10000SB2807sam001- 7 -LRB100 17655 SMS 38355 a

1out-of-network provider at the provider's price and, upon
2request by the enrollee, shall apply the payments made by the
3enrollee for that health care service toward the enrollee's
4deductible and out-of-pocket maximum as specified in the
5enrollee's health plan as if the health care services had been
6provided by a network provider. The carrier shall provide a
7downloadable or interactive online form to the enrollee for the
8purpose of submitting proof of payment to an out-of-network
9provider for purposes of administering this Section.
10    (b) A carrier may base the average paid to a network
11provider on what that carrier pays to providers in the network
12applicable to the enrollee's specific health plan or across all
13of its plans offered in this State. A carrier shall, at a
14minimum, inform enrollees of its ability to pay and the process
15to request the average allowed amount paid for a procedure or
16service, both on its website and in benefit plan material.
 
17    Section 35. State group health benefits plan; analysis. The
18Director of Central Management Services shall conduct an
19analysis no later than one year from the effective date of this
20Act of the cost effectiveness of implementing an
21incentive-based program for enrollees and retirees of the State
22group health benefits plan offered under the State Employees
23Group Insurance Act of 1971. A program found to be cost
24effective shall be implemented as part of the next open
25enrollment. The Director of Central Management Services shall

 

 

10000SB2807sam001- 8 -LRB100 17655 SMS 38355 a

1communicate the rationale for the decision to relevant General
2Assembly committees in writing.
 
3    Section 40. Rulemaking authority. The Director may adopt
4reasonable rules as necessary to implement the purposes and
5provisions of this Act.
 
6    Section 99. Effective date. This Act takes effect upon
7becoming law.".