State of Illinois
90th General Assembly
Legislation

   [ Search ]   [ Legislation ]   [ Bill Summary ]
[ Home ]   [ Back ]   [ Bottom ]



90_SB0704

      5 ILCS 375/6.9 new
      30 ILCS 805/8.21 new
      55 ILCS 5/5-1069.3 new
      65 ILCS 5/10-4-2.3 new
      105 ILCS 5/10-22.3f new
      215 ILCS 5/155.31 new
      215 ILCS 5/511.114 new
      215 ILCS 105/8.7 new
      215 ILCS 125/4-6.5 new
      215 ILCS 130/4003         from Ch. 73, par. 1504-3
      215 ILCS 165/10           from Ch. 32, par. 604
          Amends the State Employees Group Insurance Act  of  1971,
      Counties Code, Illinois Municipal Code, School Code, Illinois
      Insurance  Code,  Comprehensive  Health  Insurance  Plan Act,
      Health Maintenance Organization Act, Limited  Health  Service
      Organization  Act,  and  Voluntary Health Services Plans Act.
      Provides that notices of payment and denial  of  health  care
      benefits  subject  to those Acts and under managed care plans
      must provide detailed statements of  payment  and  denial  of
      benefits.   Requires  notices  of  denial to be signed by the
      individual responsible for the denial.  Requires  the  notice
      to   disclose   the  address  and  telephone  number  of  the
      individual responsible for the denial.  Provides that  appeal
      procedures  must  be  clearly set forth in the notice. Amends
      the State Mandates Act to provide that reimbursement  is  not
      required under that Act.
                                                    LRB9000252JSccA
                                              LRB9000252JSccA
 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 6.9 as follows:
 7        (5 ILCS 375/6.9 new)
 8        Sec.  6.9.  Benefit  notices.  The  program   of   health
 9    benefits shall provide the benefit payment and denial notices
10    required under Section 155.31 of the Illinois Insurance Code.
11        Section  10.  The State Mandates Act is amended by adding
12    Section 8.21 as follows:
13        (30 ILCS 805/8.21 new)
14        Sec. 8.21.  Exempt mandate.  Notwithstanding  Sections  6
15    and  8 of this Act, no reimbursement by the State is required
16    for  the  implementation  of  any  mandate  created  by  this
17    amendatory Act of 1997.
18        Section 15.  The  Counties  Code  is  amended  by  adding
19    Section 5-1069.3 as follows:
20        (55 ILCS 5/5-1069.3 new)
21        Sec.  5-1069.3.  Health  benefit  notices.  If  a county,
22    including a home rule county, is a self-insurer for  purposes
23    of providing health insurance coverage for its employees, the
24    county  must  provide  benefit  payment and denial notices as
25    required under Section 155.31 of the Illinois Insurance Code.
26    The requirement that benefit payment and  denial  notices  be
27    provided  in  accordance  with  this  Section is an exclusive
                            -2-               LRB9000252JSccA
 1    power  and  function  of  the  State  and  is  a  denial  and
 2    limitation under Article VII, Section 6,  subsection  (h)  of
 3    the  Illinois Constitution.  A home rule county to which this
 4    Section applies must comply  with  every  provision  of  this
 5    Section.
 6        Section  20.   The  Illinois Municipal Code is amended by
 7    adding Section 10-4-2.3 as follows:
 8        (65 ILCS 5/10-4-2.3 new)
 9        Sec.   10-4-2.3.  Health   benefit   notices.     If    a
10    municipality,  including  a  home  rule  municipality,  is  a
11    self-insurer  for  purposes  of  providing  health  insurance
12    coverage  for  its  employees,  the municipality must provide
13    benefit payment and denial notices as required under  Section
14    155.31  of the Illinois Insurance Code.  The requirement that
15    benefit payment and denial notices be provided in  accordance
16    with  this  Section is an exclusive power and function of the
17    State and is a  denial  and  limitation  under  Article  VII,
18    Section  6,  subsection  (h) of the Illinois Constitution.  A
19    home rule municipality to which  this  Section  applies  must
20    comply with every provision of this Section.
21        Section 25.  The School Code is amended by adding Section
22    10-22.3f as follows:
23        (105 ILCS 5/10-22.3f new)
24        Sec.   10-22.3f.  Health   benefit   notices.   Insurance
25    protection and  benefits  for  employees  shall  provide  the
26    benefit  payment  and  denial  notices required under Section
27    155.31 of the Illinois Insurance Code.
28        Section 30.  The Illinois Insurance Code  is  amended  by
29    adding Sections 155.31 and 511.114 as follows:
                            -3-               LRB9000252JSccA
 1        (215 ILCS 5/155.31 new)
 2        Sec. 155.31.  Benefit payment and denial notices.
 3        (a)  An  insurance company or managed care plan providing
 4    health care benefits shall provide its insureds and enrollees
 5    with detailed notices  of  benefit  payment  and  denial.   A
 6    notice   of   denial   shall  be  signed  by  the  individual
 7    responsible for denying payment and include  an  address  and
 8    accessible  telephone  number  for the individual responsible
 9    for denying payment.  In addition, a notice of  denial  shall
10    clearly  state  the procedures for appealing the denial.  The
11    insured or enrollee shall be given the opportunity to respond
12    to any denial and explain any discrepancies.
13        (b)  For the purposes of this Section "managed care plan"
14    means a plan  that  establishes,  operates,  or  maintains  a
15    network  of  health  care  providers  that  have entered into
16    agreements with the plan to provide health care  services  to
17    enrollees   where  the  plan  has  the  ultimate  and  direct
18    contractual obligation to the enrollee  to  arrange  for  the
19    provision of or pay for services through:
20             (1)  organizational arrangements for ongoing quality
21        assurance,   utilization   review  programs,  or  dispute
22        resolution; or
23             (2)  financial incentives for  persons  enrolled  in
24        the   plan   to   use  the  participating  providers  and
25        procedures covered by the plan.
26        A managed care plan may be established or operated by any
27    entity including a licensed insurance  company,  hospital  or
28    medical   service   plan,  health  maintenance  organization,
29    limited  health  service  organization,  preferred   provider
30    organization,  third  party  administrator, or an employer or
31    employee organization.
32        (215 ILCS 5/511.114 new)
33        Sec. 511.114.  Benefit payment and  denial  notices.   An
                            -4-               LRB9000252JSccA
 1    administrator  must  comply  with the requirements of Section
 2    155.31 of this Code.
 3        Section 35.  The Comprehensive Health Insurance Plan  Act
 4    is amended by adding Section 8.7 as follows:
 5        (215 ILCS 105/8.7 new)
 6        Sec.  8.7.  Benefit  notices.  The plan is subject to the
 7    provisions of Section 155.31 of the Illinois Insurance Code.
 8        Section 40.  The Health Maintenance Organization  Act  is
 9    amended by adding Section 4-6.5 as follows:
10        (215 ILCS 125/4-6.5 new)
11        Sec.   4-6.5.  Benefit  notices.   A  health  maintenance
12    organization is subject to the provisions of  Section  155.31
13    of the Illinois Insurance Code.
14        Section  45.  The Limited Health Service Organization Act
15    is amended by changing Section 4003 as follows:
16        (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
17        Sec. 4003.  Illinois Insurance Code provisions.   Limited
18    health   service   organizations  shall  be  subject  to  the
19    provisions of Sections 133,  134,  137,  140,  141.1,  141.2,
20    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
21    154.6, 154.7, 154.8, 155.04, 155.31, 355.2, 401, 401.1,  402,
22    403,  403A,  408, 408.2, and 412, and Articles VIII 1/2, XII,
23    XII 1/2, XIII, XIII 1/2, and XXVI of the  Illinois  Insurance
24    Code.   For  purposes  of the Illinois Insurance Code, except
25    for Articles  XIII  and  XIII  1/2,  limited  health  service
26    organizations  in  the  following categories are deemed to be
27    domestic companies:
28             (1)  a corporation under the laws of this State; or
                            -5-               LRB9000252JSccA
 1             (2)  a  corporation  organized  under  the  laws  of
 2        another state, 30% of more of the enrollees of which  are
 3        residents  of this State, except a corporation subject to
 4        substantially the  same  requirements  in  its  state  of
 5        organization  as is a domestic company under Article VIII
 6        1/2 of the Illinois Insurance Code.
 7    (Source: P.A. 86-600; 87-587; 87-1090.)
 8        Section  50.  The Voluntary Health Services Plans Act  is
 9    amended by changing Section 10 as follows:
10        (215 ILCS 165/10) (from Ch. 32, par. 604)
11        Sec.   10.  Application  of  Insurance  Code  provisions.
12    Health services plan corporations and all persons  interested
13    therein   or  dealing  therewith  shall  be  subject  to  the
14    provisions of Article XII 1/2 and  Sections  3.1,  133,  140,
15    143,  143c, 149, 155.31, 354, 355.2, 356r, 367.2, 401, 401.1,
16    402, 403, 403A, 408, 408.2, and 412, and paragraphs  (7)  and
17    (15) of Section 367 of the Illinois Insurance Code.
18    (Source: P.A. 89-514, eff. 7-17-96.)

[ Top ]