101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB2435

 

Introduced , by Rep. Mary E. Flowers - LaToya Greenwood

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 134/87 new

    Amends the Managed Care Reform and Patient Rights Act. Provides that a health insurance carrier, health maintenance organization, or other managed care entity for a health care plan and its employees and other representatives are liable for damages for harm to an enrollee proximately caused by their failure to exercise ordinary care. Prohibits a health insurance carrier, health maintenance organization, or other managed care entity from removing a provider from its health care plan for advocating on behalf of an enrollee for appropriate and medically necessary health care. Prohibits a health insurance carrier, health maintenance organization, or other managed care entity from entering into a contract with a provider that indemnifies the health insurance carrier, health maintenance organization, or other managed care entity. Provides that an insured or enrollee seeking damages has the right and duty to submit the claim to arbitration in accordance with the Uniform Arbitration Act. Provides that the provisions do not apply to workers' compensation insurance coverage, actions seeking only a review of an adverse utilization review determination, and licensed insurance agents.


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A BILL FOR

 

HB2435LRB101 02846 SMS 50300 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Managed Care Reform and Patient Rights Act
5is amended by adding Section 87 as follows:
 
6    (215 ILCS 134/87 new)
7    Sec. 87. Health care entity liability.
8    (a) As used in this Section:
9    "Appropriate and medically necessary" means the standard
10for health care services as determined by physicians and health
11care providers in accordance with the prevailing practices and
12standards of the medical profession and community.
13    "Enrollee" means an individual who is enrolled in a health
14care plan, including covered dependents.
15    "Health care plan" means any plan whereby any person
16undertakes to provide, arrange for, pay for, or reimburse any
17part of the cost of any health care services.
18    "Health care provider" means a person or entity as defined
19in Section 10.
20    "Health care treatment decision" means a determination
21made when medical services are actually provided by the health
22care plan and a decision that affects the quality of the
23diagnosis, care, or treatment provided to the health care

 

 

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1plan's insureds or enrollees.
2    "Health insurance carrier" means an authorized insurance
3company that issues policies of accident and health insurance
4under the Illinois Insurance Code.
5    "Health maintenance organization" means an organization
6licensed under the Health Maintenance Organization Act.
7    "Managed care entity" means any entity that delivers,
8administers, or assumes risk for health care services with
9systems or techniques to control or influence the quality,
10accessibility, utilization, or costs and prices of those
11services to a defined enrollee population. "Managed care
12entity" does not include an employer purchasing coverage or
13acting on behalf of its employees or the employees of one or
14more subsidiaries or affiliated corporations of the employer.
15    "Physician" means: (1) an individual licensed to practice
16medicine in all its branches in this State; (2) a professional
17association, professional service corporation, partnership,
18medical corporation, or limited liability company entitled to
19lawfully engage in the practice of medicine; or (3) another
20person wholly owned by physicians.
21    "Ordinary care" means, in the case of a health insurance
22carrier, health maintenance organization, or managed care
23entity, that degree of care that a health insurance carrier,
24health maintenance organization, or managed care entity of
25ordinary prudence would use under the same or similar
26circumstances. In the case of a person who is an employee,

 

 

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1agent, ostensible agent, or representative of a health
2insurance carrier, health maintenance organization, or managed
3care entity, "ordinary care" means that degree of care that a
4person of ordinary prudence in the same profession, specialty,
5or area of practice as such person would use in the same or
6similar circumstances.
7    (b) A health insurance carrier, health maintenance
8organization, or other managed care entity for a health care
9plan has the duty to exercise ordinary care when making health
10care treatment decisions and is liable for damages for harm to
11an insured or enrollee proximately caused by its failure to
12exercise such ordinary care.
13    (c) A health insurance carrier, health maintenance
14organization, or other managed care entity for a health care
15plan is also liable for damages for harm to an insured or
16enrollee proximately caused by the health care treatment
17decisions made by its:
18        (1) employees;
19        (2) agents;
20        (3) ostensible agents; or
21        (4) representatives who are acting on its behalf and
22    over whom it has the right to exercise influence or control
23    or has actually exercised influence or control that results
24    in the failure to exercise ordinary care.
25    (d) The standards in subsections (b) and (c) create no
26obligation on the part of the health insurance carrier, health

 

 

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1maintenance organization, or other managed care entity to
2provide to an insured or enrollee treatment that is not covered
3by the health care plan of the entity.
4    (e) The determination of whether a procedure or treatment
5is medically necessary must be made by a physician.
6    (f) If the physician determines that a procedure or
7treatment is medically necessary, the health care plan must pay
8for the procedure or treatment.
9    (g) A health insurance carrier, health maintenance
10organization, or managed care entity may not remove a physician
11or health care provider from its health care plan or refuse to
12renew the physician or health care provider with its health
13care plan for advocating on behalf of an enrollee for
14appropriate and medically necessary health care for the
15enrollee.
16    (h) A health insurance carrier, health maintenance
17organization, or other managed care entity may not enter into a
18contract with a physician, hospital, or other health care
19provider or pharmaceutical company that includes an
20indemnification or hold harmless clause for the acts or conduct
21of the health insurance carrier, health maintenance
22organization, or other managed care entity. Any such
23indemnification or hold harmless clause in an existing contract
24is hereby declared void.
25    (i) Nothing in any law of this State prohibiting a health
26insurance carrier, health maintenance organization, or other

 

 

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1managed care entity from practicing medicine or being licensed
2to practice medicine may be asserted as a defense by the health
3insurance carrier, health maintenance organization, or other
4managed care entity in an action brought against it under this
5Section or any other law.
6    (j) In an action against a health insurance carrier, health
7maintenance organization, or managed care entity, a finding
8that a physician or other health care provider is an employee,
9agent, ostensible agent, or representative of the health
10insurance carrier, health maintenance organization, or managed
11care entity shall not be based solely on proof that the
12person's name appears in a listing of approved physicians or
13health care providers made available to insureds or enrollees
14under a health care plan.
15    (k) This Section applies only to causes of action that
16accrue on or after the effective date of this amendatory Act of
17the 101st General Assembly. An insured or enrollee seeking
18damages under this Section has the right and duty to submit the
19claim to arbitration in accordance with the Uniform Arbitration
20Act. No agreement between the parties to submit the claim to
21arbitration is necessary. A health insurance carrier, health
22maintenance organization, or managed care entity shall have no
23liability under this Section unless the claim is first
24submitted to arbitration in accordance with the Uniform
25Arbitration Act. The award in matters arbitrated under this
26Section shall be made within 30 days after notification of the

 

 

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1arbitration is provided to all parties.
2    (l) This Section does not apply to:
3        (1) workers' compensation insurance coverage subject
4    to the Workers' Compensation Act;
5        (2) licensed insurance agents; or
6        (3) actions seeking only a review of an adverse
7    utilization review determination.