101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB4789

 

Introduced 2/18/2020, by Rep. Daniel Swanson

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.17 new
55 ILCS 5/5-1069.9 new
65 ILCS 5/10-4-2.9 new
215 ILCS 124/5
215 ILCS 124/35 new

    Amends the State Employees Group Insurance Act of 1971, the Counties Code, and the Illinois Municipal Code. Provides that the program of health benefits for persons in the service of the State, a self-insuring county, or a self-insuring municipality may not deny a claim from a medical facility operated by the Veterans Health Administration of the U.S. Department of Veterans Affairs on the basis that the medical facility is an out-of-network provider and may not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on a claim from a medical facility operated by the Veterans Health Administration of the U.S. Department of Veterans Affairs unless cost sharing is applied to such a claim from an in-network provider. Amends the Network Adequacy and Transparency Act. Provides that an insurer providing a network plan may not deny a claim from a medical facility operated by the Veterans Health Administration on the basis that the medical facility is a non-preferred provider and may not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on a claim from a medical facility operated by the Veterans Health Administration unless cost sharing is applied to such a claim from a preferred provider. Defines "Veterans Health Administration".


LRB101 17586 BMS 67005 b

FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

HB4789LRB101 17586 BMS 67005 b

1    AN ACT concerning health insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by adding Section 6.17 as follows:
 
6    (5 ILCS 375/6.17 new)
7    Sec. 6.17. Veterans Health Administration claims. The
8program of health benefits may not deny a claim from a medical
9facility operated by the Veterans Health Administration of the
10U.S. Department of Veterans Affairs on the basis that the
11medical facility is an out-of-network provider and may not
12impose a deductible, coinsurance, copayment, or any other
13cost-sharing requirement on a claim from a medical facility
14operated by the Veterans Health Administration of the U.S.
15Department of Veterans Affairs unless cost sharing is applied
16to such a claim from an in-network provider.
 
17    Section 10. The Counties Code is amended by adding Section
185-1069.9 as follows:
 
19    (55 ILCS 5/5-1069.9 new)
20    Sec. 5-1069.9. Veterans Health Administration claims. If a
21county, including a home rule county, is a self-insurer for the

 

 

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1purposes of providing health insurance coverage for its
2employees, it may not:
3        (1) deny a claim from a medical facility operated by
4    the Veterans Health Administration of the U.S. Department
5    of Veterans Affairs on the basis that the medical facility
6    is an out-of-network provider; or
7        (2) impose a deductible, coinsurance, copayment, or
8    any other cost-sharing requirement on a claim from a
9    medical facility operated by the Veterans Health
10    Administration of the U.S. Department of Veterans Affairs
11    unless cost sharing is applied to such a claim from an
12    in-network provider.
 
13    Section 15. The Illinois Municipal Code is amended by
14adding Section 10-4-2.9 as follows:
 
15    (65 ILCS 5/10-4-2.9 new)
16    Sec. 10-4-2.9. Veterans Health Administration claims. If a
17municipality, including a home rule municipality, is a
18self-insurer for the purposes of providing health insurance
19coverage for its employees, it may not:
20        (1) deny a claim from a medical facility operated by
21    the Veterans Health Administration of the U.S. Department
22    of Veterans Affairs on the basis that the medical facility
23    is an out-of-network provider; or
24        (2) impose a deductible, coinsurance, copayment, or

 

 

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1    any other cost-sharing requirement on a claim from a
2    medical facility operated by the Veterans Health
3    Administration of the U.S. Department of Veterans Affairs
4    unless cost sharing is applied to such a claim from an
5    in-network provider.
 
6    Section 20. The Network Adequacy and Transparency Act is
7amended by changing Section 5 and by adding Section 35 as
8follows:
 
9    (215 ILCS 124/5)
10    Sec. 5. Definitions. In this Act:
11    "Authorized representative" means a person to whom a
12beneficiary has given express written consent to represent the
13beneficiary; a person authorized by law to provide substituted
14consent for a beneficiary; or the beneficiary's treating
15provider only when the beneficiary or his or her family member
16is unable to provide consent.
17    "Beneficiary" means an individual, an enrollee, an
18insured, a participant, or any other person entitled to
19reimbursement for covered expenses of or the discounting of
20provider fees for health care services under a program in which
21the beneficiary has an incentive to utilize the services of a
22provider that has entered into an agreement or arrangement with
23an insurer.
24    "Department" means the Department of Insurance.

 

 

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1    "Director" means the Director of Insurance.
2    "Insurer" means any entity that offers individual or group
3accident and health insurance, including, but not limited to,
4health maintenance organizations, preferred provider
5organizations, exclusive provider organizations, and other
6plan structures requiring network participation, excluding the
7medical assistance program under the Illinois Public Aid Code,
8the State employees group health insurance program, workers
9compensation insurance, and pharmacy benefit managers.
10    "Material change" means a significant reduction in the
11number of providers available in a network plan, including, but
12not limited to, a reduction of 10% or more in a specific type
13of providers, the removal of a major health system that causes
14a network to be significantly different from the network when
15the beneficiary purchased the network plan, or any change that
16would cause the network to no longer satisfy the requirements
17of this Act or the Department's rules for network adequacy and
18transparency.
19    "Network" means the group or groups of preferred providers
20providing services to a network plan.
21    "Network plan" means an individual or group policy of
22accident and health insurance that either requires a covered
23person to use or creates incentives, including financial
24incentives, for a covered person to use providers managed,
25owned, under contract with, or employed by the insurer.
26    "Ongoing course of treatment" means (1) treatment for a

 

 

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1life-threatening condition, which is a disease or condition for
2which likelihood of death is probable unless the course of the
3disease or condition is interrupted; (2) treatment for a
4serious acute condition, defined as a disease or condition
5requiring complex ongoing care that the covered person is
6currently receiving, such as chemotherapy, radiation therapy,
7or post-operative visits; (3) a course of treatment for a
8health condition that a treating provider attests that
9discontinuing care by that provider would worsen the condition
10or interfere with anticipated outcomes; or (4) the third
11trimester of pregnancy through the post-partum period.
12    "Preferred provider" means any provider who has entered,
13either directly or indirectly, into an agreement with an
14employer or risk-bearing entity relating to health care
15services that may be rendered to beneficiaries under a network
16plan.
17    "Providers" means physicians licensed to practice medicine
18in all its branches, other health care professionals,
19hospitals, or other health care institutions that provide
20health care services.
21    "Telehealth" has the meaning given to that term in Section
22356z.22 of the Illinois Insurance Code.
23    "Telemedicine" has the meaning given to that term in
24Section 49.5 of the Medical Practice Act of 1987.
25    "Tiered network" means a network that identifies and groups
26some or all types of provider and facilities into specific

 

 

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1groups to which different provider reimbursement, covered
2person cost-sharing or provider access requirements, or any
3combination thereof, apply for the same services.
4    "Veterans Health Administration" means the agency within
5the U.S. Department of Veterans Affairs as set forth under 38
6U.S.C. 7301.
7    "Woman's principal health care provider" means a physician
8licensed to practice medicine in all of its branches
9specializing in obstetrics, gynecology, or family practice.
10(Source: P.A. 100-502, eff. 9-15-17.)
 
11    (215 ILCS 124/35 new)
12    Sec. 35. Veterans Health Administration claims.
13    (a) An insurer providing a network plan may not deny a
14claim from a medical facility operated by the Veterans Health
15Administration on the basis that the medical facility is a
16non-preferred provider.
17    (b) A network plan may not impose a deductible,
18coinsurance, copayment, or any other cost-sharing requirement
19on a claim from a medical facility operated by the Veterans
20Health Administration unless cost sharing is applied to such a
21claim from a preferred provider under the network plan.