Rep. Lou Lang

Filed: 3/4/2014

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 1547

2    AMENDMENT NO. ______. Amend Senate Bill 1547, AS AMENDED,
3by replacing everything after the enacting clause with the
4following:
 
5    "Section 5. The Illinois Insurance Code is amended by
6changing Sections 370g and 370h and by adding Sections 370d.1
7and 370u as follows:
 
8    (215 ILCS 5/370d.1 new)
9    Sec. 370d.1. Exclusive provider organization plans.
10    (a) For the purpose of this Section:
11        "Exclusive provider organization plan" or "EPO" means
12    a benefit plan that utilizes a network of contracted health
13    care providers and that excludes benefits for services
14    provided by non-contracted health care providers, except
15    for emergency services or when services are not available
16    to an insured from a contracted provider within a

 

 

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1    designated service area.
2        "Designated service area" means a geographic service
3    area as specified in a health insurance policy for an EPO
4    with approval from the Department.
5        "Emergency services" means, with respect to an
6    enrollee of a health care plan, transportation services,
7    including, but not limited to, ambulance services, and
8    covered inpatient and outpatient hospital services
9    furnished by a provider qualified to furnish those services
10    that are needed to evaluate or stabilize an emergency
11    medical condition. "Emergency services" does not include
12    post-stabilization medical services.
13    (b) An insurer having authority under Class 1(b) or 2(a) of
14Section 4 of this Code to write accident and health insurance
15under the provisions of this Code shall be authorized to issue
16policies for exclusive provider organization plans for either
17group or individual policies, provided such policies otherwise
18conform to the terms of this Section, the Uniform Health Care
19Service Benefits Information Card Act, and the Health Carrier
20External Review Act. An insurer issuing exclusive provider
21organization plans under this Section shall not be required to
22be licensed as a health maintenance organization under the
23Health Maintenance Organization Act in order to issue a policy
24under this Section.
25    (c) An insurer writing policies for an EPO shall limit
26enrollment in such a plan solely to those individuals who

 

 

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1either live, work, or reside in the designated service area.
2    (d) Except as otherwise stated in this Section, an EPO
3shall comply with all other provisions of this Code, and
4regulations issued hereunder, relating to accident and health
5insurance policies that utilize a contracted health care
6provider network to provide the benefits under such policies.
7    (e) This Section does not apply to:
8        (1) the Children's Health Insurance Program issued
9    under the Children's Health Insurance Program Act;
10        (2) a Medicaid managed care program issued under
11    Article V of the Illinois Public Aid Code; or
12        (3) the State Employees' Group Insurance Act.
13    (f) An insurer writing policies for an EPO shall provide
14within the contract and evidence of coverage a description of
15benefits and services available out of the EPO's designated
16service area, including any limitations and exclusions.
17    (g) An insurer shall not require a health care professional
18or health care provider, as a condition of participating in the
19EPO, to sign a contract requiring the health care professional
20or health care provider to provide services under another of
21the company's networks or plans.
22    (h) An insurer shall not require a health care professional
23or health care provider, as a condition of participating in any
24of the company's networks or plans, to sign a contract
25requiring the health care professional or health care provider
26to provide services under the insurer's EPO.

 

 

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1    (i) An EPO issued or renewed in this State must prominently
2display on the cover page of the policy, evidence of coverage,
3and any marketing materials, that it is an exclusive provider
4organization benefit plan and that services, other than
5emergency services, provided by non-contracted health care
6providers may not be covered under the plan, as well as the
7components of an EPO plan, including explanations of in-network
8and out-of-network services.
9    (j) An EPO must clearly state on the health care benefit
10information card that it is an EPO.
11    (k) An insurer that issues, delivers, amends, or renews an
12individual or group EPO in this State after the effective date
13of this amendatory Act of the 98th General Assembly must
14include the following disclosure on its contracts and evidences
15of coverage: "WARNING, NO BENEFITS WILL BE PAID WHEN NON-
16PARTICIPATING PROVIDERS ARE USED. You should be aware that no
17benefits shall be available under this plan except for
18emergency services or when services are not available from a
19contracted provider within the designated service area. YOU
20WILL HAVE TO PAY FOR ANY SERVICE OR TREATMENT OUTSIDE OF THE
21EXCLUSIVE PROVIDER ORGANIZATION PLAN NETWORK.
22Non-participating providers may bill members for any
23treatments and services provided to the patient. Participating
24providers have agreed to accept discounted payments for
25services with no additional billing to the member other than
26copayments, co-insurance, and deductible amounts. You may

 

 

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1obtain further information about the participating status of
2professional providers by calling the toll-free telephone
3number on your identification card.".
4    (l) Any insurer that issues, delivers, amends, or renews an
5individual or group EPO in this State after the effective date
6of this amendatory Act of the 98th General Assembly must comply
7with Sections 20, 25, 30, 35, 45, 65, 70, 85, 95, and 100 of the
8Managed Care Reform and Patient Rights Act.
9    (m) Any insurer that issues, delivers, amends, or renews an
10individual or group EPO in this State after the effective date
11of this amendatory Act of the 98th General Assembly must comply
12with the following provisions:
13        (1) An EPO shall provide annually to enrollees and
14    prospective enrollees, upon request, a complete list of
15    participating health care providers in the health care
16    plan's service area and a description of the following
17    terms of coverage:
18            (A) the service area;
19            (B) the covered benefits and services with all
20        exclusions, exceptions, and limitations;
21            (C) the pre-certification and other utilization
22        review procedures and requirements;
23            (D) the emergency coverage and benefits, including
24        specifics on the differences in benefits between
25        emergency care and non-emergency care, including any
26        restrictions on emergency care services, so long as

 

 

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1        such specifics and restrictions allow coverage for
2        medical conditions within the meaning of an emergency
3        medical condition as defined in Section 10 of the
4        Managed Care Reform and Patient Rights Act;
5            (E) the out-of-area coverage and benefits, if any;
6            (F) the enrollee's financial responsibility for
7        copayments, deductibles, premiums, and any other
8        out-of-pocket expenses;
9            (G) the provisions for continuity of treatment in
10        the event a health care provider's participation
11        terminates during the course of an enrollee's
12        treatment by that provider; and
13            (H) the appeals process, forms, and time frames for
14        health care services appeals, complaints, and external
15        independent reviews, administrative complaints, and
16        utilization review complaints, including a phone
17        number to call to receive more information from the
18        health care plan concerning the appeals process.
19        (2) An EPO shall provide the information required to be
20    disclosed under this Section upon enrollment and annually
21    thereafter in a legible and understandable format.
22        (3) The written disclosure requirements of this
23    Section may be met by disclosure to one enrollee in a
24    household.
25    (n) The following provisions shall apply concerning EPO
26restrictions on primary care physicians.

 

 

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1        (1) An EPO is prohibited from requiring enrollees to
2    choose a primary care physician for the coordination of
3    care.
4        (2) Enrollees may at any time select any physician from
5    within the EPO network to provide care.
6        (3) An EPO is prohibited from requiring enrollees to
7    obtain prior authorization from any participating
8    physician in the network before seeing an EPO network
9    provider of their choice.
10    (o) An insurer that issues, delivers, amends, or renews an
11individual or group EPO shall provide an internal claims and
12appeals process that incorporates the claims and appeals
13procedures set forth in Section 45 of the Managed Care Reform
14and Patient Rights Act.
15    (p) The Director of Insurance shall adopt rules necessary
16to implement this Section.
 
17    (215 ILCS 5/370g)  (from Ch. 73, par. 982g)
18    Sec. 370g. Definitions. As used in this Article, the
19following definitions apply:
20    (a) "Health care services" means health care services or
21products rendered or sold by a provider within the scope of the
22provider's license or legal authorization. The term includes,
23but is not limited to, hospital, medical, surgical, dental,
24vision and pharmaceutical services or products.
25    (b) "Insurer" means an insurance company or a health

 

 

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1service corporation authorized in this State to issue policies
2or subscriber contracts which reimburse for expenses of health
3care services.
4    (c) "Insured" means an individual entitled to
5reimbursement for expenses of health care services under a
6policy or subscriber contract issued or administered by an
7insurer.
8    (d) "Provider" means an individual or entity duly licensed
9or legally authorized to provide health care services.
10    (e) "Noninstitutional provider" means any person licensed
11under the Medical Practice Act of 1987, as now or hereafter
12amended.
13    (f) "Beneficiary" means an individual entitled to
14reimbursement for expenses of or the discount of provider fees
15for health care services under a program where the beneficiary
16has an incentive to utilize the services of a provider which
17has entered into an agreement or arrangement with an
18administrator.
19    (g) "Administrator" means any person, partnership or
20corporation, other than an insurer or health maintenance
21organization holding a certificate of authority under the
22"Health Maintenance Organization Act", as now or hereafter
23amended, that arranges, contracts with, or administers
24contracts with a provider whereby beneficiaries are provided an
25incentive to use the services of such provider.
26    (h) "Emergency medical condition" means a medical

 

 

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1condition manifesting itself by acute symptoms of sufficient
2severity (including severe pain) such that a prudent layperson,
3who possesses an average knowledge of health and medicine,
4could reasonably expect the absence of immediate medical
5attention to result in:
6        (1) placing the health of the individual (or, with
7    respect to a pregnant woman, the health of the woman or her
8    unborn child) in serious jeopardy;
9        (2) serious impairment to bodily functions; or
10        (3) serious dysfunction of any bodily organ or part.
11    (i) "Exclusive provider organization plan" or "EPO" means a
12benefit plan that utilizes a network of contracted health care
13providers and that excludes benefits for services provided by
14non-contracted health care providers, except for emergency
15services and subject to the requirements of Section 356z.3a or
16when services are not available to an insured from a contracted
17provider within a designated service area.
18    (j) "Designated service area" means a geographic area as
19specified in a health insurance policy for an EPO.
20(Source: P.A. 91-617, eff. 1-1-00.)
 
21    (215 ILCS 5/370h)  (from Ch. 73, par. 982h)
22    Sec. 370h. Noninstitutional providers.
23    (a) Before entering into any agreement under this Article
24an insurer or administrator shall establish terms and
25conditions that must be met by noninstitutional providers

 

 

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1wishing to enter into an agreement with the insurer or
2administrator. These terms and conditions may not discriminate
3unreasonably against or among noninstitutional providers.
4Neither difference in prices among noninstitutional providers
5produced by a process of individual negotiation nor price
6differences among other noninstitutional providers in
7different geographical areas or different specialties
8constitutes unreasonable discrimination.
9    (b) An insurer or administrator shall not refuse to
10contract with any noninstitutional provider who meets the terms
11and conditions established by the insurer or administrator.
12    (c) Any insurer that issues, delivers, amends, or renews an
13individual or group EPO in this State after the effective date
14of this amendatory Act of the 98th General Assembly shall not
15be obligated to comply with this Section solely with respect to
16the EPO product.
17(Source: P.A. 90-655, eff. 7-30-98.)
 
18    (215 ILCS 5/370u new)
19    Sec. 370u. Exclusive provider organization plans
20permitted.
21    (a) An insurer having authority under Class 1(b) or 2(a) of
22Section 4 of this Code to write accident and health insurance
23as applicable under this Code, may offer an EPO, provided that
24the administrator meets the requirements of this Code and the
25Director determines that:

 

 

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1        (1) the level of coverage, including deductibles,
2    copayments, coinsurance, or other cost-sharing provisions
3    to beneficiaries, or insured individuals does not operate
4    unreasonably to restrict the access and availability of
5    health care services for the insured; or
6        (2) the EPO has established an exclusive network that
7    is adequate to provide health care services as required.
8    (b) Until the effective date of the rules adopted by the
9Director for EPO plans, insurers must file a description of the
10services to be offered through an EPO. The description shall
11include all of the following:
12        (1) The method of marketing the program.
13        (2) A geographic map of the area proposed to be served
14    by the program by county and zip code, including marked
15    locations for providers.
16        (3) The names, addresses, and specialties of the
17    providers who have entered into EPO contracts under the
18    program.
19        (4) The names of available primary care physicians and
20    the encouragement of each enrollee to select such a
21    physician to handle their care coordination.
22        (5) The number of beneficiaries anticipated to be
23    covered by the providers listed in paragraph (3) of this
24    subsection (b).
25        (6) An Internet website and toll-free telephone number
26    for beneficiaries and prospective beneficiaries to access

 

 

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1    regarding up-to-date lists of providers. A plan shall
2    identify specific providers in a beneficiary's area,
3    confirm specific provider participation, or provide a
4    listing of providers by mail. Provider lists requested by
5    phone must be sent within 3 working days after the request
6    is made. The up-to-date provider list applies to all
7    providers that have entered arrangements to provide
8    services under the program either directly or indirectly
9    through another administrator. Insurers' Internet website
10    addresses shall be prominently displayed on all
11    advertisements, marketing materials, brochures, benefit
12    cards, and identification cards.
13        (7) A description of how health care services to be
14    rendered under the EPO provider program are reasonably
15    accessible and available to beneficiaries. Standards shall
16    address the following:
17            (A) The ratio of providers to beneficiaries, by
18        specialty applicable under the contract, necessary to
19        meet the health care needs and service demands of the
20        currently enrolled population such that there shall be
21        at least one full-time physician for each 1,200
22        enrollees.
23            (B) The greatest distance or time that the
24        beneficiary may be required to travel to access:
25                (i) provider hospital services when applicable
26            under the contract;

 

 

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1                (ii) primary care physician and women's
2            principal health care provider services when
3            applicable under the contract; and
4                (iii) any applicable health care service
5            providers.
6            (C) A process for tracking when providers within
7        the network stop accepting new EPO patients.
8            (D) A process for encouraging all EPO providers to
9        utilize an electronic system to ensure the timely
10        exchange of health records between and among providers
11        who have entered into EPO contracts listed in paragraph
12        (3) of this subsection (b).
13            (E) Written policies and procedures for
14        determining when the program is closed to new providers
15        desiring to enter into EPO arrangements.
16            (F) Written policies and procedures for adding
17        providers to meet patient needs based on increases in
18        the number of beneficiaries, changes in the patient to
19        provider ratio, changes in medical and health care
20        capabilities, changes in number of providers accepting
21        new patients, and increased demand for services.
22            (G) The provision of 24 hour, 7 day-per-week access
23        to network-affiliated primary care and women's
24        principal health care providers.
25            (H) The procedures for making referrals outside
26        the network when procedures cannot be provided within

 

 

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1        the network.
2            (I) A provision that whenever a beneficiary has
3        made a good faith effort to utilize EPO providers for a
4        covered service and it is determined the insurer does
5        not have the appropriate EPO providers due to
6        insufficient number or type or distance, the insurer
7        shall ensure, directly or indirectly, by terms
8        contained in the payor contract, that the beneficiary
9        will be provided the covered service at no greater cost
10        to the beneficiary than if the service had been
11        provided by an EPO provider. This subparagraph (G) does
12        not apply to a beneficiary who willfully chooses to
13        access a non-preferred provider for health care
14        services reasonably available through the insurer's
15        panel of participating providers. In these
16        circumstances, the contractual requirements for
17        non-preferred provider reimbursements shall apply.
18            (J) The procedures for paying benefits when
19        particular physician specialties are not represented
20        within the provider network or the services of such
21        providers are not available at the time care is sought.
22        In any case in which a beneficiary has made a good
23        faith effort to utilize network providers, by
24        satisfying contractual obligations specified in the
25        benefit contract or certificate, for a covered service
26        and the insurer does not have the appropriate preferred

 

 

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1        specialty providers (including, but not limited to,
2        radiologists, anesthesiologists, pathologists and
3        emergency room physicians) under contract due to the
4        inability of the insurer to contract with the
5        specialists, or due to the insufficient number or type
6        of, or travel distance to, specialists, the insurer
7        shall ensure that the beneficiary will be provided the
8        covered service at no greater cost to the beneficiary
9        than if the service had been provided by an EPO
10        provider. This subparagraph (J) does not apply to a
11        beneficiary who willfully chooses to access a
12        non-preferred provider for health care services
13        reasonably available through the insurer's panel of
14        participating providers. In these circumstances, the
15        contractual requirements for non-preferred provider
16        reimbursements shall apply.
17            (K) A provision that the beneficiary shall receive
18        emergency care coverage such that payment for the
19        coverage is not dependent upon whether the services are
20        performed by a preferred or non-preferred provider and
21        the coverage shall be at the same benefit level as if
22        the service or treatment had been rendered by a
23        preferred provider. For the purposes of this
24        subparagraph (K), "the same benefit level" means that
25        the beneficiary will be provided the covered service at
26        no greater cost to the beneficiary than if the service

 

 

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1        had been provided by a preferred provider.
2            (L) A limitation that, if the plan provides that
3        the beneficiary will incur a penalty for failing to
4        pre-certify inpatient hospital treatment, the penalty
5        may not exceed $1,000 per occurrence.
6            (M) Efforts to address the needs of beneficiaries
7        with limited English proficiency and literacy or
8        diverse cultural and ethnic backgrounds, and to comply
9        with the Americans With Disabilities Act of 1990.
10            (N) A sample beneficiary identification card in
11        conformity with the Uniform Health Care Service
12        Benefits Information Card Act and the Uniform
13        Prescription Drug Information Card Act when
14        pharmaceutical services are provided as part of the
15        program's health care services.
16        (8) The process for encouraging EPO providers to
17    utilize an electronic system to ensure the timely exchange
18    of health records between and among providers who have
19    entered into EPO agreements listed in paragraph (3) of this
20    subsection (b).
21        (9) The educational efforts the insurer will use to
22    inform beneficiaries that they are purchasing an EPO
23    product, including the major differences between an EPO, an
24    HMO and a PPO.
25    (c) The Director of Insurance shall adopt rules necessary
26to implement this Section.".