Illinois General Assembly - Full Text of SB1547
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Full Text of SB1547  98th General Assembly


Rep. Lou Lang

Filed: 5/27/2013





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



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1        "Designated service area" means a geographic area as
2    specified in a health insurance policy for an EPO.
3    (b) An insurer that is licensed to write accident and
4health insurance under the provisions of this Code shall be
5authorized to issue policies for exclusive provider
6organization plans for either group or individual policies,
7provided such policies otherwise conform to the terms of this
8Section, and to the extent applicable to insurers, the Uniform
9Health Care Service Benefits Information Card Act, and the
10Health Carrier External Review Act. An insurer issuing
11exclusive provider organization plans under this Section shall
12not be required to be licensed as a health maintenance
13organization under the Health Maintenance Organization Act in
14order to issue a policy under this Section.
15    (c) An insurer writing policies for an EPO may limit
16enrollment in such a plan solely to those individuals who
17either live, work, or reside in the designated service area.
18    (d) Except as otherwise stated in this Section, an EPO
19shall comply with all other provisions of this Code, and
20regulations issued hereunder, relating to accident and health
21insurance policies that utilize a contracted health care
22provider network to provide the benefits under such policies.
23To the extent of any conflict between this Section and any
24other statutory provision, this Section prevails over the
25conflicting provision.
26    (e) This Section does not apply to:



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1        (1) the Children's Health Insurance Program issued
2    under the Children's Health Insurance Program Act;
3        (2) a Medicaid managed care program issued under
4    Article V of the Illinois Public Aid Code; or
5        (3) the State Employees' Group Insurance Act.
6    (f) An insurer writing policies for an EPO shall provide
7within the contract and evidence of coverage a description of
8benefits and services available out of the EPO's designated
9service area, including any limitations and exclusions.
10    (g) An insurer shall not require a health care professional
11or health care provider, as a condition of participating in the
12EPO, to sign a contract requiring the health care professional
13or health care provider to provide services under another of
14the company's networks or plans.
15    (h) An insurer shall not require a health care professional
16or health care provider, as a condition of participating in any
17of the company's networks or plans, to sign a contract
18requiring the health care professional or health care provider
19to provide services under the insurer's EPO.
20    (i) An EPO issued or renewed in this State must prominently
21display on the cover page of the policy, evidence of coverage,
22and any marketing materials, that it is an exclusive provider
23organization benefit plan and that services, other than
24emergency services, provided by non-contracted health care
25providers may not be covered under the plan.
26    (j) An EPO must clearly state on the health care benefit



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1information card that it is an EPO.
2    (k) An insurer that issues, delivers, amends, or renews an
3individual or group EPO in this State after the effective date
4of this amendatory Act of the 98th General Assembly must
5include the following disclosure on its contracts and evidences
7PARTICIPATING PROVIDERS ARE USED. You should be aware that when
8you elect to utilize the services of a non-participating
9provider for a covered service in non-emergency situations,
10there will be NO benefit payments to such non-participating
13Non-participating providers may bill members for any
14treatments and services provided to the patient. Participating
15providers have agreed to accept discounted payments for
16services with no additional billing to the member other than
17copayments, co-insurance, and deductible amounts. You may
18obtain further information about the participating status of
19professional providers by calling the toll-free telephone
20number on your identification card.".
21    (l) Any insurer that issues, delivers, amends, or renews an
22individual or group EPO in this State after the effective date
23of this amendatory Act of the 98th General Assembly must comply
24with Sections 20, 25, 30, 35, 65, 70, 85, 95, and 100 of the
25Managed Care Reform and Patient Rights Act.
26    (m) Any insurer that issues, delivers, amends, or renews an



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1individual or group EPO in this State after the effective date
2of this amendatory Act of the 98th General Assembly must comply
3with the following provisions:
4        (1) An EPO shall provide annually to enrollees and
5    prospective enrollees, upon request, a complete list of
6    participating health care providers in the health care
7    plan's service area and a description of the following
8    terms of coverage:
9            (A) the service area;
10            (B) the covered benefits and services with all
11        exclusions, exceptions, and limitations;
12            (C) the pre-certification and other utilization
13        review procedures and requirements;
14            (D) the emergency coverage and benefits, including
15        any restrictions on emergency care services;
16            (E) the out-of-area coverage and benefits, if any;
17            (F) the enrollee's financial responsibility for
18        copayments, deductibles, premiums, and any other
19        out-of-pocket expenses;
20            (G) the provisions for continuity of treatment in
21        the event a health care provider's participation
22        terminates during the course of an enrollee's
23        treatment by that provider; and
24            (H) the appeals process, forms, and time frames for
25        health care services appeals, complaints, and external
26        independent reviews, administrative complaints, and



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1        utilization review complaints, including a phone
2        number to call to receive more information from the
3        health care plan concerning the appeals process.
4        (2) An EPO shall provide the information required to be
5    disclosed under this Section upon enrollment and annually
6    thereafter in a legible and understandable format.
7        (3) The written disclosure requirements of this
8    Section may be met by disclosure to one enrollee in a
9    household.
10    (n) The following provisions shall apply concerning EPO
11restrictions on primary care physicians.
12        (1) An EPO is prohibited from requiring enrollees to
13    choose a primary care physician for the coordination of
14    care.
15        (2) Enrollees may at any time select any physician from
16    within the EPO network to provide care.
17        (3) An EPO is prohibited from requiring enrollees to
18    obtain prior authorization from any participating
19    physician in the network before seeing an EPO network
20    provider of their choice.
21    (o) An insurer that issues, delivers, amends, or renews an
22individual or group EPO shall provide an internal claims and
23appeals process that incorporates the claims and appeals
24procedures set forth in Section 2719 of the Patient Protection
25and Affordable Care Act and Section 300gg-19 of the Public
26Health Service Act (42 USC 300gg-19) and any regulations issued



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1thereunder by the Secretary of Labor or by the Secretary of
2Health and Human Services for such plans and issuers.
3    (p) The Director of Insurance may adopt rules necessary to
4implement this Section.
5    (215 ILCS 5/370g)  (from Ch. 73, par. 982g)
6    Sec. 370g. Definitions. As used in this Article, the
7following definitions apply:
8    (a) "Health care services" means health care services or
9products rendered or sold by a provider within the scope of the
10provider's license or legal authorization. The term includes,
11but is not limited to, hospital, medical, surgical, dental,
12vision and pharmaceutical services or products.
13    (b) "Insurer" means an insurance company or a health
14service corporation authorized in this State to issue policies
15or subscriber contracts which reimburse for expenses of health
16care services.
17    (c) "Insured" means an individual entitled to
18reimbursement for expenses of health care services under a
19policy or subscriber contract issued or administered by an
21    (d) "Provider" means an individual or entity duly licensed
22or legally authorized to provide health care services.
23    (e) "Noninstitutional provider" means any person licensed
24under the Medical Practice Act of 1987, as now or hereafter



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1    (f) "Beneficiary" means an individual entitled to
2reimbursement for expenses of or the discount of provider fees
3for health care services under a program where the beneficiary
4has an incentive to utilize the services of a provider which
5has entered into an agreement or arrangement with an
7    (g) "Administrator" means any person, partnership or
8corporation, other than an insurer or health maintenance
9organization holding a certificate of authority under the
10"Health Maintenance Organization Act", as now or hereafter
11amended, that arranges, contracts with, or administers
12contracts with a provider whereby beneficiaries are provided an
13incentive to use the services of such provider.
14    (h) "Emergency medical condition" means a medical
15condition manifesting itself by acute symptoms of sufficient
16severity (including severe pain) such that a prudent layperson,
17who possesses an average knowledge of health and medicine,
18could reasonably expect the absence of immediate medical
19attention to result in:
20        (1) placing the health of the individual (or, with
21    respect to a pregnant woman, the health of the woman or her
22    unborn child) in serious jeopardy;
23        (2) serious impairment to bodily functions; or
24        (3) serious dysfunction of any bodily organ or part.
25    (i) "Exclusive provider organization plan" or "EPO" means a
26benefit plan that utilizes a network of contracted health care



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1providers and that excludes benefits for services provided by
2non-contracted health care providers, except for emergency
3services or when services are not available to an insured from
4a contracted provider within a Designated Service Area.
5    (j) "Designated service area" means a geographic area as
6specified in a health insurance policy for an EPO.
7(Source: P.A. 91-617, eff. 1-1-00.)
8    (215 ILCS 5/370h)  (from Ch. 73, par. 982h)
9    Sec. 370h. Noninstitutional providers.
10    (a) Before entering into any agreement under this Article
11an insurer or administrator shall establish terms and
12conditions that must be met by noninstitutional providers
13wishing to enter into an agreement with the insurer or
14administrator. These terms and conditions may not discriminate
15unreasonably against or among noninstitutional providers.
16Neither difference in prices among noninstitutional providers
17produced by a process of individual negotiation nor price
18differences among other noninstitutional providers in
19different geographical areas or different specialties
20constitutes unreasonable discrimination.
21    (b) An insurer or administrator shall not refuse to
22contract with any noninstitutional provider who meets the terms
23and conditions established by the insurer or administrator.
24    (c) Any insurer that issues, delivers, amends, or renews an
25individual or group EPO in this State after the effective date



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1of this amendatory Act of the 98th General Assembly shall not
2be obligated to comply with this Section solely with respect to
3the EPO product.
4(Source: P.A. 90-655, eff. 7-30-98.)
5    (215 ILCS 5/370u new)
6    Sec. 370u. Exclusive provider organization plans
7permitted. An administrator, or an insurer as applicable under
8this Code, may offer an EPO, provided that the administrator
9meets the requirements of this Code and the Director determines
11        (1) the level of coverage, including deductibles,
12    copayments, coinsurance, or other cost-sharing provisions
13    to beneficiaries, or insured individuals does not operate
14    unreasonably to restrict the access and availability of
15    health care services for the insured; or
16        (2) the EPO has established an exclusive network that
17    is adequate to provide health care services as required by
18    this Code.".