Full Text of SB1547 98th General Assembly
SB1547ham001 98TH GENERAL ASSEMBLY | Rep. Lou Lang Filed: 5/27/2013
| | 09800SB1547ham001 | | LRB098 07852 RPM 46509 a |
|
| 1 | | AMENDMENT TO SENATE BILL 1547
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1547 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Insurance Code is amended by | 5 | | changing Sections 370g and 370h and by adding Sections 370d.1 | 6 | | and 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. |
| | | 09800SB1547ham001 | - 2 - | LRB098 07852 RPM 46509 a |
|
| 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 | 4 | | health insurance under the provisions of this Code shall be | 5 | | authorized to issue policies for exclusive provider | 6 | | organization plans for either group or individual policies, | 7 | | provided such policies otherwise conform to the terms of this | 8 | | Section, and to the extent applicable to insurers, the Uniform | 9 | | Health Care Service Benefits Information Card Act, and the | 10 | | Health Carrier External Review Act. An insurer issuing | 11 | | exclusive provider organization plans under this Section shall | 12 | | not be required to be licensed as a health maintenance | 13 | | organization under the Health Maintenance Organization Act in | 14 | | order to issue a policy under this Section. | 15 | | (c) An insurer writing policies for an EPO may limit | 16 | | enrollment in such a plan solely to those individuals who | 17 | | either live, work, or reside in the designated service area. | 18 | | (d) Except as otherwise stated in this Section, an EPO | 19 | | shall comply with all other provisions of this Code, and | 20 | | regulations issued hereunder, relating to accident and health | 21 | | insurance policies that utilize a contracted health care | 22 | | provider network to provide the benefits under such policies. | 23 | | To the extent of any conflict between this Section and any | 24 | | other statutory provision, this Section prevails over the | 25 | | conflicting provision. | 26 | | (e) This Section does not apply to: |
| | | 09800SB1547ham001 | - 3 - | LRB098 07852 RPM 46509 a |
|
| 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 | 7 | | within the contract and evidence of coverage a description of | 8 | | benefits and services available out of the EPO's designated | 9 | | service area, including any limitations and exclusions. | 10 | | (g) An insurer shall not require a health care professional | 11 | | or health care provider, as a condition of participating in the | 12 | | EPO, to sign a contract requiring the health care professional | 13 | | or health care provider to provide services under another of | 14 | | the company's networks or plans. | 15 | | (h) An insurer shall not require a health care professional | 16 | | or health care provider, as a condition of participating in any | 17 | | of the company's networks or plans, to sign a contract | 18 | | requiring the health care professional or health care provider | 19 | | to provide services under the insurer's EPO. | 20 | | (i) An EPO issued or renewed in this State must prominently | 21 | | display on the cover page of the policy, evidence of coverage, | 22 | | and any marketing materials, that it is an exclusive provider | 23 | | organization benefit plan and that services, other than | 24 | | emergency services, provided by non-contracted health care | 25 | | providers may not be covered under the plan. | 26 | | (j) An EPO must clearly state on the health care benefit |
| | | 09800SB1547ham001 | - 4 - | LRB098 07852 RPM 46509 a |
|
| 1 | | information card that it is an EPO. | 2 | | (k) An insurer that issues, delivers, amends, or renews an | 3 | | individual or group EPO in this State after the effective date | 4 | | of this amendatory Act of the 98th General Assembly must | 5 | | include the following disclosure on its contracts and evidences | 6 | | of coverage: "WARNING, NO BENEFITS WILL BE PAID WHEN NON- | 7 | | PARTICIPATING PROVIDERS ARE USED. You should be aware that when | 8 | | you elect to utilize the services of a non-participating | 9 | | provider for a covered service in non-emergency situations, | 10 | | there will be NO benefit payments to such non-participating | 11 | | providers. YOU WILL HAVE TO PAY FOR ANY SERVICE OR TREATMENT | 12 | | OUTSIDE OF THE EXCLUSIVE PROVIDER ORGANIZATION PLAN NETWORK. | 13 | | Non-participating providers may bill members for any | 14 | | treatments and services provided to the patient. Participating | 15 | | providers have agreed to accept discounted payments for | 16 | | services with no additional billing to the member other than | 17 | | copayments, co-insurance, and deductible amounts. You may | 18 | | obtain further information about the participating status of | 19 | | professional providers by calling the toll-free telephone | 20 | | number on your identification card.". | 21 | | (l) Any insurer that issues, delivers, amends, or renews an | 22 | | individual or group EPO in this State after the effective date | 23 | | of this amendatory Act of the 98th General Assembly must comply | 24 | | with Sections 20, 25, 30, 35, 65, 70, 85, 95, and 100 of the | 25 | | Managed Care Reform and Patient Rights Act. | 26 | | (m) Any insurer that issues, delivers, amends, or renews an |
| | | 09800SB1547ham001 | - 5 - | LRB098 07852 RPM 46509 a |
|
| 1 | | individual or group EPO in this State after the effective date | 2 | | of this amendatory Act of the 98th General Assembly must comply | 3 | | with 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 |
| | | 09800SB1547ham001 | - 6 - | LRB098 07852 RPM 46509 a |
|
| 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 | 11 | | restrictions 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 | 22 | | individual or group EPO shall provide an internal claims and | 23 | | appeals process that incorporates the claims and appeals | 24 | | procedures set forth in Section 2719 of the Patient Protection | 25 | | and Affordable Care Act and Section 300gg-19 of the Public | 26 | | Health Service Act (42 USC 300gg-19) and any regulations issued |
| | | 09800SB1547ham001 | - 7 - | LRB098 07852 RPM 46509 a |
|
| 1 | | thereunder by the Secretary of Labor or by the Secretary of | 2 | | Health and Human Services for such plans and issuers. | 3 | | (p) The Director of Insurance may adopt rules necessary to | 4 | | implement this Section.
| 5 | | (215 ILCS 5/370g) (from Ch. 73, par. 982g)
| 6 | | Sec. 370g. Definitions. As used in this Article, the | 7 | | following definitions
apply:
| 8 | | (a) "Health care services" means health care services or | 9 | | products
rendered or sold by a provider within the scope of the | 10 | | provider's license
or legal authorization. The term includes, | 11 | | but is not limited to, hospital,
medical, surgical, dental, | 12 | | vision and pharmaceutical services or products.
| 13 | | (b) "Insurer" means an insurance company or a health | 14 | | service corporation
authorized in this State to issue policies | 15 | | or subscriber contracts which
reimburse for expenses of health | 16 | | care services.
| 17 | | (c) "Insured" means an individual entitled to | 18 | | reimbursement for expenses
of health care services under a | 19 | | policy or subscriber contract issued or
administered by an | 20 | | insurer.
| 21 | | (d) "Provider" means an individual or entity duly licensed | 22 | | or legally
authorized to provide health care services.
| 23 | | (e) "Noninstitutional provider" means any person licensed | 24 | | under the Medical
Practice Act of 1987, as now or hereafter | 25 | | amended.
|
| | | 09800SB1547ham001 | - 8 - | LRB098 07852 RPM 46509 a |
|
| 1 | | (f) "Beneficiary" means an individual entitled to | 2 | | reimbursement for
expenses of or the discount of provider fees | 3 | | for health care services under
a program where the beneficiary | 4 | | has an incentive to utilize the services of a
provider which | 5 | | has entered into an agreement or arrangement with an
| 6 | | administrator.
| 7 | | (g) "Administrator" means any person, partnership or | 8 | | corporation, other
than an insurer or health maintenance | 9 | | organization holding a certificate of
authority under the | 10 | | "Health Maintenance Organization Act", as now or hereafter
| 11 | | amended, that arranges, contracts with, or administers | 12 | | contracts with a
provider whereby beneficiaries are provided an | 13 | | incentive to use the services of
such provider.
| 14 | | (h) "Emergency medical condition" means a medical | 15 | | condition manifesting
itself
by
acute symptoms of sufficient | 16 | | severity (including severe
pain) such that a prudent
layperson, | 17 | | who possesses an average knowledge of health and medicine, | 18 | | could
reasonably expect the absence of immediate medical | 19 | | attention 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 | 26 | | benefit plan that utilizes a network of contracted health care |
| | | 09800SB1547ham001 | - 9 - | LRB098 07852 RPM 46509 a |
|
| 1 | | providers and that excludes benefits for services provided by | 2 | | non-contracted health care providers, except for emergency | 3 | | services or when services are not available to an insured from | 4 | | a contracted provider within a Designated Service Area. | 5 | | (j) "Designated service area" means a geographic area as | 6 | | specified 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 | 11 | | an insurer or administrator shall establish terms and
| 12 | | conditions that must be met by noninstitutional providers | 13 | | wishing to enter into
an agreement with the insurer or | 14 | | administrator. These terms and conditions may
not discriminate | 15 | | unreasonably against or among noninstitutional providers.
| 16 | | Neither difference in prices among noninstitutional providers | 17 | | produced by
a process of individual negotiation nor price | 18 | | differences among other
noninstitutional providers in | 19 | | different geographical areas or different
specialties | 20 | | constitutes unreasonable discrimination.
| 21 | | (b) An insurer or administrator shall not refuse to | 22 | | contract with any
noninstitutional provider who meets the terms | 23 | | and conditions
established by the insurer or administrator.
| 24 | | (c) Any insurer that issues, delivers, amends, or renews an | 25 | | individual or group EPO in this State after the effective date |
| | | 09800SB1547ham001 | - 10 - | LRB098 07852 RPM 46509 a |
|
| 1 | | of this amendatory Act of the 98th General Assembly shall not | 2 | | be obligated to comply with this Section solely with respect to | 3 | | the 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 | 7 | | permitted. An administrator, or an insurer as applicable under | 8 | | this Code, may offer an EPO, provided that the administrator | 9 | | meets the requirements of this Code and the Director determines | 10 | | that: | 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. ".
|
|