Bill Text: IL HB3812 | 2011-2012 | 97th General Assembly | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Amends the Illinois Insurance Code. Provides that prior to providing care to a person, a health care professional or health care provider shall verify whether that health care professional or health care provider is in the network of participating providers whose services are covered by the person's policy of accident and health insurance and shall notify the person of this information.

Spectrum: Partisan Bill (Democrat 3-0)

Status: (Failed) 2013-01-08 - Session Sine Die [HB3812 Detail]

Download: Illinois-2011-HB3812-Amended.html

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Rep. Daniel J. Burke

Filed: 3/5/2012

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AMENDMENT TO HOUSE BILL 3812
AMENDMENT NO. ______. Amend House Bill 3812 by replacing
everything after the enacting clause with the following:
"Section 5. The Illinois Insurance Code is amended by
changing Section 368c as follows:
(215 ILCS 5/368c)
Sec. 368c. Remittance advice and procedures.
(a) A remittance advice shall be furnished to a health care
professional or health care provider that identifies the
disposition of each claim. The remittance advice shall identify
the services billed; the patient responsibility, if any; the
actual payment, if any, for the services billed; and the reason
for any reduction to the amount for which the claim was
submitted. For any reductions to the amount for which the claim
was submitted, the remittance shall identify any withholds and
the reason for any denial or reduction.

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A remittance advice for capitation or prospective payment
arrangements shall be furnished to a health care professional
or health care provider pursuant to a contract with an insurer,
health maintenance organization, independent practice
association, or physician hospital organization in accordance
with the terms of the contract.
(b) When health care services are provided by a
non-participating health care professional or health care
provider, an insurer, health maintenance organization,
independent practice association, or physician hospital
organization may pay for covered services either to a patient
directly or to the non-participating health care professional
or health care provider.
(c) When a person presents a benefits information card, a
health care professional or health care provider shall make a
good faith effort to inform the person if the health care
professional or health care provider is not a participating
provider has a participation contract with the insurer, health
maintenance organization, or other entity identified on the
card.
(Source: P.A. 93-261, eff. 1-1-04.)
Section 10. The Managed Care Reform and Patient Rights Act
is amended by changing Section 15 as follows:
(215 ILCS 134/15)

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Sec. 15. Provision of information.
(a) A health care plan shall provide annually to enrollees
and prospective enrollees, upon request, a complete list of
participating health care providers in the health care plan's
service area and a description of the following terms of
coverage:
(1) the service area;
(2) the covered benefits and services with all
exclusions, exceptions, and limitations;
(3) the pre-certification and other utilization review
procedures and requirements;
(4) a description of the process for the selection of a
primary care physician, any limitation on access to
specialists, and the plan's standing referral policy for
participating providers and participating health care
professionals;
(5) the emergency coverage and benefits, including any
restrictions on emergency care services;
(6) the out-of-area coverage and benefits, if any;
(7) the enrollee's financial responsibility for
copayments, deductibles, premiums, and any other
out-of-pocket expenses;
(8) the provisions for continuity of treatment in the
event a health care provider's participation terminates
during the course of an enrollee's treatment by that
provider;

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(9) the appeals process, forms, and time frames for
health care services appeals, complaints, and external
independent reviews, administrative complaints, and
utilization review complaints, including a phone number to
call to receive more information from the health care plan
concerning the appeals process; and
(10) a statement of all basic health care services and
all specific benefits and services mandated to be provided
to enrollees by any State law or administrative rule.
In the event of an inconsistency between any separate
written disclosure statement and the enrollee contract or
certificate, the terms of the enrollee contract or certificate
shall control.
(a-5) The required list of participating health care
providers shall be provided via the health care plan's Internet
website and shall be updated at least every 30 days on a
good-faith effort based on information made available to the
plan for credentialed providers. The health care plan shall
regularly inform policyholders, insureds, or enrollees to
consult the list of participating health care providers to
allow policyholders, insureds, or enrollees to make informed
decisions prior to making appointments. The health plan shall
also make available the procedures for making referrals both
within and outside the network to insureds, enrollees, and
participating health care providers and health care
professionals, as well as the possibility of reduced benefits

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for services provided by a non-participating health care
provider or a non-participating health care professional.
Further, the health care plan shall maintain a toll-free
telephone number for policyholders, insureds, enrollees, or
health care providers to verify whether a health care provider
is a participating provider.
(a-10) Notwithstanding any other provision of this Act or
the Illinois Insurance Code, when a person presents a benefits
information card, a health care provider shall make a good
faith effort to inform the person if the health care provider
is not a participating provider with the insurer, health
maintenance organization, or other entity identified on the
card.
(b) Upon written request, a health care plan shall provide
to enrollees a description of the financial relationships
between the health care plan and any health care provider and,
if requested, the percentage of copayments, deductibles, and
total premiums spent on healthcare related expenses and the
percentage of copayments, deductibles, and total premiums
spent on other expenses, including administrative expenses,
except that no health care plan shall be required to disclose
specific provider reimbursement.
(c) A participating health care provider shall provide all
of the following, where applicable, to enrollees upon request:
(1) Information related to the health care provider's
educational background, experience, training, specialty,

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and board certification, if applicable.
(2) The names of licensed facilities on the provider
panel where the health care provider presently has
privileges for the treatment, illness, or procedure that is
the subject of the request.
(3) Information regarding the health care provider's
participation in continuing education programs and
compliance with any licensure, certification, or
registration requirements, if applicable.
(d) A health care plan shall provide the information
required to be disclosed under this Act upon enrollment and
annually thereafter in a legible and understandable format,
except as provided in item (a-5). The Department shall
promulgate rules to establish the format based, to the extent
practical, on the standards developed for supplemental
insurance coverage under Title XVIII of the federal Social
Security Act as a guide, so that a person can compare the
attributes of the various health care plans.
(e) The written disclosure requirements of this Section may
be met by disclosure to one enrollee in a household.
(Source: P.A. 91-617, eff. 1-1-00.)".