Bill Text: IL SB1762 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code. In provisions concerning required disclosures on contracts and evidences of coverage of accident and health insurance, provides that insurers must notify beneficiaries that nonparticipating providers may bill members for any amount up to the billed charge after the plan has paid its portion of the bill, except for specified services, including items or services provided to a Medicare beneficiary, insured, or enrollee. Provides that a health care provider shall not charge or collect from a Medicare beneficiary, insured, or enrollee any amount in excess of the Medicare-approved amount for any Medicare-covered item or service provided, and provides that the Department of Insurance has the authority to enforce that requirement. Defines terms. Makes a conforming change in the Health Maintenance Organization Act. Effective immediately.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced) 2024-04-15 - Chief Sponsor Changed to Sen. Don Harmon [SB1762 Detail]

Download: Illinois-2023-SB1762-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB1762 Introduced 2/9/2023, by Sen. Ann Gillespie SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.3
215 ILCS 5/356z.3a
215 ILCS 125/4.5-1
Amends the Illinois Insurance Code. In provisions concerning required disclosures on contracts and evidences of coverage of accident and health insurance, provides that insurers must notify beneficiaries that nonparticipating providers may bill members for any amount up to the billed charge after the plan has paid its portion of the bill, except for specified services, including items or services provided to a Medicare beneficiary, insured, or enrollee. Provides that a health care provider shall not charge or collect from a Medicare beneficiary, insured, or enrollee any amount in excess of the Medicare-approved amount for any Medicare-covered item or service provided, and provides that the Department of Insurance has the authority to enforce that requirement. Defines terms. Makes a conforming change in the Health Maintenance Organization Act. Effective immediately.
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A BILL FOR
SB1762 LRB103 05845 BMS 50865 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
changing Sections 356z.3 and 356z.3a as follows:
(215 ILCS 5/356z.3)
Sec. 356z.3. Disclosure of limited benefit. An insurer
that issues, delivers, amends, or renews an individual or
group policy of accident and health insurance in this State
after the effective date of this amendatory Act of the 92nd
General Assembly and arranges, contracts with, or administers
contracts with a provider whereby beneficiaries are provided
an incentive to use the services of such provider must include
the following disclosure on its contracts and evidences of
coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that
when you elect to utilize the services of a non-participating
provider for a covered service in non-emergency situations,
benefit payments to such non-participating provider are not
based upon the amount billed. The basis of your benefit
payment will be determined according to your policy's fee
schedule, usual and customary charge (which is determined by
comparing charges for similar services adjusted to the

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geographical area where the services are performed), or other
method as defined by the policy. YOU CAN EXPECT TO PAY MORE
THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE
PLAN HAS PAID ITS REQUIRED PORTION. Non-participating
providers may bill members for any amount up to the billed
charge after the plan has paid its portion of the bill, except
as provided in Section 356z.3a of the Illinois Insurance Code
for covered services received at a participating health care
facility from a nonparticipating provider that are: (a)
ancillary services, (b) items or services furnished as a
result of unforeseen, urgent medical needs that arise at the
time the item or service is furnished, or (c) items or services
received when the facility or the non-participating provider
fails to satisfy the notice and consent criteria specified
under Section 356z.3a, or (d) items or services provided to a
Medicare beneficiary, insured, or enrollee. Participating
providers have agreed to accept discounted payments for
services with no additional billing to the member other than
co-insurance and deductible amounts. You may obtain further
information about the participating status of professional
providers and information on out-of-pocket expenses by calling
the toll free telephone number on your identification card.".
(Source: P.A. 102-901, eff. 1-1-23.)
(215 ILCS 5/356z.3a)
Sec. 356z.3a. Billing; emergency services;

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nonparticipating providers.
(a) As used in this Section:
"Ancillary services" means:
(1) items and services related to emergency medicine,
anesthesiology, pathology, radiology, and neonatology that
are provided by any health care provider;
(2) items and services provided by assistant surgeons,
hospitalists, and intensivists;
(3) diagnostic services, including radiology and
laboratory services, except for advanced diagnostic
laboratory tests identified on the most current list
published by the United States Secretary of Health and
Human Services under 42 U.S.C. 300gg-132(b)(3);
(4) items and services provided by other specialty
practitioners as the United States Secretary of Health and
Human Services specifies through rulemaking under 42
U.S.C. 300gg-132(b)(3); and
(5) items and services provided by a nonparticipating
provider if there is no participating provider who can
furnish the item or service at the facility.
"Cost sharing" means the amount an insured, beneficiary,
or enrollee is responsible for paying for a covered item or
service under the terms of the policy or certificate. "Cost
sharing" includes copayments, coinsurance, and amounts paid
toward deductibles, but does not include amounts paid towards
premiums, balance billing by out-of-network providers, or the

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cost of items or services that are not covered under the policy
or certificate.
"Emergency department of a hospital" means any hospital
department that provides emergency services, including a
hospital outpatient department.
"Emergency medical condition" has the meaning ascribed to
that term in Section 10 of the Managed Care Reform and Patient
Rights Act.
"Emergency medical screening examination" has the meaning
ascribed to that term in Section 10 of the Managed Care Reform
and Patient Rights Act.
"Emergency services" means, with respect to an emergency
medical condition:
(1) in general, an emergency medical screening
examination, including ancillary services routinely
available to the emergency department to evaluate such
emergency medical condition, and such further medical
examination and treatment as would be required to
stabilize the patient regardless of the department of the
hospital or other facility in which such further
examination or treatment is furnished; or
(2) additional items and services for which benefits
are provided or covered under the coverage and that are
furnished by a nonparticipating provider or
nonparticipating emergency facility regardless of the
department of the hospital or other facility in which such

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items are furnished after the insured, beneficiary, or
enrollee is stabilized and as part of outpatient
observation or an inpatient or outpatient stay with
respect to the visit in which the services described in
paragraph (1) are furnished. Services after stabilization
cease to be emergency services only when all the
conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
regulations thereunder are met.
"Freestanding Emergency Center" means a facility licensed
under Section 32.5 of the Emergency Medical Services (EMS)
Systems Act.
"Health care facility" means, in the context of
non-emergency services, any of the following:
(1) a hospital as defined in 42 U.S.C. 1395x(e);
(2) a hospital outpatient department;
(3) a critical access hospital certified under 42
U.S.C. 1395i-4(e);
(4) an ambulatory surgical treatment center as defined
in the Ambulatory Surgical Treatment Center Act; or
(5) any recipient of a license under the Hospital
Licensing Act that is not otherwise described in this
definition.
"Health care provider" means a provider as defined in
subsection (d) of Section 370g. "Health care provider" does
not include a provider of air ambulance or ground ambulance
services.

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"Health care services" has the meaning ascribed to that
term in subsection (a) of Section 370g.
"Health insurance issuer" has the meaning ascribed to that
term in Section 5 of the Illinois Health Insurance Portability
and Accountability Act.
"Medicare" means the health insurance program for the aged
and disabled under Title XVIII of the Social Security Act.
"Medicare-approved amount" means the total payment that
Medicare has agreed to pay a health care provider for a service
or item.
"Nonparticipating emergency facility" means, with respect
to the furnishing of an item or service under a policy of group
or individual health insurance coverage, any of the following
facilities that does not have a contractual relationship
directly or indirectly with a health insurance issuer in
relation to the coverage:
(1) an emergency department of a hospital;
(2) a Freestanding Emergency Center;
(3) an ambulatory surgical treatment center as defined
in the Ambulatory Surgical Treatment Center Act; or
(4) with respect to emergency services described in
paragraph (2) of the definition of "emergency services", a
hospital.
"Nonparticipating provider" means, with respect to the
furnishing of an item or service under a policy of group or
individual health insurance coverage, any health care provider

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who does not have a contractual relationship directly or
indirectly with a health insurance issuer in relation to the
coverage.
"Participating emergency facility" means any of the
following facilities that has a contractual relationship
directly or indirectly with a health insurance issuer offering
group or individual health insurance coverage setting forth
the terms and conditions on which a relevant health care
service is provided to an insured, beneficiary, or enrollee
under the coverage:
(1) an emergency department of a hospital;
(2) a Freestanding Emergency Center;
(3) an ambulatory surgical treatment center as defined
in the Ambulatory Surgical Treatment Center Act; or
(4) with respect to emergency services described in
paragraph (2) of the definition of "emergency services", a
hospital.
For purposes of this definition, a single case agreement
between an emergency facility and an issuer that is used to
address unique situations in which an insured, beneficiary, or
enrollee requires services that typically occur out-of-network
constitutes a contractual relationship and is limited to the
parties to the agreement.
"Participating health care facility" means any health care
facility that has a contractual relationship directly or
indirectly with a health insurance issuer offering group or

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individual health insurance coverage setting forth the terms
and conditions on which a relevant health care service is
provided to an insured, beneficiary, or enrollee under the
coverage. A single case agreement between an emergency
facility and an issuer that is used to address unique
situations in which an insured, beneficiary, or enrollee
requires services that typically occur out-of-network
constitutes a contractual relationship for purposes of this
definition and is limited to the parties to the agreement.
"Participating provider" means any health care provider
that has a contractual relationship directly or indirectly
with a health insurance issuer offering group or individual
health insurance coverage setting forth the terms and
conditions on which a relevant health care service is provided
to an insured, beneficiary, or enrollee under the coverage.
"Qualifying payment amount" has the meaning given to that
term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
promulgated thereunder.
"Recognized amount" means the lesser of the amount
initially billed by the provider or the qualifying payment
amount.
"Stabilize" means "stabilization" as defined in Section 10
of the Managed Care Reform and Patient Rights Act.
"Treating provider" means a health care provider who has
evaluated the individual.
"Visit" means, with respect to health care services

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furnished to an individual at a health care facility, health
care services furnished by a provider at the facility, as well
as equipment, devices, telehealth services, imaging services,
laboratory services, and preoperative and postoperative
services regardless of whether the provider furnishing such
services is at the facility.
(b) Emergency services. When a beneficiary, insured, or
enrollee receives emergency services from a nonparticipating
provider or a nonparticipating emergency facility, the health
insurance issuer shall ensure that the beneficiary, insured,
or enrollee shall incur no greater out-of-pocket costs than
the beneficiary, insured, or enrollee would have incurred with
a participating provider or a participating emergency
facility. Any cost-sharing requirements shall be applied as
though the emergency services had been received from a
participating provider or a participating facility. Cost
sharing shall be calculated based on the recognized amount for
the emergency services. If the cost sharing for the same item
or service furnished by a participating provider would have
been a flat-dollar copayment, that amount shall be the
cost-sharing amount unless the provider has billed a lesser
total amount. In no event shall the beneficiary, insured,
enrollee, or any group policyholder or plan sponsor be liable
to or billed by the health insurance issuer, the
nonparticipating provider, or the nonparticipating emergency
facility for any amount beyond the cost sharing calculated in

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accordance with this subsection with respect to the emergency
services delivered. Administrative requirements or limitations
shall be no greater than those applicable to emergency
services received from a participating provider or a
participating emergency facility.
(b-5) Non-emergency services at participating health care
facilities.
(1) When a beneficiary, insured, or enrollee utilizes
a participating health care facility and, due to any
reason, covered ancillary services are provided by a
nonparticipating provider during or resulting from the
visit, the health insurance issuer shall ensure that the
beneficiary, insured, or enrollee shall incur no greater
out-of-pocket costs than the beneficiary, insured, or
enrollee would have incurred with a participating provider
for the ancillary services. Any cost-sharing requirements
shall be applied as though the ancillary services had been
received from a participating provider. Cost sharing shall
be calculated based on the recognized amount for the
ancillary services. If the cost sharing for the same item
or service furnished by a participating provider would
have been a flat-dollar copayment, that amount shall be
the cost-sharing amount unless the provider has billed a
lesser total amount. In no event shall the beneficiary,
insured, enrollee, or any group policyholder or plan
sponsor be liable to or billed by the health insurance

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issuer, the nonparticipating provider, or the
participating health care facility for any amount beyond
the cost sharing calculated in accordance with this
subsection with respect to the ancillary services
delivered. In addition to ancillary services, the
requirements of this paragraph shall also apply with
respect to covered items or services furnished as a result
of unforeseen, urgent medical needs that arise at the time
an item or service is furnished, regardless of whether the
nonparticipating provider satisfied the notice and consent
criteria under paragraph (2) of this subsection.
(2) When a beneficiary, insured, or enrollee utilizes
a participating health care facility and receives
non-emergency covered health care services other than
those described in paragraph (1) of this subsection from a
nonparticipating provider during or resulting from the
visit, the health insurance issuer shall ensure that the
beneficiary, insured, or enrollee incurs no greater
out-of-pocket costs than the beneficiary, insured, or
enrollee would have incurred with a participating provider
unless the nonparticipating provider, or the participating
health care facility on behalf of the nonparticipating
provider, satisfies the notice and consent criteria
provided in 42 U.S.C. 300gg-132 and regulations
promulgated thereunder. If the notice and consent criteria
are not satisfied, then:

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(A) any cost-sharing requirements shall be applied
as though the health care services had been received
from a participating provider;
(B) cost sharing shall be calculated based on the
recognized amount for the health care services; and
(C) in no event shall the beneficiary, insured,
enrollee, or any group policyholder or plan sponsor be
liable to or billed by the health insurance issuer,
the nonparticipating provider, or the participating
health care facility for any amount beyond the cost
sharing calculated in accordance with this subsection
with respect to the health care services delivered.
(c) Notwithstanding any other provision of this Code,
except when the notice and consent criteria are satisfied for
the situation in paragraph (2) of subsection (b-5), any
benefits a beneficiary, insured, or enrollee receives for
services under the situations in subsection subsections (b) or
(b-5) are assigned to the nonparticipating providers or the
facility acting on their behalf. Upon receipt of the
provider's bill or facility's bill, the health insurance
issuer shall provide the nonparticipating provider or the
facility with a written explanation of benefits that specifies
the proposed reimbursement and the applicable deductible,
copayment, or coinsurance amounts owed by the insured,
beneficiary, or enrollee. The health insurance issuer shall
pay any reimbursement subject to this Section directly to the

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nonparticipating provider or the facility.
(d) For bills assigned under subsection (c), the
nonparticipating provider or the facility may bill the health
insurance issuer for the services rendered, and the health
insurance issuer may pay the billed amount or attempt to
negotiate reimbursement with the nonparticipating provider or
the facility. Within 30 calendar days after the provider or
facility transmits the bill to the health insurance issuer,
the issuer shall send an initial payment or notice of denial of
payment with the written explanation of benefits to the
provider or facility. If attempts to negotiate reimbursement
for services provided by a nonparticipating provider do not
result in a resolution of the payment dispute within 30 days
after receipt of written explanation of benefits by the health
insurance issuer, then the health insurance issuer or
nonparticipating provider or the facility may initiate binding
arbitration to determine payment for services provided on a
per-bill per bill basis. The party requesting arbitration
shall notify the other party arbitration has been initiated
and state its final offer before arbitration. In response to
this notice, the nonrequesting party shall inform the
requesting party of its final offer before the arbitration
occurs. Arbitration shall be initiated by filing a request
with the Department of Insurance.
(e) The Department of Insurance shall publish a list of
approved arbitrators or entities that shall provide binding

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arbitration. These arbitrators shall be American Arbitration
Association or American Health Lawyers Association trained
arbitrators. Both parties must agree on an arbitrator from the
Department of Insurance's or its approved entity's list of
arbitrators. If no agreement can be reached, then a list of 5
arbitrators shall be provided by the Department of Insurance
or the approved entity. From the list of 5 arbitrators, the
health insurance issuer can veto 2 arbitrators and the
provider or facility can veto 2 arbitrators. The remaining
arbitrator shall be the chosen arbitrator. This arbitration
shall consist of a review of the written submissions by both
parties. The arbitrator shall not establish a rebuttable
presumption that the qualifying payment amount should be the
total amount owed to the provider or facility by the
combination of the issuer and the insured, beneficiary, or
enrollee. Binding arbitration shall provide for a written
decision within 45 days after the request is filed with the
Department of Insurance. Both parties shall be bound by the
arbitrator's decision. The arbitrator's expenses and fees,
together with other expenses, not including attorney's fees,
incurred in the conduct of the arbitration, shall be paid as
provided in the decision.
(f) (Blank).
(f-1) A health care provider shall not charge or collect
from a Medicare beneficiary, insured, or enrollee any amount
in excess of the Medicare-approved amount for any

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Medicare-covered item or service provided.
(g) Section 368a of this Act shall not apply during the
pendency of a decision under subsection (d). Upon the issuance
of the arbitrator's decision, Section 368a applies with
respect to the amount, if any, by which the arbitrator's
determination exceeds the issuer's initial payment under
subsection (c), or the entire amount of the arbitrator's
determination if initial payment was denied. Any interest
required to be paid to a provider under Section 368a shall not
accrue until after 30 days of an arbitrator's decision as
provided in subsection (d), but in no circumstances longer
than 150 days from the date the nonparticipating
facility-based provider billed for services rendered.
(h) Nothing in this Section shall be interpreted to change
the prudent layperson provisions with respect to emergency
services under the Managed Care Reform and Patient Rights Act.
(i) Nothing in this Section shall preclude a health care
provider from billing a beneficiary, insured, or enrollee for
reasonable administrative fees, such as service fees for
checks returned for nonsufficient funds and missed
appointments.
(j) Nothing in this Section shall preclude a beneficiary,
insured, or enrollee from assigning benefits to a
nonparticipating provider when the notice and consent criteria
are satisfied under paragraph (2) of subsection (b-5) or in
any other situation not described in subsection subsections

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(b) or (b-5).
(k) Except when the notice and consent criteria are
satisfied under paragraph (2) of subsection (b-5), if an
individual receives health care services under the situations
described in subsections (b) or (b-5), no referral requirement
or any other provision contained in the policy or certificate
of coverage shall deny coverage, reduce benefits, or otherwise
defeat the requirements of this Section for services that
would have been covered with a participating provider.
However, this subsection shall not be construed to preclude a
provider contract with a health insurance issuer, or with an
administrator or similar entity acting on the issuer's behalf,
from imposing requirements on the participating provider,
participating emergency facility, or participating health care
facility relating to the referral of covered individuals to
nonparticipating providers.
(l) Except if the notice and consent criteria are
satisfied under paragraph (2) of subsection (b-5),
cost-sharing amounts calculated in conformity with this
Section shall count toward any deductible or out-of-pocket
maximum applicable to in-network coverage.
(m) The Department has the authority to enforce the
requirements of this Section in the situations described in
subsections (b), and (b-5), and (f-1), and in any other
situation for which 42 U.S.C. Chapter 6A, Subchapter XXV,
Parts D or E and regulations promulgated thereunder would

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prohibit an individual from being billed or liable for
emergency services furnished by a nonparticipating provider or
nonparticipating emergency facility or for non-emergency
health care services furnished by a nonparticipating provider
at a participating health care facility.
(n) This Section does not apply with respect to air
ambulance or ground ambulance services. This Section does not
apply to any policy of excepted benefits or to short-term,
limited-duration health insurance coverage.
(Source: P.A. 102-901, eff. 7-1-22; revised 8-19-22.)
Section 10. The Health Maintenance Organization Act is
amended by changing Section 4.5-1 as follows:
(215 ILCS 125/4.5-1)
Sec. 4.5-1. Point-of-service health service contracts.
(a) A health maintenance organization that offers a
point-of-service contract:
(1) must include as in-plan covered services all
services required by law to be provided by a health
maintenance organization;
(2) must provide incentives, which shall include
financial incentives, for enrollees to use in-plan covered
services;
(3) may not offer services out-of-plan without
providing those services on an in-plan basis;

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(4) may include annual out-of-pocket limits and
lifetime maximum benefits allowances for out-of-plan
services that are separate from any limits or allowances
applied to in-plan services;
(5) may not consider emergency services, authorized
referral services, or non-routine services obtained out of
the service area to be point-of-service services;
(6) may treat as out-of-plan services those services
that an enrollee obtains from a participating provider,
but for which the proper authorization was not given by
the health maintenance organization; and
(7) after January 1, 2003 (the effective date of
Public Act 92-579) this amendatory Act of the 92nd General
Assembly, must include the following disclosure on its
point-of-service contracts and evidences of coverage:
"WARNING, LIMITED BENEFITS WILL BE PAID WHEN
NON-PARTICIPATING PROVIDERS ARE USED. You should be aware
that when you elect to utilize the services of a
non-participating provider for a covered service in
non-emergency situations, benefit payments to such
non-participating provider are not based upon the amount
billed. The basis of your benefit payment will be
determined according to your policy's fee schedule, usual
and customary charge (which is determined by comparing
charges for similar services adjusted to the geographical
area where the services are performed), or other method as

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defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE
COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN
HAS PAID ITS REQUIRED PORTION. Non-participating providers
may bill members for any amount up to the billed charge
after the plan has paid its portion of the bill, except as
provided in Section 356z.3a of the Illinois Insurance Code
for covered services received at a participating health
care facility from a non-participating provider that are:
(a) ancillary services, (b) items or services furnished as
a result of unforeseen, urgent medical needs that arise at
the time the item or service is furnished, or (c) items or
services received when the facility or the
non-participating provider fails to satisfy the notice and
consent criteria specified under Section 356z.3a, or (d)
items or services provided to a Medicare beneficiary,
insured, or enrollee. Participating providers have agreed
to accept discounted payments for services with no
additional billing to the member other than co-insurance
and deductible amounts. You may obtain further information
about the participating status of professional providers
and information on out-of-pocket expenses by calling the
toll free telephone number on your identification card.".
(b) A health maintenance organization offering a
point-of-service contract is subject to all of the following
limitations:
(1) The health maintenance organization may not expend

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in any calendar quarter more than 20% of its total
expenditures for all its members for out-of-plan covered
services.
(2) If the amount specified in item (1) of this
subsection is exceeded by 2% in a quarter, the health
maintenance organization must effect compliance with item
(1) of this subsection by the end of the following
quarter.
(3) If compliance with the amount specified in item
(1) of this subsection is not demonstrated in the health
maintenance organization's next quarterly report, the
health maintenance organization may not offer the
point-of-service contract to new groups or include the
point-of-service option in the renewal of an existing
group until compliance with the amount specified in item
(1) of this subsection is demonstrated or until otherwise
allowed by the Director.
(4) A health maintenance organization failing, without
just cause, to comply with the provisions of this
subsection shall be required, after notice and hearing, to
pay a penalty of $250 for each day out of compliance, to be
recovered by the Director. Any penalty recovered shall be
paid into the General Revenue Fund. The Director may
reduce the penalty if the health maintenance organization
demonstrates to the Director that the imposition of the
penalty would constitute a financial hardship to the

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health maintenance organization.
(c) A health maintenance organization that offers a
point-of-service product must do all of the following:
(1) File a quarterly financial statement detailing
compliance with the requirements of subsection (b).
(2) Track out-of-plan, point-of-service utilization
separately from in-plan or non-point-of-service,
out-of-plan emergency care, referral care, and urgent care
out of the service area utilization.
(3) Record out-of-plan utilization in a manner that
will permit such utilization and cost reporting as the
Director may, by rule, require.
(4) Demonstrate to the Director's satisfaction that
the health maintenance organization has the fiscal,
administrative, and marketing capacity to control its
point-of-service enrollment, utilization, and costs so as
not to jeopardize the financial security of the health
maintenance organization.
(5) Maintain, in addition to any other deposit
required under this Act, the deposit required by Section
2-6.
(6) Maintain cash and cash equivalents of sufficient
amount to fully liquidate 10 days' average claim payments,
subject to review by the Director.
(7) Maintain and file with the Director, reinsurance
coverage protecting against catastrophic losses on

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out-of-network out of network point-of-service services.
Deductibles may not exceed $100,000 per covered life per
year, and the portion of risk retained by the health
maintenance organization once deductibles have been
satisfied may not exceed 20%. Reinsurance must be placed
with licensed authorized reinsurers qualified to do
business in this State.
(d) A health maintenance organization may not issue a
point-of-service contract until it has filed and had approved
by the Director a plan to comply with the provisions of this
Section. The compliance plan must, at a minimum, include
provisions demonstrating that the health maintenance
organization will do all of the following:
(1) Design the benefit levels and conditions of
coverage for in-plan covered services and out-of-plan
covered services as required by this Article.
(2) Provide or arrange for the provision of adequate
systems to:
(A) process and pay claims for all out-of-plan
covered services;
(B) meet the requirements for point-of-service
contracts set forth in this Section and any additional
requirements that may be set forth by the Director;
and
(C) generate accurate data and financial and
regulatory reports on a timely basis so that the

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Department of Insurance can evaluate the health
maintenance organization's experience with the
point-of-service contract and monitor compliance with
point-of-service contract provisions.
(3) Comply with the requirements of subsections (b)
and (c).
(Source: P.A. 102-901, eff. 1-1-23; revised 12-9-22.)
Section 99. Effective date. This Act takes effect upon
becoming law.