Full Text of SB0650 101st General Assembly
SB0650sam004 101ST GENERAL ASSEMBLY | Sen. Ann Gillespie Filed: 4/29/2019
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| 1 | | AMENDMENT TO SENATE BILL 650
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 650 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. Short title. This Act may be cited as the | 5 | | Dialysis Patient Protection Act. | 6 | | Section 5. Definitions. As used in this Act, unless the | 7 | | context requires otherwise:
| 8 | | "Affordable Care Act" means the federal Patient Protection | 9 | | and Affordable Care Act, as amended by the federal Health Care | 10 | | and Education Reconciliation Act of 2010, and any amendments | 11 | | thereto or regulations or guidance issued under those Acts. | 12 | | "Health insurance marketplace" means the health insurance | 13 | | marketplace established for Illinois under the Affordable Care | 14 | | Act.
| 15 | | "Outpatient dialysis provider" means any professional | 16 | | person, organization, health facility, or other person or |
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| 1 | | institution certified by the Centers for Medicare and Medicaid | 2 | | Services as an independent dialysis facility as described in | 3 | | Part 494 of Title 42 of the Code of Federal Regulations.
| 4 | | "Qualified health plan" means a plan of health insurance | 5 | | that is certified by the health insurance marketplace and meets | 6 | | the requirements of the Affordable Care Act, including coverage | 7 | | of essential health benefits. | 8 | | "Qualified individual" means an individual who has been | 9 | | determined to be eligible to enroll through the health | 10 | | insurance marketplace in a qualified health plan in the | 11 | | individual market.
| 12 | | "Third-party premium payment" means any premium payment | 13 | | for a health care plan or accident and health insurance plan | 14 | | made directly or indirectly by an outpatient dialysis provider | 15 | | or other third party, made indirectly through payments to the | 16 | | individual for the purpose of making health care plan premium | 17 | | payments or accident and health insurance premium payments, or | 18 | | provided to one or more intermediaries with the intention that | 19 | | the funds be used to make health care plan premium payments or | 20 | | accident and health insurance premium payments for the | 21 | | individual.
| 22 | | Section 10. Third-party premium payments. | 23 | | (a) A qualified individual enrolled in a qualified health | 24 | | plan on the health insurance marketplace may allow a | 25 | | third-party premium payment to be made on his or her behalf to |
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| 1 | | pay any applicable premium or cost-sharing owed by the | 2 | | qualified individual to the health insurance issuer issuing the | 3 | | qualified health plan, and the health insurance issuer issuing | 4 | | the qualified health plan shall accept a third-party premium | 5 | | payment made on behalf of the qualified individual that | 6 | | complies with the requirements of this Act. | 7 | | (b) An outpatient dialysis provider shall notify the health | 8 | | care plan or accident and health insurance plan the first time | 9 | | in a calendar year that the outpatient dialysis provider bills | 10 | | a health care service plan for reimbursement resulting from | 11 | | services provided to an enrollee who meets any of the following | 12 | | descriptions: | 13 | | (1) During the calendar year, premiums for the | 14 | | enrollee's health care plan or accident and health | 15 | | insurance plan have been paid, directly or indirectly, by | 16 | | the outpatient dialysis provider, parent company of the | 17 | | outpatient dialysis provider, a subsidiary of the | 18 | | outpatient dialysis provider, or a related entity. | 19 | | (2) During the calendar year, premiums for the | 20 | | enrollee's health care plan or accident and health | 21 | | insurance plan have been paid directly or indirectly by a | 22 | | third party.
| 23 | | (c) An outpatient dialysis provider shall make a good faith | 24 | | effort to identify all patients to which it provides health | 25 | | care services whose premiums have been paid under an | 26 | | arrangement described in subsection (b). That good faith effort |
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| 1 | | includes, but is not limited to, the following: | 2 | | (1) The outpatient dialysis provider receives | 3 | | notification from a patient or from the entity making the | 4 | | premium payments that the patient's premiums were paid | 5 | | under an arrangement described in paragraph (1) or (2) of | 6 | | subsection (b). | 7 | | (2) The parent company of the outpatient dialysis | 8 | | provider, a subsidiary of the outpatient dialysis | 9 | | provider, or a related entity becomes aware that a | 10 | | patient's premiums were paid under an arrangement | 11 | | described in paragraph (1) or (2) of subsection (b). | 12 | | (3) The outpatient dialysis provider receives | 13 | | notification as required by federal Health and Human | 14 | | Services Office of Inspector General Advisory Opinion | 15 | | 97-1, or a related successor advisory opinion, that a | 16 | | patient's premiums were paid under an arrangement | 17 | | authorized by that advisory opinion. | 18 | | Section 15. Patient rights. An outpatient dialysis | 19 | | provider shall always keep the best interests of patients in | 20 | | mind when providing patients with information about a | 21 | | third-party health insurance premium program's eligibility, | 22 | | benefits, conditions, and related information, and when | 23 | | assisting patients in applying for the health insurance premium | 24 | | program or other assistance from a third party. The outpatient | 25 | | dialysis provider shall remind patients that the patients are |
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| 1 | | the persons who should make any decisions concerning their | 2 | | health insurance premium program assistance, including, but | 3 | | not limited to, applying for, changing, stopping, or | 4 | | re-enrolling in health insurance coverage. The outpatient | 5 | | dialysis provider shall take reasonable steps to overcome | 6 | | educational, linguistic, and cultural barriers in informing | 7 | | patients about their health insurance options. The outpatient | 8 | | dialysis provider shall provide accurate and impartial | 9 | | information designed to enable patients to make informed | 10 | | decisions about their health insurance coverage choice. Where | 11 | | applicable, such information shall include financial | 12 | | implications associated with the choice of a particular | 13 | | coverage option to the extent such information is available. | 14 | | Information provided may include, but is not limited to: | 15 | | (1) out-of-pocket expenses, including, but not limited | 16 | | to, co-pays, deductibles, and other uncovered costs; | 17 | | (2) reenrollment requirements; | 18 | | (3) potential Medicare late enrollment penalties, if | 19 | | any; and | 20 | | (4) a recommendation that the patient review with his | 21 | | or her transplant center the impact, if any, of his or her | 22 | | health care coverage choice on transplant status. | 23 | | Section 90. The Illinois Insurance Code is amended by | 24 | | adding Section 356z.33 as follows: |
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| 1 | | (215 ILCS 5/356z.33 new) | 2 | | Sec. 356z.33. Third-party premium payments; determination
| 3 | | of reimbursement. | 4 | | (a) As used in this Section, unless the context requires
| 5 | | otherwise: | 6 | | "Outpatient dialysis provider" means any professional
| 7 | | person, organization, health facility, or other person or
| 8 | | institution certified by the Centers for Medicare and Medicaid
| 9 | | Services as an independent dialysis facility as described in
| 10 | | Part 494 of Title 42 of the Code of Federal Regulations. | 11 | | "Third-party premium payment" means any accident and
| 12 | | health plan premium payment made directly or indirectly by an
| 13 | | outpatient dialysis provider or other third party, made
| 14 | | indirectly through payments to the individual for the purpose
| 15 | | of making health care plan premium payments, or provided to one
| 16 | | or more intermediaries with the intention that the funds be
| 17 | | used to make health care plan premium payments for the
| 18 | | individuals. | 19 | | (b) If an accident and health insurer receives notification | 20 | | under Section 10 of the Dialysis Patient Protection Act on | 21 | | behalf of an enrollee, reimbursement to the outpatient dialysis | 22 | | provider for covered services provided on behalf of the | 23 | | enrollee shall be determined by the following: | 24 | | (1) For a contracted outpatient dialysis provider, the | 25 | | amount of reimbursement for covered services shall be | 26 | | governed by the terms and conditions of the enrollee's |
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| 1 | | accident and health insurance plan contract or the Medicare | 2 | | reimbursement rate, whichever is lower. Outpatient | 3 | | dialysis providers shall not bill the enrollee or seek | 4 | | reimbursement from the enrollee for any services provided, | 5 | | except for cost sharing pursuant to the terms and | 6 | | conditions of the enrollee's accident and health insurance | 7 | | plan contract. If an enrollee's contract imposes a | 8 | | coinsurance payment for a claim that is subject to this | 9 | | paragraph, the coinsurance payment shall be based on the | 10 | | amount paid by the accident and health insurance plan | 11 | | pursuant to this paragraph. | 12 | | (2) For a noncontracting outpatient dialysis provider, | 13 | | the amount of reimbursement for covered services shall be | 14 | | governed by the terms and conditions of the enrollee's | 15 | | accident and health insurance plan contract or the Medicare | 16 | | reimbursement rate, whichever is lower. Outpatient | 17 | | dialysis providers shall not bill the enrollee or seek | 18 | | reimbursement from the enrollee for any services provided, | 19 | | except for cost sharing pursuant to the terms and | 20 | | conditions of the enrollee's accident and health insurance | 21 | | plan contract. If an enrollee's contract imposes a | 22 | | coinsurance payment for a claim that is subject to this | 23 | | paragraph, the coinsurance payment shall be based on the | 24 | | amount paid by the accident and health insurance plan | 25 | | pursuant to this paragraph. A claim submitted to an | 26 | | accident and health insurance plan by a noncontracting |
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| 1 | | outpatient dialysis provider may be considered an | 2 | | incomplete claim and contested by the accident and health | 3 | | insurance plan if the outpatient dialysis provider has not | 4 | | provided the information as required in subsection (b) of | 5 | | Section 10 of the Dialysis Patient Protection Act. | 6 | | (c) The following shall occur if an accident and health | 7 | | insurer subsequently discovers that an outpatient dialysis | 8 | | provider fails to provide disclosure pursuant to subsection (b) | 9 | | of Section 10 of the Dialysis Patient Protection Act: | 10 | | (1) The accident and health insurer shall be entitled | 11 | | to recover 120% of the difference between any payment made | 12 | | to an outpatient dialysis provider and the payment to which | 13 | | the outpatient dialysis provider would have been entitled | 14 | | pursuant to subsection (b), including interest on that | 15 | | difference. | 16 | | (2) The accident and health insurer shall notify the | 17 | | Department of Insurance of the amount by which the | 18 | | outpatient dialysis provider was overpaid and shall remit | 19 | | to the Department of Insurance any amount exceeding the | 20 | | difference between the payment made to the outpatient | 21 | | dialysis provider and the payment to which the outpatient | 22 | | dialysis provider would have been entitled pursuant to | 23 | | subsection (b), including interest on that difference that | 24 | | was recovered pursuant to paragraph (1). | 25 | | (d) This Section does not give an insurer any additional | 26 | | ability to refuse to accept premium payments or to cancel or |
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| 1 | | refuse to renew an existing enrollment or subscription, | 2 | | regardless of the source of payment. | 3 | | Section 95. The Health Maintenance Organization Act is | 4 | | amended by changing Section 1-2 and by adding Section 4-5.1 as | 5 | | follows:
| 6 | | (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
| 7 | | Sec. 1-2. Definitions. As used in this Act, unless the | 8 | | context otherwise
requires, the following terms shall have the | 9 | | meanings ascribed to them:
| 10 | | (1) "Advertisement" means any printed or published | 11 | | material,
audiovisual material and descriptive literature of | 12 | | the health care plan
used in direct mail, newspapers, | 13 | | magazines, radio scripts, television
scripts, billboards and | 14 | | similar displays; and any descriptive literature or
sales aids | 15 | | of all kinds disseminated by a representative of the health | 16 | | care
plan for presentation to the public including, but not | 17 | | limited to, circulars,
leaflets, booklets, depictions, | 18 | | illustrations, form letters and prepared
sales presentations.
| 19 | | (2) "Director" means the Director of Insurance.
| 20 | | (3) "Basic health care services" means emergency care, and | 21 | | inpatient
hospital and physician care, outpatient medical | 22 | | services, mental
health services and care for alcohol and drug | 23 | | abuse, including any
reasonable deductibles and co-payments, | 24 | | all of which are subject to the
limitations described in |
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| 1 | | Section 4-20 of this Act and as determined by the Director | 2 | | pursuant to rule.
| 3 | | (4) "Enrollee" means an individual who has been enrolled in | 4 | | a health
care plan.
| 5 | | (5) "Evidence of coverage" means any certificate, | 6 | | agreement,
or contract issued to an enrollee setting out the | 7 | | coverage to which he is
entitled in exchange for a per capita | 8 | | prepaid sum.
| 9 | | (6) "Group contract" means a contract for health care | 10 | | services which
by its terms limits eligibility to members of a | 11 | | specified group.
| 12 | | (7) "Health care plan" means any arrangement whereby any | 13 | | organization
undertakes to provide or arrange for and pay for | 14 | | or reimburse the
cost of basic health care services, excluding | 15 | | any reasonable deductibles and copayments, from providers | 16 | | selected by
the Health Maintenance Organization and such | 17 | | arrangement
consists of arranging for or the provision of such | 18 | | health care services, as
distinguished from mere | 19 | | indemnification against the cost of such services,
except as | 20 | | otherwise authorized by Section 2-3 of this Act,
on a per | 21 | | capita prepaid basis, through insurance or otherwise. A "health
| 22 | | care plan" also includes any arrangement whereby an | 23 | | organization undertakes to
provide or arrange for or pay for or | 24 | | reimburse the cost of any health care
service for persons who | 25 | | are enrolled under Article V of the Illinois Public Aid
Code or | 26 | | under the Children's Health Insurance Program Act through
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| 1 | | providers selected by the organization and the arrangement | 2 | | consists of making
provision for the delivery of health care | 3 | | services, as distinguished from mere
indemnification. A | 4 | | "health care plan" also includes any arrangement pursuant
to | 5 | | Section 4-17. Nothing in this definition, however, affects the | 6 | | total
medical services available to persons eligible for | 7 | | medical assistance under the
Illinois Public Aid Code.
| 8 | | (8) "Health care services" means any services included in | 9 | | the furnishing
to any individual of medical or dental care, or | 10 | | the hospitalization or
incident to the furnishing of such care | 11 | | or hospitalization as well as the
furnishing to any person of | 12 | | any and all other services for the purpose of
preventing, | 13 | | alleviating, curing or healing human illness or injury.
| 14 | | (9) "Health Maintenance Organization" means any | 15 | | organization formed
under the laws of this or another state to | 16 | | provide or arrange for one or
more health care plans under a | 17 | | system which causes any part of the risk of
health care | 18 | | delivery to be borne by the organization or its providers.
| 19 | | (10) "Net worth" means admitted assets, as defined in | 20 | | Section 1-3 of
this Act, minus liabilities.
| 21 | | (11) "Organization" means any insurance company, a | 22 | | nonprofit
corporation authorized under the Dental
Service Plan | 23 | | Act or the Voluntary
Health Services Plans Act,
or a | 24 | | corporation organized under the laws of this or another state | 25 | | for the
purpose of operating one or more health care plans and | 26 | | doing no business other
than that of a Health Maintenance |
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| 1 | | Organization or an insurance company.
"Organization" shall | 2 | | also mean the University of Illinois Hospital as
defined in the | 3 | | University of Illinois Hospital Act or a unit of local | 4 | | government health system operating within a county with a | 5 | | population of 3,000,000 or more.
| 6 | | (11.5) "Outpatient dialysis provider" means any | 7 | | professional person, organization, health facility, or other | 8 | | person or institution certified by the Centers for Medicare and | 9 | | Medicaid Services as an independent dialysis facility as | 10 | | described in Part 494 of Title 42 of the Code of Federal | 11 | | Regulations. | 12 | | (12) "Provider" means any physician, hospital facility,
| 13 | | facility licensed under the Nursing Home Care Act, or facility | 14 | | or long-term care facility as those terms are defined in the | 15 | | Nursing Home Care Act or other person which is licensed or | 16 | | otherwise authorized
to furnish health care services and also | 17 | | includes any other entity that
arranges for the delivery or | 18 | | furnishing of health care service.
| 19 | | (13) "Producer" means a person directly or indirectly | 20 | | associated with a
health care plan who engages in solicitation | 21 | | or enrollment.
| 22 | | (14) "Per capita prepaid" means a basis of prepayment by | 23 | | which a fixed
amount of money is prepaid per individual or any | 24 | | other enrollment unit to
the Health Maintenance Organization or | 25 | | for health care services which are
provided during a definite | 26 | | time period regardless of the frequency or
extent of the |
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| 1 | | services rendered
by the Health Maintenance Organization, | 2 | | except for copayments and deductibles
and except as provided in | 3 | | subsection (f) of Section 5-3 of this Act.
| 4 | | (15) "Subscriber" means a person who has entered into a | 5 | | contractual
relationship with the Health Maintenance | 6 | | Organization for the provision of
or arrangement of at least | 7 | | basic health care services to the beneficiaries
of such | 8 | | contract. | 9 | | (16) "Third-party premium payment" means any health care | 10 | | plan premium payment made directly or indirectly by an | 11 | | outpatient dialysis provider or other third party, made | 12 | | indirectly through payments to the individual for the purpose | 13 | | of making health care plan premium payments, or provided to one | 14 | | or more intermediaries with the intention that the funds be | 15 | | used to make health care plan premium payments for the | 16 | | individuals.
| 17 | | (Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 99-78, | 18 | | eff. 7-20-15.)
| 19 | | (215 ILCS 125/4-5.1 new) | 20 | | Sec. 4-5.1. Third-party premium payments; determination of | 21 | | reimbursement. | 22 | | (a) If a Health Maintenance Organization receives | 23 | | notification under Section 10 of the Dialysis Patient | 24 | | Protection Act on behalf of an enrollee, reimbursement to the | 25 | | outpatient dialysis provider for covered services provided on |
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| 1 | | behalf of the enrollee shall be determined by the following: | 2 | | (1) For a contracted outpatient dialysis provider, the | 3 | | amount of reimbursement for covered services shall be | 4 | | governed by the terms and conditions of the enrollee's | 5 | | health care plan contract or the Medicare reimbursement | 6 | | rate, whichever is lower. Outpatient dialysis providers | 7 | | shall not bill the enrollee or seek reimbursement from the | 8 | | enrollee for any services provided, except for cost sharing | 9 | | pursuant to the terms and conditions of the enrollee's | 10 | | health care plan contract. If an enrollee's contract | 11 | | imposes a coinsurance payment for a claim that is subject | 12 | | to this paragraph, the coinsurance payment shall be based | 13 | | on the amount paid by the Health Maintenance Organization | 14 | | pursuant to this paragraph. | 15 | | (2) For a noncontracting outpatient dialysis provider, | 16 | | the amount of reimbursement for covered shall be governed | 17 | | by the terms and conditions of the enrollee's health care | 18 | | plan contract or the Medicare reimbursement rate, | 19 | | whichever is lower. Outpatient dialysis providers shall | 20 | | not bill the enrollee or seek reimbursement from the | 21 | | enrollee for any services provided, except for cost sharing | 22 | | pursuant to the terms and conditions of the enrollee's | 23 | | health care plan contract. If an enrollee's contract | 24 | | imposes a coinsurance payment for a claim that is subject | 25 | | to this paragraph, the coinsurance payment shall be based | 26 | | on the amount paid by the Health Maintenance Organization |
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| 1 | | pursuant to this paragraph. A claim submitted to a Health | 2 | | Maintenance Organization by a noncontracting outpatient | 3 | | dialysis provider may be considered an incomplete claim and | 4 | | contested by the Health Maintenance Organization if the | 5 | | outpatient dialysis provider has not provided the | 6 | | information as required in subsection (b) of Section 10 of | 7 | | the Dialysis Patient Protection Act. | 8 | | (b) The following shall occur if a Health Maintenance | 9 | | Organization subsequently discovers that an outpatient | 10 | | dialysis provider fails to provide disclosure pursuant to | 11 | | subsection (b) of Section 10 of the Dialysis Patient Protection | 12 | | Act: | 13 | | (1) The Health Maintenance Organization shall be | 14 | | entitled to recover 120% of the difference between any | 15 | | payment made to an outpatient dialysis provider and the | 16 | | payment to which the outpatient dialysis provider would | 17 | | have been entitled pursuant to subsection (a), including | 18 | | interest on that difference. | 19 | | (2) The Health Maintenance Organization shall notify | 20 | | the Department of Insurance of the amount by which the | 21 | | outpatient dialysis provider was overpaid and shall remit | 22 | | to the Department of Insurance any amount exceeding the | 23 | | difference between the payment made to the outpatient | 24 | | dialysis provider and the payment to which the outpatient | 25 | | dialysis provider would have been entitled pursuant to | 26 | | subsection (a), including interest on that difference that |
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| 1 | | was recovered pursuant to paragraph (1). | 2 | | (c) This Section does not give an insurer any additional | 3 | | ability to refuse to accept premium payments or to cancel or | 4 | | refuse to renew an existing enrollment or subscription, | 5 | | regardless of the source of payment.
| 6 | | Section 99. Effective date. This Act takes effect upon | 7 | | becoming law.".
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