HB2435 101ST GENERAL ASSEMBLY

LRB101 02846 SMS 50300 b

101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB2435

Introduced , by Rep. Mary E. Flowers - LaToya Greenwood

SYNOPSIS AS INTRODUCED:

215 ILCS 134/87 new

Amends the Managed Care Reform and Patient Rights Act. Provides that a health insurance carrier, health maintenance organization, or other managed care entity for a health care plan and its employees and other representatives are liable for damages for harm to an enrollee proximately caused by their failure to exercise ordinary care. Prohibits a health insurance carrier, health maintenance organization, or other managed care entity from removing a provider from its health care plan for advocating on behalf of an enrollee for appropriate and medically necessary health care. Prohibits a health insurance carrier, health maintenance organization, or other managed care entity from entering into a contract with a provider that indemnifies the health insurance carrier, health maintenance organization, or other managed care entity. Provides that an insured or enrollee seeking damages has the right and duty to submit the claim to arbitration in accordance with the Uniform Arbitration Act. Provides that the provisions do not apply to workers' compensation insurance coverage, actions seeking only a review of an adverse utilization review determination, and licensed insurance agents.

A BILL FOR

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Managed Care Reform and Patient Rights Act is amended by adding Section 87 as follows:

(215 ILCS 134/87 new)

Sec. 87. Health care entity liability.

(a) As used in this Section:

"Appropriate and medically necessary" means the standard for health care services as determined by physicians and health care providers in accordance with the prevailing practices and standards of the medical profession and community.

"Enrollee" means an individual who is enrolled in a health care plan, including covered dependents.

"Health care plan" means any plan whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services.

"Health care provider" means a person or entity as defined in Section 10.

"Health care treatment decision" means a determination made when medical services are actually provided by the health care plan and a decision that affects the quality of the diagnosis, care, or treatment provided to the health care plan's insureds or enrollees.

"Health insurance carrier" means an authorized insurance company that issues policies of accident and health insurance under the Illinois Insurance Code.

"Health maintenance organization" means an organization licensed under the Health Maintenance Organization Act.

"Managed care entity" means any entity that delivers, administers, or assumes risk for health care services with systems or techniques to control or influence the quality, accessibility, utilization, or costs and prices of those services to a defined enrollee population. "Managed care entity" does not include an employer purchasing coverage or acting on behalf of its employees or the employees of one or more subsidiaries or affiliated corporations of the employer.

"Physician" means: (1) an individual licensed to practice medicine in all its branches in this State; (2) a professional association, professional service corporation, partnership, medical corporation, or limited liability company entitled to lawfully engage in the practice of medicine; or (3) another person wholly owned by physicians.

"Ordinary care" means, in the case of a health insurance carrier, health maintenance organization, or managed care entity, that degree of care that a health insurance carrier, health maintenance organization, or managed care entity of ordinary prudence would use under the same or similar circumstances. In the case of a person who is an employee, agent, ostensible agent, or representative of a health insurance carrier, health maintenance organization, or managed care entity, "ordinary care" means that degree of care that a person of ordinary prudence in the same profession, specialty, or area of practice as such person would use in the same or similar circumstances.

(b) A health insurance carrier, health maintenance organization, or other managed care entity for a health care plan has the duty to exercise ordinary care when making health care treatment decisions and is liable for damages for harm to an insured or enrollee proximately caused by its failure to exercise such ordinary care.

(c) A health insurance carrier, health maintenance organization, or other managed care entity for a health care plan is also liable for damages for harm to an insured or enrollee proximately caused by the health care treatment decisions made by its:

(1) employees;

(2) agents;

(3) ostensible agents; or

(4) representatives who are acting on its behalf and over whom it has the right to exercise influence or control or has actually exercised influence or control that results in the failure to exercise ordinary care.

(d) The standards in subsections (b) and (c) create no obligation on the part of the health insurance carrier, health maintenance organization, or other managed care entity to provide to an insured or enrollee treatment that is not covered by the health care plan of the entity.

(e) The determination of whether a procedure or treatment is medically necessary must be made by a physician.

(f) If the physician determines that a procedure or treatment is medically necessary, the health care plan must pay for the procedure or treatment.

(g) A health insurance carrier, health maintenance organization, or managed care entity may not remove a physician or health care provider from its health care plan or refuse to renew the physician or health care provider with its health care plan for advocating on behalf of an enrollee for appropriate and medically necessary health care for the enrollee.

(h) A health insurance carrier, health maintenance organization, or other managed care entity may not enter into a contract with a physician, hospital, or other health care provider or pharmaceutical company that includes an indemnification or hold harmless clause for the acts or conduct of the health insurance carrier, health maintenance organization, or other managed care entity. Any such indemnification or hold harmless clause in an existing contract is hereby declared void.

(i) Nothing in any law of this State prohibiting a health insurance carrier, health maintenance organization, or other managed care entity from practicing medicine or being licensed to practice medicine may be asserted as a defense by the health insurance carrier, health maintenance organization, or other managed care entity in an action brought against it under this Section or any other law.

(j) In an action against a health insurance carrier, health maintenance organization, or managed care entity, a finding that a physician or other health care provider is an employee, agent, ostensible agent, or representative of the health insurance carrier, health maintenance organization, or managed care entity shall not be based solely on proof that the person's name appears in a listing of approved physicians or health care providers made available to insureds or enrollees under a health care plan.

(k) This Section applies only to causes of action that accrue on or after the effective date of this amendatory Act of the 101st General Assembly. An insured or enrollee seeking damages under this Section has the right and duty to submit the claim to arbitration in accordance with the Uniform Arbitration Act. No agreement between the parties to submit the claim to arbitration is necessary. A health insurance carrier, health maintenance organization, or managed care entity shall have no liability under this Section unless the claim is first submitted to arbitration in accordance with the Uniform Arbitration Act. The award in matters arbitrated under this Section shall be made within 30 days after notification of the arbitration is provided to all parties.

(l) This Section does not apply to:

(1) workers' compensation insurance coverage subject to the Workers' Compensation Act;

(2) licensed insurance agents; or

(3) actions seeking only a review of an adverse utilization review determination.