94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB4086


 
Introduced 6/27/2005, by Rep. Mary E. Flowers
 
SYNOPSIS AS INTRODUCED:
 		














215 ILCS 134/15









    Amends the Managed Care Reform and Patient Rights Act.  Requires health care plans to provide certain information on participating physicians to enrollees and prospective enrollees. Requires the removal of physicians who are deceased or are no longer practicing medicine from the list. Requires health care plans to provide periodic updates of physician listings with new and corrected information in printed form and on the plan's Internet website.
















LRB094 12785 LJB 47629 b

















 


 


A BILL FOR









 











HB4086

LRB094 12785 LJB 47629 b






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    AN ACT concerning insurance.

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


 
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    Section 5. The Managed Care Reform and Patient Rights Act 
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is amended  by changing Section 15 as follows:
 



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    (215 ILCS 134/15)



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    Sec. 15. Provision of information. 

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    (a) A health care plan shall provide annually to enrollees 
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and prospective
enrollees, upon request, a complete list of 
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participating health care providers
in the
health care plan's 
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service area and a description of the following terms of

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coverage:


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        (1) the service area;


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        (2) the covered benefits and services with all 
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    exclusions, exceptions, and
limitations;


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        (3) the pre-certification and other utilization review 
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    procedures
and requirements;


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        (4) a description of the process for the selection of a 
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    primary care
physician,
any limitation on access to 
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    specialists, and the plan's standing referral
policy;


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        (5) the emergency coverage and benefits, including any 
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    restrictions on
emergency
care services;


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        (6) the out-of-area coverage and benefits, if any;


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        (7) the enrollee's financial responsibility for 
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    copayments, deductibles,
premiums, and any other 
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    out-of-pocket expenses;


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        (8) the provisions for continuity of treatment in the 
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    event a health care
provider's
participation terminates 
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    during the course of an enrollee's treatment by that

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    provider;


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        (9) the appeals process, forms, and time frames for 
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    health care services
appeals, complaints, and external 
 


 






HB4086
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    independent reviews, administrative
complaints,
 and 
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    utilization review complaints, including a phone
number
to 
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    call to receive more information from the health care plan 
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    concerning the
appeals process; and


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        (10) a statement of all basic health care services and 
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    all specific
benefits and
services mandated to be provided 
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    to enrollees by any State law or
administrative
rule.

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    In the event of an inconsistency between any separate 
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written disclosure
statement and the enrollee contract or 
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certificate, the terms of the enrollee
contract or certificate 
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shall control.

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    (b) Upon written request, a health care plan shall provide 
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to enrollees a
description of the financial relationships 
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between the health care plan and any
health care provider
and, 
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if requested, the percentage
of copayments, deductibles, and 
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total premiums spent on healthcare related
expenses and the 
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percentage of
copayments, deductibles, and total premiums 
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spent on other expenses, including
administrative expenses,

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except that no health care plan shall be required to disclose 
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specific provider
reimbursement.

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    (c) A participating health care provider shall provide all 
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of the
following, where applicable, to enrollees upon request:


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        (1) Information related to the health care provider's 
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    educational
background,
experience, training, specialty, 
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    and board certification, if applicable.


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        (2) The names of licensed facilities on the provider 
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    panel where
the health
care provider presently has 
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    privileges for the treatment, illness, or
procedure
that is 
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    the subject of the request.


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        (3) Information regarding the health care provider's 
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    participation
in
 continuing education programs and 
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    compliance with any licensure,
certification, or 
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    registration requirements, if applicable.

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    (d) A health care plan shall provide the information 
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required to be
disclosed under this Act upon enrollment and 
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annually thereafter in a legible
and understandable format. The 
 


 






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Department
shall promulgate rules to establish the format 
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based, to the extent
practical,
on
the standards developed for 
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supplemental insurance coverage under Title XVIII
of
the 
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federal Social Security Act as a guide, so that a person can 
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compare the
attributes of the various health care plans.

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    (e) The written disclosure requirements of this Section may 
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be met by
disclosure to one enrollee in a household.

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    (f) As part of the list of participating health care 
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providers required to be provided to enrollees and prospective 
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enrollees under subsection (a) of this Section, a health care 
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plan shall provide current and accurate information on 
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participating physicians, which shall include, but not be 
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limited to, the specialty practice area of each participating 
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physician. Any participating physician who is deceased or is no 
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longer practicing medicine shall be removed from the list.
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    Health care plans shall provide periodic updates of 
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participating physician listings with new and corrected 
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information in both printed form and on the plan's Internet 
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website, if applicable.

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(Source: P.A. 91-617, eff. 1-1-00.)