103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5580

 

Introduced 2/9/2024, by Rep. Hoan Huynh

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 134/20
215 ILCS 134/62 new

    Amends the Managed Care Reform and Patient Rights Act. Sets forth requirements for carriers that offer a provider panel. Requires notice of the development of a provider panel to be filed with Department of Public Health prior to establishment. Provides that a carrier that uses a provider panel shall establish procedure for notifying an enrollee of the termination of a health care provider. Sets forth provisions permitting, under certain circumstances, a health care provider to continue to render health care services following termination from the carrier's provider panel. Requires a carrier to provide a list of members in the carrier's provider panel. Establishes notice requirements for benefit reductions and termination of health care providers from the carrier's provider panel. Requires any carrier requiring preauthorization for medical treatment to have personnel available to provide preauthorization at all times when the preauthorization is required. Provides that no contract between a health care provider and a carrier shall include provisions that require a health care provider to deny covered services that the provider knows to be medically necessary and appropriate that are provided with respect to a specific enrollee or group of enrollees with similar medical conditions. Sets forth prohibited provisions in a contract between a carrier and a health care provider. Defines terms. Makes other and conforming changes.


LRB103 38270 RPS 68405 b

 

 

A BILL FOR

 

HB5580LRB103 38270 RPS 68405 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Managed Care Reform and Patient Rights Act
5is amended by changing Section 20 and by adding Section 62 as
6follows:
 
7    (215 ILCS 134/20)
8    Sec. 20. Notice of nonrenewal or termination. A health
9care plan must give at least 60 days' days notice of nonrenewal
10or termination of a health care provider from the health care
11plan's provider panel or termination of any other contractual
12relationship to the health care provider and to the enrollees
13served by the health care provider. The notice shall include a
14name and address to which an enrollee or health care provider
15may direct comments and concerns regarding the nonrenewal or
16termination. Immediate written notice may be provided without
1760 days' days notice when a health care provider's license has
18been disciplined by a State licensing board.
19(Source: P.A. 91-617, eff. 1-1-00.)
 
20    (215 ILCS 134/62 new)
21    Sec. 62. Provider panels.
22    (a) In this Section:

 

 

HB5580- 2 -LRB103 38270 RPS 68405 b

1    "Carrier" means:
2        (1) any insurer proposing to issue or that issues
3    individual or group policies of accident and health
4    insurance providing hospital, medical, surgical, or other
5    major medical coverage on an expense-incurred basis;
6        (2) any corporation providing individual or group
7    health or accident subscription contracts;
8        (3) any health maintenance organization providing
9    health care plans or health care services;
10        (4) any corporation offering or providing prepaid
11    dental or optometric services plans; or
12        (5) any other person or organization that provides
13    health benefit plans subject to State regulation.
14    "Carrier" includes an entity that arranges a provider
15panel for compensation.
16    "Provider panel" means the health care providers with
17which a carrier contracts to provide health care services to
18the carrier's enrollees under the carrier's health care or
19health benefit plan. "Provider panel" does not include an
20arrangement between a carrier and providers in which any
21provider may participate solely on the basis of the provider's
22contracting with the carrier to provide services at a
23discounted fee-for-service rate.
24    (b) Any carrier that offers a provider panel shall
25establish and use the provider panel according to the
26following requirements:

 

 

HB5580- 3 -LRB103 38270 RPS 68405 b

1        (1) Notice of the development of a provider panel
2    serving residents of the State must be filed with the
3    Department of Public Health prior to establishment.
4        (2) Carriers shall provide a provider application and
5    the relevant terms and conditions to a health care
6    provider upon request.
7    (c) A carrier that uses a provider panel shall establish
8procedures for:
9        (1) notifying an enrollee of:
10            (A) the termination or nonrenewal from the
11        carrier's provider panel of a health care provider who
12        was furnishing health care services to the enrollee or
13        furnished health care services to the enrollee in the
14        6 months prior to the notice; and
15            (B) the right of an enrollee to continue to
16        receive health care services, as provided in
17        subsection (e), following the health care provider's
18        termination from a carrier's provider panel, except
19        when a health care provider is terminated for cause.
20        The notice required under this paragraph (1) shall be
21        provided at least 60 days prior to the date of
22        termination of the health care provider from a
23        carrier's provider panel in accordance with Section
24        20; and
25        (2) notifying a health care provider at least 60 days
26    prior to the termination of the health care provider from

 

 

HB5580- 4 -LRB103 38270 RPS 68405 b

1    a carrier's provider panel in accordance with Section 20.
2    (d) A carrier may not deny an application for
3participation or terminate participation on its provider panel
4on the basis of gender, race, age, sexual orientation, gender
5identity, religion, or national origin.
6    (e)(1) A health care provider shall be permitted by the
7carrier to render health care services to any of the carrier's
8enrollees for a period of at least 90 days from the date of the
9health care provider's termination from the carrier's provider
10panel, except when a health care provider is terminated for
11cause.
12    (2) Notwithstanding paragraph (1) of this subsection, any
13health care provider shall be permitted by the carrier to
14continue rendering health services to any enrollee who has
15been medically confirmed to be pregnant at the time of a
16provider's termination of participation, except when a health
17care provider is terminated for cause. That treatment shall,
18at the enrollee's option, continue through the provision of
19postpartum care directly relating to the delivery.
20    (3) Notwithstanding paragraph (1) of this subsection, any
21health care provider shall be permitted by the carrier to
22continue rendering health services to any enrollee who is
23determined to be terminally ill, as defined under Section
241861(dd)(3)(A) of the Social Security Act, at the time of a
25health care provider's termination of participation, except
26when a health care provider is terminated for cause. The

 

 

HB5580- 5 -LRB103 38270 RPS 68405 b

1treatment shall, at the enrollee's option, continue for the
2remainder of the enrollee's life for care directly related to
3the treatment of the terminal illness.
4    (4) Notwithstanding paragraph (1) of this subsection, any
5health care provider shall be permitted by the carrier to
6continue rendering health services to any enrollee who has
7been determined by a medical professional to have a
8life-threatening condition at the time of a health care
9provider's termination of participation. The treatment shall,
10at the enrollee's option, continue for up to 180 days for care
11directly related to the life-threatening condition.
12    (5) Notwithstanding paragraph (1) of this subsection, any
13health care provider shall be permitted by the carrier to
14continue rendering health services to any enrollee who is
15admitted to and receiving treatment in any inpatient facility
16at the time of a health care provider's termination of
17participation. Such admission and treatment shall continue
18until the enrollee is discharged from the inpatient facility.
19    (f) For any health care services received by an enrollee
20from a provider after the date the provider has been
21terminated from the carrier's provider panel:
22        (1) the carrier shall reimburse a health care provider
23    under this subsection in accordance with the carrier's
24    agreement with the health care provider existing
25    immediately before the health care provider's termination
26    of participation;

 

 

HB5580- 6 -LRB103 38270 RPS 68405 b

1        (2) the health care provider shall accept such
2    reimbursement from the carrier and any cost-sharing
3    payment from the enrollee for items and services as
4    payment in full; and
5        (3) the health care provider shall continue to adhere
6    to all policies and procedures and quality standards
7    imposed by the carrier for an enrollee that were required
8    of the provider immediately before the provider's
9    termination of participation.
10    (g) A carrier shall provide to a purchaser upon enrollment
11and make available to existing enrollees at least once a year a
12list of members in its provider panel, which list shall also
13indicate those providers who are not currently accepting new
14patients. This list shall also include all the information
15specified in subsection (a) of Section 15. This list may be
16made available in a form other than a printed document if the
17purchaser or existing enrollee is given the means to request
18and receive a printed copy of the list. If this information is
19provided in paper form, it shall be updated at least once a
20year. If this information is provided in electronic form, it
21shall be updated monthly.
22    (h) No contract between a carrier and a health care
23provider may require that the health care provider indemnify
24the carrier for the carrier's negligence, willful misconduct,
25or breach of contract, if any.
26    (i) No contract between a carrier and a health care

 

 

HB5580- 7 -LRB103 38270 RPS 68405 b

1provider shall require a provider, as a condition of
2participation on the panel, to waive any right to seek legal
3redress against the carrier.
4    (j) No contract between a carrier and a health care
5provider shall prohibit, impede, or interfere in the
6discussion of medical treatment options between a patient and
7a health care provider.
8    (k) Any carrier requiring preauthorization for medical
9treatment shall have personnel available to provide
10preauthorization at all times when the preauthorization is
11required.
12    (l) Carriers shall provide to their group policyholders
13written notice of any benefit reductions during the contract
14period at least 60 days before the benefit reductions take
15effect. Thereafter, group policyholders shall provide to their
16enrollees written notice of any benefit reductions during the
17contract period at least 30 days before the benefit reductions
18take effect. The notice shall be provided to the group
19policyholder as a separate distinct notification and may not
20be combined with any other notification or marketing
21materials.
22    (m) No contract between a health care provider and a
23carrier shall include provisions that require a health care
24provider to deny covered services that the provider knows to
25be medically necessary and appropriate that are provided with
26respect to a specific enrollee or group of enrollees with

 

 

HB5580- 8 -LRB103 38270 RPS 68405 b

1similar medical conditions.
2    (n) If a provider panel contract between a health care
3provider and a carrier, or other entity that provides
4hospital, physician, or other health care services to a
5carrier, includes provisions that require a provider, as a
6condition of participating in one of the carrier's or other
7entity's provider panels, to participate in any other provider
8panel owned or operated by that carrier or other entity, the
9contract shall contain a provision permitting the health care
10provider to refuse participation in one or more such other
11provider panels at the time the contract is executed. If a
12health care provider contracts with a carrier or other entity
13that subsequently contracts with one or more unaffiliated
14carriers to include the health care provider in the provider
15panels of the unaffiliated carriers, and the contract permits
16an unaffiliated carrier to impose participation terms with
17respect to the health care provider that differ materially in
18reimbursement rates or in managed care procedures, such as
19conducting economic profiling or requiring a patient to obtain
20primary care physician referral to a specialist, from the
21terms agreed to by the provider in the original contract, the
22provider panel contract shall contain a provision permitting
23the health care provider to refuse participation with any such
24unaffiliated carrier.
25    (o) A carrier that rents or leases its provider panel to
26unaffiliated carriers shall make available, upon request, to

 

 

HB5580- 9 -LRB103 38270 RPS 68405 b

1its health care providers a list of unaffiliated carriers that
2rent or lease its provider panel. If the list is provided in
3electronic form, the list shall be updated monthly. The health
4care provider shall be given the means to request and receive a
5printed copy of the list.