99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB2379

 

Introduced 2/3/2016, by Sen. William R. Haine

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/368d.1 new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003  from Ch. 73, par. 1504-3
215 ILCS 134/37 new
215 ILCS 165/10  from Ch. 32, par. 604
305 ILCS 5/5-16.8

    Amends the Illinois Insurance Code. Provides that on and after the effective date of the amendatory Act, no insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance or a qualified health plan offered through the health insurance marketplace in this State providing coverage for hospital or any other health care service shall use extrapolation or any other form of statistical sampling methodology to recoup payments for services rendered by any health care professional or provider. Provides that the use of extrapolation or any other form of statistical sampling methodology shall be an unfair and deceptive act under the Code. Requires any request for recoupment or offset be in writing and include every contested Current Procedural Terminology code and patient encounter data. Requires a minimum of 120 days after the information is provided to respond to requests for recoupment and offsets. Provides that no recoupment or offset may be made unless the provisions are complied with. Provides that the provisions may be enforced by a health care professional or provider through a court of competent jurisdiction or through mandatory arbitration with the right to recover attorney's fees. Makes similar changes in the Managed Care Reform and Patient Rights Act for health care plans. Amends the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Health Maintenance Organization Act, Limited Health Service Organization Act, Voluntary Health Services Plans Act, and Illinois Public Aide Code to make conforming changes.


LRB099 15726 MLM 40025 b

 

 

A BILL FOR

 

SB2379LRB099 15726 MLM 40025 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 State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, 356z.17, and 356z.22 of the Illinois
16Insurance Code. The program of health benefits must comply with
17Sections 155.22a, 155.37, 355b, 356z.19, 368d.1, 370c, and
18370c.1 of the Illinois Insurance Code.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2(Source: P.A. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15;
399-480, eff. 9-9-15.)
 
4    Section 10. The Counties Code is amended by changing
5Section 5-1069.3 as follows:
 
6    (55 ILCS 5/5-1069.3)
7    Sec. 5-1069.3. Required health benefits. If a county,
8including a home rule county, is a self-insurer for purposes of
9providing health insurance coverage for its employees, the
10coverage shall include coverage for the post-mastectomy care
11benefits required to be covered by a policy of accident and
12health insurance under Section 356t and the coverage required
13under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, and 356z.22 of the Illinois Insurance Code.
16The coverage shall comply with Sections 155.22a, 355b, 356z.19,
17368d.1, and 370c of the Illinois Insurance Code. The
18requirement that health benefits be covered as provided in this
19Section is an exclusive power and function of the State and is
20a denial and limitation under Article VII, Section 6,
21subsection (h) of the Illinois Constitution. A home rule county
22to which this Section applies must comply with every provision
23of this Section.
24    Rulemaking authority to implement Public Act 95-1045, if

 

 

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1any, is conditioned on the rules being adopted in accordance
2with all provisions of the Illinois Administrative Procedure
3Act and all rules and procedures of the Joint Committee on
4Administrative Rules; any purported rule not so adopted, for
5whatever reason, is unauthorized.
6(Source: P.A. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15;
799-480, eff. 9-9-15.)
 
8    Section 15. The Illinois Municipal Code is amended by
9changing Section 10-4-2.3 as follows:
 
10    (65 ILCS 5/10-4-2.3)
11    Sec. 10-4-2.3. Required health benefits. If a
12municipality, including a home rule municipality, is a
13self-insurer for purposes of providing health insurance
14coverage for its employees, the coverage shall include coverage
15for the post-mastectomy care benefits required to be covered by
16a policy of accident and health insurance under Section 356t
17and the coverage required under Sections 356g, 356g.5,
18356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
19356z.11, 356z.12, 356z.13, 356z.14, 356z.15, and 356z.22 of the
20Illinois Insurance Code. The coverage shall comply with
21Sections 155.22a, 355b, 356z.19, 368d.1, and 370c of the
22Illinois Insurance Code. The requirement that health benefits
23be covered as provided in this is an exclusive power and
24function of the State and is a denial and limitation under

 

 

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1Article VII, Section 6, subsection (h) of the Illinois
2Constitution. A home rule municipality to which this Section
3applies must comply with every provision of this Section.
4    Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15;
1199-480, eff. 9-9-15.)
 
12    Section 20. The School Code is amended by changing Section
1310-22.3f as follows:
 
14    (105 ILCS 5/10-22.3f)
15    Sec. 10-22.3f. Required health benefits. Insurance
16protection and benefits for employees shall provide the
17post-mastectomy care benefits required to be covered by a
18policy of accident and health insurance under Section 356t and
19the coverage required under Sections 356g, 356g.5, 356g.5-1,
20356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
21356z.13, 356z.14, 356z.15, and 356z.22 of the Illinois
22Insurance Code. Insurance policies shall comply with Section
23356z.19 of the Illinois Insurance Code. The coverage shall
24comply with Sections 155.22a, and 355b, and 368d.1 of the

 

 

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1Illinois Insurance Code.
2    Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
9eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
10    Section 25. The Illinois Insurance Code is amended by
11adding Section 368d.1 as follows:
 
12    (215 ILCS 5/368d.1 new)
13    Sec. 368d.1. Recoupment and offsets for medical benefit
14payments. On and after the effective date of this amendatory
15Act of the 99th General Assembly, no insurer that amends,
16delivers, issues, or renews a group or individual policy of
17accident and health insurance or a qualified health plan
18offered through the health insurance marketplace in this State
19providing coverage for hospital or any other health care
20service shall use extrapolation or any other form of
21statistical sampling methodology to recoup payments for
22services rendered by any health care professional or provider.
23The use of extrapolation or any other form of statistical
24sampling methodology shall be an unfair and deceptive act under

 

 

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1Section 424 of this Code. Any request for recoupment or offset
2must be in writing and include every contested Current
3Procedural Terminology (CPT) code and patient encounter data,
4complete with date of service and patient name. A minimum of
5120 days shall be provided to respond to requests for
6recoupment or offsets once the information required by this
7Section is provided to the health care professional or
8provider. No recoupment or offset may be made unless the
9requirements of this Section are complied with. Any violation
10of this provision may be enforced by a health care professional
11or provider through a court of competent jurisdiction in
12Illinois or through mandatory arbitration with the right to
13recover attorney's fees.
 
14    Section 30. The Health Maintenance Organization Act is
15amended by changing Section 5-3 as follows:
 
16    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
17    Sec. 5-3. Insurance Code provisions.
18    (a) Health Maintenance Organizations shall be subject to
19the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
20141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
21154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
22355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
23356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
24356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,

 

 

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1356z.22, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
2368d.1, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408,
3408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
4(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
5XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
6    (b) For purposes of the Illinois Insurance Code, except for
7Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
8Maintenance Organizations in the following categories are
9deemed to be "domestic companies":
10        (1) a corporation authorized under the Dental Service
11    Plan Act or the Voluntary Health Services Plans Act;
12        (2) a corporation organized under the laws of this
13    State; or
14        (3) a corporation organized under the laws of another
15    state, 30% or more of the enrollees of which are residents
16    of this State, except a corporation subject to
17    substantially the same requirements in its state of
18    organization as is a "domestic company" under Article VIII
19    1/2 of the Illinois Insurance Code.
20    (c) In considering the merger, consolidation, or other
21acquisition of control of a Health Maintenance Organization
22pursuant to Article VIII 1/2 of the Illinois Insurance Code,
23        (1) the Director shall give primary consideration to
24    the continuation of benefits to enrollees and the financial
25    conditions of the acquired Health Maintenance Organization
26    after the merger, consolidation, or other acquisition of

 

 

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1    control takes effect;
2        (2)(i) the criteria specified in subsection (1)(b) of
3    Section 131.8 of the Illinois Insurance Code shall not
4    apply and (ii) the Director, in making his determination
5    with respect to the merger, consolidation, or other
6    acquisition of control, need not take into account the
7    effect on competition of the merger, consolidation, or
8    other acquisition of control;
9        (3) the Director shall have the power to require the
10    following information:
11            (A) certification by an independent actuary of the
12        adequacy of the reserves of the Health Maintenance
13        Organization sought to be acquired;
14            (B) pro forma financial statements reflecting the
15        combined balance sheets of the acquiring company and
16        the Health Maintenance Organization sought to be
17        acquired as of the end of the preceding year and as of
18        a date 90 days prior to the acquisition, as well as pro
19        forma financial statements reflecting projected
20        combined operation for a period of 2 years;
21            (C) a pro forma business plan detailing an
22        acquiring party's plans with respect to the operation
23        of the Health Maintenance Organization sought to be
24        acquired for a period of not less than 3 years; and
25            (D) such other information as the Director shall
26        require.

 

 

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1    (d) The provisions of Article VIII 1/2 of the Illinois
2Insurance Code and this Section 5-3 shall apply to the sale by
3any health maintenance organization of greater than 10% of its
4enrollee population (including without limitation the health
5maintenance organization's right, title, and interest in and to
6its health care certificates).
7    (e) In considering any management contract or service
8agreement subject to Section 141.1 of the Illinois Insurance
9Code, the Director (i) shall, in addition to the criteria
10specified in Section 141.2 of the Illinois Insurance Code, take
11into account the effect of the management contract or service
12agreement on the continuation of benefits to enrollees and the
13financial condition of the health maintenance organization to
14be managed or serviced, and (ii) need not take into account the
15effect of the management contract or service agreement on
16competition.
17    (f) Except for small employer groups as defined in the
18Small Employer Rating, Renewability and Portability Health
19Insurance Act and except for medicare supplement policies as
20defined in Section 363 of the Illinois Insurance Code, a Health
21Maintenance Organization may by contract agree with a group or
22other enrollment unit to effect refunds or charge additional
23premiums under the following terms and conditions:
24        (i) the amount of, and other terms and conditions with
25    respect to, the refund or additional premium are set forth
26    in the group or enrollment unit contract agreed in advance

 

 

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1    of the period for which a refund is to be paid or
2    additional premium is to be charged (which period shall not
3    be less than one year); and
4        (ii) the amount of the refund or additional premium
5    shall not exceed 20% of the Health Maintenance
6    Organization's profitable or unprofitable experience with
7    respect to the group or other enrollment unit for the
8    period (and, for purposes of a refund or additional
9    premium, the profitable or unprofitable experience shall
10    be calculated taking into account a pro rata share of the
11    Health Maintenance Organization's administrative and
12    marketing expenses, but shall not include any refund to be
13    made or additional premium to be paid pursuant to this
14    subsection (f)). The Health Maintenance Organization and
15    the group or enrollment unit may agree that the profitable
16    or unprofitable experience may be calculated taking into
17    account the refund period and the immediately preceding 2
18    plan years.
19    The Health Maintenance Organization shall include a
20statement in the evidence of coverage issued to each enrollee
21describing the possibility of a refund or additional premium,
22and upon request of any group or enrollment unit, provide to
23the group or enrollment unit a description of the method used
24to calculate (1) the Health Maintenance Organization's
25profitable experience with respect to the group or enrollment
26unit and the resulting refund to the group or enrollment unit

 

 

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1or (2) the Health Maintenance Organization's unprofitable
2experience with respect to the group or enrollment unit and the
3resulting additional premium to be paid by the group or
4enrollment unit.
5    In no event shall the Illinois Health Maintenance
6Organization Guaranty Association be liable to pay any
7contractual obligation of an insolvent organization to pay any
8refund authorized under this Section.
9    (g) Rulemaking authority to implement Public Act 95-1045,
10if any, is conditioned on the rules being adopted in accordance
11with all provisions of the Illinois Administrative Procedure
12Act and all rules and procedures of the Joint Committee on
13Administrative Rules; any purported rule not so adopted, for
14whatever reason, is unauthorized.
15(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437,
16eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805,
17eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14;
1898-1091, eff. 1-1-15.)
 
19    Section 35. The Limited Health Service Organization Act is
20amended by changing Section 4003 as follows:
 
21    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
22    Sec. 4003. Illinois Insurance Code provisions. Limited
23health service organizations shall be subject to the provisions
24of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,

 

 

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1143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
2154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v,
3356z.10, 356z.21, 356z.22, 368a, 368d.1, 401, 401.1, 402, 403,
4403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles IIA,
5VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the
6Illinois Insurance Code. For purposes of the Illinois Insurance
7Code, except for Sections 444 and 444.1 and Articles XIII and
8XIII 1/2, limited health service organizations in the following
9categories are deemed to be domestic companies:
10        (1) a corporation under the laws of this State; or
11        (2) a corporation organized under the laws of another
12    state, 30% of more of the enrollees of which are residents
13    of this State, except a corporation subject to
14    substantially the same requirements in its state of
15    organization as is a domestic company under Article VIII
16    1/2 of the Illinois Insurance Code.
17(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff.
181-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091,
19eff. 1-1-15.)
 
20    Section 40. The Managed Care Reform and Patient Rights Act
21is amended by adding Section 37 as follows:
 
22    (215 ILCS 134/37 new)
23    Sec. 37. Recoupment and offsets for medical benefit
24payments. On and after the effective date of this amendatory

 

 

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1Act of the 99th General Assembly, no health care plan providing
2coverage for hospital or any other health care service shall
3use extrapolation, offsets, or any other form of statistical
4sampling methodology to recoup payments for services rendered
5by any health care professional or provider. The use of
6extrapolation or any other form of statistical sampling
7methodology shall be an unfair and deceptive act under Section
8424 of the Illinois Insurance Code. Any request for recoupment
9or offset must be in writing and include every contested
10Current Procedural Terminology (CPT) code and patient
11encounter data, complete with date of service and patient name.
12A minimum of 120 days shall be provided to respond to requests
13for recoupment or offsets once the information required by this
14Section is provided to the health care professional or
15provider. No recoupment or offset may be made unless the
16requirements of this Section are complied with. Any violation
17of this provision may be enforced by a health care professional
18or provider through a court of competent jurisdiction in
19Illinois or through mandatory arbitration with the right to
20recover attorney's fees.
 
21    Section 45. The Voluntary Health Services Plans Act is
22amended by changing Section 10 as follows:
 
23    (215 ILCS 165/10)  (from Ch. 32, par. 604)
24    Sec. 10. Application of Insurance Code provisions. Health

 

 

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1services plan corporations and all persons interested therein
2or dealing therewith shall be subject to the provisions of
3Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
4143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
5356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
6356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
7356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
8356z.19, 356z.21, 356z.22, 364.01, 367.2, 368a, 368d.1, 401,
9401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
10and (15) of Section 367 of the Illinois Insurance Code.
11    Rulemaking authority to implement Public Act 95-1045, if
12any, is conditioned on the rules being adopted in accordance
13with all provisions of the Illinois Administrative Procedure
14Act and all rules and procedures of the Joint Committee on
15Administrative Rules; any purported rule not so adopted, for
16whatever reason, is unauthorized.
17(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486,
18eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813,
19eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
20    Section 50. The Illinois Public Aid Code is amended by
21changing Section 5-16.8 as follows:
 
22    (305 ILCS 5/5-16.8)
23    Sec. 5-16.8. Required health benefits. The medical
24assistance program shall (i) provide the post-mastectomy care

 

 

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1benefits required to be covered by a policy of accident and
2health insurance under Section 356t and the coverage required
3under Sections 356g.5, 356u, 356w, 356x, and 356z.6 of the
4Illinois Insurance Code and (ii) be subject to the provisions
5of Sections 356z.19, 364.01, 368d.1, 370c, and 370c.1 of the
6Illinois Insurance Code.
7    On and after July 1, 2012, the Department shall reduce any
8rate of reimbursement for services or other payments or alter
9any methodologies authorized by this Code to reduce any rate of
10reimbursement for services or other payments in accordance with
11Section 5-5e.
12    To ensure full access to the benefits set forth in this
13Section, on and after January 1, 2016, the Department shall
14ensure that provider and hospital reimbursement for
15post-mastectomy care benefits required under this Section are
16no lower than the Medicare reimbursement rate.
17(Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15;
18revised 10-21-15.)