Illinois General Assembly - Full Text of SB1474
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Full Text of SB1474  99th General Assembly

SB1474 99TH GENERAL ASSEMBLY

  
  

 


 
99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB1474

 

Introduced 2/20/2015, by Sen. William R. Haine

 

SYNOPSIS AS INTRODUCED:
 
New Act

    Creates the Health Care Professional and Provider Notification of Patients in Health Insurance Exchange Grace Period Act. Provides that when a health care professional or provider or a representative of the health care professional or provider requests information from a QHP issuer regarding (i) an enrollee's eligibility, (ii) an enrollee's coverage or health plan benefits, or (iii) the status of a claim or claims for services provided to an enrollee, or reports a claim in a remittance advice, and the request or service is for a date within the second or third month of a grace period, the QHP issuer shall clearly identify that the applicable enrollee is in the grace period and provide additional information. Provides that if the QHP issuer informs the health care professional or provider or a representative of the health care professional or provider that the enrollee is eligible for services, and does not inform the health care professional or provider that the enrollee is in the grace period, that determination shall be binding on the QHP issuer, and the claim or claims for services rendered shall be paid by the QHP issuer. Requires QHP issuers to maintain a hotline for questions from a health care professional or provider. Requires that QHP issuers seeking to recoup claims made during the last 60 days of the grace period must commence such recovery or recoupment efforts no later than 60 days after the expiration of the grace period. Provides that the Director of Insurance shall investigate all complaints of violations of the Act. Provides that the Director shall issue cease and desist orders to any QHP issuers found to be in violation of the Act. Provides that failure to comply with a cease and desist order shall result in fines of $1,000 for each violation, and each day the QHP issuer is in violation of the Act is a separate offense. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be cited as the Health
5Care Professional and Provider Notification of Patients in
6Health Insurance Exchange Grace Period Act.
 
7    Section 5. Purpose. The General Assembly hereby finds that:
8        (1) the federal Patient Protection and Affordable Care
9    Act provides that, for enrollees who receive an Advance
10    Premium Tax Credit, if they fail to pay their premiums,
11    they may remain eligible for services for 90 days;
12        (2) this 90-day grace period is provided for in 45 CFR
13    156.270(d);
14        (3) for the first month of the grace period, the PPACA
15    requires that Qualified Health Plan or QHP issuers pay
16    health care professionals or providers for services
17    rendered to enrollees;
18        (4) for the second and third months of the grace
19    period, the QHP issuer may pend claim or claims for
20    services rendered;
21        (5) if the enrollee fails to pay his or her outstanding
22    premium before the end of the grace period, the QHP issuer
23    may deny the claim or claims for services rendered to the

 

 

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1    enrollee during the second and third months of the grace
2    period;
3        (6) if a QHP issuer denies the claim or claims for
4    services rendered, this will create a financial burden on
5    health care professionals and providers as well as a
6    disincentive for participating in the health care exchange
7    in our state;
8        (7) when a patient enters into the second and third
9    months of the grace period, the PPACA requires that QHP
10    issuers notify the enrollee's health care professional or
11    provider, but this notification requirement is vague and
12    does not indicate when such notification must be made; and
13        (8) unless health care professionals and providers are
14    notified as soon as possible that an enrollee has entered
15    into the second or third month of the grace period, health
16    care professionals and providers cannot anticipate or
17    mitigate the effect of claims denials and otherwise manage
18    the financial aspects of their practices.
 
19    Section 10. Definitions. For purposes of this Act:
20    "Director" means the Director of Insurance.
21    "Enrollee" means a qualified individual or qualified
22employee enrolled in a QHP or other health insurance plan.
23    "Grace period" means a period that applies to recipients of
24advance payments of the premium tax credit allowed for certain
25individuals to purchase health insurance coverage on the

 

 

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1Exchange. The grace period provides 3 consecutive months of
2eligibility for health care services to an enrollee when that
3enrollee has paid at least one full month's premium during the
4benefit year. The grace period begins when the enrollee fails
5to pay the premium for a particular month.
6    "Health care professional or provider" means any
7physician, hospital facility, facility licensed under the
8Nursing Home Care Act, or other person that is licensed or
9otherwise authorized to deliver health care services.
10    "Health insurance exchange" or "Exchange" means a
11governmental agency or non-profit entity that meets the
12applicable standards of the PPACA and makes QHPs available to
13qualified individuals and qualified employers.
14    "PPACA" means the federal Patient Protection and
15Affordable Care Act.
16    "Qualified health plan" or "QHP" means a health insurance
17plan that has in effect a certification that the health
18insurance plan meets applicable State or federal standards, or
19both, required for participation in a health insurance
20exchange. These may include minimum standards for essential
21health benefits, deductibles, copayments, out-of-pocket
22maximum amounts, and other requirements.
23    "Qualified health plan issuer" or "QHP issuer" means a
24health insurance issuer that offers a QHP in accordance with a
25certification from an exchange.
 

 

 

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1    Section 15. Notice requirements.
2    (a) Timing of notice to health care professional or
3provider of grace period status.
4        (1) When a health care professional or provider or a
5    representative of the health care professional or provider
6    requests information from a QHP issuer regarding (i) an
7    enrollee's eligibility, (ii) an enrollee's coverage or
8    health plan benefits, or (iii) the status of a claim or
9    claims for services provided to an enrollee, or reports a
10    claim in a remittance advice, and the request or service is
11    for a date within the second or third month of a grace
12    period, the QHP issuer shall clearly identify that the
13    applicable enrollee is in the grace period and provide
14    information as required by subsection (c) of this Section.
15        (2) The QHP issuer must provide this notice through the
16    same medium through which the health care professional or
17    provider or representative sought information from the QHP
18    issuer concerning the enrollee's eligibility, coverage or
19    health plan benefits, or related claims status, or normally
20    receives claim remittance advice information.
21        (3) The information provided about the enrollee's
22    grace period status shall be binding on the QHP pursuant to
23    this Act.
24        (4) The Department of Insurance shall provide specific
25    technical guidance governing these notice requirements
26    within 60 days after the effective date of this Act.

 

 

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1    (b) Specific notice requirements.
2        (1) If the QHP issuer informs the health care
3    professional or provider or a representative of the health
4    care professional or provider that the enrollee is eligible
5    for services, and does not inform the health care
6    professional or provider that the enrollee is in the grace
7    period, that determination shall be binding on the QHP
8    issuer, and the claim or claims for services rendered shall
9    be paid by the QHP issuer.
10        (2) This binding determination shall further preclude
11    the QHP issuer from seeking to recoup payment from the
12    health care professional or provider.
13        (3) If the QHP informs the health care professional or
14    provider that the enrollee is in the grace period, then the
15    QHP issuer must provide notification pursuant to
16    subsection (c) of this Section.
17    (c) Contents of notice. The notice to the health care
18professional or provider shall include, but not be limited to,
19the following:
20        (1) the purpose of the notice;
21        (2) the enrollee's full legal name and any unique
22    numbers identifying the enrollee;
23        (3) the name of the QHP;
24        (4) the QHP's unique health plan identifier;
25        (5) the name of the QHP issuer; and
26        (6) the specific date upon which the grace period for

 

 

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1    the enrollee began and the specific date upon which the
2    grace period will expire.
3    (d) The QHP issuer shall include in a conspicuous manner on
4the Exchange's and the QHP's website, an explanation of the
5action the QHP issuer intends to take, both during the grace
6period and upon the grace period's exhaustion, for the enrollee
7and the health care professional or provider, including further
8options for the health care professional or provider. This
9shall include:
10        (1) whether the QHP issuer will pend any claims of the
11    health care professional or provider for services that the
12    health care professional or provider furnishes to the
13    enrollee during the grace period;
14        (2) a statement indicating that, should the QHP issuer
15    indicate that it will pay some or all of the claims for
16    services provided to an enrollee during the grace period,
17    whether and how the QHP issuer will seek to recoup claims
18    payments made to health care professionals or providers for
19    services furnished during the grace period.
 
20    Section 20. Health care professional/provider assistance
21hotline. The QHP issuer must make available a health care
22professional/provider assistance hotline that is staffed by
23qualified personnel who are available within 24 hours to speak
24directly with the health care professional or provider, or the
25health care professional's or provider's representative. Staff

 

 

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1must be available from at least 8:00 a.m. to 5:00 p.m. on
2weekdays and 8:00 a.m. to 12:00 p.m. on Saturdays.
 
3    Section 25. Strict compliance required. If the QHP issuer
4fails to strictly comply with the requirements of this Act,
5then the QHP issuer is obligated to pay for any and all claims
6for services furnished by the health care professional or
7provider to an enrollee during the time in which the enrollee
8is in the grace period.
 
9    Section 30. Deadline for overpayment recoveries. If the QHP
10issuer seeks to recoup or otherwise recover payments made to
11the health care professional or provider for services the
12health care professional or provider furnished to an enrollee
13during the grace period, then the QHP issuer must commence such
14recovery or recoupment efforts no later than 60 days after the
15expiration of the grace period. Any attempts to recover these
16payments that are commenced subsequent to this 60-day period
17shall be null and void.
 
18    Section 35. Waiver prohibited. The provisions of this Act
19may not be waived by contract, and any contractual arrangements
20in conflict with the provisions of this Act or that purport to
21waive any requirements of this Act are null and void.
 
22    Section 40. Injunction. Any health care professional or

 

 

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1provider may request an appropriate court of competent
2jurisdiction to issue an injunction to enforce any provision of
3this Act.
 
4    Section 45. Penalties. The Director shall investigate all
5complaints of violations of this Act. The Director shall issue
6a cease and desist order to any QHP issuers found to be in
7violation of this Act. Failure to comply with a cease and
8desist order shall automatically result in fines of $1,000 for
9each violation, and each day the QHP issuer is in violation of
10this Act constitutes a separate offense.
 
11    Section 97. Severability. The provisions of this Act are
12severable under Section 1.31 of the Statute on Statutes.
 
13    Section 99. Effective date. This Act takes effect upon
14becoming law.