Full Text of SB0174 101st General Assembly
SB0174 101ST GENERAL ASSEMBLY |
| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020 SB0174 Introduced 1/30/2019, by Sen. John G. Mulroe SYNOPSIS AS INTRODUCED: |
| New Act | | 215 ILCS 5/352 | from Ch. 73, par. 964 |
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Creates the In-Office Membership Care Act. Provides the requirements for an in-office membership care agreement between a primary care provider and patient. Provides where in-office membership care services may be provided. Provides that an in-office membership care agreement is not subject to the Illinois Insurance Code and that services provided under an in-office membership care agreement shall not be submitted to an insurer for payment. Provides a disclaimer each in-office membership care agreement shall include concerning not providing health insurance coverage. Provides restrictions on the transfer of an in-office membership care agreement. Provides that the Act does not prohibit health care providers who are not primary care providers from entering into agreements with patients. Makes conforming changes in the Illinois Insurance Code. Effective immediately.
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 1. Short title. This Act may be cited as the | 5 | | In-Office Membership Care Act. | 6 | | Section 5. Public policy. It is the policy of the State of | 7 | | Illinois to promote personal responsibility for health care and | 8 | | the cost-effective delivery of medical and dental services by | 9 | | encouraging innovative use of in-office membership care | 10 | | practices for primary medical care. In-office membership care | 11 | | practices utilize a model of periodic fees for provider access | 12 | | and management over time, rather than simply a fee for visit or | 13 | | procedure service model. Some patients and individual primary | 14 | | care providers may wish to establish direct agreements with one | 15 | | another as an alternative to traditional fee-for-service care | 16 | | financed through health insurance. The purpose of this Act is | 17 | | to confirm that in-office membership care agreements that | 18 | | satisfy the provisions of this Act do not constitute insurance | 19 | | and as such are not subject to the Illinois Insurance Code. | 20 | | Section 10. Definitions. In this Act: | 21 | | "Direct fee" means an agreed-upon fee charged by a primary | 22 | | care provider as consideration for providing and being |
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| 1 | | available to provide in-office membership care services | 2 | | described in an in-office membership care agreement. | 3 | | "In-office membership care agreement" means a written | 4 | | contract between a primary care provider or group of providers | 5 | | and an individual patient, the patient's family, or the | 6 | | patient's representative in which the primary care provider | 7 | | agrees to provide in-office membership care services to the | 8 | | patient over a specified period of time for payment of a direct | 9 | | fee. | 10 | | "In-office membership care services" means services that a | 11 | | primary care provider is licensed or otherwise legally | 12 | | authorized to provide, including, but not limited to, (i) | 13 | | screening, assessment, diagnosis, and treatment for the | 14 | | purpose of promoting health; (ii) detection, management, and | 15 | | care of disease or injury; and (iii) routine preventive or | 16 | | diagnostic dental treatment. | 17 | | "Patient" means a person who is entitled to receive | 18 | | in-office membership care services under an in-office | 19 | | membership care agreement. | 20 | | "Primary care provider" means a natural person or persons | 21 | | licensed or otherwise legally authorized to provide health care | 22 | | services in the State of Illinois in the field of pediatrics, | 23 | | family medicine, internal medicine, or dentistry who provides | 24 | | such services either alone or with others at the same location | 25 | | or other location affiliated with the practice in a form and | 26 | | within a scope permitted by such licensure or legal |
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| 1 | | authorization for the provision of such services and who enters | 2 | | into an in-office membership care agreement. | 3 | | Section 15. In-office membership care agreement | 4 | | provisions. | 5 | | (a) An in-office membership care agreement shall identify: | 6 | | (1) the primary care provider or providers and the | 7 | | patient or patients; | 8 | | (2) the general scope of services as well as the | 9 | | specific services to be provided by the primary care | 10 | | provider as part of the in-office membership care | 11 | | agreement; | 12 | | (3) the location or locations where services are to be | 13 | | provided; | 14 | | (4) the amount of the direct fee and the time interval | 15 | | at which it is to be paid; and | 16 | | (5) the term of the in-office membership care agreement | 17 | | and the conditions upon which it may be terminated by the | 18 | | primary care provider. | 19 | | (b) An in-office membership care agreement shall be | 20 | | terminable at will by written notice from the patient to the | 21 | | primary care provider. | 22 | | (c) If a party provides written notice of termination of | 23 | | the in-office membership care agreement, the primary care | 24 | | provider may refund to the patient all unearned direct fees | 25 | | associated with the covered services under the in-office |
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| 1 | | membership care agreement. | 2 | | Section 20. Location of in-office membership care | 3 | | services. In-office membership care services may be provided in | 4 | | a primary care provider's office, the patient's home, or | 5 | | another location in which a patient visit with the primary care | 6 | | provider needs to occur. | 7 | | Section 25. Insurance billing prohibited. Neither the | 8 | | patient nor the primary care provider shall submit a bill to an | 9 | | insurer for the services provided under an in-office membership | 10 | | care agreement. | 11 | | Section 30. In-office membership care agreements not | 12 | | classified as insurance. In-office membership care agreements | 13 | | are not subject to regulation as insurance under the Illinois | 14 | | Insurance Code. | 15 | | Section 35. Disclaimer. An in-office membership care | 16 | | agreement shall include the following disclaimer: "This | 17 | | agreement does not provide health insurance coverage, | 18 | | including the minimal essential coverage required by | 19 | | applicable federal law. It provides only the services described | 20 | | herein. It is recommended that health care insurance be | 21 | | obtained to cover medical or dental services not provided for | 22 | | under this in-office membership care agreement.". |
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| 1 | | Section 40. Restrictions on transfer. An in-office | 2 | | membership care agreement may not be sold or transferred by the | 3 | | primary care provider without the written consent of the | 4 | | patient and may be transferred only to another primary care | 5 | | provider. An in-office membership care agreement may not be | 6 | | sold to a group, employer or group of subscribers because it is | 7 | | an individual agreement between a primary care provider and a | 8 | | patient. These limitations do not prohibit the presentation of | 9 | | marketing materials to groups of potential patients or their | 10 | | representatives. | 11 | | Section 45. Effect of this Act. This Act does not prohibit | 12 | | health care providers who are not primary care providers from | 13 | | entering into agreements with patients to the extent such | 14 | | agreements do not violate the provisions of the Illinois | 15 | | Insurance Code. | 16 | | Section 80. The Illinois Insurance Code is amended by | 17 | | changing Section 352 as follows:
| 18 | | (215 ILCS 5/352) (from Ch. 73, par. 964)
| 19 | | Sec. 352. Scope of Article.
| 20 | | (a) Except as provided in subsections (b), (c), (d), and | 21 | | (e),
this Article shall
apply to all companies transacting in | 22 | | this State the kinds of business
enumerated in clause (b) of |
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| 1 | | Class 1 and clause (a) of Class 2 of section 4.
Nothing in this | 2 | | Article shall apply to, or in any way affect policies or
| 3 | | contracts described in clause (a) of Class 1 of Section 4; | 4 | | however, this
Article shall apply to policies and contracts | 5 | | which contain benefits
providing reimbursement for the | 6 | | expenses of long term health care which are
certified or | 7 | | ordered by a physician including but not limited to
| 8 | | professional nursing care, custodial nursing care, and | 9 | | non-nursing
custodial care provided in a nursing home or at a | 10 | | residence of the insured.
| 11 | | (b) (Blank).
| 12 | | (c) A policy issued and delivered in this State
that | 13 | | provides coverage under that policy for
certificate holders who | 14 | | are neither residents of nor employed in this State
does not | 15 | | need to provide to those nonresident
certificate holders who | 16 | | are not employed in this State the coverages or
services | 17 | | mandated by this Article.
| 18 | | (d) Stop-loss insurance is exempt from all Sections
of this | 19 | | Article, except this Section and Sections 353a, 354, 357.30, | 20 | | and
370. For purposes of this exemption, stop-loss insurance is | 21 | | further defined as
follows:
| 22 | | (1) The policy must be issued to and insure an | 23 | | employer, trustee, or other
sponsor of the plan, or the | 24 | | plan itself, but not employees, members, or
participants.
| 25 | | (2) Payments by the insurer must be made to the | 26 | | employer, trustee, or
other sponsors of the plan, or the |
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| 1 | | plan itself, but not to the employees,
members, | 2 | | participants, or health care providers.
| 3 | | (e) A policy issued or delivered in this State to the | 4 | | Department of Healthcare and Family Services (formerly
| 5 | | Illinois Department
of Public Aid) and providing coverage, | 6 | | under clause (b) of Class 1 or clause (a)
of Class 2 as | 7 | | described in Section 4, to persons who are enrolled under | 8 | | Article V of the Illinois
Public Aid Code or under the | 9 | | Children's Health Insurance Program Act is
exempt from all | 10 | | restrictions, limitations,
standards, rules, or regulations | 11 | | respecting benefits imposed by or under
authority of this Code, | 12 | | except those specified by subsection (1) of Section
143, | 13 | | Section 370c, and Section 370c.1. Nothing in this subsection, | 14 | | however, affects the total medical services
available to | 15 | | persons eligible for medical assistance under the Illinois | 16 | | Public
Aid Code.
| 17 | | (f) An in-office membership care agreement provided under | 18 | | the In-Office Membership Care Act is not insurance for the | 19 | | purposes of this Code. | 20 | | (Source: P.A. 99-480, eff. 9-9-15.)
| 21 | | Section 99. Effective date. This Act takes effect upon | 22 | | becoming law.
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