Full Text of SB2735 103rd General Assembly
SB2735eng 103RD GENERAL ASSEMBLY | | | SB2735 Engrossed | | LRB103 34765 RPS 64615 b |
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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 5. The Illinois Insurance Code is amended by | 5 | | adding Section 355.6 as follows: | 6 | | (215 ILCS 5/355.6 new) | 7 | | Sec. 355.6. Health care provider reimbursement. | 8 | | (a) In this Section, "health care provider" has the | 9 | | meaning given to the term "provider" in Section 370g. | 10 | | (b) Any group or individual policy of accident and health | 11 | | insurance or managed care plan amended, delivered, issued, or | 12 | | renewed on or after January 1, 2026 shall offer all reasonably | 13 | | available methods of payment from the insurer or managed care | 14 | | plan, or its contracted vendor, to the contracted health care | 15 | | provider, which shall include, but not be limited to, payment | 16 | | by check and electronic funds transfer. An insurer or managed | 17 | | care plan shall not mandate payment by credit card. For | 18 | | purposes of this subsection, "credit card" means a single-use | 19 | | or virtual credit card provided in an electronic, digital, | 20 | | facsimile, physical, or paper format. | 21 | | (c) If one of the available payment methods has a fee | 22 | | associated with it, the insurer or managed care plan, or its | 23 | | contracted vendor, shall, prior to initiating the first |
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| 1 | | payment to an in-network health care provider or upon changing | 2 | | the payment methods available to a health care provider: | 3 | | (1) notify the health care provider that there may be | 4 | | fees associated with a particular payment method and that | 5 | | the insurer or managed care plan, or its contracted | 6 | | vendor, shall disclose any fees beyond what the health | 7 | | care provider would normally pay to process a payment | 8 | | using that payment method; and | 9 | | (2) provide the health care provider with clear | 10 | | instructions on the insurer's or managed care plan's, or | 11 | | its contracted vendor's, website or through means other | 12 | | than the contract offered to the health care provider as | 13 | | to how to select each method. | 14 | | (d) If a health care provider requests a change in the | 15 | | available payment method, the insurer or managed care plan, or | 16 | | its contracted vendor, shall implement the change to the | 17 | | payment method selected by the health care provider within 30 | 18 | | business days, subject to federal and State verification | 19 | | measures to prevent fraud and abuse. | 20 | | (e) An insurer or managed care plan shall not use a health | 21 | | care provider's preferred method of payment as a factor when | 22 | | deciding whether to provide credentials to a health care | 23 | | provider. | 24 | | Section 10. The Health Maintenance Organization Act is | 25 | | amended by changing Section 5-3 as follows: |
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| 1 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | 2 | | Sec. 5-3. Insurance Code provisions. | 3 | | (a) Health Maintenance Organizations shall be subject to | 4 | | the provisions of Sections 133, 134, 136, 137, 139, 140, | 5 | | 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | 6 | | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | 7 | | 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1, 356m, 356q, | 8 | | 356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | 9 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 10 | | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | 11 | | 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, | 12 | | 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | 13 | | 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, | 14 | | 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | 15 | | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | 16 | | 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | 17 | | 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | 18 | | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | 19 | | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | 20 | | subsection (2) of Section 367, and Articles IIA, VIII 1/2, | 21 | | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | 22 | | Illinois Insurance Code. | 23 | | (b) For purposes of the Illinois Insurance Code, except | 24 | | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | 25 | | Health Maintenance Organizations in the following categories |
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| 1 | | are deemed to be "domestic companies": | 2 | | (1) a corporation authorized under the Dental Service | 3 | | Plan Act or the Voluntary Health Services Plans Act; | 4 | | (2) a corporation organized under the laws of this | 5 | | State; or | 6 | | (3) a corporation organized under the laws of another | 7 | | state, 30% or more of the enrollees of which are residents | 8 | | of this State, except a corporation subject to | 9 | | substantially the same requirements in its state of | 10 | | organization as is a "domestic company" under Article VIII | 11 | | 1/2 of the Illinois Insurance Code. | 12 | | (c) In considering the merger, consolidation, or other | 13 | | acquisition of control of a Health Maintenance Organization | 14 | | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | 15 | | (1) the Director shall give primary consideration to | 16 | | the continuation of benefits to enrollees and the | 17 | | financial conditions of the acquired Health Maintenance | 18 | | Organization after the merger, consolidation, or other | 19 | | acquisition of control takes effect; | 20 | | (2)(i) the criteria specified in subsection (1)(b) of | 21 | | Section 131.8 of the Illinois Insurance Code shall not | 22 | | apply and (ii) the Director, in making his determination | 23 | | with respect to the merger, consolidation, or other | 24 | | acquisition of control, need not take into account the | 25 | | effect on competition of the merger, consolidation, or | 26 | | other acquisition of control; |
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| 1 | | (3) the Director shall have the power to require the | 2 | | following information: | 3 | | (A) certification by an independent actuary of the | 4 | | adequacy of the reserves of the Health Maintenance | 5 | | Organization sought to be acquired; | 6 | | (B) pro forma financial statements reflecting the | 7 | | combined balance sheets of the acquiring company and | 8 | | the Health Maintenance Organization sought to be | 9 | | acquired as of the end of the preceding year and as of | 10 | | a date 90 days prior to the acquisition, as well as pro | 11 | | forma financial statements reflecting projected | 12 | | combined operation for a period of 2 years; | 13 | | (C) a pro forma business plan detailing an | 14 | | acquiring party's plans with respect to the operation | 15 | | of the Health Maintenance Organization sought to be | 16 | | acquired for a period of not less than 3 years; and | 17 | | (D) such other information as the Director shall | 18 | | require. | 19 | | (d) The provisions of Article VIII 1/2 of the Illinois | 20 | | Insurance Code and this Section 5-3 shall apply to the sale by | 21 | | any health maintenance organization of greater than 10% of its | 22 | | enrollee population (including , without limitation , the health | 23 | | maintenance organization's right, title, and interest in and | 24 | | to its health care certificates). | 25 | | (e) In considering any management contract or service | 26 | | agreement subject to Section 141.1 of the Illinois Insurance |
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| 1 | | Code, the Director (i) shall, in addition to the criteria | 2 | | specified in Section 141.2 of the Illinois Insurance Code, | 3 | | take into account the effect of the management contract or | 4 | | service agreement on the continuation of benefits to enrollees | 5 | | and the financial condition of the health maintenance | 6 | | organization to be managed or serviced, and (ii) need not take | 7 | | into account the effect of the management contract or service | 8 | | agreement on competition. | 9 | | (f) Except for small employer groups as defined in the | 10 | | Small Employer Rating, Renewability and Portability Health | 11 | | Insurance Act and except for medicare supplement policies as | 12 | | defined in Section 363 of the Illinois Insurance Code, a | 13 | | Health Maintenance Organization may by contract agree with a | 14 | | group or other enrollment unit to effect refunds or charge | 15 | | additional premiums under the following terms and conditions: | 16 | | (i) the amount of, and other terms and conditions with | 17 | | respect to, the refund or additional premium are set forth | 18 | | in the group or enrollment unit contract agreed in advance | 19 | | of the period for which a refund is to be paid or | 20 | | additional premium is to be charged (which period shall | 21 | | not be less than one year); and | 22 | | (ii) the amount of the refund or additional premium | 23 | | shall not exceed 20% of the Health Maintenance | 24 | | Organization's profitable or unprofitable experience with | 25 | | respect to the group or other enrollment unit for the | 26 | | period (and, for purposes of a refund or additional |
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| 1 | | premium, the profitable or unprofitable experience shall | 2 | | be calculated taking into account a pro rata share of the | 3 | | Health Maintenance Organization's administrative and | 4 | | marketing expenses, but shall not include any refund to be | 5 | | made or additional premium to be paid pursuant to this | 6 | | subsection (f)). The Health Maintenance Organization and | 7 | | the group or enrollment unit may agree that the profitable | 8 | | or unprofitable experience may be calculated taking into | 9 | | account the refund period and the immediately preceding 2 | 10 | | plan years. | 11 | | The Health Maintenance Organization shall include a | 12 | | statement in the evidence of coverage issued to each enrollee | 13 | | describing the possibility of a refund or additional premium, | 14 | | and upon request of any group or enrollment unit, provide to | 15 | | the group or enrollment unit a description of the method used | 16 | | to calculate (1) the Health Maintenance Organization's | 17 | | profitable experience with respect to the group or enrollment | 18 | | unit and the resulting refund to the group or enrollment unit | 19 | | or (2) the Health Maintenance Organization's unprofitable | 20 | | experience with respect to the group or enrollment unit and | 21 | | the resulting additional premium to be paid by the group or | 22 | | enrollment unit. | 23 | | In no event shall the Illinois Health Maintenance | 24 | | Organization Guaranty Association be liable to pay any | 25 | | contractual obligation of an insolvent organization to pay any | 26 | | refund authorized under this Section. |
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| 1 | | (g) Rulemaking authority to implement Public Act 95-1045, | 2 | | if any, is conditioned on the rules being adopted in | 3 | | accordance with all provisions of the Illinois Administrative | 4 | | Procedure Act and all rules and procedures of the Joint | 5 | | Committee on Administrative Rules; any purported rule not so | 6 | | adopted, for whatever reason, is unauthorized. | 7 | | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | 8 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | 9 | | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | 10 | | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | 11 | | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | 12 | | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | 13 | | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | 14 | | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | 15 | | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | 16 | | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | | | |
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