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90_HB0535eng
5 ILCS 375/6.9 new
30 ILCS 805/8.21 new
55 ILCS 5/5-1069.3 new
65 ILCS 5/10-4-2.3 new
105 ILCS 5/10-22.3f new
215 ILCS 5/155.31 new
215 ILCS 5/511.114 new
215 ILCS 105/8.7 new
215 ILCS 125/4-6.5 new
215 ILCS 130/4003 from Ch. 73, par. 1504-3
215 ILCS 165/10 from Ch. 32, par. 604
Amends the State Employees Group Insurance Act of 1971,
Counties Code, Illinois Municipal Code, School Code, Illinois
Insurance Code, Comprehensive Health Insurance Plan Act,
Health Maintenance Organization Act, Limited Health Service
Organization Act, and Voluntary Health Services Plans Act.
Provides that notices of payment and denial of health care
benefits subject to those Acts and under managed care plans
must provide detailed statements of payment and denial of
benefits. Requires notices of denial to be signed by the
individual responsible for the denial. Requires the notice
to disclose the address and telephone number of the
individual responsible for the denial. Provides that appeal
procedures must be clearly set forth in the notice. Amends
the State Mandates Act to provide that reimbursement is not
required under that Act.
LRB9002122JSgc
HB0535 Engrossed LRB9002122JSgc
1 AN ACT concerning health benefit notices, amending named
2 Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The State Employees Group Insurance Act of
6 1971 is amended by adding Section 6.9 as follows:
7 (5 ILCS 375/6.9 new)
8 Sec. 6.9. Benefit notices. The program of health
9 benefits shall provide the benefit payment and denial notices
10 required under Section 155.31 of the Illinois Insurance Code.
11 Section 10. The State Mandates Act is amended by adding
12 Section 8.21 as follows:
13 (30 ILCS 805/8.21 new)
14 Sec. 8.21. Exempt mandate. Notwithstanding Sections 6
15 and 8 of this Act, no reimbursement by the State is required
16 for the implementation of any mandate created by this
17 amendatory Act of 1997.
18 Section 15. The Counties Code is amended by adding
19 Section 5-1069.3 as follows:
20 (55 ILCS 5/5-1069.3 new)
21 Sec. 5-1069.3. Health benefit notices. If a county,
22 including a home rule county, is a self-insurer for purposes
23 of providing health insurance coverage for its employees, the
24 county must provide benefit payment and denial notices as
25 required under Section 155.31 of the Illinois Insurance Code.
26 The requirement that benefit payment and denial notices be
27 provided in accordance with this Section is an exclusive
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1 power and function of the State and is a denial and
2 limitation under Article VII, Section 6, subsection (h) of
3 the Illinois Constitution. A home rule county to which this
4 Section applies must comply with every provision of this
5 Section.
6 Section 20. The Illinois Municipal Code is amended by
7 adding Section 10-4-2.3 as follows:
8 (65 ILCS 5/10-4-2.3 new)
9 Sec. 10-4-2.3. Health benefit notices. If a
10 municipality, including a home rule municipality, is a
11 self-insurer for purposes of providing health insurance
12 coverage for its employees, the municipality must provide
13 benefit payment and denial notices as required under Section
14 155.31 of the Illinois Insurance Code. The requirement that
15 benefit payment and denial notices be provided in accordance
16 with this Section is an exclusive power and function of the
17 State and is a denial and limitation under Article VII,
18 Section 6, subsection (h) of the Illinois Constitution. A
19 home rule municipality to which this Section applies must
20 comply with every provision of this Section.
21 Section 25. The School Code is amended by adding Section
22 10-22.3f as follows:
23 (105 ILCS 5/10-22.3f new)
24 Sec. 10-22.3f. Health benefit notices. Insurance
25 protection and benefits for employees shall provide the
26 benefit payment and denial notices required under Section
27 155.31 of the Illinois Insurance Code.
28 Section 30. The Illinois Insurance Code is amended by
29 adding Sections 155.31 and 511.114 as follows:
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1 (215 ILCS 5/155.31 new)
2 Sec. 155.31. Benefit payment and denial notices.
3 (a) An insurance company or managed care plan providing
4 health care benefits shall provide its insureds and enrollees
5 with detailed notices of benefit payment and denial. A
6 notice of denial shall be signed by the individual
7 responsible for denying payment and include an address and
8 accessible telephone number for the individual responsible
9 for denying payment. In addition, a notice of denial shall
10 clearly state the procedures for appealing the denial. The
11 insured or enrollee shall be given the opportunity to respond
12 to any denial and explain any discrepancies.
13 (b) For the purposes of this Section "managed care plan"
14 means a plan that establishes, operates, or maintains a
15 network of health care providers that have entered into
16 agreements with the plan to provide health care services to
17 enrollees where the plan has the ultimate and direct
18 contractual obligation to the enrollee to arrange for the
19 provision of or pay for services through:
20 (1) organizational arrangements for ongoing quality
21 assurance, utilization review programs, or dispute
22 resolution; or
23 (2) financial incentives for persons enrolled in
24 the plan to use the participating providers and
25 procedures covered by the plan.
26 A managed care plan may be established or operated by any
27 entity including a licensed insurance company, hospital or
28 medical service plan, health maintenance organization,
29 limited health service organization, preferred provider
30 organization, third party administrator, or an employer or
31 employee organization.
32 (215 ILCS 5/511.114 new)
33 Sec. 511.114. Benefit payment and denial notices. An
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1 administrator must comply with the requirements of Section
2 155.31 of this Code.
3 Section 35. The Comprehensive Health Insurance Plan Act
4 is amended by adding Section 8.7 as follows:
5 (215 ILCS 105/8.7 new)
6 Sec. 8.7. Benefit notices. The plan is subject to the
7 provisions of Section 155.31 of the Illinois Insurance Code.
8 Section 40. The Health Maintenance Organization Act is
9 amended by adding Section 4-6.5 as follows:
10 (215 ILCS 125/4-6.5 new)
11 Sec. 4-6.5. Benefit notices. A health maintenance
12 organization is subject to the provisions of Section 155.31
13 of the Illinois Insurance Code.
14 Section 45. The Limited Health Service Organization Act
15 is amended by changing Section 4003 as follows:
16 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
17 Sec. 4003. Illinois Insurance Code provisions. Limited
18 health service organizations shall be subject to the
19 provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
20 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
21 154.6, 154.7, 154.8, 155.04, 155.31, 355.2, 401, 401.1, 402,
22 403, 403A, 408, 408.2, and 412, and Articles VIII 1/2, XII,
23 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
24 Code. For purposes of the Illinois Insurance Code, except
25 for Articles XIII and XIII 1/2, limited health service
26 organizations in the following categories are deemed to be
27 domestic companies:
28 (1) a corporation under the laws of this State; or
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1 (2) a corporation organized under the laws of
2 another state, 30% of more of the enrollees of which are
3 residents of this State, except a corporation subject to
4 substantially the same requirements in its state of
5 organization as is a domestic company under Article VIII
6 1/2 of the Illinois Insurance Code.
7 (Source: P.A. 86-600; 87-587; 87-1090.)
8 Section 50. The Voluntary Health Services Plans Act is
9 amended by changing Section 10 as follows:
10 (215 ILCS 165/10) (from Ch. 32, par. 604)
11 Sec. 10. Application of Insurance Code provisions.
12 Health services plan corporations and all persons interested
13 therein or dealing therewith shall be subject to the
14 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
15 143, 143c, 149, 155.31, 354, 355.2, 356r, 367.2, 401, 401.1,
16 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
17 (15) of Section 367 of the Illinois Insurance Code.
18 (Source: P.A. 89-514, eff. 7-17-96.)