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91_HB2713eng HB2713 Engrossed LRB9103967SMpr 1 AN ACT regarding managed care. 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 changing Section 370b as follows: 6 (215 ILCS 5/370b) (from Ch. 73, par. 982b) 7 Sec. 370b. Timely reimbursement on equal basis. 8 (a) Notwithstanding any provision of any individual or 9 group policy of accident and health insurance, or any 10 provision of a policy, contract, plan or agreement for 11 hospital or medical service or indemnity, wherever such 12 policy, contract, plan or agreement provides for 13 reimbursement for any service provided by persons licensed 14 under the Medical Practice Act of 1987 or the Podiatric 15 Medical Practice Act of 1987, the person entitled to benefits 16 or person performing services under such policy, contract, 17 plan or agreement is entitled to reimbursement on an equal 18 basis for such service within 30 days after the date of 19 receipt of due proof of loss, when the service is performed 20 by a person licensed under the Medical Practice Act of 1987 21 or the Podiatric Medical Practice Act of 1987. The 22 provisions of this Section do not apply to any policy, 23 contract, plan or agreement in effect prior to September 19, 24 1969 or to preferred provider arrangements or benefit 25 agreements. 26 (b) If the maker of a policy, contract, plan, or 27 agreement for hospital or medical service or indemnity fails 28 to provide reimbursement for hospital or medical service 29 performed by a person licensed under the Medical Practice Act 30 of 1987 or the Podiatric Medical Practice Act of 1987 on an 31 equal basis for such service within 30 days after the date of HB2713 Engrossed -2- LRB9103967SMpr 1 receipt of due proof of loss, the service provider may file a 2 complaint with the Illinois Department of Insurance to seek 3 immediate relief for non-payment. Beginning on the 31st day 4 after the date of receipt of due proof of loss, the service 5 provider shall be entitled to receive interest for each day 6 that the reimbursement is unpaid. The interest rate shall be 7 equivalent to the applicable federal rate as provided for 8 under the Internal Revenue Code. 9 (Source: P.A. 90-14, eff. 7-1-97.) 10 Section 10. The Health Maintenance Organization Act is 11 amended by adding Section 5-7.1a as follows: 12 (215 ILCS 125/5-7.1a new) 13 Sec. 5-7.1a. Timely reimbursement for services. 14 (a) A health maintenance organization shall provide 15 reimbursement to a service provider for a service provided to 16 an enrollee under a health care plan within 30 days after the 17 date of receipt of due proof of loss when the service is 18 performed by a person licensed under the Medical Practice Act 19 of 1987 or the Podiatric Medical Practice Act of 1987. 20 (b) If a health maintenance organization fails to 21 provide reimbursement for hospital or medical service covered 22 under a health care plan performed by a person licensed under 23 the Medical Practice Act of 1987 or the Podiatric Medical 24 Practice Act of 1987 on an equal basis for such service 25 within 30 days after the date of receipt of due proof of 26 loss, the service provider may file a complaint with the 27 Illinois Department of Insurance to seek immediate relief for 28 non-payment. Beginning on the 31st day after the date of 29 receipt of due proof of loss, the service provider shall be 30 entitled to receive interest for each day that the 31 reimbursement is unpaid. The interest rate shall be 32 equivalent to the applicable federal rate as provided for HB2713 Engrossed -3- LRB9103967SMpr 1 under the Internal Revenue Code. 2 Section 15. The Illinois Public Aid Code is amended by 3 changing Section 5-16 as follows: 4 (305 ILCS 5/5-16) (from Ch. 23, par. 5-16) 5 Sec. 5-16. Managed Care. The Illinois Department may 6 develop and implement a Primary Care Sponsor System 7 consistent with the provisions of this Section. The purpose 8 of this managed care delivery system shall be to contain the 9 costs of providing medical care to Medicaid recipients by 10 having one provider responsible for managing all aspects of a 11 recipient's medical care. This managed care system shall 12 have the following characteristics: 13 (a) The Department, by rule, shall establish 14 criteria to determine which clients must participate in 15 this program; 16 (b) Providers participating in the program may be 17 paid an amount per patient per month, to be set by the 18 Illinois Department, for managing each recipient's 19 medical care; 20 (b-1) Providers shall receive reimbursement for a 21 service provided to a recipient under this program within 22 30 days after the date of receipt of due proof of loss 23 when the service is performed by a person licensed under 24 the Medical Practice Act of 1987 or the Podiatric Medical 25 Practice Act of 1987. If reimbursement for hospital or 26 medical service performed by a person licensed under the 27 Medical Practice Act of 1987 or the Podiatric Medical 28 Practice Act of 1987 is not made within 30 days after the 29 date of receipt of due proof of loss, the provider may 30 file a complaint with the Illinois Department of 31 Insurance to seek immediate relief for non-payment. 32 Beginning on the 31st day after the date of receipt of HB2713 Engrossed -4- LRB9103967SMpr 1 due proof of loss, the service provider shall be entitled 2 to receive interest for each day that the reimbursement 3 is unpaid. The interest rate shall be equivalent to the 4 applicable federal rate as provided for under the 5 Internal Revenue Code. 6 (c) Providers eligible to participate in the 7 program shall be physicians licensed to practice medicine 8 in all its branches, and the Illinois Department may 9 terminate a provider's participation if the provider is 10 determined to have failed to comply with any applicable 11 program standard or procedure established by the Illinois 12 Department; 13 (d) Each recipient required to participate in the 14 program must select from a panel of primary care 15 providers or networks established by the Department in 16 their communities; 17 (e) A recipient may change his designated primary 18 care provider: 19 (1) when the designated source becomes 20 unavailable, as the Illinois Department shall 21 determine by rule; or 22 (2) when the designated primary care provider 23 notifies the Illinois Department that it wishes to 24 withdraw from any obligation as primary care 25 provider; or 26 (3) in other situations, as the Illinois 27 Department shall provide by rule; 28 (f) The Illinois Department shall, by rule, 29 establish procedures for providing medical services when 30 the designated source becomes unavailable or wishes to 31 withdraw from any obligation as primary care provider 32 taking into consideration the need for emergency or 33 temporary medical assistance and ensuring that the 34 recipient has continuous and unrestricted access to HB2713 Engrossed -5- LRB9103967SMpr 1 medical care from the date on which such unavailability 2 or withdrawal becomes effective until such time as the 3 recipient designates a primary care source; 4 (g) Only medical care services authorized by a 5 recipient's designated provider, except for emergency 6 services, services performed by a provider that is owned 7 or operated by a county and that provides non-emergency 8 services without regard to ability to pay and such other 9 services as provided by the Illinois Department, shall be 10 subject to payment by the Illinois Department. The 11 Illinois Department shall enter into an intergovernmental 12 agreement with each county that owns or operates such a 13 provider to develop and implement policies to minimize 14 the provision of medical care services provided by county 15 owned or operated providers pursuant to the foregoing 16 exception. 17 The Illinois Department shall seek and obtain necessary 18 authorization provided under federal law to implement such a 19 program including the waiver of any federal regulations. 20 The Illinois Department may implement the amendatory 21 changes to this Section made by this amendatory Act of 1991 22 through the use of emergency rules in accordance with the 23 provisions of Section 5.02 of the Illinois Administrative 24 Procedure Act. For purposes of the Illinois Administrative 25 Procedure Act, the adoption of rules to implement the 26 amendatory changes to this Section made by this amendatory 27 Act of 1991 shall be deemed an emergency and necessary for 28 the public interest, safety and welfare. 29 The Illinois Department may establish a managed care 30 system demonstration program, on a limited basis, as 31 described in this Section. The demonstration program shall 32 terminate on June 30, 1997. Within 30 days after the end of 33 each year of the demonstration program's operation, the 34 Illinois Department shall report to the Governor and the HB2713 Engrossed -6- LRB9103967SMpr 1 General Assembly concerning the operation of the 2 demonstration program. 3 (Source: P.A. 87-14; 88-490.) 4 Section 99. Effective date. This Act takes effect upon 5 becoming law.