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91_HB2713ham003
LRB9103967SMdvam03
1 AMENDMENT TO HOUSE BILL 2713
2 AMENDMENT NO. . Amend House Bill 2713 by replacing
3 the title with the following:
4 "AN ACT regarding managed care."; and
5 by replacing everything after the enacting clause with the
6 following:
7 "Section 5. The Illinois Insurance Code is amended by
8 changing Section 370b as follows:
9 (215 ILCS 5/370b) (from Ch. 73, par. 982b)
10 Sec. 370b. Timely reimbursement on equal basis.
11 (a) Notwithstanding any provision of any individual or
12 group policy of accident and health insurance, or any
13 provision of a policy, contract, plan or agreement for
14 hospital or medical service or indemnity, wherever such
15 policy, contract, plan or agreement provides for
16 reimbursement for any service provided by persons licensed
17 under the Medical Practice Act of 1987 or the Podiatric
18 Medical Practice Act of 1987, the person entitled to benefits
19 or person performing services under such policy, contract,
20 plan or agreement is entitled to reimbursement on an equal
21 basis for such service within 30 days after the date of
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1 receipt of due proof of loss, when the service is performed
2 by a person licensed under the Medical Practice Act of 1987
3 or the Podiatric Medical Practice Act of 1987. The
4 provisions of this Section do not apply to any policy,
5 contract, plan or agreement in effect prior to September 19,
6 1969 or to preferred provider arrangements or benefit
7 agreements.
8 (b) If the maker of a policy, contract, plan, or
9 agreement for hospital or medical service or indemnity fails
10 to provide reimbursement for hospital or medical service
11 performed by a person licensed under the Medical Practice Act
12 of 1987 or the Podiatric Medical Practice Act of 1987 on an
13 equal basis for such service within 30 days after the date of
14 receipt of due proof of loss, the service provider may file a
15 complaint with the Illinois Department of Insurance to seek
16 immediate relief for non-payment. Beginning on the 31st day
17 after the date of receipt of due proof of loss, the service
18 provider shall be entitled to receive interest for each day
19 that the reimbursement is unpaid. The interest rate shall be
20 equivalent to the applicable federal rate as provided for
21 under the Internal Revenue Code.
22 (Source: P.A. 90-14, eff. 7-1-97.)
23 Section 10. The Health Maintenance Organization Act is
24 amended by adding Section 5-7.1a as follows:
25 (215 ILCS 125/5-7.1a new)
26 Sec. 5-7.1a. Timely reimbursement for services.
27 (a) A health maintenance organization shall provide
28 reimbursement to a service provider for a service provided to
29 an enrollee under a health care plan within 30 days after the
30 date of receipt of due proof of loss when the service is
31 performed by a person licensed under the Medical Practice Act
32 of 1987 or the Podiatric Medical Practice Act of 1987.
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1 (b) If a health maintenance organization fails to
2 provide reimbursement for hospital or medical service covered
3 under a health care plan performed by a person licensed under
4 the Medical Practice Act of 1987 or the Podiatric Medical
5 Practice Act of 1987 on an equal basis for such service
6 within 30 days after the date of receipt of due proof of
7 loss, the service provider may file a complaint with the
8 Illinois Department of Insurance to seek immediate relief for
9 non-payment. Beginning on the 31st day after the date of
10 receipt of due proof of loss, the service provider shall be
11 entitled to receive interest for each day that the
12 reimbursement is unpaid. The interest rate shall be
13 equivalent to the applicable federal rate as provided for
14 under the Internal Revenue Code.
15 Section 15. The Illinois Public Aid Code is amended by
16 changing Section 5-16 as follows:
17 (305 ILCS 5/5-16) (from Ch. 23, par. 5-16)
18 Sec. 5-16. Managed Care. The Illinois Department may
19 develop and implement a Primary Care Sponsor System
20 consistent with the provisions of this Section. The purpose
21 of this managed care delivery system shall be to contain the
22 costs of providing medical care to Medicaid recipients by
23 having one provider responsible for managing all aspects of a
24 recipient's medical care. This managed care system shall
25 have the following characteristics:
26 (a) The Department, by rule, shall establish
27 criteria to determine which clients must participate in
28 this program;
29 (b) Providers participating in the program may be
30 paid an amount per patient per month, to be set by the
31 Illinois Department, for managing each recipient's
32 medical care;
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1 (b-1) Providers shall receive reimbursement for a
2 service provided to a recipient under this program within
3 30 days after the date of receipt of due proof of loss
4 when the service is performed by a person licensed under
5 the Medical Practice Act of 1987 or the Podiatric Medical
6 Practice Act of 1987. If reimbursement for hospital or
7 medical service performed by a person licensed under the
8 Medical Practice Act of 1987 or the Podiatric Medical
9 Practice Act of 1987 is not made within 30 days after the
10 date of receipt of due proof of loss, the provider may
11 file a complaint with the Illinois Department of
12 Insurance to seek immediate relief for non-payment.
13 Beginning on the 31st day after the date of receipt of
14 due proof of loss, the service provider shall be entitled
15 to receive interest for each day that the reimbursement
16 is unpaid. The interest rate shall be equivalent to the
17 applicable federal rate as provided for under the
18 Internal Revenue Code.
19 (c) Providers eligible to participate in the
20 program shall be physicians licensed to practice medicine
21 in all its branches, and the Illinois Department may
22 terminate a provider's participation if the provider is
23 determined to have failed to comply with any applicable
24 program standard or procedure established by the Illinois
25 Department;
26 (d) Each recipient required to participate in the
27 program must select from a panel of primary care
28 providers or networks established by the Department in
29 their communities;
30 (e) A recipient may change his designated primary
31 care provider:
32 (1) when the designated source becomes
33 unavailable, as the Illinois Department shall
34 determine by rule; or
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1 (2) when the designated primary care provider
2 notifies the Illinois Department that it wishes to
3 withdraw from any obligation as primary care
4 provider; or
5 (3) in other situations, as the Illinois
6 Department shall provide by rule;
7 (f) The Illinois Department shall, by rule,
8 establish procedures for providing medical services when
9 the designated source becomes unavailable or wishes to
10 withdraw from any obligation as primary care provider
11 taking into consideration the need for emergency or
12 temporary medical assistance and ensuring that the
13 recipient has continuous and unrestricted access to
14 medical care from the date on which such unavailability
15 or withdrawal becomes effective until such time as the
16 recipient designates a primary care source;
17 (g) Only medical care services authorized by a
18 recipient's designated provider, except for emergency
19 services, services performed by a provider that is owned
20 or operated by a county and that provides non-emergency
21 services without regard to ability to pay and such other
22 services as provided by the Illinois Department, shall be
23 subject to payment by the Illinois Department. The
24 Illinois Department shall enter into an intergovernmental
25 agreement with each county that owns or operates such a
26 provider to develop and implement policies to minimize
27 the provision of medical care services provided by county
28 owned or operated providers pursuant to the foregoing
29 exception.
30 The Illinois Department shall seek and obtain necessary
31 authorization provided under federal law to implement such a
32 program including the waiver of any federal regulations.
33 The Illinois Department may implement the amendatory
34 changes to this Section made by this amendatory Act of 1991
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1 through the use of emergency rules in accordance with the
2 provisions of Section 5.02 of the Illinois Administrative
3 Procedure Act. For purposes of the Illinois Administrative
4 Procedure Act, the adoption of rules to implement the
5 amendatory changes to this Section made by this amendatory
6 Act of 1991 shall be deemed an emergency and necessary for
7 the public interest, safety and welfare.
8 The Illinois Department may establish a managed care
9 system demonstration program, on a limited basis, as
10 described in this Section. The demonstration program shall
11 terminate on June 30, 1997. Within 30 days after the end of
12 each year of the demonstration program's operation, the
13 Illinois Department shall report to the Governor and the
14 General Assembly concerning the operation of the
15 demonstration program.
16 (Source: P.A. 87-14; 88-490.)
17 Section 99. Effective date. This Act takes effect upon
18 becoming law.".