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91_HB2841eng HB2841 Engrossed LRB9105213JSks 1 AN ACT to create the Patient Access to Treatment Act. 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 Patient Access to Treatment Act. 6 Section 5. Definitions. In this Act: 7 "Cost-sharing requirements" means requirements in a 8 contract, agreement or other arrangement with, or that is 9 issued, underwritten, or administered by, a managed care 10 entity under which a member is required to pay for part of 11 health care services that are covered by the managed care 12 entity, and those cost-sharing requirements shall include, 13 but shall not be limited to, deductibles, copayments, and 14 coinsurance. 15 "Department" means the Department of Insurance. 16 "Enrollee" means an individual entitled to the provision 17 of or reimbursement for health care services under a group or 18 individual contract, agreement, or other arrangement with, or 19 that has been issued by, a health maintenance organization. 20 "Health care services" means health care related items, 21 treatment, and services sold or rendered by a provider within 22 the scope of the provider's license or legal authorization, 23 and includes, but is not limited to, hospital, medical, 24 surgical, dental, vision, and pharmaceutical items, 25 treatment, and services. 26 "Health maintenance organization" means an entity 27 required to be licensed under the Health Maintenance 28 Organization Act. 29 "Insured" means an individual entitled to reimbursement 30 for expenses of health care services under a group or 31 individual policy underwritten, issued, or administered by an HB2841 Engrossed -2- LRB9105213JSks 1 insurer. 2 "Insurer" means any entity that is required to be 3 licensed under the Illinois Insurance Code. 4 "Managed care entity" means a health maintenance 5 organization, an insurer, a hospital, or medical service plan 6 licensed under the Health Maintenance Organization Act, 7 Illinois Insurance Code, Voluntary Health Services Plans Act, 8 an employer or employee organization or plan, and any other 9 entity, including a preferred provider organization, that 10 establishes, operates, or maintains a network of providers, 11 conducts or arranges for utilization review activities, and 12 contracts with a health maintenance organization, an insurer, 13 a hospital or medical service plan, an employer, an employer 14 organization, or with any other entity providing coverage for 15 health care services. 16 "Member" means an enrollee, an insured, and any other 17 person entitled to receive health care coverage for health 18 care services from a managed care entity. 19 "Person" means an individual, an agency, a political 20 subdivision, a partnership, a corporation, a limited 21 liability company, an association, or any other entity. 22 "Provider" means a person duly licensed or legally 23 authorized to provide health care services. 24 "Provider network" means, with respect to a managed care 25 entity, providers who have entered into an agreement, either 26 directly or indirectly through another person, with the 27 managed care entity under which the providers are obligated 28 to provide health care services to members of the managed 29 care entity in return for reimbursement as set forth in the 30 agreement and in accordance with any other requirements set 31 forth in the agreement. 32 Section 10. Direct access. Managed care entities shall 33 not deny or limit reimbursement for health care services HB2841 Engrossed -3- LRB9105213JSks 1 provided to a member by a dermatologist, or deny the 2 provision of health care services to a member by a 3 dermatologist, on the grounds that the member was not 4 referred to the dermatologist by a provider or other person 5 acting on behalf of, pursuant to an agreement with, or under 6 the direction of, whether direct or indirect, the managed 7 care entity. As frequently as reasonably necessary to 8 facilitate direct access to providers, but no less frequently 9 than once each year, a managed care entity shall deliver to 10 members a complete listing of all providers of dermatological 11 services in any provider network selected by the managed care 12 entity. 13 Section 15. Prohibition on unreasonable cost-sharing 14 requirements. Managed care entities shall not impose 15 unreasonable cost-sharing requirements on members who receive 16 health care services from dermatologists that are covered by 17 the managed care entity and that are medically necessary. By 18 way of example, but not in limitation, a cost-sharing 19 requirement shall be deemed to be unreasonable if it requires 20 or effectively causes a member to pay the following amounts; 21 (1) more than 20% of the costs of medically 22 necessary health care services covered by the managed 23 care entity; or 24 (2) more than $1,500 per individual or $3,000 per 25 family of the costs of medically necessary health care 26 services covered by the managed care entity. 27 Section 20. Prohibited reimbursement arrangements. 28 Managed care entities may pay providers using incentive 29 payments, but only if no specific payment or withholding of 30 payment has the direct or indirect effect of reducing or 31 limiting medically necessary health care services that a 32 provider would otherwise be responsible for providing to HB2841 Engrossed -4- LRB9105213JSks 1 members. 2 Section 25. Required disclosure of information. 3 Prospective members shall be provided information as to the 4 terms and conditions of the coverage that they will receive 5 from the managed care entity so that they can make informed 6 decisions about accepting the coverage. When the coverage is 7 described orally to members, then easily understood, 8 truthful, and objective terms shall be used. All written 9 descriptions shall be in readable and understandable format, 10 consistent with standards developed for supplemental 11 insurance coverage under Title XVII of the Social Security 12 Act. This format shall be standardized so that potential 13 members can compare the attributes of the various managed 14 care entities. Specific items that must be included in any 15 oral or written description of the managed care entity are: 16 (1) covered provisions, benefits, and any 17 exclusions by category of service, provider, or physician 18 and, if applicable, by specific service; 19 (2) any and all prior authorization or other review 20 requirements, including preauthorization review, 21 concurrent review, post-service review, post-payment 22 review, and any procedures that may lead the member to be 23 denied coverage or not be provided a particular service; 24 (3) financial arrangements or contractual 25 provisions with providers, utilization review companies, 26 and third party administrators that would limit the 27 services offered, restrict referral or treatment options, 28 or negatively affect any provider's fiduciary 29 responsibility to the provider's patients, including but 30 not limited to financial incentives not to provide 31 medical or other services; 32 (4) explanation of how coverage limitations affect 33 members, including information on member financial HB2841 Engrossed -5- LRB9105213JSks 1 responsibility for cost-sharing requirements, for payment 2 of noncovered services, and for payment of out-of-plan 3 services; 4 (5) loss ratios of the managed care entity; and 5 (6) member satisfaction statistics, including but 6 not limited to percent of re-enrollment and reasons for 7 leaving the coverage. 8 Section 30. Enforcement and rules. This Act shall be 9 enforced by the Department. The Department is authorized to 10 issue rules clarifying the requirements of this Act. Each 11 violation of this Act by a managed care entity shall subject 12 the managed care entity to a fine of $5,000 per violation as 13 determined by the Department. The Department is also 14 authorized to take any action necessary to prevent violation 15 of this Act, including but not limited to seeking an 16 injunction against the managed care entity and revoking the 17 managed care entity's license. 18 Section 35. Limitations. Nothing in this Act shall be 19 construed as requiring or allowing any provider to provide 20 health care services that the provider is not duly licensed 21 or legally authorized to provide or to provide any health 22 care services that the provider is not qualified to provide. 23 Section 99. Effective date. This Act takes effect upon 24 becoming law.