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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
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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
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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
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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.
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