Bill Text: IL HB5539 | 2021-2022 | 102nd General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code. Provides that each insurer shall make available on its publicly accessible website or through a toll-free telephone number an interactive mechanism where any member of the public may access specified health care cost information. Provides that the Department of Insurance shall adopt rules to define specified terms. Provides that an insurer shall provide notification on its website that the actual amount that a covered person will be responsible to pay following the receipt of a particular health care service may vary due to unforeseen costs that arise during the provision of the service. Provides that each estimate of out-of-pocket costs provided shall provide the out-of-pocket costs a covered person may owe if he or she has exceeded his or her deductible and the out-of-pocket costs a covered person may owe if he or she has not exceeded his or her deductible. Provides that an insurer may contract with a third party to satisfy part or all of the requirements. Provides that nothing in the provisions shall prohibit an insurer from charging a covered person cost sharing beyond that included in the estimate provided if the additional cost sharing resulted from unforeseen provisions of additional health care services and the cost-sharing requirements of the unforeseen health care services were disclosed in the covered person's policy or certificate of insurance. Provides that some of the provisions do not apply to a health maintenance organization.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2022-02-18 - Rule 19(a) / Re-referred to Rules Committee [HB5539 Detail]

Download: Illinois-2021-HB5539-Introduced.html

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102ND GENERAL ASSEMBLY State of Illinois 2021 and 2022 HB5539 Introduced , by Rep. Michael Kelly SYNOPSIS AS INTRODUCED:
215 ILCS 5/364.4 new
Amends the Illinois Insurance Code. Provides that each insurer shall make available on its publicly accessible website or through a toll-free telephone number an interactive mechanism where any member of the public may access specified health care cost information. Provides that the Department of Insurance shall adopt rules to define specified terms. Provides that an insurer shall provide notification on its website that the actual amount that a covered person will be responsible to pay following the receipt of a particular health care service may vary due to unforeseen costs that arise during the provision of the service. Provides that each estimate of out-of-pocket costs provided shall provide the out-of-pocket costs a covered person may owe if he or she has exceeded his or her deductible and the out-of-pocket costs a covered person may owe if he or she has not exceeded his or her deductible. Provides that an insurer may contract with a third party to satisfy part or all of the requirements. Provides that nothing in the provisions shall prohibit an insurer from charging a covered person cost sharing beyond that included in the estimate provided if the additional cost sharing resulted from unforeseen provisions of additional health care services and the cost-sharing requirements of the unforeseen health care services were disclosed in the covered person's policy or certificate of insurance. Provides that some of the provisions do not apply to a health maintenance organization.
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A BILL FOR
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AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
adding Section 364.4 as follows:
(215 ILCS 5/364.4 new)
Sec. 364.4. Health care cost information disclosure.
(a) As used in this Section:
"Emergency services" means health care services that are
provided for a condition of recent onset and sufficient
severity, including, but not limited to, severe pain that
would lead a prudent layperson, possessing an average
knowledge of medicine and health, to believe that his or her
condition, sickness, or injury is of such a nature that
failure to obtain immediate medical care could result in:
(1) placing the patient's health in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
"Health benefit policy" or "policy" means any individual
or group plan, policy, or contract for health care services
amended, delivered, issued, or renewed in this State.
"Health care provider" means any physician, dentist,
podiatric physician, pharmacist, optometrist, psychologist,

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clinical social worker, advanced practice registered nurse,
optician, licensed professional counselor, physical therapist,
marriage and family therapist, athletic trainer, occupational
therapist, speech-language pathologist, audiologist,
dietitian, or physician assistant.
"Health care services" means:
(1) physical and occupational therapy services;
(2) obstetrical and gynecological services;
(3) radiology and imaging services;
(4) laboratory services;
(5) infusion services;
(6) inpatient or outpatient surgical procedures;
(7) outpatient nonsurgical diagnostic tests or
procedures; and
(8) any services designated by the Director as
shoppable by health care consumers.
"Hierarchical Condition Category Methodology" means a
coding system designed by the Centers for Medicare and
Medicaid Services to estimate future health care costs for
patients.
(b) Each insurer shall make available on its publicly
accessible website or through a toll-free telephone number an
interactive mechanism where any member of the public may:
(1) for each health benefit policy offered, compare
the payment amounts accepted by in-network providers from
the insurer for the provision of a particular health care

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service within the previous year;
(2) for each health benefit policy offered, obtain an
estimate of the average amount accepted by in-network
providers from the insurer for the provision of a
particular health care service within the previous year;
(3) for each health benefit policy offered, obtain an
estimate of the out-of-pocket costs that the covered
person would owe his or her provider following the
provision of a particular health care service;
(4) compare quality metrics applicable to in-network
providers for major diagnostic categories with adjustments
by risk and severity based upon the Hierarchical Condition
Category Methodology or a nationally recognized health
care quality reporting standard designated by the
Director. Metrics shall be based on reasonably universal
and uniform databases with sufficient claim volume. If
applicable to the provider, quality metrics include, but
are not limited to:
(A) risk-adjusted readmission rates and absolute
hospital readmission rates;
(B) risk-adjusted hospitalization rates and
absolute hospitalization rates;
(C) admission volume;
(D) utilization volume;
(E) risk-adjusted rates of adverse events; and
(F) risk-adjusted total cost of care and absolute

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relative total cost of care; and
(5) access any all-payer health claims database that
may be maintained by the Department.
The Department shall adopt rules that define the following
terms: "risk-adjusted hospital readmission rates", "absolute
hospital readmission rates", "risk-adjusted hospitalization
rates", "absolute hospitalization rates", "admission volume",
"utilization volume", "risk-adjusted rates of adverse events",
"risk-adjusted total cost of care", and "absolute relative
total cost of care".
(c) An insurer shall provide notification on its website
that the actual amount that a covered person will be
responsible to pay following the receipt of a particular
health care service may vary due to unforeseen costs that
arise during the provision of the service.
(d) Each estimate of out-of-pocket costs provided pursuant
to paragraph (3) of subsection (b) shall provide:
(1) the out-of-pocket costs a covered person may owe
if he or she has exceeded his or her deductible; and
(2) the out-of-pocket costs a covered person may owe
if he or she has not exceeded his or her deductible.
(e) An insurer may contract with a third party to satisfy
part or all of the requirements of this Section.
(f) Nothing in this Section shall prohibit an insurer from
charging a covered person cost sharing beyond that included in
the estimate provided pursuant to paragraph (3) of subsection

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(b) if the additional cost sharing resulted from unforeseen
provisions of additional health care services and the
cost-sharing requirements of the unforeseen health care
services were disclosed in the covered person's policy or
certificate of insurance.
(g) The requirements of this Section, with the exception
of paragraph (4) of subsection (b), do not apply to a health
maintenance organization, as defined in the Health Maintenance
Organization Act.