Bill Text: IL SB1187 | 2019-2020 | 101st General Assembly | Introduced

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Bill Title: Creates the Right to Shop Act. Requires a carrier offering a health plan to develop and implement a program that provides incentives for enrollees in a health plan who elect to receive a comparable health care service from a provider that collects less than the average in-network allowed amount paid by that carrier to a network provider for that comparable health care service. Provides how incentives may be calculated, distributed, and offered. Requires the carrier to file a description of the health care service incentive program with the Department of Insurance. Requires a carrier to establish an interactive mechanism on its website to enable an enrollee to request the estimated amount the carrier would pay to a network provider for a comparable health care service. Requires the Director of Central Management Services to conduct an analysis on the cost effectiveness of implementing an incentive-based program for current enrollees and retirees of the State group health benefits plan. Requires a program found to be cost effective to be implemented as part of the next open enrollment. Effective immediately.

Sponsorship: Moderate Partisan Bill (Democrat 17-2)

Status: (Failed) 2021-01-13 - Session Sine Die [SB1187 Detail]

Download: Illinois-2019-SB1187-Introduced.html

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101ST GENERAL ASSEMBLY State of Illinois 2019 and 2020 SB1187 Introduced 2/5/2019, by Sen. Jim Oberweis SYNOPSIS AS INTRODUCED:
New Act
Creates the Right to Shop Act. Requires a carrier offering a health plan to develop and implement a program that provides incentives for enrollees in a health plan who elect to receive a comparable health care service from a provider that collects less than the average in-network allowed amount paid by that carrier to a network provider for that comparable health care service. Provides how incentives may be calculated, distributed, and offered. Requires the carrier to file a description of the health care service incentive program with the Department of Insurance. Requires a carrier to establish an interactive mechanism on its website to enable an enrollee to request the estimated amount the carrier would pay to a network provider for a comparable health care service. Requires the Director of Central Management Services to conduct an analysis on the cost effectiveness of implementing an incentive-based program for current enrollees and retirees of the State group health benefits plan. Requires a program found to be cost effective to be implemented as part of the next open enrollment. Effective immediately.
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FISCAL NOTE ACT MAY APPLY
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 1. Short title. This Act may be cited as the Right
to Shop Act.
Section 5. Applicability. This Act applies to health
benefit plans amended, delivered, issued, or renewed in this
State on or after January 1, 2020.
Section 10. Definitions. In this Act:
"Allowed amount" means the contractually agreed upon
amount paid by a carrier to a provider participating in the
carrier's network.
"Carrier" means an entity that provides a health benefit
plan in this State and is subject to State insurance
regulation.
"Comparable health care service" means a covered
non-emergency health care service or bundle of services. The
Director may limit what is considered a comparable health care
service if a carrier demonstrates that the allowed amount
variation among network providers is less than $50.
"Department" means the Department of Insurance.
"Director" means the Director of Insurance.

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"Enrollee" means an individual enrolled in a health benefit
plan.
"Health benefit plan" or "health plan" means a policy,
contract, certificate, plan, or agreement offered or issued by
a carrier to provide, deliver, arrange for, pay for, or
reimburse any of the costs of health care services. "Health
benefit plan" or "health plan" does not include individual,
accident-only, credit, dental, vision, Medicare supplement,
hospital indemnity, long term care, specific disease,
stop-loss or disability income insurance, coverage issued as a
supplement to liability insurance, workers' compensation or
similar insurance, or automobile medical payment insurance.
"Health care services" means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition,
illness, injury, or disease.
"Network" means the group or groups of preferred providers
providing services to a network plan.
"Network plan" means an individual or group policy of
health plans that either requires a covered person to use or
creates incentives, including financial incentives, for an
enrollee to use providers managed, owned, under contract with,
or employed by the carrier.
"Program" means the comparable health care service
incentive program established by a carrier pursuant to this
Act.
"Provider" means a physician, hospital facility, or other

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health care practitioner licensed or otherwise authorized to
furnish health care services consistent with State law.
Section 15. Health care service incentive program.
(a) Beginning January 1, 2020, a carrier offering a health
benefit plan in this State shall develop and implement a
program that provides incentives for enrollees in a health plan
who elect to receive a comparable health care service that is
covered by the health plan from a provider that collects less
than the average in-network allowed amount paid by that carrier
to a network provider for that comparable health care service.
(b) Incentives may be calculated as a percentage of the
difference in allowed amounts to the average, as a flat dollar
amount, or by some other reasonable methodology approved by the
Department. The carrier shall provide the incentive as a cash
payment, gift cards, or credits toward the enrollee's annual
in-network deductible and out-of-pocket limit or premium
reductions.
(c) A carrier shall make the health care service incentive
program available as a component of all health plans offered in
the individual and small group markets by the carrier in this
State, but not including plans in which enrollees receive a
premium subsidy under the federal Patient Protection and
Affordable Care Act. Annually at enrollment or renewal, a
carrier shall provide notice about the availability of the
program, a description of the incentives available to an

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enrollee and how to earn such incentives to an enrollee who is
enrolled in a health plan eligible for the program. A carrier
may contract with a third-party vendor to satisfy the
requirements of this subsection.
Section 20. Administrative expense; filing requirements.
(a) A comparable health care service incentive payment made
by a carrier in accordance with this Act is not an
administrative expense of the carrier for rate development or
rate filing purposes.
(b) Prior to offering the health care service incentive
program to an enrollee, a carrier shall file a description of
the program with the Department in the manner determined by the
Department. The Director may review the filing made by the
carrier to determine whether the carrier's program complies
with the requirements of this Act. Filings and any supporting
documentation are confidential until the filing has been
approved or denied by the Department.
Section 25. Health care price transparency tools.
(a) Beginning upon approval of the next health insurance
rate filing after the effective date of this Act, a carrier
offering a health plan in this State shall comply with the
following requirements:
(1) A carrier shall establish an interactive mechanism
on its publicly-accessible website that enables an

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enrollee to request and obtain from the carrier information
on the payments made by the carrier to network providers
for comparable health care services, as well as quality
data for those providers, to the extent available. The
interactive mechanism must allow an enrollee seeking
information about the cost of a particular health care
service to:
(A) compare allowed amounts among network
providers;
(B) estimate out-of-pocket costs applicable to
that enrollee's health plan; and
(C) provide the average paid within a reasonable
timeframe (not to exceed one year) to network providers
for the procedure or service under the enrollee's
health plan.
The out-of-pocket estimate must provide a good faith
estimate of the amount the enrollee will be responsible to
pay out-of-pocket for a proposed non-emergency procedure
or service that is a medically necessary covered benefit
from a carrier's network provider, including a copayment,
deductible, coinsurance, or other out-of-pocket amount for
a covered benefit, based on the information available to
the carrier at the time the request is made. A carrier may
contract with a third-party vendor to satisfy the
requirements of this paragraph.
(2) A carrier shall notify an enrollee that the

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information provided under paragraph (1) is an estimation
of costs and that the actual amount the enrollee will be
responsible to pay may vary due to unforeseen services that
arise out of the proposed non-emergency procedure or
service.
(b) Nothing in this Section prohibits a carrier from
imposing cost-sharing requirements disclosed in the enrollee's
certificate of coverage for unforeseen health care services
that arise out of the non-emergency procedure or service or for
a procedure or service provided to an enrollee that was not
included in the original estimate.
Section 30. Patient freedom and choice; lower prices.
(a) If an enrollee elects to receive a covered health care
service from an out-of-network provider at a price that is the
same or less than the average that an enrollee's carrier pays
for that service to providers in its provider network within a
reasonable timeframe, not to exceed one year, the carrier shall
allow the enrollee to obtain the service from the
out-of-network provider at the provider's price and, upon
request by the enrollee, shall apply the payments made by the
enrollee for that health care service toward the enrollee's
deductible and out-of-pocket maximum as specified in the
enrollee's health plan as if the health care services had been
provided by a network provider. The carrier shall provide a
downloadable or interactive online form to the enrollee for the

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purpose of submitting proof of payment to an out-of-network
provider for purposes of administering this Section.
(b) A carrier may base the average paid to a network
provider on what that carrier pays to providers in the network
applicable to the enrollee's specific health plan or across all
of its plans offered in this State. A carrier shall, at a
minimum, inform enrollees of its ability to pay and the process
to request the average allowed amount paid for a procedure or
service, both on its website and in benefit plan material.
Section 35. State group health benefits plan; analysis. The
Director of Central Management Services shall conduct an
analysis no later than one year from the effective date of this
Act of the cost effectiveness of implementing an
incentive-based program for enrollees and retirees of the State
group health benefits plan offered under the State Employees
Group Insurance Act of 1971. A program found to be cost
effective shall be implemented as part of the next open
enrollment. The Director of Central Management Services shall
communicate the rationale for the decision to relevant General
Assembly committees in writing.
Section 40. Rulemaking authority. The Director may adopt
reasonable rules as necessary to implement the purposes and
provisions of this Act.
Section 99. Effective date. This Act takes effect upon

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becoming law.