Bill Text: IL SB1187 | 2019-2020 | 101st General Assembly | Introduced
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.
Spectrum: 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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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 1. Short title. This Act may be cited as the Right | ||||||||||||||||||||||||
5 | to Shop Act.
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6 | Section 5. Applicability. This Act applies to health | ||||||||||||||||||||||||
7 | benefit plans amended, delivered, issued, or renewed in this | ||||||||||||||||||||||||
8 | State on or after January 1, 2020.
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9 | Section 10. Definitions. In this Act: | ||||||||||||||||||||||||
10 | "Allowed amount" means the contractually agreed upon | ||||||||||||||||||||||||
11 | amount paid by a carrier
to a provider participating in the | ||||||||||||||||||||||||
12 | carrier's network. | ||||||||||||||||||||||||
13 | "Carrier" means an entity that provides a health benefit | ||||||||||||||||||||||||
14 | plan in this State and is subject to State insurance | ||||||||||||||||||||||||
15 | regulation. | ||||||||||||||||||||||||
16 | "Comparable health care service" means a covered | ||||||||||||||||||||||||
17 | non-emergency health care service or bundle of services. The | ||||||||||||||||||||||||
18 | Director may limit what is considered a comparable health care | ||||||||||||||||||||||||
19 | service if a carrier demonstrates that the allowed amount | ||||||||||||||||||||||||
20 | variation among network providers is less than $50. | ||||||||||||||||||||||||
21 | "Department" means the Department of Insurance. | ||||||||||||||||||||||||
22 | "Director" means the Director of Insurance. |
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1 | "Enrollee" means an individual enrolled in a health benefit | ||||||
2 | plan. | ||||||
3 | "Health benefit plan" or "health plan" means a policy, | ||||||
4 | contract, certificate, plan, or agreement offered or issued by | ||||||
5 | a carrier to provide, deliver, arrange for, pay for, or | ||||||
6 | reimburse any of the costs of health care services. "Health | ||||||
7 | benefit plan" or "health plan" does not include individual, | ||||||
8 | accident-only, credit, dental, vision, Medicare supplement, | ||||||
9 | hospital indemnity, long term care, specific disease, | ||||||
10 | stop-loss or disability income insurance, coverage issued as a | ||||||
11 | supplement to liability insurance, workers' compensation or | ||||||
12 | similar insurance, or automobile medical payment insurance. | ||||||
13 | "Health care services" means services for the diagnosis, | ||||||
14 | prevention, treatment, cure, or relief of a health condition, | ||||||
15 | illness, injury, or disease. | ||||||
16 | "Network" means the group or groups of preferred providers | ||||||
17 | providing services to a network plan. | ||||||
18 | "Network plan" means an individual or group policy of | ||||||
19 | health plans that either requires a covered person to use or | ||||||
20 | creates incentives, including financial incentives, for an | ||||||
21 | enrollee to use providers managed, owned, under contract with, | ||||||
22 | or employed by the carrier. | ||||||
23 | "Program" means the comparable health care service | ||||||
24 | incentive program established by a carrier pursuant to this | ||||||
25 | Act. | ||||||
26 | "Provider" means a physician, hospital facility, or other |
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1 | health care practitioner licensed or otherwise authorized to | ||||||
2 | furnish health care services consistent with State law.
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3 | Section 15. Health care service incentive program. | ||||||
4 | (a) Beginning January 1, 2020, a carrier offering a health | ||||||
5 | benefit plan in this State shall develop and implement a | ||||||
6 | program that provides incentives for enrollees in a health plan | ||||||
7 | who elect to receive a comparable health care service that is | ||||||
8 | covered by the health plan from a provider that collects less | ||||||
9 | than the average in-network allowed amount paid by that carrier | ||||||
10 | to a network provider for that comparable health care service. | ||||||
11 | (b) Incentives may be calculated as a percentage of the | ||||||
12 | difference in allowed amounts to the average, as a flat dollar | ||||||
13 | amount, or by some other reasonable methodology approved by the | ||||||
14 | Department. The carrier shall provide the incentive as a cash | ||||||
15 | payment, gift cards, or credits toward the enrollee's annual | ||||||
16 | in-network deductible and out-of-pocket limit or premium | ||||||
17 | reductions. | ||||||
18 | (c) A carrier shall make the health care service incentive | ||||||
19 | program available as a component of all health plans offered in | ||||||
20 | the individual and small group markets by the carrier in this | ||||||
21 | State, but not including plans in which enrollees receive a | ||||||
22 | premium subsidy under the federal Patient Protection and | ||||||
23 | Affordable Care Act. Annually at enrollment or renewal, a | ||||||
24 | carrier shall provide notice about the availability of the | ||||||
25 | program, a description of the incentives available to an |
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1 | enrollee and how to earn such incentives to an enrollee who is | ||||||
2 | enrolled in a health plan eligible for the program. A carrier | ||||||
3 | may contract with a third-party vendor to satisfy the | ||||||
4 | requirements of this subsection.
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5 | Section 20. Administrative expense; filing requirements. | ||||||
6 | (a) A comparable health care service incentive payment made | ||||||
7 | by a carrier in accordance with this Act is not an | ||||||
8 | administrative expense of the carrier for rate development or | ||||||
9 | rate filing purposes. | ||||||
10 | (b) Prior to offering the health care service incentive | ||||||
11 | program to an enrollee, a carrier shall file a description of | ||||||
12 | the program with the Department in the manner determined by the | ||||||
13 | Department. The Director may review the filing made by the | ||||||
14 | carrier to determine whether the carrier's program complies | ||||||
15 | with the requirements of this Act. Filings and any supporting | ||||||
16 | documentation are confidential until the filing has been | ||||||
17 | approved or denied by the Department.
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18 | Section 25. Health care price transparency tools. | ||||||
19 | (a) Beginning upon approval of the next health insurance | ||||||
20 | rate filing after the effective date of this Act, a carrier | ||||||
21 | offering a health plan in this State shall comply with the | ||||||
22 | following requirements: | ||||||
23 | (1) A carrier shall establish an interactive mechanism | ||||||
24 | on its publicly-accessible website that enables an |
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1 | enrollee to request and obtain from the carrier information | ||||||
2 | on the payments made by the carrier to network providers | ||||||
3 | for comparable health care services, as well as quality | ||||||
4 | data for those providers, to the extent available. The | ||||||
5 | interactive mechanism must allow an enrollee seeking | ||||||
6 | information about the cost of a particular health care | ||||||
7 | service to: | ||||||
8 | (A) compare allowed amounts among network | ||||||
9 | providers; | ||||||
10 | (B) estimate out-of-pocket costs applicable to | ||||||
11 | that enrollee's health plan; and | ||||||
12 | (C) provide the average paid within a reasonable | ||||||
13 | timeframe (not to exceed one year) to network providers | ||||||
14 | for the procedure or service under the enrollee's | ||||||
15 | health plan. | ||||||
16 | The out-of-pocket estimate must provide a good faith | ||||||
17 | estimate of the amount the enrollee will be responsible to | ||||||
18 | pay out-of-pocket for a proposed non-emergency procedure | ||||||
19 | or service that is a medically necessary covered benefit | ||||||
20 | from a carrier's network provider, including a copayment, | ||||||
21 | deductible, coinsurance, or other out-of-pocket amount for | ||||||
22 | a covered benefit, based on the information available to | ||||||
23 | the carrier at the time the request is made. A carrier may | ||||||
24 | contract with a third-party vendor to satisfy the | ||||||
25 | requirements of this paragraph. | ||||||
26 | (2) A carrier shall notify an enrollee that the |
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1 | information provided under paragraph (1) is an estimation | ||||||
2 | of costs and that the actual amount the enrollee will be | ||||||
3 | responsible to pay may vary due to unforeseen services that | ||||||
4 | arise out of the proposed non-emergency procedure or | ||||||
5 | service. | ||||||
6 | (b) Nothing in this Section prohibits a carrier from | ||||||
7 | imposing cost-sharing requirements disclosed in the enrollee's | ||||||
8 | certificate of coverage for unforeseen health care services | ||||||
9 | that arise out of the non-emergency procedure or service or for | ||||||
10 | a procedure or service provided to an enrollee that was not | ||||||
11 | included in the original estimate.
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12 | Section 30. Patient freedom and choice; lower prices. | ||||||
13 | (a) If an enrollee elects to receive a covered health care | ||||||
14 | service from an out-of-network provider at a price that is the | ||||||
15 | same or less than the average that an enrollee's carrier pays | ||||||
16 | for that service to providers in its provider network within a | ||||||
17 | reasonable timeframe, not to exceed one year, the carrier shall | ||||||
18 | allow the enrollee to obtain the service from the | ||||||
19 | out-of-network provider at the provider's price and, upon | ||||||
20 | request by the enrollee, shall apply the payments made by the | ||||||
21 | enrollee for that health care service toward the enrollee's | ||||||
22 | deductible and out-of-pocket maximum as specified in the | ||||||
23 | enrollee's health plan as if the health care services had been | ||||||
24 | provided by a network provider. The carrier shall provide a | ||||||
25 | downloadable or interactive online form to the enrollee for the |
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1 | purpose of submitting proof of payment to an out-of-network | ||||||
2 | provider for purposes of administering this Section. | ||||||
3 | (b) A carrier may base the average paid to a network | ||||||
4 | provider on what that carrier pays to providers in the network | ||||||
5 | applicable to the enrollee's specific health plan or across all | ||||||
6 | of its plans offered in this State. A carrier shall, at a | ||||||
7 | minimum, inform enrollees of its ability to pay and the process | ||||||
8 | to request the average allowed amount paid for a procedure or | ||||||
9 | service, both on its website and in benefit plan material.
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10 | Section 35. State group health benefits plan; analysis. The | ||||||
11 | Director of Central Management Services shall conduct an | ||||||
12 | analysis no later than one year from the effective date of this | ||||||
13 | Act of the cost effectiveness of implementing an | ||||||
14 | incentive-based program for enrollees and retirees of the State | ||||||
15 | group health benefits plan offered under the State Employees | ||||||
16 | Group Insurance Act of 1971. A program found to be cost | ||||||
17 | effective shall be implemented as part of the next open | ||||||
18 | enrollment. The Director of Central Management Services shall | ||||||
19 | communicate the rationale for the decision to relevant General | ||||||
20 | Assembly committees in writing.
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21 | Section 40. Rulemaking authority. The Director may adopt | ||||||
22 | reasonable rules as necessary to implement the purposes and | ||||||
23 | provisions of this Act.
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24 | Section 99. Effective date. This Act takes effect upon |
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1 | becoming law.
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