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: (Introduced) 2019-03-28 - Rule 3-9(a) / Re-referred to Assignments [SB1187 Detail]

Download: Illinois-2019-SB1187-Introduced.html


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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1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the Right
5to Shop Act.
6 Section 5. Applicability. This Act applies to health
7benefit plans amended, delivered, issued, or renewed in this
8State on or after January 1, 2020.
9 Section 10. Definitions. In this Act:
10 "Allowed amount" means the contractually agreed upon
11amount paid by a carrier to a provider participating in the
12carrier's network.
13 "Carrier" means an entity that provides a health benefit
14plan in this State and is subject to State insurance
15regulation.
16 "Comparable health care service" means a covered
17non-emergency health care service or bundle of services. The
18Director may limit what is considered a comparable health care
19service if a carrier demonstrates that the allowed amount
20variation 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
2plan.
3 "Health benefit plan" or "health plan" means a policy,
4contract, certificate, plan, or agreement offered or issued by
5a carrier to provide, deliver, arrange for, pay for, or
6reimburse any of the costs of health care services. "Health
7benefit plan" or "health plan" does not include individual,
8accident-only, credit, dental, vision, Medicare supplement,
9hospital indemnity, long term care, specific disease,
10stop-loss or disability income insurance, coverage issued as a
11supplement to liability insurance, workers' compensation or
12similar insurance, or automobile medical payment insurance.
13 "Health care services" means services for the diagnosis,
14prevention, treatment, cure, or relief of a health condition,
15illness, injury, or disease.
16 "Network" means the group or groups of preferred providers
17providing services to a network plan.
18 "Network plan" means an individual or group policy of
19health plans that either requires a covered person to use or
20creates incentives, including financial incentives, for an
21enrollee to use providers managed, owned, under contract with,
22or employed by the carrier.
23 "Program" means the comparable health care service
24incentive program established by a carrier pursuant to this
25Act.
26 "Provider" means a physician, hospital facility, or other

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1health care practitioner licensed or otherwise authorized to
2furnish health care services consistent with State law.
3 Section 15. Health care service incentive program.
4 (a) Beginning January 1, 2020, a carrier offering a health
5benefit plan in this State shall develop and implement a
6program that provides incentives for enrollees in a health plan
7who elect to receive a comparable health care service that is
8covered by the health plan from a provider that collects less
9than the average in-network allowed amount paid by that carrier
10to a network provider for that comparable health care service.
11 (b) Incentives may be calculated as a percentage of the
12difference in allowed amounts to the average, as a flat dollar
13amount, or by some other reasonable methodology approved by the
14Department. The carrier shall provide the incentive as a cash
15payment, gift cards, or credits toward the enrollee's annual
16in-network deductible and out-of-pocket limit or premium
17reductions.
18 (c) A carrier shall make the health care service incentive
19program available as a component of all health plans offered in
20the individual and small group markets by the carrier in this
21State, but not including plans in which enrollees receive a
22premium subsidy under the federal Patient Protection and
23Affordable Care Act. Annually at enrollment or renewal, a
24carrier shall provide notice about the availability of the
25program, a description of the incentives available to an

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1enrollee and how to earn such incentives to an enrollee who is
2enrolled in a health plan eligible for the program. A carrier
3may contract with a third-party vendor to satisfy the
4requirements of this subsection.
5 Section 20. Administrative expense; filing requirements.
6 (a) A comparable health care service incentive payment made
7by a carrier in accordance with this Act is not an
8administrative expense of the carrier for rate development or
9rate filing purposes.
10 (b) Prior to offering the health care service incentive
11program to an enrollee, a carrier shall file a description of
12the program with the Department in the manner determined by the
13Department. The Director may review the filing made by the
14carrier to determine whether the carrier's program complies
15with the requirements of this Act. Filings and any supporting
16documentation are confidential until the filing has been
17approved or denied by the Department.
18 Section 25. Health care price transparency tools.
19 (a) Beginning upon approval of the next health insurance
20rate filing after the effective date of this Act, a carrier
21offering a health plan in this State shall comply with the
22following 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
7imposing cost-sharing requirements disclosed in the enrollee's
8certificate of coverage for unforeseen health care services
9that arise out of the non-emergency procedure or service or for
10a procedure or service provided to an enrollee that was not
11included in the original estimate.
12 Section 30. Patient freedom and choice; lower prices.
13 (a) If an enrollee elects to receive a covered health care
14service from an out-of-network provider at a price that is the
15same or less than the average that an enrollee's carrier pays
16for that service to providers in its provider network within a
17reasonable timeframe, not to exceed one year, the carrier shall
18allow the enrollee to obtain the service from the
19out-of-network provider at the provider's price and, upon
20request by the enrollee, shall apply the payments made by the
21enrollee for that health care service toward the enrollee's
22deductible and out-of-pocket maximum as specified in the
23enrollee's health plan as if the health care services had been
24provided by a network provider. The carrier shall provide a
25downloadable or interactive online form to the enrollee for the

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1purpose of submitting proof of payment to an out-of-network
2provider for purposes of administering this Section.
3 (b) A carrier may base the average paid to a network
4provider on what that carrier pays to providers in the network
5applicable to the enrollee's specific health plan or across all
6of its plans offered in this State. A carrier shall, at a
7minimum, inform enrollees of its ability to pay and the process
8to request the average allowed amount paid for a procedure or
9service, both on its website and in benefit plan material.
10 Section 35. State group health benefits plan; analysis. The
11Director of Central Management Services shall conduct an
12analysis no later than one year from the effective date of this
13Act of the cost effectiveness of implementing an
14incentive-based program for enrollees and retirees of the State
15group health benefits plan offered under the State Employees
16Group Insurance Act of 1971. A program found to be cost
17effective shall be implemented as part of the next open
18enrollment. The Director of Central Management Services shall
19communicate the rationale for the decision to relevant General
20Assembly committees in writing.
21 Section 40. Rulemaking authority. The Director may adopt
22reasonable rules as necessary to implement the purposes and
23provisions of this Act.
24 Section 99. Effective date. This Act takes effect upon

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1becoming law.
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