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Insurance

Payment issues with health insurance companies continue to cause headaches for physicians and their practices. Delays in payment to physicians threaten the economic sustainability for their practices, especially during an unprecedented pandemic.

Access to quality patient care is often disrupted due to delays from health insurance companies that ultimately threaten the care Illinois patients’ need. ISMS has worked to streamline onerous prior authorization requests and ensure transparency from insurance companies.

ISMS has worked to address numerous health insurance related issues, including but not limited to:

  • Network Adequacy & Transparency Act: ISMS crafted law which ensures the adequacy, accessibility and transparency of health care network plans.
  • Prevented Prescription Drug Formulary Disruptions: ISMS helped enact legislation that will prevent insurance companies from modifying an enrollee’s drug formulary coverage after the enrollee is already locked into a health plan for the year.
  • Right-to-Shop: ISMS blocked legislation that would encourage patients to focus exclusively on cost when seeking medical care, with complete disregard for physician experience, expertise or other factors related to quality of care, amongst other harmful provisions.
  • Drug Pricing: ISMS stopped legislation by insurers that would have coerced patients to choose the lowest-cost healthcare option by offering financial incentives.

To see ISMS’ specific work on more insurance related issues, please view the end of session legislative reports.

Currently Tracked Bills

ISMS Supports

Prior Authorization HB 711See Prior Authorization Tab

Eliminating Barriers to Mental Health and Substance Abuse Disorders HB 2595 (Sponsor: Rep. Deb Conroy) - amends the Illinois Insurance Code to ensure that all Medicaid MCOs and commercial insurer medical necessity determinations concerning mental health and substance use disorders are fully consistent with generally accepted standards of care.

  • Establishes a clear definition and standards for when services and treatment qualify as medically necessary.
  • Requires insurers to rely on the transparent, publicly available guidelines published by nonprofit clinical societies for mental health disorder medical necessity determinations, as Illinois already requires for substance use disorders.
  • Requires insurers to cover all medically necessary mental health and substance use disorder care and explicitly prohibits insurers from limiting benefits to short-term, acute care or from excluding certain levels of care (e.g., residential treatment).
  • Encourages compliance with Illinois’ parity law by making sure illegal practices are appropriately penalized.

ISMS supported HB 2595, which passed both chambers and will be sent to the Governor for further action.

Bill Status: House Bill 2595

Telehealth HB 3308 (Sponsor: Rep. Deb Conroy / Sen. Mattie Hunter) establishes the following protections on Telehealth:

  • Bars insurers from requiring patients to prove a hardship or access barrier in order to receive healthcare services through telehealth.
  • Prohibits geographic or facility restrictions on telehealth services, allowing patients to be treated via telehealth in their home.
  • Protects patient preference by establishing that a patient cannot be required to use telehealth services.
  • Ensures patients will not be required to use a separate panel of providers or practitioners to receive telehealth services.
  • Aligns telehealth practice with privacy laws for in-person practice, while giving healthcare providers the professional latitude to determine the appropriateness of specific sites and technology platforms for telehealth services.
  • Aligns telehealth coverage and payment with in-person care, making appropriate patient access to care the priority and removing harmful barriers that shift costs to the patient and healthcare provider.
  • Equal coverage eliminates policy loopholes that allow insurers to create separate telehealth networks which ship tax dollars to out-of-state providers that work outside of a patient’s care team.

The insurance industry was very much opposed to the bill. ISMS supported House Bill 3308 as amended. This bill passed both chambers and will be sent to the Governor for further action.

Read more on ISMS’ advocacy efforts to help pass House Bill 3308 in this year’s ISMS Legislative Report.

Related Resources

Understanding the Patient’s Out-of-Pocket Expenses
Understanding the Patient’s Out-of-Pocket Expenses
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