Patient Access & Insurance Providers

A key issue for ICS members is codifying into State statute the provider “non-discrimination” language from the Affordable Care Act. That provision requires insurance and health plans to refrain from discriminating against provider categories in terms of participation and coverage in a health plan. When speaking with legislators, the ICS refers to this issue as a problem for “patient access.” It is important to communicate the message that we want this issue to be focused on patient access and not that chiropractic physicians are discriminated against by insurance companies, because patient choice truly is what the issue is about. We want to convey that we are simply trying to protect the patient by allowing that patient to be able to choose the provider of his or her choice and have insurance pay for the care received.

 

In 2017, ICS introduced HB 694 (Martwick), which addressed this very issue. The goal of the legislation was to codify the terminology from the Affordable Care Act and make state law consistent with that language. Due to strong insurance opposition, this legislation did not move during this past legislative session. HB 694 had three main points:

 

Insurers May Not Discriminate in Coverage Between Provides Acting Within Their State Scope

The language comes directly from the Affordable Care Act, with the small exception of Illinois’ preference to say “may not” as opposed to “shall not.” This distinction is important. The terms “may not” would allow an insurance company the option to follow the law. The terms “shall not” require the insurance companies to follow the law.

 

Insurers May Not Deny Certain Provider Types Based on Their Type of Licensure

Illinois law already has what is called an “Any Willing Provider” section. Illinois’ “Any Willing Provider” provision in the Insurance Code (215 ILCS 5/370 (h) requires that: “An insurer or administrator shall not refuse to contract with any noninstutional provider who meets the terms and conditions established by the insurer or administrator” and “these terms and conditions may not discriminate unreasonably against or among noninstitutional providers.” This language means that a health plan must accept into the network any provider who meets the qualifications of the plan.

 

The non-discrimination provision of the Affordable Care Act states it does not require States to adopt “Any Willing Provider” language, evidencing its intent to leave the issue to the individual States. The non-discrimination language proposed by the ICS would affirm Illinois’ existing “Any Willing Provider” provision, as well as incorporating the general non-discrimination language of the Affordable Care Act.

 

Nothing Shall Prevent Insurers From Varying Rates Based on Quality of Performance Measures

The final line of the proposed ICS non-discrimination language is a clarification carried over from the Affordable Care Act. The language preserves a health plan’s right to pay varying reimbursement based on a provider’s performance or quality measures. The ICS has retained this language in its proposed law. The only difference is the removal of reference to the Secretary or Department, due to differences in agency structure at the federal and state level.