The Transparency in Downcoding Act prohibits automated downcoding of health insurance claims, requires decisions by a licensed physician, and enforces penalties for discriminatory practices. The Act excludes employee or employer self-insured health benefit plans under ERISA and health care provided pursuant to the Workers' Compensation Act or the Workers' Occupational Diseases Act.
What do these statuses mean? ▼
Affected Industries
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What This Means
The Transparency in Downcoding Act applies to certain health insurance policies in Illinois, prohibiting automated downcoding, requiring decisions by a licensed physician of similar specialty, and enforcing penalties for discriminatory practices. It excludes employee or employer self-insured health benefit plans under ERISA and health care provided pursuant to the Workers' Compensation Act or the Workers' Occupational Diseases Act.
Key Provisions
- Section 10: Applicability and scope of the Act, excluding employee or employer self-insured health benefit plans under ERISA and health care provided pursuant to the Workers' Compensation Act or the Workers' Occupational Diseases Act.
- Section 15: Prohibition of automatic downcoding.
- Section 20: Prohibition on diagnosis-based downcoding.
- Section 25: Notification requirements for downcoded claims.
- Section 30: Appeal process for downcoded claims.
- Section 35: Protections for patients with chronic conditions and targeting discriminatory practices.
- Section 40: Enforcement and penalties, including fines, restitution, or suspension of license for discriminatory practices.
Latest Legislative Action
Senate Floor Amendment No. 1 Recommend Do Adopt Insurance; 011-000-000
Bill Sponsors
| Name | Role | District |
|---|---|---|
| David Koehler D | Sponsor | SD-046 |
| Julie Morrison D | Sponsor | SD-029 |
| Cristina Castro D | Sponsor | SD-022 |
| Robert Peters D | Sponsor | SD-013 |
| Laura Fine D | Sponsor | SD-009 |
| Andrew Chesney R | Sponsor | SD-045 |
| Christopher Belt D | Sponsor | SD-057 |
| Graciela Guzman D | Sponsor | SD-020 |
| Paul Faraci D | Sponsor | SD-052 |
| Suzanne Glowiak Hilton D | Sponsor | SD-023 |
| Linda Holmes D | Sponsor | SD-042 |
| Ram Villivalam D | Sponsor | SD-008 |
| Mike Porfirio D | Sponsor | SD-011 |
| Meg Loughran Cappel D | Sponsor | SD-049 |
| Doris Turner D | Sponsor | SD-048 |
| Sally Turner R | Sponsor | SD-044 |
| Susan Rezin R | Sponsor | SD-038 |
| Napoleon Harris D | Sponsor | SD-015 |
| Rachel Ventura D | Sponsor | SD-043 |
| Elgie Sims D | Sponsor | SD-017 |
| Lakesia Collins D | Sponsor | SD-005 |
Amendments (1)
Compliance Checklist
Who: Health insurance issuers
Penalty: Potential fines and license suspension.
Who: Health insurance issuers
Penalty: Monetary penalties for violations.
Who: Health insurance issuers
Penalty: Fines for non-compliance.
Who: Health insurance issuers
Penalty: Fines and reprocessing orders.
Related & Companion Bills
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