House Sponsors: FLOWERS-FEIGENHOLTZ-SCHOENBERG-WOJCIK-KRAUSE, GASH, MURPHY, JONES,SHIRLEY, MCKEON, HARTKE, DART, SCOTT, SMITH,MICHAEL, HOLBROOK, ACEVEDO, STROGER, SCHAKOWSKY, LANG, ERWIN, RONEN, CURRY,JULIE, FANTIN, O'BRIEN, HANNIG, DAVIS,STEVE, WOOLARD, YOUNGE, LYONS,JOSEPH, CROTTY, MCGUIRE, BROSNAHAN, GIGLIO, PUGH, TURNER,ART, MCCARTHY, GILES, HOWARD, MULLIGAN, KLINGLER, JONES,LOU, BUGIELSKI, KENNER, BRADLEY, CAPPARELLI, FRITCHEY, SCULLY AND SLONE. Senate Sponsors: CRONIN-BERMAN-HALVORSON-TROTTER-FARLEY Short description: HMO UTILIZATION REVIEW Synopsis of Bill as introduced: Amends the Health Maintenance Organization Act. Establishes requirements for disclosure of information to subscribers and enrollees. Sets forth standards for the handling of grievances by enrollees. Specifies procedures and timelines. Establishes the procedures for terminating health care professionals. Prohibits an organization from restricting information that a health care provider may give to a patient. Requires that an adequate network of providers be maintained. Creates the Utilization Review Law. Sets forth standards and procedures for determining whether services are covered. Establishes timeframes for making utilization review determinations. Sets forth requirements for appeals from adverse decisions. FISCAL NOTE (Dept. of Insurance) HB626 could cost as much as $500,000 for nurse assessment costs and funding a new staff for regulation of the entities. HOUSE AMENDMENT NO. 1. Deletes reference to: 215 ILCS 125/2-1.1 new 215 ILCS 125/2-1.2 new 215 ILCS 125/2-1.3 new 215 ILCS 125/2-1.4 new 215 ILCS 125/2-1.5 new 215 ILCS 125/2-1.6 new 215 ILCS 125/2-1.7 new 215 ILCS 125/Art. VII heading new 215 ILCS 125/7-1 new 215 ILCS 125/7-5 new 215 ILCS 125/7-10 new 215 ILCS 125/7-15 new 215 ILCS 125/7-20 new 215 ILCS 125/7-25 new 215 ILCS 125/7-30 new 215 ILCS 125/7-35 new 215 ILCS 125/7-40 new 215 ILCS 125/4-6 rep. Adds reference to: New Act Replaces everything after the clause. Creates the Managed Care Entity Responsibility and Patient Rights Act. Establishes requirements for disclosure of information to subscribers and enrollees. Sets forth standards for the handling of grievances by enrollees. Specifies procedures and timelines. Establishes the procedures for terminating health care professionals. Prohibits a managed care plan from restricting information that a health care provider may give to a patient. Requires that an adequate network of providers be maintained. Establishes grievance procedures. Provides for the registration of utilization review agents. Sets forth standards and procedures for determining whether services are covered. Establishes timeframes for making utilization review determinations. Sets forth requirements for appeals from adverse decisions. Provides for administration by the Department of Public Health. Authorizes the Attorney General to seek civil penalties for violations. HOUSE AMENDMENT NO. 2. Adds reference to: 5 ILCS 375/6.9 new 55 ILCS 5/5-1069.8 new 65 ILCS 5/10-4-2.8 new 105 ILCS 5/10-22.3f new 215 ILCS 5/356t new 215 ILCS 125/2-2 from Ch. 111 1/2, par. 1404 215 ILCS 125/6-7 from Ch. 111 1/2, par. 1418.7 Replaces the title and everything after the enacting clause. Creates the Managed Care Reform Act. Specifies information that must be disclosed by a managed care plan. Establishes a multi-level grievance procedure and also provides for an independent external review. Requires a managed care plan to maintain a grievance register. Requires managed care plans to be certified by the Director of Public Health with respect to adequacy of provider networks. Authorizes the Department of Public Health to impose civil penalties. Establishes a process, including hearings, for termination of a health care provid- er. Requires managed care plans to report to professional disciplinary agencies. Provides for the registration of utilization service agents. Establishes utilization review program standards. Provides for general administration of the Act by the Department of Insurance. Requires the Department of Insurance to establish a Managed Care Ombudsman Program. Amends the Illinois Insurance Code to require point-of-service coverage for managed care plans. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to impose the requirements of the Managed Care Reform Act upon the provision of health care under those Acts. Amends the Health Maintenance Organization Act to provide for 2 public members to be appointed to the Health Maintenance Advisory Board and the Board of Directors of the Health Maintenance Organiza- tion Guaranty Association Board. Effective immediately. FISCAL NOTE, H-AMS 1 & 2 (Dept. of Insurance) No change from previous note. FISCAL NOTE, H-AM 2 (Dept. of Public Health) This program would cost approximately $219,800 annually and would require at least 3 additional nurse surveyors and 2 clerical/administrative staff. CORRECTIONAL NOTE, H-AM 2 There would be no prison population impact on DOC. STATE MANDATES FISCAL NOTE, H-AM 2 (DCCA) HB626, with H-am 2, creates a personnel mandate which requires 100% reimbursement. HOME RULE NOTE, H-AM 2 HB626, with H-am 2, does not preempt home rule authority. JUDICIAL NOTE, H-AMS 1 & 2 Impact on the number of judges needed cannot be determined. JUDICIAL NOTE, H-AM 3 There may be an increase in judicial workloads; impact on the number of judges needed cannot be determined. FISCAL NOTE, H-AM 3 (Dept. of Public Health) Adding a minimum of 25 FTEs would cost approximately $2,000,000 annually. STATE MANDATES FISCAL NOTE, H-AM 3 (DCCA) No change from previous mandates note. HOME RULE NOTE, H-AM 3 HB626, with H-am 3, contains an express denial and limitation under the Ill. Constitution, and, therefore preempts home rule. HOUSE AMENDMENT NO. 3. Adds reference to: 5 ILCS 375/6.9 new 30 ILCS 105/5.449 new 30 ILCS 805/8.21 new 55 ILCS 5/5-1069.8 new 65 ILCS 5/10-4-2.8 new 105 ILCS 5/10-22.3f new 215 ILCS 125/2-2 from Ch. 111 1/2, par. 1404 215 ILCS 125/6-7 from Ch. 111 1/2, par. 1418.7 Replaces the title and everything after the enacting clause. Creates the Managed Care Reform Act. Specifies information that must be disclosed by a managed care plan. Establishes a multi-level grievance procedure and also provides for an independent external review. Requires a managed care plan to maintain a grievance register. Requires managed care plans to be certified by the Director of Public Health with respect to adequacy of provider networks. Authorizes the Department of Public Health to impose civil penalties. Establishes a process, including hearing, for termination of a health care provider. Requires managed care plans to report to professional disciplinary agencies. Provides for the registration of utilization service agents. Establishes utilization review program standards. Provides for general administration of the Act by the Department of Insurance. Requires the Department of Insurance to establish a Managed Care Ombudsman Program. Amends the State Finance Act to create the Manag- ed Care Entity Responsibility and Patients Rights Fund. Amends the State Mandates Act to require implementation without reimbursement. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to impose the requirements of the Managed Care Reform Act upon the provision of health care under those Acts. Amends the Health Maintenance Organiza- tion Act to provide for 2 public members to be appointed to the Health Maintenance Organization Guaranty Association Board. Effective immedi- ately. HOUSE AMENDMENT NO. 5 Requires physician peer reviewers to be State licensed. Excludes State government agencies from the definition of "utilization review agent". Shortens the time within which certain notices must be provided to enrollees and within which actions must be taken in a grievance proceeding. Changes the effective date to July 1, 1998. Makes other changes. Last action on Bill: SESSION SINE DIE Last action date: 99-01-12 Location: House Amendments to Bill: AMENDMENTS ADOPTED: HOUSE - 4 SENATE - 0 END OF INQUIRY Full Text Bill Status