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Public Act 096-0857 |
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 1. Short title. This Act may be cited as the Health | ||||
Carrier External Review Act. | ||||
Section 5. Purpose and intent. The purpose of this Act is | ||||
to provide uniform standards for the establishment and | ||||
maintenance of external review procedures to assure that | ||||
covered persons have the opportunity for an independent review | ||||
of an adverse determination or final adverse determination, as | ||||
defined in this Act. | ||||
Section 10. Definitions. For the purposes of this Act: | ||||
"Adverse determination" means a determination by a health | ||||
carrier or its designee utilization review organization that an | ||||
admission, availability of care, continued stay, or other | ||||
health care service that is a covered benefit has been reviewed | ||||
and, based upon the information provided, does not meet the | ||||
health carrier's requirements for medical necessity, | ||||
appropriateness, health care setting, level of care, or | ||||
effectiveness, and the requested service or payment for the | ||||
service is therefore denied, reduced, or terminated. | ||||
"Authorized representative" means: |
(1) a person to whom a covered person has given express | ||
written consent to represent the covered person in an | ||
external review, including the covered person's health | ||
care provider; | ||
(2) a person authorized by law to provide substituted | ||
consent for a covered person; or | ||
(3) the covered person's health care provider when the | ||
covered person is unable to provide consent. | ||
"Best evidence" means evidence based on: | ||
(1) randomized clinical trials; | ||
(2) if randomized clinical trials are not available, | ||
then cohort studies or case-control studies; | ||
(3) if items (1) and (2) are not available, then | ||
case-series; or | ||
(4) if items (1), (2), and (3) are not available, then | ||
expert opinion. | ||
"Case-series" means an evaluation of a series of patients | ||
with a particular outcome, without the use of a control group. | ||
"Clinical review criteria" means the written screening | ||
procedures, decision abstracts, clinical protocols, and | ||
practice guidelines used by a health carrier to determine the | ||
necessity and appropriateness of health care services. | ||
"Cohort study" means a prospective evaluation of 2 groups | ||
of patients with only one group of patients receiving specific | ||
intervention. | ||
"Covered benefits" or "benefits" means those health care |
services to which a covered person is entitled under the terms | ||
of a health benefit plan. | ||
"Covered person" means a policyholder, subscriber, | ||
enrollee, or other individual participating in a health benefit | ||
plan. | ||
"Director" means the Director of the Department of | ||
Insurance. | ||
"Emergency medical condition" means a medical condition | ||
manifesting itself by acute symptoms of sufficient severity, | ||
including, but not limited to, severe pain, such that a prudent | ||
layperson who possesses an average knowledge of health and | ||
medicine could reasonably expect the absence of immediate | ||
medical attention to result in: | ||
(1) placing the health of the individual or, with | ||
respect to a pregnant woman, the health of the woman or her | ||
unborn child, in serious jeopardy; | ||
(2) serious impairment to bodily functions; or
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(3) serious dysfunction of any bodily organ or part. | ||
"Emergency services" means health care items and services | ||
furnished or required to evaluate and treat an emergency | ||
medical condition. | ||
"Evidence-based standard" means the conscientious, | ||
explicit, and judicious use of the current best evidence based | ||
on an overall systematic review of the research in making | ||
decisions about the care of individual patients. | ||
"Expert opinion" means a belief or an interpretation by |
specialists with experience in a specific area about the | ||
scientific evidence pertaining to a particular service, | ||
intervention, or therapy. | ||
"Facility" means an institution providing health care | ||
services or a health care setting. | ||
"Final adverse determination" means an adverse | ||
determination involving a covered benefit that has been upheld | ||
by a health carrier, or its designee utilization review | ||
organization, at the completion of the health carrier's | ||
internal grievance process procedures as set forth by the | ||
Managed Care Reform and Patient Rights Act. | ||
"Health benefit plan" means a policy, contract, | ||
certificate, plan, or agreement offered or issued by a health | ||
carrier to provide, deliver, arrange for, pay for, or reimburse | ||
any of the costs of health care services. | ||
"Health care provider" or "provider" means a physician, | ||
hospital facility, or other health care practitioner licensed, | ||
accredited, or certified to perform specified health care | ||
services consistent with State law, responsible for | ||
recommending health care services on behalf of a covered | ||
person. | ||
"Health care services" means services for the diagnosis, | ||
prevention, treatment, cure, or relief of a health condition, | ||
illness, injury, or disease. | ||
"Health carrier" means an entity subject to the insurance | ||
laws and regulations of this State, or subject to the |
jurisdiction of the Director, that contracts or offers to | ||
contract to provide, deliver, arrange for, pay for, or | ||
reimburse any of the costs of health care services, including a | ||
sickness and accident insurance company, a health maintenance | ||
organization, or any other entity providing a plan of health | ||
insurance, health benefits, or health care services. "Health | ||
carrier" also means Limited Health Service Organizations | ||
(LHSO) and Voluntary Health Service Plans. | ||
"Health information" means information or data, whether | ||
oral or recorded in any form or medium, and personal facts or | ||
information about events or relationships that relate to:
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(1) the past, present, or future physical, mental, or | ||
behavioral health or condition of an individual or a member | ||
of the individual's family; | ||
(2) the provision of health care services to an | ||
individual; or | ||
(3) payment for the provision of health care services | ||
to an individual. | ||
"Independent review organization" means an entity that | ||
conducts independent external reviews of adverse | ||
determinations and final adverse determinations. | ||
"Medical or scientific evidence" means evidence found in | ||
the following sources: | ||
(1) peer-reviewed scientific studies published in or | ||
accepted for publication by medical journals that meet | ||
nationally recognized requirements for scientific |
manuscripts and that submit most of their published | ||
articles for review by experts who are not part of the | ||
editorial staff; | ||
(2) peer-reviewed medical literature, including | ||
literature relating to therapies reviewed and approved by a | ||
qualified institutional review board, biomedical | ||
compendia, and other medical literature that meet the | ||
criteria of the National Institutes of Health's Library of | ||
Medicine for indexing in Index Medicus (Medline) and | ||
Elsevier Science Ltd. for indexing in Excerpta Medicus | ||
(EMBASE); | ||
(3) medical journals recognized by the Secretary of | ||
Health and Human Services under Section 1861(t)(2) of the | ||
federal Social Security Act; | ||
(4) the following standard reference compendia:
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(a) The American Hospital Formulary Service-Drug | ||
Information; | ||
(b) Drug Facts and Comparisons; | ||
(c) The American Dental Association Accepted | ||
Dental Therapeutics; and | ||
(d) The United States Pharmacopoeia-Drug | ||
Information; | ||
(5) findings, studies, or research conducted by or | ||
under the auspices of federal government agencies and | ||
nationally recognized federal research institutes, | ||
including: |
(a) the federal Agency for Healthcare Research and | ||
Quality; | ||
(b) the National Institutes of Health; | ||
(c) the National Cancer Institute; | ||
(d) the National Academy of Sciences; | ||
(e) the Centers for Medicare & Medicaid Services; | ||
(f) the federal Food and Drug Administration; and | ||
(g) any national board recognized by the National | ||
Institutes of Health for the purpose of evaluating the | ||
medical value of health care services; or | ||
(6) any other medical or scientific evidence that is | ||
comparable to the sources listed in items (1) through (5). | ||
"Protected health information" means health information | ||
(i) that identifies an individual who is the subject of the | ||
information; or (ii) with respect to which there is a | ||
reasonable basis to believe that the information could be used | ||
to identify an individual. | ||
"Retrospective review" means a review of medical necessity | ||
conducted after services have been provided to a patient, but | ||
does not include the review of a claim that is limited to an | ||
evaluation of reimbursement levels, veracity of documentation, | ||
accuracy of coding, or adjudication for payment. | ||
"Utilization review" has the meaning provided by the | ||
Managed Care Reform and Patient Rights Act. | ||
"Utilization review organization" means a utilization | ||
review program as defined in the Managed Care Reform and |
Patient Rights Act. | ||
Section 15. Applicability and scope. | ||
(a) Except as provided in subsection (b) of this Section, | ||
this Act shall apply to all health carriers. | ||
(b) The provisions of this Act shall not apply to a policy | ||
or certificate that provides coverage only for a specified | ||
disease, specified accident or accident-only coverage, credit, | ||
dental, disability income, hospital indemnity, long-term care | ||
insurance as defined by Article XIXA of the Illinois Insurance | ||
Code, vision care, or any other limited supplemental benefit; a | ||
Medicare supplement policy of insurance as defined by the | ||
Director by regulation; coverage under a plan through Medicare, | ||
Medicaid, or the federal employees health benefits program; any | ||
coverage issued under Chapter 55 of Title 10, U.S. Code and any | ||
coverage issued as supplement to that coverage; any coverage | ||
issued as supplemental to liability insurance, workers' | ||
compensation, or similar insurance; automobile medical-payment | ||
insurance or any insurance under which benefits are payable | ||
with or without regard to fault, whether written on a group | ||
blanket or individual basis. | ||
Section 20. Notice of right to external review. | ||
(a) At the same time the health carrier sends written | ||
notice of a covered person's right to appeal a coverage | ||
decision upon an adverse determination or a final adverse |
determination as provided by the Managed Care Reform and | ||
Patient Rights Act, a health carrier shall notify a covered | ||
person and a covered person's health care provider in writing | ||
of the covered person's right to request an external review as | ||
provided by this Act. The written notice required shall include | ||
the following, or substantially equivalent, language: "We have | ||
denied your request for the provision of or payment for a | ||
health care service or course of treatment. You have the right | ||
to have our decision reviewed by an independent review | ||
organization not associated with us if our decision involved | ||
making a judgment as to the medical necessity, appropriateness, | ||
health care setting, level of care, or effectiveness of the | ||
health care service or treatment you requested by submitting a | ||
written request for an external review to us. Upon receipt of | ||
your request an independent review organization registered | ||
with the Department of Insurance will be assigned to review our | ||
decision. | ||
(b) This subsection (b) shall apply to an expedited review | ||
prior to a final adverse determination. In addition to the | ||
notice required in subsection (a), the health carrier shall | ||
include a notice related to an adverse determination, a | ||
statement informing the covered person all of the following: | ||
(1) If the covered person has a medical condition where | ||
the timeframe for completion of (A) an expedited internal | ||
review of a grievance involving an adverse determination, | ||
(B) a final adverse determination as set forth in the |
Managed Care Reform and Patient Rights Act, or (C) a | ||
standard external review as established in this Act, would | ||
seriously jeopardize the life or health of the covered | ||
person or would jeopardize the covered person's ability to | ||
regain maximum function, then the covered person or the | ||
covered person's authorized representative may file a | ||
request for an expedited external review. | ||
(2) The covered person or the covered person's | ||
authorized representative may file a request for an | ||
expedited external review at the same time the covered | ||
person or the covered person's authorized representative | ||
files a request for an expedited internal appeal involving | ||
an adverse determination as set forth in the Managed Care | ||
Reform and Patient Rights Act if the adverse determination | ||
involves a denial of coverage based on a determination that | ||
the recommended or requested health care service or | ||
treatment is experimental or investigational and the | ||
covered person's health care provider certifies in writing | ||
that the recommended or requested health care service or | ||
treatment that is the subject of the adverse determination | ||
would be significantly less effective if not promptly | ||
initiated. The independent review organization assigned to | ||
conduct the expedited external review will determine | ||
whether the covered person shall be required to complete | ||
the expedited review of the grievance prior to conducting | ||
the expedited external review. |
(3) If an adverse determination concerns a denial of | ||
coverage based on a determination that the recommended or | ||
requested health care service or treatment is experimental | ||
or investigational and the covered person's health care | ||
provider certifies in writing that the recommended or | ||
requested health care service or treatment that is the | ||
subject of the request would be significantly less | ||
effective if not promptly initiated, then the covered | ||
person or the covered person's authorized representative | ||
may request an expedited external review. | ||
(c) This subsection (c) shall apply to an expedited review | ||
upon final adverse determination. In addition to the notice | ||
required in subsection (a), the health carrier shall include a | ||
notice related to a final adverse determination, a statement | ||
informing the covered person all of the following: | ||
(1) if the covered person has a medical condition where | ||
the timeframe for completion of a standard external review | ||
would seriously jeopardize the life or health of the | ||
covered person or would jeopardize the covered person's | ||
ability to regain maximum function, then the covered person | ||
or the covered person's authorized representative may file | ||
a request for an expedited external review; or | ||
(2) if a final adverse determination concerns an | ||
admission, availability of care, continued stay, or health | ||
care service for which the covered person received | ||
emergency services, but has not been discharged from a |
facility, then the covered person, or the covered person's | ||
authorized representative, may request an expedited | ||
external review; or | ||
(3) if a final adverse determination concerns a denial | ||
of coverage based on a determination that the recommended | ||
or requested health care service or treatment is | ||
experimental or investigational, and the covered person's | ||
health care provider certifies in writing that the | ||
recommended or requested health care service or treatment | ||
that is the subject of the request would be significantly | ||
less effective if not promptly initiated, then the covered | ||
person or the covered person's authorized representative | ||
may request an expedited external review. | ||
(d) In addition to the information to be provided pursuant | ||
to subsections (a), (b), and (c) of this Section, the health | ||
carrier shall include a copy of the description of both the | ||
required standard and expedited external review procedures. | ||
The description shall highlight the external review procedures | ||
that give the covered person or the covered person's authorized | ||
representative the opportunity to submit additional | ||
information, including any forms used to process an external | ||
review. | ||
Section 25. Request for external review. A covered person | ||
or the covered person's authorized representative may make a | ||
request for a standard external or expedited external review of |
an adverse determination or final adverse determination. | ||
Requests under this Section shall be made directly to the | ||
health carrier that made the adverse or final adverse | ||
determination. All requests for external review shall be in | ||
writing except for requests for expedited external reviews | ||
which may me made orally. Health carriers must provide covered | ||
persons with forms to request external reviews. | ||
Section 30. Exhaustion of internal grievance process. | ||
Except as provided in subsection (b) of Section 20, a | ||
request for an external review shall not be made until the | ||
covered person has exhausted the health carrier's internal | ||
grievance process as set forth in the Managed Care Reform and | ||
Patient Rights Act. A covered person shall also be considered | ||
to have exhausted the health carrier's internal grievance | ||
process for purposes of this Section if: | ||
(1) the covered person or the covered person's | ||
authorized representative filed a request for an internal | ||
review of an adverse determination pursuant to the Managed | ||
Care Reform and Patient Rights Act and has not received a | ||
written decision on the request from the health carrier | ||
within 15 days after receipt of the required information | ||
but not more than 30 days after the request was filed by | ||
the covered person or the covered person's authorized | ||
representative, except to the extent the covered person or | ||
the covered person's authorized representative requested |
or agreed to a delay; however, a covered person or the | ||
covered person's authorized representative may not make a | ||
request for an external review of an adverse determination | ||
involving a retrospective review determination until the | ||
covered person has exhausted the health carrier's internal | ||
grievance process; | ||
(2) the covered person or the covered person's | ||
authorized representative filed a request for an expedited | ||
internal review of an adverse determination pursuant to the | ||
Managed Care Reform and Patient Rights Act and has not | ||
received a decision on request from the health carrier | ||
within 48 hours, except to the extent the covered person or | ||
the covered person's authorized representative requested | ||
or agreed to a delay; or | ||
(3) the health carrier agrees to waive the exhaustion | ||
requirement. | ||
Section 35. Standard external review. | ||
(a) Within 4 months after the date of receipt of a notice | ||
of an adverse determination or final adverse determination, a | ||
covered person or the covered person's authorized | ||
representative may file a request for an external review with | ||
the health carrier. | ||
(b) Within 5 business days following the date of receipt of | ||
the external review request, the health carrier shall complete | ||
a preliminary review of the request to determine whether:
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(1) the individual is or was a covered person in the | ||
health benefit plan at the time the health care service was | ||
requested or at the time the health care service was | ||
provided; | ||
(2) the health care service that is the subject of the | ||
adverse determination or the final adverse determination | ||
is a covered service under the covered person's health | ||
benefit plan, but the health carrier has determined that | ||
the health care service is not covered because it does not | ||
meet the health carrier's requirements for medical | ||
necessity, appropriateness, health care setting, level of | ||
care, or effectiveness; | ||
(3) the covered person has exhausted the health | ||
carrier's internal grievance process as set forth in this | ||
Act; | ||
(4) for appeals relating to a determination based on | ||
treatment being experimental or investigational, the | ||
requested health care service or treatment that is the | ||
subject of the adverse determination or final adverse | ||
determination is a covered benefit under the covered | ||
person's health benefit plan except for the health | ||
carrier's determination that the service or treatment is | ||
experimental or investigational for a particular medical | ||
condition and is not explicitly listed as an excluded | ||
benefit under the covered person's health benefit plan with | ||
the health carrier and that the covered person's health |
care provider, who is a physician licensed to practice | ||
medicine in all its branches, has certified that one of the | ||
following situations is applicable: | ||
(A) standard health care services or treatments | ||
have not been effective in improving the condition of | ||
the covered person; | ||
(B) standard health care services or treatments | ||
are not medically appropriate for the covered person; | ||
(C) there is no available standard health care | ||
service or treatment covered by the health carrier that | ||
is more beneficial than the recommended or requested | ||
health care service or treatment;
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(D) the health care service or treatment is likely | ||
to be more beneficial to the covered person, in the | ||
health care provider's opinion, than any available | ||
standard health care services or treatments; or | ||
(E) that scientifically valid studies using | ||
accepted protocols demonstrate that the health care | ||
service or treatment requested is likely to be more | ||
beneficial to the covered person than any available | ||
standard health care services or treatments; and | ||
(5) the covered person has provided all the information | ||
and forms required to process an external review, as | ||
specified in this Act. | ||
(c) Within one business day after completion of the | ||
preliminary review, the health carrier shall notify the covered |
person and, if applicable, the covered person's authorized | ||
representative in writing whether the request is complete and | ||
eligible for external review. If the request: | ||
(1) is not complete, the health carrier shall inform | ||
the covered person and, if applicable, the covered person's | ||
authorized representative in writing and include in the | ||
notice what information or materials are required by this | ||
Act to make the request complete; or | ||
(2) is not eligible for external review, the health | ||
carrier shall inform the covered person and, if applicable, | ||
the covered person's authorized representative in writing | ||
and include in the notice the reasons for its | ||
ineligibility.
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The notice of initial determination of ineligibility shall | ||
include a statement informing the covered person and, if | ||
applicable, the covered person's authorized representative | ||
that a health carrier's initial determination that the external | ||
review request is ineligible for review may be appealed to the | ||
Director by filing a complaint with the Director. | ||
Notwithstanding a health carrier's initial determination | ||
that the request is ineligible for external review, the | ||
Director may determine that a request is eligible for external | ||
review and require that it be referred for external review. In | ||
making such determination, the Director's decision shall be in | ||
accordance with the terms of the covered person's health | ||
benefit plan and shall be subject to all applicable provisions |
of this Act. | ||
(d) Whenever a request is eligible for external review the | ||
health carrier shall, within 5 business days: | ||
(1) assign an independent review organization from the | ||
list of approved independent review organizations compiled | ||
and maintained by the Director; and | ||
(2) notify in writing the covered person and, if | ||
applicable, the covered person's authorized representative | ||
of the request's eligibility and acceptance for external | ||
review and the name of the independent review organization. | ||
The health carrier shall include in the notice provided to | ||
the covered person and, if applicable, the covered person's | ||
authorized representative a statement that the covered person | ||
or the covered person's authorized representative may, within 5 | ||
business days following the date of receipt of the notice | ||
provided pursuant to item (2) of this subsection (d), submit in | ||
writing to the assigned independent review organization | ||
additional information that the independent review | ||
organization shall consider when conducting the external | ||
review. The independent review organization is not required to, | ||
but may, accept and consider additional information submitted | ||
after 5 business days. | ||
(e) The assignment of an approved independent review | ||
organization to conduct an external review in accordance with | ||
this Section shall be made from those approved independent | ||
review organizations qualified to conduct external review as |
required by Sections 50 and 55 of this Act. | ||
(f) Upon assignment of an independent review organization, | ||
the health carrier or its designee utilization review | ||
organization shall, within 5 business days, provide to the | ||
assigned independent review organization the documents and any | ||
information considered in making the adverse determination or | ||
final adverse determination; in such cases, the following | ||
provisions shall apply: | ||
(1) Except as provided in item (2) of this subsection | ||
(f), failure by the health carrier or its utilization | ||
review organization to provide the documents and | ||
information within the specified time frame shall not delay | ||
the conduct of the external review. | ||
(2) If the health carrier or its utilization review | ||
organization fails to provide the documents and | ||
information within the specified time frame, the assigned | ||
independent review organization may terminate the external | ||
review and make a decision to reverse the adverse | ||
determination or final adverse determination. | ||
(3) Within one business day after making the decision | ||
to terminate the external review and make a decision to | ||
reverse the adverse determination or final adverse | ||
determination under item (2) of this subsection (f), the | ||
independent review organization shall notify the health | ||
carrier, the covered person and, if applicable, the covered | ||
person's authorized representative, of its decision to |
reverse the adverse determination. | ||
(g) Upon receipt of the information from the health carrier | ||
or its utilization review organization, the assigned | ||
independent review organization shall review all of the | ||
information and documents and any other information submitted | ||
in writing to the independent review organization by the | ||
covered person and the covered person's authorized | ||
representative. | ||
(h) Upon receipt of any information submitted by the | ||
covered person or the covered person's authorized | ||
representative, the independent review organization shall | ||
forward the information to the health carrier within 1 business | ||
day. | ||
(1) Upon receipt of the information, if any, the health | ||
carrier may reconsider its adverse determination or final | ||
adverse determination that is the subject of the external | ||
review.
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(2) Reconsideration by the health carrier of its | ||
adverse determination or final adverse determination shall | ||
not delay or terminate the external review.
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(3) The external review may only be terminated if the | ||
health carrier decides, upon completion of its | ||
reconsideration, to reverse its adverse determination or | ||
final adverse determination and provide coverage or | ||
payment for the health care service that is the subject of | ||
the adverse determination or final adverse determination. |
In such cases, the following provisions shall apply: | ||
(A) Within one business day after making the | ||
decision to reverse its adverse determination or final | ||
adverse determination, the health carrier shall notify | ||
the covered person and if applicable, the covered | ||
person's authorized representative, and the assigned | ||
independent review organization in writing of its | ||
decision. | ||
(B) Upon notice from the health carrier that the | ||
health carrier has made a decision to reverse its | ||
adverse determination or final adverse determination, | ||
the assigned independent review organization shall | ||
terminate the external review. | ||
(i) In addition to the documents and information provided | ||
by the health carrier or its utilization review organization | ||
and the covered person and the covered person's authorized | ||
representative, if any, the independent review organization, | ||
to the extent the information or documents are available and | ||
the independent review organization considers them | ||
appropriate, shall consider the following in reaching a | ||
decision: | ||
(1) the covered person's pertinent medical records; | ||
(2) the covered person's health care provider's | ||
recommendation; | ||
(3) consulting reports from appropriate health care | ||
providers and other documents submitted by the health |
carrier, the covered person, the covered person's | ||
authorized representative, or the covered person's | ||
treating provider; | ||
(4) the terms of coverage under the covered person's | ||
health benefit plan with the health carrier to ensure that | ||
the independent review organization's decision is not | ||
contrary to the terms of coverage under the covered | ||
person's health benefit plan with the health carrier; | ||
(5) the most appropriate practice guidelines, which | ||
shall include applicable evidence-based standards and may | ||
include any other practice guidelines developed by the | ||
federal government, national or professional medical | ||
societies, boards, and associations; | ||
(6) any applicable clinical review criteria developed | ||
and used by the health carrier or its designee utilization | ||
review organization; and | ||
(7) the opinion of the independent review | ||
organization's clinical reviewer or reviewers after | ||
considering items (1) through (6) of this subsection (i) to | ||
the extent the information or documents are available and | ||
the clinical reviewer or reviewers considers the | ||
information or documents appropriate; and | ||
(8) for a denial of coverage based on a determination | ||
that the health care service or treatment recommended or | ||
requested is experimental or investigational, whether and | ||
to what extent: |
(A) the recommended or requested health care | ||
service or treatment has been approved by the federal | ||
Food and Drug Administration, if applicable, for the | ||
condition; | ||
(B) medical or scientific evidence or | ||
evidence-based standards demonstrate that the expected | ||
benefits of the recommended or requested health care | ||
service or treatment is more likely than not to be | ||
beneficial to the covered person than any available | ||
standard health care service or treatment and the | ||
adverse risks of the recommended or requested health | ||
care service or treatment would not be substantially | ||
increased over those of available standard health care | ||
services or treatments; or | ||
(C) the terms of coverage under the covered | ||
person's health benefit plan with the health carrier to | ||
ensure that the health care service or treatment that | ||
is the subject of the opinion is experimental or | ||
investigational would otherwise be covered under the | ||
terms of coverage of the covered person's health | ||
benefit plan with the health carrier. | ||
(j) Within 5 days after the date of receipt of all | ||
necessary information, the assigned independent review | ||
organization shall provide written notice of its decision to | ||
uphold or reverse the adverse determination or the final | ||
adverse determination to the health carrier, the covered person |
and, if applicable, the covered person's authorized | ||
representative. In reaching a decision, the assigned | ||
independent review organization is not bound by any claim | ||
determinations reached prior to the submission of information | ||
to the independent review organization. In such cases, the | ||
following provisions shall apply: | ||
(1) The independent review organization shall include | ||
in the notice: | ||
(A) a general description of the reason for the | ||
request for external review; | ||
(B) the date the independent review organization | ||
received the assignment from the health carrier to | ||
conduct the external review; | ||
(C) the time period during which the external | ||
review was conducted; | ||
(D) references to the evidence or documentation, | ||
including the evidence-based standards, considered in | ||
reaching its decision; | ||
(E) the date of its decision; and | ||
(F) the principal reason or reasons for its | ||
decision, including what applicable, if any, | ||
evidence-based standards that were a basis for its | ||
decision.
| ||
(2) For reviews of experimental or investigational | ||
treatments, the notice shall include the following | ||
information: |
(A) a description of the covered person's medical | ||
condition; | ||
(B) a description of the indicators relevant to | ||
whether there is sufficient evidence to demonstrate | ||
that the recommended or requested health care service | ||
or treatment is more likely than not to be more | ||
beneficial to the covered person than any available | ||
standard health care services or treatments and the | ||
adverse risks of the recommended or requested health | ||
care service or treatment would not be substantially | ||
increased over those of available standard health care | ||
services or treatments; | ||
(C) a description and analysis of any medical or | ||
scientific evidence considered in reaching the | ||
opinion; | ||
(D) a description and analysis of any | ||
evidence-based standards; | ||
(E) whether the recommended or requested health | ||
care service or treatment has been approved by the | ||
federal Food and Drug Administration, for the | ||
condition; | ||
(F) whether medical or scientific evidence or | ||
evidence-based standards demonstrate that the expected | ||
benefits of the recommended or requested health care | ||
service or treatment is more likely than not to be more | ||
beneficial to the covered person than any available |
standard health care service or treatment and the | ||
adverse risks of the recommended or requested health | ||
care service or treatment would not be substantially | ||
increased over those of available standard health care | ||
services or treatments; and | ||
(G) the written opinion of the clinical reviewer, | ||
including the reviewer's recommendation as to whether | ||
the recommended or requested health care service or | ||
treatment should be covered and the rationale for the | ||
reviewer's recommendation. | ||
(3) In reaching a decision, the assigned independent | ||
review organization is not bound by any decisions or | ||
conclusions reached during the health carrier's | ||
utilization review process or the health carrier's | ||
internal grievance or appeals process. | ||
(4) Upon receipt of a notice of a decision reversing | ||
the adverse determination or final adverse determination, | ||
the health carrier immediately shall approve the coverage | ||
that was the subject of the adverse determination or final | ||
adverse determination. | ||
Section 40. Expedited external review. | ||
(a) A covered person or a covered person's authorized | ||
representative may file a request for an expedited external | ||
review with the health carrier either orally or in writing: | ||
(1) immediately after the date of receipt of a notice |
prior to a final adverse determination as provided by | ||
subsection (b) of Section 20 of this Act; | ||
(2) immediately after the date of receipt of a notice a | ||
final adverse determination as provided by subsection (c) | ||
of Section 20 of this Act; or | ||
(3) if a health carrier fails to provide a decision on | ||
request for an expedited internal appeal within 48 hours as | ||
provided by item (2) of Section 30 of this Act. | ||
(b) Immediately upon receipt of the request for an | ||
expedited external review as provided under subsections (b) and | ||
(c) of Section 20, the health carrier shall determine whether | ||
the request meets the reviewability requirements set forth in | ||
items (1), (2), and (4) of subsection (b) of Section 35. In | ||
such cases, the following provisions shall apply: | ||
(1) The health carrier shall immediately notify the | ||
covered person and, if applicable, the covered person's | ||
authorized representative of its eligibility | ||
determination. | ||
(2) The notice of initial determination shall include a | ||
statement informing the covered person and, if applicable, | ||
the covered person's authorized representative that a | ||
health carrier's initial determination that an external | ||
review request is ineligible for review may be appealed to | ||
the Director. | ||
(3) The Director may determine that a request is | ||
eligible for expedited external review notwithstanding a |
health carrier's initial determination that the request is | ||
ineligible and require that it be referred for external | ||
review. | ||
(4) In making a determination under item (3) of this | ||
subsection (b), the Director's decision shall be made in | ||
accordance with the terms of the covered person's health | ||
benefit plan and shall be subject to all applicable | ||
provisions of this Act. | ||
(c) Upon determining that a request meets the requirements | ||
of subsections (b) and (c) of Section 20, the health
carrier | ||
shall immediately assign an independent review organization | ||
from the list of approved independent review organizations | ||
compiled and maintained by the Director to conduct the | ||
expedited review. In such cases, the following provisions shall | ||
apply: | ||
(1) The assignment of an approved independent review | ||
organization to conduct an external review in accordance | ||
with this Section shall be made from those approved | ||
independent review organizations qualified to conduct | ||
external review as required by Sections 50 and 55 of this | ||
Act.
| ||
(2) Immediately upon assigning an independent review | ||
organization to perform an expedited external review, but | ||
in no case more than 24 hours after assigning the | ||
independent review organization, the health carrier or its | ||
designee utilization review organization shall provide or |
transmit all necessary documents and information | ||
considered in making the final adverse determination to the | ||
assigned independent review organization electronically or | ||
by telephone or facsimile or any other available | ||
expeditious method. | ||
(3) If the health carrier or its utilization review | ||
organization fails to provide the documents and | ||
information within the specified timeframe, the assigned | ||
independent review organization may terminate the external | ||
review and make a decision to reverse the adverse | ||
determination or final adverse determination. | ||
(4) Within one business day after making the decision | ||
to terminate the external review and make a decision to | ||
reverse the adverse determination or final adverse | ||
determination under item (3) of this subsection (c), the | ||
independent review organization shall notify the health | ||
carrier, the covered person and, if applicable, the covered | ||
person's authorized representative of its decision to | ||
reverse the adverse determination.
| ||
(d) In addition to the documents and information provided | ||
by the health carrier or its utilization review organization | ||
and any documents and information provided by the covered | ||
person and the covered person's authorized representative, the | ||
independent review organization shall consider information as | ||
required by subsection (i) of Section 35 of this Act in | ||
reaching a decision. |
(e) As expeditiously as the covered person's medical | ||
condition or circumstances requires, but in no event more than | ||
2 business days after the receipt of all pertinent information, | ||
the assigned independent review organization shall: | ||
(1) make a decision to uphold or reverse the final | ||
adverse determination; and | ||
(2) notify the health carrier, the covered person, the | ||
covered person's health care provider, and if applicable, | ||
the covered person's authorized representative, of the | ||
decision. | ||
(f) In reaching a decision, the assigned independent review | ||
organization is not bound by any decisions or conclusions | ||
reached during the health carrier's utilization review process | ||
or the health carrier's internal grievance process as set forth | ||
in the Managed Care Reform and Patient Rights Act.
| ||
(g) Upon receipt of notice of a decision reversing the | ||
final adverse determination, the health carrier shall | ||
immediately approve the coverage that was the subject of the | ||
final adverse determination. | ||
(h) Within 48 hours after the date of providing the notice | ||
required in item (2) of subsection (e), the assigned | ||
independent review organization shall provide written | ||
confirmation of the decision to the health carrier, the covered | ||
person, and if applicable, the covered person's authorized | ||
representative including the information set forth in | ||
subsection (j) of Section 35 of this Act as applicable. |
(i) An expedited external review may not be provided for | ||
retrospective adverse or final adverse determinations. | ||
Section 45. Binding nature of external review decision. An | ||
external review decision is binding on the health carrier. An | ||
external review decision is binding on the covered person | ||
except to the extent the covered person has other remedies | ||
available under applicable federal or State law. A covered | ||
person or the covered person's authorized representative may | ||
not file a subsequent request for external review involving the | ||
same adverse determination or final adverse determination for | ||
which the covered person has already received an external | ||
review decision pursuant to this Act.
| ||
Section 50. Approval of independent review organizations. | ||
(a) The Director shall approve independent review | ||
organizations eligible to be assigned to conduct external | ||
reviews under this Act. | ||
(b) In order to be eligible for approval by the Director | ||
under this Section to conduct external reviews under this Act | ||
an independent review organization:
| ||
(1) except as otherwise provided in this Section, shall | ||
be accredited by a nationally recognized private | ||
accrediting entity that the Director has determined has | ||
independent review organization accreditation standards | ||
that are equivalent to or exceed the minimum qualifications |
for independent review; and | ||
(2) shall submit an application for approval in | ||
accordance with subsection (d) of this Section.
| ||
(c) The Director shall develop an application form for | ||
initially approving and for reapproving independent review | ||
organizations to conduct external reviews. | ||
(d) Any independent review organization wishing to be | ||
approved to conduct external reviews under this Act shall | ||
submit the application form and include with the form all | ||
documentation and information necessary for the Director to | ||
determine if the independent review organization satisfies the | ||
minimum qualifications established under this Act.
The | ||
Director may: | ||
(1) approve independent review organizations that are | ||
not accredited by a nationally recognized private | ||
accrediting entity if there are no acceptable nationally | ||
recognized private accrediting entities providing | ||
independent review organization accreditation; and | ||
(2) by rule establish an application fee that | ||
independent review organizations shall submit to the | ||
Director with an application for approval and renewing.
| ||
(e) An approval is effective for 2 years, unless the | ||
Director determines before its expiration that the independent | ||
review organization is not satisfying the minimum | ||
qualifications established under this Act. | ||
(f) Whenever the Director determines that an independent |
review organization has lost its accreditation or no longer | ||
satisfies the minimum requirements established under this Act, | ||
the Director shall terminate the approval of the independent | ||
review organization and remove the independent review | ||
organization from the list of independent review organizations | ||
approved to conduct external reviews under this Act that is | ||
maintained by the Director. | ||
(g) The Director shall maintain and periodically update a | ||
list of approved independent review organizations. | ||
(h) The Director may promulgate regulations to carry out | ||
the provisions of this Section. | ||
Section 55. Minimum qualifications for independent review | ||
organizations.
| ||
(a) To be approved to conduct external reviews, an | ||
independent review organization shall have and maintain | ||
written policies and procedures that govern all aspects of both | ||
the standard external review process and the expedited external | ||
review process set forth in this Act that include, at a | ||
minimum: | ||
(1) a quality assurance mechanism that ensures that: | ||
(A) external reviews are conducted within the | ||
specified timeframes and required notices are provided | ||
in a timely manner; | ||
(B) selection of qualified and impartial clinical | ||
reviewers to conduct external reviews on behalf of the |
independent review organization and suitable matching | ||
of reviewers to specific cases and that the independent | ||
review organization employs or contracts with an | ||
adequate number of clinical reviewers to meet this | ||
objective; | ||
(C) for adverse determinations involving | ||
experimental or investigational treatments, in | ||
assigning clinical reviewers, the independent review | ||
organization selects physicians or other health care | ||
professionals who, through clinical experience in the | ||
past 3 years, are experts in the treatment of the | ||
covered person's condition and knowledgeable about the | ||
recommended or requested health care service or | ||
treatment; | ||
(D) the health carrier, the covered person, and the | ||
covered person's authorized representative shall not | ||
choose or control the choice of the physicians or other | ||
health care professionals to be selected to conduct the | ||
external review; | ||
(E) confidentiality of medical and treatment | ||
records and clinical review criteria; and | ||
(F) any person employed by or under contract with | ||
the independent review organization adheres to the | ||
requirements of this Act; | ||
(2) a toll-free telephone service operating on a | ||
24-hour-day, 7-day-a-week basis that accepts, receives, |
and records information related to external reviews and | ||
provides appropriate instructions; and | ||
(3) an agreement to maintain and provide to the | ||
Director the information set out in Section 70 of this Act. | ||
(b) All clinical reviewers assigned by an independent | ||
review organization to conduct external reviews shall be | ||
physicians or other appropriate health care providers who meet | ||
the following minimum qualifications:
| ||
(1) be an expert in the treatment of the covered | ||
person's medical condition that is the subject of the | ||
external review; | ||
(2) be knowledgeable about the recommended health care | ||
service or treatment through recent or current actual | ||
clinical experience treating patients with the same or | ||
similar medical condition of the covered person; | ||
(3) hold a non-restricted license in a state of the | ||
United States and, for physicians, a current certification | ||
by a recognized American medical specialty board in the | ||
area or areas appropriate to the subject of the external | ||
review; and | ||
(4) have no history of disciplinary actions or | ||
sanctions, including loss of staff privileges or | ||
participation restrictions, that have been taken or are | ||
pending by any hospital, governmental agency or unit, or | ||
regulatory body that raise a substantial question as to the | ||
clinical reviewer's physical, mental, or professional |
competence or moral character. | ||
(c) In addition to the requirements set forth in subsection | ||
(a), an independent review organization may not own or control, | ||
be a subsidiary of, or in any way be owned, or controlled by, | ||
or exercise control with a health benefit plan, a national, | ||
State, or local trade association of health benefit plans, or a | ||
national, State, or local trade association of health care | ||
providers. | ||
(d) Conflicts of interest prohibited.
In addition to the | ||
requirements set forth in subsections (a), (b), and (c) of this | ||
Section, to be approved pursuant to this Act to conduct an | ||
external review of a specified case, neither the independent | ||
review organization selected to conduct the external review nor | ||
any clinical reviewer assigned by the independent organization | ||
to conduct the external review may have a material | ||
professional, familial or financial conflict of interest with | ||
any of the following: | ||
(1) the health carrier that is the subject of the | ||
external review; | ||
(2) the covered person whose treatment is the subject | ||
of the external review or the covered person's authorized | ||
representative; | ||
(3) any officer, director or management employee of the | ||
health carrier that is the subject of the external review; | ||
(4) the health care provider, the health care | ||
provider's medical group or independent practice |
association recommending the health care service or | ||
treatment that is the subject of the external review; | ||
(5) the facility at which the recommended health care | ||
service or treatment would be provided; or | ||
(6) the developer or manufacturer of the principal | ||
drug, device, procedure, or other therapy being | ||
recommended for the covered person whose treatment is the | ||
subject of the external review.
| ||
(e) An independent review organization that is accredited | ||
by a nationally recognized private accrediting entity that has | ||
independent review accreditation standards that the Director | ||
has determined are equivalent to or exceed the minimum | ||
qualifications of this Section shall be presumed to be in | ||
compliance with this Section and shall be eligible for approval | ||
under this Act. | ||
(f) An independent review organization shall be unbiased. | ||
An independent review organization shall establish and | ||
maintain written procedures to ensure that it is unbiased in | ||
addition to any other procedures required under this Section. | ||
(g) Nothing in this Act precludes or shall be interpreted | ||
to preclude a health carrier from contracting with approved | ||
independent review organizations to conduct external reviews | ||
assigned to it from such health carrier. | ||
Section 60. Hold harmless for independent review | ||
organizations. No independent review organization or clinical |
reviewer working on behalf of an independent review | ||
organization or an employee, agent or contractor of an | ||
independent review organization shall be liable for damages to | ||
any person for any opinions rendered or acts or omissions | ||
performed within the scope of the organization's or person's | ||
duties under the law during or upon completion of an external | ||
review conducted pursuant to this Act, unless the opinion was | ||
rendered or act or omission performed in bad faith or involved | ||
gross negligence. | ||
Section 65. External review reporting requirements. | ||
(a) Each health carrier shall maintain written records in | ||
the aggregate on all requests for external review for each | ||
calendar year and submit a report to the Director in the format | ||
specified by the Director by March 1 of each year. | ||
(b) The report shall include in the aggregate:
| ||
(1) the total number of requests for external review; | ||
(2) the total number of requests for expedited external | ||
review;
| ||
(3) the total number of requests for external review | ||
denied; | ||
(4) the number of requests for external review | ||
resolved, including: | ||
(A) the number of requests for external review | ||
resolved upholding the adverse determination or final | ||
adverse determination; |
(B) the number of requests for external review | ||
resolved reversing the adverse determination or final | ||
adverse determination; | ||
(C) the number of requests for expedited external | ||
review resolved upholding the adverse determination or | ||
final adverse determination; and | ||
(D) the number of requests for expedited external | ||
review resolved reversing the adverse determination or | ||
final adverse determination; | ||
(5) the average length of time for resolution for an | ||
external review; | ||
(6) the average length of time for resolution for an | ||
expedited external review; | ||
(7) a summary of the types of coverages or cases for | ||
which an external review was sought, as specified below:
| ||
(A) denial of care or treatment (dissatisfaction | ||
regarding prospective non-authorization of a request | ||
for care or treatment recommended by a provider | ||
excluding diagnostic procedures and referral requests; | ||
partial approvals and care terminations are also | ||
considered to be denials); | ||
(B) denial of diagnostic procedure | ||
(dissatisfaction regarding prospective | ||
non-authorization of a request for a diagnostic | ||
procedure recommended by a provider; partial approvals | ||
are also considered to be denials); |
(C) denial of referral request (dissatisfaction | ||
regarding non-authorization of a request for a | ||
referral to another provider recommended by a PCP); | ||
(D) claims and utilization review (dissatisfaction | ||
regarding the concurrent or retrospective evaluation | ||
of the coverage, medical necessity, efficiency or | ||
appropriateness of health care services or treatment | ||
plans; prospective "Denials of care or treatment", | ||
"Denials of diagnostic procedures" and "Denials of | ||
referral requests" should not be classified in this | ||
category, but the appropriate one above);
| ||
(8) the number of external reviews that were terminated | ||
as the result of a reconsideration by the health carrier of | ||
its adverse determination or final adverse determination | ||
after the receipt of additional information from the | ||
covered person or the covered person's authorized | ||
representative; and | ||
(9) any other information the Director may request or | ||
require.
| ||
Section 70. Funding of external review. The health carrier | ||
shall be solely responsible for paying the cost of external | ||
reviews conducted by independent review organizations. | ||
Section 75. Disclosure requirements. | ||
(a) Each health carrier shall include a description of the |
external review procedures in, or attached to, the policy, | ||
certificate, membership booklet, and outline of coverage or | ||
other evidence of coverage it provides to covered persons. | ||
(b) The description required under subsection (a) of this | ||
Section shall include a statement that informs the covered | ||
person of the right of the covered person to file a request for | ||
an external review of an adverse determination or final adverse | ||
determination with the health carrier. The statement shall | ||
explain that external review is available when the adverse | ||
determination or final adverse determination involves an issue | ||
of medical necessity, appropriateness, health care setting, | ||
level of care, or effectiveness. The statement shall include | ||
the toll-free telephone number and address of the Office of | ||
Consumer Health Insurance within the Department of Insurance.
| ||
Section 90. The Illinois Insurance Code is amended by | ||
changing Section 155.36 and by adding Sections 359b and 359c as | ||
follows:
| ||
(215 ILCS 5/155.36)
| ||
Sec. 155.36. Managed Care Reform and Patient Rights Act. | ||
Insurance
companies that transact the kinds of insurance | ||
authorized under Class 1(b) or
Class 2(a) of Section 4 of this | ||
Code shall comply
with Sections 45 and Section 85 and the | ||
definition of the term "emergency medical
condition" in Section
| ||
10 of the Managed Care Reform and Patient Rights Act.
|
(Source: P.A. 91-617, eff. 1-1-00.)
| ||
(215 ILCS 5/359b new)
| ||
Sec. 359b. Committee to create a uniform small employer | ||
group-health status questionnaire and individual health | ||
statement. | ||
(a) For the purposes of this Section: | ||
"Employee health-status questionnaire" means a | ||
questionnaire that poses questions about an individual | ||
employee's or covered dependent's health history and that is to | ||
be completed by the individual employee or covered dependent of | ||
a small employer that seeks health insurance coverage from a | ||
small employer carrier. | ||
"Health benefit plan", "small employer", and "small | ||
employer carrier" shall have the meaning given the terms in the | ||
Small Employer Health Insurance Rating Act. | ||
"Individual health insurance coverage" and "individual | ||
market" shall have the meaning given the terms in the Illinois | ||
Health Insurance Portability and Accountability Act. | ||
(b) A committee is established in the Department consisting | ||
of 11 members, including the Director or the Director's | ||
designee, who are appointed by the Director. The Director shall | ||
appoint to the committee 5 representatives as recommended by | ||
the Illinois Insurance Association, Illinois Life Insurance | ||
Council, Professional Independent Insurance Agents of | ||
Illinois, Illinois Association of Health Underwriters, |
Illinois Chamber of Commerce, Illinois Manufacturers | ||
Association, Illinois Retail Merchants Association, and | ||
National Federation of Independent Businesses and 5 consumer | ||
representatives. The Director or the Director's designee shall | ||
serve as chairperson of the committee. | ||
(c) The committee shall develop a uniform employee | ||
health-status questionnaire to simplify the health insurance | ||
application process for small employers. The committee shall | ||
study employee-health status questionnaires currently used by | ||
major small employer carriers in this State and consolidate the | ||
questionnaires into a uniform questionnaire. The questionnaire | ||
shall be designed to permit its use both as a written document | ||
and through electronic or other alternative delivery formats. | ||
A uniform employee health-status questionnaire shall allow | ||
small employers that are required to provide information | ||
regarding their employees to a small employer carrier when | ||
applying for a small employer group health insurance policy to | ||
use a standardized questionnaire that small employer carriers | ||
shall be required to use. The development of the uniform | ||
employee health-status questionnaire is intended to relieve | ||
small employers of the burden of completing separate | ||
application forms for each small employer carrier with which | ||
the employer applies for insurance or from which the employer | ||
seeks information regarding such matters as rates, coverage, | ||
and availability. The use of the uniform employee health-status | ||
questionnaire by small employer carriers and small employers |
shall be mandatory. | ||
(d) On or before July 1, 2010, the committee shall develop | ||
the uniform employee health-status questionnaire for adoption | ||
by the Department. Beginning January 1, 2011, a small employer | ||
carrier shall use the questionnaire for all small employer | ||
groups for which it requires employees and their covered | ||
dependents to complete questionnaires. | ||
(e) The Director, as needed, may reconvene the committee to | ||
consider whether changes are necessary to the uniform employee | ||
health status questionnaire. If the committee determines that | ||
changes to the questionnaire are necessary, then the Director | ||
may adopt revisions to the questionnaire as recommended by the | ||
committee. Small employer carriers shall use the revised | ||
questionnaire beginning 90 days after the Director adopts any | ||
revision. | ||
(f) Nothing in this Section shall be construed to limit or | ||
restrict a small employer carrier's ability to appropriately | ||
rate risk under a small employer health benefit plan. | ||
(g) On or before July 1, 2010, the committee shall develop | ||
a standard individual market health statement to simplify the | ||
health insurance application process for individuals. The | ||
committee shall study health statements currently used by major | ||
carriers in this State who offer individual health insurance | ||
coverage and consolidate the statements into a standard | ||
individual market health statement. The standard individual | ||
market health statement shall be designed to permit its use |
both as a written document and through electronic or other | ||
alternative delivery formats. For purposes of the individual | ||
market health statement, the Director may, but shall not be | ||
required to, establish a committee distinct from that formed to | ||
develop an application for small employers. In that event, the | ||
composition of the committee shall be as prescribed in | ||
subsection (b) of this Section, although individual | ||
participants may change. | ||
(h) Beginning January 1, 2011, all carriers who offer | ||
individual health insurance coverage and evaluate the health | ||
status of individuals shall use the standard individual market | ||
health statement. | ||
(i) The Director, as needed, may reconvene the committee to | ||
consider whether changes are necessary to the standard | ||
individual market health statement. If the committee | ||
determines that changes to the statement are necessary, the | ||
Director may adopt revisions to the statement as recommended by | ||
the committee. All carriers who offer individual health | ||
insurance coverage shall use the revised statement beginning 90 | ||
days after the Director adopts any revision. | ||
(j) Nothing in this Section shall prevent a carrier from | ||
using health information after enrollment for the purpose of | ||
providing services or arranging for the provision of services
| ||
under a health benefit plan or a policy of individual health | ||
insurance coverage. | ||
(k) Nothing in this Section shall be construed to limit or |
restrict a health carrier's ability to appropriately rate risk, | ||
refuse to issue or renew coverage, or otherwise rescind, | ||
terminate, or restrict coverage under a health benefit plan or | ||
a policy of individual health insurance coverage or conduct | ||
further review of the information submitted on the statement by | ||
contacting an individual, the individual's health care | ||
provider, or any other entity for additional health status | ||
related information. | ||
(l) Committee members are not eligible for compensation but | ||
may receive reimbursement of expenses. | ||
(215 ILCS 5/359c new)
| ||
Sec. 359c. Accident and health expense reporting. | ||
(a) Beginning January 1, 2011 and every 6 months | ||
thereafter, any carrier providing a group or individual major | ||
medical policy of accident or health insurance shall prepare | ||
and provide to the Department of Insurance a statement of the | ||
aggregate administrative expenses of the carrier, based on the | ||
premiums earned in the immediately preceding 6-month period on | ||
the accident or health insurance business of the carrier. The | ||
semi-annual statements shall be filed on or before July 31 for | ||
the preceding 6-month period ending June 30 and on or before | ||
February 1 for the preceding 6-month period ending December 31. | ||
The statements shall itemize and separately detail all of the | ||
following information with respect to the carrier's accident or | ||
health insurance business: |
(1) the amount of premiums earned by the carrier both | ||
before and after any costs related to the carrier's | ||
purchase of reinsurance coverage; | ||
(2) the total amount of claims for losses paid by the | ||
carrier both before and after any reimbursement from | ||
reinsurance coverage including any costs incurred related | ||
to: | ||
(A) disease, case, or chronic care management | ||
programs; | ||
(B) wellness and health education programs; | ||
(C) fraud prevention; | ||
(D) maintaining provider networks and provider | ||
credentialing; | ||
(E) health information technology for personal | ||
electronic health records; and | ||
(F) utilization review and utilization management; | ||
(3) the amount of any losses incurred by the carrier | ||
but not reported to the carrier in the current or prior | ||
reporting period; | ||
(4) the amount of costs incurred by the carrier for | ||
State fees and federal and State taxes including: | ||
(A) any high risk pool and guaranty fund | ||
assessments levied on the carrier by the State; and | ||
(B) any regulatory compliance costs including | ||
State fees for form and rate filings, licensures, | ||
market conduct exams, and financial reports; |
(5) the amount of costs incurred by the carrier for | ||
reinsurance coverage; | ||
(6) the amount of costs incurred by the carrier that | ||
are related to the carrier's payment of marketing expenses | ||
including commissions; and | ||
(7) any other administrative expenses incurred by the | ||
carrier. | ||
(b) The information provided pursuant to subsection (a) of | ||
this Section shall be separately aggregated for the following | ||
lines of major medical insurance: | ||
(1) individually underwritten; | ||
(2) groups of 2 to 25 members; | ||
(3) groups of 26 to 50 members; | ||
(4) groups of 51 or more members. | ||
(c) The Department shall make the submitted information | ||
publicly available on the Department's website or such other | ||
media as appropriate in a form useful for consumers.
| ||
Section 95. The Managed Care Reform and Patient Rights Act | ||
is amended by changing Sections 40 and 45 as follows:
| ||
(215 ILCS 134/40)
| ||
Sec. 40. Access to specialists.
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(a) All health care plans that require each enrollee to | ||
select a
health care provider for any purpose including | ||
coordination of
care shall
permit an enrollee to choose any |
available primary care physician licensed to
practice
medicine | ||
in all its branches participating in
the health care plan for | ||
that purpose.
The health care plan shall provide the enrollee | ||
with a choice of licensed
health care providers who are | ||
accessible and
qualified. Nothing in
this Act shall be | ||
construed to prohibit a health care plan from requiring a
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health care provider to meet the health care plan's criteria in | ||
order to
coordinate access to health care.
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(b) A health care plan shall establish a procedure by which | ||
an enrollee who
has a condition that requires ongoing care from | ||
a specialist physician
or other health care provider may apply | ||
for a
standing referral to a specialist physician or other | ||
health care provider if a
referral to a specialist
physician or | ||
other health care provider is required for
coverage.
The | ||
application shall be made to the enrollee's primary care | ||
physician.
This procedure for a standing referral must specify
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the necessary criteria and conditions that must be met in order | ||
for an enrollee
to obtain a standing referral.
A standing | ||
referral shall be effective for the period
necessary to provide | ||
the referred services or one year, except in the event of
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termination of a contract or policy in which case Section 25 on | ||
transition of
services shall apply, if applicable.
A primary | ||
care physician may renew and re-renew a standing referral.
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(c) The enrollee may be required by the health care plan to | ||
select a
specialist physician or other health care provider who | ||
has a referral
arrangement with the enrollee's
primary care |
physician or to select a new primary care physician who has a
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referral arrangement with the specialist physician or other | ||
health care
provider chosen by the enrollee.
If a health care | ||
plan requires an enrollee to select a new physician under
this | ||
subsection, the health care plan must provide the enrollee with
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both
options provided in this subsection.
When a participating | ||
specialist with a referral arrangement is not available,
the | ||
primary care physician, in consultation with the enrollee, | ||
shall arrange
for the enrollee to have access to a qualified | ||
participating health care
provider, and the enrollee shall be | ||
allowed to stay with his or her primary
care physician.
If a | ||
secondary referral is necessary, the specialist physician or | ||
other health
care provider shall advise the primary care | ||
physician. The primary care
physician shall be responsible for | ||
making the secondary referral. In addition,
the health care | ||
plan shall require the specialist physician or other health
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care
provider to provide regular updates to the enrollee's | ||
primary care physician.
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(d) When the type of specialist physician or other health | ||
care provider
needed to provide ongoing care
for a
specific | ||
condition is not represented in the health care plan's provider
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network, the primary care physician shall arrange for the | ||
enrollee to have
access to
a qualified non-participating health | ||
care provider
within a reasonable distance and travel
time at | ||
no additional cost beyond what the enrollee would otherwise pay | ||
for
services received within the network. The referring |
physician
shall notify the plan when a referral is made outside | ||
the network.
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(e) The enrollee's primary care physician shall remain | ||
responsible for
coordinating the care of an enrollee who has | ||
received a standing referral to a
specialist physician or other | ||
health care provider.
If a secondary referral is necessary, the | ||
specialist physician or other health
care provider shall advise
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the primary care physician. The primary care physician shall be | ||
responsible
for making the secondary referral.
In addition,
the | ||
health care plan shall require the specialist physician or | ||
other health
care
provider to provide
regular updates to the | ||
enrollee's primary care physician.
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(f) If an enrollee's application for any referral is | ||
denied, an
enrollee may appeal the decision through the
health | ||
care plan's external independent review process as provided by | ||
the Illinois Health Carrier External Review Act in accordance | ||
with
subsection (f) of Section 45 of this Act .
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(g) Nothing in this Act shall be construed to require an | ||
enrollee to select
a new primary care physician when no | ||
referral arrangement exists between the
enrollee's primary | ||
care physician and the specialist selected by the enrollee
and | ||
when the enrollee has a long-standing relationship with his or | ||
her primary
care physician.
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(h) In promulgating rules to implement this Act, the | ||
Department shall
define
"standing referral" and "ongoing | ||
course of treatment".
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(Source: P.A. 91-617, eff. 1-1-00.)
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(215 ILCS 134/45)
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Sec. 45.
Health care services appeals,
complaints, and
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external independent reviews.
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(a) A health care plan shall establish and maintain an | ||
appeals procedure as
outlined in this Act. Compliance with this | ||
Act's appeals procedures shall
satisfy a health care plan's | ||
obligation to provide appeal procedures under any
other State | ||
law or rules.
All appeals of a health care plan's | ||
administrative determinations and
complaints regarding its | ||
administrative decisions shall be handled as required
under | ||
Section 50.
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(b) When an appeal concerns a decision or action by a | ||
health care plan,
its
employees, or its subcontractors that | ||
relates to (i) health care services,
including, but not limited | ||
to, procedures or
treatments,
for an enrollee with an ongoing | ||
course of treatment ordered
by a health care provider,
the | ||
denial of which could significantly
increase the risk to an
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enrollee's health,
or (ii) a treatment referral, service,
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procedure, or other health care service,
the denial of which | ||
could significantly
increase the risk to an
enrollee's health,
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the health care plan must allow for the filing of an appeal
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either orally or in writing. Upon submission of the appeal, a | ||
health care plan
must notify the party filing the appeal, as | ||
soon as possible, but in no event
more than 24 hours after the |
submission of the appeal, of all information
that the plan | ||
requires to evaluate the appeal.
The health care plan shall | ||
render a decision on the appeal within
24 hours after receipt | ||
of the required information. The health care plan shall
notify | ||
the party filing the
appeal and the enrollee, enrollee's | ||
primary care physician, and any health care
provider who | ||
recommended the health care service involved in the appeal of | ||
its
decision orally
followed-up by a written notice of the | ||
determination.
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(c) For all appeals related to health care services | ||
including, but not
limited to, procedures or treatments for an | ||
enrollee and not covered by
subsection (b) above, the health | ||
care
plan shall establish a procedure for the filing of such | ||
appeals. Upon
submission of an appeal under this subsection, a | ||
health care plan must notify
the party filing an appeal, within | ||
3 business days, of all information that the
plan requires to | ||
evaluate the appeal.
The health care plan shall render a | ||
decision on the appeal within 15 business
days after receipt of | ||
the required information. The health care plan shall
notify the | ||
party filing the appeal,
the enrollee, the enrollee's primary | ||
care physician, and any health care
provider
who recommended | ||
the health care service involved in the appeal orally of its
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decision followed-up by a written notice of the determination.
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(d) An appeal under subsection (b) or (c) may be filed by | ||
the
enrollee, the enrollee's designee or guardian, the | ||
enrollee's primary care
physician, or the enrollee's health |
care provider. A health care plan shall
designate a clinical | ||
peer to review
appeals, because these appeals pertain to | ||
medical or clinical matters
and such an appeal must be reviewed | ||
by an appropriate
health care professional. No one reviewing an | ||
appeal may have had any
involvement
in the initial | ||
determination that is the subject of the appeal. The written
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notice of determination required under subsections (b) and (c) | ||
shall
include (i) clear and detailed reasons for the | ||
determination, (ii)
the medical or
clinical criteria for the | ||
determination, which shall be based upon sound
clinical | ||
evidence and reviewed on a periodic basis, and (iii) in the | ||
case of an
adverse determination, the
procedures for requesting | ||
an external independent review as provided by the Illinois | ||
Health Carrier External Review Act under subsection (f) .
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(e) If an appeal filed under subsection (b) or (c) is | ||
denied for a reason
including, but not limited to, the
service, | ||
procedure, or treatment is not viewed as medically necessary,
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denial of specific tests or procedures, denial of referral
to | ||
specialist physicians or denial of hospitalization requests or | ||
length of
stay requests, any involved party may request an | ||
external independent review as provided by the Illinois Health | ||
Carrier External Review Act
under subsection (f) of the adverse | ||
determination .
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(f) Until July 1, 2013, if an external independent review | ||
decision made pursuant to the Illinois Health Carrier External | ||
Review Act upholds a determination adverse to the covered |
person, the covered person has the right to appeal the final | ||
decision to the Department; if the external review decision is | ||
found by the Director to have been arbitrary and capricious, | ||
then the Director, with consultation from a licensed medical | ||
professional, may overturn the external review decision and | ||
require the health carrier to pay for the health care service
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or treatment; such decision, if any, shall be made solely on
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the legal or medical merits of the claim. If an external review | ||
decision is overturned by the Director pursuant to this Section | ||
and the health carrier so requests, then the Director shall | ||
assign a new independent review organization to reconsider the | ||
overturned decision. The new independent review organization | ||
shall follow subsection (d) of Section 40 of the Health Carrier | ||
External Review Act in rendering a decision. External | ||
independent review.
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(1) The party seeking an external independent review | ||
shall so notify the
health care plan.
The health care plan | ||
shall seek to resolve all
external independent
reviews in | ||
the most expeditious manner and shall make a determination | ||
and
provide notice of the determination no more
than 24 | ||
hours after the receipt of all necessary information when a | ||
delay would
significantly increase
the risk to an | ||
enrollee's health or when extended health care services for | ||
an
enrollee undergoing a
course of treatment prescribed by | ||
a health care provider are at issue.
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(2) Within 30 days after the enrollee receives written |
notice of an
adverse
determination,
if the enrollee decides | ||
to initiate an external independent review, the
enrollee | ||
shall send to the health
care plan a written request for an | ||
external independent review, including any
information or
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documentation to support the enrollee's request for the | ||
covered service or
claim for a covered
service.
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(3) Within 30 days after the health care plan receives | ||
a request for an
external
independent review from an | ||
enrollee, the health care plan shall:
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(A) provide a mechanism for joint selection of an | ||
external independent
reviewer by the enrollee, the | ||
enrollee's physician or other health care
provider,
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and the health care plan; and
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(B) forward to the independent reviewer all | ||
medical records and
supporting
documentation | ||
pertaining to the case, a summary description of the | ||
applicable
issues including a
statement of the health | ||
care plan's decision, the criteria used, and the
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medical and clinical reasons
for that decision.
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(4) Within 5 days after receipt of all necessary | ||
information, the
independent
reviewer
shall evaluate and | ||
analyze the case and render a decision that is based on
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whether or not the health
care service or claim for the | ||
health care service is medically appropriate. The
decision | ||
by the
independent reviewer is final. If the external | ||
independent reviewer determines
the health care
service to |
be medically
appropriate, the health
care plan shall pay | ||
for the health care service.
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(5) The health care plan shall be solely responsible | ||
for paying the fees
of the external
independent reviewer | ||
who is selected to perform the review.
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(6) An external independent reviewer who acts in good | ||
faith shall have
immunity
from any civil or criminal | ||
liability or professional discipline as a result of
acts or | ||
omissions with
respect to any external independent review, | ||
unless the acts or omissions
constitute wilful and wanton
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misconduct. For purposes of any proceeding, the good faith | ||
of the person
participating shall be
presumed.
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(g) (7) Future contractual or employment action by the | ||
health care plan
regarding the
patient's physician or other | ||
health care provider shall not be based solely on
the | ||
physician's or other
health care provider's participation | ||
in health care services appeals,
complaints, or
external | ||
independent reviews under the Illinois Health Carrier | ||
External Review Act this procedure .
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(8) For the purposes of this Section, an external | ||
independent reviewer
shall:
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(A) be a clinical peer;
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(B) have no direct financial interest in | ||
connection with the case; and
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(C) have not been informed of the specific identity | ||
of the enrollee.
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(h) (g) Nothing in this Section shall be construed to | ||
require a health care
plan to pay for a health care service not | ||
covered under the enrollee's
certificate of coverage or policy.
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(Source: P.A. 91-617, eff. 1-1-00.)
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Section 96. No acceleration or delay. Where this Act makes | ||
changes in a statute that is represented in this Act by text | ||
that is not yet or no longer in effect (for example, a Section | ||
represented by multiple versions), the use of that text does | ||
not accelerate or delay the taking effect of (i) the changes | ||
made by this Act or (ii) provisions derived from any other | ||
Public Act. | ||
Section 97. Severability. The provisions of this Act are | ||
severable under Section 1.31 of the Statute on Statutes. | ||
Section 99. Effective date. This Act takes effect January | ||
1, 2010, except that the changes to Section 155.36 of the | ||
Illinois Insurance Code and Sections 40 and 45 of the Managed | ||
Care Reform and Patient Rights Act and the Health Carrier | ||
External Review Act take effect July 1, 2010. |