Section 2051.210  Purpose

 

a)         The purpose of this Part is to implement Article XX½ of the Illinois Insurance Code, which, in part, provides for the regulation of preferred provider programs for health care benefit plans and for the provision of workers' compensation medical benefits by employers, including those programs that provide insureds or beneficiaries access to discounted health care provider fees. This Part defines the authority of an administrator to operate preferred provider programs in this State, establishes criteria for the registration of administrators with the Director of Insurance and establishes appropriate fees for the registration and regulation of programs. This Part also establishes requirements for any person, partnership or corporation engaged in any conduct regulated by the Act, including, but not limited to, administrators, discounted health care services plan administrators, and insurers that, under Sections 370h and 370i of the Act, enters into a preferred provider arrangement or offers a preferred provider program. The entity must comply with this Part when offering incentives to insureds or beneficiaries to utilize the services of contracted providers. This Part does not apply to employee benefit trust funds, other ERISA exempt organizations, self-funded State of Illinois health benefit plans, Medicare approved prescription drug plans or any State of Illinois discount drug program, except as otherwise set forth in this Part. 

 

b)         This Part also implements Section 8.1a of the Workers' Compensation Act [820 ILCS 305], which provides for the regulation of certain preferred provider programs for the provision of health care services to employees under the Workers' Compensation Act. This Part defines the authority of a workers' compensation preferred provider program administrator to operate the preferred provider programs in this State, establishes criteria for the registration of those administrators with the Director of Insurance and establishes appropriate fees for the registration and regulation of the programs. This Part also establishes requirements for any person, partnership or corporation engaged in any conduct regulated by Section 8.1a, including, but not limited to, workers' compensation preferred provider program administrators, employers, including self-funded employers, and insurers that offer a preferred provider program. The entity must comply with this Part when requiring employees to make a choice of a health care services provider from within the preferred provider program under Section 8(a)(4) of the Workers' Compensation Act.

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.220  Definitions

 

"Act" means the Health Care Reimbursement Reform Act of 1985 [215 ILCS 5/Art. XX½].

 

"Administrator", "Preferred Provider Program Administrator" or "PPP Administrator" means any person, partnership or corporation, other than a risk-bearing entity that arranges, contracts with, or administers contracts with a provider under which insureds or beneficiaries are provided an incentive to use the services of the provider. Administrator also includes any person, partnership or corporation, other than a risk-bearing entity, that enters into a contract with another administrator to enroll beneficiaries or insureds in a preferred provider program marketed as an independently identifiable program based on marketing materials or member benefit identification cards. For the purposes of this Part, an employer shall be considered an administrator.

 

"Administrator Trust Fund" or "ATF" means a special fiduciary account established and maintained by an administrator pursuant to Section 370l of the Act in which contributions and/or premiums are deposited.

 

"Advertisement" means any printed or published material, audiovisual material and descriptive literature of the administrator, discounted health care services plan administrator, or private label marketer used in direct mail, newspapers, magazines, radio scripts, television scripts, billboards and similar displays; and any descriptive literature or sales aids of all kinds disseminated by a representative of the administrator, discounted health care services plan administrator, or private label marketer for presentation to the public, including, but not limited to, circulars, leaflets, booklets, depictions, illustrations, form letters and prepared sales presentations.

 

"Affiliate" means a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the persons specified.

 

"Beneficiary" means an individual, enrollee, insured, participant or any other person entitled to reimbursement for covered expenses of, or the discounting of provider fees for, health care services under a program in which the beneficiary has an incentive to utilize the services of a provider that has entered into an agreement or arrangement with an administrator pursuant to Section 370g(f) of the Act. Beneficiary, for the purposes of a workers' compensation preferred provider program (WC PPP), shall also include covered employees.

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Control", "controlling", "controlled by" and "under common control with" means the possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, the holding of policyholders' proxies, by contract other than a commercial contract for goods or non-management services, or otherwise, unless the power is solely the result of an official position with or corporate office held by the person.  Control is presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds shareholders' proxies representing 10% or more of the voting securities of any other person, or holds or controls sufficient policyholders' proxies to elect the majority of the board of directors of the domestic company.  This presumption may be rebutted by a showing made to the Director. 

 

"Covered Employee" means an employee or former employee whose employer has established or contracted for an approved WC PPP for the provision of health care services to injured employees in accordance with Section 8.1a of the Workers' Compensation Act.

 

"Department" means the Illinois Department of Insurance.

 

"Director" means the Director of the Illinois Department of Insurance. 

 

"Discounted Health Care Services" means health care services provided by health care services providers under a discounted health care services plan when there are no other incentives, such as copayment, coinsurance or any other reimbursement differential, for beneficiaries to utilize the provider.

 

"Discounted Health Care Services Plan" or "DHCSP" means a preferred provider program by which beneficiaries, in exchange for fees, dues, charges or other consideration, are provided an incentive, in the form of discounted health care services, to use the services of the provider.

 

"Discounted Health Care Services Plan Administrator" or "DHCSP Administrator" means an administrator that arranges, contracts with, or administers contracts with a provider under which insureds or beneficiaries are provided an incentive to use health care services provided by health care services providers under a discounted health care services plan in which there are no other incentives, such as copayment, coinsurance or any other reimbursement differential, for beneficiaries to utilize the provider. DHCSP administrator also includes any person, partnership or corporation, other than a risk-bearing entity, that enters into a contract with another DHCSP administrator to enroll beneficiaries or insureds in a DHCSP marketed as an independently identifiable program based on marketing materials or member benefit identification cards.

 

"Doing Business As" or "DBA" means the name under which discounted health care services are marketed.

 

"Economic Evaluation" means any evaluation, as described in Section 8.1a(b) of the Workers' Compensation Act, of a particular physician, provider, medical group or individual practice association based in whole or in part on the economic costs or utilization of services associated with medical care provided or authorized by the physician, provider, medical group or individual practice association. Negotiated rates with a provider are not a form of economic evaluation.

 

"Employer" means an employer contracting directly with providers, or with multiple WC PPP administrators for the purposes of implementing a preferred provider program under Section 8.1a of the Workers' Compensation Act.

 

"Exclusive Provider Organization" or "EPO" means any arrangement, other than a health maintenance organization, limited health service organization, voluntary health services plans, or a DHCSP, under which the beneficiary receives no coverage or benefits when utilizing non-preferred providers, except when such an arrangement is shown to be in the best interest of the beneficiaries and has been expressly approved by the Director in writing. WC PPPs are not a form of EPO.

 

"Financial Institution" means a federal or State chartered bank or savings and loan institution.

 

"Gatekeeper Option" means an option offered by or through a preferred provider program that requires the beneficiary to preselect a particular primary care physician, from a list of participating primary care physicians, who shall coordinate all of the non-emergency primary, specialty, hospital and other health care services, including referrals to other providers, as a condition for receipt of a higher level of benefits or reimbursement level, or both.

 

"Health Care Preferred Provider Program" or "HC PPP" means a preferred provider program for the provision of health care services provided for health insurance or discounted health care services coverage.

 

"Health Care Preferred Provider Program Administrator" or "HC PPP Administrator" means an administrator of an HC PPP. HC PPP administrator also includes any person, partnership or corporation, other than a risk-bearing entity, that enters into a contract with another HC PPP administrator to enroll beneficiaries or insureds in an HC PPP marketed as an independently identifiable program based on marketing materials or member benefit identification cards.

 

"Health Care Services" means health care services or products rendered or sold by a provider within the scope of the provider's license or legal authorization.  The term includes, but is not limited to, hospital, medical, surgical, dental, vision and pharmaceutical services or products.

 

"Health Service Corporation" means a voluntary health service plan and/or a dental service plan licensed under the Voluntary Health Services Plans Act [215 ILCS 165] or the Dental Service Plan Act [215 ILCS 110].

 

"HMO Act" means the Health Maintenance Organization Act [215 ILCS 125].

 

"Non-preferred Provider" means any provider that does not have a contractual relationship, directly or indirectly, with the administrator or DHCSP administrator for the provision of, or discounting of, health care services.

 

"Payor" means an entity responsible for bearing the risk of health care services. An administrator other than a self-insured employer implementing a WC PPP, is prohibited from being a payor and may not bear or assume any underwriting risk.

 

"Preferred Provider" means any provider who has entered, either directly or indirectly, into an agreement with an administrator, employer or risk-bearing entity relating to health care services that may be rendered to beneficiaries under a preferred provider program, including providing discounts for health care services.

 

"Preferred Provider Arrangements" means policies, agreements or arrangements with providers relating to the amounts to be charged to beneficiaries or, in the case of Workers' Compensation preferred provider programs, employers, for health care services that include incentives for the beneficiary to use those services, including discounted health care services.

 

"Preferred Provider Program" or "PPP" means a system to make preferred provider arrangements available to beneficiaries.

 

"Primary Care Physician" means a provider who has contracted with an administrator to provide primary care services as defined by the contract and who is a physician licensed to practice medicine in all of its branches who spends a majority of clinical time engaged in general practice or in the practice of internal medicine, pediatrics, gynecology, obstetrics or family practice, or a chiropractic physician licensed to treat human ailments without the use of drugs or operative surgery. (See 77 Ill. Adm. Code 240.20.)

 

"Primary Treating Physician" means a provider who has contracted with a WC PPP administrator to provide health care services and who is a type of physician licensed to treat the injury experienced by the covered employee. This physician will be responsible for managing the care of the covered employee, including rendering and prescribing treatment.

 

"Private Label Marketer" means any entity, other than a DHCSP administrator, that directly or indirectly contracts with an administrator respecting the marketing or use of a DHCSP under a name other than that of the administrator.

 

"Provider" means an individual or entity duly licensed or legally authorized to provide health care services.

 

"Risk-Bearing Entity" means an insurer, health service corporation, limited health service organization holding a certificate of authority under the Limited Health Service Organization Act [215 ILCS 130], or health maintenance organization holding a certificate of authority under the HMO Act.

 

"Specialty Preferred Provider Program Administrator" or "SPPP Administrator" means an administrator of a preferred provider program for the provision of workers' compensation benefits that contracts with preferred providers for health care services in one or a limited number of health care specialties, including but not limited to ambulance services, durable medical equipment, lab and imaging services, home health services, physical and occupational therapy and pharmacy benefits. SPPP administrators are subject to the requirements of a WC PPP administrator, unless specifically exempted, and must contract with a WC PPP administrator to supplement WC PPPs approved by the Director of Insurance.

 

"Workers' Compensation Preferred Provider Program" or "WC PPP" means a preferred provider program for the provision of workers' compensation benefits that meets the requirements of Section 8.1a of the Workers' Compensation Act.

 

"Workers' Compensation Preferred Provider Program Administrator" or "WC PPP Administrator" means an administrator of a WC PPP.

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)

 

Section 2051.230  Administrators Not to Assume Underwriting Risk

 

An administrator may negotiate and make arrangements with providers in compliance with the Act, and market and otherwise make available such arrangements to insurance companies, HMO's, limited health service organizations, health service corporations, fraternal benefit societies, self-insuring employers or health and welfare trust funds and to their subscribers; provided, however, that in performing these functions the administrator shall not accept any underwriting risk in the form of a premium or capitation payment for its services.

 

Section 2051.240  Registration, Renewals and Appeals

 

a)         No person, partnership or corporation shall act as an administrator until that person, partnership or corporation has registered with the Director as required by this Section. In addition, all administrators shall annually renew their registration with the Director as required by this Section.

 

b)         Upon the filing of an application to register as a preferred provider program administrator and the payment of the registration fee required by Section 2051.250, the Director shall register the applicant if the Director finds that the applicant: 

 

1)         Has provided a detailed plan of operation;

 

2)         Is competent and trustworthy and intends to act in good faith in the capacity authorized by the license; 

 

3)         Has a good business reputation and has had experience, training or education so as to be qualified in the business for which the license is applied for; and 

 

4)         Has incorporated under the laws of this State or, if a foreign corporation or limited liability corporation, is authorized to transact business in this State. 

 

c)         A registered administrator may continue to operate if a completed renewal application and the fee required by Section 2051.250 have been filed prior to the renewal date, unless the renewal is denied by the Director.

 

d)         If a completed renewal application and appropriate fee are not received prior to the renewal date, the registration will automatically expire. An administrator whose registration has expired may not operate in this State until the administrator reapplies and pays the initial registration fee established by Section 2051.250 and the Director registers the administrator as provided by Sections 2051.240 and 2051.250.

 

e)         The Director may suspend, revoke or refuse to issue or renew an administrator's registration or may levy a civil penalty, or take any combination of actions, if the applicant:

 

1)         Provides unjust, unfair, inequitable, ambiguous, incorrect, misleading, incomplete, inconsistent, deceptive or materially untrue information, or if the program is administered in a way that is contrary to law or to the public policy of this State; 

 

2)         Has violated any insurance laws or any rule, subpoena or Order of the Director or of another state's insurance commissioner; 

 

3)         Is registered or attempts to register through misrepresentation or fraud; 

 

4)         Improperly withholds, misappropriates or converts any moneys or properties received in the course of doing business;

 

5)         Intentionally misrepresents the terms of an actual or proposed DHCSP; 

 

6)        Has been convicted of a felony; 

 

7)         Has admitted or been found to have committed any unfair trade practice or fraud; 

 

8)         Uses fraudulent, coercive or dishonest practices, or demonstrates incompetence, untrustworthiness or financial irresponsibility in the conduct of business in this State or elsewhere; 

 

9)         Has an administrator's registration, or its equivalent, denied, suspended or revoked in any other state, province, district or territory; 

 

10)        Knowingly contracts with an administrator who is not registered.

 

f)        If an application for registration or renewal is denied under this Section or if the registration is suspended or revoked, the applicant may appeal that action by requesting a hearing under the terms of Article 10 of the Illinois Administrative Procedure Act [5 ILCS 100/Art. 10] and 50 Ill. Adm. Code 2402. A petition for hearing must be postmarked no later than 30 days after the date of initial denial.  A hearing shall be scheduled within 45 days after the petition is filed with the Director.  An Order shall be issued by the Director within 60 days after the close of the hearing.

 

g)        Each administrator must keep current the information required to be disclosed in its registration statements by reporting any change or alteration in existing materials that would have an effect on the operation of the administrator, the availability and accessibility of health care, or any parties directly or indirectly contracted with the administrator to the Director within 30 days after the end of the month of each change or addition.  All information filed with the Director pursuant to this Part regarding the methods and/or amounts of reimbursement between providers and the administrator under a preferred provider program, or between administrators, is deemed to be confidential.

 

h)        For the purposes of a WC PPP, the Director of the Department of Insurance shall make each administrator's filing available to the public upon request. The Director may not publicly disclose any information submitted pursuant to Section 8.1a that is determined by the Director to be confidential, proprietary or trade secret information pursuant to State and federal law.

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.250  Fees

 

On or after January 1, 2010, each new administrator doing business in this State shall pay to the Director an initial registration fee of $1000.  Each administrator doing business in this State shall annually pay to the Director a renewal fee of $500 in order to maintain the registration.

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.260  Administrator Requirements

 

Each applicant for registration shall file the following information and documents with the Director in the format provided in the Health Care Preferred Provider Program Administrator Checklist.  DHCSP administrators who only administer DHCSPs shall instead file in the format provided in the Discounted Health Care Services Plan Only Registration Checklist. WC PPP administrators shall instead file in the format provided in the Workers' Compensation Preferred Provider Program Administrator Registration Checklist.  All of these checklists are located under "Managed Care License/Registration Information" on the Department's website at http://insurance.illinois.gov/company/companyMain.html.

 

a)         Organizational requirements identified in Section 2051.270;

 

b)         Sample copies of all payor and provider agreements identified in Sections 2051.280 and 2051.290, when applicable. If the terms and conditions in an agreement include significant, substantial or material change or additions, the filing of one complete sample of each type of agreement, together with a description of all variable terms and conditions, will satisfy this requirement;

 

c)         Signed copies of all current administrative agreements with any entity with which the applicant contracts to provide services or to meet the requirements of the Act.  Examples of these contracts may include, but are not necessarily limited to, agreements with other administrators, utilization review organizations, third party administrators, third party prescription program administrators, risk-bearing entities, and employers or employer groups for the purposes of WC PPPs. Agreements at a minimum shall contain the following provisions:

 

1)         Network availability and adequacy requirements identified in Section 2051.310 or 2051.315;

 

2)         If applicable, any DHCSP beneficiary agreement requirements identified in Section 2051.320;

 

3)         Copies of the preferred provider program disclosure statements required to be furnished to beneficiaries by Section 370m of the Act and illustrative advertising material to be used by the applicant;

 

4)         A description of programs for utilization review, including procedures for timely investigation, resolution of questions concerning medical necessity and appropriateness of medical services and supplies and appeals from beneficiaries and providers as provided by Section 370s of the Act and Section 85 of the Managed Care Reform and Patient Rights Act [215 ILCS 134/85] or, for the purposes of WC PPP, Section 8.7 of the Workers' Compensation Act. Administrators who administer only DHCSPs need not comply with this subsection;

 

5)         A description of any fiduciary account established by the administrator, including the location and identification number of the account, established and maintained pursuant to Section 370l of the Act and Section 2051.340 of this Part; and/or a bond in compliance with Section 370l of the Act and Section 2051.340 of this Part.  If a bond is submitted, the administrator shall also furnish a certification of the total estimated annual reimbursements under the preferred provider program, supported by the methodology used to arrive at that figure;

 

6)         Administrators may not participate in an exclusive provider organization in this State, except when such an arrangement is shown to be in the best interest of the beneficiaries and has been expressly approved by the Director in writing.  This subsection (c)(6) does not apply to administrators offering only DHCSPs.

 

7)         WC PPP administrators that utilize economic evaluation of their providers shall file a description of any policies and procedures related to the economic evaluation utilized by the program. The filing shall describe how these policies and procedures are used in utilization review, peer review, incentive and penalty programs, and in provider retention and termination decisions.

 

8)         WC PPP administrators shall provide those policies and procedures instituted to insure the employer is providing proper notification to the covered employee in accordance with the form promulgated by the Workers' Compensation Commission.

 

d)         A listing containing the name, address and FEIN of all entities that private label a DHCSP of the administrator, including:

 

1)         The name of the private label marketer;

 

2)         Any DBA used by the private label marketer; and

 

3)         All product names used by the private label marketer.

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)

 

Section 2051.270  Organizational Requirements

 

Upon application for registration, administrators must file the following information:

 

a)         An organizational chart describing the relationship between the administrator, its parent organization and any affiliates, including the state of domicile and the primary business of each entity;

 

b)         Proof of registration with the Illinois Secretary of State and the company's FEIN;

 

c)         Names, addresses, official positions and biographical affidavits of the person or persons responsible for the conduct of the affairs of the administrator. The biographical affidavits shall include, but not be limited to, the following information:  identifying information of the administrator; affiant's identifying and contact information; affiant's educational, residential and employment history; affiant's professional, business and technical licenses and memberships; a complete history of affiant's fidelity bonding; criminal charges and convictions; civil, regulatory, administrative and disciplinary actions in an individual or corporate capacity; a complete history of affiant's bankruptcy, insolvency, liens and foreclosures in an individual or corporate capacity; affiant's consent to release background reports to the Department and consent for third parties to cooperate in the gathering of background information; and affiant's and his or her immediate family's equity holdings in any entity subject to insurance regulation. The Department will accept the biographical affidavit, and any supplement thereto, obtained from the website of the NAIC or the Department. A copy of the NAIC Biographical Affidavit form is available under "Managed Care License/Registration Information" on the Department's website at http://insurance.illinois.gov/company/companyMain.html; and

 

d)         Location of all administrative offices of the administrator located in this State and regular business hours during which offices are open.

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)

 

Section 2051.280  Health Care Preferred Provider Program Payor Agreements

 

Administrators shall file with the Department a sample copy of all payor agreements. WC PPPs are exempt from the requirements of this Section, but must instead comply with the requirements of Section 2051.285.  These agreements shall contain at a minimum:

 

a)         Terms requiring and specifying all incentives to be provided to the insured or beneficiary to utilize services of a provider that has entered into an agreement with the administrator;

 

b)         Terms stating that, whenever an administrator or a preferred provider finds it medically necessary to refer a beneficiary to a non-preferred provider, the payor shall ensure that the beneficiary so referred shall incur no greater out of pocket liability than had the beneficiary received services from a preferred provider. This subsection does not apply to a beneficiary who willfully chooses to access a non-preferred provider for health care services available through the administrator's panel of participating providers. In these circumstances, the contractual requirements for non-preferred provider reimbursements will apply. This subsection does not apply to administrators offering only a DHCSP;

 

c)         Terms requiring that both the payor's and administrator's name and toll-free telephone numbers be contained on all beneficiaries' identification cards;

 

d)         Terms specifying that only the payor may assume any underwriting risk when that risk is part of the delivery of services.

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.285  Workers' Compensation Preferred Provider Program Payor Agreements

 

Any payor agreements between WC PPP administrators and payors shall contain, at a minimum:

 

a)         Terms requiring and specifying all incentives to be provided to the insured to utilize services of a provider that has entered into an agreement with the administrator;

 

b)         Terms stating that, whenever an administrator or a preferred provider finds it medically necessary to refer a beneficiary to a non-preferred provider because the preferred provider program does not contain a provider who can provide the approved treatment, and if the beneficiary has complied with any reasonable pre-authorization requirements, the payor shall ensure that the beneficiary so referred shall incur no greater liability than had the beneficiary received services from a preferred provider, except as provided under Section 8.1a(c)(2) and Section 8.2(e) of the Workers' Compensation Act;

 

c)         Terms stating that, whenever an administrator or a preferred provider finds it medically necessary to refer a beneficiary to a non-preferred provider because the preferred provider program does not contain a provider who can provide the approved treatment, and if the beneficiary has complied with any reasonable pre-authorization requirements consistent with Section 8.1a of the Workers' Compensation Act, the WC PPP shall ensure that the covered employee will be provided the covered services by a non-preferred provider in accordance with the fees established by the Workers' Compensation Fee Schedule (see 50 Ill. Adm. Code 9110.90 and the WCC website at https://iwcc.ingenix.com/ iwcc.asp).

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)

 

Section 2051.290  Health Care Preferred Provider Program Administrator Provider Agreements

 

Administrators shall file a sample of copy of all provider agreements. WC PPPs are exempt from the requirements of this Section, but must instead comply with the requirements of Section 2051.295. The agreements shall contain, at a minimum:

 

a)         A provision identifying the specific covered health care services for which the preferred provider will be responsible, including any discount services, copayments, benefit maximums, limitations and exclusions, as well as any discount amount or discounted fee schedule reflecting discounted rates;

 

b)         A provision requiring the provider to comply with applicable administrative policies and procedures of the administrator including, but not limited to credentialing or recredentialing requirements; and, except for DHCSP administrators, utilization review requirements, and referral procedures;

 

c)         Medical Records

 

1)         A provision requiring that, when payments are due to the provider for services rendered to a beneficiary, the provider must maintain and make medical records available:

 

A)        To the administrator and/or insurer for the purpose of determining, on a concurrent or retrospective basis, the medical necessity and appropriateness of care provided to beneficiaries;

 

B)        To appropriate State and federal authorities and their agents involved in assessing the accessibility and availability of care or investigating member grievances or complaints; and

 

C)        To show compliance with the applicable State and federal laws related to privacy and confidentiality of medical records.

 

2)         This subsection (c) does not apply to administrators offering only a DHCSP;

 

d)         A provision requiring providers to be licensed by the State, and to notify the administrator immediately whenever there is a change in licensure or certification status;

 

e)         A provision requiring all physician providers licensed to practice medicine in all its branches to have admitting privileges in at least one hospital with which the administrator has a written provider contract.  The administrator shall be notified immediately of any changes in privileges at any hospital or admitting facility.  Reasonable exceptions shall be made for physicians who, because of the type of clinical specialty, or location or type of practice, do not customarily have admitting privileges. This subsection (e) does not apply to administrators offering only DHCSPs;

 

f)         A provision describing notification procedures for contract termination. Termination provisions shall require:

 

1)         Not less than 30 days prior written notice by either party who wishes to terminate the contract without cause;

 

2)         That the administrator may immediately terminate the provider contract for cause; and

 

3)         If applicable, that a provider, acting as primary care physician under plans requiring a gatekeeper option, must provide the administrator with a list of all patients using that provider as a gatekeeper within 5 working days after the date that the provider either gives or receives notice of termination;

 

g)         A provision explaining the provider responsibilities for continuation of covered services in the event of contract termination, to the extent that an extension of benefits is required by law or regulation, or that continuation is voluntarily provided by the administrator. This subsection (g) does not apply to administrators offering only a DHCSP;

 

h)         A provision stating that the rights and responsibilities under the contract cannot be sold, leased, assigned, assumed or otherwise delegated by either party without the prior written consent of the other party. The provider's written consent must be obtained for any assignment or assumption of the provider contract whenever an administrator or insurer is bought by another administrator or insurer. A clause within the provider contract allowing assignment will be deemed consent so long as the assignment is in accordance with the terms of the contract. The assignee must comply with all the terms and conditions of the contract being assigned, including all checklists, policies and fee schedules;

 

i)          A provision stating that the preferred provider has and will maintain adequate professional liability and malpractice coverage, through insurance, self-funding, or other means satisfactory to the administrator.  The administrator must be notified within no less than 10 days after the provider's receipt of notice of any reduction or cancellation of the required coverage;

 

j)          A provision stating that the provider will provide health care services without discrimination against any beneficiary on the basis of participation in the preferred provider program, source of payment, age, sex, ethnicity, religion, sexual preference, health status or disability;

 

k)         A provision regarding the preferred provider's obligation, if any, to collect applicable copayments, coinsurance and/or deductibles from beneficiaries as provided by the beneficiary's health care services contract, and to provide notice to beneficiaries of their personal financial obligations for non-covered services. This provision shall include any amount of applicable discounts or, alternatively, a fee schedule that reflects any discounted rates. For DHCSPs only, a provision that providers may not charge beneficiaries more than any applicable discounted rates in accordance with payment terms and provisions contained in a DHCSP agreement signed by a beneficiary;

 

l)          A provision regarding any obligation to provide covered health services on a 24 hour per day, 7 day per week basis;

 

m)        A provision clearly describing the administrator's and payor's payment obligations to the provider. For DHCSPs, neither administrators nor payors may pay providers for health care services provided to beneficiaries. For DHCSPs, neither administrators nor payors may accept money from a beneficiary for payment to a provider for specific health care services furnished or to be furnished to the beneficiary;

 

n)         A provision identifying the administrative services, if any, the administrator will perform and the types of information (e.g., financial, enrollment, utilization) that will be submitted to the provider, as well as other information that is accessible to the provider;

 

o)         A provision obligating the administrator to provide a method for providers to access each payor to obtain benefit information and adequate notice of change in benefits and copayments, and a provision obligating the administrator to provide all of the administrator's operational policies. This subsection does not apply to administrators offering only a DHCSP; and

 

p)         A provision identifying applicable internal appeal or arbitration procedures for settling contractual disputes or disagreements between the administrator and preferred provider.

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)

 

Section 2051.295  Workers' Compensation Preferred Provider Program Provider Agreements

 

All provider agreements between providers and insurers, employers or WC PPP administrators with regard to a WC PPP shall contain, at a minimum:

 

a)         A provision stating, within the preamble, that the agreement conforms to the requirements of Section 8.1a of the Illinois Workers' Compensation Act;

 

b)         A provision identifying the specific covered health care services for which the preferred provider will be responsible, including any discount services, limitations and exclusions, as well as any discount amount or discounted fee schedule reflecting discounted rates;

 

c)         A provision requiring the provider to comply with applicable administrative policies and procedures of the administrator, including, but not limited to, credentialing or recredentialing requirements, utilization review requirements, and referral procedures;

 

d)         A provision requiring that, when payments are due to the provider for services rendered to a beneficiary, the provider must maintain and make the beneficiary's medical records available:

 

1)         To the administrator and/or payor for the purpose of determining, on a concurrent or retrospective basis, the compensability, medical necessity and appropriateness of care provided to beneficiaries;

 

2)         To appropriate State and federal authorities and their agents involved in assessing the accessibility and availability of care or investigating member grievances or complaints; and

 

3)         To show compliance with the applicable State and federal laws related to privacy and confidentiality of medical records;

 

e)         A provision requiring providers to be licensed by the state and to notify the administrator immediately whenever there is a change in licensure or certification status;

 

f)         A provision requiring all physician providers licensed to practice medicine in all its branches to have admitting privileges in at least one hospital. The administrator shall be notified immediately of any changes in privileges at any hospital or admitting facility. Reasonable exceptions shall be made for physicians who, because of the type of clinical specialty or location or type of practice, do not customarily have admitting privileges;

 

g)         A provision describing notification procedures for contract termination. Termination provisions shall require:

 

1)         Not less than 30 days prior written notice by either party who wishes to terminate the contract without cause; and

 

2)         that the administrator may immediately terminate the provider contract for cause;

 

h)         A provision explaining the provider's responsibilities for continuation of covered services in the event of contract termination, to the extent that an extension of benefits is required by law or regulation or that continuation is voluntarily provided by the administrator;

 

i)          A provision stating that the rights and responsibilities under the contract cannot be sold, leased, assigned, assumed or otherwise delegated by either party without the prior written consent of the other party. Similarly, the provider's written consent must be obtained for any assignment or assumption of the provider contract whenever an administrator or insurer is bought by another administrator or insurer. A clause within the provider contract allowing assignment will be deemed consent so long as the assignment is in accordance with the terms of the contract. The assignee must comply with all the terms and conditions of the contract being assigned, including all checklists, policies and fee schedules;

 

j)          A provision stating that the preferred provider has and will maintain adequate professional liability and malpractice coverage, through insurance, self-funding or other means satisfactory to the administrator. The administrator must be notified within no less than 10 days after the preferred provider's receipt of notice of any reduction or cancellation of the required coverage;

 

k)         A provision stating that the provider will provide health care services without discrimination against any beneficiary on the basis of participation in the preferred provider program, source of payment, age, sex, ethnicity, religion, sexual preference, health status or disability;

 

l)          A provision regarding the preferred provider's obligation to provide notice to beneficiaries of their personal financial obligations for non-covered services;

 

m)        A provision that providers may charge covered employees for those services determined to be not compensable under the Workers' Compensation Act;

 

n)         A provision regarding any obligation to provide covered health services on a 24 hour per day, 7 day per week basis;

 

o)         A provision clearly describing the administrator's and payor's payment obligations to the provider, including but not limited to the payment of statutory interest on late payments as required in Section 8.2(d)(3) of the Workers' Compensation Act;

 

p)         A provision identifying the administrative services, if any, the administrator will perform and the types of information (e.g., financial, enrollment, utilization) that will be submitted to the provider, as well as other information that is accessible to the provider;

 

q)         A provision obligating the administrator to provide a method for providers to access each payor to obtain benefit information and a provision obligating the administrator to provide all of the administrator's operational policies; and

 

r)          A provision identifying applicable internal appeal or arbitration procedures for settling contractual disputes or disagreements between the administrator and preferred provider.

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)

 

Section 2051.300  Requirements for Agreements with Other Administrators 

 

a)         Before entering into a contract with another administrator to administer programs, policies or subscriber contracts in this State as provided by Section 370i(b)(2) of the Act, an administrator shall perform due diligence to ensure the other entity is properly registered under this Part or otherwise appropriately licensed under the Code.

 

b)         Any provider contract or preferred provider program that is sold, leased, assigned, assumed or otherwise delegated must have the terms of that transaction affecting the provision of health care services by providers, including any additional discount, repricing or other consideration, clearly described in the contract.  The administrator or payor accessing the provider network shall be contractually obligated to comply with all applicable terms, limitations and conditions of the provider network contract, including all appendices, policies and fee schedules.  An administrator shall provide to the provider upon request a written or electronic list of all current payors to which the provider contract or program has been sold, leased, assigned, assumed or otherwise delegated.

 

c)         An administrator shall approve in writing, prior to use, all advertisements, marketing materials, brochures and, if applicable, identification cards used by any other administrator to market, promote, sell or enroll members in its preferred provider program.

 

d)         No preferred provider program may be sold, leased, assigned, assumed or otherwise delegated to another administrator without the prior written consent of the providers contracting under the program. A clause within the provider contract allowing assignment will be deemed consent so long as the assignment is in accordance with terms of the contract. The assignee must comply with all the terms and conditions of the contract being assigned, including all checklists, policies and fee schedules.

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)

 

Section 2051.310  Health Care Preferred Provider Program Administrator Network Availability and Adequacy Requirements

 

a)         Administrators and insurers must file a description of the services to be offered through the preferred provider program. WC PPPs are exempt from the requirements of this Section, but must instead comply with the requirements of Section 2051.315. The description shall include:

 

1)         The method of marketing the program;

 

2)         A geographic map of the area proposed to be served by the program by county and zip code, including marked locations for preferred providers;

 

3)         The names, addresses and specialties of the providers who have entered into preferred provider agreements under the program;

 

4)         The number of beneficiaries anticipated to be covered by the providers listed in subsection (a)(3);

 

5)         An Internet website and toll-free telephone number for beneficiaries and prospective beneficiaries to access regarding up-to-date lists of preferred providers, additional information about the DHCSP, as well as any other information necessary to conform to this Part.  A plan shall identify specific providers in a beneficiary's area, confirm specific provider participation or provide a listing of preferred providers by mail. Preferred provider lists requested by phone must be sent within 3 working days. The up-to-date provider list applies to all providers that have entered arrangements to provide services under the program either directly, or indirectly through another administrator. Administrators' and insurers' Internet website addresses shall be prominently displayed on all advertisements, marketing materials, brochures, benefit cards and identification cards; and

 

6)         A description of how health care services to be rendered under the preferred provider program are reasonably accessible and available to beneficiaries. Standards shall address:

 

A)        The type of health care services to be provided by the administrator;

 

B)        The ratio of providers to beneficiaries, by specialty and including primary care physicians when applicable under the contract, necessary to meet the health care needs and service demands of the currently enrolled population;

 

C)        The greatest distance or time that the beneficiary may be required to travel to access:

 

i)          Preferred provider hospital services when applicable under the contract;

 

ii)         Primary care physician and woman's principal health care provider services when applicable under the contract;

 

iii)        Any applicable health care service providers;

 

D)        Written policies and procedures for determining when the program is closed to new providers desiring to enter into preferred provider arrangements;

 

E)        Written policies and procedures for adding providers to meet patient needs based on increases in the number of beneficiaries, changes in the patient to provider ratio, changes in medical and health care capabilities, and increased demand for services;

 

F)         The provision of 24 hour, 7 day per week access to network affiliated primary care and woman's principal health care providers.  This subsection (a)(6)(F) does not apply to administrators offering only a DHCSP;

 

G)        The procedures for making referrals within and outside the network. This subsection (a)(6)(G) does not apply to administrators offering only a DHCSP;

 

H)        A provision ensuring that whenever a beneficiary has made a good faith effort to utilize preferred providers for a covered service and it is determined the administrator does not have the appropriate preferred providers due to insufficient number, type or distance, the administrator shall ensure, directly or indirectly, by terms contained in the payor contract, that the beneficiary will be provided the covered service at no greater cost to the beneficiary than if the service had been provided by a preferred provider. This subsection (a)(6)(H) does not apply to a beneficiary who willfully chooses to access a non-preferred provider for health care services available through the administrator's panel of participating providers. In these circumstances, the contractual requirements for non-preferred provider reimbursements will apply. This subsection (a)(6)(H) does not apply to administrators offering only a DHCSP;

 

I)         The procedures for paying benefits when particular physician specialties are not represented within the provider network, or the services of such providers are not available at the time care is sought. In any case in which a beneficiary has made a good faith effort to utilize network providers, by satisfying contractual obligation specified in the benefit contract or certificate, for a covered service and the administrator does not have the appropriate preferred specialty providers (including but not limited to radiologists, anesthesiologists, pathologists and emergency room physicians) under contract due to the inability of the administrator to contract with the specialists, or due to the insufficient number or type of, or travel distance to, specialists, the administrator shall ensure that the beneficiary will be provided the covered service at no greater cost to the beneficiary than if the service had been provided by a preferred provider.  This subsection (a)(6)(I) does not apply to a beneficiary who willfully chooses to access a non-preferred provider for health care services available through the administrator's panel of participating providers. In these circumstances, the contractual requirements for non-preferred provider reimbursements will apply. This subsection (a)(6)(I) does not apply to administrators offering only a DHCSP;

 

J)         A provision that the beneficiary shall receive emergency care coverage such that payment for this coverage is not dependent upon whether the services are performed by a preferred or non-preferred provider and the coverage shall be at the same benefit level as if the service or treatment had been rendered by a preferred provider.  For purposes of this subsection (a)(6)(J), "the same benefit level" means that the beneficiary will be provided the covered service at no greater cost to the beneficiary than if the service had been provided by a preferred provider. This subsection (a)(6)(J) does not apply to administrators offering only a DHCSP;

 

K)        A limitation that, if the plan provides that the beneficiary will incur a penalty for failing to pre-certify inpatient hospital treatment, the penalty may not exceed $1,000 per occurrence;

 

L)        Efforts to address the needs of beneficiaries with limited English proficiency and literacy and/or diverse cultural and ethnic backgrounds, and to comply with the Americans With Disabilities Act of 1990;

 

M)       A sample beneficiary identification card in conformity with the Uniform Health Care Service Benefits Information Card Act [215 ILCS 139], and the Uniform Prescription Drug Information Card Act [215 ILCS 138] when pharmaceutical services are provided as part of the program's health care services;

 

N)        When a gatekeeper option is included as part of the program, a requirement that the administrator make a good faith effort to provide written notice of termination of the gatekeeper to all beneficiaries who are patients seen on a regular basis by the gatekeeper whose contract is terminating. In a gatekeeper option, when a contract termination involves a primary care physician, all beneficiaries who are patients of that primary care physician shall also be notified. This subsection (a)(6)(N) does not apply to administrators offering only a DHCSP.

 

b)         If an administrator is leasing, buying or otherwise using another administrator's or insurer's program, and the required information has previously been filed by the other administrator or insurer, then only the administrative agreement and verification that the providers have consented to the agreement pursuant to Section 2051.300(d) need to be filed. A clause within the provider contract allowing assignment will be deemed consent in the absence of material modification of the provider's obligations under the contract.

 

c)         Enrollees are not responsible for any costs associated with medical record transmission or duplication in order to have a claim adjudicated. This subsection (c) does not apply to administrators offering only a discounted health care services plan.

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.315  Workers' Compensation Network Availability and Adequacy Requirements

 

a)         WC PPP administrators and insurers must file a description of the services to be offered through a WC PPP. The description shall include:

 

1)         The method of marketing the program;

 

2)         A geographic map of the area proposed to be served by the program by county and zip code, including marked locations for preferred providers;

 

3)         The names, addresses and specialties of the providers who have entered into preferred provider agreements under the program;

 

4)         The number of beneficiaries estimated to be covered by the providers listed in subsection (a)(3);

 

5)         An Internet website and toll-free telephone number for insureds, beneficiaries and prospective beneficiaries to access up-to-date lists of preferred providers, as well as any other information necessary to conform to this Part. A WC PPP shall identify specific providers in a beneficiary's area, confirm specific provider participation or provide a listing of specific preferred providers in the delivery mode requested by the beneficiary. Preferred provider lists requested by phone must be sent within 3 working days. The up-to-date provider list applies to all providers that have entered arrangements to provide services directly under the program or indirectly through another administrator. WC PPP administrators' and insurers' Internet website addresses shall be prominently displayed on all advertisements, marketing materials and brochures;

 

6)         A description of how health care services to be rendered under the preferred provider program are reasonably accessible and available to beneficiaries. Standards shall address:

 

A)        The type of health care services to be provided by the administrator;

 

B)        The ratio of providers to beneficiaries, by specialty and including primary treating physicians, when applicable under the contract, necessary to meet the health care needs and service demands of the estimated covered employees;

 

C)        Written policies and procedures for determining when the program is closed to new providers desiring to enter into preferred provider arrangements;

 

D)        Written policies and procedures for adding providers to meet patient needs based on increases in the number of beneficiaries, changes in the patient to provider ratio, changes in medical and health care capabilities, and increased demand for services;

 

E)        If applicable, procedures for making referrals within and outside the network;

 

F)         Efforts to address the needs of beneficiaries with limited English proficiency and literacy and/or diverse cultural and ethnic backgrounds, and to comply with the Americans With Disabilities Act of 1990;

 

7)         If a WC PPP administrator is leasing, buying or otherwise using another administrator's or insurer's program and the required information has previously been filed by the other administrator or insurer, only the administrative agreement and verification that the providers have consented to the agreement pursuant to Section 2051.300(d) need to be filed. A clause within the provider contract allowing assignment will be deemed consent in the absence of material modification of the provider's obligations under the contract; and

 

8)         A statement that covered employees are not responsible for any costs associated with medical record transmission or duplication in order to have a claim adjudicated.

 

b)         Additional Requirements

 

1)         WC PPP administrators and insurers must, in addition to those requirements established in subsection (a):

 

A)        File a description of how health care services to be rendered under the preferred provider program are reasonably accessible and available to beneficiaries;

 

B)        File a provision ensuring that, whenever a covered employee has made a good faith effort to utilize network providers for a covered service and it is determined the administrator does not have the appropriate preferred providers due to insufficient number, type or distance, the administrator shall ensure, directly or indirectly, by terms contained in the payor contract, that the covered employee will be provided the covered services by the non-preferred provider in accordance with the fees established by the Workers' Compensation Fee Schedule.  This subsection (b)(1)(B) does not apply to a covered employee who violates Section 8.1a(c) and (d) of the Worker's Compensation Act for health care services available through the administrator's panel of participating providers.  In these circumstances, the requirements of Section 8.2 of the Workers' Compensation Act for non-preferred provider reimbursements will apply.  This subsection (b)(1)(B) does not apply to SPPP administrators;

 

C)        File policies and procedures ensuring, directly or indirectly, that, whenever a covered employee has made a good faith effort to utilize network providers for a covered service and it is determined the administrator does not have the appropriate preferred providers due to insufficient number, type or distance, the administrator shall ensure, directly or indirectly, by terms contained in the payor contract, that the covered employee will be provided the covered services as if they been provided by a preferred provider, without any loss of provider choice under Section 8 or 8.1a(c) of the Workers' Compensation Act.  This subsection (b)(1)(C) does not apply to a covered employee who violates Section 8.1a(c) and (d) of the Workers' Compensation Act for health care services available through the administrator's panel of preferred providers.  In these circumstances, the requirements of Section 8.2 of the Workers' Compensation Act, including the Workers' Compensation Medical Fee Schedule, for non-preferred provider reimbursements will apply.  This subsection (b)(1)(C) does not apply to SPPP administrators;

 

D)        Provide geographical maps indicating primary treating physician and hospital health care services for emergency health care services, within 30 minutes or 15 miles of each covered employee's residence;

 

E)        Provide geographical maps indicating providers of occupational health services and specialists within 60 minutes or 30 miles of a covered employee's residence;

 

F)         If the WC PPP administrator believes that, given the facts and circumstances with regard to a portion of its service area (specifically rural areas, including those in which health facilities are located at least 30 miles apart), the accessibility standards set forth in subsections (b)(1)(D) and/or (E) are unreasonably restrictive, the administrator shall include proposed alternative standards in writing in its application or in a notice of program modification.  The alternative standards shall provide that all services shall be available and accessible at reasonable times to all covered employees;

 

G)        Coverage Outside the PPP

 

i)          Provide written policy for arranging or approving non-emergency medical care for:

 

•           A covered employee authorized by the employer to temporarily work or travel for work outside the preferred provider program geographic service area when the need for medical care arises;

 

•           A former employee whose employer has ongoing workers' compensation obligations and who permanently resides outside the preferred provider program geographic service area; and

 

•           A covered employee who decides to temporarily reside outside the preferred provider program geographic service area during recovery.

 

ii)         In the written policy, provide covered employees described in subsection (b)(1)(G)(i) with the choice of at least three providers outside the PPP geographic service area who either have been referred by the covered employee's primary treating physician within the PPP or have been selected by the WC PPP administrator. The referred providers shall be located within the access standards described in subsections (b)(1)(D) and (E);

 

H)        For non-emergency services:

 

i)          Ensure that an appointment for initial treatment is available within 3 business days after the WC PPP administrator's receipt of a request for treatment within the PPP.

 

ii)         For treatment of common injuries experienced by covered employees, based on the type of occupation or industry in which the covered employee is engaged, ensure that an appointment is available within 20 business days after the WC PPP administrator's receipt of a referral to a specialist within the PPP.

 

2)         For purposes of subsection (b)(1)(G), nothing precludes a WC PPP administrator from having a written policy that allows a covered employee outside the preferred provider program geographic service area to choose his or her own provider for non-emergency medical care. This Section does not apply to SPPP administrators.

 

(Source:  Added at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.320  Discounted Health Care Services Plan Requirements

 

a)         A DHCSP administrator shall have a written agreement between the administrator and its beneficiaries that specifies the benefits a beneficiary is to receive under the DHCSP and that complies with this Section. For insurers offering a DHCSP as part of a policy of insurance, the certificate or policy may act as the written agreement.

 

b)         All agreements between DHCSP administrators and beneficiaries shall contain at a minimum:

 

1)         A provision establishing the right of the beneficiary to cancel the plan, in writing, at any time.  If a beneficiary cancels within 30 days after the date of receipt of the identification card and other membership materials, the beneficiary will be reimbursed all money paid except any fee authorized by subsection (f);

 

2)         A provision establishing that beneficiaries will have free access to DHCSP providers without restrictions such as waiting periods, notification periods, etc. (except for hospital discounts);

 

3)         A provision allowing a beneficiary to modify the method of payment upon request, unless a specific method of payment is stipulated within the agreement. DHCSP administrators must discontinue using any automatic account withdrawals, including, but not limited to, electronic fund transfers and automatic credit card and/or debit card charges, upon receiving a beneficiary's written request to terminate or alter the method of payment;

 

4)         The procedures for filing complaints with the plan and the availability and contact information for the Illinois Department of Insurance. These procedures must contain, at a minimum, a statement that the DHCSP shall provide specific contact information for the Department upon request.

 

c)         If a DHCSP cancels a membership for any reason other than nonpayment of charges by the beneficiary, the DHCSP shall make a pro rata reimbursement of all periodic charges to the member.

 

d)         DHCSP administrators must provide the following disclosures in writing to any prospective beneficiary of a DHCSP before purchase, as well as in all beneficiary agreements.  If the initial contact with the prospective beneficiary is by telephone, the disclosures shall be made orally and included in the written agreement required by subsection (a).  The disclosures shall also be provided on the first page of any advertisements, marketing materials or brochures relating to a DHCSP or, if that is not possible, on the first page listing plan information. The following disclosures must be prominently displayed:

 

1)         That it is not insurance;

 

2)         That the plan provides discounts at certain providers for health care services and that the range of discounts will vary depending on the type of provider and service received;

 

3)         That the plan does not make payments directly to the providers of discounted health care services;

 

4)         That the plan beneficiary is obligated to pay for all discounted health care services, but will receive a discount from those providers that have contracted with the DHCSP administrator;

 

5)         The DHCSP administrator's toll-free telephone number and Internet website where beneficiaries and prospective beneficiaries may obtain additional information about the DHCSP and lists of providers participating in the DHCSP.

 

e)         Whenever a DHCSP is sold in conjunction with any other product that can be purchased separately, including a policy of insurance, the administrator or DHCSP administrator must provide in writing to the beneficiary the charges for the DHCSP product.

 

f)         Any initial one-time processing, administrative or other such non-regular or periodic charge may not exceed $30.

 

g)         A DHCSP administrator shall annually file with the Director a listing of all private label marketers with whom it has a direct or indirect contractual relationship respecting the marketing or use of the administrator's DHCSP under a name other than that of the administrator.  A DHCSP administrator shall inform the Department of any additional private label marketers with whom it contracts and of any cancellation or non-renewal of a contract within 30 days after the execution, cancellation or non-renewal of those contracts. A listing of private label marketers must contain:

 

1)         The name, address and FEIN of the private label marketer;

 

2)         Any DBA used by the private label marketer; and

 

3)         All product names used by the private label marketer.

 

h)         A DHCSP administrator shall ensure that any private label marketer whom it identifies under subsection (g) or with whom it has an obligation to identify under subsection (g):

 

1)         Prominently discloses within all description of benefits and member materials the name of the administrator and DHCSP administrator whose DHCSP is being provided;

 

2)         Prominently discloses within all marketing materials the name of any DHCSP administrator whose DHCSP is being provided;

 

3)         Prominently discloses the private label marketer's product name and the name or name and logo of available networks on the member's identification card; and 

 

4)         Complies with the applicable DHCSP administrator provisions of this Part.

 

i)          A private label marketer that is not identified as such pursuant to subsection (g) must register as a DHCSP administrator under this Part.

 

j)          A DHCSP shall identify specific providers in a beneficiary's area, confirm specific provider participation or provide a listing of participating providers by mail.  Participating provider lists requested by phone must be sent within 3 working days.  Any provider listing must include all participating providers with whom the administrator has contracted either directly or indirectly through another DHCSP administrator.

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.330  Insurer Requirements

 

a)         As required by Section 143(1) of the Code and consistent with the requirements of 50 Ill. Adm. Code 916, insurers must file the following compliance documents in the format prescribed in the Insurer Filing Requirements Form, located under "Managed Care License/Registration Information" on the Department's website at http://insurance.illinois.gov/company/companyMain.html, each time a policy incorporating a preferred provider arrangement is filed, or when the insurer markets, leases, sells or otherwise issues DHCSPs to beneficiaries, either directly or indirectly, independent of insurance coverage:

 

1)         Sample copies of all payor agreements as required by Section 2051.280, when applicable, and provider agreements as required by Section 2051.290. If the terms and conditions in the agreements include significant, substantial or material changes or additions, the filing of one complete sample of each type of agreement, together with a description of all variable terms and conditions, will satisfy this requirement;

 

2)         Valid and current signed administrator agreements pursuant to Section 2051.300;

 

3)         Network availability and adequacy requirements pursuant to Section 2051.310; and

 

4)         DHCSPs' requirements pursuant to Section 2051.320, if applicable.

 

b)         When incorporated in a policy filing, the filing requirements of subsection (a) may be waived if the preferred provider arrangement information had previously been filed and is identified in the subsequent filing.

 

c)         Any material changes or additions to the preferred provider program filed in accordance with subsection (a) must be reported to the Director within 30 days after the end of the month of each change or addition. The change or addition shall be filed informationally in accordance with Section 143(1) of the Code and consistent with the requirements of 50 Ill. Adm. Code 916. A material change or addition includes any modification of the information required by this Part that has significant effect on the operation of the administrator or DHCSP administrator or on the availability and accessibility of health care.

 

d)         All advertising and solicitation by an insurer regarding a DHCSP must comply with the requirements established by Section 2051.360.

 

e)         Insurers may not market EPO plans in this State, except when such an arrangement is shown to be in the best interest of the beneficiaries and has been expressly approved by the Director in writing.

 

f)         Insurers offering a DHCSP as part of a policy of insurance must set off the DHCSP provisions from the insurance coverage and disclose information as required by Section 2051.320(d)(3) through (5).

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)

 

Section 2051.340  Fiduciary and Bond Requirements

 

a)         This Section outlines requirements for administrators who must establish either a bond or a fiduciary account pursuant to Section 370l of the Act. Administrators who administer only DHCSPs need not comply with these requirements because, by definition, they do not handle money for purposes of payment for provider services. Employers and insurers contracting directly with providers or with multiple administrators to implement a WC PPP need not comply with these requirements, as they are exempted by Section 8.1a of the Worker's Compensation Act.

 

b)         Administrators who establish and maintain a fiduciary account pursuant to Section 370l of the Act are subject to the following requirements:

 

1)         Monies collected for reimbursement under preferred provider programs that the administrator holds more than 15 days shall be deposited in a special fiduciary account in a financial institution located in this State. The account shall be designated as an Administrator Trust Fund or ATF. All checks drawn on the ATF shall indicate on their face that they are drawn on the ATF of the administrator.

 

2)         An administrator that operates more than one preferred provider program may establish separate fiduciary accounts for each program, or may maintain a consolidated fiduciary account for multiple programs.  If a consolidated ATF account is maintained, the administrator's records shall clearly indicate fund deposits and disbursements for each program.

 

3)         No disbursement shall be made from the ATF account other than payment for provider services under the preferred provider program operated by the administrator and administrative fees due the administrator pursuant to a written agreement.

 

4)         For each preferred provider program for which an ATF is maintained, the balance in the ATF shall at all times be the amount of funds deposited plus accrued interest, if any, less authorized disbursements.

 

5)         If the ATF is interest bearing or income producing, the full nature of the account must first be disclosed to the principal, whether insurer or other payor of services under the preferred provider program, on whose behalf the funds are or will be held.  At this time the administrator must procure the written consent and authorization from the principal for the investment of money and retention of interest or earnings.

 

6)         An administrator may place ATF funds in interest-bearing or income-producing investments and retain the interest or income, providing the administrator obtains the prior written authorization of the principals on whose behalf the funds are to be held.  In addition to savings and checking accounts, an administrator may invest in the following:

 

A)        Direct obligations of the United States of America or U.S. Government agency securities with maturities of not more than one year;

 

B)        Certificates of deposit, with a maturity of not more than one year, issued by the Federal Deposit Insurance Corporation (FDIC) or Federal Savings and Loan Insurance Corporation (FSLIC), so long as any deposit does not exceed the maximum level of insurance protection provided to certificates of deposits held by the institutions;

 

C)        Repurchase agreements with financial institutions or government securities dealers recognized as primary dealers by the Federal Reserve System, provided:

 

i)          The value of the repurchase agreement is collateralized with assets that are allowable investments for ATF funds;

 

ii)         The collateral has a market value at the time the repurchase agreement is entered into at least equal to the value of the repurchase agreement;

 

iii)        The repurchase agreement does not exceed 30 days;

 

D)        Commercial paper, provided the commercial paper is rated at least P-l by Moody's Investors Service, Inc. or at least A-1 by Standard & Poor's Corporation;

 

E)        Money market funds, provided the money market fund invests exclusively in assets that are allowable investments pursuant to subsections (b)(6)(A) through (D) of this Section for ATF funds;

 

F)         Each investment transaction must be made in the name of the administrator's ATF.  The administrator must maintain evidence of any such investments.  Each investment transaction must flow through the administrator's ATF.

 

7)         Recordkeeping

 

A)        Administrators shall maintain detailed books and records that reflect all transactions involving the receipt and disbursement of funds from the ATF.

 

B)        The detailed preparation, journalizing and posting of the books and records must be maintained on a timely basis and all journal entries for receipts and disbursements shall be supported by evidential matter, which must be referenced in the journal entry so that it may be traced for verification. Administrators shall prepare and maintain monthly financial institution account reconciliations of any ATF established by the administrator.  The minimum detail required shall be as follows:

 

i)          The sources, amounts and dates of monies received and deposited by the administrator.

 

ii)         The date and person to whom a disbursement is made.  If the amount disbursed does not agree with the amount billed or authorized, the administrator shall prepare a written record as to the reason.

 

iii)        A description of the disbursement in such detail to identify the source document substantiating the purpose of the disbursement.

 

c)         An administrator who posts or causes to be posted a bond of indemnity pursuant to Section 370l of the Act shall do so subject to the following requirements:

 

1)         An administrator who operates more than one preferred provider program subject to the Act may maintain a bond of indemnity for any such programs.

 

2)         The bond shall be held by the Director in favor of the beneficiaries and payors of services under the preferred provider program operated by the administrator.  The bond shall be executed by a surety company and payable to any party injured under the terms of the bond.

 

3)         The bond shall be in continuous form and shall be in an amount of not less than 10% of the total estimated annual reimbursements under the preferred provider program covered by the bond.  The amount of the bond shall be determined in accordance with the methodology submitted by the administrator pursuant to Section 2051.260(c)(5).

 

4)         The bond shall remain in force and effect until the surety is released from liability by the Director or until the bond is cancelled by the surety. The surety may cancel the bond and be released from further liability under the bond upon 30 days advance written notice to the Director.  The cancellation shall not affect any liability incurred or accrued under the bond before the termination of the 30-day period.  Upon receipt of any notice of cancellation, the Director shall immediately notify the administrator.

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.350  Maintenance of Records

 

a)         All administrators shall maintain detailed books and records of all of their transactions as an administrator of preferred provider programs.  The records required to be maintained by this Section shall include, but are not limited to:

 

1)         Books and records of ATF transactions required by Section 2051.340;

 

2)         Books and records regarding all funds received or disbursed by the administrator;

 

3)         All contracts or agreements with providers, insurers or other payors of the services under a PPP; and

 

4)         All documents relating to the administrator's PPP, including but not limited to beneficiary disclosure documents required by Section 370m of the Act, beneficiary complaints and documents relating to the administrator's utilization review program.

 

b)         Records shall be maintained for at least 3 years after termination of the PPP to which they relate.

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.360  Advertising and Solicitation

 

a)         No administrator  or its representative shall cause, or knowingly permit the use of, advertising, solicitation, or any form of evidence of coverage that encourages misrepresentation, or is untrue, misleading or deceptive, unjust, unfair, inequitable, ambiguous, inconsistent, or contrary to law or to the public policy of this State;

 

b)         No administrator may represent or describe itself in its name, contracts or literature as a "health maintenance organization" or "HMO", nor may it hold itself out or represent itself as being an insurance company, limited health service organization or a health service corporation, unless such is the case;

 

c)         No DHCSP administrator may use the following terms in its advertisements, marketing material, brochures or DHCSP cards:  "health plan", "coverage", "copay", "copayments", "deductible", "preexisting conditions", "guaranteed issue", "premium", or other terms in a manner that could reasonably mislead an individual into believing that the product being offered is health insurance;

 

d)         No DHCSP administrator may use language in its advertisements, marketing material, brochures or DHCSP cards with respect to being "licensed" or "registered" by the Department in a manner that could mislead an individual into believing that the DHCSP is health insurance;

 

e)         Whether an advertisement has a capacity or tendency to mislead or deceive shall be determined by the Director from the overall impression that the advertisement may be reasonably expected to create upon a person of average education or intelligence within the segment of the public to which it is directed;

 

f)         If the Director finds that any advertisement of a preferred provider program has materially failed to comply with this Part, the Director may, pursuant to the authority in Section 149 of the Code, by Order, require the administrator  to publish in the same or similar medium an approved correction or retraction of any untrue, misleading or deceptive statement contained in the advertising.  The Director may prohibit the administrator from publishing or distributing, or allowing to be published or distributed on its behalf, the advertisement or any new materially revised advertisement without first having filed a copy of the advertisement with the Director 30 days prior to its publication or distribution, or within any shorter period specified in the Order.

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

 

Section 2051.370  Examination

 

a)         The Director or his or her designee may examine any applicant for registration or any registrant when he or she obtains information that gives him or her reason to believe that the applicant or registrant may be in violation of this Part, or any applicable provision of the Code, when he or she receives a complaint or when the applicant has a history of violations of the Code.

 

b)         Any administrator being examined shall provide to the Director or his or her designee convenient and free access, at all reasonable hours at their offices, to all books, records, documents and other papers relating to the administrator's business affairs. 

 

c)         The Director or his or her designee may administer oaths and thereafter examine any individual about the business of the administrator.

 

d)         The expenses of examination under this Section shall be assessed against the administrator being examined in accordance with Section 408(3) of the Code.

 

e)         The examiner designated by the Director shall make a written report if he or she alleges a violation of this Part, any applicable provisions of the Code or any other applicable Part of Title 50 of the Illinois Administrative Code.  The report shall be verified by the examiner. The report must be made to the Director within 45 days after the conclusion of the examination.  If no report is to be made, the administrator shall be so notified.

 

f)         If a report is made, the Director shall either deliver a duplicate of the report to the administrator being examined or send the duplicate by certified or registered mail to the administrator's address specified in the records of the Department.  The Director shall afford the administrator an opportunity to request a hearing to object to the report.  The administrator may request a hearing within 30 days after receipt of the duplicate examination report by giving the Director written notice of the request, together with written objections to the report.  Any hearing shall be conducted in accordance with Sections 402 and 403 of the Code and 50 Ill. Adm. Code 2402.  The right to hearing is waived if the delivery of the report is refused, the report is otherwise undeliverable to the address on file with the Department or the administrator does not timely request a hearing.  After the hearing, or upon expiration of the time period during which an administrator may request a hearing, if the examination reveals that the administrator is operating in violation of any applicable provisions of the Code, any applicable Part of Title 50 of the Illinois Administrative Code or prior Order, the Director, in the written Order, may require the administrator to take action to correct the violation in accordance with the report or examination hearing. If the Director issues an Order, it shall be issued within 90 days after the report is filed, or, if there is a hearing, within 90 days after the conclusion of the hearing.  The Order is subject to review under the Administrative Review Law [735 ILCS 5/Art.III].

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)

Section 2051.APPENDIX A   Health Care Preferred Provider Program Administrator Registration Form (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 11356, effective September 24, 2019)

Section 2051.APPENDIX B   Discounted Health Care Services Plan Only Registration (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 11356, effective September 24, 2019)

Section 2051.APPENDIX C   Insurer Filing Requirements (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 11356, effective September 24, 2019)

Section 2051.APPENDIX D   Workers' Compensation Preferred Provider Program Administrator Registration Form (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 11356, effective September 24, 2019)

Section 2051.APPENDIX E   Illinois or NAIC Biographical Affidavit (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 11356, effective September 24, 2019)

Section 2051.APPENDIX F   Preferred Provider Program Administrator Bond/Fiduciary

Account Requirement (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 11356, effective September 24, 2019)