TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.210 PURPOSE
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)
 | TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.220 DEFINITIONS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.230 ADMINISTRATORS NOT TO ASSUME UNDERWRITING RISK
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.
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.240 REGISTRATION, RENEWALS AND APPEALS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.250 FEES
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.260 ADMINISTRATOR REQUIREMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.270 ORGANIZATIONAL REQUIREMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.280 HEALTH CARE PREFERRED PROVIDER PROGRAM PAYOR AGREEMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.285 WORKERS' COMPENSATION PREFERRED PROVIDER PROGRAM PAYOR AGREEMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.290 HEALTH CARE PREFERRED PROVIDER PROGRAM ADMINISTRATOR PROVIDER AGREEMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.295 WORKERS' COMPENSATION PREFERRED PROVIDER PROGRAM PROVIDER AGREEMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.300 REQUIREMENTS FOR AGREEMENTS WITH OTHER ADMINISTRATORS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.310 HEALTH CARE PREFERRED PROVIDER PROGRAM ADMINISTRATOR NETWORK AVAILABILITY AND ADEQUACY REQUIREMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.315 WORKERS' COMPENSATION NETWORK AVAILABILITY AND ADEQUACY REQUIREMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.320 DISCOUNTED HEALTH CARE SERVICES PLAN REQUIREMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.330 INSURER REQUIREMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.340 FIDUCIARY AND BOND REQUIREMENTS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.350 MAINTENANCE OF RECORDS
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.360 ADVERTISING AND SOLICITATION
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.370 EXAMINATION
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)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.APPENDIX A HEALTH CARE PREFERRED PROVIDER PROGRAM ADMINISTRATOR REGISTRATION FORM (REPEALED)
Section 2051.APPENDIX A Health Care Preferred Provider Program
Administrator Registration Form (Repealed)
(Source: Repealed at 43 Ill.
Reg. 11356, effective September 24, 2019)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.APPENDIX B DISCOUNTED HEALTH CARE SERVICES PLAN ONLY REGISTRATION (REPEALED)
Section 2051.APPENDIX B Discounted Health Care Services
Plan Only Registration (Repealed)
(Source: Repealed at 43 Ill.
Reg. 11356, effective September 24, 2019)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.APPENDIX C INSURER FILING REQUIREMENTS (REPEALED)
Section 2051.APPENDIX C Insurer Filing Requirements
(Repealed)
(Source: Repealed at 43 Ill.
Reg. 11356, effective September 24, 2019)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.APPENDIX D WORKERS' COMPENSATION PREFERRED PROVIDER PROGRAM ADMINISTRATOR REGISTRATION FORM (REPEALED)
Section 2051.APPENDIX D Workers' Compensation Preferred
Provider Program Administrator Registration Form (Repealed)
(Source: Repealed at 43 Ill.
Reg. 11356, effective September 24, 2019)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.APPENDIX E ILLINOIS OR NAIC BIOGRAPHICAL AFFIDAVIT (REPEALED)
Section 2051.APPENDIX E Illinois or NAIC Biographical
Affidavit (Repealed)
(Source: Repealed at 43 Ill.
Reg. 11356, effective September 24, 2019)
| TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051
PREFERRED PROVIDER PROGRAMS
SECTION 2051.APPENDIX F PREFERRED PROVIDER PROGRAM ADMINISTRATOR BOND/FIDUCIARY
Section 2051.APPENDIX F Preferred Provider Program
Administrator Bond/Fiduciary
Account Requirement (Repealed)
(Source: Repealed at 43 Ill.
Reg. 11356, effective September 24, 2019)
AUTHORITY: Implementing Article XX½ of the Illinois Insurance Code [215 ILCS 5/Art. XX½] and the Workers' Compensation Act [820 ILCS 305], and authorized by Section 401 of the Illinois Insurance Code [215 ILCS 5/401].
SOURCE: Adopted at 20 Ill. Reg. 9960, effective July 15, 1996; expedited correction at 20 Ill. Reg. 13435, effective July 15, 1996; amended at 21 Ill. Reg. 16364, effective December 9, 1997; expedited correction at 22 Ill. Reg. 5126, effective December 9, 1997; old Part repealed at 34 Ill. Reg. 161 and new Part adopted at 34 Ill. Reg. 163, effective December 16, 2009; amended at 37 Ill. Reg. 2895, effective March 4, 2013; amended at 43 Ill. Reg. 11356, effective September 24, 2019.
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