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)