Section 240.110  Department Interventions

a)         The Department of Public Health shall make an examination concerning the quality of health care services of any health maintenance organization and providers with whom such organization has contracts, agreements, or other arrangements, pursuant to its health care plan as often as they deem it necessary for the protection of the interest of the people of this state, but not less frequently than once every three years (Section 5-4 of the Act). In determining whether an examination is necessary, the Department will consider whether health care services are being made available and accessible and will determine what constitutes a material violation of a contract or evidence of coverage, or what constitutes good faith regarding certification (Section 5-5(d) of the Act) as evidenced by the following factors:

1)         The number and nature of grievances received by the HMO;

2)         The number of enrollees in the plan service area relative to the number participating health care providers in the plan service area;

3)         The distribution of the enrollees and the providers throughout the plan service area;

4)         The hours providers are available;

5)         The method by which after hours service is provided;

6)         The HMO's ability to meet its obligations to provide coverage to its enrollees;

7)         The HMO's ability to provide for or arrange for basic health services; and

8)         The HMO's ability to meet its obligations outlined in the contractual agreement with providers.

b)         Upon completion of the Department's inspection of an HMO provider site, the Department will provide verbal notification to the provider site of areas of provider site operations and records found during the inspection that fail to comply with this Part. HMO representatives may also be present at this conference.

c)         Upon completion of the Department's inspection of an HMO or HMO provider, the Department will provide the HMO written notification of findings of noncompliance with this Part.

d)         The HMO shall respond to the Department's inspection findings of noncompliance within ten working days of receipt of the findings. The HMO's response shall indicate the actions to be taken by the HMO to remedy the noncompliance noted by the Department. When the HMO's response does not remedy the noncompliance, the Department will provide the HMO a written explanation of the reasons the response is unsatisfactory.

e)         When the Department determines that the HMO has failed to secure a provider's compliance with this Part, the Department will recommend to the Department of Insurance that the HMO be prohibited from adding more enrollees who would be provided health care services at the noncompliant site. This recommendation shall be made only when the noncompliance adversely affects the enrollees' availability and accessibility to health care services described in the evidence of coverage, and the HMO has demonstrated repeated inability to correct the deficiencies.

f)         When the Department determines that an HMO does not meet the minimum standards contained in this Part, and has repeatedly failed to remedy the noncompliance, the Department will certify the following to the Director of The Department of Insurance:

1)         That the Health Maintenance Organization does not meet the requirements of the Act and this Part; or

2)         That the Health Maintenance Organization is unable to fulfill its obligations to furnish health care services as required under its health care plan.  This certification will inform the Department of Insurance that administrative review is warranted to consider suspension or revocation of the HMO's Certificate of Authority pursuant to Section 5-5 of the Act. (Section 5-5(d) of the Act)

(Source:  Amended at 49 Ill. Reg. 7969, effective May 21, 2025)