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91_SB0579eng
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1 AN ACT concerning the delivery of health care services.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Managed Care Patient Rights Act.
6 Section 5. Health care patient rights.
7 (a) A patient has the right to care consistent with
8 professional standards of practice to assure quality nursing
9 and medical practices, to choose the participating physician
10 responsible for coordinating his or her care, to receive
11 information concerning his or her condition and proposed
12 treatment, to refuse any treatment to the extent permitted by
13 law, and to privacy and confidentiality of records except as
14 otherwise provided by law.
15 (b) A patient has the right, regardless of source of
16 payment, to examine and to receive a reasonable explanation
17 of his or her total bill for health care services rendered by
18 his or her physician or other health care provider, including
19 the itemized charges for specific health care services
20 received. A physician or other health care provider shall be
21 responsible only for a reasonable explanation of those
22 specific health care services provided by the health care
23 provider.
24 (c) A patient has the right to timely prior notice of
25 the termination in the event a health care plan cancels or
26 refuses to renew an enrollee's participation in the plan.
27 (d) A patient has the right to privacy and
28 confidentiality in health care. This right may be expressly
29 waived in writing by the patient or the patient's guardian.
30 (e) An individual has the right to purchase any health
31 care services with that individual's own funds.
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1 (f) Nothing in this Section shall preclude the health
2 care plan from sharing information for plan quality
3 assessment and improvement purposes as required by Section
4 70.
5 Section 10. Definitions:
6 "Department" means the Department of Insurance.
7 "Emergency medical condition" means a medical condition
8 manifesting itself by acute symptoms of sufficient severity
9 (including, but not limited to, severe pain) such that a
10 prudent layperson, who possesses an average knowledge of
11 health and medicine, could reasonably expect the absence of
12 immediate medical attention to result in:
13 (1) placing the health of the individual (or, with
14 respect to a pregnant woman, the health of the woman or
15 her unborn child) in serious jeopardy;
16 (2) serious impairment to bodily functions; or
17 (3) serious dysfunction of any bodily organ or
18 part.
19 "Emergency medical screening examination" means a medical
20 screening examination and evaluation by a physician licensed
21 to practice medicine in all its branches, or to the extent
22 permitted by applicable laws, by other appropriately licensed
23 personnel under the supervision of or in collaboration with a
24 physician licensed to practice medicine in all its branches
25 to determine whether the need for emergency services exists.
26 "Emergency services" means, with respect to an enrollee
27 of a health plan, transportation services and covered
28 inpatient and outpatient hospital services furnished by a
29 provider qualified to furnish those services that are needed
30 to evaluate or stabilize an emergency medical condition.
31 "Emergency services" does not refer to post-stabilization
32 medical services.
33 "Enrollee" means any person and his or her dependents
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1 enrolled in or covered by a health care plan.
2 "Health care plan" means a plan that establishes,
3 operates, or maintains a network of health care providers
4 that have entered into agreements with the plan to provide
5 health care services to enrollees to whom the plan has the
6 obligation to arrange for the provision of or payment for
7 services through organizational arrangements for ongoing
8 quality assurance, utilization review programs, or dispute
9 resolution.
10 For purposes of this definition, "health care plan" shall
11 not include the following:
12 (1) indemnity health insurance policies including
13 those using a contracted provider network;
14 (2) health care plans that offer only dental or
15 only vision coverage;
16 (3) preferred provider administrators, as defined
17 in Section 370g(g) of the Illinois Insurance Code;
18 (4) employee or employer self-insured health
19 benefit plans under the federal Employee Retirement
20 Income Security Act of 1974; and
21 (5) health care provided pursuant to the Workers'
22 Compensation Act or the Workers' Occupational Diseases
23 Act.
24 "Health care provider" means any physician, hospital
25 facility, or other person that is licensed or otherwise
26 authorized to deliver health care services. Nothing in this
27 Act shall be construed to define Independent Practice
28 Associations or Physician-Hospital Organizations as health
29 care providers.
30 "Health care services" means any services included in the
31 furnishing to any individual of medical care, or the
32 hospitalization incident to the furnishing of such care, as
33 well as the furnishing to any person of any and all other
34 services for the purpose of preventing, alleviating, curing,
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1 or healing human illness or injury including home health and
2 pharmaceutical services and products.
3 "Medical director" means a physician licensed in any
4 state to practice medicine in all its branches appointed by a
5 health care plan.
6 "Person" means a corporation, association, partnership,
7 limited liability company, sole proprietorship, or any other
8 legal entity.
9 "Physician" means a person licensed under the Medical
10 Practice Act of 1987.
11 "Post-stabilization medical services" means health care
12 services provided to an enrollee that are furnished in a
13 licensed hospital by a provider that is qualified to furnish
14 such services, and determined to be medically necessary and
15 directly related to the emergency medical condition following
16 stabilization.
17 "Stabilization" means, with respect to an emergency
18 medical condition, to provide such medical treatment of the
19 condition as may be necessary to assure, within reasonable
20 medical probability, that no material deterioration of the
21 condition is likely to result.
22 "Utilization review" means the evaluation of the medical
23 necessity, appropriateness, and efficiency of the use of
24 health care services, procedures, and facilities.
25 "Utilization review program" means a program established
26 by a person to perform utilization review.
27 Section 15. Provision of information.
28 (a) A health care plan shall provide to enrollees and
29 prospective enrollees, upon request, a list of participating
30 health care providers in the health care plan's service area
31 and a description of the following terms of coverage:
32 (1) the service area;
33 (2) covered benefits and services, exclusions or
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1 limitations;
2 (3) precertification and other utilization review
3 procedures and requirements;
4 (4) a description of the limitations on access to
5 specialists;
6 (5) emergency coverage and benefits;
7 (6) out-of-area coverages and benefits, if any;
8 (7) the enrollee's financial responsibility for
9 copayments, deductibles, and any other out-of-pocket
10 expenses;
11 (8) provisions for continuity of treatment in the
12 event a health care provider's participation terminates
13 during the course of an enrollee's treatment by that
14 provider; and
15 (9) the grievance process, including the telephone
16 number to call to receive information concerning
17 grievance procedures.
18 (b) Upon written request, a health care plan shall
19 provide to enrollees a description of the financial
20 relationships between the health care plan and any health
21 care provider, except that no health care plan shall be
22 required to disclose specific reimbursement to providers.
23 (c) A participating health care provider shall provide
24 all of the following, where applicable, to enrollees upon
25 request:
26 (1) Information related to the health care
27 provider's educational background, experience, training,
28 specialty, and board certification, if applicable.
29 (2) The names of licensed facilities on the
30 provider panel where the health care provider presently
31 has privileges for the treatment, illness, or procedure
32 that is the subject of the request.
33 (3) Information regarding the health care
34 provider's participation in continuing education programs
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1 and compliance with any licensure, certification, or
2 registration requirements, if applicable.
3 (d) A health care plan shall provide the information
4 required to be disclosed under this Act in a legible and
5 understandable format consistent with the standards developed
6 for supplemental insurance coverage under Title XVIII of the
7 federal Social Security Act.
8 Section 20. Notice of nonrenewal or termination. A
9 health care plan must give at least 60 days notice of
10 nonrenewal or termination of a health care provider to the
11 health care provider and to the enrollees served by the
12 health care provider. The notice shall include a name and
13 address to which an enrollee or health care provider may
14 direct comments and concerns regarding the nonrenewal or
15 termination. Immediate written notice may be provided without
16 60 days notice when a health care provider's license has been
17 disciplined by a State licensing board.
18 Section 25. Transition of services.
19 (a) A health care plan shall provide for continuity of
20 care for its enrollees as follows:
21 (1) If an enrollee's physician leaves the health
22 care plan's network of health care providers for reasons
23 other than termination of a contract in situations
24 involving imminent harm to a patient or a final
25 disciplinary action by a State licensing board and the
26 physician remains within the health care plan's service
27 area, the health care plan shall permit the enrollee to
28 continue an ongoing course of treatment with that
29 physician during a transitional period:
30 (A) of 90 days from the date of the notice of
31 physician's termination from the health care plan to
32 the enrollee of the physician's disaffiliation from
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1 the health care plan if the enrollee has an ongoing
2 course of treatment; or
3 (B) if the enrollee has entered the third
4 trimester of pregnancy at the time of the
5 physician's disaffiliation, that includes the
6 provision of post-partum care directly related to
7 the delivery.
8 (2) Notwithstanding the provisions in item (1) of
9 this subsection, such care shall be authorized by the
10 health care plan during the transitional period only if
11 the physician agrees:
12 (A) to continue to accept reimbursement from
13 the health care plan at the rates applicable prior
14 to the start of the transitional period;
15 (B) to adhere to the health care plan's
16 quality assurance requirements and to provide to the
17 health care plan necessary medical information
18 related to such care; and
19 (C) to otherwise adhere to the health care
20 plan's policies and procedures, including but not
21 limited to procedures regarding referrals and
22 obtaining preauthorizations for treatment.
23 (b) A health care plan shall provide for continuity of
24 care for new enrollees as follows:
25 (1) If a new enrollee whose physician is not a
26 member of the health care plan's provider network, but is
27 within the health care plan's service area, enrolls in
28 the health care plan, the health care plan shall permit
29 the enrollee to continue an ongoing course of treatment
30 with the enrollee's current physician during a
31 transitional period:
32 (A) of 90 days from the effective date of
33 enrollment if the enrollee has an ongoing course of
34 treatment; or
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1 (B) if the enrollee has entered the third
2 trimester of pregnancy at the effective date of
3 enrollment, that includes the provision of
4 post-partum care directly related to the delivery.
5 (2) If an enrollee elects to continue to receive
6 care from such physician pursuant to item (1) of this
7 subsection, such care shall be authorized by the health
8 care plan for the transitional period only if the
9 physician agrees:
10 (A) to accept reimbursement from the health
11 care plan at rates established by the health care
12 plan; such rates shall be the level of reimbursement
13 applicable to similar physicians within the health
14 care plan for such services;
15 (B) to adhere to the health care plan's
16 quality assurance requirements and to provide to the
17 health care plan necessary medical information
18 related to such care; and
19 (C) to otherwise adhere to the health care
20 plan's policies and procedures including, but not
21 limited to procedures regarding referrals and
22 obtaining preauthorization for treatment.
23 (c) In no event shall this Section be construed to
24 require a health care plan to provide coverage for benefits
25 not otherwise covered or to diminish or impair preexisting
26 condition limitations contained in the enrollee's contract.
27 Section 30. Restraints on communications prohibited.
28 (a) No health care plan or its subcontractors may
29 prohibit or discourage health care providers by contract or
30 policy from discussing any health care services and health
31 care providers, utilization review and quality assurance
32 policies, terms and conditions of plans and plan policy with
33 enrollees, prospective enrollees, providers, or the public.
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1 (b) Any violation of this Section shall be subject to
2 the penalties under this Act.
3 Section 35. Medically appropriate health care
4 protection.
5 (a) No health care plan or its subcontractors shall
6 retaliate against a physician or other health care provider
7 who advocates for appropriate health care services for
8 patients.
9 (b) It is the public policy of the State of Illinois
10 that a physician or any other health care provider be
11 encouraged to advocate for medically appropriate health care
12 services for his or her patients. For purposes of this
13 Section, "to advocate for medically appropriate health care
14 services" means to appeal a decision to deny payment for a
15 health care service pursuant to the reasonable grievance or
16 appeal procedure established by a health care plan or to
17 protest a decision, policy, or practice that the physician or
18 other health care provider, consistent with that degree of
19 learning and skill ordinarily possessed by physicians or
20 other health care providers practicing in the same or a
21 similar locality and under similar circumstances, reasonably
22 believes impairs the physician's or other health care
23 provider's ability to provide appropriate health care
24 services to his or her patients.
25 (c) This Section shall not be construed to prohibit a
26 health care plan or its subcontractors from making a
27 determination not to pay for a particular health care service
28 or to prohibit a medical group, independent practice
29 association, preferred provider organization, foundation,
30 hospital medical staff, hospital governing body or health
31 care plan from enforcing reasonable peer review or
32 utilization review protocols or determining whether a
33 physician or other health care provider has complied with
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1 those protocols.
2 (d) Nothing in this Section shall be construed to
3 prohibit the governing body of a hospital or the hospital
4 medical staff from taking disciplinary actions against a
5 physician as authorized by law.
6 (e) Nothing in this Section shall be construed to
7 prohibit the Department of Professional Regulation from
8 taking disciplinary actions against a physician or other
9 health care provider under the appropriate licensing Act.
10 Section 40. Access to specialists.
11 (a) All health care plans that require each enrollee to
12 select a health care provider for any purpose including
13 coordination of care shall ensure that any enrollee may
14 choose any primary care physician licensed to practice
15 medicine in all its branches participating in the health care
16 plan for that purpose. The health care plan shall provide the
17 enrollee with a choice of licensed health care providers who
18 are accessible and qualified. Nothing in this Act shall be
19 construed to prohibit a health care plan from requiring a
20 health care provider to meet the health care plan's criteria
21 in order to coordinate access to health care.
22 (b) A health care plan shall establish a procedure by
23 which an enrollee who has a condition that requires ongoing
24 care from a specialist physician or other health care
25 provider may apply for a standing referral to a specialist
26 physician or other health care provider if a referral to a
27 specialist physician or other health care provider is
28 required for coverage. The application shall be made to the
29 enrollee's primary care physician. This procedure for a
30 standing referral must specify the necessary criteria and
31 conditions that must be met in order for an enrollee to
32 obtain a standing referral. A standing referral shall be
33 effective for the period necessary to provide the referred
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1 services or one year, except in the event of termination of a
2 contract or policy in which case Section 25 on transition of
3 services shall apply, if applicable. A primary care physician
4 may renew a standing referral.
5 (c) The enrollee may be required by the health care plan
6 to select a specialist physician or other health care
7 provider who has a referral arrangement with the enrollee's
8 primary care physician or to select a new primary care
9 physician who has a referral arrangement with the specialist
10 physician or other health care provider chosen by the
11 enrollee. If a health care plan requires an enrollee to
12 select a new physician under this subsection, the health care
13 plan must provide the enrollee with both options provided in
14 this subsection.
15 (d) When the type of specialist physician or other
16 health care provider needed to provide ongoing care for a
17 specific condition is not represented in the health care
18 plan's provider network, the primary care physician shall
19 arrange for the enrollee to have access to a qualified
20 non-participating health care provider within a reasonable
21 distance and travel time. The referring physician shall
22 notify the plan when a referral is made outside the network.
23 (e) The enrollee's primary care physician shall remain
24 responsible for coordinating the care of an enrollee who has
25 received a standing referral to a specialist physician or
26 other health care provider. If a secondary referral is
27 necessary, the specialist physician or other health care
28 provider shall advise the primary care physician. The
29 primary care physician shall be responsible for making the
30 secondary referral. In addition, the health care plan shall
31 require the specialist physician or other health care
32 provider to provide regular updates to the enrollee's primary
33 care physician.
34 (f) If an enrollee's application for any referral is
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1 denied, an enrollee may appeal the decision through the
2 health care plan's medical necessity second opinion process
3 in accordance with Section 45 of this Act.
4 Section 45. Medical necessity; second opinion. A health
5 care plan shall provide a mechanism for the timely review by
6 a physician or other health care provider holding the same
7 class of license as the patient's physician or other health
8 care provider, who is unaffiliated with the health care plan,
9 jointly selected by the patient (or the patient's next of kin
10 or legal representative if the patient is unable to act for
11 himself), the patient's physician or other health care
12 provider, and the health care plan in the event of a dispute
13 between the patient's physician or other health care provider
14 and the health care plan regarding the medical necessity of a
15 service or a referral. If the reviewing physician or other
16 health care provider determines the service to be medically
17 necessary or the referral to be appropriate, the health care
18 plan shall pay for the service. Future contractual or
19 employment action by the health care plan regarding the
20 patient's physician or other health care provider shall not
21 be based solely on the physician's or other health care
22 provider's participation in this procedure.
23 Section 50. Choosing a physician.
24 (a) A health care plan may also offer other arrangements
25 under which enrollees may access health care services from
26 contracted providers without a referral or authorization from
27 their primary care physician.
28 (b) The enrollee may be required by the health care plan
29 to select a specialist physician or other health care
30 provider who has a referral arrangement with the enrollee's
31 primary care physician or to select a new primary care
32 physician who has a referral arrangement with the specialist
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1 physician or other health care provider chosen by the
2 enrollee. If a health care plan requires an enrollee to
3 select a new physician under this subsection, the health care
4 plan must provide the enrollee with both options provided in
5 this subsection.
6 (c) The Director of Insurance and the Department of
7 Public Health each may promulgate rules to ensure appropriate
8 access to and quality of care for enrollees in any plan that
9 allows enrollees to access health care services from
10 contractual providers without a referral or authorization
11 from the primary care physician. The rules may include, but
12 shall not be limited to, a system for the retrieval and
13 compilation of enrollees' medical records.
14 Section 55. Emergency services prior to stabilization.
15 (a) A health care plan that provides or that is required
16 by law to provide coverage for emergency services shall
17 provide coverage such that payment under this coverage is not
18 dependent upon whether the services are performed by a plan
19 or non-plan health care provider and without regard to prior
20 authorization. This coverage shall be at the same benefit
21 level as if the services or treatment had been rendered by
22 the health care plan physician licensed to practice medicine
23 in all its branches or health care provider.
24 (b) Prior authorization or approval by the plan shall
25 not be required for emergency services.
26 (c) Coverage and payment shall not be retrospectively
27 denied, with the following exceptions:
28 (1) upon reasonable determination that the
29 emergency services claimed were never performed;
30 (2) upon determination that the emergency
31 evaluation and treatment were rendered to an enrollee who
32 sought emergency services and whose circumstance did not
33 meet the definition of emergency medical condition;
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1 (3) upon determination that the patient receiving
2 such services was not an enrollee of the health care
3 plan; or
4 (4) upon material misrepresentation by the enrollee
5 or health care provider; "material" means a fact or
6 situation that is not merely technical in nature and
7 results or could result in a substantial change in the
8 situation.
9 (d) When an enrollee presents to a hospital seeking
10 emergency services, the determination as to whether the need
11 for those services exists shall be made for purposes of
12 treatment by a physician licensed to practice medicine in
13 all its branches or, to the extent permitted by applicable
14 law, by other appropriately licensed personnel under the
15 supervision of or in collaboration with a physician licensed
16 to practice medicine in all its branches. The physician or
17 other appropriate personnel shall indicate in the patient's
18 chart the results of the emergency medical screening
19 examination.
20 (e) The appropriate use of the 911 emergency telephone
21 system or its local equivalent shall not be discouraged or
22 penalized by the health care plan when an emergency medical
23 condition exists. This provision shall not imply that the use
24 of 911 or its local equivalent is a factor in determining the
25 existence of an emergency medical condition.
26 (f) The medical director's or his or her designee's
27 determination of whether the enrollee meets the standard of
28 an emergency medical condition shall be based solely upon the
29 presenting symptoms documented in the medical record at the
30 time care was sought.
31 (g) Nothing in this Section shall prohibit the
32 imposition of deductibles, co-payments, and co-insurance.
33 Section 60. Post-stabilization medical services.
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1 (a) If prior authorization for covered post-stabilization
2 services is required by the health care plan, the plan shall
3 provide access 24 hours a day, 7 days a week to persons
4 designated by the plan to make such determinations.
5 (b) The treating physician licensed to practice medicine
6 in all its branches or health care provider shall contact
7 the health care plan or delegated health care provider as
8 designated on the enrollee's health insurance card to obtain
9 authorization, denial, or arrangements for an alternate plan
10 of treatment or transfer of the enrollee.
11 (c) The treating physician licensed to practice
12 medicine in all its branches or health care provider shall
13 document in the enrollee's medical record the enrollee's
14 presenting symptoms; emergency medical condition; and time,
15 phone number dialed, and result of the communication for
16 request for authorization of post-stabilization medical
17 services. The health care plan shall provide reimbursement
18 for covered post-stabilization medical services if:
19 (1) authorization to render them is received from
20 the health care plan or its delegated health care
21 provider, or
22 (2) after 2 documented good faith efforts, the
23 treating health care provider has attempted to contact
24 the enrollee's health care plan or its delegated health
25 care provider, as designated on the enrollee's health
26 insurance card, for prior authorization of
27 post-stabilization medical services and neither the plan
28 nor designated persons were accessible or the
29 authorization was not denied within 60 minutes of the
30 request. "Two documented good faith efforts" means the
31 health care provider has called the telephone number on
32 the enrollee's health insurance card or other available
33 number either 2 times or one time and an additional call
34 to any referral number provided. "Good faith" means
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1 honesty of purpose, freedom from intention to defraud,
2 and being faithful to one's duty or obligation. For the
3 purpose of this Act, good faith shall be presumed.
4 (d) After rendering any post-stabilization medical
5 services, the treating physician licensed to practice
6 medicine in all its branches or health care provider shall
7 continue to make every reasonable effort to contact the
8 health care plan or its delegated health care provider
9 regarding authorization, denial, or arrangements for an
10 alternate plan of treatment or transfer of the enrollee until
11 the treating health care provider receives instructions from
12 the health care plan or delegated health care provider for
13 continued care or the care is transferred to another health
14 care provider or the patient is discharged.
15 (e) Payment for covered post-stabilization services may
16 be denied:
17 (1) if the treating health care provider does not
18 meet the conditions outlined in subsection (c);
19 (2) upon determination that the post-stabilization
20 services claimed were not performed;
21 (3) upon determination that the post-stabilization
22 services rendered were contrary to the instructions of
23 the health care plan or its delegated health care
24 provider if contact was made between those parties prior
25 to the service being rendered;
26 (4) upon determination that the patient receiving
27 such services was not an enrollee of the health care
28 plan; or
29 (5) upon material misrepresentation by the enrollee
30 or health care provider; "material" means a fact or
31 situation that is not merely technical in nature and
32 results or could result in a substantial change in the
33 situation.
34 (f) Nothing in this Section prohibits a health care plan
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1 from delegating tasks associated with the responsibilities
2 enumerated in this Section to the health care plan's
3 contracted health care providers or another entity.
4 However, the ultimate responsibility for coverage and payment
5 decisions may not be delegated.
6 (g) Coverage and payment for post-stabilization medical
7 services for which prior authorization or deemed approval is
8 received shall not be retrospectively denied.
9 (h) Nothing in this Section shall prohibit the
10 imposition of deductibles, co-payments, and co-insurance.
11 Section 65. Consumer advisory committee.
12 (a) A health care plan shall establish a consumer
13 advisory committee. The consumer advisory committee shall
14 have the authority to identify and review consumer concerns
15 and make advisory recommendations to the health care plan.
16 The health care plan may also make requests of the consumer
17 advisory committee to provide feedback to proposed changes in
18 plan policies and procedures which will affect enrollees.
19 However, the consumer advisory committee shall not have the
20 authority to hear or resolve specific complaints or
21 grievances, but instead shall refer such complaints or
22 grievances to the health care plan's grievance committee.
23 (b) The health care plan shall randomly select 8
24 enrollees meeting the requirements of this Section to serve
25 on the consumer advisory committee. Upon initial formation
26 of the consumer advisory committee, the health care plan
27 shall appoint 4 enrollees to a 2 year term and 4 enrollees to
28 a one year term. Thereafter, as an enrollee's term expires,
29 the health care plan shall re-appoint or appoint an enrollee
30 to serve on the consumer advisory committee for a 2 year
31 term. Members of the consumer advisory committee shall by
32 majority vote elect a member of the committee to serve as
33 chair of the committee.
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1 (c) An enrollee may not serve on the consumer advisory
2 committee if during the 2 years preceding service the
3 enrollee:
4 (1) has been an employee, officer, or director of
5 the plan, an affiliate of the plan, or a provider or
6 affiliate of a provider that furnishes health care
7 services to the plan or affiliate of the plan; or
8 (2) is a relative of a person specified in item
9 (1).
10 (d) A health care plan's consumer advisory committee
11 shall meet not less than quarterly.
12 (e) All meetings shall be held within the State of
13 Illinois. The costs of the meetings shall be borne by the
14 health care plan.
15 Section 70. Quality assessment program.
16 (a) A health care plan shall develop and implement a
17 quality assessment and improvement strategy designed to
18 identify and evaluate accessibility, continuity, and quality
19 of care. The health care plan shall have:
20 (1) an ongoing, written, internal quality
21 assessment program;
22 (2) specific written guidelines for monitoring and
23 evaluating the quality and appropriateness of care and
24 services provided to enrollees requiring the health care
25 plan to assess:
26 (A) the accessibility to health care
27 providers;
28 (B) appropriateness of utilization;
29 (C) concerns identified by the health care
30 plan's medical or administrative staff and
31 enrollees; and
32 (D) other aspects of care and service directly
33 related to the improvement of quality of care;
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1 (3) a procedure for remedial action to correct
2 quality problems that have been verified in accordance
3 with the written plan's methodology and criteria,
4 including written procedures for taking appropriate
5 corrective action;
6 (4) follow-up measures implemented to evaluate the
7 effectiveness of the action plan.
8 (b) The health care plan shall establish a committee
9 that oversees the quality assessment and improvement strategy
10 which includes physician and enrollee participation.
11 (c) Reports on quality assessment and improvement
12 activities shall be made to the governing body of the health
13 care plan not less than quarterly.
14 (d) The health care plan shall make available its
15 written description of the quality assessment program to the
16 Department of Public Health.
17 (e) With the exception of subsection (d), the Department
18 of Public Health shall accept evidence of accreditation with
19 regard to the health care network quality management and
20 performance improvement standards of:
21 (1) the National Commission on Quality Assurance
22 (NCQA);
23 (2) the American Accreditation Healthcare
24 Commission (URAC);
25 (3) the Joint Commission on Accreditation of
26 Healthcare Organizations (JCAHO); or
27 (4) any other entity that the Director of Public
28 Health deems has substantially similar or more stringent
29 standards than provided for in this Section.
30 Section 75. Complaints.
31 (a) A health care plan shall establish and maintain a
32 complaint system providing reasonable procedures for
33 resolving complaints initiated by enrollees (complainant)
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1 which shall provide for an expedited review of cases
2 involving imminent threat to the health of an enrollee.
3 Nothing in this Act shall be construed to preclude an
4 enrollee from filing a complaint with the Department or as
5 limiting the Department's ability to investigate complaints.
6 In addition, any enrollee not satisfied with the plan's
7 resolution of any complaint may appeal that final plan
8 decision to the Department.
9 (b) When a complaint against a health care plan
10 (respondent) is received by the Department, the respondent
11 shall be notified of the complaint. The Department shall, in
12 its notification, specify the date when a report is to be
13 received from the respondent, which shall be no later than 21
14 days after notification is sent to the respondent. A failure
15 to reply by the date specified may be followed by a collect
16 telephone call or collect telegram. Repeated instances of
17 failing to reply by the date specified may result in further
18 regulatory action.
19 (c) The respondent's report shall supply adequate
20 documentation that explains all actions taken or not taken
21 and that were the basis for the complaint. The report shall
22 include documents necessary to support the respondent's
23 position and any information requested by the Department. The
24 respondent's reply shall be in duplicate, but duplicate
25 copies of supporting documents shall not be required. The
26 respondent's reply shall include the name, telephone number,
27 and address of the individual assigned to investigate or
28 process the complaint. The Department shall respect the
29 confidentiality of medical reports and other documents that
30 by law are confidential. Any other information furnished by
31 a respondent shall be marked "confidential" if the respondent
32 does not wish it to be released to the complainant.
33 (d) The Department shall review the plan decision to
34 determine whether it is consistent with the plan and Illinois
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1 law and rules.
2 (e) Upon receipt of the respondent's report, the
3 Department shall evaluate the material submitted; and
4 (1) advise the complainant of the action taken and
5 disposition of its complaint;
6 (2) pursue further investigation with respondent or
7 complainant; or
8 (3) refer the investigation report to the
9 appropriate branch within the Department for further
10 regulatory action.
11 (f) The Department of Insurance and the Department of
12 Public Health shall coordinate the complaint review and
13 investigation process. The Department of Insurance and the
14 Department of Public Health shall jointly establish rules
15 under the Illinois Administrative Procedure Act implementing
16 this complaint process.
17 Section 80. Record of complaints.
18 (a) The Department shall maintain records concerning the
19 complaints filed against health care plans with the
20 Department and shall require health care plans to annually
21 report complaints made to and resolutions by health care
22 plans in a manner determined by rule. The Department shall
23 make a summary of all data collected available upon request
24 and publish the summary on the World Wide Web.
25 (b) The Department shall maintain records on the number
26 of complaints filed against each health care plan.
27 (c) The Department shall maintain records classifying
28 each complaint by whether the complaint was filed by:
29 (1) a consumer or enrollee;
30 (2) a provider; or
31 (3) any other individual.
32 (d) The Department shall maintain records classifying
33 each complaint according to the nature of the complaint as it
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1 pertains to a specific function of the health care plan. The
2 complaints shall be classified under the following
3 categories:
4 (1) denial of care or treatment;
5 (2) denial of a diagnostic procedure;
6 (3) denial of a referral request;
7 (4) sufficient choice and accessibility of health
8 care providers;
9 (5) underwriting;
10 (6) marketing and sales;
11 (7) claims and utilization review;
12 (8) member services;
13 (9) provider relations; and
14 (10) miscellaneous.
15 (e) The Department shall maintain records classifying
16 the disposition of each complaint. The disposition of the
17 complaint shall be classified in one of the following
18 categories:
19 (1) complaint referred to the health care plan and
20 no further action necessary by the Department;
21 (2) no corrective action deemed necessary by the
22 Department; or
23 (3) corrective action taken by the Department.
24 (f) No Department publication or release of information
25 shall identify any enrollee, health care provider, or
26 individual complainant.
27 Section 85. Utilization review program registration.
28 (a) No person may conduct a utilization review program
29 in this State unless once every 2 years the person registers
30 the utilization review program with the Department and
31 certifies compliance with all of the Health Utilization
32 Management Standards of the American Accreditation Healthcare
33 Commission (URAC) or submits evidence of accreditation by the
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1 American Accreditation Healthcare Commission (URAC) for its
2 Health Utilization Management Standards.
3 (b) In addition, the Director of the Department, in
4 consultation with the Director of the Department of Public
5 Health, may certify alternative utilization review standards
6 of national accreditation organizations or entities in order
7 for plans to comply with this Section. Any alternative
8 utilization review standards shall meet or exceed those
9 standards required under subsection (a).
10 (c) The provisions of this Section do not apply to:
11 (1) persons providing utilization review program
12 services only to the federal government;
13 (2) self-insured health plans under the federal
14 Employee Retirement Income Security Act of 1974, however,
15 this Section does apply to persons conducting a
16 utilization review program on behalf of these health
17 plans;
18 (3) hospitals and medical groups performing
19 utilization review activities for internal purposes
20 unless the utilization review program is conducted for
21 another person.
22 Nothing in this Act prohibits a health care plan or other
23 entity from contractually requiring an entity designated in
24 item (3) of this subsection to adhere to the utilization
25 review program requirements of this Act.
26 (d) This registration shall include submission of all of
27 the following information regarding utilization review
28 program activities:
29 (1) The name, address, and telephone number of the
30 utilization review programs.
31 (2) The organization and governing structure of the
32 utilization review programs.
33 (3) The number of lives for which utilization
34 review is conducted by each utilization review program.
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1 (4) Hours of operation of each utilization review
2 program.
3 (5) Description of the grievance process for each
4 utilization review program.
5 (6) Number of covered lives for which utilization
6 review was conducted for the previous calendar year for
7 each utilization review program.
8 (7) Written policies and procedures for protecting
9 confidential information according to applicable State
10 and federal laws for each utilization review program.
11 (e) If the Department finds that a utilization review
12 program is not in compliance with this Section, the
13 Department shall issue a corrective action plan and allow a
14 reasonable amount of time for compliance with the plan. If
15 the utilization review program does not come into compliance,
16 the Department may issue a cease and desist order. Before
17 issuing a cease and desist order under this Section, the
18 Department shall provide the utilization review program with
19 a written notice of the reasons for the order and allow a
20 reasonable amount of time to supply additional information
21 demonstrating compliance with requirements of this Section
22 and to request a hearing. The hearing notice shall be sent
23 by certified mail, return receipt requested, and the hearing
24 shall be conducted in accordance with the Illinois
25 Administrative Procedure Act.
26 (f) A utilization review program subject to a corrective
27 action may continue to conduct business until a final
28 decision has been issued by the Department.
29 Section 90. Prohibited activity. No health care plan or
30 its subcontractors by contract, written policy, or procedure
31 shall contain any clause attempting to transfer or
32 transferring to a health care provider by indemnification,
33 hold harmless, or contribution requirements concerning any
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1 liability relating to activities, actions, or omissions of
2 the health care plan or its officers, employees, or agents.
3 Nothing in this Section shall relieve any person or health
4 care provider from liability for his, her, or its own
5 negligence in the performance of his, her, or its duties
6 arising from treatment of a patient. The Illinois General
7 Assembly finds it to be against public policy for a person to
8 transfer liability in such a manner.
9 Section 95. Prohibition of waiver of rights. No health
10 care plan or contract shall contain any provision, policy, or
11 procedure that limits, restricts, or waives any of the rights
12 set forth in this Act. Any such policy or procedure shall be
13 void and unenforceable.
14 Section 100. Administration and enforcement. The
15 Director of Insurance may adopt rules necessary to implement
16 the Department's responsibilities under this Act.
17 To enforce the provisions of this Act, the Director may
18 issue a cease and desist order or require a health care plan
19 to submit a plan of correction for violations of this Act, or
20 both. Subject to the provisions of the Illinois
21 Administrative Procedure Act, the Director may impose an
22 administrative fine on a health care plan of up to $5,000 for
23 failure to submit a requested plan of correction, failure to
24 comply with its plan of correction, or repeated violations of
25 the Act.
26 Section 105. Applicability and scope. This Act applies
27 to policies and contracts amended, delivered, issued, or
28 renewed on or after the effective date of this Act. This Act
29 does not diminish a health care plan's duties and
30 responsibilities under other federal or State law or rules
31 promulgated thereunder.
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1 Section 110. Effect on benefits under Workers'
2 Compensation Act and Workers' Occupational Diseases Act.
3 Nothing in this Act shall be construed to expand, modify, or
4 restrict the health care benefits provided to employees under
5 the Workers' Compensation Act and Workers' Occupational
6 Diseases Act.
7 Section 115. Severability. The provisions of this Act
8 are severable under Section 1.31 of the Statute on Statutes.
9 Section 200. The State Employees Group Insurance Act of
10 1971 is amended by adding Section 6.12 as follows:
11 (5 ILCS 375/6.12 new)
12 Sec. 6.12. Managed Care Patient Rights Act. The program
13 of health benefits is subject to the provisions of the
14 Managed Care Patient Rights Act.
15 Section 205. The State Mandates Act is amended by adding
16 Section 8.23 as follows:
17 (30 ILCS 805/8.23 new)
18 Sec. 8.23. Exempt mandate. Notwithstanding Sections 6
19 and 8 of this Act, no reimbursement by the State is required
20 for the implementation of any mandate created by this
21 amendatory Act of 1999.
22 Section 210. The Counties Code is amended by adding
23 Section 5-1069.8 as follows:
24 (55 ILCS 5/5-1069.8 new)
25 Sec. 5-1069.8. Managed Care Patient Rights Act. All
26 counties, including home rule counties, are subject to the
27 provisions of the Managed Care Patient Rights Act. The
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1 requirement under this Section that health care benefits
2 provided by counties comply with the Managed Care Patient
3 Rights Act is an exclusive power and function of the State
4 and is a denial and limitation of home rule county powers
5 under Article VII, Section 6, subsection (h) of the Illinois
6 Constitution.
7 Section 215. The Illinois Municipal Code is amended by
8 adding Section 10-4-2.8 as follows:
9 (65 ILCS 5/10-4-2.8 new)
10 Sec. 10-4-2.8. Managed Care Patient Rights Act. The
11 corporate authorities of all municipalities are subject to
12 the provisions of the Managed Care Patient Rights Act. The
13 requirement under this Section that health care benefits
14 provided by municipalities comply with the Managed Care
15 Patient Rights Act is an exclusive power and function of the
16 State and is a denial and limitation of home rule
17 municipality powers under Article VII, Section 6, subsection
18 (h) of the Illinois Constitution.
19 Section 220. The Illinois Insurance Code is amended by
20 changing Section 370g and adding Sections 155.36, 370s and
21 511.118 as follows:
22 (215 ILCS 5/155.36 new)
23 Sec. 155.36. Managed Care Patient Rights Act. Insurance
24 companies that transact the kinds of insurance authorized
25 under Class 1(b) or Class 2(a) of Section 4 of this Code
26 shall comply with Section 85 and the definition of the term
27 "emergency medical condition" in Section 10 of the Managed
28 Care Patient Rights Act.
29 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
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1 Sec. 370g. Definitions. As used in this Article, the
2 following definitions apply:
3 (a) "Health care services" means health care services or
4 products rendered or sold by a provider within the scope of
5 the provider's license or legal authorization. The term
6 includes, but is not limited to, hospital, medical, surgical,
7 dental, vision and pharmaceutical services or products.
8 (b) "Insurer" means an insurance company or a health
9 service corporation authorized in this State to issue
10 policies or subscriber contracts which reimburse for expenses
11 of health care services.
12 (c) "Insured" means an individual entitled to
13 reimbursement for expenses of health care services under a
14 policy or subscriber contract issued or administered by an
15 insurer.
16 (d) "Provider" means an individual or entity duly
17 licensed or legally authorized to provide health care
18 services.
19 (e) "Noninstitutional provider" means any person
20 licensed under the Medical Practice Act of 1987, as now or
21 hereafter amended.
22 (f) "Beneficiary" means an individual entitled to
23 reimbursement for expenses of or the discount of provider
24 fees for health care services under a program where the
25 beneficiary has an incentive to utilize the services of a
26 provider which has entered into an agreement or arrangement
27 with an administrator.
28 (g) "Administrator" means any person, partnership or
29 corporation, other than an insurer or health maintenance
30 organization holding a certificate of authority under the
31 "Health Maintenance Organization Act", as now or hereafter
32 amended, that arranges, contracts with, or administers
33 contracts with a provider whereby beneficiaries are provided
34 an incentive to use the services of such provider.
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1 (h) "Emergency medical condition" means a medical
2 condition manifesting itself by acute symptoms of sufficient
3 severity (including severe pain) such that a prudent
4 layperson, who possesses an average knowledge of health and
5 medicine, could reasonably expect the absence of immediate
6 medical attention to result in:
7 (1) placing the health of the individual (or, with
8 respect to a pregnant woman, the health of the woman or
9 her unborn child) in serious jeopardy;
10 (2) serious impairment to bodily functions; or
11 (3) serious dysfunction of any bodily organ or
12 part. "Emergency" means an accidental bodily injury or
13 emergency medical condition which reasonably requires the
14 beneficiary or insured to seek immediate medical care
15 under circumstances or at locations which reasonably
16 preclude the beneficiary or insured from obtaining needed
17 medical care from a preferred provider.
18 (Source: P.A. 88-400.)
19 (215 ILCS 5/370s new)
20 Sec. 370s. Managed Care Patient Rights Act. All
21 administrators shall comply with Sections 80 and 85 of the
22 Managed Care Patient Rights Act.
23 (215 ILCS 5/511.118 new)
24 Sec. 511.118. Managed Care Patient Rights Act. All
25 administrators are subject to the provisions of Sections 80
26 and 85 of the Managed Care Patient Rights Act.
27 Section 225. The Comprehensive Health Insurance Plan Act
28 is amended by adding Section 8.6 as follows:
29 (215 ILCS 105/8.6 new)
30 Sec. 8.6. Managed Care Patient Rights Act. The plan is
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1 subject to the provisions of the Managed Care Patient Rights
2 Act.
3 Section 230. The Health Care Purchasing Group Act is
4 amended by changing Sections 15 and 20 as follows:
5 (215 ILCS 123/15)
6 Sec. 15. Health care purchasing groups; membership;
7 formation.
8 (a) An HPG may be an organization formed by 2 or more
9 employers with no more than 500 covered employees each 2,500
10 covered individuals, an HPG sponsor or a risk-bearer for
11 purposes of contracting for health insurance under this Act
12 to cover employees and dependents of HPG members. An HPG
13 shall not be prevented from supplementing health insurance
14 coverage purchased under this Act by contracting for services
15 from entities licensed and authorized in Illinois to provide
16 those services under the Dental Service Plan Act, the Limited
17 Health Service Organization Act, or Voluntary Health Services
18 Plans Act. An HPG may be a separate legal entity or simply a
19 group of 2 or more employers with no more than 500 covered
20 employees each 2,500 covered individuals aggregated under
21 this Act by an HPG sponsor or risk-bearer for insurance
22 purposes. There shall be no limit as to the number of HPGs
23 that may operate in any geographic area of the State. No
24 insurance risk may be borne or retained by the HPG. All
25 health insurance contracts issued to the HPG must be
26 delivered or issued for delivery in Illinois.
27 (b) Members of an HPG must be Illinois domiciled
28 employers, except that an employer domiciled elsewhere may
29 become a member of an Illinois HPG for the sole purpose of
30 insuring its employees whose place of employment is located
31 within this State. HPG membership may include employers
32 having no more than 500 covered employees each 2,500 covered
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1 individuals.
2 (c) If an HPG is formed by any 2 or more employers with
3 no more than 500 covered employees each 2,500 covered
4 individuals, it is authorized to negotiate, solicit, market,
5 obtain proposals for, and enter into group or master health
6 insurance contracts on behalf of its members and their
7 employees and employee dependents so long as it meets all of
8 the following requirements:
9 (1) The HPG must be an organization having the
10 legal capacity to contract and having its legal situs in
11 Illinois.
12 (2) The principal persons responsible for the
13 conduct of the HPG must perform their HPG related
14 functions in Illinois.
15 (3) No HPG may collect premium in its name or hold
16 or manage premium or claim fund accounts unless duly
17 licensed and qualified as a managing general agent
18 pursuant to Section 141a of the Illinois Insurance Code
19 or a third party administrator pursuant to Section
20 511.105 of the Illinois Insurance Code.
21 (4) If the HPG gives an offer, application, notice,
22 or proposal of insurance to an employer, it must disclose
23 to that employer the total cost of the insurance. Dues,
24 fees, or charges to be paid to the HPG, HPG sponsor, or
25 any other entity as a condition to purchasing the
26 insurance must be itemized. The HPG shall also disclose
27 to its members the amount of any dividends, experience
28 refunds, or other such payments it receives from the
29 risk-bearer.
30 (5) An HPG must register with the Director before
31 entering into a group or master health insurance contract
32 on behalf of its members and must renew the registration
33 annually on forms and at times prescribed by the Director
34 in rules specifying, at minimum, (i) the identity of the
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1 officers and directors, trustees, or attorney-in-fact of
2 the HPG; (ii) a certification that those persons have not
3 been convicted of any felony offense involving a breach
4 of fiduciary duty or improper manipulation of accounts;
5 and (iii) the number of employer members then enrolled in
6 the HPG, together with any other information that may be
7 needed to carry out the purposes of this Act.
8 (6) At the time of initial registration and each
9 renewal thereof an HPG shall pay a fee of $100 to the
10 Director.
11 (d) If an HPG is formed by an HPG sponsor or risk-bearer
12 and the HPG performs no marketing, negotiation, solicitation,
13 or proposing of insurance to HPG members, exclusive of
14 ministerial acts performed by individual employers to service
15 their own employees, then a group or master health insurance
16 contract may be issued in the name of the HPG and held by an
17 HPG sponsor, risk-bearer, or designated employer member
18 within the State. In these cases the HPG requirements
19 specified in subsection (c) shall not be applicable, however:
20 (1) the group or master health insurance contract
21 must contain a provision permitting the contract to be
22 enforced through legal action initiated by any employer
23 member or by an employee of an HPG member who has paid
24 premium for the coverage provided;
25 (2) the group or master health insurance contract
26 must be available for inspection and copying by any HPG
27 member, employee, or insured dependent at a designated
28 location within the State at all normal business hours;
29 and
30 (3) any information concerning HPG membership
31 required by rule under item (5) of subsection (c) must be
32 provided by the HPG sponsor in its registration and
33 renewal forms or by the risk-bearer in its annual
34 reports.
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1 (Source: P.A. 90-337, eff. 1-1-98; 90-655, eff. 7-30-98.)
2 (215 ILCS 123/20)
3 Sec. 20. HPG sponsors. Except as provided by Sections 15
4 and 25 of this Act, only a corporation authorized by the
5 Secretary of State to transact business in Illinois may
6 sponsor one or more HPGs with no more than 100,000 10,000
7 covered individuals by negotiating, soliciting, or servicing
8 health insurance contracts for HPGs and their members. Such a
9 corporation may assert and maintain authority to act as an
10 HPG sponsor by complying with all of the following
11 requirements:
12 (1) The principal officers and directors
13 responsible for the conduct of the HPG sponsor must
14 perform their HPG sponsor related functions in Illinois.
15 (2) No insurance risk may be borne or retained by
16 the HPG sponsor; all health insurance contracts issued to
17 HPGs through the HPG sponsor must be delivered in
18 Illinois.
19 (3) No HPG sponsor may collect premium in its name
20 or hold or manage premium or claim fund accounts unless
21 duly qualified and licensed as a managing general agent
22 pursuant to Section 141a of the Illinois Insurance Code
23 or as a third party administrator pursuant to Section
24 511.105 of the Illinois Insurance Code.
25 (4) If the HPG gives an offer, application, notice,
26 or proposal of insurance to an employer, it must disclose
27 the total cost of the insurance. Dues, fees, or charges
28 to be paid to the HPG, HPG sponsor, or any other entity
29 as a condition to purchasing the insurance must be
30 itemized. The HPG shall also disclose to its members the
31 amount of any dividends, experience refunds, or other
32 such payments it receives from the risk-bearer.
33 (5) An HPG sponsor must register with the Director
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1 before negotiating or soliciting any group or master
2 health insurance contract for any HPG and must renew the
3 registration annually on forms and at times prescribed by
4 the Director in rules specifying, at minimum, (i) the
5 identity of the officers and directors of the HPG sponsor
6 corporation; (ii) a certification that those persons have
7 not been convicted of any felony offense involving a
8 breach of fiduciary duty or improper manipulation of
9 accounts; (iii) the number of employer members then
10 enrolled in each HPG sponsored; (iv) the date on which
11 each HPG was issued a group or master health insurance
12 contract, if any; and (v) the date on which each such
13 contract, if any, was terminated.
14 (6) At the time of initial registration and each
15 renewal thereof an HPG sponsor shall pay a fee of $100 to
16 the Director.
17 (Source: P.A. 90-337, eff. 1-1-98.)
18 Section 235. The Health Maintenance Organization Act is
19 amended by changing Sections 2-2 and 6-7 and adding Section
20 5-3.6 as follows:
21 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
22 Sec. 2-2. Determination by Director; Health Maintenance
23 Advisory Board.
24 (a) Upon receipt of an application for issuance of a
25 certificate of authority, the Director shall transmit copies
26 of such application and accompanying documents to the
27 Director of the Illinois Department of Public Health. The
28 Director of the Department of Public Health shall then
29 determine whether the applicant for certificate of authority,
30 with respect to health care services to be furnished: (1) has
31 demonstrated the willingness and potential ability to assure
32 that such health care service will be provided in a manner to
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1 insure both availability and accessibility of adequate
2 personnel and facilities and in a manner enhancing
3 availability, accessibility, and continuity of service; and
4 (2) has arrangements, established in accordance with
5 regulations promulgated by the Department of Public Health
6 for an ongoing quality of health care assurance program
7 concerning health care processes and outcomes. Upon
8 investigation, the Director of the Department of Public
9 Health shall certify to the Director whether the proposed
10 Health Maintenance Organization meets the requirements of
11 this subsection (a). If the Director of the Department of
12 Public Health certifies that the Health Maintenance
13 Organization does not meet such requirements, he shall
14 specify in what respect it is deficient.
15 There is created in the Department of Public Health a
16 Health Maintenance Advisory Board composed of 11 members.
17 Nine 9 members shall who have practiced in the health field,
18 4 of which shall have been or are currently affiliated with a
19 Health Maintenance Organization. Two of the members shall be
20 members of the general public, one of whom is over 50 years
21 of age. Each member shall be appointed by the Director of
22 the Department of Public Health and serve at the pleasure of
23 that Director and shall receive no compensation for services
24 rendered other than reimbursement for expenses. Six Five
25 members of the Board shall constitute a quorum. A vacancy in
26 the membership of the Advisory Board shall not impair the
27 right of a quorum to exercise all rights and perform all
28 duties of the Board. The Health Maintenance Advisory Board
29 has the power to review and comment on proposed rules and
30 regulations to be promulgated by the Director of the
31 Department of Public Health within 30 days after those
32 proposed rules and regulations have been submitted to the
33 Advisory Board.
34 (b) Issuance of a certificate of authority shall be
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1 granted if the following conditions are met:
2 (1) the requirements of subsection (c) of Section
3 2-1 have been fulfilled;
4 (2) the persons responsible for the conduct of the
5 affairs of the applicant are competent, trustworthy, and
6 possess good reputations, and have had appropriate
7 experience, training or education;
8 (3) the Director of the Department of Public Health
9 certifies that the Health Maintenance Organization's
10 proposed plan of operation meets the requirements of this
11 Act;
12 (4) the Health Care Plan furnishes basic health
13 care services on a prepaid basis, through insurance or
14 otherwise, except to the extent of reasonable
15 requirements for co-payments or deductibles as authorized
16 by this Act;
17 (5) the Health Maintenance Organization is
18 financially responsible and may reasonably be expected to
19 meet its obligations to enrollees and prospective
20 enrollees; in making this determination, the Director
21 shall consider:
22 (A) the financial soundness of the applicant's
23 arrangements for health services and the minimum
24 standard rates, co-payments and other patient
25 charges used in connection therewith;
26 (B) the adequacy of working capital, other
27 sources of funding, and provisions for
28 contingencies; and
29 (C) that no certificate of authority shall be
30 issued if the initial minimum net worth of the
31 applicant is less than $2,000,000. The initial net
32 worth shall be provided in cash and securities in
33 combination and form acceptable to the Director;
34 (6) the agreements with providers for the provision
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1 of health services contain the provisions required by
2 Section 2-8 of this Act; and
3 (7) any deficiencies identified by the Director
4 have been corrected.
5 (Source: P.A. 86-620; 86-1475.)
6 (215 ILCS 125/5-3.6 new)
7 Sec. 5-3.6. Managed Care Patient Rights Act. Health
8 maintenance organizations are subject to the provisions of
9 the Managed Care Patient Rights Act.
10 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
11 Sec. 6-7. Board of Directors. The board of directors of
12 the Association consists of not less than 7 5 nor more than
13 11 9 members serving terms as established in the plan of
14 operation. The members of the board are to be selected by
15 member organizations subject to the approval of the Director,
16 except the Director shall name 2 members who are current
17 enrollees, one of whom is over 50 years of age. Vacancies on
18 the board must be filled for the remaining period of the term
19 in the manner described in the plan of operation. To select
20 the initial board of directors, and initially organize the
21 Association, the Director must give notice to all member
22 organizations of the time and place of the organizational
23 meeting. In determining voting rights at the organizational
24 meeting each member organization is entitled to one vote in
25 person or by proxy. If the board of directors is not
26 selected at the organizational meeting, the Director may
27 appoint the initial members.
28 In approving selections or in appointing members to the
29 board, the Director must consider, whether all member
30 organizations are fairly represented.
31 Members of the board may be reimbursed from the assets of
32 the Association for expenses incurred by them as members of
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1 the board of directors but members of the board may not
2 otherwise be compensated by the Association for their
3 services.
4 (Source: P.A. 85-20.)
5 Section 240. The Limited Health Service Organization Act
6 is amended by adding Section 4002.6 as follows:
7 (215 ILCS 130/4002.6 new)
8 Sec. 4002.6. Managed Care Patient Rights Act. Except
9 for health care plans offering only dental services or only
10 vision services, limited health service organizations are
11 subject to the provisions of the Managed Care Patient Rights
12 Act.
13 Section 245. The Voluntary Health Services Plans Act is
14 amended by adding Section 15.30 as follows:
15 (215 ILCS 165/15.30 new)
16 Sec. 15.30. Managed Care Patient Rights Act. A health
17 service plan corporation is subject to the provisions of the
18 Managed Care Patient Rights Act.
19 Section 250. The Illinois Public Aid Code is amended by
20 adding Section 5-16.12 as follows:
21 (305 ILCS 5/5-16.12 new)
22 Sec. 5-16.12. Managed Care Patient Rights Act. The
23 medical assistance program and other programs administered by
24 the Department are subject to the provisions of the Managed
25 Care Patient Rights Act. The Department may adopt rules to
26 implement those provisions. These rules shall require
27 compliance with that Act in the medical assistance managed
28 care programs and other programs administered by the
SB579 Engrossed -39- LRB9101022JSpc
1 Department. The medical assistance fee-for-service program
2 is not subject to the provisions of the Managed Care Patient
3 Rights Act.
4 Section 299. Effective date. This Act takes effect
5 January 1, 2000, except that Section 85 takes effect July 1,
6 2000.
SB579 Engrossed -40- LRB9101022JSpc
1 INDEX
2 Statutes amended in order of appearance
3 5 ILCS 375/6.12 new
4 30 ILCS 805/8.23 new
5 55 ILCS 5/5-1069.8 new
6 65 ILCS 5/10-4-2.8 new
7 215 ILCS 5/155.36 new
8 215 ILCS 5/370g from Ch. 73, par. 982g
9 215 ILCS 5/370s new
10 215 ILCS 5/511.118 new
11 215 ILCS 105/8.6 new
12 215 ILCS 123/15
13 215 ILCS 123/20
14 215 ILCS 125/2-2 from Ch. 111 1/2, par. 1404
15 215 ILCS 125/5-3.6 new
16 215 ILCS 125/6-7 from Ch. 111 1/2, par. 1418.7
17 215 ILCS 130/4002.6 new
18 215 ILCS 165/15.30 new
19 305 ILCS 5/5-16.12 new
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