Public Act 099-0111
 
HB2788 EnrolledLRB099 08001 MLM 28141 b


  
    AN ACT concerning insurance.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  
 
 
    Section 5. The Managed Care Reform and Patient Rights Act 
is amended  by changing Sections 80 and 85 as follows:
 



    (215 ILCS 134/80)



    Sec. 80. Quality assessment program. 

    (a) A health care plan shall develop and implement a 
quality assessment and
improvement strategy designed to 
identify and evaluate accessibility,
continuity, and quality 
of care.  The health care plan shall have:


        (1) an ongoing, written, internal quality assessment 
    program;


        (2) specific written guidelines for monitoring and 
    evaluating the quality
and appropriateness of care and 
    services provided to enrollees requiring the
health care 
    plan to assess:


            (A) the accessibility to health care providers;


            (B) appropriateness of utilization;


            (C) concerns identified by the health care plan's 
        medical or
administrative staff and enrollees; and


            (D) other aspects of care and service directly 
        related to the
improvement of quality of care;


        (3) a procedure for remedial action to correct quality 
    problems that have
been verified in accordance with the 
    written plan's methodology and criteria,
including written 
    procedures for taking appropriate corrective action;


        (4) follow-up measures implemented to evaluate the 
    effectiveness of the
action plan.

    (b) The health care plan shall establish a committee that 
oversees the
quality assessment and improvement strategy which 
includes physician
and enrollee participation.

    (c) Reports on quality assessment and improvement 
activities shall be made
to the governing body of the health 
care plan not less than quarterly.

    (d) The health care plan shall make available its written 
description of
the quality assessment program to the Department 
of
Public Health.

    (e) With the exception of subsection (d), the Department of 
Public Health
shall accept evidence of accreditation with 
regard to the health care network
quality management and 
performance improvement standards of:


        (1) the National Commission on Quality Assurance 
    (NCQA);


        (2) the American Accreditation Healthcare Commission 
    (URAC);


        (3) the Joint Commission on Accreditation of 
    Healthcare Organizations
(JCAHO); or
        (4) the Accreditation Association for Ambulatory 
    Health Care (AAAHC); or 


        (5) (4) any other entity that the Director of Public 
    Health deems has
substantially similar or
more stringent 
    standards than provided for in this Section.

    (f) If the Department of Public Health determines that a 
health care plan
is not in compliance with the terms of this 
Section, it shall certify the
finding to the Department of 
Insurance. The Department of Insurance shall
subject a health 
care plan to penalties, as provided in this Act, for such

non-compliance.

(Source: P.A. 91-617, eff. 1-1-00.)

 



    (215 ILCS 134/85)



    Sec. 85. Utilization review program registration. 

    (a) No person may conduct a utilization review program in 
this State unless
once every 2 years the person
registers the 
utilization review program with the Department and certifies

compliance with the Health
Utilization Management Standards of 
the American Accreditation Healthcare
Commission (URAC) 
sufficient to achieve American Accreditation Healthcare

Commission (URAC) accreditation or submits evidence of 
accreditation by the
American
Accreditation Healthcare 
Commission (URAC) for its Health Utilization
Management 
Standards.
Nothing in this Act shall be construed to require a 
health care plan or its
subcontractors to become American 
Accreditation Healthcare Commission (URAC)
accredited.

    (b) In addition, the Director of the Department, in 
consultation with the
Director of the Department of Public 
Health, may certify alternative
utilization review standards 
of national accreditation organizations or
entities in order 
for plans to comply with this Section.  Any alternative

utilization review standards shall meet or exceed those 
standards required
under subsection (a).

    (b-5) The Department shall recognize the Accreditation 
Association for Ambulatory Health Care among the list of 
accreditors from which utilization organizations may receive 
accreditation and qualify for reduced registration and renewal 
fees. 
    (c) The provisions of this Section do not apply to:


        (1) persons providing utilization review program 
    services only to the
federal
government;


        (2) self-insured health plans under the federal 
    Employee Retirement Income
Security Act of 1974, however, 
    this Section does apply to persons conducting
a utilization 
    review program on behalf of these health plans;


        (3) hospitals and medical groups performing 
    utilization review activities
for
internal purposes unless 
    the utilization review program is conducted for
another 
    person.

    Nothing in this Act prohibits a health care plan or other 
entity from
contractually requiring an entity designated in 
item (3) of this subsection
 to adhere to
the
utilization review 
program requirements of
this Act.

    (d) This registration shall include submission of all of 
the following
information
regarding utilization review program 
activities:


        (1) The name, address, and telephone number of the 
    utilization review
programs.


        (2) The organization and governing structure of the 
    utilization review
programs.


        (3) The
number of lives for which utilization review is 
    conducted by each utilization
review program.


        (4) Hours of operation of each utilization review 
    program.


        (5) Description of the grievance process for each 
    utilization review
program.


        (6) Number of covered lives for which utilization 
    review was conducted for
the previous calendar year for 
    each utilization review program.


        (7) Written policies and procedures for protecting 
    confidential
information
according to applicable State and 
    federal laws for each utilization review
program.

    (e) (1) A utilization review program shall have written 
procedures for
assuring that patient-specific information 
obtained during the process of
utilization review will be:


        (A) kept confidential in accordance with applicable 
    State and
federal laws; and


        (B) shared only with the enrollee, the enrollee's 
    designee, the
enrollee's health
care provider, and those 
    who are authorized by law to receive the information.

    Summary data shall not be considered confidential if it 
does not provide
information to allow identification  of 
individual patients or health care
providers.


        (2) Only a  health care professional may make 
    determinations regarding
the medical
 necessity of health 
    care services during the course of utilization review.


        (3) When making retrospective reviews, utilization 
    review programs shall
base
reviews solely on the medical 
    information available to the attending physician
or 
    ordering provider at the time the health care services were 
    provided.


        (4) When making prospective, concurrent, and 
    retrospective determinations,
utilization review programs 
    shall collect only information that is necessary to
make 
    the determination and shall not routinely require health 
    care providers to
numerically code diagnoses or procedures 
    to be considered for certification,
unless required under 
    State or federal Medicare or Medicaid rules or
regulations, 
    but may request such code if available, or routinely 
    request
copies
of medical records of all enrollees

    reviewed. During prospective or concurrent review, copies 
    of medical records
shall only be required when necessary to 
    verify that the health care services
subject to review are 
    medically necessary. In these cases, only the necessary
or

    relevant sections of the medical record shall be required.

    (f) If the Department finds that a utilization review 
program is
not in compliance with this Section, the Department 
shall issue a corrective
action plan and allow a reasonable 
amount of time for compliance with the plan.
 If the utilization 
review program does not come into compliance, the
Department 
may issue a cease and desist order.  Before issuing a cease and

desist order under this Section, the Department shall provide 
the
utilization review program with a written notice of the 
reasons for the
order and allow a reasonable amount of time to 
supply additional information
demonstrating compliance with 
requirements of this Section and to request a
hearing.  The 
hearing notice shall be sent by certified mail, return receipt

requested, and the hearing shall be conducted in accordance 
with the Illinois
Administrative Procedure Act.

    (g) A utilization review program subject to a corrective 
action may continue
to conduct business
until a final decision 
has been issued by the Department.

    (h) Any adverse determination made by a health care plan or 
its
subcontractors may be appealed
in accordance with 
subsection (f) of Section 45.

    (i) The Director may by rule establish a registration fee 
for each person
conducting a utilization review program.  All 
fees paid to and collected by the
Director under this Section 
shall be deposited into
the Insurance Producer Administration 
Fund.

(Source: P.A. 91-617, eff. 7-1-00.)