|
|||||||||||||||||||||||||
|
|||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
1 | AN ACT concerning insurance.
| ||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| ||||||||||||||||||||||||
3 | represented in the General Assembly:
| ||||||||||||||||||||||||
4 | ARTICLE 5. CONSUMER CHOICE AND PROMOTING | ||||||||||||||||||||||||
5 | RATE FAIRNESS IN ILLINOIS' INDIVIDUAL | ||||||||||||||||||||||||
6 | HEALTH INSURANCE MARKET | ||||||||||||||||||||||||
7 | Section 5-1. Short title. This Law may be cited as the | ||||||||||||||||||||||||
8 | Individual Market Fairness Reform Law. | ||||||||||||||||||||||||
9 | Section 5-5. Purpose. Illinois health insurance markets | ||||||||||||||||||||||||
10 | are critical to the health and well being of Illinois citizens. | ||||||||||||||||||||||||
11 | The General Assembly recognizes that the design of Illinois | ||||||||||||||||||||||||
12 | health insurance markets, therefore, must promote the public's | ||||||||||||||||||||||||
13 | health and welfare. It is the intent of this Law to do both of | ||||||||||||||||||||||||
14 | the following: | ||||||||||||||||||||||||
15 | (1) Guarantee the availability and renewability of | ||||||||||||||||||||||||
16 | health coverage through the private health insurance | ||||||||||||||||||||||||
17 | market to individuals. | ||||||||||||||||||||||||
18 | (2) Require that health maintenance organizations and | ||||||||||||||||||||||||
19 | health insurers issuing coverage in the individual market | ||||||||||||||||||||||||
20 | compete on the basis of price, quality, and service and not | ||||||||||||||||||||||||
21 | on risk selection. |
| |||||||
| |||||||
1 | Section 5-10. Definitions. In this Law: | ||||||
2 | "Anniversary date" means the calendar date one year from, | ||||||
3 | and each subsequent year thereafter, the date an individual | ||||||
4 | enrolls in a managed care plan.
| ||||||
5 | "Coverage choice category" means one of the 5 categories of | ||||||
6 | managed care plans established by the Division pursuant to this | ||||||
7 | Law. | ||||||
8 | "Creditable coverage" means creditable coverage as defined | ||||||
9 | by Section 20 of the Illinois Health Insurance Portability and | ||||||
10 | Accountability Act.
| ||||||
11 | "Dependent" means the spouse, domestic partner, or child of | ||||||
12 | an individual, subject to applicable laws and the applicable | ||||||
13 | terms of the managed care plan covering the individual. | ||||||
14 | "Division" means the Division of Insurance within the | ||||||
15 | Illinois Department of Financial and Professional Regulation. | ||||||
16 | "Enrollment date" means the first day of coverage of an | ||||||
17 | individual under a managed care plan or, if earlier, the first | ||||||
18 | day of the waiting period that must pass with respect to an | ||||||
19 | individual before such individual is eligible to be covered for | ||||||
20 | benefits. | ||||||
21 | "Health care plan" means a health care plan as defined by | ||||||
22 | Section 1-2 of the Health Maintenance Organization Act that is | ||||||
23 | offered to individuals. | ||||||
24 |
"Health insurance policy" means an individual policy of | ||||||
25 | accident and health insurance offered, sold, amended, or | ||||||
26 | renewed to individuals and their dependents that provides |
| |||||||
| |||||||
1 | coverage for hospital, medical, or surgical benefits. The term | ||||||
2 | shall not include any of the following kinds of insurance: | ||||||
3 | hospital indemnity, accidental death and dismemberment, | ||||||
4 | workers' compensation, credit accident and health, short-term | ||||||
5 | accident and health, accident only, long term care, Medicare | ||||||
6 | supplement, student blanket, stand-alone policies, dental, | ||||||
7 | vision care, prescription drug benefits, disability income, | ||||||
8 | specified disease, or similar supplementary benefits. | ||||||
9 | "Health insurer" means any insurance company authorized to | ||||||
10 | sell health insurance policies.
| ||||||
11 | "Health maintenance organization" means commercial health | ||||||
12 | maintenance organizations as defined by Section 1-2 of the | ||||||
13 | Health Maintenance Organization Act and shall not include | ||||||
14 | health maintenance organizations which participate solely in | ||||||
15 | government-sponsored programs.
| ||||||
16 | "Managed care entity" means any health maintenance | ||||||
17 | organization or health insurer, as those terms are defined in | ||||||
18 | this Section. | ||||||
19 | "Managed care plan" means any health care plan or health | ||||||
20 | insurance policy, as those terms are defined in this Section, | ||||||
21 | offered, issued, sold, amended, or renewed by a managed care | ||||||
22 | entity.
| ||||||
23 | "Policyholder" means an individual who is enrolled in a | ||||||
24 | health insurance policy or health care plan, is the basis for | ||||||
25 | eligibility for enrollment in the policy or plan, and is | ||||||
26 | responsible for payment to the managed care entity. |
| |||||||
| |||||||
1 | "Preexisting condition exclusion" means "preexisting | ||||||
2 | condition exclusion" as defined in Section 5 of the Illinois | ||||||
3 | Health Insurance Portability and Accountability Act. The term | ||||||
4 | shall include exclusionary riders. | ||||||
5 | "Rating period" means the period for which premium rates | ||||||
6 | established by a managed care entity are in effect and shall be | ||||||
7 | no less than 12 months beginning on the effective date of the | ||||||
8 | policyholder's managed care plan. | ||||||
9 | "Risk adjustment factor" means the percentage adjustment | ||||||
10 | to be applied to the standard risk rate for a particular | ||||||
11 | individual, based upon expected deviations from standard | ||||||
12 | claims due to the health status of the individual. | ||||||
13 | "Risk category" means the following characteristics of an | ||||||
14 | individual: age, geographic region, and family composition of | ||||||
15 | the individual, plus the managed care plan selected by the | ||||||
16 | individual. The following provisions apply to rates: | ||||||
17 | (1) No more than the following age categories may be | ||||||
18 | used in determining premium rates:
under one;
1-18; 19-24; | ||||||
19 | 25-29; 30-34; 35-39; 40-44; 45-49; 50-54; 55-59; 60-64; 65 | ||||||
20 | and over. | ||||||
21 | However, for the 65 and over age category, separate | ||||||
22 | premium rates may be specified depending upon whether | ||||||
23 | coverage under the managed care plan will be primary or | ||||||
24 | secondary to benefits provided by the federal Medicare | ||||||
25 | Program pursuant to Title XVIII of the federal Social | ||||||
26 | Security Act. |
| |||||||
| |||||||
1 | (2) Managed care entities shall determine rates using | ||||||
2 | no more than the following family size categories: | ||||||
3 | (A) Single. | ||||||
4 | (B) More than one child 18 years of age or under | ||||||
5 | and no adults. | ||||||
6 | (C) Married couple or domestic partners. | ||||||
7 | (D) One adult and child. | ||||||
8 | (E) One adult and children. | ||||||
9 | (F) Married couple and child or children, or | ||||||
10 | domestic partners and child or children.
| ||||||
11 | (3) The following provisions shall apply to rates: | ||||||
12 | (A) In determining rates for individuals, a | ||||||
13 | managed care entity that operates statewide shall use | ||||||
14 | no more than 5 geographic regions in the State, | ||||||
15 | according to the following provisions: | ||||||
16 | (i) The area encompassed in a geographic | ||||||
17 | region shall be separate and distinct from areas | ||||||
18 | encompassed in other geographic regions. | ||||||
19 | Geographic regions established pursuant to this | ||||||
20 | Section shall, as a group, cover the entire State. | ||||||
21 | (ii) The rate for each geographic region must | ||||||
22 | be based on the different costs and availability of | ||||||
23 | providing health services in the respective | ||||||
24 | regions. | ||||||
25 | (iii) A rate must not be established for a | ||||||
26 | region smaller than a single county. |
| |||||||
| |||||||
1 | (iv) A proposed region must not appear, in the | ||||||
2 | determination of the Division, to contain | ||||||
3 | configurations designed to avoid, or segregate | ||||||
4 | into a separate region, particular areas within a | ||||||
5 | county. | ||||||
6 | Managed care entities shall be deemed to be | ||||||
7 | operating statewide if their coverage area includes | ||||||
8 | 90% or more of the State's population. | ||||||
9 | (B) The following provisions shall apply to rates | ||||||
10 | for individuals: | ||||||
11 | (i) In determining rates for individuals, a | ||||||
12 | managed care entity that does not operate | ||||||
13 | statewide shall use no more than the number of | ||||||
14 | geographic regions in the State that is determined | ||||||
15 | by the following formula: the population, as | ||||||
16 | determined in the last federal census, of all | ||||||
17 | counties that are included in their entirety in a | ||||||
18 | managed care entity's service area divided by the | ||||||
19 | total population of the State, as determined in the | ||||||
20 | last federal census, multiplied by 5. The | ||||||
21 | resulting number shall be rounded to the nearest | ||||||
22 | whole integer. No managed care entity shall have | ||||||
23 | less than one geographic region. Geographic | ||||||
24 | regions must be determined according to the | ||||||
25 | requirements in sub-items (i) through (iv) of item | ||||||
26 | (3) of this definition of "risk category". |
| |||||||
| |||||||
1 | (ii) If the formula in clause (i) results in a | ||||||
2 | managed care entity that operates in more than one | ||||||
3 | county having only one geographic region, then the | ||||||
4 | formula in clause (i) shall not apply and the | ||||||
5 | managed care entity may have 2 geographic regions, | ||||||
6 | provided that no county is divided into more than | ||||||
7 | one region. | ||||||
8 | Nothing in this Section shall be construed to | ||||||
9 | require a managed care entity to establish a new | ||||||
10 | service area or to offer managed care plans on a | ||||||
11 | statewide basis, outside of the managed care entity's | ||||||
12 | existing service area. | ||||||
13 | (4) A managed care entity may rate all its managed care | ||||||
14 | plans in accordance with expected costs or other market | ||||||
15 | considerations, but the rate for each managed care plan | ||||||
16 | shall be set in relation to all the other managed care | ||||||
17 | plans offered by the managed care entity, as certified by | ||||||
18 | an actuary. | ||||||
19 | (5) Each managed care plan shall be priced as | ||||||
20 | determined by each managed care entity to reflect the | ||||||
21 | difference in benefit variation, or the effectiveness of a | ||||||
22 | provider network, and each managed care entity may adjust | ||||||
23 | the rate for a specific managed care plan for risk | ||||||
24 | selection only to the extent permitted by subsection (d) of | ||||||
25 | Section 5-30 of this Law. | ||||||
26 | "Standard risk rate" means the rate applicable to an |
| |||||||
| |||||||
1 | individual in a particular risk category. | ||||||
2 | "Waiting period" means, with respect to an individual who | ||||||
3 | seeks and obtains coverage under a managed care plan, any | ||||||
4 | period after the date the individual files a substantially | ||||||
5 | complete application for coverage and before the first day of | ||||||
6 | coverage. | ||||||
7 | Section 5-15. Guaranteed issue of all plans in the | ||||||
8 | individual market. | ||||||
9 | (a) A managed care entity shall fairly and affirmatively | ||||||
10 | offer, market, and sell all of its managed care plans that are | ||||||
11 | sold to all individuals in each service area in which the | ||||||
12 | managed care entity provides or arranges for the provision of | ||||||
13 | health care services. | ||||||
14 | (b) A managed care entity may not reject an application | ||||||
15 | from an individual, or his or her dependents, for an individual | ||||||
16 | managed care plan, or refuse to renew an individual managed | ||||||
17 | care plan, if all of the following requirements are met: | ||||||
18 | (1) The individual agrees to make the required premium | ||||||
19 | payments. | ||||||
20 | (2) The individual and his or her dependents who are to | ||||||
21 | be covered by the managed care plan work or reside in the | ||||||
22 | service area in which the managed care entity provides or | ||||||
23 | otherwise arranges for the provision of health care | ||||||
24 | services. | ||||||
25 | (3) The individual provides the information requested |
| |||||||
| |||||||
1 | on the application to determine the appropriate rate.
| ||||||
2 | (c) Notwithstanding subsection (b) of this Section, if an | ||||||
3 | individual, or his or her dependents, applies for a managed | ||||||
4 | care plan in a coverage choice category for which he or she is | ||||||
5 | not eligible pursuant to subsections (h), (i), and (j) of | ||||||
6 | Section 5-20 of this Law, the managed care entity may reject | ||||||
7 | that application, provided that the managed care entity also | ||||||
8 | offers the individual and his or her dependents coverage in the | ||||||
9 | appropriate coverage choice category. | ||||||
10 | (d) Notwithstanding subsection (b) of this Section, a | ||||||
11 | managed care entity is not required to renew an individual | ||||||
12 | health insurance policy if any of the conditions listed in item | ||||||
13 | (B) of Section 50 of the Illinois Health Insurance Portability | ||||||
14 | and Accountability Act are met. | ||||||
15 | (e) Notwithstanding subsection (b) of this Section, a | ||||||
16 | managed care entity is not required to offer an individual | ||||||
17 | managed care plan and may reject an application for an | ||||||
18 | individual managed care plan in the case of any of the | ||||||
19 | following: | ||||||
20 | (1) The individual and dependents who are to be covered | ||||||
21 | by the managed care plan do not work or reside in a managed | ||||||
22 | care entity's approved service area. | ||||||
23 | (2) Within a specific service area or portion of a | ||||||
24 | service area, if a managed care entity reasonably | ||||||
25 | anticipates and demonstrates to the satisfaction of the | ||||||
26 | Division that it will not have sufficient health care |
| |||||||
| |||||||
1 | delivery resources to ensure that health care services will | ||||||
2 | be available and accessible to the eligible individual and | ||||||
3 | dependents of the individual because of its obligations to | ||||||
4 | existing policyholders.
| ||||||
5 | (2.5) A managed care entity that cannot offer a managed | ||||||
6 | care plan to individuals because it is lacking in | ||||||
7 | sufficient health care delivery resources within a service | ||||||
8 | area or a portion of a service area may not offer a managed | ||||||
9 | care plan in the area in which the managed care entity is | ||||||
10 | not offering coverage to individuals until the managed care | ||||||
11 | entity notifies the Division that it has the ability to | ||||||
12 | deliver services to new policyholders, and certifies to the | ||||||
13 | Division that from the date of the notice it will enroll | ||||||
14 | all individuals and groups requesting coverage in that area | ||||||
15 | from the managed care entity. | ||||||
16 | (3) A person who has been a resident of Illinois for 6 | ||||||
17 | months or less, unless one of the following applies: | ||||||
18 | (A) the person is a federally eligible individual | ||||||
19 | as defined by Section 2 of the Comprehensive Health | ||||||
20 | Insurance Plan Act; or | ||||||
21 | (B) the person can demonstrate a minimum of 2 years | ||||||
22 | of prior creditable coverage and providing the person | ||||||
23 | applies for coverage in Illinois within 62 days after | ||||||
24 | termination or cancellation of the prior creditable | ||||||
25 | coverage.
| ||||||
26 | (f) A managed care entity may require an individual to |
| |||||||
| |||||||
1 | provide information on his or her health status or health | ||||||
2 | history, or that of his or her dependents, in the application | ||||||
3 | for enrollment to the extent required to apply the risk | ||||||
4 | adjustment factor permitted pursuant to subsection (d) of | ||||||
5 | Section 5-30 of this Law. The managed care entity shall use the | ||||||
6 | standard individual market health statement developed by the | ||||||
7 | Division pursuant to Section 359a.2 of the Illinois Insurance | ||||||
8 | Code for the purpose of collecting health status or health | ||||||
9 | history information. After the individual managed care plan's | ||||||
10 | effective date of coverage, a managed care entity may request | ||||||
11 | that the policyholder provide information voluntarily on his or | ||||||
12 | her health history or health status, or that of his or her | ||||||
13 | dependents, for purposes of providing care management | ||||||
14 | services, including disease management services. | ||||||
15 | (g) A managed care entity shall not impose any preexisting | ||||||
16 | condition exclusions on any managed care plan issued, amended, | ||||||
17 | or renewed pursuant to this Law, except as provided under | ||||||
18 | subsection (h) of this Section.
| ||||||
19 | (h) The following provisions shall apply concerning | ||||||
20 | preexisting conditions: | ||||||
21 | (1) A managed care entity may impose a preexisting | ||||||
22 | condition exclusion only if: | ||||||
23 | (A) the exclusion relates to a condition, whether | ||||||
24 | physical or mental, regardless of the cause of the | ||||||
25 | condition, for which medical advice, diagnosis, care, | ||||||
26 | or treatment was recommended or received within the |
| |||||||
| |||||||
1 | 6-month period ending on the enrollment date; and | ||||||
2 | (B) the exclusion extends for a period of not more | ||||||
3 | than 12 months after the enrollment date. | ||||||
4 | (2) In determining whether a preexisting condition | ||||||
5 | exclusion applies to a covered individual, the managed care | ||||||
6 | entity shall credit the time the individual was previously | ||||||
7 | covered under creditable coverage, if the previous | ||||||
8 | creditable coverage was continuous to a date not more than | ||||||
9 | 63 days prior to the enrollment date of the new coverage. | ||||||
10 | (3) A managed care entity may not impose any | ||||||
11 | preexisting condition exclusion relating to pregnancy as a | ||||||
12 | preexisting condition. | ||||||
13 | (4) Genetic information shall not be treated as a | ||||||
14 | condition described in paragraph (A) of item (1) of this | ||||||
15 | subsection (h) in the absence of a diagnosis of the | ||||||
16 | condition related to such information. | ||||||
17 | (5) All preexisting condition exclusions must comply | ||||||
18 | with rules relating to crediting previous coverage as | ||||||
19 | promulgated by the Division.
| ||||||
20 | (i) This Law shall not apply to managed care plans for | ||||||
21 | coverage of Medicare services pursuant to contracts with the | ||||||
22 | United States government, a Medicare supplement, medical | ||||||
23 | program contracts with the State Department of Healthcare and | ||||||
24 | Family Services, or long-term care coverage. | ||||||
25 | Section 5-20. Coverage choice categories. |
| |||||||
| |||||||
1 | (a) On or before March 1, 2010, the Division shall, by | ||||||
2 | rule, develop a system to categorize all managed care plans | ||||||
3 | offered and sold to individuals pursuant to this Law into 5 | ||||||
4 | coverage choice categories. These coverage choice categories | ||||||
5 | shall do all of the following: | ||||||
6 | (1) Reflect a reasonable continuum between the | ||||||
7 | coverage choice category with the lowest level of health | ||||||
8 | care benefits and the coverage choice category with the | ||||||
9 | highest level of health care benefits. | ||||||
10 | (2) Permit reasonable benefit variation that will | ||||||
11 | allow for diverse options within each coverage choice | ||||||
12 | category. | ||||||
13 | (3) Be enforced consistently among managed care | ||||||
14 | entities in the same marketplace regardless of licensure. | ||||||
15 | (4) Within each coverage choice category, include one | ||||||
16 | standard managed care plan, which is the managed care plan | ||||||
17 | with the lowest benefit level in that category.
| ||||||
18 | (b) All managed care entities shall submit the filings | ||||||
19 | required pursuant to subsections (d), (e), (f), and (g) of | ||||||
20 | Section 5-35 of this Law no later than September 1, 2010, for | ||||||
21 | all individual managed care plans to be sold on or after June | ||||||
22 | 1, 2011, to comply with this Law, and thereafter any additional | ||||||
23 | managed care plans shall be filed pursuant to subsections (d), | ||||||
24 | (e), (f), and (g) of Section 5-35. The Division shall | ||||||
25 | categorize each managed care plan offered by a managed care | ||||||
26 | entity into the appropriate coverage choice category on or |
| |||||||
| |||||||
1 | before February 28, 2011. | ||||||
2 | (c) To facilitate consumer comparisons, all managed care | ||||||
3 | entities that offer coverage on an individual basis shall offer | ||||||
4 | at least one managed care plan in each coverage choice | ||||||
5 | category, including offering at least one of the standard | ||||||
6 | managed care plans developed pursuant to item (4) of subsection | ||||||
7 | (a) of this Section, but a managed care entity may offer | ||||||
8 | multiple managed care plans in each category. | ||||||
9 | (d) If a managed care entity offers a specific type of | ||||||
10 | managed care plan in one coverage choice category, it must | ||||||
11 | offer that specific type of managed care plan in each coverage | ||||||
12 | choice category. A "type of managed care plan" includes a | ||||||
13 | health maintenance organization model, a preferred provider | ||||||
14 | organization model, an exclusive provider organization model, | ||||||
15 | a traditional indemnity model, and a point of service model. | ||||||
16 | (e) A provider network offered for one managed care plan in | ||||||
17 | one coverage choice category shall be offered for at least one | ||||||
18 | managed care plan in each coverage choice category. | ||||||
19 | (f) A managed care entity shall establish prices for its | ||||||
20 | managed care plans that reflect a reasonable continuum between | ||||||
21 | the managed care plans offered in the coverage choice category | ||||||
22 | with the lowest level of benefits and the managed care plans | ||||||
23 | offered in the coverage choice category with the highest level | ||||||
24 | of benefits. A managed care entity shall not establish a | ||||||
25 | standard risk rate for a managed care plan in a coverage choice | ||||||
26 | category at a lower rate than a managed care plan offered in a |
| |||||||
| |||||||
1 | lower coverage choice category. | ||||||
2 | (g) A managed care entity shall offer coverage for a | ||||||
3 | wellness program in at least one managed care plan in every | ||||||
4 | coverage choice category. The Division shall by rule define | ||||||
5 | "wellness program" for the purposes of this Section.
| ||||||
6 | (h) If an individual disenrolls from a managed care plan or | ||||||
7 | if the individual's managed care plan is canceled pursuant to | ||||||
8 | one of the general exceptions listed in item (B) of Section 50 | ||||||
9 | of the Illinois Health Insurance Portability and | ||||||
10 | Accountability Act prior to the anniversary date of the managed | ||||||
11 | care plan, subsequent enrollment in an individual managed care | ||||||
12 | plan shall be limited to the same coverage choice category the | ||||||
13 | individual was enrolled in prior to disenrollment or | ||||||
14 | cancellation.
| ||||||
15 | (i) The following provisions shall apply: | ||||||
16 | (1) An individual may change to a managed care plan in | ||||||
17 | a different coverage choice category only on the | ||||||
18 | anniversary date of the policyholder or upon a qualifying | ||||||
19 | event. | ||||||
20 | (2) In no case, however, may an individual move up more | ||||||
21 | than one coverage choice category on the anniversary date | ||||||
22 | of the policyholder unless there is also a qualifying | ||||||
23 | event.
| ||||||
24 | (j) For purposes of this Section, a qualifying event occurs | ||||||
25 | upon any of the following: | ||||||
26 | (1) Upon the death of the policyholder, on whose |
| |||||||
| |||||||
1 | coverage an individual was a dependent. | ||||||
2 | (2) Upon marriage of the policyholder or entrance by | ||||||
3 | the policyholder into a domestic partnership.
| ||||||
4 | (3) Upon divorce or legal separation of an individual | ||||||
5 | from the policyholder. | ||||||
6 | (4) Upon loss of dependent status by a dependent | ||||||
7 | enrolled in group health care coverage through a managed | ||||||
8 | care entity.
| ||||||
9 | (5) Upon the birth or adoption of a child. | ||||||
10 | Section 5-25. Policy rescissions. | ||||||
11 | (a) On or after June 1, 2011, a managed care entity shall | ||||||
12 | not rescind the managed care plan of any individual. | ||||||
13 | (b) Nothing in this Law shall limit any other remedies | ||||||
14 | available at law to a health insurer.
| ||||||
15 | Section 5-30. Adjusted community rating for individual | ||||||
16 | market premiums. Premiums for managed care plans offered or | ||||||
17 | delivered by managed care entities on or after the effective | ||||||
18 | date of this Section shall be subject to the following | ||||||
19 | requirements: | ||||||
20 | (1) The premium for a new or existing business shall be | ||||||
21 | the standard risk rate for an individual in a particular | ||||||
22 | risk category. | ||||||
23 | (2) The premium rates charged to a policyholder shall | ||||||
24 | be in effect for no less than 12 months from the date of |
| |||||||
| |||||||
1 | the managed care plan's issuance or renewal. | ||||||
2 | (3) When determining the premium rate for more than one | ||||||
3 | covered individual, the managed care entity shall | ||||||
4 | determine the rate based on the standard risk rate for the | ||||||
5 | policyholder. If more than one individual is a | ||||||
6 | policyholder, the premium rate shall be based on the age of | ||||||
7 | the youngest spouse or domestic partner. | ||||||
8 | (4) The following provisions shall apply: | ||||||
9 | (A) Notwithstanding subsection (a), for the first | ||||||
10 | 2 years following the implementation of this Section, a | ||||||
11 | managed care entity may apply a risk adjustment factor | ||||||
12 | to the standard risk rate that may not be more than | ||||||
13 | 120% or less than 80% of the applicable standard risk | ||||||
14 | rate. In determining the risk adjustment factor, a | ||||||
15 | managed care entity shall use the standard individual | ||||||
16 | market health statement developed pursuant to Section | ||||||
17 | 359a.2 of the Illinois Insurance Code. | ||||||
18 | (B) After the first 2 years following the | ||||||
19 | implementation of this Section, the adjustments | ||||||
20 | applicable under paragraph (A) shall not be more than | ||||||
21 | 110% or less than 90% of the standard risk rate. | ||||||
22 | (C) Upon the renewal of any managed care plan, the | ||||||
23 | risk adjustment factor applied to the individual's | ||||||
24 | rate may not be more than 5 percentage points different | ||||||
25 | than the factor applied to that rate prior to renewal. | ||||||
26 | The same limitation shall be applied to individuals |
| |||||||
| |||||||
1 | with respect to the risk adjustment factor applicable | ||||||
2 | for the purchase of a new managed care plan where the | ||||||
3 | individual's prior managed care entity has | ||||||
4 | discontinued that managed care plan. | ||||||
5 | (D) After the first 4 years following the | ||||||
6 | implementation of this Section, a managed care entity | ||||||
7 | shall base rates on the standard risk rate with no risk | ||||||
8 | adjustment factor. | ||||||
9 | (5) The Division shall establish limits on allowable | ||||||
10 | variation between the standard risk rates for individuals | ||||||
11 | in the age categories established by Section 5-10 of this | ||||||
12 | Law. | ||||||
13 | (6) A discount for wellness activities shall be | ||||||
14 | permitted to reflect actuarially justified differences in | ||||||
15 | utilization or cost attributed to such programs. | ||||||
16 | (7) This Section shall become operative on June 1, | ||||||
17 | 2010.
| ||||||
18 | Section 5-35. Disclosure requirements and filing of rates | ||||||
19 | with the Division. | ||||||
20 | (a) In connection with the offering for sale of any managed | ||||||
21 | care plan to an individual, each managed care entity shall make | ||||||
22 | a reasonable disclosure, as part of its solicitation and sales | ||||||
23 | materials, of all of the following: | ||||||
24 | (1) The provisions concerning the managed care | ||||||
25 | entity's right to change premium rates on an annual basis |
| |||||||
| |||||||
1 | and the factors other than provision of services experience | ||||||
2 | that affect changes in premium rates.
| ||||||
3 | (2) Provisions relating to the guaranteed issue and | ||||||
4 | renewal of individual managed care plans. | ||||||
5 | (3) Provisions relating to the individual's right to | ||||||
6 | obtain any managed care plan the individual is eligible to | ||||||
7 | enroll in pursuant to Sections 5-15 and 5-20 of this Law. | ||||||
8 | (4) The availability, upon request, of a listing of all | ||||||
9 | the individual managed care plans offered by the managed | ||||||
10 | care entity, including the rates for each managed care | ||||||
11 | plan. | ||||||
12 | (b) Every insurance producer contracting with one or more | ||||||
13 | managed care plans to solicit enrollments or subscriptions from | ||||||
14 | individuals shall, before making recommendations on any | ||||||
15 | particular managed care plan, do both of the following: | ||||||
16 | (1) Advise the individual of a managed care entity's | ||||||
17 | obligation to sell to any individual any managed care plan | ||||||
18 | it offers to individuals and provide him or her, upon | ||||||
19 | request, with the actual rates that would be charged to | ||||||
20 | that individual for a given managed care plan.
| ||||||
21 | (2) Notify the individual that the insurance producer | ||||||
22 | will procure rate and benefit information for the | ||||||
23 | individual on any managed care plan offered by a managed | ||||||
24 | care entity whose managed care plan the insurance producer | ||||||
25 | sells.
| ||||||
26 | (c) Prior to filing an application for a particular |
| |||||||
| |||||||
1 | individual managed care plan, the managed care entity shall | ||||||
2 | obtain a signed statement from the individual acknowledging | ||||||
3 | that the individual has received the disclosures required by | ||||||
4 | this Section.
| ||||||
5 | (d) At least 20 business days prior to offering a managed | ||||||
6 | care plan subject to this Law, all managed care entities shall | ||||||
7 | file with the Division a statement certifying that the managed | ||||||
8 | care entity is in compliance with Sections 5-15 and 5-30 of | ||||||
9 | this Law. The certified statement shall set forth the standard | ||||||
10 | risk rate for each risk category that will be used in setting | ||||||
11 | the rates at which the managed care plan will be offered. Any | ||||||
12 | action by the Division to disapprove, suspend, or postpone the | ||||||
13 | managed care entity's use of a managed care plan shall be in | ||||||
14 | writing, specifying the reasons that the managed care plan does | ||||||
15 | not comply with the requirements of this Law. | ||||||
16 | (e) Prior to making any changes in the standard risk rates | ||||||
17 | filed with the Division pursuant to subsection (d) of this | ||||||
18 | Section, the managed care entity shall file as an amendment a | ||||||
19 | statement setting forth the changes and certifying that the | ||||||
20 | managed care entity is in compliance with Sections 5-15 and | ||||||
21 | 5-30 of this Law. If the standard risk rate is being changed, a | ||||||
22 | managed care entity may commence offering managed care plans | ||||||
23 | utilizing the changed standard risk rate upon filing the | ||||||
24 | certified statement, unless the Division disapproves the | ||||||
25 | amendment by written notice. | ||||||
26 | (f) Periodic changes to the standard risk rate that a |
| |||||||
| |||||||
1 | managed care plan proposes to implement over the course of up | ||||||
2 | to 12 consecutive months may be filed in conjunction with the | ||||||
3 | certified statement filed under subsection (d) or (e) of this | ||||||
4 | Section. | ||||||
5 | (g) Each managed care entity shall maintain at its | ||||||
6 | principal place of business all of the information required to | ||||||
7 | be filed with the Division pursuant to this Law. | ||||||
8 | (h) A managed care entity shall include all of the | ||||||
9 | following in the statement filed pursuant to subsection (d):
| ||||||
10 | (1) A summary explanation of the following for each | ||||||
11 | managed care plan offered to individuals: | ||||||
12 | (A) Eligibility requirements.
| ||||||
13 | (B) The full premium cost of each managed care plan | ||||||
14 | in each risk category, as defined in Section 5-10 of | ||||||
15 | this Law. | ||||||
16 | (C) When and under what circumstances benefits | ||||||
17 | cease. | ||||||
18 | (D) Other coverage that may be available if | ||||||
19 | benefits under the described managed care plan cease. | ||||||
20 | (E) The circumstances under which choice in the | ||||||
21 | selection of physicians and providers is permitted. | ||||||
22 | (F) Deductibles. | ||||||
23 | (G) Annual out-of-pocket maximums. | ||||||
24 | (2) A summary explanation of coverage for the | ||||||
25 | following, together with the corresponding copayments, | ||||||
26 | coinsurance, and applicable limitations for each managed |
| |||||||
| |||||||
1 | care plan offered to individuals: | ||||||
2 | (A) Professional services. | ||||||
3 | (B) Outpatient services.
| ||||||
4 | (C) Preventive services. | ||||||
5 | (D) Hospitalization services. | ||||||
6 | (E) Emergency health coverage. | ||||||
7 | (F) Ambulance services. | ||||||
8 | (G) Prescription drug coverage. | ||||||
9 | (H) Durable medical equipment. | ||||||
10 | (I) Mental health and substance abuse services. | ||||||
11 | (J) Home health services.
| ||||||
12 | (3) The telephone number or numbers that may be used by | ||||||
13 | an applicant to access a managed care entity customer | ||||||
14 | service representative to request additional information | ||||||
15 | about the managed care plan. | ||||||
16 | (i) If any information provided pursuant to subsection (h) | ||||||
17 | of this Section changes, the managed care entity shall provide | ||||||
18 | to the Division, on an annual basis, an update of that | ||||||
19 | information. | ||||||
20 | (j) This Section shall become operative on June 1, 2010. | ||||||
21 | Section 5-40. Any contrary provisions. The provisions | ||||||
22 | contained in this Law shall supersede any contrary provisions | ||||||
23 | in the Illinois Insurance Code or in any other insurance law of | ||||||
24 | this State. |
| |||||||
| |||||||
1 | ARTICLE 10. ENSURING ACCOUNTABILITY IN | ||||||
2 | ILLINOIS' INDIVIDUAL AND SMALL | ||||||
3 | GROUP HEALTH INSURANCE MARKETS | ||||||
4 | Section 10-1. Short title. This Law may be cited as the | ||||||
5 | Minimum Medical Loss Ratio Law. | ||||||
6 | Section 10-5. Purpose. The General Assembly recognizes | ||||||
7 | that a significant share of the premium dollars paid by | ||||||
8 | individuals and small employers to health insurers and health | ||||||
9 | maintenance organizations is directed toward administrative | ||||||
10 | and marketing activities and profit. It is the intent of this | ||||||
11 | Law to ensure that premium costs for consumers more accurately | ||||||
12 | reflect the value of health care they receive by increasing the | ||||||
13 | portion of premium dollars dedicated to medical services. | ||||||
14 | Section 10-10. Definitions. In this Law: | ||||||
15 | "Company" means any entity that provides health insurance | ||||||
16 | in this State. For the purposes of this Law, company includes a | ||||||
17 | licensed insurance company, a health maintenance organization, | ||||||
18 | or any other entity providing a plan of health insurance or | ||||||
19 | health benefits subject to State insurance regulation. | ||||||
20 | "Division" means the Division of Insurance within the | ||||||
21 | Illinois Department of Financial and Professional Regulation. | ||||||
22 | "Health benefit plan" means any hospital or medical | ||||||
23 | expense-incurred policy, hospital or medical service plan |
| |||||||
| |||||||
1 | contract, or health maintenance organization subscriber | ||||||
2 | contract. "Health benefit plan" shall not include | ||||||
3 | accident-only, credit, dental, vision, Medicare supplement, | ||||||
4 | hospital indemnity, long term care, specific disease, stop loss | ||||||
5 | or disability income insurance, coverage issued as a supplement | ||||||
6 | to liability insurance, workers' compensation or similar | ||||||
7 | insurance, or automobile medical payment insurance. | ||||||
8 | "Health care benefits" means health care services that are | ||||||
9 | either provided or reimbursed by a managed care entity or its | ||||||
10 | contracted providers as benefits to its policyholders and | ||||||
11 | insurers. Health care benefits shall include: | ||||||
12 | (A) The costs of programs or activities, including | ||||||
13 | training and the provision of informational materials that | ||||||
14 | are determined as part of the regulation to improve the | ||||||
15 | provision of quality care, improve health care outcomes, or | ||||||
16 | encourage the use of evidence-based medicine. | ||||||
17 | (B) Disease management expenses using cost-effective | ||||||
18 | evidence-based guidelines. | ||||||
19 | (C) Plan medical advice by telephone. | ||||||
20 | (D) Payments to providers as risk pool payments of | ||||||
21 | pay-for-performance initiatives. | ||||||
22 | "Health care benefits" shall not include administrative costs | ||||||
23 | as determined by the Division. | ||||||
24 | "Individual market" means the individual market as defined | ||||||
25 | by the Illinois Health Insurance Portability and | ||||||
26 | Accountability Act. |
| |||||||
| |||||||
1 | "Small group market" means "small group market" as defined | ||||||
2 | by the Illinois Health Insurance Portability and | ||||||
3 | Accountability Act. | ||||||
4 | Section 10-15. Minimum medical loss requirement for | ||||||
5 | companies offering coverage in the individual and small group | ||||||
6 | market. | ||||||
7 | (a) Any company selling a health benefit plan in the | ||||||
8 | individual or small group market shall, on and after June 1, | ||||||
9 | 2011, expend in the form of health care benefits no less than | ||||||
10 | 85% of the aggregate dues, fees, premiums, or other periodic | ||||||
11 | payments received by the company. For purposes of this Section, | ||||||
12 | the company may deduct from the aggregate dues, fees, premiums, | ||||||
13 | or other periodic payments received by the company the amount | ||||||
14 | of income taxes or other taxes that the company expensed. | ||||||
15 | (b) To assess compliance with this Section, a company with | ||||||
16 | a valid certificate of authority may average its total costs | ||||||
17 | across all health benefit plans issued, amended, or renewed in | ||||||
18 | Illinois, and all health benefit plans issued, amended, or | ||||||
19 | renewed by its affiliated companies that are licensed to | ||||||
20 | operate in Illinois. | ||||||
21 | (c) The Division shall adopt rules to implement this | ||||||
22 | Section and to establish uniform reporting by companies of the | ||||||
23 | information necessary to determine compliance with this | ||||||
24 | Section. | ||||||
25 | (d) The Division may exclude from the determination of |
| |||||||
| |||||||
1 | compliance with the requirement of subsection (a) of this | ||||||
2 | Section any new health benefit plans for up to the first 2 | ||||||
3 | years that these health benefit plans are offered for sale in | ||||||
4 | Illinois, provided that the Division determines that the new | ||||||
5 | health benefit plans are substantially different from the | ||||||
6 | existing health benefit plans being issued, amended, or renewed | ||||||
7 | by the company seeking the exclusion.
| ||||||
8 | ARTICLE 15. EXPANDING ACCESS TO HEALTH INSURANCE | ||||||
9 | THROUGH THE HEALTH SURE ILLINOIS PROGRAM | ||||||
10 | Section 15-1. Short title. This Article may be cited as the | ||||||
11 | Health Sure Illinois Law. | ||||||
12 | Section 15-5. Purpose. The General Assembly recognizes | ||||||
13 | that individuals and small employers in this State struggle | ||||||
14 | every day to pay the costs of health insurance coverage that | ||||||
15 | allows for the delivery of comprehensive and quality health | ||||||
16 | care services. The General Assembly acknowledges that the high | ||||||
17 | cost of health care for individuals and small groups is driven | ||||||
18 | by unpredictable and high cost medical events. Therefore, the | ||||||
19 | General Assembly, in order to provide Illinoisans greater | ||||||
20 | access to affordable health insurance, seeks to reduce the | ||||||
21 | premium impact of high-cost medical events by enacting this | ||||||
22 | Law. |
| |||||||
| |||||||
1 | Section 15-10. Definitions. In this Law: | ||||||
2 | "Active managed care entity" means any health maintenance | ||||||
3 | organization or insurer, as those terms are defined in this | ||||||
4 | Section, whose gross Illinois premium equals or exceeds 1% of | ||||||
5 | the applicable market share. | ||||||
6 | "Department" means the Department of Healthcare and Family | ||||||
7 | Services. | ||||||
8 | "Division" means the Division of Insurance within the | ||||||
9 | Department of Financial and Professional Regulation. | ||||||
10 | "Employed person" means, for purposes of determining | ||||||
11 | eligibility for Sure Standard individual managed care plans, | ||||||
12 | any person employed on a full-time or part-time basis either | ||||||
13 | currently or within the past 12 months for which monetary | ||||||
14 | compensation was received. | ||||||
15 | "Federal poverty level" means the federal poverty level | ||||||
16 | income guidelines updated periodically in the Federal Register | ||||||
17 | by the U.S. Department of Health and Human Services under the | ||||||
18 | authority of 42 U.S.C. 9902 (2). | ||||||
19 | "Full-time employee" means a full-time employee as defined | ||||||
20 | by Section 5-5 of the Economic Development for a Growing | ||||||
21 | Economy Tax Credit Act. | ||||||
22 | "Health care plan" means a health care plan as defined by | ||||||
23 | Section 1-2 of the Health Maintenance Organization Act. | ||||||
24 | "Health maintenance organization" means commercial health | ||||||
25 | maintenance organizations as defined by Section 1-2 of the | ||||||
26 | Health Maintenance Organization Act and shall not include |
| |||||||
| |||||||
1 | health maintenance organizations that participate solely in | ||||||
2 | government-sponsored programs. | ||||||
3 | "Health Sure Illinois" means the program established under | ||||||
4 | this Law. | ||||||
5 | "Individual market" means the individual market as defined | ||||||
6 | by the Illinois Health Insurance Portability and | ||||||
7 | Accountability Act. | ||||||
8 | "Insurer" means any insurance company authorized to sell | ||||||
9 | group or individual policies of hospital, surgical, or major | ||||||
10 | medical insurance coverage, or any combination thereof, that | ||||||
11 | contains agreements or arrangements with providers relating to | ||||||
12 | health care services that may be rendered to beneficiaries as | ||||||
13 | defined by the Health Care Reimbursement Reform Act of 1985 in | ||||||
14 | Sections 370f and following of the Illinois Insurance Code and | ||||||
15 | its accompanying rule, 50 Illinois Administrative Code 2051. | ||||||
16 | The term "insurer" does not include insurers that sell only | ||||||
17 | policies of hospital indemnity, accidental death and | ||||||
18 | dismemberment, workers' compensation, credit accident and | ||||||
19 | health, short-term accident and health, accident only, long | ||||||
20 | term care, Medicare supplement, student blanket, stand-alone | ||||||
21 | policies, dental, vision care, prescription drug benefits, | ||||||
22 | disability income, specified disease, or similar supplementary | ||||||
23 | benefits. | ||||||
24 | "Small employer" means "small employer" as defined by the | ||||||
25 | Illinois Health Insurance Portability and Accountability Act. | ||||||
26 | "Small group market" means "small group market" as defined |
| |||||||
| |||||||
1 | by the Illinois Health Insurance Portability and | ||||||
2 | Accountability Act. | ||||||
3 | "Sure Standard group managed care plan" means any group | ||||||
4 | plan offered pursuant to Section 15-15 of this Law. | ||||||
5 | "Sure Standard individual managed care plan" means any | ||||||
6 | individual plan offered pursuant to Section 15-15 of this Law. | ||||||
7 | "Veteran" means "veteran" as defined by Section 5 of the | ||||||
8 | Veterans' Health Insurance Program Act. | ||||||
9 | Section 15-15. Sure Standard managed care plans for | ||||||
10 | eligible small employers and individuals. | ||||||
11 | (a) The State hereby establishes a program for the purpose | ||||||
12 | of making managed care plans affordable and accessible to small | ||||||
13 | employers and individuals as defined in this Section. The | ||||||
14 | program is designed to encourage small employers to offer | ||||||
15 | affordable health insurance to employees and to make affordable | ||||||
16 | health insurance available to eligible Illinoisans, including | ||||||
17 | small business employees, veterans, and individuals whose | ||||||
18 | employers do not offer or sponsor group health insurance. | ||||||
19 | (b) Participation in this program is limited to active | ||||||
20 | managed care entities as defined by Section 15-10 of this Law. | ||||||
21 | Participation by all active managed care entities is mandatory. | ||||||
22 | On January 1, 2010, or as soon as practicable as determined by | ||||||
23 | the Department, all active managed care entities offering | ||||||
24 | health insurance coverage or a health care plan in the small | ||||||
25 | group market shall offer one or more Sure Standard group |
| |||||||
| |||||||
1 | managed care plans to qualifying small employers as defined in | ||||||
2 | subsection (c) of this Section. All active managed care | ||||||
3 | entities offering health insurance coverage or a health care | ||||||
4 | plan in the individual market shall offer one or more Sure | ||||||
5 | Standard individual managed care plans. For purposes of this | ||||||
6 | Section and Section 15-20 of this Law, all active managed care | ||||||
7 | entities that comply with the program requirements shall be | ||||||
8 | eligible for reimbursement from the Health Sure Illinois stop | ||||||
9 | loss funds made available pursuant to Section 15-20 of this | ||||||
10 | Law. | ||||||
11 | (c) For purposes of this Law, a qualifying small employer | ||||||
12 | is a small employer that:
| ||||||
13 | (1) employs not more than 50 eligible employees; | ||||||
14 | (2) does not sponsor group health insurance and has not | ||||||
15 | sponsored group health insurance with benefits on an | ||||||
16 | expense-reimbursed or prepaid basis covering employees in | ||||||
17 | effect during the 12-month period prior to the small | ||||||
18 | employer's application for group health insurance under | ||||||
19 | the program established by this Section; | ||||||
20 | (3) contributes towards the Sure Standard group | ||||||
21 | managed care plan at least 50% of an individual employee's | ||||||
22 | premium; | ||||||
23 | (4) has at least 30% of its eligible employees | ||||||
24 | receiving annual wages from the employer at a level equal | ||||||
25 | to or less than $34,000; this dollar figure shall be | ||||||
26 | adjusted periodically pursuant to subsection (g) of this |
| |||||||
| |||||||
1 | Section; and | ||||||
2 | (5) uses Illinois as its principal place of business, | ||||||
3 | management, and administration.
| ||||||
4 | For purposes of this Section, "eligible employee" shall | ||||||
5 | include any individual who receives compensation from the | ||||||
6 | qualifying employer for at least 20 hours of work per week. | ||||||
7 | (c-5) The employer premium contribution must be the same | ||||||
8 | percentage for all covered employees and may not vary based on | ||||||
9 | class of employee. | ||||||
10 | (c-10) The Division shall by rule define "health insurance" | ||||||
11 | for the purposes of this Section. | ||||||
12 | (d) For purposes of this Section, a self-employed | ||||||
13 | individual shall be considered a qualifying employer only if | ||||||
14 | the self-employed individual: | ||||||
15 | (1) does not have and has not had health insurance with | ||||||
16 | benefits on an expense-reimbursed or prepaid basis during | ||||||
17 | the 12-month period prior to the individual's application | ||||||
18 | for health insurance under the program established by this | ||||||
19 | Law; | ||||||
20 | (2) resides in a household having a household income at | ||||||
21 | or below 250% of the federal poverty level; | ||||||
22 | (3) is ineligible for Medicare, except that the | ||||||
23 | Department may determine that it shall require an | ||||||
24 | individual who is eligible under subdivision 2(b) of | ||||||
25 | Section 5-2 of the Illinois Public Aid Code to participate | ||||||
26 | as a qualifying individual; and |
| |||||||
| |||||||
1 | (4) is a resident of Illinois. | ||||||
2 | However, the requirements set forth in item (1) of this | ||||||
3 | subsection (d) shall not be applicable where a self-employed | ||||||
4 | individual had health insurance coverage during the previous 12 | ||||||
5 | months and such coverage terminated due to one of the reasons | ||||||
6 | set forth in items (1) through (8) of subsection (m) of this | ||||||
7 | Section.
| ||||||
8 | (e) A small employer or self-employed individual shall | ||||||
9 | cease to be a qualifying small employer if any health insurance | ||||||
10 | that provides benefits on an expense reimbursed or prepaid | ||||||
11 | basis covering the self-employed individual or an employer's | ||||||
12 | employees, other than a Sure Standard group managed care plan | ||||||
13 | purchased pursuant to this Section, is purchased or otherwise | ||||||
14 | takes effect subsequent to purchase of a Sure Standard group | ||||||
15 | managed care plan under the program established by this | ||||||
16 | Section. | ||||||
17 | (f) An active managed care entity may enter into an | ||||||
18 | agreement with an employer to offer a Sure Standard managed | ||||||
19 | care plan pursuant to this Section only if that employer offers | ||||||
20 | that plan to all eligible employees. | ||||||
21 | (g) The wage levels utilized in item (4) of subsection (c) | ||||||
22 | of this Section shall be adjusted annually, beginning in 2011. | ||||||
23 | The adjustment shall take effect on July 1st of each year. For | ||||||
24 | July 1, 2011, the adjustment shall be a percentage of the | ||||||
25 | annual wage figure specified in item (4) of subsection (c). For | ||||||
26 | subsequent years, the adjustment shall be a percentage of the |
| |||||||
| |||||||
1 | annual wage figure that took effect on July 1st of the prior | ||||||
2 | year. The percentage adjustment shall be the same percentage by | ||||||
3 | which the current year's non-farm federal poverty level, as | ||||||
4 | defined and updated by the federal Department of Health and | ||||||
5 | Human Services, for a family unit of 4 persons for the 48 | ||||||
6 | contiguous states and Washington, D.C., changed from the same | ||||||
7 | level established for the prior year. | ||||||
8 | (h) Illinois-based chambers of commerce or other | ||||||
9 | associations, including bona fide associations as defined by | ||||||
10 | the Illinois Health Insurance Portability and Accountability | ||||||
11 | Act, may be eligible to participate in the Health Sure Illinois | ||||||
12 | Program subject to approval by the Division. | ||||||
13 | (i) A qualifying small employer shall elect whether to make | ||||||
14 | coverage under the Sure Standard group managed care plan | ||||||
15 | available to dependents of employees. Any employee or dependent | ||||||
16 | who is enrolled in Medicare is ineligible for coverage, unless | ||||||
17 | required by federal law. Dependents of an employee who is | ||||||
18 | enrolled in Medicare shall be eligible for dependent coverage | ||||||
19 | provided the dependent is not also enrolled in Medicare.
| ||||||
20 | (j) A Sure Standard group managed care plan must provide | ||||||
21 | the benefits set forth in subsection (q) of this Section. The | ||||||
22 | contract must insure not less than 50% of the eligible | ||||||
23 | employees. | ||||||
24 | (k) For purposes of this Law, a qualifying individual is an | ||||||
25 | employed individual:
| ||||||
26 | (1) who does not have and has not had health insurance |
| |||||||
| |||||||
1 | with benefits on an expense-reimbursed or prepaid basis | ||||||
2 | during the 12-month period prior to the individual's | ||||||
3 | application for health insurance under the program | ||||||
4 | established by this Section; | ||||||
5 | (2) who is not an eligible employee as defined in | ||||||
6 | subsection (c) of this Section, or whose employer does not | ||||||
7 | sponsor group health insurance and has not sponsored group | ||||||
8 | health insurance with benefits on an expense-reimbursed or | ||||||
9 | prepaid basis in effect during the 12-month period prior to | ||||||
10 | the individual's application for health insurance under | ||||||
11 | the program established by this Section; | ||||||
12 | (3) who resides in a household having a household | ||||||
13 | income at or below 250% of the federal poverty level; | ||||||
14 | (4) who is ineligible for Medicare, except that the | ||||||
15 | Department may determine that it shall require an | ||||||
16 | individual who is eligible under subdivision 2(b) of | ||||||
17 | Section 5-2 of the Illinois Public Aid Code to participate | ||||||
18 | as a qualifying individual; and | ||||||
19 | (5) who is a resident of Illinois. | ||||||
20 | (l) The requirements set forth in item (3) of subsection | ||||||
21 | (k) of this Section shall not be applicable to individuals who | ||||||
22 | have served as a member of the active or reserve components of | ||||||
23 | any of the branches of the Armed Forces of the United States, | ||||||
24 | and have received a release or discharge other than | ||||||
25 | dishonorable discharge. | ||||||
26 | (m) The requirements set forth in items (1) and (3) of |
| |||||||
| |||||||
1 | subsection (k) of this Section shall not be applicable to | ||||||
2 | individuals who had health insurance coverage during the | ||||||
3 | previous 12 months and such coverage terminated due to:
| ||||||
4 | (1) loss of employment due to factors other than | ||||||
5 | voluntary separation; | ||||||
6 | (2) death of a family member that results in | ||||||
7 | termination of coverage under a health insurance contract | ||||||
8 | under which the individual is covered; | ||||||
9 | (3) change to a new employer that does not provide | ||||||
10 | group health insurance with benefits on an | ||||||
11 | expense-reimbursed or prepaid basis; | ||||||
12 | (4) change of residence so that no employer-based | ||||||
13 | health insurance with benefits on an expense-reimbursed or | ||||||
14 | prepaid basis is available; | ||||||
15 | (5) discontinuation of a group health insurance | ||||||
16 | contract with benefits on an expense-reimbursed or prepaid | ||||||
17 | basis covering the qualifying individual as an employee or | ||||||
18 | dependent; | ||||||
19 | (6) expiration of the coverage periods established by | ||||||
20 | the continuation provisions of the Employee Retirement | ||||||
21 | Income Security Act, 29 U.S.C. Section 1161 et seq. and the | ||||||
22 | Public Health Service Act, 42 U.S.C. Section 300bb-1 et | ||||||
23 | seq. established by the Consolidated Omnibus Budget | ||||||
24 | Reconciliation Act of 1985, as amended, or the continuation | ||||||
25 | provisions of Sections 367.2, 367.2-5, or 367e of the | ||||||
26 | Illinois Insurance Code.
|
| |||||||
| |||||||
1 | (7) legal separation, dissolution of marriage or | ||||||
2 | domestic partnership, or declaration of invalidity of | ||||||
3 | marriage or domestic partnership that results in | ||||||
4 | termination of coverage under a health insurance contract | ||||||
5 | under which the individual is covered; or | ||||||
6 | (8) loss of eligibility under a group health plan.
| ||||||
7 | (n) The 12-month period set forth in item (1) of subsection | ||||||
8 | (k), item (2) of subsection (c), and item (1) of subsection (d) | ||||||
9 | of this Section may be adjusted by the Division from 12 months | ||||||
10 | to 18 months if the Division determines that the 12-month | ||||||
11 | period is insufficient to prevent inappropriate substitution | ||||||
12 | of Sure Standard individual and group managed care plans for | ||||||
13 | other health insurance contracts. | ||||||
14 | (o) A Sure Standard individual managed care plan must | ||||||
15 | provide the benefits set forth in subsection (q) of this | ||||||
16 | Section. At the option of the qualifying individual, such | ||||||
17 | contract may include coverage for dependents of the qualifying | ||||||
18 | individual. | ||||||
19 | (p) The contracts issued pursuant to this Section by | ||||||
20 | participating managed care entities and approved by the | ||||||
21 | Department shall provide only in-plan benefits, except for | ||||||
22 | emergency care or where services are not available through a | ||||||
23 | plan provider. | ||||||
24 | (q) Covered services shall include only the following:
| ||||||
25 | (1) inpatient hospital services consisting of daily | ||||||
26 | room and board, general nursing care, special diets, and |
| |||||||
| |||||||
1 | miscellaneous hospital services and supplies; | ||||||
2 | (2) outpatient hospital services consisting of | ||||||
3 | diagnostic and treatment services; | ||||||
4 | (3) physician services consisting of diagnostic and | ||||||
5 | treatment services, consultant and referral services, | ||||||
6 | surgical services, including breast reconstruction surgery | ||||||
7 | after a mastectomy, anesthesia services, second surgical | ||||||
8 | opinion, and a second opinion for cancer treatment; | ||||||
9 | (4) outpatient surgical facility charges related to a | ||||||
10 | covered surgical procedure; | ||||||
11 | (5) preadmission testing; | ||||||
12 | (6) maternity care; | ||||||
13 | (7) adult preventive health services consisting of | ||||||
14 | mammography screening; cervical cytology screening; | ||||||
15 | periodic physical examinations no more than once every 3 | ||||||
16 | years; and adult immunizations; | ||||||
17 | (8) preventive and primary health care services for | ||||||
18 | dependent children including routine well-child visits and | ||||||
19 | necessary immunizations; | ||||||
20 | (9) equipment, supplies, and self-management education | ||||||
21 | for the treatment of diabetes; | ||||||
22 | (10) diagnostic x-ray and laboratory services; | ||||||
23 | (11) emergency services; | ||||||
24 | (12) therapeutic services consisting of radiologic | ||||||
25 | services, chemotherapy, and hemodialysis; | ||||||
26 | (13) blood and blood products furnished in connection |
| |||||||
| |||||||
1 | with surgery or inpatient hospital services; | ||||||
2 | (14) prescription drugs obtained at a participating | ||||||
3 | pharmacy. In addition to providing coverage at a | ||||||
4 | participating pharmacy, managed care entities may utilize | ||||||
5 | a mail order prescription drug program. Managed care | ||||||
6 | entities may provide prescription drugs pursuant to a drug | ||||||
7 | formulary; however, managed care entities must implement | ||||||
8 | an appeals process so that the use of non-formulary | ||||||
9 | prescription drugs may be requested by a physician; | ||||||
10 | (15) mental health benefits in accordance with item (2) | ||||||
11 | of subdivision (c) of Section 370c of the Illinois | ||||||
12 | Insurance Code; and | ||||||
13 | (16) inpatient and outpatient services for the | ||||||
14 | treatment of alcohol and substance abuse, including | ||||||
15 | inpatient residential treatment. | ||||||
16 | Active managed care entities may offer dental and vision | ||||||
17 | coverage at the option and expense of the eligible individual. | ||||||
18 | (r) The benefits described in subsection (q) of this | ||||||
19 | Section shall be subject to the following deductibles and | ||||||
20 | copayments: | ||||||
21 | (1) in-patient hospital services shall have a $500 | ||||||
22 | copayment for each continuous hospital confinement as | ||||||
23 | defined in Part 2007 of Title 50 of the Illinois | ||||||
24 | Administrative Code; | ||||||
25 | (2) surgical services shall be subject to a copayment | ||||||
26 | of the lesser of 20% of the cost of such services or $200 |
| |||||||
| |||||||
1 | per occurrence; | ||||||
2 | (3) outpatient surgical facility charges shall be | ||||||
3 | subject to a facility copayment charge of $75 per | ||||||
4 | occurrence; | ||||||
5 | (4) emergency services shall have a $50 copayment, | ||||||
6 | which must be waived if hospital admission results from the | ||||||
7 | emergency room visit; | ||||||
8 | (5) prescription drugs shall have a $100 calendar year | ||||||
9 | deductible per individual; after the deductible is | ||||||
10 | satisfied, each 34-day supply of a prescription drug shall | ||||||
11 | be subject to a copayment; the copayment shall be $10 if | ||||||
12 | the drug is generic. The copayment for a brand name drug | ||||||
13 | shall be $20 plus the difference in cost between the brand | ||||||
14 | name drug and the equivalent generic drug. If a mail order | ||||||
15 | drug program is utilized, a $20 copayment shall be imposed | ||||||
16 | on a 90-day supply of generic prescription drugs. A $40 | ||||||
17 | copayment plus the difference in cost between the brand | ||||||
18 | name drug and the equivalent generic drug shall be imposed | ||||||
19 | on a 90-day supply of brand name prescription drugs; in no | ||||||
20 | event shall the copayment exceed the cost of the prescribed | ||||||
21 | drug; | ||||||
22 | (6) the maximum coverage for prescription drugs shall | ||||||
23 | be $3,000 per individual in a calendar year; and | ||||||
24 | (7) all other services shall have a $20 copayment with | ||||||
25 | the exception of prenatal care, which shall have no | ||||||
26 | copayment.
|
| |||||||
| |||||||
1 | (s) The Department may determine rates for providers of | ||||||
2 | services, but such rates shall in aggregate be no lower than | ||||||
3 | base Medicare. Hospitals shall be reimbursed under the Health | ||||||
4 | Sure Illinois Program in an amount that equals the actuarial | ||||||
5 | equivalent of 105% of base Medicare for critical access | ||||||
6 | hospitals and equals the actuarial equivalent of 112% of base | ||||||
7 | Medicare for all other hospitals. The Department shall define | ||||||
8 | what constitutes "base Medicare" by rule, which shall include | ||||||
9 | the weighting factors used by Medicare, the wage index | ||||||
10 | adjustment, capital costs, and outlier adjustments. For | ||||||
11 | hospital services provided for which a Medicare rate is not | ||||||
12 | prescribed or cannot be calculated, the hospital shall be | ||||||
13 | reimbursed 90% of the lowest rate paid by the applicable | ||||||
14 | insurer under its contract with that hospital for that same | ||||||
15 | service. The Department may by rule heighten the 112% rate | ||||||
16 | ceiling for hospitals engaged in medical research, medical | ||||||
17 | education, and highly complex medical care and for hospitals | ||||||
18 | that serve a disproportionate share of patients covered by | ||||||
19 | governmental sponsored programs and uninsured patients. | ||||||
20 | (s-5) Nothing in this Law shall be used by any private or | ||||||
21 | public managed care entity or health care plan as a basis for | ||||||
22 | reducing the managed care entity's or health care plan's rates | ||||||
23 | or policies with any hospital. Notwithstanding any other | ||||||
24 | provision of law, rates authorized under this Law shall not be | ||||||
25 | used by any private or public managed care entities or health | ||||||
26 | care plans to determine a hospital's usual and customary |
| |||||||
| |||||||
1 | charges for any health care service. | ||||||
2 | (t) Except as included in the list of covered services in | ||||||
3 | subsection (q) of this Section, the mandated benefits set forth | ||||||
4 | in the Illinois Insurance Code and the Managed Care Reform and | ||||||
5 | Patients Rights Act shall not be applicable to the contracts | ||||||
6 | issued pursuant to this Section. Mandated benefits included in | ||||||
7 | such contracts shall be subject to the deductibles and | ||||||
8 | copayments set forth in subsection (r) of this Section. | ||||||
9 | (u) The Division shall be authorized to modify, by rule, | ||||||
10 | the copayment and deductible amounts described in this Section | ||||||
11 | if the Division determines such amendments are necessary to | ||||||
12 | facilitate implementation of this Section. The modifications | ||||||
13 | authorized by this subsection (u) shall not exceed 20% of the | ||||||
14 | original copayment or deductible amounts. On or after January | ||||||
15 | 1, 2011, the Division shall be authorized to establish, by | ||||||
16 | regulation, one or more additional standardized benefit | ||||||
17 | packages if the Division determines additional benefit | ||||||
18 | packages with different levels of benefits are necessary to | ||||||
19 | meet the needs of the public. | ||||||
20 | (v) An active managed care entity must offer the benefit | ||||||
21 | package without change or additional benefits. Qualifying | ||||||
22 | small employers shall be issued the benefit package in a Sure | ||||||
23 | Standard group managed care plan. Qualifying individuals shall | ||||||
24 | be issued the benefit package in a Sure Standard individual | ||||||
25 | managed care plan. | ||||||
26 | (w) No active managed care entity shall issue a Sure |
| |||||||
| |||||||
1 | Standard group managed care plan or Sure Standard individual | ||||||
2 | managed care plan until the plan has been certified as such by | ||||||
3 | the Department. | ||||||
4 | (x) A participating managed care entity shall obtain from | ||||||
5 | the employer or individual, on forms approved by the Department | ||||||
6 | or in a manner prescribed by the Department, written | ||||||
7 | certification at the time of initial application and annually | ||||||
8 | thereafter 90 days prior to the contract renewal date that the | ||||||
9 | employer or individual meets and expects to continue to meet | ||||||
10 | the requirements of a qualifying small employer or a qualifying | ||||||
11 | individual pursuant to this Section. A participating managed | ||||||
12 | care entity may require the submission of appropriate | ||||||
13 | documentation in support of the certification, including proof | ||||||
14 | of income status. | ||||||
15 | (y) Applications to enroll in Sure Standard group managed | ||||||
16 | care plans and Sure Standard individual managed care plans must | ||||||
17 | be received and processed from any qualifying individual and | ||||||
18 | any qualifying small employer during the open enrollment period | ||||||
19 | each year. This subsection (y) does not restrict open | ||||||
20 | enrollment guidelines set by Sure Standard managed care plan | ||||||
21 | contracts, but every such contract must include standard | ||||||
22 | employer group open enrollment guidelines. | ||||||
23 | (z) All coverage under Sure Standard group managed care | ||||||
24 | plans and Sure Standard individual managed care plans must be | ||||||
25 | subject to a preexisting condition limitation provision, | ||||||
26 | including the crediting requirements thereunder. Prenatal care |
| |||||||
| |||||||
1 | shall be available without consideration of pregnancy as a | ||||||
2 | preexisting condition. An active managed care entity may waive | ||||||
3 | or reduce deductibles and other cost-sharing payments for | ||||||
4 | individuals participating in chronic care management or | ||||||
5 | wellness and prevention programs.
| ||||||
6 | (aa) Premium rates for qualifying individuals under Sure | ||||||
7 | Standard individual managed care plans shall be determined | ||||||
8 | consistent with the rate-setting provisions in the Individual | ||||||
9 | Market Fairness Reform Act. Premium rates for qualifying groups | ||||||
10 | under Sure Standard group managed care plans shall be | ||||||
11 | determined consistent with the rate-setting provisions in the | ||||||
12 | Small Employer Health Insurance Rating Act. | ||||||
13 | (aa-5) Claims experience under contracts issued to | ||||||
14 | qualifying small employers and to qualifying individuals must | ||||||
15 | be combined for rate setting purposes. | ||||||
16 | (bb) Participating managed care entities shall submit | ||||||
17 | reports to the Department in such form and such media as the | ||||||
18 | Department shall prescribe. The reports shall be submitted at | ||||||
19 | times as may be reasonably required by the Department to | ||||||
20 | evaluate the operations and results of Sure Standard managed | ||||||
21 | care plans established by this Section. The Department shall | ||||||
22 | make such reports available to the Division. | ||||||
23 | (cc) All providers that contract with an active managed | ||||||
24 | care entity for any other network established by that active | ||||||
25 | managed care entity, as defined by this Law, must participate | ||||||
26 | as a network provider under the same active managed care |
| |||||||
| |||||||
1 | entity's Sure Standard managed care plan or plans under this | ||||||
2 | Law. | ||||||
3 | (dd) The Department shall conduct public education and | ||||||
4 | outreach to facilitate enrollment of qualifying small | ||||||
5 | employers, eligible employees, and qualifying individuals in | ||||||
6 | the Health Sure Illinois Program. | ||||||
7 | Section 15-20. Stop loss funding for Sure Standard managed | ||||||
8 | care plans issued to qualifying small employers and qualifying | ||||||
9 | individuals. | ||||||
10 | (a) The Department shall provide a claims reimbursement | ||||||
11 | program for participating managed care entities. | ||||||
12 | (b) The claims reimbursement program, also known as "Health | ||||||
13 | Sure Illinois Stop Loss Protection", shall operate as a stop | ||||||
14 | loss program for participating managed care entities and shall | ||||||
15 | reimburse participating managed care entities for a certain | ||||||
16 | percentage of health care claims above a certain attachment | ||||||
17 | amount or within certain attachment amounts. The stop loss | ||||||
18 | attachment amount or amounts shall be determined by the | ||||||
19 | Division consistent with the purpose of the Health Sure | ||||||
20 | Illinois Program. | ||||||
21 | (c) Commencing on January 1, 2010, participating managed | ||||||
22 | care entities shall be eligible to receive reimbursement for | ||||||
23 | 90% of claims paid between $5,000 and $75,000 in a calendar | ||||||
24 | year for any member covered under a contract issued pursuant to | ||||||
25 | Section 15-15 of this Law after the participating managed care |
| |||||||
| |||||||
1 | entity pays claims for that same member in the same calendar | ||||||
2 | year. Based on pre-determined attachment amounts, verified | ||||||
3 | claims paid for members covered under Sure Standard group and | ||||||
4 | individual managed care plans shall be reimbursable from the | ||||||
5 | Health Sure Illinois Stop Loss Protection Program. For purposes | ||||||
6 | of this Section, claims shall include health care claims paid | ||||||
7 | by or on behalf of a covered member pursuant to such Sure | ||||||
8 | Standard contracts. | ||||||
9 | (d) The Department shall set forth procedures for operation | ||||||
10 | of the Health Sure Illinois Stop Loss Protection Program and | ||||||
11 | distribution of monies therefrom. | ||||||
12 | (e) Claims shall be reported and funds shall be distributed | ||||||
13 | by the Department on a calendar year basis. Claims shall be | ||||||
14 | eligible for reimbursement only for the calendar year in which | ||||||
15 | the claims are paid. Once claims paid on behalf of a covered | ||||||
16 | member reach or exceed $75,000 in a given calendar year, no | ||||||
17 | further claims paid on behalf of such member in that calendar | ||||||
18 | year shall be eligible for reimbursement. | ||||||
19 | (f) Each participating managed care entity shall submit a | ||||||
20 | request for reimbursement from the Health Sure Illinois Stop | ||||||
21 | Loss Protection Program on forms prescribed by the Department. | ||||||
22 | Each request for reimbursement shall be submitted no later than | ||||||
23 | April 1 following the end of the calendar year for which the | ||||||
24 | reimbursement requests are being made. In connection with | ||||||
25 | reimbursement requests, the Department may require | ||||||
26 | participating managed care entities to submit such claims data |
| |||||||
| |||||||
1 | deemed necessary to enable proper distribution of funds and to | ||||||
2 | oversee the effective operation of the Health Sure Illinois | ||||||
3 | Stop Loss Protection Program. The Department may require that | ||||||
4 | such data be submitted on a per-member, aggregate, or | ||||||
5 | categorical basis, or any combination of those. Data shall be | ||||||
6 | reported separately for Sure Standard group managed care plans | ||||||
7 | and Sure Standard individual managed care plans issued pursuant | ||||||
8 | to Section 15-15 of this Law.
| ||||||
9 | (f-5) In each request for reimbursement from the Health | ||||||
10 | Sure Illinois Stop Loss Protection Program, active managed care | ||||||
11 | entities shall certify that provider reimbursement rates are | ||||||
12 | consistent with the reimbursement rates as defined by | ||||||
13 | subsection (s) of Section 15-15 of this Law. The Department, in | ||||||
14 | collaboration with the Division, shall audit, as necessary, | ||||||
15 | claims data submitted pursuant to subsection (f) of this | ||||||
16 | Section to ensure that reimbursement rates paid by active | ||||||
17 | managed care entities are consistent with reimbursement rates | ||||||
18 | as defined by subsection (s) of Section 15-15 of this Law. | ||||||
19 | (g) At all times, the Health Sure Illinois Stop Loss | ||||||
20 | Protection Program shall be implemented and operated subject to | ||||||
21 | limitations made necessary by the funds available for its | ||||||
22 | operation. The Department shall calculate the total claims | ||||||
23 | reimbursement amount for all participating managed care | ||||||
24 | entities for the calendar year for which claims are being | ||||||
25 | reported. In the event that the total amount requested for | ||||||
26 | reimbursement for a calendar year exceeds appropriations |
| |||||||
| |||||||
1 | available for distribution for claims paid during that same | ||||||
2 | calendar year, the Department shall provide for the pro-rata | ||||||
3 | distribution of the available funds. Each participating | ||||||
4 | managed care entity shall be eligible to receive only such | ||||||
5 | proportionate amount of the available appropriations as the | ||||||
6 | individual participating managed care entity's total eligible | ||||||
7 | claims paid bears to the total eligible claims paid by all | ||||||
8 | participating managed care entities. | ||||||
9 | (h) Each participating managed care entity shall provide | ||||||
10 | the Department with monthly reports of the total enrollment | ||||||
11 | under the Sure Standard group managed care plans and Sure | ||||||
12 | Standard individual managed care plans issued pursuant to | ||||||
13 | Section 15-15 of this Law. The reports shall be in a form | ||||||
14 | prescribed by the Department. | ||||||
15 | (i) The Department shall estimate the per member annual | ||||||
16 | cost of total claims reimbursement from the Health Sure | ||||||
17 | Illinois Stop Loss Protection Program based upon available data | ||||||
18 | and appropriate actuarial assumptions. Upon request, each | ||||||
19 | participating managed care entity shall furnish to the | ||||||
20 | Department claims experience data for use in such estimations. | ||||||
21 | (j) Every participating managed care entity shall file with | ||||||
22 | the Division the base rates and rating schedules it uses to | ||||||
23 | provide Sure Standard group managed care plans and Sure | ||||||
24 | Standard individual managed care plans. All rates proposed for | ||||||
25 | Sure Standard managed care plans are subject to the prior | ||||||
26 | regulatory review of the Division and shall be effective only |
| |||||||
| |||||||
1 | upon approval by the Division. The Division has authority to | ||||||
2 | approve, reject, or modify the proposed base rate subject to | ||||||
3 | the following:
| ||||||
4 | (1) Rates for suitable managed care plans must account | ||||||
5 | for the availability of reimbursement pursuant to this | ||||||
6 | Section. | ||||||
7 | (2) Rates must not be excessive or inadequate nor shall | ||||||
8 | the rates be unfairly discriminatory. | ||||||
9 | (3) Consideration shall be given to the managed care | ||||||
10 | entity's actuarial support, enrollment levels, premium | ||||||
11 | volume and risk-based capital. | ||||||
12 | (k) If the Department deems it appropriate for the proper | ||||||
13 | administration of the program, the Department shall be | ||||||
14 | authorized to purchase stop loss insurance or reinsurance, or | ||||||
15 | both, from an insurance company licensed to write such type of | ||||||
16 | insurance in Illinois. | ||||||
17 | (k-5) Nothing in this Section shall require modification of | ||||||
18 | stop loss provisions of an existing contract between the | ||||||
19 | managed care entity and a healthcare provider. | ||||||
20 | (l) The Department may obtain the services of an | ||||||
21 | organization to administer the stop loss program established by | ||||||
22 | this Section. The Department shall establish guidelines for the | ||||||
23 | submission of proposals by organizations for the purposes of | ||||||
24 | administering the program. The Department shall make a | ||||||
25 | determination whether to approve, disapprove, or recommend | ||||||
26 | modification to the proposal of an applicant to administer the |
| |||||||
| |||||||
1 | program. An organization approved to administer the program | ||||||
2 | shall submit reports to the Department in such form and at | ||||||
3 | times as may be required by the Department in order to | ||||||
4 | facilitate evaluation and ensure orderly operation of the | ||||||
5 | program, including, but not limited to, an annual report of the | ||||||
6 | affairs and operations of the program. An organization approved | ||||||
7 | to administer the program shall maintain records in a form | ||||||
8 | prescribed by the Department and which shall be available for | ||||||
9 | inspection by or at the request of the Department. The | ||||||
10 | Department shall determine the amount of compensation to be | ||||||
11 | allocated to an approved organization as payment for program | ||||||
12 | administration. An organization approved to administer the | ||||||
13 | program may be removed by the Department and must cooperate in | ||||||
14 | the orderly transition of services to another approved | ||||||
15 | organization or to the Department.
| ||||||
16 | Section 15-25. Program publicity duties of active managed | ||||||
17 | care entities and Department. | ||||||
18 | (a) In conjunction with the Department, all active managed | ||||||
19 | care entities shall participate in and share the cost of | ||||||
20 | annually publishing and disseminating a consumer's shopping | ||||||
21 | guide or guides for Sure Standard group managed care plans and | ||||||
22 | Sure Standard individual managed care plans issued pursuant to | ||||||
23 | Section 15-15 of this Law. The contents of all consumer | ||||||
24 | shopping guides published pursuant to this Section shall be | ||||||
25 | subject to review and approval by the Department. |
| |||||||
| |||||||
1 | (b) Participating managed care entities may distribute | ||||||
2 | additional sales or marketing brochures describing Sure | ||||||
3 | Standard group managed care plans and Sure Standard individual | ||||||
4 | managed care plans subject to review and approval by the | ||||||
5 | Department. | ||||||
6 | (c) Commissions available to insurance producers from | ||||||
7 | active managed care entities for sales of Sure Standard managed | ||||||
8 | care plans shall not be less than those available for sale of | ||||||
9 | plans other than plans issued pursuant to the Health Sure | ||||||
10 | Illinois Program. Information on such commissions shall be | ||||||
11 | reported to the Division in the rate approval process. | ||||||
12 | Section 15-30. Data reporting. | ||||||
13 | (a) The Department, in consultation with the Division and | ||||||
14 | other State agencies, shall report on the program established | ||||||
15 | pursuant to Sections 15-15 and 15-20 of this Law. The report | ||||||
16 | shall examine: | ||||||
17 | (1) employer and individual participation, including | ||||||
18 | an income profile of covered employees and individuals and | ||||||
19 | an estimate of the per-member annual cost of total claims | ||||||
20 | reimbursement as required by subsection (i) of Section | ||||||
21 | 15-20 of this Law; | ||||||
22 | (2) claims experience and the program's projected | ||||||
23 | costs through December 31, 2015; and | ||||||
24 | (3) the impact of the program on the uninsured | ||||||
25 | population in Illinois and the impact of the program on |
| |||||||
| |||||||
1 | health insurance rates paid by Illinois residents. | ||||||
2 | (b) The study shall be completed and a report submitted by | ||||||
3 | October 1, 2011 to the Governor, the President of the Senate, | ||||||
4 | and the Speaker of the House of Representatives. | ||||||
5 | Section 15-35. Duties assigned to the Department. Unless | ||||||
6 | otherwise specified, all duties assigned to the Department by | ||||||
7 | this Law shall be carried out in consultation with the | ||||||
8 | Division. | ||||||
9 | Section 15-40. Applicability of other Illinois Insurance | ||||||
10 | Code provisions. Unless otherwise specified in this Section, | ||||||
11 | policies for all Sure Standard group managed care plans and | ||||||
12 | Sure Standard individual managed care plans must meet all other | ||||||
13 | applicable provisions of the Illinois Insurance Code.
| ||||||
14 | ARTICLE 90. AMENDATORY PROVISIONS | ||||||
15 | Section 90-5. The Illinois Insurance Code is amended by | ||||||
16 | adding Sections 359a.1 and 359a.2 and Articles XLV and XLVI and | ||||||
17 | by changing Sections 155.36, 368b, and Section 370c as follows:
| ||||||
18 | (215 ILCS 5/155.36)
| ||||||
19 | Sec. 155.36. Managed Care Reform and Patient Rights Act. | ||||||
20 | Insurance
companies that transact the kinds of insurance | ||||||
21 | authorized under Class 1(b) or
Class 2(a) of Section 4 of this |
| |||||||
| |||||||
1 | Code shall comply
with Sections 45 and Section 85 and the | ||||||
2 | definition of the term "emergency medical
condition" in Section
| ||||||
3 | 10 of the Managed Care Reform and Patient Rights Act.
| ||||||
4 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
5 | (215 ILCS 5/359a.1 new) | ||||||
6 | Sec. 359a.1. Standard Small Group Applications. The | ||||||
7 | Director shall develop, by rule, a standard application form | ||||||
8 | for use by small employers applying for coverage under a health | ||||||
9 | benefit plan offered by small employer carriers. Small employer | ||||||
10 | carriers shall be required to use the standard application form | ||||||
11 | not less than 6 months after the rules developing the form | ||||||
12 | become effective. The Director shall revise the standard | ||||||
13 | application form at least every 3 years. For purposes of this | ||||||
14 | Section, "health benefit plan", "small employer", and "small | ||||||
15 | employer carrier" shall have the meaning given those terms in | ||||||
16 | the Small Employer Health Insurance Rating Act. | ||||||
17 | (215 ILCS 5/359a.2 new) | ||||||
18 | Sec. 359a.2. Standard Individual Market Health Statements. | ||||||
19 | The Director shall develop, by rule, a standard health | ||||||
20 | statement for use by individuals applying for a health benefit | ||||||
21 | plan in the individual market. All carriers who offer health | ||||||
22 | benefit plans in the individual market and evaluate the health | ||||||
23 | status of individuals shall be required to use the standard | ||||||
24 | health statement not less than 6 months after the statement |
| |||||||
| |||||||
1 | becomes effective and thereafter may not use any other method | ||||||
2 | to determine the health status of an individual. Nothing in | ||||||
3 | this Section shall prevent a carrier from using health | ||||||
4 | information after enrollment for the purpose of providing | ||||||
5 | services or arranging for the provision of services under a | ||||||
6 | health benefit plan. For purposes of this Section, "health | ||||||
7 | benefit plan" shall have the meaning given the term in the | ||||||
8 | Small Employer Health Insurance Rating Act and "individual | ||||||
9 | market" shall have meaning given the term in the Illinois | ||||||
10 | Health Insurance Portability and Accountability Act.
| ||||||
11 | (215 ILCS 5/368b)
| ||||||
12 | Sec. 368b. Contracting procedures.
| ||||||
13 | (a) A health care professional or health care provider | ||||||
14 | offered a contract by
an
insurer, health maintenance | ||||||
15 | organization,
independent practice association, or physician
| ||||||
16 | hospital organization for signature after the effective date of | ||||||
17 | this amendatory
Act of the
93rd General Assembly shall be | ||||||
18 | provided with a proposed health care
professional or
health | ||||||
19 | care provider
services contract including, if any, exhibits and | ||||||
20 | attachments that the contract
indicates are
to be attached. | ||||||
21 | Within 35 days after a written request, the health care
| ||||||
22 | professional or health
care provider offered a contract shall | ||||||
23 | be given the opportunity to review and
obtain a
copy of the | ||||||
24 | following: a specialty-specific fee schedule sample based on a
| ||||||
25 | minimum of
the 50 highest volume fee schedule codes with the |
| |||||||
| |||||||
1 | rates applicable to the
health care
professional or health care | ||||||
2 | provider to whom the contract is offered, the
network
provider
| ||||||
3 | administration manual, and a summary capitation schedule, if | ||||||
4 | payment is made on
a
capitation basis. If 50 codes do not exist | ||||||
5 | for a particular specialty, the
health care
professional or | ||||||
6 | health care provider offered a contract shall be given the
| ||||||
7 | opportunity to
review or obtain a copy of a fee schedule sample | ||||||
8 | with the codes applicable to
that
particular specialty. This | ||||||
9 | information may be provided electronically. An
insurer, health
| ||||||
10 | maintenance organization, independent practice
association, or | ||||||
11 | physician hospital
organization may substitute the fee | ||||||
12 | schedule sample with a document providing
reference
to the | ||||||
13 | information needed to calculate the fee schedule that is | ||||||
14 | available to
the public at no
charge and the percentage or | ||||||
15 | conversion factor at which the insurer, health
maintenance
| ||||||
16 | organization, preferred provider organization, independent | ||||||
17 | practice
association, or physician hospital organization sets | ||||||
18 | its rates.
| ||||||
19 | (b) The fee schedule, the capitation schedule, and
the | ||||||
20 | network provider
administration manual constitute | ||||||
21 | confidential, proprietary, and trade secret
information and | ||||||
22 | are subject to the provisions of the Illinois Trade Secrets
| ||||||
23 | Act.
The health
care professional or health care provider | ||||||
24 | receiving such protected information
may disclose
the | ||||||
25 | information on a need to know basis and only to individuals and | ||||||
26 | entities
that provide
services directly related to the health |
| |||||||
| |||||||
1 | care professional's or health care
provider's decision
to enter | ||||||
2 | into the contract or keep the contract in force. Any person or | ||||||
3 | entity
receiving or
reviewing such protected information | ||||||
4 | pursuant to this Section shall not
disclose
the
information to | ||||||
5 | any other person, organization, or entity, unless the | ||||||
6 | disclosure
is requested
pursuant to a valid court order or | ||||||
7 | required by a state or federal government
agency.
Individuals | ||||||
8 | or entities receiving such information from a health care
| ||||||
9 | professional
or health care provider as delineated in this | ||||||
10 | subsection are subject to the
provisions of the
Illinois Trade | ||||||
11 | Secrets Act.
| ||||||
12 | (c) The health care professional or health care provider | ||||||
13 | shall be allowed at
least
30 days to review the health care | ||||||
14 | professional or health care provider services
contract, | ||||||
15 | including
exhibits and
attachments, if any, before signing. The | ||||||
16 | 30-day review period begins upon
receipt of the
health care
| ||||||
17 | professional or health care provider services contract, unless | ||||||
18 | the information
available
upon request
in subsection (a) is not | ||||||
19 | included. If information is not included in the
professional
| ||||||
20 | services contract and is requested pursuant to subsection (a), | ||||||
21 | the 30-day
review period
begins on the date of receipt of the | ||||||
22 | information. Nothing in this subsection
shall prohibit
a health | ||||||
23 | care professional or health care provider from signing a | ||||||
24 | contract
prior to the
expiration of the 30-day review period.
| ||||||
25 | (d) The insurer, health maintenance organization,
| ||||||
26 | independent practice
association, or physician hospital |
| |||||||
| |||||||
1 | organization shall provide all contracted
health care
| ||||||
2 | professionals or health care providers with any changes to the | ||||||
3 | fee schedule
provided
under subsection (a) not later than 35 | ||||||
4 | days after the effective date of the
changes,
unless such
| ||||||
5 | changes are specified in the contract and the health care | ||||||
6 | professional or
health care
provider is able to calculate the | ||||||
7 | changed rates based on information in the
contract and
| ||||||
8 | information available to the public at no charge. For the | ||||||
9 | purposes of this
subsection,
"changes" means an increase or | ||||||
10 | decrease in the fee schedule referred to in
subsection (a).
| ||||||
11 | This information may be made available by mail, e-mail, | ||||||
12 | newsletter, website
listing, or
other reasonable method. Upon | ||||||
13 | request, a health care professional or health
care provider
may | ||||||
14 | request an updated copy of the fee schedule referred to in | ||||||
15 | subsection (a)
every
calendar quarter.
| ||||||
16 | (e) Upon termination of a contract with an insurer, health | ||||||
17 | maintenance
organization, independent practice
association, or | ||||||
18 | physician hospital
organization and at
the request of the | ||||||
19 | patient, a health care professional or health care provider
| ||||||
20 | shall transfer
copies of the patient's medical records. Any | ||||||
21 | other provision of law
notwithstanding, the
costs for copying | ||||||
22 | and transferring copies of medical records shall be assigned
| ||||||
23 | per the
arrangements agreed upon, if any, in the health care | ||||||
24 | professional or health
care provider services
contract.
| ||||||
25 | (f) On and after January 1, 2010, all providers that | ||||||
26 | contract with an active managed care entity as defined by the |
| |||||||
| |||||||
1 | Health Sure Illinois Law must participate as a network provider | ||||||
2 | under the same active managed care entity's Sure Standard | ||||||
3 | managed care plan or plans as authorized by the Health Sure | ||||||
4 | Illinois Law. | ||||||
5 | (Source: P.A. 93-261, eff. 1-1-04.)
| ||||||
6 | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| ||||||
7 | Sec. 370c. Mental and emotional disorders.
| ||||||
8 | (a) (1) On and after the effective date of this Section,
| ||||||
9 | every insurer which delivers, issues for delivery or renews or | ||||||
10 | modifies
group A&H policies providing coverage for hospital or | ||||||
11 | medical treatment or
services for illness on an | ||||||
12 | expense-incurred basis shall offer to the
applicant or group | ||||||
13 | policyholder subject to the insurers standards of
| ||||||
14 | insurability, coverage for reasonable and necessary treatment | ||||||
15 | and services
for mental, emotional or nervous disorders or | ||||||
16 | conditions, other than serious
mental illnesses as defined in | ||||||
17 | item (2) of subsection (b), up to the limits
provided in the | ||||||
18 | policy for other disorders or conditions, except (i) the
| ||||||
19 | insured may be required to pay up to 50% of expenses incurred | ||||||
20 | as a result
of the treatment or services, and (ii) the annual | ||||||
21 | benefit limit may be
limited to the lesser of $10,000 or 25% of | ||||||
22 | the lifetime policy limit.
| ||||||
23 | (2) Each insured that is covered for mental, emotional or | ||||||
24 | nervous
disorders or conditions shall be free to select the | ||||||
25 | physician licensed to
practice medicine in all its branches, |
| |||||||
| |||||||
1 | licensed clinical psychologist,
licensed clinical social | ||||||
2 | worker, licensed clinical professional counselor, or licensed | ||||||
3 | marriage and family therapist of
his choice to treat such | ||||||
4 | disorders, and
the insurer shall pay the covered charges of | ||||||
5 | such physician licensed to
practice medicine in all its | ||||||
6 | branches, licensed clinical psychologist,
licensed clinical | ||||||
7 | social worker, licensed clinical professional counselor, or | ||||||
8 | licensed marriage and family therapist up
to the limits of | ||||||
9 | coverage, provided (i)
the disorder or condition treated is | ||||||
10 | covered by the policy, and (ii) the
physician, licensed | ||||||
11 | psychologist, licensed clinical social worker, licensed
| ||||||
12 | clinical professional counselor, or licensed marriage and | ||||||
13 | family therapist is
authorized to provide said services under | ||||||
14 | the statutes of this State and in
accordance with accepted | ||||||
15 | principles of his profession.
| ||||||
16 | (3) Insofar as this Section applies solely to licensed | ||||||
17 | clinical social
workers, licensed clinical professional | ||||||
18 | counselors, and licensed marriage and family therapists, those | ||||||
19 | persons who may
provide services to individuals shall do so
| ||||||
20 | after the licensed clinical social worker, licensed clinical | ||||||
21 | professional
counselor, or licensed marriage and family | ||||||
22 | therapist has informed the patient of the
desirability of the | ||||||
23 | patient conferring with the patient's primary care
physician | ||||||
24 | and the licensed clinical social worker, licensed clinical
| ||||||
25 | professional counselor, or licensed marriage and family | ||||||
26 | therapist has
provided written
notification to the patient's |
| |||||||
| |||||||
1 | primary care physician, if any, that services
are being | ||||||
2 | provided to the patient. That notification may, however, be
| ||||||
3 | waived by the patient on a written form. Those forms shall be | ||||||
4 | retained by
the licensed clinical social worker, licensed | ||||||
5 | clinical professional counselor, or licensed marriage and | ||||||
6 | family therapist
for a period of not less than 5 years.
| ||||||
7 | (b) (1) An insurer that provides coverage for hospital or | ||||||
8 | medical
expenses under a group policy of accident and health | ||||||
9 | insurance or
health care plan amended, delivered, issued, or | ||||||
10 | renewed after the effective
date of this amendatory Act of the | ||||||
11 | 92nd General Assembly shall provide coverage
under the policy | ||||||
12 | for treatment of serious mental illness under the same terms
| ||||||
13 | and conditions as coverage for hospital or medical expenses | ||||||
14 | related to other
illnesses and diseases. The coverage required | ||||||
15 | under this Section must provide
for same durational limits, | ||||||
16 | amount limits, deductibles, and co-insurance
requirements for | ||||||
17 | serious mental illness as are provided for other illnesses
and | ||||||
18 | diseases. This subsection does not apply to coverage provided | ||||||
19 | to
employees by employers who have 50 or fewer employees.
| ||||||
20 | (2) "Serious mental illness" means the following | ||||||
21 | psychiatric illnesses as
defined in the most current edition of | ||||||
22 | the Diagnostic and Statistical Manual
(DSM) published by the | ||||||
23 | American Psychiatric Association:
| ||||||
24 | (A) schizophrenia;
| ||||||
25 | (B) paranoid and other psychotic disorders;
| ||||||
26 | (C) bipolar disorders (hypomanic, manic, depressive, |
| |||||||
| |||||||
1 | and mixed);
| ||||||
2 | (D) major depressive disorders (single episode or | ||||||
3 | recurrent);
| ||||||
4 | (E) schizoaffective disorders (bipolar or depressive);
| ||||||
5 | (F) pervasive developmental disorders;
| ||||||
6 | (G) obsessive-compulsive disorders;
| ||||||
7 | (H) depression in childhood and adolescence;
| ||||||
8 | (I) panic disorder; | ||||||
9 | (J) post-traumatic stress disorders (acute, chronic, | ||||||
10 | or with delayed onset); and
| ||||||
11 | (K) anorexia nervosa and bulimia nervosa. | ||||||
12 | (3) (Blank). Upon request of the reimbursing insurer, a | ||||||
13 | provider of treatment of
serious mental illness shall furnish | ||||||
14 | medical records or other necessary data
that substantiate that | ||||||
15 | initial or continued treatment is at all times medically
| ||||||
16 | necessary. An insurer shall provide a mechanism for the timely | ||||||
17 | review by a
provider holding the same license and practicing in | ||||||
18 | the same specialty as the
patient's provider, who is | ||||||
19 | unaffiliated with the insurer, jointly selected by
the patient | ||||||
20 | (or the patient's next of kin or legal representative if the
| ||||||
21 | patient is unable to act for himself or herself), the patient's | ||||||
22 | provider, and
the insurer in the event of a dispute between the | ||||||
23 | insurer and patient's
provider regarding the medical necessity | ||||||
24 | of a treatment proposed by a patient's
provider. If the | ||||||
25 | reviewing provider determines the treatment to be medically
| ||||||
26 | necessary, the insurer shall provide reimbursement for the |
| |||||||
| |||||||
1 | treatment. Future
contractual or employment actions by the | ||||||
2 | insurer regarding the patient's
provider may not be based on | ||||||
3 | the provider's participation in this procedure.
Nothing | ||||||
4 | prevents
the insured from agreeing in writing to continue | ||||||
5 | treatment at his or her
expense. When making a determination of | ||||||
6 | the medical necessity for a treatment
modality for serous | ||||||
7 | mental illness, an insurer must make the determination in a
| ||||||
8 | manner that is consistent with the manner used to make that | ||||||
9 | determination with
respect to other diseases or illnesses | ||||||
10 | covered under the policy, including an
appeals process.
| ||||||
11 | (4) A group health benefit plan:
| ||||||
12 | (A) shall provide coverage based upon medical | ||||||
13 | necessity for the following
treatment of mental illness in | ||||||
14 | each calendar year:
| ||||||
15 | (i) 45 days of inpatient treatment; and
| ||||||
16 | (ii) beginning on June 26, 2006 (the effective date | ||||||
17 | of Public Act 94-921), 60 visits for outpatient | ||||||
18 | treatment including group and individual
outpatient | ||||||
19 | treatment; and | ||||||
20 | (iii) for plans or policies delivered, issued for | ||||||
21 | delivery, renewed, or modified after January 1, 2007 | ||||||
22 | (the effective date of Public Act 94-906),
20 | ||||||
23 | additional outpatient visits for speech therapy for | ||||||
24 | treatment of pervasive developmental disorders that | ||||||
25 | will be in addition to speech therapy provided pursuant | ||||||
26 | to item (ii) of this subparagraph (A);
|
| |||||||
| |||||||
1 | (B) may not include a lifetime limit on the number of | ||||||
2 | days of inpatient
treatment or the number of outpatient | ||||||
3 | visits covered under the plan; and
| ||||||
4 | (C) shall include the same amount limits, deductibles, | ||||||
5 | copayments, and
coinsurance factors for serious mental | ||||||
6 | illness as for physical illness.
| ||||||
7 | (5) An issuer of a group health benefit plan may not count | ||||||
8 | toward the number
of outpatient visits required to be covered | ||||||
9 | under this Section an outpatient
visit for the purpose of | ||||||
10 | medication management and shall cover the outpatient
visits | ||||||
11 | under the same terms and conditions as it covers outpatient | ||||||
12 | visits for
the treatment of physical illness.
| ||||||
13 | (6) An issuer of a group health benefit
plan may provide or | ||||||
14 | offer coverage required under this Section through a
managed | ||||||
15 | care plan.
| ||||||
16 | (7) This Section shall not be interpreted to require a | ||||||
17 | group health benefit
plan to provide coverage for treatment of:
| ||||||
18 | (A) an addiction to a controlled substance or cannabis | ||||||
19 | that is used in
violation of law; or
| ||||||
20 | (B) mental illness resulting from the use of a | ||||||
21 | controlled substance or
cannabis in violation of law.
| ||||||
22 | (8)
(Blank).
| ||||||
23 | (9) On and after June 1, 2010, coverage for the treatment | ||||||
24 | of mental and emotional disorders as provided by subsections | ||||||
25 | (a) and (b) of this Section shall not be denied under the | ||||||
26 | policy, provided that services are medically necessary as |
| |||||||
| |||||||
1 | determined by the insured's treating physician. For purposes of | ||||||
2 | this Section, "medically necessary" means health care services | ||||||
3 | appropriate, in terms of type, frequency, level, setting, and | ||||||
4 | duration, to the enrollee's diagnosis or condition, and | ||||||
5 | diagnostic testing and preventive services. Medically | ||||||
6 | necessary care must be consistent with generally accepted | ||||||
7 | practice parameters as determined by health care providers in | ||||||
8 | the same or similar general specialty as typically manages the | ||||||
9 | condition, procedure, or treatment at issue and must be | ||||||
10 | intended to either help restore or maintain the enrollee's | ||||||
11 | health or prevent deterioration of the enrollee's condition. | ||||||
12 | Upon request of the reimbursing insurer, a provider of | ||||||
13 | treatment of serious mental illness shall furnish medical | ||||||
14 | records or other necessary data that substantiate that initial | ||||||
15 | or continued treatment is at all times medically necessary. | ||||||
16 | (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; | ||||||
17 | 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff. | ||||||
18 | 8-21-07; 95-972, eff. 9-22-08; 95-973, eff. 1-1-09; revised | ||||||
19 | 10-14-08.)
| ||||||
20 | (215 ILCS 5/Art. XLV heading new) | ||||||
21 | ARTICLE XLV. PATIENT PROTECTION | ||||||
22 | (215 ILCS 5/1501 new) | ||||||
23 | Sec. 1501. Office of Patient Protection. There is hereby | ||||||
24 | established within the Division of Insurance an Office of |
| |||||||
| |||||||
1 | Patient Protection to ensure that persons covered by health | ||||||
2 | insurance companies or health care plans are provided benefits | ||||||
3 | due them under this Code and related statutes and are protected | ||||||
4 | from health insurance company and health care plan actions or | ||||||
5 | policy provisions that are unjust, unfair, inequitable, | ||||||
6 | ambiguous, misleading, inconsistent, deceptive, or contrary to | ||||||
7 | the law or to the public policy of this State or that | ||||||
8 | unreasonably or deceptively affect the risk purposed to be | ||||||
9 | assumed. | ||||||
10 | (215 ILCS 5/1505 new) | ||||||
11 | Sec. 1505. Powers of the Office of Patient Protection. | ||||||
12 | Acting under the authority of the Director, the Office of | ||||||
13 | Patient Protection shall: (1) have the power established by | ||||||
14 | Section 401 of this Code to institute such actions or other | ||||||
15 | lawful procedures as may by necessary for the enforcement of | ||||||
16 | this Code; and (2) oversee the responsibilities of the Office | ||||||
17 | of Consumer Health Insurance, including, but not limited to, | ||||||
18 | responding to consumer questions relating to health insurance. | ||||||
19 | (215 ILCS 5/1510 new) | ||||||
20 | Sec. 1510. External review responsibilities of the Office | ||||||
21 | of Patient Protection. The Office of Patient Protection shall | ||||||
22 | assist health insurance company and health care plan consumers | ||||||
23 | with respect to the exercise of the grievance and appeals | ||||||
24 | rights established by Section 1520 of this Article. |
| |||||||
| |||||||
1 | (215 ILCS 5/1515 new) | ||||||
2 | Sec. 1515. Health insurance oversight. The | ||||||
3 | responsibilities of the Office of Patient Protection shall | ||||||
4 | include, but not be limited to, the oversight of health | ||||||
5 | insurance companies and health care plans with respect to: | ||||||
6 | (1) Improper claims practices (Sections 154.5 and | ||||||
7 | 154.6 of this Code). | ||||||
8 | (2) Emergency services. | ||||||
9 | (3) Compliance with the Managed Care Reform and Patient | ||||||
10 | Rights Act and the Illinois Health Carrier External Review | ||||||
11 | Law. | ||||||
12 | (4) Ensuring proper coverage for mental health | ||||||
13 | treatment. | ||||||
14 | (5) Reviewing insurance company and health care plan | ||||||
15 | underwriting, rating, and rescission practices. | ||||||
16 | (6) Reviewing insurance company and health care plan | ||||||
17 | billing practices, including, but not limited to, consumer | ||||||
18 | cost-sharing that results from co-pay, deductible, and | ||||||
19 | provider network provisions. | ||||||
20 | (7) Ensuring insurance company and health care plan | ||||||
21 | compliance with the Health Sure Illinois Law and the | ||||||
22 | Individual Market Fairness Reform Law. | ||||||
23 | (215 ILCS 5/1520 new) | ||||||
24 | Sec. 1520. Powers of the Director. |
| |||||||
| |||||||
1 | (a) The Director, in his or her discretion, may issue a | ||||||
2 | Notice of Hearing requiring a health insurance company or | ||||||
3 | health care plan to appear at a hearing for the purpose of | ||||||
4 | determining the health insurance company's or health care | ||||||
5 | plan's compliance with the duties and responsibilities listed | ||||||
6 | in Section 1520. | ||||||
7 | (b) Nothing in this Article XLV shall diminish or affect | ||||||
8 | the powers and authority of the Director of Insurance otherwise | ||||||
9 | set forth in this Code. | ||||||
10 | (215 ILCS 5/1525 new) | ||||||
11 | Sec. 1525. Operative date. This Article XLV is operative on | ||||||
12 | and after January 1, 2010. | ||||||
13 | (215 ILCS 5/Art. XLVI heading new) | ||||||
14 | ARTICLE XLVI. HEALTH CARRIER EXTERNAL | ||||||
15 | REVIEW LAW | ||||||
16 | (215 ILCS 5/1601 new)
| ||||||
17 | Sec. 1601. Short title. This Law may be cited as the | ||||||
18 | Illinois Health Carrier External Review Law. | ||||||
19 | (215 ILCS 5/1605 new) | ||||||
20 | Sec. 1605. Purpose and intent. The purpose of this Law is | ||||||
21 | to provide uniform standards for the establishment and | ||||||
22 | maintenance of external review procedures to ensure that |
| |||||||
| |||||||
1 | covered persons have the opportunity for an independent review | ||||||
2 | of an adverse determination or final adverse determination, as | ||||||
3 | defined in this Law. | ||||||
4 | (215 ILCS 5/1610 new) | ||||||
5 | Sec. 1610. Definitions. For purposes of this Law: | ||||||
6 | "Adverse determination" means a determination by a health | ||||||
7 | carrier or its designee utilization review organization that an | ||||||
8 | admission, availability of care, continued stay, or other | ||||||
9 | health care service that is a covered benefit has been reviewed | ||||||
10 | and, based upon the information provided, does not meet the | ||||||
11 | health carrier's requirements for medical necessity, | ||||||
12 | appropriateness, health care setting, level of care, or | ||||||
13 | effectiveness, and the requested service or payment for the | ||||||
14 | service is therefore denied, reduced, or terminated. | ||||||
15 | "Authorized representative" means: | ||||||
16 | (1) a person to whom a covered person has given express | ||||||
17 | written consent to represent the covered person in an | ||||||
18 | external review; | ||||||
19 | (2) a person authorized by law to provide substituted | ||||||
20 | consent for a covered person; | ||||||
21 | (3) a family member of the covered person; or | ||||||
22 | (4) the covered person's health care provider. | ||||||
23 | "Clinical review criteria" means the written screening | ||||||
24 | procedures, decision abstracts, clinical protocols, and | ||||||
25 | practice guidelines used by a health carrier to determine the |
| |||||||
| |||||||
1 | necessity and appropriateness of health care services. | ||||||
2 | "Director" means the Director of the Division of Insurance | ||||||
3 | within the Illinois Department of Financial and Professional | ||||||
4 | Regulation. | ||||||
5 | "Covered benefits" or "benefits" means those health care | ||||||
6 | services to which a covered person is entitled under the terms | ||||||
7 | of a health benefit plan. | ||||||
8 | "Covered person" means a policyholder, subscriber, | ||||||
9 | enrollee, or other individual participating in a health benefit | ||||||
10 | plan. | ||||||
11 | "Emergency medical condition" means the sudden onset of a | ||||||
12 | health condition or illness that requires immediate medical | ||||||
13 | attention, where failure to provide medical attention would | ||||||
14 | result in a serious impairment to bodily functions or a serious | ||||||
15 | dysfunction of a bodily organ or part or would place the | ||||||
16 | person's health in serious jeopardy. | ||||||
17 | "Emergency services" means health care items and services | ||||||
18 | furnished or required to evaluate and treat an emergency | ||||||
19 | medical condition. | ||||||
20 | "Evidence-based standard" means a standard of care | ||||||
21 | developed through the judicious use of the current best | ||||||
22 | evidence and based on an overall systematic review of | ||||||
23 | applicable research. | ||||||
24 | "Facility" means an institution providing health care | ||||||
25 | services or a health care setting. | ||||||
26 | "Final adverse determination" means an adverse |
| |||||||
| |||||||
1 | determination involving a covered benefit that has been upheld | ||||||
2 | by a health carrier, or its designee utilization review | ||||||
3 | organization, at the completion of the health carrier's | ||||||
4 | internal grievance process procedures as set forth in the | ||||||
5 | Managed Care Reform and Patient Rights Act. | ||||||
6 | "Health benefit plan" means a policy, contract, | ||||||
7 | certificate, plan, or agreement offered or issued by a health | ||||||
8 | carrier to provide, deliver, arrange for, pay for, or reimburse | ||||||
9 | any of the costs of health care services. | ||||||
10 | "Health care provider" or "provider" means a physician or | ||||||
11 | other health care practitioner licensed, accredited, or | ||||||
12 | certified to perform specified health care services consistent | ||||||
13 | with State law, responsible for recommending health care | ||||||
14 | services on behalf of a covered person. | ||||||
15 | "Health care services" means services for the diagnosis, | ||||||
16 | prevention, treatment, cure, or relief of a health condition, | ||||||
17 | illness, injury, or disease. | ||||||
18 | "Health carrier" means an entity subject to the insurance | ||||||
19 | laws and rules of this State, or subject to the jurisdiction of | ||||||
20 | the Director, that contracts or offers to contract to provide, | ||||||
21 | deliver, arrange for, pay for, or reimburse any of the costs of | ||||||
22 | health care services, including a sickness and accident | ||||||
23 | insurance company, a health maintenance organization, a | ||||||
24 | nonprofit hospital and health service corporation, or any other | ||||||
25 | entity providing a plan of health insurance, health benefits, | ||||||
26 | or health care services. "Health carrier" also means Limited |
| |||||||
| |||||||
1 | Health Service Organizations (LHSO) and Voluntary Health | ||||||
2 | Service Plans. | ||||||
3 | "Health information" means information or data, whether | ||||||
4 | oral or recorded in any form or medium, and personal facts or | ||||||
5 | information about events or relationships that relates to: | ||||||
6 | (1) the past, present or future physical, mental, or | ||||||
7 | behavioral health or condition of an individual or a member | ||||||
8 | of the individual's family; | ||||||
9 | (2) the provision of health care services to an | ||||||
10 | individual; or | ||||||
11 | (3) payment for the provision of health care services | ||||||
12 | to an individual. | ||||||
13 | "Independent review organization" means an entity that | ||||||
14 | conducts independent external reviews of adverse | ||||||
15 | determinations and final adverse determinations. | ||||||
16 | "Medical or scientific evidence" means evidence found in | ||||||
17 | the following sources: | ||||||
18 | (1) peer-reviewed scientific studies published in or | ||||||
19 | accepted for publication by medical journals that meet | ||||||
20 | nationally recognized requirements for scientific | ||||||
21 | manuscripts and that submit most of their published | ||||||
22 | articles for review by experts who are not part of the | ||||||
23 | editorial staff; | ||||||
24 | (2) peer-reviewed medical literature, including | ||||||
25 | literature relating to therapies reviewed and approved by a | ||||||
26 | qualified institutional review board, biomedical |
| |||||||
| |||||||
1 | compendia, and other medical literature that meet the | ||||||
2 | criteria of the National Institutes of Health's Library of | ||||||
3 | Medicine for indexing in Index Medicus (Medline) and | ||||||
4 | Elsevier Science Ltd. for indexing in Excerpta Medicus | ||||||
5 | (EMBASE); | ||||||
6 | (3) medical journals recognized by the Secretary of | ||||||
7 | Health and Human Services under Section 1861(t)(2) of the | ||||||
8 | federal Social Security Act; | ||||||
9 | (4) the following standard reference compendia: | ||||||
10 | (a) the American Hospital Formulary Service-Drug | ||||||
11 | Information; | ||||||
12 | (b) Drug Facts and Comparisons; | ||||||
13 | (c) the American Dental Association Accepted | ||||||
14 | Dental Therapeutics; and | ||||||
15 | (d) the United States Pharmacopoeia-Drug | ||||||
16 | Information; | ||||||
17 | (5) findings, studies, or research conducted by or | ||||||
18 | under the auspices of federal government agencies and | ||||||
19 | nationally recognized federal research institutes, | ||||||
20 | including: | ||||||
21 | (a) the federal Agency for Healthcare Research and | ||||||
22 | Quality; | ||||||
23 | (b) the National Institutes of Health; | ||||||
24 | (c) the National Cancer Institute; | ||||||
25 | (d) the National Academy of Sciences; | ||||||
26 | (e) the Centers for Medicare & Medicaid Services; |
| |||||||
| |||||||
1 | (f) the federal Food and Drug Administration; and | ||||||
2 | (g) any national board recognized by the National | ||||||
3 | Institutes of Health for the purpose of evaluating the | ||||||
4 | medical value of health care services; or | ||||||
5 | (6) any other medical or scientific evidence that is | ||||||
6 | comparable to the sources listed in items (1) through (5). | ||||||
7 | "Protected health information" means health information: | ||||||
8 | (1) that identifies an individual who is the subject of | ||||||
9 | the information; or | ||||||
10 | (2) with respect to which there is a reasonable basis | ||||||
11 | to believe that the information could be used to identify | ||||||
12 | an individual. | ||||||
13 | "Utilization review" has the meaning provided by the | ||||||
14 | Managed Care Reform and Patient Rights Act. | ||||||
15 | "Utilization review organization" means a utilization | ||||||
16 | review program as defined by the Managed Care Reform and | ||||||
17 | Patient Rights Act. | ||||||
18 | (215 ILCS 5/1615 new) | ||||||
19 | Sec. 1615. Applicability and scope. | ||||||
20 | (a) Except as provided in subsection (b), this Law shall | ||||||
21 | apply to all health carriers. | ||||||
22 | (b) The provisions of this Law shall not apply to a policy | ||||||
23 | or certificate that provides coverage only for a specified | ||||||
24 | disease, specified accident or accident-only coverage, credit, | ||||||
25 | dental, disability income, hospital indemnity, long-term care |
| |||||||
| |||||||
1 | insurance, as defined by Article XIXA of this Code, vision care | ||||||
2 | or any other limited supplemental benefit or to a Medicare | ||||||
3 | supplement policy of insurance, as defined by the Director by | ||||||
4 | rule, coverage under a plan through Medicare, Medicaid, or the | ||||||
5 | federal employees health benefits program, any coverage issued | ||||||
6 | under Chapter 55 of Title 10, U.S. Code and any coverage issued | ||||||
7 | as a supplement to that coverage, any coverage issued as | ||||||
8 | supplemental to liability insurance, workers' compensation or | ||||||
9 | similar insurance, automobile medical-payment insurance, or | ||||||
10 | any insurance under which benefits are payable with or without | ||||||
11 | regard to fault, whether written on a group blanket or | ||||||
12 | individual basis. | ||||||
13 | (215 ILCS 5/1620 new) | ||||||
14 | Sec. 1620. Notice of right to external review. | ||||||
15 | (a) At the same time the health carrier sends written | ||||||
16 | notice of a covered person's right to appeal a coverage | ||||||
17 | decision as provided by the Managed Care Reform and Patient | ||||||
18 | Rights Act, a health carrier shall notify a covered person and | ||||||
19 | a covered person's health care provider in writing of the | ||||||
20 | covered person's right to request an external review as | ||||||
21 | provided by this Law. | ||||||
22 | (1) The written notice required shall include the | ||||||
23 | following, or substantially equivalent, language: "We have | ||||||
24 | denied your request for the provision of or payment for a | ||||||
25 | health care service or course of treatment. You have the |
| |||||||
| |||||||
1 | right to have our decision reviewed by an independent | ||||||
2 | review organization not associated with us if our decision | ||||||
3 | involved making a judgment as to the medical necessity, | ||||||
4 | appropriateness, health care setting, level of care, or | ||||||
5 | effectiveness of the health care service or treatment you | ||||||
6 | requested by submitting a written request for an external | ||||||
7 | review to us. Upon receipt of your request, an independent | ||||||
8 | review organization registered with the Department of | ||||||
9 | Financial and Professional Regulation, Division of | ||||||
10 | Insurance will be assigned to review our decision. | ||||||
11 | (2) The notice shall also include the appropriate | ||||||
12 | statements and information set forth in subsection (b) of | ||||||
13 | this Section. | ||||||
14 | (b) The health carrier shall inform the insured of his or | ||||||
15 | her right to an expedited review prior to a final adverse | ||||||
16 | determination. The health carrier shall include in the notice | ||||||
17 | required under subsection (a) for a notice related to an | ||||||
18 | adverse determination, a statement informing the covered | ||||||
19 | person that: | ||||||
20 | (1) If the covered person has a medical condition where | ||||||
21 | the timeframe for completion of an expedited internal | ||||||
22 | review of a grievance involving an adverse determination | ||||||
23 | set forth in the Managed Care Reform and Patient Rights Act | ||||||
24 | (215 ILCS 134/45(b)) would seriously jeopardize the life or | ||||||
25 | health of the covered person or would jeopardize the | ||||||
26 | covered person's ability to regain maximum function, the |
| |||||||
| |||||||
1 | covered person or the covered person's authorized | ||||||
2 | representative may file a request for an expedited external | ||||||
3 | review. | ||||||
4 | (2) The covered person, or the covered person's | ||||||
5 | authorized representative may file a request for an | ||||||
6 | expedited external review at the same time the covered | ||||||
7 | person or the covered person's authorized representative | ||||||
8 | files a request for an expedited internal appeal involving | ||||||
9 | an adverse determination as set forth in the Managed Care | ||||||
10 | Reform and Patient Rights Act (215 ILCS 134/45(b)), if the | ||||||
11 | adverse determination involves a denial of coverage based | ||||||
12 | on a determination that the recommended or requested health | ||||||
13 | care service or treatment is experimental or | ||||||
14 | investigational and the covered person's health care | ||||||
15 | provider certifies in writing that the recommended or | ||||||
16 | requested health care service or treatment that is the | ||||||
17 | subject of the adverse determination would be | ||||||
18 | significantly less effective if not promptly initiated. | ||||||
19 | The independent review organization assigned to conduct | ||||||
20 | the expedited external review shall determine whether the | ||||||
21 | covered person shall be required to complete the expedited | ||||||
22 | review of the grievance prior to conducting the expedited | ||||||
23 | external review. | ||||||
24 | (c) The health carrier shall include in the notice required | ||||||
25 | under subsection (a) for a notice related to an adverse | ||||||
26 | determination, a statement informing the covered person that: |
| |||||||
| |||||||
1 | (1) if the covered person has a medical condition where | ||||||
2 | the timeframe for completion of a standard external review | ||||||
3 | would seriously jeopardize the life or health of the | ||||||
4 | covered person or would jeopardize the covered person's | ||||||
5 | ability to regain maximum function, the covered person or | ||||||
6 | the covered person's authorized representative may file a | ||||||
7 | request for an expedited external review; | ||||||
8 | (2) if a final adverse determination concerns an | ||||||
9 | admission, availability of care, continued stay, or health | ||||||
10 | care service for which the covered person received | ||||||
11 | emergency services, but has not been discharged from a | ||||||
12 | facility, the covered person, or the covered person's | ||||||
13 | authorized representative, may request an expedited | ||||||
14 | external review; or | ||||||
15 | (3) if a final adverse determination concerns a denial | ||||||
16 | of coverage based on a determination that the recommended | ||||||
17 | or requested health care service or treatment is | ||||||
18 | experimental or investigational, and the covered person's | ||||||
19 | health care provider certifies in writing that the | ||||||
20 | recommended or requested health care service or treatment | ||||||
21 | that is the subject of the request would be significantly | ||||||
22 | less effective if not promptly initiated, the covered | ||||||
23 | person or the covered person's authorized representative | ||||||
24 | may request an expedited external review. | ||||||
25 | (d) In addition to the information to be provided pursuant | ||||||
26 | to subsections (a), (b), and (c), the health carrier shall |
| |||||||
| |||||||
1 | include a copy of the description of both the required standard | ||||||
2 | and expedited external review procedures. The description | ||||||
3 | shall highlight the external review procedures that give the | ||||||
4 | covered person or the covered person's authorized | ||||||
5 | representative the opportunity to submit additional | ||||||
6 | information, including any forms used to process an external | ||||||
7 | review. | ||||||
8 | (e) In addition to the information to be provided under | ||||||
9 | subsection (a), (b), or (c), the health carrier shall include | ||||||
10 | an authorization form that complies with the requirements of | ||||||
11 | the federal Health Insurance Portability and Accountability | ||||||
12 | Act (HIPAA) (45 CFR Section 164.508), by which the covered | ||||||
13 | person, for purposes of conducting an external review under | ||||||
14 | this Law, authorizes the health carrier and the covered | ||||||
15 | person's health care provider to disclose protected health | ||||||
16 | information, including medical records, concerning the covered | ||||||
17 | person that are pertinent to the external review. | ||||||
18 | (215 ILCS 5/1625 new) | ||||||
19 | Sec. 1625. Request for external review. | ||||||
20 | (a) A covered person or the covered person's authorized | ||||||
21 | representative may make a request for an external or expedited | ||||||
22 | external review of an adverse determination or final adverse | ||||||
23 | determination. | ||||||
24 | (b) Requests under subsection (a) shall be made directly to | ||||||
25 | the health carrier that made the adverse or final adverse |
| |||||||
| |||||||
1 | determination. | ||||||
2 | (c) All requests for external review shall be in writing | ||||||
3 | except for requests for expedited external reviews, which may | ||||||
4 | be made orally. | ||||||
5 | (d) Health carriers must provide covered persons with forms | ||||||
6 | to request external reviews. | ||||||
7 | (215 ILCS 5/1630 new) | ||||||
8 | Sec. 1630. Exhaustion of internal grievance process. | ||||||
9 | Except as provided in subsection (b) of Section 1620, a request | ||||||
10 | for an external review shall not be made until the covered | ||||||
11 | person has exhausted the health carrier's internal grievance | ||||||
12 | process as set forth in the Managed Care Reform and Patient | ||||||
13 | Rights Act. A covered person shall also be considered to have | ||||||
14 | exhausted the health carrier's internal grievance process for | ||||||
15 | purposes of this Section: | ||||||
16 | (1) if the covered person or the covered person's | ||||||
17 | authorized representative filed a request for an internal | ||||||
18 | review of an adverse determination pursuant to the Managed | ||||||
19 | Care Reform and Patient Rights Act and has not received a | ||||||
20 | written decision on the request from the health carrier | ||||||
21 | within 15 days, except to the extent the covered person or | ||||||
22 | the covered person's authorized representative requested | ||||||
23 | or agreed to a delay; or | ||||||
24 | (2) if the covered person or the covered person's | ||||||
25 | authorized representative filed a request for an expedited |
| |||||||
| |||||||
1 | internal review of an adverse determination pursuant to the | ||||||
2 | Managed Care Reform and Patient Rights Act and has not | ||||||
3 | received a decision on request from the health carrier | ||||||
4 | within 48 hours, except to the extent the covered person or | ||||||
5 | the covered person's authorized representative requested | ||||||
6 | or agreed to a delay. | ||||||
7 | A covered person need not exhaust a heath carrier's | ||||||
8 | internal grievance procedures as set forth in the Managed Care | ||||||
9 | Reform and Patient Rights Act if the health carrier agrees to | ||||||
10 | waive the exhaustion requirement. | ||||||
11 | (215 ILCS 5/1635 new) | ||||||
12 | Sec. 1635. Standard external review. | ||||||
13 | (a) Within 4 months after the date of receipt of a notice | ||||||
14 | of an adverse determination or final adverse determination, a | ||||||
15 | covered person or the covered person's authorized | ||||||
16 | representative may file a request for an external review with | ||||||
17 | the health carrier.
Within 5 business days following the date | ||||||
18 | of receipt of the external review request, the health carrier | ||||||
19 | shall complete a preliminary review of the request to determine | ||||||
20 | whether: | ||||||
21 | (1) the individual is or was a covered person in the | ||||||
22 | health benefit plan at the time the health care service was | ||||||
23 | requested or at the time the health care service was | ||||||
24 | provided; | ||||||
25 | (2) the health care service that is the subject of the |
| |||||||
| |||||||
1 | adverse determination or the final adverse determination | ||||||
2 | is a covered service under the covered person's health | ||||||
3 | benefit plan, but the health carrier has determined that | ||||||
4 | the health care service is not covered because it does not | ||||||
5 | meet the health carrier's requirements for medical | ||||||
6 | necessity, appropriateness, health care setting, level of | ||||||
7 | care, or effectiveness; | ||||||
8 | (3) the covered person has exhausted the health | ||||||
9 | carrier's internal grievance process as set forth in | ||||||
10 | Section 1635 of this Law; | ||||||
11 | (4) for appeals relating to determination based on | ||||||
12 | treatment being experimental or investigational, the | ||||||
13 | covered person's health care provider has certified that | ||||||
14 | one of the following situations is applicable: | ||||||
15 | (A) standard health care services or treatments | ||||||
16 | have not been effective in improving the condition of | ||||||
17 | the covered person; | ||||||
18 | (B) standard health care services or treatments | ||||||
19 | are not medically appropriate for the covered person; | ||||||
20 | (C) there is no available standard health care | ||||||
21 | service or treatment covered by the health carrier that | ||||||
22 | is more beneficial than the recommended or requested | ||||||
23 | health care service or treatment; | ||||||
24 | (D) the health care service or treatment is likely | ||||||
25 | to be more beneficial to the covered person, in the | ||||||
26 | health care provider's opinion, than any available |
| |||||||
| |||||||
1 | standard health care services or treatments; or | ||||||
2 | (E) that scientifically valid studies using | ||||||
3 | accepted protocols demonstrate that the health care | ||||||
4 | service or treatment requested is likely to be more | ||||||
5 | beneficial to the covered person than any available | ||||||
6 | standard health care services or treatments; and | ||||||
7 | (5) the covered person has attempted to provide all the | ||||||
8 | information and forms minimally required to process an | ||||||
9 | external review, as specified in this Law. | ||||||
10 | (c) Within one business day after completion of the | ||||||
11 | preliminary review, the health carrier shall notify the covered | ||||||
12 | person, the covered person's health care provider, and, if | ||||||
13 | applicable, the covered person's authorized representative in | ||||||
14 | writing whether the request is complete and eligible for | ||||||
15 | external review. | ||||||
16 | (1) If the request: | ||||||
17 | (A) is not complete, the health carrier shall | ||||||
18 | inform the covered person, the covered person's health | ||||||
19 | care provider, and, if applicable, the covered | ||||||
20 | person's authorized representative in writing and | ||||||
21 | include in the notice what information or materials are | ||||||
22 | required by this Law to make the request complete; or | ||||||
23 | (B) is not eligible for external review, the health | ||||||
24 | carrier shall inform the covered person, the covered | ||||||
25 | person's health care provider and, if applicable, the | ||||||
26 | covered person's authorized representative in writing |
| |||||||
| |||||||
1 | and include in the notice the reasons for its | ||||||
2 | ineligibility. | ||||||
3 | (2) The notice of initial determination of | ||||||
4 | ineligibility shall include a statement informing the | ||||||
5 | covered person, the covered person's health care provider | ||||||
6 | and, if applicable, the covered person's authorized | ||||||
7 | representative that a health carrier's initial | ||||||
8 | determination that the external review request is | ||||||
9 | ineligible for review may be appealed to the Director by | ||||||
10 | filing a complaint with the Director. | ||||||
11 | (3) Notwithstanding a health carrier's initial | ||||||
12 | determination that the request is ineligible and requires | ||||||
13 | that it be referred for external review, the Director may | ||||||
14 | determine that a request is eligible for external review. | ||||||
15 | (d) Whenever a request is eligible for external review the | ||||||
16 | health carrier shall, within 3 business days: | ||||||
17 | (1) assign an independent review organization from the | ||||||
18 | list of approved independent review organizations compiled | ||||||
19 | and maintained by the Director; and | ||||||
20 | (2) notify in writing the covered person, the covered | ||||||
21 | person's health care provider, and, if applicable, the | ||||||
22 | covered person's authorized representative of the | ||||||
23 | request's eligibility and acceptance for external review | ||||||
24 | and the name of the independent review organization. | ||||||
25 | (3) the health carrier shall include in the notice | ||||||
26 | provided to the covered person, the covered person's health |
| |||||||
| |||||||
1 | care provider, and, if applicable, the covered person's | ||||||
2 | authorized representative a statement that the covered | ||||||
3 | person or the covered person's authorized representative | ||||||
4 | may, within 5 business days following the date of receipt | ||||||
5 | of the notice provided pursuant to item (1) of this | ||||||
6 | subsection (d), submit in writing to the assigned | ||||||
7 | independent review organization additional information | ||||||
8 | that the independent review organization shall consider | ||||||
9 | when conducting the external review; the independent | ||||||
10 | review organization is not required to, but may, accept and | ||||||
11 | consider additional information submitted after 5 business | ||||||
12 | days. | ||||||
13 | (e) The assignment of an approved independent review | ||||||
14 | organization to conduct an external review in accordance with | ||||||
15 | this Section shall be done on a random basis among those | ||||||
16 | approved independent review organizations qualified to conduct | ||||||
17 | external review, except for instances of conflict of interest | ||||||
18 | concerns pursuant to this Law. | ||||||
19 | (f) Upon assignment of an independent review organization, | ||||||
20 | the health carrier or its designee utilization review | ||||||
21 | organization shall, within 5 business days, provide to the | ||||||
22 | assigned independent review organization the documents and any | ||||||
23 | information considered in making the adverse determination or | ||||||
24 | final adverse determination. | ||||||
25 | (1) Except as provided in item (2) of this subsection | ||||||
26 | (f), failure by the health carrier or its utilization |
| |||||||
| |||||||
1 | review organization to provide the documents and | ||||||
2 | information within the specified time frame shall not delay | ||||||
3 | the conduct of the external review. | ||||||
4 | (2) If the health carrier or its utilization review | ||||||
5 | organization fails to provide the documents and | ||||||
6 | information within the specified time frame, the assigned | ||||||
7 | independent review organization may terminate the external | ||||||
8 | review and make a decision to reverse the adverse | ||||||
9 | determination or final adverse determination. | ||||||
10 | (3) Within one business day after making the decision | ||||||
11 | to terminate the external review and make a decision to | ||||||
12 | reverse the adverse determination or final adverse | ||||||
13 | determination under item (2) of this subsection (f), the | ||||||
14 | independent review organization shall notify the health | ||||||
15 | carrier, the covered person, the covered person's health | ||||||
16 | care provider, and, if applicable, the covered person's | ||||||
17 | authorized representative of its decision to reverse the | ||||||
18 | adverse determination. | ||||||
19 | (g) Upon receipt of the information from the health carrier | ||||||
20 | or its utilization review organization, the assigned | ||||||
21 | independent review organization shall review all of the | ||||||
22 | information and documents and any other information submitted | ||||||
23 | in writing to the independent review organization by the | ||||||
24 | covered person and the covered person's authorized | ||||||
25 | representative. | ||||||
26 | (h) Upon receipt of any information submitted by the |
| |||||||
| |||||||
1 | covered person or the covered person's authorized | ||||||
2 | representative, the independent review organization shall | ||||||
3 | forward the information to the health carrier within one | ||||||
4 | business day. | ||||||
5 | (1) Upon receipt of the information, if any, the health | ||||||
6 | carrier may reconsider its adverse determination or final | ||||||
7 | adverse determination that is the subject of the external | ||||||
8 | review. | ||||||
9 | (2) Reconsideration by the health carrier of its | ||||||
10 | adverse determination or final adverse determination shall | ||||||
11 | not delay or terminate the external review. | ||||||
12 | (3) The external review may only be terminated if the | ||||||
13 | health carrier decides, upon completion of its | ||||||
14 | reconsideration, to reverse its adverse determination or | ||||||
15 | final adverse determination and provide coverage or | ||||||
16 | payment for the health care service that is the subject of | ||||||
17 | the adverse determination or final adverse determination. | ||||||
18 | (A) Within one business day after making the | ||||||
19 | decision to reverse its adverse determination or final | ||||||
20 | adverse determination, the health carrier shall notify | ||||||
21 | the covered person, the covered person's health care | ||||||
22 | provider, if applicable, the covered person's | ||||||
23 | authorized representative, and the assigned | ||||||
24 | independent review organization in writing of its | ||||||
25 | decision. | ||||||
26 | (B) Upon notice from the health carrier that the |
| |||||||
| |||||||
1 | health carrier has made a decision to reverse its | ||||||
2 | adverse determination or final adverse determination, | ||||||
3 | the assigned independent review organization shall | ||||||
4 | terminate the external review. | ||||||
5 | (i) In addition to the documents and information provided | ||||||
6 | by the health carrier or its utilization review organization, | ||||||
7 | and the covered person and the covered person's authorized | ||||||
8 | representative, if any, the independent review organization, | ||||||
9 | to the extent the information or documents are available and | ||||||
10 | the independent review organization considers them | ||||||
11 | appropriate, shall consider the following in reaching a | ||||||
12 | decision: | ||||||
13 | (1) the covered person's pertinent medical records; | ||||||
14 | (2) the covered person's health care provider's | ||||||
15 | recommendation; | ||||||
16 | (3) consulting reports from appropriate health care | ||||||
17 | providers and other documents submitted by the health | ||||||
18 | carrier, the covered person, and the covered person's | ||||||
19 | authorized representative; | ||||||
20 | (4) the terms of coverage under the covered person's | ||||||
21 | health benefit plan with the health carrier to ensure that | ||||||
22 | the health care service or treatment that is the subject of | ||||||
23 | the opinion is experimental or investigational would | ||||||
24 | otherwise be covered under the terms of coverage of the | ||||||
25 | covered person's health benefit plan with the health | ||||||
26 | carrier; |
| |||||||
| |||||||
1 | (5) the most appropriate practice guidelines, which | ||||||
2 | shall include applicable evidence-based standards and may | ||||||
3 | include any other practice guidelines developed by the | ||||||
4 | federal government, national or professional medical | ||||||
5 | societies, boards, and associations; | ||||||
6 | (6) any applicable clinical review criteria developed | ||||||
7 | and used by the health carrier or its designee utilization | ||||||
8 | review organization; and | ||||||
9 | (7) the opinion of the independent review | ||||||
10 | organization's clinical reviewer or reviewers after | ||||||
11 | considering items (1) through (6) of this subsection (i) to | ||||||
12 | the extent the information or documents are available and | ||||||
13 | the clinical reviewer or reviewers considers the | ||||||
14 | information or documents relevant. | ||||||
15 | (j) Within 5 days after the date of receipt of all | ||||||
16 | necessary information, the assigned independent review | ||||||
17 | organization shall provide written notice of its decision to | ||||||
18 | uphold or reverse the adverse determination or the final | ||||||
19 | adverse determination to the health carrier, the covered | ||||||
20 | person, the covered person's health care provider, and, if | ||||||
21 | applicable, the covered person's authorized representative. | ||||||
22 | (1) The independent review organization shall include | ||||||
23 | in the notice: | ||||||
24 | (A) a general description of the reason for the | ||||||
25 | request for external review; | ||||||
26 | (B) the date the independent review organization |
| |||||||
| |||||||
1 | received the assignment from the health carrier to | ||||||
2 | conduct the external review; | ||||||
3 | (C) the time period during which the external | ||||||
4 | review was conducted; | ||||||
5 | (D) references to the evidence or documentation, | ||||||
6 | including the evidence-based standards, considered in | ||||||
7 | reaching its decision; | ||||||
8 | (E) the date of its decision; and | ||||||
9 | (F) the principal reason or reasons for its | ||||||
10 | decision, including what applicable, if any, | ||||||
11 | evidence-based standards were a basis for its | ||||||
12 | decision. | ||||||
13 | (2) For reviews of experimental or investigational | ||||||
14 | treatments, the notice shall include the following | ||||||
15 | information: | ||||||
16 | (A) a description of the covered person's medical | ||||||
17 | condition; | ||||||
18 | (B) a description of the indicators relevant to | ||||||
19 | whether there is sufficient evidence to demonstrate | ||||||
20 | that the recommended or requested health care service | ||||||
21 | or treatment is more likely than not to be more | ||||||
22 | beneficial to the covered person than any available | ||||||
23 | standard health care services or treatments and the | ||||||
24 | adverse risks of the recommended or requested health | ||||||
25 | care service or treatment would not be substantially | ||||||
26 | increased over those of available standard health care |
| |||||||
| |||||||
1 | services or treatments; | ||||||
2 | (C) a description and analysis of any medical or | ||||||
3 | scientific evidence considered in reaching the | ||||||
4 | opinion; | ||||||
5 | (D) a description and analysis of any | ||||||
6 | evidence-based standards; and | ||||||
7 | (E) whether the recommended or requested health | ||||||
8 | care service or treatment has been approved by the | ||||||
9 | federal Food and Drug Administration, for the | ||||||
10 | condition; or | ||||||
11 | (F) whether medical or scientific evidence or | ||||||
12 | evidence-based standards demonstrate that the expected | ||||||
13 | benefits of the recommended or requested health care | ||||||
14 | service or treatment is more likely than not to be more | ||||||
15 | beneficial to the covered person than any available | ||||||
16 | standard health care service or treatment and the | ||||||
17 | adverse risks of the recommended or requested health | ||||||
18 | care service or treatment would not be substantially | ||||||
19 | increased over those of available standard health care | ||||||
20 | services or treatments. In reaching a decision, the | ||||||
21 | assigned independent review organization is not bound | ||||||
22 | by any decisions or conclusions reached during the | ||||||
23 | health carrier's utilization review process or the | ||||||
24 | health carrier's internal grievance or appeals | ||||||
25 | process. | ||||||
26 | (3) Upon receipt of a notice of a decision reversing |
| |||||||
| |||||||
1 | the adverse determination or final adverse determination, | ||||||
2 | the health carrier immediately shall approve the coverage | ||||||
3 | that was the subject of the adverse determination or final | ||||||
4 | adverse determination. | ||||||
5 | (215 ILCS 5/1640 new) | ||||||
6 | Sec. 1640. Expedited external review. | ||||||
7 | (a) A covered person or a covered person's authorized | ||||||
8 | representative may file a request for an expedited external | ||||||
9 | review with the health carrier either orally or in writing: | ||||||
10 | (1) immediately after the date of receipt of a notice a | ||||||
11 | final adverse determination; or | ||||||
12 | (2) if a health carrier fails to provide a decision on | ||||||
13 | request for an expedited internal appeal within 48 hours. | ||||||
14 | (b) Upon receipt of a request for an expedited external | ||||||
15 | review as provided in subsections (b) and (c) of Section 1620 | ||||||
16 | of this Law, the health carrier shall immediately assign an | ||||||
17 | independent review organization from the list of approved | ||||||
18 | independent review organizations compiled and maintained by | ||||||
19 | the Director to conduct the expedited review. | ||||||
20 | (1) The assignment by the health carrier of an approved | ||||||
21 | independent review organization to conduct an external | ||||||
22 | review in accordance with this Section shall be done on a | ||||||
23 | random basis among those approved independent review | ||||||
24 | organizations except as may be prohibited by conflict of | ||||||
25 | interest concerns pursuant to this Law. |
| |||||||
| |||||||
1 | (2) Immediately upon assigning an independent review | ||||||
2 | organization to perform an expedited external review, but | ||||||
3 | in no case less than 24 hours after assigning the | ||||||
4 | independent review organization, the health carrier or its | ||||||
5 | designee utilization review organization shall provide or | ||||||
6 | transmit all necessary documents and information | ||||||
7 | considered in making the final adverse determination to the | ||||||
8 | assigned independent review organization electronically or | ||||||
9 | by telephone or facsimile or any other available | ||||||
10 | expeditious method. | ||||||
11 | (3) If the health carrier or its utilization review | ||||||
12 | organization fails to provide the documents and | ||||||
13 | information within the specified time frame, the assigned | ||||||
14 | independent review organization may terminate the external | ||||||
15 | review and make a decision to reverse the adverse | ||||||
16 | determination or final adverse determination. | ||||||
17 | (4) Within one business day after making the decision | ||||||
18 | to terminate the external review and make a decision to | ||||||
19 | reverse the adverse determination or final adverse | ||||||
20 | determination under item (2) of this subsection (b), the | ||||||
21 | independent review organization shall notify the health | ||||||
22 | carrier, the covered person, the covered person's health | ||||||
23 | care provider, and, if applicable, the covered person's | ||||||
24 | authorized representative of its decision to reverse the | ||||||
25 | adverse determination. | ||||||
26 | (c) In addition to the documents and information provided |
| |||||||
| |||||||
1 | by the health carrier or its utilization review organization, | ||||||
2 | and any documents and information provided by the covered | ||||||
3 | person and the covered person's authorized representative, the | ||||||
4 | independent review organization shall consider the following | ||||||
5 | in reaching a decision: | ||||||
6 | (1) the covered person's pertinent medical records; | ||||||
7 | (2) the covered person's health care provider's | ||||||
8 | recommendation; | ||||||
9 | (3) consulting reports from appropriate health care | ||||||
10 | providers and other documents submitted by the health | ||||||
11 | carrier, the covered person, and the covered person's | ||||||
12 | authorized representative; | ||||||
13 | (4) the terms of coverage under the covered person's | ||||||
14 | health benefit plan with the health carrier to ensure that | ||||||
15 | the health care service or treatment that is the subject of | ||||||
16 | the opinion is experimental or investigational would | ||||||
17 | otherwise be covered under the terms of coverage of the | ||||||
18 | covered person's health benefit plan with the health | ||||||
19 | carrier; | ||||||
20 | (5) the most appropriate practice guidelines, which | ||||||
21 | shall include applicable evidence-based standards and may | ||||||
22 | include any other practice guidelines developed by the | ||||||
23 | federal government, national or professional medical | ||||||
24 | societies, boards, and associations; | ||||||
25 | (6) any applicable clinical review criteria developed | ||||||
26 | and used by the health carrier or its designee utilization |
| |||||||
| |||||||
1 | review organization; and | ||||||
2 | (7) whether for experimental or investigational | ||||||
3 | denials: | ||||||
4 | (A) the recommended or requested health care | ||||||
5 | service or treatment has been approved by the federal | ||||||
6 | Food and Drug Administration, if applicable, for the | ||||||
7 | condition; or | ||||||
8 | (B) medical or scientific evidence or | ||||||
9 | evidence-based standards demonstrate that the expected | ||||||
10 | benefits of the recommended or requested health care | ||||||
11 | service or treatment is more likely than not to be | ||||||
12 | beneficial to the covered person than any available | ||||||
13 | standard health care service or treatment and the | ||||||
14 | adverse risks of the recommended or requested health | ||||||
15 | care service or treatment would not be substantially | ||||||
16 | increased over those of available standard health care | ||||||
17 | services or treatments. | ||||||
18 | (d) As expeditiously as the covered person's medical | ||||||
19 | condition or circumstances requires, but in no event more than | ||||||
20 | 48 hours after the receipt of all pertinent information, the | ||||||
21 | assigned independent review organization shall: | ||||||
22 | (1) make a decision to uphold or reverse the final | ||||||
23 | adverse determination; | ||||||
24 | (2) notify the health carrier, the covered person, the | ||||||
25 | covered person's health care provider, and, if applicable, | ||||||
26 | the covered person's authorized representative of the |
| |||||||
| |||||||
1 | decision; | ||||||
2 | (3) in reaching a decision, the assigned independent | ||||||
3 | review organization is not bound by any decisions or | ||||||
4 | conclusions reached during the health carrier's | ||||||
5 | utilization review process or the health carrier's | ||||||
6 | internal grievance process as set forth in the Managed Care | ||||||
7 | Reform and Patient Rights Act; | ||||||
8 | (4) upon receipt of notice of a decision reversing the | ||||||
9 | final adverse determination, the health carrier shall | ||||||
10 | immediately approve the coverage that was the subject of | ||||||
11 | the final adverse determination; and | ||||||
12 | (5) within 48 hours after the date of providing the | ||||||
13 | notice required in item (2) of this subsection (d), the | ||||||
14 | assigned independent review organization shall provide | ||||||
15 | written confirmation of the decision to the health carrier, | ||||||
16 | the covered person, the covered person's health care | ||||||
17 | provider, and, if applicable, the covered person's | ||||||
18 | authorized representative, including: | ||||||
19 | (A) a general description of the reason for the | ||||||
20 | request for external review; | ||||||
21 | (B) the date the independent review organization | ||||||
22 | received the assignment from the health carrier to | ||||||
23 | conduct the external review; | ||||||
24 | (C) the date the external review was conducted; | ||||||
25 | (D) the date of its decision; | ||||||
26 | (E) the principal reason or reasons for its |
| |||||||
| |||||||
1 | decision, including what applicable, if any, | ||||||
2 | evidence-based standards were a basis for its | ||||||
3 | decision; and | ||||||
4 | (F) references to the evidence or documentation, | ||||||
5 | including the evidence-based standards, considered in | ||||||
6 | reaching its decision. | ||||||
7 | (215 ILCS 5/1645 new) | ||||||
8 | Sec. 1645. Binding nature of external review decision and | ||||||
9 | final appeal for covered persons. | ||||||
10 | (a) An external review decision is binding on the health | ||||||
11 | carrier. | ||||||
12 | (b) A covered person or the covered person's authorized | ||||||
13 | representative may not file a subsequent request for external | ||||||
14 | review involving the same adverse determination or final | ||||||
15 | adverse determination for which the covered person has already | ||||||
16 | received an external review decision pursuant to this Law. | ||||||
17 | (c) If the external review decision upholds the adverse | ||||||
18 | determination, the covered person has the right to appeal the | ||||||
19 | final decision to the Office of Patient Protection. | ||||||
20 | (1) In cases where the external review decision is | ||||||
21 | found by the Director, through the Office of Patient | ||||||
22 | Protection, to have been made in an arbitrary and | ||||||
23 | capricious manner, the Director may overturn the external | ||||||
24 | review decision and require the health carrier to pay for | ||||||
25 | the health care service or treatment. |
| |||||||
| |||||||
1 | (d) Nothing in this Section shall limit other remedies that | ||||||
2 | may be available to the covered person under applicable federal | ||||||
3 | or State law. | ||||||
4 | (215 ILCS 5/1650 new) | ||||||
5 | Sec. 1650. Approval of independent review organizations. | ||||||
6 | (a) The Director shall approve independent review | ||||||
7 | organizations eligible to be assigned to conduct external | ||||||
8 | reviews under this Law. | ||||||
9 | (b) In order to be eligible for approval by the Director | ||||||
10 | under this Section to conduct external reviews under this Law | ||||||
11 | an independent review organization: | ||||||
12 | (1) except as otherwise provided in this Section, shall | ||||||
13 | be accredited by a nationally recognized private | ||||||
14 | accrediting entity that the Director has determined has | ||||||
15 | independent review organization accreditation standards | ||||||
16 | that are equivalent to or exceed the minimum qualifications | ||||||
17 | for independent review; and | ||||||
18 | (2) shall submit an application for approval in | ||||||
19 | accordance with subsection (d) of this Section. | ||||||
20 | (c) The Director shall develop an application form for | ||||||
21 | initially approving and for reapproving independent review | ||||||
22 | organizations to conduct external reviews. | ||||||
23 | (d) Any independent review organization wishing to be | ||||||
24 | approved to conduct external reviews under this Law shall | ||||||
25 | submit the application form and include with the form all |
| |||||||
| |||||||
1 | documentation and information necessary for the Director to | ||||||
2 | determine if the independent review organization satisfies the | ||||||
3 | minimum qualifications established under this Law. | ||||||
4 | (1) The Director may approve independent review | ||||||
5 | organizations that are not accredited by a nationally | ||||||
6 | recognized private accrediting entity if there are no | ||||||
7 | acceptable nationally recognized private accrediting | ||||||
8 | entities providing independent review organization | ||||||
9 | accreditation. | ||||||
10 | (2) The Director may by rule establish an application | ||||||
11 | fee that independent review organizations shall submit to | ||||||
12 | the Director with an application for approval and renewing. | ||||||
13 | (e) An approval is effective for 2 years, unless the | ||||||
14 | Director determines before its expiration that the independent | ||||||
15 | review organization is not satisfying the minimum | ||||||
16 | qualifications established under this Law. | ||||||
17 | (f) Whenever the Director determines that an independent | ||||||
18 | review organization has lost its accreditation or no longer | ||||||
19 | satisfies the minimum requirements established under this Law, | ||||||
20 | the Director shall terminate the approval of the independent | ||||||
21 | review organization and remove the independent review | ||||||
22 | organization from the list of independent review organizations | ||||||
23 | approved to conduct external reviews under this Law that is | ||||||
24 | maintained by the Director. | ||||||
25 | (g) The Director shall maintain and periodically update a | ||||||
26 | list of approved independent review organizations. |
| |||||||
| |||||||
1 | (h) The Department may promulgate rules to carry out the | ||||||
2 | provisions of this Section. | ||||||
3 | (215 ILCS 5/1655 new) | ||||||
4 | Sec. 1655. Minimum qualifications for independent review | ||||||
5 | organizations. | ||||||
6 | (a) To be approved to conduct external reviews, an | ||||||
7 | independent review organization shall have and maintain | ||||||
8 | written policies and procedures that govern all aspects of both | ||||||
9 | the standard external review process and the expedited external | ||||||
10 | review process set forth in this Law that include, at a | ||||||
11 | minimum: | ||||||
12 | (1) a quality assurance mechanism that ensures: | ||||||
13 | (A) that external reviews are conducted within the | ||||||
14 | specified time frames and required notices are | ||||||
15 | provided in a timely manner; | ||||||
16 | (B) the selection of qualified and impartial | ||||||
17 | clinical reviewers to conduct external reviews on | ||||||
18 | behalf of the independent review organization and the | ||||||
19 | suitable matching of reviewers to specific cases and | ||||||
20 | that the independent review organization employs or | ||||||
21 | contracts with an adequate number of clinical | ||||||
22 | reviewers to meet this objective; | ||||||
23 | (C) in assigning clinical reviewers, the | ||||||
24 | independent review organization selects physicians or | ||||||
25 | other health care professionals who, through clinical |
| |||||||
| |||||||
1 | experience in the past 3 years, are experts in the | ||||||
2 | treatment of the covered person's condition and | ||||||
3 | knowledgeable about the recommended or requested | ||||||
4 | health care service or treatment. | ||||||
5 | (D) the health carrier, the covered person, and the | ||||||
6 | covered person's authorized representative shall not | ||||||
7 | choose or control the choice of the physicians or other | ||||||
8 | health care professionals to be selected to conduct the | ||||||
9 | external review; | ||||||
10 | (E) confidentiality of medical and treatment | ||||||
11 | records and clinical review criteria; and | ||||||
12 | (F) any person employed by or under contract with | ||||||
13 | the independent review organization adheres to the | ||||||
14 | requirements of this Law. | ||||||
15 | (2) a toll-free telephone service operating on a | ||||||
16 | 24-hour-day, 7-day-a-week basis that accepts, receives, | ||||||
17 | and records information related to external reviews and | ||||||
18 | provides appropriate instructions; and | ||||||
19 | (3) an agreement to maintain and provide to the | ||||||
20 | Director the information set out in Section 1670 of this | ||||||
21 | Law. | ||||||
22 | (b) All clinical reviewers assigned by an independent | ||||||
23 | review organization to conduct external reviews shall be | ||||||
24 | physicians or other appropriate health care providers who meet | ||||||
25 | the following minimum qualifications: | ||||||
26 | (1) be an expert in the treatment of the covered |
| |||||||
| |||||||
1 | person's medical condition that is the subject of the | ||||||
2 | external review; | ||||||
3 | (2) be knowledgeable about the recommended health care | ||||||
4 | service or treatment through recent or current actual | ||||||
5 | clinical experience treating patients with the same or | ||||||
6 | similar medical condition of the covered person; | ||||||
7 | (3) hold a non-restricted license in a state of the | ||||||
8 | United States and, for physicians, a current certification | ||||||
9 | by a recognized American medical specialty board in the | ||||||
10 | area or areas appropriate to the subject of the external | ||||||
11 | review; and | ||||||
12 | (4) have no history of disciplinary actions or | ||||||
13 | sanctions, including loss of staff privileges or | ||||||
14 | participation restrictions, that have been taken or are | ||||||
15 | pending by any hospital, governmental agency or unit, or | ||||||
16 | regulatory body that raise a substantial question as to the | ||||||
17 | clinical reviewer's physical, mental or professional | ||||||
18 | competence or moral character. | ||||||
19 | (c) In addition to the requirements set forth in subsection | ||||||
20 | (a) of this Section, an independent review organization may not | ||||||
21 | own or control, be a subsidiary of, or in any way be owned or | ||||||
22 | controlled by or exercise control with a health benefit plan, a | ||||||
23 | national, State, or local trade association of health benefit | ||||||
24 | plans, or a national, State, or local trade association of | ||||||
25 | health care providers. | ||||||
26 | (d) Conflicts of interest are prohibited as follows: |
| |||||||
| |||||||
1 | (1) In addition to the requirements set forth in | ||||||
2 | subsections (a), (b), and (c), to be approved pursuant to | ||||||
3 | this Law to conduct an external review of a specified case, | ||||||
4 | neither the independent review organization selected to | ||||||
5 | conduct the external review nor any clinical reviewer | ||||||
6 | assigned by the independent organization to conduct the | ||||||
7 | external review may have a material professional, | ||||||
8 | familial, or financial conflict of interest with any of the | ||||||
9 | following: | ||||||
10 | (A) the health carrier that is the subject of the | ||||||
11 | external review; | ||||||
12 | (B) the covered person whose treatment is the | ||||||
13 | subject of the external review or the covered person's | ||||||
14 | authorized representative; | ||||||
15 | (C) any officer, director, or management employee | ||||||
16 | of the health carrier that is the subject of the | ||||||
17 | external review; | ||||||
18 | (D) the health care provider, the health care | ||||||
19 | provider's medical group, or the independent practice | ||||||
20 | association recommending the health care service or | ||||||
21 | treatment that is the subject of the external review; | ||||||
22 | (E) the facility at which the recommended health | ||||||
23 | care service or treatment would be provided; or | ||||||
24 | (F) the developer or manufacturer of the principal | ||||||
25 | drug, device, procedure or other therapy being | ||||||
26 | recommended for the covered person whose treatment is |
| |||||||
| |||||||
1 | the subject of the external review. | ||||||
2 | (e) An independent review organization that is accredited | ||||||
3 | by a nationally recognized private accrediting entity that has | ||||||
4 | independent review accreditation standards that the Director | ||||||
5 | has determined are equivalent to or exceed the minimum | ||||||
6 | qualifications of this Section shall be presumed to be in | ||||||
7 | compliance with this Section and shall be eligible for approval | ||||||
8 | under Section 1655 of this Law. | ||||||
9 | (f) An independent review organization shall be unbiased. | ||||||
10 | An independent review organization shall establish and | ||||||
11 | maintain written procedures to ensure that it is unbiased in | ||||||
12 | addition to any other procedures required under this Section. | ||||||
13 | (215 ILCS 5/1660 new) | ||||||
14 | Sec. 1660. Hold harmless for independent review | ||||||
15 | organizations.
No independent review organization or clinical | ||||||
16 | reviewer working on behalf of an independent review | ||||||
17 | organization or an employee, agent, or contractor of an | ||||||
18 | independent review organization shall be liable in damages to | ||||||
19 | any person for any opinions rendered or acts or omissions | ||||||
20 | performed within the scope of the organization's or person's | ||||||
21 | duties under the law during or upon completion of an external | ||||||
22 | review conducted pursuant to this Law, unless the opinion was | ||||||
23 | rendered or act or omission performed in bad faith or involved | ||||||
24 | gross negligence. |
| |||||||
| |||||||
1 | (215 ILCS 5/1665 new) | ||||||
2 | Sec. 1665. External review reporting requirements. | ||||||
3 | (a) Each health carrier shall maintain written records in | ||||||
4 | the aggregate on all requests for external review for each | ||||||
5 | calendar year and submit a report to the Director in the format | ||||||
6 | specified by the Director by March 1 of each year. | ||||||
7 | (b) The report shall include in the aggregate: | ||||||
8 | (1) the total number of requests for external review; | ||||||
9 | (2) the total number of requests for expedited external | ||||||
10 | review; | ||||||
11 | (3) the total number of requests for external review | ||||||
12 | denied; | ||||||
13 | (4) the number of requests for external review | ||||||
14 | resolved, including: | ||||||
15 | (A) the number of requests for external review | ||||||
16 | resolved upholding the adverse determination or final | ||||||
17 | adverse determination; | ||||||
18 | (B) the number of requests for external review | ||||||
19 | resolved reversing the adverse determination or final | ||||||
20 | adverse determination; | ||||||
21 | (C) the number of requests for expedited external | ||||||
22 | review resolved upholding the adverse determination or | ||||||
23 | final adverse determination; and | ||||||
24 | (D) the number of requests for expedited external | ||||||
25 | review resolved reversing the adverse determination or | ||||||
26 | final adverse determination; |
| |||||||
| |||||||
1 | (5) the average length of time for resolution for an | ||||||
2 | external review; | ||||||
3 | (6) the average length of time for resolution for an | ||||||
4 | expedited external review; | ||||||
5 | (7) a summary of the types of coverages or cases for | ||||||
6 | which an external review was sought, as specified below: | ||||||
7 | (A) denial of care or treatment; dissatisfaction | ||||||
8 | regarding prospective non-authorization of a request | ||||||
9 | for care or treatment recommended by a provider, | ||||||
10 | excluding diagnostic procedures and referral requests; | ||||||
11 | partial approvals and care terminations are also | ||||||
12 | considered to be denials; | ||||||
13 | (B) denial of diagnostic procedure; | ||||||
14 | dissatisfaction regarding prospective | ||||||
15 | non-authorization of a request for a diagnostic | ||||||
16 | procedure recommended by a provider; partial approvals | ||||||
17 | are also considered to be denials; | ||||||
18 | (C) denial of referral request; dissatisfaction | ||||||
19 | regarding non-authorization of a request for a | ||||||
20 | referral to another provider recommended by a primary | ||||||
21 | care provider; and | ||||||
22 | (D) claims and utilization review; dissatisfaction | ||||||
23 | regarding the concurrent or retrospective evaluation | ||||||
24 | of the coverage, medical necessity, efficiency or | ||||||
25 | appropriateness of health care services or treatment | ||||||
26 | plans; prospective "denials of care or treatment", |
| |||||||
| |||||||
1 | "denials of diagnostic procedures", and "denials of | ||||||
2 | referral requests" must not be classified in this | ||||||
3 | category, but the appropriate one above; | ||||||
4 | (8) the number of external reviews that were terminated | ||||||
5 | as the result of a reconsideration by the health carrier of | ||||||
6 | its adverse determination or final adverse determination | ||||||
7 | after the receipt of additional information from the | ||||||
8 | covered person or the covered person's authorized | ||||||
9 | representative; and | ||||||
10 | (9) any other information the Director may request or | ||||||
11 | require. | ||||||
12 | (215 ILCS 5/1670 new) | ||||||
13 | Sec. 1670. Funding of external review. The health carrier | ||||||
14 | shall be solely responsible for paying the cost of external | ||||||
15 | reviews conducted by independent review organizations. | ||||||
16 | (215 ILCS 5/1675 new) | ||||||
17 | Sec. 1675. Disclosure requirements. | ||||||
18 | (a) Each health carrier shall include a description of the | ||||||
19 | external review procedures in, or attached to, the policy, | ||||||
20 | certificate, membership booklet, and outline of coverage or | ||||||
21 | other evidence of coverage it provides to covered persons. | ||||||
22 | (b) The description required under subsection (a) of this | ||||||
23 | Section shall include a statement that informs the covered | ||||||
24 | person of the right of the covered person to file a request for |
| |||||||
| |||||||
1 | an external review of an adverse determination or final adverse | ||||||
2 | determination with the health carrier. The statement shall | ||||||
3 | explain that external review is available when the adverse | ||||||
4 | determination or final adverse determination involves an issue | ||||||
5 | of medical necessity, appropriateness, health care setting, | ||||||
6 | level of care, or effectiveness. The statement shall include | ||||||
7 | the toll-free telephone number and address of the Office of | ||||||
8 | Consumer Health Insurance within the Division of Insurance. | ||||||
9 | (c) In addition to subsection (b), the statement shall | ||||||
10 | inform the covered person that, when filing a request for an | ||||||
11 | external review, the covered person will be required to | ||||||
12 | authorize the release of any medical records of the covered | ||||||
13 | person that may be required to be reviewed for the purpose of | ||||||
14 | reaching a decision on the external review. | ||||||
15 | Section 90-10. The Small Employer Health Insurance Rating | ||||||
16 | Act is amended by changing Sections 1, 5, 10, 15, 25, and 30 as | ||||||
17 | follows:
| ||||||
18 | (215 ILCS 93/1)
| ||||||
19 | Sec. 1. Short title. This Act may be cited as the Small | ||||||
20 | Employer Health Insurance Rating Act.
| ||||||
21 | (Source: P.A. 91-510, eff. 1-1-00.)
| ||||||
22 | (215 ILCS 93/5)
| ||||||
23 | Sec. 5. Purpose. The legislature recognizes that all too |
| |||||||
| |||||||
1 | often, small
employers are forced to increase employee co-pays | ||||||
2 | and deductibles or drop
health insurance coverage altogether | ||||||
3 | because of unexpected rate increases as a
result of one major | ||||||
4 | medical problem. It is the intent of this Act to
improve the | ||||||
5 | efficiency and fairness of the small employer group health | ||||||
6 | insurance
marketplace.
| ||||||
7 | (Source: P.A. 91-510, eff. 1-1-00.)
| ||||||
8 | (215 ILCS 93/10)
| ||||||
9 | Sec. 10. Definitions. For purposes of this Act:
| ||||||
10 | "Actuarial certification" means a written statement by a | ||||||
11 | member of the
American Academy of Actuaries or other individual | ||||||
12 | acceptable to the Director
that a small employer carrier is in | ||||||
13 | compliance with the provisions of Section
25 of this Act, based | ||||||
14 | upon an examination which includes a review of the
appropriate | ||||||
15 | records and of the actuarial assumptions and methods utilized | ||||||
16 | by
the small employer carrier in establishing premium rates for | ||||||
17 | the applicable
health benefit plans.
| ||||||
18 | "Base premium rate" means for each class of business as to | ||||||
19 | a rating period,
the lowest premium rate charged or which could | ||||||
20 | be charged under a rating system
for that class of business by | ||||||
21 | the small employer carrier to small employers
with similar case | ||||||
22 | characteristics for health benefit plans with the same or
| ||||||
23 | similar coverage.
| ||||||
24 | "Carrier" means any entity which provides health insurance | ||||||
25 | in this State.
For the purposes of this Act, carrier includes a |
| |||||||
| |||||||
1 | licensed insurance company, a
prepaid hospital or medical | ||||||
2 | service plan, a health maintenance organization,
or any other | ||||||
3 | entity providing a plan of
health insurance or health benefits | ||||||
4 | subject to state insurance regulation.
| ||||||
5 | "Case characteristics" means demographic, geographic or | ||||||
6 | other objective
characteristics of a small employer, that are | ||||||
7 | considered by the small employer
carrier, in the determination | ||||||
8 | of premium rates for the small employer. Claim
experience, | ||||||
9 | health status, and duration of coverage shall not be
| ||||||
10 | characteristics
for the purposes of the Small Employer Health | ||||||
11 | Insurance Rating Act.
| ||||||
12 | "Class of business" means all or a separate grouping of | ||||||
13 | small employers
established pursuant to Section 20.
| ||||||
14 | "Director" means the Director of the Division of Insurance.
| ||||||
15 | " Division Department " means the Division of Insurance | ||||||
16 | within the Department of Financial and Professional Regulation | ||||||
17 | Insurance .
| ||||||
18 | "Health benefit plan" or "plan" shall mean any hospital or | ||||||
19 | medical
expense-incurred policy, hospital or medical service | ||||||
20 | plan
contract, or health maintenance organization subscriber | ||||||
21 | contract. Health
benefit plan shall not include individual, | ||||||
22 | accident-only, credit, dental,
vision, medicare supplement, | ||||||
23 | hospital indemnity, long term care, specific
disease, stop loss | ||||||
24 | or disability
income insurance,
coverage issued as a supplement | ||||||
25 | to liability insurance, workers' compensation
or similar | ||||||
26 | insurance, or automobile medical payment insurance.
|
| |||||||
| |||||||
1 | "Index rate" means, for each class of business as to a | ||||||
2 | rating period for
small employers with similar case | ||||||
3 | characteristics, the arithmetic mean of
the applicable base | ||||||
4 | premium rate and the corresponding highest premium rate.
| ||||||
5 | "Late enrollee" has the meaning given that term in the | ||||||
6 | Illinois Health
Insurance Portability and Accountability Act.
| ||||||
7 | "New business premium rate" means, for each class of | ||||||
8 | business as to a rating
period, the lowest premium rate charged | ||||||
9 | or offered or which could have been
charged or offered by the | ||||||
10 | small employer carrier to small employers with
similar case | ||||||
11 | characteristics for newly issued health benefit plans with the
| ||||||
12 | same or similar coverage.
| ||||||
13 | "Objective characteristics" means measurable or observable | ||||||
14 | phenomena. An
example of a measurable characteristic would be | ||||||
15 | the number of employees who
were late enrollees. Examples of | ||||||
16 | observable characteristics would be
geographic location of the | ||||||
17 | employer or gender of the employee.
| ||||||
18 | "Premium" means all monies paid by a small employer and | ||||||
19 | eligible employees as
a condition of receiving coverage from a | ||||||
20 | small employer carrier, including any
fees or other | ||||||
21 | contributions associated with the health benefit plan.
| ||||||
22 | "Rating period" means the calendar period for which premium | ||||||
23 | rates established
by a small employer carrier are assumed to be | ||||||
24 | in effect.
| ||||||
25 | "Small employer" has the meaning given that term in the | ||||||
26 | Illinois Health
Insurance Portability and Accountability Act.
|
| |||||||
| |||||||
1 | "Small employer carrier" means a carrier that offers health | ||||||
2 | benefit plans
covering employees of one or more small employers | ||||||
3 | in this State.
| ||||||
4 | (Source: P.A. 91-510, eff. 1-1-00.)
| ||||||
5 | (215 ILCS 93/15)
| ||||||
6 | Sec. 15. Applicability and scope. This Act shall apply to | ||||||
7 | each
health benefit plan for a small employer that is | ||||||
8 | delivered, issued for
delivery, renewed, or continued in this | ||||||
9 | State after July 1, 2000. For
purposes of this Section, the | ||||||
10 | date a plan is continued shall be the first
rating period which | ||||||
11 | commences after July 1, 2000. The Act shall apply to
any such | ||||||
12 | health benefit plan which provides coverage to employees of a | ||||||
13 | small
employer, except that the Act shall not apply to | ||||||
14 | individual health insurance
policies.
| ||||||
15 | (Source: P.A. 91-510, eff. 1-1-00; 92-16, eff. 6-28-01.)
| ||||||
16 | (215 ILCS 93/25)
| ||||||
17 | Sec. 25. Premium Rates. Premium rates for health benefit | ||||||
18 | plans for small employers as defined in this Section shall be | ||||||
19 | subject to the following provisions: | ||||||
20 | (a) The insurer shall develop its rates based on an | ||||||
21 | adjusted community rate and may only vary the adjusted | ||||||
22 | community rate based on: | ||||||
23 | (i) geographic area; | ||||||
24 | (ii) family size; |
| |||||||
| |||||||
1 | (iii) age; and | ||||||
2 | (iv) wellness activities. | ||||||
3 | (b) The adjustment for age in paragraph (a) may not use age | ||||||
4 | brackets smaller than 5-year increments, which shall begin with | ||||||
5 | age 20 and end with age 65. Employees under the age of 20 shall | ||||||
6 | be treated as those age 20. | ||||||
7 | (c) The insurer shall be permitted to develop separate | ||||||
8 | rates for individuals age 65 or older for coverage for which | ||||||
9 | Medicare is the primary payer and coverage for which Medicare | ||||||
10 | is not the primary payer. Both rates shall be subject to the | ||||||
11 | requirements of this Section. | ||||||
12 | (d) The permitted rates for any age group shall be no more | ||||||
13 | than 425% of the lowest rate for all age groups on January 1, | ||||||
14 | 2010, 400% on January 1, 2011, and 375% on January 1, 2013, and | ||||||
15 | thereafter. | ||||||
16 | (e) A discount for wellness activities shall be permitted | ||||||
17 | to reflect actuarially justified differences in utilization or | ||||||
18 | cost attributed to such programs. | ||||||
19 | (f) The rate charged for a health benefit plan offered | ||||||
20 | under this Section may not be adjusted more frequently than | ||||||
21 | annually, except that the premium may be changed to reflect: | ||||||
22 | (i) changes to the enrollment of the small employer; | ||||||
23 | (ii) changes to the family composition of the employee; | ||||||
24 | (iii) changes to the health benefit plan requested by | ||||||
25 | the small employer; or | ||||||
26 | (iv) changes in government requirements affecting the |
| |||||||
| |||||||
1 | health benefit plan. | ||||||
2 | (g) Rating factors shall produce premiums for identical | ||||||
3 | groups that differ only by the amounts attributable to plan | ||||||
4 | design, with the exception of discounts for health improvement | ||||||
5 | programs. | ||||||
6 | (h) For the purposes of this Section, a health benefit plan | ||||||
7 | that contains a restricted network provision shall not be | ||||||
8 | considered similar coverage to a health benefit plan that does | ||||||
9 | not contain such a provision, provided that the restrictions of | ||||||
10 | benefits to network providers result in substantial | ||||||
11 | differences in claims costs. A carrier may develop its rates | ||||||
12 | based on claims costs due to network provider reimbursement | ||||||
13 | schedules or type of network. | ||||||
14 | (i) Adjusted community rates established under this | ||||||
15 | Section shall pool the medical experience of all small | ||||||
16 | employers purchasing coverage. However, annual rate | ||||||
17 | adjustments for each small employer health benefit plan may | ||||||
18 | vary by up to plus or minus 4 percentage points from the | ||||||
19 | overall adjustment of a carrier's entire small employer pool, | ||||||
20 | such overall adjustment to be approved by the Director, upon a | ||||||
21 | showing by the carrier, certified by a member of the American | ||||||
22 | Academy of Actuaries, that: (i) the variation is a result of | ||||||
23 | deductible levels, benefit design, or provider network | ||||||
24 | characteristics; and (ii) for a rate renewal period, the | ||||||
25 | projected weighted average of all small employer benefit plans | ||||||
26 | will have a revenue neutral effect on the carrier's small |
| |||||||
| |||||||
1 | employer pool. Variations of greater than 4 percentage points | ||||||
2 | are subject to review by the Director, and must be approved or | ||||||
3 | denied within 60 days after submittal. A variation that is not | ||||||
4 | denied within 60 days shall be deemed approved. The Director | ||||||
5 | must provide to the carrier an actuarial justification for any | ||||||
6 | denial within 30 days of the denial. (a) Premium rates for | ||||||
7 | health benefit plans subject to this Act shall be
subject to | ||||||
8 | all of the following provisions:
| ||||||
9 | (1) The index rate for a rating period for any class of | ||||||
10 | business shall not
exceed the index rate for any other | ||||||
11 | class of business by more than
20%.
| ||||||
12 | (2) For a class of business, the premium rates charged | ||||||
13 | during a rating
period
to small employers with similar case | ||||||
14 | characteristics for the same or similar
coverage, or the | ||||||
15 | rates that could be charged to such employers under the
| ||||||
16 | rating system for that class of business, shall not vary | ||||||
17 | from the index rate by
more than 25% of the index rate.
| ||||||
18 | (3) The percentage increase in the premium rate charged | ||||||
19 | to a small
employer
for a new rating period shall not | ||||||
20 | exceed the sum of the following:
| ||||||
21 | (A) the percentage change in the new business | ||||||
22 | premium rate measured from
the
first day of the prior | ||||||
23 | rating period to the first day of the new rating | ||||||
24 | period.
In the case of a health benefit plan into which | ||||||
25 | the small employer carrier is
no longer enrolling new | ||||||
26 | small employers, the small employer carrier shall use
|
| |||||||
| |||||||
1 | the percentage change in the base premium rate;
| ||||||
2 | (B) an adjustment, not to exceed 15% annually and
| ||||||
3 | adjusted
pro rata for rating periods of less than one | ||||||
4 | year, due to claim experience,
health status, or | ||||||
5 | duration of coverage of the employees or dependents of | ||||||
6 | the
small employer as determined from the small | ||||||
7 | employer carrier's rate manual for
the class of | ||||||
8 | business; and
| ||||||
9 | (C) any adjustment due to change in coverage or | ||||||
10 | change in the case
characteristics of the small | ||||||
11 | employer as determined from the small employer
| ||||||
12 | carrier's rate manual for the class of business.
| ||||||
13 | (4) Adjustments in rates for a new rating period due to | ||||||
14 | claim experience,
health status and duration of coverage | ||||||
15 | shall not be charged to individual
employees or dependents. | ||||||
16 | Any such adjustment shall be applied uniformly to the
rates | ||||||
17 | charged for all employees and dependents of the small | ||||||
18 | employer.
| ||||||
19 | (5) In the case of health benefit plans delivered or | ||||||
20 | issued for delivery
prior
to the effective date of this | ||||||
21 | Act, a premium rate for a rating period may
exceed the | ||||||
22 | ranges set forth in items (1) and (2) of subsection
(a) for | ||||||
23 | a period
of 3 years following the effective date of this | ||||||
24 | Act. In such case, the
percentage increase in the premium | ||||||
25 | rate charged to a small employer for a new
rating period | ||||||
26 | shall not exceed the sum of the following:
|
| |||||||
| |||||||
1 | (A) the percentage change in the new business | ||||||
2 | premium rate measured from
the
first day of the prior | ||||||
3 | rating period to the first day of the new rating | ||||||
4 | period;
in
the case of a class of business into which | ||||||
5 | the small employer carrier is no
longer enrolling new | ||||||
6 | small employes, the small employer carrier shall use | ||||||
7 | the
percentage change in the base premium rate, | ||||||
8 | provided that such change does not
exceed, on a | ||||||
9 | percentage basis, the change in the new business | ||||||
10 | premium rate for
the most similar class of business | ||||||
11 | into which the small employer carrier is
actively | ||||||
12 | enrolling new small employers; and
| ||||||
13 | (B) any adjustment due to change in coverage or | ||||||
14 | change in the case
characteristics of the small | ||||||
15 | employer as determined from the carrier's rate
manual | ||||||
16 | for the class of business.
| ||||||
17 | (6) Small employer carriers shall apply rating | ||||||
18 | factors, including case
characteristics, consistently with | ||||||
19 | respect to all small employers in a class of
business.
A | ||||||
20 | small employer carrier shall treat all health benefit plans | ||||||
21 | issued or
renewed in the same calendar month as having the | ||||||
22 | same rating period.
| ||||||
23 | (7) For the purposes of this subsection, a health | ||||||
24 | benefit plan that
contains
a restricted network provision | ||||||
25 | shall not be considered similar coverage to a
health | ||||||
26 | benefit plan that does not contain such a provision, |
| |||||||
| |||||||
1 | provided that the
restriction of benefits to network | ||||||
2 | providers results in substantial differences
in claim | ||||||
3 | costs.
| ||||||
4 | (b) A small employer carrier shall not transfer a small | ||||||
5 | employer
involuntarily into or out of a class of business. A | ||||||
6 | small employer carrier
shall not offer to transfer a small | ||||||
7 | employer into or out of a class of business
unless such offer | ||||||
8 | is made to transfer all small employers in the class of
| ||||||
9 | business without regard to case characteristics, claim | ||||||
10 | experience, health
status or duration of coverage since issue.
| ||||||
11 | (Source: P.A. 91-510, eff. 1-1-00.)
| ||||||
12 | (215 ILCS 93/30)
| ||||||
13 | Sec. 30. Rating and underwriting records.
| ||||||
14 | (a) A small employer carrier shall maintain at its | ||||||
15 | principal place of
business a complete and detailed description | ||||||
16 | of its rating practices and
renewal underwriting practices, | ||||||
17 | including information and documentation that
demonstrates that | ||||||
18 | its rating methods and practices are based upon commonly
| ||||||
19 | accepted actuarial assumptions and are in accordance with sound | ||||||
20 | actuarial
principles.
| ||||||
21 | (b) A small employer carrier shall file with the Director | ||||||
22 | annually on or
before May 15, an actuarial certification | ||||||
23 | certifying that the carrier is in
compliance with this Act, and | ||||||
24 | that the rating methods of the small employer
carrier are | ||||||
25 | actuarially sound. Such certification shall be in a form and
|
| |||||||
| |||||||
1 | manner, and shall contain such information, as specified by the | ||||||
2 | Director. A
copy of the certification shall be retained by the | ||||||
3 | small employer carrier at
its principal place of business for a | ||||||
4 | period of three years from the date of
certification. This | ||||||
5 | shall include any work papers prepared in support of the
| ||||||
6 | actuarial certification.
| ||||||
7 | (c) A small employer carrier shall make the information and | ||||||
8 | documentation
described in subsection (a) available to the | ||||||
9 | Director upon request. Except in
cases of violations of this | ||||||
10 | Act, the information shall be considered
proprietary and trade | ||||||
11 | secret information and shall not be subject to disclosure
by | ||||||
12 | the Director to persons outside of the Division Department | ||||||
13 | except as agreed to by the
small employer carrier or as ordered | ||||||
14 | by a court of competent jurisdiction.
| ||||||
15 | (Source: P.A. 91-510, eff. 1-1-00.)
| ||||||
16 | Section 90-15. The Illinois Health Insurance Portability | ||||||
17 | and Accountability Act is amended by changing Section 5 as | ||||||
18 | follows:
| ||||||
19 | (215 ILCS 97/5)
| ||||||
20 | Sec. 5. Definitions.
| ||||||
21 | "Affiliate" means a person that directly, or indirectly | ||||||
22 | through one or more intermediaries, controls, is controlled by, | ||||||
23 | or is under common control with the person specified.
| ||||||
24 | "Beneficiary" has the meaning given such term under Section
|
| |||||||
| |||||||
1 | 3(8) of the Employee Retirement Income Security Act of 1974.
| ||||||
2 | "Bona fide association" means, with respect to health
| ||||||
3 | insurance coverage offered in a State, an association which:
| ||||||
4 | (1) has been actively in existence for at least 5
| ||||||
5 | years;
| ||||||
6 | (2) has been formed and maintained in good faith for
| ||||||
7 | purposes other than obtaining insurance;
| ||||||
8 | (3) does not condition membership in the association on
| ||||||
9 | any health status-related factor relating to an individual | ||||||
10 | (including an
employee of an employer or a
dependent of an | ||||||
11 | employee);
| ||||||
12 | (4) makes health insurance coverage offered through | ||||||
13 | the
association available to all members regardless of any
| ||||||
14 | health status-related factor relating to such members
(or | ||||||
15 | individuals eligible for coverage through a member);
| ||||||
16 | (5) does not make health insurance coverage offered
| ||||||
17 | through the association available other than in
connection | ||||||
18 | with a member of the association; and
| ||||||
19 | (6) meets such additional requirements as may be
| ||||||
20 | imposed under State law.
| ||||||
21 | "Church plan" has the meaning given that term under Section
| ||||||
22 | 3(33) of the Employee Retirement Income Security Act of 1974.
| ||||||
23 | "COBRA continuation provision" means any of the following:
| ||||||
24 | (1) Section 4980B of the Internal Revenue Code of 1986,
| ||||||
25 | other than subsection (f)(1) of that Section insofar
as it | ||||||
26 | relates to pediatric vaccines.
|
| |||||||
| |||||||
1 | (2) Part 6 of subtitle B of title I of the Employee
| ||||||
2 | Retirement Income Security Act of 1974, other than
Section | ||||||
3 | 609 of that Act.
| ||||||
4 | (3) Title XXII of federal Public Health Service Act.
| ||||||
5 | "Control" means the possession, direct or indirect, of the | ||||||
6 | power to direct or cause the direction of the management and | ||||||
7 | policies of a person, whether through the ownership of voting | ||||||
8 | securities, the holding of policyholders' proxies by contract | ||||||
9 | other than a commercial contract for goods or non-management | ||||||
10 | services, or otherwise, unless the power is solely the result | ||||||
11 | of an official position with or corporate office held by the | ||||||
12 | person. Control is presumed to exist if any person, directly or | ||||||
13 | indirectly, owns, controls, holds with the power to vote, or | ||||||
14 | holds shareholders' proxies representing 10% or more of the | ||||||
15 | voting securities of any other person or holds or controls | ||||||
16 | sufficient policyholders' proxies to elect the majority of the | ||||||
17 | board of directors of the domestic company. This presumption | ||||||
18 | may be rebutted by a showing made in a manner as the Secretary | ||||||
19 | may provide by rule. The Secretary may determine, after | ||||||
20 | furnishing all persons in interest notice and opportunity to be | ||||||
21 | heard and making specific findings of fact to support such | ||||||
22 | determination, that control exists in fact, notwithstanding | ||||||
23 | the absence of a presumption to that effect.
| ||||||
24 | "Department" means the Department of Insurance.
| ||||||
25 | "Employee" has the meaning given that term under Section | ||||||
26 | 3(6)
of the Employee Retirement Income Security Act of 1974.
|
| |||||||
| |||||||
1 | "Employer" has the meaning given that term under Section | ||||||
2 | 3(5)
of the Employee Retirement Income Security Act of 1974 , | ||||||
3 | except
that the term shall include only employers of 2 or more
| ||||||
4 | employees .
| ||||||
5 | "Enrollment date" means, with respect to an individual | ||||||
6 | covered under a group
health plan or group health insurance | ||||||
7 | coverage, the date of enrollment of the
individual in the plan | ||||||
8 | or coverage, or if earlier, the first day of the waiting
period | ||||||
9 | for enrollment.
| ||||||
10 | "Federal governmental plan" means a governmental plan | ||||||
11 | established
or maintained for its employees by the government | ||||||
12 | of
the United States or by any agency or instrumentality of | ||||||
13 | that
government.
| ||||||
14 | "Governmental plan" has the meaning given that term under
| ||||||
15 | Section 3(32) of the Employee Retirement Income Security Act
of | ||||||
16 | 1974 and any federal governmental plan.
| ||||||
17 | "Group health insurance coverage" means, in connection | ||||||
18 | with a
group health plan, health insurance coverage offered in
| ||||||
19 | connection with the plan.
| ||||||
20 | "Group health plan" means an employee welfare benefit plan | ||||||
21 | (as
defined in Section 3(1) of the Employee Retirement Income
| ||||||
22 | Security Act of 1974) to the extent that the plan provides
| ||||||
23 | medical care (as defined in paragraph (2) of that Section and | ||||||
24 | including items
and services paid for as medical care) to | ||||||
25 | employees or their
dependents (as defined under the terms of | ||||||
26 | the plan) directly
or through insurance, reimbursement, or |
| |||||||
| |||||||
1 | otherwise.
| ||||||
2 | "Health insurance coverage" means benefits consisting of
| ||||||
3 | medical care (provided directly, through insurance or
| ||||||
4 | reimbursement, or otherwise and including items and services | ||||||
5 | paid for
as medical care) under any hospital or medical service | ||||||
6 | policy
or certificate, hospital or medical service plan | ||||||
7 | contract, or
health maintenance organization contract offered | ||||||
8 | by a health
insurance issuer.
| ||||||
9 | "Health insurance issuer" means an insurance company,
| ||||||
10 | insurance service, or insurance organization (including a
| ||||||
11 | health maintenance organization, as defined herein) which is
| ||||||
12 | licensed to engage in the business of insurance in a state and
| ||||||
13 | which is subject to Illinois law which regulates insurance | ||||||
14 | (within the
meaning of Section 514(b)(2) of the Employee | ||||||
15 | Retirement Income
Security Act of 1974). The term does not | ||||||
16 | include a group
health plan.
| ||||||
17 | "Health maintenance organization (HMO)" means:
| ||||||
18 | (1) a Federally qualified health maintenance | ||||||
19 | organization
(as defined in Section 1301(a) of the Public | ||||||
20 | Health Service Act.);
| ||||||
21 | (2) an organization recognized under State law as a | ||||||
22 | health
maintenance organization; or
| ||||||
23 | (3) a similar organization regulated under State law | ||||||
24 | for
solvency in the same manner and to the same extent as
| ||||||
25 | such a health maintenance organization.
| ||||||
26 | "Individual health insurance coverage" means health |
| |||||||
| |||||||
1 | insurance
coverage offered to individuals in the individual | ||||||
2 | market, but
does not include short-term limited duration | ||||||
3 | insurance.
| ||||||
4 | "Individual market" means the market for health insurance
| ||||||
5 | coverage offered to individuals other than in connection with a
| ||||||
6 | group health plan.
| ||||||
7 | "Large employer" means, in connection with a group health | ||||||
8 | plan
with respect to a calendar year and a plan year, an | ||||||
9 | employer
who employed an average of at least 51 employees on | ||||||
10 | business
days during the preceding calendar year and who | ||||||
11 | employs at
least 2 employees on the first day of the plan year.
| ||||||
12 | (1) Application of aggregation rule for large | ||||||
13 | employers. All persons
treated as a single employer under | ||||||
14 | subsection (b), (c), (m),
or (o) of Section 414 of the | ||||||
15 | Internal Revenue Code of 1986
shall be treated as one | ||||||
16 | employer.
| ||||||
17 | (2) Employers not in existence in preceding year. In | ||||||
18 | the case
of an employer which was not in existence | ||||||
19 | throughout the
preceding calendar year, the determination | ||||||
20 | of whether the
employer is a large employer shall be based | ||||||
21 | on the average
number of
employees that it is reasonably | ||||||
22 | expected the employer will
employ on business days in the | ||||||
23 | current calendar year.
| ||||||
24 | (3) Predecessors. Any reference in this Act to an
| ||||||
25 | employer shall include a reference to any predecessor of | ||||||
26 | such
employer.
|
| |||||||
| |||||||
1 | "Large group market" means the health insurance market | ||||||
2 | under
which individuals obtain health insurance coverage | ||||||
3 | (directly
or through any arrangement) on behalf of themselves | ||||||
4 | (and their
dependents) through a group health plan maintained | ||||||
5 | by a large
employer.
| ||||||
6 | "Late enrollee" means with respect to coverage under a | ||||||
7 | group health plan, a
participant or beneficiary who enrolls | ||||||
8 | under the plan other than during:
| ||||||
9 | (1) the first period in which the individual is | ||||||
10 | eligible to enroll under
the plan; or
| ||||||
11 | (2) a special enrollment period under subsection (F) of | ||||||
12 | Section 20.
| ||||||
13 | "Medical care" means amounts paid for:
| ||||||
14 | (1) the diagnosis, cure, mitigation, treatment, or
| ||||||
15 | prevention of disease, or amounts paid for the purpose
of | ||||||
16 | affecting any structure or function of the body;
| ||||||
17 | (2) amounts paid for transportation primarily for and
| ||||||
18 | essential to medical care referred to in item (1); and
| ||||||
19 | (3) amounts paid for insurance covering medical care
| ||||||
20 | referred to in items (1) and (2).
| ||||||
21 | "Nonfederal governmental plan" means a governmental plan | ||||||
22 | that
is not a federal governmental plan.
| ||||||
23 | "Network plan" means health insurance coverage of a health
| ||||||
24 | insurance issuer under which the financing and delivery of
| ||||||
25 | medical care (including items and services paid for as medical
| ||||||
26 | care) are provided, in whole or in part, through a defined set
|
| |||||||
| |||||||
1 | of providers under contract with the issuer.
| ||||||
2 | "Participant" has the meaning given that term under Section
| ||||||
3 | 3(7) of the Employee Retirement Income Security Act of 1974.
| ||||||
4 | "Person" means an individual, a corporation, a | ||||||
5 | partnership, an association, a joint stock company, a trust, an | ||||||
6 | unincorporated organization, any similar entity, or any | ||||||
7 | combination of the foregoing acting in concert, but does not | ||||||
8 | include any securities broker performing no more than the usual | ||||||
9 | and customary broker's function or joint venture partnership | ||||||
10 | exclusively engaged in owning, managing, leasing, or | ||||||
11 | developing real or tangible personal property other than | ||||||
12 | capital stock.
| ||||||
13 | "Placement" or being "placed" for adoption, in connection
| ||||||
14 | with any placement for adoption of a child with any person,
| ||||||
15 | means the assumption and retention by the person of a legal
| ||||||
16 | obligation for total or partial support of the child in
| ||||||
17 | anticipation of adoption of the child. The child's placement
| ||||||
18 | with the person terminates upon the termination of the legal
| ||||||
19 | obligation.
| ||||||
20 | "Plan sponsor" has the meaning given that term under | ||||||
21 | Section
3(16)(B) of the Employee Retirement Income Security Act | ||||||
22 | of
1974.
| ||||||
23 | "Preexisting condition
exclusion" means, with respect to | ||||||
24 | coverage, a
limitation or exclusion of benefits relating to a
| ||||||
25 | condition based on the fact that the condition was
present | ||||||
26 | before the date of enrollment for such
coverage, whether or not |
| |||||||
| |||||||
1 | any medical advice,
diagnosis, care, or treatment was | ||||||
2 | recommended or
received before such date.
| ||||||
3 | "Small employer" means, in connection with a group
health | ||||||
4 | plan with respect to a calendar year and a plan year,
an | ||||||
5 | employer who employed an average of at least 2 but not more
| ||||||
6 | than 50 employees on business days during the preceding | ||||||
7 | calendar year and who
employs at least one employee 2 employees | ||||||
8 | on the first day
of the plan year. This term shall include | ||||||
9 | self-employed persons.
| ||||||
10 | (1) Application of aggregation rule for small | ||||||
11 | employers. All persons
treated as a single employer under | ||||||
12 | subsection (b), (c), (m),
or (o) of Section 414 of the | ||||||
13 | Internal Revenue Code of 1986
shall be treated as one | ||||||
14 | employer.
| ||||||
15 | (2) Employers not in existence in preceding year. In | ||||||
16 | the case
of an employer which was not in existence | ||||||
17 | throughout the
preceding calendar year, the determination | ||||||
18 | of whether the
employer is a small employer shall be based | ||||||
19 | on the average
number of employees that it is reasonably | ||||||
20 | expected the
employer will employ on business days in the | ||||||
21 | current calendar
year.
| ||||||
22 | (3) Predecessors. Any reference in this Act to a small
| ||||||
23 | employer shall include a reference to any predecessor of | ||||||
24 | that
employer.
| ||||||
25 | "Small group market" means the health insurance market | ||||||
26 | under
which individuals obtain health insurance coverage |
| |||||||
| |||||||
1 | (directly
or through any arrangement) on behalf of themselves | ||||||
2 | (and their
dependents) through a group health plan maintained | ||||||
3 | by a small
employer.
| ||||||
4 | "State" means each of the several States, the District of
| ||||||
5 | Columbia, Puerto Rico, the Virgin Islands, Guam, American
| ||||||
6 | Samoa, and the Northern Mariana Islands.
| ||||||
7 | "Waiting period" means with respect to a group health plan | ||||||
8 | and an individual
who is a potential participant or beneficiary | ||||||
9 | in the plan, the period of time
that must pass with respect to | ||||||
10 | the individual before the individual is eligible
to be covered | ||||||
11 | for benefits under the terms of the plan.
| ||||||
12 | (Source: P.A. 94-502, eff. 8-8-05.)
| ||||||
13 | Section 90-20. The Managed Care Reform and Patient Rights | ||||||
14 | Act is amended by changing Sections 40 and 45 as follows:
| ||||||
15 | (215 ILCS 134/40)
| ||||||
16 | Sec. 40. Access to specialists.
| ||||||
17 | (a) All health care plans that require each enrollee to | ||||||
18 | select a
health care provider for any purpose including | ||||||
19 | coordination of
care shall
permit an enrollee to choose any | ||||||
20 | available primary care physician licensed to
practice
medicine | ||||||
21 | in all its branches participating in
the health care plan for | ||||||
22 | that purpose.
The health care plan shall provide the enrollee | ||||||
23 | with a choice of licensed
health care providers who are | ||||||
24 | accessible and
qualified. Nothing in
this Act shall be |
| |||||||
| |||||||
1 | construed to prohibit a health care plan from requiring a
| ||||||
2 | health care provider to meet the health care plan's criteria in | ||||||
3 | order to
coordinate access to health care.
| ||||||
4 | (b) A health care plan shall establish a procedure by which | ||||||
5 | an enrollee who
has a condition that requires ongoing care from | ||||||
6 | a specialist physician
or other health care provider may apply | ||||||
7 | for a
standing referral to a specialist physician or other | ||||||
8 | health care provider if a
referral to a specialist
physician or | ||||||
9 | other health care provider is required for
coverage.
The | ||||||
10 | application shall be made to the enrollee's primary care | ||||||
11 | physician.
This procedure for a standing referral must specify
| ||||||
12 | the necessary criteria and conditions that must be met in order | ||||||
13 | for an enrollee
to obtain a standing referral.
A standing | ||||||
14 | referral shall be effective for the period
necessary to provide | ||||||
15 | the referred services or one year, except in the event of
| ||||||
16 | termination of a contract or policy in which case Section 25 on | ||||||
17 | transition of
services shall apply, if applicable.
A primary | ||||||
18 | care physician may renew and re-renew a standing referral.
| ||||||
19 | (c) The enrollee may be required by the health care plan to | ||||||
20 | select a
specialist physician or other health care provider who | ||||||
21 | has a referral
arrangement with the enrollee's
primary care | ||||||
22 | physician or to select a new primary care physician who has a
| ||||||
23 | referral arrangement with the specialist physician or other | ||||||
24 | health care
provider chosen by the enrollee.
If a health care | ||||||
25 | plan requires an enrollee to select a new physician under
this | ||||||
26 | subsection, the health care plan must provide the enrollee with
|
| |||||||
| |||||||
1 | both
options provided in this subsection.
When a participating | ||||||
2 | specialist with a referral arrangement is not available,
the | ||||||
3 | primary care physician, in consultation with the enrollee, | ||||||
4 | shall arrange
for the enrollee to have access to a qualified | ||||||
5 | participating health care
provider, and the enrollee shall be | ||||||
6 | allowed to stay with his or her primary
care physician.
If a | ||||||
7 | secondary referral is necessary, the specialist physician or | ||||||
8 | other health
care provider shall advise the primary care | ||||||
9 | physician. The primary care
physician shall be responsible for | ||||||
10 | making the secondary referral. In addition,
the health care | ||||||
11 | plan shall require the specialist physician or other health
| ||||||
12 | care
provider to provide regular updates to the enrollee's | ||||||
13 | primary care physician.
| ||||||
14 | (d) When the type of specialist physician or other health | ||||||
15 | care provider
needed to provide ongoing care
for a
specific | ||||||
16 | condition is not represented in the health care plan's provider
| ||||||
17 | network, the primary care physician shall arrange for the | ||||||
18 | enrollee to have
access to
a qualified non-participating health | ||||||
19 | care provider
within a reasonable distance and travel
time at | ||||||
20 | no additional cost beyond what the enrollee would otherwise pay | ||||||
21 | for
services received within the network. The referring | ||||||
22 | physician
shall notify the plan when a referral is made outside | ||||||
23 | the network.
| ||||||
24 | (e) The enrollee's primary care physician shall remain | ||||||
25 | responsible for
coordinating the care of an enrollee who has | ||||||
26 | received a standing referral to a
specialist physician or other |
| |||||||
| |||||||
1 | health care provider.
If a secondary referral is necessary, the | ||||||
2 | specialist physician or other health
care provider shall advise
| ||||||
3 | the primary care physician. The primary care physician shall be | ||||||
4 | responsible
for making the secondary referral.
In addition,
the | ||||||
5 | health care plan shall require the specialist physician or | ||||||
6 | other health
care
provider to provide
regular updates to the | ||||||
7 | enrollee's primary care physician.
| ||||||
8 | (f) If an enrollee's application for any referral is | ||||||
9 | denied, an
enrollee may appeal the decision through the
health | ||||||
10 | care plan's external independent review process as provided by | ||||||
11 | the Illinois Health Carrier External Review Law in accordance | ||||||
12 | with
subsection (f) of Section 45 of this Act .
| ||||||
13 | (g) Nothing in this Act shall be construed to require an | ||||||
14 | enrollee to select
a new primary care physician when no | ||||||
15 | referral arrangement exists between the
enrollee's primary | ||||||
16 | care physician and the specialist selected by the enrollee
and | ||||||
17 | when the enrollee has a long-standing relationship with his or | ||||||
18 | her primary
care physician.
| ||||||
19 | (h) In promulgating rules to implement this Act, the | ||||||
20 | Department shall
define
"standing referral" and "ongoing | ||||||
21 | course of treatment".
| ||||||
22 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
23 | (215 ILCS 134/45)
| ||||||
24 | Sec. 45. Health care services appeals and ,
complaints , and
| ||||||
25 | external independent reviews . |
| |||||||
| |||||||
1 | (a) A health care plan shall establish and maintain an | ||||||
2 | appeals procedure as
outlined in this Act. Compliance with this | ||||||
3 | Act's appeals procedures shall
satisfy a health care plan's | ||||||
4 | obligation to provide appeal procedures under any
other State | ||||||
5 | law or rules.
All appeals of a health care plan's | ||||||
6 | administrative determinations and
complaints regarding its | ||||||
7 | administrative decisions shall be handled as required
under | ||||||
8 | Section 50.
| ||||||
9 | (b) When an appeal concerns a decision or action by a | ||||||
10 | health care plan,
its
employees, or its subcontractors that | ||||||
11 | relates to (i) health care services,
including, but not limited | ||||||
12 | to, procedures or
treatments,
for an enrollee with an ongoing | ||||||
13 | course of treatment ordered
by a health care provider,
the | ||||||
14 | denial of which could significantly
increase the risk to an
| ||||||
15 | enrollee's health,
or (ii) a treatment referral, service,
| ||||||
16 | procedure, or other health care service,
the denial of which | ||||||
17 | could significantly
increase the risk to an
enrollee's health,
| ||||||
18 | the health care plan must allow for the filing of an appeal
| ||||||
19 | either orally or in writing. Upon submission of the appeal, a | ||||||
20 | health care plan
must notify the party filing the appeal, as | ||||||
21 | soon as possible, but in no event
more than 24 hours after the | ||||||
22 | submission of the appeal, of all information
that the plan | ||||||
23 | requires to evaluate the appeal.
The health care plan shall | ||||||
24 | render a decision on the appeal within
24 hours after receipt | ||||||
25 | of the required information. The health care plan shall
notify | ||||||
26 | the party filing the
appeal and the enrollee, enrollee's |
| |||||||
| |||||||
1 | primary care physician, and any health care
provider who | ||||||
2 | recommended the health care service involved in the appeal of | ||||||
3 | its
decision orally
followed-up by a written notice of the | ||||||
4 | determination.
| ||||||
5 | (c) For all appeals related to health care services | ||||||
6 | including, but not
limited to, procedures or treatments for an | ||||||
7 | enrollee and not covered by
subsection (b) above, the health | ||||||
8 | care
plan shall establish a procedure for the filing of such | ||||||
9 | appeals. Upon
submission of an appeal under this subsection, a | ||||||
10 | health care plan must notify
the party filing an appeal, within | ||||||
11 | 3 business days, of all information that the
plan requires to | ||||||
12 | evaluate the appeal.
The health care plan shall render a | ||||||
13 | decision on the appeal within 15 business
days after receipt of | ||||||
14 | the required information. The health care plan shall
notify the | ||||||
15 | party filing the appeal,
the enrollee, the enrollee's primary | ||||||
16 | care physician, and any health care
provider
who recommended | ||||||
17 | the health care service involved in the appeal orally of its
| ||||||
18 | decision followed-up by a written notice of the determination.
| ||||||
19 | (d) An appeal under subsection (b) or (c) may be filed by | ||||||
20 | the
enrollee, the enrollee's designee or guardian, the | ||||||
21 | enrollee's primary care
physician, or the enrollee's health | ||||||
22 | care provider. A health care plan shall
designate a clinical | ||||||
23 | peer to review
appeals, because these appeals pertain to | ||||||
24 | medical or clinical matters
and such an appeal must be reviewed | ||||||
25 | by an appropriate
health care professional. No one reviewing an | ||||||
26 | appeal may have had any
involvement
in the initial |
| |||||||
| |||||||
1 | determination that is the subject of the appeal. The written
| ||||||
2 | notice of determination required under subsections (b) and (c) | ||||||
3 | shall
include (i) clear and detailed reasons for the | ||||||
4 | determination, (ii)
the medical or
clinical criteria for the | ||||||
5 | determination, which shall be based upon sound
clinical | ||||||
6 | evidence and reviewed on a periodic basis, and (iii) in the | ||||||
7 | case of an
adverse determination, the
procedures for requesting | ||||||
8 | an external independent review as provided by the Illinois | ||||||
9 | Health Carrier External Review Law under subsection (f) .
| ||||||
10 | (e) If an appeal filed under subsection (b) or (c) is | ||||||
11 | denied for a reason
including, but not limited to, the
service, | ||||||
12 | procedure, or treatment is not viewed as medically necessary,
| ||||||
13 | denial of specific tests or procedures, denial of referral
to | ||||||
14 | specialist physicians or denial of hospitalization requests or | ||||||
15 | length of
stay requests, any involved party may request an | ||||||
16 | external independent review as provided by the Illinois Health | ||||||
17 | Carrier External Review Law
under subsection (f) of the adverse | ||||||
18 | determination .
| ||||||
19 | (f) External independent review.
| ||||||
20 | (1) The party seeking an external independent review | ||||||
21 | shall so notify the
health care plan.
The health care plan | ||||||
22 | shall seek to resolve all
external independent
reviews in | ||||||
23 | the most expeditious manner and shall make a determination | ||||||
24 | and
provide notice of the determination no more
than 24 | ||||||
25 | hours after the receipt of all necessary information when a | ||||||
26 | delay would
significantly increase
the risk to an |
| |||||||
| |||||||
1 | enrollee's health or when extended health care services for | ||||||
2 | an
enrollee undergoing a
course of treatment prescribed by | ||||||
3 | a health care provider are at issue.
| ||||||
4 | (2) Within 30 days after the enrollee receives written | ||||||
5 | notice of an
adverse
determination,
if the enrollee decides | ||||||
6 | to initiate an external independent review, the
enrollee | ||||||
7 | shall send to the health
care plan a written request for an | ||||||
8 | external independent review, including any
information or
| ||||||
9 | documentation to support the enrollee's request for the | ||||||
10 | covered service or
claim for a covered
service.
| ||||||
11 | (3) Within 30 days after the health care plan receives | ||||||
12 | a request for an
external
independent review from an | ||||||
13 | enrollee, the health care plan shall:
| ||||||
14 | (A) provide a mechanism for joint selection of an | ||||||
15 | external independent
reviewer by the enrollee, the | ||||||
16 | enrollee's physician or other health care
provider,
| ||||||
17 | and the health care plan; and
| ||||||
18 | (B) forward to the independent reviewer all | ||||||
19 | medical records and
supporting
documentation | ||||||
20 | pertaining to the case, a summary description of the | ||||||
21 | applicable
issues including a
statement of the health | ||||||
22 | care plan's decision, the criteria used, and the
| ||||||
23 | medical and clinical reasons
for that decision.
| ||||||
24 | (4) Within 5 days after receipt of all necessary | ||||||
25 | information, the
independent
reviewer
shall evaluate and | ||||||
26 | analyze the case and render a decision that is based on
|
| |||||||
| |||||||
1 | whether or not the health
care service or claim for the | ||||||
2 | health care service is medically appropriate. The
decision | ||||||
3 | by the
independent reviewer is final. If the external | ||||||
4 | independent reviewer determines
the health care
service to | ||||||
5 | be medically
appropriate, the health
care plan shall pay | ||||||
6 | for the health care service.
| ||||||
7 | (5) The health care plan shall be solely responsible | ||||||
8 | for paying the fees
of the external
independent reviewer | ||||||
9 | who is selected to perform the review.
| ||||||
10 | (6) An external independent reviewer who acts in good | ||||||
11 | faith shall have
immunity
from any civil or criminal | ||||||
12 | liability or professional discipline as a result of
acts or | ||||||
13 | omissions with
respect to any external independent review, | ||||||
14 | unless the acts or omissions
constitute wilful and wanton
| ||||||
15 | misconduct. For purposes of any proceeding, the good faith | ||||||
16 | of the person
participating shall be
presumed.
| ||||||
17 | (7) Future contractual or employment action by the | ||||||
18 | health care plan
regarding the
patient's physician or other | ||||||
19 | health care provider shall not be based solely on
the | ||||||
20 | physician's or other
health care provider's participation | ||||||
21 | in this procedure.
| ||||||
22 | (8) For the purposes of this Section, an external | ||||||
23 | independent reviewer
shall:
| ||||||
24 | (A) be a clinical peer;
| ||||||
25 | (B) have no direct financial interest in | ||||||
26 | connection with the case; and
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1 | (C) have not been informed of the specific identity | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2 | of the enrollee.
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3 | (g) Nothing in this Section shall be construed to require a | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4 | health care
plan to pay for a health care service not covered | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5 | under the enrollee's
certificate of coverage or policy.
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6 | (Source: P.A. 91-617, eff. 1-1-00.)
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7 | (215 ILCS 93/20 rep.)
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8 | Section 90-25. The Small Employer Health Insurance Rating | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9 | Act is amended by repealing Section 20.
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||