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1 | AN ACT concerning insurance.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by adding | ||||||
5 | Sections 359a.1 and 359a.2 and Article XLV and by changing | ||||||
6 | Section 370c as follows: | ||||||
7 | (215 ILCS 5/359a.1 new) | ||||||
8 | Sec. 359a.1. Standard small group applications. The | ||||||
9 | Director shall develop, by rule, a standard application form | ||||||
10 | for use by small employers applying for coverage under a health | ||||||
11 | benefit plan offered by small employer carriers. Small employer | ||||||
12 | carriers shall be required to use the standard application form | ||||||
13 | not less than 6 months after the rules developing the form | ||||||
14 | become effective. The Director shall revise the standard | ||||||
15 | application form at least every 3 years. For purposes of this | ||||||
16 | Section, "health benefit plan", "small employer", and "small | ||||||
17 | employer carrier" shall have the meaning given those terms in | ||||||
18 | the Small Employer Health Insurance Rating Act. | ||||||
19 | (215 ILCS 5/359a.2 new) | ||||||
20 | Sec. 359a.2. Standard individual market health statements. | ||||||
21 | The Director shall develop, by rule, a standard health | ||||||
22 | statement for use by individuals applying for a health benefit |
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1 | plan in the individual market. All carriers who offer health | ||||||
2 | benefit plans in the individual market and evaluate the health | ||||||
3 | status of individuals shall be required to use the standard | ||||||
4 | health statement not less than 6 months after the statement | ||||||
5 | becomes effective and thereafter may not use any other method | ||||||
6 | to determine the health status of an individual. Nothing in | ||||||
7 | this Section shall prevent a carrier from using health | ||||||
8 | information after enrollment for the purpose of providing | ||||||
9 | services or arranging for the provision of services under a | ||||||
10 | health benefit plan. For purposes of this Section, "health | ||||||
11 | benefit plan" shall have the meaning given the term in the | ||||||
12 | Small Employer Health Insurance Rating Act and "individual | ||||||
13 | market" shall have meaning given the term in the Illinois | ||||||
14 | Health Insurance Portability and Accountability Act.
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15 | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
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16 | Sec. 370c. Mental and emotional disorders.
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17 | (a) (1) On and after the effective date of this Section,
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18 | every insurer which delivers, issues for delivery or renews or | ||||||
19 | modifies
group A&H policies providing coverage for hospital or | ||||||
20 | medical treatment or
services for illness on an | ||||||
21 | expense-incurred basis shall offer to the
applicant or group | ||||||
22 | policyholder subject to the insurers standards of
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23 | insurability, coverage for reasonable and necessary treatment | ||||||
24 | and services
for mental, emotional or nervous disorders or | ||||||
25 | conditions, other than serious
mental illnesses as defined in |
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1 | item (2) of subsection (b), up to the limits
provided in the | ||||||
2 | policy for other disorders or conditions, except (i) the
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3 | insured may be required to pay up to 50% of expenses incurred | ||||||
4 | as a result
of the treatment or services, and (ii) the annual | ||||||
5 | benefit limit may be
limited to the lesser of $10,000 or 25% of | ||||||
6 | the lifetime policy limit.
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7 | (2) Each insured that is covered for mental, emotional or | ||||||
8 | nervous
disorders or conditions shall be free to select the | ||||||
9 | physician licensed to
practice medicine in all its branches, | ||||||
10 | licensed clinical psychologist,
licensed clinical social | ||||||
11 | worker, licensed clinical professional counselor, or licensed | ||||||
12 | marriage and family therapist of
his choice to treat such | ||||||
13 | disorders, and
the insurer shall pay the covered charges of | ||||||
14 | such physician licensed to
practice medicine in all its | ||||||
15 | branches, licensed clinical psychologist,
licensed clinical | ||||||
16 | social worker, licensed clinical professional counselor, or | ||||||
17 | licensed marriage and family therapist up
to the limits of | ||||||
18 | coverage, provided (i)
the disorder or condition treated is | ||||||
19 | covered by the policy, and (ii) the
physician, licensed | ||||||
20 | psychologist, licensed clinical social worker, licensed
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21 | clinical professional counselor, or licensed marriage and | ||||||
22 | family therapist is
authorized to provide said services under | ||||||
23 | the statutes of this State and in
accordance with accepted | ||||||
24 | principles of his profession.
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25 | (3) Insofar as this Section applies solely to licensed | ||||||
26 | clinical social
workers, licensed clinical professional |
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1 | counselors, and licensed marriage and family therapists, those | ||||||
2 | persons who may
provide services to individuals shall do so
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3 | after the licensed clinical social worker, licensed clinical | ||||||
4 | professional
counselor, or licensed marriage and family | ||||||
5 | therapist has informed the patient of the
desirability of the | ||||||
6 | patient conferring with the patient's primary care
physician | ||||||
7 | and the licensed clinical social worker, licensed clinical
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8 | professional counselor, or licensed marriage and family | ||||||
9 | therapist has
provided written
notification to the patient's | ||||||
10 | primary care physician, if any, that services
are being | ||||||
11 | provided to the patient. That notification may, however, be
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12 | waived by the patient on a written form. Those forms shall be | ||||||
13 | retained by
the licensed clinical social worker, licensed | ||||||
14 | clinical professional counselor, or licensed marriage and | ||||||
15 | family therapist
for a period of not less than 5 years.
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16 | (b) (1) An insurer that provides coverage for hospital or | ||||||
17 | medical
expenses under a group policy of accident and health | ||||||
18 | insurance or
health care plan amended, delivered, issued, or | ||||||
19 | renewed after the effective
date of this amendatory Act of the | ||||||
20 | 92nd General Assembly shall provide coverage
under the policy | ||||||
21 | for treatment of serious mental illness under the same terms
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22 | and conditions as coverage for hospital or medical expenses | ||||||
23 | related to other
illnesses and diseases. The coverage required | ||||||
24 | under this Section must provide
for same durational limits, | ||||||
25 | amount limits, deductibles, and co-insurance
requirements for | ||||||
26 | serious mental illness as are provided for other illnesses
and |
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1 | diseases. This subsection does not apply to coverage provided | ||||||
2 | to
employees by employers who have 50 or fewer employees.
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3 | (2) "Serious mental illness" means the following | ||||||
4 | psychiatric illnesses as
defined in the most current edition of | ||||||
5 | the Diagnostic and Statistical Manual
(DSM) published by the | ||||||
6 | American Psychiatric Association:
| ||||||
7 | (A) schizophrenia;
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8 | (B) paranoid and other psychotic disorders;
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9 | (C) bipolar disorders (hypomanic, manic, depressive, | ||||||
10 | and mixed);
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11 | (D) major depressive disorders (single episode or | ||||||
12 | recurrent);
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13 | (E) schizoaffective disorders (bipolar or depressive);
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14 | (F) pervasive developmental disorders;
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15 | (G) obsessive-compulsive disorders;
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16 | (H) depression in childhood and adolescence;
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17 | (I) panic disorder; | ||||||
18 | (J) post-traumatic stress disorders (acute, chronic, | ||||||
19 | or with delayed onset); and
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20 | (K) anorexia nervosa and bulimia nervosa. | ||||||
21 | (3) (Blank). Upon request of the reimbursing insurer, a | ||||||
22 | provider of treatment of
serious mental illness shall furnish | ||||||
23 | medical records or other necessary data
that substantiate that | ||||||
24 | initial or continued treatment is at all times medically
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25 | necessary. An insurer shall provide a mechanism for the timely | ||||||
26 | review by a
provider holding the same license and practicing in |
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1 | the same specialty as the
patient's provider, who is | ||||||
2 | unaffiliated with the insurer, jointly selected by
the patient | ||||||
3 | (or the patient's next of kin or legal representative if the
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4 | patient is unable to act for himself or herself), the patient's | ||||||
5 | provider, and
the insurer in the event of a dispute between the | ||||||
6 | insurer and patient's
provider regarding the medical necessity | ||||||
7 | of a treatment proposed by a patient's
provider. If the | ||||||
8 | reviewing provider determines the treatment to be medically
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9 | necessary, the insurer shall provide reimbursement for the | ||||||
10 | treatment. Future
contractual or employment actions by the | ||||||
11 | insurer regarding the patient's
provider may not be based on | ||||||
12 | the provider's participation in this procedure.
Nothing | ||||||
13 | prevents
the insured from agreeing in writing to continue | ||||||
14 | treatment at his or her
expense. When making a determination of | ||||||
15 | the medical necessity for a treatment
modality for serous | ||||||
16 | mental illness, an insurer must make the determination in a
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17 | manner that is consistent with the manner used to make that | ||||||
18 | determination with
respect to other diseases or illnesses | ||||||
19 | covered under the policy, including an
appeals process.
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20 | (4) A group health benefit plan:
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21 | (A) shall provide coverage based upon medical | ||||||
22 | necessity for the following
treatment of mental illness in | ||||||
23 | each calendar year:
| ||||||
24 | (i) 45 days of inpatient treatment; and
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25 | (ii) beginning on June 26, 2006 (the effective date | ||||||
26 | of Public Act 94-921), 60 visits for outpatient |
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1 | treatment including group and individual
outpatient | ||||||
2 | treatment; and | ||||||
3 | (iii) for plans or policies delivered, issued for | ||||||
4 | delivery, renewed, or modified after January 1, 2007 | ||||||
5 | (the effective date of Public Act 94-906),
20 | ||||||
6 | additional outpatient visits for speech therapy for | ||||||
7 | treatment of pervasive developmental disorders that | ||||||
8 | will be in addition to speech therapy provided pursuant | ||||||
9 | to item (ii) of this subparagraph (A);
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10 | (B) may not include a lifetime limit on the number of | ||||||
11 | days of inpatient
treatment or the number of outpatient | ||||||
12 | visits covered under the plan; and
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13 | (C) shall include the same amount limits, deductibles, | ||||||
14 | copayments, and
coinsurance factors for serious mental | ||||||
15 | illness as for physical illness.
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16 | (5) An issuer of a group health benefit plan may not count | ||||||
17 | toward the number
of outpatient visits required to be covered | ||||||
18 | under this Section an outpatient
visit for the purpose of | ||||||
19 | medication management and shall cover the outpatient
visits | ||||||
20 | under the same terms and conditions as it covers outpatient | ||||||
21 | visits for
the treatment of physical illness.
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22 | (6) An issuer of a group health benefit
plan may provide or | ||||||
23 | offer coverage required under this Section through a
managed | ||||||
24 | care plan.
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25 | (7) This Section shall not be interpreted to require a | ||||||
26 | group health benefit
plan to provide coverage for treatment of:
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1 | (A) an addiction to a controlled substance or cannabis | ||||||
2 | that is used in
violation of law; or
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3 | (B) mental illness resulting from the use of a | ||||||
4 | controlled substance or
cannabis in violation of law.
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5 | (8)
(Blank).
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6 | (9) On and after June 1, 2010, coverage for the treatment | ||||||
7 | of mental and emotional disorders as provided by subsections | ||||||
8 | (a) and (b) of this Section shall not be denied under the | ||||||
9 | policy, provided that services are medically necessary as | ||||||
10 | determined by the insured's treating physician. For purposes of | ||||||
11 | this Section, "medically necessary" means health care services | ||||||
12 | appropriate, in terms of type, frequency, level, setting, and | ||||||
13 | duration, to the enrollee's diagnosis or condition, and | ||||||
14 | diagnostic testing and preventive services. Medically | ||||||
15 | necessary care must be consistent with generally accepted | ||||||
16 | practice parameters as determined by health care providers in | ||||||
17 | the same or similar general specialty as typically manages the | ||||||
18 | condition, procedure, or treatment at issue and must be | ||||||
19 | intended to either help restore or maintain the enrollee's | ||||||
20 | health or prevent deterioration of the enrollee's condition. | ||||||
21 | Upon request of the reimbursing insurer, a provider of | ||||||
22 | treatment of serious mental illness shall furnish medical | ||||||
23 | records or other necessary data that substantiate that initial | ||||||
24 | or continued treatment is at all times medically necessary. | ||||||
25 | (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; | ||||||
26 | 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff. |
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1 | 8-21-07; 95-972, eff. 9-22-08; 95-973, eff. 1-1-09; revised | ||||||
2 | 10-14-08.)
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3 | (215 ILCS 5/Art. XLV heading new) | ||||||
4 | ARTICLE XLV. MINIMUM MEDICAL LOSS RATIO LAW | ||||||
5 | (215 ILCS 5/1501 new) | ||||||
6 | Sec. 1501. Short title. This Law may be cited as the | ||||||
7 | Minimum Medical Loss Ratio Law. | ||||||
8 | (215 ILCS 5/1505 new)
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9 | Sec. 1505. Purpose. The General Assembly recognizes that a | ||||||
10 | significant share of the premium dollars paid by individuals | ||||||
11 | and small employers to health insurers and health maintenance | ||||||
12 | organizations is directed toward administrative and marketing | ||||||
13 | activities and profit. It is the intent of this Law to ensure | ||||||
14 | that premium costs for consumers more accurately reflect the | ||||||
15 | value of health care they receive by increasing the portion of | ||||||
16 | premium dollars dedicated to medical services. | ||||||
17 | (215 ILCS 5/1510 new)
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18 | Sec. 1510. Definitions. In this Law: | ||||||
19 | "Company" means any entity that provides health insurance | ||||||
20 | in this State. For the purposes of this Law, company includes a | ||||||
21 | licensed insurance company, a health maintenance organization, | ||||||
22 | or any other entity providing a plan of health insurance or |
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1 | health benefits subject to State insurance regulation. | ||||||
2 | "Division" means the Division of Insurance within the | ||||||
3 | Illinois Department of Financial and Professional Regulation. | ||||||
4 | "Health benefit plan" means any hospital or medical | ||||||
5 | expense-incurred policy, hospital or medical service plan | ||||||
6 | contract, or health maintenance organization subscriber | ||||||
7 | contract. "Health benefit plan" shall not include | ||||||
8 | accident-only, credit, dental, vision, Medicare supplement, | ||||||
9 | hospital indemnity, long term care, specific disease, stop loss | ||||||
10 | or disability income insurance, coverage issued as a supplement | ||||||
11 | to liability insurance, workers' compensation or similar | ||||||
12 | insurance, or automobile medical payment insurance. | ||||||
13 | "Health care benefits" means health care services that are | ||||||
14 | either provided or reimbursed by a managed care entity or its | ||||||
15 | contracted providers as benefits to its policyholders and | ||||||
16 | insurers. Health care benefits shall include: | ||||||
17 | (A) The costs of programs or activities, including | ||||||
18 | training and the provision of informational materials that | ||||||
19 | are determined as part of the regulation to improve the | ||||||
20 | provision of quality care, improve health care outcomes, or | ||||||
21 | encourage the use of evidence-based medicine. | ||||||
22 | (B) Disease management expenses using cost-effective | ||||||
23 | evidence-based guidelines. | ||||||
24 | (C) Plan medical advice by telephone. | ||||||
25 | (D) Payments to providers as risk pool payments of | ||||||
26 | pay-for-performance initiatives. |
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1 | "Health care benefits" shall not include administrative | ||||||
2 | costs as determined by the Division. | ||||||
3 | "Individual market" means the individual market as defined | ||||||
4 | by the Illinois Health Insurance Portability and | ||||||
5 | Accountability Act. | ||||||
6 | "Small group market" means small group market as defined by | ||||||
7 | the Illinois Health Insurance Portability and Accountability | ||||||
8 | Act. | ||||||
9 | (215 ILCS 5/1515 new)
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10 | Sec. 1515. Minimum medical loss requirement for companies | ||||||
11 | offering coverage in the individual and small group market. | ||||||
12 | (a) Any company selling a health benefit plan in the | ||||||
13 | individual or small group market shall, on and after June 1, | ||||||
14 | 2011, expend in the form of health care benefits no less than | ||||||
15 | 75% of the aggregate dues, fees, premiums, or other periodic | ||||||
16 | payments received by the company. For purposes of this Section, | ||||||
17 | the company may deduct from the aggregate dues, fees, premiums, | ||||||
18 | or other periodic payments received by the company the amount | ||||||
19 | of income taxes or other taxes that the company expensed. | ||||||
20 | (b) To assess compliance with this Section, a company with | ||||||
21 | a valid certificate of authority may average its total costs | ||||||
22 | across all health benefit plans issued, amended, or renewed in | ||||||
23 | Illinois, and all health benefit plans issued, amended, or | ||||||
24 | renewed by its affiliated companies that are licensed to | ||||||
25 | operate in Illinois. |
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1 | (c) The Division shall adopt rules to implement this | ||||||
2 | Section and to establish uniform reporting by companies of the | ||||||
3 | information necessary to determine compliance with this | ||||||
4 | Section. | ||||||
5 | (d) The Division may exclude from the determination of | ||||||
6 | compliance with the requirement of subsection (a) of this | ||||||
7 | Section any new health benefit plans for up to the first 2 | ||||||
8 | years that these health benefit plans are offered for sale in | ||||||
9 | Illinois, provided that the Division determines that the new | ||||||
10 | health benefit plans are substantially different from the | ||||||
11 | existing health benefit plans being issued, amended, or renewed | ||||||
12 | by the company seeking the exclusion.
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13 | Section 10. The Managed Care Reform and Patient Rights Act | ||||||
14 | is amended by changing Section 90 as follows:
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15 | (215 ILCS 134/90)
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16 | Sec. 90. Office of Consumer Health Insurance.
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17 | (a) The Director of Insurance shall establish the Office of | ||||||
18 | Consumer
Health Insurance within the Department of Insurance to | ||||||
19 | provide assistance and
information to all health care consumers | ||||||
20 | within the State and to ensure that persons covered by health | ||||||
21 | insurance companies or health care plans are provided benefits | ||||||
22 | due under the Illinois Insurance Code and related statutes and | ||||||
23 | are protected from health insurance company and health care | ||||||
24 | plan actions or policy provisions that are unjust, unfair, |
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1 | inequitable, ambiguous, misleading, inconsistent, deceptive, | ||||||
2 | or contrary to the law or to the public policy of this State or | ||||||
3 | that unreasonably or deceptively affect the risk purposed to be | ||||||
4 | assumed . Within the
appropriation allocated, the Office shall | ||||||
5 | provide information and assistance to
all health care | ||||||
6 | consumers . by The responsibilities of the Office shall include, | ||||||
7 | but not be limited to, the following :
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8 | (1) assisting consumers in understanding health | ||||||
9 | insurance marketing
materials and
the coverage provisions | ||||||
10 | of individual plans;
| ||||||
11 | (2) educating enrollees about their rights within | ||||||
12 | individual plans;
| ||||||
13 | (3) assisting enrollees with the process of filing | ||||||
14 | formal
grievances and appeals;
| ||||||
15 | (4) establishing and operating a toll-free "800" | ||||||
16 | telephone number
line to handle
consumer inquiries;
| ||||||
17 | (5) making related information available in languages | ||||||
18 | other than English
that
are spoken as a primary language by | ||||||
19 | a significant portion of the State's
population, as | ||||||
20 | determined by the Department;
| ||||||
21 | (6) analyzing, commenting on, monitoring, and making | ||||||
22 | publicly available
reports
on the development and | ||||||
23 | implementation of federal, State, and local laws,
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24 | regulations, and other governmental policies and actions | ||||||
25 | that pertain to the
adequacy of health care plans, | ||||||
26 | facilities, and services in the State;
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| |||||||
1 | (7) filing an annual report with the Governor, the | ||||||
2 | Director, and the
General
Assembly, which shall contain | ||||||
3 | recommendations for improvement of the regulation
of | ||||||
4 | health insurance plans, including recommendations on | ||||||
5 | improving health care
consumer assistance and patterns, | ||||||
6 | abuses, and progress that it has identified
from its | ||||||
7 | interaction with health care consumers; and
| ||||||
8 | (8) performing oversight of health insurance companies | ||||||
9 | and health care plans with respect to: | ||||||
10 | (A) improper claims practices as set forth in | ||||||
11 | Sections 154.5 and 154.6 of the Illinois Insurance | ||||||
12 | Code; | ||||||
13 | (B) emergency services; | ||||||
14 | (C) compliance with this Act; | ||||||
15 | (D) ensuring proper coverage for mental health | ||||||
16 | treatment; | ||||||
17 | (E) reviewing insurance company and health care | ||||||
18 | plan underwriting, rating, and rescission practices; | ||||||
19 | and | ||||||
20 | (F) reviewing insurance company and health care | ||||||
21 | plan billing practices, including, but not limited to, | ||||||
22 | consumer cost-sharing that results from co-pay, | ||||||
23 | deductible, and provider network provisions; | ||||||
24 | (9) assisting health insurance companies and health | ||||||
25 | care plan consumers with respect to the exercise of the | ||||||
26 | grievance and appeals rights established in the Illinois |
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1 | Insurance Code; | ||||||
2 | (10) if an external independent review decision | ||||||
3 | upholds a determination adverse to the patient, the patient | ||||||
4 | has the right to appeal the final decision to the Office; | ||||||
5 | if the external review decision is found by the Director | ||||||
6 | through the Office to have been arbitrary and capricious, | ||||||
7 | then the Director, with consultation from a licensed | ||||||
8 | medical professional, may overturn the external review | ||||||
9 | decision and require the health insurance company or health | ||||||
10 | care plan to pay for the health care service or treatment; | ||||||
11 | such decision, if any, shall be made solely on the legal or | ||||||
12 | medical merits of the claim; and
| ||||||
13 | (11) (8) performing all duties assigned to the Office | ||||||
14 | by the Director.
| ||||||
15 | (b) The report required under subsection (a)(7) shall be | ||||||
16 | filed by January
31, 2001 and each January 31 thereafter.
| ||||||
17 | (c) Nothing in this Section shall be interpreted to | ||||||
18 | authorize access to or
disclosure of individual patient or | ||||||
19 | health care professional or provider
records.
| ||||||
20 | (d) The Director, in his or her discretion, may issue a | ||||||
21 | Notice of Hearing requiring a health insurance company or | ||||||
22 | health care plan to appear at a hearing for the purpose of | ||||||
23 | determining the health insurance company or health care plan's | ||||||
24 | compliance with the duties and responsibilities listed in this | ||||||
25 | Act and in the Illinois Insurance Code. | ||||||
26 | (e) Nothing in this Section shall diminish or affect the |
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1 | powers and authority of the Director of Insurance otherwise set | ||||||
2 | forth in this Act and in the Illinois Insurance Code. | ||||||
3 | (Source: P.A. 91-617, eff. 1-1-00.)
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4 | Section 99. Effective date. This Act takes effect January | ||||||
5 | 1, 2010. |