Rep. Mary E. Flowers
Filed: 3/22/2010
|
|||||||
| |||||||
| |||||||
1 | AMENDMENT TO HOUSE BILL 6417
| ||||||
2 | AMENDMENT NO. ______. Amend House Bill 6417 by replacing | ||||||
3 | everything after the enacting clause with the following:
| ||||||
4 | "Section 5. The State Employees Group Insurance Act of 1971 | ||||||
5 | is amended by
changing Section 6.11 as follows:
| ||||||
6 | (5 ILCS 375/6.11)
| ||||||
7 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
8 | Code
requirements. The program of health
benefits shall provide | ||||||
9 | the post-mastectomy care benefits required to be covered
by a | ||||||
10 | policy of accident and health insurance under Section 356t of | ||||||
11 | the Illinois
Insurance Code. The program of health benefits | ||||||
12 | shall provide the coverage
required under Sections 356g, | ||||||
13 | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | ||||||
14 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and | ||||||
15 | 356z.13, and 356z.14, 356z.15 and 356z.14 , and 356z.17, 356z.15 | ||||||
16 | 356z.19, 356z.20, and 356z.21 of the
Illinois Insurance Code.
|
| |||||||
| |||||||
1 | The program of health benefits must comply with Section 155.37 | ||||||
2 | of the
Illinois Insurance Code.
| ||||||
3 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
4 | amendatory Act of the 95th General Assembly , if any, is | ||||||
5 | conditioned on the rules being adopted in accordance with all | ||||||
6 | provisions of the Illinois Administrative Procedure Act and all | ||||||
7 | rules and procedures of the Joint Committee on Administrative | ||||||
8 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
9 | is unauthorized. | ||||||
10 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
11 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
12 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, | ||||||
13 | eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||||||
14 | 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; | ||||||
15 | revised 10-22-09.)
| ||||||
16 | Section 10. The Counties Code is amended by changing | ||||||
17 | Section 5-1069.3 as
follows:
| ||||||
18 | (55 ILCS 5/5-1069.3)
| ||||||
19 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
20 | including a home
rule
county, is a self-insurer for purposes of | ||||||
21 | providing health insurance coverage
for its employees, the | ||||||
22 | coverage shall include coverage for the post-mastectomy
care | ||||||
23 | benefits required to be covered by a policy of accident and | ||||||
24 | health
insurance under Section 356t and the coverage required |
| |||||||
| |||||||
1 | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | ||||||
2 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and | ||||||
3 | 356z.13, and 356z.14, and 356z.15, 356z.14 356z.19, 356z.20, | ||||||
4 | and 356z.21 of
the Illinois Insurance Code. The requirement | ||||||
5 | that health benefits be covered
as provided in this Section is | ||||||
6 | an
exclusive power and function of the State and is a denial | ||||||
7 | and limitation under
Article VII, Section 6, subsection (h) of | ||||||
8 | the Illinois Constitution. A home
rule county to which this | ||||||
9 | Section applies must comply with every provision of
this | ||||||
10 | Section.
| ||||||
11 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
12 | amendatory Act of the 95th General Assembly , if any, is | ||||||
13 | conditioned on the rules being adopted in accordance with all | ||||||
14 | provisions of the Illinois Administrative Procedure Act and all | ||||||
15 | rules and procedures of the Joint Committee on Administrative | ||||||
16 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
17 | is unauthorized. | ||||||
18 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
19 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
20 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, | ||||||
21 | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | ||||||
22 | 96-328, eff. 8-11-09; revised 10-22-09.)
| ||||||
23 | Section 15. The Illinois Municipal Code is amended by | ||||||
24 | changing Section
10-4-2.3 as follows:
|
| |||||||
| |||||||
1 | (65 ILCS 5/10-4-2.3)
| ||||||
2 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
3 | municipality, including a
home rule municipality, is a | ||||||
4 | self-insurer for purposes of providing health
insurance | ||||||
5 | coverage for its employees, the coverage shall include coverage | ||||||
6 | for
the post-mastectomy care benefits required to be covered by | ||||||
7 | a policy of
accident and health insurance under Section 356t | ||||||
8 | and the coverage required
under Sections 356g, 356g.5, | ||||||
9 | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
10 | 356z.11, 356z.12, and 356z.13, and 356z.14, and 356z.15, | ||||||
11 | 356z.14 356z.19, 356z.20, and 356z.21 of the Illinois
Insurance
| ||||||
12 | Code. The requirement that health
benefits be covered as | ||||||
13 | provided in this is an exclusive power and function of
the | ||||||
14 | State and is a denial and limitation under Article VII, Section | ||||||
15 | 6,
subsection (h) of the Illinois Constitution. A home rule | ||||||
16 | municipality to which
this Section applies must comply with | ||||||
17 | every provision of this Section.
| ||||||
18 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
19 | amendatory Act of the 95th General Assembly , if any, is | ||||||
20 | conditioned on the rules being adopted in accordance with all | ||||||
21 | provisions of the Illinois Administrative Procedure Act and all | ||||||
22 | rules and procedures of the Joint Committee on Administrative | ||||||
23 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
24 | is unauthorized. | ||||||
25 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
26 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
| |||||||
| |||||||
1 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, | ||||||
2 | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | ||||||
3 | 96-328, eff. 8-11-09; revised 10-23-09.)
| ||||||
4 | Section 20. The School Code is amended by changing Section | ||||||
5 | 10-22.3f as
follows:
| ||||||
6 | (105 ILCS 5/10-22.3f)
| ||||||
7 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
8 | protection and
benefits
for employees shall provide the | ||||||
9 | post-mastectomy care benefits required to be
covered by a | ||||||
10 | policy of accident and health insurance under Section 356t and | ||||||
11 | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | ||||||
12 | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | ||||||
13 | 356z.13, and 356z.14, and 356z.15, 356z.14 356z.19, and 356z.20 | ||||||
14 | of
the
Illinois Insurance Code.
| ||||||
15 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
16 | amendatory Act of the 95th General Assembly , if any, is | ||||||
17 | conditioned on the rules being adopted in accordance with all | ||||||
18 | provisions of the Illinois Administrative Procedure Act and all | ||||||
19 | rules and procedures of the Joint Committee on Administrative | ||||||
20 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
21 | is unauthorized. | ||||||
22 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
23 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
24 | 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
| |||||||
| |||||||
1 | 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; revised | ||||||
2 | 10-23-09.)
| ||||||
3 | Section 25. The Emergency Medical Treatment Act is amended | ||||||
4 | by changing Section 1 as follows:
| ||||||
5 | (210 ILCS 70/1) (from Ch. 111 1/2, par. 6151)
| ||||||
6 | Sec. 1.
No hospital, physician, dentist or other provider | ||||||
7 | of professional
health care licensed under the laws of this | ||||||
8 | State may refuse to provide
needed emergency treatment to any | ||||||
9 | person whose life would be threatened
in the absence of such | ||||||
10 | treatment, because of that person's inability to
pay therefor, | ||||||
11 | nor because of the source of any payment promised therefor. | ||||||
12 | Every hospital licensed under the Hospital Licensing Act shall | ||||||
13 | comply with the Hospital Emergency Service Act.
| ||||||
14 | (Source: P.A. 83-723.)
| ||||||
15 | Section 30. The Hospital Emergency Service Act is amended | ||||||
16 | by changing Section 1 as follows:
| ||||||
17 | (210 ILCS 80/1) (from Ch. 111 1/2, par. 86)
| ||||||
18 | Sec. 1.
Every hospital required to be licensed by the | ||||||
19 | Department of Public
Health pursuant to the Hospital Licensing | ||||||
20 | Act which provides general medical
and surgical
hospital | ||||||
21 | services shall provide a hospital emergency service in | ||||||
22 | accordance
with rules and regulations adopted by the Department |
| |||||||
| |||||||
1 | of Public Health which shall be consistent with the federal | ||||||
2 | Emergency Medical Treatment and Active Labor Act (42 U.S.C. | ||||||
3 | 1395dd) and
shall furnish such hospital emergency services to | ||||||
4 | any applicant who applies
for the same in case of injury or | ||||||
5 | acute medical condition where the same is
liable to cause death | ||||||
6 | or severe injury or serious illness.
For purposes of this Act, | ||||||
7 | "applicant" includes any person who is brought
to a hospital by | ||||||
8 | ambulance or specialized emergency medical services
vehicle as | ||||||
9 | defined in the Emergency Medical Services (EMS) Systems Act.
| ||||||
10 | (Source: P.A. 86-1461.)
| ||||||
11 | Section 35. The Illinois Insurance Code is amended by | ||||||
12 | adding Sections
356z.19, 356z.20, and
356z.21
as
follows:
| ||||||
13 | (215 ILCS 5/356z.19 new)
| ||||||
14 | Sec. 356z.19. Intravenous feeding. A group or individual | ||||||
15 | policy of
accident and health insurance or managed care plan | ||||||
16 | amended, delivered, issued,
or renewed after the effective date | ||||||
17 | of this amendatory Act of the 96th General
Assembly must | ||||||
18 | provide coverage for intravenous feeding. The benefits under
| ||||||
19 | this Section shall be at least as favorable as for other | ||||||
20 | coverages under the
policy and may be subject to the same | ||||||
21 | dollar amount limits, deductibles, and
co-insurance | ||||||
22 | requirements applicable generally to other coverages under the
| ||||||
23 | policy. |
| |||||||
| |||||||
1 | (215 ILCS 5/356z.20 new)
| ||||||
2 | Sec. 356z.20. Prescription nutritional supplements. A | ||||||
3 | group or individual
policy of
accident and health insurance or | ||||||
4 | managed care plan amended, delivered, issued,
or renewed
after | ||||||
5 | the effective date of this amendatory Act of the 96th General | ||||||
6 | Assembly
that provides
coverage for prescription drugs must | ||||||
7 | provide coverage for reimbursement for
medically
appropriate | ||||||
8 | prescription nutritional supplements when ordered by a | ||||||
9 | physician
licensed to
practice medicine in all its branches and | ||||||
10 | the insured suffers from a condition
that prevents
him or her | ||||||
11 | from taking sufficient oral nourishment to sustain life. | ||||||
12 | (215 ILCS 5/356z.21 new) | ||||||
13 | Sec. 356z.21. Hospital patient assessments. A group or | ||||||
14 | individual policy of accident and health insurance or managed | ||||||
15 | care plan amended, delivered, issued, or renewed after the | ||||||
16 | effective date of this amendatory Act of the 96th General | ||||||
17 | Assembly that provides coverage for hospital care shall include | ||||||
18 | in that coverage all services ordered by a physician and | ||||||
19 | provided in the hospital that are considered medically | ||||||
20 | necessary for the evaluation, assessment, and diagnosis of the | ||||||
21 | illness or condition that resulted in the hospital stay of the | ||||||
22 | enrollee or recipient. Such services are subject to reasonable | ||||||
23 | review and utilization standards required by the policy or plan | ||||||
24 | for all hospital services, as defined by the Department of | ||||||
25 | Insurance or its successor agency.
|
| |||||||
| |||||||
1 | Section 40. The Health Maintenance Organization Act is | ||||||
2 | amended by changing
Section 5-3 as follows:
| ||||||
3 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
4 | (Text of Section before amendment by P.A. 96-833 ) | ||||||
5 | Sec. 5-3. Insurance Code provisions.
| ||||||
6 | (a) Health Maintenance Organizations
shall be subject to | ||||||
7 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
8 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
9 | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||||||
10 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
11 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14 , | ||||||
12 | 356z.17 356z.15 , 356z.19, 356z.20, 364.01, 367.2, 367.2-5, | ||||||
13 | 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, | ||||||
14 | 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of | ||||||
15 | subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
| ||||||
16 | XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | ||||||
17 | Insurance Code.
| ||||||
18 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
19 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
20 | Maintenance Organizations in
the following categories are | ||||||
21 | deemed to be "domestic companies":
| ||||||
22 | (1) a corporation authorized under the
Dental Service | ||||||
23 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
24 | (2) a corporation organized under the laws of this |
| |||||||
| |||||||
1 | State; or
| ||||||
2 | (3) a corporation organized under the laws of another | ||||||
3 | state, 30% or more
of the enrollees of which are residents | ||||||
4 | of this State, except a
corporation subject to | ||||||
5 | substantially the same requirements in its state of
| ||||||
6 | organization as is a "domestic company" under Article VIII | ||||||
7 | 1/2 of the
Illinois Insurance Code.
| ||||||
8 | (c) In considering the merger, consolidation, or other | ||||||
9 | acquisition of
control of a Health Maintenance Organization | ||||||
10 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
11 | (1) the Director shall give primary consideration to | ||||||
12 | the continuation of
benefits to enrollees and the financial | ||||||
13 | conditions of the acquired Health
Maintenance Organization | ||||||
14 | after the merger, consolidation, or other
acquisition of | ||||||
15 | control takes effect;
| ||||||
16 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
17 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
18 | apply and (ii) the Director, in making
his determination | ||||||
19 | with respect to the merger, consolidation, or other
| ||||||
20 | acquisition of control, need not take into account the | ||||||
21 | effect on
competition of the merger, consolidation, or | ||||||
22 | other acquisition of control;
| ||||||
23 | (3) the Director shall have the power to require the | ||||||
24 | following
information:
| ||||||
25 | (A) certification by an independent actuary of the | ||||||
26 | adequacy
of the reserves of the Health Maintenance |
| |||||||
| |||||||
1 | Organization sought to be acquired;
| ||||||
2 | (B) pro forma financial statements reflecting the | ||||||
3 | combined balance
sheets of the acquiring company and | ||||||
4 | the Health Maintenance Organization sought
to be | ||||||
5 | acquired as of the end of the preceding year and as of | ||||||
6 | a date 90 days
prior to the acquisition, as well as pro | ||||||
7 | forma financial statements
reflecting projected | ||||||
8 | combined operation for a period of 2 years;
| ||||||
9 | (C) a pro forma business plan detailing an | ||||||
10 | acquiring party's plans with
respect to the operation | ||||||
11 | of the Health Maintenance Organization sought to
be | ||||||
12 | acquired for a period of not less than 3 years; and
| ||||||
13 | (D) such other information as the Director shall | ||||||
14 | require.
| ||||||
15 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
16 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
17 | any health maintenance
organization of greater than 10% of its
| ||||||
18 | enrollee population (including without limitation the health | ||||||
19 | maintenance
organization's right, title, and interest in and to | ||||||
20 | its health care
certificates).
| ||||||
21 | (e) In considering any management contract or service | ||||||
22 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
23 | Code, the Director (i) shall, in
addition to the criteria | ||||||
24 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
25 | into account the effect of the management contract or
service | ||||||
26 | agreement on the continuation of benefits to enrollees and the
|
| |||||||
| |||||||
1 | financial condition of the health maintenance organization to | ||||||
2 | be managed or
serviced, and (ii) need not take into account the | ||||||
3 | effect of the management
contract or service agreement on | ||||||
4 | competition.
| ||||||
5 | (f) Except for small employer groups as defined in the | ||||||
6 | Small Employer
Rating, Renewability and Portability Health | ||||||
7 | Insurance Act and except for
medicare supplement policies as | ||||||
8 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
9 | Maintenance Organization may by contract agree with a
group or | ||||||
10 | other enrollment unit to effect refunds or charge additional | ||||||
11 | premiums
under the following terms and conditions:
| ||||||
12 | (i) the amount of, and other terms and conditions with | ||||||
13 | respect to, the
refund or additional premium are set forth | ||||||
14 | in the group or enrollment unit
contract agreed in advance | ||||||
15 | of the period for which a refund is to be paid or
| ||||||
16 | additional premium is to be charged (which period shall not | ||||||
17 | be less than one
year); and
| ||||||
18 | (ii) the amount of the refund or additional premium | ||||||
19 | shall not exceed 20%
of the Health Maintenance | ||||||
20 | Organization's profitable or unprofitable experience
with | ||||||
21 | respect to the group or other enrollment unit for the | ||||||
22 | period (and, for
purposes of a refund or additional | ||||||
23 | premium, the profitable or unprofitable
experience shall | ||||||
24 | be calculated taking into account a pro rata share of the
| ||||||
25 | Health Maintenance Organization's administrative and | ||||||
26 | marketing expenses, but
shall not include any refund to be |
| |||||||
| |||||||
1 | made or additional premium to be paid
pursuant to this | ||||||
2 | subsection (f)). The Health Maintenance Organization and | ||||||
3 | the
group or enrollment unit may agree that the profitable | ||||||
4 | or unprofitable
experience may be calculated taking into | ||||||
5 | account the refund period and the
immediately preceding 2 | ||||||
6 | plan years.
| ||||||
7 | The Health Maintenance Organization shall include a | ||||||
8 | statement in the
evidence of coverage issued to each enrollee | ||||||
9 | describing the possibility of a
refund or additional premium, | ||||||
10 | and upon request of any group or enrollment unit,
provide to | ||||||
11 | the group or enrollment unit a description of the method used | ||||||
12 | to
calculate (1) the Health Maintenance Organization's | ||||||
13 | profitable experience with
respect to the group or enrollment | ||||||
14 | unit and the resulting refund to the group
or enrollment unit | ||||||
15 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
16 | experience with respect to the group or enrollment unit and the | ||||||
17 | resulting
additional premium to be paid by the group or | ||||||
18 | enrollment unit.
| ||||||
19 | In no event shall the Illinois Health Maintenance | ||||||
20 | Organization
Guaranty Association be liable to pay any | ||||||
21 | contractual obligation of an
insolvent organization to pay any | ||||||
22 | refund authorized under this Section.
| ||||||
23 | (g) Rulemaking authority to implement Public Act 95-1045 | ||||||
24 | this amendatory Act of the 95th General Assembly , if any, is | ||||||
25 | conditioned on the rules being adopted in accordance with all | ||||||
26 | provisions of the Illinois Administrative Procedure Act and all |
| |||||||
| |||||||
1 | rules and procedures of the Joint Committee on Administrative | ||||||
2 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
3 | is unauthorized. | ||||||
4 | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | ||||||
5 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
6 | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
7 | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised | ||||||
8 | 10-23-09.) | ||||||
9 | (Text of Section after amendment by P.A. 96-833 ) | ||||||
10 | Sec. 5-3. Insurance Code provisions.
| ||||||
11 | (a) Health Maintenance Organizations
shall be subject to | ||||||
12 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
13 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
14 | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||||||
15 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
16 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | ||||||
17 | 356z.18, 356z.19, 356z.20, 364.01, 367.2, 367.2-5, 367i, 368a, | ||||||
18 | 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, | ||||||
19 | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | ||||||
20 | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | ||||||
21 | XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| ||||||
22 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
23 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
24 | Maintenance Organizations in
the following categories are | ||||||
25 | deemed to be "domestic companies":
|
| |||||||
| |||||||
1 | (1) a corporation authorized under the
Dental Service | ||||||
2 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
3 | (2) a corporation organized under the laws of this | ||||||
4 | State; or
| ||||||
5 | (3) a corporation organized under the laws of another | ||||||
6 | state, 30% or more
of the enrollees of which are residents | ||||||
7 | of this State, except a
corporation subject to | ||||||
8 | substantially the same requirements in its state of
| ||||||
9 | organization as is a "domestic company" under Article VIII | ||||||
10 | 1/2 of the
Illinois Insurance Code.
| ||||||
11 | (c) In considering the merger, consolidation, or other | ||||||
12 | acquisition of
control of a Health Maintenance Organization | ||||||
13 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
14 | (1) the Director shall give primary consideration to | ||||||
15 | the continuation of
benefits to enrollees and the financial | ||||||
16 | conditions of the acquired Health
Maintenance Organization | ||||||
17 | after the merger, consolidation, or other
acquisition of | ||||||
18 | control takes effect;
| ||||||
19 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
20 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
21 | apply and (ii) the Director, in making
his determination | ||||||
22 | with respect to the merger, consolidation, or other
| ||||||
23 | acquisition of control, need not take into account the | ||||||
24 | effect on
competition of the merger, consolidation, or | ||||||
25 | other acquisition of control;
| ||||||
26 | (3) the Director shall have the power to require the |
| |||||||
| |||||||
1 | following
information:
| ||||||
2 | (A) certification by an independent actuary of the | ||||||
3 | adequacy
of the reserves of the Health Maintenance | ||||||
4 | Organization sought to be acquired;
| ||||||
5 | (B) pro forma financial statements reflecting the | ||||||
6 | combined balance
sheets of the acquiring company and | ||||||
7 | the Health Maintenance Organization sought
to be | ||||||
8 | acquired as of the end of the preceding year and as of | ||||||
9 | a date 90 days
prior to the acquisition, as well as pro | ||||||
10 | forma financial statements
reflecting projected | ||||||
11 | combined operation for a period of 2 years;
| ||||||
12 | (C) a pro forma business plan detailing an | ||||||
13 | acquiring party's plans with
respect to the operation | ||||||
14 | of the Health Maintenance Organization sought to
be | ||||||
15 | acquired for a period of not less than 3 years; and
| ||||||
16 | (D) such other information as the Director shall | ||||||
17 | require.
| ||||||
18 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
19 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
20 | any health maintenance
organization of greater than 10% of its
| ||||||
21 | enrollee population (including without limitation the health | ||||||
22 | maintenance
organization's right, title, and interest in and to | ||||||
23 | its health care
certificates).
| ||||||
24 | (e) In considering any management contract or service | ||||||
25 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
26 | Code, the Director (i) shall, in
addition to the criteria |
| |||||||
| |||||||
1 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
2 | into account the effect of the management contract or
service | ||||||
3 | agreement on the continuation of benefits to enrollees and the
| ||||||
4 | financial condition of the health maintenance organization to | ||||||
5 | be managed or
serviced, and (ii) need not take into account the | ||||||
6 | effect of the management
contract or service agreement on | ||||||
7 | competition.
| ||||||
8 | (f) Except for small employer groups as defined in the | ||||||
9 | Small Employer
Rating, Renewability and Portability Health | ||||||
10 | Insurance Act and except for
medicare supplement policies as | ||||||
11 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
12 | Maintenance Organization may by contract agree with a
group or | ||||||
13 | other enrollment unit to effect refunds or charge additional | ||||||
14 | premiums
under the following terms and conditions:
| ||||||
15 | (i) the amount of, and other terms and conditions with | ||||||
16 | respect to, the
refund or additional premium are set forth | ||||||
17 | in the group or enrollment unit
contract agreed in advance | ||||||
18 | of the period for which a refund is to be paid or
| ||||||
19 | additional premium is to be charged (which period shall not | ||||||
20 | be less than one
year); and
| ||||||
21 | (ii) the amount of the refund or additional premium | ||||||
22 | shall not exceed 20%
of the Health Maintenance | ||||||
23 | Organization's profitable or unprofitable experience
with | ||||||
24 | respect to the group or other enrollment unit for the | ||||||
25 | period (and, for
purposes of a refund or additional | ||||||
26 | premium, the profitable or unprofitable
experience shall |
| |||||||
| |||||||
1 | be calculated taking into account a pro rata share of the
| ||||||
2 | Health Maintenance Organization's administrative and | ||||||
3 | marketing expenses, but
shall not include any refund to be | ||||||
4 | made or additional premium to be paid
pursuant to this | ||||||
5 | subsection (f)). The Health Maintenance Organization and | ||||||
6 | the
group or enrollment unit may agree that the profitable | ||||||
7 | or unprofitable
experience may be calculated taking into | ||||||
8 | account the refund period and the
immediately preceding 2 | ||||||
9 | plan years.
| ||||||
10 | The Health Maintenance Organization shall include a | ||||||
11 | statement in the
evidence of coverage issued to each enrollee | ||||||
12 | describing the possibility of a
refund or additional premium, | ||||||
13 | and upon request of any group or enrollment unit,
provide to | ||||||
14 | the group or enrollment unit a description of the method used | ||||||
15 | to
calculate (1) the Health Maintenance Organization's | ||||||
16 | profitable experience with
respect to the group or enrollment | ||||||
17 | unit and the resulting refund to the group
or enrollment unit | ||||||
18 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
19 | experience with respect to the group or enrollment unit and the | ||||||
20 | resulting
additional premium to be paid by the group or | ||||||
21 | enrollment unit.
| ||||||
22 | In no event shall the Illinois Health Maintenance | ||||||
23 | Organization
Guaranty Association be liable to pay any | ||||||
24 | contractual obligation of an
insolvent organization to pay any | ||||||
25 | refund authorized under this Section.
| ||||||
26 | (g) Rulemaking authority to implement Public Act 95-1045, |
| |||||||
| |||||||
1 | if any, is conditioned on the rules being adopted in accordance | ||||||
2 | with all provisions of the Illinois Administrative Procedure | ||||||
3 | Act and all rules and procedures of the Joint Committee on | ||||||
4 | Administrative Rules; any purported rule not so adopted, for | ||||||
5 | whatever reason, is unauthorized. | ||||||
6 | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | ||||||
7 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
8 | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
9 | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | ||||||
10 | 6-1-10.)
| ||||||
11 | Section 45. The Voluntary Health Services Plans Act is | ||||||
12 | amended by changing
Section 10 as follows:
| ||||||
13 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
14 | (Text of Section before amendment by P.A. 96-833 ) | ||||||
15 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
16 | services
plan corporations and all persons interested therein | ||||||
17 | or dealing therewith
shall be subject to the provisions of | ||||||
18 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
19 | 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | ||||||
20 | 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | ||||||
21 | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | ||||||
22 | 356z.14, 356z.15
356z.14 , 356z.19, 356z.20, 364.01, 367.2, | ||||||
23 | 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and | ||||||
24 | paragraphs (7) and (15) of Section 367 of the Illinois
|
| |||||||
| |||||||
1 | Insurance Code.
| ||||||
2 | Rulemaking authority to implement Public Act 95-1045
this | ||||||
3 | amendatory Act of the 95th General Assembly , if any, is | ||||||
4 | conditioned on the rules being adopted in accordance with all | ||||||
5 | provisions of the Illinois Administrative Procedure Act and all | ||||||
6 | rules and procedures of the Joint Committee on Administrative | ||||||
7 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
8 | is unauthorized. | ||||||
9 | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | ||||||
10 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
11 | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||||||
12 | eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||||||
13 | 96-328, eff. 8-11-09; revised 9-25-09.) | ||||||
14 | (Text of Section after amendment by P.A. 96-833 ) | ||||||
15 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
16 | services
plan corporations and all persons interested therein | ||||||
17 | or dealing therewith
shall be subject to the provisions of | ||||||
18 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
19 | 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | ||||||
20 | 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | ||||||
21 | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | ||||||
22 | 356z.14, 356z.15, 356z.18, 356z.19, 356z.20, 364.01, 367.2, | ||||||
23 | 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and | ||||||
24 | paragraphs (7) and (15) of Section 367 of the Illinois
| ||||||
25 | Insurance Code.
|
| |||||||
| |||||||
1 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
2 | any, is conditioned on the rules being adopted in accordance | ||||||
3 | with all provisions of the Illinois Administrative Procedure | ||||||
4 | Act and all rules and procedures of the Joint Committee on | ||||||
5 | Administrative Rules; any purported rule not so adopted, for | ||||||
6 | whatever reason, is unauthorized. | ||||||
7 | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | ||||||
8 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
9 | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||||||
10 | eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||||||
11 | 96-328, eff. 8-11-09; 96-833, eff. 6-1-10.)
| ||||||
12 | Section 50. The Health Carrier External Review Act is | ||||||
13 | amended by changing Section 35 and by adding Sections 25.1, | ||||||
14 | 25.2, 25.3, 25.4, 25.5, and 25.6 as follows: | ||||||
15 | (215 ILCS 180/25.1 new) | ||||||
16 | Sec. 25.1. Standard
information for application forms. | ||||||
17 | (a) The Director shall establish standard
information and | ||||||
18 | health history questions that shall be used by all
health care | ||||||
19 | service plans for their individual health care coverage
| ||||||
20 | application forms for individual health plan contracts and
| ||||||
21 | individual health insurance policies. The health care service | ||||||
22 | plan
and health insurance application forms for individual | ||||||
23 | health plan
contracts and health insurance policies may only | ||||||
24 | contain questions
approved by the Director. |
| |||||||
| |||||||
1 | (b) The standard information and health history questions
| ||||||
2 | developed by the Director shall contain clear and unambiguous
| ||||||
3 | information and questions designed to ascertain the health | ||||||
4 | history of
the applicant and shall be based on the medical | ||||||
5 | information that is
reasonable and necessary for medical | ||||||
6 | underwriting purposes. | ||||||
7 | (c) The application form shall include a prominently | ||||||
8 | displayed
notice that shall read:
"Illinois law prohibits an | ||||||
9 | HIV test from being required or used
by health care service | ||||||
10 | plans as a condition of obtaining coverage.". | ||||||
11 | (d) No later than 6 months after the adoption of the | ||||||
12 | regulation
under subsection (a) of this Section, all individual | ||||||
13 | health care service plan
application forms shall utilize only | ||||||
14 | the pool of approved questions
and the standardized information | ||||||
15 | established pursuant to subsection (a). | ||||||
16 | (e) On and after January 1, 2011, all individual health | ||||||
17 | care
service plan applications shall be reviewed and approved | ||||||
18 | by the
Director before they may be used by a health care | ||||||
19 | service plan. | ||||||
20 | (215 ILCS 180/25.2 new) | ||||||
21 | Sec. 25.2. Medical
underwriting. | ||||||
22 | (a) "Medical underwriting" means the completion of a | ||||||
23 | reasonable
investigation of the applicant's health history | ||||||
24 | information, which
includes, but is not limited to, the | ||||||
25 | following: |
| |||||||
| |||||||
1 | (1) Ensuring that the information submitted on the | ||||||
2 | application
form and the material submitted with the | ||||||
3 | application form are
complete and accurate. | ||||||
4 | (2) Resolving all reasonable questions arising from | ||||||
5 | the
application form or any materials submitted with the | ||||||
6 | application form or
any information obtained by the health | ||||||
7 | care service plan as part of
its verification of the | ||||||
8 | accuracy and completeness of the application
form. | ||||||
9 | (b) A health care service plan shall complete medical
| ||||||
10 | underwriting prior to issuing an enrollee or subscriber health | ||||||
11 | care
service plan contract. | ||||||
12 | (c) A health care service plan shall adopt and implement | ||||||
13 | written
medical underwriting policies and procedures to ensure | ||||||
14 | that the
health care service plan does all of the following | ||||||
15 | with respect to an
application for health care coverage: | ||||||
16 | (1) Reviews all of the following:
| ||||||
17 | (A) Information on the application and any | ||||||
18 | materials submitted
with the application form for | ||||||
19 | accuracy and completeness.
| ||||||
20 | (B) Claims information about the applicant that is | ||||||
21 | within the
health care service plan's own claims | ||||||
22 | information.
| ||||||
23 | (C) At least one commercially available | ||||||
24 | prescription drug database
for information about the | ||||||
25 | applicant.
| ||||||
26 | (2) Identifies and makes inquiries, including |
| |||||||
| |||||||
1 | contacting the
applicant about any questions raised by | ||||||
2 | omissions, ambiguities, or
inconsistencies based upon the | ||||||
3 | information collected pursuant to
item (1) of this | ||||||
4 | subsection (c).
| ||||||
5 | (d) The plan shall document all information collected | ||||||
6 | during the
underwriting review process.
| ||||||
7 | (e) On or before January 1, 2011, a health care service | ||||||
8 | plan shall
file its medical underwriting policies and | ||||||
9 | procedures with the
Department.
| ||||||
10 | (215 ILCS 180/25.3 new) | ||||||
11 | Sec. 25.3. Copies of application and contract; notice. | ||||||
12 | (a) Within 10 business days after issuing a health care
| ||||||
13 | service plan contract, the health care service plan shall send | ||||||
14 | a copy
of the completed written application to the applicant | ||||||
15 | with a copy of
the health care service plan contract issued by | ||||||
16 | the health care
service plan, along with a notice that states | ||||||
17 | all of the following:
| ||||||
18 | (1) The applicant should review the completed | ||||||
19 | application
carefully and notify the health care service | ||||||
20 | plan within 30 days of
any inaccuracy in the application.
| ||||||
21 | (2) Any intentional material misrepresentation or | ||||||
22 | intentional
material omission in the information submitted | ||||||
23 | in the application may
result in the cancellation or | ||||||
24 | rescission of the plan contract.
| ||||||
25 | (3) The applicant should retain a copy of the completed |
| |||||||
| |||||||
1 | written
application for the applicant's records.
| ||||||
2 | (b) If new information is provided by the applicant within | ||||||
3 | the
30-day period permitted by subsection (a), then the | ||||||
4 | provisions concerning medical underwriting shall apply to the | ||||||
5 | new information.
| ||||||
6 | (215 ILCS 180/25.4 new) | ||||||
7 | Sec. 25.4. Rescission; cancellation. | ||||||
8 | (a) Once a plan has issued an individual health care
| ||||||
9 | service plan contract, the health care service plan shall not | ||||||
10 | rescind
or cancel the health care service plan contract unless | ||||||
11 | all of the
following apply:
| ||||||
12 | (1) There was a material misrepresentation or material | ||||||
13 | omission in
the information submitted by the applicant in | ||||||
14 | the written
application to the health care service plan | ||||||
15 | prior to the issuance of
the health care service plan | ||||||
16 | contract that would have prevented the
contract from being | ||||||
17 | entered into.
| ||||||
18 | (2) The health care service plan completed medical | ||||||
19 | underwriting before issuing the plan contract.
| ||||||
20 | (3) The health care service plan demonstrates that the | ||||||
21 | applicant
intentionally misrepresented or intentionally | ||||||
22 | omitted material
information on the application prior to | ||||||
23 | the issuance of the plan
contract with the purpose of | ||||||
24 | misrepresenting his or her health
history in order to | ||||||
25 | obtain health care coverage.
|
| |||||||
| |||||||
1 | (4) The application form was approved by the | ||||||
2 | Department.
| ||||||
3 | (5) The health care service plan sent a copy of the | ||||||
4 | completed
written application to the applicant with a copy | ||||||
5 | of the health care
service plan contract issued by the | ||||||
6 | health care service plan.
| ||||||
7 | (b) Notwithstanding subsection (a) of this Section, an | ||||||
8 | enrollment or subscription
may be canceled or not renewed for | ||||||
9 | failure to pay the fees for
that coverage.
| ||||||
10 | (215 ILCS 180/25.5 new) | ||||||
11 | Sec. 25.5. Postcontract investigation. | ||||||
12 | (a) If a health care service plan obtains information
after | ||||||
13 | issuing an individual health care service plan contract that
| ||||||
14 | the subscriber or enrollee may have intentionally omitted or
| ||||||
15 | intentionally misrepresented material information during the
| ||||||
16 | application for coverage process, then the health care service | ||||||
17 | plan may
investigate the potential omissions or | ||||||
18 | misrepresentations in order to
determine whether the | ||||||
19 | subscriber's or enrollee's health care service
plan contract | ||||||
20 | may be rescinded or canceled.
| ||||||
21 | (b) The following provisions shall apply to a postcontract | ||||||
22 | issuance investigation: | ||||||
23 | (1) Upon initiating a postcontract issuance | ||||||
24 | investigation for
potential rescission or cancellation of | ||||||
25 | health care coverage, the
plan shall provide a written |
| |||||||
| |||||||
1 | notice to the enrollee or subscriber by
regular and | ||||||
2 | certified mail that it has initiated an investigation of
| ||||||
3 | intentional material misrepresentation or intentional | ||||||
4 | material
omission on the part of the enrollee or subscriber | ||||||
5 | and that the
investigation could lead to the rescission or | ||||||
6 | cancellation of the
enrollee's or subscriber's health care | ||||||
7 | service plan contract. The
notice shall be provided by the | ||||||
8 | health care service plan within 5
days of the initiation of | ||||||
9 | the investigation.
| ||||||
10 | (2) The written notice required under item (1) of this | ||||||
11 | subsection (b) shall include
full disclosure of the | ||||||
12 | allegedly intentional material omission or
| ||||||
13 | misrepresentation and a clear and concise explanation of | ||||||
14 | why the
information has resulted in the health care service | ||||||
15 | plan's initiation
of an investigation to determine whether | ||||||
16 | rescission or cancellation
is warranted. The notice shall | ||||||
17 | invite the enrollee or subscriber to
provide any evidence | ||||||
18 | or information within 45 business days to negate
the plan's | ||||||
19 | reasons for initiating the postissuance investigation.
| ||||||
20 | (3) The plan shall complete its investigation no later | ||||||
21 | than 90
days after the date that the notice is sent to the | ||||||
22 | enrollee or subscriber
pursuant to item (1) of this | ||||||
23 | subsection (b).
| ||||||
24 | (4) Upon completion of its postissuance investigation, | ||||||
25 | the plan
shall provide written notice by regular and | ||||||
26 | certified mail to the
subscriber or enrollee that it has |
| |||||||
| |||||||
1 | concluded its investigation and
has made one of the | ||||||
2 | following determinations:
| ||||||
3 | (A) The plan has determined that the enrollee or | ||||||
4 | subscriber did
not intentionally misrepresent or | ||||||
5 | intentionally omit material
information during the | ||||||
6 | application process and that the subscriber's
or | ||||||
7 | enrollee's health care coverage will not be canceled or | ||||||
8 | rescinded.
| ||||||
9 | (B) The plan intends to seek approval from the | ||||||
10 | Director to cancel
or rescind the enrollee's or | ||||||
11 | subscriber's health care service plan
contract for | ||||||
12 | intentional misrepresentation or intentional omission | ||||||
13 | of
material information during the application for | ||||||
14 | coverage process.
| ||||||
15 | (5) The written notice required under paragraph (B) of
| ||||||
16 | item (4) of this subsection (b) shall do all of the | ||||||
17 | following:
| ||||||
18 | (A) Include full disclosure of the nature and | ||||||
19 | substance of any
information that led to the plan's | ||||||
20 | determination that the enrollee or
subscriber | ||||||
21 | intentionally misrepresented or intentionally omitted
| ||||||
22 | material information on the application form.
| ||||||
23 | (B) Provide the enrollee or subscriber with | ||||||
24 | information indicating
that the health plan's | ||||||
25 | determination shall not become final until it
is | ||||||
26 | reviewed and approved by the Department's independent |
| |||||||
| |||||||
1 | review
process.
| ||||||
2 | (C) Provide the enrollee or subscriber with | ||||||
3 | information regarding
the Department's independent | ||||||
4 | review process and the right of the
enrollee or | ||||||
5 | subscriber to opt out of that review process within 45
| ||||||
6 | days of the date upon which an independent review | ||||||
7 | organization
receives a request for independent | ||||||
8 | review.
| ||||||
9 | (D) Provide a statement that the health care | ||||||
10 | service plan's
proposed decision to cancel or rescind | ||||||
11 | the health care service plan
contract shall not become | ||||||
12 | effective unless the Department's
independent review | ||||||
13 | organization upholds the health care service plan'
s | ||||||
14 | decision or unless the enrollee or subscriber has opted | ||||||
15 | out of the
independent review. | ||||||
16 | (215 ILCS 180/25.6 new) | ||||||
17 | Sec. 25.6. Continuation. | ||||||
18 | (a) A health care service plan shall continue to
authorize | ||||||
19 | and provide all medically necessary health care services
| ||||||
20 | required to be covered under an enrollee's or subscriber's | ||||||
21 | health
care service plan contract until the effective date of | ||||||
22 | cancellation
or rescission.
| ||||||
23 | (b) The effective date of the health care service plan's
| ||||||
24 | cancellation or the date upon which the plan may initiate a
| ||||||
25 | rescission shall be no earlier than the date that the enrollee |
| |||||||
| |||||||
1 | or
subscriber receives notification via regular and certified | ||||||
2 | mail that
the independent review organization has made a | ||||||
3 | determination
upholding the health care service plan's | ||||||
4 | decision to rescind or
cancel.
| ||||||
5 | (215 ILCS 180/35) | ||||||
6 | (This Section may contain text from a Public Act with a | ||||||
7 | delayed effective date )
| ||||||
8 | Sec. 35. Standard external review. | ||||||
9 | (a) Within 4 months after the date of receipt of a notice | ||||||
10 | of an adverse determination or final adverse determination, a | ||||||
11 | covered person or the covered person's authorized | ||||||
12 | representative may file a request for an external review with | ||||||
13 | the health carrier. | ||||||
14 | (b) Within 5 business days following the date of receipt of | ||||||
15 | the external review request, the health carrier shall complete | ||||||
16 | a preliminary review of the request to determine whether:
| ||||||
17 | (1) the individual is or was a covered person in the | ||||||
18 | health benefit plan at the time the health care service was | ||||||
19 | requested or at the time the health care service was | ||||||
20 | provided; | ||||||
21 | (2) the health care service that is the subject of the | ||||||
22 | adverse determination or the final adverse determination | ||||||
23 | is a covered service under the covered person's health | ||||||
24 | benefit plan, but the health carrier has determined that | ||||||
25 | the health care service is not covered because it does not |
| |||||||
| |||||||
1 | meet the health carrier's requirements for medical | ||||||
2 | necessity, appropriateness, health care setting, level of | ||||||
3 | care, or effectiveness; | ||||||
4 | (3) the covered person has exhausted the health | ||||||
5 | carrier's internal grievance process as set forth in this | ||||||
6 | Act; | ||||||
7 | (4) for appeals relating to a determination based on | ||||||
8 | treatment being experimental or investigational, the | ||||||
9 | requested health care service or treatment that is the | ||||||
10 | subject of the adverse determination or final adverse | ||||||
11 | determination is a covered benefit under the covered | ||||||
12 | person's health benefit plan except for the health | ||||||
13 | carrier's determination that the service or treatment is | ||||||
14 | experimental or investigational for a particular medical | ||||||
15 | condition and is not explicitly listed as an excluded | ||||||
16 | benefit under the covered person's health benefit plan with | ||||||
17 | the health carrier and that the covered person's health | ||||||
18 | care provider, who is a physician licensed to practice | ||||||
19 | medicine in all its branches, has certified that one of the | ||||||
20 | following situations is applicable: | ||||||
21 | (A) standard health care services or treatments | ||||||
22 | have not been effective in improving the condition of | ||||||
23 | the covered person; | ||||||
24 | (B) standard health care services or treatments | ||||||
25 | are not medically appropriate for the covered person; | ||||||
26 | (C) there is no available standard health care |
| |||||||
| |||||||
1 | service or treatment covered by the health carrier that | ||||||
2 | is more beneficial than the recommended or requested | ||||||
3 | health care service or treatment;
| ||||||
4 | (D) the health care service or treatment is likely | ||||||
5 | to be more beneficial to the covered person, in the | ||||||
6 | health care provider's opinion, than any available | ||||||
7 | standard health care services or treatments; or | ||||||
8 | (E) that scientifically valid studies using | ||||||
9 | accepted protocols demonstrate that the health care | ||||||
10 | service or treatment requested is likely to be more | ||||||
11 | beneficial to the covered person than any available | ||||||
12 | standard health care services or treatments; and | ||||||
13 | (5) the covered person has provided all the information | ||||||
14 | and forms required to process an external review, as | ||||||
15 | specified in this Act. | ||||||
16 | (c) Within one business day after completion of the | ||||||
17 | preliminary review, the health carrier shall notify the covered | ||||||
18 | person and, if applicable, the covered person's authorized | ||||||
19 | representative in writing whether the request is complete and | ||||||
20 | eligible for external review. If the request: | ||||||
21 | (1) is not complete, the health carrier shall inform | ||||||
22 | the covered person and, if applicable, the covered person's | ||||||
23 | authorized representative in writing and include in the | ||||||
24 | notice what information or materials are required by this | ||||||
25 | Act to make the request complete; or | ||||||
26 | (2) is not eligible for external review, the health |
| |||||||
| |||||||
1 | carrier shall inform the covered person and, if applicable, | ||||||
2 | the covered person's authorized representative in writing | ||||||
3 | and include in the notice the reasons for its | ||||||
4 | ineligibility.
| ||||||
5 | The notice of initial determination of ineligibility shall | ||||||
6 | include a statement informing the covered person and, if | ||||||
7 | applicable, the covered person's authorized representative | ||||||
8 | that a health carrier's initial determination that the external | ||||||
9 | review request is ineligible for review may be appealed to the | ||||||
10 | Director by filing a complaint with the Director. | ||||||
11 | Notwithstanding a health carrier's initial determination | ||||||
12 | that the request is ineligible for external review, the | ||||||
13 | Director may determine that a request is eligible for external | ||||||
14 | review and require that it be referred for external review. In | ||||||
15 | making such determination, the Director's decision shall be in | ||||||
16 | accordance with the terms of the covered person's health | ||||||
17 | benefit plan and shall be subject to all applicable provisions | ||||||
18 | of this Act. | ||||||
19 | (d) Whenever a request is eligible for external review the | ||||||
20 | health carrier shall, within 5 business days: | ||||||
21 | (1) assign an independent review organization from the | ||||||
22 | list of approved independent review organizations compiled | ||||||
23 | and maintained by the Director; and | ||||||
24 | (2) notify in writing the covered person and, if | ||||||
25 | applicable, the covered person's authorized representative | ||||||
26 | of the request's eligibility and acceptance for external |
| |||||||
| |||||||
1 | review and the name of the independent review organization. | ||||||
2 | The health carrier shall include in the notice provided to | ||||||
3 | the covered person and, if applicable, the covered person's | ||||||
4 | authorized representative a statement that the covered person | ||||||
5 | or the covered person's authorized representative may, within 5 | ||||||
6 | business days following the date of receipt of the notice | ||||||
7 | provided pursuant to item (2) of this subsection (d), submit in | ||||||
8 | writing to the assigned independent review organization | ||||||
9 | additional information that the independent review | ||||||
10 | organization shall consider when conducting the external | ||||||
11 | review. The independent review organization is not required to, | ||||||
12 | but may, accept and consider additional information submitted | ||||||
13 | after 5 business days. | ||||||
14 | (e) The assignment of an approved independent review | ||||||
15 | organization to conduct an external review in accordance with | ||||||
16 | this Section shall be made from those approved independent | ||||||
17 | review organizations qualified to conduct external review as | ||||||
18 | required by Sections 50 and 55 of this Act. | ||||||
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; in such cases, the following | ||||||
25 | provisions shall apply: | ||||||
26 | (1) Except as provided in item (2) of this subsection |
| |||||||
| |||||||
1 | (f), failure by the health carrier or its utilization | ||||||
2 | review organization to provide the documents and | ||||||
3 | information within the specified time frame shall not delay | ||||||
4 | the conduct of the external review. | ||||||
5 | (2) If the health carrier or its utilization review | ||||||
6 | organization fails to provide the documents and | ||||||
7 | information within the specified time frame, the assigned | ||||||
8 | independent review organization may terminate the external | ||||||
9 | review and make a decision to reverse the adverse | ||||||
10 | determination or final adverse determination. | ||||||
11 | (3) Within one business day after making the decision | ||||||
12 | to terminate the external review and make a decision to | ||||||
13 | reverse the adverse determination or final adverse | ||||||
14 | determination under item (2) of this subsection (f), the | ||||||
15 | independent review organization shall notify the health | ||||||
16 | carrier, the covered person and, if applicable, the covered | ||||||
17 | person's authorized representative, of its decision to | ||||||
18 | reverse the 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 1 business | ||||||
4 | 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 | In such cases, the following provisions shall apply: | ||||||
19 | (A) Within one business day after making the | ||||||
20 | decision to reverse its adverse determination or final | ||||||
21 | adverse determination, the health carrier shall notify | ||||||
22 | the covered person and if applicable, the covered | ||||||
23 | person's 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, the covered person's | ||||||
19 | authorized representative, or the covered person's | ||||||
20 | treating provider; | ||||||
21 | (4) the terms of coverage under the covered person's | ||||||
22 | health benefit plan with the health carrier to ensure that | ||||||
23 | the independent review organization's decision is not | ||||||
24 | contrary to the terms of coverage under the covered | ||||||
25 | person's health benefit plan with the health carrier; | ||||||
26 | (5) the most appropriate practice guidelines, which |
| |||||||
| |||||||
1 | shall include applicable evidence-based standards and may | ||||||
2 | include any other practice guidelines developed by the | ||||||
3 | federal government, national or professional medical | ||||||
4 | societies, boards, and associations; | ||||||
5 | (6) any applicable clinical review criteria developed | ||||||
6 | and used by the health carrier or its designee utilization | ||||||
7 | review organization; and | ||||||
8 | (7) the opinion of the independent review | ||||||
9 | organization's clinical reviewer or reviewers after | ||||||
10 | considering items (1) through (6) of this subsection (i) to | ||||||
11 | the extent the information or documents are available and | ||||||
12 | the clinical reviewer or reviewers considers the | ||||||
13 | information or documents appropriate; and | ||||||
14 | (8) for a denial of coverage based on a determination | ||||||
15 | that the health care service or treatment recommended or | ||||||
16 | requested is experimental or investigational, whether and | ||||||
17 | to what extent: | ||||||
18 | (A) the recommended or requested health care | ||||||
19 | service or treatment has been approved by the federal | ||||||
20 | Food and Drug Administration, if applicable, for the | ||||||
21 | condition; | ||||||
22 | (B) medical or scientific evidence or | ||||||
23 | evidence-based standards demonstrate that the expected | ||||||
24 | benefits of the recommended or requested health care | ||||||
25 | service or treatment is more likely than not to be | ||||||
26 | beneficial to the covered person than any available |
| |||||||
| |||||||
1 | standard health care service or treatment and the | ||||||
2 | adverse risks of the recommended or requested health | ||||||
3 | care service or treatment would not be substantially | ||||||
4 | increased over those of available standard health care | ||||||
5 | services or treatments; or | ||||||
6 | (C) the terms of coverage under the covered | ||||||
7 | person's health benefit plan with the health carrier to | ||||||
8 | ensure that the health care service or treatment that | ||||||
9 | is the subject of the opinion is experimental or | ||||||
10 | investigational would otherwise be covered under the | ||||||
11 | terms of coverage of the covered person's health | ||||||
12 | benefit plan with the health carrier. | ||||||
13 | (j) Within 5 days after the date of receipt of all | ||||||
14 | necessary information, the assigned independent review | ||||||
15 | organization shall provide written notice of its decision to | ||||||
16 | uphold or reverse the adverse determination or the final | ||||||
17 | adverse determination to the health carrier, the covered person | ||||||
18 | and, if applicable, the covered person's authorized | ||||||
19 | representative. In reaching a decision, the assigned | ||||||
20 | independent review organization is not bound by any claim | ||||||
21 | determinations reached prior to the submission of information | ||||||
22 | to the independent review organization. The assigned | ||||||
23 | independent review organization shall independently determine | ||||||
24 | if the health care services under review are the medically | ||||||
25 | necessary health care services that a physician, exercising | ||||||
26 | prudent clinical judgment, would provide to a patient for the |
| |||||||
| |||||||
1 | purpose of preventing, evaluating, diagnosing, or treating an | ||||||
2 | illness, injury, disease, or its symptoms and are: (i) in | ||||||
3 | accordance with generally accepted standards of medical | ||||||
4 | practice; (ii) clinically appropriate, in terms of type, | ||||||
5 | frequency, extent, site, and duration and considered effective | ||||||
6 | for the patient's illness, injury, or disease; and (iii) not | ||||||
7 | primarily for the convenience of the patient, physician, or | ||||||
8 | other health care provider. For the purposes of this subsection | ||||||
9 | (j), "generally accepted standards of medical practice" means | ||||||
10 | standards that are based on credible scientific evidence | ||||||
11 | published in peer-reviewed medical literature generally | ||||||
12 | recognized by the relevant medical community, physician | ||||||
13 | specialty society recommendations, and the views of physicians | ||||||
14 | practicing in relevant clinical areas and any other relevant | ||||||
15 | factors. In such cases, the following provisions shall apply: | ||||||
16 | (1) The independent review organization shall include | ||||||
17 | in the notice: | ||||||
18 | (A) a general description of the reason for the | ||||||
19 | request for external review; | ||||||
20 | (B) the date the independent review organization | ||||||
21 | received the assignment from the health carrier to | ||||||
22 | conduct the external review; | ||||||
23 | (C) the time period during which the external | ||||||
24 | review was conducted; | ||||||
25 | (D) references to the evidence or documentation, | ||||||
26 | including the evidence-based standards, considered in |
| |||||||
| |||||||
1 | reaching its decision; | ||||||
2 | (E) the date of its decision; and | ||||||
3 | (F) the principal reason or reasons for its | ||||||
4 | decision, including what applicable, if any, | ||||||
5 | evidence-based standards that were a basis for its | ||||||
6 | decision.
| ||||||
7 | (2) For reviews of experimental or investigational | ||||||
8 | treatments, the notice shall include the following | ||||||
9 | information: | ||||||
10 | (A) a description of the covered person's medical | ||||||
11 | condition; | ||||||
12 | (B) a description of the indicators relevant to | ||||||
13 | whether there is sufficient evidence to demonstrate | ||||||
14 | that the recommended or requested health care service | ||||||
15 | or treatment is more likely than not to be more | ||||||
16 | beneficial to the covered person than any available | ||||||
17 | standard health care services or treatments and the | ||||||
18 | adverse risks of the recommended or requested health | ||||||
19 | care service or treatment would not be substantially | ||||||
20 | increased over those of available standard health care | ||||||
21 | services or treatments; | ||||||
22 | (C) a description and analysis of any medical or | ||||||
23 | scientific evidence considered in reaching the | ||||||
24 | opinion; | ||||||
25 | (D) a description and analysis of any | ||||||
26 | evidence-based standards; |
| |||||||
| |||||||
1 | (E) whether the recommended or requested health | ||||||
2 | care service or treatment has been approved by the | ||||||
3 | federal Food and Drug Administration, for the | ||||||
4 | condition; | ||||||
5 | (F) whether medical or scientific evidence or | ||||||
6 | evidence-based standards demonstrate that the expected | ||||||
7 | benefits of the recommended or requested health care | ||||||
8 | service or treatment is more likely than not to be more | ||||||
9 | beneficial to the covered person than any available | ||||||
10 | standard health care service or treatment and the | ||||||
11 | adverse risks of the recommended or requested health | ||||||
12 | care service or treatment would not be substantially | ||||||
13 | increased over those of available standard health care | ||||||
14 | services or treatments; and | ||||||
15 | (G) the written opinion of the clinical reviewer, | ||||||
16 | including the reviewer's recommendation as to whether | ||||||
17 | the recommended or requested health care service or | ||||||
18 | treatment should be covered and the rationale for the | ||||||
19 | reviewer's recommendation. | ||||||
20 | (3) In reaching a decision, the assigned independent | ||||||
21 | review organization is not bound by any decisions or | ||||||
22 | conclusions reached during the health carrier's | ||||||
23 | utilization review process or the health carrier's | ||||||
24 | internal grievance or appeals process. | ||||||
25 | (4) Upon receipt of a notice of a decision reversing | ||||||
26 | the adverse determination or final adverse determination, |
| |||||||
| |||||||
1 | the health carrier immediately shall approve the coverage | ||||||
2 | that was the subject of the adverse determination or final | ||||||
3 | adverse determination.
| ||||||
4 | (Source: P.A. 96-857, eff. 7-1-10.) | ||||||
5 | Section 55. The Illinois Public Aid Code is amended by | ||||||
6 | changing Section 5-16.8 as follows:
| ||||||
7 | (305 ILCS 5/5-16.8)
| ||||||
8 | Sec. 5-16.8. Required health benefits. The medical | ||||||
9 | assistance program
shall
(i) provide the post-mastectomy care | ||||||
10 | benefits required to be covered by a policy of
accident and | ||||||
11 | health insurance under Section 356t and the coverage required
| ||||||
12 | under Sections 356g.5, 356u, 356w, 356x, and 356z.6 , and | ||||||
13 | 356z.21 of the Illinois
Insurance Code and (ii) be subject to | ||||||
14 | the provisions of Section 364.01 of the Illinois
Insurance | ||||||
15 | Code.
| ||||||
16 | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07.)
| ||||||
17 | Section 60. The Medical Patient Rights Act is amended by | ||||||
18 | changing Sections 2.04, 3, and 5 and adding Sections 2.06, 5.1, | ||||||
19 | and 5.2 as follows:
| ||||||
20 | (410 ILCS 50/2.04) (from Ch. 111 1/2, par. 5402.04)
| ||||||
21 | Sec. 2.04.
"Insurance company" means (1) an insurance | ||||||
22 | company, fraternal
benefit society, and any other insurer |
| |||||||
| |||||||
1 | subject to regulation under the
Illinois Insurance Code; or (2) | ||||||
2 | a health maintenance organization , a limited health service | ||||||
3 | organization under the Limited Health Service Organization | ||||||
4 | Act, or a voluntary health services plan under the Voluntary | ||||||
5 | Health Services Plans Act .
| ||||||
6 | (Source: P.A. 85-677; 85-679.)
| ||||||
7 | (410 ILCS 50/2.06 new) | ||||||
8 | Sec. 2.06. "Health insurance policy or health care plan" | ||||||
9 | means any policy of health or accident insurance provided by a | ||||||
10 | health insurance company or under the Counties Code, the | ||||||
11 | Municipal Code, the State Employees Group Insurance Act or | ||||||
12 | Medical Assistance provided under the Public Aid Code.
| ||||||
13 | (410 ILCS 50/3) (from Ch. 111 1/2, par. 5403)
| ||||||
14 | Sec. 3. The following rights are hereby established:
| ||||||
15 | (a) The right of each patient to care consistent with sound | ||||||
16 | nursing and
medical practices, to be informed of the name of | ||||||
17 | the physician responsible
for coordinating his or her care, to | ||||||
18 | receive information concerning his or
her condition and | ||||||
19 | proposed treatment, to refuse any treatment to the extent
| ||||||
20 | permitted by law, and to privacy and confidentiality of records | ||||||
21 | except as
otherwise provided by law. Each patient has a right | ||||||
22 | to be informed of his or her inpatient or outpatient status | ||||||
23 | while undergoing evaluation, assessment, diagnosis, treatment, | ||||||
24 | or observation in a hospital. The patient must be informed of |
| |||||||
| |||||||
1 | this status and put on notice that this admission status may | ||||||
2 | affect coverage by his or her health insurance policy or health | ||||||
3 | care plan or his or her personal responsibility for payment.
| ||||||
4 | (b) The right of each patient, regardless of source of | ||||||
5 | payment, to examine
and receive a reasonable explanation of his | ||||||
6 | total bill for services rendered
by his physician or health | ||||||
7 | care provider, including the itemized charges
for specific | ||||||
8 | services received. Each physician or health care provider
shall | ||||||
9 | be responsible only for a reasonable explanation of those | ||||||
10 | specific
services provided by such physician or health care | ||||||
11 | provider.
| ||||||
12 | (c) In the event an insurance company or health services | ||||||
13 | corporation cancels
or refuses to renew an individual policy or | ||||||
14 | plan, the insured patient shall
be entitled to timely, prior | ||||||
15 | notice of the termination of such policy or plan.
| ||||||
16 | An insurance company or health services corporation that | ||||||
17 | requires any
insured patient or applicant for new or continued | ||||||
18 | insurance or coverage to
be tested for infection with human | ||||||
19 | immunodeficiency virus (HIV) or any
other identified causative | ||||||
20 | agent of acquired immunodeficiency syndrome
(AIDS) shall (1) | ||||||
21 | give the patient or applicant prior written notice of such
| ||||||
22 | requirement, (2) proceed with such testing only upon the | ||||||
23 | written
authorization of the applicant or patient, and (3) keep | ||||||
24 | the results of such
testing confidential. Notice of an adverse | ||||||
25 | underwriting or coverage
decision may be given to any | ||||||
26 | appropriately interested party, but the
insurer may only |
| |||||||
| |||||||
1 | disclose the test result itself to a physician designated
by | ||||||
2 | the applicant or patient, and any such disclosure shall be in a | ||||||
3 | manner
that assures confidentiality.
| ||||||
4 | The Department of Insurance shall enforce the provisions of | ||||||
5 | this subsection.
| ||||||
6 | (d) The right of each patient to privacy and | ||||||
7 | confidentiality in health
care. Each physician, health care | ||||||
8 | provider, health services corporation and
insurance company | ||||||
9 | shall refrain from disclosing the nature or details of
services | ||||||
10 | provided to patients, except that such information may be | ||||||
11 | disclosed to the
patient, the party making treatment decisions | ||||||
12 | if the patient is incapable
of making decisions regarding the | ||||||
13 | health services provided, those parties
directly involved with | ||||||
14 | providing treatment to the patient or processing the
payment | ||||||
15 | for that treatment, those parties responsible for peer review,
| ||||||
16 | utilization review and quality assurance, and those parties | ||||||
17 | required to
be notified under the Abused and Neglected Child | ||||||
18 | Reporting Act, the
Illinois Sexually Transmissible Disease | ||||||
19 | Control Act or where otherwise
authorized or required by law. | ||||||
20 | This right may be waived in writing by the
patient or the | ||||||
21 | patient's guardian, but a physician or other health care
| ||||||
22 | provider may not condition the provision of services on the | ||||||
23 | patient's or
guardian's agreement to sign such a waiver.
| ||||||
24 | (Source: P.A. 86-895; 86-902; 86-1028; 87-334.)
| ||||||
25 | (410 ILCS 50/5)
|
| |||||||
| |||||||
1 | Sec. 5. Statement of hospital patient's rights.
| ||||||
2 | (a) Each patient admitted to a hospital, and the guardian | ||||||
3 | or authorized
representative or parent of a minor patient, | ||||||
4 | shall be given a written
statement of all the rights enumerated | ||||||
5 | in this Act, or a similar statement of
patients' rights | ||||||
6 | required of the hospital by the Joint Commission on
| ||||||
7 | Accreditation of Healthcare Organizations or a similar | ||||||
8 | accrediting
organization. The statement shall be given at the | ||||||
9 | time of admission or as soon
thereafter as the condition of the | ||||||
10 | patient permits.
| ||||||
11 | (b) If a patient is unable to read the written statement, a | ||||||
12 | hospital
shall make a reasonable effort to provide it to the | ||||||
13 | guardian or authorized
representative of the patient.
| ||||||
14 | (c) The statement shall also include the right not to be | ||||||
15 | discriminated against by the hospital due to the patient's | ||||||
16 | race, color, or national origin where such characteristics are | ||||||
17 | not relevant to the patient's medical diagnosis and treatment. | ||||||
18 | The statement shall further provide each admitted patient or | ||||||
19 | the patient's representative or guardian with notice of how to | ||||||
20 | initiate a grievance regarding improper discrimination with | ||||||
21 | the hospital and how the patient may lodge a grievance with the | ||||||
22 | Illinois Department of Public Health regardless of whether the | ||||||
23 | patient has first used the hospital's grievance process. | ||||||
24 | (Source: P.A. 88-56; 88-670, eff. 12-2-94.)
| ||||||
25 | (410 ILCS 50/5.1 new)
|
| |||||||
| |||||||
1 | Sec. 5.1. Discrimination grievance procedures. Upon | ||||||
2 | receipt of a grievance alleging unlawful discrimination on the | ||||||
3 | basis of race, color, or national origin, the hospital must | ||||||
4 | investigate the claim and work with the patient to address | ||||||
5 | valid or proven concerns in accordance with the hospital's | ||||||
6 | grievance process. At the conclusion of the hospital's | ||||||
7 | grievance process, the hospital shall inform the patient that | ||||||
8 | such grievances may be reported to the Illinois Department of | ||||||
9 | Public Health if not resolved to the patient's satisfaction at | ||||||
10 | the hospital level. | ||||||
11 | (410 ILCS 50/5.2 new)
| ||||||
12 | Sec. 5.2. Emergency room antidiscrimination notice. Every | ||||||
13 | hospital shall post a sign next to or in close proximity of its | ||||||
14 | sign required by Section 489.20 (q)(1) of Title 42 of the Code | ||||||
15 | of Federal Regulations stating the following: | ||||||
16 | "You have the right not to be discriminated against by the | ||||||
17 | hospital due to your race, color, or national origin if these | ||||||
18 | characteristics are unrelated to your diagnosis or treatment. | ||||||
19 | If you believe this right has been violated, please call | ||||||
20 | (insert number for hospital grievance officer).". | ||||||
21 | Section 90. The State Mandates Act is amended by adding | ||||||
22 | Section 8.34 as follows: | ||||||
23 | (30 ILCS 805/8.34 new) |
| |||||||
| |||||||
1 | Sec. 8.34. Exempt mandate. Notwithstanding Sections 6 and 8 | ||||||
2 | of this Act, no reimbursement by the State is required for the | ||||||
3 | implementation of any mandate created by this amendatory Act of | ||||||
4 | the 96th General Assembly. | ||||||
5 | Section 95. No acceleration or delay. Where this Act makes | ||||||
6 | changes in a statute that is represented in this Act by text | ||||||
7 | that is not yet or no longer in effect (for example, a Section | ||||||
8 | represented by multiple versions), the use of that text does | ||||||
9 | not accelerate or delay the taking effect of (i) the changes | ||||||
10 | made by this Act or (ii) provisions derived from any other | ||||||
11 | Public Act.
| ||||||
12 | Section 99. Effective date. This Act takes effect upon | ||||||
13 | becoming law.".
|