State of Illinois
2003 and 2004


Introduced 2/6/2004, by William E. Peterson


215 ILCS 134/15

    Amends the Managed Care Reform and Patient Rights Act. Provides that an enrollee may waive the right to a receive a statement, in printed form, concerning the nature of the health services to be provided and the period during which the certificate shall be effective if the information is readily accessible on the health care plan's Internet site. Provides that the enrollee may revoke the waiver at any time by notifying the health care plan by telephone or in writing, and any enrollee who does not execute a waiver must receive a statement in printed form. Effective immediately.

LRB093 20699 SAS 46578 b





SB2938 LRB093 20699 SAS 46578 b

1     AN ACT concerning insurance.
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4     Section 5. The Managed Care Reform and Patient Rights Act
5 is amended by changing Section 15 as follows:
6     (215 ILCS 134/15)
7     Sec. 15. Provision of information.
8     (a) A health care plan shall provide annually to enrollees
9 and prospective enrollees, upon request, a complete list of
10 participating health care providers in the health care plan's
11 service area and a description of the following terms of
12 coverage:
13         (1) the service area;
14         (2) the covered benefits and services with all
15     exclusions, exceptions, and limitations;
16         (3) the pre-certification and other utilization review
17     procedures and requirements;
18         (4) a description of the process for the selection of a
19     primary care physician, any limitation on access to
20     specialists, and the plan's standing referral policy;
21         (5) the emergency coverage and benefits, including any
22     restrictions on emergency care services;
23         (6) the out-of-area coverage and benefits, if any;
24         (7) the enrollee's financial responsibility for
25     copayments, deductibles, premiums, and any other
26     out-of-pocket expenses;
27         (8) the provisions for continuity of treatment in the
28     event a health care provider's participation terminates
29     during the course of an enrollee's treatment by that
30     provider;
31         (9) the appeals process, forms, and time frames for
32     health care services appeals, complaints, and external



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1     independent reviews, administrative complaints, and
2     utilization review complaints, including a phone number to
3     call to receive more information from the health care plan
4     concerning the appeals process; and
5         (10) a statement of all basic health care services and
6     all specific benefits and services mandated to be provided
7     to enrollees by any State law or administrative rule.
8     In the event of an inconsistency between any separate
9 written disclosure statement and the enrollee contract or
10 certificate, the terms of the enrollee contract or certificate
11 shall control.
12     (b) Upon written request, a health care plan shall provide
13 to enrollees a description of the financial relationships
14 between the health care plan and any health care provider and,
15 if requested, the percentage of copayments, deductibles, and
16 total premiums spent on healthcare related expenses and the
17 percentage of copayments, deductibles, and total premiums
18 spent on other expenses, including administrative expenses,
19 except that no health care plan shall be required to disclose
20 specific provider reimbursement.
21     (c) A participating health care provider shall provide all
22 of the following, where applicable, to enrollees upon request:
23         (1) Information related to the health care provider's
24     educational background, experience, training, specialty,
25     and board certification, if applicable.
26         (2) The names of licensed facilities on the provider
27     panel where the health care provider presently has
28     privileges for the treatment, illness, or procedure that is
29     the subject of the request.
30         (3) Information regarding the health care provider's
31     participation in continuing education programs and
32     compliance with any licensure, certification, or
33     registration requirements, if applicable.
34     (d) A health care plan shall provide the information
35 required to be disclosed under this Act upon enrollment and
36 annually thereafter in a legible and understandable format. The



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1 Department shall promulgate rules to establish the format
2 based, to the extent practical, on the standards developed for
3 supplemental insurance coverage under Title XVIII of the
4 federal Social Security Act as a guide, so that a person can
5 compare the attributes of the various health care plans.
6     (e) The written disclosure requirements of this Section may
7 be met by disclosure to one enrollee in a household.
8     (f) An enrollee entitled to the information set forth in
9 subsection (a) of this Section may choose to waive his or her
10 rights to receive such information in a printed form from his
11 or her health care plan so long as such information is readily
12 accessible on the health care plan's Internet site. An enrollee
13 may revoke such a waiver at any time by notifying the health
14 care plan by phone or in writing. Any enrollee who does not
15 execute such a waiver and prospective enrollees shall have the
16 information set forth in subsection (a) of this Section
17 provided in printed form.
18 (Source: P.A. 91-617, eff. 1-1-00.)
19     Section 99. Effective date. This Act takes effect upon
20 becoming law.