Full Text of HB4223 95th General Assembly
HB4223ham003 95TH GENERAL ASSEMBLY
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Rep. Mary E. Flowers
Filed: 3/26/2008
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| AMENDMENT TO HOUSE BILL 4223
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| AMENDMENT NO. ______. Amend House Bill 4223, AS AMENDED, by | 3 |
| replacing everything after the enacting clause with the | 4 |
| following:
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| "Section 5. The State Employees Group Insurance Act of 1971 | 6 |
| is amended by changing Section 6.11 as follows:
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| (5 ILCS 375/6.11)
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| Sec. 6.11. Required health benefits; Illinois Insurance | 9 |
| Code
requirements. The program of health
benefits shall provide | 10 |
| the post-mastectomy care benefits required to be covered
by a | 11 |
| policy of accident and health insurance under Section 356t of | 12 |
| the Illinois
Insurance Code. The program of health benefits | 13 |
| shall provide the coverage
required under Sections 356f.1, | 14 |
| 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, | 15 |
| and 356z.10
356z.9 of the
Illinois Insurance Code.
The program | 16 |
| of health benefits must comply with Section 155.37 of the
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| Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 3 |
| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 10. The Counties Code is amended by changing | 5 |
| Section 5-1069.3 as follows: | 6 |
| (55 ILCS 5/5-1069.3)
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| Sec. 5-1069.3. Required health benefits. If a county, | 8 |
| including a home
rule
county, is a self-insurer for purposes of | 9 |
| providing health insurance coverage
for its employees, the | 10 |
| coverage shall include coverage for the post-mastectomy
care | 11 |
| benefits required to be covered by a policy of accident and | 12 |
| health
insurance under Section 356t and the coverage required | 13 |
| under Sections 356f.1, 356g.5, 356u,
356w, 356x, 356z.6, and | 14 |
| 356z.9, and 356z.10
356z.9 of
the Illinois Insurance Code. The | 15 |
| requirement that health benefits be covered
as provided in this | 16 |
| Section is an
exclusive power and function of the State and is | 17 |
| a denial and limitation under
Article VII, Section 6, | 18 |
| subsection (h) of the Illinois Constitution. A home
rule county | 19 |
| to which this Section applies must comply with every provision | 20 |
| of
this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 22 |
| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 15. The Illinois Municipal Code is amended by |
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| changing Section 10-4-2.3 as follows: | 2 |
| (65 ILCS 5/10-4-2.3)
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| Sec. 10-4-2.3. Required health benefits. If a | 4 |
| municipality, including a
home rule municipality, is a | 5 |
| self-insurer for purposes of providing health
insurance | 6 |
| coverage for its employees, the coverage shall include coverage | 7 |
| for
the post-mastectomy care benefits required to be covered by | 8 |
| a policy of
accident and health insurance under Section 356t | 9 |
| and the coverage required
under Sections 356f.1, 356g.5, 356u, | 10 |
| 356w, 356x, 356z.6, and 356z.9, and 356z.10
356z.9 of the | 11 |
| Illinois
Insurance
Code. The requirement that health
benefits | 12 |
| be covered as provided in this is an exclusive power and | 13 |
| function of
the State and is a denial and limitation under | 14 |
| Article VII, Section 6,
subsection (h) of the Illinois | 15 |
| Constitution. A home rule municipality to which
this Section | 16 |
| applies must comply with every provision of this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 18 |
| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 20. The School Code is amended by changing Section | 20 |
| 10-22.3f as follows: | 21 |
| (105 ILCS 5/10-22.3f)
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| Sec. 10-22.3f. Required health benefits. Insurance | 23 |
| protection and
benefits
for employees shall provide the |
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| post-mastectomy care benefits required to be
covered by a | 2 |
| policy of accident and health insurance under Section 356t and | 3 |
| the
coverage required under Sections 356f.1, 356g.5, 356u, | 4 |
| 356w, 356x,
356z.6, and 356z.9 of
the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 6 |
| revised 12-4-07.)
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| Section 25. The Illinois Insurance Code is amended by | 8 |
| adding Section 356f.1 as follows: | 9 |
| (215 ILCS 5/356f.1 new) | 10 |
| Sec. 356f.1. Health care services appeals,
complaints, and
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| external independent reviews. | 12 |
| (a) A policy of accident or health insurance or managed | 13 |
| care plan shall establish and maintain an appeals procedure as
| 14 |
| outlined in this Section. Compliance with this Section's | 15 |
| appeals procedures shall
satisfy a policy or plan's obligation | 16 |
| to provide appeal procedures under any
other State law or | 17 |
| rules. | 18 |
| (b) When an appeal concerns a decision or action by a | 19 |
| policy of accident or health insurance or managed care plan,
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| its
employees, or its subcontractors that relates to (i) health | 21 |
| care services,
including, but not limited to, procedures or
| 22 |
| treatments
for an enrollee with an ongoing course of treatment | 23 |
| ordered
by a health care provider,
the denial of which could | 24 |
| significantly
increase the risk to an
enrollee's health,
(ii) a |
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| treatment referral, service,
procedure, or other health care | 2 |
| service,
the denial of which could significantly
increase the | 3 |
| risk to an
enrollee's health, or (iii) nonrenewal or | 4 |
| termination of a policy or plan,
the policy or plan must allow | 5 |
| for the filing of an appeal
either orally or in writing. Upon | 6 |
| submission of the appeal, a policy or plan
must notify the | 7 |
| party filing the appeal, as soon as possible, but in no event
| 8 |
| more than 24 hours after the submission of the appeal, of all | 9 |
| information
that the plan requires to evaluate the appeal.
The | 10 |
| policy or plan shall render a decision on the appeal within
24 | 11 |
| hours after receipt of the required information. The policy or | 12 |
| plan shall
notify the party filing the
appeal and the enrollee, | 13 |
| enrollee's primary care physician, and any health care
provider | 14 |
| who recommended the health care service involved in the appeal | 15 |
| of its
decision orally
followed-up by a written notice of the | 16 |
| determination. | 17 |
| (c) For all appeals related to health care services | 18 |
| including, but not
limited to, procedures or treatments for an | 19 |
| enrollee and not covered by
subsection (b) above, the policy or | 20 |
| plan shall establish a procedure for the filing of such | 21 |
| appeals. Upon
submission of an appeal under this subsection, a | 22 |
| policy or plan must notify
the party filing an appeal, within 3 | 23 |
| business days, of all information that the
policy or plan | 24 |
| requires to evaluate the appeal.
The policy or plan shall | 25 |
| render a decision on the appeal within 15 business
days after | 26 |
| receipt of the required information. The policy or plan shall
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| notify the party filing the appeal,
the enrollee, the | 2 |
| enrollee's primary care physician, and any health care
provider
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| who recommended the health care service involved in the appeal | 4 |
| orally of its
decision followed-up by a written notice of the | 5 |
| determination. | 6 |
| (d) An appeal under subsection (b) or (c) may be filed by | 7 |
| the
enrollee, the enrollee's designee or guardian, the | 8 |
| enrollee's primary care
physician, or the enrollee's health | 9 |
| care provider. A policy or plan shall
designate a clinical peer | 10 |
| to review
appeals, because these appeals pertain to medical or | 11 |
| clinical matters
and such an appeal must be reviewed by an | 12 |
| appropriate
health care professional. No one reviewing an | 13 |
| appeal may have had any
involvement
in the initial | 14 |
| determination that is the subject of the appeal. The written
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| notice of determination required under subsections (b) and (c) | 16 |
| shall
include (i) clear and detailed reasons for the | 17 |
| determination, (ii)
the medical or
clinical criteria for the | 18 |
| determination, which shall be based upon sound
clinical | 19 |
| evidence and reviewed on a periodic basis, and (iii) in the | 20 |
| case of an
adverse determination, the
procedures for requesting | 21 |
| an external independent review under subsection (f). | 22 |
| (e) If an appeal filed under subsection (b) or (c) is | 23 |
| denied for a reason
including, but not limited to, the
service, | 24 |
| procedure, or treatment is not viewed as medically necessary,
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| denial of specific tests or procedures, denial of referral
to | 26 |
| specialist physicians or denial of hospitalization requests or |
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| length of
stay requests, any involved party may request an | 2 |
| external independent review
under subsection (f) of the adverse | 3 |
| determination. | 4 |
| (f) The party seeking an external independent review shall | 5 |
| so notify the
policy or plan.
The policy or plan shall seek to | 6 |
| resolve all
external independent
reviews in the most | 7 |
| expeditious manner and shall make a determination and
provide | 8 |
| notice of the determination no more
than 24 hours after the | 9 |
| receipt of all necessary information when a delay would
| 10 |
| significantly increase
the risk to an enrollee's health or when | 11 |
| extended health care services for an
enrollee undergoing a
| 12 |
| course of treatment prescribed by a health care provider are at | 13 |
| issue. | 14 |
| (1) Within 30 days after the enrollee receives written | 15 |
| notice of an
adverse
determination,
if the enrollee decides | 16 |
| to initiate an external independent review, the
enrollee | 17 |
| shall send to the policy or plan a written request for an | 18 |
| external independent review, including any
information or
| 19 |
| documentation to support the enrollee's request for the | 20 |
| covered service or
claim for a covered
service. | 21 |
| (2) Within 30 days after the policy or plan receives a | 22 |
| request for an
external
independent review from an enrollee | 23 |
| or, within 24 hours after the receipt of a request if a | 24 |
| delay would significantly increase the risk to the | 25 |
| enrollee's health, the policy or plan shall: | 26 |
| (A) select an external independent reviewer as |
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| provided in subsection (h) of this Section; and | 2 |
| (B) forward to the independent reviewer all | 3 |
| medical records and
supporting
documentation | 4 |
| pertaining to the case, a summary description of the | 5 |
| applicable
issues including a
statement of the | 6 |
| decision made by, the criteria used, and the
medical | 7 |
| and clinical reasons
for that decision. | 8 |
| (3) Within 5 days after receipt of all necessary | 9 |
| information or within 24 hours when a delay would
| 10 |
| significantly increase
the risk to an enrollee's health, | 11 |
| the
independent
reviewer
shall evaluate and analyze the | 12 |
| case and render a decision that is based on
whether or not | 13 |
| the health
care service or claim for the health care | 14 |
| service is medically appropriate. The
decision by the
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| independent reviewer is final. If the external independent | 16 |
| reviewer determines
the health care
service to be medically
| 17 |
| appropriate, the policy or plan shall pay for the health | 18 |
| care service. | 19 |
| (4) The policy or plan shall be solely responsible for | 20 |
| paying the fees
of the external
independent reviewer who is | 21 |
| selected to perform the review. | 22 |
| (5) An external independent reviewer who acts in good | 23 |
| faith shall have
immunity
from any civil or criminal | 24 |
| liability or professional discipline as a result of
acts or | 25 |
| omissions with
respect to any external independent review, | 26 |
| unless the acts or omissions
constitute wilful and wanton
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| misconduct. For purposes of any proceeding, the good faith | 2 |
| of the person
participating shall be
presumed. | 3 |
| (6) Future contractual or employment action by the | 4 |
| policy or plan
regarding the
patient's physician or other | 5 |
| health care provider shall not be based solely on
the | 6 |
| physician's or other
health care provider's participation | 7 |
| in this procedure. | 8 |
| (7) For the purposes of this Section, an external | 9 |
| independent reviewer
shall: | 10 |
| (A) be a clinical peer; | 11 |
| (B) have no direct financial interest in | 12 |
| connection with the case; and | 13 |
| (C) have not been informed of the specific identity | 14 |
| of the enrollee. | 15 |
| (g) The external independent reviewer and the medical | 16 |
| review professional conducting the external review under this | 17 |
| Section may not have a material professional, familial, | 18 |
| financial, or other affiliation with any of the following: | 19 |
| (1) The insurer. | 20 |
| (2) Any officer, director, or management employee of | 21 |
| the insurer. | 22 |
| (3) The health care provider or the health care | 23 |
| provider's medical group that is proposing the service. | 24 |
| (4) The facility at which the service would be | 25 |
| provided. | 26 |
| (5) The development or manufacture of the principal |
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| drug, device, procedure, or other therapy that is proposed | 2 |
| for use by the treating health care provider. | 3 |
| (6) The covered individual requesting the external | 4 |
| grievance review. | 5 |
| However, the medical review professional may have an | 6 |
| affiliation under which the medical review professional | 7 |
| provides health care services to covered individuals of the | 8 |
| insurer and may have an affiliation that is limited to staff | 9 |
| privileges at the health facility, if the affiliation is | 10 |
| disclosed to the covered individual and the insurer before | 11 |
| commencing the review and neither the covered individual nor | 12 |
| the insurer objects. | 13 |
| A covered individual shall not pay any of the costs | 14 |
| associated with the services of an external independent | 15 |
| reviewer under this Section. All costs must be paid by the | 16 |
| insurer. | 17 |
| (h) When a request for appeal is filed, the insurer shall: | 18 |
| (1) select a different external independent reviewer | 19 |
| for each external independent review requested under this | 20 |
| Section from the list of external independent reviewers | 21 |
| that are certified by the Division under subsection (i) of | 22 |
| this Section; and | 23 |
| (2) rotate the choice of an external independent | 24 |
| reviewer among all certified external independent | 25 |
| reviewers before repeating a selection. | 26 |
| (i) The Division of Insurance of the Department of |
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| Financial and Professional Regulation shall establish and | 2 |
| maintain a process for annual certification of external | 3 |
| independent reviewers. The Division shall certify a number of | 4 |
| external independent reviewers determined by the Division to be | 5 |
| sufficient to fulfill the purposes of this Section. An external | 6 |
| independent reviewer must meet the following minimum | 7 |
| requirements for certification by the Division: | 8 |
| (1) Medical review professionals assigned by the | 9 |
| external independent reviewer to perform external | 10 |
| grievance reviews under this Section must: | 11 |
| (A) be board certified in the specialty in which a | 12 |
| covered individual's proposed service would be | 13 |
| provided; | 14 |
| (B) be knowledgeable about a proposed service | 15 |
| through actual clinical experience; | 16 |
| (C) hold an unlimited license to practice in a | 17 |
| state of the United States; and | 18 |
| (D) not have any history of disciplinary actions or | 19 |
| sanctions, including: | 20 |
| (i) loss of staff privileges; or | 21 |
| (ii) restriction on participation; | 22 |
| taken or pending by any hospital, government, or | 23 |
| regulatory body. | 24 |
| (2) The external independent reviewer must have a | 25 |
| quality assurance mechanism to ensure: | 26 |
| (A) the timeliness and quality of reviews; |
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| (B) the qualifications and independence of medical | 2 |
| review professionals; | 3 |
| (C) the confidentiality of medical records and | 4 |
| other review materials; and | 5 |
| (D) the satisfaction of covered individuals with | 6 |
| the procedures utilized by the external independent | 7 |
| reviewer, including the use of covered individual | 8 |
| satisfaction surveys. | 9 |
| (3) The external independent reviewer must file with | 10 |
| the Division all of the following information on or before | 11 |
| March 1 of each year: | 12 |
| (A) The number and percentage of determinations | 13 |
| made in favor of covered individuals. | 14 |
| (B) The number and percentage of determinations | 15 |
| made in favor of insurers. | 16 |
| (C) The average time to process a determination. | 17 |
| (D) Any other information required by the | 18 |
| Division. | 19 |
| The information required under this item (3) must be | 20 |
| specified for each insurer for which the external | 21 |
| independent reviewer performed reviews during the | 22 |
| reporting year. | 23 |
| (4) The external independent reviewer must meet any | 24 |
| additional requirements established by the Division. | 25 |
| The Division may not certify an external independent | 26 |
| reviewer that is either (i) a professional or trade association |
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| of health care providers or a subsidiary or an affiliate of a | 2 |
| professional or trade association of health care providers or | 3 |
| (ii) an insurer, a health maintenance organization, or a health | 4 |
| plan association or a subsidiary or an affiliate of an insurer, | 5 |
| health maintenance organization, or health plan association. | 6 |
| The Division may suspend or revoke an external independent | 7 |
| reviewer's certification if the Division finds that the | 8 |
| external independent reviewer is not in substantial compliance | 9 |
| with the certification requirements under this subsection (i). | 10 |
| The Division shall make available to insurers a list of all | 11 |
| certified external independent reviewers. | 12 |
| (j) The Division shall make the information provided to the | 13 |
| Division under item (3) of subsection (i) available to the | 14 |
| public in a format that does not identify individual covered | 15 |
| individuals. | 16 |
| (k) An insurer shall each year file with the Division a | 17 |
| description of the external independent review procedure | 18 |
| established by the insurer under this Section, including the | 19 |
| following for each external independent reviewer used by the | 20 |
| insurer during the reporting year: | 21 |
| (1) the total number of external independent reviews | 22 |
| handled through the procedure during the preceding | 23 |
| calendar year; | 24 |
| (2) a compilation of the causes underlying those | 25 |
| reviews; and | 26 |
| (3) a summary of the final disposition of those |
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| reviews. | 2 |
| The information required by this subsection (k) must be | 3 |
| filed with the Division on or before March 1 of each year. | 4 |
| The Division shall make the information required to be | 5 |
| filed under this subsection (k) available to the public and | 6 |
| prepare an annual compilation of the data that allows for | 7 |
| comparative analysis.
The Division may require any additional | 8 |
| reports that are necessary and appropriate for the Division to | 9 |
| carry out its duties under this Section. | 10 |
| (l) Nothing in this Section shall be construed to require a | 11 |
| policy or
plan to pay for a health care service not covered | 12 |
| under the enrollee's
certificate of coverage or policy. | 13 |
| (m) Notwithstanding any other rulemaking authority that | 14 |
| may exist, neither the Governor nor any agency or agency head | 15 |
| under the jurisdiction of the Governor has any authority to | 16 |
| make or promulgate rules to implement or enforce the provisions | 17 |
| of this amendatory Act of the 95th General Assembly. If, | 18 |
| however, the Governor believes that rules are necessary to | 19 |
| implement or enforce the provisions of this amendatory Act of | 20 |
| the 95th General Assembly, the Governor may suggest rules to | 21 |
| the General Assembly by filing them with the Clerk of the House | 22 |
| and the Secretary of the Senate and by requesting that the | 23 |
| General Assembly authorize such rulemaking by law, enact those | 24 |
| suggested rules into law, or take any other appropriate action | 25 |
| in the General Assembly's discretion. Nothing contained in this | 26 |
| amendatory Act of the 95th General Assembly shall be |
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| interpreted to grant rulemaking authority under any other | 2 |
| Illinois statute where such authority is not otherwise | 3 |
| explicitly given. For the purposes of this subsection, "rules" | 4 |
| is given the meaning contained in Section 1-70 of the Illinois | 5 |
| Administrative Procedure Act, and "agency" and "agency head" | 6 |
| are given the meanings contained in Sections 1-20 and 1-25 of | 7 |
| the Illinois Administrative Procedure Act to the extent that | 8 |
| such definitions apply to agencies or agency heads under the | 9 |
| jurisdiction of the Governor.
| 10 |
| Section 30. The Health Maintenance Organization Act is | 11 |
| amended by changing Section 5-3 as follows:
| 12 |
| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 13 |
| Sec. 5-3. Insurance Code provisions.
| 14 |
| (a) Health Maintenance Organizations
shall be subject to | 15 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 16 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 17 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356f.1, 356m, 356v, 356w, | 18 |
| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | 19 |
| 356z.10
356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | 20 |
| 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, | 21 |
| 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section | 22 |
| 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, | 23 |
| XXV, and XXVI of the Illinois Insurance Code.
| 24 |
| (b) For purposes of the Illinois Insurance Code, except for |
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| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 2 |
| Maintenance Organizations in
the following categories are | 3 |
| deemed to be "domestic companies":
| 4 |
| (1) a corporation authorized under the
Dental Service | 5 |
| Plan Act or the Voluntary Health Services Plans Act;
| 6 |
| (2) a corporation organized under the laws of this | 7 |
| State; or
| 8 |
| (3) a corporation organized under the laws of another | 9 |
| state, 30% or more
of the enrollees of which are residents | 10 |
| of this State, except a
corporation subject to | 11 |
| substantially the same requirements in its state of
| 12 |
| organization as is a "domestic company" under Article VIII | 13 |
| 1/2 of the
Illinois Insurance Code.
| 14 |
| (c) In considering the merger, consolidation, or other | 15 |
| acquisition of
control of a Health Maintenance Organization | 16 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 17 |
| (1) the Director shall give primary consideration to | 18 |
| the continuation of
benefits to enrollees and the financial | 19 |
| conditions of the acquired Health
Maintenance Organization | 20 |
| after the merger, consolidation, or other
acquisition of | 21 |
| control takes effect;
| 22 |
| (2)(i) the criteria specified in subsection (1)(b) of | 23 |
| Section 131.8 of
the Illinois Insurance Code shall not | 24 |
| apply and (ii) the Director, in making
his determination | 25 |
| with respect to the merger, consolidation, or other
| 26 |
| acquisition of control, need not take into account the |
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| effect on
competition of the merger, consolidation, or | 2 |
| other acquisition of control;
| 3 |
| (3) the Director shall have the power to require the | 4 |
| following
information:
| 5 |
| (A) certification by an independent actuary of the | 6 |
| adequacy
of the reserves of the Health Maintenance | 7 |
| Organization sought to be acquired;
| 8 |
| (B) pro forma financial statements reflecting the | 9 |
| combined balance
sheets of the acquiring company and | 10 |
| the Health Maintenance Organization sought
to be | 11 |
| acquired as of the end of the preceding year and as of | 12 |
| a date 90 days
prior to the acquisition, as well as pro | 13 |
| forma financial statements
reflecting projected | 14 |
| combined operation for a period of 2 years;
| 15 |
| (C) a pro forma business plan detailing an | 16 |
| acquiring party's plans with
respect to the operation | 17 |
| of the Health Maintenance Organization sought to
be | 18 |
| acquired for a period of not less than 3 years; and
| 19 |
| (D) such other information as the Director shall | 20 |
| require.
| 21 |
| (d) The provisions of Article VIII 1/2 of the Illinois | 22 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 23 |
| any health maintenance
organization of greater than 10% of its
| 24 |
| enrollee population (including without limitation the health | 25 |
| maintenance
organization's right, title, and interest in and to | 26 |
| its health care
certificates).
|
|
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| (e) In considering any management contract or service | 2 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 3 |
| Code, the Director (i) shall, in
addition to the criteria | 4 |
| specified in Section 141.2 of the Illinois
Insurance Code, take | 5 |
| into account the effect of the management contract or
service | 6 |
| agreement on the continuation of benefits to enrollees and the
| 7 |
| financial condition of the health maintenance organization to | 8 |
| be managed or
serviced, and (ii) need not take into account the | 9 |
| effect of the management
contract or service agreement on | 10 |
| competition.
| 11 |
| (f) Except for small employer groups as defined in the | 12 |
| Small Employer
Rating, Renewability and Portability Health | 13 |
| Insurance Act and except for
medicare supplement policies as | 14 |
| defined in Section 363 of the Illinois
Insurance Code, a Health | 15 |
| Maintenance Organization may by contract agree with a
group or | 16 |
| other enrollment unit to effect refunds or charge additional | 17 |
| premiums
under the following terms and conditions:
| 18 |
| (i) the amount of, and other terms and conditions with | 19 |
| respect to, the
refund or additional premium are set forth | 20 |
| in the group or enrollment unit
contract agreed in advance | 21 |
| of the period for which a refund is to be paid or
| 22 |
| additional premium is to be charged (which period shall not | 23 |
| be less than one
year); and
| 24 |
| (ii) the amount of the refund or additional premium | 25 |
| shall not exceed 20%
of the Health Maintenance | 26 |
| Organization's profitable or unprofitable experience
with |
|
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| respect to the group or other enrollment unit for the | 2 |
| period (and, for
purposes of a refund or additional | 3 |
| premium, the profitable or unprofitable
experience shall | 4 |
| be calculated taking into account a pro rata share of the
| 5 |
| Health Maintenance Organization's administrative and | 6 |
| marketing expenses, but
shall not include any refund to be | 7 |
| made or additional premium to be paid
pursuant to this | 8 |
| subsection (f)). The Health Maintenance Organization and | 9 |
| the
group or enrollment unit may agree that the profitable | 10 |
| or unprofitable
experience may be calculated taking into | 11 |
| account the refund period and the
immediately preceding 2 | 12 |
| plan years.
| 13 |
| The Health Maintenance Organization shall include a | 14 |
| statement in the
evidence of coverage issued to each enrollee | 15 |
| describing the possibility of a
refund or additional premium, | 16 |
| and upon request of any group or enrollment unit,
provide to | 17 |
| the group or enrollment unit a description of the method used | 18 |
| to
calculate (1) the Health Maintenance Organization's | 19 |
| profitable experience with
respect to the group or enrollment | 20 |
| unit and the resulting refund to the group
or enrollment unit | 21 |
| or (2) the Health Maintenance Organization's unprofitable
| 22 |
| experience with respect to the group or enrollment unit and the | 23 |
| resulting
additional premium to be paid by the group or | 24 |
| enrollment unit.
| 25 |
| In no event shall the Illinois Health Maintenance | 26 |
| Organization
Guaranty Association be liable to pay any |
|
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| contractual obligation of an
insolvent organization to pay any | 2 |
| refund authorized under this Section.
| 3 |
| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | 4 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
| 5 |
| Section 35. The Limited Health Service Organization Act is | 6 |
| amended by changing Section 4003 as follows:
| 7 |
| (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| 8 |
| Sec. 4003. Illinois Insurance Code provisions. Limited | 9 |
| health service
organizations shall be subject to the provisions | 10 |
| of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | 11 |
| 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | 12 |
| 155.04, 155.37, 355.2, 356f.1, 356v, 356z.10
356z.9 , 368a, 401, | 13 |
| 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and | 14 |
| Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and | 15 |
| XXVI of the Illinois Insurance Code. For purposes of the
| 16 |
| Illinois Insurance Code, except for Sections 444 and 444.1 and | 17 |
| Articles XIII
and XIII 1/2, limited health service | 18 |
| organizations in the following categories
are deemed to be | 19 |
| domestic companies:
| 20 |
| (1) a corporation under the laws of this State; or
| 21 |
| (2) a corporation organized under the laws of another | 22 |
| state, 30% of more
of the enrollees of which are residents | 23 |
| of this State, except a corporation
subject to | 24 |
| substantially the same requirements in its state of |
|
|
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| organization as
is a domestic company under Article VIII | 2 |
| 1/2 of the Illinois Insurance Code.
| 3 |
| (Source: P.A. 95-520, eff. 8-28-07; revised 12-5-07.)
| 4 |
| Section 37. The Managed Care Reform and Patient Rights Act | 5 |
| is amended by changing Section 45 as follows:
| 6 |
| (215 ILCS 134/45)
| 7 |
| Sec. 45. Health care services appeals,
complaints, and
| 8 |
| external independent reviews.
| 9 |
| (a) A health care plan shall establish and maintain an | 10 |
| appeals procedure as
outlined in this Act. Compliance with this | 11 |
| Act's appeals procedures shall
satisfy a health care plan's | 12 |
| obligation to provide appeal procedures under any
other State | 13 |
| law or rules.
All appeals of a health care plan's | 14 |
| administrative determinations and
complaints regarding its | 15 |
| administrative decisions shall be handled as required
under | 16 |
| Section 50.
| 17 |
| (b) When an appeal concerns a decision or action by a | 18 |
| health care plan,
its
employees, or its subcontractors that | 19 |
| relates to (i) health care services,
including, but not limited | 20 |
| to, procedures or
treatments,
for an enrollee with an ongoing | 21 |
| course of treatment ordered
by a health care provider,
the | 22 |
| denial of which could significantly
increase the risk to an
| 23 |
| enrollee's health,
or (ii) a treatment referral, service,
| 24 |
| procedure, or other health care service,
the denial of which |
|
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| 1 |
| could significantly
increase the risk to an
enrollee's health , | 2 |
| or (iii) nonrenewal or termination of a plan ,
the health care | 3 |
| plan must allow for the filing of an appeal
either orally or in | 4 |
| writing. Upon submission of the appeal, a health care plan
must | 5 |
| notify the party filing the appeal, as soon as possible, but in | 6 |
| no event
more than 24 hours after the submission of the appeal, | 7 |
| of all information
that the plan requires to evaluate the | 8 |
| appeal.
The health care plan shall render a decision on the | 9 |
| appeal within
24 hours after receipt of the required | 10 |
| information. The health care plan shall
notify the party filing | 11 |
| the
appeal and the enrollee, enrollee's primary care physician, | 12 |
| and any health care
provider who recommended the health care | 13 |
| service involved in the appeal of its
decision orally
| 14 |
| followed-up by a written notice of the determination.
| 15 |
| (c) For all appeals related to health care services | 16 |
| including, but not
limited to, procedures or treatments for an | 17 |
| enrollee and not covered by
subsection (b) above, the health | 18 |
| care
plan shall establish a procedure for the filing of such | 19 |
| appeals. Upon
submission of an appeal under this subsection, a | 20 |
| health care plan must notify
the party filing an appeal, within | 21 |
| 3 business days, of all information that the
plan requires to | 22 |
| evaluate the appeal.
The health care plan shall render a | 23 |
| decision on the appeal within 15 business
days after receipt of | 24 |
| the required information. The health care plan shall
notify the | 25 |
| party filing the appeal,
the enrollee, the enrollee's primary | 26 |
| care physician, and any health care
provider
who recommended |
|
|
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| the health care service involved in the appeal orally of its
| 2 |
| decision followed-up by a written notice of the determination.
| 3 |
| (d) An appeal under subsection (b) or (c) may be filed by | 4 |
| the
enrollee, the enrollee's designee or guardian, the | 5 |
| enrollee's primary care
physician, or the enrollee's health | 6 |
| care provider. A health care plan shall
designate a clinical | 7 |
| peer to review
appeals, because these appeals pertain to | 8 |
| medical or clinical matters
and such an appeal must be reviewed | 9 |
| by an appropriate
health care professional. No one reviewing an | 10 |
| appeal may have had any
involvement
in the initial | 11 |
| determination that is the subject of the appeal. The written
| 12 |
| notice of determination required under subsections (b) and (c) | 13 |
| shall
include (i) clear and detailed reasons for the | 14 |
| determination, (ii)
the medical or
clinical criteria for the | 15 |
| determination, which shall be based upon sound
clinical | 16 |
| evidence and reviewed on a periodic basis, and (iii) in the | 17 |
| case of an
adverse determination, the
procedures for requesting | 18 |
| an external independent review under subsection (f).
| 19 |
| (e) If an appeal filed under subsection (b) or (c) is | 20 |
| denied for a reason
including, but not limited to, the
service, | 21 |
| procedure, or treatment is not viewed as medically necessary,
| 22 |
| denial of specific tests or procedures, denial of referral
to | 23 |
| specialist physicians or denial of hospitalization requests or | 24 |
| length of
stay requests, any involved party may request an | 25 |
| external independent review
under subsection (f) of the adverse | 26 |
| determination.
|
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| (f) External independent review.
| 2 |
| (1) The party seeking an external independent review | 3 |
| shall so notify the
health care plan.
The health care plan | 4 |
| shall seek to resolve all
external independent
reviews in | 5 |
| the most expeditious manner and shall make a determination | 6 |
| and
provide notice of the determination no more
than 24 | 7 |
| hours after the receipt of all necessary information when a | 8 |
| delay would
significantly increase
the risk to an | 9 |
| enrollee's health or when extended health care services for | 10 |
| an
enrollee undergoing a
course of treatment prescribed by | 11 |
| a health care provider are at issue.
| 12 |
| (2) Within 30 days after the enrollee receives written | 13 |
| notice of an
adverse
determination,
if the enrollee decides | 14 |
| to initiate an external independent review, the
enrollee | 15 |
| shall send to the health
care plan a written request for an | 16 |
| external independent review, including any
information or
| 17 |
| documentation to support the enrollee's request for the | 18 |
| covered service or
claim for a covered
service.
| 19 |
| (3) Within 30 days after the health care plan receives | 20 |
| a request for an
external
independent review from an | 21 |
| enrollee, the health care plan shall:
| 22 |
| (A) select an external independent reviewer as | 23 |
| provided in subsection (h) of this Section; and provide | 24 |
| a mechanism for joint selection of an external | 25 |
| independent
reviewer by the enrollee, the enrollee's | 26 |
| physician or other health care
provider,
and the health |
|
|
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| care plan; and
| 2 |
| (B) forward to the independent reviewer all | 3 |
| medical records and
supporting
documentation | 4 |
| pertaining to the case, a summary description of the | 5 |
| applicable
issues including a
statement of the health | 6 |
| care plan's decision, the criteria used, and the
| 7 |
| medical and clinical reasons
for that decision.
| 8 |
| (4) Within 5 days after receipt of all necessary | 9 |
| information, the
independent
reviewer
shall evaluate and | 10 |
| analyze the case and render a decision that is based on
| 11 |
| whether or not the health
care service or claim for the | 12 |
| health care service is medically appropriate. The
decision | 13 |
| by the
independent reviewer is final. If the external | 14 |
| independent reviewer determines
the health care
service to | 15 |
| be medically
appropriate, the health
care plan shall pay | 16 |
| for the health care service.
| 17 |
| (5) The health care plan shall be solely responsible | 18 |
| for paying the fees
of the external
independent reviewer | 19 |
| who is selected to perform the review.
| 20 |
| (6) An external independent reviewer who acts in good | 21 |
| faith shall have
immunity
from any civil or criminal | 22 |
| liability or professional discipline as a result of
acts or | 23 |
| omissions with
respect to any external independent review, | 24 |
| unless the acts or omissions
constitute wilful and wanton
| 25 |
| misconduct. For purposes of any proceeding, the good faith | 26 |
| of the person
participating shall be
presumed.
|
|
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| (7) Future contractual or employment action by the | 2 |
| health care plan
regarding the
patient's physician or other | 3 |
| health care provider shall not be based solely on
the | 4 |
| physician's or other
health care provider's participation | 5 |
| in this procedure.
| 6 |
| (8) For the purposes of this Section, an external | 7 |
| independent reviewer
shall:
| 8 |
| (A) be a clinical peer;
| 9 |
| (B) have no direct financial interest in | 10 |
| connection with the case; and
| 11 |
| (C) have not been informed of the specific identity | 12 |
| of the enrollee.
| 13 |
| (g) The external independent reviewer and the medical | 14 |
| review professional conducting the external review under this | 15 |
| Section may not have a material professional, familial, | 16 |
| financial, or other affiliation with any of the following: | 17 |
| (1) The insurer. | 18 |
| (2) Any officer, director, or management employee of | 19 |
| the insurer. | 20 |
| (3) The health care provider or the health care | 21 |
| provider's medical group that is proposing the service. | 22 |
| (4) The facility at which the service would be | 23 |
| provided. | 24 |
| (5) The development or manufacture of the principal | 25 |
| drug, device, procedure, or other therapy that is proposed | 26 |
| for use by the treating health care provider. |
|
|
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| (6) The covered individual requesting the external | 2 |
| grievance review.
| 3 |
| However, the medical review professional may have an | 4 |
| affiliation under which the medical review professional | 5 |
| provides health care services to covered individuals of the | 6 |
| insurer and may have an affiliation that is limited to staff | 7 |
| privileges at the health facility, if the affiliation is | 8 |
| disclosed to the covered individual and the insurer before | 9 |
| commencing the review and neither the covered individual nor | 10 |
| the insurer objects. | 11 |
| A covered individual shall not pay any of the costs | 12 |
| associated with the services of an external independent | 13 |
| reviewer under this Section. All costs must be paid by the | 14 |
| insurer. | 15 |
| (h) When a request for appeal is filed, the insurer shall: | 16 |
| (1) select a different external independent reviewer | 17 |
| for each external independent review requested under this | 18 |
| Section from the list of external independent reviewers | 19 |
| that are certified by the Division under subsection (i) of | 20 |
| this Section; and | 21 |
| (2) rotate the choice of an external independent | 22 |
| reviewer among all certified external independent | 23 |
| reviewers before repeating a selection. | 24 |
| (i) The Division of Insurance of the Department of | 25 |
| Financial and Professional Regulation shall establish and | 26 |
| maintain a process for annual certification of external |
|
|
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| independent reviewers. The Division shall certify a number of | 2 |
| external independent reviewers determined by the Division to be | 3 |
| sufficient to fulfill the purposes of this Section. An external | 4 |
| independent reviewer must meet the following minimum | 5 |
| requirements for certification by the Division: | 6 |
| (1) Medical review professionals assigned by the | 7 |
| external independent reviewer to perform external | 8 |
| grievance reviews under this Section must: | 9 |
| (A) be board certified in the specialty in which a | 10 |
| covered individual's proposed service would be | 11 |
| provided; | 12 |
| (B) be knowledgeable about a proposed service | 13 |
| through actual clinical experience; | 14 |
| (C) hold an unlimited license to practice in a | 15 |
| state of the United States; and | 16 |
| (D) not have any history of disciplinary actions or | 17 |
| sanctions, including: | 18 |
| (i) loss of staff privileges; or | 19 |
| (ii) restriction on participation; | 20 |
| taken or pending by any hospital, government, or | 21 |
| regulatory body. | 22 |
| (2) The external independent reviewer must have a | 23 |
| quality assurance mechanism to ensure: | 24 |
| (A) the timeliness and quality of reviews; | 25 |
| (B) the qualifications and independence of medical | 26 |
| review professionals; |
|
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|
09500HB4223ham003 |
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| (C) the confidentiality of medical records and | 2 |
| other review materials; and | 3 |
| (D) the satisfaction of covered individuals with | 4 |
| the procedures utilized by the external independent | 5 |
| reviewer, including the use of covered individual | 6 |
| satisfaction surveys. | 7 |
| (3) The external independent reviewer must file with | 8 |
| the Division all of the following information on or before | 9 |
| March 1 of each year: | 10 |
| (A) The number and percentage of determinations | 11 |
| made in favor of covered individuals. | 12 |
| (B) The number and percentage of determinations | 13 |
| made in favor of insurers. | 14 |
| (C) The average time to process a determination. | 15 |
| (D) Any other information required by the | 16 |
| Division. | 17 |
| The information required under this item (3) must be | 18 |
| specified for each insurer for which the external | 19 |
| independent reviewer performed reviews during the | 20 |
| reporting year. | 21 |
| (4) The external independent reviewer must meet any | 22 |
| additional requirements established by the Division. | 23 |
| The Division may not certify an external independent | 24 |
| reviewer that is either (i) a professional or trade association | 25 |
| of health care providers or a subsidiary or an affiliate of a | 26 |
| professional or trade association of health care providers or |
|
|
|
09500HB4223ham003 |
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| (ii) an insurer, a health maintenance organization, or a health | 2 |
| plan association or a subsidiary or an affiliate of an insurer, | 3 |
| health maintenance organization, or health plan association. | 4 |
| The Division may suspend or revoke an external independent | 5 |
| reviewer's certification if the Division finds that the | 6 |
| external independent reviewer is not in substantial compliance | 7 |
| with the certification requirements under this subsection (i). | 8 |
| The Division shall make available to insurers a list of all | 9 |
| certified external independent reviewers. | 10 |
| (j) The Division shall make the information provided to the | 11 |
| Division under item (3) of subsection (i) available to the | 12 |
| public in a format that does not identify individual covered | 13 |
| individuals. | 14 |
| (k) An insurer shall each year file with the Division a | 15 |
| description of the external independent review procedure | 16 |
| established by the insurer under this Section, including the | 17 |
| following for each external independent reviewer used by the | 18 |
| insurer during the reporting year: | 19 |
| (1) the total number of external independent reviews | 20 |
| handled through the procedure during the preceding | 21 |
| calendar year; | 22 |
| (2) a compilation of the causes underlying those | 23 |
| reviews; and | 24 |
| (3) a summary of the final disposition of those | 25 |
| reviews. | 26 |
| The information required by this subsection (k) must be |
|
|
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| 1 |
| filed with the Division on or before March 1 of each year. | 2 |
| The Division shall make the information required to be | 3 |
| filed under this subsection (k) available to the public and | 4 |
| prepare an annual compilation of the data that allows for | 5 |
| comparative analysis.
The Division may require any additional | 6 |
| reports that are necessary and appropriate for the Division to | 7 |
| carry out its duties under this Section. | 8 |
| (l) (g) Nothing in this Section shall be construed to | 9 |
| require a health care
plan to pay for a health care service not | 10 |
| covered under the enrollee's
certificate of coverage or policy.
| 11 |
| (m) Notwithstanding any other rulemaking authority that | 12 |
| may exist, neither the Governor nor any agency or agency head | 13 |
| under the jurisdiction of the Governor has any authority to | 14 |
| make or promulgate rules to implement or enforce the provisions | 15 |
| of this amendatory Act of the 95th General Assembly. If, | 16 |
| however, the Governor believes that rules are necessary to | 17 |
| implement or enforce the provisions of this amendatory Act of | 18 |
| the 95th General Assembly, the Governor may suggest rules to | 19 |
| the General Assembly by filing them with the Clerk of the House | 20 |
| and the Secretary of the Senate and by requesting that the | 21 |
| General Assembly authorize such rulemaking by law, enact those | 22 |
| suggested rules into law, or take any other appropriate action | 23 |
| in the General Assembly's discretion. Nothing contained in this | 24 |
| amendatory Act of the 95th General Assembly shall be | 25 |
| interpreted to grant rulemaking authority under any other | 26 |
| Illinois statute where such authority is not otherwise |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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| 1 |
| explicitly given. For the purposes of this amendatory Act of | 2 |
| the 95th General Assembly, "rules" is given the meaning | 3 |
| contained in Section 1-70 of the Illinois Administrative | 4 |
| Procedure Act, and "agency" and "agency head" are given the | 5 |
| meanings contained in Sections 1-20 and 1-25 of the Illinois | 6 |
| Administrative Procedure Act to the extent that such | 7 |
| definitions apply to agencies or agency heads under the | 8 |
| jurisdiction of the Governor. | 9 |
| (Source: P.A. 91-617, eff. 1-1-00.)
| 10 |
| Section 40. The Voluntary Health Services Plans Act is | 11 |
| amended by changing Section 10 as follows:
| 12 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
| 13 |
| Sec. 10. Application of Insurance Code provisions. Health | 14 |
| services
plan corporations and all persons interested therein | 15 |
| or dealing therewith
shall be subject to the provisions of | 16 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | 17 |
| 149, 155.37, 354, 355.2, 356f.1, 356g.5, 356r, 356t, 356u, | 18 |
| 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | 19 |
| 356z.8, 356z.9,
356z.10
356z.9 , 364.01, 367.2, 368a, 401, | 20 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | 21 |
| and (15) of Section 367 of the Illinois
Insurance Code.
| 22 |
| (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | 23 |
| 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | 24 |
| 8-28-07; revised 12-5-07.)".
|
|