Full Text of HB3923 96th General Assembly
HB3923sam001 96TH GENERAL ASSEMBLY
|
Sen. William R. Haine
Filed: 5/18/2009
|
|
09600HB3923sam001 |
|
LRB096 08394 RPM 26320 a |
|
| 1 |
| AMENDMENT TO HOUSE BILL 3923
| 2 |
| AMENDMENT NO. ______. Amend House Bill 3923 by replacing | 3 |
| everything after the enacting clause with the following:
| 4 |
| "Section 1. Short title. This Act may be cited as the | 5 |
| Health Carrier External Review Act. | 6 |
| Section 5. Purpose and intent. The purpose of this Act is | 7 |
| to provide uniform standards for the establishment and | 8 |
| maintenance of external review procedures to assure that | 9 |
| covered persons have the opportunity for an independent review | 10 |
| of an adverse determination or final adverse determination, as | 11 |
| defined in this Act. | 12 |
| Section 10. Definitions. For the purposes of this Act: | 13 |
| "Adverse determination" means a determination by a health | 14 |
| carrier or its designee utilization review organization that an | 15 |
| admission, availability of care, continued stay, or other |
|
|
|
09600HB3923sam001 |
- 2 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| health care service that is a covered benefit has been reviewed | 2 |
| and, based upon the information provided, does not meet the | 3 |
| health carrier's requirements for medical necessity, | 4 |
| appropriateness, health care setting, level of care, or | 5 |
| effectiveness, and the requested service or payment for the | 6 |
| service is therefore denied, reduced, or terminated. | 7 |
| "Authorized representative" means: | 8 |
| (1) a person to whom a covered person has given express | 9 |
| written consent to represent the covered person in an | 10 |
| external review; | 11 |
| (2) a person authorized by law to provide substituted | 12 |
| consent for a covered person; or | 13 |
| (3) the covered person's health care provider only when | 14 |
| the covered person is unable to provide consent. | 15 |
| "Best evidence" means evidence based on: | 16 |
| (1) randomized clinical trials; | 17 |
| (2) if randomized clinical trials are not available, | 18 |
| then cohort studies or case-control studies; | 19 |
| (3) if items (1) and (2) are not available, then | 20 |
| case-series; or | 21 |
| (4) if items (1), (2), and (3) are not available, then | 22 |
| expert opinion. | 23 |
| "Case-series" means an evaluation of a series of patients | 24 |
| with a particular outcome, without the use of a control group. | 25 |
| "Clinical review criteria" means the written screening | 26 |
| procedures, decision abstracts, clinical protocols, and |
|
|
|
09600HB3923sam001 |
- 3 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| practice guidelines used by a health carrier to determine the | 2 |
| necessity and appropriateness of health care services. | 3 |
| "Cohort study" means a prospective evaluation of 2 groups | 4 |
| of patients with only one group of patients receiving specific | 5 |
| intervention. | 6 |
| "Covered benefits" or "benefits" means those health care | 7 |
| services to which a covered person is entitled under the terms | 8 |
| of a health benefit plan. | 9 |
| "Covered person" means a policyholder, subscriber, | 10 |
| enrollee, or other individual participating in a health benefit | 11 |
| plan. | 12 |
| "Director" means the Director of the Division of Insurance | 13 |
| within the Illinois Department of Financial and Professional | 14 |
| Regulation. | 15 |
| "Emergency medical condition" means the sudden onset of a | 16 |
| health condition or illness that requires immediate medical | 17 |
| attention, where failure to provide medical attention would | 18 |
| result in a serious impairment to bodily functions, serious | 19 |
| dysfunction of a bodily organ or part, or would place the | 20 |
| person's health in serious jeopardy. | 21 |
| "Emergency services" means health care items and services | 22 |
| furnished or required to evaluate and treat an emergency | 23 |
| medical condition. | 24 |
| "Evidence-based standard" means the conscientious, | 25 |
| explicit, and judicious use of the current best evidence based | 26 |
| on an overall systematic review of the research in making |
|
|
|
09600HB3923sam001 |
- 4 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| decisions about the care of individual patients. | 2 |
| "Expert opinion" means a belief or an interpretation by | 3 |
| specialists with experience in a specific area about the | 4 |
| scientific evidence pertaining to a particular service, | 5 |
| intervention, or therapy. | 6 |
| "Facility" means an institution providing health care | 7 |
| services or a health care setting. | 8 |
| "Final adverse determination" means an adverse | 9 |
| determination involving a covered benefit that has been upheld | 10 |
| by a health carrier, or its designee utilization review | 11 |
| organization, at the completion of the health carrier's | 12 |
| internal grievance process procedures as set forth by the | 13 |
| Managed Care Reform and Patient Rights Act. | 14 |
| "Health benefit plan" means a policy, contract, | 15 |
| certificate, plan, or agreement offered or issued by a health | 16 |
| carrier to provide, deliver, arrange for, pay for, or reimburse | 17 |
| any of the costs of health care services. | 18 |
| "Health care provider" or "provider" means a physician or | 19 |
| other health care practitioner licensed, accredited, or | 20 |
| certified to perform specified health care services consistent | 21 |
| with State law, responsible for recommending health care | 22 |
| services on behalf of a covered person. | 23 |
| "Health care services" means services for the diagnosis, | 24 |
| prevention, treatment, cure, or relief of a health condition, | 25 |
| illness, injury, or disease. | 26 |
| "Health carrier" means an entity subject to the insurance |
|
|
|
09600HB3923sam001 |
- 5 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| laws and regulations of this State, or subject to the | 2 |
| jurisdiction of the Director, that contracts or offers to | 3 |
| contract to provide, deliver, arrange for, pay for, or | 4 |
| reimburse any of the costs of health care services, including a | 5 |
| sickness and accident insurance company, a health maintenance | 6 |
| organization, a nonprofit hospital and health service | 7 |
| corporation, or any other entity providing a plan of health | 8 |
| insurance, health benefits, or health care services. "Health | 9 |
| carrier" also means Limited Health Service Organizations | 10 |
| (LHSO) and Voluntary Health Service Plans. | 11 |
| "Health information" means information or data, whether | 12 |
| oral or recorded in any form or medium, and personal facts or | 13 |
| information about events or relationships that relate to:
| 14 |
| (1) the past, present, or future physical, mental, or | 15 |
| behavioral health or condition of an individual or a member | 16 |
| of the individual's family; | 17 |
| (2) the provision of health care services to an | 18 |
| individual; or | 19 |
| (3) payment for the provision of health care services | 20 |
| to an individual. | 21 |
| "Independent review organization" means an entity that | 22 |
| conducts independent external reviews of adverse | 23 |
| determinations and final adverse determinations. | 24 |
| "Medical or scientific evidence" means evidence found in | 25 |
| the following sources: | 26 |
| (1) peer-reviewed scientific studies published in or |
|
|
|
09600HB3923sam001 |
- 6 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| accepted for publication by medical journals that meet | 2 |
| nationally recognized requirements for scientific | 3 |
| manuscripts and that submit most of their published | 4 |
| articles for review by experts who are not part of the | 5 |
| editorial staff; | 6 |
| (2) peer-reviewed medical literature, including | 7 |
| literature relating to therapies reviewed and approved by a | 8 |
| qualified institutional review board, biomedical | 9 |
| compendia, and other medical literature that meet the | 10 |
| criteria of the National Institutes of Health's Library of | 11 |
| Medicine for indexing in Index Medicus (Medline) and | 12 |
| Elsevier Science Ltd. for indexing in Excerpta Medicus | 13 |
| (EMBASE); | 14 |
| (3) medical journals recognized by the Secretary of | 15 |
| Health and Human Services under Section 1861(t)(2) of the | 16 |
| federal Social Security Act; | 17 |
| (4) the following standard reference compendia:
| 18 |
| (a) The American Hospital Formulary Service-Drug | 19 |
| Information; | 20 |
| (b) Drug Facts and Comparisons; | 21 |
| (c) The American Dental Association Accepted | 22 |
| Dental Therapeutics; and | 23 |
| (d) The United States Pharmacopoeia-Drug | 24 |
| Information; | 25 |
| (5) findings, studies, or research conducted by or | 26 |
| under the auspices of federal government agencies and |
|
|
|
09600HB3923sam001 |
- 7 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| nationally recognized federal research institutes, | 2 |
| including: | 3 |
| (a) the federal Agency for Healthcare Research and | 4 |
| Quality; | 5 |
| (b) the National Institutes of Health; | 6 |
| (c) the National Cancer Institute; | 7 |
| (d) the National Academy of Sciences; | 8 |
| (e) the Centers for Medicare & Medicaid Services; | 9 |
| (f) the federal Food and Drug Administration; and | 10 |
| (g) any national board recognized by the National | 11 |
| Institutes of Health for the purpose of evaluating the | 12 |
| medical value of health care services; or | 13 |
| (6) any other medical or scientific evidence that is | 14 |
| comparable to the sources listed in items (1) through (5). | 15 |
| "Protected health information" means health information | 16 |
| (i) that identifies an individual who is the subject of the | 17 |
| information; or (ii) with respect to which there is a | 18 |
| reasonable basis to believe that the information could be used | 19 |
| to identify an individual. | 20 |
| "Retrospective review" means a review of medical necessity | 21 |
| conducted after services have been provided to a patient, but | 22 |
| does not include the review of a claim that is limited to an | 23 |
| evaluation of reimbursement levels, veracity of documentation, | 24 |
| accuracy of coding, or adjudication for payment. | 25 |
| "Utilization review" has the meaning provided by the | 26 |
| Managed Care Reform and Patient Rights Act. |
|
|
|
09600HB3923sam001 |
- 8 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| "Utilization review organization" means a utilization | 2 |
| review program as defined in the Managed Care Reform and | 3 |
| Patient Rights Act. | 4 |
| Section 15. Applicability and scope. | 5 |
| (a) Except as provided in subsection (b) of this Section, | 6 |
| this Act shall apply to all health carriers. | 7 |
| (b) The provisions of this Act shall not apply to a policy | 8 |
| or certificate that provides coverage only for a specified | 9 |
| disease, specified accident or accident-only coverage, credit, | 10 |
| dental, disability income, hospital indemnity, long-term care | 11 |
| insurance as defined by Article XIXA of the Illinois Insurance | 12 |
| Code, vision care, or any other limited supplemental benefit; a | 13 |
| Medicare supplement policy of insurance as defined by the | 14 |
| Director by regulation; coverage under a plan through Medicare, | 15 |
| Medicaid, or the federal employees health benefits program; any | 16 |
| coverage issued under Chapter 55 of Title 10, U.S. Code and any | 17 |
| coverage issued as supplement to that coverage; any coverage | 18 |
| issued as supplemental to liability insurance, workers' | 19 |
| compensation, or similar insurance; automobile medical-payment | 20 |
| insurance or any insurance under which benefits are payable | 21 |
| with or without regard to fault, whether written on a group | 22 |
| blanket or individual basis. | 23 |
| Section 20. Notice of right to external review. | 24 |
| (a) At the same time the health carrier sends written |
|
|
|
09600HB3923sam001 |
- 9 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| notice of a covered person's right to appeal a coverage | 2 |
| decision upon an adverse determination or a final adverse | 3 |
| determination as provided by the Managed Care Reform and | 4 |
| Patient Rights Act, a health carrier shall notify a covered | 5 |
| person and a covered person's health care provider in writing | 6 |
| of the covered person's right to request an external review as | 7 |
| provided by this Act. The written notice required shall include | 8 |
| the following, or substantially equivalent, language: "We have | 9 |
| denied your request for the provision of or payment for a | 10 |
| health care service or course of treatment. You have the right | 11 |
| to have our decision reviewed by an independent review | 12 |
| organization not associated with us if our decision involved | 13 |
| making a judgment as to the medical necessity, appropriateness, | 14 |
| health care setting, level of care, or effectiveness of the | 15 |
| health care service or treatment you requested by submitting a | 16 |
| written request for an external review to us. Upon receipt of | 17 |
| your request an independent review organization registered | 18 |
| with the Department of Financial and Professional Regulation, | 19 |
| Division of Insurance will be assigned to review our | 20 |
| decision.". | 21 |
| (b) This subsection (b) shall apply to an expedited review | 22 |
| prior to a final adverse determination. In addition to the | 23 |
| notice required in subsection (a), the health carrier shall | 24 |
| include a notice related to an adverse determination, a | 25 |
| statement informing the covered person all of the following: | 26 |
| (1) If the covered person has a medical condition where |
|
|
|
09600HB3923sam001 |
- 10 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| the timeframe for completion of (A) an expedited internal | 2 |
| review of a grievance involving an adverse determination, | 3 |
| (B) a final adverse determination as set forth in the | 4 |
| Managed Care Reform and Patient Rights Act, or (C) a | 5 |
| standard external review as established in this Act, would | 6 |
| seriously jeopardize the life or health of the covered | 7 |
| person or would jeopardize the covered person's ability to | 8 |
| regain maximum function, then the covered person or the | 9 |
| covered person's authorized representative may file a | 10 |
| request for an expedited external review. | 11 |
| (2) The covered person or the covered person's | 12 |
| authorized representative may file a request for an | 13 |
| expedited external review at the same time the covered | 14 |
| person or the covered person's authorized representative | 15 |
| files a request for an expedited internal appeal involving | 16 |
| an adverse determination as set forth in the Managed Care | 17 |
| Reform and Patient Rights Act if the adverse determination | 18 |
| involves a denial of coverage based on a determination that | 19 |
| the recommended or requested health care service or | 20 |
| treatment is experimental or investigational and the | 21 |
| covered person's health care provider certifies in writing | 22 |
| that the recommended or requested health care service or | 23 |
| treatment that is the subject of the adverse determination | 24 |
| would be significantly less effective if not promptly | 25 |
| initiated. The independent review organization assigned to | 26 |
| conduct the expedited external review will determine |
|
|
|
09600HB3923sam001 |
- 11 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| whether the covered person shall be required to complete | 2 |
| the expedited review of the grievance prior to conducting | 3 |
| the expedited external review. | 4 |
| (3) If an adverse determination concerns a denial of | 5 |
| coverage based on a determination that the recommended or | 6 |
| requested health care service or treatment is experimental | 7 |
| or investigational and the covered person's health care | 8 |
| provider certifies in writing that the recommended or | 9 |
| requested health care service or treatment that is the | 10 |
| subject of the request would be significantly less | 11 |
| effective if not promptly initiated, then the covered | 12 |
| person or the covered person's authorized representative | 13 |
| may request an expedited external review. | 14 |
| (c) This subsection (c) shall apply to an expedited review | 15 |
| upon final adverse determination. In addition to the notice | 16 |
| required in subsection (a), the health carrier shall include a | 17 |
| notice related to a final adverse determination, a statement | 18 |
| informing the covered person all of the following: | 19 |
| (1) if the covered person has a medical condition where | 20 |
| the timeframe for completion of a standard external review | 21 |
| would seriously jeopardize the life or health of the | 22 |
| covered person or would jeopardize the covered person's | 23 |
| ability to regain maximum function, then the covered person | 24 |
| or the covered person's authorized representative may file | 25 |
| a request for an expedited external review; or | 26 |
| (2) if a final adverse determination concerns an |
|
|
|
09600HB3923sam001 |
- 12 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| admission, availability of care, continued stay, or health | 2 |
| care service for which the covered person received | 3 |
| emergency services, but has not been discharged from a | 4 |
| facility, then the covered person, or the covered person's | 5 |
| authorized representative, may request an expedited | 6 |
| external review; or | 7 |
| (3) if a final adverse determination concerns a denial | 8 |
| of coverage based on a determination that the recommended | 9 |
| or requested health care service or treatment is | 10 |
| experimental or investigational, and the covered person's | 11 |
| health care provider certifies in writing that the | 12 |
| recommended or requested health care service or treatment | 13 |
| that is the subject of the request would be significantly | 14 |
| less effective if not promptly initiated, then the covered | 15 |
| person or the covered person's authorized representative | 16 |
| may request an expedited external review. | 17 |
| (d) In addition to the information to be provided pursuant | 18 |
| to subsections (a), (b), and (c) of this Section, the health | 19 |
| carrier shall include a copy of the description of both the | 20 |
| required standard and expedited external review procedures. | 21 |
| The description shall highlight the external review procedures | 22 |
| that give the covered person or the covered person's authorized | 23 |
| representative the opportunity to submit additional | 24 |
| information, including any forms used to process an external | 25 |
| review. |
|
|
|
09600HB3923sam001 |
- 13 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| Section 25. Request for external review. A covered person | 2 |
| or the covered person's authorized representative may make a | 3 |
| request for a standard external or expedited external review of | 4 |
| an adverse determination or final adverse determination. | 5 |
| Requests under this Section shall be made directly to the | 6 |
| health carrier that made the adverse or final adverse | 7 |
| determination. All requests for external review shall be in | 8 |
| writing except for requests for expedited external reviews | 9 |
| which may me made orally. Health carriers must provide covered | 10 |
| persons with forms to request external reviews. | 11 |
| Section 30. Exhaustion of internal grievance process. | 12 |
| Except as provided in subsection (b) of Section 20, a | 13 |
| request for an external review shall not be made until the | 14 |
| covered person has exhausted the health carrier's internal | 15 |
| grievance process as set forth in the Managed Care Reform and | 16 |
| Patient Rights Act. A covered person shall also be considered | 17 |
| to have exhausted the health carrier's internal grievance | 18 |
| process for purposes of this section if: | 19 |
| (1) the covered person or the covered person's | 20 |
| authorized representative filed a request for an internal | 21 |
| review of an adverse determination pursuant to the Managed | 22 |
| Care Reform and Patient Rights Act and has not received a | 23 |
| written decision on the request from the health carrier | 24 |
| within 30 days, except to the extent the covered person or | 25 |
| the covered person's authorized representative requested |
|
|
|
09600HB3923sam001 |
- 14 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| or agreed to a delay; however, a covered person or the | 2 |
| covered person's authorized representative may not make a | 3 |
| request for an external review of an adverse determination | 4 |
| involving a retrospective review determination until the | 5 |
| covered person has exhausted the health carrier's internal | 6 |
| grievance process; | 7 |
| (2) the covered person or the covered person's | 8 |
| authorized representative filed a request for an expedited | 9 |
| internal review of an adverse determination pursuant to the | 10 |
| Managed Care Reform and Patient Rights Act and has not | 11 |
| received a decision on request from the health carrier | 12 |
| within 48 hours, except to the extent the covered person or | 13 |
| the covered person's authorized representative requested | 14 |
| or agreed to a delay; or | 15 |
| (3) the health carrier agrees to waive the exhaustion | 16 |
| requirement. | 17 |
| Section 35. Standard external review. | 18 |
| (a) Within 4 months after the date of receipt of a notice | 19 |
| of an adverse determination or final adverse determination, a | 20 |
| covered person or the covered person's authorized | 21 |
| representative may file a request for an external review with | 22 |
| the health carrier. | 23 |
| (b) Within 5 business days following the date of receipt of | 24 |
| the external review request, the health carrier shall complete | 25 |
| a preliminary review of the request to determine whether:
|
|
|
|
09600HB3923sam001 |
- 15 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (1) the individual is or was a covered person in the | 2 |
| health benefit plan at the time the health care service was | 3 |
| requested or at the time the health care service was | 4 |
| provided; | 5 |
| (2) the health care service that is the subject of the | 6 |
| adverse determination or the final adverse determination | 7 |
| is a covered service under the covered person's health | 8 |
| benefit plan, but the health carrier has determined that | 9 |
| the health care service is not covered because it does not | 10 |
| meet the health carrier's requirements for medical | 11 |
| necessity, appropriateness, health care setting, level of | 12 |
| care, or effectiveness; | 13 |
| (3) the covered person has exhausted the health | 14 |
| carrier's internal grievance process as set forth in this | 15 |
| Act; | 16 |
| (4) for appeals relating to a determination based on | 17 |
| treatment being experimental or investigational, the | 18 |
| requested health care service or treatment that is the | 19 |
| subject of the adverse determination or final adverse | 20 |
| determination is a covered benefit under the covered | 21 |
| person's health benefit plan except for the health | 22 |
| carrier's determination that the service or treatment is | 23 |
| experimental or investigational for a particular medical | 24 |
| condition and is not explicitly listed as an excluded | 25 |
| benefit under the covered person's health benefit plan with | 26 |
| the health carrier and that the covered person's health |
|
|
|
09600HB3923sam001 |
- 16 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| care provider, who is a physician licensed to practice | 2 |
| medicine in all its branches, has certified that one of the | 3 |
| following situations is applicable: | 4 |
| (A) standard health care services or treatments | 5 |
| have not been effective in improving the condition of | 6 |
| the covered person; | 7 |
| (B) standard health care services or treatments | 8 |
| are not medically appropriate for the covered person; | 9 |
| (C) there is no available standard health care | 10 |
| service or treatment covered by the health carrier that | 11 |
| is more beneficial than the recommended or requested | 12 |
| health care service or treatment;
| 13 |
| (D) the health care service or treatment is likely | 14 |
| to be more beneficial to the covered person, in the | 15 |
| health care provider's opinion, than any available | 16 |
| standard health care services or treatments; or | 17 |
| (E) that scientifically valid studies using | 18 |
| accepted protocols demonstrate that the health care | 19 |
| service or treatment requested is likely to be more | 20 |
| beneficial to the covered person than any available | 21 |
| standard health care services or treatments; and | 22 |
| (5) the covered person has provided all the information | 23 |
| and forms required to process an external review, as | 24 |
| specified in this Act. | 25 |
| (c) Within one business day after completion of the | 26 |
| preliminary review, the health carrier shall notify the covered |
|
|
|
09600HB3923sam001 |
- 17 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| person and, if applicable, the covered person's authorized | 2 |
| representative in writing whether the request is complete and | 3 |
| eligible for external review. If the request: | 4 |
| (1) is not complete, the health carrier shall inform | 5 |
| the covered person and, if applicable, the covered person's | 6 |
| authorized representative in writing and include in the | 7 |
| notice what information or materials are required by this | 8 |
| Act to make the request complete; or | 9 |
| (2) is not eligible for external review, the health | 10 |
| carrier shall inform the covered person and, if applicable, | 11 |
| the covered person's authorized representative in writing | 12 |
| and include in the notice the reasons for its | 13 |
| ineligibility.
| 14 |
| The notice of initial determination of ineligibility shall | 15 |
| include a statement informing the covered person and, if | 16 |
| applicable, the covered person's authorized representative | 17 |
| that a health carrier's initial determination that the external | 18 |
| review request is ineligible for review may be appealed to the | 19 |
| Director by filing a complaint with the Director. | 20 |
| Notwithstanding a health carrier's initial determination | 21 |
| that the request is ineligible for external review, the | 22 |
| Director may determine that a request is eligible for external | 23 |
| review and require that it be referred for external review. In | 24 |
| making such determination, the Director's decision shall be in | 25 |
| accordance with the terms of the covered person's health | 26 |
| benefit plan and shall be subject to all applicable provisions |
|
|
|
09600HB3923sam001 |
- 18 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| of this Act. | 2 |
| (d) Whenever a request is eligible for external review the | 3 |
| health carrier shall, within 5 business days: | 4 |
| (1) assign an independent review organization from the | 5 |
| list of approved independent review organizations compiled | 6 |
| and maintained by the Director; and | 7 |
| (2) notify in writing the covered person and, if | 8 |
| applicable, the covered person's authorized representative | 9 |
| of the request's eligibility and acceptance for external | 10 |
| review and the name of the independent review organization. | 11 |
| The health carrier shall include in the notice provided to | 12 |
| the covered person and, if applicable, the covered person's | 13 |
| authorized representative a statement that the covered person | 14 |
| or the covered person's authorized representative may, within 5 | 15 |
| business days following the date of receipt of the notice | 16 |
| provided pursuant to item (2) of this subsection (d), submit in | 17 |
| writing to the assigned independent review organization | 18 |
| additional information that the independent review | 19 |
| organization shall consider when conducting the external | 20 |
| review. The independent review organization is not required to, | 21 |
| but may, accept and consider additional information submitted | 22 |
| after 5 business days. | 23 |
| (e) The assignment of an approved independent review | 24 |
| organization to conduct an external review in accordance with | 25 |
| this Section shall be made from those approved independent | 26 |
| review organizations qualified to conduct external review as |
|
|
|
09600HB3923sam001 |
- 19 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| required by Sections 50 and 55 of this Act. | 2 |
| (f) Upon assignment of an independent review organization, | 3 |
| the health carrier or its designee utilization review | 4 |
| organization shall, within 5 business days, provide to the | 5 |
| assigned independent review organization the documents and any | 6 |
| information considered in making the adverse determination or | 7 |
| final adverse determination; in such cases, the following | 8 |
| provisions shall apply: | 9 |
| (1) Except as provided in item (2) of this subsection | 10 |
| (f), failure by the health carrier or its utilization | 11 |
| review organization to provide the documents and | 12 |
| information within the specified time frame shall not delay | 13 |
| the conduct of the external review. | 14 |
| (2) If the health carrier or its utilization review | 15 |
| organization fails to provide the documents and | 16 |
| information within the specified time frame, the assigned | 17 |
| independent review organization may terminate the external | 18 |
| review and make a decision to reverse the adverse | 19 |
| determination or final adverse determination. | 20 |
| (3) Within one business day after making the decision | 21 |
| to terminate the external review and make a decision to | 22 |
| reverse the adverse determination or final adverse | 23 |
| determination under item (2) of this subsection (f), the | 24 |
| independent review organization shall notify the health | 25 |
| carrier, the covered person and, if applicable, the covered | 26 |
| person's authorized representative, of its decision to |
|
|
|
09600HB3923sam001 |
- 20 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| reverse the adverse determination. | 2 |
| (g) Upon receipt of the information from the health carrier | 3 |
| or its utilization review organization, the assigned | 4 |
| independent review organization shall review all of the | 5 |
| information and documents and any other information submitted | 6 |
| in writing to the independent review organization by the | 7 |
| covered person and the covered person's authorized | 8 |
| representative. | 9 |
| (h) Upon receipt of any information submitted by the | 10 |
| covered person or the covered person's authorized | 11 |
| representative, the independent review organization shall | 12 |
| forward the information to the health carrier within 1 business | 13 |
| day. | 14 |
| (1) Upon receipt of the information, if any, the health | 15 |
| carrier may reconsider its adverse determination or final | 16 |
| adverse determination that is the subject of the external | 17 |
| review.
| 18 |
| (2) Reconsideration by the health carrier of its | 19 |
| adverse determination or final adverse determination shall | 20 |
| not delay or terminate the external review.
| 21 |
| (3) The external review may only be terminated if the | 22 |
| health carrier decides, upon completion of its | 23 |
| reconsideration, to reverse its adverse determination or | 24 |
| final adverse determination and provide coverage or | 25 |
| payment for the health care service that is the subject of | 26 |
| the adverse determination or final adverse determination. |
|
|
|
09600HB3923sam001 |
- 21 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| In such cases, the following provisions shall apply: | 2 |
| (A) Within one business day after making the | 3 |
| decision to reverse its adverse determination or final | 4 |
| adverse determination, the health carrier shall notify | 5 |
| the covered person and if applicable, the covered | 6 |
| person's authorized representative, and the assigned | 7 |
| independent review organization in writing of its | 8 |
| decision. | 9 |
| (B) Upon notice from the health carrier that the | 10 |
| health carrier has made a decision to reverse its | 11 |
| adverse determination or final adverse determination, | 12 |
| the assigned independent review organization shall | 13 |
| terminate the external review. | 14 |
| (i) In addition to the documents and information provided | 15 |
| by the health carrier or its utilization review organization | 16 |
| and the covered person and the covered person's authorized | 17 |
| representative, if any, the independent review organization, | 18 |
| to the extent the information or documents are available and | 19 |
| the independent review organization considers them | 20 |
| appropriate, shall consider the following in reaching a | 21 |
| decision: | 22 |
| (1) the covered person's pertinent medical records; | 23 |
| (2) the covered person's health care provider's | 24 |
| recommendation; | 25 |
| (3) consulting reports from appropriate health care | 26 |
| providers and other documents submitted by the health |
|
|
|
09600HB3923sam001 |
- 22 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| carrier, the covered person, the covered person's | 2 |
| authorized representative, or the covered person's | 3 |
| treating provider; | 4 |
| (4) the terms of coverage under the covered person's | 5 |
| health benefit plan with the health carrier to ensure that | 6 |
| the independent review organization's decision is not | 7 |
| contrary to the terms of coverage under the covered | 8 |
| person's health benefit plan with the health carrier; | 9 |
| (5) the most appropriate practice guidelines, which | 10 |
| shall include applicable evidence-based standards and may | 11 |
| include any other practice guidelines developed by the | 12 |
| federal government, national or professional medical | 13 |
| societies, boards, and associations; | 14 |
| (6) any applicable clinical review criteria developed | 15 |
| and used by the health carrier or its designee utilization | 16 |
| review organization; and | 17 |
| (7) the opinion of the independent review | 18 |
| organization's clinical reviewer or reviewers after | 19 |
| considering items (1) through (6) of this subsection (i) to | 20 |
| the extent the information or documents are available and | 21 |
| the clinical reviewer or reviewers considers the | 22 |
| information or documents appropriate; and | 23 |
| (8) for a denial of coverage based on a determination | 24 |
| that the health care service or treatment recommended or | 25 |
| requested is experimental or investigational, whether and | 26 |
| to what extent: |
|
|
|
09600HB3923sam001 |
- 23 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (A) the recommended or requested health care | 2 |
| service or treatment has been approved by the federal | 3 |
| Food and Drug Administration, if applicable, for the | 4 |
| condition; | 5 |
| (B) 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 | 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; or | 15 |
| (C) the terms of coverage under the covered | 16 |
| person's health benefit plan with the health carrier to | 17 |
| ensure that the health care service or treatment that | 18 |
| is the subject of the opinion is experimental or | 19 |
| investigational would otherwise be covered under the | 20 |
| terms of coverage of the covered person's health | 21 |
| benefit plan with the health carrier. | 22 |
| (j) Within 5 days after the date of receipt of all | 23 |
| necessary information, the assigned independent review | 24 |
| organization shall provide written notice of its decision to | 25 |
| uphold or reverse the adverse determination or the final | 26 |
| adverse determination to the health carrier, the covered person |
|
|
|
09600HB3923sam001 |
- 24 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| and, if applicable, the covered person's authorized | 2 |
| representative. In reaching a decision, the assigned | 3 |
| independent review organization is not bound by any claim | 4 |
| determinations reached prior to the submission of information | 5 |
| the independent review organization. In such cases, the | 6 |
| following provisions shall apply: | 7 |
| (1) The independent review organization shall include | 8 |
| in the notice: | 9 |
| (A) a general description of the reason for the | 10 |
| request for external review; | 11 |
| (B) the date the independent review organization | 12 |
| received the assignment from the health carrier to | 13 |
| conduct the external review; | 14 |
| (C) the time period during which the external | 15 |
| review was conducted; | 16 |
| (D) references to the evidence or documentation, | 17 |
| including the evidence-based standards, considered in | 18 |
| reaching its decision; | 19 |
| (E) the date of its decision; and | 20 |
| (F) the principal reason or reasons for its | 21 |
| decision, including what applicable, if any, | 22 |
| evidence-based standards that were a basis for its | 23 |
| decision.
| 24 |
| (2) For reviews of experimental or investigational | 25 |
| treatments, the notice shall include the following | 26 |
| information: |
|
|
|
09600HB3923sam001 |
- 25 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (A) a description of the covered person's medical | 2 |
| condition; | 3 |
| (B) a description of the indicators relevant to | 4 |
| whether there is sufficient evidence to demonstrate | 5 |
| that the recommended or requested health care service | 6 |
| or treatment is more likely than not to be more | 7 |
| beneficial to the covered person than any available | 8 |
| standard health care services or treatments and the | 9 |
| adverse risks of the recommended or requested health | 10 |
| care service or treatment would not be substantially | 11 |
| increased over those of available standard health care | 12 |
| services or treatments; | 13 |
| (C) a description and analysis of any medical or | 14 |
| scientific evidence considered in reaching the | 15 |
| opinion; | 16 |
| (D) a description and analysis of any | 17 |
| evidence-based standards; and | 18 |
| (E) whether the recommended or requested health | 19 |
| care service or treatment has been approved by the | 20 |
| federal Food and Drug Administration, for the | 21 |
| condition; | 22 |
| (F) whether 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 more | 26 |
| beneficial to the covered person than any available |
|
|
|
09600HB3923sam001 |
- 26 - |
LRB096 08394 RPM 26320 a |
|
| 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; and | 6 |
| (G) the written opinion of the clinical reviewer, | 7 |
| including the reviewer's recommendation as to whether | 8 |
| the recommended or requested health care service or | 9 |
| treatment should be covered and the rationale for the | 10 |
| reviewer's recommendation. | 11 |
| (3) In reaching a decision, the assigned independent | 12 |
| review organization is not bound by any decisions or | 13 |
| conclusions reached during the health carrier's | 14 |
| utilization review process or the health carrier's | 15 |
| internal grievance or appeals process. | 16 |
| (4) Upon receipt of a notice of a decision reversing | 17 |
| the adverse determination or final adverse determination, | 18 |
| the health carrier immediately shall approve the coverage | 19 |
| that was the subject of the adverse determination or final | 20 |
| adverse determination. | 21 |
| Section 40. Expedited external review. | 22 |
| (a) A covered person or a covered person's authorized | 23 |
| representative may file a request for an expedited external | 24 |
| review with the health carrier either orally or in writing: | 25 |
| (1) immediately after the date of receipt of a notice |
|
|
|
09600HB3923sam001 |
- 27 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| prior to a final adverse determination as provided by | 2 |
| subsection (b) of Section 20 of this Act; | 3 |
| (2) immediately after the date of receipt of a notice a | 4 |
| final adverse determination as provided by subsection (c) | 5 |
| of Section 20 of this Act; or | 6 |
| (3) if a health carrier fails to provide a decision on | 7 |
| request for an expedited internal appeal within 48 hours as | 8 |
| provided by item (2) of Section 30 of this Act. | 9 |
| (b) Immediately upon receipt of the request for an | 10 |
| expedited external review as provided under subsections (b) and | 11 |
| (c) of Section 20, the health carrier shall determine whether | 12 |
| the request meets the reviewability requirements set forth in | 13 |
| items (1), (2), and (4) of subsection (b) of Section 35. In | 14 |
| such cases, the following provisions shall apply: | 15 |
| (1) The health carrier shall immediately notify the | 16 |
| covered person and, if applicable, the covered person's | 17 |
| authorized representative of its eligibility | 18 |
| determination. | 19 |
| (2) The notice of initial determination shall include a | 20 |
| statement informing the covered person and, if applicable, | 21 |
| the covered person's authorized representative that a | 22 |
| health carrier's initial determination that an external | 23 |
| review request is ineligible for review may be appealed to | 24 |
| the Director. | 25 |
| (3) The Director may determine that a request is | 26 |
| eligible for expedited external review notwithstanding a |
|
|
|
09600HB3923sam001 |
- 28 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| health carrier's initial determination that the request is | 2 |
| ineligible and require that it be referred for external | 3 |
| review. | 4 |
| (4) In making a determination under item (3) of this | 5 |
| subsection (b), the Director's decision shall be made in | 6 |
| accordance with the terms of the covered person's health | 7 |
| benefit plan and shall be subject to all applicable | 8 |
| provisions of this Act. | 9 |
| (c) Upon determining that a request meets the requirements | 10 |
| of subsections (b) and (c) of Section 20, the health
carrier | 11 |
| shall immediately assign an independent review organization | 12 |
| from the list of approved independent review organizations | 13 |
| compiled and maintained by the Director to conduct the | 14 |
| expedited review. In such cases, the following provisions shall | 15 |
| apply: | 16 |
| (1) The assignment of an approved independent review | 17 |
| organization to conduct an external review in accordance | 18 |
| with this Section shall be made from those approved | 19 |
| independent review organizations qualified to conduct | 20 |
| external review as required by Sections 50 and 55 of this | 21 |
| Act.
| 22 |
| (2) Immediately upon assigning an independent review | 23 |
| organization to perform an expedited external review, but | 24 |
| in no case less than 24 hours after assigning the | 25 |
| independent review organization, the health carrier or its | 26 |
| designee utilization review organization shall provide or |
|
|
|
09600HB3923sam001 |
- 29 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| transmit all necessary documents and information | 2 |
| considered in making the final adverse determination to the | 3 |
| assigned independent review organization electronically or | 4 |
| by telephone or facsimile or any other available | 5 |
| expeditious method. | 6 |
| (3) If the health carrier or its utilization review | 7 |
| organization fails to provide the documents and | 8 |
| information within the specified timeframe, the assigned | 9 |
| independent review organization may terminate the external | 10 |
| review and make a decision to reverse the adverse | 11 |
| determination or final adverse determination. | 12 |
| (4) Within one business day after making the decision | 13 |
| to terminate the external review and make a decision to | 14 |
| reverse the adverse determination or final adverse | 15 |
| determination under item (2) of this subsection (b), the | 16 |
| independent review organization shall notify the health | 17 |
| carrier, the covered person and, if applicable, the covered | 18 |
| person's authorized representative of its decision to | 19 |
| reverse the adverse determination.
| 20 |
| (c) In addition to the documents and information provided | 21 |
| by the health carrier or its utilization review organization | 22 |
| and any documents and information provided by the covered | 23 |
| person and the covered person's authorized representative, the | 24 |
| independent review organization shall consider information as | 25 |
| required by subsection (i) of Section 35 of this Act in | 26 |
| reaching a decision. |
|
|
|
09600HB3923sam001 |
- 30 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (d) As expeditiously as the covered person's medical | 2 |
| condition or circumstances requires, but in no event more than | 3 |
| 72 hours after the receipt of all pertinent information, the | 4 |
| assigned independent review organization shall: | 5 |
| (1) make a decision to uphold or reverse the final | 6 |
| adverse determination; and | 7 |
| (2) notify the health carrier, the covered person, the | 8 |
| covered person's health care provider, and if applicable, | 9 |
| the covered person's authorized representative, of the | 10 |
| decision. | 11 |
| (e) In reaching a decision, the assigned independent review | 12 |
| organization is not bound by any decisions or conclusions | 13 |
| reached during the health carrier's utilization review process | 14 |
| or the health carrier's internal grievance process as set forth | 15 |
| in the Managed Care Reform and Patient Rights Act.
| 16 |
| (f) Upon receipt of notice of a decision reversing the | 17 |
| final adverse determination, the health carrier shall | 18 |
| immediately approve the coverage that was the subject of the | 19 |
| final adverse determination. | 20 |
| (g) Within 48 hours after the date of providing the notice | 21 |
| required in item (2) of subsection (d), the assigned | 22 |
| independent review organization shall provide written | 23 |
| confirmation of the decision to the health carrier, the covered | 24 |
| person, and if applicable, the covered person's authorized | 25 |
| representative including the information set forth in | 26 |
| subsection (j) of Section 35 of this Act as applicable. |
|
|
|
09600HB3923sam001 |
- 31 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (h) An expedited external review may not be provided for | 2 |
| retrospective adverse or final adverse determinations. | 3 |
| Section 45. Binding nature of external review decision. An | 4 |
| external review decision is binding on the health carrier. An | 5 |
| external review decision is binding on the covered person | 6 |
| except to the extent the covered person has other remedies | 7 |
| available under applicable federal or State law. A covered | 8 |
| person or the covered person's authorized representative may | 9 |
| not file a subsequent request for external review involving the | 10 |
| same adverse determination or final adverse determination for | 11 |
| which the covered person has already received an external | 12 |
| review decision pursuant to this Act.
| 13 |
| Section 50. Approval of independent review organizations. | 14 |
| (a) The Director shall approve independent review | 15 |
| organizations eligible to be assigned to conduct external | 16 |
| reviews under this Act. | 17 |
| (b) In order to be eligible for approval by the Director | 18 |
| under this Section to conduct external reviews under this Act | 19 |
| an independent review organization:
| 20 |
| (1) except as otherwise provided in this Section, shall | 21 |
| be accredited by a nationally recognized private | 22 |
| accrediting entity that the Director has determined has | 23 |
| independent review organization accreditation standards | 24 |
| that are equivalent to or exceed the minimum qualifications |
|
|
|
09600HB3923sam001 |
- 32 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| for independent review; and | 2 |
| (2) shall submit an application for approval in | 3 |
| accordance with subsection (d) of this Section.
| 4 |
| (c) The Director shall develop an application form for | 5 |
| initially approving and for reapproving independent review | 6 |
| organizations to conduct external reviews. | 7 |
| (d) Any independent review organization wishing to be | 8 |
| approved to conduct external reviews under this Act shall | 9 |
| submit the application form and include with the form all | 10 |
| documentation and information necessary for the Director to | 11 |
| determine if the independent review organization satisfies the | 12 |
| minimum qualifications established under this Act.
The | 13 |
| Director may: | 14 |
| (1) approve independent review organizations that are | 15 |
| not accredited by a nationally recognized private | 16 |
| accrediting entity if there are no acceptable nationally | 17 |
| recognized private accrediting entities providing | 18 |
| independent review organization accreditation; and | 19 |
| (2) by rule establish an application fee that | 20 |
| independent review organizations shall submit to the | 21 |
| Director with an application for approval and renewing.
| 22 |
| (e) An approval is effective for 2 years, unless the | 23 |
| Director determines before its expiration that the independent | 24 |
| review organization is not satisfying the minimum | 25 |
| qualifications established under this Act. | 26 |
| (f) Whenever the Director determines that an independent |
|
|
|
09600HB3923sam001 |
- 33 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| review organization has lost its accreditation or no longer | 2 |
| satisfies the minimum requirements established under this Act, | 3 |
| the Director shall terminate the approval of the independent | 4 |
| review organization and remove the independent review | 5 |
| organization from the list of independent review organizations | 6 |
| approved to conduct external reviews under this Act that is | 7 |
| maintained by the Director. | 8 |
| (g) The Director shall maintain and periodically update a | 9 |
| list of approved independent review organizations. | 10 |
| (h) The Director may promulgate regulations to carry out | 11 |
| the provisions of this Section. | 12 |
| Section 55. Minimum qualifications for independent review | 13 |
| organizations.
| 14 |
| (a) To be approved to conduct external reviews, an | 15 |
| independent review organization shall have and maintain | 16 |
| written policies and procedures that govern all aspects of both | 17 |
| the standard external review process and the expedited external | 18 |
| review process set forth in this Act that include, at a | 19 |
| minimum: | 20 |
| (1) a quality assurance mechanism that ensures that: | 21 |
| (A) external reviews are conducted within the | 22 |
| specified timeframes and required notices are provided | 23 |
| in a timely manner; | 24 |
| (B) selection of qualified and impartial clinical | 25 |
| reviewers to conduct external reviews on behalf of the |
|
|
|
09600HB3923sam001 |
- 34 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| independent review organization and suitable matching | 2 |
| of reviewers to specific cases and that the independent | 3 |
| review organization employs or contracts with an | 4 |
| adequate number of clinical reviewers to meet this | 5 |
| objective; | 6 |
| (C) for adverse determinations involving | 7 |
| experimental or investigational treatments, in | 8 |
| assigning clinical reviewers, the independent review | 9 |
| organization selects physicians or other health care | 10 |
| professionals who, through clinical experience in the | 11 |
| past 3 years, are experts in the treatment of the | 12 |
| covered person's condition and knowledgeable about the | 13 |
| recommended or requested health care service or | 14 |
| treatment; | 15 |
| (D) the health carrier, the covered person, and the | 16 |
| covered person's authorized representative shall not | 17 |
| choose or control the choice of the physicians or other | 18 |
| health care professionals to be selected to conduct the | 19 |
| external review; | 20 |
| (E) confidentiality of medical and treatment | 21 |
| records and clinical review criteria; and | 22 |
| (F) any person employed by or under contract with | 23 |
| the independent review organization adheres to the | 24 |
| requirements of this Act; | 25 |
| (2) a toll-free telephone service operating on a | 26 |
| 24-hour-day, 7-day-a-week basis that accepts, receives, |
|
|
|
09600HB3923sam001 |
- 35 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| and records information related to external reviews and | 2 |
| provides appropriate instructions; and | 3 |
| (3) an agreement to maintain and provide to the | 4 |
| Director the information set out in Section 70 of this Act. | 5 |
| (b) All clinical reviewers assigned by an independent | 6 |
| review organization to conduct external reviews shall be | 7 |
| physicians or other appropriate health care providers who meet | 8 |
| the following minimum qualifications:
| 9 |
| (1) be an expert in the treatment of the covered | 10 |
| person's medical condition that is the subject of the | 11 |
| external review; | 12 |
| (2) be knowledgeable about the recommended health care | 13 |
| service or treatment through recent or current actual | 14 |
| clinical experience treating patients with the same or | 15 |
| similar medical condition of the covered person; | 16 |
| (3) hold a non-restricted license in a state of the | 17 |
| United States and, for physicians, a current certification | 18 |
| by a recognized American medical specialty board in the | 19 |
| area or areas appropriate to the subject of the external | 20 |
| review; and | 21 |
| (4) have no history of disciplinary actions or | 22 |
| sanctions, including loss of staff privileges or | 23 |
| participation restrictions, that have been taken or are | 24 |
| pending by any hospital, governmental agency or unit, or | 25 |
| regulatory body that raise a substantial question as to the | 26 |
| clinical reviewer's physical, mental, or professional |
|
|
|
09600HB3923sam001 |
- 36 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| competence or moral character. | 2 |
| (c) In addition to the requirements set forth in subsection | 3 |
| (a), an independent review organization may not own or control, | 4 |
| be a subsidiary of, or in any way be owned, or controlled by, | 5 |
| or exercise control with a health benefit plan, a national, | 6 |
| State, or local trade association of health benefit plans, or a | 7 |
| national, State, or local trade association of health care | 8 |
| providers. | 9 |
| (d) Conflicts of interest prohibited.
In addition to the | 10 |
| requirements set forth in subsections (a), (b), and (c) of this | 11 |
| Section, to be approved pursuant to this Act to conduct an | 12 |
| external review of a specified case, neither the independent | 13 |
| review organization selected to conduct the external review nor | 14 |
| any clinical reviewer assigned by the independent organization | 15 |
| to conduct the external review may have a material | 16 |
| professional, familial or financial conflict of interest with | 17 |
| any of the following: | 18 |
| (1) the health carrier that is the subject of the | 19 |
| external review; | 20 |
| (2) the covered person whose treatment is the subject | 21 |
| of the external review or the covered person's authorized | 22 |
| representative; | 23 |
| (3) any officer, director or management employee of the | 24 |
| health carrier that is the subject of the external review; | 25 |
| (4) the health care provider, the health care | 26 |
| provider's medical group or independent practice |
|
|
|
09600HB3923sam001 |
- 37 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| association recommending the health care service or | 2 |
| treatment that is the subject of the external review; | 3 |
| (5) the facility at which the recommended health care | 4 |
| service or treatment would be provided; or | 5 |
| (6) the developer or manufacturer of the principal | 6 |
| drug, device, procedure, or other therapy being | 7 |
| recommended for the covered person whose treatment is the | 8 |
| subject of the external review.
| 9 |
| (e) An independent review organization that is accredited | 10 |
| by a nationally recognized private accrediting entity that has | 11 |
| independent review accreditation standards that the Director | 12 |
| has determined are equivalent to or exceed the minimum | 13 |
| qualifications of this Section shall be presumed to be in | 14 |
| compliance with this Section and shall be eligible for approval | 15 |
| under this Act. | 16 |
| (f) An independent review organization shall be unbiased. | 17 |
| An independent review organization shall establish and | 18 |
| maintain written procedures to ensure that it is unbiased in | 19 |
| addition to any other procedures required under this Section. | 20 |
| (g) Nothing in this Act precludes or shall be interpreted | 21 |
| to preclude a health carrier from contracting with approved | 22 |
| independent review organizations to conduct external reviews | 23 |
| assigned to it from such health carrier. | 24 |
| Section 60. Hold harmless for independent review | 25 |
| organizations. No independent review organization or clinical |
|
|
|
09600HB3923sam001 |
- 38 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| reviewer working on behalf of an independent review | 2 |
| organization or an employee, agent or contractor of an | 3 |
| independent review organization shall be liable for damages to | 4 |
| any person for any opinions rendered or acts or omissions | 5 |
| performed within the scope of the organization's or person's | 6 |
| duties under the law during or upon completion of an external | 7 |
| review conducted pursuant to this Act, unless the opinion was | 8 |
| rendered or act or omission performed in bad faith or involved | 9 |
| gross negligence. | 10 |
| Section 65. External review reporting requirements. | 11 |
| (a) Each health carrier shall maintain written records in | 12 |
| the aggregate on all requests for external review for each | 13 |
| calendar year and submit a report to the Director in the format | 14 |
| specified by the Director by March 1 of each year. | 15 |
| (b) The report shall include in the aggregate:
| 16 |
| (1) the total number of requests for external review; | 17 |
| (2) the total number of requests for expedited external | 18 |
| review;
| 19 |
| (3) the total number of requests for external review | 20 |
| denied; | 21 |
| (4) the number of requests for external review | 22 |
| resolved, including: | 23 |
| (A) the number of requests for external review | 24 |
| resolved upholding the adverse determination or final | 25 |
| adverse determination; |
|
|
|
09600HB3923sam001 |
- 39 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (B) the number of requests for external review | 2 |
| resolved reversing the adverse determination or final | 3 |
| adverse determination; | 4 |
| (C) the number of requests for expedited external | 5 |
| review resolved upholding the adverse determination or | 6 |
| final adverse determination; and | 7 |
| (D) the number of requests for expedited external | 8 |
| review resolved reversing the adverse determination or | 9 |
| final adverse determination; | 10 |
| (5) the average length of time for resolution for an | 11 |
| external review; | 12 |
| (6) the average length of time for resolution for an | 13 |
| expedited external review; | 14 |
| (7) a summary of the types of coverages or cases for | 15 |
| which an external review was sought, as specified below:
| 16 |
| (A) denial of care or treatment (dissatisfaction | 17 |
| regarding prospective non-authorization of a request | 18 |
| for care or treatment recommended by a provider | 19 |
| excluding diagnostic procedures and referral requests; | 20 |
| partial approvals and care terminations are also | 21 |
| considered to be denials); | 22 |
| (B) denial of diagnostic procedure | 23 |
| (dissatisfaction regarding prospective | 24 |
| non-authorization of a request for a diagnostic | 25 |
| procedure recommended by a provider; partial approvals | 26 |
| are also considered to be denials); |
|
|
|
09600HB3923sam001 |
- 40 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (C) denial of referral request (dissatisfaction | 2 |
| regarding non-authorization of a request for a | 3 |
| referral to another provider recommended by a PCP); | 4 |
| (D) claims and utilization review (dissatisfaction | 5 |
| regarding the concurrent or retrospective evaluation | 6 |
| of the coverage, medical necessity, efficiency or | 7 |
| appropriateness of health care services or treatment | 8 |
| plans; prospective "Denials of care or treatment", | 9 |
| "Denials of diagnostic procedures" and "Denials of | 10 |
| referral requests" should not be classified in this | 11 |
| category, but the appropriate one above);
| 12 |
| (8) the number of external reviews that were terminated | 13 |
| as the result of a reconsideration by the health carrier of | 14 |
| its adverse determination or final adverse determination | 15 |
| after the receipt of additional information from the | 16 |
| covered person or the covered person's authorized | 17 |
| representative; and | 18 |
| (9) any other information the Director may request or | 19 |
| require.
| 20 |
| Section 70. Funding of external review. The health carrier | 21 |
| shall be solely responsible for paying the cost of external | 22 |
| reviews conducted by independent review organizations. | 23 |
| Section 75. Disclosure requirements. | 24 |
| (a) Each health carrier shall include a description of the |
|
|
|
09600HB3923sam001 |
- 41 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| external review procedures in, or attached to, the policy, | 2 |
| certificate, membership booklet, and outline of coverage or | 3 |
| other evidence of coverage it provides to covered persons. | 4 |
| (b) The description required under subsection (a) of this | 5 |
| Section shall include a statement that informs the covered | 6 |
| person of the right of the covered person to file a request for | 7 |
| an external review of an adverse determination or final adverse | 8 |
| determination with the health carrier. The statement shall | 9 |
| explain that external review is available when the adverse | 10 |
| determination or final adverse determination involves an issue | 11 |
| of medical necessity, appropriateness, health care setting, | 12 |
| level of care, or effectiveness. The statement shall include | 13 |
| the toll-free telephone number and address of the Office of | 14 |
| Consumer Health Insurance within the Division of Insurance.
| 15 |
| Section 90. The Illinois Insurance Code is amended by | 16 |
| changing Sections 155.36 and 370c and by adding Sections 359b, | 17 |
| 359c, and 359d as follows:
| 18 |
| (215 ILCS 5/155.36)
| 19 |
| Sec. 155.36. Managed Care Reform and Patient Rights Act. | 20 |
| Insurance
companies that transact the kinds of insurance | 21 |
| authorized under Class 1(b) or
Class 2(a) of Section 4 of this | 22 |
| Code shall comply
with Sections 45 and Section 85 and the | 23 |
| definition of the term "emergency medical
condition" in Section
| 24 |
| 10 of the Managed Care Reform and Patient Rights Act.
|
|
|
|
09600HB3923sam001 |
- 42 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (Source: P.A. 91-617, eff. 1-1-00.)
| 2 |
| (215 ILCS 5/359b new)
| 3 |
| Sec. 359b. Committee to create a uniform small employer | 4 |
| group health status questionnaire and individual health | 5 |
| statement. | 6 |
| (a) For the purposes of this Section: | 7 |
| "Employee health status questionnaire" means a | 8 |
| questionnaire that poses questions about an individual | 9 |
| employee or covered dependent's health history and that is | 10 |
| to be completed by the individual employee or covered | 11 |
| dependent of a small employer that seeks health insurance | 12 |
| coverage from a small employer carrier. | 13 |
| "Health benefit plan", "small employer", and "small | 14 |
| employer carrier" shall have the meaning given those terms | 15 |
| in the Small Employer Health Insurance Rating Act. | 16 |
| "Individual market" shall have the meaning given the | 17 |
| term in the Illinois Health Insurance Portability and | 18 |
| Accountability Act. | 19 |
| (b) A committee is established in the Department consisting | 20 |
| of 11 members, including the Director or the Director's | 21 |
| designee, who are appointed by the Director. The Director shall | 22 |
| appoint to the committee 2 representatives each from the | 23 |
| Illinois Insurance Association and the Illinois Life Insurance | 24 |
| Council, one representative each from the Professional | 25 |
| Independent Insurance Agents of Illinois and the Illinois |
|
|
|
09600HB3923sam001 |
- 43 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| Association of Health Underwriters, and one representative | 2 |
| each from the Illinois Chamber of Commerce, Illinois | 3 |
| Manufacturers Association, Illinois Retail Merchants | 4 |
| Association, and National Federation of Independent | 5 |
| Businesses. The Director or the Director's designee shall serve | 6 |
| as chairperson of the committee. | 7 |
| (c) The committee shall develop a uniform employee | 8 |
| health-status questionnaire to simplify the health insurance | 9 |
| application process for small employers. The committee shall | 10 |
| study employee health status questionnaires currently used by | 11 |
| major small employer carriers in this State and consolidate the | 12 |
| questionnaires into a uniform questionnaire. The questionnaire | 13 |
| shall be designed to permit its use both as a written document | 14 |
| and through electronic or other alternative delivery formats. | 15 |
| A uniform employee health-status questionnaire shall allow | 16 |
| small employers that are required to provide information | 17 |
| regarding their employees to a small employer carrier when | 18 |
| applying for a small employer group health insurance policy to | 19 |
| use a standardized questionnaire that small employer carriers | 20 |
| may elect to accept. The development of the uniform employee | 21 |
| health-status questionnaire is intended to relieve small | 22 |
| employers of the burden of completing separate application | 23 |
| forms for each small employer carrier with which the employer | 24 |
| applies for insurance or from which the employer seeks | 25 |
| information regarding such matters as rates, coverage, and | 26 |
| availability. The use of the uniform employee health-status |
|
|
|
09600HB3923sam001 |
- 44 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| questionnaire by small employer carriers and small employers | 2 |
| shall be voluntary. | 3 |
| (d) On or before July 1,2010, the committee shall develop | 4 |
| the uniform employee health-status questionnaire for adoption | 5 |
| by the Department. Beginning January 1, 2011, a small employer | 6 |
| carrier may use the questionnaire for all small employer groups | 7 |
| for which it requires employees and their covered dependents to | 8 |
| complete questionnaires. | 9 |
| (e) The Director, as needed, may reconvene the committee to | 10 |
| consider whether changes are necessary to the uniform employee | 11 |
| health status questionnaire. If the committee determines that | 12 |
| changes to the questionnaire are necessary, then the Director | 13 |
| may adopt revisions to the questionnaire as recommended by the | 14 |
| committee. Small employer carriers may use the revised | 15 |
| questionnaire beginning 90 days after the director adopts any | 16 |
| revision. | 17 |
| (f) Nothing in this Section shall be construed to limit or | 18 |
| restrict a small employer carrier's ability to appropriately | 19 |
| rate risk under a small employer health benefit plan. | 20 |
| (g) The committee shall develop a standard individual | 21 |
| market health statement to simplify the health insurance | 22 |
| application process for individuals. The committee shall study | 23 |
| health statements currently used by major carriers in this | 24 |
| State who offer health benefit plans in the individual market | 25 |
| and consolidate the statements into a standard individual | 26 |
| market health statement. The standard individual market health |
|
|
|
09600HB3923sam001 |
- 45 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| statement shall be designed to permit its use both as a written | 2 |
| document and through electronic or other alternative delivery | 3 |
| formats. | 4 |
| (h) All carriers who offer health benefit plans in the | 5 |
| individual market and evaluate the health status of individuals | 6 |
| may use the standard individual market health statement on a | 7 |
| voluntary basis not less than 6 months after the statement | 8 |
| becomes effective. | 9 |
| (i) The Director, as needed, may reconvene the committee to | 10 |
| consider whether changes are necessary to the standard | 11 |
| individual market health statement. If the committee | 12 |
| determines that changes to the statement are necessary, the | 13 |
| Director may adopt revisions to the statement as recommended by | 14 |
| the committee. Individual market carriers may use the revised | 15 |
| statement beginning 90 days after the Director adopts any | 16 |
| revision. | 17 |
| (j) Nothing in this Section shall prevent a carrier from | 18 |
| using health information after enrollment for the purpose of | 19 |
| providing services or arranging for the provision of services | 20 |
| under a health benefit plan. | 21 |
| (k) Nothing in this Section shall be construed to limit or | 22 |
| restrict a health carrier's ability to appropriately rate risk, | 23 |
| refuse to issue or renew coverage, or otherwise rescind, | 24 |
| terminate, restrict coverage under a policy of accident and | 25 |
| health insurance or managed care plan, or conduct further | 26 |
| review of the information submitted on the statement by |
|
|
|
09600HB3923sam001 |
- 46 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| contacting an individual, the individual's health care | 2 |
| provider, or other entity for additional health status related | 3 |
| information. | 4 |
| (l) Committee members serve at the pleasure of the Director | 5 |
| and are not eligible to receive compensation or reimbursement | 6 |
| of expenses. | 7 |
| (215 ILCS 5/359c new)
| 8 |
| Sec. 359c. Accident and health expense reporting. An | 9 |
| insurer or managed care plan providing group or individual | 10 |
| major medical policy of accident or health insurance shall, | 11 |
| beginning on the first day of January or within 60 days | 12 |
| thereafter, annually prepare and provide to the Department of | 13 |
| Insurance a statement of the aggregate administrative expenses | 14 |
| of the insurer or managed care plan, based on the premiums | 15 |
| earned in the immediately preceding calendar year on the | 16 |
| accident or health insurance business of the insurer or managed | 17 |
| care plan. The statement shall itemize and separately detail | 18 |
| all of the following information with respect to the insurer's | 19 |
| or managed care plan's accident or health insurance business: | 20 |
| (1) the amount of premiums earned by the insurer or | 21 |
| managed care plan both before and after any costs related | 22 |
| to the insurer's purchase of reinsurance coverage; | 23 |
| (2) the total amount of claims for losses paid by the | 24 |
| insurer or managed care plan both before and after any | 25 |
| reimbursement from reinsurance coverage including any |
|
|
|
09600HB3923sam001 |
- 47 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| costs incurred related to: | 2 |
| (A) disease, case, or chronic care management | 3 |
| programs; | 4 |
| (B) wellness and health education programs; | 5 |
| (C) fraud prevention; | 6 |
| (D) maintaining provider networks and provider | 7 |
| credentialing; | 8 |
| (E) health information technology for personal | 9 |
| electronic health records; and | 10 |
| (F) utilization review and utilization management; | 11 |
| (3) the amount of any losses incurred by the insurer or | 12 |
| managed care plan but not reported to the insurer or | 13 |
| managed care plan in the current or prior year; | 14 |
| (4) the amount of costs incurred by the insurer or | 15 |
| managed care plan for State fees and federal and State | 16 |
| taxes including: | 17 |
| (A) any high risk pool and guaranty fund | 18 |
| assessments levied on the insurer or managed care plan | 19 |
| by the State; and | 20 |
| (B) any regulatory compliance costs including | 21 |
| State fees for form and rate filings, licensures, | 22 |
| market conduct exams, and financial reports; | 23 |
| (5) the amount of costs incurred by the insurer or | 24 |
| managed care plan for reinsurance coverage; | 25 |
| (6) the amount of costs incurred by the insurer that | 26 |
| are related to the insurer's payment of marketing expenses |
|
|
|
09600HB3923sam001 |
- 48 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| including commissions; and | 2 |
| (7) any other administrative expenses incurred by the | 3 |
| insurer. | 4 |
| (215 ILCS 5/359d new)
| 5 |
| Sec. 359d. State-mandated health benefits; actuarial cost | 6 |
| analysis; moratorium on additional mandates. | 7 |
| (a) For purposes of this Section: | 8 |
| "Actuarial cost analysis" means an analysis conducted | 9 |
| by the Department of Insurance of the costs associated with | 10 |
| the State-mandated health benefit, including, but not | 11 |
| limited to, the actual premium cost of the specific mandate | 12 |
| and the effect of the mandate on insurance premiums charged | 13 |
| to the citizens of this State. | 14 |
| "State-mandated health benefits" means coverage | 15 |
| required under the laws of this State to be provided in a | 16 |
| group major medical policy for accident and health | 17 |
| insurance or a contract for a health-related condition | 18 |
| that: (i) includes coverage for specific health care | 19 |
| services or benefits; (ii) places limitations or | 20 |
| restrictions on deductibles, coinsurance, co-payments, or | 21 |
| any annual or lifetime maximum benefit amounts; or (iii) | 22 |
| includes coverage for a specific category of licensed | 23 |
| health practitioner from whom an insured is entitled to | 24 |
| receive care.
State-mandated health benefits shall not | 25 |
| include any federally mandated benefit or mandated option. |
|
|
|
09600HB3923sam001 |
- 49 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (b) Any State-mandated health benefit introduced into the | 2 |
| General Assembly after January 1, 2010, shall undergo an | 3 |
| actuarial cost analysis, the results of which shall be reported | 4 |
| to the House and Senate Committees on Insurance prior to any | 5 |
| State-mandated health benefit legislation being considered by | 6 |
| either the House or Senate. | 7 |
| (c) Notwithstanding any other provision of law to the | 8 |
| contrary, a health insurance issuer shall not be required to | 9 |
| deliver, issue, or renew a health benefit plan on or after | 10 |
| January 1, 2010, and before December 31, 2013, that includes | 11 |
| any additional State-mandated health benefit or mandated | 12 |
| option beyond those statutory requirements in effect for health | 13 |
| benefit plans on July 1, 2009. This subsection (c) shall apply | 14 |
| to any health benefit plan delivered or issued for delivery in | 15 |
| this State, including any hospital, health, or medical expense | 16 |
| insurance policy, hospital or medical service contract, | 17 |
| employee welfare plan, health and accident insurance policy, or | 18 |
| any policy of group, family group, blanket, or franchise health | 19 |
| and accident insurance, health maintenance organization, or | 20 |
| preferred provider organization. | 21 |
| Nothing in this subsection (c) shall be construed to | 22 |
| prohibit an employer from electing to expand coverage on any | 23 |
| group or individual health benefit plan or policy covering the | 24 |
| employer and the employees of the employer. | 25 |
| Nothing in this subsection (c) shall be construed to | 26 |
| prohibit a health insurance issuer from electing to expand |
|
|
|
09600HB3923sam001 |
- 50 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| coverage on any group or individual health benefit plan. | 2 |
| (d) Nothing in this Section shall be construed to allow a | 3 |
| health benefit plan policy delivered, issued, or renewed after | 4 |
| January 1, 2010, to suspend, limit, or modify any mandates in | 5 |
| effect prior to July 1, 2009.
| 6 |
| (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| 7 |
| (Text of Section before amendment by P.A. 95-1049 )
| 8 |
| Sec. 370c. Mental and emotional disorders.
| 9 |
| (a) (1) On and after the effective date of this Section,
| 10 |
| every insurer which delivers, issues for delivery or renews or | 11 |
| modifies
group A&H policies providing coverage for hospital or | 12 |
| medical treatment or
services for illness on an | 13 |
| expense-incurred basis shall offer to the
applicant or group | 14 |
| policyholder subject to the insurers standards of
| 15 |
| insurability, coverage for reasonable and necessary treatment | 16 |
| and services
for mental, emotional or nervous disorders or | 17 |
| conditions, other than serious
mental illnesses as defined in | 18 |
| item (2) of subsection (b), up to the limits
provided in the | 19 |
| policy for other disorders or conditions, except (i) the
| 20 |
| insured may be required to pay up to 50% of expenses incurred | 21 |
| as a result
of the treatment or services, and (ii) the annual | 22 |
| benefit limit may be
limited to the lesser of $10,000 or 25% of | 23 |
| the lifetime policy limit.
| 24 |
| (2) Each insured that is covered for mental, emotional or | 25 |
| nervous
disorders or conditions shall be free to select the |
|
|
|
09600HB3923sam001 |
- 51 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| physician licensed to
practice medicine in all its branches, | 2 |
| licensed clinical psychologist,
licensed clinical social | 3 |
| worker, licensed clinical professional counselor, or licensed | 4 |
| marriage and family therapist of
his choice to treat such | 5 |
| disorders, and
the insurer shall pay the covered charges of | 6 |
| such physician licensed to
practice medicine in all its | 7 |
| branches, licensed clinical psychologist,
licensed clinical | 8 |
| social worker, licensed clinical professional counselor, or | 9 |
| licensed marriage and family therapist up
to the limits of | 10 |
| coverage, provided (i)
the disorder or condition treated is | 11 |
| covered by the policy, and (ii) the
physician, licensed | 12 |
| psychologist, licensed clinical social worker, licensed
| 13 |
| clinical professional counselor, or licensed marriage and | 14 |
| family therapist is
authorized to provide said services under | 15 |
| the statutes of this State and in
accordance with accepted | 16 |
| principles of his profession.
| 17 |
| (3) Insofar as this Section applies solely to licensed | 18 |
| clinical social
workers, licensed clinical professional | 19 |
| counselors, and licensed marriage and family therapists, those | 20 |
| persons who may
provide services to individuals shall do so
| 21 |
| after the licensed clinical social worker, licensed clinical | 22 |
| professional
counselor, or licensed marriage and family | 23 |
| therapist has informed the patient of the
desirability of the | 24 |
| patient conferring with the patient's primary care
physician | 25 |
| and the licensed clinical social worker, licensed clinical
| 26 |
| professional counselor, or licensed marriage and family |
|
|
|
09600HB3923sam001 |
- 52 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| therapist has
provided written
notification to the patient's | 2 |
| primary care physician, if any, that services
are being | 3 |
| provided to the patient. That notification may, however, be
| 4 |
| waived by the patient on a written form. Those forms shall be | 5 |
| retained by
the licensed clinical social worker, licensed | 6 |
| clinical professional counselor, or licensed marriage and | 7 |
| family therapist
for a period of not less than 5 years.
| 8 |
| (b) (1) An insurer that provides coverage for hospital or | 9 |
| medical
expenses under a group policy of accident and health | 10 |
| insurance or
health care plan amended, delivered, issued, or | 11 |
| renewed after the effective
date of this amendatory Act of the | 12 |
| 92nd General Assembly shall provide coverage
under the policy | 13 |
| for treatment of serious mental illness under the same terms
| 14 |
| and conditions as coverage for hospital or medical expenses | 15 |
| related to other
illnesses and diseases. The coverage required | 16 |
| under this Section must provide
for same durational limits, | 17 |
| amount limits, deductibles, and co-insurance
requirements for | 18 |
| serious mental illness as are provided for other illnesses
and | 19 |
| diseases. This subsection does not apply to coverage provided | 20 |
| to
employees by employers who have 50 or fewer employees.
| 21 |
| (2) "Serious mental illness" means the following | 22 |
| psychiatric illnesses as
defined in the most current edition of | 23 |
| the Diagnostic and Statistical Manual
(DSM) published by the | 24 |
| American Psychiatric Association:
| 25 |
| (A) schizophrenia;
| 26 |
| (B) paranoid and other psychotic disorders;
|
|
|
|
09600HB3923sam001 |
- 53 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (C) bipolar disorders (hypomanic, manic, depressive, | 2 |
| and mixed);
| 3 |
| (D) major depressive disorders (single episode or | 4 |
| recurrent);
| 5 |
| (E) schizoaffective disorders (bipolar or depressive);
| 6 |
| (F) pervasive developmental disorders;
| 7 |
| (G) obsessive-compulsive disorders;
| 8 |
| (H) depression in childhood and adolescence;
| 9 |
| (I) panic disorder; | 10 |
| (J) post-traumatic stress disorders (acute, chronic, | 11 |
| or with delayed onset); and
| 12 |
| (K) anorexia nervosa and bulimia nervosa. | 13 |
| (3) A qualifying group health benefit plan, in accordance | 14 |
| with the Emergency Economic Stabilization Act of 2008, | 15 |
| specifically, the Paul Wellstone and Pete Domenici Mental | 16 |
| Health Parity and Addiction Equity Act of 2008, providing | 17 |
| coverage for mental health and substance use disorders | 18 |
| benefits, including those mental and emotional disorders | 19 |
| required in subsection (a) and (b), must have the same | 20 |
| treatment and financial levels as the predominant medical and | 21 |
| surgical benefits provided in the benefit plan. Group health | 22 |
| benefit plans are not restricted from applying utilization | 23 |
| review, medical necessity determinations or other tools to | 24 |
| encourage appropriate and effective care. Utilization review, | 25 |
| medical necessity determinations or other tools to encourage | 26 |
| appropriate and effective care shall be administered for mental |
|
|
|
09600HB3923sam001 |
- 54 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| illness in a manner consistent with those for medical and | 2 |
| surgical benefits offered in the plan. Upon request of the | 3 |
| reimbursing insurer, a provider of treatment of
serious mental | 4 |
| illness shall furnish medical records or other necessary data
| 5 |
| that substantiate that initial or continued treatment is at all | 6 |
| times medically
necessary. An insurer shall provide a mechanism | 7 |
| for the timely review by a
provider holding the same license | 8 |
| and practicing in the same specialty as the
patient's provider, | 9 |
| who is unaffiliated with the insurer, jointly selected by
the | 10 |
| patient (or the patient's next of kin or legal representative | 11 |
| if the
patient is unable to act for himself or herself), the | 12 |
| patient's provider, and
the insurer in the event of a dispute | 13 |
| between the insurer and patient's
provider regarding the | 14 |
| medical necessity of a treatment proposed by a patient's
| 15 |
| provider. If the reviewing provider determines the treatment to | 16 |
| be medically
necessary, the insurer shall provide | 17 |
| reimbursement for the treatment. Future
contractual or | 18 |
| employment actions by the insurer regarding the patient's
| 19 |
| provider may not be based on the provider's participation in | 20 |
| this procedure.
Nothing prevents
the insured from agreeing in | 21 |
| writing to continue treatment at his or her
expense. When | 22 |
| making a determination of the medical necessity for a treatment
| 23 |
| modality for serous mental illness, an insurer must make the | 24 |
| determination in a
manner that is consistent with the manner | 25 |
| used to make that determination with
respect to other diseases | 26 |
| or illnesses covered under the policy, including an
appeals |
|
|
|
09600HB3923sam001 |
- 55 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| process.
| 2 |
| (4) A group health benefit plan:
| 3 |
| (A) shall provide coverage based upon medical | 4 |
| necessity for the following
treatment of mental illness in | 5 |
| each calendar year:
| 6 |
| (i) 45 days of inpatient treatment; and
| 7 |
| (ii) beginning on June 26, 2006 (the effective date | 8 |
| of Public Act 94-921), 60 visits for outpatient | 9 |
| treatment including group and individual
outpatient | 10 |
| treatment; and | 11 |
| (iii) for plans or policies delivered, issued for | 12 |
| delivery, renewed, or modified after January 1, 2007 | 13 |
| (the effective date of Public Act 94-906),
20 | 14 |
| additional outpatient visits for speech therapy for | 15 |
| treatment of pervasive developmental disorders that | 16 |
| will be in addition to speech therapy provided pursuant | 17 |
| to item (ii) of this subparagraph (A);
| 18 |
| (B) may not include a lifetime limit on the number of | 19 |
| days of inpatient
treatment or the number of outpatient | 20 |
| visits covered under the plan; and
| 21 |
| (C) shall include the same amount limits, deductibles, | 22 |
| copayments, and
coinsurance factors for serious mental | 23 |
| illness as for physical illness.
| 24 |
| (5) An issuer of a group health benefit plan may not count | 25 |
| toward the number
of outpatient visits required to be covered | 26 |
| under this Section an outpatient
visit for the purpose of |
|
|
|
09600HB3923sam001 |
- 56 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| medication management and shall cover the outpatient
visits | 2 |
| under the same terms and conditions as it covers outpatient | 3 |
| visits for
the treatment of physical illness.
| 4 |
| (6) An issuer of a group health benefit
plan may provide or | 5 |
| offer coverage required under this Section through a
managed | 6 |
| care plan.
| 7 |
| (7) This Section shall not be interpreted to require a | 8 |
| group health benefit
plan to provide coverage for treatment of:
| 9 |
| (A) an addiction to a controlled substance or cannabis | 10 |
| that is used in
violation of law; or
| 11 |
| (B) mental illness resulting from the use of a | 12 |
| controlled substance or
cannabis in violation of law.
| 13 |
| (8)
(Blank).
| 14 |
| (9) On and after June 1, 2010, coverage for the treatment | 15 |
| of mental and emotional disorders as provided by subsections | 16 |
| (a) and (b) of this Section shall not be denied under the | 17 |
| policy, provided that services are medically necessary as | 18 |
| determined by the insurer. | 19 |
| (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; | 20 |
| 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff. | 21 |
| 8-21-07; 95-972, eff. 9-22-08; 95-973, eff. 1-1-09; revised | 22 |
| 10-14-08.)
| 23 |
| (Text of Section after amendment by P.A. 95-1049 ) | 24 |
| Sec. 370c. Mental and emotional disorders.
| 25 |
| (a) (1) On and after the effective date of this Section,
|
|
|
|
09600HB3923sam001 |
- 57 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| every insurer which delivers, issues for delivery or renews or | 2 |
| modifies
group A&H policies providing coverage for hospital or | 3 |
| medical treatment or
services for illness on an | 4 |
| expense-incurred basis shall offer to the
applicant or group | 5 |
| policyholder subject to the insurers standards of
| 6 |
| insurability, coverage for reasonable and necessary treatment | 7 |
| and services
for mental, emotional or nervous disorders or | 8 |
| conditions, other than serious
mental illnesses as defined in | 9 |
| item (2) of subsection (b), up to the limits
provided in the | 10 |
| policy for other disorders or conditions, except (i) the
| 11 |
| insured may be required to pay up to 50% of expenses incurred | 12 |
| as a result
of the treatment or services, and (ii) the annual | 13 |
| benefit limit may be
limited to the lesser of $10,000 or 25% of | 14 |
| the lifetime policy limit.
| 15 |
| (2) Each insured that is covered for mental, emotional or | 16 |
| nervous
disorders or conditions shall be free to select the | 17 |
| physician licensed to
practice medicine in all its branches, | 18 |
| licensed clinical psychologist,
licensed clinical social | 19 |
| worker, licensed clinical professional counselor, or licensed | 20 |
| marriage and family therapist of
his choice to treat such | 21 |
| disorders, and
the insurer shall pay the covered charges of | 22 |
| such physician licensed to
practice medicine in all its | 23 |
| branches, licensed clinical psychologist,
licensed clinical | 24 |
| social worker, licensed clinical professional counselor, or | 25 |
| licensed marriage and family therapist up
to the limits of | 26 |
| coverage, provided (i)
the disorder or condition treated is |
|
|
|
09600HB3923sam001 |
- 58 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| covered by the policy, and (ii) the
physician, licensed | 2 |
| psychologist, licensed clinical social worker, licensed
| 3 |
| clinical professional counselor, or licensed marriage and | 4 |
| family therapist is
authorized to provide said services under | 5 |
| the statutes of this State and in
accordance with accepted | 6 |
| principles of his profession.
| 7 |
| (3) Insofar as this Section applies solely to licensed | 8 |
| clinical social
workers, licensed clinical professional | 9 |
| counselors, and licensed marriage and family therapists, those | 10 |
| persons who may
provide services to individuals shall do so
| 11 |
| after the licensed clinical social worker, licensed clinical | 12 |
| professional
counselor, or licensed marriage and family | 13 |
| therapist has informed the patient of the
desirability of the | 14 |
| patient conferring with the patient's primary care
physician | 15 |
| and the licensed clinical social worker, licensed clinical
| 16 |
| professional counselor, or licensed marriage and family | 17 |
| therapist has
provided written
notification to the patient's | 18 |
| primary care physician, if any, that services
are being | 19 |
| provided to the patient. That notification may, however, be
| 20 |
| waived by the patient on a written form. Those forms shall be | 21 |
| retained by
the licensed clinical social worker, licensed | 22 |
| clinical professional counselor, or licensed marriage and | 23 |
| family therapist
for a period of not less than 5 years.
| 24 |
| (b) (1) An insurer that provides coverage for hospital or | 25 |
| medical
expenses under a group policy of accident and health | 26 |
| insurance or
health care plan amended, delivered, issued, or |
|
|
|
09600HB3923sam001 |
- 59 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| renewed after the effective
date of this amendatory Act of the | 2 |
| 92nd General Assembly shall provide coverage
under the policy | 3 |
| for treatment of serious mental illness under the same terms
| 4 |
| and conditions as coverage for hospital or medical expenses | 5 |
| related to other
illnesses and diseases. The coverage required | 6 |
| under this Section must provide
for same durational limits, | 7 |
| amount limits, deductibles, and co-insurance
requirements for | 8 |
| serious mental illness as are provided for other illnesses
and | 9 |
| diseases. This subsection does not apply to coverage provided | 10 |
| to
employees by employers who have 50 or fewer employees.
| 11 |
| (2) "Serious mental illness" means the following | 12 |
| psychiatric illnesses as
defined in the most current edition of | 13 |
| the Diagnostic and Statistical Manual
(DSM) published by the | 14 |
| American Psychiatric Association:
| 15 |
| (A) schizophrenia;
| 16 |
| (B) paranoid and other psychotic disorders;
| 17 |
| (C) bipolar disorders (hypomanic, manic, depressive, | 18 |
| and mixed);
| 19 |
| (D) major depressive disorders (single episode or | 20 |
| recurrent);
| 21 |
| (E) schizoaffective disorders (bipolar or depressive);
| 22 |
| (F) pervasive developmental disorders;
| 23 |
| (G) obsessive-compulsive disorders;
| 24 |
| (H) depression in childhood and adolescence;
| 25 |
| (I) panic disorder; | 26 |
| (J) post-traumatic stress disorders (acute, chronic, |
|
|
|
09600HB3923sam001 |
- 60 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| or with delayed onset); and
| 2 |
| (K) anorexia nervosa and bulimia nervosa. | 3 |
| (3) A qualifying group health benefit plan, in accordance | 4 |
| with the Emergency Economic Stabilization Act of 2008, | 5 |
| specifically, the Paul Wellstone and Pete Domenici Mental | 6 |
| Health Parity and Addiction Equity Act of 2008, providing | 7 |
| coverage for mental health and substance use disorders | 8 |
| benefits, including those mental and emotional disorders | 9 |
| required in subsection (a) and (b), must have the same | 10 |
| treatment and financial levels as the predominant medical and | 11 |
| surgical benefits provided in the benefit plan. Group health | 12 |
| benefit plans are not restricted from applying utilization | 13 |
| review, medical necessity determinations or other tools to | 14 |
| encourage appropriate and effective care. Utilization review, | 15 |
| medical necessity determinations or other tools to encourage | 16 |
| appropriate and effective care shall be administered for mental | 17 |
| illness in a manner consistent with those for medical and | 18 |
| surgical benefits offered in the plan. Upon request of the | 19 |
| reimbursing insurer, a provider of treatment of
serious mental | 20 |
| illness shall furnish medical records or other necessary data
| 21 |
| that substantiate that initial or continued treatment is at all | 22 |
| times medically
necessary. An insurer shall provide a mechanism | 23 |
| for the timely review by a
provider holding the same license | 24 |
| and practicing in the same specialty as the
patient's provider, | 25 |
| who is unaffiliated with the insurer, jointly selected by
the | 26 |
| patient (or the patient's next of kin or legal representative |
|
|
|
09600HB3923sam001 |
- 61 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| if the
patient is unable to act for himself or herself), the | 2 |
| patient's provider, and
the insurer in the event of a dispute | 3 |
| between the insurer and patient's
provider regarding the | 4 |
| medical necessity of a treatment proposed by a patient's
| 5 |
| provider. If the reviewing provider determines the treatment to | 6 |
| be medically
necessary, the insurer shall provide | 7 |
| reimbursement for the treatment. Future
contractual or | 8 |
| employment actions by the insurer regarding the patient's
| 9 |
| provider may not be based on the provider's participation in | 10 |
| this procedure.
Nothing prevents
the insured from agreeing in | 11 |
| writing to continue treatment at his or her
expense. When | 12 |
| making a determination of the medical necessity for a treatment
| 13 |
| modality for serous mental illness, an insurer must make the | 14 |
| determination in a
manner that is consistent with the manner | 15 |
| used to make that determination with
respect to other diseases | 16 |
| or illnesses covered under the policy, including an
appeals | 17 |
| process.
| 18 |
| (4) A group health benefit plan:
| 19 |
| (A) shall provide coverage based upon medical | 20 |
| necessity for the following
treatment of mental illness in | 21 |
| each calendar year:
| 22 |
| (i) 45 days of inpatient treatment; and
| 23 |
| (ii) beginning on June 26, 2006 (the effective date | 24 |
| of Public Act 94-921), 60 visits for outpatient | 25 |
| treatment including group and individual
outpatient | 26 |
| treatment; and |
|
|
|
09600HB3923sam001 |
- 62 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (iii) for plans or policies delivered, issued for | 2 |
| delivery, renewed, or modified after January 1, 2007 | 3 |
| (the effective date of Public Act 94-906),
20 | 4 |
| additional outpatient visits for speech therapy for | 5 |
| treatment of pervasive developmental disorders that | 6 |
| will be in addition to speech therapy provided pursuant | 7 |
| to item (ii) of this subparagraph (A);
| 8 |
| (B) may not include a lifetime limit on the number of | 9 |
| days of inpatient
treatment or the number of outpatient | 10 |
| visits covered under the plan; and
| 11 |
| (C) shall include the same amount limits, deductibles, | 12 |
| copayments, and
coinsurance factors for serious mental | 13 |
| illness as for physical illness.
| 14 |
| (5) An issuer of a group health benefit plan may not count | 15 |
| toward the number
of outpatient visits required to be covered | 16 |
| under this Section an outpatient
visit for the purpose of | 17 |
| medication management and shall cover the outpatient
visits | 18 |
| under the same terms and conditions as it covers outpatient | 19 |
| visits for
the treatment of physical illness.
| 20 |
| (6) An issuer of a group health benefit
plan may provide or | 21 |
| offer coverage required under this Section through a
managed | 22 |
| care plan.
| 23 |
| (7) This Section shall not be interpreted to require a | 24 |
| group health benefit
plan to provide coverage for treatment of:
| 25 |
| (A) an addiction to a controlled substance or cannabis | 26 |
| that is used in
violation of law; or
|
|
|
|
09600HB3923sam001 |
- 63 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (B) mental illness resulting from the use of a | 2 |
| controlled substance or
cannabis in violation of law.
| 3 |
| (8)
(Blank).
| 4 |
| (9) On and after June 1, 2010, coverage for the treatment | 5 |
| of mental and emotional disorders as provided by subsections | 6 |
| (a) and (b) of this Section shall not be denied under the | 7 |
| policy, provided that services are medically necessary as | 8 |
| determined by the insurer. | 9 |
| (c) This Section shall not be interpreted to require | 10 |
| coverage for speech therapy or other habilitative services for | 11 |
| those individuals covered under Section 356z.15
356z.14 of this | 12 |
| Code. | 13 |
| (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; | 14 |
| 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff. | 15 |
| 8-21-07; 95-972, eff. 9-22-08; 95-973, eff. 1-1-09; 95-1049, | 16 |
| eff. 1-1-10; revised 4-10-09.)
| 17 |
| Section 95. The Managed Care Reform and Patient Rights Act | 18 |
| is amended by changing Sections 40, 45, and 90 as follows:
| 19 |
| (215 ILCS 134/40)
| 20 |
| Sec. 40. Access to specialists.
| 21 |
| (a) All health care plans that require each enrollee to | 22 |
| select a
health care provider for any purpose including | 23 |
| coordination of
care shall
permit an enrollee to choose any | 24 |
| available primary care physician licensed to
practice
medicine |
|
|
|
09600HB3923sam001 |
- 64 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| in all its branches participating in
the health care plan for | 2 |
| that purpose.
The health care plan shall provide the enrollee | 3 |
| with a choice of licensed
health care providers who are | 4 |
| accessible and
qualified. Nothing in
this Act shall be | 5 |
| construed to prohibit a health care plan from requiring a
| 6 |
| health care provider to meet the health care plan's criteria in | 7 |
| order to
coordinate access to health care.
| 8 |
| (b) A health care plan shall establish a procedure by which | 9 |
| an enrollee who
has a condition that requires ongoing care from | 10 |
| a specialist physician
or other health care provider may apply | 11 |
| for a
standing referral to a specialist physician or other | 12 |
| health care provider if a
referral to a specialist
physician or | 13 |
| other health care provider is required for
coverage.
The | 14 |
| application shall be made to the enrollee's primary care | 15 |
| physician.
This procedure for a standing referral must specify
| 16 |
| the necessary criteria and conditions that must be met in order | 17 |
| for an enrollee
to obtain a standing referral.
A standing | 18 |
| referral shall be effective for the period
necessary to provide | 19 |
| the referred services or one year, except in the event of
| 20 |
| termination of a contract or policy in which case Section 25 on | 21 |
| transition of
services shall apply, if applicable.
A primary | 22 |
| care physician may renew and re-renew a standing referral.
| 23 |
| (c) The enrollee may be required by the health care plan to | 24 |
| select a
specialist physician or other health care provider who | 25 |
| has a referral
arrangement with the enrollee's
primary care | 26 |
| physician or to select a new primary care physician who has a
|
|
|
|
09600HB3923sam001 |
- 65 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| referral arrangement with the specialist physician or other | 2 |
| health care
provider chosen by the enrollee.
If a health care | 3 |
| plan requires an enrollee to select a new physician under
this | 4 |
| subsection, the health care plan must provide the enrollee with
| 5 |
| both
options provided in this subsection.
When a participating | 6 |
| specialist with a referral arrangement is not available,
the | 7 |
| primary care physician, in consultation with the enrollee, | 8 |
| shall arrange
for the enrollee to have access to a qualified | 9 |
| participating health care
provider, and the enrollee shall be | 10 |
| allowed to stay with his or her primary
care physician.
If a | 11 |
| secondary referral is necessary, the specialist physician or | 12 |
| other health
care provider shall advise the primary care | 13 |
| physician. The primary care
physician shall be responsible for | 14 |
| making the secondary referral. In addition,
the health care | 15 |
| plan shall require the specialist physician or other health
| 16 |
| care
provider to provide regular updates to the enrollee's | 17 |
| primary care physician.
| 18 |
| (d) When the type of specialist physician or other health | 19 |
| care provider
needed to provide ongoing care
for a
specific | 20 |
| condition is not represented in the health care plan's provider
| 21 |
| network, the primary care physician shall arrange for the | 22 |
| enrollee to have
access to
a qualified non-participating health | 23 |
| care provider
within a reasonable distance and travel
time at | 24 |
| no additional cost beyond what the enrollee would otherwise pay | 25 |
| for
services received within the network. The referring | 26 |
| physician
shall notify the plan when a referral is made outside |
|
|
|
09600HB3923sam001 |
- 66 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| the network.
| 2 |
| (e) The enrollee's primary care physician shall remain | 3 |
| responsible for
coordinating the care of an enrollee who has | 4 |
| received a standing referral to a
specialist physician or other | 5 |
| health care provider.
If a secondary referral is necessary, the | 6 |
| specialist physician or other health
care provider shall advise
| 7 |
| the primary care physician. The primary care physician shall be | 8 |
| responsible
for making the secondary referral.
In addition,
the | 9 |
| health care plan shall require the specialist physician or | 10 |
| other health
care
provider to provide
regular updates to the | 11 |
| enrollee's primary care physician.
| 12 |
| (f) If an enrollee's application for any referral is | 13 |
| denied, an
enrollee may appeal the decision through the
health | 14 |
| care plan's external independent review process as provided by | 15 |
| the Illinois Health Carrier External Review Act in accordance | 16 |
| with
subsection (f) of Section 45 of this Act .
| 17 |
| (g) Nothing in this Act shall be construed to require an | 18 |
| enrollee to select
a new primary care physician when no | 19 |
| referral arrangement exists between the
enrollee's primary | 20 |
| care physician and the specialist selected by the enrollee
and | 21 |
| when the enrollee has a long-standing relationship with his or | 22 |
| her primary
care physician.
| 23 |
| (h) In promulgating rules to implement this Act, the | 24 |
| Department shall
define
"standing referral" and "ongoing | 25 |
| course of treatment".
| 26 |
| (Source: P.A. 91-617, eff. 1-1-00.)
|
|
|
|
09600HB3923sam001 |
- 67 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (215 ILCS 134/45)
| 2 |
| Sec. 45.
Health care services appeals,
complaints, and
| 3 |
| external independent reviews.
| 4 |
| (a) A health care plan shall establish and maintain an | 5 |
| appeals procedure as
outlined in this Act. Compliance with this | 6 |
| Act's appeals procedures shall
satisfy a health care plan's | 7 |
| obligation to provide appeal procedures under any
other State | 8 |
| law or rules.
All appeals of a health care plan's | 9 |
| administrative determinations and
complaints regarding its | 10 |
| administrative decisions shall be handled as required
under | 11 |
| Section 50.
| 12 |
| (b) When an appeal concerns a decision or action by a | 13 |
| health care plan,
its
employees, or its subcontractors that | 14 |
| relates to (i) health care services,
including, but not limited | 15 |
| to, procedures or
treatments,
for an enrollee with an ongoing | 16 |
| course of treatment ordered
by a health care provider,
the | 17 |
| denial of which could significantly
increase the risk to an
| 18 |
| enrollee's health,
or (ii) a treatment referral, service,
| 19 |
| procedure, or other health care service,
the denial of which | 20 |
| could significantly
increase the risk to an
enrollee's health,
| 21 |
| the health care plan must allow for the filing of an appeal
| 22 |
| either orally or in writing. Upon submission of the appeal, a | 23 |
| health care plan
must notify the party filing the appeal, as | 24 |
| soon as possible, but in no event
more than 24 hours after the | 25 |
| submission of the appeal, of all information
that the plan |
|
|
|
09600HB3923sam001 |
- 68 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| requires to evaluate the appeal.
The health care plan shall | 2 |
| render a decision on the appeal within
24 hours after receipt | 3 |
| of the required information. The health care plan shall
notify | 4 |
| the party filing the
appeal and the enrollee, enrollee's | 5 |
| primary care physician, and any health care
provider who | 6 |
| recommended the health care service involved in the appeal of | 7 |
| its
decision orally
followed-up by a written notice of the | 8 |
| determination.
| 9 |
| (c) For all appeals related to health care services | 10 |
| including, but not
limited to, procedures or treatments for an | 11 |
| enrollee and not covered by
subsection (b) above, the health | 12 |
| care
plan shall establish a procedure for the filing of such | 13 |
| appeals. Upon
submission of an appeal under this subsection, a | 14 |
| health care plan must notify
the party filing an appeal, within | 15 |
| 3 business days, of all information that the
plan requires to | 16 |
| evaluate the appeal.
The health care plan shall render a | 17 |
| decision on the appeal within 15 business
days after receipt of | 18 |
| the required information. The health care plan shall
notify the | 19 |
| party filing the appeal,
the enrollee, the enrollee's primary | 20 |
| care physician, and any health care
provider
who recommended | 21 |
| the health care service involved in the appeal orally of its
| 22 |
| decision followed-up by a written notice of the determination.
| 23 |
| (d) An appeal under subsection (b) or (c) may be filed by | 24 |
| the
enrollee, the enrollee's designee or guardian, the | 25 |
| enrollee's primary care
physician, or the enrollee's health | 26 |
| care provider. A health care plan shall
designate a clinical |
|
|
|
09600HB3923sam001 |
- 69 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| peer to review
appeals, because these appeals pertain to | 2 |
| medical or clinical matters
and such an appeal must be reviewed | 3 |
| by an appropriate
health care professional. No one reviewing an | 4 |
| appeal may have had any
involvement
in the initial | 5 |
| determination that is the subject of the appeal. The written
| 6 |
| notice of determination required under subsections (b) and (c) | 7 |
| shall
include (i) clear and detailed reasons for the | 8 |
| determination, (ii)
the medical or
clinical criteria for the | 9 |
| determination, which shall be based upon sound
clinical | 10 |
| evidence and reviewed on a periodic basis, and (iii) in the | 11 |
| case of an
adverse determination, the
procedures for requesting | 12 |
| an external independent review as provided by the Illinois | 13 |
| Health Carrier External Review Act under subsection (f) .
| 14 |
| (e) If an appeal filed under subsection (b) or (c) is | 15 |
| denied for a reason
including, but not limited to, the
service, | 16 |
| procedure, or treatment is not viewed as medically necessary,
| 17 |
| denial of specific tests or procedures, denial of referral
to | 18 |
| specialist physicians or denial of hospitalization requests or | 19 |
| length of
stay requests, any involved party may request an | 20 |
| external independent review as provided by the Illinois Health | 21 |
| Carrier External Review Act
under subsection (f) of the adverse | 22 |
| determination .
| 23 |
| (f) (Blank). External independent review.
| 24 |
| (1) The party seeking an external independent review | 25 |
| shall so notify the
health care plan.
The health care plan | 26 |
| shall seek to resolve all
external independent
reviews in |
|
|
|
09600HB3923sam001 |
- 70 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| the most expeditious manner and shall make a determination | 2 |
| and
provide notice of the determination no more
than 24 | 3 |
| hours after the receipt of all necessary information when a | 4 |
| delay would
significantly increase
the risk to an | 5 |
| enrollee's health or when extended health care services for | 6 |
| an
enrollee undergoing a
course of treatment prescribed by | 7 |
| a health care provider are at issue.
| 8 |
| (2) Within 30 days after the enrollee receives written | 9 |
| notice of an
adverse
determination,
if the enrollee decides | 10 |
| to initiate an external independent review, the
enrollee | 11 |
| shall send to the health
care plan a written request for an | 12 |
| external independent review, including any
information or
| 13 |
| documentation to support the enrollee's request for the | 14 |
| covered service or
claim for a covered
service.
| 15 |
| (3) Within 30 days after the health care plan receives | 16 |
| a request for an
external
independent review from an | 17 |
| enrollee, the health care plan shall:
| 18 |
| (A) provide a mechanism for joint selection of an | 19 |
| external independent
reviewer by the enrollee, the | 20 |
| enrollee's physician or other health care
provider,
| 21 |
| and the health care plan; and
| 22 |
| (B) forward to the independent reviewer all | 23 |
| medical records and
supporting
documentation | 24 |
| pertaining to the case, a summary description of the | 25 |
| applicable
issues including a
statement of the health | 26 |
| care plan's decision, the criteria used, and the
|
|
|
|
09600HB3923sam001 |
- 71 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| medical and clinical reasons
for that decision.
| 2 |
| (4) Within 5 days after receipt of all necessary | 3 |
| information, the
independent
reviewer
shall evaluate and | 4 |
| analyze the case and render a decision that is based on
| 5 |
| whether or not the health
care service or claim for the | 6 |
| health care service is medically appropriate. The
decision | 7 |
| by the
independent reviewer is final. If the external | 8 |
| independent reviewer determines
the health care
service to | 9 |
| be medically
appropriate, the health
care plan shall pay | 10 |
| for the health care service.
| 11 |
| (5) The health care plan shall be solely responsible | 12 |
| for paying the fees
of the external
independent reviewer | 13 |
| who is selected to perform the review.
| 14 |
| (6) An external independent reviewer who acts in good | 15 |
| faith shall have
immunity
from any civil or criminal | 16 |
| liability or professional discipline as a result of
acts or | 17 |
| omissions with
respect to any external independent review, | 18 |
| unless the acts or omissions
constitute wilful and wanton
| 19 |
| misconduct. For purposes of any proceeding, the good faith | 20 |
| of the person
participating shall be
presumed.
| 21 |
| (7) Future contractual or employment action by the | 22 |
| health care plan
regarding the
patient's physician or other | 23 |
| health care provider shall not be based solely on
the | 24 |
| physician's or other
health care provider's participation | 25 |
| in this procedure.
| 26 |
| (8) For the purposes of this Section, an external |
|
|
|
09600HB3923sam001 |
- 72 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| independent reviewer
shall:
| 2 |
| (A) be a clinical peer;
| 3 |
| (B) have no direct financial interest in | 4 |
| connection with the case; and
| 5 |
| (C) have not been informed of the specific identity | 6 |
| of the enrollee.
| 7 |
| (g) Nothing in this Section shall be construed to require a | 8 |
| health care
plan to pay for a health care service not covered | 9 |
| under the enrollee's
certificate of coverage or policy.
| 10 |
| (Source: P.A. 91-617, eff. 1-1-00.)
| 11 |
| (215 ILCS 134/90)
| 12 |
| Sec. 90. Office of Consumer Health Insurance.
| 13 |
| (a) The Director of Insurance shall establish the Office of | 14 |
| Consumer
Health Insurance within the Department of Insurance to | 15 |
| provide assistance and
information to all health care consumers | 16 |
| within the State. Within the
appropriation allocated, the | 17 |
| Office shall provide information and assistance to
all health | 18 |
| care consumers by:
| 19 |
| (1) assisting consumers in understanding health | 20 |
| insurance marketing
materials and
the coverage provisions | 21 |
| of individual plans;
| 22 |
| (2) educating enrollees about their rights within | 23 |
| individual plans;
| 24 |
| (3) assisting enrollees with the process of filing | 25 |
| formal
grievances and appeals;
|
|
|
|
09600HB3923sam001 |
- 73 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (4) establishing and operating a toll-free "800" | 2 |
| telephone number
line to handle
consumer inquiries;
| 3 |
| (5) making related information available in languages | 4 |
| other than English
that
are spoken as a primary language by | 5 |
| a significant portion of the State's
population, as | 6 |
| determined by the Department;
| 7 |
| (6) analyzing, commenting on, monitoring, and making | 8 |
| publicly available
reports
on the development and | 9 |
| implementation of federal, State, and local laws,
| 10 |
| regulations, and other governmental policies and actions | 11 |
| that pertain to the
adequacy of health care plans, | 12 |
| facilities, and services in the State;
| 13 |
| (7) filing an annual report with the Governor, the | 14 |
| Director, and the
General
Assembly, which shall contain | 15 |
| recommendations for improvement of the regulation
of | 16 |
| health insurance plans, including recommendations on | 17 |
| improving health care
consumer assistance and patterns, | 18 |
| abuses, and progress that it has identified
from its | 19 |
| interaction with health care consumers; and
| 20 |
| (8) performing all duties assigned to the Office by the | 21 |
| Director.
| 22 |
| (b) The report required under subsection (a)(7) shall be | 23 |
| filed by January
31, 2001 and each January 31 thereafter.
| 24 |
| (c) Nothing in this Section shall be interpreted to | 25 |
| authorize access to or
disclosure of individual patient or | 26 |
| health care professional or provider
records.
|
|
|
|
09600HB3923sam001 |
- 74 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (d) The Office of Consumer Health Insurance shall do all of the | 2 |
| following: | 3 |
| (1) Develop and implement a health coverage public | 4 |
| awareness and education program by: | 5 |
| (A) increasing public awareness of health coverage | 6 |
| options available in this State; | 7 |
| (B) educating the public on the value of health | 8 |
| insurance coverage; and | 9 |
| (C) providing information on health insurance
| 10 |
| coverage options, including explanations of | 11 |
| deductibles and copayments and the differences between | 12 |
| health maintenance organizations, preferred provider | 13 |
| organizations, point of service plans, health savings | 14 |
| accounts and compatible high deductible health benefit | 15 |
| plans, and other forms of health insurance coverage. | 16 |
| (2) Provide information, including financial ratings
| 17 |
| about specific health insurance coverage insurers, but the
| 18 |
| Office may not favor or endorse one particular insurer over
| 19 |
| another. | 20 |
| (3) Develop and release public service announcements
| 21 |
| to educate consumers and employers about the types of
| 22 |
| policies and availability of health coverage in this State, | 23 |
| including providing of information as to availability and | 24 |
| eligibility for health plans provided by the State. | 25 |
| (4) Provide other appropriate education to the public | 26 |
| regarding the value of health insurance coverage. |
|
|
|
09600HB3923sam001 |
- 75 - |
LRB096 08394 RPM 26320 a |
|
| 1 |
| (5) Provide information and guidance regarding a | 2 |
| consumers rights to an internal and external review process | 3 |
| as provided in the Health Carrier External Review Act. | 4 |
| (Source: P.A. 91-617, eff. 1-1-00.)
| 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 97. Severability. The provisions of this Act are | 13 |
| severable under Section 1.31 of the Statute on Statutes.".
|
|