Full Text of HB6417 96th General Assembly
HB6417ham001 96TH GENERAL ASSEMBLY
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Rep. Mary E. Flowers
Filed: 3/22/2010
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| AMENDMENT TO HOUSE BILL 6417
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| AMENDMENT NO. ______. Amend House Bill 6417 by replacing | 3 |
| everything after the enacting clause with the following:
| 4 |
| "Section 5. The State Employees Group Insurance Act of 1971 | 5 |
| is amended by
changing Section 6.11 as follows:
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| (5 ILCS 375/6.11)
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| Sec. 6.11. Required health benefits; Illinois Insurance | 8 |
| Code
requirements. The program of health
benefits shall provide | 9 |
| the post-mastectomy care benefits required to be covered
by a | 10 |
| policy of accident and health insurance under Section 356t of | 11 |
| the Illinois
Insurance Code. The program of health benefits | 12 |
| shall provide the coverage
required under Sections 356g, | 13 |
| 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 14 |
| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and | 15 |
| 356z.13, and 356z.14, 356z.15 and 356z.14 , and 356z.17, 356z.15 | 16 |
| 356z.19, 356z.20, and 356z.21 of the
Illinois Insurance Code.
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| The program of health benefits must comply with Section 155.37 | 2 |
| of the
Illinois Insurance Code.
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| Rulemaking authority to implement Public Act 95-1045 this | 4 |
| amendatory Act of the 95th General Assembly , if any, is | 5 |
| conditioned on the rules being adopted in accordance with all | 6 |
| provisions of the Illinois Administrative Procedure Act and all | 7 |
| rules and procedures of the Joint Committee on Administrative | 8 |
| Rules; any purported rule not so adopted, for whatever reason, | 9 |
| is unauthorized. | 10 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 11 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | 12 |
| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, | 13 |
| eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | 14 |
| 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; | 15 |
| revised 10-22-09.)
| 16 |
| Section 10. The Counties Code is amended by changing | 17 |
| Section 5-1069.3 as
follows:
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| (55 ILCS 5/5-1069.3)
| 19 |
| Sec. 5-1069.3. Required health benefits. If a county, | 20 |
| including a home
rule
county, is a self-insurer for purposes of | 21 |
| providing health insurance coverage
for its employees, the | 22 |
| coverage shall include coverage for the post-mastectomy
care | 23 |
| benefits required to be covered by a policy of accident and | 24 |
| health
insurance under Section 356t and the coverage required |
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| under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 2 |
| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and | 3 |
| 356z.13, and 356z.14, and 356z.15, 356z.14 356z.19, 356z.20, | 4 |
| and 356z.21 of
the Illinois Insurance Code. The requirement | 5 |
| that health benefits be covered
as provided in this Section is | 6 |
| an
exclusive power and function of the State and is a denial | 7 |
| and limitation under
Article VII, Section 6, subsection (h) of | 8 |
| the Illinois Constitution. A home
rule county to which this | 9 |
| Section applies must comply with every provision of
this | 10 |
| Section.
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| Rulemaking authority to implement Public Act 95-1045 this | 12 |
| amendatory Act of the 95th General Assembly , if any, is | 13 |
| conditioned on the rules being adopted in accordance with all | 14 |
| provisions of the Illinois Administrative Procedure Act and all | 15 |
| rules and procedures of the Joint Committee on Administrative | 16 |
| Rules; any purported rule not so adopted, for whatever reason, | 17 |
| is unauthorized. | 18 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 19 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | 20 |
| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, | 21 |
| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | 22 |
| 96-328, eff. 8-11-09; revised 10-22-09.)
| 23 |
| Section 15. The Illinois Municipal Code is amended by | 24 |
| changing Section
10-4-2.3 as follows:
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| (65 ILCS 5/10-4-2.3)
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| Sec. 10-4-2.3. Required health benefits. If a | 3 |
| municipality, including a
home rule municipality, is a | 4 |
| self-insurer for purposes of providing health
insurance | 5 |
| coverage for its employees, the coverage shall include coverage | 6 |
| for
the post-mastectomy care benefits required to be covered by | 7 |
| a policy of
accident and health insurance under Section 356t | 8 |
| and the coverage required
under Sections 356g, 356g.5, | 9 |
| 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 10 |
| 356z.11, 356z.12, and 356z.13, and 356z.14, and 356z.15, | 11 |
| 356z.14 356z.19, 356z.20, and 356z.21 of the Illinois
Insurance
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| Code. The requirement that health
benefits be covered as | 13 |
| provided in this is an exclusive power and function of
the | 14 |
| State and is a denial and limitation under Article VII, Section | 15 |
| 6,
subsection (h) of the Illinois Constitution. A home rule | 16 |
| municipality to which
this Section applies must comply with | 17 |
| every provision of this Section.
| 18 |
| Rulemaking authority to implement Public Act 95-1045 this | 19 |
| amendatory Act of the 95th General Assembly , if any, is | 20 |
| conditioned on the rules being adopted in accordance with all | 21 |
| provisions of the Illinois Administrative Procedure Act and all | 22 |
| rules and procedures of the Joint Committee on Administrative | 23 |
| Rules; any purported rule not so adopted, for whatever reason, | 24 |
| is unauthorized. | 25 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 26 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, | 2 |
| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | 3 |
| 96-328, eff. 8-11-09; revised 10-23-09.)
| 4 |
| Section 20. The School Code is amended by changing Section | 5 |
| 10-22.3f as
follows:
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| (105 ILCS 5/10-22.3f)
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| Sec. 10-22.3f. Required health benefits. Insurance | 8 |
| protection and
benefits
for employees shall provide the | 9 |
| post-mastectomy care benefits required to be
covered by a | 10 |
| policy of accident and health insurance under Section 356t and | 11 |
| the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 12 |
| 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 13 |
| 356z.13, and 356z.14, and 356z.15, 356z.14 356z.19, and 356z.20 | 14 |
| of
the
Illinois Insurance Code.
| 15 |
| Rulemaking authority to implement Public Act 95-1045 this | 16 |
| amendatory Act of the 95th General Assembly , if any, is | 17 |
| conditioned on the rules being adopted in accordance with all | 18 |
| provisions of the Illinois Administrative Procedure Act and all | 19 |
| rules and procedures of the Joint Committee on Administrative | 20 |
| Rules; any purported rule not so adopted, for whatever reason, | 21 |
| is unauthorized. | 22 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 23 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | 24 |
| 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
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| 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; revised | 2 |
| 10-23-09.)
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| Section 25. The Emergency Medical Treatment Act is amended | 4 |
| by changing Section 1 as follows:
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| (210 ILCS 70/1) (from Ch. 111 1/2, par. 6151)
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| Sec. 1.
No hospital, physician, dentist or other provider | 7 |
| of professional
health care licensed under the laws of this | 8 |
| State may refuse to provide
needed emergency treatment to any | 9 |
| person whose life would be threatened
in the absence of such | 10 |
| treatment, because of that person's inability to
pay therefor, | 11 |
| nor because of the source of any payment promised therefor. | 12 |
| Every hospital licensed under the Hospital Licensing Act shall | 13 |
| comply with the Hospital Emergency Service Act.
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| (Source: P.A. 83-723.)
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| Section 30. The Hospital Emergency Service Act is amended | 16 |
| by changing Section 1 as follows:
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| (210 ILCS 80/1) (from Ch. 111 1/2, par. 86)
| 18 |
| Sec. 1.
Every hospital required to be licensed by the | 19 |
| Department of Public
Health pursuant to the Hospital Licensing | 20 |
| Act which provides general medical
and surgical
hospital | 21 |
| services shall provide a hospital emergency service in | 22 |
| accordance
with rules and regulations adopted by the Department |
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| of Public Health which shall be consistent with the federal | 2 |
| Emergency Medical Treatment and Active Labor Act (42 U.S.C. | 3 |
| 1395dd) and
shall furnish such hospital emergency services to | 4 |
| any applicant who applies
for the same in case of injury or | 5 |
| acute medical condition where the same is
liable to cause death | 6 |
| or severe injury or serious illness.
For purposes of this Act, | 7 |
| "applicant" includes any person who is brought
to a hospital by | 8 |
| ambulance or specialized emergency medical services
vehicle as | 9 |
| defined in the Emergency Medical Services (EMS) Systems Act.
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| (Source: P.A. 86-1461.)
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| Section 35. The Illinois Insurance Code is amended by | 12 |
| adding Sections
356z.19, 356z.20, and
356z.21
as
follows:
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| (215 ILCS 5/356z.19 new)
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| Sec. 356z.19. Intravenous feeding. A group or individual | 15 |
| policy of
accident and health insurance or managed care plan | 16 |
| amended, delivered, issued,
or renewed after the effective date | 17 |
| of this amendatory Act of the 96th General
Assembly must | 18 |
| provide coverage for intravenous feeding. The benefits under
| 19 |
| this Section shall be at least as favorable as for other | 20 |
| coverages under the
policy and may be subject to the same | 21 |
| dollar amount limits, deductibles, and
co-insurance | 22 |
| requirements applicable generally to other coverages under the
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| policy. |
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| (215 ILCS 5/356z.20 new)
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| Sec. 356z.20. Prescription nutritional supplements. A | 3 |
| group or individual
policy of
accident and health insurance or | 4 |
| managed care plan amended, delivered, issued,
or renewed
after | 5 |
| the effective date of this amendatory Act of the 96th General | 6 |
| Assembly
that provides
coverage for prescription drugs must | 7 |
| provide coverage for reimbursement for
medically
appropriate | 8 |
| prescription nutritional supplements when ordered by a | 9 |
| physician
licensed to
practice medicine in all its branches and | 10 |
| the insured suffers from a condition
that prevents
him or her | 11 |
| from taking sufficient oral nourishment to sustain life. | 12 |
| (215 ILCS 5/356z.21 new) | 13 |
| Sec. 356z.21. Hospital patient assessments. A group or | 14 |
| individual policy of accident and health insurance or managed | 15 |
| care plan amended, delivered, issued, or renewed after the | 16 |
| effective date of this amendatory Act of the 96th General | 17 |
| Assembly that provides coverage for hospital care shall include | 18 |
| in that coverage all services ordered by a physician and | 19 |
| provided in the hospital that are considered medically | 20 |
| necessary for the evaluation, assessment, and diagnosis of the | 21 |
| illness or condition that resulted in the hospital stay of the | 22 |
| enrollee or recipient. Such services are subject to reasonable | 23 |
| review and utilization standards required by the policy or plan | 24 |
| for all hospital services, as defined by the Department of | 25 |
| Insurance or its successor agency.
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| Section 40. The Health Maintenance Organization Act is | 2 |
| amended by changing
Section 5-3 as follows:
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| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 4 |
| (Text of Section before amendment by P.A. 96-833 ) | 5 |
| Sec. 5-3. Insurance Code provisions.
| 6 |
| (a) Health Maintenance Organizations
shall be subject to | 7 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 8 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 9 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | 10 |
| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | 11 |
| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14 , | 12 |
| 356z.17 356z.15 , 356z.19, 356z.20, 364.01, 367.2, 367.2-5, | 13 |
| 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, | 14 |
| 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of | 15 |
| subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
| 16 |
| XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | 17 |
| Insurance Code.
| 18 |
| (b) For purposes of the Illinois Insurance Code, except for | 19 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 20 |
| Maintenance Organizations in
the following categories are | 21 |
| deemed to be "domestic companies":
| 22 |
| (1) a corporation authorized under the
Dental Service | 23 |
| Plan Act or the Voluntary Health Services Plans Act;
| 24 |
| (2) a corporation organized under the laws of this |
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| State; or
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| (3) a corporation organized under the laws of another | 3 |
| state, 30% or more
of the enrollees of which are residents | 4 |
| of this State, except a
corporation subject to | 5 |
| substantially the same requirements in its state of
| 6 |
| organization as is a "domestic company" under Article VIII | 7 |
| 1/2 of the
Illinois Insurance Code.
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| (c) In considering the merger, consolidation, or other | 9 |
| acquisition of
control of a Health Maintenance Organization | 10 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 11 |
| (1) the Director shall give primary consideration to | 12 |
| the continuation of
benefits to enrollees and the financial | 13 |
| conditions of the acquired Health
Maintenance Organization | 14 |
| after the merger, consolidation, or other
acquisition of | 15 |
| control takes effect;
| 16 |
| (2)(i) the criteria specified in subsection (1)(b) of | 17 |
| Section 131.8 of
the Illinois Insurance Code shall not | 18 |
| apply and (ii) the Director, in making
his determination | 19 |
| with respect to the merger, consolidation, or other
| 20 |
| acquisition of control, need not take into account the | 21 |
| effect on
competition of the merger, consolidation, or | 22 |
| other acquisition of control;
| 23 |
| (3) the Director shall have the power to require the | 24 |
| following
information:
| 25 |
| (A) certification by an independent actuary of the | 26 |
| adequacy
of the reserves of the Health Maintenance |
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| Organization sought to be acquired;
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| (B) pro forma financial statements reflecting the | 3 |
| combined balance
sheets of the acquiring company and | 4 |
| the Health Maintenance Organization sought
to be | 5 |
| acquired as of the end of the preceding year and as of | 6 |
| a date 90 days
prior to the acquisition, as well as pro | 7 |
| forma financial statements
reflecting projected | 8 |
| combined operation for a period of 2 years;
| 9 |
| (C) a pro forma business plan detailing an | 10 |
| acquiring party's plans with
respect to the operation | 11 |
| of the Health Maintenance Organization sought to
be | 12 |
| acquired for a period of not less than 3 years; and
| 13 |
| (D) such other information as the Director shall | 14 |
| require.
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| (d) The provisions of Article VIII 1/2 of the Illinois | 16 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 17 |
| any health maintenance
organization of greater than 10% of its
| 18 |
| enrollee population (including without limitation the health | 19 |
| maintenance
organization's right, title, and interest in and to | 20 |
| its health care
certificates).
| 21 |
| (e) In considering any management contract or service | 22 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 23 |
| Code, the Director (i) shall, in
addition to the criteria | 24 |
| specified in Section 141.2 of the Illinois
Insurance Code, take | 25 |
| into account the effect of the management contract or
service | 26 |
| agreement on the continuation of benefits to enrollees and the
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| financial condition of the health maintenance organization to | 2 |
| be managed or
serviced, and (ii) need not take into account the | 3 |
| effect of the management
contract or service agreement on | 4 |
| competition.
| 5 |
| (f) Except for small employer groups as defined in the | 6 |
| Small Employer
Rating, Renewability and Portability Health | 7 |
| Insurance Act and except for
medicare supplement policies as | 8 |
| defined in Section 363 of the Illinois
Insurance Code, a Health | 9 |
| Maintenance Organization may by contract agree with a
group or | 10 |
| other enrollment unit to effect refunds or charge additional | 11 |
| premiums
under the following terms and conditions:
| 12 |
| (i) the amount of, and other terms and conditions with | 13 |
| respect to, the
refund or additional premium are set forth | 14 |
| in the group or enrollment unit
contract agreed in advance | 15 |
| of the period for which a refund is to be paid or
| 16 |
| additional premium is to be charged (which period shall not | 17 |
| be less than one
year); and
| 18 |
| (ii) the amount of the refund or additional premium | 19 |
| shall not exceed 20%
of the Health Maintenance | 20 |
| Organization's profitable or unprofitable experience
with | 21 |
| respect to the group or other enrollment unit for the | 22 |
| period (and, for
purposes of a refund or additional | 23 |
| premium, the profitable or unprofitable
experience shall | 24 |
| be calculated taking into account a pro rata share of the
| 25 |
| Health Maintenance Organization's administrative and | 26 |
| marketing expenses, but
shall not include any refund to be |
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| made or additional premium to be paid
pursuant to this | 2 |
| subsection (f)). The Health Maintenance Organization and | 3 |
| the
group or enrollment unit may agree that the profitable | 4 |
| or unprofitable
experience may be calculated taking into | 5 |
| account the refund period and the
immediately preceding 2 | 6 |
| plan years.
| 7 |
| The Health Maintenance Organization shall include a | 8 |
| statement in the
evidence of coverage issued to each enrollee | 9 |
| describing the possibility of a
refund or additional premium, | 10 |
| and upon request of any group or enrollment unit,
provide to | 11 |
| the group or enrollment unit a description of the method used | 12 |
| to
calculate (1) the Health Maintenance Organization's | 13 |
| profitable experience with
respect to the group or enrollment | 14 |
| unit and the resulting refund to the group
or enrollment unit | 15 |
| or (2) the Health Maintenance Organization's unprofitable
| 16 |
| experience with respect to the group or enrollment unit and the | 17 |
| resulting
additional premium to be paid by the group or | 18 |
| enrollment unit.
| 19 |
| In no event shall the Illinois Health Maintenance | 20 |
| Organization
Guaranty Association be liable to pay any | 21 |
| contractual obligation of an
insolvent organization to pay any | 22 |
| refund authorized under this Section.
| 23 |
| (g) Rulemaking authority to implement Public Act 95-1045 | 24 |
| this amendatory Act of the 95th General Assembly , if any, is | 25 |
| conditioned on the rules being adopted in accordance with all | 26 |
| provisions of the Illinois Administrative Procedure Act and all |
|
|
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| rules and procedures of the Joint Committee on Administrative | 2 |
| Rules; any purported rule not so adopted, for whatever reason, | 3 |
| is unauthorized. | 4 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | 5 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | 6 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | 7 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised | 8 |
| 10-23-09.) | 9 |
| (Text of Section after amendment by P.A. 96-833 ) | 10 |
| Sec. 5-3. Insurance Code provisions.
| 11 |
| (a) Health Maintenance Organizations
shall be subject to | 12 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 13 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 14 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | 15 |
| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | 16 |
| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | 17 |
| 356z.18, 356z.19, 356z.20, 364.01, 367.2, 367.2-5, 367i, 368a, | 18 |
| 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, | 19 |
| 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | 20 |
| (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | 21 |
| XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| 22 |
| (b) For purposes of the Illinois Insurance Code, except for | 23 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 24 |
| Maintenance Organizations in
the following categories are | 25 |
| deemed to be "domestic companies":
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LRB096 21045 AMC 39407 a |
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| (1) a corporation authorized under the
Dental Service | 2 |
| Plan Act or the Voluntary Health Services Plans Act;
| 3 |
| (2) a corporation organized under the laws of this | 4 |
| State; or
| 5 |
| (3) a corporation organized under the laws of another | 6 |
| state, 30% or more
of the enrollees of which are residents | 7 |
| of this State, except a
corporation subject to | 8 |
| substantially the same requirements in its state of
| 9 |
| organization as is a "domestic company" under Article VIII | 10 |
| 1/2 of the
Illinois Insurance Code.
| 11 |
| (c) In considering the merger, consolidation, or other | 12 |
| acquisition of
control of a Health Maintenance Organization | 13 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 14 |
| (1) the Director shall give primary consideration to | 15 |
| the continuation of
benefits to enrollees and the financial | 16 |
| conditions of the acquired Health
Maintenance Organization | 17 |
| after the merger, consolidation, or other
acquisition of | 18 |
| control takes effect;
| 19 |
| (2)(i) the criteria specified in subsection (1)(b) of | 20 |
| Section 131.8 of
the Illinois Insurance Code shall not | 21 |
| apply and (ii) the Director, in making
his determination | 22 |
| with respect to the merger, consolidation, or other
| 23 |
| acquisition of control, need not take into account the | 24 |
| effect on
competition of the merger, consolidation, or | 25 |
| other acquisition of control;
| 26 |
| (3) the Director shall have the power to require the |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| following
information:
| 2 |
| (A) certification by an independent actuary of the | 3 |
| adequacy
of the reserves of the Health Maintenance | 4 |
| Organization sought to be acquired;
| 5 |
| (B) pro forma financial statements reflecting the | 6 |
| combined balance
sheets of the acquiring company and | 7 |
| the Health Maintenance Organization sought
to be | 8 |
| acquired as of the end of the preceding year and as of | 9 |
| a date 90 days
prior to the acquisition, as well as pro | 10 |
| forma financial statements
reflecting projected | 11 |
| combined operation for a period of 2 years;
| 12 |
| (C) a pro forma business plan detailing an | 13 |
| acquiring party's plans with
respect to the operation | 14 |
| of the Health Maintenance Organization sought to
be | 15 |
| acquired for a period of not less than 3 years; and
| 16 |
| (D) such other information as the Director shall | 17 |
| require.
| 18 |
| (d) The provisions of Article VIII 1/2 of the Illinois | 19 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 20 |
| any health maintenance
organization of greater than 10% of its
| 21 |
| enrollee population (including without limitation the health | 22 |
| maintenance
organization's right, title, and interest in and to | 23 |
| its health care
certificates).
| 24 |
| (e) In considering any management contract or service | 25 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 26 |
| Code, the Director (i) shall, in
addition to the criteria |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| specified in Section 141.2 of the Illinois
Insurance Code, take | 2 |
| into account the effect of the management contract or
service | 3 |
| agreement on the continuation of benefits to enrollees and the
| 4 |
| financial condition of the health maintenance organization to | 5 |
| be managed or
serviced, and (ii) need not take into account the | 6 |
| effect of the management
contract or service agreement on | 7 |
| competition.
| 8 |
| (f) Except for small employer groups as defined in the | 9 |
| Small Employer
Rating, Renewability and Portability Health | 10 |
| Insurance Act and except for
medicare supplement policies as | 11 |
| defined in Section 363 of the Illinois
Insurance Code, a Health | 12 |
| Maintenance Organization may by contract agree with a
group or | 13 |
| other enrollment unit to effect refunds or charge additional | 14 |
| premiums
under the following terms and conditions:
| 15 |
| (i) the amount of, and other terms and conditions with | 16 |
| respect to, the
refund or additional premium are set forth | 17 |
| in the group or enrollment unit
contract agreed in advance | 18 |
| of the period for which a refund is to be paid or
| 19 |
| additional premium is to be charged (which period shall not | 20 |
| be less than one
year); and
| 21 |
| (ii) the amount of the refund or additional premium | 22 |
| shall not exceed 20%
of the Health Maintenance | 23 |
| Organization's profitable or unprofitable experience
with | 24 |
| respect to the group or other enrollment unit for the | 25 |
| period (and, for
purposes of a refund or additional | 26 |
| premium, the profitable or unprofitable
experience shall |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| be calculated taking into account a pro rata share of the
| 2 |
| Health Maintenance Organization's administrative and | 3 |
| marketing expenses, but
shall not include any refund to be | 4 |
| made or additional premium to be paid
pursuant to this | 5 |
| subsection (f)). The Health Maintenance Organization and | 6 |
| the
group or enrollment unit may agree that the profitable | 7 |
| or unprofitable
experience may be calculated taking into | 8 |
| account the refund period and the
immediately preceding 2 | 9 |
| plan years.
| 10 |
| The Health Maintenance Organization shall include a | 11 |
| statement in the
evidence of coverage issued to each enrollee | 12 |
| describing the possibility of a
refund or additional premium, | 13 |
| and upon request of any group or enrollment unit,
provide to | 14 |
| the group or enrollment unit a description of the method used | 15 |
| to
calculate (1) the Health Maintenance Organization's | 16 |
| profitable experience with
respect to the group or enrollment | 17 |
| unit and the resulting refund to the group
or enrollment unit | 18 |
| or (2) the Health Maintenance Organization's unprofitable
| 19 |
| experience with respect to the group or enrollment unit and the | 20 |
| resulting
additional premium to be paid by the group or | 21 |
| enrollment unit.
| 22 |
| In no event shall the Illinois Health Maintenance | 23 |
| Organization
Guaranty Association be liable to pay any | 24 |
| contractual obligation of an
insolvent organization to pay any | 25 |
| refund authorized under this Section.
| 26 |
| (g) Rulemaking authority to implement Public Act 95-1045, |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| if any, is conditioned on the rules being adopted in accordance | 2 |
| with all provisions of the Illinois Administrative Procedure | 3 |
| Act and all rules and procedures of the Joint Committee on | 4 |
| Administrative Rules; any purported rule not so adopted, for | 5 |
| whatever reason, is unauthorized. | 6 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | 7 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | 8 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | 9 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | 10 |
| 6-1-10.)
| 11 |
| Section 45. The Voluntary Health Services Plans Act is | 12 |
| amended by changing
Section 10 as follows:
| 13 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
| 14 |
| (Text of Section before amendment by P.A. 96-833 ) | 15 |
| Sec. 10. Application of Insurance Code provisions. Health | 16 |
| services
plan corporations and all persons interested therein | 17 |
| or dealing therewith
shall be subject to the provisions of | 18 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | 19 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | 20 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | 21 |
| 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | 22 |
| 356z.14, 356z.15
356z.14 , 356z.19, 356z.20, 364.01, 367.2, | 23 |
| 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and | 24 |
| paragraphs (7) and (15) of Section 367 of the Illinois
|
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| Insurance Code.
| 2 |
| Rulemaking authority to implement Public Act 95-1045
this | 3 |
| amendatory Act of the 95th General Assembly , if any, is | 4 |
| conditioned on the rules being adopted in accordance with all | 5 |
| provisions of the Illinois Administrative Procedure Act and all | 6 |
| rules and procedures of the Joint Committee on Administrative | 7 |
| Rules; any purported rule not so adopted, for whatever reason, | 8 |
| is unauthorized. | 9 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | 10 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | 11 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | 12 |
| eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | 13 |
| 96-328, eff. 8-11-09; revised 9-25-09.) | 14 |
| (Text of Section after amendment by P.A. 96-833 ) | 15 |
| Sec. 10. Application of Insurance Code provisions. Health | 16 |
| services
plan corporations and all persons interested therein | 17 |
| or dealing therewith
shall be subject to the provisions of | 18 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | 19 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | 20 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | 21 |
| 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | 22 |
| 356z.14, 356z.15, 356z.18, 356z.19, 356z.20, 364.01, 367.2, | 23 |
| 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and | 24 |
| paragraphs (7) and (15) of Section 367 of the Illinois
| 25 |
| Insurance Code.
|
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| Rulemaking authority to implement Public Act 95-1045, if | 2 |
| any, is conditioned on the rules being adopted in accordance | 3 |
| with all provisions of the Illinois Administrative Procedure | 4 |
| Act and all rules and procedures of the Joint Committee on | 5 |
| Administrative Rules; any purported rule not so adopted, for | 6 |
| whatever reason, is unauthorized. | 7 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | 8 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | 9 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | 10 |
| eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | 11 |
| 96-328, eff. 8-11-09; 96-833, eff. 6-1-10.)
| 12 |
| Section 50. The Health Carrier External Review Act is | 13 |
| amended by changing Section 35 and by adding Sections 25.1, | 14 |
| 25.2, 25.3, 25.4, 25.5, and 25.6 as follows: | 15 |
| (215 ILCS 180/25.1 new) | 16 |
| Sec. 25.1. Standard
information for application forms. | 17 |
| (a) The Director shall establish standard
information and | 18 |
| health history questions that shall be used by all
health care | 19 |
| service plans for their individual health care coverage
| 20 |
| application forms for individual health plan contracts and
| 21 |
| individual health insurance policies. The health care service | 22 |
| plan
and health insurance application forms for individual | 23 |
| health plan
contracts and health insurance policies may only | 24 |
| contain questions
approved by the Director. |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| (b) The standard information and health history questions
| 2 |
| developed by the Director shall contain clear and unambiguous
| 3 |
| information and questions designed to ascertain the health | 4 |
| history of
the applicant and shall be based on the medical | 5 |
| information that is
reasonable and necessary for medical | 6 |
| underwriting purposes. | 7 |
| (c) The application form shall include a prominently | 8 |
| displayed
notice that shall read:
"Illinois law prohibits an | 9 |
| HIV test from being required or used
by health care service | 10 |
| plans as a condition of obtaining coverage.". | 11 |
| (d) No later than 6 months after the adoption of the | 12 |
| regulation
under subsection (a) of this Section, all individual | 13 |
| health care service plan
application forms shall utilize only | 14 |
| the pool of approved questions
and the standardized information | 15 |
| established pursuant to subsection (a). | 16 |
| (e) On and after January 1, 2011, all individual health | 17 |
| care
service plan applications shall be reviewed and approved | 18 |
| by the
Director before they may be used by a health care | 19 |
| service plan. | 20 |
| (215 ILCS 180/25.2 new) | 21 |
| Sec. 25.2. Medical
underwriting. | 22 |
| (a) "Medical underwriting" means the completion of a | 23 |
| reasonable
investigation of the applicant's health history | 24 |
| information, which
includes, but is not limited to, the | 25 |
| following: |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| (1) Ensuring that the information submitted on the | 2 |
| application
form and the material submitted with the | 3 |
| application form are
complete and accurate. | 4 |
| (2) Resolving all reasonable questions arising from | 5 |
| the
application form or any materials submitted with the | 6 |
| application form or
any information obtained by the health | 7 |
| care service plan as part of
its verification of the | 8 |
| accuracy and completeness of the application
form. | 9 |
| (b) A health care service plan shall complete medical
| 10 |
| underwriting prior to issuing an enrollee or subscriber health | 11 |
| care
service plan contract. | 12 |
| (c) A health care service plan shall adopt and implement | 13 |
| written
medical underwriting policies and procedures to ensure | 14 |
| that the
health care service plan does all of the following | 15 |
| with respect to an
application for health care coverage: | 16 |
| (1) Reviews all of the following:
| 17 |
| (A) Information on the application and any | 18 |
| materials submitted
with the application form for | 19 |
| accuracy and completeness.
| 20 |
| (B) Claims information about the applicant that is | 21 |
| within the
health care service plan's own claims | 22 |
| information.
| 23 |
| (C) At least one commercially available | 24 |
| prescription drug database
for information about the | 25 |
| applicant.
| 26 |
| (2) Identifies and makes inquiries, including |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| contacting the
applicant about any questions raised by | 2 |
| omissions, ambiguities, or
inconsistencies based upon the | 3 |
| information collected pursuant to
item (1) of this | 4 |
| subsection (c).
| 5 |
| (d) The plan shall document all information collected | 6 |
| during the
underwriting review process.
| 7 |
| (e) On or before January 1, 2011, a health care service | 8 |
| plan shall
file its medical underwriting policies and | 9 |
| procedures with the
Department.
| 10 |
| (215 ILCS 180/25.3 new) | 11 |
| Sec. 25.3. Copies of application and contract; notice. | 12 |
| (a) Within 10 business days after issuing a health care
| 13 |
| service plan contract, the health care service plan shall send | 14 |
| a copy
of the completed written application to the applicant | 15 |
| with a copy of
the health care service plan contract issued by | 16 |
| the health care
service plan, along with a notice that states | 17 |
| all of the following:
| 18 |
| (1) The applicant should review the completed | 19 |
| application
carefully and notify the health care service | 20 |
| plan within 30 days of
any inaccuracy in the application.
| 21 |
| (2) Any intentional material misrepresentation or | 22 |
| intentional
material omission in the information submitted | 23 |
| in the application may
result in the cancellation or | 24 |
| rescission of the plan contract.
| 25 |
| (3) The applicant should retain a copy of the completed |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| written
application for the applicant's records.
| 2 |
| (b) If new information is provided by the applicant within | 3 |
| the
30-day period permitted by subsection (a), then the | 4 |
| provisions concerning medical underwriting shall apply to the | 5 |
| new information.
| 6 |
| (215 ILCS 180/25.4 new) | 7 |
| Sec. 25.4. Rescission; cancellation. | 8 |
| (a) Once a plan has issued an individual health care
| 9 |
| service plan contract, the health care service plan shall not | 10 |
| rescind
or cancel the health care service plan contract unless | 11 |
| all of the
following apply:
| 12 |
| (1) There was a material misrepresentation or material | 13 |
| omission in
the information submitted by the applicant in | 14 |
| the written
application to the health care service plan | 15 |
| prior to the issuance of
the health care service plan | 16 |
| contract that would have prevented the
contract from being | 17 |
| entered into.
| 18 |
| (2) The health care service plan completed medical | 19 |
| underwriting before issuing the plan contract.
| 20 |
| (3) The health care service plan demonstrates that the | 21 |
| applicant
intentionally misrepresented or intentionally | 22 |
| omitted material
information on the application prior to | 23 |
| the issuance of the plan
contract with the purpose of | 24 |
| misrepresenting his or her health
history in order to | 25 |
| obtain health care coverage.
|
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| (4) The application form was approved by the | 2 |
| Department.
| 3 |
| (5) The health care service plan sent a copy of the | 4 |
| completed
written application to the applicant with a copy | 5 |
| of the health care
service plan contract issued by the | 6 |
| health care service plan.
| 7 |
| (b) Notwithstanding subsection (a) of this Section, an | 8 |
| enrollment or subscription
may be canceled or not renewed for | 9 |
| failure to pay the fees for
that coverage.
| 10 |
| (215 ILCS 180/25.5 new) | 11 |
| Sec. 25.5. Postcontract investigation. | 12 |
| (a) If a health care service plan obtains information
after | 13 |
| issuing an individual health care service plan contract that
| 14 |
| the subscriber or enrollee may have intentionally omitted or
| 15 |
| intentionally misrepresented material information during the
| 16 |
| application for coverage process, then the health care service | 17 |
| plan may
investigate the potential omissions or | 18 |
| misrepresentations in order to
determine whether the | 19 |
| subscriber's or enrollee's health care service
plan contract | 20 |
| may be rescinded or canceled.
| 21 |
| (b) The following provisions shall apply to a postcontract | 22 |
| issuance investigation: | 23 |
| (1) Upon initiating a postcontract issuance | 24 |
| investigation for
potential rescission or cancellation of | 25 |
| health care coverage, the
plan shall provide a written |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| notice to the enrollee or subscriber by
regular and | 2 |
| certified mail that it has initiated an investigation of
| 3 |
| intentional material misrepresentation or intentional | 4 |
| material
omission on the part of the enrollee or subscriber | 5 |
| and that the
investigation could lead to the rescission or | 6 |
| cancellation of the
enrollee's or subscriber's health care | 7 |
| service plan contract. The
notice shall be provided by the | 8 |
| health care service plan within 5
days of the initiation of | 9 |
| the investigation.
| 10 |
| (2) The written notice required under item (1) of this | 11 |
| subsection (b) shall include
full disclosure of the | 12 |
| allegedly intentional material omission or
| 13 |
| misrepresentation and a clear and concise explanation of | 14 |
| why the
information has resulted in the health care service | 15 |
| plan's initiation
of an investigation to determine whether | 16 |
| rescission or cancellation
is warranted. The notice shall | 17 |
| invite the enrollee or subscriber to
provide any evidence | 18 |
| or information within 45 business days to negate
the plan's | 19 |
| reasons for initiating the postissuance investigation.
| 20 |
| (3) The plan shall complete its investigation no later | 21 |
| than 90
days after the date that the notice is sent to the | 22 |
| enrollee or subscriber
pursuant to item (1) of this | 23 |
| subsection (b).
| 24 |
| (4) Upon completion of its postissuance investigation, | 25 |
| the plan
shall provide written notice by regular and | 26 |
| certified mail to the
subscriber or enrollee that it has |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| concluded its investigation and
has made one of the | 2 |
| following determinations:
| 3 |
| (A) The plan has determined that the enrollee or | 4 |
| subscriber did
not intentionally misrepresent or | 5 |
| intentionally omit material
information during the | 6 |
| application process and that the subscriber's
or | 7 |
| enrollee's health care coverage will not be canceled or | 8 |
| rescinded.
| 9 |
| (B) The plan intends to seek approval from the | 10 |
| Director to cancel
or rescind the enrollee's or | 11 |
| subscriber's health care service plan
contract for | 12 |
| intentional misrepresentation or intentional omission | 13 |
| of
material information during the application for | 14 |
| coverage process.
| 15 |
| (5) The written notice required under paragraph (B) of
| 16 |
| item (4) of this subsection (b) shall do all of the | 17 |
| following:
| 18 |
| (A) Include full disclosure of the nature and | 19 |
| substance of any
information that led to the plan's | 20 |
| determination that the enrollee or
subscriber | 21 |
| intentionally misrepresented or intentionally omitted
| 22 |
| material information on the application form.
| 23 |
| (B) Provide the enrollee or subscriber with | 24 |
| information indicating
that the health plan's | 25 |
| determination shall not become final until it
is | 26 |
| reviewed and approved by the Department's independent |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| review
process.
| 2 |
| (C) Provide the enrollee or subscriber with | 3 |
| information regarding
the Department's independent | 4 |
| review process and the right of the
enrollee or | 5 |
| subscriber to opt out of that review process within 45
| 6 |
| days of the date upon which an independent review | 7 |
| organization
receives a request for independent | 8 |
| review.
| 9 |
| (D) Provide a statement that the health care | 10 |
| service plan's
proposed decision to cancel or rescind | 11 |
| the health care service plan
contract shall not become | 12 |
| effective unless the Department's
independent review | 13 |
| organization upholds the health care service plan'
s | 14 |
| decision or unless the enrollee or subscriber has opted | 15 |
| out of the
independent review. | 16 |
| (215 ILCS 180/25.6 new) | 17 |
| Sec. 25.6. Continuation. | 18 |
| (a) A health care service plan shall continue to
authorize | 19 |
| and provide all medically necessary health care services
| 20 |
| required to be covered under an enrollee's or subscriber's | 21 |
| health
care service plan contract until the effective date of | 22 |
| cancellation
or rescission.
| 23 |
| (b) The effective date of the health care service plan's
| 24 |
| cancellation or the date upon which the plan may initiate a
| 25 |
| rescission shall be no earlier than the date that the enrollee |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| or
subscriber receives notification via regular and certified | 2 |
| mail that
the independent review organization has made a | 3 |
| determination
upholding the health care service plan's | 4 |
| decision to rescind or
cancel.
| 5 |
| (215 ILCS 180/35) | 6 |
| (This Section may contain text from a Public Act with a | 7 |
| delayed effective date )
| 8 |
| Sec. 35. Standard external review. | 9 |
| (a) Within 4 months after the date of receipt of a notice | 10 |
| of an adverse determination or final adverse determination, a | 11 |
| covered person or the covered person's authorized | 12 |
| representative may file a request for an external review with | 13 |
| the health carrier. | 14 |
| (b) Within 5 business days following the date of receipt of | 15 |
| the external review request, the health carrier shall complete | 16 |
| a preliminary review of the request to determine whether:
| 17 |
| (1) the individual is or was a covered person in the | 18 |
| health benefit plan at the time the health care service was | 19 |
| requested or at the time the health care service was | 20 |
| provided; | 21 |
| (2) the health care service that is the subject of the | 22 |
| adverse determination or the final adverse determination | 23 |
| is a covered service under the covered person's health | 24 |
| benefit plan, but the health carrier has determined that | 25 |
| the health care service is not covered because it does not |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| meet the health carrier's requirements for medical | 2 |
| necessity, appropriateness, health care setting, level of | 3 |
| care, or effectiveness; | 4 |
| (3) the covered person has exhausted the health | 5 |
| carrier's internal grievance process as set forth in this | 6 |
| Act; | 7 |
| (4) for appeals relating to a determination based on | 8 |
| treatment being experimental or investigational, the | 9 |
| requested health care service or treatment that is the | 10 |
| subject of the adverse determination or final adverse | 11 |
| determination is a covered benefit under the covered | 12 |
| person's health benefit plan except for the health | 13 |
| carrier's determination that the service or treatment is | 14 |
| experimental or investigational for a particular medical | 15 |
| condition and is not explicitly listed as an excluded | 16 |
| benefit under the covered person's health benefit plan with | 17 |
| the health carrier and that the covered person's health | 18 |
| care provider, who is a physician licensed to practice | 19 |
| medicine in all its branches, has certified that one of the | 20 |
| following situations is applicable: | 21 |
| (A) standard health care services or treatments | 22 |
| have not been effective in improving the condition of | 23 |
| the covered person; | 24 |
| (B) standard health care services or treatments | 25 |
| are not medically appropriate for the covered person; | 26 |
| (C) there is no available standard health care |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| service or treatment covered by the health carrier that | 2 |
| is more beneficial than the recommended or requested | 3 |
| health care service or treatment;
| 4 |
| (D) the health care service or treatment is likely | 5 |
| to be more beneficial to the covered person, in the | 6 |
| health care provider's opinion, than any available | 7 |
| standard health care services or treatments; or | 8 |
| (E) that scientifically valid studies using | 9 |
| accepted protocols demonstrate that the health care | 10 |
| service or treatment requested is likely to be more | 11 |
| beneficial to the covered person than any available | 12 |
| standard health care services or treatments; and | 13 |
| (5) the covered person has provided all the information | 14 |
| and forms required to process an external review, as | 15 |
| specified in this Act. | 16 |
| (c) Within one business day after completion of the | 17 |
| preliminary review, the health carrier shall notify the covered | 18 |
| person and, if applicable, the covered person's authorized | 19 |
| representative in writing whether the request is complete and | 20 |
| eligible for external review. If the request: | 21 |
| (1) is not complete, the health carrier shall inform | 22 |
| the covered person and, if applicable, the covered person's | 23 |
| authorized representative in writing and include in the | 24 |
| notice what information or materials are required by this | 25 |
| Act to make the request complete; or | 26 |
| (2) is not eligible for external review, the health |
|
|
|
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| 1 |
| carrier shall inform the covered person and, if applicable, | 2 |
| the covered person's authorized representative in writing | 3 |
| and include in the notice the reasons for its | 4 |
| ineligibility.
| 5 |
| The notice of initial determination of ineligibility shall | 6 |
| include a statement informing the covered person and, if | 7 |
| applicable, the covered person's authorized representative | 8 |
| that a health carrier's initial determination that the external | 9 |
| review request is ineligible for review may be appealed to the | 10 |
| Director by filing a complaint with the Director. | 11 |
| Notwithstanding a health carrier's initial determination | 12 |
| that the request is ineligible for external review, the | 13 |
| Director may determine that a request is eligible for external | 14 |
| review and require that it be referred for external review. In | 15 |
| making such determination, the Director's decision shall be in | 16 |
| accordance with the terms of the covered person's health | 17 |
| benefit plan and shall be subject to all applicable provisions | 18 |
| of this Act. | 19 |
| (d) Whenever a request is eligible for external review the | 20 |
| health carrier shall, within 5 business days: | 21 |
| (1) assign an independent review organization from the | 22 |
| list of approved independent review organizations compiled | 23 |
| and maintained by the Director; and | 24 |
| (2) notify in writing the covered person and, if | 25 |
| applicable, the covered person's authorized representative | 26 |
| of the request's eligibility and acceptance for external |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| 1 |
| review and the name of the independent review organization. | 2 |
| The health carrier shall include in the notice provided to | 3 |
| the covered person and, if applicable, the covered person's | 4 |
| authorized representative a statement that the covered person | 5 |
| or the covered person's authorized representative may, within 5 | 6 |
| business days following the date of receipt of the notice | 7 |
| provided pursuant to item (2) of this subsection (d), submit in | 8 |
| writing to the assigned independent review organization | 9 |
| additional information that the independent review | 10 |
| organization shall consider when conducting the external | 11 |
| review. The independent review organization is not required to, | 12 |
| but may, accept and consider additional information submitted | 13 |
| after 5 business days. | 14 |
| (e) The assignment of an approved independent review | 15 |
| organization to conduct an external review in accordance with | 16 |
| this Section shall be made from those approved independent | 17 |
| review organizations qualified to conduct external review as | 18 |
| required by Sections 50 and 55 of this Act. | 19 |
| (f) Upon assignment of an independent review organization, | 20 |
| the health carrier or its designee utilization review | 21 |
| organization shall, within 5 business days, provide to the | 22 |
| assigned independent review organization the documents and any | 23 |
| information considered in making the adverse determination or | 24 |
| final adverse determination; in such cases, the following | 25 |
| provisions shall apply: | 26 |
| (1) Except as provided in item (2) of this subsection |
|
|
|
09600HB6417ham001 |
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| 1 |
| (f), failure by the health carrier or its utilization | 2 |
| review organization to provide the documents and | 3 |
| information within the specified time frame shall not delay | 4 |
| the conduct of the external review. | 5 |
| (2) If the health carrier or its utilization review | 6 |
| organization fails to provide the documents and | 7 |
| information within the specified time frame, the assigned | 8 |
| independent review organization may terminate the external | 9 |
| review and make a decision to reverse the adverse | 10 |
| determination or final adverse determination. | 11 |
| (3) Within one business day after making the decision | 12 |
| to terminate the external review and make a decision to | 13 |
| reverse the adverse determination or final adverse | 14 |
| determination under item (2) of this subsection (f), the | 15 |
| independent review organization shall notify the health | 16 |
| carrier, the covered person and, if applicable, the covered | 17 |
| person's authorized representative, of its decision to | 18 |
| reverse the adverse determination. | 19 |
| (g) Upon receipt of the information from the health carrier | 20 |
| or its utilization review organization, the assigned | 21 |
| independent review organization shall review all of the | 22 |
| information and documents and any other information submitted | 23 |
| in writing to the independent review organization by the | 24 |
| covered person and the covered person's authorized | 25 |
| representative. | 26 |
| (h) Upon receipt of any information submitted by the |
|
|
|
09600HB6417ham001 |
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| 1 |
| covered person or the covered person's authorized | 2 |
| representative, the independent review organization shall | 3 |
| forward the information to the health carrier within 1 business | 4 |
| day. | 5 |
| (1) Upon receipt of the information, if any, the health | 6 |
| carrier may reconsider its adverse determination or final | 7 |
| adverse determination that is the subject of the external | 8 |
| review.
| 9 |
| (2) Reconsideration by the health carrier of its | 10 |
| adverse determination or final adverse determination shall | 11 |
| not delay or terminate the external review.
| 12 |
| (3) The external review may only be terminated if the | 13 |
| health carrier decides, upon completion of its | 14 |
| reconsideration, to reverse its adverse determination or | 15 |
| final adverse determination and provide coverage or | 16 |
| payment for the health care service that is the subject of | 17 |
| the adverse determination or final adverse determination. | 18 |
| In such cases, the following provisions shall apply: | 19 |
| (A) Within one business day after making the | 20 |
| decision to reverse its adverse determination or final | 21 |
| adverse determination, the health carrier shall notify | 22 |
| the covered person and if applicable, the covered | 23 |
| person's authorized representative, and the assigned | 24 |
| independent review organization in writing of its | 25 |
| decision. | 26 |
| (B) Upon notice from the health carrier that the |
|
|
|
09600HB6417ham001 |
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|
| 1 |
| health carrier has made a decision to reverse its | 2 |
| adverse determination or final adverse determination, | 3 |
| the assigned independent review organization shall | 4 |
| terminate the external review. | 5 |
| (i) In addition to the documents and information provided | 6 |
| by the health carrier or its utilization review organization | 7 |
| and the covered person and the covered person's authorized | 8 |
| representative, if any, the independent review organization, | 9 |
| to the extent the information or documents are available and | 10 |
| the independent review organization considers them | 11 |
| appropriate, shall consider the following in reaching a | 12 |
| decision: | 13 |
| (1) the covered person's pertinent medical records; | 14 |
| (2) the covered person's health care provider's | 15 |
| recommendation; | 16 |
| (3) consulting reports from appropriate health care | 17 |
| providers and other documents submitted by the health | 18 |
| carrier, the covered person, the covered person's | 19 |
| authorized representative, or the covered person's | 20 |
| treating provider; | 21 |
| (4) the terms of coverage under the covered person's | 22 |
| health benefit plan with the health carrier to ensure that | 23 |
| the independent review organization's decision is not | 24 |
| contrary to the terms of coverage under the covered | 25 |
| person's health benefit plan with the health carrier; | 26 |
| (5) the most appropriate practice guidelines, which |
|
|
|
09600HB6417ham001 |
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|
| 1 |
| shall include applicable evidence-based standards and may | 2 |
| include any other practice guidelines developed by the | 3 |
| federal government, national or professional medical | 4 |
| societies, boards, and associations; | 5 |
| (6) any applicable clinical review criteria developed | 6 |
| and used by the health carrier or its designee utilization | 7 |
| review organization; and | 8 |
| (7) the opinion of the independent review | 9 |
| organization's clinical reviewer or reviewers after | 10 |
| considering items (1) through (6) of this subsection (i) to | 11 |
| the extent the information or documents are available and | 12 |
| the clinical reviewer or reviewers considers the | 13 |
| information or documents appropriate; and | 14 |
| (8) for a denial of coverage based on a determination | 15 |
| that the health care service or treatment recommended or | 16 |
| requested is experimental or investigational, whether and | 17 |
| to what extent: | 18 |
| (A) the recommended or requested health care | 19 |
| service or treatment has been approved by the federal | 20 |
| Food and Drug Administration, if applicable, for the | 21 |
| condition; | 22 |
| (B) medical or scientific evidence or | 23 |
| evidence-based standards demonstrate that the expected | 24 |
| benefits of the recommended or requested health care | 25 |
| service or treatment is more likely than not to be | 26 |
| beneficial to the covered person than any available |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 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; or | 6 |
| (C) the terms of coverage under the covered | 7 |
| person's health benefit plan with the health carrier to | 8 |
| ensure that the health care service or treatment that | 9 |
| is the subject of the opinion is experimental or | 10 |
| investigational would otherwise be covered under the | 11 |
| terms of coverage of the covered person's health | 12 |
| benefit plan with the health carrier. | 13 |
| (j) Within 5 days after the date of receipt of all | 14 |
| necessary information, the assigned independent review | 15 |
| organization shall provide written notice of its decision to | 16 |
| uphold or reverse the adverse determination or the final | 17 |
| adverse determination to the health carrier, the covered person | 18 |
| and, if applicable, the covered person's authorized | 19 |
| representative. In reaching a decision, the assigned | 20 |
| independent review organization is not bound by any claim | 21 |
| determinations reached prior to the submission of information | 22 |
| to the independent review organization. The assigned | 23 |
| independent review organization shall independently determine | 24 |
| if the health care services under review are the medically | 25 |
| necessary health care services that a physician, exercising | 26 |
| prudent clinical judgment, would provide to a patient for the |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| purpose of preventing, evaluating, diagnosing, or treating an | 2 |
| illness, injury, disease, or its symptoms and are: (i) in | 3 |
| accordance with generally accepted standards of medical | 4 |
| practice; (ii) clinically appropriate, in terms of type, | 5 |
| frequency, extent, site, and duration and considered effective | 6 |
| for the patient's illness, injury, or disease; and (iii) not | 7 |
| primarily for the convenience of the patient, physician, or | 8 |
| other health care provider. For the purposes of this subsection | 9 |
| (j), "generally accepted standards of medical practice" means | 10 |
| standards that are based on credible scientific evidence | 11 |
| published in peer-reviewed medical literature generally | 12 |
| recognized by the relevant medical community, physician | 13 |
| specialty society recommendations, and the views of physicians | 14 |
| practicing in relevant clinical areas and any other relevant | 15 |
| factors. In such cases, the following provisions shall apply: | 16 |
| (1) The independent review organization shall include | 17 |
| in the notice: | 18 |
| (A) a general description of the reason for the | 19 |
| request for external review; | 20 |
| (B) the date the independent review organization | 21 |
| received the assignment from the health carrier to | 22 |
| conduct the external review; | 23 |
| (C) the time period during which the external | 24 |
| review was conducted; | 25 |
| (D) references to the evidence or documentation, | 26 |
| including the evidence-based standards, considered in |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| reaching its decision; | 2 |
| (E) the date of its decision; and | 3 |
| (F) the principal reason or reasons for its | 4 |
| decision, including what applicable, if any, | 5 |
| evidence-based standards that were a basis for its | 6 |
| decision.
| 7 |
| (2) For reviews of experimental or investigational | 8 |
| treatments, the notice shall include the following | 9 |
| information: | 10 |
| (A) a description of the covered person's medical | 11 |
| condition; | 12 |
| (B) a description of the indicators relevant to | 13 |
| whether there is sufficient evidence to demonstrate | 14 |
| that the recommended or requested health care service | 15 |
| or treatment is more likely than not to be more | 16 |
| beneficial to the covered person than any available | 17 |
| standard health care services or treatments and the | 18 |
| adverse risks of the recommended or requested health | 19 |
| care service or treatment would not be substantially | 20 |
| increased over those of available standard health care | 21 |
| services or treatments; | 22 |
| (C) a description and analysis of any medical or | 23 |
| scientific evidence considered in reaching the | 24 |
| opinion; | 25 |
| (D) a description and analysis of any | 26 |
| evidence-based standards; |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| (E) whether the recommended or requested health | 2 |
| care service or treatment has been approved by the | 3 |
| federal Food and Drug Administration, for the | 4 |
| condition; | 5 |
| (F) whether medical or scientific evidence or | 6 |
| evidence-based standards demonstrate that the expected | 7 |
| benefits of the recommended or requested health care | 8 |
| service or treatment is more likely than not to be more | 9 |
| beneficial to the covered person than any available | 10 |
| standard health care service or treatment and the | 11 |
| adverse risks of the recommended or requested health | 12 |
| care service or treatment would not be substantially | 13 |
| increased over those of available standard health care | 14 |
| services or treatments; and | 15 |
| (G) the written opinion of the clinical reviewer, | 16 |
| including the reviewer's recommendation as to whether | 17 |
| the recommended or requested health care service or | 18 |
| treatment should be covered and the rationale for the | 19 |
| reviewer's recommendation. | 20 |
| (3) In reaching a decision, the assigned independent | 21 |
| review organization is not bound by any decisions or | 22 |
| conclusions reached during the health carrier's | 23 |
| utilization review process or the health carrier's | 24 |
| internal grievance or appeals process. | 25 |
| (4) Upon receipt of a notice of a decision reversing | 26 |
| the adverse determination or final adverse determination, |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| the health carrier immediately shall approve the coverage | 2 |
| that was the subject of the adverse determination or final | 3 |
| adverse determination.
| 4 |
| (Source: P.A. 96-857, eff. 7-1-10.) | 5 |
| Section 55. The Illinois Public Aid Code is amended by | 6 |
| changing Section 5-16.8 as follows:
| 7 |
| (305 ILCS 5/5-16.8)
| 8 |
| Sec. 5-16.8. Required health benefits. The medical | 9 |
| assistance program
shall
(i) provide the post-mastectomy care | 10 |
| benefits required to be covered by a policy of
accident and | 11 |
| health insurance under Section 356t and the coverage required
| 12 |
| under Sections 356g.5, 356u, 356w, 356x, and 356z.6 , and | 13 |
| 356z.21 of the Illinois
Insurance Code and (ii) be subject to | 14 |
| the provisions of Section 364.01 of the Illinois
Insurance | 15 |
| Code.
| 16 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07.)
| 17 |
| Section 60. The Medical Patient Rights Act is amended by | 18 |
| changing Sections 2.04, 3, and 5 and adding Sections 2.06, 5.1, | 19 |
| and 5.2 as follows:
| 20 |
| (410 ILCS 50/2.04) (from Ch. 111 1/2, par. 5402.04)
| 21 |
| Sec. 2.04.
"Insurance company" means (1) an insurance | 22 |
| company, fraternal
benefit society, and any other insurer |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| subject to regulation under the
Illinois Insurance Code; or (2) | 2 |
| a health maintenance organization , a limited health service | 3 |
| organization under the Limited Health Service Organization | 4 |
| Act, or a voluntary health services plan under the Voluntary | 5 |
| Health Services Plans Act .
| 6 |
| (Source: P.A. 85-677; 85-679.)
| 7 |
| (410 ILCS 50/2.06 new) | 8 |
| Sec. 2.06. "Health insurance policy or health care plan" | 9 |
| means any policy of health or accident insurance provided by a | 10 |
| health insurance company or under the Counties Code, the | 11 |
| Municipal Code, the State Employees Group Insurance Act or | 12 |
| Medical Assistance provided under the Public Aid Code.
| 13 |
| (410 ILCS 50/3) (from Ch. 111 1/2, par. 5403)
| 14 |
| Sec. 3. The following rights are hereby established:
| 15 |
| (a) The right of each patient to care consistent with sound | 16 |
| nursing and
medical practices, to be informed of the name of | 17 |
| the physician responsible
for coordinating his or her care, to | 18 |
| receive information concerning his or
her condition and | 19 |
| proposed treatment, to refuse any treatment to the extent
| 20 |
| permitted by law, and to privacy and confidentiality of records | 21 |
| except as
otherwise provided by law. Each patient has a right | 22 |
| to be informed of his or her inpatient or outpatient status | 23 |
| while undergoing evaluation, assessment, diagnosis, treatment, | 24 |
| or observation in a hospital. The patient must be informed of |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| this status and put on notice that this admission status may | 2 |
| affect coverage by his or her health insurance policy or health | 3 |
| care plan or his or her personal responsibility for payment.
| 4 |
| (b) The right of each patient, regardless of source of | 5 |
| payment, to examine
and receive a reasonable explanation of his | 6 |
| total bill for services rendered
by his physician or health | 7 |
| care provider, including the itemized charges
for specific | 8 |
| services received. Each physician or health care provider
shall | 9 |
| be responsible only for a reasonable explanation of those | 10 |
| specific
services provided by such physician or health care | 11 |
| provider.
| 12 |
| (c) In the event an insurance company or health services | 13 |
| corporation cancels
or refuses to renew an individual policy or | 14 |
| plan, the insured patient shall
be entitled to timely, prior | 15 |
| notice of the termination of such policy or plan.
| 16 |
| An insurance company or health services corporation that | 17 |
| requires any
insured patient or applicant for new or continued | 18 |
| insurance or coverage to
be tested for infection with human | 19 |
| immunodeficiency virus (HIV) or any
other identified causative | 20 |
| agent of acquired immunodeficiency syndrome
(AIDS) shall (1) | 21 |
| give the patient or applicant prior written notice of such
| 22 |
| requirement, (2) proceed with such testing only upon the | 23 |
| written
authorization of the applicant or patient, and (3) keep | 24 |
| the results of such
testing confidential. Notice of an adverse | 25 |
| underwriting or coverage
decision may be given to any | 26 |
| appropriately interested party, but the
insurer may only |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| disclose the test result itself to a physician designated
by | 2 |
| the applicant or patient, and any such disclosure shall be in a | 3 |
| manner
that assures confidentiality.
| 4 |
| The Department of Insurance shall enforce the provisions of | 5 |
| this subsection.
| 6 |
| (d) The right of each patient to privacy and | 7 |
| confidentiality in health
care. Each physician, health care | 8 |
| provider, health services corporation and
insurance company | 9 |
| shall refrain from disclosing the nature or details of
services | 10 |
| provided to patients, except that such information may be | 11 |
| disclosed to the
patient, the party making treatment decisions | 12 |
| if the patient is incapable
of making decisions regarding the | 13 |
| health services provided, those parties
directly involved with | 14 |
| providing treatment to the patient or processing the
payment | 15 |
| for that treatment, those parties responsible for peer review,
| 16 |
| utilization review and quality assurance, and those parties | 17 |
| required to
be notified under the Abused and Neglected Child | 18 |
| Reporting Act, the
Illinois Sexually Transmissible Disease | 19 |
| Control Act or where otherwise
authorized or required by law. | 20 |
| This right may be waived in writing by the
patient or the | 21 |
| patient's guardian, but a physician or other health care
| 22 |
| provider may not condition the provision of services on the | 23 |
| patient's or
guardian's agreement to sign such a waiver.
| 24 |
| (Source: P.A. 86-895; 86-902; 86-1028; 87-334.)
| 25 |
| (410 ILCS 50/5)
|
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| Sec. 5. Statement of hospital patient's rights.
| 2 |
| (a) Each patient admitted to a hospital, and the guardian | 3 |
| or authorized
representative or parent of a minor patient, | 4 |
| shall be given a written
statement of all the rights enumerated | 5 |
| in this Act, or a similar statement of
patients' rights | 6 |
| required of the hospital by the Joint Commission on
| 7 |
| Accreditation of Healthcare Organizations or a similar | 8 |
| accrediting
organization. The statement shall be given at the | 9 |
| time of admission or as soon
thereafter as the condition of the | 10 |
| patient permits.
| 11 |
| (b) If a patient is unable to read the written statement, a | 12 |
| hospital
shall make a reasonable effort to provide it to the | 13 |
| guardian or authorized
representative of the patient.
| 14 |
| (c) The statement shall also include the right not to be | 15 |
| discriminated against by the hospital due to the patient's | 16 |
| race, color, or national origin where such characteristics are | 17 |
| not relevant to the patient's medical diagnosis and treatment. | 18 |
| The statement shall further provide each admitted patient or | 19 |
| the patient's representative or guardian with notice of how to | 20 |
| initiate a grievance regarding improper discrimination with | 21 |
| the hospital and how the patient may lodge a grievance with the | 22 |
| Illinois Department of Public Health regardless of whether the | 23 |
| patient has first used the hospital's grievance process. | 24 |
| (Source: P.A. 88-56; 88-670, eff. 12-2-94.)
| 25 |
| (410 ILCS 50/5.1 new)
|
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| Sec. 5.1. Discrimination grievance procedures. Upon | 2 |
| receipt of a grievance alleging unlawful discrimination on the | 3 |
| basis of race, color, or national origin, the hospital must | 4 |
| investigate the claim and work with the patient to address | 5 |
| valid or proven concerns in accordance with the hospital's | 6 |
| grievance process. At the conclusion of the hospital's | 7 |
| grievance process, the hospital shall inform the patient that | 8 |
| such grievances may be reported to the Illinois Department of | 9 |
| Public Health if not resolved to the patient's satisfaction at | 10 |
| the hospital level. | 11 |
| (410 ILCS 50/5.2 new)
| 12 |
| Sec. 5.2. Emergency room antidiscrimination notice. Every | 13 |
| hospital shall post a sign next to or in close proximity of its | 14 |
| sign required by Section 489.20 (q)(1) of Title 42 of the Code | 15 |
| of Federal Regulations stating the following: | 16 |
| "You have the right not to be discriminated against by the | 17 |
| hospital due to your race, color, or national origin if these | 18 |
| characteristics are unrelated to your diagnosis or treatment. | 19 |
| If you believe this right has been violated, please call | 20 |
| (insert number for hospital grievance officer).". | 21 |
| Section 90. The State Mandates Act is amended by adding | 22 |
| Section 8.34 as follows: | 23 |
| (30 ILCS 805/8.34 new) |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
| 1 |
| Sec. 8.34. Exempt mandate. Notwithstanding Sections 6 and 8 | 2 |
| of this Act, no reimbursement by the State is required for the | 3 |
| implementation of any mandate created by this amendatory Act of | 4 |
| the 96th General Assembly. | 5 |
| Section 95. No acceleration or delay. Where this Act makes | 6 |
| changes in a statute that is represented in this Act by text | 7 |
| that is not yet or no longer in effect (for example, a Section | 8 |
| represented by multiple versions), the use of that text does | 9 |
| not accelerate or delay the taking effect of (i) the changes | 10 |
| made by this Act or (ii) provisions derived from any other | 11 |
| Public Act.
| 12 |
| Section 99. Effective date. This Act takes effect upon | 13 |
| becoming law.".
|
|