Full Text of HB3650 096th General Assembly
HB3650eng 96TH GENERAL ASSEMBLY
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| 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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| (Text of Section before amendment by P.A. 95-958 ) | 8 |
| Sec. 6.11. Required health benefits; Illinois Insurance | 9 |
| Code
requirements. The program of health
benefits shall provide | 10 |
| the post-mastectomy care benefits required to be covered
by a | 11 |
| policy of accident and health insurance under Section 356t of | 12 |
| the Illinois
Insurance Code. The program of health benefits | 13 |
| shall provide the coverage
required under Sections 356f.1, | 14 |
| 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, | 15 |
| 356z.10, 356z.13
356z.11 , and 356z.14
of the
Illinois Insurance | 16 |
| Code.
The program of health benefits must comply with Section | 17 |
| 155.37 of the
Illinois Insurance Code.
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| (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; 95-978, eff. | 20 |
| 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
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| (Text of Section after amendment by P.A. 95-958 )
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| Sec. 6.11. Required health benefits; Illinois Insurance |
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HB3650 Engrossed |
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| Code
requirements. The program of health
benefits shall provide | 2 |
| the post-mastectomy care benefits required to be covered
by a | 3 |
| policy of accident and health insurance under Section 356t of | 4 |
| the Illinois
Insurance Code. The program of health benefits | 5 |
| shall provide the coverage
required under Sections 356f.1, | 6 |
| 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, | 7 |
| 356z.10, 356z.11, and 356z.12 , 356z.13
356z.11 , and 356z.14 of | 8 |
| the
Illinois Insurance Code.
The program of health benefits | 9 |
| must comply with Section 155.37 of the
Illinois Insurance Code.
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| (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; revised | 13 |
| 12-15-08.) | 14 |
| Section 10. The Counties Code is amended by changing | 15 |
| Section 5-1069.3 as follows: | 16 |
| (55 ILCS 5/5-1069.3)
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| (Text of Section before amendment by P.A. 95-958 )
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| Sec. 5-1069.3. Required health benefits. If a county, | 19 |
| including a home
rule
county, is a self-insurer for purposes of | 20 |
| providing health insurance coverage
for its employees, the | 21 |
| coverage shall include coverage for the post-mastectomy
care | 22 |
| benefits required to be covered by a policy of accident and | 23 |
| health
insurance under Section 356t and the coverage required | 24 |
| under Sections 356f.1, 356g.5, 356u,
356w, 356x, 356z.6, |
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| 356z.9, 356z.10, 356z.13
356z.11 , and 356z.14 of
the Illinois | 2 |
| Insurance Code. The requirement that health benefits be covered
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| as provided in this Section is an
exclusive power and function | 4 |
| of the State and is a denial and limitation under
Article VII, | 5 |
| Section 6, subsection (h) of the Illinois Constitution. A home
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| rule county to which this Section applies must comply with | 7 |
| every provision of
this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 9 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | 10 |
| 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
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| (Text of Section after amendment by P.A. 95-958 ) | 12 |
| Sec. 5-1069.3. Required health benefits. If a county, | 13 |
| including a home
rule
county, is a self-insurer for purposes of | 14 |
| providing health insurance coverage
for its employees, the | 15 |
| coverage shall include coverage for the post-mastectomy
care | 16 |
| benefits required to be covered by a policy of accident and | 17 |
| health
insurance under Section 356t and the coverage required | 18 |
| under Sections 356f.1, 356g.5, 356u,
356w, 356x, 356z.6, | 19 |
| 356z.9, 356z.10, 356z.11, and 356z.12 , 356z.13
356z.11 , and | 20 |
| 356z.14 of
the Illinois Insurance Code. The requirement that | 21 |
| health benefits be covered
as provided in this Section is an
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| exclusive power and function of the State and is a denial and | 23 |
| limitation under
Article VII, Section 6, subsection (h) of the | 24 |
| Illinois Constitution. A home
rule county to which this Section | 25 |
| applies must comply with every provision of
this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 2 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | 3 |
| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | 4 |
| 12-15-08.) | 5 |
| Section 15. The Illinois Municipal Code is amended by | 6 |
| changing Section 10-4-2.3 as follows: | 7 |
| (65 ILCS 5/10-4-2.3)
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| (Text of Section before amendment by P.A. 95-958 )
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| Sec. 10-4-2.3. Required health benefits. If a | 10 |
| municipality, including a
home rule municipality, is a | 11 |
| self-insurer for purposes of providing health
insurance | 12 |
| coverage for its employees, the coverage shall include coverage | 13 |
| for
the post-mastectomy care benefits required to be covered by | 14 |
| a policy of
accident and health insurance under Section 356t | 15 |
| and the coverage required
under Sections 356f.1, 356g.5, 356u, | 16 |
| 356w, 356x, 356z.6, 356z.9, 356z.10, 356z.13
356z.11 , and | 17 |
| 356z.14 of the Illinois
Insurance
Code. The requirement that | 18 |
| health
benefits be covered as provided in this is an exclusive | 19 |
| power and function of
the State and is a denial and limitation | 20 |
| under Article VII, Section 6,
subsection (h) of the Illinois | 21 |
| Constitution. A home rule municipality to which
this Section | 22 |
| applies must comply with every provision of this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 24 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. |
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HB3650 Engrossed |
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| 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
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| (Text of Section after amendment by P.A. 95-958 ) | 3 |
| Sec. 10-4-2.3. Required health benefits. If a | 4 |
| municipality, including a
home rule municipality, is a | 5 |
| self-insurer for purposes of providing health
insurance | 6 |
| coverage for its employees, the coverage shall include coverage | 7 |
| for
the post-mastectomy care benefits required to be covered by | 8 |
| a policy of
accident and health insurance under Section 356t | 9 |
| and the coverage required
under Sections 356f.1, 356g.5, 356u, | 10 |
| 356w, 356x, 356z.6, 356z.9, 356z.10, 356z.11, and 356z.12 , | 11 |
| 356z.13
356z.11 , and 356z.14 of the Illinois
Insurance
Code. | 12 |
| The requirement that health
benefits be covered as provided in | 13 |
| this is an exclusive power and function of
the State and is a | 14 |
| denial and limitation under Article VII, Section 6,
subsection | 15 |
| (h) of the Illinois Constitution. A home rule municipality to | 16 |
| which
this Section applies must comply with every provision of | 17 |
| this Section.
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| (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; revised | 21 |
| 12-15-08.)
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| Section 20. The School Code is amended by changing Section | 23 |
| 10-22.3f as follows: |
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| (105 ILCS 5/10-22.3f)
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| (Text of Section before amendment by P.A. 95-958 )
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| Sec. 10-22.3f. Required health benefits. Insurance | 4 |
| protection and
benefits
for employees shall provide the | 5 |
| post-mastectomy care benefits required to be
covered by a | 6 |
| policy of accident and health insurance under Section 356t and | 7 |
| the
coverage required under Sections 356f.1, 356g.5, 356u, | 8 |
| 356w, 356x,
356z.6, 356z.9, 356z.13
and 356z.11 , and 356z.14 of
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| the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 11 |
| 95-876, eff. 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. | 12 |
| 12-12-08; revised 12-15-08.)
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| (Text of Section after amendment by P.A. 95-958 ) | 14 |
| Sec. 10-22.3f. Required health benefits. Insurance | 15 |
| protection and
benefits
for employees shall provide the | 16 |
| post-mastectomy care benefits required to be
covered by a | 17 |
| policy of accident and health insurance under Section 356t and | 18 |
| the
coverage required under Sections 356f.1, 356g.5, 356u, | 19 |
| 356w, 356x,
356z.6, 356z.9, 356z.11, and 356z.12, 356z.13
and | 20 |
| 356z.11 , and 356z.14 of
the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 22 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | 23 |
| 95-1005, 12-12-08; revised 12-15-08.)
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| Section 25. The Illinois Insurance Code is amended by |
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| adding Section 356f.1 as follows: | 2 |
| (215 ILCS 5/356f.1 new) | 3 |
| Sec. 356f.1. Health care services appeals,
complaints, and
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| external independent reviews. | 5 |
| (a) A policy of accident or health insurance or managed | 6 |
| care plan shall establish and maintain an appeals procedure as
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| outlined in this Section. Compliance with this Section's | 8 |
| appeals procedures shall
satisfy a policy or plan's obligation | 9 |
| to provide appeal procedures under any
other State law or | 10 |
| rules. | 11 |
| (b) When an appeal concerns a decision or action by a | 12 |
| policy of accident or health insurance or managed care plan,
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| its
employees, or its subcontractors that relates to (i) health | 14 |
| care services,
including, but not limited to, procedures or
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| treatments
for an enrollee with an ongoing course of treatment | 16 |
| ordered
by a health care provider,
the denial of which could | 17 |
| significantly
increase the risk to an
enrollee's health,
or | 18 |
| (ii) a treatment referral, service,
procedure, or other health | 19 |
| care service,
the denial of which could significantly
increase | 20 |
| the risk to an
enrollee's health, or (iii) the non-renewal or | 21 |
| termination of a plan,
the policy or plan must allow for the | 22 |
| filing of an appeal
either orally or in writing. Upon | 23 |
| submission of the appeal, a policy or plan
must notify the | 24 |
| party filing the appeal, as soon as possible, but in no event
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| more than 24 hours after the submission of the appeal, of all |
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| information
that the plan requires to evaluate the appeal.
The | 2 |
| policy or plan shall render a decision on the appeal within
24 | 3 |
| hours after receipt of the required information. The policy or | 4 |
| plan shall
notify the party filing the
appeal and the enrollee, | 5 |
| enrollee's primary care physician, and any health care
provider | 6 |
| who recommended the health care service involved in the appeal | 7 |
| of 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 policy or | 12 |
| plan shall establish a procedure for the filing of such | 13 |
| appeals. Upon
submission of an appeal under this subsection, a | 14 |
| policy or plan must notify
the party filing an appeal, within 3 | 15 |
| business days, of all information that the
policy or plan | 16 |
| requires to evaluate the appeal.
The policy or plan shall | 17 |
| render a decision on the appeal within 15 business
days after | 18 |
| receipt of the required information. The policy or plan shall
| 19 |
| notify the party filing the appeal,
the enrollee, the | 20 |
| enrollee's primary care physician, and any health care
provider
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| who recommended the health care service involved in the appeal | 22 |
| orally of its
decision followed-up by a written notice of the | 23 |
| determination. | 24 |
| (d) An appeal under subsection (b) or (c) may be filed by | 25 |
| the
enrollee, the enrollee's designee or guardian, the | 26 |
| enrollee's primary care
physician, or the enrollee's health |
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| care provider. A policy or plan shall
designate a clinical peer | 2 |
| to review
appeals, because these appeals pertain to medical or | 3 |
| clinical matters
and such an appeal must be reviewed by an | 4 |
| appropriate
health care professional. No one reviewing an | 5 |
| appeal may have had any
involvement
in the initial | 6 |
| determination that is the subject of the appeal. The written
| 7 |
| notice of determination required under subsections (b) and (c) | 8 |
| shall
include (i) clear and detailed reasons for the | 9 |
| determination, (ii)
the medical or
clinical criteria for the | 10 |
| determination, which shall be based upon sound
clinical | 11 |
| evidence and reviewed on a periodic basis, and (iii) in the | 12 |
| case of an
adverse determination, the
procedures for requesting | 13 |
| an external independent review 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,
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| 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
under subsection (f) of the adverse | 21 |
| determination. | 22 |
| (f) The party seeking an external independent review shall | 23 |
| so notify the
policy or plan.
The policy or plan shall seek to | 24 |
| resolve all
external independent
reviews in the most | 25 |
| expeditious manner and shall make a determination and
provide | 26 |
| notice of the determination no more
than 24 hours after the |
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| receipt of all necessary information when a delay would
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| significantly increase
the risk to an enrollee's health or when | 3 |
| extended health care services for an
enrollee undergoing a
| 4 |
| course of treatment prescribed by a health care provider are at | 5 |
| issue. | 6 |
| (1) Within 30 days after the enrollee receives written | 7 |
| notice of an
adverse
determination,
if the enrollee decides | 8 |
| to initiate an external independent review, the
enrollee | 9 |
| shall send to the policy or plan a written request for an | 10 |
| external independent review, including any
information or
| 11 |
| documentation to support the enrollee's request for the | 12 |
| covered service or
claim for a covered
service. | 13 |
| (2) Within 30 days after the policy or plan receives a | 14 |
| request for an
external
independent review from an enrollee | 15 |
| or, within 24 hours after the receipt of a request if a | 16 |
| delay would significantly increase the risk to the | 17 |
| enrollee's health, the policy or 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,
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| and the policy or 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 | 26 |
| decision made by, the criteria used, and the
medical |
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| and clinical reasons
for that decision. | 2 |
| (3) Within 5 days after receipt of all necessary | 3 |
| information or within 24 hours when a delay would
| 4 |
| significantly increase
the risk to an enrollee's health, | 5 |
| the
independent
reviewer
shall evaluate and analyze the | 6 |
| case and render a decision that is based on
whether or not | 7 |
| the health
care service or claim for the health care | 8 |
| service is medically appropriate. The
decision by the
| 9 |
| independent reviewer is final. If the external independent | 10 |
| reviewer determines
the health care
service to be medically
| 11 |
| appropriate, the policy or plan shall pay for the health | 12 |
| care service. | 13 |
| (4) The policy or plan shall be solely responsible for | 14 |
| paying the fees
of the external
independent reviewer who is | 15 |
| selected to perform the review. | 16 |
| (5) An external independent reviewer who acts in good | 17 |
| faith shall have
immunity
from any civil or criminal | 18 |
| liability or professional discipline as a result of
acts or | 19 |
| omissions with
respect to any external independent review, | 20 |
| unless the acts or omissions
constitute wilful and wanton
| 21 |
| misconduct. For purposes of any proceeding, the good faith | 22 |
| of the person
participating shall be
presumed. | 23 |
| (6) Future contractual or employment action by the | 24 |
| policy or plan
regarding the
patient's physician or other | 25 |
| health care provider shall not be based solely on
the | 26 |
| physician's or other
health care provider's participation |
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| in this procedure. | 2 |
| (7) For the purposes of this Section, an external | 3 |
| independent reviewer
shall: | 4 |
| (a) be a clinical peer; | 5 |
| (b) have no direct financial interest in | 6 |
| connection with the case; and | 7 |
| (c) have not been informed of the specific identity | 8 |
| of the enrollee. | 9 |
| (g) Nothing in this Section shall be construed to require a | 10 |
| policy or
plan to pay for a health care service not covered | 11 |
| under the enrollee's
certificate of coverage or policy. | 12 |
| (h) A policy of accident or health insurance or managed | 13 |
| care plan shall provide each enrollee, prospective enrollee, | 14 |
| and enrollee representative with written notification of the | 15 |
| policy's or plan's appeal process and any external review | 16 |
| appeals process that is available to the enrollee. This | 17 |
| notification shall be provided at the time the insured enrolls | 18 |
| in the health insurance or managed care plan, renews such | 19 |
| enrollment, or requests to reverse or modify an adverse | 20 |
| determination made by the insurer or managed care plan.
The | 21 |
| notice outlined in this subsection (h) shall describe the | 22 |
| policy's or plan's appeals process, any applicable forms, and | 23 |
| the time frames for appeals, complaints, and external review | 24 |
| appeals and shall include a phone number to call for more | 25 |
| information from the policy or plan concerning the appeals | 26 |
| process.
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| Section 30. The Health Maintenance Organization Act is | 2 |
| amended by changing Section 5-3 as follows:
| 3 |
| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 4 |
| (Text of Section before amendment by P.A. 95-958 )
| 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, 356f.1, 356m, 356v, 356w, | 10 |
| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | 11 |
| 356z.10, 356z.13
356z.11 , 356z.14,
364.01, 367.2, 367.2-5, | 12 |
| 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, | 13 |
| 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of | 14 |
| subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
| 15 |
| XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | 16 |
| Insurance Code.
| 17 |
| (b) For purposes of the Illinois Insurance Code, except for | 18 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 19 |
| Maintenance Organizations in
the following categories are | 20 |
| deemed to be "domestic companies":
| 21 |
| (1) a corporation authorized under the
Dental Service | 22 |
| Plan Act or the Voluntary Health Services Plans Act;
| 23 |
| (2) a corporation organized under the laws of this | 24 |
| State; or
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| (3) a corporation organized under the laws of another | 2 |
| state, 30% or more
of the enrollees of which are residents | 3 |
| of this State, except a
corporation subject to | 4 |
| substantially the same requirements in its state of
| 5 |
| organization as is a "domestic company" under Article VIII | 6 |
| 1/2 of the
Illinois Insurance Code.
| 7 |
| (c) In considering the merger, consolidation, or other | 8 |
| acquisition of
control of a Health Maintenance Organization | 9 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 10 |
| (1) the Director shall give primary consideration to | 11 |
| the continuation of
benefits to enrollees and the financial | 12 |
| conditions of the acquired Health
Maintenance Organization | 13 |
| after the merger, consolidation, or other
acquisition of | 14 |
| control takes effect;
| 15 |
| (2)(i) the criteria specified in subsection (1)(b) of | 16 |
| Section 131.8 of
the Illinois Insurance Code shall not | 17 |
| apply and (ii) the Director, in making
his determination | 18 |
| with respect to the merger, consolidation, or other
| 19 |
| acquisition of control, need not take into account the | 20 |
| effect on
competition of the merger, consolidation, or | 21 |
| other acquisition of control;
| 22 |
| (3) the Director shall have the power to require the | 23 |
| following
information:
| 24 |
| (A) certification by an independent actuary of the | 25 |
| adequacy
of the reserves of the Health Maintenance | 26 |
| Organization sought to be acquired;
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| (B) pro forma financial statements reflecting the | 2 |
| combined balance
sheets of the acquiring company and | 3 |
| the Health Maintenance Organization sought
to be | 4 |
| acquired as of the end of the preceding year and as of | 5 |
| a date 90 days
prior to the acquisition, as well as pro | 6 |
| forma financial statements
reflecting projected | 7 |
| combined operation for a period of 2 years;
| 8 |
| (C) a pro forma business plan detailing an | 9 |
| acquiring party's plans with
respect to the operation | 10 |
| of the Health Maintenance Organization sought to
be | 11 |
| acquired for a period of not less than 3 years; and
| 12 |
| (D) such other information as the Director shall | 13 |
| require.
| 14 |
| (d) The provisions of Article VIII 1/2 of the Illinois | 15 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 16 |
| any health maintenance
organization of greater than 10% of its
| 17 |
| enrollee population (including without limitation the health | 18 |
| maintenance
organization's right, title, and interest in and to | 19 |
| its health care
certificates).
| 20 |
| (e) In considering any management contract or service | 21 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 22 |
| Code, the Director (i) shall, in
addition to the criteria | 23 |
| specified in Section 141.2 of the Illinois
Insurance Code, take | 24 |
| into account the effect of the management contract or
service | 25 |
| agreement on the continuation of benefits to enrollees and the
| 26 |
| financial condition of the health maintenance organization to |
|
|
|
HB3650 Engrossed |
- 16 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| be managed or
serviced, and (ii) need not take into account the | 2 |
| effect of the management
contract or service agreement on | 3 |
| competition.
| 4 |
| (f) Except for small employer groups as defined in the | 5 |
| Small Employer
Rating, Renewability and Portability Health | 6 |
| Insurance Act and except for
medicare supplement policies as | 7 |
| defined in Section 363 of the Illinois
Insurance Code, a Health | 8 |
| Maintenance Organization may by contract agree with a
group or | 9 |
| other enrollment unit to effect refunds or charge additional | 10 |
| premiums
under the following terms and conditions:
| 11 |
| (i) the amount of, and other terms and conditions with | 12 |
| respect to, the
refund or additional premium are set forth | 13 |
| in the group or enrollment unit
contract agreed in advance | 14 |
| of the period for which a refund is to be paid or
| 15 |
| additional premium is to be charged (which period shall not | 16 |
| be less than one
year); and
| 17 |
| (ii) the amount of the refund or additional premium | 18 |
| shall not exceed 20%
of the Health Maintenance | 19 |
| Organization's profitable or unprofitable experience
with | 20 |
| respect to the group or other enrollment unit for the | 21 |
| period (and, for
purposes of a refund or additional | 22 |
| premium, the profitable or unprofitable
experience shall | 23 |
| be calculated taking into account a pro rata share of the
| 24 |
| Health Maintenance Organization's administrative and | 25 |
| marketing expenses, but
shall not include any refund to be | 26 |
| made or additional premium to be paid
pursuant to this |
|
|
|
HB3650 Engrossed |
- 17 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| subsection (f)). The Health Maintenance Organization and | 2 |
| the
group or enrollment unit may agree that the profitable | 3 |
| or unprofitable
experience may be calculated taking into | 4 |
| account the refund period and the
immediately preceding 2 | 5 |
| plan years.
| 6 |
| The Health Maintenance Organization shall include a | 7 |
| statement in the
evidence of coverage issued to each enrollee | 8 |
| describing the possibility of a
refund or additional premium, | 9 |
| and upon request of any group or enrollment unit,
provide to | 10 |
| the group or enrollment unit a description of the method used | 11 |
| to
calculate (1) the Health Maintenance Organization's | 12 |
| profitable experience with
respect to the group or enrollment | 13 |
| unit and the resulting refund to the group
or enrollment unit | 14 |
| or (2) the Health Maintenance Organization's unprofitable
| 15 |
| experience with respect to the group or enrollment unit and the | 16 |
| resulting
additional premium to be paid by the group or | 17 |
| enrollment unit.
| 18 |
| In no event shall the Illinois Health Maintenance | 19 |
| Organization
Guaranty Association be liable to pay any | 20 |
| contractual obligation of an
insolvent organization to pay any | 21 |
| refund authorized under this Section.
| 22 |
| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | 23 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | 24 |
| 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | 25 |
| 12-15-08.)
|
|
|
|
HB3650 Engrossed |
- 18 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| (Text of Section after amendment by P.A. 95-958 ) | 2 |
| Sec. 5-3. Insurance Code provisions.
| 3 |
| (a) Health Maintenance Organizations
shall be subject to | 4 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 5 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 6 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356f.1, 356m, 356v, 356w, | 7 |
| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | 8 |
| 356z.10, 356z.11, 356z.12 , 356z.13
356z.11 , 356z.14, 364.01, | 9 |
| 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, | 10 |
| 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
| 11 |
| paragraph (c) of subsection (2) of Section 367, and Articles | 12 |
| IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | 13 |
| the Illinois Insurance Code.
| 14 |
| (b) For purposes of the Illinois Insurance Code, except for | 15 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 16 |
| Maintenance Organizations in
the following categories are | 17 |
| deemed to be "domestic companies":
| 18 |
| (1) a corporation authorized under the
Dental Service | 19 |
| Plan Act or the Voluntary Health Services Plans Act;
| 20 |
| (2) a corporation organized under the laws of this | 21 |
| State; or
| 22 |
| (3) a corporation organized under the laws of another | 23 |
| state, 30% or more
of the enrollees of which are residents | 24 |
| of this State, except a
corporation subject to | 25 |
| substantially the same requirements in its state of
| 26 |
| organization as is a "domestic company" under Article VIII |
|
|
|
HB3650 Engrossed |
- 19 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| 1/2 of the
Illinois Insurance Code.
| 2 |
| (c) In considering the merger, consolidation, or other | 3 |
| acquisition of
control of a Health Maintenance Organization | 4 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 5 |
| (1) the Director shall give primary consideration to | 6 |
| the continuation of
benefits to enrollees and the financial | 7 |
| conditions of the acquired Health
Maintenance Organization | 8 |
| after the merger, consolidation, or other
acquisition of | 9 |
| control takes effect;
| 10 |
| (2)(i) the criteria specified in subsection (1)(b) of | 11 |
| Section 131.8 of
the Illinois Insurance Code shall not | 12 |
| apply and (ii) the Director, in making
his determination | 13 |
| with respect to the merger, consolidation, or other
| 14 |
| acquisition of control, need not take into account the | 15 |
| effect on
competition of the merger, consolidation, or | 16 |
| other acquisition of control;
| 17 |
| (3) the Director shall have the power to require the | 18 |
| following
information:
| 19 |
| (A) certification by an independent actuary of the | 20 |
| adequacy
of the reserves of the Health Maintenance | 21 |
| Organization sought to be acquired;
| 22 |
| (B) pro forma financial statements reflecting the | 23 |
| combined balance
sheets of the acquiring company and | 24 |
| the Health Maintenance Organization sought
to be | 25 |
| acquired as of the end of the preceding year and as of | 26 |
| a date 90 days
prior to the acquisition, as well as pro |
|
|
|
HB3650 Engrossed |
- 20 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| forma financial statements
reflecting projected | 2 |
| combined operation for a period of 2 years;
| 3 |
| (C) a pro forma business plan detailing an | 4 |
| acquiring party's plans with
respect to the operation | 5 |
| of the Health Maintenance Organization sought to
be | 6 |
| acquired for a period of not less than 3 years; and
| 7 |
| (D) such other information as the Director shall | 8 |
| require.
| 9 |
| (d) The provisions of Article VIII 1/2 of the Illinois | 10 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 11 |
| any health maintenance
organization of greater than 10% of its
| 12 |
| enrollee population (including without limitation the health | 13 |
| maintenance
organization's right, title, and interest in and to | 14 |
| its health care
certificates).
| 15 |
| (e) In considering any management contract or service | 16 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 17 |
| Code, the Director (i) shall, in
addition to the criteria | 18 |
| specified in Section 141.2 of the Illinois
Insurance Code, take | 19 |
| into account the effect of the management contract or
service | 20 |
| agreement on the continuation of benefits to enrollees and the
| 21 |
| financial condition of the health maintenance organization to | 22 |
| be managed or
serviced, and (ii) need not take into account the | 23 |
| effect of the management
contract or service agreement on | 24 |
| competition.
| 25 |
| (f) Except for small employer groups as defined in the | 26 |
| Small Employer
Rating, Renewability and Portability Health |
|
|
|
HB3650 Engrossed |
- 21 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| Insurance Act and except for
medicare supplement policies as | 2 |
| defined in Section 363 of the Illinois
Insurance Code, a Health | 3 |
| Maintenance Organization may by contract agree with a
group or | 4 |
| other enrollment unit to effect refunds or charge additional | 5 |
| premiums
under the following terms and conditions:
| 6 |
| (i) the amount of, and other terms and conditions with | 7 |
| respect to, the
refund or additional premium are set forth | 8 |
| in the group or enrollment unit
contract agreed in advance | 9 |
| of the period for which a refund is to be paid or
| 10 |
| additional premium is to be charged (which period shall not | 11 |
| be less than one
year); and
| 12 |
| (ii) the amount of the refund or additional premium | 13 |
| shall not exceed 20%
of the Health Maintenance | 14 |
| Organization's profitable or unprofitable experience
with | 15 |
| respect to the group or other enrollment unit for the | 16 |
| period (and, for
purposes of a refund or additional | 17 |
| premium, the profitable or unprofitable
experience shall | 18 |
| be calculated taking into account a pro rata share of the
| 19 |
| Health Maintenance Organization's administrative and | 20 |
| marketing expenses, but
shall not include any refund to be | 21 |
| made or additional premium to be paid
pursuant to this | 22 |
| subsection (f)). The Health Maintenance Organization and | 23 |
| the
group or enrollment unit may agree that the profitable | 24 |
| or unprofitable
experience may be calculated taking into | 25 |
| account the refund period and the
immediately preceding 2 | 26 |
| plan years.
|
|
|
|
HB3650 Engrossed |
- 22 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| The Health Maintenance Organization shall include a | 2 |
| statement in the
evidence of coverage issued to each enrollee | 3 |
| describing the possibility of a
refund or additional premium, | 4 |
| and upon request of any group or enrollment unit,
provide to | 5 |
| the group or enrollment unit a description of the method used | 6 |
| to
calculate (1) the Health Maintenance Organization's | 7 |
| profitable experience with
respect to the group or enrollment | 8 |
| unit and the resulting refund to the group
or enrollment unit | 9 |
| or (2) the Health Maintenance Organization's unprofitable
| 10 |
| experience with respect to the group or enrollment unit and the | 11 |
| resulting
additional premium to be paid by the group or | 12 |
| enrollment unit.
| 13 |
| In no event shall the Illinois Health Maintenance | 14 |
| Organization
Guaranty Association be liable to pay any | 15 |
| contractual obligation of an
insolvent organization to pay any | 16 |
| refund authorized under this Section.
| 17 |
| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | 18 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | 19 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | 20 |
| eff. 12-12-08; revised 12-15-08.) | 21 |
| Section 35. The Limited Health Service Organization Act is | 22 |
| amended by changing Section 4003 as follows:
| 23 |
| (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| 24 |
| Sec. 4003. Illinois Insurance Code provisions. Limited |
|
|
|
HB3650 Engrossed |
- 23 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| health service
organizations shall be subject to the provisions | 2 |
| of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | 3 |
| 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | 4 |
| 155.04, 155.37, 355.2, 356f.1, 356v, 356z.10, 368a, 401, 401.1,
| 5 |
| 402,
403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and | 6 |
| Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and | 7 |
| XXVI of the Illinois Insurance Code. For purposes of the
| 8 |
| Illinois Insurance Code, except for Sections 444 and 444.1 and | 9 |
| Articles XIII
and XIII 1/2, limited health service | 10 |
| organizations in the following categories
are deemed to be | 11 |
| domestic companies:
| 12 |
| (1) a corporation under the laws of this State; or
| 13 |
| (2) a corporation organized under the laws of another | 14 |
| state, 30% of more
of the enrollees of which are residents | 15 |
| of this State, except a corporation
subject to | 16 |
| substantially the same requirements in its state of | 17 |
| organization as
is a domestic company under Article VIII | 18 |
| 1/2 of the Illinois Insurance Code.
| 19 |
| (Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
| 20 |
| Section 40. The Managed Care Reform and Patient Rights Act | 21 |
| is amended by changing Section 45 as follows:
| 22 |
| (215 ILCS 134/45)
| 23 |
| Sec. 45.
Health care services appeals,
complaints, and
| 24 |
| external independent reviews.
|
|
|
|
HB3650 Engrossed |
- 24 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| (a) A health care plan shall establish and maintain an | 2 |
| appeals procedure as
outlined in this Act. Compliance with this | 3 |
| Act's appeals procedures shall
satisfy a health care plan's | 4 |
| obligation to provide appeal procedures under any
other State | 5 |
| law or rules.
All appeals of a health care plan's | 6 |
| administrative determinations and
complaints regarding its | 7 |
| administrative decisions shall be handled as required
under | 8 |
| Section 50.
| 9 |
| (b) When an appeal concerns a decision or action by a | 10 |
| health care plan,
its
employees, or its subcontractors that | 11 |
| relates to (i) health care services,
including, but not limited | 12 |
| to, procedures or
treatments,
for an enrollee with an ongoing | 13 |
| course of treatment ordered
by a health care provider,
the | 14 |
| denial of which could significantly
increase the risk to an
| 15 |
| enrollee's health,
or (ii) a treatment referral, service,
| 16 |
| procedure, or other health care service,
the denial of which | 17 |
| could significantly
increase the risk to an
enrollee's health, | 18 |
| or (iii) the nonrenewal or termination of a plan,
the health | 19 |
| care plan must allow for the filing of an appeal
either orally | 20 |
| or in writing. Upon submission of the appeal, a health care | 21 |
| plan
must notify the party filing the appeal, as soon as | 22 |
| possible, but in no event
more than 24 hours after the | 23 |
| submission of the appeal, of all information
that the plan | 24 |
| requires to evaluate the appeal.
The health care plan shall | 25 |
| render a decision on the appeal within
24 hours after receipt | 26 |
| of the required information. The health care plan shall
notify |
|
|
|
HB3650 Engrossed |
- 25 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| the party filing the
appeal and the enrollee, enrollee's | 2 |
| primary care physician, and any health care
provider who | 3 |
| recommended the health care service involved in the appeal of | 4 |
| its
decision orally
followed-up by a written notice of the | 5 |
| determination.
| 6 |
| (c) For all appeals related to health care services | 7 |
| including, but not
limited to, procedures or treatments for an | 8 |
| enrollee and not covered by
subsection (b) above, the health | 9 |
| care
plan shall establish a procedure for the filing of such | 10 |
| appeals. Upon
submission of an appeal under this subsection, a | 11 |
| health care plan must notify
the party filing an appeal, within | 12 |
| 3 business days, of all information that the
plan requires to | 13 |
| evaluate the appeal.
The health care plan shall render a | 14 |
| decision on the appeal within 15 business
days after receipt of | 15 |
| the required information. The health care plan shall
notify the | 16 |
| party filing the appeal,
the enrollee, the enrollee's primary | 17 |
| care physician, and any health care
provider
who recommended | 18 |
| the health care service involved in the appeal orally of its
| 19 |
| decision followed-up by a written notice of the determination.
| 20 |
| (d) An appeal under subsection (b) or (c) may be filed by | 21 |
| the
enrollee, the enrollee's designee or guardian, the | 22 |
| enrollee's primary care
physician, or the enrollee's health | 23 |
| care provider. A health care plan shall
designate a clinical | 24 |
| peer to review
appeals, because these appeals pertain to | 25 |
| medical or clinical matters
and such an appeal must be reviewed | 26 |
| by an appropriate
health care professional. No one reviewing an |
|
|
|
HB3650 Engrossed |
- 26 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| appeal may have had any
involvement
in the initial | 2 |
| determination that is the subject of the appeal. The written
| 3 |
| notice of determination required under subsections (b) and (c) | 4 |
| shall
include (i) clear and detailed reasons for the | 5 |
| determination, (ii)
the medical or
clinical criteria for the | 6 |
| determination, which shall be based upon sound
clinical | 7 |
| evidence and reviewed on a periodic basis, and (iii) in the | 8 |
| case of an
adverse determination, the
procedures for requesting | 9 |
| an external independent review under subsection (f).
| 10 |
| (e) If an appeal filed under subsection (b) or (c) is | 11 |
| denied for a reason
including, but not limited to, the
service, | 12 |
| procedure, or treatment is not viewed as medically necessary,
| 13 |
| denial of specific tests or procedures, denial of referral
to | 14 |
| specialist physicians or denial of hospitalization requests or | 15 |
| length of
stay requests, any involved party may request an | 16 |
| external independent review
under subsection (f) of the adverse | 17 |
| determination.
| 18 |
| (f) External independent review.
| 19 |
| (1) The party seeking an external independent review | 20 |
| shall so notify the
health care plan.
The health care plan | 21 |
| shall seek to resolve all
external independent
reviews in | 22 |
| the most expeditious manner and shall make a determination | 23 |
| and
provide notice of the determination no more
than 24 | 24 |
| hours after the receipt of all necessary information when a | 25 |
| delay would
significantly increase
the risk to an | 26 |
| enrollee's health or when extended health care services for |
|
|
|
HB3650 Engrossed |
- 27 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| an
enrollee undergoing a
course of treatment prescribed by | 2 |
| a health care provider are at issue.
| 3 |
| (2) Within 30 days after the enrollee receives written | 4 |
| notice of an
adverse
determination,
if the enrollee decides | 5 |
| to initiate an external independent review, the
enrollee | 6 |
| shall send to the health
care plan a written request for an | 7 |
| external independent review, including any
information or
| 8 |
| documentation to support the enrollee's request for the | 9 |
| covered service or
claim for a covered
service.
| 10 |
| (3) Within 30 days after the health care plan receives | 11 |
| a request for an
external
independent review from an | 12 |
| enrollee, the health care plan shall:
| 13 |
| (A) provide a mechanism for joint selection of an | 14 |
| external independent
reviewer by the enrollee, the | 15 |
| enrollee's physician or other health care
provider,
| 16 |
| and the health care plan; and
| 17 |
| (B) forward to the independent reviewer all | 18 |
| medical records and
supporting
documentation | 19 |
| pertaining to the case, a summary description of the | 20 |
| applicable
issues including a
statement of the health | 21 |
| care plan's decision, the criteria used, and the
| 22 |
| medical and clinical reasons
for that decision.
| 23 |
| (4) Within 5 days after receipt of all necessary | 24 |
| information, the
independent
reviewer
shall evaluate and | 25 |
| analyze the case and render a decision that is based on
| 26 |
| whether or not the health
care service or claim for the |
|
|
|
HB3650 Engrossed |
- 28 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| health care service is medically appropriate. The
decision | 2 |
| by the
independent reviewer is final. If the external | 3 |
| independent reviewer determines
the health care
service to | 4 |
| be medically
appropriate, the health
care plan shall pay | 5 |
| for the health care service.
| 6 |
| (5) The health care plan shall be solely responsible | 7 |
| for paying the fees
of the external
independent reviewer | 8 |
| who is selected to perform the review.
| 9 |
| (6) An external independent reviewer who acts in good | 10 |
| faith shall have
immunity
from any civil or criminal | 11 |
| liability or professional discipline as a result of
acts or | 12 |
| omissions with
respect to any external independent review, | 13 |
| unless the acts or omissions
constitute wilful and wanton
| 14 |
| misconduct. For purposes of any proceeding, the good faith | 15 |
| of the person
participating shall be
presumed.
| 16 |
| (7) Future contractual or employment action by the | 17 |
| health care plan
regarding the
patient's physician or other | 18 |
| health care provider shall not be based solely on
the | 19 |
| physician's or other
health care provider's participation | 20 |
| in this procedure.
| 21 |
| (8) For the purposes of this Section, an external | 22 |
| independent reviewer
shall:
| 23 |
| (A) be a clinical peer;
| 24 |
| (B) have no direct financial interest in | 25 |
| connection with the case; and
| 26 |
| (C) have not been informed of the specific identity |
|
|
|
HB3650 Engrossed |
- 29 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| of the enrollee.
| 2 |
| (g) Nothing in this Section shall be construed to require a | 3 |
| health care
plan to pay for a health care service not covered | 4 |
| under the enrollee's
certificate of coverage or policy.
| 5 |
| (Source: P.A. 91-617, eff. 1-1-00.)
| 6 |
| Section 45. The Voluntary Health Services Plans Act is | 7 |
| amended by changing Section 10 as follows:
| 8 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
| 9 |
| (Text of Section before amendment by P.A. 95-958 )
| 10 |
| Sec. 10. Application of Insurance Code provisions. Health | 11 |
| services
plan corporations and all persons interested therein | 12 |
| or dealing therewith
shall be subject to the provisions of | 13 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | 14 |
| 149, 155.37, 354, 355.2, 356f.1, 356g.5, 356r, 356t, 356u, | 15 |
| 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | 16 |
| 356z.8, 356z.9,
356z.10, 356z.13
356z.11 , 356z.14,
364.01, | 17 |
| 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, | 18 |
| and paragraphs (7) and (15) of Section 367 of the Illinois
| 19 |
| Insurance Code.
| 20 |
| (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | 21 |
| 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | 22 |
| 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. 1-1-09; 95-1005, | 23 |
| eff. 12-12-08; revised 12-15-08.)
|
|
|
|
HB3650 Engrossed |
- 30 - |
LRB096 04626 RPM 14685 b |
|
| 1 |
| (Text of Section after amendment by P.A. 95-958 ) | 2 |
| Sec. 10. Application of Insurance Code provisions. Health | 3 |
| services
plan corporations and all persons interested therein | 4 |
| or dealing therewith
shall be subject to the provisions of | 5 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | 6 |
| 149, 155.37, 354, 355.2, 356f.1, 356g.5, 356r, 356t, 356u, | 7 |
| 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | 8 |
| 356z.8, 356z.9,
356z.10, 356z.11, 356z.12 , 356z.13
356z.11 , | 9 |
| 356z.14, 364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
| 10 |
| 408.2, and 412, and paragraphs (7) and (15) of Section 367 of | 11 |
| the Illinois
Insurance Code.
| 12 |
| (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | 13 |
| 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | 14 |
| 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, | 15 |
| eff. 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
| 16 |
| Section 95. No acceleration or delay. Where this Act makes | 17 |
| changes in a statute that is represented in this Act by text | 18 |
| that is not yet or no longer in effect (for example, a Section | 19 |
| represented by multiple versions), the use of that text does | 20 |
| not accelerate or delay the taking effect of (i) the changes | 21 |
| made by this Act or (ii) provisions derived from any other | 22 |
| Public Act. |
|