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90_HB0626eng
215 ILCS 125/2-1.1 new
215 ILCS 125/2-1.2 new
215 ILCS 125/2-1.3 new
215 ILCS 125/2-1.4 new
215 ILCS 125/2-1.5 new
215 ILCS 125/2-1.6 new
215 ILCS 125/2-1.7 new
215 ILCS 125/Art. VII heading new
215 ILCS 125/7-1 new
215 ILCS 125/7-5 new
215 ILCS 125/7-10 new
215 ILCS 125/7-15 new
215 ILCS 125/7-20 new
215 ILCS 125/7-25 new
215 ILCS 125/7-30 new
215 ILCS 125/7-35 new
215 ILCS 125/7-40 new
215 ILCS 125/4-6 rep.
Amends the Health Maintenance Organization Act.
Establishes requirements for disclosure of information to
subscribers and enrollees. Sets forth standards for the
handling of grievances by enrollees. Specifies procedures
and timelines. Establishes the procedures for terminating
health care professionals. Prohibits an organization from
restricting information that a health care provider may give
to a patient. Requires that an adequate network of providers
be maintained. Creates the Utilization Review Law. Sets
forth standards and procedures for determining whether
services are covered. Establishes timeframes for making
utilization review determinations. Sets forth requirements
for appeals from adverse decisions.
LRB9000248JSmb
HB0626 Engrossed LRB9000248JSmb
1 AN ACT relating to the delivery of health care services.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Managed Care Reform Act.
6 Section 5. Definitions. For purposes of this Act, the
7 following words shall have the meanings provided in this
8 Section, unless otherwise indicated:
9 "Adverse determination" means a determination by a
10 utilization review agent that an admission, extension of a
11 stay, or other health care service has been reviewed and,
12 based on the information provided, is not medically
13 necessary.
14 "Clinical peer reviewer" or "clinical personnel" means:
15 (1) in the case of physician reviewers, a State
16 licensed physician who is of the same category in the
17 same or similar specialty as the health care provider who
18 typically manages the medical condition, procedure or
19 treatment under review; or
20 (2) in the case of non-physician reviewers, a State
21 licensed or registered health care professional who is
22 in the same profession and same or similar specialty
23 as the health care provider who typically manages the
24 medical condition, procedure, or treatment under review.
25 Nothing herein shall be construed to change any
26 statutorily defined scope of practice.
27 "Culturally and linguistically competent care" means that
28 a managed care plan has staff and procedures in place to
29 provide all covered services and policy procedures in
30 English, Spanish, and any other language spoken as a primary
31 language by 5% or more of its enrollees.
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1 "Degenerative or disabling condition or disease" means a
2 condition or disease that is permanent or of indefinite
3 duration, that is likely to become worse or more advanced
4 over time, and that substantially impairs a major life
5 function.
6 "Department" means the Department of Public Health.
7 "Director" means the Director of Public Health.
8 "Emergency medical screening examination" means a medical
9 screening examination and evaluation by a physician or, to
10 the extent permitted by applicable laws, by other appropriate
11 personnel under the supervision of a physician to determine
12 whether the need for emergency services exists.
13 "Emergency services" means the provision of health care
14 services for sudden and, at the time, unexpected onset of a
15 health condition that would lead a prudent layperson to
16 believe that failure to receive immediate medical attention
17 would result in serious impairment to bodily function or
18 serious dysfunction of any body organ or part or would place
19 the person's health in serious jeopardy.
20 "Enrollee" means a person enrolled in a managed care
21 plan.
22 "Health care professional" means a physician, registered
23 professional nurse, or other person appropriately licensed or
24 registered pursuant to the laws of this State to provide
25 health care services.
26 "Health care provider" means a health care professional,
27 hospital, facility, or other person appropriately licensed or
28 otherwise authorized to furnish health care services or
29 arrange for the delivery of health care services in this
30 State.
31 "Health care services" means services included in the (i)
32 furnishing of medical care, (ii) hospitalization incident to
33 the furnishing of medical care, and (iii) furnishing of
34 services, including pharmaceuticals, for the purpose of
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1 preventing, alleviating, curing, or healing human illness or
2 injury to an individual.
3 "Informal policy or procedure" means a nonwritten policy
4 or procedure, the existence of which may be proven by an
5 admission of an authorized agent of a managed care plan or
6 statistical evidence supported by anecdotal evidence.
7 "Life threatening condition or disease" means any
8 condition, illness, or injury that, in the opinion of a
9 licensed physician, (i) may directly lead to a patient's
10 death, (ii) results in a period of unconsciousness which is
11 indeterminate at the present, or (iii) imposes severe pain or
12 an inhumane burden on the patient.
13 "Managed care plan" means a plan that establishes,
14 operates, or maintains a network of health care providers
15 that have entered into agreements with the plan to provide
16 health care services to enrollees where the plan has the
17 obligation to the enrollee to arrange for the provision of or
18 pay for services through:
19 (1) organizational arrangements for ongoing quality
20 assurance, utilization review programs, or dispute
21 resolution; or
22 (2) financial incentives for persons enrolled in
23 the plan to use the participating providers and
24 procedures covered by the plan.
25 A managed care plan may be established or operated by any
26 entity including, but not necessarily limited to, a licensed
27 insurance company, hospital or medical service plan, health
28 maintenance organization, limited health service
29 organization, preferred provider organization, third party
30 administrator, independent practice association, or employer
31 or employee organization.
32 For purposes of this definition, "managed care plan"
33 shall not include the following:
34 (1) strict indemnity health insurance policies or
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1 plans issued by an insurer that does not require approval
2 of a primary care provider or other similar coordinator
3 to access health care services; and
4 (2) managed care plans that offer only dental or
5 vision coverage.
6 "Post-stabilization services" means those health care
7 services determined by a treating provider to be promptly and
8 medically necessary following stabilization of an emergency
9 condition.
10 "Primary care provider" means a physician licensed to
11 practice medicine in all its branches who provides a broad
12 range of personal medical care (preventive, diagnostic,
13 curative, counseling, or rehabilitative) in a comprehensive
14 and coordinated manner over time for a managed care plan.
15 "Specialist" means a health care professional who
16 concentrates practice in a recognized specialty field of
17 care.
18 "Speciality care center" means only a center that is
19 accredited by an agency of the State or federal government or
20 by a voluntary national health organization as having special
21 expertise in treating the life-threatening disease or
22 condition or degenerative or disabling disease or condition
23 for which it is accredited.
24 "Utilization review" means the review, undertaken by a
25 entity other than the managed care plan itself, to determine
26 whether health care services that have been provided, are
27 being provided or are proposed to be provided to an
28 individual by a managed care plan, whether undertaken prior
29 to, concurrent with, or subsequent to the delivery of
30 such services are medically necessary. For the purposes
31 of this Act, none of the following shall be considered
32 utilization review:
33 (1) denials based on failure to obtain health care
34 services from a designated or approved health care
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1 provider as required under an enrollee's contract;
2 (2) the review of the appropriateness of the
3 application of a particular coding to a patient,
4 including the assignment of diagnosis and procedure;
5 (3) any issues relating to the determination of
6 the amount or extent of payment other than determinations
7 to deny payment based on an adverse determination; and
8 (4) any determination of any coverage issues other
9 than whether health care services are or were medically
10 necessary.
11 "Utilization review agent" means any company,
12 organization, or other entity performing utilization review,
13 except:
14 (1) an agency of the State or federal government;
15 (2) an agent acting on behalf of the federal
16 government, but only to the extent that the agent is
17 providing services to the federal government;
18 (3) an agent acting on behalf of the State and
19 local government for services provided pursuant to
20 Title XIX of the federal Social Security Act, but only to
21 the extent that the agent is providing services to the
22 State or local government;
23 (4) a hospital's internal quality assurance program
24 except if associated with a health care financing
25 mechanism.
26 "Utilization review plan" means:
27 (1) a description of the process for developing the
28 written clinical review criteria;
29 (2) a description of the types of written clinical
30 information which the plan might consider in its clinical
31 review including, but not limited to, a set of specific
32 written clinical review criteria;
33 (3) a description of practice guidelines and
34 standards used by a utilization review agent in making a
HB0626 Engrossed -6- LRB9000248JSmb
1 determination of medical necessity;
2 (4) the procedures for scheduled review and
3 evaluation of the written clinical review criteria; and
4 (5) a description of the qualifications and
5 experience of the health care professionals who
6 developed the criteria, who are responsible for periodic
7 evaluation of the criteria and of the health care
8 professionals or others who use the written clinical
9 review criteria in the process of utilization review.
10 Section 10. Disclosure of information.
11 (a) An enrollee, and upon request a prospective enrollee
12 prior to enrollment, shall be supplied with written
13 disclosure information, containing at least the information
14 specified in this Section, if applicable, which may be
15 incorporated into the member handbook or the enrollee
16 contract or certificate. All written descriptions shall be
17 in readable and understandable format, consistent with
18 standards developed for supplemental insurance coverage under
19 Title XVIII of the Social Security Act. The Department shall
20 promulgate rules to standardize this format so that potential
21 members can compare the attributes of the various managed
22 care entities. In the event of any inconsistency between any
23 separate written disclosure statement and the enrollee
24 contract or certificate, the terms of the enrollee
25 contract or certificate shall be controlling. The
26 information to be disclosed shall include, at a minimum,
27 all of the following:
28 (1) A description of coverage provisions, health
29 care benefits, benefit maximums, including benefit
30 limitations, and exclusions of coverage, including the
31 definition of medical necessity used in determining
32 whether benefits will be covered.
33 (2) A description of all prior authorization or
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1 other requirements for treatments, pharmaceuticals, and
2 services.
3 (3) A description of utilization review policies
4 and procedures used by the managed care plan,
5 including the circumstances under which utilization
6 review will be undertaken, the toll-free telephone
7 number of the utilization review agent, the timeframes
8 under which utilization review decisions must be made for
9 prospective, retrospective, and concurrent decisions,
10 the right to reconsideration, the right to an appeal,
11 including the expedited and standard appeals processes
12 and the timeframes for those appeals, the right to
13 designate a representative, a notice that all denials of
14 claims will be made by clinical personnel, and that
15 all notices of denials will include information about the
16 basis of the decision and further appeal rights, if any.
17 (4) A description prepared annually of the types of
18 methodologies the managed care plan uses to reimburse
19 providers specifying the type of methodology that is
20 used to reimburse particular types of providers or
21 reimburse for the provision of particular types of
22 services, provided, however, that nothing in this item
23 should be construed to require disclosure of individual
24 contracts or the specific details of any financial
25 arrangement between a managed care plan and a health care
26 provider.
27 (5) An explanation of a enrollee's financial
28 responsibility for payment of premiums, coinsurance,
29 co-payments, deductibles, and any other charges, annual
30 limits on an enrollee's financial responsibility, caps
31 on payments for covered services and financial
32 responsibility for non-covered health care procedures,
33 treatments, or services provided within the managed
34 care plan.
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1 (6) An explanation of an enrollee's financial
2 responsibility for payment when services are provided by
3 a health care provider who is not part of the managed
4 care plan or by any provider without required
5 authorization or when a procedure, treatment, or service
6 is not a covered health care benefit.
7 (7) A description of the grievance procedures to
8 be used to resolve disputes between a managed care plan
9 and an enrollee, including the right to file a
10 grievance regarding any dispute between an enrollee and a
11 managed care plan, the right to file a grievance
12 orally when the dispute is about referrals or covered
13 benefits, the toll-free telephone number that enrollees
14 may use to file an oral grievance, the timeframes and
15 circumstances for expedited and standard grievances, the
16 right to appeal a grievance determination and the
17 procedures for filing the appeal, the timeframes and
18 circumstances for expedited and standard appeals, the
19 right to designate a representative, a notice that all
20 disputes involving clinical decisions will be made by
21 clinical personnel, and that all notices of determination
22 will include information about the basis of the
23 decision and further appeal rights, if any.
24 (8) A description of the procedure for providing
25 care and coverage 24 hours a day for emergency services.
26 The description shall include the definition of
27 emergency services, notice that emergency services are
28 not subject to prior approval, and an explanation of
29 the enrollee's financial and other responsibilities
30 regarding obtaining those services, including when
31 those services are received outside the managed care
32 plan's service area.
33 (9) A description of procedures for enrollees to
34 select and access the managed care plan's primary and
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1 specialty care providers, including notice of how to
2 determine whether a participating provider is accepting
3 new patients.
4 (10) A description of the procedures for changing
5 primary and specialty care providers within the managed
6 care plan.
7 (11) Notice that an enrollee may obtain a referral
8 to a health care provider outside of the managed care
9 plan's network or panel when the managed care plan
10 does not have a health care provider with appropriate
11 training and experience in the network or panel to meet
12 the particular health care needs of the enrollee and
13 the procedure by which the enrollee can obtain the
14 referral.
15 (12) Notice that an enrollee with a condition
16 that requires ongoing care from a specialist may
17 request a standing referral to the specialist and
18 the procedure for requesting and obtaining a standing
19 referral.
20 (13) Notice that an enrollee with (i) a
21 life-threatening condition or disease or (ii) a
22 degenerative or disabling condition or disease, either of
23 which requires specialized medical care over a prolonged
24 period of time, may request a specialist responsible for
25 providing or coordinating the enrollee's medical care and
26 the procedure for requesting and obtaining the
27 specialist.
28 (14) A description of the mechanisms by which
29 enrollees may participate in the development of the
30 policies of the managed care plan.
31 (15) A description of how the managed care plan
32 addresses the needs of non-English speaking enrollees.
33 (16) Notice of all appropriate mailing addresses
34 and telephone numbers to be utilized by enrollees
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1 seeking information or authorization.
2 (17) A listing by specialty, which may be in a
3 separate document that is updated annually, of the name,
4 address, and telephone number of all participating
5 providers, including facilities, and, in addition, in the
6 case of physicians, category of license and board
7 certification, if applicable.
8 (b) Upon request of an enrollee or prospective enrollee,
9 a managed care plan shall do all of the following:
10 (1) Provide a list of the names, business
11 addresses, and official positions of the members of the
12 board of directors, officers, controlling persons,
13 owners, and partners of the managed care plan.
14 (2) Provide a copy of the most recent annual
15 certified financial statement of the managed care plan,
16 including a balance sheet and summary of receipts and
17 disbursements and the ratio of (i) premium dollars going
18 to administrative expenses to (ii) premium dollars going
19 to direct care, prepared by a certified public
20 accountant. The Department shall promulgate rules to
21 standardize the information that must be contained in the
22 statement and the statement's format.
23 (3) Provide information relating to consumer
24 complaints compiled in accordance with subsection (b) of
25 Section 30 of this Act and the rules promulgated under
26 this Act.
27 (4) Provide the procedures for protecting the
28 confidentiality of medical records and other enrollee
29 information.
30 (5) Allow enrollees and prospective enrollees to
31 inspect drug formularies used by the managed care plan
32 and disclose whether individual drugs are included or
33 excluded from coverage and whether a drug requires prior
34 authorization. An enrollee or prospective enrollee may
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1 seek information as to the inclusion or exclusion of a
2 specific drug. A managed care plan need only release the
3 information if the enrollee or prospective enrollee or
4 his or her dependent needs, used, or may need or use the
5 drug.
6 (6) Provide a written description of the
7 organizational arrangements and ongoing procedures of
8 the managed care plan's quality assurance program.
9 (7) Provide a description of the procedures
10 followed by the managed care plan in making decisions
11 about the experimental or investigational nature of
12 individual drugs, medical devices, or treatments in
13 clinical trials.
14 (8) Provide individual health care professional
15 affiliations with participating hospitals, if any.
16 (9) Upon written request, provide specific
17 written clinical review criteria relating to a
18 particular condition or disease and, where appropriate,
19 other clinical information that the managed care plan
20 might consider in its utilization review; the managed
21 care plan may include with the information a description
22 of how it will be used in the utilization review
23 process. An enrollee or prospective enrollee may seek
24 information as to specific clinical review criteria. A
25 managed care plan need only release the information if
26 the enrollee or prospective enrollee or his or her
27 dependent has, may have, or is at risk of contracting a
28 particular condition or disease.
29 (10) Provide the written application procedures and
30 minimum qualification requirements for health care
31 providers to be considered by the managed care plan.
32 (11) Disclose other information as required by
33 the Director.
34 (12) To the extent the information provided under
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1 item (5) or (9) of this subsection is proprietary to the
2 managed care plan, the enrollee or prospective enrollee
3 shall only use the information for the purposes of
4 assisting the enrollee or prospective enrollee in
5 evaluating the covered services provided by the managed
6 care plan. Any misuse of proprietary data is prohibited,
7 provided that the managed care plan has labeled or
8 identified the data as proprietary.
9 (c) Nothing in this Section shall prevent a managed care
10 plan from changing or updating the materials that are made
11 available to enrollees or prospective enrollees.
12 (d) If a primary care provider ceases participation in
13 the managed care plan, the managed care plan shall provide
14 written notice within 15 business days from the date that the
15 managed care plan becomes aware of the change in status to
16 each of the enrollees who have chosen the provider as
17 their primary care provider. If an enrollee is in an
18 ongoing course of treatment with any other participating
19 provider who becomes unavailable to continue to provide
20 services to the enrollee and the managed care plan is aware
21 of the ongoing course of treatment, the managed care plan
22 shall provide written notice within 15 business days from
23 the date that the managed care plan becomes aware of the
24 unavailability to the enrollee. The notice shall also
25 describe the procedures for continuing care.
26 (e) A managed care plan offering to indemnify enrollees
27 for non-participating provider services shall file a report
28 with the Director twice a year showing the percentage
29 utilization for the preceding 6 month period of
30 non-participating provider services in such form and
31 providing such other information as the Director shall
32 prescribe.
33 (f) The written information disclosure requirements of
34 this Section may be met by disclosure to one enrollee in a
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1 household.
2 Section 15. General grievance procedure.
3 (a) A managed care plan shall establish and maintain a
4 grievance procedure, as described in this Act. Compliance
5 with this Act's grievance procedures shall satisfy a managed
6 care plan's obligation to provide grievance procedures under
7 any other State law or rules.
8 A copy of the grievance procedures, including all forms
9 used to process a grievance, shall be filed with the
10 Director. Any subsequent material modifications to the
11 documents also shall be filed. In addition, a managed care
12 plan shall file annually with the Director a certificate of
13 compliance stating that the managed care plan has established
14 and maintains, for each of its plans, grievance procedures
15 that fully comply with the provisions of this Act. The
16 Director has authority to disapprove a filing that fails to
17 comply with this Act or applicable rules.
18 (b) A managed care plan shall provide written notice of
19 the grievance procedure to all enrollees in the member
20 handbook and to an enrollee at any time that the managed care
21 plan denies access to a referral or determines that a
22 requested benefit is not covered pursuant to the terms of the
23 contract. In the event that a managed care plan denies a
24 service as an adverse determination, the managed care plan
25 shall inform the enrollee or the enrollee's designee of
26 the appeal rights under this Act.
27 The notice to an enrollee describing the grievance
28 process shall explain the process for filing a grievance
29 with the managed care plan, the timeframes within which a
30 grievance determination must be made, and the right of an
31 enrollee to designate a representative to file a grievance on
32 behalf of the enrollee. Information required to be disclosed
33 or provided under this Section must be provided in a
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1 reasonable and understandable format.
2 The managed care plan shall assure that the grievance
3 procedure is reasonably accessible to those who do not speak
4 English.
5 (c) A managed care plan shall not retaliate or take
6 any discriminatory action against an enrollee because an
7 enrollee has filed a grievance or appeal.
8 Section 20. First level grievance review.
9 (a) The managed care plan may require an enrollee to
10 file a grievance in writing, by letter or by a grievance
11 form which shall be made available by the managed care plan,
12 however, an enrollee must be allowed to submit an oral
13 grievance in connection with (i) a denial of, or failure to
14 pay for, a referral or service or (ii) a determination as to
15 whether a benefit is covered pursuant to the terms of the
16 enrollee's contract. In connection with the submission of
17 an oral grievance, a managed care plan shall, within 24
18 hours, reduce the complaint to writing and give the enrollee
19 written acknowledgment of the grievance prepared by the
20 managed care plan summarizing the nature of the grievance
21 and requesting any information that the enrollee needs to
22 provide before the grievance can be processed. The
23 acknowledgment shall be mailed within the 24-hour period
24 to the enrollee, who shall sign and return the
25 acknowledgment, with any amendments and requested
26 information, in order to initiate the grievance. The
27 grievance acknowledgment shall prominently state that the
28 enrollee must sign and return the acknowledgment to
29 initiate the grievance. A managed care plan may elect not to
30 require a signed acknowledgment when no additional
31 information is necessary to process the grievance, and an
32 oral grievance shall be initiated at the time of the
33 telephone call.
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1 Except as authorized in this subsection, a managed care
2 plan shall designate personnel to accept the filing of an
3 enrollee's grievance by toll-free telephone no less than
4 40 hours per week during normal business hours and shall
5 have a telephone system available to take calls during other
6 than normal business hours and shall respond to all such
7 calls no later than the next business day after the call was
8 recorded. In the case of grievances subject to item (i) of
9 subsection (b) of this Section, telephone access must be
10 available on a 24 hour a day, 7 day a week basis.
11 (b) Within 48 hours of receipt of a written grievance,
12 the managed care plan shall provide written acknowledgment
13 of the grievance, including the name, address,
14 qualifying credentials, and telephone number of the
15 individuals or department designated by the managed care plan
16 to respond to the grievance. All grievances shall be
17 resolved in an expeditious manner, and in any event, no more
18 than (i) 24 hours after the receipt of all necessary
19 information when a delay would significantly increase the
20 risk to an enrollee's health or when extended health care
21 services, procedures, or treatments for an enrollee
22 undergoing a course of treatment prescribed by a health care
23 provider are at issue, (ii) 15 days after the receipt of all
24 necessary information in the case of requests for referrals
25 or determinations concerning whether a requested benefit
26 is covered pursuant to the contract, and (iii) 30 days after
27 the receipt of all necessary information in all other
28 instances.
29 (c) The managed care plan shall designate one or more
30 qualified personnel to review the grievance. When the
31 grievance pertains to clinical matters, the personnel shall
32 include, but not be limited to, one or more appropriately
33 licensed or registered health care professionals.
34 (d) The notice of a determination of the grievance
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1 shall be made in writing to the enrollee or to the enrollee's
2 designee. In the case of a determination made in conformance
3 with item (i) of subsection (b) of this Section, notice
4 shall be made by telephone directly to the enrollee with
5 written notice to follow within 2 business days.
6 (e) The notice of a determination shall include (i)
7 clear and detailed reasons for the determination, including
8 any contract basis for the determination, and the evidence
9 relied upon in making that determination, (ii) in cases where
10 the determination has a clinical basis, the clinical
11 rationale for the determination, and (iii) the procedures for
12 the filing of an appeal of the determination, including a
13 form for the filing of an appeal.
14 Section 25. Second level grievance review.
15 (a) A managed care plan shall establish a second level
16 grievance review process to give those enrollees who are
17 dissatisfied with the first level grievance review decision
18 the option to request a second level review, at which the
19 enrollee shall have the right to appear in person before
20 authorized individuals designated to respond to the appeal.
21 (b) An enrollee or an enrollee's designee shall
22 have not less than 60 days after receipt of notice of the
23 grievance determination to file a written appeal, which may
24 be submitted by letter or by a form supplied by the managed
25 care plan. The enrollee shall indicate in his or her written
26 appeal whether he or she wants the right to appear in person
27 before the person or panel designated to respond to the
28 appeal.
29 (c) Within 48 hours of receipt of the second level
30 grievance review, the managed care plan shall provide written
31 acknowledgment of the appeal, including the name, address,
32 qualifying credentials, and telephone number of the
33 individual designated by the managed care plan to respond
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1 to the appeal and what additional information, if any, must
2 be provided in order for the managed care plan to render a
3 decision.
4 (d) The determination of a second level grievance review
5 on a clinical matter must be made by personnel qualified
6 to review the appeal, including appropriately licensed or
7 registered health care professionals who did not make
8 the initial determination, a majority of whom must be
9 clinical peer reviewers. The determination of a second
10 level grievance review on a matter that is not clinical shall
11 be made by qualified personnel at a higher level than the
12 personnel who made the initial grievance determination.
13 (e) The managed care plan shall seek to resolve all
14 second level grievance reviews in the most expeditious manner
15 and shall make a determination and provide notice no more
16 than (i) 24 hours after the receipt of all necessary
17 information when a delay would significantly increase the
18 risk to an enrollee's health or when extended health care
19 services, procedures, or treatments for an enrollee
20 undergoing a course of treatment prescribed by a health care
21 provider are at issue and (ii) 30 business days after the
22 receipt of all necessary information in all other instances.
23 (f) The notice of a determination on a second level
24 grievance review shall include (i) the detailed reasons for
25 the determination, including any contract basis for the
26 determination and the evidence relied upon in making the
27 determination and (ii) in cases where the determination has a
28 clinical basis, the clinical rationale for the
29 determination.
30 (g) If an enrollee has requested the opportunity to
31 appear in person before the authorized representatives of the
32 managed care plan designated to respond to the appeal, the
33 review panel shall schedule and hold a review meeting within
34 30 days of receiving a request from an enrollee for a second
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1 level review with a right to appear. The review meeting
2 shall be held during regular business hours at a location
3 reasonably accessible to the enrollee. The enrollee shall be
4 notified in writing at least 14 days in advance of the review
5 date.
6 Upon the request of an enrollee, a managed care plan
7 shall provide to the enrollee all relevant information that
8 is not confidential or privileged.
9 An enrollee has the right to:
10 (1) attend the second level review;
11 (2) present his or her case to the review panel;
12 (3) submit supporting material both before and at
13 the review meeting;
14 (4) ask questions of any representative of the
15 managed care plan; and
16 (5) be assisted or represented by persons of his or
17 her choice.
18 The notice shall advise the enrollee of the rights
19 specified in this subsection.
20 If the managed care plan desires to have an attorney
21 present to represent its interests, it shall notify the
22 enrollee at least 14 days in advance of the review that an
23 attorney will be present and that the enrollee may wish to
24 obtain legal representation of his or her own.
25 Section 30. Grievance register and reporting
26 requirements.
27 (a) A managed care plan shall maintain a register
28 consisting of a written record of all complaints initiated
29 during the past 3 years. The register shall be maintained in
30 a manner that is reasonably clear and accessible to the
31 Director. The register shall include at a minimum the
32 following:
33 (1) the name of the enrollee;
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1 (2) a description of the reason for the complaint;
2 (3) the dates when first level and second level
3 review were requested and completed;
4 (4) a copy of the written decision rendered at each
5 level of review;
6 (5) if required time limits were exceeded, an
7 explanation of why they were exceeded and a copy of the
8 enrollee's consent to an extension of time;
9 (6) whether expedited review was requested and the
10 response to the request;
11 (7) whether the complaint resulted in litigation
12 and the result of the litigation.
13 (b) A managed care plan shall report annually to the
14 Department the numbers, and related information where
15 indicated, for the following:
16 (1) covered lives;
17 (2) total complaints initiated;
18 (3) total complaints involving medical necessity or
19 appropriateness;
20 (4) complaints involving termination or reduction
21 of inpatient hospital services;
22 (5) complaints involving termination or reduction
23 of other health care services;
24 (6) complaints involving denial of health care
25 services where the enrollee had not received the services
26 at the time the complaint was initiated;
27 (7) complaints involving payment for health care
28 services that the enrollee had already received at the
29 time of initiating the complaint;
30 (8) complaints resolved at each level of review and
31 how they were resolved;
32 (9) complaints where expedited review was provided
33 because adherence to regular time limits would have
34 jeopardized the enrollee's life, health, or ability to
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1 regain maximum function; and
2 (10) complaints that resulted in litigation and the
3 outcome of the litigation.
4 The Department shall promulgate rules regarding the
5 format of the report, the timing of the report, and other
6 matters related to the report.
7 Section 35. External independent review.
8 (a) If an enrollee's or enrollee's designee's request
9 for a covered service or claim for a covered service is
10 denied under the grievance review under Section 25 because
11 the service is not viewed as medically necessary, the
12 enrollee may initiate an external independent review.
13 (b) Within 30 days after the enrollee receives written
14 notice of such an adverse decision made under the second
15 level grievance review procedures of Section 25, if the
16 enrollee decides to initiate an external independent review,
17 the enrollee shall send to the managed care plan a written
18 request for an external independent review, including any
19 material justification or documentation to support the
20 enrollee's request for the covered service or claim for a
21 covered service.
22 (c) Within 30 days after the managed care plan receives
23 a request for an external independent review from an
24 enrollee, the managed care plan shall:
25 (1) provide a mechanism for jointly selecting an
26 external independent reviewer by the enrollee, primary
27 care physician, and managed care plan; and
28 (2) forward to the independent reviewer all medical
29 records and supporting documentation pertaining to the
30 case, a summary description of the applicable issues
31 including a statement of the managed care plan's
32 decision, and the criteria used and the clinical reasons
33 for that decision.
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1 (d) Within 5 days of receipt of all necessary
2 information, the independent reviewer or reviewers shall
3 evaluate and analyze the case and render a decision that is
4 based on whether or not the service or claim for the service
5 is medically necessary. The decision by the independent
6 reviewer or reviewers is final.
7 (e) Pursuant to subsection (c) of this Section, an
8 external independent reviewer shall:
9 (1) have no direct financial interest in or
10 connection to the case;
11 (2) be State licensed physicians, who are board
12 certified or board eligible by the appropriate American
13 Medical Specialty Board, if applicable, and who are in
14 the same or similar scope of practice as a physician who
15 typically manages the medical condition, procedure, or
16 treatment under review; and
17 (3) have not been informed of the specific identity
18 of the enrollee or the enrollee's treating provider.
19 (f) If an appropriate reviewer pursuant to subsection
20 (e) of this Section for a particular case is not on the list
21 established by the Director, the parties shall choose a
22 reviewer who is mutually acceptable.
23 Section 40. Independent reviewers.
24 (a) From information filed with the Director on or
25 before March 1 of each year, the Director shall compile a
26 list of external independent reviewers and organizations that
27 represent external independent reviewers from lists provided
28 by managed care plans and by any State and county public
29 health department and State medical associations that wish to
30 submit a list to the Director. The Director may consult with
31 other persons about the suitability of any reviewer or any
32 potential reviewer. The Director shall annually review the
33 list and add and remove names as appropriate. On or before
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1 June 1 of each year, the Director shall publish the list in
2 the Illinois Register.
3 (b) The managed care plan shall be solely responsible
4 for paying the fees of the external independent reviewer who
5 is selected to perform the review.
6 (c) An external independent reviewer who acts in good
7 faith shall have immunity from any civil or criminal
8 liability or professional discipline as a result of acts or
9 omissions with respect to any external independent review,
10 unless the acts or omissions constitute wilful and wanton
11 misconduct. For purposes of any proceeding, the good faith
12 of the person participating shall be presumed.
13 (d) The Director's decision to add a name to or remove a
14 name from the list of independent reviewers pursuant to
15 subsection (a) is not subject to administrative appeal or
16 judicial review.
17 Section 45. Health care professional applications and
18 terminations.
19 (a) A managed care plan shall, upon request, make
20 available and disclose to health care professionals written
21 application procedures and minimum qualification
22 requirements that a health care professional must meet in
23 order to be considered by the managed care plan. The
24 managed care plan shall consult with appropriately qualified
25 health care professionals in developing its qualification
26 requirements.
27 (b) A managed care plan may not terminate a contract of
28 employment or refuse to renew a contract on the basis of any
29 action protected under Section 50 of this Act or solely
30 because a health care professional has:
31 (1) filed a complaint against the managed care
32 plan;
33 (2) appealed a decision of the managed care plan;
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1 or
2 (3) requested a hearing pursuant to this Section.
3 (c) A managed care plan shall provide to a health care
4 professional, in writing, the reasons for the contract
5 termination or non-renewal.
6 (d) A managed care plan shall provide an opportunity
7 for a hearing to any health care professional terminated by
8 the managed care plan, or non-renewed if the health care
9 professional has had a contract or contracts with the managed
10 care plan for at least 24 of the past 36 months.
11 (e) After the notice provided pursuant to subsection
12 (c), the health care professional shall have 21 days to
13 request a hearing, and the hearing must be held within 15
14 days after receipt of the request for a hearing. The hearing
15 shall be held before a panel appointed by the managed care
16 plan.
17 The hearing panel shall be composed of 5 individuals, the
18 majority of whom shall be clinical peer reviewers and, to the
19 extent possible, in the same discipline and the same or
20 similar specialty as the health care professional under
21 review.
22 The hearing panel shall render a written decision on the
23 proposed action within 14 business days. The decision shall
24 be one of the following:
25 (1) reinstatement of the health care professional
26 by the managed care plan;
27 (2) provisional reinstatement subject to
28 conditions set forth by the panel; or
29 (3) termination of the health care professional.
30 The decision of the hearing panel shall be final.
31 A decision by the hearing panel to terminate a health
32 care professional shall be effective not less than 15 days
33 after the receipt by the health care professional of the
34 hearing panel's decision.
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1 A hearing under this subsection shall provide the health
2 care professional in question with the right to examine
3 pertinent information, to present witnesses, and to ask
4 questions of an authorized representative of the plan.
5 (f) A managed care plan may terminate or decline to
6 renew a health care professional, without a prior hearing, in
7 cases involving imminent harm to patient care, a
8 determination of intentional falsification of reports to the
9 plan or a final disciplinary action by a state licensing
10 board or other governmental agency that impairs the health
11 care professional's ability to practice. A professional
12 terminated for one of the these reasons shall be given
13 written notice to that effect. Within 21 days after the
14 termination, a health care professional terminated because of
15 imminent harm to patient care or a determination of
16 intentional falsification of reports to the plan shall
17 receive a hearing. The hearing shall be held before a panel
18 appointed by the managed care plan. The panel shall be
19 composed of 5 individuals the majority of whom shall be
20 clinical peer reviewers and, to the extent possible, in the
21 same discipline and the same or similar specialty as the
22 health care professional under review. The hearing panel
23 shall render a decision on the proposed action within 14
24 days. The panel shall issue a written decision either
25 supporting the termination or ordering the health care
26 professional's reinstatement. The decision of the hearing
27 panel shall be final.
28 If the hearing panel upholds the managed care plan's
29 termination of the health care professional under this
30 subsection, the managed care plan shall forward the decision
31 to the appropriate professional disciplinary agency in
32 accordance with subsection (b) of Section 60.
33 Any hearing under this subsection shall provide the
34 health care professional in question with the right to
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1 examine pertinent information, to present witnesses, and to
2 ask questions of an authorized representative of the plan.
3 For any hearing under this Section, because the candid
4 and conscientious evaluation of clinical practices is
5 essential to the provision of health care, it is the policy
6 of this State to encourage peer review by health care
7 professionals. Therefore, no managed care plan and no
8 individual who participates in a hearing or who is a member,
9 agent, or employee of a managed care plan shall be liable for
10 criminal or civil damages or professional discipline as a
11 result of the acts, omissions, decisions, or any other
12 conduct, direct or indirect, associated with a hearing panel,
13 except for wilful and wanton misconduct. Nothing in this
14 Section shall relieve any person, health care provider,
15 health care professional, facility, organization, or
16 corporation from liability for his, her, or its own
17 negligence in the performance of his, her, or its duties or
18 arising from treatment of a patient. The hearing panel
19 information shall not be subject to inspection or disclosure
20 except upon formal written request by an authorized
21 representative of a duly authorized State agency or pursuant
22 to a court order issued in a pending action or proceeding.
23 (g) A managed care plan shall develop and implement
24 policies and procedures to ensure that health care
25 professionals are at least annually informed of information
26 maintained by the managed care plan to evaluate the
27 performance or practice of the health care professional. The
28 managed care plan shall consult with health care
29 professionals in developing methodologies to collect and
30 analyze health care professional data. Managed care plans
31 shall provide the information and data and analysis to health
32 care professionals. The information, data, or analysis
33 shall be provided on at least an annual basis in a format
34 appropriate to the nature and amount of data and the volume
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1 and scope of services provided. Any data used to evaluate
2 the performance or practice of a health care professional
3 shall be measured against stated criteria and a comparable
4 group of health care professionals who use similar treatment
5 modalities and serve a comparable patient population. Upon
6 receipt of the information or data, a health care
7 professional shall be given the opportunity to explain the
8 unique nature of the health care professional's patient
9 population that may have a bearing on the health care
10 professional's data and to work cooperatively with the
11 managed care plan to improve performance.
12 (h) Any contract provision or procedure or informal
13 policy or procedure in violation of this Section violates the
14 public policy of the State of Illinois and is void and
15 unenforceable.
16 Section 50. Prohibitions.
17 (a) No managed care plan shall by contract, written
18 policy or written procedure, or informal policy or procedure
19 prohibit or restrict any health care provider from
20 disclosing to any enrollee, patient, designated
21 representative or, where appropriate, prospective
22 enrollee, (hereinafter collectively referred to as
23 enrollee) any information that the provider deems appropriate
24 regarding:
25 (1) a condition or a course of treatment with an
26 enrollee including the availability of other therapies,
27 consultations, or tests; or
28 (2) the provisions, terms, or requirements of the
29 managed care plan's products as they relate to the
30 enrollee, where applicable.
31 (b) No managed care plan shall by contract, written
32 policy or procedure, or informal policy or procedure prohibit
33 or restrict any health care provider from filing a
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1 complaint, making a report, or commenting to an appropriate
2 governmental body regarding the policies or practices of the
3 managed care plan that the provider believes may
4 negatively impact upon the quality of, or access to, patient
5 care.
6 (c) No managed care plan shall by contract, written
7 policy or procedure, or informal policy or procedure prohibit
8 or restrict any health care provider from advocating to the
9 managed care plan on behalf of the enrollee for approval or
10 coverage of a particular course of treatment or for the
11 provision of health care services.
12 (d) No contract or agreement between a managed care
13 plan and a health care provider shall contain any clause
14 purporting to transfer to the health care provider by
15 indemnification or otherwise any liability relating to
16 activities, actions, or omissions of the managed care plan
17 as opposed to those of the health care provider.
18 (e) No contract between a managed care plan and a health
19 care provider shall contain any incentive plan that includes
20 specific payment made directly, in any form, to a health care
21 provider as an inducement to deny, reduce, limit, or delay
22 specific, medically necessary and appropriate services
23 provided with respect to a specific enrollee or groups of
24 enrollees with similar medical conditions. Nothing in this
25 Section shall be construed to prohibit contracts that contain
26 incentive plans that involve general payments, such as
27 capitation payments or shared-risk arrangements, that are not
28 tied to specific medical decisions involving specific
29 enrollees or groups of enrollees with similar medical
30 conditions. The payments rendered or to be rendered to
31 health care provider under these arrangements shall be deemed
32 confidential information.
33 (f) No managed care plan shall by contract, written
34 policy or procedure, or informal policy or procedure permit,
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1 allow, or encourage an individual or entity to dispense a
2 different drug in place of the drug or brand of drug ordered
3 or prescribed without the express permission of the person
4 ordering or prescribing, except this prohibition does not
5 prohibit the interchange of different brands of the same
6 generically equivalent drug product, as provided under
7 Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
8 (g) Any contract provision, written policy or
9 procedure, or informal policy or procedure in violation of
10 this Section violates the public policy of the State of
11 Illinois and is void and unenforceable.
12 Section 55. Network of providers.
13 (a) At least once every 3 years, and upon application
14 for expansion of service area, a managed care plan shall
15 obtain certification from the Director of Public Health that
16 the managed care plan maintains a network of health care
17 providers and facilities adequate to meet the comprehensive
18 health needs of its enrollees and to provide an appropriate
19 choice of providers sufficient to provide the services
20 covered under its enrollee's contracts by determining that:
21 (1) there are a sufficient number of geographically
22 accessible participating providers and facilities;
23 (2) there are opportunities to select from at least
24 3 primary care providers pursuant to travel and
25 distance time standards, providing that these standards
26 account for the conditions of accessing providers in
27 rural areas; and
28 (3) there are sufficient providers in all covered
29 areas of specialty practice to meet the needs of the
30 enrollment population.
31 (b) The following criteria shall be considered by the
32 Director of Public Health at the time of a review:
33 (1) provider-enrollee ratios by specialty;
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1 (2) primary care provider-enrollee ratios;
2 (3) safe and adequate staffing of health care
3 providers in all participating facilities based on:
4 (A) severity of patient illness and functional
5 capacity;
6 (B) factors affecting the period and quality
7 of patient recovery; and
8 (C) any other factor substantially related to
9 the condition and health care needs of patients;
10 (4) geographic accessibility;
11 (5) the number of grievances filed by enrollees
12 relating to waiting times for appointments,
13 appropriateness of referrals, and other indicators of a
14 managed care plan's capacity;
15 (6) hours of operation;
16 (7) the managed care plan's ability to provide
17 culturally and linguistically competent care to meet the
18 needs of its enrollee population; and
19 (8) the volume of technological and speciality
20 services available to serve the needs of enrollees
21 requiring technologically advanced or specialty care.
22 (c) A managed care plan shall report on an annual basis
23 the number of enrollees and the number of participating
24 providers in the managed care plan.
25 (d) If a managed care plan determines that it does not
26 have a health care provider with appropriate training and
27 experience in its panel or network to meet the particular
28 health care needs of an enrollee, the managed care plan
29 shall make a referral to an appropriate provider, pursuant to
30 a treatment plan approved by the primary care provider, in
31 consultation with the managed care plan, the
32 non-participating provider, and the enrollee or enrollee's
33 designee, at no additional cost to the enrollee beyond what
34 the enrollee would otherwise pay for services received within
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1 the network.
2 (e) A managed care plan shall have a procedure by which
3 an enrollee who needs ongoing health care services,
4 provided or coordinated by a specialist focused on a specific
5 organ system, disease or condition, shall receive a referral
6 to the specialist. If the primary care provider, after
7 consultation with the medical director or other
8 contractually authorized representative of the managed care
9 plan, determines that a referral is appropriate, the primary
10 care provider shall make such a referral to a specialist. In
11 no event shall a managed care plan be required to permit
12 an enrollee to elect to have a non-participating
13 specialist, except pursuant to the provisions of subsection
14 (d). The referral made under this subsection shall be
15 pursuant to a treatment plan approved by the enrollee or
16 enrollee's designee, the primary care provider, and the
17 specialist in consultation with the managed care plan. The
18 treatment plan shall authorize the specialist to treat the
19 ongoing injury, disease, or condition. It also may limit the
20 number of visits or the period during which visits are
21 authorized and may require the specialists to provide the
22 primary care provider with regular updates on the specialty
23 care provided, as well as all necessary medical information.
24 (f) A managed care plan shall have a procedure by which
25 a new enrollee, upon enrollment, or an enrollee, upon
26 diagnosis, with (i) a life-threatening condition or disease
27 or (ii) a degenerative or disabling condition or disease,
28 either of which requires specialized medical care over a
29 prolonged period of time shall receive a standing referral to
30 a specialist with expertise in treating the life-threatening
31 condition or disease or degenerative or disabling condition
32 or disease who shall be responsible for and capable of
33 providing and coordinating the enrollee's primary and
34 specialty care. If the primary care provider, after
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1 consultation with the enrollee or enrollee's designee and
2 medical director or other contractually authorized
3 representative of the managed care plan, determines that the
4 enrollee's care would most appropriately be coordinated
5 by a specialist, the primary care provider shall refer, on a
6 standing basis, the enrollee to a specialist. In no event
7 shall a managed care plan be required to permit an enrollee
8 to elect to have a non-participating specialist, except
9 pursuant to the provisions of subsection (d). The
10 specialist shall be permitted to treat the enrollee
11 without a referral from the enrollee's primary care
12 provider and shall be authorized to make such referrals,
13 procedures, tests, and other medical services as the
14 enrollee's primary care provider would otherwise be
15 permitted to provide or authorize including, if
16 appropriate, referral to a specialty care center. If a
17 primary care provider refers an enrollee to a
18 non-participating provider pursuant to the provisions of
19 subsection (d), the standing referral shall be pursuant to a
20 treatment plan approved by the enrollee or enrollee's
21 designee and specialist, in consultation with the managed
22 care plan. Services provided pursuant to the approved
23 treatment plan shall be provided at no additional cost to
24 the enrollee beyond what the enrollee would otherwise pay
25 for services received within the network.
26 (g) If an enrollee's health care provider leaves the
27 managed care plan's network of providers for reasons other
28 than those for which the provider would not be eligible to
29 receive a pre-termination hearing pursuant to subsection (f)
30 of Section 45, the managed care plan shall permit the
31 enrollee to continue an ongoing course of treatment
32 with the enrollee's current health care provider during a
33 transitional period of:
34 (1) up to 90 days from the date of notice to the
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1 enrollee of the provider's disaffiliation from the
2 managed care plan's network; or
3 (2) if the enrollee has entered the second trimester
4 of pregnancy at the time of the provider's
5 disaffiliation, for a transitional period that
6 includes the provision of post-partum care directly
7 related to the delivery.
8 Transitional care, however, shall be authorized by the
9 managed care plan during the transitional period only if the
10 health care provider agrees (i) to continue to accept
11 reimbursement from the managed care plan at the rates
12 applicable prior to the start of the transitional period
13 as payment in full, (ii) to adhere to the managed care plan's
14 quality assurance requirements and to provide to the managed
15 care plan necessary medical information related to the care,
16 (iii) to otherwise adhere to the managed care plan's
17 policies and procedures including, but not limited to,
18 procedures regarding referrals and obtaining
19 pre-authorization and a treatment plan approved by the
20 primary care provider or specialist in consultation with the
21 managed care plan, and (iv) if the enrollee is a recipient of
22 services under Article V of the Illinois Public Aid Code, the
23 health care provider has not been subject to a final
24 disciplinary action by a state or federal agency for
25 violations of the Medicaid or Medicare program.
26 (h) If a new enrollee whose health care provider is not
27 a member of the managed care plan's provider network enrolls
28 in the managed care plan, the managed care plan shall permit
29 the enrollee to continue an ongoing course of treatment with
30 the enrollee's current health care provider during a
31 transitional period of up to 90 days from the effective
32 date of enrollment, if (i) the enrollee has a
33 life-threatening disease or condition or a degenerative or
34 disabling disease or condition or (ii) the enrollee has
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1 entered the second trimester of pregnancy at the effective
2 date of enrollment, in which case the transitional period
3 shall include the provision of post-partum care directly
4 related to the delivery. If an enrollee elects to continue
5 to receive payment for care from a health care provider
6 pursuant to this subsection, the care shall be authorized by
7 the managed care plan for the transitional period only if
8 the health care provider agrees (i) to accept reimbursement
9 from the managed care plan at rates established by the
10 managed care plan as payment in full, which rates shall be no
11 more than the level of reimbursement applicable to similar
12 providers within the managed care plan's network for
13 those services, (ii) to adhere to the managed care plan's
14 quality assurance requirements and agrees to provide to the
15 managed care plan necessary medical information related to
16 the care, (iii) to otherwise adhere to the managed care
17 plan's policies and procedures including, but not limited
18 to, procedures regarding referrals and obtaining
19 pre-authorization and a treatment plan approved by the
20 primary care provider or specialist, in consultation with the
21 managed care plan, and (iv) if the enrollee is a recipient of
22 services under Article V of the Illinois Public Aid Code, the
23 health care provider has not been subject to a final
24 disciplinary action by a state or federal agency for
25 violations of the Medicaid or Medicare program. In no
26 event shall this subsection be construed to require a managed
27 care plan to provide coverage for benefits not otherwise
28 covered or to diminish or impair pre-existing condition
29 limitations contained within the enrollee's contract.
30 Section 60. Duty to report.
31 (a) A managed care plan shall report to the
32 appropriate professional disciplinary agency, after
33 compliance and in accordance with the provisions of this
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1 Section:
2 (1) termination of a health care provider contract
3 for commission of an act or acts that may directly
4 threaten patient care, and not of an administrative
5 nature, or that a person may be mentally or physically
6 disabled in such a manner as to endanger a patient under
7 that person's care;
8 (2) voluntary or involuntary termination of a
9 contract or employment or other affiliation with the
10 managed care plan to avoid the imposition of disciplinary
11 measures.
12 The managed care plan shall only make the report after it
13 has provided the health care professional with a hearing on
14 the matter. (This hearing shall not impair or limit the
15 managed care plan's ability to terminate the professional.
16 Its purpose is solely to ensure that a sufficient basis
17 exists for making the report.) The hearing shall be held
18 before a panel appointed by the managed care plan. The
19 hearing panel shall be composed of 5 persons appointed by the
20 plan, the majority of whom shall be clinical peer reviewers,
21 to the extent possible, in the same discipline and the same
22 specialty as the health care professional under review. The
23 hearing panel shall determine whether the proposed basis for
24 the report is supported by a preponderance of the evidence.
25 The panel shall render its determination within 14 days. If
26 a majority of the panel finds the proposed basis for the
27 report is supported by a preponderance of the evidence, the
28 managed care plan shall make the required report within 21
29 days.
30 Any hearing under this Section shall provide the health
31 care professional in question with the right to examine
32 pertinent information, to present witnesses, and to ask
33 questions of an authorized representative of the plan.
34 If a hearing has been held pursuant to subsection (f) of
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1 Section 45 and the hearing panel sustained a plan's
2 termination of a health care professional, no additional
3 hearing is required, and the plan shall make the report
4 required under this Section.
5 (b) Reports made pursuant to this Section shall be made
6 in writing to the appropriate professional disciplinary
7 agency. Written reports shall include the name, address,
8 profession, and license number of the individual and a
9 description of the action taken by the managed care plan,
10 including the reason for the action and the date thereof, or
11 the nature of the action or conduct that led to the
12 resignation, termination of contract, or withdrawal, and the
13 date thereof.
14 For any hearing under this Section, because the candid
15 and conscientious evaluation of clinical practices is
16 essential to the provision of health care, it is the policy
17 of this State to encourage peer review by health care
18 professionals. Therefore, no managed care plan and no
19 individual who participates in a hearing or who is a member,
20 agent, or employee of a managed care plan shall be liable for
21 criminal or civil damages or professional discipline as a
22 result of the acts, omissions, decisions, or any other
23 conduct, direct or indirect, associated with a hearing panel,
24 except for wilful and wanton misconduct. Nothing in this
25 Section shall relieve any person, health care provider,
26 health care professional, facility, organization, or
27 corporation from liability for his, her, or its own
28 negligence in the performance of his, her, or its duties or
29 arising from treatment of a patient. The hearing panel
30 information shall not be subject to inspection or disclosure
31 except upon formal written request by an authorized
32 representative of a duly authorized State agency or pursuant
33 to a court order issued in a pending action or proceeding.
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1 Section 65. Disclosure of information.
2 (a) A health care professional affiliated with a
3 managed care plan shall make available, in written form at
4 his or her office, to his or her patients or prospective
5 patients the following:
6 (1) information related to the health care
7 professional's educational background, experience,
8 training, specialty and board certification, if
9 applicable, number of years in practice, and hospitals
10 where he or she has privileges;
11 (2) information regarding the health care
12 professional's participation in continuing education
13 programs and compliance with any licensure,
14 certification, or registration requirements, if
15 applicable;
16 (3) information regarding the health care
17 professional's participation in clinical performance
18 reviews conducted by the Department, where applicable and
19 available; and
20 (4) the location of the health care professional's
21 primary practice setting and the identification of any
22 translation services available.
23 Section 70. Registration of utilization review agents.
24 (a) A utilization review agent who conducts the practice
25 of utilization review shall biennially register with the
26 Director and report, in a statement subscribed and affirmed
27 as true under the penalties of perjury, the information
28 required pursuant to subsection (b) of this Section.
29 (b) The report shall contain a description of the
30 following:
31 (1) the utilization review plan;
32 (2) a description of the grievance procedures by
33 which an enrollee, the enrollee's designee, or his or her
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1 health care provider may seek reconsideration of adverse
2 determinations by the utilization review agent in
3 accordance with this Act;
4 (3) procedures by which a decision on a request for
5 utilization review for services requiring
6 pre-authorization shall comply with timeframes
7 established pursuant to this Act;
8 (4) a description of an emergency care policy,
9 consistent with this Act.
10 (5) a description of personnel utilized to conduct
11 utilization review, including a description of the
12 circumstances under which utilization review may be
13 conducted by:
14 (A) administrative personnel,
15 (B) health care professionals who are not
16 clinical peer reviewers, and
17 (C) clinical peer reviewers;
18 (6) a description of the mechanisms employed to
19 assure that administrative personnel are trained in the
20 principles and procedures of intake screening and data
21 collection and are appropriately monitored by a
22 licensed health care professional while performing an
23 administrative review;
24 (7) a description of the mechanisms employed to
25 assure that health care professionals conducting
26 utilization review are:
27 (A) appropriately licensed or registered; and
28 (B) trained in the principles, procedures,
29 and standards of the utilization review agent;
30 (8) a description of the mechanisms employed to
31 assure that only a clinical peer reviewer shall render an
32 adverse determination;
33 (9) provisions to ensure that appropriate personnel
34 of the utilization review agent are reasonably accessible
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1 by toll-free telephone:
2 (A) not less than 40 hours per week during
3 normal business hours, to discuss patient care and
4 allow response to telephone requests, and to ensure
5 that the utilization review agent has a telephone
6 system capable of accepting, recording, or providing
7 instruction to incoming telephone calls during
8 other than normal business hours and to ensure
9 response to accepted or recorded messages not later
10 than the next business day after the date on which
11 the call was received; or
12 (B) notwithstanding the provisions of item (A),
13 in the case of a request submitted pursuant to
14 subsection (c) of Section 80 or an expedited appeal
15 filed pursuant to subsection (b) of Section 85, a
16 response is provided within 24 hours;
17 (10) the policies and procedures to ensure that
18 all applicable State and federal laws to protect the
19 confidentiality of individual medical and treatment
20 records are followed;
21 (11) a copy of the materials to be disclosed to an
22 enrollee or prospective enrollee pursuant to this Act;
23 (12) a description of the mechanisms employed by
24 the utilization review agent to assure that all
25 contractors, subcontractors, subvendors, agents, and
26 employees affiliated by contract or otherwise with such
27 utilization review agent will adhere to the standards and
28 requirements of this Act; and
29 (13) a list of the payors for which the
30 utilization review agent is performing utilization
31 review in this State.
32 (c) Upon receipt of the report, the Director
33 shall issue an acknowledgment of the filing.
34 (d) A registration issued under this Act shall be valid
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1 for a period of not more than 2 years, and may be renewed for
2 additional periods of not more than 2 years each.
3 Section 75. Utilization review program standards.
4 (a) A utilization review agent shall adhere to
5 utilization review program standards consistent with the
6 provisions of this Act, which shall, at a minimum, include:
7 (1) appointment of a medical director, who is a
8 licensed physician; provided, however, that the
9 utilization review agent may appoint a clinical director
10 when the utilization review performed is for a discrete
11 category of health care service and provided further that
12 the clinical director is a licensed health care
13 professional who typically manages the category of
14 service; responsibilities of the medical director, or,
15 where appropriate, the clinical director, shall
16 include, but not be limited to, the supervision and
17 oversight of the utilization review process;
18 (2) development of written policies and procedures
19 that govern all aspects of the utilization review
20 process and a requirement that a utilization review
21 agent shall maintain and make available to enrollees and
22 health care providers a written description of the
23 procedures, including the procedures to appeal an adverse
24 determination;
25 (3) utilization of written clinical review criteria
26 developed pursuant to a utilization review plan;
27 (4) consistent with the applicable Sections of this
28 Act, establishment of a process for rendering utilization
29 review determinations, which shall, at a minimum,
30 include written procedures to assure that utilization
31 reviews and determinations are conducted within the
32 required timeframes, procedures to notify an enrollee,
33 an enrollee's designee, and an enrollee's health care
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1 provider of adverse determinations, and the procedures
2 for appeal of adverse determinations, including the
3 establishment of an expedited appeals process for
4 denials of continued inpatient care or when delay would
5 significantly increase the risk to an enrollee's health;
6 (5) establishment of a requirement that
7 appropriate personnel of the utilization review agent are
8 reasonably accessible by toll-free telephone:
9 (A) not less than 40 hours per week during
10 normal business hours to discuss patient care and
11 allow response to telephone requests, and to ensure
12 that the utilization review agent has a telephone
13 system capable of accepting, recording or providing
14 instruction to incoming telephone calls during
15 other than normal business hours and to ensure
16 response to accepted or recorded messages not less
17 than one business day after the date on which the
18 call was received; or
19 (B) in the case of a request submitted
20 pursuant to subsection (c) of Section 80 or an
21 expedited appeal filed pursuant to subsection
22 (b) of Section 85, a response is provided within 24
23 hours;
24 (6) establishment of appropriate policies and
25 procedures to ensure that all applicable State and
26 federal laws to protect the confidentiality of individual
27 medical records are followed;
28 (7) establishment of a requirement that emergency
29 services, as defined in this Act, rendered to an enrollee
30 shall not be subject to prior authorization nor
31 shall reimbursement for those services be denied on
32 retrospective review, except as authorized in this Act.
33 (b) A utilization review agent shall assure adherence to
34 the requirements stated in subsection (a) of this Section by
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1 all contractors, subcontractors, subvendors, agents, and
2 employees affiliated by contract or otherwise with the
3 utilization review agent.
4 Section 80. Utilization review determinations.
5 (a) Utilization review shall be conducted by:
6 (1) administrative personnel trained in the
7 principles and procedures of intake screening and data
8 collection, provided, however, that administrative
9 personnel shall only perform intake screening, data
10 collection, and non-clinical review functions and shall
11 be supervised by a licensed health care professional;
12 (2) a health care professional who is
13 appropriately trained in the principles, procedures,
14 and standards of the utilization review agent; provided,
15 however, that a health care professional who is not a
16 clinical peer reviewer may not render an adverse
17 determination; and
18 (3) a clinical peer reviewer where the review
19 involves an adverse determination.
20 (b) A utilization review agent shall make a utilization
21 review determination involving health care services that
22 require pre-authorization and provide notice of the
23 determination, as soon as possible, to the enrollee or
24 enrollee's designee and the enrollee's health care provider
25 by telephone upon, and in writing within 2 business days of
26 receipt of the necessary information.
27 (c) A utilization review agent shall make a
28 determination involving continued or extended health care
29 services or additional services for an enrollee
30 undergoing a course of continued treatment prescribed by a
31 health care provider and provide notice of the determination
32 to the enrollee or the enrollee's designee by notice within
33 24 hours to the enrollee's health care provider by telephone
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1 upon, and in writing within 2 business days after receipt of
2 the necessary information. Notification of continued or
3 extended services shall include the number of extended
4 services approved, the new total of approved services, the
5 date of onset of services, and the next review date.
6 (d) A utilization review agent shall make a utilization
7 review determination involving health care services that have
8 already been delivered, within 30 days of receipt of the
9 necessary information.
10 (e) Notice of an adverse determination made by a
11 utilization review agent shall be given in writing in
12 accordance with the grievance procedures of this Act. The
13 notice shall also specify what, if any, additional
14 necessary information must be provided to, or obtained by,
15 the utilization review agent in order to render a decision on
16 the appeal.
17 (f) In the event that a utilization review agent
18 renders an adverse determination without attempting to
19 discuss the matter with the enrollee's health care
20 provider who specifically recommended the health care
21 service, procedure, or treatment under review, the health
22 care provider shall have the opportunity to request an
23 immediate reconsideration of the adverse determination.
24 Except in cases of retrospective reviews, the
25 reconsideration shall occur in a prompt manner, not to
26 exceed 24 hours after receipt of the necessary information,
27 and shall be conducted by the enrollee's health care
28 provider and the clinical peer reviewer making the initial
29 determination or a designated clinical peer reviewer if the
30 original clinical peer reviewer cannot be available. In
31 the event that the adverse determination is upheld after
32 reconsideration, the utilization review agent shall provide
33 notice as required pursuant to subsection (e) of this
34 Section. Nothing in this Section shall preclude the enrollee
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1 from initiating an appeal from an adverse determination.
2 Section 85. Appeal of adverse determinations by
3 utilization review agents.
4 (a) An enrollee, the enrollee's designee, and, in
5 connection with retrospective adverse determinations, the
6 enrollee's health care provider may appeal an adverse
7 determination rendered by a utilization review agent pursuant
8 to Sections 15, 20, 25, and 35.
9 (b) A utilization review agent shall establish
10 mechanisms that facilitate resolution of the appeal
11 including, but not limited to, the sharing of information
12 from the enrollee's health care provider and the utilization
13 review agent by telephonic means or by facsimile. The
14 utilization review agent shall provide reasonable access to
15 its clinical peer reviewer in a prompt manner.
16 (c) Appeals shall be reviewed by a clinical peer
17 reviewer other than the clinical peer reviewer who
18 rendered the adverse determination.
19 Section 90. Required and prohibited practices.
20 (a) A utilization review agent shall have written
21 procedures for assuring that patient-specific information
22 obtained during the process of utilization review will be:
23 (1) kept confidential in accordance with applicable
24 State and federal laws; and
25 (2) shared only with the enrollee, the
26 enrollee's designee, the enrollee's health care provider,
27 and those who are authorized by law to receive the
28 information.
29 (b) Summary data shall not be considered confidential
30 if it does not provide information to allow identification of
31 individual patients.
32 (c) Any health care professional who makes
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1 determinations regarding the medical necessity of health care
2 services during the course of utilization review shall be
3 appropriately licensed or registered.
4 (d) A utilization review agent shall not, with respect
5 to utilization review activities, permit or provide
6 compensation or anything of value to its employees, agents,
7 or contractors based on:
8 (1) either a percentage of the amount by which a
9 claim is reduced for payment or the number of claims or
10 the cost of services for which the person has denied
11 authorization or payment; or
12 (2) any other method that encourages the
13 rendering of an adverse determination.
14 (e) If a health care service has been specifically
15 pre-authorized or approved for an enrollee by a
16 utilization review agent, a utilization review agent shall
17 not, pursuant to retrospective review, revise or modify
18 the specific standards, criteria, or procedures used for
19 the utilization review for procedures, treatment, and
20 services delivered to the enrollee during the same course
21 of treatment.
22 (f) Utilization review shall not be conducted more
23 frequently than is reasonably required to assess whether the
24 health care services under review are medically necessary.
25 The Department may promulgate rules governing the frequency
26 of utilization reviews for managed care plans of differing
27 size and geographic location.
28 (g) When making prospective, concurrent, and
29 retrospective determinations, utilization review agents shall
30 collect only information that is necessary to make the
31 determination and shall not routinely require health care
32 providers to numerically code diagnoses or procedures to
33 be considered for certification, unless required under State
34 or federal Medicare or Medicaid rules or regulations, or
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1 routinely request copies of medical records of all patients
2 reviewed. During prospective or concurrent review, copies
3 of medical records shall only be required when necessary
4 to verify that the health care services subject to the review
5 are medically necessary. In these cases, only the necessary
6 or relevant sections of the medical record shall be
7 required. A utilization review agent may request copies of
8 partial or complete medical records retrospectively.
9 (h) In no event shall information be obtained from
10 health care providers for the use of the utilization
11 review agent by persons other than health care professionals,
12 medical record technologists, or administrative personnel who
13 have received appropriate training.
14 (i) The utilization review agent shall not undertake
15 utilization review at the site of the provision of health
16 care services unless the utilization review agent:
17 (1) identifies himself or herself by name and the
18 name of his or her organization, including displaying
19 photographic identification that includes the name of
20 the utilization review agent and clearly identifies the
21 individual as representative of the utilization review
22 agent;
23 (2) whenever possible, schedules review at least
24 one business day in advance with the appropriate health
25 care provider;
26 (3) if requested by a health care provider,
27 assures that the on-site review staff register with the
28 appropriate contact person, if available, prior to
29 requesting any clinical information or assistance
30 from the health care provider; and
31 (4) obtains consent from the enrollee or the
32 enrollee's designee before interviewing the patient's
33 family or observing any health care service being
34 provided to the enrollee.
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1 This subsection does not apply to health care
2 professionals engaged in providing care, case management, or
3 making on-site discharge decisions.
4 (j) A utilization review agent shall not base an adverse
5 determination on a refusal to consent to observing any health
6 care service.
7 (k) A utilization review agent shall not base an adverse
8 determination on lack of reasonable access to a health
9 care provider's medical or treatment records unless the
10 utilization review agent has provided reasonable notice
11 to both the enrollee or the enrollee's designee and the
12 enrollee's health care provider and has complied with all
13 provisions of subsection (i) of this Section. The Department
14 may promulgate rules defining reasonable notice and the time
15 period within which medical and treatment records must be
16 turned over.
17 (l) Neither the utilization review agent nor the entity
18 for which the agent provides utilization review shall take
19 any action with respect to a patient or a health care
20 provider that is intended to penalize the enrollee, the
21 enrollee's designee, or the enrollee's health care provider
22 for, or to discourage the enrollee, the enrollee's designee,
23 or the enrollee's health care provider from, undertaking an
24 appeal, dispute resolution, or judicial review of an adverse
25 determination.
26 (m) In no event shall an enrollee, an enrollee's
27 designee, an enrollee's health care provider, any other
28 health care provider, or any other person or entity be
29 required to inform or contact the utilization review agent
30 prior to the provision of emergency services as defined in
31 this Act.
32 (n) No contract or agreement between a utilization
33 review agent and a health care provider shall contain any
34 clause purporting to transfer to the health care provider by
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1 indemnification or otherwise any liability relating to
2 activities, actions, or omissions of the utilization review
3 agent.
4 (o) A health care professional providing health care
5 services to an enrollee shall be prohibited from serving
6 as the clinical peer reviewer for that enrollee in connection
7 with the health care services being provided to the
8 enrollee.
9 Section 95. Annual consumer satisfaction survey. The
10 Director shall develop and administer a survey of persons who
11 have been enrolled in a managed care plan in the most recent
12 calendar year to collect information on relative plan
13 performance. This survey shall:
14 (1) be administered annually by the Director, or by
15 an independent agency or organization selected by the
16 Director;
17 (2) be administered to a scientifically selected
18 representative sample of current enrollees from each
19 plan, as well as persons who have disenrolled from a plan
20 in the last calendar year; and
21 (3) emphasize the collection of information from
22 persons who have used the managed care plan to a
23 significant degree, as defined by rule.
24 Selected data from the annual survey shall be made
25 available to current and prospective enrollees as part of a
26 consumer guidebook of health plan performance, which the
27 Department shall develop and publish. The elements to be
28 included in the guidebook shall be reassessed on an ongoing
29 basis by the Department. The consumer guidebook shall be
30 updated at least annually.
31 Section 100. Managed care patient rights. In addition
32 to all other requirements of this Act, a managed care plan
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1 shall ensure that an enrollee has the following rights:
2 (1) A patient has the right to care consistent with
3 professional standards of practice to assure quality nursing
4 and medical practices, to be informed of the name of the
5 participating physician responsible for coordinating his or
6 her care, to receive information concerning his or her
7 condition and proposed treatment, to refuse any treatment to
8 the extent permitted by law, and to privacy and
9 confidentiality of records except as otherwise provided by
10 law.
11 (2) A patient has the right, regardless of source of
12 payment, to examine and to receive a reasonable explanation
13 of his or her total bill for health care services rendered by
14 his or her physician or other health care provider, including
15 the itemized charges for specific health care services
16 received. A physician or other health care provider shall be
17 responsible only for a reasonable explanation of these
18 specific health care services provided by the health care
19 provider.
20 (3) A patient has the right to privacy and
21 confidentiality in health care. A physician, other health
22 care provider, managed care plan, and utilization review
23 agent shall refrain from disclosing the nature or details of
24 health care services provided to patients, except that the
25 information may be disclosed to the patient, the party making
26 treatment decisions if the patient is incapable of making
27 decisions regarding the health care services provided, those
28 parties directly involved with providing treatment to the
29 patient or processing the payment for the treatment, those
30 parties responsible for peer review, utilization review, and
31 quality assurance, and those parties required to be notified
32 under the Abused and Neglected Child Reporting Act, the
33 Illinois Sexually Transmissible Disease Control Act, or where
34 otherwise authorized or required by law. This right may be
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1 expressly waived in writing by the patient or the patient's
2 guardian, but a managed care plan, a physician, or other
3 health care provider may not condition the provision of
4 health care services on the patient's or guardian's agreement
5 to sign the waiver.
6 Section 105. Managed Care Ombudsman Program.
7 (a) The Department shall establish a Managed Care
8 Ombudsman Program (MCOP). The purpose of the MCOP is to
9 assist consumers to:
10 (1) navigate the managed care system;
11 (2) select an appropriate managed care plan; and
12 (3) understand and assert their rights and
13 responsibilities as managed care plan enrollees.
14 (b) The Department shall contract with an independent
15 organization or organizations to perform the following MCOP
16 functions:
17 (1) Assist consumers with managed care plan
18 selection by providing information, referral, and
19 assistance to individuals about means of obtaining health
20 coverage and services, including, but not limited to:
21 (A) access through a toll-free telephone
22 number; and
23 (B) availability of information in languages
24 other than English that are spoken as a primary
25 language by a significant portion of the State's
26 population, as determined by the Department.
27 (2) Educate and train consumers in the use of the
28 Department's annual Consumer Guidebook of Health Plan
29 Performance, compiled in accordance with Section 95.
30 (3) Analyze, comment on, monitor, and make publicly
31 available reports on the development and implementation
32 of federal, State and local laws, regulations, and other
33 governmental policies and actions that pertain to the
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1 adequacy of managed care plans, facilities, and services
2 in the State.
3 (4) Ensure that individuals have timely access to
4 the services provided through the MCOP.
5 (5) Submit an annual report to the Department and
6 General Assembly:
7 (A) describing the activities carried out by
8 the MCOP in the year for which the report is
9 prepared;
10 (B) containing and analyzing the data
11 collected by the MCOP; and
12 (C) evaluating the problems experienced by
13 managed care plan enrollees.
14 (6) Exercise such other powers and functions as the
15 Department determines to be appropriate.
16 (c) The Department shall establish criteria for
17 selection of an independent organization or organizations to
18 perform the functions of the MCOP, including, but not limited
19 to, the following:
20 (1) Preference shall be given to private,
21 not-for-profit organizations governed by boards with
22 consumer members in the majority that represent a broad
23 spectrum of the diverse consumer interests in the State.
24 (2) No individual or organization under contract to
25 perform functions of the MCOP may:
26 (A) have a direct involvement in the
27 licensing, certification, or accreditation of a
28 health care facility, a managed care plan, or a
29 provider of a managed care plan, or have a direct
30 involvement with a provider of a health care
31 service;
32 (B) have a direct ownership or investment
33 interest in a health care facility, a managed care
34 plan, or a health care service;
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1 (C) be employed by, or participate in the
2 management of, a health care service or facility or
3 a managed care plan; or
4 (D) receive, or have the right to receive,
5 directly or indirectly, remuneration (in cash or in
6 kind) under a compensation arrangement with an owner
7 or operator of a health care service or facility or
8 managed care plan.
9 The Department shall contract with an organization or
10 organizations qualified under criteria established under this
11 Section for an initial term of 3 years. The initial contract
12 shall be renewable thereafter for additional 3 year terms
13 without reopening the competitive selection process unless
14 there has been an unfavorable written performance evaluation
15 conducted by the Department.
16 (d) The Department shall establish, by rule, policies
17 and procedures for the operation of MCOP sufficient to ensure
18 that the MCOP can perform all functions specified in this
19 Section.
20 (e) The Department shall provide adequate funding for
21 the MCOP by assessing each managed care plan an amount to be
22 determined by the Department.
23 (f) Nothing in this Section shall be interpreted to
24 authorize access to or disclosure of individual patient or
25 provider records.
26 Section 110. Waiver. Any agreement that purports to
27 waive, limit, disclaim or in any way diminish the rights set
28 forth in this Act is void as contrary to public policy.
29 Section 115. Administration of Act.
30 (a) The Department shall administer the Act.
31 (b) All managed care plans and utilization review agents
32 providing or reviewing services in Illinois shall annually
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1 certify compliance with this Act and rules adopted under this
2 Act to the Department in addition to any other licensure
3 required by law. The Director shall establish by rule a
4 process for this certification including fees to cover the
5 costs associated with implementing this Act. All fees and
6 fines assessed under this Act shall be deposited in the
7 Managed Care Reform Fund, a special fund hereby created in
8 the State treasury. Moneys in the Fund shall be used by the
9 Department only to enforce and administer this Act. The
10 certification requirements of this Act shall be incorporated
11 into program requirements of the Department of Public Aid and
12 Department of Human Services and no further certification
13 under this Act is required.
14 (c) The Director shall take enforcement action under
15 this Act including, but not limited to, the assessment of
16 civil fines and injunctive relief for any failure to comply
17 with this Act or any violation of the Act or rules by a
18 managed care plan or any utilization review agent.
19 (d) The Department shall have the authority to impose
20 fines on any managed care plan or any utilization review
21 agent. The Department shall adopt rules pursuant to this Act
22 that establish a system of fines related to the type and
23 level of violation or repeat violation, including but not
24 limited to:
25 (1) A fine not exceeding $10,000 for a violation
26 that created a condition or occurrence presenting a
27 substantial probability that death or serious harm to an
28 individual will or did result therefrom; and
29 (2) A fine not exceeding $5,000 for a violation
30 that creates or created a condition or occurrence that
31 threatens the health, safety, or welfare of an
32 individual.
33 Each day a violation continues shall constitute a
34 separate offense. These rules shall include an opportunity
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1 for a hearing in accordance with the Illinois Administrative
2 Procedure Act. All final decisions of the Department shall
3 be reviewable under the Administrative Review Law.
4 (e) Notwithstanding the existence or pursuit of any
5 other remedy, the Director may, through the Attorney General,
6 seek an injunction to restrain or prevent any person or
7 entity from functioning or operating in violation of this Act
8 or rule.
9 Section 120. Emergency services.
10 (a) Any managed care plan subject to this Act shall
11 provide the enrollee emergency services coverage such that
12 payment for this coverage is not dependent upon whether such
13 services are performed by a participating or nonparticipating
14 provider, and such coverage shall be at the same benefit
15 level as if the service or treatment had been rendered by a
16 plan provider. Nothing in this Section is intended to
17 prohibit a plan from imposing its customary and normal
18 co-payments, deductibles, co-insurance, and other like
19 charges for emergency services.
20 (b) Prior authorization or approval by the plan shall
21 not be required for emergency services rendered under this
22 Section.
23 (c) Coverage and payment shall not be retrospectively
24 denied, with the following exceptions:
25 (1) upon reasonable determination that the
26 emergency services claimed were never performed; or
27 (2) upon reasonable determination that an emergency
28 medical screening examination was performed on a patient
29 who personally sought emergency services knowing that he
30 or she did not have an emergency condition or necessity,
31 and who did not in fact require emergency services.
32 (d) When an enrollee presents to a hospital seeking
33 emergency services, as defined in this Act, the determination
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1 as to whether the need for those services exists shall be
2 made for purposes of treatment by a physician or, to the
3 extent permitted by applicable law, by other appropriate
4 licensed personnel under the supervision of a physician. The
5 physician or other appropriate personnel shall indicate in
6 the patient's chart the results of the emergency medical
7 screening examination. The plan shall compensate the
8 provider for an emergency medical screening examination that
9 is reasonably calculated to assist the health care provider
10 in determining whether the patient's condition requires
11 emergency services. A plan shall have no duty to pay for
12 services rendered after an emergency medical screening
13 examination determines the lack of a need for emergency
14 services.
15 (e) The appropriate use of the 911 emergency telephone
16 number shall not be discouraged or penalized, and coverage or
17 payment shall not be denied solely on the basis that the
18 insured used the 911 emergency telephone number to summon
19 emergency services.
20 (f) If prior authorization for post-stabilization
21 services, as defined in this Act, is required, the managed
22 care plan shall provide access 24 hours a day, 7 days a week
23 to persons designated by plan to make such determinations.
24 If a provider has attempted to contact such person for prior
25 authorization and no designated persons were accessible or
26 the authorization was not denied within one hour of the
27 request, the plan is deemed to have approved the request for
28 prior authorization.
29 (g) Coverage and payment for post-stabilization services
30 which received prior authorization or deemed approval shall
31 not be retrospectively denied. Nothing in this Section is
32 intended to prohibit a plan from imposing its customary and
33 normal co-payments, deductibles, co-insurance, and other like
34 changes for post-stabilization services.
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1 Section 125. Prescription drugs. A managed care plan
2 that provides coverage for prescribed drugs approved by the
3 federal Food and Drug Administration shall not exclude
4 coverage of any drug on the basis that the drug has been
5 prescribed for the treatment of a particular indication for
6 which the drug has not been approved by the federal Food and
7 Drug Administration. The drug, however, must be approved by
8 the federal Food and Drug Administration and must be
9 recognized for the treatment of that particular indication
10 for which the drug has been prescribed in any one of the
11 following established reference compendia:
12 (1) the American Hospital Formulary Service Drug
13 Information;
14 (2) the United States Pharmacopoeia Drug
15 Information; or
16 (3) if not recognized by the authorities in item
17 (1) or (2), recommended for that particular indication in
18 formal clinical studies, the results of which have been
19 published in at least 2 peer reviewed professional
20 medical journals published in the United States or Great
21 Britain.
22 Any coverage required by this Section shall also include
23 those medically necessary services associated with the
24 administration of a drug.
25 Despite the provisions of this Section, coverage shall
26 not be required for any experimental or investigational drugs
27 or any drug that the federal Food and Drug Administration has
28 determined to be contraindicated for treatment of the
29 specific indication for which the drug has been prescribed.
30 Nothing in this Section shall be construed, expressly or by
31 implication, to create, impair, alter, limit, notify,
32 enlarge, abrogate, or prohibit reimbursement for drugs used
33 in the treatment of any other disease or condition.
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1 Section 130. Health Care Service Delivery Review Board.
2 (a) A managed care plan shall organize a Health Care
3 Service Delivery Review Board from participants in the plan.
4 The Board shall consist of 17 members: 5 participating
5 physicians elected by participating physicians, 5 other
6 participating providers elected by the other health care
7 providers, 5 enrollees elected by the enrollees, and 2
8 representatives of the plan appointed by the plan. The
9 representatives of the plan shall not have a vote on the
10 Board, but shall have all other rights granted to Board
11 members. The plan shall devise a mechanism for the election
12 of the Board's members, subject to the approval of the
13 Department. The Department shall not unreasonably withhold
14 its approval of a mechanism.
15 (b) The Health Care Service Delivery Board shall
16 establish written rules and regulations governing its
17 operation. The managed care plan shall approve the rules,
18 but may not unilaterally amend them. A plan may not
19 unreasonably withhold approval of proposed rules and
20 regulations.
21 (c) The Health Care Service Delivery Board shall, from
22 time to time, issue nonbinding reports and reviews concerning
23 the plan's health care delivery policy, quality assurance
24 procedures, utilization review criteria and procedures, and
25 medical management procedures. The Board shall select the
26 aspects of the plan that it wishes to study or review and may
27 undertake a study or review at the request of the plan. The
28 Board shall issue its report directly to the managed care
29 plan's governing board.
30 Section 135. Conflicts with federal law. When health
31 care services are provided by a managed care plan subject to
32 this Act to a person who is a recipient of medical assistance
33 under Article V of the Illinois Public Aid Code, the rights,
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1 benefits, requirements, and procedures available or
2 authorized under this Act shall not apply to the extent that
3 there are provisions of federal law that conflict. In the
4 event of a conflict, federal law shall prevail.
5 Section 140. The State Employees Group Insurance Act of
6 1971 is amended by adding Section 6.9 as follows:
7 (5 ILCS 375/6.9 new)
8 Sec. 6.9. Managed Care Reform Act. The program of
9 health benefits is subject to the provisions of the Managed
10 Care Reform Act.
11 Section 145. The State Finance Act is amended by adding
12 Section 5.449 as follows:
13 (30 ILCS 105/5.449 new)
14 Sec. 5.449. The Managed Care Reform Fund.
15 Section 150. The State Mandates Act is amended by adding
16 Section 8.21 as follows:
17 (30 ILCS 805/8.21 new)
18 Sec. 8.21. Exempt mandate. Notwithstanding Sections 6
19 and 8 of this Act, no reimbursement by the State is required
20 for the implementation of any mandate created by this
21 amendatory Act of 1997.
22 Section 155. The Counties Code is amended by adding
23 Section 5-1069.8 as follows:
24 (55 ILCS 5/5-1069.8 new)
25 Sec. 5-1069.8. Managed Care Reform Act. All counties,
26 including home rule counties, are subject to the provisions
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1 of the Managed Care Reform Act. The requirement under this
2 Section that health care benefits provided by counties comply
3 with the Managed Care Reform Act is an exclusive power and
4 function of the State and is a denial and limitation of home
5 rule county powers under Article VII, Section 6, subsection
6 (h) of the Illinois Constitution.
7 Section 160. The Illinois Municipal Code is amended by
8 adding 10-4-2.8 as follows:
9 (65 ILCS 5/10-4-2.8 new)
10 Sec. 10-4-2.8. Managed Care Reform Act. The corporate
11 authorities of all municipalities are subject to the
12 provisions of the Managed Care Reform Act. The requirement
13 under this Section that health care benefits provided by
14 municipalities comply with the Managed Care Reform Act is an
15 exclusive power and function of the State and is a denial and
16 limitation of home rule municipality powers under Article
17 VII, Section 6, subsection (h) of the Illinois Constitution.
18 Section 165. The School Code is amended by adding
19 Section 10-22.3f as follows:
20 (105 ILCS 5/10-22.3f new)
21 Sec. 10-22.3f. Managed Care Reform Act. Insurance
22 protection and benefits for employees are subject to the
23 Managed Care Reform Act.
24 Section 170. The Health Maintenance Organization Act is
25 amended by changing Sections 2-2 and 6-7 as follows:
26 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
27 Sec. 2-2. Determination by Director; Health Maintenance
28 Advisory Board.
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1 (a) Upon receipt of an application for issuance of a
2 certificate of authority, the Director shall transmit copies
3 of such application and accompanying documents to the
4 Director of the Illinois Department of Public Health. The
5 Director of the Department of Public Health shall then
6 determine whether the applicant for certificate of authority,
7 with respect to health care services to be furnished: (1) has
8 demonstrated the willingness and potential ability to assure
9 that such health care service will be provided in a manner to
10 insure both availability and accessibility of adequate
11 personnel and facilities and in a manner enhancing
12 availability, accessibility, and continuity of service; and
13 (2) has arrangements, established in accordance with rules
14 regulations promulgated by the Department of Public Health
15 for an ongoing quality of health care assurance program
16 concerning health care processes and outcomes. Upon
17 investigation, the Director of the Department of Public
18 Health shall certify to the Director whether the proposed
19 Health Maintenance Organization meets the requirements of
20 this subsection (a). If the Director of the Department of
21 Public Health certifies that the Health Maintenance
22 Organization does not meet such requirements, he or she shall
23 specify in what respect it is deficient.
24 There is created in the Department of Public Health a
25 Health Maintenance Advisory Board composed of 11 members.
26 Nine of the 11 9 members shall who have practiced in the
27 health field and, 4 of those 9 which shall have been or shall
28 be are currently affiliated with a Health Maintenance
29 Organization. Two of the members shall be members of the
30 general public, one of whom is over 65 years of age. Each
31 member shall be appointed by the Director of the Department
32 of Public Health and serve at the pleasure of that Director
33 and shall receive no compensation for services rendered other
34 than reimbursement for expenses. Six Five members of the
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1 Board shall constitute a quorum. A vacancy in the membership
2 of the Advisory Board shall not impair the right of a quorum
3 to exercise all rights and perform all duties of the Board.
4 The Health Maintenance Advisory Board has the power to review
5 and comment on proposed rules and regulations to be
6 promulgated by the Director of the Department of Public
7 Health within 30 days after those proposed rules and
8 regulations have been submitted to the Advisory Board.
9 (b) Issuance of a certificate of authority shall be
10 granted if the following conditions are met:
11 (1) the requirements of subsection (c) of Section
12 2-1 have been fulfilled;
13 (2) the persons responsible for the conduct of the
14 affairs of the applicant are competent, trustworthy, and
15 possess good reputations, and have had appropriate
16 experience, training or education;
17 (3) the Director of the Department of Public Health
18 certifies that the Health Maintenance Organization's
19 proposed plan of operation meets the requirements of this
20 Act;
21 (4) the Health Care Plan furnishes basic health
22 care services on a prepaid basis, through insurance or
23 otherwise, except to the extent of reasonable
24 requirements for co-payments or deductibles as authorized
25 by this Act;
26 (5) the Health Maintenance Organization is
27 financially responsible and may reasonably be expected to
28 meet its obligations to enrollees and prospective
29 enrollees; in making this determination, the Director
30 shall consider:
31 (A) the financial soundness of the applicant's
32 arrangements for health services and the minimum
33 standard rates, co-payments and other patient
34 charges used in connection therewith;
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1 (B) the adequacy of working capital, other
2 sources of funding, and provisions for
3 contingencies; and
4 (C) that no certificate of authority shall be
5 issued if the initial minimum net worth of the
6 applicant is less than $2,000,000. The initial net
7 worth shall be provided in cash and securities in
8 combination and form acceptable to the Director;
9 (6) the agreements with providers for the provision
10 of health services contain the provisions required by
11 Section 2-8 of this Act; and
12 (7) any deficiencies identified by the Director
13 have been corrected.
14 (Source: P.A. 86-620; 86-1475.)
15 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
16 Sec. 6-7. Board of Directors. The board of directors of
17 the Association shall consist consists of not less than 7 5
18 nor more than 11 9 members serving terms as established in
19 the plan of operation. The members of the board are to be
20 selected by member organizations subject to the approval of
21 the Director provided, however, that 2 members shall be
22 enrollees, one of whom is over 65 years of age. Vacancies on
23 the board must be filled for the remaining period of the term
24 in the manner described in the plan of operation. To select
25 the initial board of directors, and initially organize the
26 Association, the Director must give notice to all member
27 organizations of the time and place of the organizational
28 meeting. In determining voting rights at the organizational
29 meeting each member organization is entitled to one vote in
30 person or by proxy. If the board of directors is not
31 selected at the organizational meeting, the Director may
32 appoint the initial members.
33 In approving selections or in appointing members to the
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1 board, the Director must consider, whether all member
2 organizations are fairly represented.
3 Members of the board may be reimbursed from the assets of
4 the Association for expenses incurred by them as members of
5 the board of directors but members of the board may not
6 otherwise be compensated by the Association for their
7 services.
8 (Source: P.A. 85-20.)
9 Section 175. Severability. The provisions of this Act
10 are severable under Section 1.31 of the Statute on Statutes.
11 Section 199. Effective date. This Act takes effect July
12 1, 1998.