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90_HB0626ham002
LRB9000248JSgcam03
1 AMENDMENT TO HOUSE BILL 626
2 AMENDMENT NO. . Amend House Bill 626, AS AMENDED, by
3 replacing everything after the enacting clause with the
4 following:
5 "Section 1. Short title. This Act may be cited as the
6 Managed Care Reform Act.
7 Section 5. Definitions. For purposes of this Act, the
8 following words shall have the meanings provided in this
9 Section, unless otherwise indicated:
10 "Adverse determination" means a determination by a
11 utilization review agent that an admission, extension of a
12 stay, or other health care service has been reviewed and,
13 based on the information provided, is not medically
14 necessary.
15 "Clinical peer reviewer" or "clinical personnel" means:
16 (1) a licensed physician and, in connection with
17 an appeal of an adverse determination, a licensed
18 physician who is in the same or similar specialty as the
19 health care provider who typically manages the medical
20 condition, procedure or treatment under review; or
21 (2) in the case of non-physician reviewers, a
22 health care professional who is in the same
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1 profession and same or similar specialty as the health
2 care provider who typically manages the medical
3 condition, procedure or treatment under review. Nothing
4 herein shall be construed to change any statutorily
5 defined scope of practice.
6 "Culturally and linguistically competent care" means that
7 a managed care plan has staff and procedures in place to
8 provide all covered services and policy procedures in
9 English, Spanish, and any other language spoken as a primary
10 language by 5% or more of its enrollees.
11 "Degenerative and disabling condition or disease" means a
12 condition or disease that is permanent or of indefinite
13 duration, that will become worse or more advanced over time,
14 and that substantially impairs a major life function.
15 "Department" means the Department of Insurance.
16 "Director" means the Director of Insurance.
17 "Emergency services" means those health care services
18 provided to evaluate and treat medical conditions of recent
19 onset and severity that would lead to a prudent lay person,
20 possessing an average knowledge of medicine and health, to
21 believe that urgent and unscheduled medical care is required.
22 "Enrollee" means a person enrolled in a health care or
23 managed care plan.
24 "Health care professional" means a health care
25 professional appropriately licensed or registered pursuant to
26 the laws of this State or a health care professional
27 comparably licensed or registered by another state.
28 "Health care provider" means a physician, registered
29 professional nurse, hospital facility, or other person
30 licensed or otherwise authorized to furnish health care
31 services or arrange for the delivery of health care services.
32 "Health care services" means services included in the (i)
33 furnishing of medical care, (ii) hospitalization incident to
34 the furnishing of medical care, and (iii) furnishing of
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1 services, including pharmaceuticals, for the purpose of
2 preventing, alleviating, curing, or healing human illness or
3 injury to an individual.
4 "Informal policy or procedure" means a nonwritten policy
5 or procedure, the existence of which is proven by an
6 admission of an authorized agent of a managed care plan or
7 statistical evidence supported by anecdotal evidence.
8 "Life threatening condition or disease" means any
9 condition, illness, or injury that (i) may directly lead to a
10 patient's death, (ii) results in a period of unconsciousness
11 which is indeterminate at the present, or (iii) imposes
12 severe pain or 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;
2 (2) managed care plans that offer only dental or
3 vision coverage; and
4 (3) managed care plans operated or administered
5 under the State's Medicaid Plus program.
6 "Speciality care center" means only a center that is
7 accredited by an agency of the State or federal government or
8 by a voluntary national health organization as having special
9 expertise in treating the life-threatening disease or
10 condition or degenerative and disabling disease or condition
11 for which it is accredited.
12 "Subscriber" means a person or entity that has entered
13 into a contractual relationship with a managed care plan for
14 the provision of or arrangement for health care services to
15 the beneficiaries of the contract.
16 "Utilization review" means the review to determine
17 whether health care services that have been provided, are
18 being provided or are proposed to be provided to a
19 patient, whether undertaken prior to, concurrent with, or
20 subsequent to the delivery of such services are
21 medically necessary. For the purposes of this Act,
22 none of the following shall be considered utilization review:
23 (1) denials based on failure to obtain health care
24 services from a designated or approved health care
25 provider as required under a subscriber's contract;
26 (2) the review of the appropriateness of the
27 application of a particular coding to a patient,
28 including the assignment of diagnosis and procedure;
29 (3) any issues relating to the determination of
30 the amount or extent of payment other than determinations
31 to deny payment based on an adverse determination; and
32 (4) any determination of any coverage issues other
33 than whether health care services are or were medically
34 necessary.
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1 "Utilization review agent" means any company,
2 organization, or other entity performing utilization review,
3 except:
4 (1) an agency of the federal government;
5 (2) an agent acting on behalf of the federal
6 government, but only to the extent that the agent is
7 providing services to the federal government;
8 (3) an agent acting on behalf of the state and
9 local government for services provided pursuant to
10 title XIX of the federal Social Security Act;
11 (4) a hospital's internal quality assurance program
12 except if associated with a health care financing
13 mechanism.
14 "Utilization review plan" means:
15 (1) a description of the process for developing the
16 written clinical review criteria;
17 (2) a description of the types of written clinical
18 information which the plan might consider in its clinical
19 review including, but not limited to, a set of specific
20 written clinical review criteria;
21 (3) a description of practice guidelines and
22 standards used by a utilization review agent in making a
23 determination of medical necessity;
24 (4) the procedures for scheduled review and
25 evaluation of the written clinical review criteria; and
26 (5) a description of the qualifications and
27 experience of the health care professionals who
28 developed the criteria, who are responsible for periodic
29 evaluation of the criteria and of the health care
30 professionals or others who use the written clinical
31 review criteria in the process of utilization review.
32 Section 10. Disclosure of information.
33 (a) A subscriber, and upon request a prospective
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1 enrollee prior to enrollment, shall be supplied with
2 written disclosure information, containing at least the
3 information specified in this Section, if applicable, which
4 may be incorporated into the member handbook or the
5 subscriber contract or certificate. All written
6 descriptions shall be in readable and understandable format,
7 consistent with standards developed for supplemental
8 insurance coverage under Title XVII of the Social Security
9 Act. The Department shall promulgate rules to standardize
10 this format so that potential members can compare the
11 attributes of the various managed care entities. In the event
12 of any inconsistency between any separate written disclosure
13 statement and the subscriber contract or certificate,
14 the terms of the subscriber contract or certificate shall be
15 controlling. The information to be disclosed shall
16 include, at a minimum, all of the following:
17 (1) A description of coverage provisions, health
18 care benefits, benefit maximums, including benefit
19 limitations, and exclusions of coverage, including the
20 definition of medical necessity used in determining
21 whether benefits will be covered.
22 (2) A description of all prior authorization or
23 other requirements for treatments, pharmaceuticals, and
24 services.
25 (3) A description of utilization review policies
26 and procedures used by the managed care plan,
27 including the circumstances under which utilization
28 review will be undertaken, the toll-free telephone
29 number of the utilization review agent, the timeframes
30 under which utilization review decisions must be made for
31 prospective, retrospective, and concurrent decisions,
32 the right to reconsideration, the right to an appeal,
33 including the expedited and standard appeals processes
34 and the timeframes for those appeals, the right to
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1 designate a representative, a notice that all denials of
2 claims will be made by clinical personnel, and that
3 all notices of denials will include information about the
4 basis of the decision and further appeal rights, if any.
5 (4) A description prepared annually of the types of
6 methodologies the managed care plan uses to reimburse
7 providers specifying the type of methodology that is
8 used to reimburse particular types of providers or
9 reimburse for the provision of particular types of
10 services; provided, however, that nothing in this item
11 should be construed to require disclosure of individual
12 contracts or the specific details of any financial
13 arrangement between a managed care plan and a health care
14 provider.
15 (5) An explanation of a subscriber's financial
16 responsibility for payment of premiums, coinsurance,
17 co-payments, deductibles, and any other charges, annual
18 limits on a subscriber's financial responsibility, caps
19 on payments for covered services and financial
20 responsibility for non-covered health care procedures,
21 treatments, or services provided within the managed
22 care plan.
23 (6) An explanation of a subscriber's financial
24 responsibility for payment when services are provided by
25 a health care provider who is not part of the managed
26 care plan or by any provider without required
27 authorization or when a procedure, treatment, or service
28 is not a covered health care benefit.
29 (7) A description of the grievance procedures to
30 be used to resolve disputes between a managed care plan
31 and an enrollee, including the right to file a
32 grievance regarding any dispute between an enrollee and a
33 managed care plan, the right to file a grievance
34 orally when the dispute is about referrals or covered
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1 benefits, the toll-free telephone number that enrollees
2 may use to file an oral grievance, the timeframes and
3 circumstances for expedited and standard grievances, the
4 right to appeal a grievance determination and the
5 procedures for filing the appeal, the timeframes and
6 circumstances for expedited and standard appeals, the
7 right to designate a representative, a notice that all
8 disputes involving clinical decisions will be made by
9 clinical personnel, and that all notices of determination
10 will include information about the basis of the
11 decision and further appeal rights, if any.
12 (8) A description of the procedure for providing
13 care and coverage 24 hours a day for emergency services.
14 The description shall include the definition of
15 emergency services, notice that emergency services are
16 not subject to prior approval, and an explanation of
17 the enrollee's financial and other responsibilities
18 regarding obtaining those services, including when
19 those services are received outside the managed care
20 plan's service area. Nothing in this Act is intended to
21 pre-empt, repeal, or diminish any statute that specifies
22 or mandates the type of emergency services coverage that
23 a managed care plan must offer or provide.
24 (9) A description of procedures for enrollees to
25 select and access the managed care plan's primary and
26 specialty care providers, including notice of how to
27 determine whether a participating provider is accepting
28 new patients.
29 (10) A description of the procedures for changing
30 primary and specialty care providers within the managed
31 care plan.
32 (11) Notice that an enrollee may obtain a referral
33 to a health care provider outside of the managed care
34 plan's network or panel when the managed care plan
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1 does not have a health care provider with appropriate
2 training and experience in the network or panel to meet
3 the particular health care needs of the enrollee and
4 the procedure by which the enrollee can obtain the
5 referral.
6 (12) Notice that an enrollee with a condition
7 that requires ongoing care from a specialist may
8 request a standing referral to the specialist and
9 the procedure for requesting and obtaining a standing
10 referral.
11 (13) Notice that an enrollee with (i) a
12 life-threatening condition or disease or (ii) a
13 degenerative and disabling condition or disease, either
14 of which requires specialized medical care over a
15 prolonged period of time, may request a specialist
16 responsible for providing or coordinating the enrollee's
17 medical care and the procedure for requesting and
18 obtaining the specialist.
19 (14) A description of the mechanisms by which
20 enrollees may participate in the development of the
21 policies of the managed care plan.
22 (15) A description of how the managed care plan
23 addresses the needs of non-English speaking enrollees.
24 (16) Notice of all appropriate mailing addresses
25 and telephone numbers to be utilized by enrollees
26 seeking information or authorization.
27 (17) A listing by specialty, which may be in a
28 separate document that is updated annually, of the name,
29 address, and telephone number of all participating
30 providers, including facilities, and, in addition, in the
31 case of physicians, board certification.
32 (b) Upon request of a subscriber, enrollee, or
33 prospective enrollee, a managed care plan shall do all of the
34 following:
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1 (1) Provide a list of the names, business
2 addresses, and official positions of the members of the
3 board of directors, officers, controlling persons,
4 owners, or partners of the managed care plan.
5 (2) Provide a copy of the most recent annual
6 certified financial statement of the managed care plan,
7 including a balance sheet and summary of receipts and
8 disbursements and the ratio of (i) premium dollars going
9 to administrative expenses to (ii) premium dollars going
10 to direct care, prepared by a certified public
11 accountant. The Department shall promulgate rules to
12 standardize the information that must be contained in the
13 statement and the statement's format.
14 (3) Provide information relating to consumer
15 complaints compiled in the manner set forth in Section
16 143d of the Illinois Insurance Code.
17 (4) Provide the procedures for protecting the
18 confidentiality of medical records and other enrollee
19 information.
20 (5) Allow subscribers and prospective enrollees to
21 inspect drug formularies used by the managed care plan
22 and disclose whether individual drugs are included or
23 excluded from coverage and whether a drug requires prior
24 authorization. A subscriber or prospective enrollee may
25 only inquire as to the inclusion or exclusion of a
26 specific drug if he or she or his or her dependents
27 needs, uses, or may need or use the drug.
28 (6) Provide a written description of the
29 organizational arrangements and ongoing procedures of
30 the managed care plan's quality assurance program.
31 (7) Provide a description of the procedures
32 followed by the managed care plan in making decisions
33 about the experimental or investigational nature of
34 individual drugs, medical devices, or treatments in
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1 clinical trials.
2 (8) Provide individual health practitioner
3 affiliations with participating hospitals, if any.
4 (9) Upon written request, provide specific
5 written clinical review criteria relating to a
6 particular condition or disease and, where appropriate,
7 other clinical information that the managed care plan
8 might consider in its utilization review; the managed
9 care plan may include with the information a description
10 of how it will be used in the utilization review
11 process. A subscriber or prospective enrollee may only
12 inquire as to specific clinical review criteria if he or
13 she or his or her dependent has, may have, or is at risk
14 of contracting a particular condition or disease.
15 (10) Provide the written application procedures and
16 minimum qualification requirements for health care
17 providers to be considered by the managed care plan.
18 (11) Disclose other information as required by
19 the Director.
20 (12) To the extent the information provided under
21 item (5) or (9) of this subsection is proprietary to the
22 managed care plan, the subscriber or prospective enrollee
23 shall only use the information for the purposes of
24 assisting the subscriber or prospective enrollee in
25 evaluating the covered services provided by the managed
26 care plan. Any misuse of proprietary data is prohibited,
27 provided that the managed care plan has labeled or
28 identified the data as proprietary.
29 (c) Nothing in this Section shall prevent a managed care
30 plan from changing or updating the materials that are made
31 available to subscribers and enrollees.
32 (d) If a primary care provider ceases participation in
33 the managed care plan, the managed care plan shall provide
34 written notice within 30 days from the date that the managed
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1 care plan becomes aware of the change in status to each of
2 the enrollees who have chosen the provider as their
3 primary care provider. If an enrollee is in an ongoing
4 course of treatment with any other participating provider who
5 becomes unavailable to continue to provide services to the
6 enrollee and the managed care plan is aware of the ongoing
7 course of treatment, the managed care plan shall provide
8 written notice within 30 days from the date that the managed
9 care plan becomes aware of the unavailability to the
10 enrollee. The notice shall also describe the procedures for
11 continuing care.
12 (e) A managed care plan offering to indemnify enrollees
13 for non-participating provider services shall file a report
14 with the Director twice a year showing the percentage
15 utilization for the preceding 6 month period of
16 non-participating provider services in such form and
17 providing such other information as the Director shall
18 prescribe.
19 Section 15. General grievance procedure.
20 (a) A managed care plan shall establish and maintain a
21 grievance procedure. Pursuant to such procedure, enrollees
22 shall be entitled to seek a review of determinations by the
23 managed care plan other than determinations made by
24 utilization review agents.
25 A copy of the grievance procedures, including all forms
26 used to process a grievance, shall be filed with the
27 Director. Any subsequent material modifications to the
28 documents also shall be filed. In addition, a managed care
29 plan shall file annually with the Director a certificate of
30 compliance stating that the managed care plan has established
31 and maintains, for each of its plans, grievance procedures
32 that fully comply with the provisions of this Act. The
33 Director has authority to disapprove a filing that fails to
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1 comply with this Act or applicable rules.
2 (b) A managed care plan shall provide written notice of
3 the grievance procedure to all subscribers in the member
4 handbook and to an enrollee at any time that the managed care
5 plan denies access to a referral or determines that a
6 requested benefit is not covered pursuant to the terms of the
7 contract. In the event that a managed care plan denies a
8 service as an adverse determination, the managed care plan
9 shall inform the enrollee or the enrollee's designee of
10 the appeal rights under this Act.
11 The notice to an enrollee describing the grievance
12 process shall explain the process for filing a grievance
13 with the managed care plan, the timeframes within which a
14 grievance determination must be made, and the right of an
15 enrollee to designate a representative to file a grievance on
16 behalf of the enrollee. Information required to be disclosed
17 or provided under this Section must be provided in a
18 reasonable and understandable format.
19 The managed care plan shall assure that the grievance
20 procedure is reasonably accessible to those who do not speak
21 English.
22 (c) A managed care plan shall not retaliate or take
23 any discriminatory action against an enrollee because an
24 enrollee has filed a grievance or appeal.
25 Section 20. First level grievance review.
26 (a) The managed care plan may require an enrollee to
27 file a grievance in writing, by letter or by a grievance
28 form which shall be made available by the managed care plan,
29 however, an enrollee must be allowed to submit an oral
30 grievance in connection with (i) a denial of, or failure to
31 pay for, a referral or service or (ii) a determination as to
32 whether a benefit is covered pursuant to the terms of the
33 enrollee's contract. In connection with the submission of
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1 an oral grievance, a managed care plan shall, within 24
2 hours, reduce the complaint to writing and give the enrollee
3 written acknowledgment of the grievance prepared by the
4 managed care plan summarizing the nature of the grievance
5 and any information that the enrollee needs to provide before
6 the grievance can be processed. The acknowledgment shall
7 be mailed within the 24-hour period to the enrollee, who
8 shall sign and return the acknowledgment, with any
9 amendments and requested information, in order to initiate
10 the grievance. The grievance acknowledgment shall prominently
11 state that the enrollee must sign and return the
12 acknowledgment to initiate the grievance. A managed care
13 plan may elect not to require a signed acknowledgment when no
14 additional information is necessary to process the grievance,
15 and an oral grievance shall be initiated at the time of the
16 telephone call.
17 Except as authorized in this subsection, a managed care
18 plan shall designate personnel to accept the filing of an
19 enrollee's grievance by toll-free telephone no less than
20 40 hours per week during normal business hours and shall
21 have a telephone system available to take calls during other
22 than normal business hours and shall respond to all such
23 calls no later than the next business day after the call was
24 recorded. In the case of grievances subject to item (i) of
25 subsection (b) of this Section, telephone access must be
26 available on a 24 hour a day, 7 day a week basis.
27 (b) Within 5 business days of receipt of a written
28 grievance, the managed care plan shall provide written
29 acknowledgment of the grievance, including the name,
30 address, qualifying credentials, and telephone number of the
31 individuals or department designated by the managed care plan
32 to respond to the grievance. All grievances shall be
33 resolved in an expeditious manner, and in any event, no more
34 than (i) 48 hours after the receipt of all necessary
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1 information when a delay would significantly increase the
2 risk to an enrollee's health, (ii) 15 days after the
3 receipt of all necessary information in the case of requests
4 for referrals or determinations concerning whether a
5 requested benefit is covered pursuant to the contract, and
6 (iii) 30 days after the receipt of all necessary information
7 in all other instances.
8 (c) The managed care plan shall designate one or more
9 qualified personnel to review the grievance. When the
10 grievance pertains to clinical matters, the personnel shall
11 include, but not be limited to, one or more licensed or
12 registered health care professionals.
13 (d) The notice of a determination of the grievance
14 shall be made in writing to the enrollee or to the enrollee's
15 designee. In the case of a determination made in conformance
16 with item (i) of subsection (b) of this Section, notice
17 shall be made by telephone directly to the enrollee with
18 written notice to follow within 2 business days.
19 (e) The notice of a determination shall include (i)
20 clear and detailed reasons for the determination, including
21 any contract basis for the determination, and the evidence
22 relied upon in making that determination, (ii) in cases where
23 the determination has a clinical basis, the clinical
24 rationale for the determination, and (iii) the procedures for
25 the filing of an appeal of the determination, including a
26 form for the filing of an appeal.
27 Section 25. Second level grievance review.
28 (a) A managed care plan shall establish a second level
29 grievance review process to give those enrollees who are
30 dissatisfied with the first level grievance review decision
31 the option to request a second level review, at which the
32 enrollee shall have the right to appear in person before
33 authorized individuals designated to respond to the appeal.
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1 (b) An enrollee or an enrollee's designee shall
2 have not less than 60 business days after receipt of notice
3 of the grievance determination to file a written appeal,
4 which may be submitted by letter or by a form supplied by the
5 managed care plan. The enrollee shall indicate in his or her
6 written appeal whether he or she wants the right to appear in
7 person before the person or panel designated to respond to
8 the appeal.
9 (c) Within 5 business days of receipt of the second
10 level grievance review, the managed care plan shall provide
11 written acknowledgment of the appeal, including the name,
12 address, qualifying credentials, and telephone number of the
13 individual designated by the managed care plan to respond
14 to the appeal and what additional information, if any, must
15 be provided in order for the managed care plan to render a
16 decision.
17 (d) The determination of a second level grievance review
18 on a clinical matter must be made by personnel qualified
19 to review the appeal, including licensed or registered health
20 care professionals who did not make the initial
21 determination, a majority of whom must be clinical peer
22 reviewers. The determination of a second level grievance
23 review on a matter that is not clinical shall be made by
24 qualified personnel at a higher level than the personnel who
25 made the grievance determination.
26 (e) The managed care plan shall seek to resolve all
27 second level grievance reviews in the most expeditious manner
28 and shall make a determination and provide notice no more
29 than (i) 48 hours after the receipt of all necessary
30 information when a delay would significantly increase the
31 risk to an enrollee's health and (ii) 30 business days
32 after the receipt of all necessary information in all other
33 instances.
34 (f) The notice of a determination on a second level
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1 grievance review shall include (i) the detailed reasons for
2 the determination, including any contract basis for the
3 determination and the evidence relied upon in making the
4 determination and (ii) in cases where the determination has a
5 clinical basis, the clinical rationale for the
6 determination.
7 (g) If an enrollee has requested the opportunity to
8 appear in person before the authorized representatives of the
9 managed care plan designated to respond to the appeal, the
10 review panel shall schedule and hold a review meeting within
11 35 working days of receiving a request from an enrollee for a
12 second level review with a right to appear. The review
13 meeting shall be held during regular business hours at a
14 location reasonably accessible to the enrollee. The enrollee
15 shall be notified in writing at least 14 working days in
16 advance of the review date.
17 Upon the request of an enrollee, a managed care plan
18 shall provide to the enrollee all relevant information that
19 is not confidential or privileged.
20 A covered person has the right to:
21 (1) attend the second level review;
22 (2) present his or her case to the review panel;
23 (3) submit supporting material both before and at
24 the review meeting;
25 (4) ask questions of any representative of the
26 managed care plan; and
27 (5) be assisted or represented by a person of his
28 or her choice.
29 The notice shall advise the enrollee of the rights
30 specified in this subsection.
31 If the managed care plan desires to have an attorney
32 present to represent its interests, it shall notify the
33 covered person at least 14 working days in advance of the
34 review that an attorney will be present and that the covered
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1 person may wish to obtain legal representation of his or her
2 own.
3 Section 30. Grievance register and reporting
4 requirements.
5 (a) A managed care plan shall maintain a register
6 consisting of a written record of all complaints initiated
7 during the past 3 years. The register shall be maintained in
8 a manner that is reasonably clear and accessible to the
9 Director. The register shall include at a minimum the
10 following:
11 (1) the name of the enrollee;
12 (2) a description of the reason for the complaint;
13 (3) the dates when first level and second level
14 review were requested and completed;
15 (4) a copy of the written decision rendered at each
16 level of review;
17 (5) if required time limits were exceeded, an
18 explanation of why they were exceeded and a copy of the
19 enrollee's consent to an extension of time;
20 (6) whether expedited review was requested and the
21 response to the request;
22 (7) whether the complaint resulted in litigation
23 and the result of the litigation.
24 (b) A managed care plan shall report annually to the
25 Department the numbers, and related information where
26 indicated, for the following:
27 (1) covered lives;
28 (2) total complaints initiated;
29 (3) total complaints involving medical necessity or
30 appropriateness;
31 (4) complaints involving termination or reduction
32 of inpatient hospital services;
33 (5) complaints involving termination or reduction
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1 of other health care services;
2 (6) complaints involving denial of health care
3 services where the enrollee had not received the services
4 at the time the complaint was initiated;
5 (7) complaints involving payment for health care
6 services that the enrollee had already received at the
7 time of initiating the complaint;
8 (8) complaints resolved at each level of review and
9 how they were resolved;
10 (9) complaints where expedited review was provided
11 because adherence to regular time limits would have
12 jeopardized the enrollee's life, health, or ability to
13 regain maximum function; and
14 (10) complaints that resulted in litigation and the
15 outcome of the litigation.
16 The Department shall promulgate rules regarding the
17 format of the report, the timing of the report, and other
18 matters related to the report.
19 Section 35. External independent review.
20 (a) If an enrollee's or enrollee's designee's request
21 for a covered service or claim for a covered service is
22 denied under the grievance reviews under Section 15, 20, or
23 25 because the service is not viewed as medically necessary,
24 the enrollee may initiate an external independent review.
25 (b) Within 30 days after the enrollee receives written
26 notice of such an adverse decision made under the second
27 level grievance review procedures of Section 25, if the
28 enrollee decides to initiate an external independent review,
29 the enrollee shall send to the managed care plan a written
30 request for an external independent review, including any
31 material justification or documentation to support the
32 enrollee's request for the covered service or claim for a
33 covered service.
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1 (c) Within 5 business days after the managed care plan
2 receives a request for an external independent review from
3 the enrollee, the managed care plan shall:
4 (1) send a written acknowledgment to the Director,
5 the enrollee, and the enrollee's treating provider;
6 (2) choose one or more independent reviewers in the
7 manner prescribed in subsections (g) and (h) of this
8 Section from the list established by the Director
9 pursuant to Section 40 and forward that choice to the
10 Director; and
11 (3) include in the written acknowledgment to the
12 Director, the choice made pursuant to subdivision (2) of
13 this subsection.
14 (d) Within 30 days after the managed care plan receives
15 the written request for an independent review by the
16 enrollee, the managed care plan shall:
17 (1) forward to the independent reviewer or
18 reviewers all medical records and supporting
19 documentation pertaining to the case, a summary
20 description of the applicable issues including a
21 statement of the managed care plan's decision, and the
22 criteria used and the clinical reasons for that decision;
23 and
24 (2) notify the Director, the enrollee, and the
25 enrollee's treating provider of the decision by the
26 independent reviewer or reviewers.
27 (e) For cases involving medical necessity, within 5 days
28 of receipt of all necessary information, the independent
29 reviewer or reviewers shall evaluate and analyze the case and
30 render a decision that is based on whether or not the service
31 or claim for the service is medically necessary. The
32 decision by the independent reviewer or reviewers is a final
33 decision under the Administrative Review Law and is subject
34 to review under the Administrative Review Law. The managed
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1 care plan shall provide any service determined to be
2 medically necessary by the independent reviewer or reviewers
3 for the case under review regardless of whether judicial
4 review is sought.
5 (f) After a decision is made pursuant to subsection (e)
6 of this Section, the reconsideration, appeal, and
7 administrative processes are completed.
8 (g) Pursuant to subsection (c) of this Section, the
9 managed care plan shall choose one or more independent
10 reviewers or organizations that represent independent
11 reviewers who:
12 (1) have no direct financial interest in or
13 connection to the case;
14 (2) are licensed as physicians, who are board
15 certified or board eligible by the appropriate American
16 Medical Specialty Board and who are in the same or
17 similar scope of practice as a physician who typically
18 manages the medical condition, procedure, or treatment
19 under review; and
20 (3) have not been informed of the specific identity
21 of the enrollee or the enrollee's treating provider.
22 (h) If an appropriate reviewer pursuant to subsection
23 (g) of this Section for a particular case is not on the list
24 established by the Director, the parties shall choose a
25 reviewer who is mutually acceptable.
26 Section 40. Independent reviewers.
27 (a) From information filed with the Director on or
28 before March 1 of each year, the Director shall compile a
29 list of independent reviewers and organizations that
30 represent independent reviewers from lists provided by health
31 care insurers and by any State and county health and medical
32 associations that wish to submit a list to the Director. The
33 Director may consult with other persons about the suitability
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1 of any reviewer or any potential reviewer. The Director
2 shall annually review the list and add and remove names as
3 appropriate. On or before June 1 of each year, the Director
4 shall publish the list in the Illinois Register.
5 (b) The managed care plan shall be solely responsible
6 for paying the fees of the independent reviewer who is
7 selected to perform the review.
8 (c) An independent reviewer who acts in good faith is
9 not liable for the analysis, assessment, or decision of a
10 case reviewed pursuant to this Act.
11 (d) The Director's decision to add a name to or remove a
12 name from the list of independent reviewers pursuant to
13 subsection (a) is not subject to administrative appeal or
14 judicial review.
15 Section 45. Health care professional applications and
16 terminations.
17 (a) A managed care plan shall, upon request, make
18 available and disclose to health care professionals written
19 application procedures and minimum qualification
20 requirements that a health care professional must meet in
21 order to be considered by the managed care plan. The
22 managed care plan shall consult with appropriately qualified
23 health care professionals in developing its qualification
24 requirements.
25 (b) A managed care plan may not terminate a contract or
26 employment, or refuse to renew a contract, solely because a
27 health care provider has:
28 (1) advocated on behalf of an enrollee;
29 (2) filed a complaint against the managed care
30 plan;
31 (3) appealed a decision of the managed care plan;
32 or
33 (4) requested a hearing pursuant to this Section.
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1 (c) A managed care plan shall not terminate a contract
2 for a set term with a health care professional unless the
3 managed care plan provides to the health care
4 professional, in writing, the reasons for the proposed
5 contract termination and provides an opportunity for a
6 hearing.
7 After the notice of the proposed contract termination is
8 provided by the managed care plan to the health care
9 professional, the health care professional shall have 30 days
10 to request a hearing, and the hearing must be held within 15
11 days after receipt of the request for a hearing. The hearing
12 shall be held before a panel appointed by the managed care
13 plan.
14 The hearing panel shall be composed of 5 persons
15 appointed by the managed health care plan. At least 2 persons
16 on the panel shall be clinical peers in the same discipline
17 and the same or similar specialty as the health care
18 professional under review.
19 The hearing panel shall render a decision on the
20 proposed action within 14 business days. The decision shall
21 be one of the following:
22 (1) reinstatement of the health care professional
23 by the health care plan;
24 (2) provisional reinstatement subject to
25 conditions set forth by the panel; or
26 (3) termination of the health care professional.
27 The decision shall be provided in writing to the health
28 care professional.
29 A decision by the hearing panel to terminate a health
30 care professional shall be effective not less than 15 days
31 after the receipt by the health care professional of the
32 hearing panel's decision.
33 A hearing under this subsection shall provide the health
34 care professional in question with the right to examine
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1 pertinent information, to present witnesses and to ask
2 questions of an accuser or, if the accuser is the plan, an
3 authorized representative of the plan.
4 A managed care plan's statement of reasons for a health
5 care professional's termination or hearing panel's decision
6 furnished in accordance with the provisions of this Section
7 shall be deemed a confidential communication and shall not
8 be subject to inspection or disclosure in any manner
9 except upon formal written request by a duly authorized
10 public agency or pursuant to a judicial subpoena issued
11 in a pending action or proceeding.
12 If the hearing panel upholds the managed care plan's
13 termination of the health care professional under this
14 subsection for reasons related to alleged mental or physical
15 impairment, misconduct, or impairment of patient safety or
16 welfare, the managed care plan shall forward the decision to
17 the appropriate professional disciplinary agency within 10
18 business days of issuance of the panel's decision.
19 (d) Upon at least 45 days notice to the other party,
20 either party to a contract for a set term may exercise a
21 right of non-renewal at the expiration of the contract
22 period set forth therein. For a contract without a
23 specific expiration date, either party to the contract may
24 terminate the contract, without explanation, upon 7 days
25 notice. Non-renewal shall not constitute a termination for
26 purposes of this Section.
27 (e) A managed care plan may terminate a health care
28 professional, without a prior hearing, in cases involving
29 imminent harm to patient care, a determination of fraud, or a
30 final disciplinary action by a state licensing board or other
31 governmental agency that impairs the health care
32 professional's ability to practice. A professional
33 terminated for one of the these reasons shall be given
34 written notice to that effect. Within 30 days after the
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1 termination, a health care professional terminated because of
2 imminent harm to patient care or a determination of fraud
3 shall receive a hearing. The hearing shall be held before a
4 panel appointed by the managed care plan. The hearing panel
5 shall be composed of 5 persons appointed by the plan. At
6 least 2 persons on the panel shall be clinical peers in the
7 same discipline and the same or similar specialty as the
8 health care professional under review. The hearing panel
9 shall render a decision on the proposed action within 14
10 days. The panel shall issue a decision either supporting the
11 termination or ordering the health care professional's
12 reinstatement. The decision shall be provided in writing to
13 the health care professional.
14 If the hearing panel upholds the managed care plan's
15 termination of the health care professional under this
16 subsection, the managed care plan shall forward the decision
17 to the appropriate professional disciplinary agency within 10
18 business days of issuance of the panel's decision.
19 Any hearing under this subsection shall provide the
20 health care professional in question with the right to
21 examine pertinent information, to present witnesses and to
22 ask questions of an accuser, or if the accuser is the plan,
23 an authorized representative of the plan.
24 (f) A managed care plan shall develop and implement
25 policies and procedures to ensure that health care
26 professionals are at least annually informed of information
27 maintained by the managed care plan to evaluate the
28 performance or practice of the health care professional. The
29 managed care plan shall consult with health care
30 professionals in developing methodologies to collect and
31 analyze health care professional profiling data. Managed
32 care plans shall provide the information and profiling data
33 and analysis to health care professionals. The information,
34 data, or analysis shall be provided on at least an annual
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1 basis in a format appropriate to the nature and amount of
2 data and the volume and scope of services provided. Any
3 profiling data used to evaluate the performance or practice
4 of a health care professional shall be measured against
5 stated criteria and a comparable group of health care
6 professionals who use similar treatment modalities and serve
7 a comparable patient population. Upon receipt of the
8 information or data, a health care professional shall be
9 given the opportunity to explain the unique nature of the
10 health care professional's patient population that may have a
11 bearing on the health care professional's profile and to work
12 cooperatively with the managed care plan to improve
13 performance.
14 (g) Except as provided herein, no contract for a set
15 term between a managed care plan and a health care
16 professional shall contain any provision that supersedes or
17 impairs a health care professional's right to receive, in
18 writing, the reason for termination and the opportunity for a
19 hearing concerning termination.
20 (h) Any contract provision in violation of this Section
21 violates the public policy of the State of Illinois and is
22 void and unenforceable.
23 Section 50. Prohibitions.
24 (a) No managed care plan shall by contract, written
25 policy or written procedure, or informal policy or procedure
26 prohibit or restrict any health care provider from
27 disclosing to any subscriber, enrollee, patient, designated
28 representative or, where appropriate, prospective
29 enrollee, (hereinafter collectively referred to as
30 enrollee) any information that the provider deems appropriate
31 regarding:
32 (1) a condition or a course of treatment with an
33 enrollee including the availability of other therapies,
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1 consultations, or tests; or
2 (2) the provisions, terms, or requirements of the
3 managed care plan's products as they relate to the
4 enrollee, where applicable.
5 (b) No managed care plan shall by contract, written
6 policy or procedure, or informal policy or procedure prohibit
7 or restrict any health care provider from filing a
8 complaint, making a report, or commenting to an appropriate
9 governmental body regarding the policies or practices of the
10 managed care plan organization that the provider believes
11 may negatively impact upon the quality of, or access to,
12 patient care.
13 (c) No managed care plan shall by contract, written
14 policy or procedure, or informal policy or procedure prohibit
15 or restrict any health care provider from advocating to the
16 managed care plan on behalf of the enrollee for approval or
17 coverage of a particular course of treatment or for the
18 provision of health care services.
19 (d) No contract or agreement between a managed care
20 plan and a health care provider shall contain any clause
21 purporting to transfer to the health care provider,
22 other than a medical group, by indemnification or otherwise
23 any liability relating to activities, actions, or omissions
24 of the managed care plan as opposed to those of the health
25 care provider.
26 (e) No contract between a managed care plan and a health
27 care professional shall contain any incentive plan that
28 includes specific payment made directly, in any form, to a
29 health care professional as an inducement to deny, reduce,
30 limit, or delay specific, medically necessary and appropriate
31 services provided with respect to a specific enrollee or
32 groups of enrollees with similar medical conditions. Nothing
33 in this Section shall be construed to prohibit contracts that
34 contain incentive plans that involve general payments, such
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1 as capitation payments, or shared-risk arrangements that are
2 not tied to specific medical decisions involving specific
3 enrollees or groups of enrollees with similar medical
4 conditions. The payments rendered or to be rendered to
5 health care professional under these arrangements shall be
6 deemed confidential information.
7 (f) No managed care plan shall by contract, written
8 policy or procedure, or informal policy or procedure permit,
9 allow, or encourage an individual or entity to dispense a
10 different drug in place of the drug or brand of drug ordered
11 or prescribed without the express permission of the person
12 ordering or prescribing, except this prohibition does not
13 prohibit the interchange of different brands of the same
14 generically equivalent drug product, as provided under
15 Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
16 (g) Any contract provision, written policy or
17 procedure, or informal policy or procedure in violation of
18 this Section violates the public policy of the State of
19 Illinois and is void and unenforceable.
20 Section 55. Network of providers.
21 (a) At least once every 3 years, and upon application
22 for expansion of service area, a managed care plan shall
23 obtain certification from the Director of Public Health that
24 the managed care plan maintains a network of health care
25 providers and facilities adequate to meet the comprehensive
26 health needs of its enrollees and to provide an appropriate
27 choice of providers sufficient to provide the services
28 covered under its enrollee's contracts by determining that:
29 (1) there are a sufficient number of geographically
30 accessible participating providers and facilities;
31 (2) there are opportunities to select from at least
32 3 primary care providers pursuant to travel and
33 distance time standards, providing that these standards
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1 account for the conditions of accessing providers in
2 rural areas; and
3 (3) there are sufficient providers in all covered
4 areas of specialty practice to meet the needs of the
5 enrollment population.
6 (b) The following criteria shall be considered by the
7 Director of Public Health at the time of a review:
8 (1) provider-covered person ratios by specialty;
9 (2) primary care provider-covered person ratios;
10 (3) safe and adequate staffing of health care
11 providers in all participating facilities based on:
12 (A) severity of patient illness and functional
13 capacity;
14 (B) factors affecting the period and quality
15 of patient recovery; and
16 (C) any other factor substantially related to
17 the condition and health care needs of patients;
18 (4) geographic accessibility;
19 (5) the number of grievances filed by enrollees
20 relating to waiting times for appointments,
21 appropriateness of referrals, and other indicators of a
22 managed care plan's capacity;
23 (6) hours of operation;
24 (7) the managed care plan's ability to provide
25 culturally and linguistically competent care to meet the
26 needs of its enrollee population; and
27 (8) the volume of technological and speciality
28 services available to serve the needs of covered persons
29 requiring technologically advanced or specialty care.
30 (c) A managed care plan shall report on an annual basis
31 the number of enrollees and the number of participating
32 providers in the managed care plan and any other information
33 that the Department of Public Health may require to certify a
34 network under this Section.
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1 (d) If a managed care plan determines that it does not
2 have a health care provider with appropriate training and
3 experience in its panel or network to meet the particular
4 health care needs of an enrollee, the managed care plan
5 shall make a referral to an appropriate provider, pursuant to
6 a treatment plan approved by the managed care plan in
7 consultation with the primary care provider, the
8 non-participating provider, and the enrollee or enrollee's
9 designee, at no additional cost to the enrollee beyond what
10 the enrollee would otherwise pay for services received within
11 the network.
12 (e) A managed care plan shall have a procedure by which
13 an enrollee who needs temporary but ongoing care from a
14 specialist shall receive a referral to the specialist. If
15 the primary care provider, after consultation with the
16 medical director or other contractually authorized
17 representative of the managed care plan, determines that a
18 referral is appropriate, the managed care plan shall make
19 such a referral to a specialist. In no event shall a managed
20 care plan be required to permit an enrollee to elect to
21 have a non-participating specialist, except pursuant to the
22 provisions of subsection (d). The referral, made under this
23 subsection, shall be pursuant to a treatment plan approved
24 by the managed care plan in consultation with the primary
25 care provider, the specialist, and the enrollee or the
26 enrollee's designee. The treatment plan may limit the
27 number of visits or the period during which visits are
28 authorized and may require the specialist to provide the
29 primary care provider with regular updates on the specialty
30 care provided, as well as all necessary medical information.
31 (f) A managed care plan shall have a procedure by which
32 a new enrollee, upon enrollment, or an enrollee, upon
33 diagnosis, with (i) a life-threatening condition or disease,
34 or (ii) a degenerative and disabling condition or disease,
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1 either of which requires specialized medical care over a
2 prolonged period of time, shall receive a standing referral
3 to a specialist with expertise in treating the
4 life-threatening or degenerative and disabling disease or
5 condition who shall be responsible for and capable of
6 providing and coordinating the enrollee's primary and
7 specialty care. If the primary care provider, after
8 consultation with the medical director or other contractually
9 authorized representative of the managed care plan,
10 determines that the enrollee's care would most
11 appropriately be coordinated by a specialist, the managed
12 care plan shall refer, on a standing basis, the enrollee to a
13 specialist. In no event shall a managed care plan be required
14 to permit an enrollee to elect to have a non-participating
15 specialist, except pursuant to the provisions of subsection
16 (d). The specialist shall be permitted to treat the
17 enrollee without a referral from the enrollee's primary
18 care provider and shall be authorized to make such
19 referrals, procedures, tests, and other medical services as
20 the enrollee's primary care provider would otherwise be
21 permitted to provide or authorize including, if
22 appropriate, referral to a specialty care center. If a
23 managed care plan refers an enrollee to a non-participating
24 provider, the standing referral shall be pursuant to a
25 treatment plan approved by the managed care plan, in
26 consultation with the primary care provider, if appropriate,
27 the non-participating specialist, and the enrollee or
28 enrollee's designee. Services provided pursuant to the
29 approved treatment plan shall be provided at no additional
30 cost to the enrollee beyond what the enrollee would
31 otherwise pay for services received within the network.
32 (g) If an enrollee's health care provider leaves the
33 managed care plan's network of providers for reasons other
34 than those for which the provider would not be eligible to
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1 receive a pre-termination hearing pursuant to subsection (e)
2 of Section 45, the managed care plan shall permit the
3 enrollee to continue an ongoing course of treatment
4 with the enrollee's current health care provider during a
5 transitional period of:
6 (1) up to 90 days from the date of notice to the
7 enrollee of the provider's disaffiliation from the
8 managed care plan's network; or
9 (2) if the enrollee has entered the second trimester
10 of pregnancy at the time of the provider's
11 disaffiliation, for a transitional period that
12 includes the provision of post-partum care directly
13 related to the delivery.
14 Transitional care, however, shall be authorized by the
15 managed care plan during the transitional period only if the
16 health care provider agrees (i) to continue to accept
17 reimbursement from the managed care plan at the rates
18 applicable prior to the start of the transitional period
19 as payment in full, (ii) to adhere to the managed care plan's
20 quality assurance requirements and to provide to the managed
21 care plan necessary medical information related to the care,
22 and (iii) to otherwise adhere to the managed care plan's
23 policies and procedures, including but not limited to
24 procedures regarding referrals and obtaining
25 pre-authorization and a treatment plan approved by the
26 managed care plan.
27 (i) If a new enrollee whose health care provider is not
28 a member of the managed care plan's provider network enrolls
29 in the managed care plan, the managed care plan shall permit
30 the enrollee to continue an ongoing course of treatment with
31 the enrollee's current health care provider during a
32 transitional period of up to 90 days from the effective
33 date of enrollment, if (i) the enrollee has a
34 life-threatening disease or condition or a degenerative and
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1 disabling disease or condition or (ii) the enrollee has
2 entered the second trimester of pregnancy at the effective
3 date of enrollment, in which case the transitional period
4 shall include the provision of post-partum care directly
5 related to the delivery. If an enrollee elects to continue
6 to receive care from a health care provider pursuant to this
7 subsection, the care shall be authorized by the managed care
8 plan for the transitional period only if the health care
9 provider agrees (i) to accept reimbursement from the managed
10 care plan at rates established by the managed care plan as
11 payment in full, which rates shall be no more than the level
12 of reimbursement applicable to similar providers within
13 the managed care plan's network for those services, (ii)
14 to adhere to the managed care plan's quality assurance
15 requirements and agrees to provide to the managed care plan
16 necessary medical information related to the care, and
17 (iii) to otherwise adhere to the managed care plan's policies
18 and procedures including, but not limited to, procedures
19 regarding referrals and obtaining pre-authorization and a
20 treatment plan approved by the managed care plan. In no
21 event shall this subsection be construed to require a managed
22 care plan to provide coverage for benefits not otherwise
23 covered or to diminish or impair pre-existing condition
24 limitations contained within the subscriber's contract.
25 Section 60. Duty to report.
26 (a) A managed care plan shall make a report to the
27 appropriate professional disciplinary agency upon occurrence
28 of any of the following:
29 (1) termination of a health care provider contract
30 for reasons relating to alleged mental or physical
31 impairment, misconduct, or impairment of patient safety
32 or welfare, for which no hearing was held pursuant to
33 Section 45;
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1 (2) voluntary or involuntary termination of a
2 contract or employment or other affiliation with the
3 managed care plan to avoid the imposition of disciplinary
4 measures; or
5 (3) obtaining knowledge of any information that
6 appears to show that a health professional is guilty of
7 professional misconduct.
8 The managed care plan shall only make the report after it
9 has provided the health care professional with a hearing on
10 the matter. (This hearing shall not impair or limit the
11 managed care plan's ability to terminate the professional.
12 Its purpose is solely to ensure that a sufficient basis
13 exists for making the report.) The hearing shall be held
14 before a panel appointed by the managed care plan. The
15 hearing panel shall be composed of 5 persons appointed by the
16 plan. At least 2 of the persons on the panel shall be
17 clinical peers in the same discipline and the same specialty
18 as the health care professional under review. The hearing
19 panel shall determine whether the proposed basis for the
20 report is supported by a preponderance of the evidence. The
21 panel shall render its determination within 14 business days.
22 If a majority of the panel so finds, the managed care plan
23 shall make the required report within 10 business days.
24 Any hearing under this Section shall provide the health
25 care professional in question with the right to examine
26 pertinent information, to present witness and to ask
27 questions of an accuser or, if the accuser is the plan, an
28 authorized representative of the plan.
29 (b) Reports made pursuant to this Section shall be made
30 in writing to the appropriate professional disciplinary
31 agency. Written reports shall include the name, address,
32 profession, and license number of the individual and a
33 description of the action taken by the managed care plan,
34 including the reason for the action and the date thereof, or
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1 the nature of the action or conduct that led to the
2 resignation, termination of contract, or withdrawal, and the
3 date thereof.
4 (c) Any report or information furnished to an
5 appropriate professional disciplinary agency in
6 accordance with the provisions of this Section shall be
7 deemed a confidential communication and shall not be
8 subject to inspection or disclosure in any manner except
9 upon formal written request by a duly authorized public
10 agency or pursuant to a judicial subpoena issued in a
11 pending action or proceeding.
12 Section 65. Disclosure of information.
13 (a) A health care professional affiliated with a
14 managed care plan shall, upon request, provide, in written
15 form, to his or her patient or prospective patient the
16 following:
17 (1) information related to the health care
18 professional's educational background, experience,
19 training, specialty and board certification, if
20 applicable, number of years in practice, and hospitals
21 where he or she has privileges;
22 (2) information regarding the health care
23 professional's participation in continuing education
24 programs and compliance with any licensure,
25 certification, or registration requirements, if
26 applicable;
27 (3) information regarding the health care
28 professional's participation in clinical performance
29 reviews conducted by the Department, where applicable and
30 available; and
31 (4) the location of the health care professional's
32 primary practice setting and the identification of any
33 translation services available.
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1 Section 70. Registration of utilization review agents.
2 (a) A utilization review agent who conducts the practice
3 of utilization review shall biennially register with the
4 Director and report, in a statement subscribed and affirmed
5 as true under the penalties of perjury, the information
6 required pursuant to subsection (b) of this Section.
7 (b) The report shall contain a description of the
8 following:
9 (1) the utilization review plan;
10 (2) the provisions by which an enrollee, the
11 enrollee's designee, or a health care provider may seek
12 reconsideration of, or appeal from, adverse
13 determinations by the utilization review agent, in
14 accordance with the provisions of this Act, including
15 provisions to ensure a timely appeal and that an
16 enrollee, the enrollee's designee, and, in the case of
17 an adverse determination involving a retrospective
18 determination, the enrollee's health care provider are
19 informed of their right to appeal adverse determinations;
20 (3) procedures by which a decision on a request for
21 utilization review for services requiring
22 preauthorization shall comply with timeframes
23 established pursuant to this Act;
24 (4) a description of an emergency care policy,
25 which shall include the procedures under which an
26 emergency admission shall be made or emergency treatment
27 shall be given; (Nothing in this Act is intended to
28 pre-empt, repeal, or diminish any statute that specifies
29 or mandates the type of emergency services coverage that
30 a managed care plan must offer or provide.)
31 (5) a description of the personnel utilized to
32 conduct utilization review, including a description of
33 the circumstances under which utilization review may be
34 conducted by:
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1 (A) administrative personnel,
2 (B) health care professionals who are not
3 clinical peer reviewers, and
4 (C) clinical peer reviewers;
5 (6) a description of the mechanisms employed to
6 assure that administrative personnel are trained in the
7 principles and procedures of intake screening and data
8 collection and are appropriately monitored by a
9 licensed health care professional while performing an
10 administrative review;
11 (7) a description of the mechanisms employed to
12 assure that health care professionals conducting
13 utilization review are:
14 (A) appropriately licensed or registered; and
15 (B) trained in the principles, procedures,
16 and standards of the utilization review agent;
17 (8) a description of the mechanisms employed to
18 assure that only a clinical peer reviewer shall render an
19 adverse determination;
20 (9) provisions to ensure that appropriate personnel
21 of the utilization review agent are reasonably accessible
22 by toll-free telephone:
23 (A) not less than 40 hours per week during
24 normal business hours, to discuss patient care and
25 allow response to telephone requests, and to ensure
26 that the utilization review agent has a telephone
27 system capable of accepting, recording, or providing
28 instruction to incoming telephone calls during
29 other than normal business hours and to ensure
30 response to accepted or recorded messages not later
31 than the next business day after the date on which
32 the call was received; or
33 (B) notwithstanding the provisions of item (1),
34 not less than 40 hours per week during normal
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1 business hours, to discuss patient care and allow
2 response to telephone requests, and to ensure that,
3 in the case of a request submitted pursuant to
4 subsection (c) of Section 80 or an expedited appeal
5 filed pursuant to subsection (b) of Section 85, a
6 response is provided within 24 hours;
7 (10) the policies and procedures to ensure that
8 all applicable State and federal laws to protect the
9 confidentiality of individual medical and treatment
10 records are followed;
11 (11) a copy of the materials to be disclosed to an
12 enrollee or prospective enrollee pursuant to this Act;
13 (12) a description of the mechanisms employed by
14 the utilization review agent to assure that all
15 contractors, subcontractors, subvendors, agents, and
16 employees affiliated by contract or otherwise with such
17 utilization review agent will adhere to the standards and
18 requirements of this Act; and
19 (13) a list of the payors for which the
20 utilization review agent is performing utilization
21 review in this State.
22 (c) Upon receipt of the report, the Director
23 shall issue an acknowledgment of the filing.
24 (d) A registration issued under this Act shall be valid
25 for a period of not more than 2 years, and may be renewed for
26 additional periods of not more than 2 years each.
27 Section 75. Utilization review program standards.
28 (a) A utilization review agent shall adhere to
29 utilization review program standards consistent with the
30 provisions of this Act, which shall, at a minimum, include:
31 (1) appointment of a medical director, who is a
32 licensed physician; provided, however, that the
33 utilization review agent may appoint a clinical director
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1 when the utilization review performed is for a discrete
2 category of health care service and provided further that
3 the clinical director is a licensed health care
4 professional who typically manages the category of
5 service; responsibilities of the medical director, or,
6 where appropriate, the clinical director, shall
7 include, but not be limited to, the supervision and
8 oversight of the utilization review process;
9 (2) development of written policies and procedures
10 that govern all aspects of the utilization review
11 process and a requirement that a utilization review
12 agent shall maintain and make available to enrollees and
13 health care providers a written description of the
14 procedures, including procedures to appeal an adverse
15 determination;
16 (3) utilization of written clinical review criteria
17 developed pursuant to a utilization review plan;
18 (4) establishment of a process for rendering
19 utilization review determinations, which shall, at a
20 minimum, include written procedures to assure that
21 utilization reviews and determinations are conducted
22 within the timeframes established herein, procedures to
23 notify an enrollee, an enrollee's designee, and an
24 enrollee's health care provider of adverse
25 determinations, and procedures for appeal of adverse
26 determinations, including the establishment of an
27 expedited appeals process for denials of continued
28 inpatient care or where there is imminent or serious
29 threat to the health of the enrollee;
30 (5) establishment of a written procedure to assure
31 that the notice of an adverse determination includes:
32 (A) the reasons for the determination,
33 including the clinical rationale or contract basis,
34 if any;
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1 (B) instructions on how to initiate an
2 appeal; and
3 (C) disclosure of the clinical review
4 criteria relied upon to make the determination;
5 (6) establishment of a requirement that
6 appropriate personnel of the utilization review agent are
7 reasonably accessible by toll-free telephone:
8 (A) not less than 40 hours per week during
9 normal business hours to discuss patient care and
10 allow response to telephone requests, and to ensure
11 that the utilization review agent has a telephone
12 system capable of accepting, recording or providing
13 instruction to incoming telephone calls during
14 other than normal business hours and to ensure
15 response to accepted or recorded messages not less
16 than one business day after the date on which the
17 call was received; or
18 (B) notwithstanding the provisions of item
19 (A), not less than 40 hours per week during normal
20 business hours, to discuss patient care and allow
21 response to telephone requests, and to ensure that,
22 in the case of a request submitted pursuant to
23 subsection (c) of Section 80 or an expedited
24 appeal filed pursuant to subsection (b) of
25 Section 85, a response is provided within 24 hours;
26 (7) establishment of appropriate policies and
27 procedures to ensure that all applicable State and
28 federal laws to protect the confidentiality of individual
29 medical records are followed;
30 (8) establishment of a requirement that emergency
31 services, as defined in this Act, rendered to an enrollee
32 shall not be subject to prior authorization nor
33 shall reimbursement for those services be denied on
34 retrospective review.
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1 (b) A utilization review agent shall assure adherence to
2 the requirements stated in subsection (a) of this Section by
3 all contractors, subcontractors, subvendors, agents, and
4 employees affiliated by contract or otherwise with the
5 utilization review agent.
6 Section 80. Utilization review determinations.
7 (a) Utilization review shall be conducted by:
8 (1) administrative personnel trained in the
9 principles and procedures of intake screening and data
10 collection, provided, however, that administrative
11 personnel shall only perform intake screening, data
12 collection, and non-clinical review functions and shall
13 be supervised by a licensed health care professional;
14 (2) a health care professional who is
15 appropriately trained in the principles, procedures,
16 and standards of the utilization review agent; provided,
17 however, that a health care professional who is not a
18 clinical peer reviewer may not render an adverse
19 determination; and
20 (3) a clinical peer reviewer where the review
21 involves an adverse determination.
22 (b) A utilization review agent shall make a utilization
23 review determination involving health care services that
24 require pre-authorization and provide notice of the
25 determination, as soon as possible, to the enrollee or
26 enrollee's designee and the enrollee's health care provider
27 by telephone and in writing within 2 business days of receipt
28 of the necessary information.
29 (c) A utilization review agent shall make a
30 determination involving continued or extended health care
31 services or additional services for an enrollee
32 undergoing a course of continued treatment prescribed by a
33 health care provider and provide notice of the determination
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1 to the enrollee or the enrollee's designee, which may be
2 satisfied by notice to the enrollee's health care provider,
3 by telephone and in writing within 24 hours of receipt of the
4 necessary information. Notification of continued or
5 extended services shall include the number of extended
6 services approved, the new total of approved services, the
7 date of onset of services, and the next review date.
8 (d) A utilization review agent shall make a utilization
9 review determination involving health care services that have
10 already been delivered, within 30 days of receipt of the
11 necessary information.
12 (e) Notice of an adverse determination made by a
13 utilization review agent shall be given in writing and must
14 include:
15 (1) the reasons for the determination, including
16 the clinical rationale or contract basis, if any;
17 (2) instructions on how to initiate an appeal; and
18 (3) disclosure of the clinical review criteria
19 relied upon to make the determination.
20 The notice shall also specify what, if any, additional
21 necessary information must be provided to, or obtained by,
22 the utilization review agent in order to render a decision on
23 the appeal.
24 (f) In the event that a utilization review agent
25 renders an adverse determination without attempting to
26 discuss the matter with the enrollee's health care
27 provider who specifically recommended the health care
28 service, procedure, or treatment under review, the health
29 care provider shall have the opportunity to request an
30 immediate reconsideration of the adverse determination.
31 Except in cases of retrospective reviews, the
32 reconsideration shall occur within 24 hours of receipt of
33 the request and shall be conducted by the enrollee's
34 health care provider and the clinical peer reviewer making
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1 the initial determination or a designated clinical peer
2 reviewer if the original clinical peer reviewer cannot be
3 available. In the event that the adverse determination is
4 upheld after reconsideration, the utilization review agent
5 shall provide notice as required pursuant to subsection (e)
6 of this Section. Nothing in this Section shall preclude the
7 enrollee from initiating an appeal from an adverse
8 determination.
9 Section 85. Appeal of adverse determinations by
10 utilization review agents.
11 (a) An enrollee, the enrollee's designee, and, in
12 connection with retrospective adverse determinations, the
13 enrollee's health care provider may appeal an adverse
14 determination rendered by a utilization review agent.
15 (b) A utilization review agent shall establish an
16 expedited appeal process for appeal of an adverse
17 determination involving:
18 (1) continued or extended health care services,
19 procedures, or treatments or additional services for an
20 enrollee undergoing a course of continued treatment
21 prescribed by a health care provider; or
22 (2) an adverse determination in which the
23 health care provider believes an immediate appeal is
24 warranted, other than a retrospective determination.
25 The appeal process shall include mechanisms that
26 facilitate resolution of the appeal including, but not
27 limited to, the sharing of information from the
28 enrollee's health care provider and the utilization review
29 agent by telephonic means or by facsimile. The utilization
30 review agent shall provide reasonable access to its
31 clinical peer reviewer within 24 hours of receiving notice of
32 the taking of an expedited appeal. Expedited appeals
33 must be determined within 48 hours of receipt of necessary
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1 information to conduct the appeal. Expedited appeals that
2 do not result in a resolution satisfactory to the appealing
3 party may be further appealed through the standard
4 appeal process.
5 (c) A utilization review agent shall establish a
6 standard appeal process that includes procedures for appeals
7 to be filed in writing or by telephone. A utilization
8 review agent must establish a period of no less than 45 days
9 after receipt of notification by the enrollee of the initial
10 utilization review determination and receipt of all
11 necessary information to file the appeal from the
12 determination. The utilization review agent must provide
13 written acknowledgment of the filing of the appeal to the
14 appealing party within 5 days of the filing and shall make a
15 determination with regard to the appeal within 30 days of
16 the receipt of necessary information to conduct the
17 appeal. The utilization review agent shall notify the
18 enrollee, the enrollee's designee and, where appropriate,
19 the enrollee's health care provider, in writing, of the
20 appeal determination within 48 hours of the rendering of the
21 determination. The notice of the appeal determination shall
22 include the reasons for the determination; provided, however,
23 that where the adverse determination is upheld on appeal,
24 the notice shall include the clinical rationale for the
25 determination.
26 (d) Both expedited and standard appeals shall be
27 reviewed by a clinical peer reviewer other than the
28 clinical peer reviewer who rendered the adverse
29 determination.
30 Section 90. Required and prohibited practices.
31 (a) A utilization review agent shall have written
32 procedures for assuring that patient-specific information
33 obtained during the process of utilization review will be:
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1 (1) kept confidential in accordance with applicable
2 State and federal laws; and
3 (2) shared only with the enrollee, the
4 enrollee's designee, the enrollee's health care provider,
5 and those who are authorized by law to receive the
6 information.
7 (b) Summary data shall not be considered confidential
8 if it does not provide information to allow identification of
9 individual patients.
10 (c) Any health care professional who makes
11 determinations regarding the medical necessity of health care
12 services during the course of utilization review shall be
13 appropriately licensed or registered.
14 (d) A utilization review agent shall not, with respect
15 to utilization review activities, permit or provide
16 compensation or anything of value to its employees, agents,
17 or contractors based on:
18 (1) either a percentage of the amount by which a
19 claim is reduced for payment or the number of claims or
20 the cost of services for which the person has denied
21 authorization or payment; or
22 (2) any other method that encourages the
23 rendering of an adverse determination.
24 (e) If a health care service has been specifically
25 pre-authorized or approved for an enrollee by a
26 utilization review agent, a utilization review agent shall
27 not, pursuant to retrospective review, revise or modify
28 the specific standards, criteria, or procedures used for
29 the utilization review for procedures, treatment, and
30 services delivered to the enrollee during the same course
31 of treatment.
32 (f) Utilization review shall not be conducted more
33 frequently than is reasonably required to assess whether the
34 health care services under review are medically necessary.
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1 The Department shall promulgate rules governing the frequency
2 of utilization reviews for managed care plans of differing
3 size and geographic location.
4 (g) When making prospective, concurrent, and
5 retrospective determinations, utilization review agents shall
6 collect only information that is necessary to make the
7 determination and shall not routinely require health care
8 providers to numerically code diagnoses or procedures to
9 be considered for certification or routinely request copies
10 of medical records of all patients reviewed. During
11 prospective or concurrent review, copies of medical
12 records shall only be required when necessary to verify that
13 the health care services subject to the review are medically
14 necessary. In these cases, only the necessary or relevant
15 sections of the medical record shall be required. A
16 utilization review agent may request copies of partial or
17 complete medical records retrospectively.
18 (h) In no event shall information be obtained from
19 health care providers for the use of the utilization
20 review agent by persons other than health care professionals,
21 medical record technologists, or administrative personnel who
22 have received appropriate training.
23 (i) The utilization review agent shall not undertake
24 utilization review at the site of the provision of health
25 care services unless the utilization review agent:
26 (1) identifies himself or herself by name and the
27 name of his or her organization, including displaying
28 photographic identification that includes the name of
29 the utilization review agent and clearly identifies the
30 individual as representative of the utilization review
31 agent;
32 (2) whenever possible, schedules review at least
33 one business day in advance with the appropriate health
34 care provider;
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1 (3) if requested by a health care provider,
2 assures that the on-site review staff register with the
3 appropriate contact person, if available, prior to
4 requesting any clinical information or assistance
5 from the health care provider; and
6 (4) obtains consent from the enrollee or the
7 enrollee's designee before interviewing the patient's
8 family or observing any health care service being
9 provided to the enrollee.
10 This subsection does not apply to health care
11 professionals engaged in providing care, case management, or
12 making on-site discharge decisions.
13 (j) A utilization review agent shall not base an adverse
14 determination on a refusal to consent to observing any health
15 care service.
16 (k) A utilization review agent shall not base an adverse
17 determination on lack of reasonable access to a health
18 care provider's medical or treatment records unless the
19 utilization review agent has provided reasonable notice
20 to both the enrollee or the enrollee's designee and the
21 enrollee's health care provider and has complied with all
22 provisions of subsection (i) of this Section. The Department
23 shall promulgate rules defining reasonable notice and the
24 time period within which medical and treatment records must
25 be turned over.
26 (l) Neither the utilization review agent nor the entity
27 for which the agent provides utilization review shall take
28 any action with respect to a patient or a health care
29 provider that is intended to penalize the enrollee, the
30 enrollee's designee, or the enrollee's health care provider
31 for, or to discourage the enrollee, the enrollee's designee,
32 or the enrollee's health care provider from, undertaking an
33 appeal, dispute resolution, or judicial review of an adverse
34 determination.
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1 (m) In no event shall an enrollee, an enrollee's
2 designee, an enrollee's health care provider, any other
3 health care provider, or any other person or entity be
4 required to inform or contact the utilization review agent
5 prior to the provision of emergency services as defined in
6 this Act.
7 (n) No contract or agreement between a utilization
8 review agent and a health care provider shall contain any
9 clause purporting to transfer to the health care provider by
10 indemnification or otherwise any liability relating to
11 activities, actions, or omissions of the utilization review
12 agent.
13 (o) A health care professional providing health care
14 services to an enrollee shall be prohibited from serving
15 as the clinical peer reviewer for that enrollee in connection
16 with the health care services being provided to the
17 enrollee.
18 Section 95. Annual consumer satisfaction survey. The
19 Director shall develop and administer a survey of persons who
20 have been enrolled in a managed care plan in the most recent
21 calendar year to collect information on relative plan
22 performance. This survey shall:
23 (1) be administered annually by the Director, or by
24 an independent agency or organization selected by the
25 Director;
26 (2) be administered to a scientifically selected
27 representative sample of current enrollees from each
28 plan, as well as persons who have disenrolled from a plan
29 in the last calendar year; and
30 (3) emphasize the collection of information from
31 persons who have used the health plan to a significant
32 degree, including persons with chronic disabilities or
33 medical conditions.
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1 Selected data from the annual survey shall be made
2 available to current and prospective enrollees as part of a
3 consumer guidebook of health plan performance, which the
4 Department shall develop and publish. The elements to be
5 included in the guidebook shall be reassessed on an ongoing
6 basis by the Department. The consumer guidebook shall be
7 updated at least annually.
8 Section 100. Managed care patient rights. In addition
9 to all other requirements of this Act, a managed care plan
10 shall ensure that an enrollee has the following rights:
11 (1) A patient has the right to care consistent with
12 professional standards of practice to assure quality nursing
13 and medical practices, to be informed of the name of the
14 participating physician responsible for coordinating his or
15 her care, to receive information concerning his or her
16 condition and proposed treatment, to refuse any treatment to
17 the extent permitted by law, and to privacy and
18 confidentiality of records except as otherwise provided by
19 law.
20 (2) A patient has the right, regardless of source of
21 payment, to examine and to receive a reasonable explanation
22 of his or her total bill for health care services rendered by
23 his or her physician or other health care provider, including
24 the itemized charges for specific health care services
25 received. A physician or other health care provider shall be
26 responsible only for a reasonable explanation of these
27 specific health care services provided by the health care
28 provider.
29 (3) A patient has the right to privacy and
30 confidentiality in health care. A physician, other health
31 care provider, managed care plan, and utilization review
32 program shall refrain from disclosing the nature or details
33 of health care services provided to patients, except that the
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1 information may be disclosed to the patient, the party making
2 treatment decisions if the patient is incapable of making
3 decisions regarding the health care services provided, those
4 parties directly involved with providing treatment to the
5 patient or processing the payment for the treatment, those
6 parties responsible for peer review, utilization review, and
7 quality assurance, and those parties required to be notified
8 under the Abused and Neglected Child Reporting Act, the
9 Illinois Sexually Transmissible Disease Control Act, or where
10 otherwise authorized or required by law. This right may be
11 expressly waived in writing by the patient or the patient's
12 guardian, but a managed care plan, a physician, or other
13 health care provider may not condition the provision of
14 health care services on the patient's or guardian's agreement
15 to sign the waiver.
16 Section 105. Managed Care Ombudsman Program.
17 (a) The Department shall establish a Managed Care
18 Ombudsman Program (MCOP). The purpose of the MCOP is to
19 assist consumers to:
20 (1) navigate the managed care system;
21 (2) select an appropriate managed care plan; and
22 (3) understand and assert their rights as managed
23 care plan enrollees.
24 (b) The Department shall contract with an independent
25 organization, organizations, or consortia of organizations to
26 perform the following MCOP functions:
27 (1) Assist consumers with managed care plan
28 selection by providing information, referral, and
29 assistance to individuals about means of obtaining health
30 coverage and services, including, but not limited to:
31 (A) access through a toll-free telephone
32 number; and
33 (B) availability of information in languages
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1 other than English that are spoken as a primary
2 language by a significant portion of the State's
3 population, as determined by the Department.
4 (2) Educate and train consumers in the use of a
5 State-sponsored annual Consumer Guide for Managed Care
6 Plan Selection on managed care plan performance that
7 includes all participating providers and facilities.
8 (3) Assist enrollees to understand their rights and
9 responsibilities under managed care plans by identifying,
10 investigating, publicizing, and promoting solutions to
11 practices, policies, laws, or rules that may adversely
12 affect individuals' access to quality health care,
13 including, but not limited to, practices relating to:
14 (A) access to appropriate levels of care and
15 specialty providers;
16 (B) accessibility of services and resources
17 for underserved areas and vulnerable populations;
18 and
19 (C) marketing of managed care plans.
20 (4) Identify, investigate, and resolve enrollee
21 complaints about health care services and assist
22 enrollees with filing complaints and appeals.
23 (A) Complaints may relate to action, inaction,
24 or decisions of managed care plans and public or
25 private agencies involved in the delivery, funding,
26 or regulation of health care.
27 (B) The MCOP shall notify the Department of
28 quality of care complaints.
29 (5) Advocate policies and programs that protect
30 consumer interests and rights under managed care, which
31 shall include:
32 (A) representing the interests of individuals
33 before governmental agencies and seeking
34 administrative, legal, and other remedies to protect
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1 the health, safety, welfare, and rights of the
2 individuals;
3 (B) analyzing, commenting on, and monitoring
4 the development and implementation of federal, State
5 and local laws, regulations, and other governmental
6 policies and actions that pertain to the health,
7 safety, welfare, and rights of the individuals, with
8 respect to the adequacy of managed care plans,
9 facilities, and services in the State (including
10 providing information the MCOP determines to be
11 necessary to public and private agencies,
12 legislators, and other persons);
13 (C) facilitating public comment on those laws,
14 regulations, policies, and actions;
15 (D) promoting the development of citizen
16 organizations to participate in the activities of
17 the MCOP; and
18 (E) providing technical support for the
19 development of consumer and citizen organizations to
20 protect the well-being and rights of individuals.
21 (6) Ensure that individuals have timely access to
22 the services provided through the MCOP and that
23 individuals and complainants receive timely responses
24 from representatives of the MCOP.
25 (7) Submit an annual report to the Department and
26 General Assembly:
27 (A) describing the activities carried out by
28 the MCOP in the year for which the report is
29 prepared;
30 (B) containing and analyzing the data
31 collected by the MCOP; and
32 (C) evaluating the problems experienced by,
33 and the complaints made by or on behalf of,
34 individuals.
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1 (8) Exercise such other powers and functions as the
2 Department determines to be appropriate.
3 (c) The Department shall establish criteria for
4 selection of an independent organization, organizations, or
5 consortia of organizations to perform the functions of the
6 MCOP, including, but not limited to, the following:
7 (1) Preference shall be given to private,
8 not-for-profit organizations governed by boards with
9 consumer members in the majority that represent a broad
10 spectrum of the diverse consumer interests in the State.
11 (2) No individual or organization under contract to
12 perform functions of the MCOP may:
13 (A) have a direct involvement in the
14 licensing, certification, or accreditation of a
15 health care facility, a managed care plan, or a
16 provider of a managed care plan, or have a direct
17 involvement with a provider of a health care
18 service;
19 (B) have a direct ownership or investment
20 interest in a health care facility, a managed care
21 plan, or a health care service;
22 (C) be employed by, or participate in the
23 management of, a health care service or facility or
24 a managed care plan; or
25 (D) receive, or have the right to receive,
26 directly or indirectly, remuneration (in cash or in
27 kind) under a compensation arrangement with an owner
28 or operator of a health care service or facility or
29 managed care plan.
30 The Department shall contract with an organization,
31 organizations, or consortia of organizations qualified under
32 criteria established under this Section for an initial term
33 of 3 years. The initial contract shall be renewable
34 thereafter for additional 3 year terms without reopening the
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1 competitive selection process unless there has been an
2 unfavorable written performance evaluation conducted by the
3 State specifying in detail the reasons for the unfavorable
4 evaluation.
5 (d) The Department shall establish policies and
6 procedures for the operation of MCOP, including, but not
7 limited to, policies and procedures to:
8 (1) Ensure optimal coordination among the regional
9 and local staff or representatives of the MCOP.
10 (2) Ensure that organizations performing the
11 functions of the MCOP shall have:
12 (A) access to managed care plans and their
13 participating providers and facilities;
14 (B) appropriate access to review the medical
15 records of an individual, if the representative has
16 the permission of the individual or the legal
17 representative of the individual;
18 (C) access to the administrative records,
19 policies, and documents of managed care plans, to
20 which individuals or the general public has access;
21 (D) access to and, on request, copies of all
22 licensing, certification, and data-reporting records
23 maintained by the State or reported to the federal
24 government with respect to health care providers;
25 and
26 (E) access to quality assessment and
27 improvement data maintained by the State.
28 (3) Protect the identity and confidentiality of any
29 complainant or other individual with respect to whom the
30 MCOP maintains files or records.
31 (4) Establish and implement minimum qualifications
32 and training requirements for personnel, including
33 volunteers.
34 (5) Evaluate the quality and effectiveness of the
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1 organization, organizations, or consortia of
2 organizations in carrying out the functions specified in
3 the contract based on criteria established by rule. The
4 results of the performance evaluation shall include a
5 public comment period that is advertised statewide at
6 least 4 months before the end of the contract period.
7 (6) Promote optimal coordination between the MCOP
8 and other citizen advocacy organizations.
9 (8) Submit an annual report to the legislature
10 including, but not limited to, information that:
11 (A) evaluates the organizations performing the
12 functions of the MCOP;
13 (B) contains recommendations for protecting
14 the health, safety, welfare, and rights of
15 individuals with respect to managed health care;
16 (C) analyzes the success of the MCOP and
17 barriers that prevent the optimal operation of the
18 MCOP; and
19 (D) provides policy, regulatory, and
20 legislative recommendations to solve identified
21 problems.
22 (e) The Department shall provide adequate funding for
23 the MCOP by assessing each managed care plan an amount to be
24 determined by the Department.
25 Section 110. Waiver. Any agreement that purports to
26 waive, limit, disclaim or in any way diminish the rights set
27 forth in this Act is void as contrary to public policy.
28 Section 115. Administration of Act. The Department of
29 Insurance shall administer this Act and may promulgate rules
30 for that purpose.
31 Section 120. Civil penalty; other relief.
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1 (a) If the Department of Public Health determines that
2 violation of this Act has occurred or has been notified by
3 the Department of Insurance that a violation has occurred,
4 the Department of Public Health, through the Attorney
5 General, shall bring an action in the circuit court of the
6 county in which the violation occurred to recover a civil
7 penalty of no more than $7,500 for each violation. Each day
8 that a violation continues constitutes a separate violation.
9 In addition, the Department of Public Health, through the
10 Attorney General, may petition for an order enjoining the
11 violation of this Act.
12 (b) The Department of Public Health may promulgate
13 reasonable and necessary rules to carry out the purposes of
14 this Section.
15 Section 125. The State Employees Group Insurance Act of
16 1971 is amended by adding Section 6.9 as follows:
17 (5 ILCS 375/6.9 new)
18 Sec. 6.9. Managed Care Reform Act. The program of
19 health benefits is subject to the provisions of the Managed
20 Care Reform Act and Section 356t of the Illinois Insurance
21 Code.
22 Section 130. 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
27 of the Managed Care Reform Act and Section 356t of the
28 Illinois Insurance Code. The requirement under this Section
29 that health care benefits provided by counties comply with
30 the Managed Care Reform Act is an exclusive power and
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1 function of the State and is a denial and limitation of home
2 rule county powers under Article VII, Section 6, subsection
3 (h) of the Illinois Constitution.
4 Section 135. The Illinois Municipal Code is amended by
5 adding 10-4-2.8 as follows:
6 (65 ILCS 5/10-4-2.8 new)
7 Sec. 10-4-2.8. Managed Care Reform Act. The corporate
8 authorities of all municipalities are subject to the
9 provisions of the Managed Care Reform Act and Section 356t of
10 the Illinois Insurance Code. The requirement under this
11 Section that health care benefits provided by municipalities
12 comply with the Managed Care Reform Act is an exclusive power
13 and function of the State and is a denial and limitation of
14 home rule municipality powers under Article VII, Section 6,
15 subsection (h) of the Illinois Constitution.
16 Section 140. The School Code is amended by adding
17 Section 10-22.3f as follows:
18 (105 ILCS 5/10-22.3f new)
19 Sec. 10-22.3f. Managed Care Reform Act. Insurance
20 protection and benefits for employees are subject to the
21 Managed Care Reform Act.
22 Section 145. The Illinois Insurance Code is changed by
23 adding Section 356t as follows:
24 (215 ILCS 5/356t new)
25 Sec. 356t. Choice requirements for point of service
26 plans.
27 (a) An employer, self-insured employer or employee
28 organization, labor union, association or other person
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1 providing, offering, or making available to employees or
2 individuals a managed care plan, as defined in the Managed
3 Care Reform Act, shall offer to all enrollees the
4 opportunity to obtain coverage through a "point of service"
5 plan, at the time of enrollment and once annually thereafter.
6 The "point of service" plan shall provide coverage for health
7 care services when such health care services are provided by
8 any health care provider without the necessary referrals,
9 prior authorization, or other utilization review requirements
10 of the managed care plan.
11 (b) A point of service plan may charge an enrollee who
12 opts to obtain point of service coverage an alternative
13 premium that takes into account the actuarial value of that
14 coverage.
15 (c) A point of service plan may require reasonable
16 payment of coinsurance, co-payments, or deductibles. The
17 co-insurance rate on the point of service plan shall not be
18 greater than 20 percentage points more than the co-insurance
19 rate on the underlying plan. The maximum out-of-pocket
20 amount shall not exceed $3,500 for an individual and $5,000
21 for family coverage.
22 Section 150. The Health Maintenance Organization Act is
23 amended by changing Sections 2-2 and 6-7 as follows:
24 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
25 Sec. 2-2. Determination by Director; Health Maintenance
26 Advisory Board.
27 (a) Upon receipt of an application for issuance of a
28 certificate of authority, the Director shall transmit copies
29 of such application and accompanying documents to the
30 Director of the Illinois Department of Public Health. The
31 Director of the Department of Public Health shall then
32 determine whether the applicant for certificate of authority,
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1 with respect to health care services to be furnished: (1) has
2 demonstrated the willingness and potential ability to assure
3 that such health care service will be provided in a manner to
4 insure both availability and accessibility of adequate
5 personnel and facilities and in a manner enhancing
6 availability, accessibility, and continuity of service; and
7 (2) has arrangements, established in accordance with rules
8 regulations promulgated by the Department of Public Health
9 for an ongoing quality of health care assurance program
10 concerning health care processes and outcomes. Upon
11 investigation, the Director of the Department of Public
12 Health shall certify to the Director whether the proposed
13 Health Maintenance Organization meets the requirements of
14 this subsection (a). If the Director of the Department of
15 Public Health certifies that the Health Maintenance
16 Organization does not meet such requirements, he or she shall
17 specify in what respect it is deficient.
18 There is created in the Department of Public Health a
19 Health Maintenance Advisory Board composed of 11 members.
20 Nine of the 9 members shall who have practiced in the health
21 field and, 4 of those 9 which shall have been or shall be are
22 currently affiliated with a Health Maintenance Organization.
23 Two of the members shall be members of the general public,
24 one of whom is over 65 years of age. Each member shall be
25 appointed by the Director of the Department of Public Health
26 and serve at the pleasure of that Director and shall receive
27 no compensation for services rendered other than
28 reimbursement for expenses. Six Five members of the Board
29 shall constitute a quorum. A vacancy in the membership of the
30 Advisory Board shall not impair the right of a quorum to
31 exercise all rights and perform all duties of the Board. The
32 Health Maintenance Advisory Board has the power to review and
33 comment on proposed rules and regulations to be promulgated
34 by the Director of the Department of Public Health within 30
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1 days after those proposed rules and regulations have been
2 submitted to the Advisory Board.
3 (b) Issuance of a certificate of authority shall be
4 granted if the following conditions are met:
5 (1) the requirements of subsection (c) of Section
6 2-1 have been fulfilled;
7 (2) the persons responsible for the conduct of the
8 affairs of the applicant are competent, trustworthy, and
9 possess good reputations, and have had appropriate
10 experience, training or education;
11 (3) the Director of the Department of Public Health
12 certifies that the Health Maintenance Organization's
13 proposed plan of operation meets the requirements of this
14 Act;
15 (4) the Health Care Plan furnishes basic health
16 care services on a prepaid basis, through insurance or
17 otherwise, except to the extent of reasonable
18 requirements for co-payments or deductibles as authorized
19 by this Act;
20 (5) the Health Maintenance Organization is
21 financially responsible and may reasonably be expected to
22 meet its obligations to enrollees and prospective
23 enrollees; in making this determination, the Director
24 shall consider:
25 (A) the financial soundness of the applicant's
26 arrangements for health services and the minimum
27 standard rates, co-payments and other patient
28 charges used in connection therewith;
29 (B) the adequacy of working capital, other
30 sources of funding, and provisions for
31 contingencies; and
32 (C) that no certificate of authority shall be
33 issued if the initial minimum net worth of the
34 applicant is less than $2,000,000. The initial net
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1 worth shall be provided in cash and securities in
2 combination and form acceptable to the Director;
3 (6) the agreements with providers for the provision
4 of health services contain the provisions required by
5 Section 2-8 of this Act; and
6 (7) any deficiencies identified by the Director
7 have been corrected.
8 (Source: P.A. 86-620; 86-1475.)
9 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
10 Sec. 6-7. Board of Directors. The board of directors of
11 the Association shall consist consists of not less than 7 5
12 nor more than 11 9 members serving terms as established in
13 the plan of operation. The members of the board are to be
14 selected by member organizations subject to the approval of
15 the Director provided, however, that 2 members shall be
16 enrollees, one of whom is over 65 years of age. Vacancies on
17 the board must be filled for the remaining period of the term
18 in the manner described in the plan of operation. To select
19 the initial board of directors, and initially organize the
20 Association, the Director must give notice to all member
21 organizations of the time and place of the organizational
22 meeting. In determining voting rights at the organizational
23 meeting each member organization is entitled to one vote in
24 person or by proxy. If the board of directors is not
25 selected at the organizational meeting, the Director may
26 appoint the initial members.
27 In approving selections or in appointing members to the
28 board, the Director must consider, whether all member
29 organizations are fairly represented.
30 Members of the board may be reimbursed from the assets of
31 the Association for expenses incurred by them as members of
32 the board of directors but members of the board may not
33 otherwise be compensated by the Association for their
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1 services.
2 (Source: P.A. 85-20.)
3 Section 155. Severability. The provisions of this Act
4 are severable under Section 1.31 of the Statute on Statutes.
5 Section 199. Effective date. This Act takes effect upon
6 becoming law.".