[ Search ] [ Legislation ] [ Bill Summary ]
[ Home ] [ Back ] [ Bottom ]
| [ Introduced ] | [ Engrossed ] | [ House Amendment 001 ] |
| [ House Amendment 002 ] | [ House Amendment 005 ] |
90_HB0626ham003
LRB9000248JSmgam08
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 of the same category in the same or
19 similar specialty as the health care provider who
20 typically manages the medical condition, procedure or
21 treatment under review; or
22 (2) in the case of non-physician reviewers, a
-2- LRB9000248JSmgam08
1 health care professional who is in the same
2 profession and same or similar specialty as the health
3 care provider who typically manages the medical
4 condition, procedure or treatment under review. Nothing
5 herein shall be construed to change any statutorily
6 defined scope of practice.
7 "Culturally and linguistically competent care" means that
8 a managed care plan has staff and procedures in place to
9 provide all covered services and policy procedures in
10 English, Spanish, and any other language spoken as a primary
11 language by 5% or more of its enrollees.
12 "Degenerative or disabling condition or disease" means a
13 condition or disease that is permanent or of indefinite
14 duration, that is likely to become worse or more advanced
15 over time, and that substantially impairs a major life
16 function.
17 "Department" means the Department of Public Health.
18 "Director" means the Director of Public Health.
19 "Emergency medical screening examination" means a medical
20 screening examination and evaluation by a physician or, to
21 the extent permitted by applicable laws, by other appropriate
22 personnel under the supervision of a physician to determine
23 whether the need for emergency services exists.
24 "Emergency services" means those health care services
25 provided to evaluate and treat medical conditions of recent
26 onset and severity that would lead a prudent lay person,
27 possessing an average knowledge of medicine and health, to
28 believe that urgent or unscheduled medical care is required.
29 "Enrollee" means a person enrolled in a managed care
30 plan.
31 "Health care professional" means a physician, registered
32 professional nurse, or other person appropriately licensed or
33 registered pursuant to the laws of this State to provide
34 health care services.
-3- LRB9000248JSmgam08
1 "Health care provider" means a health care professional,
2 hospital, facility, or other person appropriately licensed or
3 otherwise authorized to furnish health care services or
4 arrange for the delivery of health care services in this
5 State.
6 "Health care services" means services included in the (i)
7 furnishing of medical care, (ii) hospitalization incident to
8 the furnishing of medical care, and (iii) furnishing of
9 services, including pharmaceuticals, for the purpose of
10 preventing, alleviating, curing, or healing human illness or
11 injury to an individual.
12 "Informal policy or procedure" means a nonwritten policy
13 or procedure, the existence of which is proven by an
14 admission of an authorized agent of a managed care plan or
15 statistical evidence supported by anecdotal evidence.
16 "Life threatening condition or disease" means any
17 condition, illness, or injury that, in the opinion of a
18 licensed physician, (i) may directly lead to a patient's
19 death, (ii) results in a period of unconsciousness which is
20 indeterminate at the present, or (iii) imposes severe pain or
21 an inhumane burden on the patient.
22 "Managed care plan" means a plan that establishes,
23 operates, or maintains a network of health care providers
24 that have entered into agreements with the plan to provide
25 health care services to enrollees where the plan has the
26 obligation to the enrollee to arrange for the provision of or
27 pay for services through:
28 (1) organizational arrangements for ongoing quality
29 assurance, utilization review programs, or dispute
30 resolution; or
31 (2) financial incentives for persons enrolled in
32 the plan to use the participating providers and
33 procedures covered by the plan.
34 A managed care plan may be established or operated by any
-4- LRB9000248JSmgam08
1 entity including, but not necessarily limited to, a licensed
2 insurance company, hospital or medical service plan, health
3 maintenance organization, limited health service
4 organization, preferred provider organization, third party
5 administrator, independent practice association, or employer
6 or employee organization.
7 For purposes of this definition, "managed care plan"
8 shall not include the following:
9 (1) strict indemnity health insurance policies or
10 plans issued by an insurer that does not require approval
11 of a primary care provider or other similar coordinator
12 to access health care services; and
13 (2) managed care plans that offer only dental or
14 vision coverage.
15 "Post-stabilization services" means those health care
16 services determined by a treating provider to be promptly and
17 medically necessary following stabilization of an emergency
18 condition.
19 "Primary care provider" means a physician licensed to
20 practice medicine in all its branches who provides a broad
21 range of personal medical care (preventive, diagnostic,
22 curative, counseling, or rehabilitative) in a comprehensive
23 and coordinated manner over time.
24 "Specialist" means a health care professional who
25 concentrates practice in a recognized specialty field of
26 care.
27 "Speciality care center" means only a center that is
28 accredited by an agency of the State or federal government or
29 by a voluntary national health organization as having special
30 expertise in treating the life-threatening disease or
31 condition or degenerative or disabling disease or condition
32 for which it is accredited.
33 "Utilization review" means the review, undertaken by a
34 managed care plan, as herein defined, to determine whether
-5- LRB9000248JSmgam08
1 health care services that have been provided, are being
2 provided or are proposed to be provided to an
3 individual, whether undertaken prior to, concurrent with, or
4 subsequent to the delivery of such services are
5 medically necessary. For the purposes of this Act,
6 none of the following shall be considered utilization review:
7 (1) denials based on failure to obtain health care
8 services from a designated or approved health care
9 provider as required under an enrollee's contract;
10 (2) the review of the appropriateness of the
11 application of a particular coding to a patient,
12 including the assignment of diagnosis and procedure;
13 (3) any issues relating to the determination of
14 the amount or extent of payment other than determinations
15 to deny payment based on an adverse determination; and
16 (4) any determination of any coverage issues other
17 than whether health care services are or were medically
18 necessary.
19 "Utilization review agent" means any company,
20 organization, or other entity performing utilization review,
21 except:
22 (1) an agency of the federal government;
23 (2) an agent acting on behalf of the federal
24 government, but only to the extent that the agent is
25 providing services to the federal government;
26 (3) an agent acting on behalf of the state and
27 local government for services provided pursuant to
28 title XIX of the federal Social Security Act, but only to
29 the extent that the agent is providing services to the
30 State or local government;
31 (4) a hospital's internal quality assurance program
32 except if associated with a health care financing
33 mechanism.
34 "Utilization review plan" means:
-6- LRB9000248JSmgam08
1 (1) a description of the process for developing the
2 written clinical review criteria;
3 (2) a description of the types of written clinical
4 information which the plan might consider in its clinical
5 review including, but not limited to, a set of specific
6 written clinical review criteria;
7 (3) a description of practice guidelines and
8 standards used by a utilization review agent in making a
9 determination of medical necessity;
10 (4) the procedures for scheduled review and
11 evaluation of the written clinical review criteria; and
12 (5) a description of the qualifications and
13 experience of the health care professionals who
14 developed the criteria, who are responsible for periodic
15 evaluation of the criteria and of the health care
16 professionals or others who use the written clinical
17 review criteria in the process of utilization review.
18 Section 10. Disclosure of information.
19 (a) An enrollee, and upon request a prospective enrollee
20 prior to enrollment, shall be supplied with written
21 disclosure information, containing at least the information
22 specified in this Section, if applicable, which may be
23 incorporated into the member handbook or the enrollee
24 contract or certificate. All written descriptions shall be
25 in readable and understandable format, consistent with
26 standards developed for supplemental insurance coverage under
27 Title XVIII of the Social Security Act. The Department shall
28 promulgate rules to standardize this format so that potential
29 members can compare the attributes of the various managed
30 care entities. In the event of any inconsistency between any
31 separate written disclosure statement and the enrollee
32 contract or certificate, the terms of the enrollee
33 contract or certificate shall be controlling. The
-7- LRB9000248JSmgam08
1 information to be disclosed shall include, at a minimum,
2 all of the following:
3 (1) A description of coverage provisions, health
4 care benefits, benefit maximums, including benefit
5 limitations, and exclusions of coverage, including the
6 definition of medical necessity used in determining
7 whether benefits will be covered.
8 (2) A description of all prior authorization or
9 other requirements for treatments, pharmaceuticals, and
10 services.
11 (3) A description of utilization review policies
12 and procedures used by the managed care plan,
13 including the circumstances under which utilization
14 review will be undertaken, the toll-free telephone
15 number of the utilization review agent, the timeframes
16 under which utilization review decisions must be made for
17 prospective, retrospective, and concurrent decisions,
18 the right to reconsideration, the right to an appeal,
19 including the expedited and standard appeals processes
20 and the timeframes for those appeals, the right to
21 designate a representative, a notice that all denials of
22 claims will be made by clinical personnel, and that
23 all notices of denials will include information about the
24 basis of the decision and further appeal rights, if any.
25 (4) A description prepared annually of the types of
26 methodologies the managed care plan uses to reimburse
27 providers specifying the type of methodology that is
28 used to reimburse particular types of providers or
29 reimburse for the provision of particular types of
30 services, provided, however, that nothing in this item
31 should be construed to require disclosure of individual
32 contracts or the specific details of any financial
33 arrangement between a managed care plan and a health care
34 provider.
-8- LRB9000248JSmgam08
1 (5) An explanation of a enrollee's financial
2 responsibility for payment of premiums, coinsurance,
3 co-payments, deductibles, and any other charges, annual
4 limits on an enrollee's financial responsibility, caps
5 on payments for covered services and financial
6 responsibility for non-covered health care procedures,
7 treatments, or services provided within the managed
8 care plan.
9 (6) An explanation of an enrollee's financial
10 responsibility for payment when services are provided by
11 a health care provider who is not part of the managed
12 care plan or by any provider without required
13 authorization or when a procedure, treatment, or service
14 is not a covered health care benefit.
15 (7) A description of the grievance procedures to
16 be used to resolve disputes between a managed care plan
17 and an enrollee, including the right to file a
18 grievance regarding any dispute between an enrollee and a
19 managed care plan, the right to file a grievance
20 orally when the dispute is about referrals or covered
21 benefits, the toll-free telephone number that enrollees
22 may use to file an oral grievance, the timeframes and
23 circumstances for expedited and standard grievances, the
24 right to appeal a grievance determination and the
25 procedures for filing the appeal, the timeframes and
26 circumstances for expedited and standard appeals, the
27 right to designate a representative, a notice that all
28 disputes involving clinical decisions will be made by
29 clinical personnel, and that all notices of determination
30 will include information about the basis of the
31 decision and further appeal rights, if any.
32 (8) A description of the procedure for providing
33 care and coverage 24 hours a day for emergency services.
34 The description shall include the definition of
-9- LRB9000248JSmgam08
1 emergency services, notice that emergency services are
2 not subject to prior approval, and an explanation of
3 the enrollee's financial and other responsibilities
4 regarding obtaining those services, including when
5 those services are received outside the managed care
6 plan's service area.
7 (9) A description of procedures for enrollees to
8 select and access the managed care plan's primary and
9 specialty care providers, including notice of how to
10 determine whether a participating provider is accepting
11 new patients.
12 (10) A description of the procedures for changing
13 primary and specialty care providers within the managed
14 care plan.
15 (11) Notice that an enrollee may obtain a referral
16 to a health care provider outside of the managed care
17 plan's network or panel when the managed care plan
18 does not have a health care provider with appropriate
19 training and experience in the network or panel to meet
20 the particular health care needs of the enrollee and
21 the procedure by which the enrollee can obtain the
22 referral.
23 (12) Notice that an enrollee with a condition
24 that requires ongoing care from a specialist may
25 request a standing referral to the specialist and
26 the procedure for requesting and obtaining a standing
27 referral.
28 (13) Notice that an enrollee with (i) a
29 life-threatening condition or disease or (ii) a
30 degenerative or disabling condition or disease, either of
31 which requires specialized medical care over a prolonged
32 period of time, may request a specialist responsible for
33 providing or coordinating the enrollee's medical care and
34 the procedure for requesting and obtaining the
-10- LRB9000248JSmgam08
1 specialist.
2 (14) A description of the mechanisms by which
3 enrollees may participate in the development of the
4 policies of the managed care plan.
5 (15) A description of how the managed care plan
6 addresses the needs of non-English speaking enrollees.
7 (16) Notice of all appropriate mailing addresses
8 and telephone numbers to be utilized by enrollees
9 seeking information or authorization.
10 (17) A listing by specialty, which may be in a
11 separate document that is updated annually, of the name,
12 address, and telephone number of all participating
13 providers, including facilities, and, in addition, in the
14 case of physicians, category of license and board
15 certification, if applicable.
16 (b) Upon request of an enrollee or prospective enrollee,
17 a managed care plan shall do all of the following:
18 (1) Provide a list of the names, business
19 addresses, and official positions of the members of the
20 board of directors, officers, controlling persons,
21 owners, and partners of the managed care plan.
22 (2) Provide a copy of the most recent annual
23 certified financial statement of the managed care plan,
24 including a balance sheet and summary of receipts and
25 disbursements and the ratio of (i) premium dollars going
26 to administrative expenses to (ii) premium dollars going
27 to direct care, prepared by a certified public
28 accountant. The Department shall promulgate rules to
29 standardize the information that must be contained in the
30 statement and the statement's format.
31 (3) Provide information relating to consumer
32 complaints compiled in the manner set forth in Section
33 143d of the Illinois Insurance Code.
34 (4) Provide the procedures for protecting the
-11- LRB9000248JSmgam08
1 confidentiality of medical records and other enrollee
2 information.
3 (5) Allow enrollees and prospective enrollees to
4 inspect drug formularies used by the managed care plan
5 and disclose whether individual drugs are included or
6 excluded from coverage and whether a drug requires prior
7 authorization. An enrollee or prospective enrollee may
8 only seek the release of information as to the inclusion
9 or exclusion of a specific drug if he or she or his or
10 her dependent needs, used, or may need or use the drug.
11 (6) Provide a written description of the
12 organizational arrangements and ongoing procedures of
13 the managed care plan's quality assurance program.
14 (7) Provide a description of the procedures
15 followed by the managed care plan in making decisions
16 about the experimental or investigational nature of
17 individual drugs, medical devices, or treatments in
18 clinical trials.
19 (8) Provide individual health care professional
20 affiliations with participating hospitals, if any.
21 (9) Upon written request, provide specific
22 written clinical review criteria relating to a
23 particular condition or disease and, where appropriate,
24 other clinical information that the managed care plan
25 might consider in its utilization review; the managed
26 care plan may include with the information a description
27 of how it will be used in the utilization review
28 process. An enrollee or prospective enrollee may only
29 seek the release of information as to specific clinical
30 review criteria if he or she or his or her dependent has,
31 may have, or is at risk of contracting a particular
32 condition or disease.
33 (10) Provide the written application procedures and
34 minimum qualification requirements for health care
-12- LRB9000248JSmgam08
1 providers to be considered by the managed care plan.
2 (11) Disclose other information as required by
3 the Director.
4 (12) To the extent the information provided under
5 item (5) or (9) of this subsection is proprietary to the
6 managed care plan, the enrollee or prospective enrollee
7 shall only use the information for the purposes of
8 assisting the enrollee or prospective enrollee in
9 evaluating the covered services provided by the managed
10 care plan. Any misuse of proprietary data is prohibited,
11 provided that the managed care plan has labeled or
12 identified the data as proprietary.
13 (c) Nothing in this Section shall prevent a managed care
14 plan from changing or updating the materials that are made
15 available to enrollees or prospective enrollees.
16 (d) If a primary care provider ceases participation in
17 the managed care plan, the managed care plan shall provide
18 written notice within 15 days from the date that the managed
19 care plan becomes aware of the change in status to each of
20 the enrollees who have chosen the provider as their
21 primary care provider. If an enrollee is in an ongoing
22 course of treatment with any other participating provider who
23 becomes unavailable to continue to provide services to the
24 enrollee and the managed care plan is aware of the ongoing
25 course of treatment, the managed care plan shall provide
26 written notice within 15 days from the date that the managed
27 care plan becomes aware of the unavailability to the
28 enrollee. The notice shall also describe the procedures for
29 continuing care.
30 (e) A managed care plan offering to indemnify enrollees
31 for non-participating provider services shall file a report
32 with the Director twice a year showing the percentage
33 utilization for the preceding 6 month period of
34 non-participating provider services in such form and
-13- LRB9000248JSmgam08
1 providing such other information as the Director shall
2 prescribe.
3 (f) The written information disclosure requirements of
4 this Section may be met by disclosure to one enrollee in a
5 household.
6 Section 15. General grievance procedure.
7 (a) A managed care plan shall establish and maintain a
8 grievance procedure, as described in this Act. Compliance
9 with this Act's grievance procedures shall satisfy a managed
10 care plan's obligation to provide grievance procedures under
11 any other State law or rules. Pursuant to such procedure,
12 enrollees shall be entitled to seek a review of
13 determinations by the managed care plan other than
14 determinations made by utilization review agents.
15 A copy of the grievance procedures, including all forms
16 used to process a grievance, shall be filed with the
17 Director. Any subsequent material modifications to the
18 documents also shall be filed. In addition, a managed care
19 plan shall file annually with the Director a certificate of
20 compliance stating that the managed care plan has established
21 and maintains, for each of its plans, grievance procedures
22 that fully comply with the provisions of this Act. The
23 Director has authority to disapprove a filing that fails to
24 comply with this Act or applicable rules.
25 (b) A managed care plan shall provide written notice of
26 the grievance procedure to all enrollees in the member
27 handbook and to an enrollee at any time that the managed care
28 plan denies access to a referral or determines that a
29 requested benefit is not covered pursuant to the terms of the
30 contract. In the event that a managed care plan denies a
31 service as an adverse determination, the managed care plan
32 shall inform the enrollee or the enrollee's designee of
33 the appeal rights under this Act.
-14- LRB9000248JSmgam08
1 The notice to an enrollee describing the grievance
2 process shall explain the process for filing a grievance
3 with the managed care plan, the timeframes within which a
4 grievance determination must be made, and the right of an
5 enrollee to designate a representative to file a grievance on
6 behalf of the enrollee. Information required to be disclosed
7 or provided under this Section must be provided in a
8 reasonable and understandable format.
9 The managed care plan shall assure that the grievance
10 procedure is reasonably accessible to those who do not speak
11 English.
12 (c) A managed care plan shall not retaliate or take
13 any discriminatory action against an enrollee because an
14 enrollee has filed a grievance or appeal.
15 Section 20. First level grievance review.
16 (a) The managed care plan may require an enrollee to
17 file a grievance in writing, by letter or by a grievance
18 form which shall be made available by the managed care plan,
19 however, an enrollee must be allowed to submit an oral
20 grievance in connection with (i) a denial of, or failure to
21 pay for, a referral or service or (ii) a determination as to
22 whether a benefit is covered pursuant to the terms of the
23 enrollee's contract. In connection with the submission of
24 an oral grievance, a managed care plan shall, within 24
25 hours, reduce the complaint to writing and give the enrollee
26 written acknowledgment of the grievance prepared by the
27 managed care plan summarizing the nature of the grievance
28 and any information that the enrollee needs to provide before
29 the grievance can be processed. The acknowledgment shall
30 be mailed within the 24-hour period to the enrollee, who
31 shall sign and return the acknowledgment, with any
32 amendments and requested information, in order to initiate
33 the grievance. The grievance acknowledgment shall prominently
-15- LRB9000248JSmgam08
1 state that the enrollee must sign and return the
2 acknowledgment to initiate the grievance. A managed care
3 plan may elect not to require a signed acknowledgment when no
4 additional information is necessary to process the grievance,
5 and an oral grievance shall be initiated at the time of the
6 telephone call.
7 Except as authorized in this subsection, a managed care
8 plan shall designate personnel to accept the filing of an
9 enrollee's grievance by toll-free telephone no less than
10 40 hours per week during normal business hours and shall
11 have a telephone system available to take calls during other
12 than normal business hours and shall respond to all such
13 calls no later than the next business day after the call was
14 recorded. In the case of grievances subject to item (i) of
15 subsection (b) of this Section, telephone access must be
16 available on a 24 hour a day, 7 day a week basis.
17 (b) Within 5 business days of receipt of a written
18 grievance, the managed care plan shall provide written
19 acknowledgment of the grievance, including the name,
20 address, qualifying credentials, and telephone number of the
21 individuals or department designated by the managed care plan
22 to respond to the grievance. All grievances shall be
23 resolved in an expeditious manner, and in any event, no more
24 than (i) 24 hours after the receipt of all necessary
25 information when a delay would significantly increase the
26 risk to an enrollee's health, (ii) 15 days after the
27 receipt of all necessary information in the case of requests
28 for referrals or determinations concerning whether a
29 requested benefit is covered pursuant to the contract, and
30 (iii) 30 days after the receipt of all necessary information
31 in all other instances.
32 (c) The managed care plan shall designate one or more
33 qualified personnel to review the grievance. When the
34 grievance pertains to clinical matters, the personnel shall
-16- LRB9000248JSmgam08
1 include, but not be limited to, one or more appropriately
2 licensed or registered health care professionals.
3 (d) The notice of a determination of the grievance
4 shall be made in writing to the enrollee or to the enrollee's
5 designee. In the case of a determination made in conformance
6 with item (i) of subsection (b) of this Section, notice
7 shall be made by telephone directly to the enrollee with
8 written notice to follow within 2 business days.
9 (e) The notice of a determination shall include (i)
10 clear and detailed reasons for the determination, including
11 any contract basis for the determination, and the evidence
12 relied upon in making that determination, (ii) in cases where
13 the determination has a clinical basis, the clinical
14 rationale for the determination, and (iii) the procedures for
15 the filing of an appeal of the determination, including a
16 form for the filing of an appeal.
17 Section 25. Second level grievance review.
18 (a) A managed care plan shall establish a second level
19 grievance review process to give those enrollees who are
20 dissatisfied with the first level grievance review decision
21 the option to request a second level review, at which the
22 enrollee shall have the right to appear in person before
23 authorized individuals designated to respond to the appeal.
24 (b) An enrollee or an enrollee's designee shall
25 have not less than 60 business days after receipt of notice
26 of the grievance determination to file a written appeal,
27 which may be submitted by letter or by a form supplied by the
28 managed care plan. The enrollee shall indicate in his or her
29 written appeal whether he or she wants the right to appear in
30 person before the person or panel designated to respond to
31 the appeal.
32 (c) Within 5 business days of receipt of the second
33 level grievance review, the managed care plan shall provide
-17- LRB9000248JSmgam08
1 written acknowledgment of the appeal, including the name,
2 address, qualifying credentials, and telephone number of the
3 individual designated by the managed care plan to respond
4 to the appeal and what additional information, if any, must
5 be provided in order for the managed care plan to render a
6 decision.
7 (d) The determination of a second level grievance review
8 on a clinical matter must be made by personnel qualified
9 to review the appeal, including appropriately licensed or
10 registered health care professionals who did not make
11 the initial determination, a majority of whom must be
12 clinical peer reviewers. The determination of a second
13 level grievance review on a matter that is not clinical shall
14 be made by qualified personnel at a higher level than the
15 personnel who made the initial grievance determination.
16 (e) The managed care plan shall seek to resolve all
17 second level grievance reviews in the most expeditious manner
18 and shall make a determination and provide notice no more
19 than (i) 24 hours after the receipt of all necessary
20 information when a delay would significantly increase the
21 risk to an enrollee's health and (ii) 30 business days
22 after the receipt of all necessary information in all other
23 instances.
24 (f) The notice of a determination on a second level
25 grievance review shall include (i) the detailed reasons for
26 the determination, including any contract basis for the
27 determination and the evidence relied upon in making the
28 determination and (ii) in cases where the determination has a
29 clinical basis, the clinical rationale for the
30 determination.
31 (g) If an enrollee has requested the opportunity to
32 appear in person before the authorized representatives of the
33 managed care plan designated to respond to the appeal, the
34 review panel shall schedule and hold a review meeting within
-18- LRB9000248JSmgam08
1 30 days of receiving a request from an enrollee for a second
2 level review with a right to appear. The review meeting
3 shall be held during regular business hours at a location
4 reasonably accessible to the enrollee. The enrollee shall be
5 notified in writing at least 14 days in advance of the review
6 date.
7 Upon the request of an enrollee, a managed care plan
8 shall provide to the enrollee all relevant information that
9 is not confidential or privileged.
10 An enrollee has the right to:
11 (1) attend the second level review;
12 (2) present his or her case to the review panel;
13 (3) submit supporting material both before and at
14 the review meeting;
15 (4) ask questions of any representative of the
16 managed care plan; and
17 (5) be assisted or represented by persons of his or
18 her choice.
19 The notice shall advise the enrollee of the rights
20 specified in this subsection.
21 If the managed care plan desires to have an attorney
22 present to represent its interests, it shall notify the
23 enrollee at least 14 days in advance of the review that an
24 attorney will be present and that the enrollee may wish to
25 obtain legal representation of his or her own.
26 Section 30. Grievance register and reporting
27 requirements.
28 (a) A managed care plan shall maintain a register
29 consisting of a written record of all complaints initiated
30 during the past 3 years. The register shall be maintained in
31 a manner that is reasonably clear and accessible to the
32 Director. The register shall include at a minimum the
33 following:
-19- LRB9000248JSmgam08
1 (1) the name of the enrollee;
2 (2) a description of the reason for the complaint;
3 (3) the dates when first level and second level
4 review were requested and completed;
5 (4) a copy of the written decision rendered at each
6 level of review;
7 (5) if required time limits were exceeded, an
8 explanation of why they were exceeded and a copy of the
9 enrollee's consent to an extension of time;
10 (6) whether expedited review was requested and the
11 response to the request;
12 (7) whether the complaint resulted in litigation
13 and the result of the litigation.
14 (b) A managed care plan shall report annually to the
15 Department the numbers, and related information where
16 indicated, for the following:
17 (1) covered lives;
18 (2) total complaints initiated;
19 (3) total complaints involving medical necessity or
20 appropriateness;
21 (4) complaints involving termination or reduction
22 of inpatient hospital services;
23 (5) complaints involving termination or reduction
24 of other health care services;
25 (6) complaints involving denial of health care
26 services where the enrollee had not received the services
27 at the time the complaint was initiated;
28 (7) complaints involving payment for health care
29 services that the enrollee had already received at the
30 time of initiating the complaint;
31 (8) complaints resolved at each level of review and
32 how they were resolved;
33 (9) complaints where expedited review was provided
34 because adherence to regular time limits would have
-20- LRB9000248JSmgam08
1 jeopardized the enrollee's life, health, or ability to
2 regain maximum function; and
3 (10) complaints that resulted in litigation and the
4 outcome of the litigation.
5 The Department shall promulgate rules regarding the
6 format of the report, the timing of the report, and other
7 matters related to the report.
8 Section 35. External independent review.
9 (a) If an enrollee's or enrollee's designee's request
10 for a covered service or claim for a covered service is
11 denied under the grievance reviews under Section 15, 20, or
12 25 because the service is not viewed as medically necessary,
13 the enrollee may initiate an external independent review.
14 (b) Within 30 days after the enrollee receives written
15 notice of such an adverse decision made under the second
16 level grievance review procedures of Section 25, if the
17 enrollee decides to initiate an external independent review,
18 the enrollee shall send to the managed care plan a written
19 request for an external independent review, including any
20 material justification or documentation to support the
21 enrollee's request for the covered service or claim for a
22 covered service.
23 (c) Within 30 days after the managed care plan receives
24 a request for an external independent review from an
25 enrollee, the managed care plan shall:
26 (1) provide a mechanism for jointly selecting an
27 external independent reviewer by the enrollee, primary
28 care physician, and managed care plan; and
29 (2) forward to the independent reviewer all medical
30 records and supporting documentation pertaining to the
31 case, a summary description of the applicable issues
32 including a statement of the managed care plan's
33 decision, and the criteria used and the clinical reasons
-21- LRB9000248JSmgam08
1 for that decision.
2 (d) Within 5 days of receipt of all necessary
3 information, the independent reviewer or reviewers shall
4 evaluate and analyze the case and render a decision that is
5 based on whether or not the service or claim for the service
6 is medically necessary. The decision by the independent
7 reviewer or reviewers is final.
8 (e) Pursuant to subsection (c) of this Section, an
9 external independent reviewer shall:
10 (1) have no direct financial interest in or
11 connection to the case;
12 (2) be State licensed physicians, who are board
13 certified or board eligible by the appropriate American
14 Medical Specialty Board, if applicable, and who are in
15 the same or similar scope of practice as a physician who
16 typically manages the medical condition, procedure, or
17 treatment under review; and
18 (3) have not been informed of the specific identity
19 of the enrollee or the enrollee's treating provider.
20 (f) If an appropriate reviewer pursuant to subsection
21 (e) of this Section for a particular case is not on the list
22 established by the Director, the parties shall choose a
23 reviewer who is mutually acceptable.
24 Section 40. Independent reviewers.
25 (a) From information filed with the Director on or
26 before March 1 of each year, the Director shall compile a
27 list of external independent reviewers and organizations that
28 represent external independent reviewers from lists provided
29 by health care insurers and by any State and county public
30 health department and State medical associations in Illinois
31 that wish to submit a list to the Director. The Director may
32 consult with other persons about the suitability of any
33 reviewer or any potential reviewer. The Director shall
-22- LRB9000248JSmgam08
1 annually review the list and add and remove names as
2 appropriate. On or before June 1 of each year, the Director
3 shall publish the list in the Illinois Register.
4 (b) The managed care plan shall be solely responsible
5 for paying the fees of the external independent reviewer who
6 is selected to perform the review.
7 (c) An external independent reviewer who acts in good
8 faith shall have immunity from any civil or criminal
9 liability or professional discipline as a result of acts or
10 omissions with respect to any external independent review,
11 unless the acts or omissions constitute wilful and wanton
12 misconduct. For purposes of any proceeding, the good faith
13 of the person participating shall be presumed.
14 (d) The Director's decision to add a name to or remove a
15 name from the list of independent reviewers pursuant to
16 subsection (a) is not subject to administrative appeal or
17 judicial review.
18 Section 45. Health care professional applications and
19 terminations.
20 (a) A managed care plan shall, upon request, make
21 available and disclose to health care professionals written
22 application procedures and minimum qualification
23 requirements that a health care professional must meet in
24 order to be considered by the managed care plan. The
25 managed care plan shall consult with appropriately qualified
26 health care professionals in developing its qualification
27 requirements.
28 (b) A managed care plan may not terminate a contract of
29 employment or refuse to renew a contract on the basis of any
30 action prohibited under Section 50 of this Act or solely
31 because a health care professional has:
32 (1) filed a complaint against the managed care
33 plan;
-23- LRB9000248JSmgam08
1 (2) appealed a decision of the managed care plan;
2 or
3 (3) requested a hearing pursuant to this Section.
4 (c) A managed care plan shall provide to a health care
5 professional, in writing, the reasons for the contract
6 termination or non-renewal.
7 (d) A managed care plan shall provide an opportunity
8 for a hearing to any health care professional terminated by
9 the managed care plan or non-renewed if the health care
10 professional has had a contract or contracts with the managed
11 care plan for at least 24 of the past 36 months.
12 (e) After the notice provided pursuant to subsection
13 (c), the health care professional shall have 21 days to
14 request a hearing, and the hearing must be held within 15
15 days after receipt of the request for a hearing. The hearing
16 shall be held before a panel appointed by the managed care
17 plan.
18 The hearing panel shall be composed of 5 individuals, the
19 majority of whom shall be clinical peer reviewers in the same
20 discipline and the same or similar specialty as the health
21 care professional under review.
22 The hearing panel shall render a written decision on the
23 proposed action within 14 business days. The decision shall
24 be one of the following:
25 (1) reinstatement of the health care professional
26 by the managed care plan;
27 (2) provisional reinstatement subject to
28 conditions set forth by the panel; or
29 (3) termination of the health care professional.
30 The decision of the hearing panel shall be final.
31 A decision by the hearing panel to terminate a health
32 care professional shall be effective not less than 15 days
33 after the receipt by the health care professional of the
34 hearing panel's decision.
-24- LRB9000248JSmgam08
1 A hearing under this subsection shall provide the health
2 care professional in question with the right to examine
3 pertinent information, to present witnesses, and to ask
4 questions of an authorized representative of the plan.
5 A managed care plan's statement of reasons for a health
6 care professional's termination or hearing panel's decision
7 furnished in accordance with the provisions of this Section
8 shall be deemed a confidential communication and shall not be
9 subject to inspection or disclosure in any manner, except
10 upon formal written request by a duly authorized public
11 agency or pursuant to a judicial subpoena issued in a pending
12 action or proceeding.
13 (f) A managed care plan may terminate or decline to
14 renew a health care professional, without a prior hearing, in
15 cases involving imminent harm to patient care, a
16 determination of intentional falsification of reports to the
17 plan or a final disciplinary action by a state licensing
18 board or other governmental agency that impairs the health
19 care professional's ability to practice. A professional
20 terminated for one of the these reasons shall be given
21 written notice to that effect. Within 21 days after the
22 termination, a health care professional terminated because of
23 imminent harm to patient care or a determination of
24 intentional falsification of reports to the plan shall
25 receive a hearing. The hearing shall be held before a panel
26 appointed by the managed care plan. The panel shall be
27 composed of 5 individuals the majority of whom shall be
28 clinical peer reviewers in the same discipline and the same
29 or similar specialty as the health care professional under
30 review. The hearing panel shall render a decision on the
31 proposed action within 14 days. The panel shall issue a
32 written decision either supporting the termination or
33 ordering the health care professional's reinstatement. The
34 decision of the hearing panel shall be final.
-25- LRB9000248JSmgam08
1 If the hearing panel upholds the managed care plan's
2 termination of the health care professional under this
3 subsection, the managed care plan shall forward the decision
4 to the appropriate professional disciplinary agency in
5 accordance with Section 60.
6 Any hearing under this subsection shall provide the
7 health care professional in question with the right to
8 examine pertinent information, to present witnesses, and to
9 ask questions of an authorized representative of the plan.
10 (g) A managed care plan shall develop and implement
11 policies and procedures to ensure that health care
12 professionals are at least annually informed of information
13 maintained by the managed care plan to evaluate the
14 performance or practice of the health care professional. The
15 managed care plan shall consult with health care
16 professionals in developing methodologies to collect and
17 analyze health care professional data. Managed care plans
18 shall provide the information and data and analysis to health
19 care professionals. The information, data, or analysis
20 shall be provided on at least an annual basis in a format
21 appropriate to the nature and amount of data and the volume
22 and scope of services provided. Any data used to evaluate
23 the performance or practice of a health care professional
24 shall be measured against stated criteria and a comparable
25 group of health care professionals who use similar treatment
26 modalities and serve a comparable patient population. Upon
27 receipt of the information or data, a health care
28 professional shall be given the opportunity to explain the
29 unique nature of the health care professional's patient
30 population that may have a bearing on the health care
31 professional's data and to work cooperatively with the
32 managed care plan to improve performance.
33 (h) Any contract provision or procedure or informal
34 policy or procedure in violation of this Section violates the
-26- LRB9000248JSmgam08
1 public policy of the State of Illinois and is void and
2 unenforceable.
3 Section 50. Prohibitions.
4 (a) No managed care plan shall by contract, written
5 policy or written procedure, or informal policy or procedure
6 prohibit or restrict any health care provider from
7 disclosing to any enrollee, patient, designated
8 representative or, where appropriate, prospective
9 enrollee, (hereinafter collectively referred to as
10 enrollee) any information that the provider deems appropriate
11 regarding:
12 (1) a condition or a course of treatment with an
13 enrollee including the availability of other therapies,
14 consultations, or tests; or
15 (2) the provisions, terms, or requirements of the
16 managed care plan's products as they relate to the
17 enrollee, where applicable.
18 (b) No managed care plan shall by contract, written
19 policy or procedure, or informal policy or procedure prohibit
20 or restrict any health care provider from filing a
21 complaint, making a report, or commenting to an appropriate
22 governmental body regarding the policies or practices of the
23 managed care plan that the provider believes may
24 negatively impact upon the quality of, or access to, patient
25 care.
26 (c) No managed care plan shall by contract, written
27 policy or procedure, or informal policy or procedure prohibit
28 or restrict any health care provider from advocating to the
29 managed care plan on behalf of the enrollee for approval or
30 coverage of a particular course of treatment or for the
31 provision of health care services.
32 (d) No contract or agreement between a managed care
33 plan and a health care provider shall contain any clause
-27- LRB9000248JSmgam08
1 purporting to transfer to the health care provider by
2 indemnification or otherwise any liability relating to
3 activities, actions, or omissions of the managed care plan
4 as opposed to those of the health care provider.
5 (e) No contract between a managed care plan and a health
6 care provider shall contain any incentive plan that includes
7 specific payment made directly, in any form, to a health care
8 provider as an inducement to deny, reduce, limit, or delay
9 specific, medically necessary and appropriate services
10 provided with respect to a specific enrollee or groups of
11 enrollees with similar medical conditions. Nothing in this
12 Section shall be construed to prohibit contracts that contain
13 incentive plans that involve general payments, such as
14 capitation payments or shared-risk arrangements, that are not
15 tied to specific medical decisions involving specific
16 enrollees or groups of enrollees with similar medical
17 conditions. The payments rendered or to be rendered to
18 health care provider under these arrangements shall be deemed
19 confidential information.
20 (f) No managed care plan shall by contract, written
21 policy or procedure, or informal policy or procedure permit,
22 allow, or encourage an individual or entity to dispense a
23 different drug in place of the drug or brand of drug ordered
24 or prescribed without the express permission of the person
25 ordering or prescribing, except this prohibition does not
26 prohibit the interchange of different brands of the same
27 generically equivalent drug product, as provided under
28 Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
29 (g) Any contract provision, written policy or
30 procedure, or informal policy or procedure in violation of
31 this Section violates the public policy of the State of
32 Illinois and is void and unenforceable.
33 Section 55. Network of providers.
-28- LRB9000248JSmgam08
1 (a) At least once every 3 years, and upon application
2 for expansion of service area, a managed care plan shall
3 obtain certification from the Director of Public Health that
4 the managed care plan maintains a network of health care
5 providers and facilities adequate to meet the comprehensive
6 health needs of its enrollees and to provide an appropriate
7 choice of providers sufficient to provide the services
8 covered under its enrollee's contracts by determining that:
9 (1) there are a sufficient number of geographically
10 accessible participating providers and facilities;
11 (2) there are opportunities to select from at least
12 3 primary care providers pursuant to travel and
13 distance time standards, providing that these standards
14 account for the conditions of accessing providers in
15 rural areas; and
16 (3) there are sufficient providers in all covered
17 areas of specialty practice to meet the needs of the
18 enrollment population.
19 (b) The following criteria shall be considered by the
20 Director of Public Health at the time of a review:
21 (1) provider-enrollee ratios by specialty;
22 (2) primary care provider-enrollee ratios;
23 (3) safe and adequate staffing of health care
24 providers in all participating facilities based on:
25 (A) severity of patient illness and functional
26 capacity;
27 (B) factors affecting the period and quality
28 of patient recovery; and
29 (C) any other factor substantially related to
30 the condition and health care needs of patients;
31 (4) geographic accessibility;
32 (5) the number of grievances filed by enrollees
33 relating to waiting times for appointments,
34 appropriateness of referrals, and other indicators of a
-29- LRB9000248JSmgam08
1 managed care plan's capacity;
2 (6) hours of operation;
3 (7) the managed care plan's ability to provide
4 culturally and linguistically competent care to meet the
5 needs of its enrollee population; and
6 (8) the volume of technological and speciality
7 services available to serve the needs of enrollees
8 requiring technologically advanced or specialty care.
9 (c) A managed care plan shall report on an annual basis
10 the number of enrollees and the number of participating
11 providers in the managed care plan and any other information
12 that the Department of Public Health may require to certify a
13 network under this Section.
14 (d) If a managed care plan determines that it does not
15 have a health care provider with appropriate training and
16 experience in its panel or network to meet the particular
17 health care needs of an enrollee, the managed care plan
18 shall make a referral to an appropriate provider, pursuant to
19 a treatment plan approved by the primary care provider, in
20 consultation with the managed care plan, the
21 non-participating provider, and the enrollee or enrollee's
22 designee, at no additional cost to the enrollee beyond what
23 the enrollee would otherwise pay for services received within
24 the network.
25 (e) A managed care plan shall have a procedure by which
26 an enrollee who needs ongoing health care services,
27 provided or coordinated by a specialist focused on a specific
28 organ system, disease or condition, shall receive a referral
29 to the specialist. If the primary care provider, after
30 consultation with the medical director or other
31 contractually authorized representative of the managed care
32 plan, determines that a referral is appropriate, the primary
33 care provider shall make such a referral to a specialist. In
34 no event shall a managed care plan be required to permit
-30- LRB9000248JSmgam08
1 an enrollee to elect to have a non-participating
2 specialist, except pursuant to the provisions of subsection
3 (d). The referral made under this subsection shall be
4 pursuant to a treatment plan approved by the enrollee or
5 enrollee's designee, the primary care provider, and the
6 specialist in consultation with the managed care plan. The
7 treatment plan shall authorize the specialist to treat the
8 ongoing injury, disease, or condition. It also may limit the
9 number of visits or the period during which visits are
10 authorized and may require the specialists to provide the
11 primary care provider with regular updates on the specialty
12 care provided, as well as all necessary medical information.
13 (f) A managed care plan shall have a procedure by which
14 a new enrollee, upon enrollment, or an enrollee, upon
15 diagnosis, with (i) a life-threatening condition or disease
16 or (ii) a degenerative and disabling condition or disease,
17 either of which requires specialized medical care over a
18 prolonged period of time shall receive a standing referral to
19 a specialist with expertise in treating the life-threatening
20 condition or disease or degenerative and disabling condition
21 or disease who shall be responsible for and capable of
22 providing and coordinating the enrollee's primary and
23 specialty care. If the primary care provider, after
24 consultation with the enrollee or enrollee's designee and
25 medical director or other contractually authorized
26 representative of the managed care plan, determines that the
27 enrollee's care would most appropriately be coordinated
28 by a specialist, the primary care provider shall refer, on a
29 standing basis, the enrollee to a specialist. In no event
30 shall a managed care plan be required to permit an enrollee
31 to elect to have a non-participating specialist, except
32 pursuant to the provisions of subsection (d). The
33 specialist shall be permitted to treat the enrollee
34 without a referral from the enrollee's primary care
-31- LRB9000248JSmgam08
1 provider and shall be authorized to make such referrals,
2 procedures, tests, and other medical services as the
3 enrollee's primary care provider would otherwise be
4 permitted to provide or authorize including, if
5 appropriate, referral to a specialty care center. If a
6 primary care provider refers an enrollee to a
7 non-participating provider, the standing referral shall be
8 pursuant to a treatment plan approved by the enrollee or
9 enrollee's designee and specialist, in consultation with the
10 managed care plan. Services provided pursuant to the
11 approved treatment plan shall be provided at no additional
12 cost to the enrollee beyond what the enrollee would
13 otherwise pay for services received within the network.
14 (g) If an enrollee's health care provider leaves the
15 managed care plan's network of providers for reasons other
16 than those for which the provider would not be eligible to
17 receive a pre-termination hearing pursuant to subsection (f)
18 of Section 45, the managed care plan shall permit the
19 enrollee to continue an ongoing course of treatment
20 with the enrollee's current health care provider during a
21 transitional period of:
22 (1) up to 90 days from the date of notice to the
23 enrollee of the provider's disaffiliation from the
24 managed care plan's network; or
25 (2) if the enrollee has entered the second trimester
26 of pregnancy at the time of the provider's
27 disaffiliation, for a transitional period that
28 includes the provision of post-partum care directly
29 related to the delivery.
30 Transitional care, however, shall be authorized by the
31 managed care plan during the transitional period only if the
32 health care provider agrees (i) to continue to accept
33 reimbursement from the managed care plan at the rates
34 applicable prior to the start of the transitional period
-32- LRB9000248JSmgam08
1 as payment in full, (ii) to adhere to the managed care plan's
2 quality assurance requirements and to provide to the managed
3 care plan necessary medical information related to the care,
4 (iii) to otherwise adhere to the managed care plan's
5 policies and procedures including, but not limited to,
6 procedures regarding referrals and obtaining
7 pre-authorization and a treatment plan approved by the
8 primary care provider or specialist in consultation with the
9 managed care plan, and (iv) if the enrollee is a recipient of
10 services under Article V of the Illinois Public Aid Code, the
11 health care provider has not been subject to a final
12 disciplinary action by a state licensing board or other state
13 of federal agency for violations of the Medicaid or Medicare
14 program.
15 (h) If a new enrollee whose health care provider is not
16 a member of the managed care plan's provider network enrolls
17 in the managed care plan, the managed care plan shall permit
18 the enrollee to continue an ongoing course of treatment with
19 the enrollee's current health care provider during a
20 transitional period of up to 90 days from the effective
21 date of enrollment, if (i) the enrollee has a
22 life-threatening disease or condition or a degenerative and
23 disabling disease or condition or (ii) the enrollee has
24 entered the second trimester of pregnancy at the effective
25 date of enrollment, in which case the transitional period
26 shall include the provision of post-partum care directly
27 related to the delivery. If an enrollee elects to continue
28 to receive payment for care from a health care provider
29 pursuant to this subsection, the care shall be authorized by
30 the managed care plan for the transitional period only if
31 the health care provider agrees (i) to accept reimbursement
32 from the managed care plan at rates established by the
33 managed care plan as payment in full, which rates shall be no
34 more than the level of reimbursement applicable to similar
-33- LRB9000248JSmgam08
1 providers within the managed care plan's network for
2 those services, (ii) to adhere to the managed care plan's
3 quality assurance requirements and agrees to provide to the
4 managed care plan necessary medical information related to
5 the care, (iii) to otherwise adhere to the managed care
6 plan's policies and procedures including, but not limited
7 to, procedures regarding referrals and obtaining
8 pre-authorization and a treatment plan approved by the
9 primary care provider or specialist, in consultation with the
10 managed care plan, and (iv) if the enrollee is a recipient of
11 services under Article V of the Illinois Public Aid Code, the
12 health care provider has not been subject to a final
13 disciplinary action by a state licensing board or other state
14 of federal agency for violations of the Medicaid or Medicare
15 program. In no event shall this subsection be construed
16 to require a managed care plan to provide coverage for
17 benefits not otherwise covered or to diminish or impair
18 pre-existing condition limitations contained within the
19 enrollee's contract.
20 Section 60. Duty to report.
21 (a) A managed care plan shall report to the
22 appropriate professional disciplinary agency, after
23 compliance and in accordance with the provisions of this
24 Section:
25 (1) termination of a health care provider contract
26 for commission of an act or acts that may directly
27 threaten patient care, and not of an administrative
28 nature, or that a person may be mentally or physically
29 disabled in such a manner as to endanger a patient under
30 that person's care;
31 (2) voluntary or involuntary termination of a
32 contract or employment or other affiliation with the
33 managed care plan to avoid the imposition of disciplinary
-34- LRB9000248JSmgam08
1 measures.
2 The managed care plan shall only make the report after it
3 has provided the health care professional with a hearing on
4 the matter. (This hearing shall not impair or limit the
5 managed care plan's ability to terminate the professional.
6 Its purpose is solely to ensure that a sufficient basis
7 exists for making the report.) The hearing shall be held
8 before a panel appointed by the managed care plan. The
9 hearing panel shall be composed of 5 persons appointed by the
10 plan, the majority of whom shall be clinical peer reviewers
11 in the same discipline and the same specialty as the health
12 care professional under review. The hearing panel shall
13 determine whether the proposed basis for the report is
14 supported by a preponderance of the evidence. The panel
15 shall render its determination within 14 days. If a majority
16 of the panel finds the proposed basis for the report is
17 supported by a preponderance of the evidence, the managed
18 care plan shall make the required report within 21 days.
19 Any hearing under this Section shall provide the health
20 care professional in question with the right to examine
21 pertinent information, to present witness, and to ask
22 questions of an authorized representative of the plan.
23 (b) Reports made pursuant to this Section shall be made
24 in writing to the appropriate professional disciplinary
25 agency. Written reports shall include the name, address,
26 profession, and license number of the individual and a
27 description of the action taken by the managed care plan,
28 including the reason for the action and the date thereof, or
29 the nature of the action or conduct that led to the
30 resignation, termination of contract, or withdrawal, and the
31 date thereof.
32 (c) Any report or information furnished to an
33 appropriate professional disciplinary agency in
34 accordance with the provisions of this Section shall be
-35- LRB9000248JSmgam08
1 deemed a confidential communication and shall not be
2 subject to inspection or disclosure in any manner except upon
3 formal written request by a duly authorized public agency or
4 pursuant to a judicial subpoena issued in a pending action or
5 proceeding.
6 Section 65. Disclosure of information.
7 (a) A health care professional affiliated with a
8 managed care plan shall make available, in written form at
9 his or her office, to his or her patients or prospective
10 patients the following:
11 (1) information related to the health care
12 professional's educational background, experience,
13 training, specialty and board certification, if
14 applicable, number of years in practice, and hospitals
15 where he or she has privileges;
16 (2) information regarding the health care
17 professional's participation in continuing education
18 programs and compliance with any licensure,
19 certification, or registration requirements, if
20 applicable;
21 (3) information regarding the health care
22 professional's participation in clinical performance
23 reviews conducted by the Department, where applicable and
24 available; and
25 (4) the location of the health care professional's
26 primary practice setting and the identification of any
27 translation services available.
28 Section 70. Registration of utilization review agents.
29 (a) A utilization review agent who conducts the practice
30 of utilization review shall biennially register with the
31 Director and report, in a statement subscribed and affirmed
32 as true under the penalties of perjury, the information
-36- LRB9000248JSmgam08
1 required pursuant to subsection (b) of this Section.
2 (b) The report shall contain a description of the
3 following:
4 (1) the utilization review plan;
5 (2) the provisions by which an enrollee, the
6 enrollee's designee, or a health care provider may seek
7 reconsideration of, or appeal from, adverse
8 determinations by the utilization review agent, in
9 accordance with the provisions of this Act, including
10 provisions to ensure a timely appeal and that an
11 enrollee, the enrollee's designee, and, in the case of
12 an adverse determination involving a retrospective
13 determination, the enrollee's health care provider are
14 informed of their right to appeal adverse determinations;
15 (3) procedures by which a decision on a request for
16 utilization review for services requiring
17 preauthorization shall comply with timeframes
18 established pursuant to this Act;
19 (4) a description of an emergency care policy,
20 consistent with this Act.
21 (5) a description of personnel utilized to conduct
22 utilization review, including a description of the
23 circumstances under which utilization review may be
24 conducted by:
25 (A) administrative personnel,
26 (B) health care professionals who are not
27 clinical peer reviewers, and
28 (C) clinical peer reviewers;
29 (6) a description of the mechanisms employed to
30 assure that administrative personnel are trained in the
31 principles and procedures of intake screening and data
32 collection and are appropriately monitored by a
33 licensed health care professional while performing an
34 administrative review;
-37- LRB9000248JSmgam08
1 (7) a description of the mechanisms employed to
2 assure that health care professionals conducting
3 utilization review are:
4 (A) appropriately licensed or registered; and
5 (B) trained in the principles, procedures,
6 and standards of the utilization review agent;
7 (8) a description of the mechanisms employed to
8 assure that only a clinical peer reviewer shall render an
9 adverse determination;
10 (9) provisions to ensure that appropriate personnel
11 of the utilization review agent are reasonably accessible
12 by toll-free telephone:
13 (A) not less than 40 hours per week during
14 normal business hours, to discuss patient care and
15 allow response to telephone requests, and to ensure
16 that the utilization review agent has a telephone
17 system capable of accepting, recording, or providing
18 instruction to incoming telephone calls during
19 other than normal business hours and to ensure
20 response to accepted or recorded messages not later
21 than the next business day after the date on which
22 the call was received; or
23 (B) notwithstanding the provisions of item (1),
24 not less than 40 hours per week during normal
25 business hours, to discuss patient care and allow
26 response to telephone requests, and to ensure that,
27 in the case of a request submitted pursuant to
28 subsection (c) of Section 80 or an expedited appeal
29 filed pursuant to subsection (b) of Section 85, a
30 response is provided within 24 hours;
31 (10) the policies and procedures to ensure that
32 all applicable State and federal laws to protect the
33 confidentiality of individual medical and treatment
34 records are followed;
-38- LRB9000248JSmgam08
1 (11) a copy of the materials to be disclosed to an
2 enrollee or prospective enrollee pursuant to this Act;
3 (12) a description of the mechanisms employed by
4 the utilization review agent to assure that all
5 contractors, subcontractors, subvendors, agents, and
6 employees affiliated by contract or otherwise with such
7 utilization review agent will adhere to the standards and
8 requirements of this Act; and
9 (13) a list of the payors for which the
10 utilization review agent is performing utilization
11 review in this State.
12 (c) Upon receipt of the report, the Director
13 shall issue an acknowledgment of the filing.
14 (d) A registration issued under this Act shall be valid
15 for a period of not more than 2 years, and may be renewed for
16 additional periods of not more than 2 years each.
17 Section 75. Utilization review program standards.
18 (a) A utilization review agent shall adhere to
19 utilization review program standards consistent with the
20 provisions of this Act, which shall, at a minimum, include:
21 (1) appointment of a medical director, who is a
22 licensed physician; provided, however, that the
23 utilization review agent may appoint a clinical director
24 when the utilization review performed is for a discrete
25 category of health care service and provided further that
26 the clinical director is a licensed health care
27 professional who typically manages the category of
28 service; responsibilities of the medical director, or,
29 where appropriate, the clinical director, shall
30 include, but not be limited to, the supervision and
31 oversight of the utilization review process;
32 (2) development of written policies and procedures
33 that govern all aspects of the utilization review
-39- LRB9000248JSmgam08
1 process and a requirement that a utilization review
2 agent shall maintain and make available to enrollees and
3 health care providers a written description of the
4 procedures, including procedures to appeal an adverse
5 determination;
6 (3) utilization of written clinical review criteria
7 developed pursuant to a utilization review plan;
8 (4) establishment of a process for rendering
9 utilization review determinations, which shall, at a
10 minimum, include written procedures to assure that
11 utilization reviews and determinations are conducted
12 within the timeframes established herein, procedures to
13 notify an enrollee, an enrollee's designee, and an
14 enrollee's health care provider of adverse
15 determinations, and procedures for appeal of adverse
16 determinations, including the establishment of an
17 expedited appeals process for denials of continued
18 inpatient care or where there is imminent or serious
19 threat to the health of the enrollee;
20 (5) establishment of a written procedure to assure
21 that the notice of an adverse determination includes:
22 (A) the reasons for the determination,
23 including the clinical rationale or contract basis,
24 if any;
25 (B) instructions on how to initiate an
26 appeal; and
27 (C) disclosure of the clinical review
28 criteria relied upon to make the determination;
29 (6) establishment of a requirement that
30 appropriate personnel of the utilization review agent are
31 reasonably accessible by toll-free telephone:
32 (A) not less than 40 hours per week during
33 normal business hours to discuss patient care and
34 allow response to telephone requests, and to ensure
-40- LRB9000248JSmgam08
1 that the utilization review agent has a telephone
2 system capable of accepting, recording or providing
3 instruction to incoming telephone calls during
4 other than normal business hours and to ensure
5 response to accepted or recorded messages not less
6 than one business day after the date on which the
7 call was received; or
8 (B) notwithstanding the provisions of item
9 (A), not less than 40 hours per week during normal
10 business hours, to discuss patient care and allow
11 response to telephone requests, and to ensure that,
12 in the case of a request submitted pursuant to
13 subsection (c) of Section 80 or an expedited
14 appeal filed pursuant to subsection (b) of
15 Section 85, a response is provided within 24 hours;
16 (7) establishment of appropriate policies and
17 procedures to ensure that all applicable State and
18 federal laws to protect the confidentiality of individual
19 medical records are followed;
20 (8) establishment of a requirement that emergency
21 services, as defined in this Act, rendered to an enrollee
22 shall not be subject to prior authorization nor
23 shall reimbursement for those services be denied on
24 retrospective review.
25 (b) A utilization review agent shall assure adherence to
26 the requirements stated in subsection (a) of this Section by
27 all contractors, subcontractors, subvendors, agents, and
28 employees affiliated by contract or otherwise with the
29 utilization review agent.
30 Section 80. Utilization review determinations.
31 (a) Utilization review shall be conducted by:
32 (1) administrative personnel trained in the
33 principles and procedures of intake screening and data
-41- LRB9000248JSmgam08
1 collection, provided, however, that administrative
2 personnel shall only perform intake screening, data
3 collection, and non-clinical review functions and shall
4 be supervised by a licensed health care professional;
5 (2) a health care professional who is
6 appropriately trained in the principles, procedures,
7 and standards of the utilization review agent; provided,
8 however, that a health care professional who is not a
9 clinical peer reviewer may not render an adverse
10 determination; and
11 (3) a clinical peer reviewer where the review
12 involves an adverse determination.
13 (b) A utilization review agent shall make a utilization
14 review determination involving health care services that
15 require pre-authorization and provide notice of the
16 determination, as soon as possible, to the enrollee or
17 enrollee's designee and the enrollee's health care provider
18 by telephone and in writing within 2 business days of receipt
19 of the necessary information.
20 (c) A utilization review agent shall make a
21 determination involving continued or extended health care
22 services or additional services for an enrollee
23 undergoing a course of continued treatment prescribed by a
24 health care provider and provide notice of the determination
25 to the enrollee or the enrollee's designee, which may be
26 satisfied by notice to the enrollee's health care provider,
27 by telephone and in writing in a prompt manner, not to exceed
28 24 hours after receipt of the necessary information.
29 Notification of continued or extended services shall
30 include the number of extended services approved, the new
31 total of approved services, the date of onset of services,
32 and the next review date.
33 (d) A utilization review agent shall make a utilization
34 review determination involving health care services that have
-42- LRB9000248JSmgam08
1 already been delivered, within 30 days of receipt of the
2 necessary information.
3 (e) Notice of an adverse determination made by a
4 utilization review agent shall be given in writing and must
5 include:
6 (1) the reasons for the determination, including
7 the clinical rationale or contract basis, if any;
8 (2) instructions on how to initiate an appeal; and
9 (3) disclosure of the clinical review criteria
10 relied upon to make the determination.
11 The notice shall also specify what, if any, additional
12 necessary information must be provided to, or obtained by,
13 the utilization review agent in order to render a decision on
14 the appeal.
15 (f) In the event that a utilization review agent
16 renders an adverse determination without attempting to
17 discuss the matter with the enrollee's health care
18 provider who specifically recommended the health care
19 service, procedure, or treatment under review, the health
20 care provider shall have the opportunity to request an
21 immediate reconsideration of the adverse determination.
22 Except in cases of retrospective reviews, the
23 reconsideration shall occur in a prompt manner, not to
24 exceed 24 hours after receipt of the necessary information,
25 and shall be conducted by the enrollee's health care
26 provider and the clinical peer reviewer making the initial
27 determination or a designated clinical peer reviewer if the
28 original clinical peer reviewer cannot be available. In
29 the event that the adverse determination is upheld after
30 reconsideration, the utilization review agent shall provide
31 notice as required pursuant to subsection (e) of this
32 Section. Nothing in this Section shall preclude the enrollee
33 from initiating an appeal from an adverse determination.
-43- LRB9000248JSmgam08
1 Section 85. Appeal of adverse determinations by
2 utilization review agents.
3 (a) An enrollee, the enrollee's designee, and, in
4 connection with retrospective adverse determinations, the
5 enrollee's health care provider may appeal an adverse
6 determination rendered by a utilization review agent.
7 (b) A utilization review agent shall establish an
8 expedited appeal process for appeal of an adverse
9 determination involving:
10 (1) continued or extended health care services,
11 procedures, or treatments or additional services for an
12 enrollee undergoing a course of continued treatment
13 prescribed by a health care provider; or
14 (2) an adverse determination in which the
15 health care provider believes an immediate appeal is
16 warranted, other than a retrospective determination.
17 The appeal process shall include mechanisms that
18 facilitate resolution of the appeal including, but not
19 limited to, the sharing of information from the
20 enrollee's health care provider and the utilization review
21 agent by telephonic means or by facsimile. The utilization
22 review agent shall provide reasonable access to its
23 clinical peer reviewer in a prompt manner, not to exceed 24
24 hours after receiving notice of the taking of an expedited
25 appeal. Expedited appeals must be determined within 48 hours
26 of receipt of necessary information to conduct the appeal.
27 Expedited appeals that do not result in a resolution
28 satisfactory to the appealing party may be further appealed
29 through the standard appeal process.
30 (c) A utilization review agent shall establish a
31 standard appeal process that includes procedures for appeals
32 to be filed in writing or by telephone. A utilization
33 review agent must establish a period of no less than 45 days
34 after receipt of notification by the enrollee of the initial
-44- LRB9000248JSmgam08
1 utilization review determination and receipt of all
2 necessary information to file the appeal from the
3 determination. The utilization review agent must provide
4 written acknowledgment of the filing of the appeal to the
5 appealing party within 5 days of the filing and shall make a
6 determination with regard to the appeal within 30 days of
7 the receipt of necessary information to conduct the
8 appeal. The utilization review agent shall notify the
9 enrollee, the enrollee's designee and, where appropriate,
10 the enrollee's health care provider, in writing, of the
11 appeal determination within 48 hours of the rendering of the
12 determination. The notice of the appeal determination shall
13 include the reasons for the determination; provided, however,
14 that where the adverse determination is upheld on appeal,
15 the notice shall include the clinical rationale for the
16 determination.
17 (d) Both expedited and standard appeals shall be
18 reviewed by a clinical peer reviewer other than the
19 clinical peer reviewer who rendered the adverse
20 determination.
21 Section 90. Required and prohibited practices.
22 (a) A utilization review agent shall have written
23 procedures for assuring that patient-specific information
24 obtained during the process of utilization review will be:
25 (1) kept confidential in accordance with applicable
26 State and federal laws; and
27 (2) shared only with the enrollee, the
28 enrollee's designee, the enrollee's health care provider,
29 and those who are authorized by law to receive the
30 information.
31 (b) Summary data shall not be considered confidential
32 if it does not provide information to allow identification of
33 individual patients.
-45- LRB9000248JSmgam08
1 (c) Any health care professional who makes
2 determinations regarding the medical necessity of health care
3 services during the course of utilization review shall be
4 appropriately licensed or registered by the State.
5 (d) A utilization review agent shall not, with respect
6 to utilization review activities, permit or provide
7 compensation or anything of value to its employees, agents,
8 or contractors based on:
9 (1) either a percentage of the amount by which a
10 claim is reduced for payment or the number of claims or
11 the cost of services for which the person has denied
12 authorization or payment; or
13 (2) any other method that encourages the
14 rendering of an adverse determination.
15 (e) If a health care service has been specifically
16 pre-authorized or approved for an enrollee by a
17 utilization review agent, a utilization review agent shall
18 not, pursuant to retrospective review, revise or modify
19 the specific standards, criteria, or procedures used for
20 the utilization review for procedures, treatment, and
21 services delivered to the enrollee during the same course
22 of treatment.
23 (f) Utilization review shall not be conducted more
24 frequently than is reasonably required to assess whether the
25 health care services under review are medically necessary.
26 The Department shall promulgate rules governing the frequency
27 of utilization reviews for managed care plans of differing
28 size and geographic location.
29 (g) When making prospective, concurrent, and
30 retrospective determinations, utilization review agents shall
31 collect only information that is necessary to make the
32 determination and shall not routinely require health care
33 providers to numerically code diagnoses or procedures to
34 be considered for certification or routinely request copies
-46- LRB9000248JSmgam08
1 of medical records of all patients reviewed. During
2 prospective or concurrent review, copies of medical
3 records shall only be required when necessary to verify that
4 the health care services subject to the review are medically
5 necessary. In these cases, only the necessary or relevant
6 sections of the medical record shall be required. A
7 utilization review agent may request copies of partial or
8 complete medical records retrospectively.
9 (h) In no event shall information be obtained from
10 health care providers for the use of the utilization
11 review agent by persons other than health care professionals,
12 medical record technologists, or administrative personnel who
13 have received appropriate training.
14 (i) The utilization review agent shall not undertake
15 utilization review at the site of the provision of health
16 care services unless the utilization review agent:
17 (1) identifies himself or herself by name and the
18 name of his or her organization, including displaying
19 photographic identification that includes the name of
20 the utilization review agent and clearly identifies the
21 individual as representative of the utilization review
22 agent;
23 (2) whenever possible, schedules review at least
24 one business day in advance with the appropriate health
25 care provider;
26 (3) if requested by a health care provider,
27 assures that the on-site review staff register with the
28 appropriate contact person, if available, prior to
29 requesting any clinical information or assistance
30 from the health care provider; and
31 (4) obtains consent from the enrollee or the
32 enrollee's designee before interviewing the patient's
33 family or observing any health care service being
34 provided to the enrollee.
-47- LRB9000248JSmgam08
1 This subsection does not apply to health care
2 professionals engaged in providing care, case management, or
3 making on-site discharge decisions.
4 (j) A utilization review agent shall not base an adverse
5 determination on a refusal to consent to observing any health
6 care service.
7 (k) A utilization review agent shall not base an adverse
8 determination on lack of reasonable access to a health
9 care provider's medical or treatment records unless the
10 utilization review agent has provided reasonable notice
11 to both the enrollee or the enrollee's designee and the
12 enrollee's health care provider and has complied with all
13 provisions of subsection (i) of this Section. The Department
14 shall promulgate rules defining reasonable notice and the
15 time period within which medical and treatment records must
16 be turned over.
17 (l) Neither the utilization review agent nor the entity
18 for which the agent provides utilization review shall take
19 any action with respect to a patient or a health care
20 provider that is intended to penalize the enrollee, the
21 enrollee's designee, or the enrollee's health care provider
22 for, or to discourage the enrollee, the enrollee's designee,
23 or the enrollee's health care provider from, undertaking an
24 appeal, dispute resolution, or judicial review of an adverse
25 determination.
26 (m) In no event shall an enrollee, an enrollee's
27 designee, an enrollee's health care provider, any other
28 health care provider, or any other person or entity be
29 required to inform or contact the utilization review agent
30 prior to the provision of emergency services as defined in
31 this Act.
32 (n) No contract or agreement between a utilization
33 review agent and a health care provider shall contain any
34 clause purporting to transfer to the health care provider by
-48- LRB9000248JSmgam08
1 indemnification or otherwise any liability relating to
2 activities, actions, or omissions of the utilization review
3 agent.
4 (o) A health care professional providing health care
5 services to an enrollee shall be prohibited from serving
6 as the clinical peer reviewer for that enrollee in connection
7 with the health care services being provided to the
8 enrollee.
9 Section 95. Annual consumer satisfaction survey. The
10 Director shall develop and administer a survey of persons who
11 have been enrolled in a managed care plan in the most recent
12 calendar year to collect information on relative plan
13 performance. This survey shall:
14 (1) be administered annually by the Director, or by
15 an independent agency or organization selected by the
16 Director;
17 (2) be administered to a scientifically selected
18 representative sample of current enrollees from each
19 plan, as well as persons who have disenrolled from a plan
20 in the last calendar year; and
21 (3) emphasize the collection of information from
22 persons who have used the managed care plan to a
23 significant degree, as defined by rule.
24 Selected data from the annual survey shall be made
25 available to current and prospective enrollees as part of a
26 consumer guidebook of health plan performance, which the
27 Department shall develop and publish. The elements to be
28 included in the guidebook shall be reassessed on an ongoing
29 basis by the Department. The consumer guidebook shall be
30 updated at least annually.
31 Section 100. Managed care patient rights. In addition
32 to all other requirements of this Act, a managed care plan
-49- LRB9000248JSmgam08
1 shall ensure that an enrollee has the following rights:
2 (1) A patient has the right to care consistent with
3 professional standards of practice to assure quality nursing
4 and medical practices, to be informed of the name of the
5 participating physician responsible for coordinating his or
6 her care, to receive information concerning his or her
7 condition and proposed treatment, to refuse any treatment to
8 the extent permitted by law, and to privacy and
9 confidentiality of records except as otherwise provided by
10 law.
11 (2) A patient has the right, regardless of source of
12 payment, to examine and to receive a reasonable explanation
13 of his or her total bill for health care services rendered by
14 his or her physician or other health care provider, including
15 the itemized charges for specific health care services
16 received. A physician or other health care provider shall be
17 responsible only for a reasonable explanation of these
18 specific health care services provided by the health care
19 provider.
20 (3) A patient has the right to privacy and
21 confidentiality in health care. A physician, other health
22 care provider, managed care plan, and utilization review
23 agent shall refrain from disclosing the nature or details of
24 health care services provided to patients, except that the
25 information may be disclosed to the patient, the party making
26 treatment decisions if the patient is incapable of making
27 decisions regarding the health care services provided, those
28 parties directly involved with providing treatment to the
29 patient or processing the payment for the treatment, those
30 parties responsible for peer review, utilization review, and
31 quality assurance, and those parties required to be notified
32 under the Abused and Neglected Child Reporting Act, the
33 Illinois Sexually Transmissible Disease Control Act, or where
34 otherwise authorized or required by law. This right may be
-50- LRB9000248JSmgam08
1 expressly waived in writing by the patient or the patient's
2 guardian, but a managed care plan, a physician, or other
3 health care provider may not condition the provision of
4 health care services on the patient's or guardian's agreement
5 to sign the waiver.
6 Section 105. Managed Care Ombudsman Program.
7 (a) The Department shall establish a Managed Care
8 Ombudsman Program (MCOP). The purpose of the MCOP is to
9 assist consumers to:
10 (1) navigate the managed care system;
11 (2) select an appropriate managed care plan; and
12 (3) understand and assert their rights and
13 responsibilities as managed care plan enrollees.
14 (b) The Department shall contract with an independent
15 organization or organizations to perform the following MCOP
16 functions:
17 (1) Assist consumers with managed care plan
18 selection by providing information, referral, and
19 assistance to individuals about means of obtaining health
20 coverage and services, including, but not limited to:
21 (A) access through a toll-free telephone
22 number; and
23 (B) availability of information in languages
24 other than English that are spoken as a primary
25 language by a significant portion of the State's
26 population, as determined by the Department.
27 (2) Educate and train consumers in the use of the
28 Department's annual Consumer Guidebook of Health Plan
29 Performance, compiled in accordance with Section 95.
30 (3) Analyze, comment on, monitor, and make publicly
31 available reports on the development and implementation
32 of federal, State and local laws, regulations, and other
33 governmental policies and actions that pertain to the
-51- LRB9000248JSmgam08
1 adequacy of managed care plans, facilities, and services
2 in the State.
3 (4) Ensure that individuals have timely access to
4 the services provided through the MCOP.
5 (5) Submit an annual report to the Department and
6 General Assembly:
7 (A) describing the activities carried out by
8 the MCOP in the year for which the report is
9 prepared;
10 (B) containing and analyzing the data
11 collected by the MCOP; and
12 (C) evaluating the problems experienced by
13 managed care plan enrollees.
14 (6) Exercise such other powers and functions as the
15 Department determines to be appropriate.
16 (c) The Department shall establish criteria for
17 selection of an independent organization or organizations to
18 perform the functions of the MCOP, including, but not limited
19 to, the following:
20 (1) Preference shall be given to private,
21 not-for-profit organizations governed by boards with
22 consumer members in the majority that represent a broad
23 spectrum of the diverse consumer interests in the State.
24 (2) No individual or organization under contract to
25 perform functions of the MCOP may:
26 (A) have a direct involvement in the
27 licensing, certification, or accreditation of a
28 health care facility, a managed care plan, or a
29 provider of a managed care plan, or have a direct
30 involvement with a provider of a health care
31 service;
32 (B) have a direct ownership or investment
33 interest in a health care facility, a managed care
34 plan, or a health care service;
-52- LRB9000248JSmgam08
1 (C) be employed by, or participate in the
2 management of, a health care service or facility or
3 a managed care plan; or
4 (D) receive, or have the right to receive,
5 directly or indirectly, remuneration (in cash or in
6 kind) under a compensation arrangement with an owner
7 or operator of a health care service or facility or
8 managed care plan.
9 The Department shall contract with an organization or
10 organizations qualified under criteria established under this
11 Section for an initial term of 3 years. The initial contract
12 shall be renewable thereafter for additional 3 year terms
13 without reopening the competitive selection process unless
14 there has been an unfavorable written performance evaluation
15 conducted by the Department.
16 (d) The Department shall establish, by rule, policies
17 and procedures for the operation of MCOP sufficient to ensure
18 that the MCOP can perform all functions specified in this
19 Section.
20 (e) The Department shall provide adequate funding for
21 the MCOP by assessing each managed care plan an amount to be
22 determined by the Department.
23 (f) Nothing in this Section shall be interpreted to
24 authorize access to or disclosure of individual patient or
25 provider records.
26 Section 110. Waiver. Any agreement that purports to
27 waive, limit, disclaim or in any way diminish the rights set
28 forth in this Act is void as contrary to public policy.
29 Section 115. Administration of Act.
30 (a) The Department shall administer the Act.
31 (b) All managed care plans and utilization review agents
32 providing or reviewing services in Illinois shall annually
-53- LRB9000248JSmgam08
1 certify compliance with this Act and rules adopted this Act
2 to the Department in addition to any other licensure required
3 by law. The Director shall establish by rule a process for
4 this certification including fees to cover the costs
5 associated with implementing this Act. All fees and fines
6 assessed under this Act shall be deposited in Managed Care
7 Entity Responsibility and Patient Rights fund. The
8 certification requirements of this Act shall be incorporated
9 into program requirements of the Department of Public Aid and
10 Department of Human Services and no further certification
11 under this Act is required.
12 (c) The Director shall take enforcement action under
13 this Act including, but not limited to, the assessment of
14 civil fines and injunctive relief for any failure to comply
15 with this Act or any violation of the Act or rules by a
16 managed care plan or any utilization review agent.
17 (d) The Department shall have the authority to impose
18 fines on any managed care plan or any utilization review
19 agent. The Department shall adopt rules pursuant to this Act
20 that establish a system of fines related to the type and
21 level of violation or repeat violation, including but not
22 limited to:
23 (1) A fine not exceeding $10,000 for a violation
24 that created a condition or occurrence presenting a
25 substantial probability that death or serious harm to an
26 individual will or did result therefrom; and
27 (2) A fine not exceeding $5,000 for a violation
28 that creates or created a condition or occurrence that
29 threatens the health, safety, or welfare of an
30 individual.
31 Each day a violation continues shall constitute a
32 separate offense. These rules shall include an opportunity
33 for a hearing in accordance with the Illinois Administrative
34 Procedure Act. All final decisions of the Department shall
-54- LRB9000248JSmgam08
1 be reviewable under the Administrative Review Law.
2 (e) Notwithstanding the existence or pursuit of any
3 other remedy, the Director may, through the Attorney General,
4 seek an injunction to restrain or prevent any person or
5 entity from functioning or operating in violation of this Act
6 or rule.
7 Section 120. Emergency services.
8 (a) Any managed care plan subject to this Act shall
9 provide the enrollee emergency services coverage such that
10 payment for this coverage is not dependent upon whether such
11 services are performed by a preferred or nonpreferred
12 provider, and such coverage shall be at the same benefit
13 level as if the service or treatment had been rendered by a
14 plan provider. Nothing in this Section is intended to
15 prohibit a plan from imposing its customary and normal
16 co-payments, deductibles, co-insurance, and other like
17 charges for emergency services.
18 (b) Prior authorization or approval by the plan shall
19 not be required for services rendered under this Section.
20 (c) Coverage and payment shall not be retrospectively
21 denied, with the following exceptions:
22 (1) upon reasonable determination that the
23 emergency services claimed were never performed; or
24 (2) upon reasonable determination that an emergency
25 medical screening examination was performed on a patient
26 who personally sought emergency services knowing that he
27 or she did not have an emergency condition or necessity,
28 and who did not in fact require emergency services.
29 (d) When an enrollee presents to a hospital seeking
30 emergency services, as defined in this Act, the determination
31 as to whether the need for those services exists shall be
32 made for purposes of treatment by a physician of the hospital
33 or, to the extent permitted by applicable law, by other
-55- LRB9000248JSmgam08
1 appropriate licensed personnel under the supervision of a
2 physician. The physician or other appropriate personnel
3 shall indicate in the patient's chart the results of the
4 emergency medical screening examination. The plan shall
5 compensate the provider for an emergency medical screening
6 examination that is reasonably calculated to assist the
7 health care provider in determining whether the patient's
8 condition requires emergency services.
9 (e) The appropriate use of the 911 emergency telephone
10 number shall not be discouraged or penalized, and coverage or
11 payment shall not be denied solely on the basis that the
12 insured used the 911 emergency telephone number to summon
13 emergency services.
14 (f) If prior authorization for post-stabilization
15 services, as defined in this Act, is required, the managed
16 care plan shall provide access 24 hours a day, 7 days a week
17 to persons designated by plan to make such determinations.
18 If a provider has attempted to contact such person for prior
19 authorization and no designated persons were accessible or
20 the authorization was not denied within one hour of the
21 request, the plan is deemed to have approved the request for
22 prior authorization.
23 (g) Coverage and payment for post-stabilization services
24 which received prior authorization or deemed approval shall
25 not be retrospectively denied. Nothing in this Section is
26 intended to prohibit a plan from imposing its customary and
27 normal co-payments, deductibles, co-insurance, and other like
28 changes for post-stabilization services.
29 Section 125. Prescription drugs. A managed care plan
30 that provides coverage for prescribed drugs approved by the
31 federal Food and Drug Administration shall not exclude
32 coverage of any drug on the basis that the drug has been
33 prescribed for the treatment of a particular indication for
-56- LRB9000248JSmgam08
1 which the drug has not been approved by the federal Food and
2 Drug Administration. The drug, however, must be approved by
3 the federal Food and Drug Administration and must be
4 recognized for the treatment of that particular indication
5 for which the drug has been prescribed in any one of the
6 following established reference compendia:
7 (1) the American Hospital Formulary Service Drug
8 Information;
9 (2) the United States Pharmacopoeia Drug
10 Information; or
11 (3) if not recognized by the authorities in item
12 (1) or (2), recommended for that particular indication in
13 formal clinical studies, the results of which have been
14 published in at least 2 peer reviewed professional
15 medical journals published in the United States or Great
16 Britain.
17 Any coverage required by this Section shall also include
18 those medically necessary services associated with the
19 administration of a drug.
20 Despite the provisions of this Section, coverage shall
21 not be required for any experimental or investigational drugs
22 or any drug that the federal Food and Drug Administration has
23 determined to be contraindicated for treatment of the
24 specific indication for which the drug has been prescribed.
25 Nothing in this Section shall be construed, expressly or by
26 implication, to create, impair, alter, limit, notify,
27 enlarge, abrogate, or prohibit reimbursement for drugs used
28 in the treatment of any other disease or condition.
29 Section 130. Health Care Service Delivery Review Board.
30 (a) A managed care plan shall organize a Health Care
31 Service Delivery Review Board from participants in the plan.
32 The Board shall consist of 17 members: 5 participating
33 physicians elected by participating physicians, 5 other
-57- LRB9000248JSmgam08
1 participating providers elected by the other health care
2 providers, 5 enrollees elected by the enrollees, and 2
3 representatives of the plan appointed by the plan. The
4 representatives of the plan shall not have a vote on the
5 Board, but shall have all other rights granted to Board
6 members. The plan shall devise a mechanism for the election
7 of the Board's members, subject to the approval of the
8 Department. The Department shall not unreasonably withhold
9 its approval of a mechanism.
10 (b) The Health Care Service Delivery Board shall
11 establish written rules and regulations governing its
12 operation. The managed care plan shall approve the rules,
13 but may not unilaterally amend them. A plan may not
14 unreasonably withhold approval of proposed rules and
15 regulations.
16 (c) The Health Care Service Delivery Board shall, from
17 time to time, issue nonbinding reports and reviews concerning
18 the plan's health care delivery policy, quality assurance
19 procedures, utilization review criteria and procedures, and
20 medical management procedures. The Board shall select the
21 aspects of the plan that it wishes to study or review and may
22 undertake a study or review at the request of the plan. The
23 Board shall issue its report directly to the managed care
24 plan's governing board.
25 Section 135. Conflicts with federal law. When health
26 care services are provided by a managed care plan subject to
27 this Act to a person who is a recipient of medical assistance
28 under Article V of the Illinois Public Aid Code, the rights,
29 benefits, requirements, and procedures available or
30 authorized under this Act shall not apply to the extent that
31 there are provisions of federal law that conflict. In the
32 event of a conflict, federal law shall prevail.
-58- LRB9000248JSmgam08
1 Section 140. The State Employees Group Insurance Act of
2 1971 is amended by adding Section 6.9 as follows:
3 (5 ILCS 375/6.9 new)
4 Sec. 6.9. Managed Care Reform Act. The program of
5 health benefits is subject to the provisions of the Managed
6 Care Reform Act.
7 Section 145. The State Finance Act is amended by adding
8 Section 5.449 as follows:
9 (30 ILCS 105/5.449 new)
10 Sec. 5.449. The Managed Care Entity Responsibility and
11 Patient Rights Fund.
12 Section 150. The State Mandates Act is amended by adding
13 Section 8.21 as follows:
14 (30 ILCS 805/8.21 new)
15 Sec. 8.21. Exempt mandate. Notwithstanding Sections 6
16 and 8 of this Act, no reimbursement by the State is required
17 for the implementation of any mandate created by this
18 amendatory Act of 1997.
19 Section 155. The Counties Code is amended by adding
20 Section 5-1069.8 as follows:
21 (55 ILCS 5/5-1069.8 new)
22 Sec. 5-1069.8. Managed Care Reform Act. All counties,
23 including home rule counties, are subject to the provisions
24 of the Managed Care Reform Act. The requirement under this
25 Section that health care benefits provided by counties comply
26 with the Managed Care Reform Act is an exclusive power and
27 function of the State and is a denial and limitation of home
-59- LRB9000248JSmgam08
1 rule county powers under Article VII, Section 6, subsection
2 (h) of the Illinois Constitution.
3 Section 160. The Illinois Municipal Code is amended by
4 adding 10-4-2.8 as follows:
5 (65 ILCS 5/10-4-2.8 new)
6 Sec. 10-4-2.8. Managed Care Reform Act. The corporate
7 authorities of all municipalities are subject to the
8 provisions of the Managed Care Reform Act. The requirement
9 under this Section that health care benefits provided by
10 municipalities comply with the Managed Care Reform Act is an
11 exclusive power and function of the State and is a denial and
12 limitation of home rule municipality powers under Article
13 VII, Section 6, subsection (h) of the Illinois Constitution.
14 Section 165. The School Code is amended by adding
15 Section 10-22.3f as follows:
16 (105 ILCS 5/10-22.3f new)
17 Sec. 10-22.3f. Managed Care Reform Act. Insurance
18 protection and benefits for employees are subject to the
19 Managed Care Reform Act.
20 Section 170. The Health Maintenance Organization Act is
21 amended by changing Sections 2-2 and 6-7 as follows:
22 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
23 Sec. 2-2. Determination by Director; Health Maintenance
24 Advisory Board.
25 (a) Upon receipt of an application for issuance of a
26 certificate of authority, the Director shall transmit copies
27 of such application and accompanying documents to the
28 Director of the Illinois Department of Public Health. The
-60- LRB9000248JSmgam08
1 Director of the Department of Public Health shall then
2 determine whether the applicant for certificate of authority,
3 with respect to health care services to be furnished: (1) has
4 demonstrated the willingness and potential ability to assure
5 that such health care service will be provided in a manner to
6 insure both availability and accessibility of adequate
7 personnel and facilities and in a manner enhancing
8 availability, accessibility, and continuity of service; and
9 (2) has arrangements, established in accordance with rules
10 regulations promulgated by the Department of Public Health
11 for an ongoing quality of health care assurance program
12 concerning health care processes and outcomes. Upon
13 investigation, the Director of the Department of Public
14 Health shall certify to the Director whether the proposed
15 Health Maintenance Organization meets the requirements of
16 this subsection (a). If the Director of the Department of
17 Public Health certifies that the Health Maintenance
18 Organization does not meet such requirements, he or she shall
19 specify in what respect it is deficient.
20 There is created in the Department of Public Health a
21 Health Maintenance Advisory Board composed of 11 members.
22 Nine of the 11 9 members shall who have practiced in the
23 health field and, 4 of those 9 which shall have been or shall
24 be are currently affiliated with a Health Maintenance
25 Organization. Two of the members shall be members of the
26 general public, one of whom is over 65 years of age. Each
27 member shall be appointed by the Director of the Department
28 of Public Health and serve at the pleasure of that Director
29 and shall receive no compensation for services rendered other
30 than reimbursement for expenses. Six Five members of the
31 Board shall constitute a quorum. A vacancy in the membership
32 of the Advisory Board shall not impair the right of a quorum
33 to exercise all rights and perform all duties of the Board.
34 The Health Maintenance Advisory Board has the power to review
-61- LRB9000248JSmgam08
1 and comment on proposed rules and regulations to be
2 promulgated by the Director of the Department of Public
3 Health within 30 days after those proposed rules and
4 regulations have been submitted to the Advisory Board.
5 (b) Issuance of a certificate of authority shall be
6 granted if the following conditions are met:
7 (1) the requirements of subsection (c) of Section
8 2-1 have been fulfilled;
9 (2) the persons responsible for the conduct of the
10 affairs of the applicant are competent, trustworthy, and
11 possess good reputations, and have had appropriate
12 experience, training or education;
13 (3) the Director of the Department of Public Health
14 certifies that the Health Maintenance Organization's
15 proposed plan of operation meets the requirements of this
16 Act;
17 (4) the Health Care Plan furnishes basic health
18 care services on a prepaid basis, through insurance or
19 otherwise, except to the extent of reasonable
20 requirements for co-payments or deductibles as authorized
21 by this Act;
22 (5) the Health Maintenance Organization is
23 financially responsible and may reasonably be expected to
24 meet its obligations to enrollees and prospective
25 enrollees; in making this determination, the Director
26 shall consider:
27 (A) the financial soundness of the applicant's
28 arrangements for health services and the minimum
29 standard rates, co-payments and other patient
30 charges used in connection therewith;
31 (B) the adequacy of working capital, other
32 sources of funding, and provisions for
33 contingencies; and
34 (C) that no certificate of authority shall be
-62- LRB9000248JSmgam08
1 issued if the initial minimum net worth of the
2 applicant is less than $2,000,000. The initial net
3 worth shall be provided in cash and securities in
4 combination and form acceptable to the Director;
5 (6) the agreements with providers for the provision
6 of health services contain the provisions required by
7 Section 2-8 of this Act; and
8 (7) any deficiencies identified by the Director
9 have been corrected.
10 (Source: P.A. 86-620; 86-1475.)
11 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
12 Sec. 6-7. Board of Directors. The board of directors of
13 the Association shall consist consists of not less than 7 5
14 nor more than 11 9 members serving terms as established in
15 the plan of operation. The members of the board are to be
16 selected by member organizations subject to the approval of
17 the Director provided, however, that 2 members shall be
18 enrollees, one of whom is over 65 years of age. Vacancies on
19 the board must be filled for the remaining period of the term
20 in the manner described in the plan of operation. To select
21 the initial board of directors, and initially organize the
22 Association, the Director must give notice to all member
23 organizations of the time and place of the organizational
24 meeting. In determining voting rights at the organizational
25 meeting each member organization is entitled to one vote in
26 person or by proxy. If the board of directors is not
27 selected at the organizational meeting, the Director may
28 appoint the initial members.
29 In approving selections or in appointing members to the
30 board, the Director must consider, whether all member
31 organizations are fairly represented.
32 Members of the board may be reimbursed from the assets of
33 the Association for expenses incurred by them as members of
-63- LRB9000248JSmgam08
1 the board of directors but members of the board may not
2 otherwise be compensated by the Association for their
3 services.
4 (Source: P.A. 85-20.)
5 Section 175. Severability. The provisions of this Act
6 are severable under Section 1.31 of the Statute on Statutes.
7 Section 199. Effective date. This Act takes effect upon
8 becoming law.".