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90_HB0626ham005
LRB9000248EGfgam02
1 AMENDMENT TO HOUSE BILL 626
2 AMENDMENT NO. . Amend House Bill 626, AS AMENDED,
3 with reference to the page and line numbers of House
4 Amendment No. 3, on page 1 by replacing lines 16 and 17 with
5 the following:
6 "(1) in the case of physician reviewers, a State
7 licensed"; and
8 on page 2, line 1, by replacing "health" with "State licensed
9 or registered health"; and
10 on page 2 by replacing lines 4, 5, and 6 with the following:
11 "condition, procedure, or treatment under review.
12 Nothing herein shall be construed to change any
13 statutorily defined scope of practice."; and
14 on page 2 by replacing lines 24 through 28 with the
15 following:
16 ""Emergency services" means the provision of health care
17 services for sudden and, at the time, unexpected onset of a
18 health condition that would lead a prudent layperson to
19 believe that failure to receive immediate medical attention
20 would result in serious impairment to bodily function or
21 serious dysfunction of any body organ or part or would place
22 the person's health in serious jeopardy."; and
-2- LRB9000248EGfgam02
1 on page 3, line 13, by changing "is" to "may be"; and
2 on page 4, line 23, by replacing "time" with "time for a
3 managed care plan"; and
4 on page 4 by replacing lines 33 and 34 with the following:
5 ""Utilization review" means the review, undertaken by an
6 entity other than the managed care plan itself, to determine
7 whether"; and
8 on page 5, line 3, by replacing "individual" with "individual
9 by a managed care plan"; and
10 on page 5, line 22, by changing "federal" to "State or
11 federal"; and
12 on page 5, line 26, by changing "state" to "State"; and
13 on page 10 by replacing lines 32 and 33 with the following:
14 "complaints compiled in accordance with subsection (b) of
15 Section 30 of this Act and the rules promulgated under
16 this Act."; and
17 on page 11 by replacing lines 8 and 9 with the following:
18 "seek information as to the inclusion or exclusion of a
19 specific drug. A managed care plan need only release the
20 information if the enrollee or prospective enrollee or
21 his or"; and
22 on page 11 by replacing lines 28, 29, and 30 with the
23 following:
24 "process. An enrollee or prospective enrollee may seek
25 information as to specific clinical review criteria. A
26 managed care plan need only release the information if
27 the enrollee or prospective enrollee or his or her
28 dependent has,"; and
29 on page 12, lines 18 and 26, by changing "days" each time it
30 appears to "business days"; and
-3- LRB9000248EGfgam02
1 on page 13 by replacing lines 11 through 14 with the
2 following:
3 "any other State law or rules."; and
4 on page 14, line 28, by changing "any" to "requesting any";
5 and
6 on page 15, line 17, by changing "5 business days" to "48
7 hours"; and
8 on page 15, line 26, by changing "health" to "health or when
9 extended health care services, procedures, or treatments for
10 an enrollee undergoing a course of treatment prescribed by a
11 health care provider are at issue"; and
12 on page 16, line 25, by deleting "business"; and
13 on page 16, line 32, by changing "5 business days" to "48
14 hours"; and
15 on page 17, line 21, by changing "health" to "health or when
16 extended health care services, procedures, or treatments for
17 an enrollee undergoing a course of treatment prescribed by a
18 health care provider are at issue"; and
19 on page 20 by replacing line 11 with the following:
20 "denied under the grievance review under Section"; and
21 on page 21, line 29, by replacing "health care insurers" with
22 "managed care plans"; and
23 on page 21, line 30, by deleting "in Illinois"; and
24 on page 22, line 30, by changing "prohibited" to "protected";
25 and
26 on page 23, line 9, by changing "plan" to "plan,"; and
27 on page 23, line 19, by changing "in" to "and, to the extent
28 possible, in"; and
-4- LRB9000248EGfgam02
1 on page 24 by deleting lines 5 through 12; and
2 on page 24, line 28, by changing "in" to "and, to the extent
3 possible, in"; and
4 on page 25, line 5, by changing "with" to "with subsection
5 (b) of"; and
6 on page 25 by inserting immediately below line 9 the
7 following:
8 "For any hearing under this Section, because the candid
9 and conscientious evaluation of clinical practices is
10 essential to the provision of health care, it is the policy
11 of this State to encourage peer review by health care
12 professionals. Therefore, no managed care plan and no
13 individual who participates in a hearing or who is a member,
14 agent, or employee of a managed care plan shall be liable for
15 criminal or civil damages or professional discipline as a
16 result of the acts, omissions, decisions, or any other
17 conduct, direct or indirect, associated with a hearing panel,
18 except for wilful and wanton misconduct. Nothing in this
19 Section shall relieve any person, health care provider,
20 health care professional, facility, organization, or
21 corporation from liability for his, her, or its own
22 negligence in the performance of his, her, or its duties or
23 arising from treatment of a patient. The hearing panel
24 information shall not be subject to inspection or disclosure
25 except upon formal written request by an authorized
26 representative of a duly authorized State agency or pursuant
27 to a court order issued in a pending action or proceeding.";
28 and
29 on page 29 by replacing lines 11, 12, and 13 with the
30 following:
31 "providers in the managed care plan."; and
32 on page 30, line 16, by changing "and" to "or"; and
-5- LRB9000248EGfgam02
1 on page 30, line 20, by changing "and" to "or"; and
2 on page 31, line 7, by changing "provider" to "provider
3 pursuant to the provisions of subsection (d)"; and
4 on page 32, line 12, by deleting "state licensing board or
5 other"; and
6 on page 32, line 13, by changing "of federal" to "or
7 federal"; and
8 on page 32, line 22, by changing "and" to "or"; and
9 on page 33, line 13, by deleting "state licensing board or
10 other"; and
11 on page 33, line 14, by changing "of federal" to "or
12 federal"; and
13 on page 34, line 11, by changing "in" to ", to the extent
14 possible, in"; and
15 on page 34 by inserting immediately below line 22 the
16 following:
17 "If a hearing has been held pursuant to subsection (f) of
18 Section 45 and the hearing panel sustained a plan's
19 termination of a health care professional, no additional
20 hearing is required, and the plan shall make the report
21 required under this Section."; and
22 on page 34 by replacing lines 32, 33, and 34 with the
23 following:
24 "For any hearing under this Section, because the candid
25 and conscientious evaluation of clinical practices is
26 essential to the provision of health care, it is the policy
27 of this State to encourage peer review by health care
28 professionals. Therefore, no managed care plan and no
29 individual who participates in a hearing or who is a member,
30 agent, or employee of a managed care plan shall be liable for
-6- LRB9000248EGfgam02
1 criminal or civil damages or professional discipline as a
2 result of the acts, omissions, decisions, or any other
3 conduct, direct or indirect, associated with a hearing panel,
4 except for wilful and wanton misconduct. Nothing in this
5 Section shall relieve any person, health care provider,
6 health care professional, facility, organization, or
7 corporation from liability for his, her, or its own
8 negligence in the performance of his, her, or its duties or
9 arising from treatment of a patient. The hearing panel
10 information shall not be subject to inspection or disclosure
11 except upon formal written request by an authorized
12 representative of a duly authorized State agency or pursuant
13 to a court order issued in a pending action or proceeding.";
14 and
15 on page 35 by deleting lines 1 through 5; and
16 on page 36 by replacing lines 5 through 14 with the
17 following:
18 "(2) a description of the grievance procedures by
19 which an enrollee, the enrollee's designee, or his or her
20 health care provider may seek reconsideration of adverse
21 determinations by the utilization review agent in
22 accordance with this Act;"; and
23 on page 37 by replacing lines 23 through 26 with the
24 following:
25 "(B) notwithstanding the provisions of item
26 (A),"; and
27 on page 39, line 4, by changing "including" to "including
28 the"; and
29 on page 39, line 8, by changing "establishment" to
30 "consistent with the applicable Sections of this Act,
31 establishment"; and
-7- LRB9000248EGfgam02
1 on page 39, line 12, by changing "timeframes established
2 herein" to "required timeframes"; and
3 on page 39, line 15, by changing "and" to "and the"; and
4 on page 39 by replacing lines 18 through 28 with the
5 following:
6 "inpatient care or when delay would significantly
7 increase the risk to an enrollee's health;"; and
8 on page 40 by replacing lines 8 through 12 with the
9 following:
10 "(B) in the case of a request submitted
11 pursuant to"; and
12 on page 40, line 24, by replacing "review" with "review,
13 except as authorized in this Act"; and
14 on page 41, line 18, by changing "and" to "upon, and"; and
15 on page 41 by replacing lines 25 through 28 with the
16 following:
17 "to the enrollee or the enrollee's designee by notice within
18 24 hours to the enrollee's health care provider by telephone
19 upon, and in writing within 2 business days after receipt of
20 the necessary information."; and
21 on page 42 by replacing lines 4 through 10 with the
22 following:
23 "utilization review agent shall be given in writing in
24 accordance with the grievance procedures of this Act."; and
25 on page 43 by replacing lines 6 through 17 with the
26 following:
27 "determination rendered by a utilization review agent
28 pursuant to Sections 15, 20, 25, and 35.
29 (b) A utilization review agent shall establish
30 mechanisms that"; and
-8- LRB9000248EGfgam02
1 on page 43 by replacing lines 23 through 34 with the
2 following:
3 "clinical peer reviewer in a prompt manner."; and
4 on page 44 by replacing lines 1 through 17 with the
5 following:
6 "(c) Appeals shall be"; and
7 on page 45, line 4, by deleting "by the State"; and
8 on page 45, line 26, by changing "shall" to "may"; and
9 on page 45, line 34, by changing "or" to ", unless required
10 under State or federal Medicare or Medicaid rules or
11 regulations, or"; and
12 on page 47, line 14, by changing "shall" to "may"; and
13 on page 53, line 1, by changing "adopted" to "adopted under";
14 and
15 on page 53 by replacing line 7 with the following:
16 "Reform Fund, a special fund hereby created in the State
17 treasury. Moneys in the Fund shall be used by the Department
18 only to enforce and administer this Act."; and
19 on page 54, line 11, by replacing "preferred or nonpreferred"
20 with "participating or nonparticipating"; and
21 on page 54, line 19, by replacing "for" with "for emergency";
22 and
23 on page 54, line 32, by deleting "of the hospital"; and
24 on page 55, line 8, by replacing "services." with "services.
25 A plan shall have no duty to pay for services rendered after
26 an emergency medical screening examination determines the
27 lack of a need for emergency services."; and
28 on page 58 by replacing lines 10 and 11 with the following:
-9- LRB9000248EGfgam02
1 "Sec. 5.449. The Managed Care Reform Fund."; and
2 on page 63, by replacing line 8 with the following:
3 "July 1, 1998.".