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90_HB2285ham001
LRB9001851JSgcam01
1 AMENDMENT TO HOUSE BILL 2285
2 AMENDMENT NO. . Amend House Bill 2285 by replacing
3 the title with the following:
4 "AN ACT concerning managed care arrangements."; and
5 by replacing everything after the enacting clause with the
6 following:
7 "Section 1. Short title. This Act may be cited as the
8 Managed Care Responsibility to Members Act.
9 Section 5. Purpose. This Act addresses changes in managed
10 care practice and operations in Illinois. This Act enhances
11 quality, affordable, and accessible health care coverage for
12 Illinois citizens, families, and businesses. Through the
13 provisions of this Act, health care plan members will be
14 provided:
15 (1) Detailed information about health care plans, the
16 scope of coverage available, and the physicians' professional
17 qualifications so that they can make informed choices about
18 their health care.
19 (2) Notification of termination or change in any
20 benefits, services, or service delivery. This includes a
21 provision allowing enrollees to continue with a nonnetwork
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1 physician under certain specific circumstances.
2 (3) Detailed grievance procedures and medical necessity
3 appeals procedures, which include an expedited appeal
4 process. This Act also ensures health care plan
5 accountability for accessible hospital and physician services
6 and reimbursement for covered emergency services.
7 Section 10. Definitions. As used in this Act:
8 "Basic health care services" means emergency care, and
9 inpatient hospital and physician care, outpatient medical
10 services, mental health services and care for alcohol and
11 drug abuse, including any reasonable deductibles and
12 copayments, all of which are subject to such limitations as
13 are determined by the Director.
14 "Department" means the Department of Insurance.
15 "Director" means the Director of Insurance.
16 "Emergency services" means the provision of care for the
17 sudden and, at the time, unexpected onset of a health
18 condition which would lead a prudent lay person to believe
19 that failure to receive immediate medical attention would
20 result in serious impairment to bodily function, serious
21 dysfunction to any bodily organ or part, or would place the
22 person's health in serious jeopardy.
23 "Enrollee" means an individual enrolled in a health care
24 plan.
25 "Governing body" means the board of trustees, or
26 directors, or if otherwise designated in the basic
27 organizational document bylaws, those individuals vested with
28 the ultimate responsibility for the management of the health
29 care plan.
30 "Grievance" means any written complaint submitted to the
31 health care plan by or on behalf of an enrollee regarding any
32 aspect of the plan relative to the enrollee, but shall not
33 include a complaint by or on behalf of a provider.
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1 "Grievance committee" means individuals who have been
2 appointed by the health care plan to respond to grievances
3 which have been filed on appeal from the plan's simplified
4 complaint process. At least 50% of the individuals on this
5 committee shall be composed of enrollees who are consumers.
6 A grievance may not be heard or voted upon unless at least
7 50% of the voting individuals at the committee hearing are
8 enrollees.
9 "Health care plan" means any arrangement whereby an
10 organization undertakes to provide or arrange for and pay for
11 or reimburse the cost of basic health care services from
12 providers selected by the plan and the arrangement consists
13 of arranging for or the provision of health care services, as
14 distinguished from mere indemnification against the cost of
15 those services, on a per capita prepaid basis, through
16 insurance or otherwise.
17 "Health care services" means any services included in the
18 furnishing to any individual of medical or dental care, the
19 hospitalization incident to the furnishing of such care, and
20 the furnishing to any person of any and all other services
21 for the purpose of preventing, alleviating, curing, or
22 healing human illness or injury.
23 "Insurance company" means companies in this State
24 authorized to transact the kind or kinds of business
25 enumerated in Class 1(a), Class 1(b) or Class 2(a) of Section
26 4 of the Illinois Insurance Code.
27 "Insured" means an individual entitled to coverage of
28 expenses of health care services under a policy issued or
29 administered by an insurance company.
30 "Life threatening condition" means any condition, illness
31 or injury which (i) may directly lead to a patient's death,
32 (ii) results in a period of unconsciousness which is
33 indeterminate at the present, or (iii) imposes severe pain or
34 an inhumane burden on the patient.
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1 "Medical director" means a physician licensed to practice
2 medicine in all its branches in Illinois who is employed by
3 or contracted with a health care plan and who shall be
4 responsible for final review when questions of medical
5 practice arise in the health care plan in order to assure the
6 quality of health care services provided.
7 "Patient" means any person who has received or is
8 receiving medical care, treatment, or services from an
9 individual or institution licensed to provide medical care or
10 treatment in this State.
11 "Primary care physician" means a provider who has
12 contracted with a health care plan to provide primary care
13 services as defined by the contract and who is (1) a
14 physician licensed to practice medicine in all of its
15 branches who spends a majority of clinical time engaged in
16 general practice or in the practice of internal medicine,
17 pediatrics, gynecology, obstetrics, or family practice or (2)
18 a chiropractic physician licensed to treat human ailments
19 without the use of drugs or operative surgery.
20 "Provider" means any physician, hospital facility, or
21 other person which is licensed or otherwise authorized to
22 furnish health care services and also includes any other
23 entity that arranges for the delivery or furnishing of health
24 care services.
25 "Stabilization" means the provision of medical treatment
26 to assure within reasonable medical probability that no
27 material deterioration of the condition is likely to result
28 from the transfer of the individual from a facility.
29 "Utilization review" means the study of the
30 appropriateness of the use of particular services and the
31 appropriateness of the volume of services used.
32 "Utilization review program" means an entity performing
33 utilization review, except an agency of the federal
34 government or its agent, but only to the extent that agent is
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1 providing services to the federal government.
2 Section 15. Patient rights. The following rights are
3 hereby established:
4 (1) The right of each patient to be provided with
5 information about the health care plan and the providers
6 rendering care. For health care plans this right calls for
7 compliance with Section 20 of this Act.
8 (2) The right of each patient to a full disclosure of
9 the patient costs, benefits, risks, and alternatives related
10 to the treatment options and care, including health care plan
11 requirements, coverage, exclusions, or limitations that could
12 affect the enrollee's access to coverage or treatment
13 options. For health care plans this right calls for
14 compliance with Section 25 of this Act. Insurance companies
15 and health care plans are prohibited from terminating or
16 suspending a provider from its network for advocating
17 appropriate health care services because the provider
18 advocated for what he or she considered to be appropriate
19 health care.
20 (3) The right of each patient to care, consistent with
21 nursing and medical practices, to be informed of the name of
22 the physician responsible for coordinating his or her care,
23 to receive information from his or her physician concerning
24 his or her condition and proposed treatment, to refuse any
25 treatment to the extent permitted by law, and to privacy and
26 confidentiality of records except as otherwise provided by
27 law.
28 (4) The right of each patient, regardless of source of
29 payment, to examine and receive a reasonable explanation of
30 his or her total bill for services where such a bill is
31 rendered by his or her physician or health care provider,
32 including the itemized charges for specific services
33 received. Each provider shall be responsible for a reasonable
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1 explanation of those specific services provided by such
2 physician or health care provider.
3 (5) In the event an insurance company or health care
4 plan cancels or refuses to renew an individual policy or
5 plan, the insured or enrollee shall be entitled to timely,
6 prior notice of the termination of such policy or plan.
7 An insurance company or health care plan that requires
8 any insured, enrollee, or applicant for new or continued
9 insurance or coverage to be tested for infection with HIV or
10 any other identified causative agent of AIDS shall (i) give
11 the patient or applicant prior written notice of such
12 requirement, (ii) proceed with such testing only upon the
13 written authorization of the insured, enrollee, or applicant,
14 and (iii) keep the results of such testing confidential.
15 Notice of an adverse underwriting or coverage decision may be
16 given to any appropriately interested party, but the
17 insurance company or health care plan may only disclose the
18 test result itself to a physician designated by the insured,
19 enrollee or applicant, and any such disclosure shall be in a
20 manner that assures confidentiality.
21 (6) At the time of renewal, the right of each patient to
22 notification of termination or change in any benefits,
23 services, or service delivery location.
24 (7) The right of each patient to privacy and
25 confidentiality in health care. Each physician, health care
26 provider, health care plan and insurance company shall not
27 disclose the nature or details of services provided to
28 insureds and enrollees, except that such information may be
29 disclosed to the patient, the party making treatment
30 decisions if the patient is incapable of making decisions
31 regarding the health services provided, those parties
32 directly involved with providing treatment to the patient or
33 processing the payment for that treatment, those parties
34 responsible for peer review, utilization review and quality
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1 assurance, and those parties required to be notified under
2 the Abused and Neglected Child Reporting Act, the Illinois
3 Sexually Transmissible Disease Control Act or where otherwise
4 authorized or required by law. This right may be waived in
5 writing by the patient or the patient's guardian, but a
6 physician or other health care provider may not condition the
7 provision of services on the patient's or guardian's
8 agreement to sign such a waiver.
9 Section 20. Provision of information.
10 (a) A health care plan shall provide to enrollees a
11 description of the terms and conditions of the evidence of
12 coverage. The form shall provide a description of all of the
13 following:
14 (1) The service area.
15 (2) Covered benefits, exclusions or limitations.
16 (3) Precertification and other utilization review
17 procedures requirements.
18 (4) A list of primary care physicians in the health
19 care plan's service area and a description of the
20 limitations to access specialists.
21 (5) Emergency coverage and benefits.
22 (6) Out-of-area coverages and benefits.
23 (7) The enrollee's financial responsibility for
24 copayments, deductibles, and any other out-of-pocket
25 expenses.
26 (8) Provisions for continuity of treatment in the
27 event a provider's participation terminates during the
28 course of an insured's or enrollee's treatment by that
29 provider.
30 (9) The grievance process, including the telephone
31 number to call to receive information concerning
32 grievance procedures.
33 (b) Upon written request, a health care plan shall
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1 provide to applicants and enrollees a description of the
2 financial relationships between the health care plan and any
3 provider, except that no health care plan shall be required
4 to disclose specific reimbursement to providers.
5 (c) A participating provider shall provide all of the
6 following to enrollees upon request:
7 (1) Information related to the health care
8 professional's educational background, experience,
9 training, specialty, and board certification, if
10 applicable.
11 (2) The names of licensed facilities on the
12 provider panel where the health professional presently
13 has privileges for the treatment, illness, or procedure
14 that is the subject of the request.
15 (3) Information regarding the health care
16 professional's participation in continuing education
17 programs and compliance with any licensure,
18 certification, or registration requirements, if
19 applicable.
20 Section 25. Prohibited restraints on communication.
21 Nothing in a physician's contract with a health care plan
22 shall be construed to impair the physician's ethical and
23 legal duty to provide full informed consent and medical
24 counsel to enrollees, including full discussion of the costs,
25 benefits, risks, and alternatives related to the enrollee's
26 treatment options and care and health care plan policies
27 related to those options, including health care plan
28 requirements, coverage, exclusions, or other policies or
29 practices that affect enrollees' access to coverage or
30 treatment options.
31 Section 30. Access to personnel and facilities.
32 (a) A health care plan shall include a sufficient number
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1 and type of primary care physicians and specialists,
2 throughout the service area, to meet the needs of enrollees
3 and to provide meaningful choice. A health care plan shall
4 offer:
5 (1) accessible acute care hospital services, within
6 a reasonable distance or travel time;
7 (2) primary care physicians, within a reasonable
8 distance or travel time; and
9 (3) specialists within a reasonable distance or
10 travel time.
11 When the type of medical service needed for a specific
12 condition is not represented in the provider network, the
13 health care plan shall arrange for the enrollee to have
14 access to qualified nonparticipating health care
15 professionals as authorized by the primary care physician.
16 (b) A health care plan shall provide telephone access to
17 the health care plan for sufficient time during business
18 hours to assure enrollee access for routine care, and 24 hour
19 telephone access to the health care plan or, if so delegated
20 by the health care plan, a participating physician or group
21 for emergency care or authorization for care.
22 (c) A health care plan shall establish reasonable
23 standards for waiting times to obtain appointments, except as
24 provided below for emergency services.
25 Such standards shall include appointment scheduling
26 guidelines used for each type of health care service,
27 including prenatal care appointments, well-child visits and
28 immunizations, routine physicals, follow-up appointments for
29 chronic conditions, and urgent care.
30 (d) A health care plan shall provide for continuity of
31 care for its enrollees as follows:
32 (1) If an enrollee's physician leaves the health
33 care plan's network of providers for reasons other than
34 termination with cause and the physician remains within
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1 the health care plan's service area, the health care plan
2 shall permit the enrollee to continue an ongoing course
3 of treatment with that physician during a transitional
4 period of:
5 (A) up to 60 days from the date of the notice
6 of physician's termination from the health care plan
7 network to the enrollee of the physician's
8 disaffiliation from the health care plan's network
9 if the enrollee has a life threatening disease or
10 condition; or
11 (B) if the enrollee has entered the third
12 trimester of pregnancy at the time of the
13 physician's disaffiliation, for a transitional
14 period that includes the provision of post-partum
15 care directly related to the delivery.
16 (2) Notwithstanding the provisions in item (1) of
17 this subsection, such care shall be authorized by the
18 health care plan during the transitional period only if
19 the physician agrees:
20 (A) to continue to accept reimbursement from
21 the health care plan at the rates applicable prior
22 to the start of the transitional period as payment
23 in full;
24 (B) to adhere to the health care plan's
25 quality assurance requirements and to provide to the
26 health care plan necessary medical information
27 related to such care; and
28 (C) to otherwise adhere to the organization's
29 policies and procedures, including but not limited
30 to procedures regarding referrals and obtaining
31 preauthorizations and a treatment plan approved by
32 the health care plan.
33 (e) A health care plan shall provide for continuity of
34 care for new enrollees as follows:
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1 (1) If a new enrollee whose physician is not a
2 member of the health care plan's provider network, but is
3 within the health care plan's service area, enrolls in
4 the health care plan, the health care plan shall permit
5 the enrollee to continue an ongoing course of treatment
6 with the enrollee's current physician during a
7 transitional period of up to 60 days from the effective
8 date of enrollment, if:
9 (A) the enrollee has a life-threatening
10 disease or condition; or
11 (B) the enrollee has entered the third
12 trimester of pregnancy at the effective date of
13 enrollment, in which case the transitional period
14 shall include the provision of post-partum care
15 directly related to the delivery.
16 (2) If an enrollee elects to continue to receive
17 care from such physician pursuant to item (1) of this
18 subsection, such care shall be authorized by the health
19 care plan for the transitional period only if the
20 physician agrees:
21 (A) to accept reimbursement from the health
22 care plan at rates established by the health care
23 plan as payment in full, such rates shall be no more
24 than the level of reimbursement applicable to
25 similar physicians within the health care plan's
26 network for such services;
27 (B) to adhere to the health care plan's
28 quality assurance requirements and agrees to
29 provide to the health care plan necessary medical
30 information related to such care; and
31 (C) to otherwise adhere to the health care
32 plan's policies and procedures including, but not
33 limited to procedures regarding referrals and
34 obtaining preauthorization and a treatment plan
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1 approved by the health care plan. In no event
2 shall this section be construed to require a health
3 care plan to provide coverage for benefits not
4 otherwise covered or to diminish or impair
5 preexisting condition limitations contained in the
6 subscriber's contract.
7 Section 35. Emergency services.
8 (a) Health care plans shall provide reimbursement for
9 covered emergency services provided at a participating or
10 nonparticipating emergency department up to the point of
11 stabilization of an enrollee.
12 (b) Once the enrollee is stabilized, the emergency
13 department shall contact the primary care physician or health
14 care plan as specified on the identification card to seek
15 prior authorization for any additional nonemergency services
16 beyond stabilization.
17 (c) With any claim for reimbursement, the emergency
18 department shall provide the health plan with the medical
19 record documenting the presenting symptoms of the enrollee at
20 the time care was sought and the objective findings of the
21 medical examination.
22 (d) The health care plan's medical director's
23 determination of whether the enrollee meets the standard of
24 emergency shall take into account the presenting symptoms at
25 the time care was sought.
26 (e) Health care plans may require an enrollee to pay a
27 copayment for emergency services.
28 (f) Health care plans shall provide enrollees with
29 information on procedures for the coverage of emergency
30 services both inside and out of the plan service area.
31 Section 40. Grievance procedures.
32 (a) Every health care plan shall submit for the
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1 Director's approval, and thereafter maintain, a system for
2 the resolution of grievances concerning the provision of
3 health care services or other matters concerning operation
4 of the health care plan as follows. A health care plan shall
5 do all of the following:
6 (1) Submit to the Director for prior approval any
7 proposed changes to the system by which grievances may be
8 filed and reviewed;
9 (2) Maintain records on each grievance filed with
10 the health care plan until the grievance is resolved and
11 for a period of at least 3 years to include:
12 (A) a copy of the grievance and the date of
13 its filing;
14 (B) the date and outcome of all consultations,
15 hearings and hearing findings;
16 (C) the date and decisions of any appeal
17 proceedings; and
18 (D) the date and proceeding of any litigation.
19 (3) Submit to the Director in a form prescribed by
20 the Director, a report by March 1 for the previous
21 calendar year which shall include at least the following:
22 (A) the total number of grievances handled;
23 (B) a compilation of causes underlying the
24 grievances;
25 (C) the outcomes of the grievances;
26 (D) the elapsed time from receipt of the
27 grievance by the health care plan until its
28 conclusion; and
29 (E) the number of malpractice claims filed and
30 if such claims have been completely adjudicated, a
31 compilation of causes, disposition, form, and amount
32 of any settlements.
33 (b) A health care plan shall have a grievance committee
34 which shall have the authority to hear and resolve by
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1 majority vote grievances submitted to it as provided in
2 subsection (a).
3 Notwithstanding any other provisions of this Section, the
4 grievance committee may, but is not required to, hear any
5 grievance which alleges or indicates possible professional
6 liability, commonly known as "malpractice."
7 The committee is not empowered to resolve grievances in
8 any manner which, or prescribe any actions, that are in
9 conflict with written policies of the health care plan's
10 governing body, but the committee may hear such grievances
11 for the purpose of providing input to the governing body.
12 The grievance committee shall meet at the main office of
13 the health care plan, or such other office designated by the
14 health care plan where the main office is not within 50 miles
15 of the grievant's home address. Consideration shall be given
16 to the enrollee's request pertaining to the time and date of
17 such meeting. The enrollee shall have the right to attend
18 and participate in the formal grievance proceedings. The
19 enrollee shall have the right to be accompanied by a
20 designated representative of his or her choice.
21 The filing of a grievance shall not preclude the enrollee
22 from filing a complaint with the Department nor shall it
23 preclude the Department from investigating a complaint
24 pursuant to its authority under Section 4-6 of the Health
25 Maintenance Organization Act.
26 (c) The grievance procedures must be fully and clearly
27 communicated to all enrollees and information concerning such
28 procedures shall be readily available to the enrollee.
29 (d) A health care plan shall have simplified procedure
30 for resolving complaints. Such procedures do not require
31 review of the complaint by the grievance committee, but a
32 log, file, or other similar records must be maintained to
33 identify the general nature of such complaints. Resolution
34 of such complaints shall not preclude the enrollees' rightful
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1 access to review by the grievance committee of a grievance.
2 (e) The health care plan shall institute procedures
3 which would require grievances to have a determination made
4 by the grievance committee within 60 days from the date the
5 grievance is received by the health care plan. A grievance
6 may not be heard or voted upon unless 50% of the voting
7 individuals of the committee present at the hearing are
8 enrollees. The determination by the grievance committee may
9 be extended for a period not to exceed 30 days in the event
10 of delay in obtaining documents or records necessary for the
11 resolution of the grievance. All requests for documents or
12 records necessary for the resolution of the grievance shall
13 be maintained in the health care plan's grievance file.
14 (f) The grievance procedure shall provide the enrollee
15 with a written acknowledgment of their grievance within 10
16 business days after receipt by the health care plan.
17 (g) The enrollee shall be notified at the time of the
18 hearing of the name and affiliation of those grievance
19 committee members who are representatives of the health care
20 plan.
21 (h) The health care plan shall institute procedures
22 whereby any document furnished to the members of the
23 grievance committee shall also be made available to the
24 enrollee not less than 5 business days prior to the hearing
25 of their grievance. The health care plan shall not present
26 any evidence without the enrollee having been given the
27 opportunity to be present.
28 (i) Notice in writing of the determination of the
29 grievance committee shall be mailed to the enrollee within 5
30 business days of such determination. Notice of the
31 determination made at the final appeal step of the health
32 care plan's grievance process shall include a notice of the
33 availability of the Department to receive complaints under
34 Section 4-6 of the Health Maintenance Organization Act.
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1 (j) Prior to the resolution of a grievance filed by a
2 subscriber or enrollee, coverage shall not be terminated for
3 any reason which is the subject of the written grievance,
4 except where the health care plan has, in good faith, made a
5 reasonable effort to resolve the written grievance through
6 its grievance procedure and coverage is being terminated as a
7 result of good cause.
8 Section 45. Review of medical necessity. A health care
9 plan shall provide a mechanism for the timely review by a
10 physician holding the same class of license as the primary
11 care physician, who is unaffiliated with health care plan,
12 jointly selected by the patient (or the patient's next of kin
13 or legal representative if the patient is unable to act for
14 himself or herself), primary care physician and the health
15 care plan in the event of a dispute between the primary care
16 physician and the health care plan regarding the medical
17 necessity of a covered service proposed by the primary care
18 physician. In the event that the reviewing physician
19 determines the covered service to be medically necessary, the
20 health care plan shall provide the covered service. Future
21 contractual or employment action by the health care plan
22 regarding the primary care physician shall not be based
23 solely on the physician's participation in this procedure.
24 Section 50. Expedited review of medical necessity.
25 (a) A health care plan shall have an expedited review
26 procedure whereby an enrollee with a life-threatening
27 condition, or physician authorized in writing to act on
28 behalf of the enrollee with a life-threatening condition, may
29 appeal a health care plan's decision of medical necessity of
30 a covered service.
31 (b) The expedited review procedure shall provide that an
32 initial determination of the review will be made by the
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1 health care plan not later than 3 business days after
2 receipt of all necessary information to complete the review
3 process.
4 (c) After the initial adverse determination by the
5 health care plan, the enrollee, or physician authorized in
6 writing to act on behalf of the enrollee, may request further
7 review by the health care plan. If further review is
8 requested, a final determination by the health care plan
9 shall be made not later than 30 days after receipt of all
10 necessary information to complete further review. Upon
11 notification to the enrollee of the health care plan's final
12 determination resulting from the expedited review process,
13 the plan shall provide the enrollee a notice of the
14 availability of the Department to receive complaints as
15 provided in Section 4-6 of the Health Maintenance
16 Organization Act.
17 (d) A request for an expedited review under this Section
18 must contain a statement submitted by the physician, orally
19 or in writing, substantiating that the enrollee has a
20 life-threatening condition. This subsection does not apply to
21 a provider's complaint concerning claims payment, handling,
22 or reimbursement for health care services.
23 (e) If the expedited review process is invoked it shall
24 be in place of and not in addition to the regular review
25 process.
26 Section 55. Registration of utilization review programs.
27 (a) All utilization review programs shall register
28 annually with the Department.
29 (b) The utilization review program will submit all of
30 the following:
31 (1) The name, address and telephone of the
32 registrant.
33 (2) The organization and governing structure of the
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1 registrant.
2 (3) List of insurance companies and health care
3 plans for which the utilization review program performs
4 utilization review in this State and the number of lives
5 for which utilization review is conducted.
6 (4) Hours of operation.
7 (5) Description of the grievance process.
8 (6) Number of covered lives for which utilization
9 review was conducted for the previous calendar year.
10 (7) Written policies and procedures for protecting
11 confidential information according to applicable State
12 and federal laws.
13 (c) If the Director determines that an insurance company
14 or health care plan licensed by the Department meets the
15 provisions of the requirements of this Section under its
16 certification process, he or she may exempt the insurance
17 company or health care plan from providing duplicate
18 information.
19 Section 60. Severability. If any Section, term or
20 provision of this Act shall be adjudged invalid for any
21 reason, such judgment shall not affect, impair, or invalidate
22 any other Section, term, or provision of this Act, and the
23 remaining Sections, terms, and provisions shall be and remain
24 in full force and effect.
25 Section 65. Applicability of Act. A health care plan
26 amended, delivered, issued, or renewed in this State after
27 the effective date of this Act must comply with the terms of
28 this Act.
29 Section 70. Managed care community networks. Managed
30 care community networks providing or arranging health care
31 services under contract with the State exclusively to persons
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1 who are enrolled in the integrated health care program
2 established under Section 5-16.3 of the Illinois Public Aid
3 Code or a managed care community network owned, operated, or
4 governed by a county provider as defined in Section 15-1 of
5 that Code are required to comply with Sections 15, 20, 25,
6 and 65 of this Act and are exempt from all other Sections of
7 this Act. The Illinois Department of Public Aid shall adopt
8 rules to implement these provisions.
9 Section 99. Effective date. This Act takes effect
10 January 1, 1998.".