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| [ Introduced ] | [ House Amendment 002 ] |
90_HB3265ham001
LRB9009287JSsbam
1 AMENDMENT TO HOUSE BILL 3265
2 AMENDMENT NO. . Amend House Bill 3265 on page 1 by
3 replacing lines 1 and 2 with the following:
4 "AN ACT relating to the delivery of health care
5 services."; and
6 on page 1 by replacing lines 5, 6, and 7 with the following:
7 "Section 1. Short title. This Act may be cited as the
8 Managed Care Reform Act.
9 Section 5. Definitions. For purposes of this Act, the
10 following words shall have the meanings provided in this
11 Section, unless otherwise indicated:
12 "Adverse determination" means a determination by a
13 utilization review agent that an admission, extension of a
14 stay, or other health care service has been reviewed and,
15 based on the information provided, is not medically
16 necessary.
17 "Clinical peer reviewer" or "clinical personnel" means:
18 (1) in the case of physician reviewers, a State
19 licensed physician who is of the same category in the
20 same or similar specialty as the health care provider who
21 typically manages the medical condition, procedure or
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1 treatment under review; or
2 (2) in the case of non-physician reviewers, a State
3 licensed or registered health care professional who is
4 in the same profession and same or similar specialty
5 as the health care provider who typically manages the
6 medical condition, procedure, or treatment under review.
7 Nothing herein shall be construed to change any
8 statutorily defined scope of practice.
9 "Culturally and linguistically competent care" means that
10 a managed care plan has staff and procedures in place to
11 provide all covered services and policy procedures in
12 English, Spanish, and any other language spoken as a primary
13 language by 5% or more of its enrollees.
14 "Degenerative or disabling condition or disease" means a
15 condition or disease that is permanent or of indefinite
16 duration, that is likely to become worse or more advanced
17 over time, and that substantially impairs a major life
18 function.
19 "Department" means the Department of Public Health.
20 "Director" means the Director of Public Health.
21 "Emergency medical screening examination" means a medical
22 screening examination and evaluation by a physician or, to
23 the extent permitted by applicable laws, by other appropriate
24 personnel under the supervision of a physician to determine
25 whether the need for emergency services exists.
26 "Emergency services" means the provision of health care
27 services for sudden and, at the time, unexpected onset of a
28 health condition that would lead a prudent layperson to
29 believe that failure to receive immediate medical attention
30 would result in serious impairment to bodily function or
31 serious dysfunction of any body organ or part or would place
32 the person's health in serious jeopardy.
33 "Enrollee" means a person enrolled in a managed care
34 plan.
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1 "Health care professional" means a physician, registered
2 professional nurse, or other person appropriately licensed or
3 registered pursuant to the laws of this State to provide
4 health care services.
5 "Health care provider" means a health care professional,
6 hospital, facility, or other person appropriately licensed or
7 otherwise authorized to furnish health care services or
8 arrange for the delivery of health care services in this
9 State.
10 "Health care services" means services included in the (i)
11 furnishing of medical care, (ii) hospitalization incident to
12 the furnishing of medical care, and (iii) furnishing of
13 services, including pharmaceuticals, for the purpose of
14 preventing, alleviating, curing, or healing human illness or
15 injury to an individual.
16 "Informal policy or procedure" means a nonwritten policy
17 or procedure, the existence of which may be proven by an
18 admission of an authorized agent of a managed care plan or
19 statistical evidence supported by anecdotal evidence.
20 "Life threatening condition or disease" means any
21 condition, illness, or injury that, in the opinion of a
22 licensed physician, (i) may directly lead to a patient's
23 death, (ii) results in a period of unconsciousness which is
24 indeterminate at the present, or (iii) imposes severe pain or
25 an inhumane burden on the patient.
26 "Managed care plan" means a plan that establishes,
27 operates, or maintains a network of health care providers
28 that have entered into agreements with the plan to provide
29 health care services to enrollees where the plan has the
30 obligation to the enrollee to arrange for the provision of or
31 pay for services through:
32 (1) organizational arrangements for ongoing quality
33 assurance, utilization review programs, or dispute
34 resolution; or
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1 (2) financial incentives for persons enrolled in
2 the plan to use the participating providers and
3 procedures covered by the plan.
4 A managed care plan may be established or operated by any
5 entity including, but not necessarily limited to, a licensed
6 insurance company, hospital or medical service plan, health
7 maintenance organization, limited health service
8 organization, preferred provider organization, third party
9 administrator, independent practice association, or employer
10 or employee organization.
11 For purposes of this definition, "managed care plan"
12 shall not include the following:
13 (1) strict indemnity health insurance policies or
14 plans issued by an insurer that does not require approval
15 of a primary care provider or other similar coordinator
16 to access health care services; and
17 (2) managed care plans that offer only dental or
18 vision coverage.
19 "Post-stabilization services" means those health care
20 services determined by a treating provider to be promptly and
21 medically necessary following stabilization of an emergency
22 condition.
23 "Primary care provider" means a physician licensed to
24 practice medicine in all its branches who provides a broad
25 range of personal medical care (preventive, diagnostic,
26 curative, counseling, or rehabilitative) in a comprehensive
27 and coordinated manner over time for a managed care plan.
28 "Specialist" means a health care professional who
29 concentrates practice in a recognized specialty field of
30 care.
31 "Speciality care center" means only a center that is
32 accredited by an agency of the State or federal government or
33 by a voluntary national health organization as having special
34 expertise in treating the life-threatening disease or
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1 condition or degenerative or disabling disease or condition
2 for which it is accredited.
3 "Utilization review" means the review, undertaken by a
4 entity other than the managed care plan itself, to determine
5 whether health care services that have been provided, are
6 being provided or are proposed to be provided to an
7 individual by a managed care plan, whether undertaken prior
8 to, concurrent with, or subsequent to the delivery of
9 such services are medically necessary. For the purposes
10 of this Act, none of the following shall be considered
11 utilization review:
12 (1) denials based on failure to obtain health care
13 services from a designated or approved health care
14 provider as required under an enrollee's contract;
15 (2) the review of the appropriateness of the
16 application of a particular coding to a patient,
17 including the assignment of diagnosis and procedure;
18 (3) any issues relating to the determination of
19 the amount or extent of payment other than determinations
20 to deny payment based on an adverse determination; and
21 (4) any determination of any coverage issues other
22 than whether health care services are or were medically
23 necessary.
24 "Utilization review agent" means any company,
25 organization, or other entity performing utilization review,
26 except:
27 (1) an agency of the State or federal government;
28 (2) an agent acting on behalf of the federal
29 government, but only to the extent that the agent is
30 providing services to the federal government;
31 (3) an agent acting on behalf of the State and
32 local government for services provided pursuant to
33 Title XIX of the federal Social Security Act, but only to
34 the extent that the agent is providing services to the
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1 State or local government;
2 (4) a hospital's internal quality assurance program
3 except if associated with a health care financing
4 mechanism.
5 "Utilization review plan" means:
6 (1) a description of the process for developing the
7 written clinical review criteria;
8 (2) a description of the types of written clinical
9 information which the plan might consider in its clinical
10 review including, but not limited to, a set of specific
11 written clinical review criteria;
12 (3) a description of practice guidelines and
13 standards used by a utilization review agent in making a
14 determination of medical necessity;
15 (4) the procedures for scheduled review and
16 evaluation of the written clinical review criteria; and
17 (5) a description of the qualifications and
18 experience of the health care professionals who
19 developed the criteria, who are responsible for periodic
20 evaluation of the criteria and of the health care
21 professionals or others who use the written clinical
22 review criteria in the process of utilization review.
23 Section 10. Disclosure of information.
24 (a) An enrollee, and upon request a prospective enrollee
25 prior to enrollment, shall be supplied with written
26 disclosure information, containing at least the information
27 specified in this Section, if applicable, which may be
28 incorporated into the member handbook or the enrollee
29 contract or certificate. All written descriptions shall be
30 in readable and understandable format, consistent with
31 standards developed for supplemental insurance coverage under
32 Title XVIII of the Social Security Act. The Department shall
33 promulgate rules to standardize this format so that potential
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1 members can compare the attributes of the various managed
2 care entities. In the event of any inconsistency between any
3 separate written disclosure statement and the enrollee
4 contract or certificate, the terms of the enrollee
5 contract or certificate shall be controlling. The
6 information to be disclosed shall include, at a minimum,
7 all of the following:
8 (1) A description of coverage provisions, health
9 care benefits, benefit maximums, including benefit
10 limitations, and exclusions of coverage, including the
11 definition of medical necessity used in determining
12 whether benefits will be covered.
13 (2) A description of all prior authorization or
14 other requirements for treatments, pharmaceuticals, and
15 services.
16 (3) A description of utilization review policies
17 and procedures used by the managed care plan,
18 including the circumstances under which utilization
19 review will be undertaken, the toll-free telephone
20 number of the utilization review agent, the timeframes
21 under which utilization review decisions must be made for
22 prospective, retrospective, and concurrent decisions,
23 the right to reconsideration, the right to an appeal,
24 including the expedited and standard appeals processes
25 and the timeframes for those appeals, the right to
26 designate a representative, a notice that all denials of
27 claims will be made by clinical personnel, and that
28 all notices of denials will include information about the
29 basis of the decision and further appeal rights, if any.
30 (4) A description prepared annually of the types of
31 methodologies the managed care plan uses to reimburse
32 providers specifying the type of methodology that is
33 used to reimburse particular types of providers or
34 reimburse for the provision of particular types of
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1 services, provided, however, that nothing in this item
2 should be construed to require disclosure of individual
3 contracts or the specific details of any financial
4 arrangement between a managed care plan and a health care
5 provider.
6 (5) An explanation of a enrollee's financial
7 responsibility for payment of premiums, coinsurance,
8 co-payments, deductibles, and any other charges, annual
9 limits on an enrollee's financial responsibility, caps
10 on payments for covered services and financial
11 responsibility for non-covered health care procedures,
12 treatments, or services provided within the managed
13 care plan.
14 (6) An explanation of an enrollee's financial
15 responsibility for payment when services are provided by
16 a health care provider who is not part of the managed
17 care plan or by any provider without required
18 authorization or when a procedure, treatment, or service
19 is not a covered health care benefit.
20 (7) A description of the grievance procedures to
21 be used to resolve disputes between a managed care plan
22 and an enrollee, including the right to file a
23 grievance regarding any dispute between an enrollee and a
24 managed care plan, the right to file a grievance
25 orally when the dispute is about referrals or covered
26 benefits, the toll-free telephone number that enrollees
27 may use to file an oral grievance, the timeframes and
28 circumstances for expedited and standard grievances, the
29 right to appeal a grievance determination and the
30 procedures for filing the appeal, the timeframes and
31 circumstances for expedited and standard appeals, the
32 right to designate a representative, a notice that all
33 disputes involving clinical decisions will be made by
34 clinical personnel, and that all notices of determination
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1 will include information about the basis of the
2 decision and further appeal rights, if any.
3 (8) A description of the procedure for providing
4 care and coverage 24 hours a day for emergency services.
5 The description shall include the definition of
6 emergency services, notice that emergency services are
7 not subject to prior approval, and an explanation of
8 the enrollee's financial and other responsibilities
9 regarding obtaining those services, including when
10 those services are received outside the managed care
11 plan's service area.
12 (9) A description of procedures for enrollees to
13 select and access the managed care plan's primary and
14 specialty care providers, including notice of how to
15 determine whether a participating provider is accepting
16 new patients.
17 (10) A description of the procedures for changing
18 primary and specialty care providers within the managed
19 care plan.
20 (11) Notice that an enrollee may obtain a referral
21 to a health care provider outside of the managed care
22 plan's network or panel when the managed care plan
23 does not have a health care provider with appropriate
24 training and experience in the network or panel to meet
25 the particular health care needs of the enrollee and
26 the procedure by which the enrollee can obtain the
27 referral.
28 (12) Notice that an enrollee with a condition
29 that requires ongoing care from a specialist may
30 request a standing referral to the specialist and
31 the procedure for requesting and obtaining a standing
32 referral.
33 (13) Notice that an enrollee with (i) a
34 life-threatening condition or disease or (ii) a
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1 degenerative or disabling condition or disease, either of
2 which requires specialized medical care over a prolonged
3 period of time, may request a specialist responsible for
4 providing or coordinating the enrollee's medical care and
5 the procedure for requesting and obtaining the
6 specialist.
7 (14) A description of the mechanisms by which
8 enrollees may participate in the development of the
9 policies of the managed care plan.
10 (15) A description of how the managed care plan
11 addresses the needs of non-English speaking enrollees.
12 (16) Notice of all appropriate mailing addresses
13 and telephone numbers to be utilized by enrollees
14 seeking information or authorization.
15 (17) A listing by specialty, which may be in a
16 separate document that is updated annually, of the name,
17 address, and telephone number of all participating
18 providers, including facilities, and, in addition, in the
19 case of physicians, category of license and board
20 certification, if applicable.
21 (b) Upon request of an enrollee or prospective enrollee,
22 a managed care plan shall do all of the following:
23 (1) Provide a list of the names, business
24 addresses, and official positions of the members of the
25 board of directors, officers, controlling persons,
26 owners, and partners of the managed care plan.
27 (2) Provide a copy of the most recent annual
28 certified financial statement of the managed care plan,
29 including a balance sheet and summary of receipts and
30 disbursements and the ratio of (i) premium dollars going
31 to administrative expenses to (ii) premium dollars going
32 to direct care, prepared by a certified public
33 accountant. The Department shall promulgate rules to
34 standardize the information that must be contained in the
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1 statement and the statement's format.
2 (3) Provide information relating to consumer
3 complaints compiled in accordance with subsection (b) of
4 Section 30 of this Act and the rules promulgated under
5 this Act.
6 (4) Provide the procedures for protecting the
7 confidentiality of medical records and other enrollee
8 information.
9 (5) Allow enrollees and prospective enrollees to
10 inspect drug formularies used by the managed care plan
11 and disclose whether individual drugs are included or
12 excluded from coverage and whether a drug requires prior
13 authorization. An enrollee or prospective enrollee may
14 seek information as to the inclusion or exclusion of a
15 specific drug. A managed care plan need only release the
16 information if the enrollee or prospective enrollee or
17 his or her dependent needs, used, or may need or use the
18 drug.
19 (6) Provide a written description of the
20 organizational arrangements and ongoing procedures of
21 the managed care plan's quality assurance program.
22 (7) Provide a description of the procedures
23 followed by the managed care plan in making decisions
24 about the experimental or investigational nature of
25 individual drugs, medical devices, or treatments in
26 clinical trials.
27 (8) Provide individual health care professional
28 affiliations with participating hospitals, if any.
29 (9) Upon written request, provide specific
30 written clinical review criteria relating to a
31 particular condition or disease and, where appropriate,
32 other clinical information that the managed care plan
33 might consider in its utilization review; the managed
34 care plan may include with the information a description
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1 of how it will be used in the utilization review
2 process. An enrollee or prospective enrollee may seek
3 information as to specific clinical review criteria. A
4 managed care plan need only release the information if
5 the enrollee or prospective enrollee or his or her
6 dependent has, may have, or is at risk of contracting a
7 particular condition or disease.
8 (10) Provide the written application procedures and
9 minimum qualification requirements for health care
10 providers to be considered by the managed care plan.
11 (11) Disclose other information as required by
12 the Director.
13 (12) To the extent the information provided under
14 item (5) or (9) of this subsection is proprietary to the
15 managed care plan, the enrollee or prospective enrollee
16 shall only use the information for the purposes of
17 assisting the enrollee or prospective enrollee in
18 evaluating the covered services provided by the managed
19 care plan. Any misuse of proprietary data is prohibited,
20 provided that the managed care plan has labeled or
21 identified the data as proprietary.
22 (c) Nothing in this Section shall prevent a managed care
23 plan from changing or updating the materials that are made
24 available to enrollees or prospective enrollees.
25 (d) If a primary care provider ceases participation in
26 the managed care plan, the managed care plan shall provide
27 written notice within 15 business days from the date that the
28 managed care plan becomes aware of the change in status to
29 each of the enrollees who have chosen the provider as
30 their primary care provider. If an enrollee is in an
31 ongoing course of treatment with any other participating
32 provider who becomes unavailable to continue to provide
33 services to the enrollee and the managed care plan is aware
34 of the ongoing course of treatment, the managed care plan
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1 shall provide written notice within 15 business days from
2 the date that the managed care plan becomes aware of the
3 unavailability to the enrollee. The notice shall also
4 describe the procedures for continuing care.
5 (e) A managed care plan offering to indemnify enrollees
6 for non-participating provider services shall file a report
7 with the Director twice a year showing the percentage
8 utilization for the preceding 6 month period of
9 non-participating provider services in such form and
10 providing such other information as the Director shall
11 prescribe.
12 (f) The written information disclosure requirements of
13 this Section may be met by disclosure to one enrollee in a
14 household.
15 Section 15. General grievance procedure.
16 (a) A managed care plan shall establish and maintain a
17 grievance procedure, as described in this Act. Compliance
18 with this Act's grievance procedures shall satisfy a managed
19 care plan's obligation to provide grievance procedures under
20 any other State law or rules.
21 A copy of the grievance procedures, including all forms
22 used to process a grievance, shall be filed with the
23 Director. Any subsequent material modifications to the
24 documents also shall be filed. In addition, a managed care
25 plan shall file annually with the Director a certificate of
26 compliance stating that the managed care plan has established
27 and maintains, for each of its plans, grievance procedures
28 that fully comply with the provisions of this Act. The
29 Director has authority to disapprove a filing that fails to
30 comply with this Act or applicable rules.
31 (b) A managed care plan shall provide written notice of
32 the grievance procedure to all enrollees in the member
33 handbook and to an enrollee at any time that the managed care
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1 plan denies access to a referral or determines that a
2 requested benefit is not covered pursuant to the terms of the
3 contract. In the event that a managed care plan denies a
4 service as an adverse determination, the managed care plan
5 shall inform the enrollee or the enrollee's designee of
6 the appeal rights under this Act.
7 The notice to an enrollee describing the grievance
8 process shall explain the process for filing a grievance
9 with the managed care plan, the timeframes within which a
10 grievance determination must be made, and the right of an
11 enrollee to designate a representative to file a grievance on
12 behalf of the enrollee. Information required to be disclosed
13 or provided under this Section must be provided in a
14 reasonable and understandable format.
15 The managed care plan shall assure that the grievance
16 procedure is reasonably accessible to those who do not speak
17 English.
18 (c) A managed care plan shall not retaliate or take
19 any discriminatory action against an enrollee because an
20 enrollee has filed a grievance or appeal.
21 Section 20. First level grievance review.
22 (a) The managed care plan may require an enrollee to
23 file a grievance in writing, by letter or by a grievance
24 form which shall be made available by the managed care plan,
25 however, an enrollee must be allowed to submit an oral
26 grievance in connection with (i) a denial of, or failure to
27 pay for, a referral or service or (ii) a determination as to
28 whether a benefit is covered pursuant to the terms of the
29 enrollee's contract. In connection with the submission of
30 an oral grievance, a managed care plan shall, within 24
31 hours, reduce the complaint to writing and give the enrollee
32 written acknowledgment of the grievance prepared by the
33 managed care plan summarizing the nature of the grievance
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1 and requesting any information that the enrollee needs to
2 provide before the grievance can be processed. The
3 acknowledgment shall be mailed within the 24-hour period
4 to the enrollee, who shall sign and return the
5 acknowledgment, with any amendments and requested
6 information, in order to initiate the grievance. The
7 grievance acknowledgment shall prominently state that the
8 enrollee must sign and return the acknowledgment to
9 initiate the grievance. A managed care plan may elect not to
10 require a signed acknowledgment when no additional
11 information is necessary to process the grievance, and an
12 oral grievance shall be initiated at the time of the
13 telephone call.
14 Except as authorized in this subsection, a managed care
15 plan shall designate personnel to accept the filing of an
16 enrollee's grievance by toll-free telephone no less than
17 40 hours per week during normal business hours and shall
18 have a telephone system available to take calls during other
19 than normal business hours and shall respond to all such
20 calls no later than the next business day after the call was
21 recorded. In the case of grievances subject to item (i) of
22 subsection (b) of this Section, telephone access must be
23 available on a 24 hour a day, 7 day a week basis.
24 (b) Within 48 hours of receipt of a written grievance,
25 the managed care plan shall provide written acknowledgment
26 of the grievance, including the name, address,
27 qualifying credentials, and telephone number of the
28 individuals or department designated by the managed care plan
29 to respond to the grievance. All grievances shall be
30 resolved in an expeditious manner, and in any event, no more
31 than (i) 24 hours after the receipt of all necessary
32 information when a delay would significantly increase the
33 risk to an enrollee's health or when extended health care
34 services, procedures, or treatments for an enrollee
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1 undergoing a course of treatment prescribed by a health care
2 provider are at issue, (ii) 15 days after the receipt of all
3 necessary information in the case of requests for referrals
4 or determinations concerning whether a requested benefit
5 is covered pursuant to the contract, and (iii) 30 days after
6 the receipt of all necessary information in all other
7 instances.
8 (c) The managed care plan shall designate one or more
9 qualified personnel to review the grievance. When the
10 grievance pertains to clinical matters, the personnel shall
11 include, but not be limited to, one or more appropriately
12 licensed or registered health care professionals.
13 (d) The notice of a determination of the grievance
14 shall be made in writing to the enrollee or to the enrollee's
15 designee. In the case of a determination made in conformance
16 with item (i) of subsection (b) of this Section, notice
17 shall be made by telephone directly to the enrollee with
18 written notice to follow within 2 business days.
19 (e) The notice of a determination shall include (i)
20 clear and detailed reasons for the determination, including
21 any contract basis for the determination, and the evidence
22 relied upon in making that determination, (ii) in cases where
23 the determination has a clinical basis, the clinical
24 rationale for the determination, and (iii) the procedures for
25 the filing of an appeal of the determination, including a
26 form for the filing of an appeal.
27 Section 25. Second level grievance review.
28 (a) A managed care plan shall establish a second level
29 grievance review process to give those enrollees who are
30 dissatisfied with the first level grievance review decision
31 the option to request a second level review, at which the
32 enrollee shall have the right to appear in person before
33 authorized individuals designated to respond to the appeal.
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1 (b) An enrollee or an enrollee's designee shall
2 have not less than 60 days after receipt of notice of the
3 grievance determination to file a written appeal, which may
4 be submitted by letter or by a form supplied by the managed
5 care plan. The enrollee shall indicate in his or her written
6 appeal whether he or she wants the right to appear in person
7 before the person or panel designated to respond to the
8 appeal.
9 (c) Within 48 hours of receipt of the second level
10 grievance review, the managed care plan shall provide written
11 acknowledgment of the appeal, including the name, address,
12 qualifying credentials, and telephone number of the
13 individual designated by the managed care plan to respond
14 to the appeal and what additional information, if any, must
15 be provided in order for the managed care plan to render a
16 decision.
17 (d) The determination of a second level grievance review
18 on a clinical matter must be made by personnel qualified
19 to review the appeal, including appropriately licensed or
20 registered health care professionals who did not make
21 the initial determination, a majority of whom must be
22 clinical peer reviewers. The determination of a second
23 level grievance review on a matter that is not clinical shall
24 be made by qualified personnel at a higher level than the
25 personnel who made the initial grievance determination.
26 (e) The managed care plan shall seek to resolve all
27 second level grievance reviews in the most expeditious manner
28 and shall make a determination and provide notice no more
29 than (i) 24 hours after the receipt of all necessary
30 information when a delay would significantly increase the
31 risk to an enrollee's health or when extended health care
32 services, procedures, or treatments for an enrollee
33 undergoing a course of treatment prescribed by a health care
34 provider are at issue and (ii) 30 business days after the
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1 receipt of all necessary information in all other instances.
2 (f) The notice of a determination on a second level
3 grievance review shall include (i) the detailed reasons for
4 the determination, including any contract basis for the
5 determination and the evidence relied upon in making the
6 determination and (ii) in cases where the determination has a
7 clinical basis, the clinical rationale for the
8 determination.
9 (g) If an enrollee has requested the opportunity to
10 appear in person before the authorized representatives of the
11 managed care plan designated to respond to the appeal, the
12 review panel shall schedule and hold a review meeting within
13 30 days of receiving a request from an enrollee for a second
14 level review with a right to appear. The review meeting
15 shall be held during regular business hours at a location
16 reasonably accessible to the enrollee. The enrollee shall be
17 notified in writing at least 14 days in advance of the review
18 date.
19 Upon the request of an enrollee, a managed care plan
20 shall provide to the enrollee all relevant information that
21 is not confidential or privileged.
22 An enrollee has the right to:
23 (1) attend the second level review;
24 (2) present his or her case to the review panel;
25 (3) submit supporting material both before and at
26 the review meeting;
27 (4) ask questions of any representative of the
28 managed care plan; and
29 (5) be assisted or represented by persons of his or
30 her choice.
31 The notice shall advise the enrollee of the rights
32 specified in this subsection.
33 If the managed care plan desires to have an attorney
34 present to represent its interests, it shall notify the
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1 enrollee at least 14 days in advance of the review that an
2 attorney will be present and that the enrollee may wish to
3 obtain legal representation of his or her own.
4 Section 30. Grievance register and reporting
5 requirements.
6 (a) A managed care plan shall maintain a register
7 consisting of a written record of all complaints initiated
8 during the past 3 years. The register shall be maintained in
9 a manner that is reasonably clear and accessible to the
10 Director. The register shall include at a minimum the
11 following:
12 (1) the name of the enrollee;
13 (2) a description of the reason for the complaint;
14 (3) the dates when first level and second level
15 review were requested and completed;
16 (4) a copy of the written decision rendered at each
17 level of review;
18 (5) if required time limits were exceeded, an
19 explanation of why they were exceeded and a copy of the
20 enrollee's consent to an extension of time;
21 (6) whether expedited review was requested and the
22 response to the request;
23 (7) whether the complaint resulted in litigation
24 and the result of the litigation.
25 (b) A managed care plan shall report annually to the
26 Department the numbers, and related information where
27 indicated, for the following:
28 (1) covered lives;
29 (2) total complaints initiated;
30 (3) total complaints involving medical necessity or
31 appropriateness;
32 (4) complaints involving termination or reduction
33 of inpatient hospital services;
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1 (5) complaints involving termination or reduction
2 of other health care services;
3 (6) complaints involving denial of health care
4 services where the enrollee had not received the services
5 at the time the complaint was initiated;
6 (7) complaints involving payment for health care
7 services that the enrollee had already received at the
8 time of initiating the complaint;
9 (8) complaints resolved at each level of review and
10 how they were resolved;
11 (9) complaints where expedited review was provided
12 because adherence to regular time limits would have
13 jeopardized the enrollee's life, health, or ability to
14 regain maximum function; and
15 (10) complaints that resulted in litigation and the
16 outcome of the litigation.
17 The Department shall promulgate rules regarding the
18 format of the report, the timing of the report, and other
19 matters related to the report.
20 Section 35. External independent review.
21 (a) If an enrollee's or enrollee's designee's request
22 for a covered service or claim for a covered service is
23 denied under the grievance review under Section 25 because
24 the service is not viewed as medically necessary, the
25 enrollee may initiate an external independent review.
26 (b) Within 30 days after the enrollee receives written
27 notice of such an adverse decision made under the second
28 level grievance review procedures of Section 25, if the
29 enrollee decides to initiate an external independent review,
30 the enrollee shall send to the managed care plan a written
31 request for an external independent review, including any
32 material justification or documentation to support the
33 enrollee's request for the covered service or claim for a
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1 covered service.
2 (c) Within 30 days after the managed care plan receives
3 a request for an external independent review from an
4 enrollee, the managed care plan shall:
5 (1) provide a mechanism for jointly selecting an
6 external independent reviewer by the enrollee, primary
7 care physician, and managed care plan; and
8 (2) forward to the independent reviewer all medical
9 records and supporting documentation pertaining to the
10 case, a summary description of the applicable issues
11 including a statement of the managed care plan's
12 decision, and the criteria used and the clinical reasons
13 for that decision.
14 (d) Within 5 days of receipt of all necessary
15 information, the independent reviewer or reviewers shall
16 evaluate and analyze the case and render a decision that is
17 based on whether or not the service or claim for the service
18 is medically necessary. The decision by the independent
19 reviewer or reviewers is final.
20 (e) Pursuant to subsection (c) of this Section, an
21 external independent reviewer shall:
22 (1) have no direct financial interest in or
23 connection to the case;
24 (2) be State licensed physicians, who are board
25 certified or board eligible by the appropriate American
26 Medical Specialty Board, if applicable, and who are in
27 the same or similar scope of practice as a physician who
28 typically manages the medical condition, procedure, or
29 treatment under review; and
30 (3) have not been informed of the specific identity
31 of the enrollee or the enrollee's treating provider.
32 (f) If an appropriate reviewer pursuant to subsection
33 (e) of this Section for a particular case is not on the list
34 established by the Director, the parties shall choose a
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1 reviewer who is mutually acceptable.
2 Section 40. Independent reviewers.
3 (a) From information filed with the Director on or
4 before March 1 of each year, the Director shall compile a
5 list of external independent reviewers and organizations that
6 represent external independent reviewers from lists provided
7 by managed care plans and by any State and county public
8 health department and State medical associations that wish to
9 submit a list to the Director. The Director may consult with
10 other persons about the suitability of any reviewer or any
11 potential reviewer. The Director shall annually review the
12 list and add and remove names as appropriate. On or before
13 June 1 of each year, the Director shall publish the list in
14 the Illinois Register.
15 (b) The managed care plan shall be solely responsible
16 for paying the fees of the external independent reviewer who
17 is selected to perform the review.
18 (c) An external independent reviewer who acts in good
19 faith shall have immunity from any civil or criminal
20 liability or professional discipline as a result of acts or
21 omissions with respect to any external independent review,
22 unless the acts or omissions constitute wilful and wanton
23 misconduct. For purposes of any proceeding, the good faith
24 of the person participating shall be presumed.
25 (d) The Director's decision to add a name to or remove a
26 name from the list of independent reviewers pursuant to
27 subsection (a) is not subject to administrative appeal or
28 judicial review.
29 Section 45. Health care professional applications and
30 terminations.
31 (a) A managed care plan shall, upon request, make
32 available and disclose to health care professionals written
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1 application procedures and minimum qualification
2 requirements that a health care professional must meet in
3 order to be considered by the managed care plan. The
4 managed care plan shall consult with appropriately qualified
5 health care professionals in developing its qualification
6 requirements.
7 (b) A managed care plan may not terminate a contract of
8 employment or refuse to renew a contract on the basis of any
9 action protected under Section 50 of this Act or solely
10 because a health care professional has:
11 (1) filed a complaint against the managed care
12 plan;
13 (2) appealed a decision of the managed care plan;
14 or
15 (3) requested a hearing pursuant to this Section.
16 (c) A managed care plan shall provide to a health care
17 professional, in writing, the reasons for the contract
18 termination or non-renewal.
19 (d) A managed care plan shall provide an opportunity
20 for a hearing to any health care professional terminated by
21 the managed care plan, or non-renewed if the health care
22 professional has had a contract or contracts with the managed
23 care plan for at least 24 of the past 36 months.
24 (e) After the notice provided pursuant to subsection
25 (c), the health care professional shall have 21 days to
26 request a hearing, and the hearing must be held within 15
27 days after receipt of the request for a hearing. The hearing
28 shall be held before a panel appointed by the managed care
29 plan.
30 The hearing panel shall be composed of 5 individuals, the
31 majority of whom shall be clinical peer reviewers and, to the
32 extent possible, in the same discipline and the same or
33 similar specialty as the health care professional under
34 review.
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1 The hearing panel shall render a written decision on the
2 proposed action within 14 business days. The decision shall
3 be one of the following:
4 (1) reinstatement of the health care professional
5 by the managed care plan;
6 (2) provisional reinstatement subject to
7 conditions set forth by the panel; or
8 (3) termination of the health care professional.
9 The decision of the hearing panel shall be final.
10 A decision by the hearing panel to terminate a health
11 care professional shall be effective not less than 15 days
12 after the receipt by the health care professional of the
13 hearing panel's decision.
14 A hearing under this subsection shall provide the health
15 care professional in question with the right to examine
16 pertinent information, to present witnesses, and to ask
17 questions of an authorized representative of the plan.
18 (f) A managed care plan may terminate or decline to
19 renew a health care professional, without a prior hearing, in
20 cases involving imminent harm to patient care, a
21 determination of intentional falsification of reports to the
22 plan or a final disciplinary action by a state licensing
23 board or other governmental agency that impairs the health
24 care professional's ability to practice. A professional
25 terminated for one of the these reasons shall be given
26 written notice to that effect. Within 21 days after the
27 termination, a health care professional terminated because of
28 imminent harm to patient care or a determination of
29 intentional falsification of reports to the plan shall
30 receive a hearing. The hearing shall be held before a panel
31 appointed by the managed care plan. The panel shall be
32 composed of 5 individuals the majority of whom shall be
33 clinical peer reviewers and, to the extent possible, in the
34 same discipline and the same or similar specialty as the
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1 health care professional under review. The hearing panel
2 shall render a decision on the proposed action within 14
3 days. The panel shall issue a written decision either
4 supporting the termination or ordering the health care
5 professional's reinstatement. The decision of the hearing
6 panel shall be final.
7 If the hearing panel upholds the managed care plan's
8 termination of the health care professional under this
9 subsection, the managed care plan shall forward the decision
10 to the appropriate professional disciplinary agency in
11 accordance with subsection (b) of Section 60.
12 Any hearing under this subsection shall provide the
13 health care professional in question with the right to
14 examine pertinent information, to present witnesses, and to
15 ask questions of an authorized representative of the plan.
16 For any hearing under this Section, because the candid
17 and conscientious evaluation of clinical practices is
18 essential to the provision of health care, it is the policy
19 of this State to encourage peer review by health care
20 professionals. Therefore, no managed care plan and no
21 individual who participates in a hearing or who is a member,
22 agent, or employee of a managed care plan shall be liable for
23 criminal or civil damages or professional discipline as a
24 result of the acts, omissions, decisions, or any other
25 conduct, direct or indirect, associated with a hearing panel,
26 except for wilful and wanton misconduct. Nothing in this
27 Section shall relieve any person, health care provider,
28 health care professional, facility, organization, or
29 corporation from liability for his, her, or its own
30 negligence in the performance of his, her, or its duties or
31 arising from treatment of a patient. The hearing panel
32 information shall not be subject to inspection or disclosure
33 except upon formal written request by an authorized
34 representative of a duly authorized State agency or pursuant
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1 to a court order issued in a pending action or proceeding.
2 (g) A managed care plan shall develop and implement
3 policies and procedures to ensure that health care
4 professionals are at least annually informed of information
5 maintained by the managed care plan to evaluate the
6 performance or practice of the health care professional. The
7 managed care plan shall consult with health care
8 professionals in developing methodologies to collect and
9 analyze health care professional data. Managed care plans
10 shall provide the information and data and analysis to health
11 care professionals. The information, data, or analysis
12 shall be provided on at least an annual basis in a format
13 appropriate to the nature and amount of data and the volume
14 and scope of services provided. Any data used to evaluate
15 the performance or practice of a health care professional
16 shall be measured against stated criteria and a comparable
17 group of health care professionals who use similar treatment
18 modalities and serve a comparable patient population. Upon
19 receipt of the information or data, a health care
20 professional shall be given the opportunity to explain the
21 unique nature of the health care professional's patient
22 population that may have a bearing on the health care
23 professional's data and to work cooperatively with the
24 managed care plan to improve performance.
25 (h) Any contract provision or procedure or informal
26 policy or procedure in violation of this Section violates the
27 public policy of the State of Illinois and is void and
28 unenforceable.
29 Section 50. Prohibitions.
30 (a) No managed care plan shall by contract, written
31 policy or written procedure, or informal policy or procedure
32 prohibit or restrict any health care provider from
33 disclosing to any enrollee, patient, designated
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1 representative or, where appropriate, prospective
2 enrollee, (hereinafter collectively referred to as
3 enrollee) any information that the provider deems appropriate
4 regarding:
5 (1) a condition or a course of treatment with an
6 enrollee including the availability of other therapies,
7 consultations, or tests; or
8 (2) the provisions, terms, or requirements of the
9 managed care plan's products as they relate to the
10 enrollee, where applicable.
11 (b) No managed care plan shall by contract, written
12 policy or procedure, or informal policy or procedure prohibit
13 or restrict any health care provider from filing a
14 complaint, making a report, or commenting to an appropriate
15 governmental body regarding the policies or practices of the
16 managed care plan that the provider believes may
17 negatively impact upon the quality of, or access to, patient
18 care.
19 (c) No managed care plan shall by contract, written
20 policy or procedure, or informal policy or procedure prohibit
21 or restrict any health care provider from advocating to the
22 managed care plan on behalf of the enrollee for approval or
23 coverage of a particular course of treatment or for the
24 provision of health care services.
25 (d) No contract or agreement between a managed care
26 plan and a health care provider shall contain any clause
27 purporting to transfer to the health care provider by
28 indemnification or otherwise any liability relating to
29 activities, actions, or omissions of the managed care plan
30 as opposed to those of the health care provider.
31 (e) No contract between a managed care plan and a health
32 care provider shall contain any incentive plan that includes
33 specific payment made directly, in any form, to a health care
34 provider as an inducement to deny, reduce, limit, or delay
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1 specific, medically necessary and appropriate services
2 provided with respect to a specific enrollee or groups of
3 enrollees with similar medical conditions. Nothing in this
4 Section shall be construed to prohibit contracts that contain
5 incentive plans that involve general payments, such as
6 capitation payments or shared-risk arrangements, that are not
7 tied to specific medical decisions involving specific
8 enrollees or groups of enrollees with similar medical
9 conditions. The payments rendered or to be rendered to
10 health care provider under these arrangements shall be deemed
11 confidential information.
12 (f) No managed care plan shall by contract, written
13 policy or procedure, or informal policy or procedure permit,
14 allow, or encourage an individual or entity to dispense a
15 different drug in place of the drug or brand of drug ordered
16 or prescribed without the express permission of the person
17 ordering or prescribing, except this prohibition does not
18 prohibit the interchange of different brands of the same
19 generically equivalent drug product, as provided under
20 Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
21 (g) Any contract provision, written policy or
22 procedure, or informal policy or procedure in violation of
23 this Section violates the public policy of the State of
24 Illinois and is void and unenforceable.
25 Section 55. Network of providers.
26 (a) At least once every 3 years, and upon application
27 for expansion of service area, a managed care plan shall
28 obtain certification from the Director of Public Health that
29 the managed care plan maintains a network of health care
30 providers and facilities adequate to meet the comprehensive
31 health needs of its enrollees and to provide an appropriate
32 choice of providers sufficient to provide the services
33 covered under its enrollee's contracts by determining that:
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1 (1) there are a sufficient number of geographically
2 accessible participating providers and facilities;
3 (2) there are opportunities to select from at least
4 3 primary care providers pursuant to travel and
5 distance time standards, providing that these standards
6 account for the conditions of accessing providers in
7 rural areas; and
8 (3) there are sufficient providers in all covered
9 areas of specialty practice to meet the needs of the
10 enrollment population.
11 (b) The following criteria shall be considered by the
12 Director of Public Health at the time of a review:
13 (1) provider-enrollee ratios by specialty;
14 (2) primary care provider-enrollee ratios;
15 (3) safe and adequate staffing of health care
16 providers in all participating facilities based on:
17 (A) severity of patient illness and functional
18 capacity;
19 (B) factors affecting the period and quality
20 of patient recovery; and
21 (C) any other factor substantially related to
22 the condition and health care needs of patients;
23 (4) geographic accessibility;
24 (5) the number of grievances filed by enrollees
25 relating to waiting times for appointments,
26 appropriateness of referrals, and other indicators of a
27 managed care plan's capacity;
28 (6) hours of operation;
29 (7) the managed care plan's ability to provide
30 culturally and linguistically competent care to meet the
31 needs of its enrollee population; and
32 (8) the volume of technological and speciality
33 services available to serve the needs of enrollees
34 requiring technologically advanced or specialty care.
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1 (c) A managed care plan shall report on an annual basis
2 the number of enrollees and the number of participating
3 providers in the managed care plan.
4 (d) If a managed care plan determines that it does not
5 have a health care provider with appropriate training and
6 experience in its panel or network to meet the particular
7 health care needs of an enrollee, the managed care plan
8 shall make a referral to an appropriate provider, pursuant to
9 a treatment plan approved by the primary care provider, in
10 consultation with the managed care plan, the
11 non-participating provider, and the enrollee or enrollee's
12 designee, at no additional cost to the enrollee beyond what
13 the enrollee would otherwise pay for services received within
14 the network.
15 (e) A managed care plan shall have a procedure by which
16 an enrollee who needs ongoing health care services,
17 provided or coordinated by a specialist focused on a specific
18 organ system, disease or condition, shall receive a referral
19 to the specialist. If the primary care provider, after
20 consultation with the medical director or other
21 contractually authorized representative of the managed care
22 plan, determines that a referral is appropriate, the primary
23 care provider shall make such a referral to a specialist. In
24 no event shall a managed care plan be required to permit
25 an enrollee to elect to have a non-participating
26 specialist, except pursuant to the provisions of subsection
27 (d). The referral made under this subsection shall be
28 pursuant to a treatment plan approved by the enrollee or
29 enrollee's designee, the primary care provider, and the
30 specialist in consultation with the managed care plan. The
31 treatment plan shall authorize the specialist to treat the
32 ongoing injury, disease, or condition. It also may limit the
33 number of visits or the period during which visits are
34 authorized and may require the specialists to provide the
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1 primary care provider with regular updates on the specialty
2 care provided, as well as all necessary medical information.
3 (f) A managed care plan shall have a procedure by which
4 a new enrollee, upon enrollment, or an enrollee, upon
5 diagnosis, with (i) a life-threatening condition or disease
6 or (ii) a degenerative or disabling condition or disease,
7 either of which requires specialized medical care over a
8 prolonged period of time shall receive a standing referral to
9 a specialist with expertise in treating the life-threatening
10 condition or disease or degenerative or disabling condition
11 or disease who shall be responsible for and capable of
12 providing and coordinating the enrollee's primary and
13 specialty care. If the primary care provider, after
14 consultation with the enrollee or enrollee's designee and
15 medical director or other contractually authorized
16 representative of the managed care plan, determines that the
17 enrollee's care would most appropriately be coordinated
18 by a specialist, the primary care provider shall refer, on a
19 standing basis, the enrollee to a specialist. In no event
20 shall a managed care plan be required to permit an enrollee
21 to elect to have a non-participating specialist, except
22 pursuant to the provisions of subsection (d). The
23 specialist shall be permitted to treat the enrollee
24 without a referral from the enrollee's primary care
25 provider and shall be authorized to make such referrals,
26 procedures, tests, and other medical services as the
27 enrollee's primary care provider would otherwise be
28 permitted to provide or authorize including, if
29 appropriate, referral to a specialty care center. If a
30 primary care provider refers an enrollee to a
31 non-participating provider pursuant to the provisions of
32 subsection (d), the standing referral shall be pursuant to a
33 treatment plan approved by the enrollee or enrollee's
34 designee and specialist, in consultation with the managed
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1 care plan. Services provided pursuant to the approved
2 treatment plan shall be provided at no additional cost to
3 the enrollee beyond what the enrollee would otherwise pay
4 for services received within the network.
5 (g) If an enrollee's health care provider leaves the
6 managed care plan's network of providers for reasons other
7 than those for which the provider would not be eligible to
8 receive a pre-termination hearing pursuant to subsection (f)
9 of Section 45, the managed care plan shall permit the
10 enrollee to continue an ongoing course of treatment
11 with the enrollee's current health care provider during a
12 transitional period of:
13 (1) up to 90 days from the date of notice to the
14 enrollee of the provider's disaffiliation from the
15 managed care plan's network; or
16 (2) if the enrollee has entered the second trimester
17 of pregnancy at the time of the provider's
18 disaffiliation, for a transitional period that
19 includes the provision of post-partum care directly
20 related to the delivery.
21 Transitional care, however, shall be authorized by the
22 managed care plan during the transitional period only if the
23 health care provider agrees (i) to continue to accept
24 reimbursement from the managed care plan at the rates
25 applicable prior to the start of the transitional period
26 as payment in full, (ii) to adhere to the managed care plan's
27 quality assurance requirements and to provide to the managed
28 care plan necessary medical information related to the care,
29 (iii) to otherwise adhere to the managed care plan's
30 policies and procedures including, but not limited to,
31 procedures regarding referrals and obtaining
32 pre-authorization and a treatment plan approved by the
33 primary care provider or specialist in consultation with the
34 managed care plan, and (iv) if the enrollee is a recipient of
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1 services under Article V of the Illinois Public Aid Code, the
2 health care provider has not been subject to a final
3 disciplinary action by a state or federal agency for
4 violations of the Medicaid or Medicare program.
5 (h) If a new enrollee whose health care provider is not
6 a member of the managed care plan's provider network enrolls
7 in the managed care plan, the managed care plan shall permit
8 the enrollee to continue an ongoing course of treatment with
9 the enrollee's current health care provider during a
10 transitional period of up to 90 days from the effective
11 date of enrollment, if (i) the enrollee has a
12 life-threatening disease or condition or a degenerative or
13 disabling disease or condition or (ii) the enrollee has
14 entered the second trimester of pregnancy at the effective
15 date of enrollment, in which case the transitional period
16 shall include the provision of post-partum care directly
17 related to the delivery. If an enrollee elects to continue
18 to receive payment for care from a health care provider
19 pursuant to this subsection, the care shall be authorized by
20 the managed care plan for the transitional period only if
21 the health care provider agrees (i) to accept reimbursement
22 from the managed care plan at rates established by the
23 managed care plan as payment in full, which rates shall be no
24 more than the level of reimbursement applicable to similar
25 providers within the managed care plan's network for
26 those services, (ii) to adhere to the managed care plan's
27 quality assurance requirements and agrees to provide to the
28 managed care plan necessary medical information related to
29 the care, (iii) to otherwise adhere to the managed care
30 plan's policies and procedures including, but not limited
31 to, procedures regarding referrals and obtaining
32 pre-authorization and a treatment plan approved by the
33 primary care provider or specialist, in consultation with the
34 managed care plan, and (iv) if the enrollee is a recipient of
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1 services under Article V of the Illinois Public Aid Code, the
2 health care provider has not been subject to a final
3 disciplinary action by a state or federal agency for
4 violations of the Medicaid or Medicare program. In no
5 event shall this subsection be construed to require a managed
6 care plan to provide coverage for benefits not otherwise
7 covered or to diminish or impair pre-existing condition
8 limitations contained within the enrollee's contract.
9 Section 60. Duty to report.
10 (a) A managed care plan shall report to the
11 appropriate professional disciplinary agency, after
12 compliance and in accordance with the provisions of this
13 Section:
14 (1) termination of a health care provider contract
15 for commission of an act or acts that may directly
16 threaten patient care, and not of an administrative
17 nature, or that a person may be mentally or physically
18 disabled in such a manner as to endanger a patient under
19 that person's care;
20 (2) voluntary or involuntary termination of a
21 contract or employment or other affiliation with the
22 managed care plan to avoid the imposition of disciplinary
23 measures.
24 The managed care plan shall only make the report after it
25 has provided the health care professional with a hearing on
26 the matter. (This hearing shall not impair or limit the
27 managed care plan's ability to terminate the professional.
28 Its purpose is solely to ensure that a sufficient basis
29 exists for making the report.) The hearing shall be held
30 before a panel appointed by the managed care plan. The
31 hearing panel shall be composed of 5 persons appointed by the
32 plan, the majority of whom shall be clinical peer reviewers,
33 to the extent possible, in the same discipline and the same
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1 specialty as the health care professional under review. The
2 hearing panel shall determine whether the proposed basis for
3 the report is supported by a preponderance of the evidence.
4 The panel shall render its determination within 14 days. If
5 a majority of the panel finds the proposed basis for the
6 report is supported by a preponderance of the evidence, the
7 managed care plan shall make the required report within 21
8 days.
9 Any hearing under this Section shall provide the health
10 care professional in question with the right to examine
11 pertinent information, to present witnesses, and to ask
12 questions of an authorized representative of the plan.
13 If a hearing has been held pursuant to subsection (f) of
14 Section 45 and the hearing panel sustained a plan's
15 termination of a health care professional, no additional
16 hearing is required, and the plan shall make the report
17 required under this Section.
18 (b) Reports made pursuant to this Section shall be made
19 in writing to the appropriate professional disciplinary
20 agency. Written reports shall include the name, address,
21 profession, and license number of the individual and a
22 description of the action taken by the managed care plan,
23 including the reason for the action and the date thereof, or
24 the nature of the action or conduct that led to the
25 resignation, termination of contract, or withdrawal, and the
26 date thereof.
27 For any hearing under this Section, because the candid
28 and conscientious evaluation of clinical practices is
29 essential to the provision of health care, it is the policy
30 of this State to encourage peer review by health care
31 professionals. Therefore, no managed care plan and no
32 individual who participates in a hearing or who is a member,
33 agent, or employee of a managed care plan shall be liable for
34 criminal or civil damages or professional discipline as a
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1 result of the acts, omissions, decisions, or any other
2 conduct, direct or indirect, associated with a hearing panel,
3 except for wilful and wanton misconduct. Nothing in this
4 Section shall relieve any person, health care provider,
5 health care professional, facility, organization, or
6 corporation from liability for his, her, or its own
7 negligence in the performance of his, her, or its duties or
8 arising from treatment of a patient. The hearing panel
9 information shall not be subject to inspection or disclosure
10 except upon formal written request by an authorized
11 representative of a duly authorized State agency or pursuant
12 to a court order issued in a pending action or proceeding.
13 Section 65. Disclosure of information.
14 (a) A health care professional affiliated with a
15 managed care plan shall make available, in written form at
16 his or her office, to his or her patients or prospective
17 patients the following:
18 (1) information related to the health care
19 professional's educational background, experience,
20 training, specialty and board certification, if
21 applicable, number of years in practice, and hospitals
22 where he or she has privileges;
23 (2) information regarding the health care
24 professional's participation in continuing education
25 programs and compliance with any licensure,
26 certification, or registration requirements, if
27 applicable;
28 (3) information regarding the health care
29 professional's participation in clinical performance
30 reviews conducted by the Department, where applicable and
31 available; and
32 (4) the location of the health care professional's
33 primary practice setting and the identification of any
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1 translation services available.
2 Section 70. Registration of utilization review agents.
3 (a) A utilization review agent who conducts the practice
4 of utilization review shall biennially register with the
5 Director and report, in a statement subscribed and affirmed
6 as true under the penalties of perjury, the information
7 required pursuant to subsection (b) of this Section.
8 (b) The report shall contain a description of the
9 following:
10 (1) the utilization review plan;
11 (2) a description of the grievance procedures by
12 which an enrollee, the enrollee's designee, or his or her
13 health care provider may seek reconsideration of adverse
14 determinations by the utilization review agent in
15 accordance with this Act;
16 (3) procedures by which a decision on a request for
17 utilization review for services requiring
18 pre-authorization shall comply with timeframes
19 established pursuant to this Act;
20 (4) a description of an emergency care policy,
21 consistent with this Act.
22 (5) a description of personnel utilized to conduct
23 utilization review, including a description of the
24 circumstances under which utilization review may be
25 conducted by:
26 (A) administrative personnel,
27 (B) health care professionals who are not
28 clinical peer reviewers, and
29 (C) clinical peer reviewers;
30 (6) a description of the mechanisms employed to
31 assure that administrative personnel are trained in the
32 principles and procedures of intake screening and data
33 collection and are appropriately monitored by a
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1 licensed health care professional while performing an
2 administrative review;
3 (7) a description of the mechanisms employed to
4 assure that health care professionals conducting
5 utilization review are:
6 (A) appropriately licensed or registered; and
7 (B) trained in the principles, procedures,
8 and standards of the utilization review agent;
9 (8) a description of the mechanisms employed to
10 assure that only a clinical peer reviewer shall render an
11 adverse determination;
12 (9) provisions to ensure that appropriate personnel
13 of the utilization review agent are reasonably accessible
14 by toll-free telephone:
15 (A) not less than 40 hours per week during
16 normal business hours, to discuss patient care and
17 allow response to telephone requests, and to ensure
18 that the utilization review agent has a telephone
19 system capable of accepting, recording, or providing
20 instruction to incoming telephone calls during
21 other than normal business hours and to ensure
22 response to accepted or recorded messages not later
23 than the next business day after the date on which
24 the call was received; or
25 (B) notwithstanding the provisions of item (A),
26 in the case of a request submitted pursuant to
27 subsection (c) of Section 80 or an expedited appeal
28 filed pursuant to subsection (b) of Section 85, a
29 response is provided within 24 hours;
30 (10) the policies and procedures to ensure that
31 all applicable State and federal laws to protect the
32 confidentiality of individual medical and treatment
33 records are followed;
34 (11) a copy of the materials to be disclosed to an
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1 enrollee or prospective enrollee pursuant to this Act;
2 (12) a description of the mechanisms employed by
3 the utilization review agent to assure that all
4 contractors, subcontractors, subvendors, agents, and
5 employees affiliated by contract or otherwise with such
6 utilization review agent will adhere to the standards and
7 requirements of this Act; and
8 (13) a list of the payors for which the
9 utilization review agent is performing utilization
10 review in this State.
11 (c) Upon receipt of the report, the Director
12 shall issue an acknowledgment of the filing.
13 (d) A registration issued under this Act shall be valid
14 for a period of not more than 2 years, and may be renewed for
15 additional periods of not more than 2 years each.
16 Section 75. Utilization review program standards.
17 (a) A utilization review agent shall adhere to
18 utilization review program standards consistent with the
19 provisions of this Act, which shall, at a minimum, include:
20 (1) appointment of a medical director, who is a
21 licensed physician; provided, however, that the
22 utilization review agent may appoint a clinical director
23 when the utilization review performed is for a discrete
24 category of health care service and provided further that
25 the clinical director is a licensed health care
26 professional who typically manages the category of
27 service; responsibilities of the medical director, or,
28 where appropriate, the clinical director, shall
29 include, but not be limited to, the supervision and
30 oversight of the utilization review process;
31 (2) development of written policies and procedures
32 that govern all aspects of the utilization review
33 process and a requirement that a utilization review
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1 agent shall maintain and make available to enrollees and
2 health care providers a written description of the
3 procedures, including the procedures to appeal an adverse
4 determination;
5 (3) utilization of written clinical review criteria
6 developed pursuant to a utilization review plan;
7 (4) consistent with the applicable Sections of this
8 Act, establishment of a process for rendering utilization
9 review determinations, which shall, at a minimum,
10 include written procedures to assure that utilization
11 reviews and determinations are conducted within the
12 required timeframes, procedures to notify an enrollee,
13 an enrollee's designee, and an enrollee's health care
14 provider of adverse determinations, and the procedures
15 for appeal of adverse determinations, including the
16 establishment of an expedited appeals process for
17 denials of continued inpatient care or when delay would
18 significantly increase the risk to an enrollee's health;
19 (5) establishment of a requirement that
20 appropriate personnel of the utilization review agent are
21 reasonably accessible by toll-free telephone:
22 (A) not less than 40 hours per week during
23 normal business hours to discuss patient care and
24 allow response to telephone requests, and to ensure
25 that the utilization review agent has a telephone
26 system capable of accepting, recording or providing
27 instruction to incoming telephone calls during
28 other than normal business hours and to ensure
29 response to accepted or recorded messages not less
30 than one business day after the date on which the
31 call was received; or
32 (B) in the case of a request submitted
33 pursuant to subsection (c) of Section 80 or an
34 expedited appeal filed pursuant to subsection
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1 (b) of Section 85, a response is provided within 24
2 hours;
3 (6) establishment of appropriate policies and
4 procedures to ensure that all applicable State and
5 federal laws to protect the confidentiality of individual
6 medical records are followed;
7 (7) establishment of a requirement that emergency
8 services, as defined in this Act, rendered to an enrollee
9 shall not be subject to prior authorization nor
10 shall reimbursement for those services be denied on
11 retrospective review, except as authorized in this Act.
12 (b) A utilization review agent shall assure adherence to
13 the requirements stated in subsection (a) of this Section by
14 all contractors, subcontractors, subvendors, agents, and
15 employees affiliated by contract or otherwise with the
16 utilization review agent.
17 Section 80. Utilization review determinations.
18 (a) Utilization review shall be conducted by:
19 (1) administrative personnel trained in the
20 principles and procedures of intake screening and data
21 collection, provided, however, that administrative
22 personnel shall only perform intake screening, data
23 collection, and non-clinical review functions and shall
24 be supervised by a licensed health care professional;
25 (2) a health care professional who is
26 appropriately trained in the principles, procedures,
27 and standards of the utilization review agent; provided,
28 however, that a health care professional who is not a
29 clinical peer reviewer may not render an adverse
30 determination; and
31 (3) a clinical peer reviewer where the review
32 involves an adverse determination.
33 (b) A utilization review agent shall make a utilization
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1 review determination involving health care services that
2 require pre-authorization and provide notice of the
3 determination, as soon as possible, to the enrollee or
4 enrollee's designee and the enrollee's health care provider
5 by telephone upon, and in writing within 2 business days of
6 receipt of the necessary information.
7 (c) A utilization review agent shall make a
8 determination involving continued or extended health care
9 services or additional services for an enrollee
10 undergoing a course of continued treatment prescribed by a
11 health care provider and provide notice of the determination
12 to the enrollee or the enrollee's designee by notice within
13 24 hours to the enrollee's health care provider by telephone
14 upon, and in writing within 2 business days after receipt of
15 the necessary information. Notification of continued or
16 extended services shall include the number of extended
17 services approved, the new total of approved services, the
18 date of onset of services, and the next review date.
19 (d) A utilization review agent shall make a utilization
20 review determination involving health care services that have
21 already been delivered, within 30 days of receipt of the
22 necessary information.
23 (e) Notice of an adverse determination made by a
24 utilization review agent shall be given in writing in
25 accordance with the grievance procedures of this Act. The
26 notice shall also specify what, if any, additional
27 necessary information must be provided to, or obtained by,
28 the utilization review agent in order to render a decision on
29 the appeal.
30 (f) In the event that a utilization review agent
31 renders an adverse determination without attempting to
32 discuss the matter with the enrollee's health care
33 provider who specifically recommended the health care
34 service, procedure, or treatment under review, the health
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1 care provider shall have the opportunity to request an
2 immediate reconsideration of the adverse determination.
3 Except in cases of retrospective reviews, the
4 reconsideration shall occur in a prompt manner, not to
5 exceed 24 hours after receipt of the necessary information,
6 and shall be conducted by the enrollee's health care
7 provider and the clinical peer reviewer making the initial
8 determination or a designated clinical peer reviewer if the
9 original clinical peer reviewer cannot be available. In
10 the event that the adverse determination is upheld after
11 reconsideration, the utilization review agent shall provide
12 notice as required pursuant to subsection (e) of this
13 Section. Nothing in this Section shall preclude the enrollee
14 from initiating an appeal from an adverse determination.
15 Section 85. Appeal of adverse determinations by
16 utilization review agents.
17 (a) An enrollee, the enrollee's designee, and, in
18 connection with retrospective adverse determinations, the
19 enrollee's health care provider may appeal an adverse
20 determination rendered by a utilization review agent pursuant
21 to Sections 15, 20, 25, and 35.
22 (b) A utilization review agent shall establish
23 mechanisms that facilitate resolution of the appeal
24 including, but not limited to, the sharing of information
25 from the enrollee's health care provider and the utilization
26 review agent by telephonic means or by facsimile. The
27 utilization review agent shall provide reasonable access to
28 its clinical peer reviewer in a prompt manner.
29 (c) Appeals shall be reviewed by a clinical peer
30 reviewer other than the clinical peer reviewer who
31 rendered the adverse determination.
32 Section 90. Required and prohibited practices.
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1 (a) A utilization review agent shall have written
2 procedures for assuring that patient-specific information
3 obtained during the process of utilization review will be:
4 (1) kept confidential in accordance with applicable
5 State and federal laws; and
6 (2) shared only with the enrollee, the
7 enrollee's designee, the enrollee's health care provider,
8 and those who are authorized by law to receive the
9 information.
10 (b) Summary data shall not be considered confidential
11 if it does not provide information to allow identification of
12 individual patients.
13 (c) Any health care professional who makes
14 determinations regarding the medical necessity of health care
15 services during the course of utilization review shall be
16 appropriately licensed or registered.
17 (d) A utilization review agent shall not, with respect
18 to utilization review activities, permit or provide
19 compensation or anything of value to its employees, agents,
20 or contractors based on:
21 (1) either a percentage of the amount by which a
22 claim is reduced for payment or the number of claims or
23 the cost of services for which the person has denied
24 authorization or payment; or
25 (2) any other method that encourages the
26 rendering of an adverse determination.
27 (e) If a health care service has been specifically
28 pre-authorized or approved for an enrollee by a
29 utilization review agent, a utilization review agent shall
30 not, pursuant to retrospective review, revise or modify
31 the specific standards, criteria, or procedures used for
32 the utilization review for procedures, treatment, and
33 services delivered to the enrollee during the same course
34 of treatment.
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1 (f) Utilization review shall not be conducted more
2 frequently than is reasonably required to assess whether the
3 health care services under review are medically necessary.
4 The Department may promulgate rules governing the frequency
5 of utilization reviews for managed care plans of differing
6 size and geographic location.
7 (g) When making prospective, concurrent, and
8 retrospective determinations, utilization review agents shall
9 collect only information that is necessary to make the
10 determination and shall not routinely require health care
11 providers to numerically code diagnoses or procedures to
12 be considered for certification, unless required under State
13 or federal Medicare or Medicaid rules or regulations, or
14 routinely request copies of medical records of all patients
15 reviewed. During prospective or concurrent review, copies
16 of medical records shall only be required when necessary
17 to verify that the health care services subject to the review
18 are medically necessary. In these cases, only the necessary
19 or relevant sections of the medical record shall be
20 required. A utilization review agent may request copies of
21 partial or complete medical records retrospectively.
22 (h) In no event shall information be obtained from
23 health care providers for the use of the utilization
24 review agent by persons other than health care professionals,
25 medical record technologists, or administrative personnel who
26 have received appropriate training.
27 (i) The utilization review agent shall not undertake
28 utilization review at the site of the provision of health
29 care services unless the utilization review agent:
30 (1) identifies himself or herself by name and the
31 name of his or her organization, including displaying
32 photographic identification that includes the name of
33 the utilization review agent and clearly identifies the
34 individual as representative of the utilization review
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1 agent;
2 (2) whenever possible, schedules review at least
3 one business day in advance with the appropriate health
4 care provider;
5 (3) if requested by a health care provider,
6 assures that the on-site review staff register with the
7 appropriate contact person, if available, prior to
8 requesting any clinical information or assistance
9 from the health care provider; and
10 (4) obtains consent from the enrollee or the
11 enrollee's designee before interviewing the patient's
12 family or observing any health care service being
13 provided to the enrollee.
14 This subsection does not apply to health care
15 professionals engaged in providing care, case management, or
16 making on-site discharge decisions.
17 (j) A utilization review agent shall not base an adverse
18 determination on a refusal to consent to observing any health
19 care service.
20 (k) A utilization review agent shall not base an adverse
21 determination on lack of reasonable access to a health
22 care provider's medical or treatment records unless the
23 utilization review agent has provided reasonable notice
24 to both the enrollee or the enrollee's designee and the
25 enrollee's health care provider and has complied with all
26 provisions of subsection (i) of this Section. The Department
27 may promulgate rules defining reasonable notice and the time
28 period within which medical and treatment records must be
29 turned over.
30 (l) Neither the utilization review agent nor the entity
31 for which the agent provides utilization review shall take
32 any action with respect to a patient or a health care
33 provider that is intended to penalize the enrollee, the
34 enrollee's designee, or the enrollee's health care provider
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1 for, or to discourage the enrollee, the enrollee's designee,
2 or the enrollee's health care provider from, undertaking an
3 appeal, dispute resolution, or judicial review of an adverse
4 determination.
5 (m) In no event shall an enrollee, an enrollee's
6 designee, an enrollee's health care provider, any other
7 health care provider, or any other person or entity be
8 required to inform or contact the utilization review agent
9 prior to the provision of emergency services as defined in
10 this Act.
11 (n) No contract or agreement between a utilization
12 review agent and a health care provider shall contain any
13 clause purporting to transfer to the health care provider by
14 indemnification or otherwise any liability relating to
15 activities, actions, or omissions of the utilization review
16 agent.
17 (o) A health care professional providing health care
18 services to an enrollee shall be prohibited from serving
19 as the clinical peer reviewer for that enrollee in connection
20 with the health care services being provided to the
21 enrollee.
22 Section 95. Annual consumer satisfaction survey. The
23 Director shall develop and administer a survey of persons who
24 have been enrolled in a managed care plan in the most recent
25 calendar year to collect information on relative plan
26 performance. This survey shall:
27 (1) be administered annually by the Director, or by
28 an independent agency or organization selected by the
29 Director;
30 (2) be administered to a scientifically selected
31 representative sample of current enrollees from each
32 plan, as well as persons who have disenrolled from a plan
33 in the last calendar year; and
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1 (3) emphasize the collection of information from
2 persons who have used the managed care plan to a
3 significant degree, as defined by rule.
4 Selected data from the annual survey shall be made
5 available to current and prospective enrollees as part of a
6 consumer guidebook of health plan performance, which the
7 Department shall develop and publish. The elements to be
8 included in the guidebook shall be reassessed on an ongoing
9 basis by the Department. The consumer guidebook shall be
10 updated at least annually.
11 Section 100. Managed care patient rights. In addition
12 to all other requirements of this Act, a managed care plan
13 shall ensure that an enrollee has the following rights:
14 (1) A patient has the right to care consistent with
15 professional standards of practice to assure quality nursing
16 and medical practices, to be informed of the name of the
17 participating physician responsible for coordinating his or
18 her care, to receive information concerning his or her
19 condition and proposed treatment, to refuse any treatment to
20 the extent permitted by law, and to privacy and
21 confidentiality of records except as otherwise provided by
22 law.
23 (2) A patient has the right, regardless of source of
24 payment, to examine and to receive a reasonable explanation
25 of his or her total bill for health care services rendered by
26 his or her physician or other health care provider, including
27 the itemized charges for specific health care services
28 received. A physician or other health care provider shall be
29 responsible only for a reasonable explanation of these
30 specific health care services provided by the health care
31 provider.
32 (3) A patient has the right to privacy and
33 confidentiality in health care. A physician, other health
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1 care provider, managed care plan, and utilization review
2 agent shall refrain from disclosing the nature or details of
3 health care services provided to patients, except that the
4 information may be disclosed to the patient, the party making
5 treatment decisions if the patient is incapable of making
6 decisions regarding the health care services provided, those
7 parties directly involved with providing treatment to the
8 patient or processing the payment for the treatment, those
9 parties responsible for peer review, utilization review, and
10 quality assurance, and those parties required to be notified
11 under the Abused and Neglected Child Reporting Act, the
12 Illinois Sexually Transmissible Disease Control Act, or where
13 otherwise authorized or required by law. This right may be
14 expressly waived in writing by the patient or the patient's
15 guardian, but a managed care plan, a physician, or other
16 health care provider may not condition the provision of
17 health care services on the patient's or guardian's agreement
18 to sign the waiver.
19 Section 105. Managed Care Ombudsman Program.
20 (a) The Department shall establish a Managed Care
21 Ombudsman Program (MCOP). The purpose of the MCOP is to
22 assist consumers to:
23 (1) navigate the managed care system;
24 (2) select an appropriate managed care plan; and
25 (3) understand and assert their rights and
26 responsibilities as managed care plan enrollees.
27 (b) The Department shall contract with an independent
28 organization or organizations to perform the following MCOP
29 functions:
30 (1) Assist consumers with managed care plan
31 selection by providing information, referral, and
32 assistance to individuals about means of obtaining health
33 coverage and services, including, but not limited to:
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1 (A) access through a toll-free telephone
2 number; and
3 (B) availability of information in languages
4 other than English that are spoken as a primary
5 language by a significant portion of the State's
6 population, as determined by the Department.
7 (2) Educate and train consumers in the use of the
8 Department's annual Consumer Guidebook of Health Plan
9 Performance, compiled in accordance with Section 95.
10 (3) Analyze, comment on, monitor, and make publicly
11 available reports on the development and implementation
12 of federal, State and local laws, regulations, and other
13 governmental policies and actions that pertain to the
14 adequacy of managed care plans, facilities, and services
15 in the State.
16 (4) Ensure that individuals have timely access to
17 the services provided through the MCOP.
18 (5) Submit an annual report to the Department and
19 General Assembly:
20 (A) describing the activities carried out by
21 the MCOP in the year for which the report is
22 prepared;
23 (B) containing and analyzing the data
24 collected by the MCOP; and
25 (C) evaluating the problems experienced by
26 managed care plan enrollees.
27 (6) Exercise such other powers and functions as the
28 Department determines to be appropriate.
29 (c) The Department shall establish criteria for
30 selection of an independent organization or organizations to
31 perform the functions of the MCOP, including, but not limited
32 to, the following:
33 (1) Preference shall be given to private,
34 not-for-profit organizations governed by boards with
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1 consumer members in the majority that represent a broad
2 spectrum of the diverse consumer interests in the State.
3 (2) No individual or organization under contract to
4 perform functions of the MCOP may:
5 (A) have a direct involvement in the
6 licensing, certification, or accreditation of a
7 health care facility, a managed care plan, or a
8 provider of a managed care plan, or have a direct
9 involvement with a provider of a health care
10 service;
11 (B) have a direct ownership or investment
12 interest in a health care facility, a managed care
13 plan, or a health care service;
14 (C) be employed by, or participate in the
15 management of, a health care service or facility or
16 a managed care plan; or
17 (D) receive, or have the right to receive,
18 directly or indirectly, remuneration (in cash or in
19 kind) under a compensation arrangement with an owner
20 or operator of a health care service or facility or
21 managed care plan.
22 The Department shall contract with an organization or
23 organizations qualified under criteria established under this
24 Section for an initial term of 3 years. The initial contract
25 shall be renewable thereafter for additional 3 year terms
26 without reopening the competitive selection process unless
27 there has been an unfavorable written performance evaluation
28 conducted by the Department.
29 (d) The Department shall establish, by rule, policies
30 and procedures for the operation of MCOP sufficient to ensure
31 that the MCOP can perform all functions specified in this
32 Section.
33 (e) The Department shall provide adequate funding for
34 the MCOP by assessing each managed care plan an amount to be
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1 determined by the Department.
2 (f) Nothing in this Section shall be interpreted to
3 authorize access to or disclosure of individual patient or
4 provider records.
5 Section 110. Waiver. Any agreement that purports to
6 waive, limit, disclaim or in any way diminish the rights set
7 forth in this Act is void as contrary to public policy.
8 Section 115. Administration of Act.
9 (a) The Department shall administer the Act.
10 (b) All managed care plans and utilization review agents
11 providing or reviewing services in Illinois shall annually
12 certify compliance with this Act and rules adopted under this
13 Act to the Department in addition to any other licensure
14 required by law. The Director shall establish by rule a
15 process for this certification including fees to cover the
16 costs associated with implementing this Act. All fees and
17 fines assessed under this Act shall be deposited in the
18 Managed Care Reform Fund, a special fund hereby created in
19 the State treasury. Moneys in the Fund shall be used by the
20 Department only to enforce and administer this Act. The
21 certification requirements of this Act shall be incorporated
22 into program requirements of the Department of Public Aid and
23 Department of Human Services and no further certification
24 under this Act is required.
25 (c) The Director shall take enforcement action under
26 this Act including, but not limited to, the assessment of
27 civil fines and injunctive relief for any failure to comply
28 with this Act or any violation of the Act or rules by a
29 managed care plan or any utilization review agent.
30 (d) The Department shall have the authority to impose
31 fines on any managed care plan or any utilization review
32 agent. The Department shall adopt rules pursuant to this Act
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1 that establish a system of fines related to the type and
2 level of violation or repeat violation, including but not
3 limited to:
4 (1) A fine not exceeding $10,000 for a violation
5 that created a condition or occurrence presenting a
6 substantial probability that death or serious harm to an
7 individual will or did result therefrom; and
8 (2) A fine not exceeding $5,000 for a violation
9 that creates or created a condition or occurrence that
10 threatens the health, safety, or welfare of an
11 individual.
12 Each day a violation continues shall constitute a
13 separate offense. These rules shall include an opportunity
14 for a hearing in accordance with the Illinois Administrative
15 Procedure Act. All final decisions of the Department shall
16 be reviewable under the Administrative Review Law.
17 (e) Notwithstanding the existence or pursuit of any
18 other remedy, the Director may, through the Attorney General,
19 seek an injunction to restrain or prevent any person or
20 entity from functioning or operating in violation of this Act
21 or rule.
22 Section 120. Emergency services.
23 (a) Any managed care plan subject to this Act shall
24 provide the enrollee emergency services coverage such that
25 payment for this coverage is not dependent upon whether such
26 services are performed by a participating or nonparticipating
27 provider, and such coverage shall be at the same benefit
28 level as if the service or treatment had been rendered by a
29 plan provider. Nothing in this Section is intended to
30 prohibit a plan from imposing its customary and normal
31 co-payments, deductibles, co-insurance, and other like
32 charges for emergency services.
33 (b) Prior authorization or approval by the plan shall
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1 not be required for emergency services rendered under this
2 Section.
3 (c) Coverage and payment shall not be retrospectively
4 denied, with the following exceptions:
5 (1) upon reasonable determination that the
6 emergency services claimed were never performed; or
7 (2) upon reasonable determination that an emergency
8 medical screening examination was performed on a patient
9 who personally sought emergency services knowing that he
10 or she did not have an emergency condition or necessity,
11 and who did not in fact require emergency services.
12 (d) When an enrollee presents to a hospital seeking
13 emergency services, as defined in this Act, the determination
14 as to whether the need for those services exists shall be
15 made for purposes of treatment by a physician or, to the
16 extent permitted by applicable law, by other appropriate
17 licensed personnel under the supervision of a physician. The
18 physician or other appropriate personnel shall indicate in
19 the patient's chart the results of the emergency medical
20 screening examination. The plan shall compensate the
21 provider for an emergency medical screening examination that
22 is reasonably calculated to assist the health care provider
23 in determining whether the patient's condition requires
24 emergency services. A plan shall have no duty to pay for
25 services rendered after an emergency medical screening
26 examination determines the lack of a need for emergency
27 services.
28 (e) The appropriate use of the 911 emergency telephone
29 number shall not be discouraged or penalized, and coverage or
30 payment shall not be denied solely on the basis that the
31 insured used the 911 emergency telephone number to summon
32 emergency services.
33 (f) If prior authorization for post-stabilization
34 services, as defined in this Act, is required, the managed
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1 care plan shall provide access 24 hours a day, 7 days a week
2 to persons designated by plan to make such determinations.
3 If a provider has attempted to contact such person for prior
4 authorization and no designated persons were accessible or
5 the authorization was not denied within one hour of the
6 request, the plan is deemed to have approved the request for
7 prior authorization.
8 (g) Coverage and payment for post-stabilization services
9 which received prior authorization or deemed approval shall
10 not be retrospectively denied. Nothing in this Section is
11 intended to prohibit a plan from imposing its customary and
12 normal co-payments, deductibles, co-insurance, and other like
13 changes for post-stabilization services.
14 Section 125. Prescription drugs. A managed care plan
15 that provides coverage for prescribed drugs approved by the
16 federal Food and Drug Administration shall not exclude
17 coverage of any drug on the basis that the drug has been
18 prescribed for the treatment of a particular indication for
19 which the drug has not been approved by the federal Food and
20 Drug Administration. The drug, however, must be approved by
21 the federal Food and Drug Administration and must be
22 recognized for the treatment of that particular indication
23 for which the drug has been prescribed in any one of the
24 following established reference compendia:
25 (1) the American Hospital Formulary Service Drug
26 Information;
27 (2) the United States Pharmacopoeia Drug
28 Information; or
29 (3) if not recognized by the authorities in item
30 (1) or (2), recommended for that particular indication in
31 formal clinical studies, the results of which have been
32 published in at least 2 peer reviewed professional
33 medical journals published in the United States or Great
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1 Britain.
2 Any coverage required by this Section shall also include
3 those medically necessary services associated with the
4 administration of a drug.
5 Despite the provisions of this Section, coverage shall
6 not be required for any experimental or investigational drugs
7 or any drug that the federal Food and Drug Administration has
8 determined to be contraindicated for treatment of the
9 specific indication for which the drug has been prescribed.
10 Nothing in this Section shall be construed, expressly or by
11 implication, to create, impair, alter, limit, notify,
12 enlarge, abrogate, or prohibit reimbursement for drugs used
13 in the treatment of any other disease or condition.
14 Section 130. Health Care Service Delivery Review Board.
15 (a) A managed care plan shall organize a Health Care
16 Service Delivery Review Board from participants in the plan.
17 The Board shall consist of 17 members: 5 participating
18 physicians elected by participating physicians, 5 other
19 participating providers elected by the other health care
20 providers, 5 enrollees elected by the enrollees, and 2
21 representatives of the plan appointed by the plan. The
22 representatives of the plan shall not have a vote on the
23 Board, but shall have all other rights granted to Board
24 members. The plan shall devise a mechanism for the election
25 of the Board's members, subject to the approval of the
26 Department. The Department shall not unreasonably withhold
27 its approval of a mechanism.
28 (b) The Health Care Service Delivery Board shall
29 establish written rules and regulations governing its
30 operation. The managed care plan shall approve the rules,
31 but may not unilaterally amend them. A plan may not
32 unreasonably withhold approval of proposed rules and
33 regulations.
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1 (c) The Health Care Service Delivery Board shall, from
2 time to time, issue nonbinding reports and reviews concerning
3 the plan's health care delivery policy, quality assurance
4 procedures, utilization review criteria and procedures, and
5 medical management procedures. The Board shall select the
6 aspects of the plan that it wishes to study or review and may
7 undertake a study or review at the request of the plan. The
8 Board shall issue its report directly to the managed care
9 plan's governing board.
10 Section 135. Conflicts with federal law. When health
11 care services are provided by a managed care plan subject to
12 this Act to a person who is a recipient of medical assistance
13 under Article V of the Illinois Public Aid Code, the rights,
14 benefits, requirements, and procedures available or
15 authorized under this Act shall not apply to the extent that
16 there are provisions of federal law that conflict. In the
17 event of a conflict, federal law shall prevail.
18 Section 140. The State Employees Group Insurance Act of
19 1971 is amended by adding Section 6.12 as follows:
20 (5 ILCS 375/6.12 new)
21 Sec. 6.12. Managed Care Reform Act. The program of
22 health benefits is subject to the provisions of the Managed
23 Care Reform Act.
24 Section 145. The State Finance Act is amended by adding
25 Section 5.480 as follows:
26 (30 ILCS 105/5.480 new)
27 Sec. 5.480. The Managed Care Reform Fund.
28 Section 150. The State Mandates Act is amended by adding
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1 Section 8.22 as follows:
2 (30 ILCS 805/8.22 new)
3 Sec. 8.22. Exempt mandate. Notwithstanding Sections 6
4 and 8 of this Act, no reimbursement by the State is required
5 for the implementation of any mandate created by this
6 amendatory Act of 1998.
7 Section 155. The Counties Code is amended by adding
8 Section 5-1069.8 as follows:
9 (55 ILCS 5/5-1069.8 new)
10 Sec. 5-1069.8. Managed Care Reform Act. All counties,
11 including home rule counties, are subject to the provisions
12 of the Managed Care Reform Act. The requirement under this
13 Section that health care benefits provided by counties comply
14 with the Managed Care Reform Act is an exclusive power and
15 function of the State and is a denial and limitation of home
16 rule county powers under Article VII, Section 6, subsection
17 (h) of the Illinois Constitution.
18 Section 160. The Illinois Municipal Code is amended by
19 adding 10-4-2.8 as follows:
20 (65 ILCS 5/10-4-2.8 new)
21 Sec. 10-4-2.8. Managed Care Reform Act. The corporate
22 authorities of all municipalities are subject to the
23 provisions of the Managed Care Reform Act. The requirement
24 under this Section that health care benefits provided by
25 municipalities comply with the Managed Care Reform Act is an
26 exclusive power and function of the State and is a denial and
27 limitation of home rule municipality powers under Article
28 VII, Section 6, subsection (h) of the Illinois Constitution.
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1 Section 165. The School Code is amended by adding
2 Section 10-22.3g as follows:
3 (105 ILCS 5/10-22.3g new)
4 Sec. 10-22.3g. Managed Care Reform Act. Insurance
5 protection and benefits for employees are subject to the
6 Managed Care Reform Act.
7 Section 170. The Health Maintenance Organization Act is
8 amended by changing Sections 2-2 and 6-7 and adding Sections
9 5-10, 5-11, 5-12, and 5-13 as follows:
10 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
11 Sec. 2-2. Determination by Director; Health Maintenance
12 Advisory Board.
13 (a) Upon receipt of an application for issuance of a
14 certificate of authority, the Director shall transmit copies
15 of such application and accompanying documents to the
16 Director of the Illinois Department of Public Health. The
17 Director of the Department of Public Health shall then
18 determine whether the applicant for certificate of authority,
19 with respect to health care services to be furnished: (1) has
20 demonstrated the willingness and potential ability to assure
21 that such health care service will be provided in a manner to
22 insure both availability and accessibility of adequate
23 personnel and facilities and in a manner enhancing
24 availability, accessibility, and continuity of service; and
25 (2) has arrangements, established in accordance with rules
26 regulations promulgated by the Department of Public Health
27 for an ongoing quality of health care assurance program
28 concerning health care processes and outcomes. Upon
29 investigation, the Director of the Department of Public
30 Health shall certify to the Director whether the proposed
31 Health Maintenance Organization meets the requirements of
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1 this subsection (a). If the Director of the Department of
2 Public Health certifies that the Health Maintenance
3 Organization does not meet such requirements, he or she shall
4 specify in what respect it is deficient.
5 There is created in the Department of Public Health a
6 Health Maintenance Advisory Board composed of 11 members.
7 Nine of the 11 9 members shall who have practiced in the
8 health field and, 4 of those 9 which shall have been or shall
9 be are currently affiliated with a Health Maintenance
10 Organization. Two of the members shall be members of the
11 general public, one of whom is over 65 years of age. Each
12 member shall be appointed by the Director of the Department
13 of Public Health and serve at the pleasure of that Director
14 and shall receive no compensation for services rendered other
15 than reimbursement for expenses. Six Five members of the
16 Board shall constitute a quorum. A vacancy in the membership
17 of the Advisory Board shall not impair the right of a quorum
18 to exercise all rights and perform all duties of the Board.
19 The Health Maintenance Advisory Board has the power to review
20 and comment on proposed rules and regulations to be
21 promulgated by the Director of the Department of Public
22 Health within 30 days after those proposed rules and
23 regulations have been submitted to the Advisory Board.
24 (b) Issuance of a certificate of authority shall be
25 granted if the following conditions are met:
26 (1) the requirements of subsection (c) of Section
27 2-1 have been fulfilled;
28 (2) the persons responsible for the conduct of the
29 affairs of the applicant are competent, trustworthy, and
30 possess good reputations, and have had appropriate
31 experience, training or education;
32 (3) the Director of the Department of Public Health
33 certifies that the Health Maintenance Organization's
34 proposed plan of operation meets the requirements of this
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1 Act;
2 (4) the Health Care Plan furnishes basic health
3 care services on a prepaid basis, through insurance or
4 otherwise, except to the extent of reasonable
5 requirements for co-payments or deductibles as authorized
6 by this Act;
7 (5) the Health Maintenance Organization is
8 financially responsible and may reasonably be expected to
9 meet its obligations to enrollees and prospective
10 enrollees; in making this determination, the Director
11 shall consider:
12 (A) the financial soundness of the applicant's
13 arrangements for health services and the minimum
14 standard rates, co-payments and other patient
15 charges used in connection therewith;
16 (B) the adequacy of working capital, other
17 sources of funding, and provisions for
18 contingencies; and
19 (C) that no certificate of authority shall be
20 issued if the initial minimum net worth of the
21 applicant is less than $2,000,000. The initial net
22 worth shall be provided in cash and securities in
23 combination and form acceptable to the Director;
24 (6) the agreements with providers for the provision
25 of health services contain the provisions required by
26 Section 2-8 of this Act; and
27 (7) any deficiencies identified by the Director
28 have been corrected.
29 (Source: P.A. 86-620; 86-1475.)"; and
30 on page 3 by replacing line 31 with the following:
31 "(215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
32 Sec. 6-7. Board of Directors. The board of directors of
33 the Association shall consist consists of not less than 7 5
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1 nor more than 11 9 members serving terms as established in
2 the plan of operation. The members of the board are to be
3 selected by member organizations subject to the approval of
4 the Director provided, however, that 2 members shall be
5 enrollees, one of whom is over 65 years of age. Vacancies on
6 the board must be filled for the remaining period of the term
7 in the manner described in the plan of operation. To select
8 the initial board of directors, and initially organize the
9 Association, the Director must give notice to all member
10 organizations of the time and place of the organizational
11 meeting. In determining voting rights at the organizational
12 meeting each member organization is entitled to one vote in
13 person or by proxy. If the board of directors is not
14 selected at the organizational meeting, the Director may
15 appoint the initial members.
16 In approving selections or in appointing members to the
17 board, the Director must consider, whether all member
18 organizations are fairly represented.
19 Members of the board may be reimbursed from the assets of
20 the Association for expenses incurred by them as members of
21 the board of directors but members of the board may not
22 otherwise be compensated by the Association for their
23 services.
24 (Source: P.A. 85-20.)
25 Section 175. Severability. The provisions of this Act
26 are severable under Section 1.31 of the Statute on Statutes.
27 Section 199. Effective date. This Act takes effect July
28 1, 1999."; and
29 on page 4 by deleting line 1.