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90_HB3266
New Act
Creates the Health Care Services Disclosure Act.
Establishes disclosure standards for managed care plans.
Requires disclosure of utilization review policies, grievance
procedures, and other coverage provisions including drug
formularies used by the plan and a list of participating
providers.
LRB9011441JSmg
LRB9011441JSmg
1 AN ACT relating to disclosure of terms and conditions
2 governing the delivery of health care services.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 1. Short title. This Act may be cited as the
6 Health Care Services Disclosure Act.
7 Section 5. Definitions. For purposes of this Act, the
8 following words shall have the meanings provided in this
9 Section, unless otherwise indicated:
10 "Department" means the Department of Public Health.
11 "Director" means the Director of Public Health.
12 "Emergency services" means the provision of health care
13 services for sudden and, at the time, unexpected onset of a
14 health condition that would lead a prudent layperson to
15 believe that failure to receive immediate medical attention
16 would result in serious impairment to bodily function or
17 serious dysfunction of any body organ or part or would place
18 the person's health in serious jeopardy.
19 "Enrollee" means a person enrolled in a managed care
20 plan.
21 "Health care professional" means a physician, registered
22 professional nurse, or other person appropriately licensed or
23 registered pursuant to the laws of this State to provide
24 health care services.
25 "Health care provider" means a health care professional,
26 hospital, facility, or other person appropriately licensed or
27 otherwise authorized to furnish health care services or
28 arrange for the delivery of health care services in this
29 State.
30 "Health care services" means services included in the (i)
31 furnishing of medical care, (ii) hospitalization incident to
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1 the furnishing of medical care, and (iii) furnishing of
2 services, including pharmaceuticals, for the purpose of
3 preventing, alleviating, curing, or healing human illness or
4 injury to an individual.
5 "Life threatening condition or disease" means any
6 condition, illness, or injury that, in the opinion of a
7 licensed physician, (i) may directly lead to a patient's
8 death, (ii) results in a period of unconsciousness which is
9 indeterminate at the present, or (iii) imposes severe pain or
10 an inhumane burden on the patient.
11 "Managed care plan" means a plan that establishes,
12 operates, or maintains a network of health care providers
13 that have entered into agreements with the plan to provide
14 health care services to enrollees where the plan has the
15 obligation to the enrollee to arrange for the provision of or
16 pay for services through:
17 (1) organizational arrangements for ongoing quality
18 assurance, utilization review programs, or dispute
19 resolution; or
20 (2) financial incentives for persons enrolled in
21 the plan to use the participating providers and
22 procedures covered by the plan.
23 A managed care plan may be established or operated by any
24 entity including, but not necessarily limited to, a licensed
25 insurance company, hospital or medical service plan, health
26 maintenance organization, limited health service
27 organization, preferred provider organization, third party
28 administrator, independent practice association, or employer
29 or employee organization.
30 For purposes of this definition, "managed care plan"
31 shall not include the following:
32 (1) strict indemnity health insurance policies or
33 plans issued by an insurer that does not require approval
34 of a primary care provider or other similar coordinator
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1 to access health care services; and
2 (2) managed care plans that offer only dental or
3 vision coverage.
4 "Primary care provider" means a physician licensed to
5 practice medicine in all its branches who provides a broad
6 range of personal medical care (preventive, diagnostic,
7 curative, counseling, or rehabilitative) in a comprehensive
8 and coordinated manner over time for a managed care plan.
9 "Specialist" means a health care professional who
10 concentrates practice in a recognized specialty field of
11 care.
12 "Speciality care center" means only a center that is
13 accredited by an agency of the State or federal government or
14 by a voluntary national health organization as having special
15 expertise in treating the life-threatening disease or
16 condition or degenerative or disabling disease or condition
17 for which it is accredited.
18 Section 10. Disclosure of information.
19 (a) An enrollee, and upon request a prospective enrollee
20 prior to enrollment, shall be supplied with written
21 disclosure information, containing at least the information
22 specified in this Section, if applicable, which may be
23 incorporated into the member handbook or the enrollee
24 contract or certificate. All written descriptions shall be
25 in readable and understandable format, consistent with
26 standards developed for supplemental insurance coverage under
27 Title XVIII of the Social Security Act. The Department shall
28 promulgate rules to standardize this format so that potential
29 members can compare the attributes of the various managed
30 care entities. In the event of any inconsistency between any
31 separate written disclosure statement and the enrollee
32 contract or certificate, the terms of the enrollee
33 contract or certificate shall be controlling. The
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1 information to be disclosed shall include, at a minimum,
2 all of the following:
3 (1) A description of coverage provisions, health
4 care benefits, benefit maximums, including benefit
5 limitations, and exclusions of coverage, including the
6 definition of medical necessity used in determining
7 whether benefits will be covered.
8 (2) A description of all prior authorization or
9 other requirements for treatments, pharmaceuticals, and
10 services.
11 (3) A description of utilization review policies
12 and procedures used by the managed care plan,
13 including the circumstances under which utilization
14 review will be undertaken, the toll-free telephone
15 number of the utilization review agent, the timeframes
16 under which utilization review decisions must be made for
17 prospective, retrospective, and concurrent decisions,
18 the right to reconsideration, the right to an appeal,
19 including the expedited and standard appeals processes
20 and the timeframes for those appeals, the right to
21 designate a representative, a notice that all denials of
22 claims will be made by clinical personnel, and that
23 all notices of denials will include information about the
24 basis of the decision and further appeal rights, if any.
25 (4) A description prepared annually of the types of
26 methodologies the managed care plan uses to reimburse
27 providers specifying the type of methodology that is
28 used to reimburse particular types of providers or
29 reimburse for the provision of particular types of
30 services, provided, however, that nothing in this item
31 should be construed to require disclosure of individual
32 contracts or the specific details of any financial
33 arrangement between a managed care plan and a health care
34 provider.
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1 (5) An explanation of a enrollee's financial
2 responsibility for payment of premiums, coinsurance,
3 co-payments, deductibles, and any other charges, annual
4 limits on an enrollee's financial responsibility, caps
5 on payments for covered services and financial
6 responsibility for non-covered health care procedures,
7 treatments, or services provided within the managed
8 care plan.
9 (6) An explanation of an enrollee's financial
10 responsibility for payment when services are provided by
11 a health care provider who is not part of the managed
12 care plan or by any provider without required
13 authorization or when a procedure, treatment, or service
14 is not a covered health care benefit.
15 (7) A description of the grievance procedures to
16 be used to resolve disputes between a managed care plan
17 and an enrollee, including the right to file a
18 grievance regarding any dispute between an enrollee and a
19 managed care plan, the right to file a grievance
20 orally when the dispute is about referrals or covered
21 benefits, the toll-free telephone number that enrollees
22 may use to file an oral grievance, the timeframes and
23 circumstances for expedited and standard grievances, the
24 right to appeal a grievance determination and the
25 procedures for filing the appeal, the timeframes and
26 circumstances for expedited and standard appeals, the
27 right to designate a representative, a notice that all
28 disputes involving clinical decisions will be made by
29 clinical personnel, and that all notices of determination
30 will include information about the basis of the
31 decision and further appeal rights, if any.
32 (8) A description of the procedure for providing
33 care and coverage 24 hours a day for emergency services.
34 The description shall include the definition of
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1 emergency services, notice that emergency services are
2 not subject to prior approval, and an explanation of
3 the enrollee's financial and other responsibilities
4 regarding obtaining those services, including when
5 those services are received outside the managed care
6 plan's service area.
7 (9) A description of procedures for enrollees to
8 select and access the managed care plan's primary and
9 specialty care providers, including notice of how to
10 determine whether a participating provider is accepting
11 new patients.
12 (10) A description of the procedures for changing
13 primary and specialty care providers within the managed
14 care plan.
15 (11) Notice that an enrollee may obtain a referral
16 to a health care provider outside of the managed care
17 plan's network or panel when the managed care plan
18 does not have a health care provider with appropriate
19 training and experience in the network or panel to meet
20 the particular health care needs of the enrollee and
21 the procedure by which the enrollee can obtain the
22 referral.
23 (12) Notice that an enrollee with a condition
24 that requires ongoing care from a specialist may
25 request a standing referral to the specialist and
26 the procedure for requesting and obtaining a standing
27 referral.
28 (13) Notice that an enrollee with (i) a
29 life-threatening condition or disease or (ii) a
30 degenerative or disabling condition or disease, either of
31 which requires specialized medical care over a prolonged
32 period of time, may request a specialist responsible for
33 providing or coordinating the enrollee's medical care and
34 the procedure for requesting and obtaining the
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1 specialist.
2 (14) A description of the mechanisms by which
3 enrollees may participate in the development of the
4 policies of the managed care plan.
5 (15) A description of how the managed care plan
6 addresses the needs of non-English speaking enrollees.
7 (16) Notice of all appropriate mailing addresses
8 and telephone numbers to be utilized by enrollees
9 seeking information or authorization.
10 (17) A listing by specialty, which may be in a
11 separate document that is updated annually, of the name,
12 address, and telephone number of all participating
13 providers, including facilities, and, in addition, in the
14 case of physicians, category of license and board
15 certification, if applicable.
16 (b) Upon request of an enrollee or prospective enrollee,
17 a managed care plan shall do all of the following:
18 (1) Provide a list of the names, business
19 addresses, and official positions of the members of the
20 board of directors, officers, controlling persons,
21 owners, and partners of the managed care plan.
22 (2) Provide a copy of the most recent annual
23 certified financial statement of the managed care plan,
24 including a balance sheet and summary of receipts and
25 disbursements and the ratio of (i) premium dollars going
26 to administrative expenses to (ii) premium dollars going
27 to direct care, prepared by a certified public
28 accountant. The Department shall promulgate rules to
29 standardize the information that must be contained in the
30 statement and the statement's format.
31 (3) Provide information relating to consumer
32 complaints.
33 (4) Provide the procedures for protecting the
34 confidentiality of medical records and other enrollee
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1 information.
2 (5) Allow enrollees and prospective enrollees to
3 inspect drug formularies used by the managed care plan
4 and disclose whether individual drugs are included or
5 excluded from coverage and whether a drug requires prior
6 authorization. An enrollee or prospective enrollee may
7 seek information as to the inclusion or exclusion of a
8 specific drug. A managed care plan need only release the
9 information if the enrollee or prospective enrollee or
10 his or her dependent needs, used, or may need or use the
11 drug.
12 (6) Provide a written description of the
13 organizational arrangements and ongoing procedures of
14 the managed care plan's quality assurance program.
15 (7) Provide a description of the procedures
16 followed by the managed care plan in making decisions
17 about the experimental or investigational nature of
18 individual drugs, medical devices, or treatments in
19 clinical trials.
20 (8) Provide individual health care professional
21 affiliations with participating hospitals, if any.
22 (9) Upon written request, provide specific
23 written clinical review criteria relating to a
24 particular condition or disease and, where appropriate,
25 other clinical information that the managed care plan
26 might consider in its utilization review; the managed
27 care plan may include with the information a description
28 of how it will be used in the utilization review
29 process. An enrollee or prospective enrollee may seek
30 information as to specific clinical review criteria. A
31 managed care plan need only release the information if
32 the enrollee or prospective enrollee or his or her
33 dependent has, may have, or is at risk of contracting a
34 particular condition or disease.
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1 (10) Provide the written application procedures and
2 minimum qualification requirements for health care
3 providers to be considered by the managed care plan.
4 (11) Disclose other information as required by
5 the Director.
6 (12) To the extent the information provided under
7 item (5) or (9) of this subsection is proprietary to the
8 managed care plan, the enrollee or prospective enrollee
9 shall only use the information for the purposes of
10 assisting the enrollee or prospective enrollee in
11 evaluating the covered services provided by the managed
12 care plan. Any misuse of proprietary data is prohibited,
13 provided that the managed care plan has labeled or
14 identified the data as proprietary.
15 (c) Nothing in this Section shall prevent a managed care
16 plan from changing or updating the materials that are made
17 available to enrollees or prospective enrollees.
18 (d) If a primary care provider ceases participation in
19 the managed care plan, the managed care plan shall provide
20 written notice within 15 business days from the date that the
21 managed care plan becomes aware of the change in status to
22 each of the enrollees who have chosen the provider as
23 their primary care provider. If an enrollee is in an
24 ongoing course of treatment with any other participating
25 provider who becomes unavailable to continue to provide
26 services to the enrollee and the managed care plan is aware
27 of the ongoing course of treatment, the managed care plan
28 shall provide written notice within 15 business days from
29 the date that the managed care plan becomes aware of the
30 unavailability to the enrollee. The notice shall also
31 describe the procedures for continuing care.
32 (e) A managed care plan offering to indemnify enrollees
33 for non-participating provider services shall file a report
34 with the Director twice a year showing the percentage
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1 utilization for the preceding 6 month period of
2 non-participating provider services in such form and
3 providing such other information as the Director shall
4 prescribe.
5 (f) The written information disclosure requirements of
6 this Section may be met by disclosure to one enrollee in a
7 household.