State of Illinois
90th General Assembly
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90_HB3445

      New Act
          Creates the Managed Care Reform Act of 1998. Provides for
      the regulation of managed care plans  by  the  Department  of
      Insurance.  Creates  specific  patient  rights to disclosure,
      quality of care, and confidentiality. Prohibits restraints on
      communications between physicians and patients. Requires  the
      establishment  of  grievance procedures. Requires utilization
      review programs to register with the Department of Insurance.
      Effective January 1, 1999.
                                                    LRB9011012JSsbA
                                              LRB9011012JSsbA
 1        AN ACT concerning managed care arrangements.
 2        Be it enacted by the People of  the  State  of  Illinois,
 3    represented in the General Assembly:
 4        Section  1.  Short  title.  This  Act may be cited as the
 5    Managed Care Reform Act of 1998.
 6        Section 5. Purpose. This Act addresses changes in managed
 7    care practice and operations in Illinois. This  Act  enhances
 8    quality,  affordable, and accessible health care coverage for
 9    Illinois citizens, families,  and  businesses.   Through  the
10    provisions  of  this  Act,  health  care plan members will be
11    provided:
12        (1)  Detailed information about health  care  plans,  the
13    scope of coverage available, and the physicians' professional
14    qualifications  so that they can make  informed choices about
15    their health care.
16        (2)  Notification  of  termination  or  change   in   any
17    benefits,  services,  or  service  delivery.  This includes a
18    provision allowing enrollees to continue  with  a  nonnetwork
19    physician under certain specific circumstances.
20        (3)  Detailed  grievance procedures and medical necessity
21    appeals  procedures,  which  include  an   expedited   appeal
22    process.   This   Act   also   ensures   health   care   plan
23    accountability for accessible hospital and physician services
24    and reimbursement for covered emergency services.
25        Section 10. Definitions. As used in this Act:
26        "Basic  health  care  services" means emergency care, and
27    inpatient hospital and  physician  care,  outpatient  medical
28    services,  mental  health  services  and care for alcohol and
29    drug  abuse,  including  any   reasonable   deductibles   and
30    copayments,  all  of which are subject to such limitations as
                            -2-               LRB9011012JSsbA
 1    are determined by the Director.
 2        "Department" means the Department of Insurance.
 3        "Director" means the Director of Insurance.
 4        "Emergency services" means the provision of care for  the
 5    sudden  and,  at  the  time,  unexpected  onset  of  a health
 6    condition which would lead a prudent lay  person  to  believe
 7    that  failure  to  receive  immediate medical attention would
 8    result  in serious impairment  to  bodily  function,  serious
 9    dysfunction  to  any bodily organ or part, or would place the
10    person's health in serious jeopardy.
11        "Enrollee" means an individual enrolled in a health  care
12    plan.
13        "Governing   body"   means  the  board  of  trustees,  or
14    directors,  or  if  otherwise   designated   in   the   basic
15    organizational document bylaws, those individuals vested with
16    the  ultimate responsibility for the management of the health
17    care plan.
18        "Grievance" means any written complaint submitted to  the
19    health care plan by or on behalf of an enrollee regarding any
20    aspect  of  the  plan relative to the enrollee, but shall not
21    include a complaint by or on behalf of a provider.
22        "Grievance committee" means  individuals  who  have  been
23    appointed  by  the  health care plan to respond to grievances
24    which have been filed on appeal from  the  plan's  simplified
25    complaint  process.   At least 50% of the individuals on this
26    committee shall be composed of enrollees who  are  consumers.
27    A  grievance  may  not be heard or voted upon unless at least
28    50% of the voting individuals at the  committee  hearing  are
29    enrollees.
30        "Health  care  plan"  means  any  arrangement  whereby an
31    organization undertakes to provide or arrange for and pay for
32    or reimburse the cost of  basic  health  care  services  from
33    providers  selected  by the plan and the arrangement consists
34    of arranging for or the provision of health care services, as
                            -3-               LRB9011012JSsbA
 1    distinguished from mere indemnification against the  cost  of
 2    those  services,  on  a  per  capita  prepaid  basis, through
 3    insurance or otherwise.
 4        "Health care services" means any services included in the
 5    furnishing to any individual of medical or  dental  care,  or
 6    the  hospitalization  or  incident  to the furnishing of such
 7    care or hospitalization as well  as  the  furnishing  to  any
 8    person  of  any  and  all  other  services for the purpose of
 9    preventing, alleviating, curing, or healing human illness  or
10    injury.
11        "Insurance   company"   means  companies  in  this  State
12    authorized to  transact  the  kind  or  kinds  of    business
13    enumerated in Class 1(a), Class 1(b) or Class 2(a) of Section
14    4 of the Illinois Insurance Code.
15        "Insured"  means  an  individual  entitled to coverage of
16    expenses of health care services under  a  policy  issued  or
17    administered by an insurance company.
18        "Life threatening condition" means any condition, illness
19    or  injury  which (i) may directly lead to a patient's death,
20    (ii)  results  in  a  period  of  unconsciousness  which   is
21    indeterminate at the present, or (iii) imposes severe pain or
22    an inhumane burden on the patient.
23        "Medical director" means a physician licensed to practice
24    medicine  in  all its branches in Illinois who is employed by
25    or contracted with a  health  care  plan  and  who  shall  be
26    responsible  for  final  review  when  questions  of  medical
27    practice arise in the health care plan in order to assure the
28    quality of health care services provided.
29        "Patient"  means  any  person  who  has  received  or  is
30    receiving  medical  care,  treatment,  or  services  from  an
31    individual or institution licensed to provide medical care or
32    treatment in this State.
33        "Primary   care  physician"  means  a  provider  who  has
34    contracted with a health care plan to  provide  primary  care
                            -4-               LRB9011012JSsbA
 1    services  as  defined  by  the  contract  and  who  is  (1) a
 2    physician  licensed  to  practice  medicine  in  all  of  its
 3    branches who spends a majority of clinical  time  engaged  in
 4    general  practice  or  in  the practice of internal medicine,
 5    pediatrics, gynecology, obstetrics, or family practice or (2)
 6    a chiropractic physician licensed  to  treat  human  ailments
 7    without the use of drugs or operative  surgery.
 8        "Provider"  means  any  physician,  hospital facility, or
 9    other person which is licensed  or  otherwise  authorized  to
10    furnish  health  care  services  and  also includes any other
11    entity that arranges for the delivery or furnishing of health
12    care services.
13        "Stabilization" means the provision of medical  treatment
14    to  assure  within  reasonable  medical  probability  that no
15    material deterioration of the condition is likely  to  result
16    from the transfer of the individual from a facility.
17        "Utilization    review"    means   the   study   of   the
18    appropriateness of the use of  particular  services  and  the
19    appropriateness of the volume of services used.
20        "Utilization  review  program" means an entity performing
21    utilization  review,  except  an  agency   of   the   federal
22    government or its agent, but only to the extent that agent is
23    providing services to the federal government.
24        Section  15.  Patient  rights.  The  following rights are
25    hereby established:
26        (1)  The right  of  each  patient  to  be  provided  with
27    information  about  the  health  care  plan and the providers
28    rendering care.  For health care plans this right  calls  for
29    compliance with Section 20 of this Act.
30        (2)  The  right  of  each patient to a full disclosure of
31    the patient costs, benefits, risks, and alternatives  related
32    to the treatment options and care, including health care plan
33    requirements, coverage, exclusions, or limitations that could
                            -5-               LRB9011012JSsbA
 1    affect   the  enrollee's  access  to  coverage  or  treatment
 2    options.   For  health  care  plans  this  right  calls   for
 3    compliance  with Section 25 of this Act.  Insurance companies
 4    and health care plans  are  prohibited  from  terminating  or
 5    suspending   a  provider  from  its  network  for  advocating
 6    appropriate  health  care  services  because   the   provider
 7    advocated  for  what  he  or she considered to be appropriate
 8    health care.
 9        (3)  The right of each patient to care,  consistent  with
10    nursing  and medical practices, to be informed of the name of
11    the physician responsible for coordinating his or  her  care,
12    to  receive  information from his or her physician concerning
13    his or her condition and proposed treatment,  to  refuse  any
14    treatment to the extent permitted by law,  and to privacy and
15    confidentiality  of  records  except as otherwise provided by
16    law.
17        (4)  The right of each patient, regardless of  source  of
18    payment,  to  examine and receive a reasonable explanation of
19    his or her total bill for  services  where  such  a  bill  is
20    rendered  by  his  or  her physician or health care provider,
21    including  the  itemized  charges   for   specific   services
22    received. Each provider shall be responsible for a reasonable
23    explanation  of  those  specific  services  provided  by such
24    physician or health care provider.
25        (5)  In the event an insurance  company  or  health  care
26    plan  cancels  or  refuses  to  renew an individual policy or
27    plan, the insured or enrollee shall be  entitled  to  timely,
28    prior notice of the termination of such policy or plan.
29        An  insurance  company  or health care plan that requires
30    any insured, enrollee, or  applicant  for  new  or  continued
31    insurance  or coverage to be tested for infection with HIV or
32    any other identified causative agent of AIDS shall  (i)  give
33    the  patient  or  applicant  prior  written  notice  of  such
34    requirement,  (ii)  proceed  with  such testing only upon the
                            -6-               LRB9011012JSsbA
 1    written authorization of the insured, enrollee, or applicant,
 2    and (iii) keep the  results  of  such  testing  confidential.
 3    Notice of an adverse underwriting or coverage decision may be
 4    given   to   any  appropriately  interested  party,  but  the
 5    insurance company or health care plan may only  disclose  the
 6    test  result itself to a physician designated by the insured,
 7    enrollee or applicant, and any such disclosure shall be in  a
 8    manner that assures confidentiality.
 9        (6)  At the time of renewal, the right of each patient to
10    notification  of  termination  or  change  in  any  benefits,
11    services, or service delivery location.
12        (7)  The   right   of   each   patient   to  privacy  and
13    confidentiality in health care.  Each physician, health  care
14    provider,  health  care  plan and insurance company shall not
15    disclose the  nature  or  details  of  services  provided  to
16    insureds  and  enrollees, except that such information may be
17    disclosed  to  the  patient,  the  party   making   treatment
18    decisions  if  the  patient  is incapable of making decisions
19    regarding  the  health  services  provided,   those   parties
20    directly  involved with providing treatment to the patient or
21    processing the payment  for  that  treatment,  those  parties
22    responsible  for  peer review, utilization review and quality
23    assurance, and those parties required to  be  notified  under
24    the  Abused  and  Neglected Child Reporting Act, the Illinois
25    Sexually Transmissible Disease Control Act or where otherwise
26    authorized or required by law.  This right may be  waived  in
27    writing  by  the  patient  or  the  patient's guardian, but a
28    physician or other health care provider may not condition the
29    provision  of  services  on  the  patient's   or   guardian's
30    agreement to sign such a waiver.
31        Section 20. Provision of information.
32        (a)  A health care plan shall provide to enrollees a list
33    of  primary care physicians in the health care plan's service
                            -7-               LRB9011012JSsbA
 1    area and an evidence of coverage that contains a  description
 2    of the following terms of coverage:
 3             (1)  The service area.
 4             (2)  Covered benefits, exclusions or limitations.
 5             (3)  Precertification  and  other utilization review
 6        procedures and requirements.
 7             (4)  A description of the limitations on  access  to
 8        specialists.
 9             (5)  Emergency coverage and benefits.
10             (6)  Out-of-area coverages and benefits, if any.
11             (7)  The  enrollee's  financial  responsibility  for
12        copayments,  deductibles,  and  any  other  out-of-pocket
13        expenses.
14             (8)  Provisions  for  continuity of treatment in the
15        event a provider's participation  terminates  during  the
16        course  of  an  insured's or enrollee's treatment by that
17        provider.
18             (9)  The grievance process, including the  telephone
19        number   to   call   to  receive  information  concerning
20        grievance procedures.
21        (b)  Upon written  request,  a  health  care  plan  shall
22    provide   to   enrollees   a  description  of  the  financial
23    relationships between the health care plan and any  provider,
24    except that no health care plan shall be required to disclose
25    specific reimbursement to  providers.
26        (c)  A  participating  provider  shall provide all of the
27    following to enrollees upon request:
28             (1)  Information  related   to   the   health   care
29        professional's    educational   background,   experience,
30        training,  specialty,   and   board   certification,   if
31        applicable.
32             (2)  The   names   of  licensed  facilities  on  the
33        provider panel where the health   professional  presently
34        has  privileges  for the treatment, illness, or procedure
                            -8-               LRB9011012JSsbA
 1        that is the subject of the request.
 2             (3)  Information   regarding   the    health    care
 3        professional's   participation  in  continuing  education
 4        programs   and    compliance    with    any    licensure,
 5        certification,    or    registration   requirements,   if
 6        applicable.
 7        Section  25.  Prohibited  restraints  on   communication.
 8    Nothing  in  a  physician's  contract with a health care plan
 9    shall be construed to  impair  the  physician's  ethical  and
10    legal  duty  to  provide  full  informed  consent and medical
11    counsel to enrollees, including full discussion of the costs,
12    benefits, risks, and alternatives related to  the  enrollee's
13    treatment  options  and  care  and  health care plan policies
14    related  to  those  options,  including  health   care   plan
15    requirements,  coverage,  exclusions,  or  other  policies or
16    practices  that  affect  enrollees'  access  to  coverage  or
17    treatment options.
18        Section 30. Access to personnel and facilities.
19        (a)  A health care plan shall include a sufficient number
20    and  type  of  primary  care    physicians  and  specialists,
21    throughout the service area, to meet the needs  of  enrollees
22    and  to  provide meaningful choice.  A health care plan shall
23    offer:
24             (1)  accessible acute care hospital services, within
25        a reasonable distance or travel  time;
26             (2)  primary care physicians,  within  a  reasonable
27        distance or travel time; and
28             (3)  specialists  within  a  reasonable  distance or
29        travel time.
30        When the type of medical service needed  for  a  specific
31    condition  is  not  represented  in the provider network, the
32    health care plan shall  arrange  for  the  enrollee  to  have
                            -9-               LRB9011012JSsbA
 1    access    to    qualified    nonparticipating   health   care
 2    professionals as authorized by the primary care physician.
 3        (b)  A health care plan shall provide telephone access to
 4    the health care plan  for  sufficient  time  during  business
 5    hours to assure enrollee access for routine care, and 24 hour
 6    telephone  access to the health care plan or, if so delegated
 7    by the health care plan, a participating physician  or  group
 8    for emergency care or authorization for care.
 9        (c)  A   health  care  plan  shall  establish  reasonable
10    standards for waiting times to obtain appointments, except as
11    provided below for emergency services.
12        Such  standards  shall  include  appointment   scheduling
13    guidelines  used  for  each  type  of  health  care  service,
14    including  prenatal  care appointments, well-child visits and
15    immunizations, routine physicals, follow-up appointments  for
16    chronic conditions, and urgent care.
17        (d)  A  health  care plan shall provide for continuity of
18    care for its enrollees as follows:
19             (1)  If an enrollee's physician  leaves  the  health
20        care  plan's  network of providers for reasons other than
21        termination with cause and the physician  remains  within
22        the health care plan's service area, the health care plan
23        shall  permit  the enrollee to continue an ongoing course
24        of treatment with that physician  during  a  transitional
25        period of:
26                  (A)  up  to 60 days from the date of the notice
27             of physician's termination from the health care plan
28             network  to  the   enrollee   of   the   physician's
29             disaffiliation  from  the health care plan's network
30             if the enrollee has a life  threatening  disease  or
31             condition; or
32                  (B)  if  the  enrollee  has  entered  the third
33             trimester  of  pregnancy  at   the   time   of   the
34             physician's   disaffiliation,   for  a  transitional
                            -10-              LRB9011012JSsbA
 1             period that includes the  provision  of  post-partum
 2             care directly related to the delivery.
 3             (2)  Notwithstanding  the  provisions in item (1) of
 4        this subsection, such care shall  be  authorized  by  the
 5        health  care  plan during the transitional period only if
 6        the physician agrees:
 7                  (A)  to continue to accept  reimbursement  from
 8             the  health  care plan at the rates applicable prior
 9             to the start of the transitional period  as  payment
10             in full;
11                  (B)  to   adhere  to  the  health  care  plan's
12             quality assurance requirements and to provide to the
13             health  care  plan  necessary  medical   information
14             related to  such care; and
15                  (C)  to  otherwise adhere to the organization's
16             policies and procedures,  including but not  limited
17             to  procedures  regarding  referrals  and  obtaining
18             preauthorizations  and  a treatment plan approved by
19             the health care plan.
20        (e)  A health care plan shall provide for  continuity  of
21    care for new enrollees as follows:
22             (1)  If  a  new  enrollee  whose  physician is not a
23        member of the health care plan's provider network, but is
24        within the health care plan's service  area,  enrolls  in
25        the  health  care plan, the health care plan shall permit
26        the enrollee to continue an ongoing course  of  treatment
27        with   the   enrollee's   current   physician   during  a
28        transitional period of up to 60 days from  the  effective
29        date of enrollment, if:
30                  (A)  the   enrollee   has   a  life-threatening
31             disease or condition; or
32                  (B)  the  enrollee  has   entered   the   third
33             trimester  of  pregnancy  at  the  effective date of
34             enrollment, in which case  the  transitional  period
                            -11-              LRB9011012JSsbA
 1             shall  include  the  provision  of  post-partum care
 2             directly related to the delivery.
 3             (2)  If an enrollee elects to  continue  to  receive
 4        care  from  such  physician  pursuant to item (1) of this
 5        subsection, such care shall be authorized by  the  health
 6        care  plan  for  the  transitional  period  only  if  the
 7        physician agrees:
 8                  (A)  to  accept  reimbursement  from the health
 9             care plan at rates established by  the  health  care
10             plan as payment in full, such rates shall be no more
11             than   the  level  of  reimbursement  applicable  to
12             similar physicians within  the  health  care  plan's
13             network for such services;
14                  (B)  to   adhere  to  the  health  care  plan's
15             quality  assurance  requirements  and    agrees   to
16             provide  to  the  health care plan necessary medical
17             information  related to such care; and
18                  (C)  to otherwise adhere  to  the  health  care
19             plan's  policies  and procedures  including, but not
20             limited  to  procedures  regarding   referrals   and
21             obtaining    preauthorization  and  a treatment plan
22             approved by the health care  plan.     In  no  event
23             shall  this section be construed to require a health
24             care plan to   provide  coverage  for  benefits  not
25             otherwise   covered   or  to  diminish  or    impair
26             preexisting condition limitations contained  in  the
27             subscriber's  contract.
28        Section 35. Emergency services.
29        (a)  Health  care  plans  shall provide reimbursement for
30    covered emergency services provided  at  a  participating  or
31    nonparticipating  emergency  department  up  to  the point of
32    stabilization of an enrollee.
33        (b)  Once  the  enrollee  is  stabilized,  the  emergency
                            -12-              LRB9011012JSsbA
 1    department shall contact the primary care physician or health
 2    care plan as specified on the  identification  card  to  seek
 3    prior  authorization for any additional nonemergency services
 4    beyond stabilization.
 5        (c)  With any  claim  for  reimbursement,  the  emergency
 6    department  shall  provide  the  health  care  plan  with the
 7    medical record documenting the  presenting  symptoms  of  the
 8    enrollee  at  the  time  care  was  sought  and the objective
 9    findings of the medical examination.
10        (d)  The   health   care   plan's   medical    director's
11    determination  of whether the enrollee meets the  standard of
12    emergency shall take into account the presenting symptoms  at
13    the time care was sought.
14        (e)  Health  care  plans may require an enrollee to pay a
15    copayment for emergency services.
16        (f)  Health  care  plans  shall  provide  enrollees  with
17    information on  procedures  for  the  coverage  of  emergency
18    services both inside and out of the plan service area.
19        Section 40. Grievance procedures.
20        (a)  Every   health   care  plan  shall  submit  for  the
21    Director's approval, and thereafter maintain,  a  system  for
22    the  resolution  of  grievances  concerning  the provision of
23    health care services or  other matters  concerning  operation
24    of the health care plan as follows.  A health care plan shall
25    do all of the following:
26             (1)  Submit  to  the Director for prior approval any
27        proposed changes to the system by which grievances may be
28        filed and reviewed;
29             (2)  Maintain records on each grievance  filed  with
30        the  health care plan until the grievance is resolved and
31        for a period of at least 3 years to include:
32                  (A)  a copy of the grievance and  the  date  of
33             its filing;
                            -13-              LRB9011012JSsbA
 1                  (B)  the date and outcome of all consultations,
 2             hearings and hearing findings;
 3                  (C)  the  date  and  decisions  of  any  appeal
 4             proceedings; and
 5                  (D)  the date and proceeding of any litigation.
 6             (3)  Submit  to the Director in a form prescribed by
 7        the Director, a  report  by  March  1  for  the  previous
 8        calendar year which shall include at least the following:
 9                  (A)  the total number of grievances handled;
10                  (B)  a  compilation  of  causes  underlying the
11             grievances;
12                  (C)  the outcomes of the grievances;
13                  (D)  the  elapsed  time  from  receipt  of  the
14             grievance  by  the  health  care  plan   until   its
15             conclusion; and
16                  (E)  the number of malpractice claims filed and
17             if  such claims have been  completely adjudicated, a
18             compilation of causes, disposition, form, and amount
19             of any settlements.
20        (b)  A health care plan shall have a grievance  committee
21    which  shall  have  the  authority  to  hear  and  resolve by
22    majority vote grievances  submitted  to  it  as  provided  in
23    subsection (a).
24        Notwithstanding any other provisions of this Section, the
25    grievance  committee  may,  but  is not required to, hear any
26    grievance which alleges or  indicates  possible  professional
27    liability, commonly known as "malpractice."
28        The  committee  is not empowered to resolve grievances in
29    any manner which, or  prescribe  any  actions,  that  are  in
30    conflict  with  written  policies  of the health care  plan's
31    governing body, but the committee may  hear  such  grievances
32    for the  purpose of providing input to the governing body.
33        The  grievance committee shall meet at the main office of
34    the health care plan, or such other office designated by  the
                            -14-              LRB9011012JSsbA
 1    health care plan where the main office is not within 50 miles
 2    of the grievant's home address.  Consideration shall be given
 3    to  the enrollee's request pertaining to the time and date of
 4    such meeting.  The enrollee shall have the  right  to  attend
 5    and  participate  in  the  formal grievance proceedings.  The
 6    enrollee  shall  have  the  right  to  be  accompanied  by  a
 7    designated representative of his or her choice.
 8        The filing of a grievance shall not preclude the enrollee
 9    from filing a complaint  with the  Department  nor  shall  it
10    preclude  the  Department  from  investigating  a   complaint
11    pursuant to its authority under Section  4-6  of  the  Health
12    Maintenance Organization Act.
13        (c)  The  grievance  procedures must be fully and clearly
14    communicated to all enrollees and information concerning such
15    procedures shall be readily available to the enrollee.
16        (d)  A health care plan shall have  simplified  procedure
17    for  resolving  complaints.   Such  procedures do not require
18    review of the complaint by the  grievance  committee,  but  a
19    log,  file,  or  other  similar records must be maintained to
20    identify the general nature of such  complaints.   Resolution
21    of such complaints shall not preclude the enrollees' rightful
22    access to review by the grievance committee of a grievance.
23        (e)  The  health  care  plan  shall  institute procedures
24    which would require grievances to have a  determination  made
25    by  the  grievance committee within 60 days from the date the
26    grievance is received by the health care plan.   A  grievance
27    may  not  be  heard  or  voted  upon unless 50% of the voting
28    individuals of the  committee  present  at  the  hearing  are
29    enrollees.   The determination by the grievance committee may
30    be extended for a period not to exceed 30 days in  the  event
31    of  delay in obtaining documents or records necessary for the
32    resolution of the grievance.  All requests for  documents  or
33    records  necessary  for the resolution of the grievance shall
34    be maintained in the health care plan's grievance file.
                            -15-              LRB9011012JSsbA
 1        (f)  The grievance procedure shall provide  the  enrollee
 2    with  a  written acknowledgment of  their grievance within 10
 3    business days after receipt by the health care plan.
 4        (g)  The enrollee shall be notified at the  time  of  the
 5    hearing  of  the  name  and  affiliation  of  those grievance
 6    committee members who are representatives of the health  care
 7    plan.
 8        (h)  The  health  care  plan  shall  institute procedures
 9    whereby  any  document  furnished  to  the  members  of   the
10    grievance  committee  shall  also  be  made  available to the
11    enrollee not less than 5 business days prior to  the  hearing
12    of  their  grievance.  The health care plan shall not present
13    any evidence without  the  enrollee  having  been  given  the
14    opportunity to be present.
15        (i)  Notice  in  writing  of  the  determination  of  the
16    grievance committee shall be mailed to the  enrollee within 5
17    business   days   of   such  determination.   Notice  of  the
18    determination made at the final appeal  step  of  the  health
19    care  plan's  grievance process shall include a notice of the
20    availability of the Department to  receive  complaints  under
21    Section 4-6 of the Health Maintenance Organization Act.
22        (j)  Prior  to  the  resolution of a grievance filed by a
23    subscriber or enrollee, coverage shall not be terminated  for
24    any  reason  which  is  the subject of the written grievance,
25    except where the health care plan has, in good faith, made  a
26    reasonable  effort  to  resolve the written grievance through
27    its grievance procedure and coverage is being terminated as a
28    result of good cause.
29        Section 45. Review of medical necessity.  A  health  care
30    plan  shall  provide  a  mechanism for the timely review by a
31    physician holding the same class of license  as  the  primary
32    care  physician,  who  is unaffiliated with health care plan,
33    jointly selected by the patient (or the patient's next of kin
                            -16-              LRB9011012JSsbA
 1    or legal representative if the patient is unable to  act  for
 2    himself  or  herself),  primary care physician and the health
 3    care plan in the event of a dispute between the primary  care
 4    physician  and  the  health  care  plan regarding the medical
 5    necessity of a covered service proposed by the  primary  care
 6    physician.    In  the  event  that  the  reviewing  physician
 7    determines the covered service to be medically necessary, the
 8    health care plan shall provide the covered  service.   Future
 9    contractual  or  employment  action  by the health  care plan
10    regarding the primary  care  physician  shall  not  be  based
11    solely on the physician's participation in this procedure.
12        Section 50. Expedited review of medical necessity.
13        (a)  A  health  care  plan shall have an expedited review
14    procedure  whereby  an  enrollee  with   a   life-threatening
15    condition,  or  physician  authorized  in  writing  to act on
16    behalf of the enrollee with a life-threatening condition, may
17    appeal a health care plan's decision of medical necessity  of
18    a covered service.
19        (b)  The expedited review procedure shall provide that an
20    initial  determination  of  the  review  will  be made by the
21    health care  plan  not  later  than  3  business  days  after
22    receipt  of  all necessary information to complete the review
23    process.
24        (c)  After  the  initial  adverse  determination  by  the
25    health care plan, the enrollee, or  physician  authorized  in
26    writing to act on behalf of the enrollee, may request further
27    review  by  the  health  care  plan.   If  further  review is
28    requested, a final determination  by  the  health  care  plan
29    shall  be  made  not  later than 30 days after receipt of all
30    necessary  information  to  complete  further  review.   Upon
31    notification to the enrollee of the health care plan's  final
32    determination  resulting  from  the expedited review process,
33    the  plan  shall  provide  the  enrollee  a  notice  of   the
                            -17-              LRB9011012JSsbA
 1    availability  of  the  Department  to  receive  complaints as
 2    provided  in  Section   4-6   of   the   Health   Maintenance
 3    Organization Act.
 4        (d)  A request for an expedited review under this Section
 5    must  contain a statement  submitted by the physician, orally
 6    or  in  writing,  substantiating  that  the  enrollee  has  a
 7    life-threatening condition. This subsection does not apply to
 8    a provider's complaint concerning claims  payment,  handling,
 9    or reimbursement for health care services.
10        (e)  If  the expedited review process is invoked it shall
11    be in place of and not in  addition  to  the  regular  review
12    process.
13        Section 55. Registration of utilization review programs.
14        (a)  All   utilization  review  programs  shall  register
15    annually with the Department.
16        (b)  The utilization review program will  submit  all  of
17    the following:
18             (1)  The   name,   address   and  telephone  of  the
19        registrant.
20             (2)  The organization and governing structure of the
21        registrant.
22             (3)  List of insurance  companies  and  health  care
23        plans  for  which the utilization review program performs
24        utilization review in this State and the number of  lives
25        for which utilization review is conducted.
26             (4)  Hours of operation.
27             (5)  Description of the grievance process.
28             (6)  Number  of  covered lives for which utilization
29        review was conducted for the previous calendar year.
30             (7)  Written policies and procedures for  protecting
31        confidential  information  according  to applicable State
32        and federal laws.
33        (c)  If the Director determines that an insurance company
                            -18-              LRB9011012JSsbA
 1    or health care plan licensed  by  the  Department  meets  the
 2    provisions  of  the  requirements  of  this Section under its
 3    certification process, he or she  may  exempt  the  insurance
 4    company   or   health  care  plan  from  providing  duplicate
 5    information.
 6        Section 60.  Managed care community networks.     Managed
 7    care  community  networks  providing or arranging health care
 8    services under contract with the State exclusively to persons
 9    who are  enrolled  in  the  integrated  health  care  program
10    established  under  Section 5-16.3 of the Illinois Public Aid
11    Code or a managed care community network owned, operated,  or
12    governed  by  a county provider as defined in Section 15-1 of
13    that Code are required to comply with Sections 15, 20, and 25
14    of this Act and are exempt from all other  Sections  of  this
15    Act.  The Illinois Department of Public Aid shall adopt rules
16    to implement these provisions.
17        Section 65.  Penalties.
18        (a)  An  organization  that  violates Section 20, 25, 30,
19    35, 40, 45, 50, or  55 of this Act is guilty  of  a  Class  B
20    misdemeanor.
21        (b)  The  Director may issue a cease and desist order, as
22    provided in Article  XXIV,  Section  401.1  of  the  Illinois
23    Insurance Code, to any organization subject to this Act.
24        Section   70.  Severability.  If  any  Section,  term  or
25    provision of this Act  shall  be  adjudged  invalid  for  any
26    reason, such judgment shall not affect, impair, or invalidate
27    any  other  Section,  term, or provision of this Act, and the
28    remaining Sections, terms, and provisions shall be and remain
29    in full force and effect.
30        Section 75. Applicability of Act.   A  health  care  plan
                            -19-              LRB9011012JSsbA
 1    amended,  delivered,  issued,  or renewed in this State after
 2    the effective date of this Act must comply with the terms  of
 3    this Act.
 4        Section  99.   Effective  date.   This  Act  takes effect
 5    January 1, 1999.

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