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90_SB1666 5 ILCS 375/6.12 new 55 ILCS 5/5-1069.8 new 65 ILCS 5/10-4-2.8 new 215 ILCS 5/155.36 new 215 ILCS 5/356w new 215 ILCS 5/370s new 215 ILCS 5/511.118 new 215 ILCS 105/8.6 new 215 ILCS 125/5-3.6 new 215 ILCS 130/4002.6 new 215 ILCS 110/48 new 215 ILCS 165/15.30 new 305 ILCS 5/5-16.12 new 30 ILCS 105/5.480 new Creates the Managed Care Patient Rights Act. Provides that patients who receive health care under a managed care program have rights to certain coverage and service standards including, but not limited to, quality health care service, privacy and confidentiality, freedom of choice of physician, explanation of bills, and protection from revocation of prior authorization. Provides for the Illinois Department of Public Health to establish standards to ensure patient protection, quality of care, fairness to physicians, and utilization review safeguards. Requires utilization review plans to be licensed by the Department of Public Health. Amends various Acts to require compliance by health care providers under the Illinois Insurance Code, Comprehensive Health Insurance Plan Act, Health Maintenance Organization Act, Limited Health Service Organization Act, Dental Service Plan Act, Voluntary Health Services Plans Act, State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, and Illinois Public Aid Code. Effective immediately. LRB9008923JSgcA LRB9008923JSgcA 1 AN ACT to create the Managed Care Patient Rights Act and 2 amend various named Acts. 3 Be it enacted by the People of the State of Illinois, 4 represented in the General Assembly: 5 ARTICLE 1. SHORT TITLE, LEGISLATIVE PURPOSE, DEFINITIONS 6 Section 1-1. Short title. This Act may be cited as the 7 Managed Care Patient Rights Act. 8 Section 1-5. Legislative purpose. The legislature 9 hereby finds and declares that: 10 (a) Managed care consists of systems or techniques that 11 are used to affect access to and control payments for health 12 care services. Managed care plans can be organized in a vast 13 number of structures, including licensed and unlicensed 14 components that can restrict access to health care services. 15 As this State's health care market becomes increasingly 16 dominated by managed care plans that utilize various managed 17 care techniques that include decisions regarding coverage and 18 the appropriateness of health care, it is a vital state 19 governmental function to protect patients and ensure fair and 20 equitable managed care practices. 21 (b) Managed care plans, including insurance companies, 22 are responsible for making coverage decisions that have a 23 direct effect on the health of patients. Some of these 24 managed care plans make decisions concerning the medical 25 necessity, appropriateness of alternative treatments and 26 length of hospital stays. Further, these managed care plans 27 can restrict patients' ability to make choices about their 28 health care providers. Strong provider-patient 29 relationships, particularly for patients with acute or 30 chronic medical conditions, enhances the curative process. -2- LRB9008923JSgcA 1 Maintaining continuity of care as patients change providers 2 and health plans is essential to the health and well-being of 3 the patients enrolled in the managed care plans. It is in 4 the interest of the health of the public to insure that 5 decisions about the availability of health care providers and 6 the willingness of payors to pay for medically necessary care 7 are made in an appropriate manner. 8 (c) This legislation establishes a managed care patient's 9 right to, at a minimum, all of the following: 10 (1) Quality health care services. 11 (2) Identification of his or her participating 12 providers. 13 (3) Reasonable explanation of the patient's plan of 14 care. 15 (4) A reasonable explanation of bills for health 16 care services. 17 (5) Clear and understandable explanation of the 18 terms and conditions of coverage. 19 (6) Timely notification of individual coverage 20 termination. 21 (7) Privacy and confidentiality in health care 22 services. 23 (8) Freedom to purchase necessary health care 24 services. 25 (9) Freedom of choice of physician to coordinate 26 health care, and a prohibition of retaliation against 27 health care providers who advocate medically necessary 28 health care for their patients. 29 (10) Protection from revocation of prior 30 authorization. 31 (11) Prohibition of prior authorization for 32 emergency care. 33 (12) Timely and clear notification of provider 34 termination. -3- LRB9008923JSgcA 1 These rights are implemented through the regulation of 2 managed care plans and utilization review programs. 3 (d) Licensed insurance companies, health maintenance 4 organizations, self-insured employer or employee 5 organizations, and other managed care plans are required to 6 certify compliance with this Act to the Department of Public 7 Health. Certification of compliance is required to ensure 8 patient protection, quality of care, fairness to physician 9 and other health care providers, utilization review 10 safeguards, and coverage options for all patients, including 11 the ability to enroll in a point of service plan. 12 Section 1-10. Definitions. As used in this Act: 13 "Department" means the Department of Public Health. 14 "Director" means the Director of the Public Health. 15 "Enrollee" means an individual and his or her dependents 16 who are enrolled in a managed care plan. 17 "Emergency condition" means a medical condition of recent 18 onset and severity that would lead a prudent layperson, 19 possessing an average knowledge of medicine and health, to 20 believe that urgent or unscheduled health care services are 21 required. 22 "Emergency medical screening examination" means a medical 23 screening examination and evaluation by a physician or, to 24 the extent permitted by applicable laws, by other appropriate 25 personnel under the supervision of a physician to determine 26 whether the need for emergency services exists. 27 "Emergency services" means those health care services 28 provided to evaluate and treat medical conditions of recent 29 onset and severity that would lead a prudent layperson, 30 possessing an average knowledge of medicine and health, to 31 believe that urgent or unscheduled health care services are 32 required. 33 "Health care provider" means a physician, dentist, -4- LRB9008923JSgcA 1 podiatrist, registered professional nurse, clinic, hospital, 2 federally qualified health center, rural health clinic, 3 ambulatory surgical treatment center, pharmacy, laboratory, 4 or other appropriately licensed provider of health care 5 services. 6 "Health care services" means services, supplies or 7 products rendered or sold by a health care provider within 8 the scope of the provider's license. The term includes, but 9 is not limited to, hospital, medical, surgical, dental, 10 podiatric, pharmacy, vision, home health and pharmaceutical 11 services and products. 12 "Managed care plan" means a plan that establishes, 13 operates or maintains a network of health care providers 14 that have entered into agreements with the plan to provide 15 health care services to enrollees where the plan has the 16 ultimate and direct contractual obligation to the enrollee to 17 arrange for the provision of or pay for services through: 18 (1) organizational arrangements for ongoing quality 19 assurance, utilization review programs, or dispute 20 resolution; or 21 (2) financial incentives for enrollees enrolled in 22 the plan to use the participating providers and 23 procedures covered by the plan. 24 A managed care plan may be established or operated by any 25 entity including a licensed insurance company, hospital or 26 medical service plan, health maintenance organization, 27 limited health services organization, preferred provider 28 organization, third party administrator, or an employer or 29 employee organization. 30 "Participating provider" means a health care provider 31 that has entered into an agreement with a managed care plan 32 to provide health care services to an enrollee. 33 "Patient" means any person who has received or is 34 receiving health care services from a health care provider. -5- LRB9008923JSgcA 1 "Post-stabilization services" means those health care 2 services determined by a health care provider to be promptly 3 and medically necessary following stabilization of an 4 emergency condition. 5 "Primary care" means the provision of a broad range of 6 personal health care services (preventive, diagnostic, 7 curative, counseling, or rehabilitative) in a manner that is 8 accessible, comprehensive and coordinated by a physician 9 licensed to practice medicine in all its branches over time. 10 "Principal care" means the provision of ongoing 11 preventive, diagnostic, curative, counseling, or 12 rehabilitative care, provided or coordinated by a physician 13 licensed to practice medicine in all its branches, that is 14 focused on a specific organ system, disease or condition. 15 Principal care may be provided concurrently with or apart 16 from primary care. 17 "Utilization review program" means a system operated by 18 or on behalf of a managed care plan for the purpose of 19 reviewing the medical necessity or appropriateness of health 20 care services provided or proposed to be provided to 21 enrollees of the managed care plan using specified 22 guidelines. The system may include preadmission 23 certification, the application of appropriately developed 24 clinically based guidelines, length of stay review, discharge 25 planning, preauthorization of ambulatory procedures, and 26 retrospective review. 27 ARTICLE 5. ENUMERATED PATIENT RIGHTS 28 Section 5-5. Managed care patient rights. 29 (a) A patient has the right to care consistent with 30 professional standards of practice to assure quality nursing 31 and medical practices, to be informed of the name of the 32 participating physician responsible for coordinating his or -6- LRB9008923JSgcA 1 her care, to receive information concerning his or her 2 condition and proposed treatment, to refuse any treatment to 3 the extent permitted by law, and to privacy and 4 confidentiality of records except as otherwise provided by 5 law. 6 (b) A patient has the right, regardless of source of 7 payment, to examine and to receive a reasonable explanation 8 of his or her total bill for health care services rendered by 9 his or her physician or other health care provider, including 10 the itemized charges for specific health care services 11 received. A physician or other health care provider shall be 12 responsible only for a reasonable explanation of those 13 specific health care services provided by the health care 14 provider. 15 (c) A patient has the right to timely prior notice of the 16 termination in the event a managed care plan cancels or 17 refuses to renew an enrollee's participation in the plan. 18 (d) A patient has the right to privacy and 19 confidentiality in health care. A physician, other health 20 care provider, managed care plan, and utilization review 21 program shall refrain from disclosing the nature or details 22 of health care services provided to patients, except that the 23 information may be disclosed to the patient, the party making 24 treatment decisions if the patient is incapable of making 25 decisions regarding the health care services provided, those 26 parties directly involved with providing treatment to the 27 patient or processing the payment for that treatment only in 28 accordance with Section 5-35, those parties responsible for 29 peer review, utilization review, and quality assurance, and 30 those parties required to be notified under the Abused and 31 Neglected Child Reporting Act, the Illinois Sexually 32 Transmissible Disease Control Act, or where otherwise 33 authorized or required by law. This right may be expressly 34 waived in writing by the patient or the patient's guardian, -7- LRB9008923JSgcA 1 but a managed care plan, a physician, or other health care 2 provider may not condition the provision of health care 3 services on the patient's or guardian's agreement to sign 4 such a waiver. 5 (e) An individual has the right to purchase any health 6 care services with that individual's own funds, whether the 7 health care services are covered within the individual's 8 basic benefit package or from any health care provider or 9 plan received as a benefit of employment or from another 10 source. Employers shall not be prohibited from providing 11 coverage for benefits in addition those mandated by law. 12 Section 5-10. Medically appropriate health care 13 protection. 14 (a) No managed care plan shall retaliate against a 15 physician or other health care provider who advocates for 16 appropriate health care services for their patients. 17 (b) It is the public policy of the State of Illinois 18 that a physician or any other health care provider be 19 encouraged to advocate for medically appropriate health care 20 services for his or her patients. For purposes of this 21 Section, "to advocate for medically appropriate health care 22 services" means to appeal a decision to deny payment for a 23 health care service pursuant to the reasonable grievance or 24 appeal procedure established by a managed care plan or to 25 protest a decision, policy, or practice that the physician or 26 other health care provider, consistent with that degree of 27 learning and skill ordinarily possessed by physicians or 28 other health care providers practicing in the same or a 29 similar locality and under similar circumstances, reasonably 30 believes impairs the physician's or other health care 31 provider's ability to provide appropriate health care 32 services to his or her patients. 33 (c) The application and rendering by any person of a -8- LRB9008923JSgcA 1 decision to terminate an employment or other contractual 2 relationship with or otherwise penalize a physician or other 3 health care provider for advocating for appropriate health 4 care services consistent with the degree of learning and 5 skill ordinarily possessed by physicians or other health care 6 providers practicing in the same or a similar locality and 7 under similar circumstances violates the public policy of 8 this State and constitutes a business offense subject to the 9 penalty under this Act. 10 (d) This Section shall not be construed to prohibit a 11 managed care plan from making a determination not to pay for 12 a particular health care service or to prohibit a medical 13 group, independent practice association, preferred provider 14 organization, foundation, hospital medical staff, hospital 15 governing body or managed care plan from enforcing reasonable 16 peer review or utilization review protocols or determining 17 whether a physician or other health care provider has 18 complied with those protocols. 19 (e) Nothing in this Section shall be construed to 20 prohibit the governing body of a hospital or the hospital 21 medical staff from taking disciplinary actions against a 22 physician as authorized by law. 23 (f) Nothing in this Section shall be construed to 24 prohibit the Department of Professional Regulation from 25 taking disciplinary actions against a physician or other 26 health care provider under the appropriate licensing Act. 27 Section 5-15. Choice of physician. 28 (a) All managed care plans that require each enrollee to 29 select a participating provider for any purpose including 30 coordination of care shall allow all enrollees to choose any 31 primary care physician licensed to practice medicine in all 32 its branches participating in the managed care plan for that 33 purpose. -9- LRB9008923JSgcA 1 (b) In addition, all enrollees with an ongoing, 2 recurring or chronic disease or condition shall be allowed to 3 choose any participating physician licensed to practice 4 medicine in all its branches to provide principal care, 5 without referral from the provider coordinating care. The 6 decision regarding selection of any physician for any purpose 7 must be made by the enrollee and the physician. The managed 8 care plan's Health Care Delivery Policy Advisory Board shall 9 recommend definitions for those diseases and conditions which 10 shall be considered ongoing, recurring, or chronic diseases 11 or conditions for the managed care plan's governing body. 12 Any definitions adopted for the plan shall be mutually agreed 13 upon between the Board and the governing body. Neither may 14 unilaterally adopt definitions. 15 (c) The enrollee may be required by the managed care plan 16 to select a principal care physician who has a referral 17 arrangement with the enrollee's primary care physician or to 18 select a new primary care physician who has a referral 19 arrangement with the principal care physician chosen by the 20 enrollee. If a managed care plan requires an enrollee to 21 select a new physician under this subsection (c), the managed 22 care plan must provide the enrollee with both options 23 provided in this subsection (c). 24 (d) Nothing shall prohibit the managed care plan from 25 requiring prior authorization or approval from either a 26 primary care physician or a principal care physician for 27 referrals for additional health care services. Nothing shall 28 prohibit the managed care plan from requiring the principal 29 care physician to coordinate referrals for additional health 30 care services with the primary care physician. 31 Section 5-20. Prohibited restraints on communication or 32 practice. 33 (a) No managed care plan may prohibit or discourage -10- LRB9008923JSgcA 1 health care providers from discussing any alternative health 2 care services and providers, utilization review and quality 3 assurance policies, terms and conditions of plans and plan 4 policy with enrollees, prospective enrollees, providers, or 5 the public. 6 (b) No managed care plan shall by contract, written 7 policy or written procedure, or informal policy or procedure 8 impose any restrictions on the physicians or other health 9 care providers who treat its enrollees as to recommended 10 health care services except as approved by the Health Care 11 Delivery Policy Advisory Board. 12 (c) Any violation of this Section shall be subject to 13 the penalties under this Act. 14 Section 5-25. Prohibited activity. No managed care plan 15 by contract, written policy or procedure, or informal policy 16 or procedure shall contain any clause attempting to transfer 17 or transferring to a health care provider, by indemnification 18 or otherwise, any liability relating to activities, actions, 19 or omissions of the managed care plan or its officers, 20 employees, or agents as opposed to those of the health care 21 provider. 22 Section 5-30. Procedure authorization. A managed care 23 plan that authorizes a specific type of treatment by a health 24 care provider shall not rescind or modify the authorization 25 after the health care provider renders the health care 26 service in good faith and pursuant to the authorization. 27 This Section shall not be construed to expand or alter the 28 benefits available to the enrollee under a managed care plan. 29 Section 5-35. Patient confidential records. A managed 30 care plan shall not release any information to an employer or 31 anyone else, except as specifically authorized by law, that -11- LRB9008923JSgcA 1 would directly or indirectly indicate to the employer or 2 anyone else that an enrollee is receiving or has received 3 health care services from a health care provider unless 4 expressly authorized to do so in writing by the enrollee. 5 Section 5-40. Emergency services. 6 (a) All managed care plans shall provide the enrollee 7 emergency services coverage providing that payment for this 8 coverage is not dependent upon whether the services are 9 performed by a participating or nonparticipating provider. 10 This coverage shall be at the same benefit level as if the 11 service or treatment had been rendered by a participating 12 provider. 13 (b) Prior authorization or approval by the managed care 14 plan shall not be required. 15 (c) Coverage and payment shall not be retrospectively 16 denied, with the following exceptions: 17 (1) upon reasonable determination that the 18 emergency services claimed were never performed; or 19 (2) upon reasonable determination that an emergency 20 medical screening examination was performed on a patient 21 who personally sought emergency services knowing that he 22 or she did not have an emergency condition and who did 23 not in fact require emergency services. 24 (d) When an enrollee presents to a hospital seeking 25 emergency services, the determination as to whether the need 26 for those services exists shall be made for purposes of 27 treatment by a physician or, to the extent permitted by 28 applicable law, by other appropriate licensed personnel under 29 the supervision of a physician. The physician or other 30 appropriate personnel shall indicate in the patient's chart 31 the results of the emergency medical screening examination. 32 (e) The appropriate use of the 911 emergency telephone 33 number shall not be discouraged or penalized, and coverage or -12- LRB9008923JSgcA 1 payment shall not be denied solely on the basis that the 2 enrollee used the 911 emergency telephone number to summon 3 emergency services. 4 Section 5-45. Post-stabilization services. 5 (a) If prior authorization for post-stabilization 6 services is required, the managed care plan shall provide 7 access 24 hours a day, 7 days a week to persons designated by 8 the plan to make those determinations. If a health care 9 provider has attempted to contact a person for prior 10 authorization and no designated persons were accessible or 11 the authorization was not denied within 30 minutes of the 12 request, the managed care plan is deemed to have approved the 13 request for prior authorization. 14 (b) Coverage and payment for post-stabilization services 15 that received prior authorization or deemed approval shall 16 not be retrospectively denied. 17 Section 5-50. Notices of payment denial. All managed 18 care plans shall provide enrollees with detailed notices of 19 payment denial. The notices of denial shall be signed by the 20 individual responsible for denying payment and include the 21 name, an address and accessible phone number and facsimile 22 number of the individual responsible for denying payment. 23 Further, the notice of denial shall clearly state the 24 procedures for appealing the denial. The enrollee shall be 25 given the opportunity to respond to any denial and explain 26 any discrepancies. 27 Section 5-55. Managed care plan information. 28 (a) Prospective enrollees in managed care plans must be 29 provided written information disclosing the terms and 30 conditions of the managed care plans so that they can make 31 informed decisions about accepting a certain system of health -13- LRB9008923JSgcA 1 care delivery. Where the managed care plan is described 2 orally to prospective enrollees, this oral description must 3 be easily understood, truthful, and objective in the terms 4 used. 5 (b) All managed care plans must be described in writing 6 in a legible and understandable format, consistent with 7 standards developed for supplemental insurance coverage under 8 Title XVIII of the Social Security Act. This format must be 9 standardized so that prospective enrollees can compare the 10 attributes of the managed care plans. Specific items that 11 must be included are: 12 (1) coverage provisions, benefits, and any 13 exclusions or limitations of: (i) health care services 14 or (ii) physicians or other providers; 15 (2) any and all prior authorization or other review 16 requirements including preauthorization review, 17 concurrent review, post-service review, post payment 18 review and any procedures that may lead the patient to be 19 denied coverage for or not be provided a particular 20 health care service and an explanation of the registry of 21 review decisions and how it can be reviewed; 22 (3) a detailed explanation of the managed care plan 23 policy describing how the managed care plan shall 24 facilitate the continuity of care for enrollees receiving 25 health care services from non-participating providers; 26 (4) a detailed explanation of how managed care plan 27 limitations impact enrollees, including information on 28 enrollee financial responsibility for payment of 29 co-payments, deductibles, coinsurance and non-covered or 30 out-of-plan health care services; 31 (5) a detailed explanation of the percent of premium 32 going to pay for care and percent of premium going to pay 33 for administration; 34 (6) educational materials explaining the proper -14- LRB9008923JSgcA 1 utilization of emergency services in accordance with 2 Section 5-40 prepared by the Department of Public Health; 3 (7) enrollee satisfaction statistics, including, but 4 not limited to, reenrollment, and reasons for leaving a 5 managed care plan; and 6 (8) explanation of how the managed care plan 7 compensates health care providers and how those 8 compensation arrangements may impact the provision of 9 health care services. 10 Section 5-60. Access to providers. Managed care plans 11 must demonstrate that they have adequate access to physicians 12 in appropriate medical specialties and other health care 13 providers, so that all covered health care services will be 14 provided in a timely fashion. This requirement cannot be 15 waived and must be met in all geographic areas where the 16 managed care plan has enrollees, including rural areas. 17 Section 5-65. Fairness in contracting. All managed care 18 plans must provide that any individual physician, any 19 pharmacy, any federally qualified health center, any dentist, 20 and any podiatrist, that consistently meets the reasonable 21 terms and conditions established by a managed care plan 22 including, but not limited to credentialing standards, 23 adherence to quality assurance program requirements, 24 utilization management guidelines, contract procedures, and 25 provider network size and accessibility requirements must be 26 accepted by the managed care plan. Any physician or any 27 other health care provider who is either terminated from or 28 denied inclusion in the provider network of the managed care 29 plan shall be given, within 10 business days after that 30 determination, a written explanation of the reasons for his 31 or her exclusion or termination from the provider network and 32 an opportunity to appeal. -15- LRB9008923JSgcA 1 Section 5-70. Managed care plan health care delivery 2 policy advisory system. 3 (a) The managed care plan shall organize its network of 4 providers for the purpose of electing a Health Care Delivery 5 Policy Advisory Board from participants in the plan. The 6 Health Care Delivery Policy Advisory Board shall be 7 representative of the health care providers in the network 8 providing health care services to enrollees with at least 9 one-third participating physicians, one-third other 10 participating providers and one-third enrollees. This Board 11 shall establish written rules and regulations for its 12 deliberations. The managed care plan must approve the rules 13 and may not unilaterally amend the rules. The managed care 14 plan shall grant the Board defined rights under which the 15 Board collaborates with the managed care plan to establish 16 the plan's health care delivery policy (including, but not 17 limited to, delivery of any covered: (i) health care 18 services, (ii) pharmaceuticals, (iii) procedures and (iv) 19 technology), utilization review criteria and procedures, 20 quality assurance procedures used by plan or any utilization 21 review programs employed by the plan, credentialing criteria, 22 and medical management procedures. The Board may make 23 recommendations on health care delivery policies, but shall 24 not determine the managed care plan's covered services. The 25 Board shall report directly to the managed care plan's 26 governing body. 27 (b) The Board's rules and regulations shall provide due 28 process procedures for all actions granting, reducing, 29 restricting, suspending, revoking, denying or not renewing 30 provider network membership and privileges. The managed care 31 plan's governing body shall not control evaluation of 32 credentials of applicants for provider network membership and 33 privileges or the exercise of professional judgment. The 34 managed care plan's governing body shall make all final -16- LRB9008923JSgcA 1 provider network membership and privilege decisions. The 2 Department shall develop standardized application forms for 3 credentialing. This information shall be verified by the 4 managed care plans from primary sources. 5 Section 5-75. Credentialing. 6 (a) A managed care plan shall allow all physicians 7 within the managed care plans' geographic service area to 8 apply for a contract and clinical privileges or credentials 9 to provide services to the managed care plan under rules 10 established by the Health Care Delivery Policy Advisory Board 11 and approved by the managed care plan's governing body. This 12 process is referred to as credentialing. All physicians 13 within the managed care plan shall be recredentialed no more 14 often than once every 2 years. The Health Care Delivery 15 Policy Advisory Board shall at a minimum establish the 16 following: 17 (1) Written procedures relating to the acceptance 18 and processing of initial applicants for contracts and 19 written procedures for making renewal and adverse 20 decisions concerning health care providers who have a 21 contract with the managed care plan. 22 (2) Written procedures to be followed in determining 23 an applicant's qualifications for being granted a 24 contract. 25 (3) Written criteria to be followed in evaluating 26 qualifications. Credentialing shall be based on objective 27 standards of quality with input from physicians 28 credentialed in the managed care plan. The standards 29 shall be available to applicants and physicians 30 credentialed in the managed care plan. Any profiling of 31 physicians must be adjusted to recognize case mix, 32 severity of illness, age of patients and other features 33 of a physician's practice including all economic factors -17- LRB9008923JSgcA 1 that may account for higher than or lower than expected 2 costs. Profiles must be made available to those so 3 profiled. When graduate medical education is a 4 consideration in credentialing, equal recognition shall 5 be given to training programs accredited by the 6 Accrediting Council on Graduate Medical Education and by 7 the American Osteopathic Association. The lack of board 8 certification may not be the single or exclusive criteria 9 for denial of participation. 10 (4) An evaluation of an applicant's or contractee's 11 current health status and current license status in 12 Illinois. 13 (5) A written notice to each applicant and 14 contractee that explains the reason or reasons for any 15 adverse decision, including all reasons based in whole or 16 in part on the applicant's or contractee's medical 17 qualification or any other basis including economic 18 factors. 19 (b) In accordance with the criteria in this subsection 20 and subsection (c), credentialing shall be performed in a 21 timely manner by a credentialing committee established by the 22 Health Care Delivery Policy Advisory Board directly or 23 through a contract with a physician organization approved by 24 Health Care Delivery Policy Advisory Board and managed care 25 plan's governing body. The credentialing Committee shall have 26 representation of the applicant's medical speciality. The 27 credentialing process shall be completed in a timely manner 28 not to exceed 3 months. The managed care plan shall inform 29 physicians and other health care providers of credentialing 30 decisions within 3 months of receiving a completed 31 application. Failure to provide this notice shall result in 32 a fine under this Act. For purposes of credentialing: 33 "Adverse decision" means a decision reducing, restricting, 34 suspending, revoking, denying, or not renewing medical staff -18- LRB9008923JSgcA 1 membership including, but not limited to, limitations on 2 access to institutional equipment, facilities and personnel. 3 "Economic factor" means any information or reasons for 4 decisions unrelated to quality of care or professional 5 competency. 6 (1) A managed care plan is prohibited from excluding 7 health care providers solely because those health care 8 providers treat a substantial number of patients with 9 conditions or illnesses that may require costly care or 10 treatment. 11 (2) The Health Care Delivery Policy Advisory Board 12 shall make credentialing recommendations to the managed 13 care plan's governing body. All governing body 14 credentialing decisions shall be made on the record, and 15 the applicant shall be provided with all reasons used if 16 the application is denied or the credentials not renewed. 17 (c)(1) A managed care plan may not make an adverse 18 credentialing decision including termination of a 19 contract of employment or refuse to renew a contract on 20 the basis of any action protected under this Act or 21 solely because a health care provider has: 22 (A) filed a complaint against the managed care 23 plan; 24 (B) appealed a decision of the managed care 25 plan; or 26 (C) requested a hearing pursuant to this 27 Section. 28 (2) A managed care plan shall provide to a health 29 care provider, in writing, notice of and the reasons for 30 any adverse decision. 31 (3) A managed care plan shall provide an opportunity 32 for a hearing to any health care provider prior to 33 implementation of any adverse decision, if the health 34 care provider has had a contract or contracts with the -19- LRB9008923JSgcA 1 managed care plan for at least 12 of the past 18 months. 2 (4) After the notice provided pursuant to item (2), 3 the health care provider shall have 21 days to request a 4 hearing, and the hearing must be held within 15 days 5 after receipt of the request for a hearing. The hearing 6 shall be held before a panel appointed pursuant to the 7 requirements of this Section. The hearing panel shall be 8 composed of 3 individuals, all of whom shall be in the 9 same licensed discipline and, to the extent possible, in 10 the same or similar specialty as the health care provider 11 under review. One member shall be chosen by the managed 12 care plan, one member shall be chosen by the health care 13 provider and one shall be chosen by the plan and health 14 care provider from a list approved by the Health Care 15 Delivery Policy Advisory Board and approved by the 16 managed care plan's governing body. The hearing panel 17 shall render a written decision on the proposed action 18 within 14 business days. The decision shall be one of 19 the following: 20 (A) reinstatement of the health care provider 21 by the managed care plan; 22 (B) provisional reinstatement subject to 23 conditions set forth by the panel; or 24 (C) termination of the health care provider. 25 The decision of the hearing panel shall be final. 26 A decision by the hearing panel to terminate a 27 health care provider shall be effective not less than 60 28 days after the receipt by the health care provider of the 29 hearing panel's decision. 30 A hearing under this subsection shall provide the 31 health care provider in question with the right to 32 examine pertinent information, to present witnesses, to 33 receive a copy of all plan records related to the matter 34 free of charge, and to ask questions of authorized -20- LRB9008923JSgcA 1 representatives of the plan. 2 (5) A managed care plan may terminate or decline to 3 renew a health care provider, without a prior hearing, in 4 cases involving imminent harm to patient care, or a final 5 disciplinary action by a state licensing board or other 6 governmental agency that impairs the health care 7 provider's ability to practice. A health care provider 8 terminated for one of these reasons shall be given 9 written notice to that effect. Within 15 days after the 10 termination, a health care provider shall receive a 11 hearing which shall completed without delay. The hearing 12 shall be held before a panel chosen in the same manner as 13 a panel under item (4). The hearing panel shall issue a 14 written decision as required under item (4). 15 The decision of the hearing panel shall be final. 16 Any hearing under this subsection shall provide the 17 health care provider in question with the right to examine 18 pertinent information, to present witnesses, to receive a 19 copy of all plan records related to the matter free of 20 charge, and to ask questions of an authorized representative 21 of the plan. 22 For any hearing under this Section 5-75, because the 23 candid and conscientious evaluation of clinical practices is 24 essential to the provision of health care, it is the policy 25 of this State to encourage peer review by health care 26 providers. Therefore, no managed care plan and no individual 27 who participates in a hearing or who is a member, agent, or 28 employee of a managed care plan shall be liable for criminal 29 or civil damages or professional discipline as a result of 30 the acts, omissions, decisions, or any other conduct, direct 31 or indirect, associated with a hearing panel, except for 32 wilful and wanton misconduct. Nothing in this Section shall 33 relieve any person, health care provider, health care 34 professional, facility, organization, or corporation from -21- LRB9008923JSgcA 1 liability for his, her, or its own negligence in the 2 performance of his, her, or its duties or arising from 3 treatment of a patient. The hearing panel information shall 4 not be subject to inspection or disclosure and shall be 5 afforded the same status as is provided information 6 concerning medical studies in Part 21 of Article VIII of the 7 Code of Civil Procedure. 8 (d) Every adverse credentialing decision based 9 substantially on economic factors shall be reported by the 10 managed care plan's governing body to the Board of Health 11 before the decision takes effect. These reports shall not be 12 disclosed in any form that reveals the identity of any health 13 care providers. These reports shall be utilized to study the 14 effects that credentialing decisions based upon economic 15 factors have on access to care and the availability of health 16 care services. The Board of Health shall submit an initial 17 study to the Governor and the General Assembly by July 1, 18 1999, and subsequent reports shall be submitted periodically 19 thereafter. 20 Section 5-80. Records. Procedures shall be established 21 to ensure that all applicable federal and State laws designed 22 to protect the confidentiality of health care provider 23 records and individual medical records are followed. These 24 records shall be afforded the protections of Section 8-2101 25 through 8-2105 of the Code of Civil Procedure and may not be 26 disclosed to any court, tribunal or board except in 27 accordance with this provision. 28 Section 5-85. Health care provider termination. 29 (a) The Director shall adopt rules requiring that all 30 participating provider agreements contain provisions 31 concerning timely and reasonable notices to be given between 32 the parties and for the managed care plan to provide timely -22- LRB9008923JSgcA 1 and reasonable notice to its enrollees. In order to 2 facilitate transfer of health care services, reasonable 3 advance notice of health care provider termination shall be 4 given to the health care provider and enrollees. Notice 5 shall be given for events including, but not limited to, 6 termination of health care provider agreements or managed 7 care plan services. Notice of provider termination to 8 enrollees shall be in a form approved by the Director. 9 (b) When a managed care plan terminates a contract with 10 an entire medical group, physician organization, or other 11 health care provider organization, the managed care plan 12 shall notify enrollees who have selected that medical group, 13 physician organization or other health care provider 14 organization of the termination. 15 (c) When a managed care plan terminates a contractual 16 arrangement with an individual health care provider within a 17 medical group, physician organization, or other health care 18 provider organization, the managed care plan may request that 19 medical group, physician organization or other health care 20 provider organization to notify the enrollees who are 21 patients of that health care provider of the termination. 22 Section 5-90. Complaint handling procedure. 23 (a) A managed care plan and utilization review program 24 shall establish and maintain a complaint system providing 25 reasonable procedures for resolving complaints initiated by 26 enrollees or health care providers (complainant). Nothing 27 herein shall be construed to preclude an enrollee or a health 28 care provider from filing a complaint with the Director or as 29 limiting the Director's ability to investigate complaints. 30 In addition, any enrollee or health care provider not 31 satisfied with the plan's resolution of any complaint may 32 appeal that final plan or utilization program decision to the 33 Department for review. -23- LRB9008923JSgcA 1 (b) When a complaint is received by the Department 2 against a managed care plan (respondent), the respondent 3 shall be notified of the complaint. The Department shall, in 4 its notification, specify the date when a report is to be 5 received from the respondent, which shall be no later than 21 6 days after notification is sent to the respondent. A failure 7 to reply by the date specified may be followed by a collect 8 telephone call or collect telegram. Repeated instances of 9 failing to reply by the date specified may result in further 10 regulatory action. 11 (c) Contents of Response or Report. 12 (1) The respondent shall supply adequate 13 documentation that explains all actions taken or not 14 taken and that were the basis for the complaint. 15 (2) Documents necessary to support the respondent's 16 position and information requested by the Department 17 shall be furnished with the respondent's reply. 18 (3) The respondent's reply shall be in duplicate, 19 but duplicate copies of supporting documents shall not be 20 required. 21 (4) The respondent's reply shall include the name, 22 telephone number and address of the individual assigned 23 to investigate or process the complaint. 24 (5) The Department shall respect the confidentiality 25 of medical reports and other documents that by law are 26 confidential. Any other information furnished by a 27 respondent shall be marked "confidential" if the 28 respondent does not wish it to be released to the 29 complainant. 30 (d) The Director shall review the plan decision to 31 determine whether it is consistent with the plan and Illinois 32 law and rules. The Director may contract with individual 33 licensed health care providers for an impartial review of 34 complaints concerning plan decisions. These individuals -24- LRB9008923JSgcA 1 shall be licensed in the same discipline and, to the extent 2 possible, in the same or similar specialty as the health care 3 provider involved in the action under review. Any licensed 4 professional providing impartial review for the Director who 5 acts in good faith shall have immunity for any civil or 6 criminal liability or professional discipline as a result of 7 acts or omissions with respect to any impartial review, 8 except for wilful and wanton misconduct. For purposes of any 9 proceeding, the good faith of the individual participant is 10 presumed. 11 (e) Follow-up conclusion. Upon receipt of the 12 respondent's report, the Department shall evaluate the 13 material submitted; and 14 (1) advise the complainant of the action taken and 15 disposition of its complaint; 16 (2) pursue further investigation with respondent or 17 complainant; or 18 (3) refer the investigation report to the 19 appropriate branch within the Department for further 20 regulatory action. 21 (f) The Department of Public Health and Department of 22 Insurance shall coordinate the complaint review and 23 investigation and establish joint rules under the Illinois 24 Administrative Procedure Act implementing this coordinated 25 complaint process. 26 Section 5-95. Quality assurance requirements. 27 (a) A managed care plan shall have a Quality Assurance 28 Plan approved by the Health Care Delivery Policy Advisory 29 Board through a designated Quality Assurance Committee or 30 through a contract with a physician organization for 31 measuring, assessing and improving quality. The managed care 32 plan must: 33 (1) Have a written quality assurance plan that sets -25- LRB9008923JSgcA 1 standards and evaluates, at a minimum: 2 (A) Provider availability and accessibility. 3 (B) Appropriateness of care, including the 4 provision of all medically necessary care. 5 (C) Coordination and continuity of care. 6 (D) Patient satisfaction. 7 (2) Assess quality using: 8 (A) Enrollee and provider quality assessment 9 surveys to be conducted at least annually. 10 (B) A log maintained by the managed care plan 11 including utilization review functions identifying 12 the number and types of patient and provider 13 grievances with the resolutions to those issues. 14 (C) Utilization and outcome reports and studies 15 whereby relevant case mix and patient demographic 16 information are taken into account. 17 (3) Establish mechanisms for quality improvement, 18 which include implementation of corrective action plans 19 in response to confirmed quality of care or quality of 20 service identified problems. 21 The Department shall require managed care plans to 22 prepare and submit quarterly aggregate quality assurance 23 reports. These reports shall include, but not be limited to, 24 provider availability and accessibility and patient 25 satisfaction information compiled in aggregate, by diagnosis 26 and by participating provider category. Quality reports must 27 be made available, when requested, to prospective enrollees, 28 enrollees, health care providers and the public. The quality 29 assurance information or data may not be released in any 30 manner that tends to identify any enrollee, patient, or 31 health care provider. This information or data shall be 32 afforded the protections of Section 8-2101 through 8-2105 of 33 the Code of Civil Procedure. 34 (b) A managed care plan shall implement procedures for -26- LRB9008923JSgcA 1 ensuring that all applicable federal and State laws designed 2 to protect the confidentiality of health care provider and 3 individual medical records are followed. 4 Section 5-100. Prohibition of waiver of rights. No 5 managed care plan or contract shall contain any provision in 6 procedure or informal policy or procedure that limits, 7 restricts or waives any of the rights set forth in this Act. 8 Any such policy or procedure shall be void and unenforceable. 9 Section 5-105. Transition of services. 10 (a) If an enrollee's health care provider leaves the 11 managed care plan's network of providers for reasons other 12 than those for which the provider would not be eligible to 13 receive a pretermination hearing pursuant to subsection (b) 14 of Section 5-75, the managed care plan shall permit the 15 enrollee to continue an ongoing course of treatment with the 16 enrollee's current health care provider during a transitional 17 period of: 18 (1) at least 90 days from the date of notice to the 19 enrollee of the provider's disaffiliation from the 20 managed care plan's network; or 21 (2) if the enrollee has entered the third trimester 22 of pregnancy at the time of the provider's 23 disaffiliation, for a transitional period that extends 24 through the provision of post-partum health care services 25 directly related to the delivery. 26 Transitional care, however, shall be authorized by the 27 managed care plan during the transitional period only if the 28 health care provider agrees (i) to continue to accept 29 reimbursement from the managed care plan at the rates 30 applicable prior to the start of the transitional period as 31 payment in full, (ii) to adhere to the managed care plan's 32 quality assurance requirements and to provide to the managed -27- LRB9008923JSgcA 1 care plan necessary medical information related to the care, 2 (iii) to otherwise adhere to the managed care plan's policies 3 and procedures including, but not limited to, procedures 4 regarding referrals and obtaining preauthorization and a 5 treatment plan approved by the primary care provider or 6 specialist in consultation with the managed care plan, and 7 (iv) if the enrollee is a recipient of services under Article 8 V of the Illinois Public Aid Code, the health care provider 9 has not been subject to a final disciplinary action by a 10 state or federal agency for violations of the Medicaid or 11 Medicare program. In no event shall this subsection be 12 construed to require a managed care plan to provide coverage 13 for benefits not otherwise covered. 14 (b) If a new enrollee whose health care provider is not a 15 member of the managed care plan's provider network enrolls in 16 the managed care plan, the managed care plan shall permit the 17 enrollee to continue an ongoing course of treatment with the 18 enrollee's current health care provider during a transitional 19 period of at least 90 days from the effective date of 20 enrollment, if (i) the enrollee has an ongoing, recurring or 21 chronic disease or condition or (ii) the enrollee has entered 22 the third trimester of pregnancy at the effect date of 23 enrollment, in which case the transitional period shall 24 extend through the provision of post-partum health care 25 services directly related to the delivery. If an enrollee 26 elects to continue to receive payment for care from a health 27 care provider pursuant to this subsection, the payment for 28 the health care services shall be authorized by the managed 29 care plan for the transitional period if the health care 30 provider agrees (i) to accept reimbursement from the managed 31 care plan at rates established by the managed care plan as 32 payment in full, which rates shall be no less than the level 33 of reimbursement applicable to participating providers in the 34 managed care plan's network for those services, (ii) to -28- LRB9008923JSgcA 1 adhere to the managed care plan's quality assurance 2 requirements and to provide to the managed care plan 3 necessary medical information related to the care, (iii) to 4 otherwise adhere to the managed care plan's policies and 5 procedures including, but not limited to, procedures 6 regarding referrals and obtaining preauthorization and a 7 treatment plan approved by the primary care provider or 8 specialist in consultation with the managed care plan, and 9 (iv) if the enrollee is a recipient of services under Article 10 V of the Illinois Public Aid Code, the health care provider 11 has not been subject to a final disciplinary action by a 12 state or federal agency for violations of the Medicaid or 13 Medicare program. In no event shall this subsection be 14 construed to require a managed care plan to provide coverage 15 for benefits not otherwise covered. 16 (c) If no participating provider can be engaged to care 17 for the covered health care needs of an enrollee, the managed 18 care plan shall make arrangements for these needs to be met 19 by a non-participating provider with no expense to the 20 enrollee over the expense the enrollee would have incurred 21 had the needs been met by a participating provider. 22 Section 5-110. Grievance procedures. A managed care 23 plan shall establish at least 2 levels of appeal for any 24 enrollee or health care provider grievances. Any grievances 25 concerning an adverse claim decision based on medical 26 necessity shall be heard by a panel of health care providers 27 in the same licensed discipline and, to the extent possible, 28 in the same or similar specialty as the health care provider 29 who made the decision under review. The panel shall be 30 established by the managed care plan in consultation with the 31 Health Care Delivery Policy Advisory Board. 32 Section 5-115. Registry of complaints, grievances, -29- LRB9008923JSgcA 1 appeals and reviews. A managed care plan shall create a 2 registry that coordinates information concerning enrollee and 3 health care provider complaints, grievances and requests for 4 appeals and reviews. This information shall be made 5 available to enrollees and health care providers upon request 6 without personal identifying information. All information 7 contained in and related to this registry shall be expunged 8 after 5 years. 9 ARTICLE 10. LICENSURE OF UTILIZATION REVIEW PROGRAMS 10 Section 10-5. Licensed utilization review programs. 11 (a) The Director shall establish standards for the 12 licensure of utilization review programs. 13 (b) All programs must have a medical director, who is a 14 physician licensed to practice medicine in all its branches, 15 responsible for all decisions by the program and who shall 16 assure that the medical necessity review practices they use, 17 and the medical necessity review of payors or reviewers with 18 whom they contract, comply with the following requirements: 19 (1) Screening criteria, weighting elements, and 20 computer algorithms utilized in the medical necessity 21 review process and their method of development, must be 22 released to participating providers and be made 23 available to the public. 24 (2) The medical necessity criteria including, but 25 not limited to, preadmission, appropriateness review, 26 length of stay, discharge planning, follow-up care, and 27 medically acceptable treatment alternatives must be 28 based on sound scientific principles and developed in 29 cooperation with practicing physicians, other affected 30 health care providers, and consumer representatives. A 31 managed care plan's Health Care Delivery Policy Advisory 32 Board may be utilized for this purpose. -30- LRB9008923JSgcA 1 (3) Any person who recommends denial of coverage 2 or payment, or determines that a service shall not be 3 provided, based on medical necessity, must be licensed in 4 Illinois and of the same licensed profession as the 5 health care provider who provided, ordered, or proposed 6 the services. The basis for any denial and the name, 7 address, telephone and facsimile number, licensure, and 8 qualifications of the person making any denials shall be 9 provided in writing. 10 (4) An enrollee or provider (upon assignment of an 11 enrollee) who has had a claim denied as not medically 12 necessary must be provided an opportunity for a due 13 process appeal to a qualified physician consultant or 14 qualified provider peer review group not involved in the 15 initial review. 16 (5) Upon request, physicians and other affected 17 health care providers shall be provided the names and 18 credentials of all individuals conducting medical 19 necessity review, subject to reasonable safeguards and 20 standards. 21 (6) In accordance with Section 5-40, prior 22 authorization shall not be required for care for an 23 emergency condition, and patient or health care provider 24 requests for prior authorization of a non-emergency 25 health care service must be answered within 24 hours of 26 the request. 27 (7) Qualified personnel with the minimum licensure 28 status of registered professional nurse must be available 29 for same-day telephone responses to inquiries about 30 medical necessity, including certification of continued 31 length of stay. 32 (8) Programs and managed care plans must ensure 33 that enrollees, in managed care plans where prior 34 authorization is a condition to coverage of a service, -31- LRB9008923JSgcA 1 are informed in writing of the reasons medical 2 information is needed and provide appropriate medical 3 information release consent forms for use where services 4 requiring prior authorization are recommended or 5 proposed by their participating providers. 6 (9) When prior approval for a service or other 7 covered item is obtained, it shall be considered approval 8 for the purpose requested, and the service shall be 9 considered to be covered, in accordance with Section 10 5-30. 11 (10) Programs and managed care plans shall disclose 12 to the enrollees, prospective enrollees, and health care 13 providers, in writing, any financial incentives or other 14 inducements to individuals performing medical necessity 15 reviews and their qualifications. 16 Section 10-10. Application of licensure standards. 17 (a) Standards shall first be established, under this 18 Article, by no later than 18 months after the date of the 19 enactment of this Act. In developing standards under this 20 Article, the Director shall: 21 (1) review standards in use by national private 22 accreditation organizations; 23 (2) recognize, to the extent appropriate, 24 differences in the organizational structure and operation 25 of utilization review programs; 26 (3) establish procedures for the timely 27 consideration of applications for licensure of 28 utilization review programs; and 29 (4) establish grievance procedures for enrollees 30 and participating providers to appeal utilization review 31 program decisions. 32 (b) The Director shall periodically review the standards 33 established under this Article, and may revise the standards -32- LRB9008923JSgcA 1 from time to time to assure that the standards continue to 2 reflect appropriate policies and practices for the 3 cost-effective and medically appropriate use of health care 4 services within utilization review programs. 5 ARTICLE 20. ADMINISTRATION AND ENFORCEMENT 6 Section 20-5. Responsibilities of the Department. 7 (a) All managed care plans shall bi-annually certify 8 compliance with this Act and utilization review programs 9 providing or reviewing services in Illinois shall be licensed 10 by the Department under rules adopted under this Act. The 11 Director shall establish by rule a process for this 12 certification and licensure including fees to cover the costs 13 associated with implementing the Act. All fees and fines 14 assessed under the Act shall be deposited in Managed Care 15 Entity Responsibility and Patient Rights Fund hereby created 16 as a special fund in the State treasury. For health 17 maintenance organizations, the certification requirements of 18 this Act shall be incorporated into the licensure 19 requirements under the Health Maintenance Organization Act. 20 In addition, the certification requirements of this Act shall 21 be incorporated into the program requirements of the 22 Department of Public Aid and Department of Human Services and 23 no further certification under this Act is required. 24 (b) The Director shall take any appropriate enforcement 25 action under this Act including, but not limited to, the 26 assessment of civil fines and seeking injunctive relief for 27 any failure to certify compliance with this Act or obtain a 28 license under this Act or any violation of the Act or rules 29 by a managed care plan or any utilization review program. 30 (c) The Department shall have the authority to impose 31 fines on any managed care plan or any utilization review 32 program. The Department shall adopt rules pursuant to this -33- LRB9008923JSgcA 1 Act which 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 individual. 11 These rules shall include an opportunity for a hearing in 12 accordance with the Illinois Administrative Procedure 13 Act. All final decisions of the Department shall be 14 reviewable under the Administrative Review Law. 15 (d) Notwithstanding the existence or pursuit of any 16 other remedy, the Director may, through the Attorney General, 17 seek an injunction to restrain or prevent any person or 18 entity from functioning, or operating in violation of this 19 Act or rules adopted under this Act. 20 (e) The Department shall adopt rules for managed care 21 plan certification and utilization review program licensure 22 under this Act that shall include, but not be limited to, the 23 following: 24 (1) Further definition of managed care plans and 25 utilization review programs. 26 (2) Information required by the Department. 27 (3) Certification requirements for managed care 28 plans and utilization review programs. 29 (4) Certification and licensure programs and renewal 30 fees which may cover the cost of administering the 31 programs. 32 (5) Information including mandated reports that may 33 be necessary for the Department to monitor and evaluate, 34 managed care plans and utilization review programs. -34- LRB9008923JSgcA 1 These reports shall include but not be limited to 2 coverage decisions, credentialing decisions, 3 participating provider capacity and any other necessary 4 information. 5 (6) Administrative fines that may be assessed 6 against managed care plans or utilization review programs 7 by the Department for violations of this Act or the rules 8 adopted under this Act. 9 (f) The Department shall perform inspections of managed 10 care plans and utilization review programs as deemed 11 necessary by the Department to ensure compliance with this 12 Act or the rules adopted under this Act. 13 (g) The Department shall deposit application fees, 14 renewal fees, and fines into the Managed Care Entity 15 Responsibility and Patient Rights Fund. 16 (h) All managed care plan and utilization review program 17 records including any patient records reviewed by the 18 Department shall be afforded the protections of Sections 19 8-2101 through 8-2105 of the Code of Civil Procedure. 20 Section 20-10. Conflicts. To the extent of any conflict 21 between this Act and any other Act, this Act prevails over 22 the conflicting provision. 23 Section 20-15. Illinois Administrative Procedure Act. 24 The Illinois Administrative Procedure Act is hereby expressly 25 adopted and incorporated herein and shall apply to the 26 Department as if all of the provisions of that Act were 27 included in this Act; except that in case of a conflict 28 between the Illinois Administrative Procedure Act and this 29 Act, the provisions of this Act shall control. 30 ARTICLE 90. AMENDATORY PROVISIONS -35- LRB9008923JSgcA 1 Section 90-5. The State Employees Group Insurance Act of 2 1971 is amended by adding Section 6.12 as follows: 3 (5 ILCS 375/6.12 new) 4 Sec. 6.12. Managed Care Patient Rights Act. The program 5 of health benefits is subject to the provisions of the 6 Managed Care Patient Rights Act and Section 356w of the 7 Illinois Insurance Code. 8 Section 90-10. The Counties Code is amended by adding 9 Section 5-1069.8 as follows: 10 (55 ILCS 5/5-1069.8 new) 11 Sec. 5-1069.8. Managed Care Patient Rights Act. All 12 counties, including home rule counties, are subject to the 13 provisions of the Managed Care Patient Rights Act and Section 14 356w of the Illinois Insurance Code. The requirement under 15 this Section that health care benefits provided by counties 16 comply with the Managed Care Patient Rights Act is an 17 exclusive power and function of the State and is a denial and 18 limitation of home rule county powers under Article VII, 19 Section 6, subsection (h) of the Illinois Constitution. 20 Section 90-15. The Illinois Municipal Code is amended by 21 adding 10-4-2.8 as follows: 22 (65 ILCS 5/10-4-2.8 new) 23 Sec. 10-4-2.8. Managed Care Patient Rights Act. The 24 corporate authorities of all municipalities are subject to 25 the provisions of the Managed Care Patient Rights Act and 26 Section 356w of the Illinois Insurance Code. The requirement 27 under this Section that health care benefits provided by 28 municipalities comply with the Managed Care Patient Rights 29 Act is an exclusive power and function of the State and is a -36- LRB9008923JSgcA 1 denial and limitation of home rule municipality powers under 2 Article VII, Section 6, subsection (h) of the Illinois 3 Constitution. 4 Section 90-20. The Illinois Insurance Code is changed by 5 adding Sections 155.36, 356w, 370s, and 511.118 as follows: 6 (215 ILCS 5/155.36 new) 7 Sec. 155.36. Managed Care Patient Rights Act provisions. 8 Insurance companies providing coverage for health care 9 services are subject to the provisions of the Managed Care 10 Patient Rights Act. The provisions of Article 10 shall be 11 implemented through existing Department of Public Health 12 certification procedures. 13 (215 ILCS 5/356w new) 14 Sec. 356w. Choice requirements for point of service 15 plans. 16 (a) An employer, self-insured entity, labor union, 17 association, or other person providing, offering, or making 18 available to employees or individuals a managed care plan, 19 as defined in the Managed Care Patient Rights Act, shall 20 offer to all enrollees the opportunity to obtain coverage 21 through a "point of service" plan at the time of enrollment 22 and once annually thereafter. The "point of service" plan 23 shall provide coverage for health care services when the 24 health care services are provided by any health care provider 25 without the necessary referrals, prior authorization, or 26 other utilization review requirements of the managed care 27 plan. 28 (b) A point of service plan may charge an enrollee who 29 opts to obtain point of service coverage an alternative 30 premium that takes into account the actuarial value of the 31 coverage. -37- LRB9008923JSgcA 1 (c) A point of service plan may require reasonable 2 payment of coinsurance, co-payments, or deductibles. The 3 co-insurance rate on the point of service plan shall not be 4 greater than 20 percentage points more than the co-insurance 5 rate on the underlying plan. The maximum out-of-pocket 6 amount shall not exceed $5,000 for an individual and $7,500 7 for family coverage. 8 (215 ILCS 5/370s new) 9 Sec. 370s. Managed Care Patient Rights Act. All 10 insurers and administrators are subject to the provisions of 11 the Managed Care Patient Rights Act and Section 356w of this 12 Code. 13 (215 ILCS 5/511.118 new) 14 Sec. 511.118. Managed Care Patient Rights Act. All 15 administrators are subject to the provisions of the Managed 16 Care Patient Rights Act and Section 356w of this Code. 17 Section 90-25. The Comprehensive Health Insurance Plan 18 Act is amended by adding Section 8.6 as follows: 19 (215 ILCS 105/8.6 new) 20 Sec. 8.6. Managed Care Patient Rights Act. The plan 21 shall be subject to the provisions of the Managed Care 22 Patient Rights Act and Section 356w of the Illinois Insurance 23 Code. 24 Section 90-30. The Health Maintenance Organization Act 25 is amended by adding Section 5-3.6 as follows: 26 (215 ILCS 125/5-3.6 new) 27 Sec. 5-3.6. Managed Care Patient Rights Act provisions. 28 Health maintenance organizations are subject to the -38- LRB9008923JSgcA 1 provisions of the Managed Care Patient Rights Act and Section 2 356w of the Illinois Insurance Code. 3 Section 90-35. The Limited Health Services Organization 4 Act is amended by adding Section 4002.6 as follows: 5 (215 ILCS 130/4002.6 new) 6 Sec. 4002.6. Managed Care Patient Rights Act 7 provisions. Limited health service organizations are subject 8 to the provisions of the Managed Care Patient Rights Act and 9 Section 356w of the Illinois Insurance Code. 10 Section 90-40. The Dental Service Plan Act is amended by 11 adding Section 48 as follows: 12 (215 ILCS 110/48 new) 13 Sec. 48. Managed Care Patient Rights Act provisions. 14 Dental Service Plans are subject to the provisions of the 15 Managed Care Patient Rights Act and Section 356w of the 16 Illinois Insurance Code. For purposes of the Dental Service 17 Plan Act the term physician as used in the Managed Care 18 Patient Rights Act shall mean dentist. 19 Section 90-45. The Voluntary Health Services Plans Act 20 is amended by adding Section 15.30 as follows: 21 (215 ILCS 165/15.30 new) 22 Sec. 15.30. Managed Care Patient Rights Act. A health 23 service plan corporation is subject to the provisions of the 24 Managed Care Patient Rights Act and Section 356w of the 25 Illinois Insurance Code. 26 Section 90-50. The Illinois Public Aid Code is amended 27 by adding Section 5-16.12 as follows: -39- LRB9008923JSgcA 1 (305 ILCS 5/5-16.12 new) 2 Sec. 5-16.12. Managed Care Patient Rights Act. The 3 medical assistance program is subject to the provisions of 4 the Managed Care Patient Rights Act and Section 356w of the 5 Illinois Insurance Code. The Department shall adopt rules to 6 implement these provisions. These rules shall require 7 compliance with Article 5, and Section 10-5(b) of Article 10 8 of the Managed Care Patient Rights Act in the medical 9 assistance managed care programs. The medical assistance 10 fee-for-service program is not subject to the provisions of 11 the Managed Care Patient Rights Act. 12 Section 400. The State Finance Act is amended by adding 13 Section 5.480 as follows: 14 (30 ILCS 105/5.480 new) 15 Sec. 5.480. The Managed Care Entity Responsibility and 16 Patient Rights Fund. 17 ARTICLE 99. EFFECTIVE DATE 18 Section 99-1. Effective date. This Act takes effect 19 upon becoming law.
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