State of Illinois
90th General Assembly

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      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.
 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-               LRB9011135JSdvB
 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-               LRB9011135JSdvB
 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-               LRB9011135JSdvB
 1    services  as  defined  by the contract and who is a physician
 2    licensed to practice medicine in  all  of  its  branches  who
 3    spends  a  majority  of  clinical  time  engaged  in  general
 4    practice or in the practice of internal medicine, pediatrics,
 5    gynecology, obstetrics, or family practice.
 6        "Provider"  means  any  physician,  hospital facility, or
 7    other person which is licensed  or  otherwise  authorized  to
 8    furnish  health  care  services  and  also includes any other
 9    entity that arranges for the delivery or furnishing of health
10    care services.
11        "Stabilization" means the provision of medical  treatment
12    to  assure  within  reasonable  medical  probability  that no
13    material deterioration of the condition is likely  to  result
14    from the transfer of the individual from a facility.
15        "Utilization    review"    means   the   study   of   the
16    appropriateness of the use of  particular  services  and  the
17    appropriateness of the volume of services used.
18        "Utilization  review  program" means an entity performing
19    utilization  review,  except  an  agency   of   the   federal
20    government or its agent, but only to the extent that agent is
21    providing services to the federal government.
22        Section  15.  Patient  rights.  The  following rights are
23    hereby established:
24        (1)  The right  of  each  patient  to  be  provided  with
25    information  about  the  health  care  plan and the providers
26    rendering care.  For health care plans this right  calls  for
27    compliance with Section 20 of this Act.
28        (2)  The  right  of  each patient to a full disclosure of
29    the patient costs, benefits, risks, and alternatives  related
30    to the treatment options and care, including health care plan
31    requirements, coverage, exclusions, or limitations that could
32    affect   the  enrollee's  access  to  coverage  or  treatment
33    options.   For  health  care  plans  this  right  calls   for
                            -5-               LRB9011135JSdvB
 1    compliance  with Section 25 of this Act.  Insurance companies
 2    and health care plans  are  prohibited  from  terminating  or
 3    suspending   a  provider  from  its  network  for  advocating
 4    appropriate  health  care  services  because   the   provider
 5    advocated  for  what  he  or she considered to be appropriate
 6    health care.
 7        (3)  The right of each patient to care,  consistent  with
 8    nursing  and medical practices, to be informed of the name of
 9    the physician responsible for coordinating his or  her  care,
10    to  receive  information from his or her physician concerning
11    his or her condition and proposed treatment,  to  refuse  any
12    treatment to the extent permitted by law,  and to privacy and
13    confidentiality  of  records  except as otherwise provided by
14    law.
15        (4)  The right of each patient, regardless of  source  of
16    payment,  to  examine and receive a reasonable explanation of
17    his or her total bill for  services  where  such  a  bill  is
18    rendered  by  his  or  her physician or health care provider,
19    including  the  itemized  charges   for   specific   services
20    received. Each provider shall be responsible for a reasonable
21    explanation  of  those  specific  services  provided  by such
22    physician or health care provider.
23        (5)  In the event an insurance  company  or  health  care
24    plan  cancels  or  refuses  to  renew an individual policy or
25    plan, the insured or enrollee shall be  entitled  to  timely,
26    prior notice of the termination of such policy or plan.
27        An  insurance  company  or health care plan that requires
28    any insured, enrollee, or  applicant  for  new  or  continued
29    insurance  or coverage to be tested for infection with HIV or
30    any other identified causative agent of AIDS shall  (i)  give
31    the  patient  or  applicant  prior  written  notice  of  such
32    requirement,  (ii)  proceed  with  such testing only upon the
33    written authorization of the insured, enrollee, or applicant,
34    and (iii) keep the  results  of  such  testing  confidential.
                            -6-               LRB9011135JSdvB
 1    Notice of an adverse underwriting or coverage decision may be
 2    given   to   any  appropriately  interested  party,  but  the
 3    insurance company or health care plan may only  disclose  the
 4    test  result itself to a physician designated by the insured,
 5    enrollee or applicant, and any such disclosure shall be in  a
 6    manner that assures confidentiality.
 7        (6)  At the time of renewal, the right of each patient to
 8    notification  of  termination  or  change  in  any  benefits,
 9    services, or service delivery location.
10        (7)  The   right   of   each   patient   to  privacy  and
11    confidentiality in health care.  Each physician, health  care
12    provider,  health  care  plan and insurance company shall not
13    disclose the  nature  or  details  of  services  provided  to
14    insureds  and  enrollees, except that such information may be
15    disclosed  to  the  patient,  the  party   making   treatment
16    decisions  if  the  patient  is incapable of making decisions
17    regarding  the  health  services  provided,   those   parties
18    directly  involved with providing treatment to the patient or
19    processing the payment  for  that  treatment,  those  parties
20    responsible  for  peer review, utilization review and quality
21    assurance, and those parties required to  be  notified  under
22    the  Abused  and  Neglected Child Reporting Act, the Illinois
23    Sexually Transmissible Disease Control Act or where otherwise
24    authorized or required by law.  This right may be  waived  in
25    writing  by  the  patient  or  the  patient's guardian, but a
26    physician or other health care provider may not condition the
27    provision  of  services  on  the  patient's   or   guardian's
28    agreement to sign such a waiver.
29        Section 20. Provision of information.
30        (a)  A health care plan shall provide to enrollees a list
31    of  primary care physicians in the health care plan's service
32    area and an evidence of coverage that contains a  description
33    of the following terms of coverage:
                            -7-               LRB9011135JSdvB
 1             (1)  The service area.
 2             (2)  Covered benefits, exclusions or limitations.
 3             (3)  Precertification  and  other utilization review
 4        procedures and requirements.
 5             (4)  A description of the limitations on  access  to
 6        specialists.
 7             (5)  Emergency coverage and benefits.
 8             (6)  Out-of-area coverages and benefits, if any.
 9             (7)  The  enrollee's  financial  responsibility  for
10        copayments,  deductibles,  and  any  other  out-of-pocket
11        expenses.
12             (8)  Provisions  for  continuity of treatment in the
13        event a provider's participation  terminates  during  the
14        course  of  an  insured's or enrollee's treatment by that
15        provider.
16             (9)  The grievance process, including the  telephone
17        number   to   call   to  receive  information  concerning
18        grievance procedures.
19        (b)  Upon written  request,  a  health  care  plan  shall
20    provide   to   enrollees   a  description  of  the  financial
21    relationships between the health care plan and any  provider,
22    except that no health care plan shall be required to disclose
23    specific reimbursement to  providers.
24        (c)  A  participating  provider  shall provide all of the
25    following to enrollees upon request:
26             (1)  Information  related   to   the   health   care
27        professional's    educational   background,   experience,
28        training,  specialty,   and   board   certification,   if
29        applicable.
30             (2)  The   names   of  licensed  facilities  on  the
31        provider panel where the health   professional  presently
32        has  privileges  for the treatment, illness, or procedure
33        that is the subject of the request.
34             (3)  Information   regarding   the    health    care
                            -8-               LRB9011135JSdvB
 1        professional's   participation  in  continuing  education
 2        programs   and    compliance    with    any    licensure,
 3        certification,    or    registration   requirements,   if
 4        applicable.
 5        Section  25.  Prohibited  restraints  on   communication.
 6    Nothing  in  a  physician's  contract with a health care plan
 7    shall be construed to  impair  the  physician's  ethical  and
 8    legal  duty  to  provide  full  informed  consent and medical
 9    counsel to enrollees, including full discussion of the costs,
10    benefits, risks, and alternatives related to  the  enrollee's
11    treatment  options  and  care  and  health care plan policies
12    related  to  those  options,  including  health   care   plan
13    requirements,  coverage,  exclusions,  or  other  policies or
14    practices  that  affect  enrollees'  access  to  coverage  or
15    treatment options.
16        Section 30. Access to personnel and facilities.
17        (a)  A health care plan shall include a sufficient number
18    and  type  of  primary  care    physicians  and  specialists,
19    throughout the service area, to meet the needs  of  enrollees
20    and  to  provide meaningful choice.  A health care plan shall
21    offer:
22             (1)  accessible acute care hospital services, within
23        a reasonable distance or travel  time;
24             (2)  primary care physicians,  within  a  reasonable
25        distance or travel time; and
26             (3)  specialists  within  a  reasonable  distance or
27        travel time.
28        When the type of medical service needed  for  a  specific
29    condition  is  not  represented  in the provider network, the
30    health care plan shall  arrange  for  the  enrollee  to  have
31    access    to    qualified    nonparticipating   health   care
32    professionals as authorized by the primary care physician.
                            -9-               LRB9011135JSdvB
 1        (b)  A health care plan shall provide telephone access to
 2    the health care plan  for  sufficient  time  during  business
 3    hours to assure enrollee access for routine care, and 24 hour
 4    telephone  access to the health care plan or, if so delegated
 5    by the health care plan, a participating physician  or  group
 6    for emergency care or authorization for care.
 7        (c)  A   health  care  plan  shall  establish  reasonable
 8    standards for waiting times to obtain appointments, except as
 9    provided below for emergency services.
10        Such  standards  shall  include  appointment   scheduling
11    guidelines  used  for  each  type  of  health  care  service,
12    including  prenatal  care appointments, well-child visits and
13    immunizations, routine physicals, follow-up appointments  for
14    chronic conditions, and urgent care.
15        (d)  A  health  care plan shall provide for continuity of
16    care for its enrollees as follows:
17             (1)  If an enrollee's physician  leaves  the  health
18        care  plan's  network of providers for reasons other than
19        termination with cause and the physician  remains  within
20        the health care plan's service area, the health care plan
21        shall  permit  the enrollee to continue an ongoing course
22        of treatment with that physician  during  a  transitional
23        period of:
24                  (A)  up  to 60 days from the date of the notice
25             of physician's termination from the health care plan
26             network  to  the   enrollee   of   the   physician's
27             disaffiliation  from  the health care plan's network
28             if the enrollee has a life  threatening  disease  or
29             condition; or
30                  (B)  if  the  enrollee  has  entered  the third
31             trimester  of  pregnancy  at   the   time   of   the
32             physician's   disaffiliation,   for  a  transitional
33             period that includes the  provision  of  post-partum
34             care directly related to the delivery.
                            -10-              LRB9011135JSdvB
 1             (2)  Notwithstanding  the  provisions in item (1) of
 2        this subsection, such care shall  be  authorized  by  the
 3        health  care  plan during the transitional period only if
 4        the physician agrees:
 5                  (A)  to continue to accept  reimbursement  from
 6             the  health  care plan at the rates applicable prior
 7             to the start of the transitional period  as  payment
 8             in full;
 9                  (B)  to   adhere  to  the  health  care  plan's
10             quality assurance requirements and to provide to the
11             health  care  plan  necessary  medical   information
12             related to  such care; and
13                  (C)  to  otherwise adhere to the organization's
14             policies and procedures,  including but not  limited
15             to  procedures  regarding  referrals  and  obtaining
16             preauthorizations  and  a treatment plan approved by
17             the health care plan.
18        (e)  A health care plan shall provide for  continuity  of
19    care for new enrollees as follows:
20             (1)  If  a  new  enrollee  whose  physician is not a
21        member of the health care plan's provider network, but is
22        within the health care plan's service  area,  enrolls  in
23        the  health  care plan, the health care plan shall permit
24        the enrollee to continue an ongoing course  of  treatment
25        with   the   enrollee's   current   physician   during  a
26        transitional period of up to 60 days from  the  effective
27        date of enrollment, if:
28                  (A)  the   enrollee   has   a  life-threatening
29             disease or condition; or
30                  (B)  the  enrollee  has   entered   the   third
31             trimester  of  pregnancy  at  the  effective date of
32             enrollment, in which case  the  transitional  period
33             shall  include  the  provision  of  post-partum care
34             directly related to the delivery.
                            -11-              LRB9011135JSdvB
 1             (2)  If an enrollee elects to  continue  to  receive
 2        care  from  such  physician  pursuant to item (1) of this
 3        subsection, such care shall be authorized by  the  health
 4        care  plan  for  the  transitional  period  only  if  the
 5        physician agrees:
 6                  (A)  to  accept  reimbursement  from the health
 7             care plan at rates established by  the  health  care
 8             plan as payment in full, such rates shall be no more
 9             than   the  level  of  reimbursement  applicable  to
10             similar physicians within  the  health  care  plan's
11             network for such services;
12                  (B)  to   adhere  to  the  health  care  plan's
13             quality  assurance  requirements  and    agrees   to
14             provide  to  the  health care plan necessary medical
15             information  related to such care; and
16                  (C)  to otherwise adhere  to  the  health  care
17             plan's  policies  and procedures  including, but not
18             limited  to  procedures  regarding   referrals   and
19             obtaining    preauthorization  and  a treatment plan
20             approved by the health care  plan.     In  no  event
21             shall  this section be construed to require a health
22             care plan to   provide  coverage  for  benefits  not
23             otherwise   covered   or  to  diminish  or    impair
24             preexisting condition limitations contained  in  the
25             subscriber's  contract.
26        Section 35. Emergency services.
27        (a)  Health  care  plans  shall provide reimbursement for
28    covered emergency services provided  at  a  participating  or
29    nonparticipating  emergency  department  up  to  the point of
30    stabilization of an enrollee.
31        (b)  Once  the  enrollee  is  stabilized,  the  emergency
32    department shall contact the primary care physician or health
33    care plan as specified on the  identification  card  to  seek
                            -12-              LRB9011135JSdvB
 1    prior  authorization for any additional nonemergency services
 2    beyond stabilization.
 3        (c)  With any  claim  for  reimbursement,  the  emergency
 4    department  shall  provide  the  health  care  plan  with the
 5    medical record documenting the  presenting  symptoms  of  the
 6    enrollee  at  the  time  care  was  sought  and the objective
 7    findings of the medical examination.
 8        (d)  The   health   care   plan's   medical    director's
 9    determination  of whether the enrollee meets the  standard of
10    emergency shall take into account the presenting symptoms  at
11    the time care was sought.
12        (e)  Health  care  plans may require an enrollee to pay a
13    copayment for emergency services.
14        (f)  Health  care  plans  shall  provide  enrollees  with
15    information on  procedures  for  the  coverage  of  emergency
16    services both inside and out of the plan service area.
17        Section 40. Grievance procedures.
18        (a)  Every   health   care  plan  shall  submit  for  the
19    Director's approval, and thereafter maintain,  a  system  for
20    the  resolution  of  grievances  concerning  the provision of
21    health care services or  other matters  concerning  operation
22    of the health care plan as follows.  A health care plan shall
23    do all of the following:
24             (1)  Submit  to  the Director for prior approval any
25        proposed changes to the system by which grievances may be
26        filed and reviewed;
27             (2)  Maintain records on each grievance  filed  with
28        the  health care plan until the grievance is resolved and
29        for a period of at least 3 years to include:
30                  (A)  a copy of the grievance and  the  date  of
31             its filing;
32                  (B)  the date and outcome of all consultations,
33             hearings and hearing findings;
                            -13-              LRB9011135JSdvB
 1                  (C)  the  date  and  decisions  of  any  appeal
 2             proceedings; and
 3                  (D)  the date and proceeding of any litigation.
 4             (3)  Submit  to the Director in a form prescribed by
 5        the Director, a  report  by  March  1  for  the  previous
 6        calendar year which shall include at least the following:
 7                  (A)  the total number of grievances handled;
 8                  (B)  a  compilation  of  causes  underlying the
 9             grievances;
10                  (C)  the outcomes of the grievances;
11                  (D)  the  elapsed  time  from  receipt  of  the
12             grievance  by  the  health  care  plan   until   its
13             conclusion; and
14                  (E)  the number of malpractice claims filed and
15             if  such claims have been  completely adjudicated, a
16             compilation of causes, disposition, form, and amount
17             of any settlements.
18        (b)  A health care plan shall have a grievance  committee
19    which  shall  have  the  authority  to  hear  and  resolve by
20    majority vote grievances  submitted  to  it  as  provided  in
21    subsection (a).
22        Notwithstanding any other provisions of this Section, the
23    grievance  committee  may,  but  is not required to, hear any
24    grievance which alleges or  indicates  possible  professional
25    liability, commonly known as "malpractice."
26        The  committee  is not empowered to resolve grievances in
27    any manner which, or  prescribe  any  actions,  that  are  in
28    conflict  with  written  policies  of the health care  plan's
29    governing body, but the committee may  hear  such  grievances
30    for the  purpose of providing input to the governing body.
31        The  grievance committee shall meet at the main office of
32    the health care plan, or such other office designated by  the
33    health care plan where the main office is not within 50 miles
34    of the grievant's home address.  Consideration shall be given
                            -14-              LRB9011135JSdvB
 1    to  the enrollee's request pertaining to the time and date of
 2    such meeting.  The enrollee shall have the  right  to  attend
 3    and  participate  in  the  formal grievance proceedings.  The
 4    enrollee  shall  have  the  right  to  be  accompanied  by  a
 5    designated representative of his or her choice.
 6        The filing of a grievance shall not preclude the enrollee
 7    from filing a complaint  with the  Department  nor  shall  it
 8    preclude  the  Department  from  investigating  a   complaint
 9    pursuant to its authority under Section  4-6  of  the  Health
10    Maintenance Organization Act.
11        (c)  The  grievance  procedures must be fully and clearly
12    communicated to all enrollees and information concerning such
13    procedures shall be readily available to the enrollee.
14        (d)  A health care plan shall have  simplified  procedure
15    for  resolving  complaints.   Such  procedures do not require
16    review of the complaint by the  grievance  committee,  but  a
17    log,  file,  or  other  similar records must be maintained to
18    identify the general nature of such  complaints.   Resolution
19    of such complaints shall not preclude the enrollees' rightful
20    access to review by the grievance committee of a grievance.
21        (e)  The  health  care  plan  shall  institute procedures
22    which would require grievances to have a  determination  made
23    by  the  grievance committee within 60 days from the date the
24    grievance is received by the health care plan.   A  grievance
25    may  not  be  heard  or  voted  upon unless 50% of the voting
26    individuals of the  committee  present  at  the  hearing  are
27    enrollees.   The determination by the grievance committee may
28    be extended for a period not to exceed 30 days in  the  event
29    of  delay in obtaining documents or records necessary for the
30    resolution of the grievance.  All requests for  documents  or
31    records  necessary  for the resolution of the grievance shall
32    be maintained in the health care plan's grievance file.
33        (f)  The grievance procedure shall provide  the  enrollee
34    with  a  written acknowledgment of  their grievance within 10
                            -15-              LRB9011135JSdvB
 1    business days after receipt by the health care plan.
 2        (g)  The enrollee shall be notified at the  time  of  the
 3    hearing  of  the  name  and  affiliation  of  those grievance
 4    committee members who are representatives of the health  care
 5    plan.
 6        (h)  The  health  care  plan  shall  institute procedures
 7    whereby  any  document  furnished  to  the  members  of   the
 8    grievance  committee  shall  also  be  made  available to the
 9    enrollee not less than 5 business days prior to  the  hearing
10    of  their  grievance.  The health care plan shall not present
11    any evidence without  the  enrollee  having  been  given  the
12    opportunity to be present.
13        (i)  Notice  in  writing  of  the  determination  of  the
14    grievance committee shall be mailed to the  enrollee within 5
15    business   days   of   such  determination.   Notice  of  the
16    determination made at the final appeal  step  of  the  health
17    care  plan's  grievance process shall include a notice of the
18    availability of the Department to  receive  complaints  under
19    Section 4-6 of the Health Maintenance Organization Act.
20        (j)  Prior  to  the  resolution of a grievance filed by a
21    subscriber or enrollee, coverage shall not be terminated  for
22    any  reason  which  is  the subject of the written grievance,
23    except where the health care plan has, in good faith, made  a
24    reasonable  effort  to  resolve the written grievance through
25    its grievance procedure and coverage is being terminated as a
26    result of good cause.
27        Section 45. Review of medical necessity.  A  health  care
28    plan  shall  provide  a  mechanism for the timely review by a
29    physician holding the same class of license  as  the  primary
30    care  physician,  who  is unaffiliated with health care plan,
31    jointly selected by the patient (or the patient's next of kin
32    or legal representative if the patient is unable to  act  for
33    himself  or  herself),  primary care physician and the health
                            -16-              LRB9011135JSdvB
 1    care plan in the event of a dispute between the primary  care
 2    physician  and  the  health  care  plan regarding the medical
 3    necessity of a covered service proposed by the  primary  care
 4    physician.    In  the  event  that  the  reviewing  physician
 5    determines the covered service to be medically necessary, the
 6    health care plan shall provide the covered  service.   Future
 7    contractual  or  employment  action  by the health  care plan
 8    regarding the primary  care  physician  shall  not  be  based
 9    solely on the physician's participation in this procedure.
10        Section 50. Expedited review of medical necessity.
11        (a)  A  health  care  plan shall have an expedited review
12    procedure  whereby  an  enrollee  with   a   life-threatening
13    condition,  or  physician  authorized  in  writing  to act on
14    behalf of the enrollee with a life-threatening condition, may
15    appeal a health care plan's decision of medical necessity  of
16    a covered service.
17        (b)  The expedited review procedure shall provide that an
18    initial  determination  of  the  review  will  be made by the
19    health care  plan  not  later  than  3  business  days  after
20    receipt  of  all necessary information to complete the review
21    process.
22        (c)  After  the  initial  adverse  determination  by  the
23    health care plan, the enrollee, or  physician  authorized  in
24    writing to act on behalf of the enrollee, may request further
25    review  by  the  health  care  plan.   If  further  review is
26    requested, a final determination  by  the  health  care  plan
27    shall  be  made  not  later than 30 days after receipt of all
28    necessary  information  to  complete  further  review.   Upon
29    notification to the enrollee of the health care plan's  final
30    determination  resulting  from  the expedited review process,
31    the  plan  shall  provide  the  enrollee  a  notice  of   the
32    availability  of  the  Department  to  receive  complaints as
33    provided  in  Section   4-6   of   the   Health   Maintenance
                            -17-              LRB9011135JSdvB
 1    Organization Act.
 2        (d)  A request for an expedited review under this Section
 3    must  contain a statement  submitted by the physician, orally
 4    or  in  writing,  substantiating  that  the  enrollee  has  a
 5    life-threatening condition. This subsection does not apply to
 6    a provider's complaint concerning claims  payment,  handling,
 7    or reimbursement for health care services.
 8        (e)  If  the expedited review process is invoked it shall
 9    be in place of and not in  addition  to  the  regular  review
10    process.
11        Section 55. Registration of utilization review programs.
12        (a)  All   utilization  review  programs  shall  register
13    annually with the Department.
14        (b)  The utilization review program will  submit  all  of
15    the following:
16             (1)  The   name,   address   and  telephone  of  the
17        registrant.
18             (2)  The organization and governing structure of the
19        registrant.
20             (3)  List of insurance  companies  and  health  care
21        plans  for  which the utilization review program performs
22        utilization review in this State and the number of  lives
23        for which utilization review is conducted.
24             (4)  Hours of operation.
25             (5)  Description of the grievance process.
26             (6)  Number  of  covered lives for which utilization
27        review was conducted for the previous calendar year.
28             (7)  Written policies and procedures for  protecting
29        confidential  information  according  to applicable State
30        and federal laws.
31        (c)  If the Director determines that an insurance company
32    or health care plan licensed  by  the  Department  meets  the
33    provisions  of  the  requirements  of  this Section under its
                            -18-              LRB9011135JSdvB
 1    certification process, he or she  may  exempt  the  insurance
 2    company   or   health  care  plan  from  providing  duplicate
 3    information.
 4        Section 60.  Managed care community networks.     Managed
 5    care  community  networks  providing or arranging health care
 6    services under contract with the State exclusively to persons
 7    who are  enrolled  in  the  integrated  health  care  program
 8    established  under  Section 5-16.3 of the Illinois Public Aid
 9    Code or a managed care community network owned, operated,  or
10    governed  by  a county provider as defined in Section 15-1 of
11    that Code are required to comply with Sections 15, 20, and 25
12    of this Act and are exempt from all other  Sections  of  this
13    Act.  The Illinois Department of Public Aid shall adopt rules
14    to implement these provisions.
15        Section 65.  Penalties.
16        (a)  An  organization  that  violates Section 20, 25, 30,
17    35, 40, 45, 50, or  55 of this Act is guilty  of  a  Class  B
18    misdemeanor.
19        (b)  The  Director may issue a cease and desist order, as
20    provided in Article  XXIV,  Section  401.1  of  the  Illinois
21    Insurance Code, to any organization subject to this Act.
22        Section   70.  Severability.  If  any  Section,  term  or
23    provision of this Act  shall  be  adjudged  invalid  for  any
24    reason, such judgment shall not affect, impair, or invalidate
25    any  other  Section,  term, or provision of this Act, and the
26    remaining Sections, terms, and provisions shall be and remain
27    in full force and effect.
28        Section 75. Applicability of Act.   A  health  care  plan
29    amended,  delivered,  issued,  or renewed in this State after
30    the effective date of this Act must comply with the terms  of
                            -19-              LRB9011135JSdvB
 1    this Act.
 2        Section  99.   Effective  date.   This  Act  takes effect
 3    January 1, 1999.

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