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90_SB1904ham005
LRB9011424JSgcam10
1 AMENDMENT TO SENATE BILL 1904
2 AMENDMENT NO. . Amend Senate Bill 1904 on page 1 by
3 replacing lines 1 and 2 with the following:
4 "AN ACT concerning to the delivery of health care
5 services and other matters of insurability."; and
6 on page 1 by inserting immediately below line 4 the
7 following:
8 "Section 1. Short title. This Act may be cited as the
9 Managed Care Reform Act.
10 Section 5. Definitions. For purposes of this Act, the
11 following words shall have the meanings provided in this
12 Section, unless otherwise indicated:
13 "Adverse determination" means a determination by a
14 utilization review agent that an admission, extension of a
15 stay, or other health care service has been reviewed and,
16 based on the information provided, is not medically
17 necessary.
18 "Clinical peer reviewer" or "clinical personnel" means:
19 (1) in the case of physician reviewers, a State
20 licensed physician who is of the same category in the
21 same or similar specialty as the health care provider who
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1 typically manages the medical condition, procedure or
2 treatment under review; or
3 (2) in the case of non-physician reviewers, a State
4 licensed or registered health care professional who is
5 in the same profession and same or similar specialty
6 as the health care provider who typically manages the
7 medical condition, procedure, or treatment under review.
8 Nothing herein shall be construed to change any
9 statutorily defined scope of practice.
10 "Culturally and linguistically competent care" means that
11 a managed care plan has staff and procedures in place to
12 provide all covered services and policy procedures in
13 English, Spanish, and any other language spoken as a primary
14 language by 5% or more of its enrollees.
15 "Degenerative or disabling condition or disease" means a
16 condition or disease that is permanent or of indefinite
17 duration, that is likely to become worse or more advanced
18 over time, and that substantially impairs a major life
19 function.
20 "Department" means the Department of Public Health.
21 "Director" means the Director of Public Health.
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 the provision of health care
28 services for sudden and, at the time, unexpected onset of a
29 health condition that would lead a prudent layperson to
30 believe that failure to receive immediate medical attention
31 would result in serious impairment to bodily function or
32 serious dysfunction of any body organ or part or would place
33 the person's health in serious jeopardy.
34 "Enrollee" means a person enrolled in a managed care
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1 plan.
2 "Health care professional" means a physician, registered
3 professional nurse, or other person appropriately licensed or
4 registered pursuant to the laws of this State to provide
5 health care services.
6 "Health care provider" means a health care professional,
7 hospital, facility, or other person appropriately licensed or
8 otherwise authorized to furnish health care services or
9 arrange for the delivery of health care services in this
10 State.
11 "Health care services" means services included in the (i)
12 furnishing of medical care, (ii) hospitalization incident to
13 the furnishing of medical care, and (iii) furnishing of
14 services, including pharmaceuticals, for the purpose of
15 preventing, alleviating, curing, or healing human illness or
16 injury to an individual.
17 "Informal policy or procedure" means a nonwritten policy
18 or procedure, the existence of which may be proven by an
19 admission of an authorized agent of a managed care plan or
20 statistical evidence supported by anecdotal evidence.
21 "Life threatening condition or disease" means any
22 condition, illness, or injury that, in the opinion of a
23 licensed physician, (i) may directly lead to a patient's
24 death, (ii) results in a period of unconsciousness which is
25 indeterminate at the present, or (iii) imposes severe pain or
26 an inhumane burden on the patient.
27 "Managed care plan" means a plan that establishes,
28 operates, or maintains a network of health care providers
29 that have entered into agreements with the plan to provide
30 health care services to enrollees where the plan has the
31 obligation to the enrollee to arrange for the provision of or
32 pay for services through:
33 (1) organizational arrangements for ongoing quality
34 assurance, utilization review programs, or dispute
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1 resolution; or
2 (2) financial incentives for persons enrolled in
3 the plan to use the participating providers and
4 procedures covered by the plan.
5 A managed care plan may be established or operated by any
6 entity including, but not necessarily limited to, a licensed
7 insurance company, hospital or medical service plan, health
8 maintenance organization, limited health service
9 organization, preferred provider organization, third party
10 administrator, independent practice association, or employer
11 or employee organization.
12 For purposes of this definition, "managed care plan"
13 shall not include the following:
14 (1) strict indemnity health insurance policies or
15 plans issued by an insurer that does not require approval
16 of a primary care provider or other similar coordinator
17 to access health care services; and
18 (2) managed care plans that offer only dental or
19 vision coverage.
20 "Post-stabilization services" means those health care
21 services determined by a treating provider to be promptly and
22 medically necessary following stabilization of an emergency
23 condition.
24 "Primary care provider" means a physician licensed to
25 practice medicine in all its branches who provides a broad
26 range of personal medical care (preventive, diagnostic,
27 curative, counseling, or rehabilitative) in a comprehensive
28 and coordinated manner over time for a managed care plan.
29 "Specialist" means a health care professional who
30 concentrates practice in a recognized specialty field of
31 care.
32 "Speciality care center" means only a center that is
33 accredited by an agency of the State or federal government or
34 by a voluntary national health organization as having special
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1 expertise in treating the life-threatening disease or
2 condition or degenerative or disabling disease or condition
3 for which it is accredited.
4 "Utilization review" means the review, undertaken by a
5 entity other than the managed care plan itself, to determine
6 whether health care services that have been provided, are
7 being provided or are proposed to be provided to an
8 individual by a managed care plan, whether undertaken prior
9 to, concurrent with, or subsequent to the delivery of
10 such services are medically necessary. For the purposes
11 of this Act, none of the following shall be considered
12 utilization review:
13 (1) denials based on failure to obtain health care
14 services from a designated or approved health care
15 provider as required under an enrollee's contract;
16 (2) the review of the appropriateness of the
17 application of a particular coding to a patient,
18 including the assignment of diagnosis and procedure;
19 (3) any issues relating to the determination of
20 the amount or extent of payment other than determinations
21 to deny payment based on an adverse determination; and
22 (4) any determination of any coverage issues other
23 than whether health care services are or were medically
24 necessary.
25 "Utilization review agent" means any company,
26 organization, or other entity performing utilization review,
27 except:
28 (1) an agency of the State or federal government;
29 (2) an agent acting on behalf of the federal
30 government, but only to the extent that the agent is
31 providing services to the federal government;
32 (3) an agent acting on behalf of the State and
33 local government for services provided pursuant to
34 Title XIX of the federal Social Security Act, but only to
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1 the extent that the agent is providing services to the
2 State or local government;
3 (4) a hospital's internal quality assurance program
4 except if associated with a health care financing
5 mechanism.
6 "Utilization review plan" means:
7 (1) a description of the process for developing the
8 written clinical review criteria;
9 (2) a description of the types of written clinical
10 information which the plan might consider in its clinical
11 review including, but not limited to, a set of specific
12 written clinical review criteria;
13 (3) a description of practice guidelines and
14 standards used by a utilization review agent in making a
15 determination of medical necessity;
16 (4) the procedures for scheduled review and
17 evaluation of the written clinical review criteria; and
18 (5) a description of the qualifications and
19 experience of the health care professionals who
20 developed the criteria, who are responsible for periodic
21 evaluation of the criteria and of the health care
22 professionals or others who use the written clinical
23 review criteria in the process of utilization review.
24 Section 10. Disclosure of information.
25 (a) An enrollee, and upon request a prospective enrollee
26 prior to enrollment, shall be supplied with written
27 disclosure information, containing at least the information
28 specified in this Section, if applicable, which may be
29 incorporated into the member handbook or the enrollee
30 contract or certificate. All written descriptions shall be
31 in readable and understandable format, consistent with
32 standards developed for supplemental insurance coverage under
33 Title XVIII of the Social Security Act. The Department shall
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1 promulgate rules to standardize this format so that potential
2 members can compare the attributes of the various managed
3 care entities. In the event of any inconsistency between any
4 separate written disclosure statement and the enrollee
5 contract or certificate, the terms of the enrollee
6 contract or certificate shall be controlling. The
7 information to be disclosed shall include, at a minimum,
8 all of the following:
9 (1) A description of coverage provisions, health
10 care benefits, benefit maximums, including benefit
11 limitations, and exclusions of coverage, including the
12 definition of medical necessity used in determining
13 whether benefits will be covered.
14 (2) A description of all prior authorization or
15 other requirements for treatments, pharmaceuticals, and
16 services.
17 (3) A description of utilization review policies
18 and procedures used by the managed care plan,
19 including the circumstances under which utilization
20 review will be undertaken, the toll-free telephone
21 number of the utilization review agent, the timeframes
22 under which utilization review decisions must be made for
23 prospective, retrospective, and concurrent decisions,
24 the right to reconsideration, the right to an appeal,
25 including the expedited and standard appeals processes
26 and the timeframes for those appeals, the right to
27 designate a representative, a notice that all denials of
28 claims will be made by clinical personnel, and that
29 all notices of denials will include information about the
30 basis of the decision and further appeal rights, if any.
31 (4) A description prepared annually of the types of
32 methodologies the managed care plan uses to reimburse
33 providers specifying the type of methodology that is
34 used to reimburse particular types of providers or
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1 reimburse for the provision of particular types of
2 services, provided, however, that nothing in this item
3 should be construed to require disclosure of individual
4 contracts or the specific details of any financial
5 arrangement between a managed care plan and a health care
6 provider.
7 (5) An explanation of a enrollee's financial
8 responsibility for payment of premiums, coinsurance,
9 co-payments, deductibles, and any other charges, annual
10 limits on an enrollee's financial responsibility, caps
11 on payments for covered services and financial
12 responsibility for non-covered health care procedures,
13 treatments, or services provided within the managed
14 care plan.
15 (6) An explanation of an enrollee's financial
16 responsibility for payment when services are provided by
17 a health care provider who is not part of the managed
18 care plan or by any provider without required
19 authorization or when a procedure, treatment, or service
20 is not a covered health care benefit.
21 (7) A description of the grievance procedures to
22 be used to resolve disputes between a managed care plan
23 and an enrollee, including the right to file a
24 grievance regarding any dispute between an enrollee and a
25 managed care plan, the right to file a grievance
26 orally when the dispute is about referrals or covered
27 benefits, the toll-free telephone number that enrollees
28 may use to file an oral grievance, the timeframes and
29 circumstances for expedited and standard grievances, the
30 right to appeal a grievance determination and the
31 procedures for filing the appeal, the timeframes and
32 circumstances for expedited and standard appeals, the
33 right to designate a representative, a notice that all
34 disputes involving clinical decisions will be made by
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1 clinical personnel, and that all notices of determination
2 will include information about the basis of the
3 decision and further appeal rights, if any.
4 (8) A description of the procedure for providing
5 care and coverage 24 hours a day for emergency services.
6 The description shall include the definition of
7 emergency services, notice that emergency services are
8 not subject to prior approval, and an explanation of
9 the enrollee's financial and other responsibilities
10 regarding obtaining those services, including when
11 those services are received outside the managed care
12 plan's service area.
13 (9) A description of procedures for enrollees to
14 select and access the managed care plan's primary and
15 specialty care providers, including notice of how to
16 determine whether a participating provider is accepting
17 new patients.
18 (10) A description of the procedures for changing
19 primary and specialty care providers within the managed
20 care plan.
21 (11) Notice that an enrollee may obtain a referral
22 to a health care provider outside of the managed care
23 plan's network or panel when the managed care plan
24 does not have a health care provider with appropriate
25 training and experience in the network or panel to meet
26 the particular health care needs of the enrollee and
27 the procedure by which the enrollee can obtain the
28 referral.
29 (12) Notice that an enrollee with a condition
30 that requires ongoing care from a specialist may
31 request a standing referral to the specialist and
32 the procedure for requesting and obtaining a standing
33 referral.
34 (13) Notice that an enrollee with (i) a
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1 life-threatening condition or disease or (ii) a
2 degenerative or disabling condition or disease, either of
3 which requires specialized medical care over a prolonged
4 period of time, may request a specialist responsible for
5 providing or coordinating the enrollee's medical care and
6 the procedure for requesting and obtaining the
7 specialist.
8 (14) A description of the mechanisms by which
9 enrollees may participate in the development of the
10 policies of the managed care plan.
11 (15) A description of how the managed care plan
12 addresses the needs of non-English speaking enrollees.
13 (16) Notice of all appropriate mailing addresses
14 and telephone numbers to be utilized by enrollees
15 seeking information or authorization.
16 (17) A listing by specialty, which may be in a
17 separate document that is updated annually, of the name,
18 address, and telephone number of all participating
19 providers, including facilities, and, in addition, in the
20 case of physicians, category of license and board
21 certification, if applicable.
22 (b) Upon request of an enrollee or prospective enrollee,
23 a managed care plan shall do all of the following:
24 (1) Provide a list of the names, business
25 addresses, and official positions of the members of the
26 board of directors, officers, controlling persons,
27 owners, and partners of the managed care plan.
28 (2) Provide a copy of the most recent annual
29 certified financial statement of the managed care plan,
30 including a balance sheet and summary of receipts and
31 disbursements and the ratio of (i) premium dollars going
32 to administrative expenses to (ii) premium dollars going
33 to direct care, prepared by a certified public
34 accountant. The Department shall promulgate rules to
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1 standardize the information that must be contained in the
2 statement and the statement's format.
3 (3) Provide information relating to consumer
4 complaints compiled in accordance with subsection (b) of
5 Section 30 of this Act and the rules promulgated under
6 this Act.
7 (4) Provide the procedures for protecting the
8 confidentiality of medical records and other enrollee
9 information.
10 (5) Allow enrollees and prospective enrollees to
11 inspect drug formularies used by the managed care plan
12 and disclose whether individual drugs are included or
13 excluded from coverage and whether a drug requires prior
14 authorization. An enrollee or prospective enrollee may
15 seek information as to the inclusion or exclusion of a
16 specific drug. A managed care plan need only release the
17 information if the enrollee or prospective enrollee or
18 his or her dependent needs, used, or may need or use the
19 drug.
20 (6) Provide a written description of the
21 organizational arrangements and ongoing procedures of
22 the managed care plan's quality assurance program.
23 (7) Provide a description of the procedures
24 followed by the managed care plan in making decisions
25 about the experimental or investigational nature of
26 individual drugs, medical devices, or treatments in
27 clinical trials.
28 (8) Provide individual health care professional
29 affiliations with participating hospitals, if any.
30 (9) Upon written request, provide specific
31 written clinical review criteria relating to a
32 particular condition or disease and, where appropriate,
33 other clinical information that the managed care plan
34 might consider in its utilization review; the managed
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1 care plan may include with the information a description
2 of how it will be used in the utilization review
3 process. An enrollee or prospective enrollee may seek
4 information as to specific clinical review criteria. A
5 managed care plan need only release the information if
6 the enrollee or prospective enrollee or his or her
7 dependent has, may have, or is at risk of contracting a
8 particular condition or disease.
9 (10) Provide the written application procedures and
10 minimum qualification requirements for health care
11 providers to be considered by the managed care plan.
12 (11) Disclose other information as required by
13 the Director.
14 (12) To the extent the information provided under
15 item (5) or (9) of this subsection is proprietary to the
16 managed care plan, the enrollee or prospective enrollee
17 shall only use the information for the purposes of
18 assisting the enrollee or prospective enrollee in
19 evaluating the covered services provided by the managed
20 care plan. Any misuse of proprietary data is prohibited,
21 provided that the managed care plan has labeled or
22 identified the data as proprietary.
23 (c) Nothing in this Section shall prevent a managed care
24 plan from changing or updating the materials that are made
25 available to enrollees or prospective enrollees.
26 (d) If a primary care provider ceases participation in
27 the managed care plan, the managed care plan shall provide
28 written notice within 15 business days from the date that the
29 managed care plan becomes aware of the change in status to
30 each of the enrollees who have chosen the provider as
31 their primary care provider. If an enrollee is in an
32 ongoing course of treatment with any other participating
33 provider who becomes unavailable to continue to provide
34 services to the enrollee and the managed care plan is aware
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1 of the ongoing course of treatment, the managed care plan
2 shall provide written notice within 15 business days from
3 the date that the managed care plan becomes aware of the
4 unavailability to the enrollee. The notice shall also
5 describe the procedures for continuing care.
6 (e) A managed care plan offering to indemnify enrollees
7 for non-participating provider services shall file a report
8 with the Director twice a year showing the percentage
9 utilization for the preceding 6 month period of
10 non-participating provider services in such form and
11 providing such other information as the Director shall
12 prescribe.
13 (f) The written information disclosure requirements of
14 this Section may be met by disclosure to one enrollee in a
15 household.
16 Section 15. General grievance procedure.
17 (a) A managed care plan shall establish and maintain a
18 grievance procedure, as described in this Act. Compliance
19 with this Act's grievance procedures shall satisfy a managed
20 care plan's obligation to provide grievance procedures under
21 any other State law or rules.
22 A copy of the grievance procedures, including all forms
23 used to process a grievance, shall be filed with the
24 Director. Any subsequent material modifications to the
25 documents also shall be filed. In addition, a managed care
26 plan shall file annually with the Director a certificate of
27 compliance stating that the managed care plan has established
28 and maintains, for each of its plans, grievance procedures
29 that fully comply with the provisions of this Act. The
30 Director has authority to disapprove a filing that fails to
31 comply with this Act or applicable rules.
32 (b) A managed care plan shall provide written notice of
33 the grievance procedure to all enrollees in the member
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1 handbook and to an enrollee at any time that the managed care
2 plan denies access to a referral or determines that a
3 requested benefit is not covered pursuant to the terms of the
4 contract. In the event that a managed care plan denies a
5 service as an adverse determination, the managed care plan
6 shall inform the enrollee or the enrollee's designee of
7 the appeal rights under this Act.
8 The notice to an enrollee describing the grievance
9 process shall explain the process for filing a grievance
10 with the managed care plan, the timeframes within which a
11 grievance determination must be made, and the right of an
12 enrollee to designate a representative to file a grievance on
13 behalf of the enrollee. Information required to be disclosed
14 or provided under this Section must be provided in a
15 reasonable and understandable format.
16 The managed care plan shall assure that the grievance
17 procedure is reasonably accessible to those who do not speak
18 English.
19 (c) A managed care plan shall not retaliate or take
20 any discriminatory action against an enrollee because an
21 enrollee has filed a grievance or appeal.
22 Section 20. First level grievance review.
23 (a) The managed care plan may require an enrollee to
24 file a grievance in writing, by letter or by a grievance
25 form which shall be made available by the managed care plan,
26 however, an enrollee must be allowed to submit an oral
27 grievance in connection with (i) a denial of, or failure to
28 pay for, a referral or service or (ii) a determination as to
29 whether a benefit is covered pursuant to the terms of the
30 enrollee's contract. In connection with the submission of
31 an oral grievance, a managed care plan shall, within 24
32 hours, reduce the complaint to writing and give the enrollee
33 written acknowledgment of the grievance prepared by the
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1 managed care plan summarizing the nature of the grievance
2 and requesting any information that the enrollee needs to
3 provide before the grievance can be processed. The
4 acknowledgment shall be mailed within the 24-hour period
5 to the enrollee, who shall sign and return the
6 acknowledgment, with any amendments and requested
7 information, in order to initiate the grievance. The
8 grievance acknowledgment shall prominently state that the
9 enrollee must sign and return the acknowledgment to
10 initiate the grievance. A managed care plan may elect not to
11 require a signed acknowledgment when no additional
12 information is necessary to process the grievance, and an
13 oral grievance shall be initiated at the time of the
14 telephone call.
15 Except as authorized in this subsection, a managed care
16 plan shall designate personnel to accept the filing of an
17 enrollee's grievance by toll-free telephone no less than
18 40 hours per week during normal business hours and shall
19 have a telephone system available to take calls during other
20 than normal business hours and shall respond to all such
21 calls no later than the next business day after the call was
22 recorded. In the case of grievances subject to item (i) of
23 subsection (b) of this Section, telephone access must be
24 available on a 24 hour a day, 7 day a week basis.
25 (b) Within 48 hours of receipt of a written grievance,
26 the managed care plan shall provide written acknowledgment
27 of the grievance, including the name, address,
28 qualifying credentials, and telephone number of the
29 individuals or department designated by the managed care plan
30 to respond to the grievance. All grievances shall be
31 resolved in an expeditious manner, and in any event, no more
32 than (i) 24 hours after the receipt of all necessary
33 information when a delay would significantly increase the
34 risk to an enrollee's health or when extended health care
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1 services, procedures, or treatments for an enrollee
2 undergoing a course of treatment prescribed by a health care
3 provider are at issue, (ii) 15 days after the receipt of all
4 necessary information in the case of requests for referrals
5 or determinations concerning whether a requested benefit
6 is covered pursuant to the contract, and (iii) 30 days after
7 the receipt of all necessary information in all other
8 instances.
9 (c) The managed care plan shall designate one or more
10 qualified personnel to review the grievance. When the
11 grievance pertains to clinical matters, the personnel shall
12 include, but not be limited to, one or more appropriately
13 licensed or registered health care professionals.
14 (d) The notice of a determination of the grievance
15 shall be made in writing to the enrollee or to the enrollee's
16 designee. In the case of a determination made in conformance
17 with item (i) of subsection (b) of this Section, notice
18 shall be made by telephone directly to the enrollee with
19 written notice to follow within 2 business days.
20 (e) The notice of a determination shall include (i)
21 clear and detailed reasons for the determination, including
22 any contract basis for the determination, and the evidence
23 relied upon in making that determination, (ii) in cases where
24 the determination has a clinical basis, the clinical
25 rationale for the determination, and (iii) the procedures for
26 the filing of an appeal of the determination, including a
27 form for the filing of an appeal.
28 Section 25. Second level grievance review.
29 (a) A managed care plan shall establish a second level
30 grievance review process to give those enrollees who are
31 dissatisfied with the first level grievance review decision
32 the option to request a second level review, at which the
33 enrollee shall have the right to appear in person before
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1 authorized individuals designated to respond to the appeal.
2 (b) An enrollee or an enrollee's designee shall
3 have not less than 60 days after receipt of notice of the
4 grievance determination to file a written appeal, which may
5 be submitted by letter or by a form supplied by the managed
6 care plan. The enrollee shall indicate in his or her written
7 appeal whether he or she wants the right to appear in person
8 before the person or panel designated to respond to the
9 appeal.
10 (c) Within 48 hours of receipt of the second level
11 grievance review, the managed care plan shall provide written
12 acknowledgment of the appeal, including the name, address,
13 qualifying credentials, and telephone number of the
14 individual designated by the managed care plan to respond
15 to the appeal and what additional information, if any, must
16 be provided in order for the managed care plan to render a
17 decision.
18 (d) The determination of a second level grievance review
19 on a clinical matter must be made by personnel qualified
20 to review the appeal, including appropriately licensed or
21 registered health care professionals who did not make
22 the initial determination, a majority of whom must be
23 clinical peer reviewers. The determination of a second
24 level grievance review on a matter that is not clinical shall
25 be made by qualified personnel at a higher level than the
26 personnel who made the initial grievance determination.
27 (e) The managed care plan shall seek to resolve all
28 second level grievance reviews in the most expeditious manner
29 and shall make a determination and provide notice no more
30 than (i) 24 hours after the receipt of all necessary
31 information when a delay would significantly increase the
32 risk to an enrollee's health or when extended health care
33 services, procedures, or treatments for an enrollee
34 undergoing a course of treatment prescribed by a health care
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1 provider are at issue and (ii) 30 business days after the
2 receipt of all necessary information in all other instances.
3 (f) The notice of a determination on a second level
4 grievance review shall include (i) the detailed reasons for
5 the determination, including any contract basis for the
6 determination and the evidence relied upon in making the
7 determination and (ii) in cases where the determination has a
8 clinical basis, the clinical rationale for the
9 determination.
10 (g) If an enrollee has requested the opportunity to
11 appear in person before the authorized representatives of the
12 managed care plan designated to respond to the appeal, the
13 review panel shall schedule and hold a review meeting within
14 30 days of receiving a request from an enrollee for a second
15 level review with a right to appear. The review meeting
16 shall be held during regular business hours at a location
17 reasonably accessible to the enrollee. The enrollee shall be
18 notified in writing at least 14 days in advance of the review
19 date.
20 Upon the request of an enrollee, a managed care plan
21 shall provide to the enrollee all relevant information that
22 is not confidential or privileged.
23 An enrollee has the right to:
24 (1) attend the second level review;
25 (2) present his or her case to the review panel;
26 (3) submit supporting material both before and at
27 the review meeting;
28 (4) ask questions of any representative of the
29 managed care plan; and
30 (5) be assisted or represented by persons of his or
31 her choice.
32 The notice shall advise the enrollee of the rights
33 specified in this subsection.
34 If the managed care plan desires to have an attorney
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1 present to represent its interests, it shall notify the
2 enrollee at least 14 days in advance of the review that an
3 attorney will be present and that the enrollee may wish to
4 obtain legal representation of his or her own.
5 Section 30. Grievance register and reporting
6 requirements.
7 (a) A managed care plan shall maintain a register
8 consisting of a written record of all complaints initiated
9 during the past 3 years. The register shall be maintained in
10 a manner that is reasonably clear and accessible to the
11 Director. The register shall include at a minimum the
12 following:
13 (1) the name of the enrollee;
14 (2) a description of the reason for the complaint;
15 (3) the dates when first level and second level
16 review were requested and completed;
17 (4) a copy of the written decision rendered at each
18 level of review;
19 (5) if required time limits were exceeded, an
20 explanation of why they were exceeded and a copy of the
21 enrollee's consent to an extension of time;
22 (6) whether expedited review was requested and the
23 response to the request;
24 (7) whether the complaint resulted in litigation
25 and the result of the litigation.
26 (b) A managed care plan shall report annually to the
27 Department the numbers, and related information where
28 indicated, for the following:
29 (1) covered lives;
30 (2) total complaints initiated;
31 (3) total complaints involving medical necessity or
32 appropriateness;
33 (4) complaints involving termination or reduction
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1 of inpatient hospital services;
2 (5) complaints involving termination or reduction
3 of other health care services;
4 (6) complaints involving denial of health care
5 services where the enrollee had not received the services
6 at the time the complaint was initiated;
7 (7) complaints involving payment for health care
8 services that the enrollee had already received at the
9 time of initiating the complaint;
10 (8) complaints resolved at each level of review and
11 how they were resolved;
12 (9) complaints where expedited review was provided
13 because adherence to regular time limits would have
14 jeopardized the enrollee's life, health, or ability to
15 regain maximum function; and
16 (10) complaints that resulted in litigation and the
17 outcome of the litigation.
18 The Department shall promulgate rules regarding the
19 format of the report, the timing of the report, and other
20 matters related to the report.
21 Section 35. External independent review.
22 (a) If an enrollee's or enrollee's designee's request
23 for a covered service or claim for a covered service is
24 denied under the grievance review under Section 25 because
25 the service is not viewed as medically necessary, the
26 enrollee may initiate an external independent review.
27 (b) Within 30 days after the enrollee receives written
28 notice of such an adverse decision made under the second
29 level grievance review procedures of Section 25, if the
30 enrollee decides to initiate an external independent review,
31 the enrollee shall send to the managed care plan a written
32 request for an external independent review, including any
33 material justification or documentation to support the
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1 enrollee's request for the covered service or claim for a
2 covered service.
3 (c) Within 30 days after the managed care plan receives
4 a request for an external independent review from an
5 enrollee, the managed care plan shall:
6 (1) provide a mechanism for jointly selecting an
7 external independent reviewer by the enrollee, primary
8 care physician, and managed care plan; and
9 (2) forward to the independent reviewer all medical
10 records and supporting documentation pertaining to the
11 case, a summary description of the applicable issues
12 including a statement of the managed care plan's
13 decision, and the criteria used and the clinical reasons
14 for that decision.
15 (d) Within 5 days of receipt of all necessary
16 information, the independent reviewer or reviewers shall
17 evaluate and analyze the case and render a decision that is
18 based on whether or not the service or claim for the service
19 is medically necessary. The decision by the independent
20 reviewer or reviewers is final.
21 (e) Pursuant to subsection (c) of this Section, an
22 external independent reviewer shall:
23 (1) have no direct financial interest in or
24 connection to the case;
25 (2) be State licensed physicians, who are board
26 certified or board eligible by the appropriate American
27 Medical Specialty Board, if applicable, and who are in
28 the same or similar scope of practice as a physician who
29 typically manages the medical condition, procedure, or
30 treatment under review; and
31 (3) have not been informed of the specific identity
32 of the enrollee or the enrollee's treating provider.
33 (f) If an appropriate reviewer pursuant to subsection
34 (e) of this Section for a particular case is not on the list
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1 established by the Director, the parties shall choose a
2 reviewer who is mutually acceptable.
3 Section 40. Independent reviewers.
4 (a) From information filed with the Director on or
5 before March 1 of each year, the Director shall compile a
6 list of external independent reviewers and organizations that
7 represent external independent reviewers from lists provided
8 by managed care plans and by any State and county public
9 health department and State medical associations that wish to
10 submit a list to the Director. The Director may consult with
11 other persons about the suitability of any reviewer or any
12 potential reviewer. The Director shall annually review the
13 list and add and remove names as appropriate. On or before
14 June 1 of each year, the Director shall publish the list in
15 the Illinois Register.
16 (b) The managed care plan shall be solely responsible
17 for paying the fees of the external independent reviewer who
18 is selected to perform the review.
19 (c) An external independent reviewer who acts in good
20 faith shall have immunity from any civil or criminal
21 liability or professional discipline as a result of acts or
22 omissions with respect to any external independent review,
23 unless the acts or omissions constitute wilful and wanton
24 misconduct. For purposes of any proceeding, the good faith
25 of the person participating shall be presumed.
26 (d) The Director's decision to add a name to or remove a
27 name from the list of independent reviewers pursuant to
28 subsection (a) is not subject to administrative appeal or
29 judicial review.
30 Section 45. Health care professional applications and
31 terminations.
32 (a) A managed care plan shall, upon request, make
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1 available and disclose to health care professionals written
2 application procedures and minimum qualification
3 requirements that a health care professional must meet in
4 order to be considered by the managed care plan. The
5 managed care plan shall consult with appropriately qualified
6 health care professionals in developing its qualification
7 requirements.
8 (b) A managed care plan may not terminate a contract of
9 employment or refuse to renew a contract on the basis of any
10 action protected under Section 50 of this Act or solely
11 because a health care professional has:
12 (1) filed a complaint against the managed care
13 plan;
14 (2) appealed a decision of the managed care plan;
15 or
16 (3) requested a hearing pursuant to this Section.
17 (c) A managed care plan shall provide to a health care
18 professional, in writing, the reasons for the contract
19 termination or non-renewal.
20 (d) A managed care plan shall provide an opportunity
21 for a hearing to any health care professional terminated by
22 the managed care plan, or non-renewed if the health care
23 professional has had a contract or contracts with the managed
24 care plan for at least 24 of the past 36 months.
25 (e) After the notice provided pursuant to subsection
26 (c), the health care professional shall have 21 days to
27 request a hearing, and the hearing must be held within 15
28 days after receipt of the request for a hearing. The hearing
29 shall be held before a panel appointed by the managed care
30 plan.
31 The hearing panel shall be composed of 5 individuals, the
32 majority of whom shall be clinical peer reviewers and, to the
33 extent possible, in the same discipline and the same or
34 similar specialty as the health care professional under
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1 review.
2 The hearing panel shall render a written decision on the
3 proposed action within 14 business days. The decision shall
4 be one of the following:
5 (1) reinstatement of the health care professional
6 by the managed care plan;
7 (2) provisional reinstatement subject to
8 conditions set forth by the panel; or
9 (3) termination of the health care professional.
10 The decision of the hearing panel shall be final.
11 A decision by the hearing panel to terminate a health
12 care professional shall be effective not less than 15 days
13 after the receipt by the health care professional of the
14 hearing panel's decision.
15 A hearing under this subsection shall provide the health
16 care professional in question with the right to examine
17 pertinent information, to present witnesses, and to ask
18 questions of an authorized representative of the plan.
19 (f) A managed care plan may terminate or decline to
20 renew a health care professional, without a prior hearing, in
21 cases involving imminent harm to patient care, a
22 determination of intentional falsification of reports to the
23 plan or a final disciplinary action by a state licensing
24 board or other governmental agency that impairs the health
25 care professional's ability to practice. A professional
26 terminated for one of the these reasons shall be given
27 written notice to that effect. Within 21 days after the
28 termination, a health care professional terminated because of
29 imminent harm to patient care or a determination of
30 intentional falsification of reports to the plan shall
31 receive a hearing. The hearing shall be held before a panel
32 appointed by the managed care plan. The panel shall be
33 composed of 5 individuals the majority of whom shall be
34 clinical peer reviewers and, to the extent possible, in the
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1 same discipline and the same or similar specialty as the
2 health care professional under review. The hearing panel
3 shall render a decision on the proposed action within 14
4 days. The panel shall issue a written decision either
5 supporting the termination or ordering the health care
6 professional's reinstatement. The decision of the hearing
7 panel shall be final.
8 If the hearing panel upholds the managed care plan's
9 termination of the health care professional under this
10 subsection, the managed care plan shall forward the decision
11 to the appropriate professional disciplinary agency in
12 accordance with subsection (b) of Section 60.
13 Any hearing under this subsection shall provide the
14 health care professional in question with the right to
15 examine pertinent information, to present witnesses, and to
16 ask questions of an authorized representative of the plan.
17 For any hearing under this Section, because the candid
18 and conscientious evaluation of clinical practices is
19 essential to the provision of health care, it is the policy
20 of this State to encourage peer review by health care
21 professionals. Therefore, no managed care plan and no
22 individual who participates in a hearing or who is a member,
23 agent, or employee of a managed care plan shall be liable for
24 criminal or civil damages or professional discipline as a
25 result of the acts, omissions, decisions, or any other
26 conduct, direct or indirect, associated with a hearing panel,
27 except for wilful and wanton misconduct. Nothing in this
28 Section shall relieve any person, health care provider,
29 health care professional, facility, organization, or
30 corporation from liability for his, her, or its own
31 negligence in the performance of his, her, or its duties or
32 arising from treatment of a patient. The hearing panel
33 information shall not be subject to inspection or disclosure
34 except upon formal written request by an authorized
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1 representative of a duly authorized State agency or pursuant
2 to a court order issued in a pending action or proceeding.
3 (g) A managed care plan shall develop and implement
4 policies and procedures to ensure that health care
5 professionals are at least annually informed of information
6 maintained by the managed care plan to evaluate the
7 performance or practice of the health care professional. The
8 managed care plan shall consult with health care
9 professionals in developing methodologies to collect and
10 analyze health care professional data. Managed care plans
11 shall provide the information and data and analysis to health
12 care professionals. The information, data, or analysis
13 shall be provided on at least an annual basis in a format
14 appropriate to the nature and amount of data and the volume
15 and scope of services provided. Any data used to evaluate
16 the performance or practice of a health care professional
17 shall be measured against stated criteria and a comparable
18 group of health care professionals who use similar treatment
19 modalities and serve a comparable patient population. Upon
20 receipt of the information or data, a health care
21 professional shall be given the opportunity to explain the
22 unique nature of the health care professional's patient
23 population that may have a bearing on the health care
24 professional's data and to work cooperatively with the
25 managed care plan to improve performance.
26 (h) Any contract provision or procedure or informal
27 policy or procedure in violation of this Section violates the
28 public policy of the State of Illinois and is void and
29 unenforceable.
30 Section 50. Prohibitions.
31 (a) No managed care plan shall by contract, written
32 policy or written procedure, or informal policy or procedure
33 prohibit or restrict any health care provider from
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1 disclosing to any enrollee, patient, designated
2 representative or, where appropriate, prospective
3 enrollee, (hereinafter collectively referred to as
4 enrollee) any information that the provider deems appropriate
5 regarding:
6 (1) a condition or a course of treatment with an
7 enrollee including the availability of other therapies,
8 consultations, or tests; or
9 (2) the provisions, terms, or requirements of the
10 managed care plan's products as they relate to the
11 enrollee, where applicable.
12 (b) No managed care plan shall by contract, written
13 policy or procedure, or informal policy or procedure prohibit
14 or restrict any health care provider from filing a
15 complaint, making a report, or commenting to an appropriate
16 governmental body regarding the policies or practices of the
17 managed care plan that the provider believes may
18 negatively impact upon the quality of, or access to, patient
19 care.
20 (c) No managed care plan shall by contract, written
21 policy or procedure, or informal policy or procedure prohibit
22 or restrict any health care provider from advocating to the
23 managed care plan on behalf of the enrollee for approval or
24 coverage of a particular course of treatment or for the
25 provision of health care services.
26 (d) No contract or agreement between a managed care
27 plan and a health care provider shall contain any clause
28 purporting to transfer to the health care provider by
29 indemnification or otherwise any liability relating to
30 activities, actions, or omissions of the managed care plan
31 as opposed to those of the health care provider.
32 (e) No contract between a managed care plan and a health
33 care provider shall contain any incentive plan that includes
34 specific payment made directly, in any form, to a health care
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1 provider as an inducement to deny, reduce, limit, or delay
2 specific, medically necessary and appropriate services
3 provided with respect to a specific enrollee or groups of
4 enrollees with similar medical conditions. Nothing in this
5 Section shall be construed to prohibit contracts that contain
6 incentive plans that involve general payments, such as
7 capitation payments or shared-risk arrangements, that are not
8 tied to specific medical decisions involving specific
9 enrollees or groups of enrollees with similar medical
10 conditions. The payments rendered or to be rendered to
11 health care provider under these arrangements shall be deemed
12 confidential information.
13 (f) No managed care plan shall by contract, written
14 policy or procedure, or informal policy or procedure permit,
15 allow, or encourage an individual or entity to dispense a
16 different drug in place of the drug or brand of drug ordered
17 or prescribed without the express permission of the person
18 ordering or prescribing, except this prohibition does not
19 prohibit the interchange of different brands of the same
20 generically equivalent drug product, as provided under
21 Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
22 (g) Any contract provision, written policy or
23 procedure, or informal policy or procedure in violation of
24 this Section violates the public policy of the State of
25 Illinois and is void and unenforceable.
26 Section 55. Network of providers.
27 (a) At least once every 3 years, and upon application
28 for expansion of service area, a managed care plan shall
29 obtain certification from the Director of Public Health that
30 the managed care plan maintains a network of health care
31 providers and facilities adequate to meet the comprehensive
32 health needs of its enrollees and to provide an appropriate
33 choice of providers sufficient to provide the services
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1 covered under its enrollee's contracts by determining that:
2 (1) there are a sufficient number of geographically
3 accessible participating providers and facilities;
4 (2) there are opportunities to select from at least
5 3 primary care providers pursuant to travel and
6 distance time standards, providing that these standards
7 account for the conditions of accessing providers in
8 rural areas; and
9 (3) there are sufficient providers in all covered
10 areas of specialty practice to meet the needs of the
11 enrollment population.
12 (b) The following criteria shall be considered by the
13 Director of Public Health at the time of a review:
14 (1) provider-enrollee ratios by specialty;
15 (2) primary care provider-enrollee ratios;
16 (3) safe and adequate staffing of health care
17 providers in all participating facilities based on:
18 (A) severity of patient illness and functional
19 capacity;
20 (B) factors affecting the period and quality
21 of patient recovery; and
22 (C) any other factor substantially related to
23 the condition and health care needs of patients;
24 (4) geographic accessibility;
25 (5) the number of grievances filed by enrollees
26 relating to waiting times for appointments,
27 appropriateness of referrals, and other indicators of a
28 managed care plan's capacity;
29 (6) hours of operation;
30 (7) the managed care plan's ability to provide
31 culturally and linguistically competent care to meet the
32 needs of its enrollee population; and
33 (8) the volume of technological and speciality
34 services available to serve the needs of enrollees
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1 requiring technologically advanced or specialty care.
2 (c) A managed care plan shall report on an annual basis
3 the number of enrollees and the number of participating
4 providers in the managed care plan.
5 (d) If a managed care plan determines that it does not
6 have a health care provider with appropriate training and
7 experience in its panel or network to meet the particular
8 health care needs of an enrollee, the managed care plan
9 shall make a referral to an appropriate provider, pursuant to
10 a treatment plan approved by the primary care provider, in
11 consultation with the managed care plan, the
12 non-participating provider, and the enrollee or enrollee's
13 designee, at no additional cost to the enrollee beyond what
14 the enrollee would otherwise pay for services received within
15 the network.
16 (e) A managed care plan shall have a procedure by which
17 an enrollee who needs ongoing health care services,
18 provided or coordinated by a specialist focused on a specific
19 organ system, disease or condition, shall receive a referral
20 to the specialist. If the primary care provider, after
21 consultation with the medical director or other
22 contractually authorized representative of the managed care
23 plan, determines that a referral is appropriate, the primary
24 care provider shall make such a referral to a specialist. In
25 no event shall a managed care plan be required to permit
26 an enrollee to elect to have a non-participating
27 specialist, except pursuant to the provisions of subsection
28 (d). The referral made under this subsection shall be
29 pursuant to a treatment plan approved by the enrollee or
30 enrollee's designee, the primary care provider, and the
31 specialist in consultation with the managed care plan. The
32 treatment plan shall authorize the specialist to treat the
33 ongoing injury, disease, or condition. It also may limit the
34 number of visits or the period during which visits are
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1 authorized and may require the specialists to provide the
2 primary care provider with regular updates on the specialty
3 care provided, as well as all necessary medical information.
4 (f) A managed care plan shall have a procedure by which
5 a new enrollee, upon enrollment, or an enrollee, upon
6 diagnosis, with (i) a life-threatening condition or disease
7 or (ii) a degenerative or disabling condition or disease,
8 either of which requires specialized medical care over a
9 prolonged period of time shall receive a standing referral to
10 a specialist with expertise in treating the life-threatening
11 condition or disease or degenerative or disabling condition
12 or disease who shall be responsible for and capable of
13 providing and coordinating the enrollee's primary and
14 specialty care. If the primary care provider, after
15 consultation with the enrollee or enrollee's designee and
16 medical director or other contractually authorized
17 representative of the managed care plan, determines that the
18 enrollee's care would most appropriately be coordinated
19 by a specialist, the primary care provider shall refer, on a
20 standing basis, the enrollee to a specialist. In no event
21 shall a managed care plan be required to permit an enrollee
22 to elect to have a non-participating specialist, except
23 pursuant to the provisions of subsection (d). The
24 specialist shall be permitted to treat the enrollee
25 without a referral from the enrollee's primary care
26 provider and shall be authorized to make such referrals,
27 procedures, tests, and other medical services as the
28 enrollee's primary care provider would otherwise be
29 permitted to provide or authorize including, if
30 appropriate, referral to a specialty care center. If a
31 primary care provider refers an enrollee to a
32 non-participating provider pursuant to the provisions of
33 subsection (d), the standing referral shall be pursuant to a
34 treatment plan approved by the enrollee or enrollee's
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1 designee and specialist, in consultation with the managed
2 care plan. Services provided pursuant to the approved
3 treatment plan shall be provided at no additional cost to
4 the enrollee beyond what the enrollee would otherwise pay
5 for services received within the network.
6 (g) If an enrollee's health care provider leaves the
7 managed care plan's network of providers for reasons other
8 than those for which the provider would not be eligible to
9 receive a pre-termination hearing pursuant to subsection (f)
10 of Section 45, the managed care plan shall permit the
11 enrollee to continue an ongoing course of treatment
12 with the enrollee's current health care provider during a
13 transitional period of:
14 (1) up to 90 days from the date of notice to the
15 enrollee of the provider's disaffiliation from the
16 managed care plan's network; or
17 (2) if the enrollee has entered the second trimester
18 of pregnancy at the time of the provider's
19 disaffiliation, for a transitional period that
20 includes the provision of post-partum care directly
21 related to the delivery.
22 Transitional care, however, shall be authorized by the
23 managed care plan during the transitional period only if the
24 health care provider agrees (i) to continue to accept
25 reimbursement from the managed care plan at the rates
26 applicable prior to the start of the transitional period
27 as payment in full, (ii) to adhere to the managed care plan's
28 quality assurance requirements and to provide to the managed
29 care plan necessary medical information related to the care,
30 (iii) to otherwise adhere to the managed care plan's
31 policies and procedures including, but not limited to,
32 procedures regarding referrals and obtaining
33 pre-authorization and a treatment plan approved by the
34 primary care provider or specialist in consultation with the
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1 managed care plan, and (iv) if the enrollee is a recipient of
2 services under Article V of the Illinois Public Aid Code, the
3 health care provider has not been subject to a final
4 disciplinary action by a state or federal agency for
5 violations of the Medicaid or Medicare program.
6 (h) If a new enrollee whose health care provider is not
7 a member of the managed care plan's provider network enrolls
8 in the managed care plan, the managed care plan shall permit
9 the enrollee to continue an ongoing course of treatment with
10 the enrollee's current health care provider during a
11 transitional period of up to 90 days from the effective
12 date of enrollment, if (i) the enrollee has a
13 life-threatening disease or condition or a degenerative or
14 disabling disease or condition or (ii) the enrollee has
15 entered the second trimester of pregnancy at the effective
16 date of enrollment, in which case the transitional period
17 shall include the provision of post-partum care directly
18 related to the delivery. If an enrollee elects to continue
19 to receive payment for care from a health care provider
20 pursuant to this subsection, the care shall be authorized by
21 the managed care plan for the transitional period only if
22 the health care provider agrees (i) to accept reimbursement
23 from the managed care plan at rates established by the
24 managed care plan as payment in full, which rates shall be no
25 more than the level of reimbursement applicable to similar
26 providers within the managed care plan's network for
27 those services, (ii) to adhere to the managed care plan's
28 quality assurance requirements and agrees to provide to the
29 managed care plan necessary medical information related to
30 the care, (iii) to otherwise adhere to the managed care
31 plan's policies and procedures including, but not limited
32 to, procedures regarding referrals and obtaining
33 pre-authorization and a treatment plan approved by the
34 primary care provider or specialist, in consultation with the
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1 managed care plan, and (iv) if the enrollee is a recipient of
2 services under Article V of the Illinois Public Aid Code, the
3 health care provider has not been subject to a final
4 disciplinary action by a state or federal agency for
5 violations of the Medicaid or Medicare program. In no
6 event shall this subsection be construed to require a managed
7 care plan to provide coverage for benefits not otherwise
8 covered or to diminish or impair pre-existing condition
9 limitations contained within the enrollee's contract.
10 Section 60. Duty to report.
11 (a) A managed care plan shall report to the
12 appropriate professional disciplinary agency, after
13 compliance and in accordance with the provisions of this
14 Section:
15 (1) termination of a health care provider contract
16 for commission of an act or acts that may directly
17 threaten patient care, and not of an administrative
18 nature, or that a person may be mentally or physically
19 disabled in such a manner as to endanger a patient under
20 that person's care;
21 (2) voluntary or involuntary termination of a
22 contract or employment or other affiliation with the
23 managed care plan to avoid the imposition of disciplinary
24 measures.
25 The managed care plan shall only make the report after it
26 has provided the health care professional with a hearing on
27 the matter. (This hearing shall not impair or limit the
28 managed care plan's ability to terminate the professional.
29 Its purpose is solely to ensure that a sufficient basis
30 exists for making the report.) The hearing shall be held
31 before a panel appointed by the managed care plan. The
32 hearing panel shall be composed of 5 persons appointed by the
33 plan, the majority of whom shall be clinical peer reviewers,
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1 to the extent possible, in the same discipline and the same
2 specialty as the health care professional under review. The
3 hearing panel shall determine whether the proposed basis for
4 the report is supported by a preponderance of the evidence.
5 The panel shall render its determination within 14 days. If
6 a majority of the panel finds the proposed basis for the
7 report is supported by a preponderance of the evidence, the
8 managed care plan shall make the required report within 21
9 days.
10 Any hearing under this Section shall provide the health
11 care professional in question with the right to examine
12 pertinent information, to present witnesses, and to ask
13 questions of an authorized representative of the plan.
14 If a hearing has been held pursuant to subsection (f) of
15 Section 45 and the hearing panel sustained a plan's
16 termination of a health care professional, no additional
17 hearing is required, and the plan shall make the report
18 required under this Section.
19 (b) Reports made pursuant to this Section shall be made
20 in writing to the appropriate professional disciplinary
21 agency. Written reports shall include the name, address,
22 profession, and license number of the individual and a
23 description of the action taken by the managed care plan,
24 including the reason for the action and the date thereof, or
25 the nature of the action or conduct that led to the
26 resignation, termination of contract, or withdrawal, and the
27 date thereof.
28 For any hearing under this Section, because the candid
29 and conscientious evaluation of clinical practices is
30 essential to the provision of health care, it is the policy
31 of this State to encourage peer review by health care
32 professionals. Therefore, no managed care plan and no
33 individual who participates in a hearing or who is a member,
34 agent, or employee of a managed care plan shall be liable for
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1 criminal or civil damages or professional discipline as a
2 result of the acts, omissions, decisions, or any other
3 conduct, direct or indirect, associated with a hearing panel,
4 except for wilful and wanton misconduct. Nothing in this
5 Section shall relieve any person, health care provider,
6 health care professional, facility, organization, or
7 corporation from liability for his, her, or its own
8 negligence in the performance of his, her, or its duties or
9 arising from treatment of a patient. The hearing panel
10 information shall not be subject to inspection or disclosure
11 except upon formal written request by an authorized
12 representative of a duly authorized State agency or pursuant
13 to a court order issued in a pending action or proceeding.
14 Section 65. Disclosure of information.
15 (a) A health care professional affiliated with a
16 managed care plan shall make available, in written form at
17 his or her office, to his or her patients or prospective
18 patients the following:
19 (1) information related to the health care
20 professional's educational background, experience,
21 training, specialty and board certification, if
22 applicable, number of years in practice, and hospitals
23 where he or she has privileges;
24 (2) information regarding the health care
25 professional's participation in continuing education
26 programs and compliance with any licensure,
27 certification, or registration requirements, if
28 applicable;
29 (3) information regarding the health care
30 professional's participation in clinical performance
31 reviews conducted by the Department, where applicable and
32 available; and
33 (4) the location of the health care professional's
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1 primary practice setting and the identification of any
2 translation services available.
3 Section 70. Registration of utilization review agents.
4 (a) A utilization review agent who conducts the practice
5 of utilization review shall biennially register with the
6 Director and report, in a statement subscribed and affirmed
7 as true under the penalties of perjury, the information
8 required pursuant to subsection (b) of this Section.
9 (b) The report shall contain a description of the
10 following:
11 (1) the utilization review plan;
12 (2) a description of the grievance procedures by
13 which an enrollee, the enrollee's designee, or his or her
14 health care provider may seek reconsideration of adverse
15 determinations by the utilization review agent in
16 accordance with this Act;
17 (3) procedures by which a decision on a request for
18 utilization review for services requiring
19 pre-authorization shall comply with timeframes
20 established pursuant to this Act;
21 (4) a description of an emergency care policy,
22 consistent with this Act.
23 (5) a description of personnel utilized to conduct
24 utilization review, including a description of the
25 circumstances under which utilization review may be
26 conducted by:
27 (A) administrative personnel,
28 (B) health care professionals who are not
29 clinical peer reviewers, and
30 (C) clinical peer reviewers;
31 (6) a description of the mechanisms employed to
32 assure that administrative personnel are trained in the
33 principles and procedures of intake screening and data
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1 collection and are appropriately monitored by a
2 licensed health care professional while performing an
3 administrative review;
4 (7) a description of the mechanisms employed to
5 assure that health care professionals conducting
6 utilization review are:
7 (A) appropriately licensed or registered; and
8 (B) trained in the principles, procedures,
9 and standards of the utilization review agent;
10 (8) a description of the mechanisms employed to
11 assure that only a clinical peer reviewer shall render an
12 adverse determination;
13 (9) provisions to ensure that appropriate personnel
14 of the utilization review agent are reasonably accessible
15 by toll-free telephone:
16 (A) not less than 40 hours per week during
17 normal business hours, to discuss patient care and
18 allow response to telephone requests, and to ensure
19 that the utilization review agent has a telephone
20 system capable of accepting, recording, or providing
21 instruction to incoming telephone calls during
22 other than normal business hours and to ensure
23 response to accepted or recorded messages not later
24 than the next business day after the date on which
25 the call was received; or
26 (B) notwithstanding the provisions of item (A),
27 in the case of a request submitted pursuant to
28 subsection (c) of Section 80 or an expedited appeal
29 filed pursuant to subsection (b) of Section 85, a
30 response is provided within 24 hours;
31 (10) the policies and procedures to ensure that
32 all applicable State and federal laws to protect the
33 confidentiality of individual medical and treatment
34 records are followed;
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1 (11) a copy of the materials to be disclosed to an
2 enrollee or prospective enrollee pursuant to this Act;
3 (12) a description of the mechanisms employed by
4 the utilization review agent to assure that all
5 contractors, subcontractors, subvendors, agents, and
6 employees affiliated by contract or otherwise with such
7 utilization review agent will adhere to the standards and
8 requirements of this Act; and
9 (13) a list of the payors for which the
10 utilization review agent is performing utilization
11 review in this State.
12 (c) Upon receipt of the report, the Director
13 shall issue an acknowledgment of the filing.
14 (d) A registration issued under this Act shall be valid
15 for a period of not more than 2 years, and may be renewed for
16 additional periods of not more than 2 years each.
17 Section 75. Utilization review program standards.
18 (a) A utilization review agent shall adhere to
19 utilization review program standards consistent with the
20 provisions of this Act, which shall, at a minimum, include:
21 (1) appointment of a medical director, who is a
22 licensed physician; provided, however, that the
23 utilization review agent may appoint a clinical director
24 when the utilization review performed is for a discrete
25 category of health care service and provided further that
26 the clinical director is a licensed health care
27 professional who typically manages the category of
28 service; responsibilities of the medical director, or,
29 where appropriate, the clinical director, shall
30 include, but not be limited to, the supervision and
31 oversight of the utilization review process;
32 (2) development of written policies and procedures
33 that govern all aspects of the utilization review
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1 process and a requirement that a utilization review
2 agent shall maintain and make available to enrollees and
3 health care providers a written description of the
4 procedures, including the procedures to appeal an adverse
5 determination;
6 (3) utilization of written clinical review criteria
7 developed pursuant to a utilization review plan;
8 (4) consistent with the applicable Sections of this
9 Act, establishment of a process for rendering utilization
10 review determinations, which shall, at a minimum,
11 include written procedures to assure that utilization
12 reviews and determinations are conducted within the
13 required timeframes, procedures to notify an enrollee,
14 an enrollee's designee, and an enrollee's health care
15 provider of adverse determinations, and the procedures
16 for appeal of adverse determinations, including the
17 establishment of an expedited appeals process for
18 denials of continued inpatient care or when delay would
19 significantly increase the risk to an enrollee's health;
20 (5) establishment of a requirement that
21 appropriate personnel of the utilization review agent are
22 reasonably accessible by toll-free telephone:
23 (A) not less than 40 hours per week during
24 normal business hours to discuss patient care and
25 allow response to telephone requests, and to ensure
26 that the utilization review agent has a telephone
27 system capable of accepting, recording or providing
28 instruction to incoming telephone calls during
29 other than normal business hours and to ensure
30 response to accepted or recorded messages not less
31 than one business day after the date on which the
32 call was received; or
33 (B) in the case of a request submitted
34 pursuant to subsection (c) of Section 80 or an
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1 expedited appeal filed pursuant to subsection
2 (b) of Section 85, a response is provided within 24
3 hours;
4 (6) establishment of appropriate policies and
5 procedures to ensure that all applicable State and
6 federal laws to protect the confidentiality of individual
7 medical records are followed;
8 (7) establishment of a requirement that emergency
9 services, as defined in this Act, rendered to an enrollee
10 shall not be subject to prior authorization nor
11 shall reimbursement for those services be denied on
12 retrospective review, except as authorized in this Act.
13 (b) A utilization review agent shall assure adherence to
14 the requirements stated in subsection (a) of this Section by
15 all contractors, subcontractors, subvendors, agents, and
16 employees affiliated by contract or otherwise with the
17 utilization review agent.
18 Section 80. Utilization review determinations.
19 (a) Utilization review shall be conducted by:
20 (1) administrative personnel trained in the
21 principles and procedures of intake screening and data
22 collection, provided, however, that administrative
23 personnel shall only perform intake screening, data
24 collection, and non-clinical review functions and shall
25 be supervised by a licensed health care professional;
26 (2) a health care professional who is
27 appropriately trained in the principles, procedures,
28 and standards of the utilization review agent; provided,
29 however, that a health care professional who is not a
30 clinical peer reviewer may not render an adverse
31 determination; and
32 (3) a clinical peer reviewer where the review
33 involves an adverse determination.
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1 (b) A utilization review agent shall make a utilization
2 review determination involving health care services that
3 require pre-authorization and provide notice of the
4 determination, as soon as possible, to the enrollee or
5 enrollee's designee and the enrollee's health care provider
6 by telephone upon, and in writing within 2 business days of
7 receipt of the necessary information.
8 (c) A utilization review agent shall make a
9 determination involving continued or extended health care
10 services or additional services for an enrollee
11 undergoing a course of continued treatment prescribed by a
12 health care provider and provide notice of the determination
13 to the enrollee or the enrollee's designee by notice within
14 24 hours to the enrollee's health care provider by telephone
15 upon, and in writing within 2 business days after receipt of
16 the necessary information. Notification of continued or
17 extended services shall include the number of extended
18 services approved, the new total of approved services, the
19 date of onset of services, and the next review date.
20 (d) A utilization review agent shall make a utilization
21 review determination involving health care services that have
22 already been delivered, within 30 days of receipt of the
23 necessary information.
24 (e) Notice of an adverse determination made by a
25 utilization review agent shall be given in writing in
26 accordance with the grievance procedures of this Act. The
27 notice shall also specify what, if any, additional
28 necessary information must be provided to, or obtained by,
29 the utilization review agent in order to render a decision on
30 the appeal.
31 (f) In the event that a utilization review agent
32 renders an adverse determination without attempting to
33 discuss the matter with the enrollee's health care
34 provider who specifically recommended the health care
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1 service, procedure, or treatment under review, the health
2 care provider shall have the opportunity to request an
3 immediate reconsideration of the adverse determination.
4 Except in cases of retrospective reviews, the
5 reconsideration shall occur in a prompt manner, not to
6 exceed 24 hours after receipt of the necessary information,
7 and shall be conducted by the enrollee's health care
8 provider and the clinical peer reviewer making the initial
9 determination or a designated clinical peer reviewer if the
10 original clinical peer reviewer cannot be available. In
11 the event that the adverse determination is upheld after
12 reconsideration, the utilization review agent shall provide
13 notice as required pursuant to subsection (e) of this
14 Section. Nothing in this Section shall preclude the enrollee
15 from initiating an appeal from an adverse determination.
16 Section 85. Appeal of adverse determinations by
17 utilization review agents.
18 (a) An enrollee, the enrollee's designee, and, in
19 connection with retrospective adverse determinations, the
20 enrollee's health care provider may appeal an adverse
21 determination rendered by a utilization review agent pursuant
22 to Sections 15, 20, 25, and 35.
23 (b) A utilization review agent shall establish
24 mechanisms that facilitate resolution of the appeal
25 including, but not limited to, the sharing of information
26 from the enrollee's health care provider and the utilization
27 review agent by telephonic means or by facsimile. The
28 utilization review agent shall provide reasonable access to
29 its clinical peer reviewer in a prompt manner.
30 (c) Appeals shall be reviewed by a clinical peer
31 reviewer other than the clinical peer reviewer who
32 rendered the adverse determination.
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1 Section 90. Required and prohibited practices.
2 (a) A utilization review agent shall have written
3 procedures for assuring that patient-specific information
4 obtained during the process of utilization review will be:
5 (1) kept confidential in accordance with applicable
6 State and federal laws; and
7 (2) shared only with the enrollee, the
8 enrollee's designee, the enrollee's health care provider,
9 and those who are authorized by law to receive the
10 information.
11 (b) Summary data shall not be considered confidential
12 if it does not provide information to allow identification of
13 individual patients.
14 (c) Any health care professional who makes
15 determinations regarding the medical necessity of health care
16 services during the course of utilization review shall be
17 appropriately licensed or registered.
18 (d) A utilization review agent shall not, with respect
19 to utilization review activities, permit or provide
20 compensation or anything of value to its employees, agents,
21 or contractors based on:
22 (1) either a percentage of the amount by which a
23 claim is reduced for payment or the number of claims or
24 the cost of services for which the person has denied
25 authorization or payment; or
26 (2) any other method that encourages the
27 rendering of an adverse determination.
28 (e) If a health care service has been specifically
29 pre-authorized or approved for an enrollee by a
30 utilization review agent, a utilization review agent shall
31 not, pursuant to retrospective review, revise or modify
32 the specific standards, criteria, or procedures used for
33 the utilization review for procedures, treatment, and
34 services delivered to the enrollee during the same course
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1 of treatment.
2 (f) Utilization review shall not be conducted more
3 frequently than is reasonably required to assess whether the
4 health care services under review are medically necessary.
5 The Department may promulgate rules governing the frequency
6 of utilization reviews for managed care plans of differing
7 size and geographic location.
8 (g) When making prospective, concurrent, and
9 retrospective determinations, utilization review agents shall
10 collect only information that is necessary to make the
11 determination and shall not routinely require health care
12 providers to numerically code diagnoses or procedures to
13 be considered for certification, unless required under State
14 or federal Medicare or Medicaid rules or regulations, or
15 routinely request copies of medical records of all patients
16 reviewed. During prospective or concurrent review, copies
17 of medical records shall only be required when necessary
18 to verify that the health care services subject to the review
19 are medically necessary. In these cases, only the necessary
20 or relevant sections of the medical record shall be
21 required. A utilization review agent may request copies of
22 partial or complete medical records retrospectively.
23 (h) In no event shall information be obtained from
24 health care providers for the use of the utilization
25 review agent by persons other than health care professionals,
26 medical record technologists, or administrative personnel who
27 have received appropriate training.
28 (i) The utilization review agent shall not undertake
29 utilization review at the site of the provision of health
30 care services unless the utilization review agent:
31 (1) identifies himself or herself by name and the
32 name of his or her organization, including displaying
33 photographic identification that includes the name of
34 the utilization review agent and clearly identifies the
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1 individual as representative of the utilization review
2 agent;
3 (2) whenever possible, schedules review at least
4 one business day in advance with the appropriate health
5 care provider;
6 (3) if requested by a health care provider,
7 assures that the on-site review staff register with the
8 appropriate contact person, if available, prior to
9 requesting any clinical information or assistance
10 from the health care provider; and
11 (4) obtains consent from the enrollee or the
12 enrollee's designee before interviewing the patient's
13 family or observing any health care service being
14 provided to the enrollee.
15 This subsection does not apply to health care
16 professionals engaged in providing care, case management, or
17 making on-site discharge decisions.
18 (j) A utilization review agent shall not base an adverse
19 determination on a refusal to consent to observing any health
20 care service.
21 (k) A utilization review agent shall not base an adverse
22 determination on lack of reasonable access to a health
23 care provider's medical or treatment records unless the
24 utilization review agent has provided reasonable notice
25 to both the enrollee or the enrollee's designee and the
26 enrollee's health care provider and has complied with all
27 provisions of subsection (i) of this Section. The Department
28 may promulgate rules defining reasonable notice and the time
29 period within which medical and treatment records must be
30 turned over.
31 (l) Neither the utilization review agent nor the entity
32 for which the agent provides utilization review shall take
33 any action with respect to a patient or a health care
34 provider that is intended to penalize the enrollee, the
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1 enrollee's designee, or the enrollee's health care provider
2 for, or to discourage the enrollee, the enrollee's designee,
3 or the enrollee's health care provider from, undertaking an
4 appeal, dispute resolution, or judicial review of an adverse
5 determination.
6 (m) In no event shall an enrollee, an enrollee's
7 designee, an enrollee's health care provider, any other
8 health care provider, or any other person or entity be
9 required to inform or contact the utilization review agent
10 prior to the provision of emergency services as defined in
11 this Act.
12 (n) No contract or agreement between a utilization
13 review agent and a health care provider shall contain any
14 clause purporting to transfer to the health care provider by
15 indemnification or otherwise any liability relating to
16 activities, actions, or omissions of the utilization review
17 agent.
18 (o) A health care professional providing health care
19 services to an enrollee shall be prohibited from serving
20 as the clinical peer reviewer for that enrollee in connection
21 with the health care services being provided to the
22 enrollee.
23 Section 95. Annual consumer satisfaction survey. The
24 Director shall develop and administer a survey of persons who
25 have been enrolled in a managed care plan in the most recent
26 calendar year to collect information on relative plan
27 performance. This survey shall:
28 (1) be administered annually by the Director, or by
29 an independent agency or organization selected by the
30 Director;
31 (2) be administered to a scientifically selected
32 representative sample of current enrollees from each
33 plan, as well as persons who have disenrolled from a plan
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1 in the last calendar year; and
2 (3) emphasize the collection of information from
3 persons who have used the managed care plan to a
4 significant degree, as defined by rule.
5 Selected data from the annual survey shall be made
6 available to current and prospective enrollees as part of a
7 consumer guidebook of health plan performance, which the
8 Department shall develop and publish. The elements to be
9 included in the guidebook shall be reassessed on an ongoing
10 basis by the Department. The consumer guidebook shall be
11 updated at least annually.
12 Section 100. Managed care patient rights. In addition
13 to all other requirements of this Act, a managed care plan
14 shall ensure that an enrollee has the following rights:
15 (1) A patient has the right to care consistent with
16 professional standards of practice to assure quality nursing
17 and medical practices, to be informed of the name of the
18 participating physician responsible for coordinating his or
19 her care, to receive information concerning his or her
20 condition and proposed treatment, to refuse any treatment to
21 the extent permitted by law, and to privacy and
22 confidentiality of records except as otherwise provided by
23 law.
24 (2) A patient has the right, regardless of source of
25 payment, to examine and to receive a reasonable explanation
26 of his or her total bill for health care services rendered by
27 his or her physician or other health care provider, including
28 the itemized charges for specific health care services
29 received. A physician or other health care provider shall be
30 responsible only for a reasonable explanation of these
31 specific health care services provided by the health care
32 provider.
33 (3) A patient has the right to privacy and
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1 confidentiality in health care. A physician, other health
2 care provider, managed care plan, and utilization review
3 agent shall refrain from disclosing the nature or details of
4 health care services provided to patients, except that the
5 information may be disclosed to the patient, the party making
6 treatment decisions if the patient is incapable of making
7 decisions regarding the health care services provided, those
8 parties directly involved with providing treatment to the
9 patient or processing the payment for the treatment, those
10 parties responsible for peer review, utilization review, and
11 quality assurance, and those parties required to be notified
12 under the Abused and Neglected Child Reporting Act, the
13 Illinois Sexually Transmissible Disease Control Act, or where
14 otherwise authorized or required by law. This right may be
15 expressly waived in writing by the patient or the patient's
16 guardian, but a managed care plan, a physician, or other
17 health care provider may not condition the provision of
18 health care services on the patient's or guardian's agreement
19 to sign the waiver.
20 Section 105. Health care entity liability.
21 (a) In this Section:
22 "Appropriate and medically necessary" means the standard
23 for health care services as determined by physicians and
24 health care providers in accordance with the prevailing
25 practices and standards of the medical profession and
26 community.
27 "Enrollee" means an individual who is enrolled in a
28 health care plan, including covered dependents.
29 "Health care plan" means any plan whereby any person
30 undertakes to provide, arrange for, pay for, or reimburse any
31 part of the cost of any health care services.
32 "Health care provider" means a person or entity as
33 defined in Section 2-1003 of the Code of Civil Procedure.
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1 "Health care treatment decision" means a determination
2 made when medical services are actually provided by the
3 health care plan and a decision that affects the quality of
4 the diagnosis, care, or treatment provided to the plan's
5 insureds or enrollees.
6 "Health insurance carrier" means an authorized insurance
7 company that issues policies of accident and health insurance
8 under the Illinois Insurance Code.
9 "Health maintenance organization" means an organization
10 licensed under the Health Maintenance Organization Act.
11 "Managed care entity" means any entity that delivers,
12 administers, or assumes risk for health care services with
13 systems or techniques to control or influence the quality,
14 accessibility, utilization, or costs and prices of those
15 services to a defined enrollee population, but does not
16 include an employer purchasing coverage or acting on behalf
17 of its employees or the employees of one or more subsidiaries
18 or affiliated corporations of the employer.
19 "Physician" means: (1) an individual licensed to practice
20 medicine in this State; (2) a professional association,
21 professional service corporation, partnership, medical
22 corporation, or limited liability company, entitled to
23 lawfully engage in the practice of medicine; or (3) another
24 person wholly owned by physicians.
25 "Ordinary care" means, in the case of a health insurance
26 carrier, health maintenance organization, or managed care
27 entity, that degree of care that a health insurance carrier,
28 health maintenance organization, or managed care entity of
29 ordinary prudence would use under the same or similar
30 circumstances. In the case of a person who is an employee,
31 agent, ostensible agent, or representative of a health
32 insurance carrier, health maintenance organization, or
33 managed care entity, "ordinary care" means that degree of
34 care that a person of ordinary prudence in the same
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1 profession, specialty, or area of practice as such person
2 would use in the same or similar circumstances.
3 (b) A health insurance carrier, health maintenance
4 organization, or other managed care entity for a health care
5 plan has the duty to exercise ordinary care when making
6 health care treatment decisions and is liable for damages for
7 harm to an insured or enrollee proximately caused by its
8 failure to exercise such ordinary care.
9 (c) A health insurance carrier, health maintenance
10 organization, or other managed care entity for a health care
11 plan is also liable for damages for harm to an insured or
12 enrollee proximately caused by the health care treatment
13 decisions made by its:
14 (1) employees;
15 (2) agents;
16 (3) ostensible agents; or
17 (4) representatives who are acting on its behalf
18 and over whom it has the right to exercise influence or
19 control or has actually exercised influence or control
20 that results in the failure to exercise ordinary care.
21 (d) The standards in subsections (b) and (c) create no
22 obligation on the part of the health insurance carrier,
23 health maintenance organization, or other managed care entity
24 to provide to an insured or enrollee treatment that is not
25 covered by the health care plan of the entity.
26 (e) A health insurance carrier, health maintenance
27 organization, or managed care entity may not remove a
28 physician or health care provider from its plan or refuse to
29 renew the physician or health care provider with its plan for
30 advocating on behalf of an enrollee for appropriate and
31 medically necessary health care for the enrollee.
32 (f) A health insurance carrier, health maintenance
33 organization, or other managed care entity may not enter into
34 a contract with a physician, hospital, or other health care
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1 provider or pharmaceutical company which includes an
2 indemnification or hold harmless clause for the acts or
3 conduct of the health insurance carrier, health maintenance
4 organization, or other managed care entity. Any such
5 indemnification or hold harmless clause in an existing
6 contract is hereby declared void.
7 (g) Nothing in any law of this State prohibiting a
8 health insurance carrier, health maintenance organization, or
9 other managed care entity from practicing medicine or being
10 licensed to practice medicine may be asserted as a defense by
11 the health insurance carrier, health maintenance
12 organization, or other managed care entity in an action
13 brought against it pursuant to this Section or any other law.
14 (h) In an action against a health insurance carrier,
15 health maintenance organization, or managed care entity, a
16 finding that a physician or other health care provider is an
17 employee, agent, ostensible agent, or representative of the
18 health insurance carrier, health maintenance organization, or
19 managed care entity shall not be based solely on proof that
20 the person's name appears in a listing of approved physicians
21 or health care providers made available to insureds or
22 enrollees under a health care plan.
23 (i) This Section does not apply to workers' compensation
24 insurance coverage subject to the Workers' Compensation Act.
25 (j) This Section does not apply to actions seeking only
26 a review of an adverse utilization review determination.
27 This Section applies only to causes of action that accrue on
28 or after the effective date of this Act. An insured or
29 enrollee seeking damages under this Section has the right and
30 duty to submit the claim to arbitration in accordance with
31 the Uniform Arbitration Act. No agreement between the
32 parties to submit the claim to arbitration is necessary. A
33 health insurance carrier, health maintenance organization, or
34 managed care entity shall have no liability under this
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1 Section unless the claim is first submitted to arbitration in
2 accordance with the Uniform Arbitration Act. The award in
3 matters arbitrated pursuant to this Section shall be made
4 within 30 days after notification of the arbitration is
5 provided to all parties.
6 (k) The determination of whether a procedure or
7 treatment is medically necessary must be made by a physician.
8 (l) If the physician determines that a procedure or
9 treatment is medically necessary, the health care plan must
10 pay for the procedure or treatment.
11 Section 110. Waiver. Any agreement that purports to
12 waive, limit, disclaim or in any way diminish the rights set
13 forth in this Act is void as contrary to public policy.
14 Section 115. Administration of Act.
15 (a) The Department shall administer the Act.
16 (b) All managed care plans and utilization review agents
17 providing or reviewing services in Illinois shall annually
18 certify compliance with this Act and rules adopted under this
19 Act to the Department in addition to any other licensure
20 required by law. The Director shall establish by rule a
21 process for this certification including fees to cover the
22 costs associated with implementing this Act. All fees and
23 fines assessed under this Act shall be deposited in the
24 Managed Care Reform Fund, a special fund hereby created in
25 the State treasury. Moneys in the Fund shall be used by the
26 Department only to enforce and administer this Act. The
27 certification requirements of this Act shall be incorporated
28 into program requirements of the Department of Public Aid and
29 Department of Human Services and no further certification
30 under this Act is required.
31 (c) The Director shall take enforcement action under
32 this Act including, but not limited to, the assessment of
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1 civil fines and injunctive relief for any failure to comply
2 with this Act or any violation of the Act or rules by a
3 managed care plan or any utilization review agent.
4 (d) The Department shall have the authority to impose
5 fines on any managed care plan or any utilization review
6 agent. The Department shall adopt rules pursuant to this Act
7 that establish a system of fines related to the type and
8 level of violation or repeat violation, including but not
9 limited to:
10 (1) A fine not exceeding $10,000 for a violation
11 that created a condition or occurrence presenting a
12 substantial probability that death or serious harm to an
13 individual will or did result therefrom; and
14 (2) A fine not exceeding $5,000 for a violation
15 that creates or created a condition or occurrence that
16 threatens the health, safety, or welfare of an
17 individual.
18 Each day a violation continues shall constitute a
19 separate offense. These rules shall include an opportunity
20 for a hearing in accordance with the Illinois Administrative
21 Procedure Act. All final decisions of the Department shall
22 be reviewable under the Administrative Review Law.
23 (e) Notwithstanding the existence or pursuit of any
24 other remedy, the Director may, through the Attorney General,
25 seek an injunction to restrain or prevent any person or
26 entity from functioning or operating in violation of this Act
27 or rule.
28 Section 120. Emergency services.
29 (a) Any managed care plan subject to this Act shall
30 provide the enrollee emergency services coverage such that
31 payment for this coverage is not dependent upon whether such
32 services are performed by a participating or nonparticipating
33 provider, and such coverage shall be at the same benefit
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1 level as if the service or treatment had been rendered by a
2 plan provider. Nothing in this Section is intended to
3 prohibit a plan from imposing its customary and normal
4 co-payments, deductibles, co-insurance, and other like
5 charges for emergency services.
6 (b) Prior authorization or approval by the plan shall
7 not be required for emergency services rendered under this
8 Section.
9 (c) Coverage and payment shall not be retrospectively
10 denied, with the following exceptions:
11 (1) upon reasonable determination that the
12 emergency services claimed were never performed; or
13 (2) upon reasonable determination that an emergency
14 medical screening examination was performed on a patient
15 who personally sought emergency services knowing that he
16 or she did not have an emergency condition or necessity,
17 and who did not in fact require emergency services.
18 (d) When an enrollee presents to a hospital seeking
19 emergency services, as defined in this Act, the determination
20 as to whether the need for those services exists shall be
21 made for purposes of treatment by a physician or, to the
22 extent permitted by applicable law, by other appropriate
23 licensed personnel under the supervision of a physician. The
24 physician or other appropriate personnel shall indicate in
25 the patient's chart the results of the emergency medical
26 screening examination. The plan shall compensate the
27 provider for an emergency medical screening examination that
28 is reasonably calculated to assist the health care provider
29 in determining whether the patient's condition requires
30 emergency services. A plan shall have no duty to pay for
31 services rendered after an emergency medical screening
32 examination determines the lack of a need for emergency
33 services.
34 (e) The appropriate use of the 911 emergency telephone
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1 number shall not be discouraged or penalized, and coverage or
2 payment shall not be denied solely on the basis that the
3 insured used the 911 emergency telephone number to summon
4 emergency services.
5 (f) If prior authorization for post-stabilization
6 services, as defined in this Act, is required, the managed
7 care plan shall provide access 24 hours a day, 7 days a week
8 to persons designated by plan to make such determinations.
9 If a provider has attempted to contact such person for prior
10 authorization and no designated persons were accessible or
11 the authorization was not denied within one hour of the
12 request, the plan is deemed to have approved the request for
13 prior authorization.
14 (g) Coverage and payment for post-stabilization services
15 which received prior authorization or deemed approval shall
16 not be retrospectively denied. Nothing in this Section is
17 intended to prohibit a plan from imposing its customary and
18 normal co-payments, deductibles, co-insurance, and other like
19 changes for post-stabilization services.
20 Section 125. Prescription drugs. A managed care plan
21 that provides coverage for prescribed drugs approved by the
22 federal Food and Drug Administration shall not exclude
23 coverage of any drug on the basis that the drug has been
24 prescribed for the treatment of a particular indication for
25 which the drug has not been approved by the federal Food and
26 Drug Administration. The drug, however, must be approved by
27 the federal Food and Drug Administration and must be
28 recognized for the treatment of that particular indication
29 for which the drug has been prescribed in any one of the
30 following established reference compendia:
31 (1) the American Hospital Formulary Service Drug
32 Information;
33 (2) the United States Pharmacopoeia Drug
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1 Information; or
2 (3) if not recognized by the authorities in item
3 (1) or (2), recommended for that particular indication in
4 formal clinical studies, the results of which have been
5 published in at least 2 peer reviewed professional
6 medical journals published in the United States or Great
7 Britain.
8 Any coverage required by this Section shall also include
9 those medically necessary services associated with the
10 administration of a drug.
11 Despite the provisions of this Section, coverage shall
12 not be required for any experimental or investigational drugs
13 or any drug that the federal Food and Drug Administration has
14 determined to be contraindicated for treatment of the
15 specific indication for which the drug has been prescribed.
16 Nothing in this Section shall be construed, expressly or by
17 implication, to create, impair, alter, limit, notify,
18 enlarge, abrogate, or prohibit reimbursement for drugs used
19 in the treatment of any other disease or condition.
20 Section 130. Health Care Service Delivery Review Board.
21 (a) A managed care plan shall organize a Health Care
22 Service Delivery Review Board from participants in the plan.
23 The Board shall consist of 17 members: 5 participating
24 physicians elected by participating physicians, 5 other
25 participating providers elected by the other health care
26 providers, 5 enrollees elected by the enrollees, and 2
27 representatives of the plan appointed by the plan. The
28 representatives of the plan shall not have a vote on the
29 Board, but shall have all other rights granted to Board
30 members. The plan shall devise a mechanism for the election
31 of the Board's members, subject to the approval of the
32 Department. The Department shall not unreasonably withhold
33 its approval of a mechanism.
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1 (b) The Health Care Service Delivery Board shall
2 establish written rules and regulations governing its
3 operation. The managed care plan shall approve the rules,
4 but may not unilaterally amend them. A plan may not
5 unreasonably withhold approval of proposed rules and
6 regulations.
7 (c) The Health Care Service Delivery Board shall, from
8 time to time, issue nonbinding reports and reviews concerning
9 the plan's health care delivery policy, quality assurance
10 procedures, utilization review criteria and procedures, and
11 medical management procedures. The Board shall select the
12 aspects of the plan that it wishes to study or review and may
13 undertake a study or review at the request of the plan. The
14 Board shall issue its report directly to the managed care
15 plan's governing board.
16 Section 135. Conflicts with federal law. When health
17 care services are provided by a managed care plan subject to
18 this Act to a person who is a recipient of medical assistance
19 under Article V of the Illinois Public Aid Code, the rights,
20 benefits, requirements, and procedures available or
21 authorized under this Act shall not apply to the extent that
22 there are provisions of federal law that conflict. In the
23 event of a conflict, federal law shall prevail.
24 Section 140. Severability. The provisions of this Act
25 are severable under Section 1.31 of the Statute on Statutes.
26 Section 145. The State Employees Group Insurance Act of
27 1971 is amended by adding Section 6.12 as follows:
28 (5 ILCS 375/6.12 new)
29 Sec. 6.12. Managed Care Reform Act. The program of
30 health benefits is subject to the provisions of the Managed
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1 Care Reform Act.
2 Section 150. The Civil Administrative Code of Illinois
3 is amended by adding Sections 56.3, 56.4, 56.5, 56.6, and
4 56.7 as follows:
5 (20 ILCS 1405/56.3 new)
6 Sec. 56.3. Office of Health Care Consumer Assistance,
7 Advocacy, and Information.
8 (a) The Office of Health Care Consumer Assistance,
9 Advocacy, and Information is established within the
10 Department of Insurance to provide assistance, advocacy, and
11 information to all health care consumers within the State.
12 The office shall have no regulatory power or authority and
13 shall not provide legal representation in a court of law.
14 (b) An executive director shall be appointed by the
15 governor for a 3-year term and may be removed only for just
16 cause.
17 (c) The executive director must:
18 (1) be selected without regard to political
19 affiliation;
20 (2) have knowledge and experience concerning the
21 needs and rights of health care consumers; and
22 (3) be qualified to analyze questions of law,
23 administrative functions, and public policy.
24 (d) No person may serve as executive director while
25 holding another public office.
26 (e) The Department shall provide office space, equipment
27 and supplies, and technical support to the Office of Health
28 Care Consumer Assistance, Advocacy, and Information.
29 (20 ILCS 1405/56.4 new)
30 Sec. 56.4. Duties and powers of the Office of Health
31 Care Consumer Assistance, Advocacy, and Information.
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1 (a) Within the appropriation allocated, the executive
2 director shall provide information and assistance to all
3 health care consumers by:
4 (1) assisting patients and enrollees in
5 understanding and asserting their contractual and legal
6 rights, including the rights under an alternative dispute
7 resolution process; this assistance may include advocacy
8 for enrollees in administrative proceedings or other
9 formal or informal dispute resolution processes;
10 (2) assisting enrollees in obtaining appropriate
11 health care referrals under their health plan company,
12 health insurance, or health coverage plan;
13 (3) assisting patients and enrollees in accessing
14 the services of governmental agencies or regulatory
15 boards or other State consumer assistance programs, or
16 advocacy services whenever appropriate so that the
17 patient or enrollee can take full advantage of existing
18 mechanisms for resolving complaints;
19 (4) referring patients and enrollees to
20 governmental agencies and regulatory boards for the
21 investigation of health care complaints and for
22 enforcement action;
23 (5) educating and training enrollees about their
24 health plan company, health insurance, or health coverage
25 plan to enable them to assert their rights and to
26 understand their responsibilities;
27 (6) assisting enrollees in receiving a timely
28 resolution of their complaints;
29 (7) monitoring health care consumer complaints
30 addressed by the Office of Health Care Consumer
31 Assistance, Advocacy, and Information to identify
32 specific complaint patterns or areas of potential
33 improvement;
34 (8) collecting public information on consumer
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1 satisfaction and outcomes data on health plan company and
2 health care provider performances from organizations
3 conducting surveys; and
4 (9) recommending to health plan companies ways to
5 identify and remove any barriers that might delay or
6 impede the health plan company's effort to resolve
7 consumer complaints.
8 (20 ILCS 1405/56.5 new)
9 Sec. 56.5. Reports by executive director.
10 (a) Beginning March 1, 1999, the executive director shall
11 report, on at least a quarterly basis, any patterns
12 identified from the consumer complaints addressed by the
13 office to the Director and the Governor.
14 (b) Beginning January 1, 2000, the executive director
15 shall make an annual written report to the General Assembly
16 regarding activities of the office, including recommendations
17 on improving health care consumer assistance and complaint
18 resolution processes. Before any recommendations are made to
19 the General Assembly, the executive director must consult
20 with the Public Service Division and other interested
21 parties.
22 (20 ILCS 1405/56.6 new)
23 Sec. 56.6. Managed Care Ombudsman Program.
24 (a) The Department shall establish a Managed Care
25 Ombudsman Program (MCOP) within the Office of Health Care
26 Consumer Assistance, Advocacy, and Information. The purpose
27 of the MCOP is to assist consumers to:
28 (1) navigate the managed care system;
29 (2) select an appropriate managed care plan; and
30 (3) understand and assert their rights and
31 responsibilities as managed care plan enrollees.
32 (b) The Department shall contract with an independent
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1 organization or organizations to perform the following MCOP
2 functions:
3 (1) Assist consumers with managed care plan
4 selection by providing information, referral, and
5 assistance to individuals about means of obtaining health
6 coverage and services, including, but not limited to:
7 (A) access through a toll-free telephone
8 number; and
9 (B) availability of information in languages
10 other than English that are spoken as a primary
11 language by a significant portion of the State's
12 population, as determined by the Department.
13 (2) Educate and train consumers in the use of the
14 Department's annual Consumer Guidebook of Health Plan
15 Performance, compiled in accordance with Section 95.
16 (3) Analyze, comment on, monitor, and make publicly
17 available reports on the development and implementation
18 of federal, State and local laws, regulations, and other
19 governmental policies and actions that pertain to the
20 adequacy of managed care plans, facilities, and services
21 in the State.
22 (4) Ensure that individuals have timely access to
23 the services provided through the MCOP.
24 (5) Submit an annual report to the Department and
25 General Assembly:
26 (A) describing the activities carried out by
27 the MCOP in the year for which the report is
28 prepared;
29 (B) containing and analyzing the data
30 collected by the MCOP; and
31 (C) evaluating the problems experienced by
32 managed care plan enrollees.
33 (6) Exercise such other powers and functions as the
34 Department determines to be appropriate.
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1 (c) The Department shall establish criteria for
2 selection of an independent organization or organizations to
3 perform the functions of the MCOP, including, but not limited
4 to, the following:
5 (1) Preference shall be given to private,
6 not-for-profit organizations governed by boards with
7 consumer members in the majority that represent a broad
8 spectrum of the diverse consumer interests in the State.
9 (2) No individual or organization under contract to
10 perform functions of the MCOP may:
11 (A) have a direct involvement in the
12 licensing, certification, or accreditation of a
13 health care facility, a managed care plan, or a
14 provider of a managed care plan, or have a direct
15 involvement with a provider of a health care
16 service;
17 (B) have a direct ownership or investment
18 interest in a health care facility, a managed care
19 plan, or a health care service;
20 (C) be employed by, or participate in the
21 management of, a health care service or facility or
22 a managed care plan; or
23 (D) receive, or have the right to receive,
24 directly or indirectly, remuneration (in cash or in
25 kind) under a compensation arrangement with an owner
26 or operator of a health care service or facility or
27 managed care plan.
28 The Department shall contract with an organization or
29 organizations qualified under criteria established under this
30 Section for an initial term of 3 years. The initial contract
31 shall be renewable thereafter for additional 3 year terms
32 without reopening the competitive selection process unless
33 there has been an unfavorable written performance evaluation
34 conducted by the Department.
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1 (d) The Department shall establish, by rule, policies
2 and procedures for the operation of MCOP sufficient to ensure
3 that the MCOP can perform all functions specified in this
4 Section.
5 (e) The Department shall provide adequate funding for
6 the MCOP by assessing each managed care plan an amount to be
7 determined by the Department.
8 (f) Nothing in this Section shall be interpreted to
9 authorize access to or disclosure of individual patient or
10 provider records.
11 (20 ILCS 1405/56.7 new)
12 Sec. 56.7. Retaliation. A health plan company or health
13 care provider may not retaliate or take adverse action
14 against an enrollee or patient who, in good faith, makes a
15 complaint against a health plan company or health care
16 provider.
17 Section 155. The State Finance Act is amended by adding
18 Section 5.480 as follows:
19 (30 ILCS 105/5.480 new)
20 Sec. 5.480. The Managed Care Reform Fund.
21 Section 160. The State Mandates Act is amended by adding
22 Section 8.22 as follows:
23 (30 ILCS 805/8.22 new)
24 Sec. 8.22. Exempt mandate. Notwithstanding Sections 6
25 and 8 of this Act, no reimbursement by the State is required
26 for the implementation of any mandate created by this
27 amendatory Act of 1998.
28 Section 165. The Counties Code is amended by adding
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1 Section 5-1069.8 as follows:
2 (55 ILCS 5/5-1069.8 new)
3 Sec. 5-1069.8. Managed Care Reform Act. All counties,
4 including home rule counties, are subject to the provisions
5 of the Managed Care Reform Act. The requirement under this
6 Section that health care benefits provided by counties comply
7 with the Managed Care Reform Act is an exclusive power and
8 function of the State and is a denial and limitation of home
9 rule county powers under Article VII, Section 6, subsection
10 (h) of the Illinois Constitution.
11 Section 170. The Illinois Municipal Code is amended by
12 adding 10-4-2.8 as follows:
13 (65 ILCS 5/10-4-2.8 new)
14 Sec. 10-4-2.8. Managed Care Reform Act. The corporate
15 authorities of all municipalities are subject to the
16 provisions of the Managed Care Reform Act. The requirement
17 under this Section that health care benefits provided by
18 municipalities comply with the Managed Care Reform Act is an
19 exclusive power and function of the State and is a denial and
20 limitation of home rule municipality powers under Article
21 VII, Section 6, subsection (h) of the Illinois Constitution.
22 Section 175. The School Code is amended by adding
23 Section 10-22.3g as follows:
24 (105 ILCS 5/10-22.3g new)
25 Sec. 10-22.3g. Managed Care Reform Act. Insurance
26 protection and benefits for employees are subject to the
27 Managed Care Reform Act."; and
28 on page 1, line 5, by changing "Section 5" to "Section 180";
29 and
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1 on page 50, line 10, by changing "Section 15" to "Section
2 185"; and
3 on page 51, line 25, by changing "Section 17" to "Section
4 190"; and
5 on page 61, line 23, by changing "Section 18" to "Section
6 195"; and
7 on page 61, line 25, by changing "Section 20" to "Section
8 200"; and
9 on page 65 by inserting immediately below line 3 the
10 following:
11 "Section 205. The Health Maintenance Organization Act is
12 amended by changing Sections 2-2 and 6-7 as follows:
13 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
14 Sec. 2-2. Determination by Director; Health Maintenance
15 Advisory Board.
16 (a) Upon receipt of an application for issuance of a
17 certificate of authority, the Director shall transmit copies
18 of such application and accompanying documents to the
19 Director of the Illinois Department of Public Health. The
20 Director of the Department of Public Health shall then
21 determine whether the applicant for certificate of authority,
22 with respect to health care services to be furnished: (1) has
23 demonstrated the willingness and potential ability to assure
24 that such health care service will be provided in a manner to
25 insure both availability and accessibility of adequate
26 personnel and facilities and in a manner enhancing
27 availability, accessibility, and continuity of service; and
28 (2) has arrangements, established in accordance with rules
29 regulations promulgated by the Department of Public Health
30 for an ongoing quality of health care assurance program
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1 concerning health care processes and outcomes. Upon
2 investigation, the Director of the Department of Public
3 Health shall certify to the Director whether the proposed
4 Health Maintenance Organization meets the requirements of
5 this subsection (a). If the Director of the Department of
6 Public Health certifies that the Health Maintenance
7 Organization does not meet such requirements, he or she shall
8 specify in what respect it is deficient.
9 There is created in the Department of Public Health a
10 Health Maintenance Advisory Board composed of 11 members.
11 Nine of the 11 9 members shall who have practiced in the
12 health field and, 4 of those 9 which shall have been or shall
13 be are currently affiliated with a Health Maintenance
14 Organization. Two of the members shall be members of the
15 general public, one of whom is over 65 years of age. Each
16 member shall be appointed by the Director of the Department
17 of Public Health and serve at the pleasure of that Director
18 and shall receive no compensation for services rendered other
19 than reimbursement for expenses. Six Five members of the
20 Board shall constitute a quorum. A vacancy in the membership
21 of the Advisory Board shall not impair the right of a quorum
22 to exercise all rights and perform all duties of the Board.
23 The Health Maintenance Advisory Board has the power to review
24 and comment on proposed rules and regulations to be
25 promulgated by the Director of the Department of Public
26 Health within 30 days after those proposed rules and
27 regulations have been submitted to the Advisory Board.
28 (b) Issuance of a certificate of authority shall be
29 granted if the following conditions are met:
30 (1) the requirements of subsection (c) of Section
31 2-1 have been fulfilled;
32 (2) the persons responsible for the conduct of the
33 affairs of the applicant are competent, trustworthy, and
34 possess good reputations, and have had appropriate
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1 experience, training or education;
2 (3) the Director of the Department of Public Health
3 certifies that the Health Maintenance Organization's
4 proposed plan of operation meets the requirements of this
5 Act;
6 (4) the Health Care Plan furnishes basic health
7 care services on a prepaid basis, through insurance or
8 otherwise, except to the extent of reasonable
9 requirements for co-payments or deductibles as authorized
10 by this Act;
11 (5) the Health Maintenance Organization is
12 financially responsible and may reasonably be expected to
13 meet its obligations to enrollees and prospective
14 enrollees; in making this determination, the Director
15 shall consider:
16 (A) the financial soundness of the applicant's
17 arrangements for health services and the minimum
18 standard rates, co-payments and other patient
19 charges used in connection therewith;
20 (B) the adequacy of working capital, other
21 sources of funding, and provisions for
22 contingencies; and
23 (C) that no certificate of authority shall be
24 issued if the initial minimum net worth of the
25 applicant is less than $2,000,000. The initial net
26 worth shall be provided in cash and securities in
27 combination and form acceptable to the Director;
28 (6) the agreements with providers for the provision
29 of health services contain the provisions required by
30 Section 2-8 of this Act; and
31 (7) any deficiencies identified by the Director
32 have been corrected.
33 (Source: P.A. 86-620; 86-1475.)
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1 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
2 Sec. 6-7. Board of Directors. The board of directors of
3 the Association shall consist consists of not less than 7 5
4 nor more than 11 9 members serving terms as established in
5 the plan of operation. The members of the board are to be
6 selected by member organizations subject to the approval of
7 the Director provided, however, that 2 members shall be
8 enrollees, one of whom is over 65 years of age. Vacancies on
9 the board must be filled for the remaining period of the term
10 in the manner described in the plan of operation. To select
11 the initial board of directors, and initially organize the
12 Association, the Director must give notice to all member
13 organizations of the time and place of the organizational
14 meeting. In determining voting rights at the organizational
15 meeting each member organization is entitled to one vote in
16 person or by proxy. If the board of directors is not
17 selected at the organizational meeting, the Director may
18 appoint the initial members.
19 In approving selections or in appointing members to the
20 board, the Director must consider, whether all member
21 organizations are fairly represented.
22 Members of the board may be reimbursed from the assets of
23 the Association for expenses incurred by them as members of
24 the board of directors but members of the board may not
25 otherwise be compensated by the Association for their
26 services.
27 (Source: P.A. 85-20.)"; and
28 on page 65, line 4, by changing "Section 25" to "Section
29 210"; and
30 on page 65 by replacing lines 30 and 31 with the following:
31 "Section 215. Effective date. This Section and Sections
32 180, 185, 190, and 195 take effect upon becoming law; Section
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1 200 takes effect January 1, 1999; and the remaining Sections
2 of this Act take effect July 1, 1999."; and
3 by deleting all of page 66.