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91_SB0579
LRB9101022JSpc
1 AN ACT concerning the delivery of health care services.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Managed Care Patient Rights Act.
6 Section 5. Health care patient rights.
7 (a) A patient has the right to care consistent with
8 professional standards of practice to assure quality nursing
9 and medical practices, to choose the participating physician
10 responsible for coordinating his or her care, to receive
11 information concerning his or her condition and proposed
12 treatment, to refuse any treatment to the extent permitted by
13 law, and to privacy and confidentiality of records except as
14 otherwise provided by law.
15 (b) A patient has the right, regardless of source of
16 payment, to examine and to receive a reasonable explanation
17 of his or her total bill for health care services rendered by
18 his or her physician or other health care provider, including
19 the itemized charges for specific health care services
20 received. A physician or other health care provider shall be
21 responsible only for a reasonable explanation of those
22 specific health care services provided by the health care
23 provider.
24 (c) A patient has the right to timely prior notice of
25 the termination in the event a health care plan cancels or
26 refuses to renew an enrollee's participation in the plan.
27 (d) A patient has the right to privacy and
28 confidentiality in health care. This right may be expressly
29 waived in writing by the patient or the patient's guardian.
30 (e) An individual has the right to purchase any health
31 care services with that individual's own funds.
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1 Section 10. Definitions:
2 "Department" means the Department of Insurance.
3 "Emergency medical condition" means a medical condition
4 manifesting itself by acute symptoms of sufficient severity
5 (including severe pain) such that a prudent layperson, who
6 possesses an average knowledge of health and medicine, could
7 reasonably expect the absence of immediate medical attention
8 to result in:
9 (1) placing the health of the individual (or, with
10 respect to a pregnant woman, the health of the woman or
11 her unborn child) in serious jeopardy;
12 (2) serious impairment to bodily functions; or
13 (3) serious dysfunction of any bodily organ or
14 part.
15 "Emergency services" means, with respect to an enrollee
16 of a health plan, transportation services and covered
17 inpatient and outpatient hospital services furnished by a
18 provider qualified to furnish those services that are needed
19 to evaluate or stabilize an emergency medical condition.
20 "Emergency services" does not refer to post-stabilization
21 medical services.
22 "Enrollee" means any person and his or her dependents
23 enrolled in or covered by a health care plan.
24 "Health care plan" means a plan that establishes,
25 operates, or maintains a network of health care providers
26 that have entered into agreements with the plan to provide
27 health care services to enrollees to whom the plan has the
28 obligation to arrange for the provision of or payment for
29 services through organizational arrangements for ongoing
30 quality assurance, utilization review programs, or dispute
31 resolution.
32 For purposes of this definition, "health care plan" shall
33 not include the following:
34 (1) indemnity health insurance policies including
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1 those using a contracted provider network;
2 (2) health care plans that offer only dental or
3 only vision coverage;
4 (3) preferred provider administrators, as defined
5 in Section 370g(g) of the Illinois Insurance Code;
6 (4) employee or employer self-insured health
7 benefit plans under the federal Employee Retirement
8 Income Security Act of 1974; and
9 (5) health care provided pursuant to the Workers'
10 Compensation Act or the Workers' Occupational Diseases
11 Act.
12 "Health care provider" means any physician, hospital
13 facility, or other person that is licensed or otherwise
14 authorized to deliver health care services.
15 "Health care services" means any services included in the
16 furnishing to any individual of medical care, or the
17 hospitalization or incident to the furnishing of such care or
18 hospitalization as well as the furnishing to any person of
19 any and all other services for the purpose of preventing,
20 alleviating, curing, or healing human illness or injury
21 including home health and pharmaceutical services and
22 products.
23 "Medical director" means a physician licensed in any
24 state to practice medicine in all its branches appointed by a
25 health care plan.
26 "Person" means a corporation, association, partnership,
27 limited liability company, sole proprietorship, or any other
28 legal entity.
29 "Physician" means a person licensed to practice medicine
30 in all its branches under the Medical Practice Act of 1987.
31 "Post-stabilization medical services" means health care
32 services provided to an enrollee that are furnished in a
33 licensed hospital by a provider that is qualified to furnish
34 such services, and determined to be medically necessary and
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1 directly related to the emergency medical condition following
2 stabilization.
3 "Primary care" means the provision of a broad range of
4 personal health care services (preventive, diagnostic,
5 curative, counseling, or rehabilitative) in a manner that is
6 accessible and comprehensive and coordinated by a physician
7 licensed to practice medicine in all its branches.
8 "Primary care physician" means a physician who has
9 contracted with a health care plan to provide primary care
10 services as defined by the contract and who is a physician
11 licensed to practice medicine in all of its branches. Nothing
12 in this definition shall be construed to prohibit a health
13 care plan from requiring a physician to meet a health care
14 plan's criteria in order to coordinate access to health care.
15 "Stabilization" means, with respect to an emergency
16 medical condition, to provide such medical treatment of the
17 condition as may be necessary to assure, within reasonable
18 medical probability, that no material deterioration of the
19 condition is likely to result.
20 "Utilization review" means the evaluation of the medical
21 necessity, appropriateness, and efficiency of the use of
22 health care services, procedures, and facilities.
23 "Utilization review program" means a program established
24 by a person to perform utilization review.
25 Section 15. Provision of information.
26 (a) A health care plan shall provide to enrollees and,
27 upon request, to prospective enrollees a list of
28 participating health care providers in the health care plan's
29 service area and an evidence of coverage that contains a
30 description of the following terms of coverage:
31 (1) the service area;
32 (2) covered benefits, exclusions or limitations;
33 (3) precertification and other utilization review
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1 procedures and requirements;
2 (4) a description of the limitations on access to
3 specialists;
4 (5) emergency coverage and benefits;
5 (6) out-of-area coverages and benefits, if any;
6 (7) the enrollee's financial responsibility for
7 copayments, deductibles, and any other out-of-pocket
8 expenses;
9 (8) provisions for continuity of treatment in the
10 event a provider's participation terminates during the
11 course of an enrollee's treatment by that provider; and
12 (9) the grievance process, including the telephone
13 number to call to receive information concerning
14 grievance procedures.
15 (b) Upon written request, a health care plan shall
16 provide to enrollees a description of the financial
17 relationships between the health care plan and any provider,
18 except that no health care plan shall be required to disclose
19 specific reimbursement to providers.
20 (c) A participating health care provider shall provide
21 all of the following, where applicable, to enrollees upon
22 request:
23 (1) Information related to the health care
24 provider's educational background, experience, training,
25 specialty, and board certification, if applicable.
26 (2) The names of licensed facilities on the
27 provider panel where the health provider presently has
28 privileges for the treatment, illness, or procedure that
29 is the subject of the request.
30 (3) Information regarding the health care
31 provider's participation in continuing education programs
32 and compliance with any licensure, certification, or
33 registration requirements, if applicable.
34 (d) A health care plan shall provide the information
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1 required to be disclosed under this Act in a legible and
2 understandable format consistent with the standards developed
3 for supplemental insurance coverage under Title XVIII of the
4 federal Social Security Act.
5 Section 20. Notice of nonrenewal or termination. A
6 health care plan must give at least 60 days notice of
7 nonrenewal or termination of a health care provider to the
8 health care provider and to the enrollees served by the
9 health care provider. The notice shall include a name and
10 address to which an enrollee or health care provider may
11 direct comments and concerns regarding the nonrenewal or
12 termination. Immediate written notice may be provided without
13 60 days notice when a health care provider's license has been
14 disciplined by a state licensing board.
15 Section 25. Transition of services.
16 (a) A health care plan shall provide for continuity of
17 care for its enrollees as follows:
18 (1) If an enrollee's physician leaves the health
19 care plan's network of providers for reasons other than
20 termination of a contract in situations involving
21 imminent harm to a patient or a final disciplinary action
22 by a State licensing board and the physician remains
23 within the health care plan's service area, the health
24 care plan shall permit the enrollee to continue an
25 ongoing course of treatment with that physician during a
26 transitional period:
27 (A) of 90 days from the date of the notice of
28 physician's termination from the health care plan to
29 the enrollee of the physician's disaffiliation from
30 the health care plan if the enrollee has an ongoing
31 course of treatment; or
32 (B) if the enrollee has entered the third
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1 trimester of pregnancy at the time of the
2 physician's disaffiliation, that includes the
3 provision of post-partum care directly related to
4 the delivery.
5 (2) Notwithstanding the provisions in item (1) of
6 this subsection, such care shall be authorized by the
7 health care plan during the transitional period only if
8 the physician agrees:
9 (A) to continue to accept reimbursement from
10 the health care plan at the rates applicable prior
11 to the start of the transitional period;
12 (B) to adhere to the health care plan's
13 quality assurance requirements and to provide to the
14 health care plan necessary medical information
15 related to such care; and
16 (C) to otherwise adhere to the health care
17 plan's policies and procedures, including but not
18 limited to procedures regarding referrals and
19 obtaining preauthorizations for treatment.
20 (b) A health care plan shall provide for continuity of
21 care for new enrollees as follows:
22 (1) If a new enrollee whose physician is not a
23 member of the health care plan's provider network, but is
24 within the health care plan's service area, enrolls in
25 the health care plan, the health care plan shall permit
26 the enrollee to continue an ongoing course of treatment
27 with the enrollee's current physician during a
28 transitional period:
29 (A) of at least 90 days from the effective
30 date of enrollment if the enrollee has an ongoing
31 course of treatment; or
32 (B) if the enrollee has entered the third
33 trimester of pregnancy at the effective date of
34 enrollment, that includes the provision of
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1 post-partum care directly related to the delivery.
2 (2) If an enrollee elects to continue to receive
3 care from such physician pursuant to item (1) of this
4 subsection, such care shall be authorized by the health
5 care plan for the transitional period only if the
6 physician agrees:
7 (A) to accept reimbursement from the health
8 care plan at rates established by the health care
9 plan; such rates shall be the level of reimbursement
10 applicable to similar physicians within the health
11 care plan for such services;
12 (B) to adhere to the health care plan's
13 quality assurance requirements and to provide to the
14 health care plan necessary medical information
15 related to such care; and
16 (C) to otherwise adhere to the health care
17 plan's policies and procedures including, but not
18 limited to procedures regarding referrals and
19 obtaining preauthorization for treatment.
20 (c) In no event shall this Section be construed to
21 require a health care plan to provide coverage for benefits
22 not otherwise covered or to diminish or impair preexisting
23 condition limitations contained in the enrollee's contract.
24 Section 30. Restraints on communications prohibited.
25 (a) No health care plan or its subcontractors may
26 prohibit or discourage health care providers from discussing
27 any alternative health care services and providers,
28 utilization review and quality assurance policies, terms and
29 conditions of plans and plan policy with enrollees,
30 prospective enrollees, providers, or the public.
31 (b) No health care plan or its subcontractors shall by
32 contract, policy, or procedure impose any restrictions on the
33 physicians or other health care providers who treat its
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1 enrollees as to recommended health care services.
2 (c) Any violation of this Section shall be subject to
3 the penalties under this Act.
4 Section 35. Medically appropriate health care
5 protection.
6 (a) No health care plan shall retaliate against a
7 physician or other health care provider who advocates for
8 appropriate health care services for patients.
9 (b) It is the public policy of the State of Illinois
10 that a physician or any other health care provider be
11 encouraged to advocate for medically appropriate health care
12 services for his or her patients. For purposes of this
13 Section, "to advocate for medically appropriate health care
14 services" means to appeal a decision to deny payment for a
15 health care service pursuant to the reasonable grievance or
16 appeal procedure established by a health care plan or to
17 protest a decision, policy, or practice that the physician or
18 other health care provider, consistent with that degree of
19 learning and skill ordinarily possessed by physicians or
20 other health care providers practicing in the same or a
21 similar locality and under similar circumstances, reasonably
22 believes impairs the physician's or other health care
23 provider's ability to provide appropriate health care
24 services to his or her patients.
25 (c) This Section shall not be construed to prohibit a
26 health care plan from making a determination not to pay for a
27 particular health care service or to prohibit a medical
28 group, independent practice association, preferred provider
29 organization, foundation, hospital medical staff, hospital
30 governing body or health care plan from enforcing reasonable
31 peer review or utilization review protocols or determining
32 whether a physician or other health care provider has
33 complied with those protocols.
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1 (d) Nothing in this Section shall be construed to
2 prohibit the governing body of a hospital or the hospital
3 medical staff from taking disciplinary actions against a
4 physician as authorized by law.
5 (e) Nothing in this Section shall be construed to
6 prohibit the Department of Professional Regulation from
7 taking disciplinary actions against a physician or other
8 health care provider under the appropriate licensing Act.
9 Section 40. Access to specialists.
10 (a) All health care plans that require each enrollee to
11 select a health care provider for any purpose including
12 coordination of care shall allow all enrollees to choose any
13 primary care physician licensed to practice medicine in all
14 its branches or any other health care provider participating
15 in the health care plan for that purpose. The health care
16 plan shall provide the enrollee with a choice of licensed
17 health care providers who are accessible and qualified.
18 (b) A health care plan shall establish a procedure by
19 which an enrollee who has a condition that requires ongoing
20 care from a specialist physician or other health care
21 provider may apply for a standing referral to a specialist
22 physician or other health care provider if a referral to a
23 specialist physician or other health care provider is
24 required for coverage. The application shall be made to the
25 enrollee's primary care physician. This procedure for a
26 standing referral must specify the necessary criteria and
27 conditions that must be met in order for an enrollee to
28 obtain a standing referral. A standing referral shall be
29 effective for a period of up to one year. A primary care
30 physician may renew a standing referral.
31 (c) The enrollee may be required by the health care plan
32 to select a specialist physician or other health care
33 provider who has a referral arrangement with the enrollee's
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1 primary care physician or to select a new primary care
2 physician who has a referral arrangement with the specialist
3 physician or other health care provider chosen by the
4 enrollee. If a health care plan requires an enrollee to
5 select a new physician under this subsection, the health care
6 plan must provide the enrollee with both options provided in
7 this subsection.
8 (d) When the type of specialist physician or other
9 health care provider needed to provide ongoing care for a
10 specific condition is not represented in the health care
11 plan's provider network, the primary care physician shall
12 arrange for the enrollee to have access to a qualified
13 non-participating health care provider within a reasonable
14 distance and travel time.
15 (e) The enrollee's primary care physician shall remain
16 responsible for coordinating the care of an enrollee who has
17 received a standing referral to a specialist physician or
18 other health care provider. If a secondary referral is
19 necessary, the specialist physician or other health care
20 provider shall advise the primary care physician. The
21 primary care physician shall be responsible for making the
22 secondary referral. In addition, the health care plan shall
23 require the specialist physician or other health care
24 provider to provide regular updates to the enrollee's primary
25 care physician.
26 (f) If an enrollee's application for any referral is
27 denied, an enrollee may appeal the decision through the
28 health care plan's medical necessity second opinion process
29 in accordance with Section 45 of this Act.
30 Section 45. Medical necessity; second opinion. A health
31 care plan shall provide a mechanism for the timely review by
32 a physician or other health care provider holding the same
33 class of license as the patient's physician or other health
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1 care provider, who is unaffiliated with the health care plan,
2 jointly selected by the patient (or the patient's next of kin
3 or legal representative if the patient is unable to act for
4 himself), the patient's physician or other health care
5 provider, and the health care plan in the event of a dispute
6 between the patient's physician or other health care provider
7 and the health care plan regarding the medical necessity of a
8 service or a referral. If the reviewing physician or other
9 health care provider determines the service to be medically
10 necessary or the referral to be appropriate, the health care
11 plan shall pay for the service. Future contractual or
12 employment action by the health care plan regarding the
13 patient's physician or other health care provider shall not
14 be based solely on the physician's or other health care
15 provider's participation in this procedure.
16 Section 50. Choosing a physician.
17 (a) A health care plan may also offer other arrangements
18 under which enrollees may access health care services from
19 contracted providers without a referral or authorization from
20 their primary care physician.
21 (b) The enrollee may be required by the health care plan
22 to select a specialist physician or other health care
23 provider who has a referral arrangement with the enrollee's
24 primary care physician or to select a new primary care
25 physician who has a referral arrangement with the specialist
26 physician or other health care provider chosen by the
27 enrollee. If a health care plan requires an enrollee to
28 select a new physician under this subsection, the health care
29 plan must provide the enrollee with both options provided in
30 this subsection.
31 (c) The Director of Insurance and the Department of
32 Public Health each may promulgate rules to ensure appropriate
33 access to and quality of care for enrollees in any plan that
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1 allows enrollees to access health care services from
2 contractual providers without a referral or authorization
3 from the primary care physician. The rules may include, but
4 shall not be limited to, a system for the retrieval and
5 compilation of enrollees' medical records.
6 Section 55. Emergency services prior to stabilization.
7 (a) A health care plan that provides or that is required
8 by law to provide coverage for emergency services shall
9 provide coverage such that payment under this coverage is not
10 dependent upon whether the services are performed by a plan
11 or non-plan health care provider and without regard to prior
12 authorization. This coverage shall be at the same benefit
13 level as if the services or treatment had been rendered by
14 the health care plan provider.
15 (b) Prior authorization or approval by the plan shall
16 not be required for emergency services.
17 (c) Payment shall not be retrospectively denied, with
18 the following exceptions:
19 (1) upon reasonable determination that the
20 emergency services claimed were never performed;
21 (2) upon determination that the emergency
22 evaluation and treatment were rendered to an enrollee who
23 sought emergency services and whose circumstance did not
24 meet the definition of emergency medical condition;
25 (3) upon determination that the patient receiving
26 such services was not an enrollee of the health care
27 plan; or
28 (4) upon material misrepresentation by the enrollee
29 or health care provider; "material" means a fact or
30 situation that is not merely technical in nature and
31 results or could result in a substantial change in the
32 situation.
33 (d) When an enrollee presents to a hospital seeking
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1 emergency services, the determination as to whether the need
2 for those services exists shall be made for purposes of
3 treatment by a physician or, to the extent permitted by
4 applicable law, by other appropriately licensed personnel
5 under the supervision of a physician. The physician or other
6 appropriate personnel shall indicate in the patient's chart
7 the results of the emergency medical screening examination.
8 (e) The appropriate use of the 911 emergency telephone
9 system or its local equivalent shall not be discouraged or
10 penalized by the health care plan when an emergency medical
11 condition exists. This provision shall not imply that the use
12 of 911 or its local equivalent is a factor in determining the
13 existence of an emergency medical condition.
14 (f) The medical director's or his or her designee's
15 determination of whether the enrollee meets the standard of
16 an emergency medical condition shall be based solely upon the
17 presenting symptoms documented in the medical record at the
18 time care was sought.
19 (g) Nothing in this Section shall prohibit the
20 imposition of deductibles, co-payments, and co-insurance.
21 Section 60. Post-stabilization medical services.
22 (a) If prior authorization for covered post-stabilization
23 services is required by the health care plan, the plan shall
24 provide access 24 hours a day, 7 days a week to persons
25 designated by the plan to make such determinations.
26 (b) The treating health care provider shall contact the
27 health care plan or delegated provider as designated on the
28 enrollee's health insurance card to obtain authorization,
29 denial, or arrangements for an alternate plan of treatment or
30 transfer of the enrollee.
31 (c) The treating health care provider shall document in
32 the enrollee's medical record the enrollee's presenting
33 symptoms; emergency medical condition; and time, phone number
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1 dialed, and result of the communication for request for
2 authorization of post stabilization medical services. The
3 health care plan shall provide reimbursement for covered
4 post-stabilization medical services if:
5 (1) authorization to render them is received from
6 the health care plan or its delegated health care
7 provider, or
8 (2) after 2 documented good faith efforts, the
9 treating health care provider has attempted to contact
10 the enrollee's health care plan or its delegated health
11 care provider, as designated on the enrollee's health
12 insurance card, for prior authorization of
13 post-stabilization medical services and neither the plan
14 nor designated persons were accessible or the
15 authorization was not denied within 60 minutes of the
16 request. Two documented good faith efforts means the
17 health care provider has called the telephone number on
18 the enrollee's health insurance card or other available
19 number either 2 times or one time and an additional call
20 to any referral number provided. Good faith means honesty
21 of purpose, freedom from intention to defraud, and being
22 faithful to one's duty or obligation. For the purpose of
23 this Act, good faith shall be presumed.
24 (d) After rendering any post-stabilization medical
25 services, the treating health care provider shall continue to
26 make every reasonable effort to contact the health care plan
27 or its delegated health care provider regarding
28 authorization, denial, or arrangements for an alternate plan
29 of treatment or transfer of the enrollee until the treating
30 health care provider receives instructions from the health
31 care plan or delegated health care provider for continued
32 care or the care is transferred to another health care
33 provider or the patient is discharged.
34 (e) Payment for covered post-stabilization services may
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1 be denied:
2 (1) if the treating health care provider does not
3 meet the conditions outlined in subsection (c);
4 (2) upon determination that the post-stabilization
5 services claimed were not performed;
6 (3) upon determination that the post-stabilization
7 services rendered were contrary to the instructions of
8 the health care plan or its delegated health care
9 provider if contact was made between those parties prior
10 to the service being rendered;
11 (4) upon determination that the patient receiving
12 such services was not an enrollee of the health care
13 plan; or
14 (5) upon material misrepresentation by the enrollee
15 or health care provider; "material" means a fact or
16 situation that is not merely technical in nature and
17 results or could result in a substantial change in the
18 situation.
19 (f) Nothing in this Section prohibits a health care plan
20 from delegating tasks associated with the responsibilities
21 enumerated in this Section to the health care plan's
22 contracted health care providers or an other entity.
23 (g) Coverage and payment for post-stabilization medical
24 services for which prior authorization or deemed approval is
25 received shall not be retrospectively denied.
26 (h) Nothing in this Section shall prohibit the
27 imposition of deductibles, co-payments, and co-insurance.
28 Section 65. Consumer advisory committee.
29 (a) A health care plan shall establish a consumer
30 advisory committee. The consumer advisory committee shall
31 have the authority to identify and review consumer concerns
32 and make advisory recommendations to the health care plan.
33 The health care plan may also make requests of the consumer
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1 advisory committee to provide feedback to proposed changes in
2 plan policies and procedures which will affect enrollees.
3 However, the consumer advisory committee shall not have the
4 authority to hear or resolve specific complaints or
5 grievances, but instead shall refer such complaints or
6 grievances to the health care plan's grievance committee.
7 (b) The health care plan shall randomly select 8
8 enrollees meeting the requirements of this Section to serve
9 on the consumer advisory committee. Upon initial formation
10 of the consumer advisory committee, the health care plan
11 shall appoint 4 enrollees to a 2 year term and 4 enrollees to
12 a one year term. Thereafter, as an enrollee's term expires,
13 the health care plan shall re-appoint or appoint an enrollee
14 to serve on the consumer advisory committee for a 2 year
15 term. Members of the consumer advisory committee shall by
16 majority vote elect a member of the committee to serve as
17 chair of the committee.
18 (c) An enrollee may not serve on the consumer advisory
19 committee if during the 2 years preceding service the
20 enrollee:
21 (1) has been an employee, officer, or director of
22 the plan, an affiliate of the plan, or a provider or
23 affiliate of a provider that furnishes health care
24 services to the plan or affiliate of the plan; or
25 (2) is a relative of a person specified in item
26 (1).
27 (d) A health care plan's consumer advisory committee
28 shall meet not less than quarterly.
29 (e) All meetings shall be held within the State of
30 Illinois. The costs of the meetings shall be borne by the
31 health care plan.
32 Section 70. Quality assessment program.
33 (a) A health care plan shall develop and implement a
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1 quality assessment and improvement strategy designed to
2 identify and evaluate accessibility, continuity, and quality
3 of care. The health care plan shall have:
4 (1) an ongoing, written, internal quality
5 assessment program;
6 (2) specific written guidelines for monitoring and
7 evaluating the quality and appropriateness of care and
8 services provided to enrollees requiring the health care
9 plan to assess:
10 (A) the accessibility to health care
11 providers;
12 (B) appropriateness of utilization;
13 (C) concerns identified by the health care
14 plan's medical or administrative staff and
15 enrollees; and
16 (D) other aspects of care and service directly
17 related to the improvement of quality of care;
18 (3) a procedure for remedial action to correct
19 quality problems that have been verified in accordance
20 with the written plan's methodology and criteria,
21 including written procedures for taking appropriate
22 corrective action;
23 (4) follow-up measures implemented to evaluate the
24 effectiveness of the action plan.
25 (b) The health care plan shall establish a committee
26 that oversees the quality assessment and improvement strategy
27 which includes physician and enrollee participation.
28 (c) Reports on quality assessment and improvement
29 activities shall be made to the governing body of the health
30 care plan not less than quarterly.
31 (d) The health care plan shall make available its
32 written description of the quality assessment program to the
33 Department of Public Health.
34 (e) With the exception of subsection (d), the Department
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1 of Public Health shall accept evidence of accreditation with
2 regard to the health care network quality management and
3 performance improvement standards of:
4 (1) the National Commission on Quality Assurance
5 (NCQA);
6 (2) the American Accreditation Healthcare
7 Commission (URAC);
8 (3) the Joint Commission on Accreditation of
9 Healthcare Organizations (JCAHO); or
10 (4) any other entity that the Director of Public
11 Health deems has substantially similar or more stringent
12 standards than provided for in this Section.
13 Section 75. Complaints.
14 (a) A health care plan shall establish and maintain a
15 complaint system providing reasonable procedures for
16 resolving complaints initiated by enrollees (complainant)
17 which shall provide for an expedited review of cases
18 involving imminent threat to the health of an enrollee.
19 Nothing in this Act shall be construed to preclude an
20 enrollee from filing a complaint with the Department or as
21 limiting the Department's ability to investigate complaints.
22 In addition, any enrollee not satisfied with the plan's
23 resolution of any complaint may appeal that final plan
24 decision to the Department.
25 (b) When a complaint against a health care plan
26 (respondent) is received by the Department, the respondent
27 shall be notified of the complaint. The Department shall, in
28 its notification, specify the date when a report is to be
29 received from the respondent, which shall be no later than 21
30 days after notification is sent to the respondent. A failure
31 to reply by the date specified may be followed by a collect
32 telephone call or collect telegram. Repeated instances of
33 failing to reply by the date specified may result in further
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1 regulatory action.
2 (c) The respondent's report shall supply adequate
3 documentation that explains all actions taken or not taken
4 and that were the basis for the complaint. The report shall
5 include documents necessary to support the respondent's
6 position and any information requested by the Department. The
7 respondent's reply shall be in duplicate, but duplicate
8 copies of supporting documents shall not be required. The
9 respondent's reply shall include the name, telephone number,
10 and address of the individual assigned to investigate or
11 process the complaint. The Department shall respect the
12 confidentiality of medical reports and other documents that
13 by law are confidential. Any other information furnished by
14 a respondent shall be marked "confidential" if the respondent
15 does not wish it to be released to the complainant.
16 (d) The Department shall review the plan decision to
17 determine whether it is consistent with the plan and Illinois
18 law and rules.
19 (e) Upon receipt of the respondent's report, the
20 Department shall evaluate the material submitted; and
21 (1) advise the complainant of the action taken and
22 disposition of its complaint;
23 (2) pursue further investigation with respondent or
24 complainant; or
25 (3) refer the investigation report to the
26 appropriate branch within the Department for further
27 regulatory action.
28 (f) The Department of Insurance and the Department of
29 Public Health shall coordinate the complaint review and
30 investigation process. The Department of Insurance and the
31 Department of Public Health shall jointly establish rules
32 under the Illinois Administrative Procedure Act implementing
33 this complaint process.
-21- LRB9101022JSpc
1 Section 80. Record of complaints.
2 (a) The Department shall maintain records concerning the
3 complaints filed against health care plans with the
4 Department and shall require health care plans to annually
5 report complaints made to and resolutions by health care
6 plans in a manner determined by rule. The Department shall
7 make a summary of all data collected available upon request
8 and publish the summary on the World Wide Web.
9 (b) The Department shall maintain records on the number
10 of complaints filed against each health care plan.
11 (c) The Department shall maintain records classifying
12 each complaint by whether the complaint was filed by:
13 (1) a consumer or enrollee;
14 (2) a provider; or
15 (3) any other individual.
16 (d) The Department shall maintain records classifying
17 each complaint according to the nature of the complaint as it
18 pertains to a specific function of the health care plan. The
19 complaints shall be classified under the following
20 categories:
21 (1) denial of care or treatment;
22 (2) denial of a diagnostic procedure;
23 (3) denial of a referral request;
24 (4) sufficient choice and accessibility of health
25 care providers;
26 (5) underwriting;
27 (6) marketing and sales;
28 (7) claims and utilization review;
29 (8) member services;
30 (9) provider relations; and
31 (10) miscellaneous.
32 (e) The Department shall maintain records classifying
33 the disposition of each complaint. The disposition of the
34 complaint shall be classified in one of the following
-22- LRB9101022JSpc
1 categories:
2 (1) complaint referred to the health care plan and
3 no further action necessary by the Department;
4 (2) no corrective action deemed necessary by the
5 Department; or
6 (3) corrective action taken by the Department.
7 (f) No Department publication or release of information
8 shall identify any enrollee, health care provider, or
9 individual complainant.
10 Section 85. Utilization review program registration.
11 (a) No person may conduct a utilization review program
12 in this State unless once every 2 years the person registers
13 the utilization review program with the Department and
14 certifies compliance with all of the Health Utilization
15 Management Standards of the American Accreditation Healthcare
16 Commission (URAC) or submits evidence of accreditation by the
17 American Accreditation Healthcare Commission (URAC) for its
18 Health Utilization Management Standards.
19 (b) In addition, the Director of the Department, in
20 consultation with the Director of the Department of Public
21 Health, may certify alternative utilization review standards
22 of national accreditation organizations or entities in order
23 for plans to comply with this Section. Any alternative
24 utilization review standards shall meet or exceed those
25 standards required under subsection (a).
26 (c) The provisions of this Section do not apply to:
27 (1) persons providing utilization review program
28 services only to the federal government;
29 (2) self-insured health plans under the federal
30 Employee Retirement Income Security Act of 1974, however,
31 this Section does apply to persons conducting a
32 utilization review program on behalf of these health
33 plans;
-23- LRB9101022JSpc
1 (3) hospitals and medical groups performing
2 utilization review activities for internal purposes
3 unless the utilization on review program is conducted for
4 another person.
5 Nothing in this Act prohibits a health care plan or other
6 entity from contractually requiring an entity designated in
7 item (3) of this subsection to adhere to the utilization
8 review program requirements of this Act.
9 (d) This registration shall include submission of all of
10 the following information regarding utilization review
11 program activities:
12 (1) The name, address, and telephone of the
13 utilization review programs.
14 (2) The organization and governing structure of the
15 utilization review programs.
16 (3) The number of lives for which utilization
17 review is conducted by each utilization review program.
18 (4) Hours of operation of each utilization review
19 program.
20 (5) Description of the grievance process for each
21 utilization review program.
22 (6) Number of covered lives for which utilization
23 review was conducted for the previous calendar year for
24 each utilization review program.
25 (7) Written policies and procedures for protecting
26 confidential information according to applicable State
27 and federal laws for each utilization review program.
28 (e) If the Department finds that a utilization review
29 program is not in compliance with this Section, the
30 Department shall issue a corrective action plan and allow a
31 reasonable amount of time for compliance with the plan. If
32 the utilization review program does not come into compliance,
33 the Department may issue a cease and desist order. Before
34 issuing a cease and desist order under this Section, the
-24- LRB9101022JSpc
1 Department shall provide the utilization review program with
2 a written notice of the reasons for the order and allow a
3 reasonable amount of time to supply additional information
4 demonstrating compliance with requirements of this Section
5 and to request a hearing. The hearing notice shall be sent
6 by certified mail, return receipt requested, and the hearing
7 shall be conducted in accordance with the Illinois
8 Administrative Procedure Act.
9 (f) A utilization review program subject to a corrective
10 action may continue to conduct business until a final
11 decision has been issued by the Department.
12 Section 90. Prohibited activity. No health care plan by
13 contract, written policy, or procedure shall contain any
14 clause attempting to transfer or transferring to a health
15 care provider by indemnification or otherwise, any liability
16 relating to activities, actions, or omissions of the health
17 care plan or its officers, employees, or agents as opposed to
18 those of the health care provider.
19 Section 95. Prohibition of waiver of rights. No health
20 care plan or contract shall contain any provision, policy, or
21 procedure that limits, restricts, or waives any of the rights
22 set forth in this Act. Any such policy or procedure shall be
23 void and unenforceable.
24 Section 100. Administration and enforcement. The
25 Director of Insurance may adopt rules necessary to implement
26 the Department's responsibilities under this Act.
27 To enforce the provisions of this Act, the Director may
28 issue a cease and desist order or require a health care plan
29 to submit a plan of correction for violations of this Act, or
30 both. Subject to the provisions of the Illinois
31 Administrative Procedure Act, the Director may impose an
-25- LRB9101022JSpc
1 administrative fine on a health care plan of up to $5,000 for
2 failure to submit a requested plan of correction, failure to
3 comply with its plan of correction, or repeated violations of
4 the Act.
5 Section 105. Applicability and scope. This Act applies
6 to policies and contracts amended, delivered, issued, or
7 renewed on or after the effective date of this Act. This Act
8 does not diminish a health care plan's duties and
9 responsibilities under other federal or State law or rules
10 promulgated thereunder.
11 Section 110. Effect on benefits under Workers'
12 Compensation Act and Workers' Occupational Diseases Act.
13 Nothing in this Act shall be construed to expand, modify, or
14 restrict the health care benefits provided to employees under
15 the Workers' Compensation Act and Workers' Occupational
16 Diseases Act.
17 Section 115. Severability. The provisions of this Act
18 are severable under Section 1.31 of the Statute on Statutes.
19 Section 200. The State Employees Group Insurance Act of
20 1971 is amended by adding Section 6.12 as follows:
21 (5 ILCS 375/6.12 new)
22 Sec. 6.12. Managed Care Patient Rights Act. The program
23 of health benefits is subject to the provisions of the
24 Managed Care Patient Rights Act.
25 Section 205. The State Mandates Act is amended by adding
26 Section 8.23 as follows:
27 (30 ILCS 805/8.23 new)
-26- LRB9101022JSpc
1 Sec. 8.23. Exempt mandate. Notwithstanding Sections 6
2 and 8 of this Act, no reimbursement by the State is required
3 for the implementation of any mandate created by this
4 amendatory Act of 1999.
5 Section 210. The Counties Code is amended by adding
6 Section 5-1069.8 as follows:
7 (55 ILCS 5/5-1069.8 new)
8 Sec. 5-1069.8. Managed Care Patient Rights Act. All
9 counties, including home rule counties, are subject to the
10 provisions of the Managed Care Patient Rights Act. The
11 requirement under this Section that health care benefits
12 provided by counties comply with the Managed Care Patient
13 Rights Act is an exclusive power and function of the State
14 and is a denial and limitation of home rule county powers
15 under Article VII, Section 6, subsection (h) of the Illinois
16 Constitution.
17 Section 215. The Illinois Municipal Code is amended by
18 adding 10-4-2.8 as follows:
19 (65 ILCS 5/10-4-2.8 new)
20 Sec. 10-4-2.8. Managed Care Patient Rights Act. The
21 corporate authorities of all municipalities are subject to
22 the provisions of the Managed Care Patients Rights Act. The
23 requirement under this Section that health care benefits
24 provided by municipalities comply with the Managed Care
25 Patient Rights Act is an exclusive power and function of the
26 State and is a denial and limitation of home rule
27 municipality powers under Article VII, Section 6, subsection
28 (h) of the Illinois Constitution.
29 Section 220. The Illinois Insurance Code is amended by
-27- LRB9101022JSpc
1 changing Sections 155.36 and 370g and adding Sections 370s
2 and 511.118 as follows:
3 (215 ILCS 5/155.36 new)
4 Sec. 155.36. Managed Care Patient Rights Act. Insurance
5 companies that transact the kinds of insurance authorized
6 under Class 1(b) or Class 2(a) of Section 4 of this Code
7 shall comply with Sections 80 and 85 and the definition of
8 the term "emergency medical condition" in Section 10 of the
9 Managed Care Patients Rights Act.
10 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
11 Sec. 370g. Definitions. As used in this Article, the
12 following definitions apply:
13 (a) "Health care services" means health care services or
14 products rendered or sold by a provider within the scope of
15 the provider's license or legal authorization. The term
16 includes, but is not limited to, hospital, medical, surgical,
17 dental, vision and pharmaceutical services or products.
18 (b) "Insurer" means an insurance company or a health
19 service corporation authorized in this State to issue
20 policies or subscriber contracts which reimburse for expenses
21 of health care services.
22 (c) "Insured" means an individual entitled to
23 reimbursement for expenses of health care services under a
24 policy or subscriber contract issued or administered by an
25 insurer.
26 (d) "Provider" means an individual or entity duly
27 licensed or legally authorized to provide health care
28 services.
29 (e) "Noninstitutional provider" means any person
30 licensed under the Medical Practice Act of 1987, as now or
31 hereafter amended.
32 (f) "Beneficiary" means an individual entitled to
-28- LRB9101022JSpc
1 reimbursement for expenses of or the discount of provider
2 fees for health care services under a program where the
3 beneficiary has an incentive to utilize the services of a
4 provider which has entered into an agreement or arrangement
5 with an administrator.
6 (g) "Administrator" means any person, partnership or
7 corporation, other than an insurer or health maintenance
8 organization holding a certificate of authority under the
9 "Health Maintenance Organization Act", as now or hereafter
10 amended, that arranges, contracts with, or administers
11 contracts with a provider whereby beneficiaries are provided
12 an incentive to use the services of such provider.
13 (h) "Emergency medical condition" means a medical
14 condition manifesting itself by acute symptoms of sufficient
15 severity (including severe pain) such that a prudent
16 layperson, who possesses an average knowledge of health and
17 medicine, could reasonably expect the absence of immediate
18 medical attention to result in:
19 (1) placing the health of the individual (or, with
20 respect to a pregnant woman, the health of the woman or
21 her unborn child) in serious jeopardy;
22 (2) serious impairment to bodily functions; or
23 (3) serious dysfunction of any bodily organ or
24 part. "Emergency" means an accidental bodily injury or
25 emergency medical condition which reasonably requires the
26 beneficiary or insured to seek immediate medical care
27 under circumstances or at locations which reasonably
28 preclude the beneficiary or insured from obtaining needed
29 medical care from a preferred provider.
30 (Source: P.A. 88-400.)
31 (215 ILCS 5/370s new)
32 Sec. 370s. Managed Care Patients Rights Act. All
33 administrators shall comply with Sections 80 and 85 of the
-29- LRB9101022JSpc
1 Managed Care Patients Rights Act.
2 (215 ILCS 5/511.118 new)
3 Sec. 511.118. Managed Care Patients Rights Act. All
4 administrators are subject to the provisions of Sections 80
5 and 85 of the Managed Care Patients Act.
6 Section 225. The Comprehensive Health Insurance Plan Act
7 is amended by adding Section 8.6 as follows:
8 (215 ILCS 105/8.6 new)
9 Sec. 8.6. Managed Care Patient Rights Act. The plan is
10 subject to the provisions of the Managed Care Patient Rights
11 Act.
12 Section 230. The Health Care Purchasing Group Act is
13 amended by changing Sections 15 and 20 as follows:
14 (215 ILCS 123/15)
15 Sec. 15. Health care purchasing groups; membership;
16 formation.
17 (a) An HPG may be an organization formed by 2 or more
18 employers with no more than 500 covered employees each 2,500
19 covered individuals, an HPG sponsor or a risk-bearer for
20 purposes of contracting for health insurance under this Act
21 to cover employees and dependents of HPG members. An HPG
22 shall not be prevented from supplementing health insurance
23 coverage purchased under this Act by contracting for services
24 from entities licensed and authorized in Illinois to provide
25 those services under the Dental Service Plan Act, the Limited
26 Health Service Organization Act, or Voluntary Health Services
27 Plans Act. An HPG may be a separate legal entity or simply a
28 group of 2 or more employers with no more than 500 covered
29 employees each 2,500 covered individuals aggregated under
-30- LRB9101022JSpc
1 this Act by an HPG sponsor or risk-bearer for insurance
2 purposes. There shall be no limit as to the number of HPGs
3 that may operate in any geographic area of the State. No
4 insurance risk may be borne or retained by the HPG. All
5 health insurance contracts issued to the HPG must be
6 delivered or issued for delivery in Illinois.
7 (b) Members of an HPG must be Illinois domiciled
8 employers, except that an employer domiciled elsewhere may
9 become a member of an Illinois HPG for the sole purpose of
10 insuring its employees whose place of employment is located
11 within this State. HPG membership may include employers
12 having no more than 500 covered employees each 2,500 covered
13 individuals.
14 (c) If an HPG is formed by any 2 or more employers with
15 no more than 500 covered employees each 2,500 covered
16 individuals, it is authorized to negotiate, solicit, market,
17 obtain proposals for, and enter into group or master health
18 insurance contracts on behalf of its members and their
19 employees and employee dependents so long as it meets all of
20 the following requirements:
21 (1) The HPG must be an organization having the
22 legal capacity to contract and having its legal situs in
23 Illinois.
24 (2) The principal persons responsible for the
25 conduct of the HPG must perform their HPG related
26 functions in Illinois.
27 (3) No HPG may collect premium in its name or hold
28 or manage premium or claim fund accounts unless duly
29 licensed and qualified as a managing general agent
30 pursuant to Section 141a of the Illinois Insurance Code
31 or a third party administrator pursuant to Section
32 511.105 of the Illinois Insurance Code.
33 (4) If the HPG gives an offer, application, notice,
34 or proposal of insurance to an employer, it must disclose
-31- LRB9101022JSpc
1 to that employer the total cost of the insurance. Dues,
2 fees, or charges to be paid to the HPG, HPG sponsor, or
3 any other entity as a condition to purchasing the
4 insurance must be itemized. The HPG shall also disclose
5 to its members the amount of any dividends, experience
6 refunds, or other such payments it receives from the
7 risk-bearer.
8 (5) An HPG must register with the Director before
9 entering into a group or master health insurance contract
10 on behalf of its members and must renew the registration
11 annually on forms and at times prescribed by the Director
12 in rules specifying, at minimum, (i) the identity of the
13 officers and directors, trustees, or attorney-in-fact of
14 the HPG; (ii) a certification that those persons have not
15 been convicted of any felony offense involving a breach
16 of fiduciary duty or improper manipulation of accounts;
17 and (iii) the number of employer members then enrolled in
18 the HPG, together with any other information that may be
19 needed to carry out the purposes of this Act.
20 (6) At the time of initial registration and each
21 renewal thereof an HPG shall pay a fee of $100 to the
22 Director.
23 (d) If an HPG is formed by an HPG sponsor or risk-bearer
24 and the HPG performs no marketing, negotiation, solicitation,
25 or proposing of insurance to HPG members, exclusive of
26 ministerial acts performed by individual employers to service
27 their own employees, then a group or master health insurance
28 contract may be issued in the name of the HPG and held by an
29 HPG sponsor, risk-bearer, or designated employer member
30 within the State. In these cases the HPG requirements
31 specified in subsection (c) shall not be applicable, however:
32 (1) the group or master health insurance contract
33 must contain a provision permitting the contract to be
34 enforced through legal action initiated by any employer
-32- LRB9101022JSpc
1 member or by an employee of an HPG member who has paid
2 premium for the coverage provided;
3 (2) the group or master health insurance contract
4 must be available for inspection and copying by any HPG
5 member, employee, or insured dependent at a designated
6 location within the State at all normal business hours;
7 and
8 (3) any information concerning HPG membership
9 required by rule under item (5) of subsection (c) must be
10 provided by the HPG sponsor in its registration and
11 renewal forms or by the risk-bearer in its annual
12 reports.
13 (Source: P.A. 90-337, eff. 1-1-98; 90-655, eff. 7-30-98.)
14 (215 ILCS 123/20)
15 Sec. 20. HPG sponsors. Except as provided by Sections 15
16 and 25 of this Act, only a corporation authorized by the
17 Secretary of State to transact business in Illinois may
18 sponsor one or more HPGs with no more than 100,000 10,000
19 covered individuals by negotiating, soliciting, or servicing
20 health insurance contracts for HPGs and their members. Such a
21 corporation may assert and maintain authority to act as an
22 HPG sponsor by complying with all of the following
23 requirements:
24 (1) The principal officers and directors
25 responsible for the conduct of the HPG sponsor must
26 perform their HPG sponsor related functions in Illinois.
27 (2) No insurance risk may be borne or retained by
28 the HPG sponsor; all health insurance contracts issued to
29 HPGs through the HPG sponsor must be delivered in
30 Illinois.
31 (3) No HPG sponsor may collect premium in its name
32 or hold or manage premium or claim fund accounts unless
33 duly qualified and licensed as a managing general agent
-33- LRB9101022JSpc
1 pursuant to Section 141a of the Illinois Insurance Code
2 or as a third party administrator pursuant to Section
3 511.105 of the Illinois Insurance Code.
4 (4) If the HPG gives an offer, application, notice,
5 or proposal of insurance to an employer, it must disclose
6 the total cost of the insurance. Dues, fees, or charges
7 to be paid to the HPG, HPG sponsor, or any other entity
8 as a condition to purchasing the insurance must be
9 itemized. The HPG shall also disclose to its members the
10 amount of any dividends, experience refunds, or other
11 such payments it receives from the risk-bearer.
12 (5) An HPG sponsor must register with the Director
13 before negotiating or soliciting any group or master
14 health insurance contract for any HPG and must renew the
15 registration annually on forms and at times prescribed by
16 the Director in rules specifying, at minimum, (i) the
17 identity of the officers and directors of the HPG sponsor
18 corporation; (ii) a certification that those persons have
19 not been convicted of any felony offense involving a
20 breach of fiduciary duty or improper manipulation of
21 accounts; (iii) the number of employer members then
22 enrolled in each HPG sponsored; (iv) the date on which
23 each HPG was issued a group or master health insurance
24 contract, if any; and (v) the date on which each such
25 contract, if any, was terminated.
26 (6) At the time of initial registration and each
27 renewal thereof an HPG sponsor shall pay a fee of $100 to
28 the Director.
29 (Source: P.A. 90-337, eff. 1-1-98.)
30 Section 235. The Health Maintenance Organization Act is
31 amended by changing Sections 2-2 and 6-7 and adding Section
32 5-3.6 as follows:
-34- LRB9101022JSpc
1 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
2 Sec. 2-2. Determination by Director; Health Maintenance
3 Advisory Board.
4 (a) Upon receipt of an application for issuance of a
5 certificate of authority, the Director shall transmit copies
6 of such application and accompanying documents to the
7 Director of the Illinois Department of Public Health. The
8 Director of the Department of Public Health shall then
9 determine whether the applicant for certificate of authority,
10 with respect to health care services to be furnished: (1) has
11 demonstrated the willingness and potential ability to assure
12 that such health care service will be provided in a manner to
13 insure both availability and accessibility of adequate
14 personnel and facilities and in a manner enhancing
15 availability, accessibility, and continuity of service; and
16 (2) has arrangements, established in accordance with
17 regulations promulgated by the Department of Public Health
18 for an ongoing quality of health care assurance program
19 concerning health care processes and outcomes. Upon
20 investigation, the Director of the Department of Public
21 Health shall certify to the Director whether the proposed
22 Health Maintenance Organization meets the requirements of
23 this subsection (a). If the Director of the Department of
24 Public Health certifies that the Health Maintenance
25 Organization does not meet such requirements, he shall
26 specify in what respect it is deficient.
27 There is created in the Department of Public Health a
28 Health Maintenance Advisory Board composed of 11 members.
29 Nine 9 members shall who have practiced in the health field,
30 4 of which shall have been or are currently affiliated with a
31 Health Maintenance Organization. Two of the members shall be
32 members of the general public, one of whom is over 50 years
33 of age. Each member shall be appointed by the Director of
34 the Department of Public Health and serve at the pleasure of
-35- LRB9101022JSpc
1 that Director and shall receive no compensation for services
2 rendered other than reimbursement for expenses. Six Five
3 members of the Board shall constitute a quorum. A vacancy in
4 the membership of the Advisory Board shall not impair the
5 right of a quorum to exercise all rights and perform all
6 duties of the Board. The Health Maintenance Advisory Board
7 has the power to review and comment on proposed rules and
8 regulations to be promulgated by the Director of the
9 Department of Public Health within 30 days after those
10 proposed rules and regulations have been submitted to the
11 Advisory Board.
12 (b) Issuance of a certificate of authority shall be
13 granted if the following conditions are met:
14 (1) the requirements of subsection (c) of Section
15 2-1 have been fulfilled;
16 (2) the persons responsible for the conduct of the
17 affairs of the applicant are competent, trustworthy, and
18 possess good reputations, and have had appropriate
19 experience, training or education;
20 (3) the Director of the Department of Public Health
21 certifies that the Health Maintenance Organization's
22 proposed plan of operation meets the requirements of this
23 Act;
24 (4) the Health Care Plan furnishes basic health
25 care services on a prepaid basis, through insurance or
26 otherwise, except to the extent of reasonable
27 requirements for co-payments or deductibles as authorized
28 by this Act;
29 (5) the Health Maintenance Organization is
30 financially responsible and may reasonably be expected to
31 meet its obligations to enrollees and prospective
32 enrollees; in making this determination, the Director
33 shall consider:
34 (A) the financial soundness of the applicant's
-36- LRB9101022JSpc
1 arrangements for health services and the minimum
2 standard rates, co-payments and other patient
3 charges used in connection therewith;
4 (B) the adequacy of working capital, other
5 sources of funding, and provisions for
6 contingencies; and
7 (C) that no certificate of authority shall be
8 issued if the initial minimum net worth of the
9 applicant is less than $2,000,000. The initial net
10 worth shall be provided in cash and securities in
11 combination and form acceptable to the Director;
12 (6) the agreements with providers for the provision
13 of health services contain the provisions required by
14 Section 2-8 of this Act; and
15 (7) any deficiencies identified by the Director
16 have been corrected.
17 (Source: P.A. 86-620; 86-1475.)
18 (215 ILCS 125/5-3.6 new)
19 Sec. 5-3.6. Managed Care Patient Rights Act. Health
20 maintenance organizations are subject to the provisions of
21 the Managed Care Patient Rights Act.
22 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
23 Sec. 6-7. Board of Directors. The board of directors of
24 the Association consists of not less than 7 5 nor more than
25 11 9 members serving terms as established in the plan of
26 operation. The members of the board are to be selected by
27 member organizations subject to the approval of the Director,
28 except the Director shall name 2 members who are current
29 enrollees, one of whom is over 50 years of age. Vacancies on
30 the board must be filled for the remaining period of the term
31 in the manner described in the plan of operation. To select
32 the initial board of directors, and initially organize the
-37- LRB9101022JSpc
1 Association, the Director must give notice to all member
2 organizations of the time and place of the organizational
3 meeting. In determining voting rights at the organizational
4 meeting each member organization is entitled to one vote in
5 person or by proxy. If the board of directors is not
6 selected at the organizational meeting, the Director may
7 appoint the initial members.
8 In approving selections or in appointing members to the
9 board, the Director must consider, whether all member
10 organizations are fairly represented.
11 Members of the board may be reimbursed from the assets of
12 the Association for expenses incurred by them as members of
13 the board of directors but members of the board may not
14 otherwise be compensated by the Association for their
15 services.
16 (Source: P.A. 85-20.)
17 Section 240. The Limited Health Service Organization Act
18 is amended by adding Section 4002.6 as follows:
19 (215 ILCS 130/4002.6 new)
20 Sec. 4002.6. Managed Care Patient Rights Act. Except
21 for health care plans offering only dental services or only
22 vision services, limited health service organizations are
23 subject to the provisions of the Managed Care Patient Rights
24 Act.
25 Section 245. The Voluntary Health Services Plans Act is
26 amended by adding Section 15.30 as follows:
27 (215 ILCS 165/15.30 new)
28 Sec. 15.30. Managed Care Patient Rights Act. A health
29 service plan corporation is subject to the provisions of the
30 Managed Care Patient Rights Act.
-38- LRB9101022JSpc
1 Section 250. The Illinois Public Aid Code is amended by
2 adding Section 5-16.12 as follows:
3 (305 ILCS 5/5-16.12 new)
4 Sec. 5-16.12. Managed Care Patient Rights Act. The
5 medical assistance program and other programs administered by
6 the Department are subject to the provisions of the Managed
7 Care Patient Rights Act. The Department may adopt rules to
8 implement those provisions. These rules shall require
9 compliance with that Act in the medical assistance managed
10 care programs and other programs administered by the
11 Department. The medical assistance fee-for-service program
12 is not subject to the provisions of the Managed Care Patient
13 Rights Act.
14 Section 299. Effective date. This Act takes effect
15 January 1, 2000.
-39- LRB9101022JSpc
1 INDEX
2 Statutes amended in order of appearance
3 5 ILCS 375/6.12 new
4 30 ILCS 805/8.23 new
5 55 ILCS 5/5-1069.8 new
6 65 ILCS 5/10-4-2.8 new
7 215 ILCS 5/155.36 new
8 215 ILCS 5/370g from Ch. 73, par. 982g
9 215 ILCS 5/370s new
10 215 ILCS 5/511.118 new
11 215 ILCS 105/8.6 new
12 215 ILCS 123/15
13 215 ILCS 123/20
14 215 ILCS 125/2-2 from Ch. 111 1/2, par. 1404
15 215 ILCS 125/5-3.6 new
16 215 ILCS 125/6-7 from Ch. 111 1/2, par. 1418.7
17 215 ILCS 130/4002.6 new
18 215 ILCS 165/15.30 new
19 305 ILCS 5/5-16.12 new