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| Public Act 099-0111 | ||||
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Managed Care Reform and Patient Rights Act | ||||
is amended by changing Sections 80 and 85 as follows:
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(215 ILCS 134/80)
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Sec. 80. Quality assessment program.
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(a) A health care plan shall develop and implement a | ||||
quality assessment and
improvement strategy designed to | ||||
identify and evaluate accessibility,
continuity, and quality | ||||
of care. The health care plan shall have:
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(1) an ongoing, written, internal quality assessment | ||||
program;
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(2) specific written guidelines for monitoring and | ||||
evaluating the quality
and appropriateness of care and | ||||
services provided to enrollees requiring the
health care | ||||
plan to assess:
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(A) the accessibility to health care providers;
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(B) appropriateness of utilization;
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(C) concerns identified by the health care plan's | ||||
medical or
administrative staff and enrollees; and
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(D) other aspects of care and service directly | ||||
related to the
improvement of quality of care;
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(3) a procedure for remedial action to correct quality | ||
problems that have
been verified in accordance with the | ||
written plan's methodology and criteria,
including written | ||
procedures for taking appropriate corrective action;
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(4) follow-up measures implemented to evaluate the | ||
effectiveness of the
action plan.
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(b) The health care plan shall establish a committee that | ||
oversees the
quality assessment and improvement strategy which | ||
includes physician
and enrollee participation.
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(c) Reports on quality assessment and improvement | ||
activities shall be made
to the governing body of the health | ||
care plan not less than quarterly.
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(d) The health care plan shall make available its written | ||
description of
the quality assessment program to the Department | ||
of
Public Health.
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(e) With the exception of subsection (d), the Department of | ||
Public Health
shall accept evidence of accreditation with | ||
regard to the health care network
quality management and | ||
performance improvement standards of:
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(1) the National Commission on Quality Assurance | ||
(NCQA);
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(2) the American Accreditation Healthcare Commission | ||
(URAC);
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(3) the Joint Commission on Accreditation of | ||
Healthcare Organizations
(JCAHO); or | ||
(4) the Accreditation Association for Ambulatory | ||
Health Care (AAAHC); or
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(5) (4) any other entity that the Director of Public | ||
Health deems has
substantially similar or
more stringent | ||
standards than provided for in this Section.
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(f) If the Department of Public Health determines that a | ||
health care plan
is not in compliance with the terms of this | ||
Section, it shall certify the
finding to the Department of | ||
Insurance. The Department of Insurance shall
subject a health | ||
care plan to penalties, as provided in this Act, for such
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non-compliance.
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(Source: P.A. 91-617, eff. 1-1-00.)
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(215 ILCS 134/85)
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Sec. 85. Utilization review program registration.
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(a) No person may conduct a utilization review program in | ||
this State unless
once every 2 years the person
registers the | ||
utilization review program with the Department and certifies
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compliance with the Health
Utilization Management Standards of | ||
the American Accreditation Healthcare
Commission (URAC) | ||
sufficient to achieve American Accreditation Healthcare
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Commission (URAC) accreditation or submits evidence of | ||
accreditation by the
American
Accreditation Healthcare | ||
Commission (URAC) for its Health Utilization
Management | ||
Standards.
Nothing in this Act shall be construed to require a | ||
health care plan or its
subcontractors to become American | ||
Accreditation Healthcare Commission (URAC)
accredited.
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(b) In addition, the Director of the Department, in | ||
consultation with the
Director of the Department of Public | ||
Health, may certify alternative
utilization review standards | ||
of national accreditation organizations or
entities in order | ||
for plans to comply with this Section. Any alternative
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utilization review standards shall meet or exceed those | ||
standards required
under subsection (a).
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(b-5) The Department shall recognize the Accreditation | ||
Association for Ambulatory Health Care among the list of | ||
accreditors from which utilization organizations may receive | ||
accreditation and qualify for reduced registration and renewal | ||
fees. | ||
(c) The provisions of this Section do not apply to:
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(1) persons providing utilization review program | ||
services only to the
federal
government;
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(2) self-insured health plans under the federal | ||
Employee Retirement Income
Security Act of 1974, however, | ||
this Section does apply to persons conducting
a utilization | ||
review program on behalf of these health plans;
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(3) hospitals and medical groups performing | ||
utilization review activities
for
internal purposes unless | ||
the utilization review program is conducted for
another | ||
person.
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Nothing in this Act prohibits a health care plan or other | ||
entity from
contractually requiring an entity designated in | ||
item (3) of this subsection
to adhere to
the
utilization review | ||
program requirements of
this Act.
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(d) This registration shall include submission of all of | ||
the following
information
regarding utilization review program | ||
activities:
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(1) The name, address, and telephone number of the | ||
utilization review
programs.
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(2) The organization and governing structure of the | ||
utilization review
programs.
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(3) The
number of lives for which utilization review is | ||
conducted by each utilization
review program.
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(4) Hours of operation of each utilization review | ||
program.
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(5) Description of the grievance process for each | ||
utilization review
program.
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(6) Number of covered lives for which utilization | ||
review was conducted for
the previous calendar year for | ||
each utilization review program.
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(7) Written policies and procedures for protecting | ||
confidential
information
according to applicable State and | ||
federal laws for each utilization review
program.
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(e) (1) A utilization review program shall have written | ||
procedures for
assuring that patient-specific information | ||
obtained during the process of
utilization review will be:
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(A) kept confidential in accordance with applicable | ||
State and
federal laws; and
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(B) shared only with the enrollee, the enrollee's | ||
designee, the
enrollee's health
care provider, and those | ||
who are authorized by law to receive the information.
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Summary data shall not be considered confidential if it | ||
does not provide
information to allow identification of | ||
individual patients or health care
providers.
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(2) Only a health care professional may make | ||
determinations regarding
the medical
necessity of health | ||
care services during the course of utilization review.
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(3) When making retrospective reviews, utilization | ||
review programs shall
base
reviews solely on the medical | ||
information available to the attending physician
or | ||
ordering provider at the time the health care services were | ||
provided.
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(4) When making prospective, concurrent, and | ||
retrospective determinations,
utilization review programs | ||
shall collect only information that is necessary to
make | ||
the determination and shall not routinely require health | ||
care providers to
numerically code diagnoses or procedures | ||
to be considered for certification,
unless required under | ||
State or federal Medicare or Medicaid rules or
regulations, | ||
but may request such code if available, or routinely | ||
request
copies
of medical records of all enrollees
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reviewed. During prospective or concurrent review, copies | ||
of medical records
shall only be required when necessary to | ||
verify that the health care services
subject to review are | ||
medically necessary. In these cases, only the necessary
or
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relevant sections of the medical record shall be required.
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(f) If the Department finds that a utilization review | ||
program is
not in compliance with this Section, the Department | ||
shall issue a corrective
action plan and allow a reasonable | ||
amount of time for compliance with the plan.
If the utilization | ||
review program does not come into compliance, the
Department | ||
may issue a cease and desist order. Before issuing a cease and
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desist order under this Section, the Department shall provide | ||
the
utilization review program with a written notice of the | ||
reasons for the
order and allow a reasonable amount of time to | ||
supply additional information
demonstrating compliance with | ||
requirements of this Section and to request a
hearing. The | ||
hearing notice shall be sent by certified mail, return receipt
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requested, and the hearing shall be conducted in accordance | ||
with the Illinois
Administrative Procedure Act.
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(g) A utilization review program subject to a corrective | ||
action may continue
to conduct business
until a final decision | ||
has been issued by the Department.
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(h) Any adverse determination made by a health care plan or | ||
its
subcontractors may be appealed
in accordance with | ||
subsection (f) of Section 45.
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(i) The Director may by rule establish a registration fee | ||
for each person
conducting a utilization review program. All | ||
fees paid to and collected by the
Director under this Section | ||
shall be deposited into
the Insurance Producer Administration | ||
Fund.
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(Source: P.A. 91-617, eff. 7-1-00.)
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