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90_HB3272
New Act
Creates the Managed Care Enrollee Rights Act. Sets forth
specific rights of an enrollee with respect to the enrollee's
relationship with a managed care entity. The rights include
a right to privacy, the right to care consistent with
professional standards of care, and the right to refuse
treatment. Establishes the Managed Care Ombudsman Program
within the Department of Public Health. Provides for the
ombudsman to assist consumers in selecting an appropriate
managed care plan and understanding their rights and
responsibilities as enrollees. Requires the Department of
Public Health to conduct an annual consumer survey and to
publish a Consumer Guidebook of Health Plan Performance.
Requires managed care plans to establish Health Care Service
Delivery Review Boards to establish rules of operation for
the managed care plan. Defines terms.
LRB9011500JSks
LRB9011500JSks
1 AN ACT concerning the provision 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 Enrollee Rights Act.
6 Section 5. Definitions. For purposes of this Act, the
7 following words shall have the meanings provided in this
8 Section, unless otherwise indicated:
9 "Department" means the Department of Public Health.
10 "Director" means the Director of Public Health.
11 "Emergency medical screening examination" means a medical
12 screening examination and evaluation by a physician or, to
13 the extent permitted by applicable laws, by other appropriate
14 personnel under the supervision of a physician to determine
15 whether the need for emergency services exists.
16 "Emergency services" means the provision of health care
17 services for sudden and, at the time, unexpected onset of a
18 health condition that would lead a prudent layperson to
19 believe that failure to receive immediate medical attention
20 would result in serious impairment to bodily function or
21 serious dysfunction of any body organ or part or would place
22 the person's health in serious jeopardy.
23 "Enrollee" means a person enrolled in a managed care
24 plan.
25 "Health care provider" means a health care professional,
26 hospital, facility, or other person appropriately licensed or
27 otherwise authorized to furnish health care services or
28 arrange for the delivery of health care services in this
29 State.
30 "Health care services" means services included in the (i)
31 furnishing of medical care, (ii) hospitalization incident to
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1 the furnishing of medical care, and (iii) furnishing of
2 services, including pharmaceuticals, for the purpose of
3 preventing, alleviating, curing, or healing human illness or
4 injury to an individual.
5 "Managed care plan" means a plan that establishes,
6 operates, or maintains a network of health care providers
7 that have entered into agreements with the plan to provide
8 health care services to enrollees where the plan has the
9 obligation to the enrollee to arrange for the provision of or
10 pay for services through:
11 (1) organizational arrangements for ongoing quality
12 assurance, utilization review programs, or dispute
13 resolution; or
14 (2) financial incentives for persons enrolled in
15 the plan to use the participating providers and
16 procedures covered by the plan.
17 A managed care plan may be established or operated by any
18 entity including, but not necessarily limited to, a licensed
19 insurance company, hospital or medical service plan, health
20 maintenance organization, limited health service
21 organization, preferred provider organization, third party
22 administrator, independent practice association, or employer
23 or employee organization.
24 For purposes of this definition, "managed care plan"
25 shall not include the following:
26 (1) strict indemnity health insurance policies or
27 plans issued by an insurer that does not require approval
28 of a primary care provider or other similar coordinator
29 to access health care services; and
30 (2) managed care plans that offer only dental or
31 vision coverage.
32 "Specialist" means a health care professional who
33 concentrates practice in a recognized specialty field of
34 care.
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1 "Speciality care center" means only a center that is
2 accredited by an agency of the State or federal government or
3 by a voluntary national health organization as having special
4 expertise in treating the life-threatening disease or
5 condition or degenerative or disabling disease or condition
6 for which it is accredited.
7 "Utilization review" means the review, undertaken by a
8 entity other than the managed care plan itself, to determine
9 whether health care services that have been provided, are
10 being provided or are proposed to be provided to an
11 individual by a managed care plan, whether undertaken prior
12 to, concurrent with, or subsequent to the delivery of
13 such services are medically necessary. For the purposes
14 of this Act, none of the following shall be considered
15 utilization review:
16 (1) denials based on failure to obtain health care
17 services from a designated or approved health care
18 provider as required under an enrollee's contract;
19 (2) the review of the appropriateness of the
20 application of a particular coding to a patient,
21 including the assignment of diagnosis and procedure;
22 (3) any issues relating to the determination of
23 the amount or extent of payment other than determinations
24 to deny payment based on an adverse determination; and
25 (4) any determination of any coverage issues other
26 than whether health care services are or were medically
27 necessary.
28 "Utilization review agent" means any company,
29 organization, or other entity performing utilization review,
30 except:
31 (1) an agency of the State or federal government;
32 (2) an agent acting on behalf of the federal
33 government, but only to the extent that the agent is
34 providing services to the federal government;
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1 (3) an agent acting on behalf of the State and
2 local government for services provided pursuant to
3 Title XIX of the federal Social Security Act, but only to
4 the extent that the agent is providing services to the
5 State or local government;
6 (4) a hospital's internal quality assurance program
7 except if associated with a health care financing
8 mechanism.
9 Section 10. Annual consumer satisfaction survey. The
10 Director shall develop and administer a survey of persons who
11 have been enrolled in a managed care plan in the most recent
12 calendar year to collect information on relative plan
13 performance. This survey shall:
14 (1) be administered annually by the Director, or by
15 an independent agency or organization selected by the
16 Director;
17 (2) be administered to a scientifically selected
18 representative sample of current enrollees from each
19 plan, as well as persons who have disenrolled from a plan
20 in the last calendar year; and
21 (3) emphasize the collection of information from
22 persons who have used the managed care plan to a
23 significant degree, as defined by rule.
24 Selected data from the annual survey shall be made
25 available to current and prospective enrollees as part of a
26 consumer guidebook of health plan performance, which the
27 Department shall develop and publish. The elements to be
28 included in the guidebook shall be reassessed on an ongoing
29 basis by the Department. The consumer guidebook shall be
30 updated at least annually.
31 Section 15. Managed care patient rights. In addition to
32 all other requirements of this Act, a managed care plan shall
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1 ensure that an enrollee has the following rights:
2 (1) A patient has the right to care consistent with
3 professional standards of practice to assure quality nursing
4 and medical practices, to be informed of the name of the
5 participating physician responsible for coordinating his or
6 her care, to receive information concerning his or her
7 condition and proposed treatment, to refuse any treatment to
8 the extent permitted by law, and to privacy and
9 confidentiality of records except as otherwise provided by
10 law.
11 (2) A patient has the right, regardless of source of
12 payment, to examine and to receive a reasonable explanation
13 of his or her total bill for health care services rendered by
14 his or her physician or other health care provider, including
15 the itemized charges for specific health care services
16 received. A physician or other health care provider shall be
17 responsible only for a reasonable explanation of these
18 specific health care services provided by the health care
19 provider.
20 (3) A patient has the right to privacy and
21 confidentiality in health care. A physician, other health
22 care provider, managed care plan, and utilization review
23 agent shall refrain from disclosing the nature or details of
24 health care services provided to patients, except that the
25 information may be disclosed to the patient, the party making
26 treatment decisions if the patient is incapable of making
27 decisions regarding the health care services provided, those
28 parties directly involved with providing treatment to the
29 patient or processing the payment for the treatment, those
30 parties responsible for peer review, utilization review, and
31 quality assurance, and those parties required to be notified
32 under the Abused and Neglected Child Reporting Act, the
33 Illinois Sexually Transmissible Disease Control Act, or where
34 otherwise authorized or required by law. This right may be
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1 expressly waived in writing by the patient or the patient's
2 guardian, but a managed care plan, a physician, or other
3 health care provider may not condition the provision of
4 health care services on the patient's or guardian's agreement
5 to sign the waiver.
6 Section 20. Managed Care Ombudsman Program.
7 (a) The Department shall establish a Managed Care
8 Ombudsman Program (MCOP). The purpose of the MCOP is to
9 assist consumers to:
10 (1) navigate the managed care system;
11 (2) select an appropriate managed care plan; and
12 (3) understand and assert their rights and
13 responsibilities as managed care plan enrollees.
14 (b) The Department shall contract with an independent
15 organization or organizations to perform the following MCOP
16 functions:
17 (1) Assist consumers with managed care plan
18 selection by providing information, referral, and
19 assistance to individuals about means of obtaining health
20 coverage and services, including, but not limited to:
21 (A) access through a toll-free telephone
22 number; and
23 (B) availability of information in languages
24 other than English that are spoken as a primary
25 language by a significant portion of the State's
26 population, as determined by the Department.
27 (2) Educate and train consumers in the use of the
28 Department's annual Consumer Guidebook of Health Plan
29 Performance, compiled in accordance with Section 10.
30 (3) Analyze, comment on, monitor, and make publicly
31 available reports on the development and implementation
32 of federal, State and local laws, regulations, and other
33 governmental policies and actions that pertain to the
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1 adequacy of managed care plans, facilities, and services
2 in the State.
3 (4) Ensure that individuals have timely access to
4 the services provided through the MCOP.
5 (5) Submit an annual report to the Department and
6 General Assembly:
7 (A) describing the activities carried out by
8 the MCOP in the year for which the report is
9 prepared;
10 (B) containing and analyzing the data
11 collected by the MCOP; and
12 (C) evaluating the problems experienced by
13 managed care plan enrollees.
14 (6) Exercise such other powers and functions as the
15 Department determines to be appropriate.
16 (c) The Department shall establish criteria for
17 selection of an independent organization or organizations to
18 perform the functions of the MCOP, including, but not limited
19 to, the following:
20 (1) Preference shall be given to private,
21 not-for-profit organizations governed by boards with
22 consumer members in the majority that represent a broad
23 spectrum of the diverse consumer interests in the State.
24 (2) No individual or organization under contract to
25 perform functions of the MCOP may:
26 (A) have a direct involvement in the
27 licensing, certification, or accreditation of a
28 health care facility, a managed care plan, or a
29 provider of a managed care plan, or have a direct
30 involvement with a provider of a health care
31 service;
32 (B) have a direct ownership or investment
33 interest in a health care facility, a managed care
34 plan, or a health care service;
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1 (C) be employed by, or participate in the
2 management of, a health care service or facility or
3 a managed care plan; or
4 (D) receive, or have the right to receive,
5 directly or indirectly, remuneration (in cash or in
6 kind) under a compensation arrangement with an owner
7 or operator of a health care service or facility or
8 managed care plan.
9 The Department shall contract with an organization or
10 organizations qualified under criteria established under this
11 Section for an initial term of 3 years. The initial contract
12 shall be renewable thereafter for additional 3 year terms
13 without reopening the competitive selection process unless
14 there has been an unfavorable written performance evaluation
15 conducted by the Department.
16 (d) The Department shall establish, by rule, policies
17 and procedures for the operation of MCOP sufficient to ensure
18 that the MCOP can perform all functions specified in this
19 Section.
20 (e) The Department shall provide adequate funding for
21 the MCOP by assessing each managed care plan an amount to be
22 determined by the Department.
23 (f) Nothing in this Section shall be interpreted to
24 authorize access to or disclosure of individual patient or
25 provider records.
26 Section 25. Waiver. Any agreement that purports to
27 waive, limit, disclaim or in any way diminish the rights set
28 forth in this Act is void as contrary to public policy.
29 Section 30. Administration of Act.
30 (a) The Department shall administer the Act.
31 (b) All managed care plans and utilization review agents
32 providing or reviewing services in Illinois shall annually
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1 certify compliance with this Act and rules adopted under this
2 Act to the Department in addition to any other licensure
3 required by law. The Director shall establish by rule a
4 process for this certification including fees to cover the
5 costs associated with implementing this Act. All fees and
6 fines assessed under this Act shall be deposited in the
7 Managed Care Reform Fund, a special fund hereby created in
8 the State treasury. Moneys in the Fund shall be used by the
9 Department only to enforce and administer this Act. The
10 certification requirements of this Act shall be incorporated
11 into program requirements of the Department of Public Aid and
12 Department of Human Services and no further certification
13 under this Act is required.
14 (c) The Director shall take enforcement action under
15 this Act including, but not limited to, the assessment of
16 civil fines and injunctive relief for any failure to comply
17 with this Act or any violation of this Act or rules by a
18 managed care plan or any utilization review agent.
19 (d) The Department shall have the authority to impose
20 fines on any managed care plan or any utilization review
21 agent. The Department shall adopt rules pursuant to this Act
22 that establish a system of fines related to the type and
23 level of violation or repeat violation, including but not
24 limited to:
25 (1) A fine not exceeding $10,000 for a violation
26 that created a condition or occurrence presenting a
27 substantial probability that death or serious harm to an
28 individual will or did result therefrom; and
29 (2) A fine not exceeding $5,000 for a violation
30 that creates or created a condition or occurrence that
31 threatens the health, safety, or welfare of an
32 individual.
33 Each day a violation continues shall constitute a
34 separate offense. These rules shall include an opportunity
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1 for a hearing in accordance with the Illinois Administrative
2 Procedure Act. All final decisions of the Department shall
3 be reviewable under the Administrative Review Law.
4 (e) Notwithstanding the existence or pursuit of any
5 other remedy, the Director may, through the Attorney General,
6 seek an injunction to restrain or prevent any person or
7 entity from functioning or operating in violation of this Act
8 or rule.
9 Section 35. Health Care Service Delivery Review Board.
10 (a) A managed care plan shall organize a Health Care
11 Service Delivery Review Board from participants in the plan.
12 The Board shall consist of 17 members: 5 participating
13 physicians elected by participating physicians, 5 other
14 participating providers elected by the other health care
15 providers, 5 enrollees elected by the enrollees, and 2
16 representatives of the plan appointed by the plan. The
17 representatives of the plan shall not have a vote on the
18 Board, but shall have all other rights granted to Board
19 members. The plan shall devise a mechanism for the election
20 of the Board's members, subject to the approval of the
21 Department. The Department shall not unreasonably withhold
22 its approval of a mechanism.
23 (b) The Health Care Service Delivery Board shall
24 establish written rules and regulations governing its
25 operation. The managed care plan shall approve the rules,
26 but may not unilaterally amend them. A plan may not
27 unreasonably withhold approval of proposed rules and
28 regulations.
29 (c) The Health Care Service Delivery Board shall, from
30 time to time, issue nonbinding reports and reviews concerning
31 the plan's health care delivery policy, quality assurance
32 procedures, utilization review criteria and procedures, and
33 medical management procedures. The Board shall select the
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1 aspects of the plan that it wishes to study or review and may
2 undertake a study or review at the request of the plan. The
3 Board shall issue its report directly to the managed care
4 plan's governing board.