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91_HB0626
LRB9100964JSpc
1 AN ACT concerning the delivery of health care services,
2 amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 1. Short title. This Act may be cited as the
6 Managed Care Reform Act.
7 Section 5. Definitions. For purposes of this Act, the
8 following words shall have the meanings provided in this
9 Section, unless otherwise indicated:
10 "Adverse determination" means a determination by a
11 utilization review agent that an admission, extension of a
12 stay, or other health care service has been reviewed and,
13 based on the information provided, is not medically
14 necessary.
15 "Clinical peer reviewer" or "clinical personnel" means:
16 (1) in the case of physician reviewers, a State
17 licensed physician who is of the same category in the
18 same or similar specialty as the health care provider who
19 typically manages the medical condition, procedure or
20 treatment under review; or
21 (2) in the case of non-physician reviewers, a State
22 licensed or registered health care professional who is
23 in the same profession and same or similar specialty
24 as the health care provider who typically manages the
25 medical condition, procedure, or treatment under review.
26 Nothing herein shall be construed to change any
27 statutorily defined scope of practice.
28 "Culturally and linguistically competent care" means that
29 a managed care plan has staff and procedures in place to
30 provide all covered services and policy procedures in
31 English, Spanish, and any other language spoken as a primary
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1 language by 5% or more of its enrollees.
2 "Degenerative or disabling condition or disease" means a
3 condition or disease that is permanent or of indefinite
4 duration, that is likely to become worse or more advanced
5 over time, and that substantially impairs a major life
6 function.
7 "Department" means the Department of Public Health.
8 "Director" means the Director of Public Health.
9 "Emergency medical screening examination" means a medical
10 screening examination and evaluation by a physician or, to
11 the extent permitted by applicable laws, by other appropriate
12 personnel under the supervision of a physician to determine
13 whether the need for emergency services exists.
14 "Emergency services" means the provision of health care
15 services for sudden and, at the time, unexpected onset of a
16 health condition that would lead a prudent layperson to
17 believe that failure to receive immediate medical attention
18 would result in serious impairment to bodily function or
19 serious dysfunction of any body organ or part or would place
20 the person's health in serious jeopardy.
21 "Enrollee" means a person enrolled in a managed care
22 plan.
23 "Health care professional" means a physician, registered
24 professional nurse, or other person appropriately licensed or
25 registered pursuant to the laws of this State to provide
26 health care services.
27 "Health care provider" means a health care professional,
28 hospital, facility, or other person appropriately licensed or
29 otherwise authorized to furnish health care services or
30 arrange for the delivery of health care services in this
31 State.
32 "Health care services" means services included in the (i)
33 furnishing of medical care, (ii) hospitalization incident to
34 the furnishing of medical care, and (iii) furnishing of
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1 services, including pharmaceuticals, for the purpose of
2 preventing, alleviating, curing, or healing human illness or
3 injury to an individual.
4 "Informal policy or procedure" means a nonwritten policy
5 or procedure, the existence of which may be proven by an
6 admission of an authorized agent of a managed care plan or
7 statistical evidence supported by anecdotal evidence.
8 "Life threatening condition or disease" means any
9 condition, illness, or injury that, in the opinion of a
10 licensed physician, (i) may directly lead to a patient's
11 death, (ii) results in a period of unconsciousness which is
12 indeterminate at the present, or (iii) imposes severe pain or
13 an inhumane burden on the patient.
14 "Managed care plan" means a plan that establishes,
15 operates, or maintains a network of health care providers
16 that have entered into agreements with the plan to provide
17 health care services to enrollees where the plan has the
18 obligation to the enrollee to arrange for the provision of or
19 pay for services through:
20 (1) organizational arrangements for ongoing quality
21 assurance, utilization review programs, or dispute
22 resolution; or
23 (2) financial incentives for persons enrolled in
24 the plan to use the participating providers and
25 procedures covered by the plan.
26 A managed care plan may be established or operated by any
27 entity including, but not necessarily limited to, a licensed
28 insurance company, hospital or medical service plan, health
29 maintenance organization, limited health service
30 organization, preferred provider organization, third party
31 administrator, independent practice association, or employer
32 or employee organization.
33 For purposes of this definition, "managed care plan"
34 shall not include the following:
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1 (1) strict indemnity health insurance policies or
2 plans issued by an insurer that does not require approval
3 of a primary care provider or other similar coordinator
4 to access health care services; and
5 (2) managed care plans that offer only dental or
6 vision coverage.
7 "Post-stabilization services" means those health care
8 services determined by a treating provider to be promptly and
9 medically necessary following stabilization of an emergency
10 condition.
11 "Primary care provider" means a physician licensed to
12 practice medicine in all its branches who provides a broad
13 range of personal medical care (preventive, diagnostic,
14 curative, counseling, or rehabilitative) in a comprehensive
15 and coordinated manner over time for a managed care plan.
16 "Specialist" means a health care professional who
17 concentrates practice in a recognized specialty field of
18 care.
19 "Speciality care center" means only a center that is
20 accredited by an agency of the State or federal government or
21 by a voluntary national health organization as having special
22 expertise in treating the life-threatening disease or
23 condition or degenerative or disabling disease or condition
24 for which it is accredited.
25 "Utilization review" means the review, undertaken by a
26 entity other than the managed care plan itself, to determine
27 whether health care services that have been provided, are
28 being provided or are proposed to be provided to an
29 individual by a managed care plan, whether undertaken prior
30 to, concurrent with, or subsequent to the delivery of
31 such services are medically necessary. For the purposes
32 of this Act, none of the following shall be considered
33 utilization review:
34 (1) denials based on failure to obtain health care
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1 services from a designated or approved health care
2 provider as required under an enrollee's contract;
3 (2) the review of the appropriateness of the
4 application of a particular coding to a patient,
5 including the assignment of diagnosis and procedure;
6 (3) any issues relating to the determination of
7 the amount or extent of payment other than determinations
8 to deny payment based on an adverse determination; and
9 (4) any determination of any coverage issues other
10 than whether health care services are or were medically
11 necessary.
12 "Utilization review agent" means any company,
13 organization, or other entity performing utilization review,
14 except:
15 (1) an agency of the State or federal government;
16 (2) an agent acting on behalf of the federal
17 government, but only to the extent that the agent is
18 providing services to the federal government;
19 (3) an agent acting on behalf of the State and
20 local government for services provided pursuant to
21 Title XIX of the federal Social Security Act, but only to
22 the extent that the agent is providing services to the
23 State or local government;
24 (4) a hospital's internal quality assurance program
25 except if associated with a health care financing
26 mechanism.
27 "Utilization review plan" means:
28 (1) a description of the process for developing the
29 written clinical review criteria;
30 (2) a description of the types of written clinical
31 information which the plan might consider in its clinical
32 review including, but not limited to, a set of specific
33 written clinical review criteria;
34 (3) a description of practice guidelines and
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1 standards used by a utilization review agent in making a
2 determination of medical necessity;
3 (4) the procedures for scheduled review and
4 evaluation of the written clinical review criteria; and
5 (5) a description of the qualifications and
6 experience of the health care professionals who
7 developed the criteria, who are responsible for periodic
8 evaluation of the criteria and of the health care
9 professionals or others who use the written clinical
10 review criteria in the process of utilization review.
11 Section 10. Disclosure of information.
12 (a) An enrollee, and upon request a prospective enrollee
13 prior to enrollment, shall be supplied with written
14 disclosure information, containing at least the information
15 specified in this Section, if applicable, which may be
16 incorporated into the member handbook or the enrollee
17 contract or certificate. All written descriptions shall be
18 in readable and understandable format, consistent with
19 standards developed for supplemental insurance coverage under
20 Title XVIII of the Social Security Act. The Department shall
21 promulgate rules to standardize this format so that potential
22 members can compare the attributes of the various managed
23 care entities. In the event of any inconsistency between any
24 separate written disclosure statement and the enrollee
25 contract or certificate, the terms of the enrollee
26 contract or certificate shall be controlling. The
27 information to be disclosed shall include, at a minimum,
28 all of the following:
29 (1) A description of coverage provisions, health
30 care benefits, benefit maximums, including benefit
31 limitations, and exclusions of coverage, including the
32 definition of medical necessity used in determining
33 whether benefits will be covered.
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1 (2) A description of all prior authorization or
2 other requirements for treatments, pharmaceuticals, and
3 services.
4 (3) A description of utilization review policies
5 and procedures used by the managed care plan,
6 including the circumstances under which utilization
7 review will be undertaken, the toll-free telephone
8 number of the utilization review agent, the timeframes
9 under which utilization review decisions must be made for
10 prospective, retrospective, and concurrent decisions,
11 the right to reconsideration, the right to an appeal,
12 including the expedited and standard appeals processes
13 and the timeframes for those appeals, the right to
14 designate a representative, a notice that all denials of
15 claims will be made by clinical personnel, and that
16 all notices of denials will include information about the
17 basis of the decision and further appeal rights, if any.
18 (4) A description prepared annually of the types of
19 methodologies the managed care plan uses to reimburse
20 providers specifying the type of methodology that is
21 used to reimburse particular types of providers or
22 reimburse for the provision of particular types of
23 services, provided, however, that nothing in this item
24 should be construed to require disclosure of individual
25 contracts or the specific details of any financial
26 arrangement between a managed care plan and a health care
27 provider.
28 (5) An explanation of a enrollee's financial
29 responsibility for payment of premiums, coinsurance,
30 co-payments, deductibles, and any other charges, annual
31 limits on an enrollee's financial responsibility, caps
32 on payments for covered services and financial
33 responsibility for non-covered health care procedures,
34 treatments, or services provided within the managed
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1 care plan.
2 (6) An explanation of an enrollee's financial
3 responsibility for payment when services are provided by
4 a health care provider who is not part of the managed
5 care plan or by any provider without required
6 authorization or when a procedure, treatment, or service
7 is not a covered health care benefit.
8 (7) A description of the grievance procedures to
9 be used to resolve disputes between a managed care plan
10 and an enrollee, including the right to file a
11 grievance regarding any dispute between an enrollee and a
12 managed care plan, the right to file a grievance
13 orally when the dispute is about referrals or covered
14 benefits, the toll-free telephone number that enrollees
15 may use to file an oral grievance, the timeframes and
16 circumstances for expedited and standard grievances, the
17 right to appeal a grievance determination and the
18 procedures for filing the appeal, the timeframes and
19 circumstances for expedited and standard appeals, the
20 right to designate a representative, a notice that all
21 disputes involving clinical decisions will be made by
22 clinical personnel, and that all notices of determination
23 will include information about the basis of the
24 decision and further appeal rights, if any.
25 (8) A description of the procedure for providing
26 care and coverage 24 hours a day for emergency services.
27 The description shall include the definition of
28 emergency services, notice that emergency services are
29 not subject to prior approval, and an explanation of
30 the enrollee's financial and other responsibilities
31 regarding obtaining those services, including when
32 those services are received outside the managed care
33 plan's service area.
34 (9) A description of procedures for enrollees to
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1 select and access the managed care plan's primary and
2 specialty care providers, including notice of how to
3 determine whether a participating provider is accepting
4 new patients.
5 (10) A description of the procedures for changing
6 primary and specialty care providers within the managed
7 care plan.
8 (11) Notice that an enrollee may obtain a referral
9 to a health care provider outside of the managed care
10 plan's network or panel when the managed care plan
11 does not have a health care provider with appropriate
12 training and experience in the network or panel to meet
13 the particular health care needs of the enrollee and
14 the procedure by which the enrollee can obtain the
15 referral.
16 (12) Notice that an enrollee with a condition
17 that requires ongoing care from a specialist may
18 request a standing referral to the specialist and
19 the procedure for requesting and obtaining a standing
20 referral.
21 (13) Notice that an enrollee with (i) a
22 life-threatening condition or disease or (ii) a
23 degenerative or disabling condition or disease, either of
24 which requires specialized medical care over a prolonged
25 period of time, may request a specialist responsible for
26 providing or coordinating the enrollee's medical care and
27 the procedure for requesting and obtaining the
28 specialist.
29 (14) A description of the mechanisms by which
30 enrollees may participate in the development of the
31 policies of the managed care plan.
32 (15) A description of how the managed care plan
33 addresses the needs of non-English speaking enrollees.
34 (16) Notice of all appropriate mailing addresses
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1 and telephone numbers to be utilized by enrollees
2 seeking information or authorization.
3 (17) A listing by specialty, which may be in a
4 separate document that is updated annually, of the name,
5 address, and telephone number of all participating
6 providers, including facilities, and, in addition, in the
7 case of physicians, category of license and board
8 certification, if applicable.
9 (b) Upon request of an enrollee or prospective enrollee,
10 a managed care plan shall do all of the following:
11 (1) Provide a list of the names, business
12 addresses, and official positions of the members of the
13 board of directors, officers, controlling persons,
14 owners, and partners of the managed care plan.
15 (2) Provide a copy of the most recent annual
16 certified financial statement of the managed care plan,
17 including a balance sheet and summary of receipts and
18 disbursements and the ratio of (i) premium dollars going
19 to administrative expenses to (ii) premium dollars going
20 to direct care, prepared by a certified public
21 accountant. The Department shall promulgate rules to
22 standardize the information that must be contained in the
23 statement and the statement's format.
24 (3) Provide information relating to consumer
25 complaints compiled in accordance with subsection (b) of
26 Section 30 of this Act and the rules promulgated under
27 this Act.
28 (4) Provide the procedures for protecting the
29 confidentiality of medical records and other enrollee
30 information.
31 (5) Allow enrollees and prospective enrollees to
32 inspect drug formularies used by the managed care plan
33 and disclose whether individual drugs are included or
34 excluded from coverage and whether a drug requires prior
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1 authorization. An enrollee or prospective enrollee may
2 seek information as to the inclusion or exclusion of a
3 specific drug. A managed care plan need only release the
4 information if the enrollee or prospective enrollee or
5 his or her dependent needs, used, or may need or use the
6 drug.
7 (6) Provide a written description of the
8 organizational arrangements and ongoing procedures of
9 the managed care plan's quality assurance program.
10 (7) Provide a description of the procedures
11 followed by the managed care plan in making decisions
12 about the experimental or investigational nature of
13 individual drugs, medical devices, or treatments in
14 clinical trials.
15 (8) Provide individual health care professional
16 affiliations with participating hospitals, if any.
17 (9) Upon written request, provide specific
18 written clinical review criteria relating to a
19 particular condition or disease and, where appropriate,
20 other clinical information that the managed care plan
21 might consider in its utilization review; the managed
22 care plan may include with the information a description
23 of how it will be used in the utilization review
24 process. An enrollee or prospective enrollee may seek
25 information as to specific clinical review criteria. A
26 managed care plan need only release the information if
27 the enrollee or prospective enrollee or his or her
28 dependent has, may have, or is at risk of contracting a
29 particular condition or disease.
30 (10) Provide the written application procedures and
31 minimum qualification requirements for health care
32 providers to be considered by the managed care plan.
33 (11) Disclose other information as required by
34 the Director.
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1 (12) To the extent the information provided under
2 item (5) or (9) of this subsection is proprietary to the
3 managed care plan, the enrollee or prospective enrollee
4 shall only use the information for the purposes of
5 assisting the enrollee or prospective enrollee in
6 evaluating the covered services provided by the managed
7 care plan. Any misuse of proprietary data is prohibited,
8 provided that the managed care plan has labeled or
9 identified the data as proprietary.
10 (c) Nothing in this Section shall prevent a managed care
11 plan from changing or updating the materials that are made
12 available to enrollees or prospective enrollees.
13 (d) If a primary care provider ceases participation in
14 the managed care plan, the managed care plan shall provide
15 written notice within 15 business days from the date that the
16 managed care plan becomes aware of the change in status to
17 each of the enrollees who have chosen the provider as
18 their primary care provider. If an enrollee is in an
19 ongoing course of treatment with any other participating
20 provider who becomes unavailable to continue to provide
21 services to the enrollee and the managed care plan is aware
22 of the ongoing course of treatment, the managed care plan
23 shall provide written notice within 15 business days from
24 the date that the managed care plan becomes aware of the
25 unavailability to the enrollee. The notice shall also
26 describe the procedures for continuing care.
27 (e) A managed care plan offering to indemnify enrollees
28 for non-participating provider services shall file a report
29 with the Director twice a year showing the percentage
30 utilization for the preceding 6 month period of
31 non-participating provider services in such form and
32 providing such other information as the Director shall
33 prescribe.
34 (f) The written information disclosure requirements of
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1 this Section may be met by disclosure to one enrollee in a
2 household.
3 Section 15. General grievance procedure.
4 (a) A managed care plan shall establish and maintain a
5 grievance procedure, as described in this Act. Compliance
6 with this Act's grievance procedures shall satisfy a managed
7 care plan's obligation to provide grievance procedures under
8 any other State law or rules.
9 A copy of the grievance procedures, including all forms
10 used to process a grievance, shall be filed with the
11 Director. Any subsequent material modifications to the
12 documents also shall be filed. In addition, a managed care
13 plan shall file annually with the Director a certificate of
14 compliance stating that the managed care plan has established
15 and maintains, for each of its plans, grievance procedures
16 that fully comply with the provisions of this Act. The
17 Director has authority to disapprove a filing that fails to
18 comply with this Act or applicable rules.
19 (b) A managed care plan shall provide written notice of
20 the grievance procedure to all enrollees in the member
21 handbook and to an enrollee at any time that the managed care
22 plan denies access to a referral or determines that a
23 requested benefit is not covered pursuant to the terms of the
24 contract. In the event that a managed care plan denies a
25 service as an adverse determination, the managed care plan
26 shall inform the enrollee or the enrollee's designee of
27 the appeal rights under this Act.
28 The notice to an enrollee describing the grievance
29 process shall explain the process for filing a grievance
30 with the managed care plan, the timeframes within which a
31 grievance determination must be made, and the right of an
32 enrollee to designate a representative to file a grievance on
33 behalf of the enrollee. Information required to be disclosed
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1 or provided under this Section must be provided in a
2 reasonable and understandable format.
3 The managed care plan shall assure that the grievance
4 procedure is reasonably accessible to those who do not speak
5 English.
6 (c) A managed care plan shall not retaliate or take
7 any discriminatory action against an enrollee because an
8 enrollee has filed a grievance or appeal.
9 Section 20. First level grievance review.
10 (a) The managed care plan may require an enrollee to
11 file a grievance in writing, by letter or by a grievance
12 form which shall be made available by the managed care plan,
13 however, an enrollee must be allowed to submit an oral
14 grievance in connection with (i) a denial of, or failure to
15 pay for, a referral or service or (ii) a determination as to
16 whether a benefit is covered pursuant to the terms of the
17 enrollee's contract. In connection with the submission of
18 an oral grievance, a managed care plan shall, within 24
19 hours, reduce the complaint to writing and give the enrollee
20 written acknowledgment of the grievance prepared by the
21 managed care plan summarizing the nature of the grievance
22 and requesting any information that the enrollee needs to
23 provide before the grievance can be processed. The
24 acknowledgment shall be mailed within the 24-hour period
25 to the enrollee, who shall sign and return the
26 acknowledgment, with any amendments and requested
27 information, in order to initiate the grievance. The
28 grievance acknowledgment shall prominently state that the
29 enrollee must sign and return the acknowledgment to
30 initiate the grievance. A managed care plan may elect not to
31 require a signed acknowledgment when no additional
32 information is necessary to process the grievance, and an
33 oral grievance shall be initiated at the time of the
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1 telephone call.
2 Except as authorized in this subsection, a managed care
3 plan shall designate personnel to accept the filing of an
4 enrollee's grievance by toll-free telephone no less than
5 40 hours per week during normal business hours and shall
6 have a telephone system available to take calls during other
7 than normal business hours and shall respond to all such
8 calls no later than the next business day after the call was
9 recorded. In the case of grievances subject to item (i) of
10 subsection (b) of this Section, telephone access must be
11 available on a 24 hour a day, 7 day a week basis.
12 (b) Within 48 hours of receipt of a written grievance,
13 the managed care plan shall provide written acknowledgment
14 of the grievance, including the name, address,
15 qualifying credentials, and telephone number of the
16 individuals or department designated by the managed care plan
17 to respond to the grievance. All grievances shall be
18 resolved in an expeditious manner, and in any event, no more
19 than (i) 24 hours after the receipt of all necessary
20 information when a delay would significantly increase the
21 risk to an enrollee's health or when extended health care
22 services, procedures, or treatments for an enrollee
23 undergoing a course of treatment prescribed by a health care
24 provider are at issue, (ii) 15 days after the receipt of all
25 necessary information in the case of requests for referrals
26 or determinations concerning whether a requested benefit
27 is covered pursuant to the contract, and (iii) 30 days after
28 the receipt of all necessary information in all other
29 instances.
30 (c) The managed care plan shall designate one or more
31 qualified personnel to review the grievance. When the
32 grievance pertains to clinical matters, the personnel shall
33 include, but not be limited to, one or more appropriately
34 licensed or registered health care professionals.
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1 (d) The notice of a determination of the grievance
2 shall be made in writing to the enrollee or to the enrollee's
3 designee. In the case of a determination made in conformance
4 with item (i) of subsection (b) of this Section, notice
5 shall be made by telephone directly to the enrollee with
6 written notice to follow within 2 business days.
7 (e) The notice of a determination shall include (i)
8 clear and detailed reasons for the determination, including
9 any contract basis for the determination, and the evidence
10 relied upon in making that determination, (ii) in cases where
11 the determination has a clinical basis, the clinical
12 rationale for the determination, and (iii) the procedures for
13 the filing of an appeal of the determination, including a
14 form for the filing of an appeal.
15 Section 25. Second level grievance review.
16 (a) A managed care plan shall establish a second level
17 grievance review process to give those enrollees who are
18 dissatisfied with the first level grievance review decision
19 the option to request a second level review, at which the
20 enrollee shall have the right to appear in person before
21 authorized individuals designated to respond to the appeal.
22 (b) An enrollee or an enrollee's designee shall
23 have not less than 60 days after receipt of notice of the
24 grievance determination to file a written appeal, which may
25 be submitted by letter or by a form supplied by the managed
26 care plan. The enrollee shall indicate in his or her written
27 appeal whether he or she wants the right to appear in person
28 before the person or panel designated to respond to the
29 appeal.
30 (c) Within 48 hours of receipt of the second level
31 grievance review, the managed care plan shall provide written
32 acknowledgment of the appeal, including the name, address,
33 qualifying credentials, and telephone number of the
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1 individual designated by the managed care plan to respond
2 to the appeal and what additional information, if any, must
3 be provided in order for the managed care plan to render a
4 decision.
5 (d) The determination of a second level grievance review
6 on a clinical matter must be made by personnel qualified
7 to review the appeal, including appropriately licensed or
8 registered health care professionals who did not make
9 the initial determination, a majority of whom must be
10 clinical peer reviewers. The determination of a second
11 level grievance review on a matter that is not clinical shall
12 be made by qualified personnel at a higher level than the
13 personnel who made the initial grievance determination.
14 (e) The managed care plan shall seek to resolve all
15 second level grievance reviews in the most expeditious manner
16 and shall make a determination and provide notice no more
17 than (i) 24 hours after the receipt of all necessary
18 information when a delay would significantly increase the
19 risk to an enrollee's health or when extended health care
20 services, procedures, or treatments for an enrollee
21 undergoing a course of treatment prescribed by a health care
22 provider are at issue and (ii) 30 business days after the
23 receipt of all necessary information in all other instances.
24 (f) The notice of a determination on a second level
25 grievance review shall include (i) the detailed reasons for
26 the determination, including any contract basis for the
27 determination and the evidence relied upon in making the
28 determination and (ii) in cases where the determination has a
29 clinical basis, the clinical rationale for the
30 determination.
31 (g) If an enrollee has requested the opportunity to
32 appear in person before the authorized representatives of the
33 managed care plan designated to respond to the appeal, the
34 review panel shall schedule and hold a review meeting within
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1 30 days of receiving a request from an enrollee for a second
2 level review with a right to appear. The review meeting
3 shall be held during regular business hours at a location
4 reasonably accessible to the enrollee. The enrollee shall be
5 notified in writing at least 14 days in advance of the review
6 date.
7 Upon the request of an enrollee, a managed care plan
8 shall provide to the enrollee all relevant information that
9 is not confidential or privileged.
10 An enrollee has the right to:
11 (1) attend the second level review;
12 (2) present his or her case to the review panel;
13 (3) submit supporting material both before and at
14 the review meeting;
15 (4) ask questions of any representative of the
16 managed care plan; and
17 (5) be assisted or represented by persons of his or
18 her choice.
19 The notice shall advise the enrollee of the rights
20 specified in this subsection.
21 If the managed care plan desires to have an attorney
22 present to represent its interests, it shall notify the
23 enrollee at least 14 days in advance of the review that an
24 attorney will be present and that the enrollee may wish to
25 obtain legal representation of his or her own.
26 Section 30. Grievance register and reporting
27 requirements.
28 (a) A managed care plan shall maintain a register
29 consisting of a written record of all complaints initiated
30 during the past 3 years. The register shall be maintained in
31 a manner that is reasonably clear and accessible to the
32 Director. The register shall include at a minimum the
33 following:
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1 (1) the name of the enrollee;
2 (2) a description of the reason for the complaint;
3 (3) the dates when first level and second level
4 review were requested and completed;
5 (4) a copy of the written decision rendered at each
6 level of review;
7 (5) if required time limits were exceeded, an
8 explanation of why they were exceeded and a copy of the
9 enrollee's consent to an extension of time;
10 (6) whether expedited review was requested and the
11 response to the request;
12 (7) whether the complaint resulted in litigation
13 and the result of the litigation.
14 (b) A managed care plan shall report annually to the
15 Department the numbers, and related information where
16 indicated, for the following:
17 (1) covered lives;
18 (2) total complaints initiated;
19 (3) total complaints involving medical necessity or
20 appropriateness;
21 (4) complaints involving termination or reduction
22 of inpatient hospital services;
23 (5) complaints involving termination or reduction
24 of other health care services;
25 (6) complaints involving denial of health care
26 services where the enrollee had not received the services
27 at the time the complaint was initiated;
28 (7) complaints involving payment for health care
29 services that the enrollee had already received at the
30 time of initiating the complaint;
31 (8) complaints resolved at each level of review and
32 how they were resolved;
33 (9) complaints where expedited review was provided
34 because adherence to regular time limits would have
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1 jeopardized the enrollee's life, health, or ability to
2 regain maximum function; and
3 (10) complaints that resulted in litigation and the
4 outcome of the litigation.
5 The Department shall promulgate rules regarding the
6 format of the report, the timing of the report, and other
7 matters related to the report.
8 Section 35. External independent review.
9 (a) If an enrollee's or enrollee's designee's request
10 for a covered service or claim for a covered service is
11 denied under the grievance review under Section 25 because
12 the service is not viewed as medically necessary, the
13 enrollee may initiate an external independent review.
14 (b) Within 30 days after the enrollee receives written
15 notice of such an adverse decision made under the second
16 level grievance review procedures of Section 25, if the
17 enrollee decides to initiate an external independent review,
18 the enrollee shall send to the managed care plan a written
19 request for an external independent review, including any
20 material justification or documentation to support the
21 enrollee's request for the covered service or claim for a
22 covered service.
23 (c) Within 30 days after the managed care plan receives
24 a request for an external independent review from an
25 enrollee, the managed care plan shall:
26 (1) provide a mechanism for jointly selecting an
27 external independent reviewer by the enrollee, primary
28 care physician, and managed care plan; and
29 (2) forward to the independent reviewer all medical
30 records and supporting documentation pertaining to the
31 case, a summary description of the applicable issues
32 including a statement of the managed care plan's
33 decision, and the criteria used and the clinical reasons
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1 for that decision.
2 (d) Within 5 days of receipt of all necessary
3 information, the independent reviewer or reviewers shall
4 evaluate and analyze the case and render a decision that is
5 based on whether or not the service or claim for the service
6 is medically necessary. The decision by the independent
7 reviewer or reviewers is final.
8 (e) Pursuant to subsection (c) of this Section, an
9 external independent reviewer shall:
10 (1) have no direct financial interest in or
11 connection to the case;
12 (2) be State licensed physicians, who are board
13 certified or board eligible by the appropriate American
14 Medical Specialty Board, if applicable, and who are in
15 the same or similar scope of practice as a physician who
16 typically manages the medical condition, procedure, or
17 treatment under review; and
18 (3) have not been informed of the specific identity
19 of the enrollee or the enrollee's treating provider.
20 (f) If an appropriate reviewer pursuant to subsection
21 (e) of this Section for a particular case is not on the list
22 established by the Director, the parties shall choose a
23 reviewer who is mutually acceptable.
24 Section 40. Independent reviewers.
25 (a) From information filed with the Director on or
26 before March 1 of each year, the Director shall compile a
27 list of external independent reviewers and organizations that
28 represent external independent reviewers from lists provided
29 by managed care plans and by any State and county public
30 health department and State medical associations that wish to
31 submit a list to the Director. The Director may consult with
32 other persons about the suitability of any reviewer or any
33 potential reviewer. The Director shall annually review the
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1 list and add and remove names as appropriate. On or before
2 June 1 of each year, the Director shall publish the list in
3 the Illinois Register.
4 (b) The managed care plan shall be solely responsible
5 for paying the fees of the external independent reviewer who
6 is selected to perform the review.
7 (c) An external independent reviewer who acts in good
8 faith shall have immunity from any civil or criminal
9 liability or professional discipline as a result of acts or
10 omissions with respect to any external independent review,
11 unless the acts or omissions constitute wilful and wanton
12 misconduct. For purposes of any proceeding, the good faith
13 of the person participating shall be presumed.
14 (d) The Director's decision to add a name to or remove a
15 name from the list of independent reviewers pursuant to
16 subsection (a) is not subject to administrative appeal or
17 judicial review.
18 Section 45. Health care professional applications and
19 terminations.
20 (a) A managed care plan shall, upon request, make
21 available and disclose to health care professionals written
22 application procedures and minimum qualification
23 requirements that a health care professional must meet in
24 order to be considered by the managed care plan. The
25 managed care plan shall consult with appropriately qualified
26 health care professionals in developing its qualification
27 requirements.
28 (b) A managed care plan may not terminate a contract of
29 employment or refuse to renew a contract on the basis of any
30 action protected under Section 50 of this Act or solely
31 because a health care professional has:
32 (1) filed a complaint against the managed care
33 plan;
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1 (2) appealed a decision of the managed care plan;
2 or
3 (3) requested a hearing pursuant to this Section.
4 (c) A managed care plan shall provide to a health care
5 professional, in writing, the reasons for the contract
6 termination or non-renewal.
7 (d) A managed care plan shall provide an opportunity
8 for a hearing to any health care professional terminated by
9 the managed care plan, or non-renewed if the health care
10 professional has had a contract or contracts with the managed
11 care plan for at least 24 of the past 36 months.
12 (e) After the notice provided pursuant to subsection
13 (c), the health care professional shall have 21 days to
14 request a hearing, and the hearing must be held within 15
15 days after receipt of the request for a hearing. The hearing
16 shall be held before a panel appointed by the managed care
17 plan.
18 The hearing panel shall be composed of 5 individuals, the
19 majority of whom shall be clinical peer reviewers and, to the
20 extent possible, in the same discipline and the same or
21 similar specialty as the health care professional under
22 review.
23 The hearing panel shall render a written decision on the
24 proposed action within 14 business days. The decision shall
25 be one of the following:
26 (1) reinstatement of the health care professional
27 by the managed care plan;
28 (2) provisional reinstatement subject to
29 conditions set forth by the panel; or
30 (3) termination of the health care professional.
31 The decision of the hearing panel shall be final.
32 A decision by the hearing panel to terminate a health
33 care professional shall be effective not less than 15 days
34 after the receipt by the health care professional of the
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1 hearing panel's decision.
2 A hearing under this subsection shall provide the health
3 care professional in question with the right to examine
4 pertinent information, to present witnesses, and to ask
5 questions of an authorized representative of the plan.
6 (f) A managed care plan may terminate or decline to
7 renew a health care professional, without a prior hearing, in
8 cases involving imminent harm to patient care, a
9 determination of intentional falsification of reports to the
10 plan or a final disciplinary action by a state licensing
11 board or other governmental agency that impairs the health
12 care professional's ability to practice. A professional
13 terminated for one of the these reasons shall be given
14 written notice to that effect. Within 21 days after the
15 termination, a health care professional terminated because of
16 imminent harm to patient care or a determination of
17 intentional falsification of reports to the plan shall
18 receive a hearing. The hearing shall be held before a panel
19 appointed by the managed care plan. The panel shall be
20 composed of 5 individuals the majority of whom shall be
21 clinical peer reviewers and, to the extent possible, in the
22 same discipline and the same or similar specialty as the
23 health care professional under review. The hearing panel
24 shall render a decision on the proposed action within 14
25 days. The panel shall issue a written decision either
26 supporting the termination or ordering the health care
27 professional's reinstatement. The decision of the hearing
28 panel shall be final.
29 If the hearing panel upholds the managed care plan's
30 termination of the health care professional under this
31 subsection, the managed care plan shall forward the decision
32 to the appropriate professional disciplinary agency in
33 accordance with subsection (b) of Section 60.
34 Any hearing under this subsection shall provide the
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1 health care professional in question with the right to
2 examine pertinent information, to present witnesses, and to
3 ask questions of an authorized representative of the plan.
4 For any hearing under this Section, because the candid
5 and conscientious evaluation of clinical practices is
6 essential to the provision of health care, it is the policy
7 of this State to encourage peer review by health care
8 professionals. Therefore, no managed care plan and no
9 individual who participates in a hearing or who is a member,
10 agent, or employee of a managed care plan shall be liable for
11 criminal or civil damages or professional discipline as a
12 result of the acts, omissions, decisions, or any other
13 conduct, direct or indirect, associated with a hearing panel,
14 except for wilful and wanton misconduct. Nothing in this
15 Section shall relieve any person, health care provider,
16 health care professional, facility, organization, or
17 corporation from liability for his, her, or its own
18 negligence in the performance of his, her, or its duties or
19 arising from treatment of a patient. The hearing panel
20 information shall not be subject to inspection or disclosure
21 except upon formal written request by an authorized
22 representative of a duly authorized State agency or pursuant
23 to a court order issued in a pending action or proceeding.
24 (g) A managed care plan shall develop and implement
25 policies and procedures to ensure that health care
26 professionals are at least annually informed of information
27 maintained by the managed care plan to evaluate the
28 performance or practice of the health care professional. The
29 managed care plan shall consult with health care
30 professionals in developing methodologies to collect and
31 analyze health care professional data. Managed care plans
32 shall provide the information and data and analysis to health
33 care professionals. The information, data, or analysis
34 shall be provided on at least an annual basis in a format
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1 appropriate to the nature and amount of data and the volume
2 and scope of services provided. Any data used to evaluate
3 the performance or practice of a health care professional
4 shall be measured against stated criteria and a comparable
5 group of health care professionals who use similar treatment
6 modalities and serve a comparable patient population. Upon
7 receipt of the information or data, a health care
8 professional shall be given the opportunity to explain the
9 unique nature of the health care professional's patient
10 population that may have a bearing on the health care
11 professional's data and to work cooperatively with the
12 managed care plan to improve performance.
13 (h) Any contract provision or procedure or informal
14 policy or procedure in violation of this Section violates the
15 public policy of the State of Illinois and is void and
16 unenforceable.
17 Section 50. Prohibitions.
18 (a) No managed care plan shall by contract, written
19 policy or written procedure, or informal policy or procedure
20 prohibit or restrict any health care provider from
21 disclosing to any enrollee, patient, designated
22 representative or, where appropriate, prospective
23 enrollee, (hereinafter collectively referred to as
24 enrollee) any information that the provider deems appropriate
25 regarding:
26 (1) a condition or a course of treatment with an
27 enrollee including the availability of other therapies,
28 consultations, or tests; or
29 (2) the provisions, terms, or requirements of the
30 managed care plan's products as they relate to the
31 enrollee, where applicable.
32 (b) No managed care plan shall by contract, written
33 policy or procedure, or informal policy or procedure prohibit
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1 or restrict any health care provider from filing a
2 complaint, making a report, or commenting to an appropriate
3 governmental body regarding the policies or practices of the
4 managed care plan that the provider believes may
5 negatively impact upon the quality of, or access to, patient
6 care.
7 (c) No managed care plan shall by contract, written
8 policy or procedure, or informal policy or procedure prohibit
9 or restrict any health care provider from advocating to the
10 managed care plan on behalf of the enrollee for approval or
11 coverage of a particular course of treatment or for the
12 provision of health care services.
13 (d) No contract or agreement between a managed care
14 plan and a health care provider shall contain any clause
15 purporting to transfer to the health care provider by
16 indemnification or otherwise any liability relating to
17 activities, actions, or omissions of the managed care plan
18 as opposed to those of the health care provider.
19 (e) No contract between a managed care plan and a health
20 care provider shall contain any incentive plan that includes
21 specific payment made directly, in any form, to a health care
22 provider as an inducement to deny, reduce, limit, or delay
23 specific, medically necessary and appropriate services
24 provided with respect to a specific enrollee or groups of
25 enrollees with similar medical conditions. Nothing in this
26 Section shall be construed to prohibit contracts that contain
27 incentive plans that involve general payments, such as
28 capitation payments or shared-risk arrangements, that are not
29 tied to specific medical decisions involving specific
30 enrollees or groups of enrollees with similar medical
31 conditions. The payments rendered or to be rendered to
32 health care provider under these arrangements shall be deemed
33 confidential information.
34 (f) No managed care plan shall by contract, written
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1 policy or procedure, or informal policy or procedure permit,
2 allow, or encourage an individual or entity to dispense a
3 different drug in place of the drug or brand of drug ordered
4 or prescribed without the express permission of the person
5 ordering or prescribing, except this prohibition does not
6 prohibit the interchange of different brands of the same
7 generically equivalent drug product, as provided under
8 Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
9 (g) Any contract provision, written policy or
10 procedure, or informal policy or procedure in violation of
11 this Section violates the public policy of the State of
12 Illinois and is void and unenforceable.
13 Section 55. Network of providers.
14 (a) At least once every 3 years, and upon application
15 for expansion of service area, a managed care plan shall
16 obtain certification from the Director of Public Health that
17 the managed care plan maintains a network of health care
18 providers and facilities adequate to meet the comprehensive
19 health needs of its enrollees and to provide an appropriate
20 choice of providers sufficient to provide the services
21 covered under its enrollee's contracts by determining that:
22 (1) there are a sufficient number of geographically
23 accessible participating providers and facilities;
24 (2) there are opportunities to select from at least
25 3 primary care providers pursuant to travel and
26 distance time standards, providing that these standards
27 account for the conditions of accessing providers in
28 rural areas; and
29 (3) there are sufficient providers in all covered
30 areas of specialty practice to meet the needs of the
31 enrollment population.
32 (b) The following criteria shall be considered by the
33 Director of Public Health at the time of a review:
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1 (1) provider-enrollee ratios by specialty;
2 (2) primary care provider-enrollee ratios;
3 (3) safe and adequate staffing of health care
4 providers in all participating facilities based on:
5 (A) severity of patient illness and functional
6 capacity;
7 (B) factors affecting the period and quality
8 of patient recovery; and
9 (C) any other factor substantially related to
10 the condition and health care needs of patients;
11 (4) geographic accessibility;
12 (5) the number of grievances filed by enrollees
13 relating to waiting times for appointments,
14 appropriateness of referrals, and other indicators of a
15 managed care plan's capacity;
16 (6) hours of operation;
17 (7) the managed care plan's ability to provide
18 culturally and linguistically competent care to meet the
19 needs of its enrollee population; and
20 (8) the volume of technological and speciality
21 services available to serve the needs of enrollees
22 requiring technologically advanced or specialty care.
23 (c) A managed care plan shall report on an annual basis
24 the number of enrollees and the number of participating
25 providers in the managed care plan.
26 (d) If a managed care plan determines that it does not
27 have a health care provider with appropriate training and
28 experience in its panel or network to meet the particular
29 health care needs of an enrollee, the managed care plan
30 shall make a referral to an appropriate provider, pursuant to
31 a treatment plan approved by the primary care provider, in
32 consultation with the managed care plan, the
33 non-participating provider, and the enrollee or enrollee's
34 designee, at no additional cost to the enrollee beyond what
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1 the enrollee would otherwise pay for services received within
2 the network.
3 (e) A managed care plan shall have a procedure by which
4 an enrollee who needs ongoing health care services,
5 provided or coordinated by a specialist focused on a specific
6 organ system, disease or condition, shall receive a referral
7 to the specialist. If the primary care provider, after
8 consultation with the medical director or other
9 contractually authorized representative of the managed care
10 plan, determines that a referral is appropriate, the primary
11 care provider shall make such a referral to a specialist. In
12 no event shall a managed care plan be required to permit
13 an enrollee to elect to have a non-participating
14 specialist, except pursuant to the provisions of subsection
15 (d). The referral made under this subsection shall be
16 pursuant to a treatment plan approved by the enrollee or
17 enrollee's designee, the primary care provider, and the
18 specialist in consultation with the managed care plan. The
19 treatment plan shall authorize the specialist to treat the
20 ongoing injury, disease, or condition. It also may limit the
21 number of visits or the period during which visits are
22 authorized and may require the specialists to provide the
23 primary care provider with regular updates on the specialty
24 care provided, as well as all necessary medical information.
25 (f) A managed care plan shall have a procedure by which
26 a new enrollee, upon enrollment, or an enrollee, upon
27 diagnosis, with (i) a life-threatening condition or disease
28 or (ii) a degenerative or disabling condition or disease,
29 either of which requires specialized medical care over a
30 prolonged period of time shall receive a standing referral to
31 a specialist with expertise in treating the life-threatening
32 condition or disease or degenerative or disabling condition
33 or disease who shall be responsible for and capable of
34 providing and coordinating the enrollee's primary and
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1 specialty care. If the primary care provider, after
2 consultation with the enrollee or enrollee's designee and
3 medical director or other contractually authorized
4 representative of the managed care plan, determines that the
5 enrollee's care would most appropriately be coordinated
6 by a specialist, the primary care provider shall refer, on a
7 standing basis, the enrollee to a specialist. In no event
8 shall a managed care plan be required to permit an enrollee
9 to elect to have a non-participating specialist, except
10 pursuant to the provisions of subsection (d). The
11 specialist shall be permitted to treat the enrollee
12 without a referral from the enrollee's primary care
13 provider and shall be authorized to make such referrals,
14 procedures, tests, and other medical services as the
15 enrollee's primary care provider would otherwise be
16 permitted to provide or authorize including, if
17 appropriate, referral to a specialty care center. If a
18 primary care provider refers an enrollee to a
19 non-participating provider pursuant to the provisions of
20 subsection (d), the standing referral shall be pursuant to a
21 treatment plan approved by the enrollee or enrollee's
22 designee and specialist, in consultation with the managed
23 care plan. Services provided pursuant to the approved
24 treatment plan shall be provided at no additional cost to
25 the enrollee beyond what the enrollee would otherwise pay
26 for services received within the network.
27 (g) If an enrollee's health care provider leaves the
28 managed care plan's network of providers for reasons other
29 than those for which the provider would not be eligible to
30 receive a pre-termination hearing pursuant to subsection (f)
31 of Section 45, the managed care plan shall permit the
32 enrollee to continue an ongoing course of treatment
33 with the enrollee's current health care provider during a
34 transitional period of:
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1 (1) up to 90 days from the date of notice to the
2 enrollee of the provider's disaffiliation from the
3 managed care plan's network; or
4 (2) if the enrollee has entered the second trimester
5 of pregnancy at the time of the provider's
6 disaffiliation, for a transitional period that
7 includes the provision of post-partum care directly
8 related to the delivery.
9 Transitional care, however, shall be authorized by the
10 managed care plan during the transitional period only if the
11 health care provider agrees (i) to continue to accept
12 reimbursement from the managed care plan at the rates
13 applicable prior to the start of the transitional period
14 as payment in full, (ii) to adhere to the managed care plan's
15 quality assurance requirements and to provide to the managed
16 care plan necessary medical information related to the care,
17 (iii) to otherwise adhere to the managed care plan's
18 policies and procedures including, but not limited to,
19 procedures regarding referrals and obtaining
20 pre-authorization and a treatment plan approved by the
21 primary care provider or specialist in consultation with the
22 managed care plan, and (iv) if the enrollee is a recipient of
23 services under Article V of the Illinois Public Aid Code, the
24 health care provider has not been subject to a final
25 disciplinary action by a state or federal agency for
26 violations of the Medicaid or Medicare program.
27 (h) If a new enrollee whose health care provider is not
28 a member of the managed care plan's provider network enrolls
29 in the managed care plan, the managed care plan shall permit
30 the enrollee to continue an ongoing course of treatment with
31 the enrollee's current health care provider during a
32 transitional period of up to 90 days from the effective
33 date of enrollment, if (i) the enrollee has a
34 life-threatening disease or condition or a degenerative or
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1 disabling disease or condition or (ii) the enrollee has
2 entered the second trimester of pregnancy at the effective
3 date of enrollment, in which case the transitional period
4 shall include the provision of post-partum care directly
5 related to the delivery. If an enrollee elects to continue
6 to receive payment for care from a health care provider
7 pursuant to this subsection, the care shall be authorized by
8 the managed care plan for the transitional period only if
9 the health care provider agrees (i) to accept reimbursement
10 from the managed care plan at rates established by the
11 managed care plan as payment in full, which rates shall be no
12 more than the level of reimbursement applicable to similar
13 providers within the managed care plan's network for
14 those services, (ii) to adhere to the managed care plan's
15 quality assurance requirements and agrees to provide to the
16 managed care plan necessary medical information related to
17 the care, (iii) to otherwise adhere to the managed care
18 plan's policies and procedures including, but not limited
19 to, procedures regarding referrals and obtaining
20 pre-authorization and a treatment plan approved by the
21 primary care provider or specialist, in consultation with the
22 managed care plan, and (iv) if the enrollee is a recipient of
23 services under Article V of the Illinois Public Aid Code, the
24 health care provider has not been subject to a final
25 disciplinary action by a state or federal agency for
26 violations of the Medicaid or Medicare program. In no
27 event shall this subsection be construed to require a managed
28 care plan to provide coverage for benefits not otherwise
29 covered or to diminish or impair pre-existing condition
30 limitations contained within the enrollee's contract.
31 Section 60. Duty to report.
32 (a) A managed care plan shall report to the
33 appropriate professional disciplinary agency, after
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1 compliance and in accordance with the provisions of this
2 Section:
3 (1) termination of a health care provider contract
4 for commission of an act or acts that may directly
5 threaten patient care, and not of an administrative
6 nature, or that a person may be mentally or physically
7 disabled in such a manner as to endanger a patient under
8 that person's care;
9 (2) voluntary or involuntary termination of a
10 contract or employment or other affiliation with the
11 managed care plan to avoid the imposition of disciplinary
12 measures.
13 The managed care plan shall only make the report after it
14 has provided the health care professional with a hearing on
15 the matter. (This hearing shall not impair or limit the
16 managed care plan's ability to terminate the professional.
17 Its purpose is solely to ensure that a sufficient basis
18 exists for making the report.) The hearing shall be held
19 before a panel appointed by the managed care plan. The
20 hearing panel shall be composed of 5 persons appointed by the
21 plan, the majority of whom shall be clinical peer reviewers,
22 to the extent possible, in the same discipline and the same
23 specialty as the health care professional under review. The
24 hearing panel shall determine whether the proposed basis for
25 the report is supported by a preponderance of the evidence.
26 The panel shall render its determination within 14 days. If
27 a majority of the panel finds the proposed basis for the
28 report is supported by a preponderance of the evidence, the
29 managed care plan shall make the required report within 21
30 days.
31 Any hearing under this Section shall provide the health
32 care professional in question with the right to examine
33 pertinent information, to present witnesses, and to ask
34 questions of an authorized representative of the plan.
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1 If a hearing has been held pursuant to subsection (f) of
2 Section 45 and the hearing panel sustained a plan's
3 termination of a health care professional, no additional
4 hearing is required, and the plan shall make the report
5 required under this Section.
6 (b) Reports made pursuant to this Section shall be made
7 in writing to the appropriate professional disciplinary
8 agency. Written reports shall include the name, address,
9 profession, and license number of the individual and a
10 description of the action taken by the managed care plan,
11 including the reason for the action and the date thereof, or
12 the nature of the action or conduct that led to the
13 resignation, termination of contract, or withdrawal, and the
14 date thereof.
15 For any hearing under this Section, because the candid
16 and conscientious evaluation of clinical practices is
17 essential to the provision of health care, it is the policy
18 of this State to encourage peer review by health care
19 professionals. Therefore, no managed care plan and no
20 individual who participates in a hearing or who is a member,
21 agent, or employee of a managed care plan shall be liable for
22 criminal or civil damages or professional discipline as a
23 result of the acts, omissions, decisions, or any other
24 conduct, direct or indirect, associated with a hearing panel,
25 except for wilful and wanton misconduct. Nothing in this
26 Section shall relieve any person, health care provider,
27 health care professional, facility, organization, or
28 corporation from liability for his, her, or its own
29 negligence in the performance of his, her, or its duties or
30 arising from treatment of a patient. The hearing panel
31 information shall not be subject to inspection or disclosure
32 except upon formal written request by an authorized
33 representative of a duly authorized State agency or pursuant
34 to a court order issued in a pending action or proceeding.
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1 Section 65. Disclosure of information.
2 (a) A health care professional affiliated with a
3 managed care plan shall make available, in written form at
4 his or her office, to his or her patients or prospective
5 patients the following:
6 (1) information related to the health care
7 professional's educational background, experience,
8 training, specialty and board certification, if
9 applicable, number of years in practice, and hospitals
10 where he or she has privileges;
11 (2) information regarding the health care
12 professional's participation in continuing education
13 programs and compliance with any licensure,
14 certification, or registration requirements, if
15 applicable;
16 (3) information regarding the health care
17 professional's participation in clinical performance
18 reviews conducted by the Department, where applicable and
19 available; and
20 (4) the location of the health care professional's
21 primary practice setting and the identification of any
22 translation services available.
23 Section 70. Registration of utilization review agents.
24 (a) A utilization review agent who conducts the practice
25 of utilization review shall biennially register with the
26 Director and report, in a statement subscribed and affirmed
27 as true under the penalties of perjury, the information
28 required pursuant to subsection (b) of this Section.
29 (b) The report shall contain a description of the
30 following:
31 (1) the utilization review plan;
32 (2) a description of the grievance procedures by
33 which an enrollee, the enrollee's designee, or his or her
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1 health care provider may seek reconsideration of adverse
2 determinations by the utilization review agent in
3 accordance with this Act;
4 (3) procedures by which a decision on a request for
5 utilization review for services requiring
6 pre-authorization shall comply with timeframes
7 established pursuant to this Act;
8 (4) a description of an emergency care policy,
9 consistent with this Act.
10 (5) a description of personnel utilized to conduct
11 utilization review, including a description of the
12 circumstances under which utilization review may be
13 conducted by:
14 (A) administrative personnel,
15 (B) health care professionals who are not
16 clinical peer reviewers, and
17 (C) clinical peer reviewers;
18 (6) a description of the mechanisms employed to
19 assure that administrative personnel are trained in the
20 principles and procedures of intake screening and data
21 collection and are appropriately monitored by a
22 licensed health care professional while performing an
23 administrative review;
24 (7) a description of the mechanisms employed to
25 assure that health care professionals conducting
26 utilization review are:
27 (A) appropriately licensed or registered; and
28 (B) trained in the principles, procedures,
29 and standards of the utilization review agent;
30 (8) a description of the mechanisms employed to
31 assure that only a clinical peer reviewer shall render an
32 adverse determination;
33 (9) provisions to ensure that appropriate personnel
34 of the utilization review agent are reasonably accessible
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1 by toll-free telephone:
2 (A) not less than 40 hours per week during
3 normal business hours, to discuss patient care and
4 allow response to telephone requests, and to ensure
5 that the utilization review agent has a telephone
6 system capable of accepting, recording, or providing
7 instruction to incoming telephone calls during
8 other than normal business hours and to ensure
9 response to accepted or recorded messages not later
10 than the next business day after the date on which
11 the call was received; or
12 (B) notwithstanding the provisions of item (A),
13 in the case of a request submitted pursuant to
14 subsection (c) of Section 80 or an expedited appeal
15 filed pursuant to subsection (b) of Section 85, a
16 response is provided within 24 hours;
17 (10) the policies and procedures to ensure that
18 all applicable State and federal laws to protect the
19 confidentiality of individual medical and treatment
20 records are followed;
21 (11) a copy of the materials to be disclosed to an
22 enrollee or prospective enrollee pursuant to this Act;
23 (12) a description of the mechanisms employed by
24 the utilization review agent to assure that all
25 contractors, subcontractors, subvendors, agents, and
26 employees affiliated by contract or otherwise with such
27 utilization review agent will adhere to the standards and
28 requirements of this Act; and
29 (13) a list of the payors for which the
30 utilization review agent is performing utilization
31 review in this State.
32 (c) Upon receipt of the report, the Director
33 shall issue an acknowledgment of the filing.
34 (d) A registration issued under this Act shall be valid
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1 for a period of not more than 2 years, and may be renewed for
2 additional periods of not more than 2 years each.
3 Section 75. Utilization review program standards.
4 (a) A utilization review agent shall adhere to
5 utilization review program standards consistent with the
6 provisions of this Act, which shall, at a minimum, include:
7 (1) appointment of a medical director, who is a
8 licensed physician; provided, however, that the
9 utilization review agent may appoint a clinical director
10 when the utilization review performed is for a discrete
11 category of health care service and provided further that
12 the clinical director is a licensed health care
13 professional who typically manages the category of
14 service; responsibilities of the medical director, or,
15 where appropriate, the clinical director, shall
16 include, but not be limited to, the supervision and
17 oversight of the utilization review process;
18 (2) development of written policies and procedures
19 that govern all aspects of the utilization review
20 process and a requirement that a utilization review
21 agent shall maintain and make available to enrollees and
22 health care providers a written description of the
23 procedures, including the procedures to appeal an adverse
24 determination;
25 (3) utilization of written clinical review criteria
26 developed pursuant to a utilization review plan;
27 (4) consistent with the applicable Sections of this
28 Act, establishment of a process for rendering utilization
29 review determinations, which shall, at a minimum,
30 include written procedures to assure that utilization
31 reviews and determinations are conducted within the
32 required timeframes, procedures to notify an enrollee,
33 an enrollee's designee, and an enrollee's health care
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1 provider of adverse determinations, and the procedures
2 for appeal of adverse determinations, including the
3 establishment of an expedited appeals process for
4 denials of continued inpatient care or when delay would
5 significantly increase the risk to an enrollee's health;
6 (5) establishment of a requirement that
7 appropriate personnel of the utilization review agent are
8 reasonably accessible by toll-free telephone:
9 (A) not less than 40 hours per week during
10 normal business hours to discuss patient care and
11 allow response to telephone requests, and to ensure
12 that the utilization review agent has a telephone
13 system capable of accepting, recording or providing
14 instruction to incoming telephone calls during
15 other than normal business hours and to ensure
16 response to accepted or recorded messages not less
17 than one business day after the date on which the
18 call was received; or
19 (B) in the case of a request submitted
20 pursuant to subsection (c) of Section 80 or an
21 expedited appeal filed pursuant to subsection
22 (b) of Section 85, a response is provided within 24
23 hours;
24 (6) establishment of appropriate policies and
25 procedures to ensure that all applicable State and
26 federal laws to protect the confidentiality of individual
27 medical records are followed;
28 (7) establishment of a requirement that emergency
29 services, as defined in this Act, rendered to an enrollee
30 shall not be subject to prior authorization nor
31 shall reimbursement for those services be denied on
32 retrospective review, except as authorized in this Act.
33 (b) A utilization review agent shall assure adherence to
34 the requirements stated in subsection (a) of this Section by
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1 all contractors, subcontractors, subvendors, agents, and
2 employees affiliated by contract or otherwise with the
3 utilization review agent.
4 Section 80. Utilization review determinations.
5 (a) Utilization review shall be conducted by:
6 (1) administrative personnel trained in the
7 principles and procedures of intake screening and data
8 collection, provided, however, that administrative
9 personnel shall only perform intake screening, data
10 collection, and non-clinical review functions and shall
11 be supervised by a licensed health care professional;
12 (2) a health care professional who is
13 appropriately trained in the principles, procedures,
14 and standards of the utilization review agent; provided,
15 however, that a health care professional who is not a
16 clinical peer reviewer may not render an adverse
17 determination; and
18 (3) a clinical peer reviewer where the review
19 involves an adverse determination.
20 (b) A utilization review agent shall make a utilization
21 review determination involving health care services that
22 require pre-authorization and provide notice of the
23 determination, as soon as possible, to the enrollee or
24 enrollee's designee and the enrollee's health care provider
25 by telephone upon, and in writing within 2 business days of
26 receipt of the necessary information.
27 (c) A utilization review agent shall make a
28 determination involving continued or extended health care
29 services or additional services for an enrollee
30 undergoing a course of continued treatment prescribed by a
31 health care provider and provide notice of the determination
32 to the enrollee or the enrollee's designee by notice within
33 24 hours to the enrollee's health care provider by telephone
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1 upon, and in writing within 2 business days after receipt of
2 the necessary information. Notification of continued or
3 extended services shall include the number of extended
4 services approved, the new total of approved services, the
5 date of onset of services, and the next review date.
6 (d) A utilization review agent shall make a utilization
7 review determination involving health care services that have
8 already been delivered, within 30 days of receipt of the
9 necessary information.
10 (e) Notice of an adverse determination made by a
11 utilization review agent shall be given in writing in
12 accordance with the grievance procedures of this Act. The
13 notice shall also specify what, if any, additional
14 necessary information must be provided to, or obtained by,
15 the utilization review agent in order to render a decision on
16 the appeal.
17 (f) In the event that a utilization review agent
18 renders an adverse determination without attempting to
19 discuss the matter with the enrollee's health care
20 provider who specifically recommended the health care
21 service, procedure, or treatment under review, the health
22 care provider shall have the opportunity to request an
23 immediate reconsideration of the adverse determination.
24 Except in cases of retrospective reviews, the
25 reconsideration shall occur in a prompt manner, not to
26 exceed 24 hours after receipt of the necessary information,
27 and shall be conducted by the enrollee's health care
28 provider and the clinical peer reviewer making the initial
29 determination or a designated clinical peer reviewer if the
30 original clinical peer reviewer cannot be available. In
31 the event that the adverse determination is upheld after
32 reconsideration, the utilization review agent shall provide
33 notice as required pursuant to subsection (e) of this
34 Section. Nothing in this Section shall preclude the enrollee
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1 from initiating an appeal from an adverse determination.
2 Section 85. Appeal of adverse determinations by
3 utilization review agents.
4 (a) An enrollee, the enrollee's designee, and, in
5 connection with retrospective adverse determinations, the
6 enrollee's health care provider may appeal an adverse
7 determination rendered by a utilization review agent pursuant
8 to Sections 15, 20, 25, and 35.
9 (b) A utilization review agent shall establish
10 mechanisms that facilitate resolution of the appeal
11 including, but not limited to, the sharing of information
12 from the enrollee's health care provider and the utilization
13 review agent by telephonic means or by facsimile. The
14 utilization review agent shall provide reasonable access to
15 its clinical peer reviewer in a prompt manner.
16 (c) Appeals shall be reviewed by a clinical peer
17 reviewer other than the clinical peer reviewer who
18 rendered the adverse determination.
19 Section 90. Required and prohibited practices.
20 (a) A utilization review agent shall have written
21 procedures for assuring that patient-specific information
22 obtained during the process of utilization review will be:
23 (1) kept confidential in accordance with applicable
24 State and federal laws; and
25 (2) shared only with the enrollee, the
26 enrollee's designee, the enrollee's health care provider,
27 and those who are authorized by law to receive the
28 information.
29 (b) Summary data shall not be considered confidential
30 if it does not provide information to allow identification of
31 individual patients.
32 (c) Any health care professional who makes
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1 determinations regarding the medical necessity of health care
2 services during the course of utilization review shall be
3 appropriately licensed or registered.
4 (d) A utilization review agent shall not, with respect
5 to utilization review activities, permit or provide
6 compensation or anything of value to its employees, agents,
7 or contractors based on:
8 (1) either a percentage of the amount by which a
9 claim is reduced for payment or the number of claims or
10 the cost of services for which the person has denied
11 authorization or payment; or
12 (2) any other method that encourages the
13 rendering of an adverse determination.
14 (e) If a health care service has been specifically
15 pre-authorized or approved for an enrollee by a
16 utilization review agent, a utilization review agent shall
17 not, pursuant to retrospective review, revise or modify
18 the specific standards, criteria, or procedures used for
19 the utilization review for procedures, treatment, and
20 services delivered to the enrollee during the same course
21 of treatment.
22 (f) Utilization review shall not be conducted more
23 frequently than is reasonably required to assess whether the
24 health care services under review are medically necessary.
25 The Department may promulgate rules governing the frequency
26 of utilization reviews for managed care plans of differing
27 size and geographic location.
28 (g) When making prospective, concurrent, and
29 retrospective determinations, utilization review agents shall
30 collect only information that is necessary to make the
31 determination and shall not routinely require health care
32 providers to numerically code diagnoses or procedures to
33 be considered for certification, unless required under State
34 or federal Medicare or Medicaid rules or regulations, or
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1 routinely request copies of medical records of all patients
2 reviewed. During prospective or concurrent review, copies
3 of medical records shall only be required when necessary
4 to verify that the health care services subject to the review
5 are medically necessary. In these cases, only the necessary
6 or relevant sections of the medical record shall be
7 required. A utilization review agent may request copies of
8 partial or complete medical records retrospectively.
9 (h) In no event shall information be obtained from
10 health care providers for the use of the utilization
11 review agent by persons other than health care professionals,
12 medical record technologists, or administrative personnel who
13 have received appropriate training.
14 (i) The utilization review agent shall not undertake
15 utilization review at the site of the provision of health
16 care services unless the utilization review agent:
17 (1) identifies himself or herself by name and the
18 name of his or her organization, including displaying
19 photographic identification that includes the name of
20 the utilization review agent and clearly identifies the
21 individual as representative of the utilization review
22 agent;
23 (2) whenever possible, schedules review at least
24 one business day in advance with the appropriate health
25 care provider;
26 (3) if requested by a health care provider,
27 assures that the on-site review staff register with the
28 appropriate contact person, if available, prior to
29 requesting any clinical information or assistance
30 from the health care provider; and
31 (4) obtains consent from the enrollee or the
32 enrollee's designee before interviewing the patient's
33 family or observing any health care service being
34 provided to the enrollee.
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1 This subsection does not apply to health care
2 professionals engaged in providing care, case management, or
3 making on-site discharge decisions.
4 (j) A utilization review agent shall not base an adverse
5 determination on a refusal to consent to observing any health
6 care service.
7 (k) A utilization review agent shall not base an adverse
8 determination on lack of reasonable access to a health
9 care provider's medical or treatment records unless the
10 utilization review agent has provided reasonable notice
11 to both the enrollee or the enrollee's designee and the
12 enrollee's health care provider and has complied with all
13 provisions of subsection (i) of this Section. The Department
14 may promulgate rules defining reasonable notice and the time
15 period within which medical and treatment records must be
16 turned over.
17 (l) Neither the utilization review agent nor the entity
18 for which the agent provides utilization review shall take
19 any action with respect to a patient or a health care
20 provider that is intended to penalize the enrollee, the
21 enrollee's designee, or the enrollee's health care provider
22 for, or to discourage the enrollee, the enrollee's designee,
23 or the enrollee's health care provider from, undertaking an
24 appeal, dispute resolution, or judicial review of an adverse
25 determination.
26 (m) In no event shall an enrollee, an enrollee's
27 designee, an enrollee's health care provider, any other
28 health care provider, or any other person or entity be
29 required to inform or contact the utilization review agent
30 prior to the provision of emergency services as defined in
31 this Act.
32 (n) No contract or agreement between a utilization
33 review agent and a health care provider shall contain any
34 clause purporting to transfer to the health care provider by
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1 indemnification or otherwise any liability relating to
2 activities, actions, or omissions of the utilization review
3 agent.
4 (o) A health care professional providing health care
5 services to an enrollee shall be prohibited from serving
6 as the clinical peer reviewer for that enrollee in connection
7 with the health care services being provided to the
8 enrollee.
9 Section 95. 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 100. Managed care patient rights. In addition
32 to all other requirements of this Act, a managed care plan
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1 shall 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 105. Health care entity liability.
7 (a) In this Section:
8 "Appropriate and medically necessary" means the standard
9 for health care services as determined by physicians and
10 health care providers in accordance with the prevailing
11 practices and standards of the medical profession and
12 community.
13 "Enrollee" means an individual who is enrolled in a
14 health care plan, including covered dependents.
15 "Health care plan" means any plan whereby any person
16 undertakes to provide, arrange for, pay for, or reimburse any
17 part of the cost of any health care services.
18 "Health care provider" means a person or entity as
19 defined in Section 2-1003 of the Code of Civil Procedure.
20 "Health care treatment decision" means a determination
21 made when medical services are actually provided by the
22 health care plan and a decision that affects the quality of
23 the diagnosis, care, or treatment provided to the plan's
24 insureds or enrollees.
25 "Health insurance carrier" means an authorized insurance
26 company that issues policies of accident and health insurance
27 under the Illinois Insurance Code.
28 "Health maintenance organization" means an organization
29 licensed under the Health Maintenance Organization Act.
30 "Managed care entity" means any entity that delivers,
31 administers, or assumes risk for health care services with
32 systems or techniques to control or influence the quality,
33 accessibility, utilization, or costs and prices of those
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1 services to a defined enrollee population, but does not
2 include an employer purchasing coverage or acting on behalf
3 of its employees or the employees of one or more subsidiaries
4 or affiliated corporations of the employer.
5 "Physician" means: (1) an individual licensed to practice
6 medicine in this State; (2) a professional association,
7 professional service corporation, partnership, medical
8 corporation, or limited liability company, entitled to
9 lawfully engage in the practice of medicine; or (3) another
10 person wholly owned by physicians.
11 "Ordinary care" means, in the case of a health insurance
12 carrier, health maintenance organization, or managed care
13 entity, that degree of care that a health insurance carrier,
14 health maintenance organization, or managed care entity of
15 ordinary prudence would use under the same or similar
16 circumstances. In the case of a person who is an employee,
17 agent, ostensible agent, or representative of a health
18 insurance carrier, health maintenance organization, or
19 managed care entity, "ordinary care" means that degree of
20 care that a person of ordinary prudence in the same
21 profession, specialty, or area of practice as such person
22 would use in the same or similar circumstances.
23 (b) A health insurance carrier, health maintenance
24 organization, or other managed care entity for a health care
25 plan has the duty to exercise ordinary care when making
26 health care treatment decisions and is liable for damages for
27 harm to an insured or enrollee proximately caused by its
28 failure to exercise such ordinary care.
29 (c) A health insurance carrier, health maintenance
30 organization, or other managed care entity for a health care
31 plan is also liable for damages for harm to an insured or
32 enrollee proximately caused by the health care treatment
33 decisions made by its:
34 (1) employees;
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1 (2) agents;
2 (3) ostensible agents; or
3 (4) representatives who are acting on its behalf
4 and over whom it has the right to exercise influence or
5 control or has actually exercised influence or control
6 that results in the failure to exercise ordinary care.
7 (d) The standards in subsections (b) and (c) create no
8 obligation on the part of the health insurance carrier,
9 health maintenance organization, or other managed care entity
10 to provide to an insured or enrollee treatment that is not
11 covered by the health care plan of the entity.
12 (e) A health insurance carrier, health maintenance
13 organization, or managed care entity may not remove a
14 physician or health care provider from its plan or refuse to
15 renew the physician or health care provider with its plan for
16 advocating on behalf of an enrollee for appropriate and
17 medically necessary health care for the enrollee.
18 (f) A health insurance carrier, health maintenance
19 organization, or other managed care entity may not enter into
20 a contract with a physician, hospital, or other health care
21 provider or pharmaceutical company which includes an
22 indemnification or hold harmless clause for the acts or
23 conduct of the health insurance carrier, health maintenance
24 organization, or other managed care entity. Any such
25 indemnification or hold harmless clause in an existing
26 contract is hereby declared void.
27 (g) Nothing in any law of this State prohibiting a
28 health insurance carrier, health maintenance organization, or
29 other managed care entity from practicing medicine or being
30 licensed to practice medicine may be asserted as a defense by
31 the health insurance carrier, health maintenance
32 organization, or other managed care entity in an action
33 brought against it pursuant to this Section or any other law.
34 (h) In an action against a health insurance carrier,
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1 health maintenance organization, or managed care entity, a
2 finding that a physician or other health care provider is an
3 employee, agent, ostensible agent, or representative of the
4 health insurance carrier, health maintenance organization, or
5 managed care entity shall not be based solely on proof that
6 the person's name appears in a listing of approved physicians
7 or health care providers made available to insureds or
8 enrollees under a health care plan.
9 (i) This Section does not apply to workers' compensation
10 insurance coverage subject to the Workers' Compensation Act.
11 (j) This Section does not apply to actions seeking only
12 a review of an adverse utilization review determination.
13 This Section applies only to causes of action that accrue on
14 or after the effective date of this Act. An insured or
15 enrollee seeking damages under this Section has the right and
16 duty to submit the claim to arbitration in accordance with
17 the Uniform Arbitration Act. No agreement between the
18 parties to submit the claim to arbitration is necessary. A
19 health insurance carrier, health maintenance organization, or
20 managed care entity shall have no liability under this
21 Section unless the claim is first submitted to arbitration in
22 accordance with the Uniform Arbitration Act. The award in
23 matters arbitrated pursuant to this Section shall be made
24 within 30 days after notification of the arbitration is
25 provided to all parties.
26 (k) The determination of whether a procedure or
27 treatment is medically necessary must be made by a physician.
28 (l) If the physician determines that a procedure or
29 treatment is medically necessary, the health care plan must
30 pay for the procedure or treatment.
31 Section 110. Waiver. Any agreement that purports to
32 waive, limit, disclaim or in any way diminish the rights set
33 forth in this Act is void as contrary to public policy.
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1 Section 115. Administration of Act.
2 (a) The Department shall administer this Act.
3 (b) All managed care plans and utilization review agents
4 providing or reviewing services in Illinois shall annually
5 certify compliance with this Act and rules adopted under this
6 Act to the Department in addition to any other licensure
7 required by law. The Director shall establish by rule a
8 process for this certification including fees to cover the
9 costs associated with implementing this Act. All fees and
10 fines assessed under this Act shall be deposited in the
11 Managed Care Reform Fund, a special fund hereby created in
12 the State treasury. Moneys in the Fund shall be used by the
13 Department only to enforce and administer this Act. The
14 certification requirements of this Act shall be incorporated
15 into program requirements of the Department of Public Aid and
16 Department of Human Services and no further certification
17 under this Act is required.
18 (c) The Director shall take enforcement action under
19 this Act including, but not limited to, the assessment of
20 civil fines and injunctive relief for any failure to comply
21 with this Act or any violation of the Act or rules by a
22 managed care plan or any utilization review agent.
23 (d) The Department shall have the authority to impose
24 fines on any managed care plan or any utilization review
25 agent. The Department shall adopt rules pursuant to this Act
26 that establish a system of fines related to the type and
27 level of violation or repeat violation, including but not
28 limited to:
29 (1) A fine not exceeding $10,000 for a violation
30 that created a condition or occurrence presenting a
31 substantial probability that death or serious harm to an
32 individual will or did result therefrom; and
33 (2) A fine not exceeding $5,000 for a violation
34 that creates or created a condition or occurrence that
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1 threatens the health, safety, or welfare of an
2 individual.
3 Each day a violation continues shall constitute a
4 separate offense. These rules shall include an opportunity
5 for a hearing in accordance with the Illinois Administrative
6 Procedure Act. All final decisions of the Department shall
7 be reviewable under the Administrative Review Law.
8 (e) Notwithstanding the existence or pursuit of any
9 other remedy, the Director may, through the Attorney General,
10 seek an injunction to restrain or prevent any person or
11 entity from functioning or operating in violation of this Act
12 or rule.
13 Section 120. Emergency services.
14 (a) Any managed care plan subject to this Act shall
15 provide the enrollee emergency services coverage such that
16 payment for this coverage is not dependent upon whether such
17 services are performed by a participating or nonparticipating
18 provider, and such coverage shall be at the same benefit
19 level as if the service or treatment had been rendered by a
20 plan provider. Nothing in this Section is intended to
21 prohibit a plan from imposing its customary and normal
22 co-payments, deductibles, co-insurance, and other like
23 charges for emergency services.
24 (b) Prior authorization or approval by the plan shall
25 not be required for emergency services rendered under this
26 Section.
27 (c) Coverage and payment shall not be retrospectively
28 denied, with the following exceptions:
29 (1) upon reasonable determination that the
30 emergency services claimed were never performed; or
31 (2) upon reasonable determination that an emergency
32 medical screening examination was performed on a patient
33 who personally sought emergency services knowing that he
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1 or she did not have an emergency condition or necessity,
2 and who did not in fact require emergency services.
3 (d) When an enrollee presents to a hospital seeking
4 emergency services, as defined in this Act, the determination
5 as to whether the need for those services exists shall be
6 made for purposes of treatment by a physician or, to the
7 extent permitted by applicable law, by other appropriate
8 licensed personnel under the supervision of a physician. The
9 physician or other appropriate personnel shall indicate in
10 the patient's chart the results of the emergency medical
11 screening examination. The plan shall compensate the
12 provider for an emergency medical screening examination that
13 is reasonably calculated to assist the health care provider
14 in determining whether the patient's condition requires
15 emergency services. A plan shall have no duty to pay for
16 services rendered after an emergency medical screening
17 examination determines the lack of a need for emergency
18 services.
19 (e) The appropriate use of the 911 emergency telephone
20 number shall not be discouraged or penalized, and coverage or
21 payment shall not be denied solely on the basis that the
22 insured used the 911 emergency telephone number to summon
23 emergency services.
24 (f) If prior authorization for post-stabilization
25 services, as defined in this Act, is required, the managed
26 care plan shall provide access 24 hours a day, 7 days a week
27 to persons designated by plan to make such determinations.
28 If a provider has attempted to contact such person for prior
29 authorization and no designated persons were accessible or
30 the authorization was not denied within one hour of the
31 request, the plan is deemed to have approved the request for
32 prior authorization.
33 (g) Coverage and payment for post-stabilization services
34 which received prior authorization or deemed approval shall
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1 not be retrospectively denied. Nothing in this Section is
2 intended to prohibit a plan from imposing its customary and
3 normal co-payments, deductibles, co-insurance, and other like
4 changes for post-stabilization services.
5 Section 125. Prescription drugs. A managed care plan
6 that provides coverage for prescribed drugs approved by the
7 federal Food and Drug Administration shall not exclude
8 coverage of any drug on the basis that the drug has been
9 prescribed for the treatment of a particular indication for
10 which the drug has not been approved by the federal Food and
11 Drug Administration. The drug, however, must be approved by
12 the federal Food and Drug Administration and must be
13 recognized for the treatment of that particular indication
14 for which the drug has been prescribed in any one of the
15 following established reference compendia:
16 (1) the American Hospital Formulary Service Drug
17 Information;
18 (2) the United States Pharmacopoeia Drug
19 Information; or
20 (3) if not recognized by the authorities in item
21 (1) or (2), recommended for that particular indication in
22 formal clinical studies, the results of which have been
23 published in at least 2 peer reviewed professional
24 medical journals published in the United States or Great
25 Britain.
26 Any coverage required by this Section shall also include
27 those medically necessary services associated with the
28 administration of a drug.
29 Despite the provisions of this Section, coverage shall
30 not be required for any experimental or investigational drugs
31 or any drug that the federal Food and Drug Administration has
32 determined to be contraindicated for treatment of the
33 specific indication for which the drug has been prescribed.
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1 Nothing in this Section shall be construed, expressly or by
2 implication, to create, impair, alter, limit, notify,
3 enlarge, abrogate, or prohibit reimbursement for drugs used
4 in the treatment of any other disease or condition.
5 Section 130. Health Care Service Delivery Review Board.
6 (a) A managed care plan shall organize a Health Care
7 Service Delivery Review Board from participants in the plan.
8 The Board shall consist of 17 members: 5 participating
9 physicians elected by participating physicians, 5 other
10 participating providers elected by the other health care
11 providers, 5 enrollees elected by the enrollees, and 2
12 representatives of the plan appointed by the plan. The
13 representatives of the plan shall not have a vote on the
14 Board, but shall have all other rights granted to Board
15 members. The plan shall devise a mechanism for the election
16 of the Board's members, subject to the approval of the
17 Department. The Department shall not unreasonably withhold
18 its approval of a mechanism.
19 (b) The Health Care Service Delivery Board shall
20 establish written rules and regulations governing its
21 operation. The managed care plan shall approve the rules,
22 but may not unilaterally amend them. A plan may not
23 unreasonably withhold approval of proposed rules and
24 regulations.
25 (c) The Health Care Service Delivery Board shall, from
26 time to time, issue nonbinding reports and reviews concerning
27 the plan's health care delivery policy, quality assurance
28 procedures, utilization review criteria and procedures, and
29 medical management procedures. The Board shall select the
30 aspects of the plan that it wishes to study or review and may
31 undertake a study or review at the request of the plan. The
32 Board shall issue its report directly to the managed care
33 plan's governing board.
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1 Section 135. Conflicts with federal law. When health
2 care services are provided by a managed care plan subject to
3 this Act to a person who is a recipient of medical assistance
4 under Article V of the Illinois Public Aid Code, the rights,
5 benefits, requirements, and procedures available or
6 authorized under this Act shall not apply to the extent that
7 there are provisions of federal law that conflict. In the
8 event of a conflict, federal law shall prevail.
9 Section 140. Severability. The provisions of this Act
10 are severable under Section 1.31 of the Statute on Statutes.
11 Section 145. The State Employees Group Insurance Act of
12 1971 is amended by adding Section 6.12 as follows:
13 (5 ILCS 375/6.12 new)
14 Sec. 6.12. Managed Care Reform Act. The program of
15 health benefits is subject to the provisions of the Managed
16 Care Reform Act.
17 Section 150. The Civil Administrative Code of Illinois
18 is amended by adding Sections 56.3, 56.4, 56.5, 56.6, and
19 56.7 as follows:
20 (20 ILCS 1405/56.3 new)
21 Sec. 56.3. Office of Health Care Consumer Assistance,
22 Advocacy, and Information.
23 (a) The Office of Health Care Consumer Assistance,
24 Advocacy, and Information is established within the
25 Department of Insurance to provide assistance, advocacy, and
26 information to all health care consumers within the State.
27 The office shall have no regulatory power or authority and
28 shall not provide legal representation in a court of law.
29 (b) An executive director shall be appointed by the
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1 governor for a 3-year term and may be removed only for just
2 cause.
3 (c) The executive director must:
4 (1) be selected without regard to political
5 affiliation;
6 (2) have knowledge and experience concerning the
7 needs and rights of health care consumers; and
8 (3) be qualified to analyze questions of law,
9 administrative functions, and public policy.
10 (d) No person may serve as executive director while
11 holding another public office.
12 (e) The Department shall provide office space, equipment
13 and supplies, and technical support to the Office of Health
14 Care Consumer Assistance, Advocacy, and Information.
15 (20 ILCS 1405/56.4 new)
16 Sec. 56.4. Duties and powers of the Office of Health
17 Care Consumer Assistance, Advocacy, and Information.
18 (a) Within the appropriation allocated, the executive
19 director shall provide information and assistance to all
20 health care consumers by:
21 (1) assisting patients and enrollees in
22 understanding and asserting their contractual and legal
23 rights, including the rights under an alternative dispute
24 resolution process; this assistance may include advocacy
25 for enrollees in administrative proceedings or other
26 formal or informal dispute resolution processes;
27 (2) assisting enrollees in obtaining appropriate
28 health care referrals under their health plan company,
29 health insurance, or health coverage plan;
30 (3) assisting patients and enrollees in accessing
31 the services of governmental agencies or regulatory
32 boards or other State consumer assistance programs, or
33 advocacy services whenever appropriate so that the
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1 patient or enrollee can take full advantage of existing
2 mechanisms for resolving complaints;
3 (4) referring patients and enrollees to
4 governmental agencies and regulatory boards for the
5 investigation of health care complaints and for
6 enforcement action;
7 (5) educating and training enrollees about their
8 health plan company, health insurance, or health coverage
9 plan to enable them to assert their rights and to
10 understand their responsibilities;
11 (6) assisting enrollees in receiving a timely
12 resolution of their complaints;
13 (7) monitoring health care consumer complaints
14 addressed by the Office of Health Care Consumer
15 Assistance, Advocacy, and Information to identify
16 specific complaint patterns or areas of potential
17 improvement;
18 (8) collecting public information on consumer
19 satisfaction and outcomes data on health plan company and
20 health care provider performances from organizations
21 conducting surveys; and
22 (9) recommending to health plan companies ways to
23 identify and remove any barriers that might delay or
24 impede the health plan company's effort to resolve
25 consumer complaints.
26 (20 ILCS 1405/56.5 new)
27 Sec. 56.5. Reports by executive director.
28 (a) Beginning March 1, 2000, the executive director shall
29 report, on at least a quarterly basis, any patterns
30 identified from the consumer complaints addressed by the
31 office to the Director and the Governor.
32 (b) By January 1, 2001, and each January 1 thereafter,
33 the executive director shall make an annual written report to
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1 the General Assembly regarding activities of the office,
2 including recommendations on improving health care consumer
3 assistance and complaint resolution processes. Before any
4 recommendations are made to the General Assembly, the
5 executive director must consult with the Public Service
6 Division and other interested parties.
7 (20 ILCS 1405/56.6 new)
8 Sec. 56.6. Managed Care Ombudsman Program.
9 (a) The Department shall establish a Managed Care
10 Ombudsman Program (MCOP) within the Office of Health Care
11 Consumer Assistance, Advocacy, and Information. The purpose
12 of the MCOP is to assist consumers to:
13 (1) navigate the managed care system;
14 (2) select an appropriate managed care plan; and
15 (3) understand and assert their rights and
16 responsibilities as managed care plan enrollees.
17 (b) The Department shall contract with an independent
18 organization or organizations to perform the following MCOP
19 functions:
20 (1) Assist consumers with managed care plan
21 selection by providing information, referral, and
22 assistance to individuals about means of obtaining health
23 coverage and services, including, but not limited to:
24 (A) access through a toll-free telephone
25 number; and
26 (B) availability of information in languages
27 other than English that are spoken as a primary
28 language by a significant portion of the State's
29 population, as determined by the Department.
30 (2) Educate and train consumers in the use of the
31 Department's annual Consumer Guidebook of Health Plan
32 Performance, compiled in accordance with Section 95.
33 (3) Analyze, comment on, monitor, and make publicly
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1 available reports on the development and implementation
2 of federal, State and local laws, regulations, and other
3 governmental policies and actions that pertain to the
4 adequacy of managed care plans, facilities, and services
5 in the State.
6 (4) Ensure that individuals have timely access to
7 the services provided through the MCOP.
8 (5) Submit an annual report to the Department and
9 General Assembly:
10 (A) describing the activities carried out by
11 the MCOP in the year for which the report is
12 prepared;
13 (B) containing and analyzing the data
14 collected by the MCOP; and
15 (C) evaluating the problems experienced by
16 managed care plan enrollees.
17 (6) Exercise such other powers and functions as the
18 Department determines to be appropriate.
19 (c) The Department shall establish criteria for
20 selection of an independent organization or organizations to
21 perform the functions of the MCOP, including, but not limited
22 to, the following:
23 (1) Preference shall be given to private,
24 not-for-profit organizations governed by boards with
25 consumer members in the majority that represent a broad
26 spectrum of the diverse consumer interests in the State.
27 (2) No individual or organization under contract to
28 perform functions of the MCOP may:
29 (A) have a direct involvement in the
30 licensing, certification, or accreditation of a
31 health care facility, a managed care plan, or a
32 provider of a managed care plan, or have a direct
33 involvement with a provider of a health care
34 service;
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1 (B) have a direct ownership or investment
2 interest in a health care facility, a managed care
3 plan, or a health care service;
4 (C) be employed by, or participate in the
5 management of, a health care service or facility or
6 a managed care plan; or
7 (D) receive, or have the right to receive,
8 directly or indirectly, remuneration (in cash or in
9 kind) under a compensation arrangement with an owner
10 or operator of a health care service or facility or
11 managed care plan.
12 The Department shall contract with an organization or
13 organizations qualified under criteria established under this
14 Section for an initial term of 3 years. The initial contract
15 shall be renewable thereafter for additional 3 year terms
16 without reopening the competitive selection process unless
17 there has been an unfavorable written performance evaluation
18 conducted by the Department.
19 (d) The Department shall establish, by rule, policies
20 and procedures for the operation of MCOP sufficient to ensure
21 that the MCOP can perform all functions specified in this
22 Section.
23 (e) Nothing in this Section shall be interpreted to
24 authorize access to or disclosure of individual patient or
25 provider records.
26 (20 ILCS 1405/56.7 new)
27 Sec. 56.7. Retaliation. A health plan company or health
28 care provider may not retaliate or take adverse action
29 against an enrollee or patient who, in good faith, makes a
30 complaint against a health plan company or health care
31 provider.
32 Section 155. The State Finance Act is amended by adding
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1 Section 5.490 as follows:
2 (30 ILCS 105/5.490 new)
3 Sec. 5.490. The Managed Care Reform Fund.
4 Section 160. The State Mandates Act is amended by adding
5 Section 8.23 as follows:
6 (30 ILCS 805/8.23 new)
7 Sec. 8.23. Exempt mandate. Notwithstanding Sections 6
8 and 8 of this Act, no reimbursement by the State is required
9 for the implementation of any mandate created by this
10 amendatory Act of 1999.
11 Section 165. The Counties Code is amended by adding
12 Section 5-1069.8 as follows:
13 (55 ILCS 5/5-1069.8 new)
14 Sec. 5-1069.8. Managed Care Reform Act. All counties,
15 including home rule counties, are subject to the provisions
16 of the Managed Care Reform Act. The requirement under this
17 Section that health care benefits provided by counties comply
18 with the Managed Care Reform Act is an exclusive power and
19 function of the State and is a denial and limitation of home
20 rule county powers under Article VII, Section 6, subsection
21 (h) of the Illinois Constitution.
22 Section 170. The Illinois Municipal Code is amended by
23 adding 10-4-2.8 as follows:
24 (65 ILCS 5/10-4-2.8 new)
25 Sec. 10-4-2.8. Managed Care Reform Act. The corporate
26 authorities of all municipalities are subject to the
27 provisions of the Managed Care Reform Act. The requirement
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1 under this Section that health care benefits provided by
2 municipalities comply with the Managed Care Reform Act is an
3 exclusive power and function of the State and is a denial and
4 limitation of home rule municipality powers under Article
5 VII, Section 6, subsection (h) of the Illinois Constitution.
6 Section 175. The School Code is amended by adding
7 Section 10-22.3g as follows:
8 (105 ILCS 5/10-22.3g new)
9 Sec. 10-22.3g. Managed Care Reform Act. Insurance
10 protection and benefits for employees are subject to the
11 Managed Care Reform Act.
12 Section 180. The Health Maintenance Organization Act is
13 amended by changing Sections 2-2 and 6-7 as follows:
14 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
15 Sec. 2-2. Determination by Director; Health Maintenance
16 Advisory Board.
17 (a) Upon receipt of an application for issuance of a
18 certificate of authority, the Director shall transmit copies
19 of such application and accompanying documents to the
20 Director of the Illinois Department of Public Health. The
21 Director of the Department of Public Health shall then
22 determine whether the applicant for certificate of authority,
23 with respect to health care services to be furnished: (1) has
24 demonstrated the willingness and potential ability to assure
25 that such health care service will be provided in a manner to
26 insure both availability and accessibility of adequate
27 personnel and facilities and in a manner enhancing
28 availability, accessibility, and continuity of service; and
29 (2) has arrangements, established in accordance with rules
30 regulations promulgated by the Department of Public Health
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1 for an ongoing quality of health care assurance program
2 concerning health care processes and outcomes. Upon
3 investigation, the Director of the Department of Public
4 Health shall certify to the Director whether the proposed
5 Health Maintenance Organization meets the requirements of
6 this subsection (a). If the Director of the Department of
7 Public Health certifies that the Health Maintenance
8 Organization does not meet such requirements, he or she shall
9 specify in what respect it is deficient.
10 There is created in the Department of Public Health a
11 Health Maintenance Advisory Board composed of 11 members.
12 Nine of the 11 9 members shall who have practiced in the
13 health field and, 4 of those 9 which shall have been or shall
14 be are currently affiliated with a Health Maintenance
15 Organization. Two of the members shall be members of the
16 general public, one of whom is over 65 years of age. Each
17 member shall be appointed by the Director of the Department
18 of Public Health and serve at the pleasure of that Director
19 and shall receive no compensation for services rendered other
20 than reimbursement for expenses. Six Five members of the
21 Board shall constitute a quorum. A vacancy in the membership
22 of the Advisory Board shall not impair the right of a quorum
23 to exercise all rights and perform all duties of the Board.
24 The Health Maintenance Advisory Board has the power to review
25 and comment on proposed rules and regulations to be
26 promulgated by the Director of the Department of Public
27 Health within 30 days after those proposed rules and
28 regulations have been submitted to the Advisory Board.
29 (b) Issuance of a certificate of authority shall be
30 granted if the following conditions are met:
31 (1) the requirements of subsection (c) of Section
32 2-1 have been fulfilled;
33 (2) the persons responsible for the conduct of the
34 affairs of the applicant are competent, trustworthy, and
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1 possess good reputations, and have had appropriate
2 experience, training or education;
3 (3) the Director of the Department of Public Health
4 certifies that the Health Maintenance Organization's
5 proposed plan of operation meets the requirements of this
6 Act;
7 (4) the Health Care Plan furnishes basic health
8 care services on a prepaid basis, through insurance or
9 otherwise, except to the extent of reasonable
10 requirements for co-payments or deductibles as authorized
11 by this Act;
12 (5) the Health Maintenance Organization is
13 financially responsible and may reasonably be expected to
14 meet its obligations to enrollees and prospective
15 enrollees; in making this determination, the Director
16 shall consider:
17 (A) the financial soundness of the applicant's
18 arrangements for health services and the minimum
19 standard rates, co-payments and other patient
20 charges used in connection therewith;
21 (B) the adequacy of working capital, other
22 sources of funding, and provisions for
23 contingencies; and
24 (C) that no certificate of authority shall be
25 issued if the initial minimum net worth of the
26 applicant is less than $2,000,000. The initial net
27 worth shall be provided in cash and securities in
28 combination and form acceptable to the Director;
29 (6) the agreements with providers for the provision
30 of health services contain the provisions required by
31 Section 2-8 of this Act; and
32 (7) any deficiencies identified by the Director
33 have been corrected.
34 (Source: P.A. 86-620; 86-1475.)
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1 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
2 Sec. 6-7. Board of Directors. The board of directors of
3 the Association shall consist consists of not less than 7 5
4 nor more than 11 9 members serving terms as established in
5 the plan of operation. The members of the board are to be
6 selected by member organizations subject to the approval of
7 the Director provided, however, that 2 members shall be
8 enrollees, one of whom is over 65 years of age. Vacancies on
9 the board must be filled for the remaining period of the term
10 in the manner described in the plan of operation. To select
11 the initial board of directors, and initially organize the
12 Association, the Director must give notice to all member
13 organizations of the time and place of the organizational
14 meeting. In determining voting rights at the organizational
15 meeting each member organization is entitled to one vote in
16 person or by proxy. If the board of directors is not
17 selected at the organizational meeting, the Director may
18 appoint the initial members.
19 In approving selections or in appointing members to the
20 board, the Director must consider, whether all member
21 organizations are fairly represented.
22 Members of the board may be reimbursed from the assets of
23 the Association for expenses incurred by them as members of
24 the board of directors but members of the board may not
25 otherwise be compensated by the Association for their
26 services.
27 (Source: P.A. 85-20.)
28 Section 199. Effective date. This Act takes effect
29 January 1, 2000.
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1 INDEX
2 Statutes amended in order of appearance
3 New Act
4 5 ILCS 375/6.12 new
5 20 ILCS 1405/56.3 new
6 20 ILCS 1405/56.4 new
7 20 ILCS 1405/56.5 new
8 20 ILCS 1405/56.6 new
9 20 ILCS 1405/56.7 new
10 30 ILCS 105/5.490 new
11 30 ILCS 805/8.23 new
12 55 ILCS 5/5-1069.8 new
13 65 ILCS 5/10-4-2.8 new
14 105 ILCS 5/10-22.3g new
15 215 ILCS 125/2-2 from Ch. 111 1/2, par. 1404
16 215 ILCS 125/6-7 from Ch. 111 1/2, par. 1418.7