[ Search ] [ Legislation ]
[ Home ] [ Back ] [ Bottom ]
| [ Introduced ] | [ House Amendment 001 ] |
91_HB0626eng HB0626 Engrossed 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 program 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" means medical, nursing, or other health care 16 professional opinion, decision, or judgment. 17 "Clinical peer reviewer" or "clinical personnel" means: 18 (1) in the case of physician reviewers, a State 19 licensed physician who is of the same category in the 20 same or similar specialty as the health care provider who 21 typically manages the medical condition, procedure or 22 treatment under review; or 23 (2) in the case of non-physician reviewers, a State 24 licensed or registered health care professional who is in 25 the same profession and same or similar specialty as the 26 health care provider who typically manages the medical 27 condition, procedure, or treatment under review. 28 Nothing herein shall be construed to change any 29 statutorily defined scope of practice. 30 "Department" means the Department of Insurance. 31 "Director" means the Director of Insurance. HB0626 Engrossed -2- LRB9100964JSpc 1 "Emergency medical condition" means a medical condition 2 manifesting itself by acute symptoms of sufficient severity 3 (including but not limited to severe pain) such that a 4 prudent layperson, who possesses an average knowledge of 5 health and medicine, could reasonably expect the absence of 6 immediate medical attention to result in: 7 (1) placing the health of the individual (or, with 8 respect to a pregnant woman, the health of the woman or 9 her unborn child) in serious jeopardy; 10 (2) serious impairment to bodily functions; or 11 (3) serious dysfunction of any bodily organ or 12 part. 13 "Emergency medical screening examination" means a medical 14 screening examination and evaluation by a physician licensed 15 to practice medicine in all its branches or, to the extent 16 permitted by applicable laws, by other appropriate personnel 17 under the supervision of or in collaboration with a physician 18 licensed to practice medicine in all its branches to 19 determine whether the need for emergency services exists. 20 "Emergency services" means, with respect to an enrollee 21 of a managed care plan, transportation services and covered 22 inpatient and outpatient hospital services furnished by a 23 provider qualified to furnish those services that are needed 24 to evaluate or stabilize an emergency medical condition. 25 "Emergency services" does not refer to post-stabilization 26 medical services. 27 "Enrollee" means a person enrolled in a managed care 28 plan. 29 "Health care professional" means a physician, registered 30 professional nurse, or other person appropriately licensed or 31 registered pursuant to the laws of this State to provide 32 health care services. 33 "Health care provider" means a health care professional, 34 hospital, facility, or other person appropriately licensed or HB0626 Engrossed -3- LRB9100964JSpc 1 otherwise authorized to furnish health care services or 2 arrange for the delivery of health care services in this 3 State. 4 "Health care services" means any services included in the 5 furnishing to any individual of medical care, or the 6 hospitalization or incident to the furnishing of such care or 7 hospitalization as well as the furnishing to any person of 8 any and all other services for the purpose of preventing, 9 alleviating, curing, or healing human illness or injury 10 including home health and pharmaceutical services and 11 products. 12 "Informal policy or procedure" means a nonwritten policy 13 or procedure, the existence of which may be proven by an 14 admission of an authorized agent of a managed care plan or 15 statistical evidence supported by anecdotal evidence. 16 "Managed care plan" means a plan that establishes, 17 operates, or maintains a network of health care providers 18 that have entered into agreements with the plan to provide 19 health care services to enrollees where the plan has the 20 ultimate obligation to the enrollee to arrange for the 21 provision of or pay for services through: 22 (1) organizational arrangements for ongoing quality 23 assurance, utilization review programs, or dispute 24 resolution; or 25 (2) financial incentives for persons enrolled in 26 the plan to use the participating providers and 27 procedures covered by the plan. 28 A managed care plan may be established or operated by any 29 entity including, but not necessarily limited to, a licensed 30 insurance company, hospital or medical service plan, health 31 maintenance organization, limited health service 32 organization, preferred provider organization, third party 33 administrator, independent practice association, or employer 34 or employee organization. HB0626 Engrossed -4- LRB9100964JSpc 1 For purposes of this definition, "managed care plan" 2 shall not include the following: 3 (1) strict indemnity health insurance policies or 4 plans issued by an insurer that does not require approval 5 of a primary care provider or other similar coordinator 6 to access health care services; 7 (2) managed care plans that offer only dental or 8 vision coverage; 9 (3) employee or employer self-insured health 10 benefit plans preempted from State regulation under the 11 federal Employee Retirement Income Security Act of 1974; 12 (4) not-for-profit health maintenance organizations 13 in existence as of January 1, 1999 and affiliated with a 14 union which only extend coverage to union members; and 15 (5) health care provided pursuant to the Workers' 16 Compensation Act or the Workers' Occupational Diseases 17 Act. 18 "Medical director" means a physician licensed in any 19 state to practice medicine in all its branches appointed by a 20 managed care plan. 21 "Person" means a corporation, association, partnership, 22 limited liability company, sole proprietorship, or any other 23 legal entity. 24 "Physician" means a person licensed under the Medical 25 Practice Act of 1987. 26 "Post-stabilization medical services" means health care 27 services provided to an enrollee that are furnished in a 28 licensed hospital by a physician or health care provider that 29 is qualified to furnish such services, and determined to be 30 medically necessary and directly related to the emergency 31 medical condition following stabilization. 32 "Primary care" means the provision of a broad range of 33 personal health care services (preventive, diagnostic, 34 curative, counseling, or rehabilitative) in a manner that is HB0626 Engrossed -5- LRB9100964JSpc 1 accessible and comprehensive and coordinated by a physician 2 licensed to practice medicine in all its branches. 3 "Primary care physician" means a physician who has 4 contracted with a managed care plan to provide primary care 5 services as defined by the contract and who is a physician 6 licensed to practice medicine in all of its branches. Nothing 7 in this definition shall be construed to prohibit a managed 8 care plan from requiring a physician to meet a managed care 9 plan's criteria in order to coordinate access to health care. 10 "Stabilization" means, with respect to an emergency 11 medical condition, to provide such medical treatment of the 12 condition as may be necessary to assure, within reasonable 13 medical probability, that no material deterioration of the 14 condition is likely to result from or occur during the 15 transfer of the enrollee from a facility. 16 "Specialist" means a health care professional who 17 concentrates practice in a recognized specialty field of 18 care. 19 "Utilization review" means the evaluation of the medical 20 necessity, appropriateness, and efficiency of the use of 21 health care services, procedures, and facilities. 22 "Utilization review program" means a program established 23 by a person to perform utilization review. 24 Section 10. Disclosure of information. 25 (a) An enrollee, and upon request a prospective enrollee 26 prior to enrollment, shall be supplied with written 27 disclosure information, containing at least the information 28 specified in this Section, if applicable, which may be 29 incorporated into the member handbook or the enrollee 30 contract or certificate. All written descriptions shall be in 31 readable and understandable format, consistent with standards 32 developed for supplemental insurance coverage under Title 33 XVIII of the Social Security Act. The Department shall HB0626 Engrossed -6- LRB9100964JSpc 1 promulgate rules to standardize this format so that potential 2 enrollees can compare the attributes of the various managed 3 care plans. In the event of any inconsistency between any 4 separate written disclosure statement and the enrollee 5 contract or certificate, the terms of the enrollee contract 6 or certificate shall be controlling. The information to be 7 disclosed shall include, at a minimum, all of the following: 8 (1) A description of coverage provisions, health 9 care benefits, benefit maximums, including benefit 10 limitations, and exclusions of coverage, including the 11 definition of medical necessity used in determining 12 whether benefits will be covered. 13 (2) A description of all prior authorization or 14 other requirements for treatments, pharmaceuticals, and 15 services. 16 (3) A description of utilization review policies 17 and procedures used by the managed care plan, including 18 the circumstances under which utilization review will be 19 undertaken, the toll-free telephone number of the 20 utilization review program, the time frames under which 21 utilization review decisions must be made for 22 prospective, retrospective, and concurrent decisions, the 23 right to reconsideration, the right to an appeal, 24 including the expedited and standard appeals processes 25 and the time frames for those appeals, the right to 26 designate a representative, a notice that all denials of 27 claims will be made by clinical personnel, and that all 28 notices of denials will include information about the 29 basis of the decision and further appeal rights, if any. 30 (4) A description prepared annually of the types of 31 methodologies the managed care plan uses to reimburse 32 providers specifying the type of methodology that is used 33 to reimburse particular types of providers or reimburse 34 for the provision of particular types of services, HB0626 Engrossed -7- LRB9100964JSpc 1 provided, however, that nothing in this item should be 2 construed to require disclosure of individual contracts 3 or the specific details of any financial arrangement 4 between a managed care plan and a health care provider. 5 (5) An explanation of an enrollee's financial 6 responsibility for payment of premiums, coinsurance, 7 co-payments, deductibles, and any other charges, annual 8 limits on an enrollee's financial responsibility, caps on 9 payments for covered services and financial 10 responsibility for non-covered health care procedures, 11 treatments, or services provided within the managed care 12 plan. 13 (6) An explanation of an enrollee's financial 14 responsibility for payment when services are provided by 15 a health care provider who is not part of the managed 16 care plan or by any provider without required 17 authorization or when a procedure, treatment, or service 18 is not a covered health care benefit. 19 (7) A description of the grievance procedures to be 20 used to resolve disputes between a managed care plan and 21 an enrollee, including the right to file a grievance 22 regarding any dispute between an enrollee and a managed 23 care plan, the right to file a grievance orally when the 24 dispute is about referrals or covered benefits, the 25 toll-free telephone number that enrollees may use to file 26 an oral grievance, the time frames and circumstances for 27 expedited and standard grievances, the right to appeal a 28 grievance determination and the procedures for filing the 29 appeal, the time frames and circumstances for expedited 30 and standard appeals, the right to designate a 31 representative, a notice that all disputes involving 32 clinical decisions will be made by clinical personnel, 33 and that all notices of determination will include 34 information about the basis of the decision and further HB0626 Engrossed -8- LRB9100964JSpc 1 appeal rights, if any. 2 (8) A description of the procedure for providing 3 care and coverage 24 hours a day for emergency services. 4 The description shall include the definition of emergency 5 services, notice that emergency services are not subject 6 to prior approval, and an explanation of the enrollee's 7 financial and other responsibilities regarding obtaining 8 those services, including when those services are 9 received outside the managed care plan's service area. 10 (9) A description of procedures for enrollees to 11 select and access the managed care plan's primary and 12 specialty care providers, including notice of how to 13 determine whether a participating provider is accepting 14 new patients. 15 (10) A description of the procedures for changing 16 primary and specialty care providers within the managed 17 care plan. 18 (11) Notice that an enrollee may obtain a referral 19 to a health care provider outside of the managed care 20 plan's network or panel when the managed care plan does 21 not have a health care provider with appropriate training 22 and experience in the network or panel to meet the 23 particular health care needs of the enrollee and the 24 procedure by which the enrollee can obtain the referral. 25 (12) Notice that an enrollee with a condition that 26 requires ongoing care from a specialist may request a 27 standing referral to the specialist and the procedure for 28 requesting and obtaining a standing referral. 29 (13) Notice that an enrollee with (i) a 30 life-threatening condition or disease or (ii) a 31 degenerative or disabling condition or disease, either of 32 which requires specialized medical care over a prolonged 33 period of time, may request a specialist responsible for 34 providing or coordinating the enrollee's medical care and HB0626 Engrossed -9- LRB9100964JSpc 1 the procedure for requesting and obtaining the 2 specialist. 3 (14) A description of the mechanisms by which 4 enrollees may participate in the development of the 5 policies of the managed care plan. 6 (15) A description of how the managed care plan 7 addresses the needs of non-English speaking enrollees. 8 (16) Notice of all appropriate mailing addresses 9 and telephone numbers to be utilized by enrollees seeking 10 information or authorization. 11 (17) A listing by specialty, which may be in a 12 separate document that is updated annually, of the name, 13 address, and telephone number of all participating 14 providers, including facilities, and, in addition, in the 15 case of physicians, category of license and board 16 certification, if applicable. 17 (b) Upon request of an enrollee or prospective enrollee, 18 a managed care plan shall do all of the following: 19 (1) Provide a list of the names, business 20 addresses, and official positions of the members of the 21 board of directors, officers, controlling persons, 22 owners, and partners of the managed care plan. 23 (2) Provide a copy of the most recent annual 24 certified financial statement of the managed care plan, 25 including a balance sheet and summary of receipts and 26 disbursements and the ratio of (i) premium dollars going 27 to administrative expenses to (ii) premium dollars going 28 to direct care, prepared by a certified public 29 accountant. The Department shall promulgate rules to 30 standardize the information that must be contained in the 31 statement and the statement's format. 32 (3) Provide information relating to consumer 33 complaints compiled in accordance with subsection (b) of 34 Section 25 of this Act and the rules promulgated under HB0626 Engrossed -10- LRB9100964JSpc 1 this Act. 2 (4) Provide the procedures for protecting the 3 confidentiality of medical records and other enrollee 4 information. 5 (5) Allow enrollees and prospective enrollees to 6 inspect drug formularies used by the managed care plan 7 and disclose whether individual drugs are included or 8 excluded from coverage and whether a drug requires prior 9 authorization. An enrollee or prospective enrollee may 10 seek information as to the inclusion or exclusion of a 11 specific drug. A managed care plan need only release the 12 information if the enrollee or prospective enrollee or 13 his or her dependent needs, used, or may need or use the 14 drug. 15 (6) Provide a written description of the 16 organizational arrangements and ongoing procedures of the 17 managed care plan's quality assurance program. 18 (7) Provide a description of the procedures 19 followed by the managed care plan in making decisions 20 about the experimental or investigational nature of 21 individual drugs, medical devices, or treatments in 22 clinical trials. 23 (8) Provide individual health care professional 24 affiliations with participating hospitals, if any. 25 (9) Upon written request, provide specific written 26 clinical review criteria relating to a particular 27 condition or disease and, where appropriate, other 28 clinical information that the managed care plan might 29 consider in its utilization review; the managed care plan 30 may include with the information a description of how it 31 will be used in the utilization review process. An 32 enrollee or prospective enrollee may seek information as 33 to specific clinical review criteria. A managed care 34 plan need only release the information if the enrollee or HB0626 Engrossed -11- LRB9100964JSpc 1 prospective enrollee or his or her dependent has, may 2 have, or is at risk of contracting a particular condition 3 or disease. 4 (10) Provide the written application procedures and 5 minimum qualification requirements for health care 6 providers to be considered by the managed care plan. 7 (11) Disclose other information as required by the 8 Director. 9 (12) To the extent the information provided under 10 item (5) or (9) of this subsection is proprietary to the 11 managed care plan, the enrollee or prospective enrollee 12 shall only use the information for the purposes of 13 assisting the enrollee or prospective enrollee in 14 evaluating the covered services provided by the managed 15 care plan. Any misuse of proprietary data is prohibited, 16 provided that the managed care plan has labeled or 17 identified the data as proprietary. 18 (c) Nothing in this Section shall prevent a managed care 19 plan from changing or updating the materials that are made 20 available to enrollees or prospective enrollees. 21 (d) If a primary care provider ceases participation in 22 the managed care plan, the managed care plan shall provide 23 written notice within 15 business days from the date that the 24 managed care plan becomes aware of the change in status to 25 each of the enrollees who have chosen the provider as their 26 primary care provider. If an enrollee is in an ongoing course 27 of treatment with any other participating provider who 28 becomes unavailable to continue to provide services to the 29 enrollee and the managed care plan is aware of the ongoing 30 course of treatment, the managed care plan shall provide 31 written notice within 15 business days from the date that the 32 managed care plan becomes aware of the unavailability to the 33 enrollee. The notice shall also describe the procedures for 34 continuing care. HB0626 Engrossed -12- LRB9100964JSpc 1 (e) A managed care plan offering to indemnify enrollees 2 for non-participating provider services shall file a report 3 with the Director twice a year showing the percentage 4 utilization for the preceding 6 month period of 5 non-participating provider services in such form and 6 providing such other information as the Director shall 7 prescribe. 8 (f) The written information disclosure requirements of 9 this Section may be met by disclosure to one enrollee in a 10 household. 11 Section 15. General grievance procedure. 12 (a) A managed care plan shall establish and maintain a 13 grievance procedure, as described in this Act. Compliance 14 with this Act's grievance procedures shall satisfy a managed 15 care plan's obligation to provide grievance procedures under 16 any other State law or rules. 17 A copy of the grievance procedures, including all forms 18 used to process a grievance, shall be filed with the 19 Director. Any subsequent material modifications to the 20 documents also shall be filed. In addition, a managed care 21 plan shall file annually with the Director a certificate of 22 compliance stating that the managed care plan has established 23 and maintains, for each of its plans, grievance procedures 24 that fully comply with the provisions of this Act. The 25 Director has authority to disapprove a filing that fails to 26 comply with this Act or applicable rules. 27 (b) A managed care plan shall provide written notice of 28 the grievance procedure to all enrollees in the member 29 handbook and to an enrollee at any time that the managed care 30 plan denies access to a referral or determines that a 31 requested benefit is not covered pursuant to the terms of the 32 contract. In the event that a managed care plan denies a 33 service as an adverse determination, the managed care plan HB0626 Engrossed -13- LRB9100964JSpc 1 shall inform the enrollee or the enrollee's designee of the 2 appeal rights under this Act. 3 The notice to an enrollee describing the grievance 4 process shall explain the process for filing a grievance with 5 the managed care plan, the time frames within which a 6 grievance determination must be made, and the right of an 7 enrollee to designate a representative to file a grievance on 8 behalf of the enrollee. Information required to be disclosed 9 or provided under this Section must be provided in a 10 reasonable and understandable format. 11 The managed care plan shall assure that the grievance 12 procedure is reasonably accessible to those who do not speak 13 English. 14 (c) A managed care plan shall not retaliate or take any 15 discriminatory action against an enrollee because an enrollee 16 has filed a grievance or appeal or requested an external 17 independent review. 18 Section 20. Grievance review. 19 (a) The managed care plan may require an enrollee to 20 file a grievance in writing, by letter or by a grievance form 21 which shall be made available by the managed care plan, 22 however, an enrollee must be allowed to submit an oral 23 grievance in connection with (i) a denial of, or failure to 24 pay for, a referral or service or (ii) a determination as to 25 whether a benefit is covered pursuant to the terms of the 26 enrollee's contract. A grievance may also be filed by a 27 health care professional or health care provider. In 28 connection with the submission of an oral grievance, a 29 managed care plan shall, within 24 hours, reduce the 30 complaint to writing and give the enrollee written 31 acknowledgment of the grievance prepared by the managed care 32 plan summarizing the nature of the grievance and requesting 33 any information that the enrollee needs to provide before the HB0626 Engrossed -14- LRB9100964JSpc 1 grievance can be processed. The acknowledgment shall be 2 mailed within the 24-hour period to the enrollee, who shall 3 sign and return the acknowledgment, with any amendments and 4 requested information, in order to initiate the grievance. 5 The grievance acknowledgment shall prominently state that the 6 enrollee must sign and return the acknowledgment to initiate 7 the grievance. A managed care plan may elect not to require a 8 signed acknowledgment when no additional information is 9 necessary to process the grievance, and an oral grievance 10 shall be initiated at the time of the telephone call. 11 Except as authorized in this subsection, a managed care 12 plan shall designate personnel to accept the filing of an 13 enrollee's grievance by toll-free telephone no less than 40 14 hours per week during normal business hours and shall have a 15 telephone system available to take calls during other than 16 normal business hours and shall respond to all such calls no 17 later than the next business day after the call was recorded. 18 In the case of grievances subject to item (i) of subsection 19 (b) of this Section, telephone access must be available on a 20 24 hour a day, 7 day a week basis. 21 (b) Within 48 hours of receipt of a written grievance, 22 the managed care plan shall provide written acknowledgment of 23 the grievance, including the name, address, qualifying 24 credentials, and telephone number of the individuals or 25 department designated by the managed care plan to respond to 26 the grievance. All grievances shall be resolved in an 27 expeditious manner, and in any event, no more than (i) 24 28 hours after the receipt of all necessary information when a 29 delay would significantly increase the risk to an enrollee's 30 health or when extended health care services, procedures, or 31 treatments for an enrollee undergoing a course of treatment 32 prescribed by a health care provider are at issue, (ii) 15 33 days after the receipt of all necessary information in the 34 case of requests for referrals or determinations concerning HB0626 Engrossed -15- LRB9100964JSpc 1 whether a requested benefit is covered pursuant to the 2 contract, and (iii) 30 days after the receipt of all 3 necessary information in all other instances. 4 (c) The managed care plan shall designate one or more 5 qualified personnel to review the grievance. When the 6 grievance pertains to medical or clinical matters, the 7 personnel shall include, but not be limited to, one or more 8 appropriately licensed or registered health care 9 professionals. When the grievance pertains to non-medical or 10 non-clinical matters, the personnel making the determination 11 must have had no involvement in the initial determination and 12 be at a higher level than the personnel who made the initial 13 grievance determination. 14 (d) The notice of a determination of the grievance shall 15 be made in writing to the enrollee or to the enrollee's 16 designee. In the case of a determination made in conformance 17 with item (i) of subsection (b) of this Section, notice shall 18 be made by telephone directly to the enrollee with written 19 notice to follow within 2 business days. 20 (e) The notice of a determination shall include (i) 21 clear and detailed reasons for the determination, including 22 any contract basis for the determination, and the evidence 23 relied upon in making that determination, (ii) in cases where 24 the determination has a medical or clinical basis, the 25 medical or clinical criteria for the determination, and (iii) 26 the procedures for the filing of an appeal of the 27 determination, including a form for the filing of an appeal, 28 requesting an external independent review, and filing a 29 complaint with the Department of Insurance. 30 Section 25. Grievance and complaint registry. 31 (a) A managed care plan shall maintain a register 32 consisting of a written record of all grievances and 33 complaints initiated during the past 3 years. The register HB0626 Engrossed -16- LRB9100964JSpc 1 shall be maintained in a manner that is reasonably clear and 2 accessible to the Director. 3 (b) The Department shall maintain records concerning the 4 complaints filed against managed care plans with the 5 Department and shall require managed care plans to annually 6 report complaints made to and resolutions by managed care 7 plans in a manner determined by rule. The Department shall 8 make a summary of all data collected available upon request 9 and publish the summary on the World Wide Web. 10 (c) The Department shall maintain records on the number 11 of complaints filed against each managed care plan. 12 (d) The Department shall maintain records classifying 13 each complaint by whether the complaint was filed by: 14 (1) a consumer or enrollee; 15 (2) a physician or health care provider; or 16 (3) any other individual. 17 (e) The Department shall maintain records classifying 18 each complaint according to the nature of the complaint as it 19 pertains to a specific function of the managed care plan. 20 The complaints shall be classified under the following 21 categories: 22 (1) denial of care or treatment; 23 (2) denial of a diagnostic procedure; 24 (3) denial of a referral request; 25 (4) sufficient choice and accessibility of health 26 care providers; 27 (5) underwriting; 28 (6) marketing and sales; 29 (7) claims and utilization review; 30 (8) member services; 31 (9) provider relations; and 32 (10) miscellaneous. 33 (f) The Department shall maintain records classifying 34 the disposition of each complaint. The disposition of the HB0626 Engrossed -17- LRB9100964JSpc 1 complaint shall be classified in one of the following 2 categories: 3 (1) complaint referred to the managed care plan and 4 no further action necessary by the Department; 5 (2) no corrective action deemed necessary by the 6 Department; or 7 (3) corrective action taken by the Department. 8 (g) No Department publication or release of information 9 shall identify any enrollee, physician, health care provider, 10 or individual complainant. 11 Section 30. External independent review. 12 (a) If an enrollee's or enrollee's health care 13 professional's or health care provider's or designee's 14 request for a covered service or claim for a covered service 15 is denied under the grievance review under Section 20 because 16 the service is not viewed as medically necessary including, 17 but not limited to, denial of specific tests or procedures, 18 denial of referral to specialist physicians, denial of 19 hospitalization requests or length of stay requests, the 20 enrollee or enrollee's health care professional or health 21 care provider or designee may initiate an external 22 independent review. 23 The managed care plan shall seek to resolve all external 24 independent reviews in the most expeditious manner and shall 25 make a determination and provide notice no more than 24 hours 26 after the receipt of all necessary information when a delay 27 would significantly increase the risk to an enrollee's health 28 or when extended health care services, procedures, or 29 treatments for an enrollee undergoing a course of treatment 30 prescribed by a health care provider are at issue. 31 (b) Within 30 days after the enrollee receives written 32 notice of such an adverse decision, if the enrollee decides 33 to initiate an external independent review, the enrollee HB0626 Engrossed -18- LRB9100964JSpc 1 shall send to the managed care plan a written request for an 2 external independent review, including any material 3 justification or documentation to support the enrollee's 4 request for the covered service or claim for a covered 5 service. 6 (c) Within 30 days after the managed care plan receives 7 a request for an external independent review from an 8 enrollee, the managed care plan shall: 9 (1) provide a mechanism for jointly selecting an 10 external independent reviewer by the enrollee, primary 11 care physician, and managed care plan; and 12 (2) forward to the independent reviewer all medical 13 records and supporting documentation pertaining to the 14 case, a summary description of the applicable issues 15 including a statement of the managed care plan's 16 decision, and the criteria used and the medical or 17 clinical reasons for that decision. 18 (d) Within 5 days of receipt of all necessary 19 information, the independent reviewer or reviewers shall 20 evaluate and analyze the case and render a decision that is 21 based on whether or not the service or claim for the service 22 is medically necessary. The decision by the independent 23 reviewer or reviewers is final. 24 (e) Pursuant to subsection (c) of this Section, an 25 external independent reviewer shall: 26 (1) have no direct financial interest in or 27 connection to the case; 28 (2) for physician services, be State licensed 29 physicians who are board certified or board eligible by 30 the appropriate American Medical Specialty Board, if 31 applicable, and who are in the same or similar scope of 32 practice as a physician who typically manages the medical 33 condition, procedure, or treatment under review; 34 (3) for other health care professional services, be HB0626 Engrossed -19- LRB9100964JSpc 1 State licensed health care professionals with the same 2 category of license as the health care professional 3 recommending the services; and 4 (4) have not been informed of the specific identity 5 of the enrollee or the enrollee's treating provider. 6 (f) If an appropriate reviewer pursuant to subsection 7 (e) of this Section for a particular case is not on the list 8 established by the Director, the parties shall choose a 9 reviewer who is mutually acceptable. 10 Section 35. Independent reviewers. 11 (a) From information filed with the Director on or 12 before March 1 of each year, the Director of the Illinois 13 Department of Public Health shall compile a list of external 14 independent reviewers and organizations that represent 15 external independent reviewers from lists provided by managed 16 care plans and by any State and county public health 17 department and State professional associations that wish to 18 submit a list to the Director. The Director may consult with 19 other persons about the suitability of any reviewer or any 20 potential reviewer. The Director shall annually review the 21 list and add and remove names as appropriate. On or before 22 June 1 of each year, the Director shall publish the list in 23 the Illinois Register. 24 (b) The managed care plan shall be solely responsible 25 for paying the fees of the external independent reviewer who 26 is selected to perform the review. 27 (c) An external independent reviewer who acts in good 28 faith shall have immunity from any civil or criminal 29 liability or professional discipline as a result of acts or 30 omissions with respect to any external independent review, 31 unless the acts or omissions constitute wilful and wanton 32 misconduct. For purposes of any proceeding, the good faith 33 of the person participating shall be presumed. HB0626 Engrossed -20- LRB9100964JSpc 1 (d) The Director's decision to add a name to or remove a 2 name from the list of independent reviewers pursuant to 3 subsection (a) is not subject to administrative appeal or 4 judicial review. 5 Section 40. Health care professional applications and 6 terminations. 7 (a) A managed care plan shall, upon request, make 8 available and disclose to health care professionals written 9 application procedures and minimum qualification requirements 10 that a health care professional must meet in order to be 11 considered by the managed care plan. The managed care plan 12 shall consult with appropriately qualified health care 13 professionals in developing its qualification requirements. 14 (b) A managed care plan may not terminate a contract of 15 employment or refuse to renew a contract on the basis of any 16 action protected under Section 45 of this Act or solely 17 because a health care professional has: 18 (1) filed a complaint against the managed care 19 plan; 20 (2) appealed a decision of the managed care plan 21 including requesting an external independent review; or 22 (3) requested a hearing pursuant to this Section. 23 (c) A managed care plan shall provide to a health care 24 professional, in writing, the reasons for the contract 25 termination or non-renewal. 26 (d) A managed care plan shall provide an opportunity for 27 a hearing to any health care professional terminated by the 28 managed care plan, or non-renewed if the health care 29 professional has had a contract or contracts with the managed 30 care plan for at least 24 of the past 36 months. 31 (e) After the notice provided pursuant to subsection 32 (c), the health care professional shall have 21 days to 33 request a hearing, and the hearing must be held within 15 HB0626 Engrossed -21- LRB9100964JSpc 1 days after receipt of the request for a hearing. The hearing 2 shall be held before a panel appointed by the managed care 3 plan. 4 The hearing panel shall be composed of 5 individuals, the 5 majority of whom shall be clinical peer reviewers and, to the 6 extent possible, in the same discipline and the same or 7 similar specialty as the health care professional under 8 review. 9 The hearing panel shall render a written decision on the 10 proposed action within 14 business days. The decision shall 11 be one of the following: 12 (1) reinstatement of the health care professional 13 by the managed care plan; 14 (2) provisional reinstatement subject to conditions 15 set forth by the panel; or 16 (3) termination of the health care professional. 17 The decision of the hearing panel shall be final. 18 A decision by the hearing panel to terminate a health 19 care professional shall be effective not less than 15 days 20 after the receipt by the health care professional of the 21 hearing panel's decision. 22 A hearing under this subsection shall provide the health 23 care professional in question with the right to examine 24 pertinent information, to present witnesses, and to ask 25 questions of an authorized representative of the plan. 26 (f) A managed care plan may terminate or decline to 27 renew a health care professional, without a prior hearing, in 28 cases involving imminent harm to patient care, a 29 determination of intentional falsification of reports to the 30 plan or a final disciplinary action by a state licensing 31 board or other governmental agency that impairs the health 32 care professional's ability to practice. A professional 33 terminated for one of the these reasons shall be given 34 written notice to that effect. Within 21 days after the HB0626 Engrossed -22- LRB9100964JSpc 1 termination, a health care professional terminated because of 2 imminent harm to patient care or a determination of 3 intentional falsification of reports to the plan shall 4 receive a hearing. The hearing shall be held before a panel 5 appointed by the managed care plan. The panel shall be 6 composed of 5 individuals the majority of whom shall be 7 clinical peer reviewers and, to the extent possible, in the 8 same discipline and the same or similar specialty as the 9 health care professional under review. The hearing panel 10 shall render a decision on the proposed action within 14 11 days. The panel shall issue a written decision either 12 supporting the termination or ordering the health care 13 professional's reinstatement. The decision of the hearing 14 panel shall be final. 15 If the hearing panel upholds the managed care plan's 16 termination of the health care professional under this 17 subsection, the managed care plan shall forward the decision 18 to the appropriate professional disciplinary agency in 19 accordance with subsection (b) of Section 65. 20 Any hearing under this subsection shall provide the 21 health care professional in question with the right to 22 examine pertinent information, to present witnesses, and to 23 ask questions of an authorized representative of the plan. 24 (g) For any hearing under this Section, because the 25 candid and conscientious evaluation of clinical practices is 26 essential to the provision of health care, it is the policy 27 of this State to encourage peer review by health care 28 professionals. Therefore, no managed care plan and no 29 individual who participates in a hearing or who is a member, 30 agent, or employee of a managed care plan shall be liable for 31 criminal or civil damages or professional discipline as a 32 result of the acts, omissions, decisions, or any other 33 conduct, direct or indirect, associated with a hearing panel, 34 except for wilful and wanton misconduct. Nothing in this HB0626 Engrossed -23- LRB9100964JSpc 1 Section shall relieve any person, health care provider, 2 health care professional, facility, organization, or 3 corporation from liability for his, her, or its own 4 negligence in the performance of his, her, or its duties or 5 arising from treatment of a patient. The hearing panel 6 information shall not be subject to inspection or disclosure 7 except upon formal written request by an authorized 8 representative of a duly authorized State agency or pursuant 9 to a court order issued in a pending action or proceeding. 10 (h) A managed care plan shall develop and implement 11 policies and procedures to ensure that health care 12 professionals are at least annually informed of information 13 maintained by the managed care plan to evaluate the 14 performance or practice of the health care professional. The 15 managed care plan shall consult with health care 16 professionals in developing methodologies to collect and 17 analyze health care professional data. Managed care plans 18 shall provide the information and data and analysis to health 19 care professionals. The information, data, or analysis shall 20 be provided on at least an annual basis in a format 21 appropriate to the nature and amount of data and the volume 22 and scope of services provided. Any data used to evaluate 23 the performance or practice of a health care professional 24 shall be measured against stated criteria and a comparable 25 group of health care professionals who use similar treatment 26 modalities and serve a comparable patient population. Upon 27 receipt of the information or data, a health care 28 professional shall be given the opportunity to explain the 29 unique nature of the health care professional's patient 30 population that may have a bearing on the health care 31 professional's data and to work cooperatively with the 32 managed care plan to improve performance. 33 (i) Any contract provision or procedure or informal 34 policy or procedure in violation of this Section violates the HB0626 Engrossed -24- LRB9100964JSpc 1 public policy of the State of Illinois and is void and 2 unenforceable. 3 Section 45. Prohibitions. 4 (a) No managed care plan or its subcontractors shall by 5 contract, written policy or written procedure, or informal 6 policy or procedure prohibit or restrict any health care 7 professional or provider from disclosing to any enrollee, 8 patient, designated representative or, where appropriate, 9 prospective enrollee, (hereinafter collectively referred to 10 as enrollee) any information that the professional or 11 provider deems appropriate regarding: 12 (1) a condition or a course of treatment with an 13 enrollee including the availability of other therapies, 14 consultations, or tests; or 15 (2) the provisions, terms, or requirements of the 16 managed care plan's products as they relate to the 17 enrollee, where applicable. 18 (b) No managed care plan or its subcontractors shall by 19 contract, written policy or procedure, or informal policy or 20 procedure prohibit or restrict any health care professional 21 or provider from filing a complaint, making a report, or 22 commenting to an appropriate governmental body regarding the 23 policies or practices of the managed care plan that the 24 provider believes may negatively impact upon the quality of, 25 or access to, patient care. 26 (c) No managed care plan or its subcontractors shall 27 retaliate against a health care professional or health care 28 provider who advocates for appropriate health care services 29 for patients. It is the public policy of the State of 30 Illinois that a health care professional or health care 31 provider be encouraged to advocate for medically appropriate 32 health care services for his or her patients. This Section 33 shall not be construed to prohibit a managed care plan from HB0626 Engrossed -25- LRB9100964JSpc 1 making a determination not to pay for a particular health 2 care service or to prohibit a medical group, independent 3 practice association, preferred provider organization, 4 foundation, hospital medical staff, hospital governing body 5 or managed care plan from enforcing reasonable peer review or 6 utilization review protocols or determining whether a health 7 care professional or health care provider has complied with 8 those protocols. Nothing in this Section shall be construed 9 to prohibit the governing body of a hospital or the hospital 10 medical staff from taking disciplinary actions against a 11 physician as authorized by law. Nothing in this Section shall 12 be construed to prohibit the Department of Professional 13 Regulation from taking disciplinary actions against a health 14 care professional or provider under the appropriate licensing 15 Act. 16 (d) No managed care plan or its subcontractors by 17 contract, written policy, or procedure shall contain any 18 clause attempting to transfer or transferring to a physician 19 or health care professional or provider by indemnification or 20 otherwise, any civil or professional liability relating to 21 activities, actions, or omissions of the managed care plan or 22 its officers, employees, or agents as opposed to those of the 23 health care provider. A managed care plan shall be 24 responsible for any civil or professional liability relating 25 to activities, actions, or omissions of the plan or its 26 officers, employees, or agents. If a physician or health 27 care professional or provider performs activities, such as 28 quality assurance or utilization review, on behalf of the 29 plan or its subcontractors, then the physician or health care 30 professional or provider is acting as agent of the plan. 31 Nothing in this Section shall relieve any person, health care 32 provider, health care professional, or facility from 33 liability for his, her, or its own negligence in the 34 performance of his, her, or its duties or arising from HB0626 Engrossed -26- LRB9100964JSpc 1 treatment of a patient. 2 (e) No contract between a managed care plan or its 3 subcontractors and a health care professional or provider 4 shall contain any incentive plan that includes specific 5 payment made directly, in any form, to a health care 6 professional or provider as an inducement to deny, reduce, 7 limit, or delay specific, medically necessary and appropriate 8 services provided with respect to a specific enrollee or 9 groups of enrollees with similar medical conditions. Nothing 10 in this Section shall be construed to prohibit contracts that 11 contain incentive plans that involve general payments, such 12 as capitation payments or shared-risk arrangements, that are 13 not tied to specific medical decisions involving specific 14 enrollees or groups of enrollees with similar medical 15 conditions. The payments rendered or to be rendered to 16 health care professionals or providers under these 17 arrangements shall be deemed confidential information. 18 (f) No managed care plan or its subcontractors shall by 19 contract, written policy or procedure, or informal policy or 20 procedure permit, allow, or encourage an individual or entity 21 to dispense a different drug in place of the drug or brand of 22 drug ordered or prescribed without the express permission of 23 the person ordering or prescribing, except this prohibition 24 does not prohibit the interchange of different brands of the 25 same generically equivalent drug product, as provided under 26 Section 3.14 of the Illinois Food, Drug and Cosmetic Act. 27 (g) Any contract provision, written policy or procedure, 28 or informal policy or procedure in violation of this Section 29 violates the public policy of the State of Illinois and is 30 void and unenforceable. 31 Section 50. Network of providers. 32 (a) At least once every 3 years, and upon application 33 for expansion of service area, a managed care plan shall HB0626 Engrossed -27- LRB9100964JSpc 1 obtain certification from the Director of Public Health that 2 the managed care plan maintains a network of health care 3 professionals, providers, and facilities adequate to meet the 4 comprehensive health needs of its enrollees and to provide an 5 appropriate choice of health care professionals and providers 6 sufficient to provide the services covered under its 7 enrollee's contracts by determining that: 8 (1) there are a sufficient number of geographically 9 accessible participating professionals, providers, and 10 facilities; 11 (2) there are opportunities to select from at least 12 3 primary care physicians pursuant to travel and distance 13 time standards, providing that these standards account 14 for the conditions of accessing physicians in rural 15 areas; and 16 (3) there are sufficient professionals or providers 17 in all covered areas of specialty practice to meet the 18 needs of the enrollment population. 19 (b) The following criteria shall be considered by the 20 Director of Public Health at the time of a review: 21 (1) professional-enrollee and provider-enrollee 22 ratios by specialty; 23 (2) primary care physician-enrollee ratios; 24 (3) safe and adequate staffing of health care 25 professionals or providers in all participating 26 facilities based on: 27 (A) severity of patient illness and functional 28 capacity; 29 (B) factors affecting the period and quality 30 of patient recovery; and 31 (C) any other factor substantially related to 32 the condition and health care needs of patients; 33 (4) geographic accessibility; 34 (5) the number of grievances filed by enrollees HB0626 Engrossed -28- LRB9100964JSpc 1 relating to waiting times for appointments, 2 appropriateness of referrals, and other indicators of a 3 managed care plan's capacity; 4 (6) hours of operation; 5 (7) the managed care plan's ability to provide 6 culturally and linguistically competent care to meet the 7 needs of its enrollee population; and 8 (8) the volume of technological and speciality 9 services available to serve the needs of enrollees 10 requiring technologically advanced or specialty care. 11 (c) A managed care plan shall report on an annual basis 12 the number of enrollees and the number of participating 13 professionals and providers in the managed care plan. 14 Section 55. Referral to specialists. 15 (a) All managed care plans that require each enrollee to 16 select a health care provider for any purpose including 17 coordination of care shall allow all enrollees to choose any 18 primary care physician licensed to practice medicine in all 19 its branches or any health care professional participating in 20 the managed care plan for that purpose. The managed care plan 21 shall provide the enrollee with a choice of licensed health 22 care professionals who are accessible and qualified. 23 (b) A managed care plan shall establish a procedure by 24 which an enrollee who has a condition that requires ongoing 25 care from a specialist physician or health care professional 26 may apply for a standing referral to a specialist physician 27 or health care professional if a referral to a specialist 28 physician or health care professional is required for 29 coverage. The application shall be made to the enrollee's 30 primary care physician. This procedure for a standing 31 referral must specify the necessary criteria and conditions 32 that must be met in order for an enrollee to obtain a 33 standing referral. A standing referral shall be effective for HB0626 Engrossed -29- LRB9100964JSpc 1 the period necessary to provide the referred services or one 2 year. A primary care physician may renew a standing referral. 3 (c) The enrollee may be required by the managed care 4 plan to select a specialist physician or health care 5 professional who has a referral arrangement with the 6 enrollee's primary care physician or to select a new primary 7 care physician who has a referral arrangement with the 8 specialist physician or health care professional chosen by 9 the enrollee. If a managed care plan requires an enrollee to 10 select a new physician under this subsection, the managed 11 care plan must provide the enrollee with both options 12 provided in this subsection. 13 (d) When the type of specialist physician or other 14 health care provider needed to provide ongoing care for a 15 specific condition does not have a referral arrangement with 16 the enrollee's primary care physician, the primary care 17 physician shall arrange for the enrollee to have access to a 18 qualified health care provider in the plan's provider network 19 who is within a reasonable distance and travel time. When the 20 type of specialist physician or health care professional 21 needed to provide ongoing care for a specific condition is 22 not represented in the managed care plan's network of 23 physicians or health care professionals, the primary care 24 physician shall arrange for the enrollee to have access to a 25 qualified non-participating physician or health care 26 professional within a reasonable distance and travel time at 27 no additional cost to the enrollee beyond what the enrollee 28 would otherwise pay for services received within the plan's 29 network. 30 (e) The enrollee's primary care physician shall remain 31 responsible for coordinating the care of an enrollee who has 32 received a standing referral to a specialist physician or 33 health care professional. If a secondary referral is 34 necessary, the specialist physician or health care HB0626 Engrossed -30- LRB9100964JSpc 1 professional shall advise the primary care physician. The 2 primary care physician shall be responsible for making the 3 secondary referral. In addition, the managed care plan shall 4 require the specialist physician or health care professional 5 to provide regular updates to the enrollee's primary care 6 physician. 7 (f) If an enrollee's application for any referral is 8 denied, an enrollee may appeal the decision through the 9 managed care plan's external independent review process in 10 accordance with Section 30 of this Act. 11 Section 60. Transition of services. 12 (a) A managed care plan shall provide for continuity of 13 care for its enrollees as follows: 14 (1) If an enrollee's physician leaves the managed 15 care plan's network of physicians or health care 16 professionals for reasons other than termination of a 17 contract in situations involving imminent harm to a 18 patient or a final disciplinary action by a State 19 licensing board and the physician remains within the 20 managed care plan's service area, the managed care plan 21 shall permit the enrollee to continue an ongoing course 22 of treatment with that physician during a transitional 23 period: 24 (A) of at least 90 days from the date of the 25 notice of physician's termination from the managed 26 care plan to the enrollee of the physician's 27 disaffiliation from the managed care plan if the 28 enrollee has an ongoing course of treatment; or 29 (B) if the enrollee has entered the second 30 trimester of pregnancy at the time of the 31 physician's disaffiliation, that includes the 32 provision of post-partum care directly related to 33 the delivery. HB0626 Engrossed -31- LRB9100964JSpc 1 (2) Notwithstanding the provisions in item (1) of 2 this subsection, such care shall be authorized by the 3 managed care plan during the transitional period only if 4 the physician agrees: 5 (A) to continue to accept reimbursement from 6 the managed care plan at the rates applicable prior 7 to the start of the transitional period; 8 (B) to adhere to the managed care plan's 9 quality assurance requirements and to provide to the 10 managed care plan necessary medical information 11 related to such care; and 12 (C) to otherwise adhere to the managed care 13 plan's policies and procedures, including but not 14 limited to procedures regarding referrals and 15 obtaining preauthorizations for treatment. 16 (b) A managed care plan shall provide for continuity of 17 care for new enrollees as follows: 18 (1) If a new enrollee whose physician is not a 19 member of the managed care plan's physician or 20 professional network, but is within the managed care 21 plan's service area, enrolls in the managed care plan, 22 the managed care plan shall permit the enrollee to 23 continue an ongoing course of treatment with the 24 enrollee's current physician during a transitional 25 period: 26 (A) of at least 90 days from the effective 27 date of enrollment if the enrollee has an ongoing 28 course of treatment; or 29 (B) if the enrollee has entered the second 30 trimester of pregnancy at the effective date of 31 enrollment, that includes the provision of 32 post-partum care directly related to the delivery. 33 (2) If an enrollee elects to continue to receive 34 care from such physician pursuant to item (1) of this HB0626 Engrossed -32- LRB9100964JSpc 1 subsection, such care shall be authorized by the managed 2 care plan for the transitional period only if the 3 physician agrees: 4 (A) to accept reimbursement from the managed 5 care plan at rates established by the managed care 6 plan; such rates shall be the level of reimbursement 7 applicable to similar physicians within the managed 8 care plan for such services; 9 (B) to adhere to the managed care plan's 10 quality assurance requirements and to provide to the 11 managed care plan necessary medical information 12 related to such care; and 13 (C) to otherwise adhere to the managed care 14 plan's policies and procedures including, but not 15 limited to procedures regarding referrals and 16 obtaining preauthorization for treatment. 17 (c) In no event shall this Section be construed to 18 require a managed care plan to provide coverage for benefits 19 not otherwise covered or to diminish or impair preexisting 20 condition limitations contained in the enrollee's contract. 21 Section 65. Duty to report. 22 (a) A managed care plan shall report to the appropriate 23 professional disciplinary agency, after compliance and in 24 accordance with the provisions of this Section: 25 (1) termination of a health care provider contract 26 for commission of an act or acts that may directly 27 threaten patient care, and not of an administrative 28 nature, or that a person may be mentally or physically 29 disabled in such a manner as to endanger a patient under 30 that person's care; 31 (2) voluntary or involuntary termination of a 32 contract or employment or other affiliation with the 33 managed care plan to avoid the imposition of disciplinary HB0626 Engrossed -33- LRB9100964JSpc 1 measures. 2 The managed care plan shall only make the report after it 3 has provided the health care professional with a hearing on 4 the matter. (This hearing shall not impair or limit the 5 managed care plan's ability to terminate the professional. 6 Its purpose is solely to ensure that a sufficient basis 7 exists for making the report.) The hearing shall be held 8 before a panel appointed by the managed care plan. The 9 hearing panel shall be composed of 5 persons appointed by the 10 plan, the majority of whom shall be clinical peer reviewers, 11 to the extent possible, in the same discipline and the same 12 specialty as the health care professional under review. The 13 hearing panel shall determine whether the proposed basis for 14 the report is supported by a preponderance of the evidence. 15 The panel shall render its determination within 14 days. If 16 a majority of the panel finds the proposed basis for the 17 report is supported by a preponderance of the evidence, the 18 managed care plan shall make the required report within 21 19 days. 20 Any hearing under this Section shall provide the health 21 care professional in question with the right to examine 22 pertinent information, to present witnesses, and to ask 23 questions of an authorized representative of the plan. 24 If a hearing has been held pursuant to subsection (f) of 25 Section 40 and the hearing panel sustained a plan's 26 termination of a health care professional, no additional 27 hearing is required, and the plan shall make the report 28 required under this Section. 29 (b) Reports made pursuant to this Section shall be made 30 in writing to the appropriate professional disciplinary 31 agency. Written reports shall include the name, address, 32 profession, and license number of the individual and a 33 description of the action taken by the managed care plan, 34 including the reason for the action and the date thereof, or HB0626 Engrossed -34- LRB9100964JSpc 1 the nature of the action or conduct that led to the 2 resignation, termination of contract, or withdrawal, and the 3 date thereof. 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 Section 70. Disclosure of information. 25 (a) A health care professional affiliated with a managed 26 care plan shall make available, upon request, in written form 27 at his or her office, to his or her patients or prospective 28 patients the following: 29 (1) information related to the health care 30 professional's educational background, experience, 31 training, specialty and board certification, if 32 applicable, number of years in practice, and hospitals 33 where he or she has privileges; HB0626 Engrossed -35- LRB9100964JSpc 1 (2) information regarding the health care 2 professional's participation in continuing education 3 programs and compliance with any licensure, 4 certification, or registration requirements, if 5 applicable; and 6 (3) the location of the health care professional's 7 primary practice setting and the identification of any 8 translation services available. 9 Section 75. Utilization review program registration. 10 (a) No person may conduct a utilization review program 11 in this State unless once every 2 years the person registers 12 the utilization review program with the Department and 13 certifies compliance with all of the Health Utilization 14 Management Standards of the American Accreditation Healthcare 15 Commission (URAC) or submits evidence of accreditation by the 16 American Accreditation Healthcare Commission (URAC) for its 17 Health Utilization Management Standards. 18 (b) The Director, in consultation with the Director of 19 Public Health, may certify alternative utilization review 20 standards of national accreditation organizations or entities 21 in order for plans to comply with this Section. Any 22 alternative utilization review standards shall meet or exceed 23 those standards required under subsection (a). In addition, 24 the Director, in consultation with the Director of Public 25 Health, may adopt additional utilization review requirements 26 by rule. 27 (c) The provisions of this Section do not apply to: 28 (1) persons providing utilization review program 29 services only to the federal government; 30 (2) self-insured managed care plans preempted from 31 State regulation under the federal Employee Retirement 32 Income Security Act of 1974, however, this Section does 33 apply to persons conducting a utilization review program HB0626 Engrossed -36- LRB9100964JSpc 1 on behalf of these managed care plans; and 2 (3) hospitals and medical groups performing 3 utilization review activities for internal purposes 4 unless the utilization review program is conducted for 5 another person. 6 Nothing in this Act prohibits a managed care plan or 7 other entity from contractually requiring an entity 8 designated in item (3) of this subsection to adhere to the 9 utilization review program requirements of this Act. 10 (d) This registration shall include submission of all of 11 the following information regarding utilization review 12 program activities: 13 (1) The name, address, and telephone of the 14 utilization review programs. 15 (2) The organization and governing structure of the 16 utilization review programs. 17 (3) The number of lives for which utilization 18 review is conducted by each utilization review program. 19 (4) Hours of operation of each utilization review 20 program. 21 (5) Description of the grievance process for each 22 utilization review program. 23 (6) Number of covered lives for which utilization 24 review was conducted for the previous calendar year for 25 each utilization review program. 26 (7) Written policies and procedures for protecting 27 confidential information according to applicable State 28 and federal laws for each utilization review program. 29 (e) The Department shall investigate utilization review 30 program compliance with the requirements of this Section. If 31 the Department finds that a utilization review program is not 32 in compliance with this Section, the Department shall issue a 33 corrective action plan and allow a reasonable amount of time 34 for compliance with the plan. If the utilization review HB0626 Engrossed -37- LRB9100964JSpc 1 program does not come into compliance, the Department may 2 issue a cease and desist order. Before issuing a cease and 3 desist order under this Section, the Department shall provide 4 the utilization review program with a written notice of the 5 reasons for the order and allow a reasonable amount of time 6 to supply additional information demonstrating compliance 7 with requirements of this Section and to request a hearing. 8 The hearing notice shall be sent by certified mail, return 9 receipt requested, and the hearing shall be conducted in 10 accordance with the Illinois Administrative Procedure Act. 11 (f) A utilization review program subject to a corrective 12 action may continue to conduct business until a final 13 decision has been issued by the Department. 14 Section 80. Appeal of adverse determinations by 15 utilization review programs. 16 (a) An enrollee, the enrollee's designee, and, in 17 connection with retrospective adverse determinations, the 18 enrollee's health care provider may appeal an adverse 19 determination rendered by a utilization review program 20 pursuant to Sections 15, 20, and 30. 21 (b) A utilization review program shall establish 22 mechanisms that facilitate resolution of the appeal 23 including, but not limited to, the sharing of information 24 from the enrollee's health care provider and the utilization 25 review program by telephonic means or by facsimile. The 26 utilization review program shall provide reasonable access to 27 its clinical peer reviewer in a prompt manner. 28 (c) Appeals shall be reviewed by a clinical peer 29 reviewer other than the clinical peer reviewer who rendered 30 the adverse determination. 31 Section 85. Required and prohibited practices. 32 (a) A utilization review program shall have written HB0626 Engrossed -38- LRB9100964JSpc 1 procedures for assuring that patient-specific information 2 obtained during the process of utilization review will be: 3 (1) kept confidential in accordance with applicable 4 State and federal laws; and 5 (2) shared only with the enrollee, the enrollee's 6 designee, the enrollee's health care provider, and those 7 who are authorized by law to receive the information. 8 (b) Summary data shall not be considered confidential 9 if it does not provide information to allow identification of 10 individual patients. 11 (c) Any health care professional who makes 12 determinations regarding the medical necessity of health care 13 services during the course of utilization review shall be 14 appropriately licensed or registered. 15 (d) A utilization review program shall not, with respect 16 to utilization review activities, permit or provide 17 compensation or anything of value to its employees, agents, 18 or contractors based on: 19 (1) either a percentage of the amount by which a 20 claim is reduced for payment or the number of claims or 21 the cost of services for which the person has denied 22 authorization or payment; or 23 (2) any other method that encourages the rendering 24 of an adverse determination. 25 (e) If a health care service has been specifically 26 pre-authorized or approved for an enrollee by a utilization 27 review program, a utilization review program shall not, 28 pursuant to retrospective review, revise or modify the 29 specific standards, criteria, or procedures used for the 30 utilization review for procedures, treatment, and services 31 delivered to the enrollee during the same course of 32 treatment. 33 (f) Utilization review shall not be conducted more 34 frequently than is reasonably required to assess whether the HB0626 Engrossed -39- LRB9100964JSpc 1 health care services under review are medically necessary. 2 The Department may promulgate rules governing the frequency 3 of utilization reviews for managed care plans of differing 4 size and geographic location. 5 (g) When making prospective, concurrent, and 6 retrospective determinations, utilization review programs 7 shall collect only information that is necessary to make the 8 determination and shall not routinely require health care 9 providers to numerically code diagnoses or procedures to be 10 considered for certification, unless required under State or 11 federal Medicare or Medicaid rules or regulations, or 12 routinely request copies of medical records of all patients 13 reviewed. During prospective or concurrent review, copies of 14 medical records shall only be required when necessary to 15 verify that the health care services subject to the review 16 are medically necessary. In these cases, only the necessary 17 or relevant sections of the medical record shall be required. 18 A utilization review program may request copies of partial or 19 complete medical records retrospectively. 20 (h) In no event shall information be obtained from 21 health care providers for the use of the utilization review 22 program by persons other than health care professionals, 23 medical record technologists, or administrative personnel who 24 have received appropriate training. 25 (i) The utilization review program shall not undertake 26 utilization review at the site of the provision of health 27 care services unless the utilization review program staff 28 person: 29 (1) identifies himself or herself by name and the 30 name of his or her organization, including displaying 31 photographic identification that includes the name of the 32 utilization review program and staff person and clearly 33 identifies the individual as representative of the 34 utilization review program; HB0626 Engrossed -40- LRB9100964JSpc 1 (2) whenever possible, schedules review at least 2 one business day in advance with the appropriate health 3 care provider; 4 (3) if requested by a health care provider, assures 5 that the on-site review staff register with the 6 appropriate contact person, if available, prior to 7 requesting any clinical information or assistance from 8 the health care provider; and 9 (4) obtains consent from the enrollee or the 10 enrollee's designee before interviewing the patient's 11 family or observing any health care service being 12 provided to the enrollee. 13 This subsection does not apply to health care 14 professionals engaged in providing care, case management, or 15 making on-site discharge decisions. 16 (j) A utilization review program shall not base an 17 adverse determination on a refusal to consent to observing 18 any health care service. 19 (k) A utilization review program shall not base an 20 adverse determination on lack of reasonable access to a 21 health care provider's medical or treatment records unless 22 the utilization review program has provided reasonable notice 23 to both the enrollee or the enrollee's designee and the 24 enrollee's health care provider and has complied with all 25 provisions of subsection (i) of this Section. The Department 26 may promulgate rules defining reasonable notice and the time 27 period within which medical and treatment records must be 28 turned over. 29 (l) Neither the utilization review program nor the 30 entity for which the program provides utilization review 31 shall take any action with respect to a patient or a health 32 care provider that is intended to penalize the enrollee, the 33 enrollee's designee, or the enrollee's health care provider 34 for, or to discourage the enrollee, the enrollee's designee, HB0626 Engrossed -41- LRB9100964JSpc 1 or the enrollee's health care provider from, undertaking an 2 appeal, dispute resolution, or judicial review of an adverse 3 determination. 4 (m) In no event shall an enrollee, an enrollee's 5 designee, an enrollee's health care provider, any other 6 health care provider, or any other person or entity be 7 required to inform or contact the utilization review program 8 prior to the provision of emergency services as defined in 9 this Act. 10 (n) A health care professional providing health care 11 services to an enrollee shall be prohibited from serving as 12 the clinical peer reviewer for that enrollee in connection 13 with the health care services being provided to the enrollee. 14 Section 90. Annual consumer satisfaction survey. The 15 Director shall develop and administer a survey of persons who 16 have been enrolled in a managed care plan in the most recent 17 calendar year to collect information on relative plan 18 performance including, but not limited to, arrangement for 19 delivery of care. This survey shall: 20 (1) be administered annually by the Director, or by 21 an independent agency or organization selected by the 22 Director; 23 (2) be administered to a scientifically selected 24 representative sample of current enrollees from each 25 plan, as well as persons who have disenrolled from a plan 26 in the last calendar year; and 27 (3) emphasize the collection of information from 28 persons who have used the managed care plan to a 29 significant degree, as defined by rule. 30 Selected data from the annual survey shall be made 31 available to current and prospective enrollees as part of a 32 consumer guidebook or managed care report card of health plan 33 performance, which the Department shall develop and publish. HB0626 Engrossed -42- LRB9100964JSpc 1 The elements to be included in the guidebook shall be 2 reassessed on an ongoing basis by the Department. The 3 consumer guidebook shall be updated at least annually. 4 Section 95. Managed care patient rights. In addition to 5 all other requirements of this Act, a managed care plan shall 6 ensure that an enrollee has the following rights: 7 (1) A patient has the right to care consistent with 8 professional standards of practice to assure quality nursing 9 and medical practices, to choose the participating physician 10 responsible for coordinating his or her care, to receive 11 information concerning his or her condition and proposed 12 treatment, to refuse any treatment to the extent permitted by 13 law, and to privacy and confidentiality of records except as 14 otherwise provided by law. 15 (2) A patient has the right, regardless of source of 16 payment, to examine and to receive a reasonable explanation 17 of his or her total bill for health care services rendered by 18 his or her physician or other health care provider, including 19 the itemized charges for specific health care services 20 received. A physician or other health care provider shall be 21 responsible only for a reasonable explanation of these 22 specific health care services provided by the health care 23 provider. 24 (3) A patient has the right to privacy and 25 confidentiality in health care. This right may be expressly 26 waived in writing by the patient or the patient's guardian. 27 Section 100. Health care entity liability. 28 (a) In this Section: 29 "Appropriate and medically necessary" means the standard 30 for health care services as determined by physicians and 31 health care providers in accordance with the prevailing 32 practices and standards of the medical profession and HB0626 Engrossed -43- LRB9100964JSpc 1 community. 2 "Enrollee" means an individual who is enrolled in a 3 health care plan, including covered dependents. 4 "Health care plan" means any plan whereby any person 5 undertakes to provide, arrange for, pay for, or reimburse any 6 part of the cost of any health care services. 7 "Health care provider" means a person or entity as 8 defined in Section 2-1003 of the Code of Civil Procedure. 9 "Health care treatment decision" means a determination 10 made when medical services are actually provided by the 11 health care plan and a decision that affects the quality of 12 the diagnosis, care, or treatment provided to the plan's 13 insureds or enrollees. 14 "Health insurance carrier" means an authorized insurance 15 company that issues policies of accident and health insurance 16 under the Illinois Insurance Code. 17 "Health maintenance organization" means an organization 18 licensed under the Health Maintenance Organization Act. 19 "Managed care entity" means any entity that delivers, 20 administers, or assumes risk for health care services with 21 systems or techniques to control or influence the quality, 22 accessibility, utilization, or costs and prices of those 23 services to a defined enrollee population, but does not 24 include an employer purchasing coverage or acting on behalf 25 of its employees or the employees of one or more subsidiaries 26 or affiliated corporations of the employer. 27 "Physician" means: (1) an individual licensed to practice 28 medicine in this State; (2) a professional association, 29 professional service corporation, partnership, medical 30 corporation, or limited liability company, entitled to 31 lawfully engage in the practice of medicine; or (3) another 32 person wholly owned by physicians. 33 "Ordinary care" means, in the case of a health insurance 34 carrier, health maintenance organization, or managed care HB0626 Engrossed -44- LRB9100964JSpc 1 entity, that degree of care that a health insurance carrier, 2 health maintenance organization, or managed care entity of 3 ordinary prudence would use under the same or similar 4 circumstances. In the case of a person who is an employee, 5 agent, ostensible agent, or representative of a health 6 insurance carrier, health maintenance organization, or 7 managed care entity, "ordinary care" means that degree of 8 care that a person of ordinary prudence in the same 9 profession, specialty, or area of practice as such person 10 would use in the same or similar circumstances. 11 (b) A health insurance carrier, health maintenance 12 organization, or other managed care entity for a health care 13 plan has the duty to exercise ordinary care when making 14 health care treatment decisions and is liable for damages for 15 harm to an insured or enrollee proximately caused by its 16 failure to exercise such ordinary care. 17 (c) A health insurance carrier, health maintenance 18 organization, or other managed care entity for a health care 19 plan is also liable for damages for harm to an insured or 20 enrollee proximately caused by the health care treatment 21 decisions made by its: 22 (1) employees; 23 (2) agents; 24 (3) ostensible agents; or 25 (4) representatives who are acting on its behalf 26 and over whom it has the right to exercise influence or 27 control or has actually exercised influence or control 28 that results in the failure to exercise ordinary care. 29 (d) The standards in subsections (b) and (c) create no 30 obligation on the part of the health insurance carrier, 31 health maintenance organization, or other managed care entity 32 to provide to an insured or enrollee treatment that is not 33 covered by the health care plan of the entity. 34 (e) A health insurance carrier, health maintenance HB0626 Engrossed -45- LRB9100964JSpc 1 organization, or managed care entity may not remove a 2 physician or health care provider from its plan or refuse to 3 renew the physician or health care provider with its plan for 4 advocating on behalf of an enrollee for appropriate and 5 medically necessary health care for the enrollee. 6 (f) A health insurance carrier, health maintenance 7 organization, or other managed care entity may not enter into 8 a contract with a physician, hospital, or other health care 9 provider or pharmaceutical company which includes an 10 indemnification or hold harmless clause for the acts or 11 conduct of the health insurance carrier, health maintenance 12 organization, or other managed care entity. Any such 13 indemnification or hold harmless clause in an existing 14 contract is hereby declared void. 15 (g) Nothing in any law of this State prohibiting a 16 health insurance carrier, health maintenance organization, or 17 other managed care entity from practicing medicine or being 18 licensed to practice medicine may be asserted as a defense by 19 the health insurance carrier, health maintenance 20 organization, or other managed care entity in an action 21 brought against it pursuant to this Section or any other law. 22 (h) In an action against a health insurance carrier, 23 health maintenance organization, or managed care entity, a 24 finding that a physician or other health care provider is an 25 employee, agent, ostensible agent, or representative of the 26 health insurance carrier, health maintenance organization, or 27 managed care entity shall not be based solely on proof that 28 the person's name appears in a listing of approved physicians 29 or health care providers made available to insureds or 30 enrollees under a health care plan. 31 (i) This Section does not apply to workers' compensation 32 insurance coverage subject to the Workers' Compensation Act. 33 (j) This Section does not apply to actions seeking only 34 a review of an adverse utilization review determination. HB0626 Engrossed -46- LRB9100964JSpc 1 This Section applies only to causes of action that accrue on 2 or after the effective date of this Act. An insured or 3 enrollee seeking damages under this Section has the right and 4 duty to submit the claim to arbitration in accordance with 5 the Uniform Arbitration Act. No agreement between the 6 parties to submit the claim to arbitration is necessary. A 7 health insurance carrier, health maintenance organization, or 8 managed care entity shall have no liability under this 9 Section unless the claim is first submitted to arbitration in 10 accordance with the Uniform Arbitration Act. The award in 11 matters arbitrated pursuant to this Section shall be made 12 within 30 days after notification of the arbitration is 13 provided to all parties. 14 (k) The determination of whether a procedure or 15 treatment is medically necessary must be made by a physician. 16 (l) If the physician determines that a procedure or 17 treatment is medically necessary, the health care plan must 18 pay for the procedure or treatment. 19 (m) This Section does not apply to licensed insurance 20 agents. 21 Section 105. Waiver. Any agreement that purports to 22 waive, limit, disclaim or in any way diminish the rights set 23 forth in this Act is void as contrary to public policy. 24 Section 110. Administration of Act. 25 (a) The Department shall administer this Act. 26 (b) All managed care plans and utilization review 27 programs providing or reviewing services in Illinois shall 28 annually certify compliance with this Act and rules adopted 29 under this Act to the Department in addition to any other 30 licensure required by law. The Director shall establish by 31 rule a process for this certification including fees to cover 32 the costs associated with implementing this Act. All fees HB0626 Engrossed -47- LRB9100964JSpc 1 and fines assessed under this Act shall be deposited in the 2 Managed Care Reform Fund, a special fund hereby created in 3 the State treasury. Moneys in the Fund shall be used by the 4 Department only to enforce and administer this Act. The 5 certification requirements of this Act shall be incorporated 6 into program requirements of the Department of Public Aid and 7 Department of Human Services and no further certification 8 under this Act is required. 9 (c) The Director shall take enforcement action under 10 this Act including, but not limited to, the assessment of 11 civil fines and injunctive relief for any failure to comply 12 with this Act or any violation of the Act or rules by a 13 managed care plan or any utilization review program. 14 (d) The Department shall have the authority to impose 15 fines on any managed care plan or any utilization review 16 program. The Department shall adopt rules pursuant to this 17 Act that establish a system of fines related to the type and 18 level of violation or repeat violation, including but not 19 limited to: 20 (1) A fine not exceeding $10,000 for a violation 21 that created a condition or occurrence presenting a 22 substantial probability that death or serious harm to an 23 individual will or did result therefrom; and 24 (2) A fine not exceeding $5,000 for a violation 25 that creates or created a condition or occurrence that 26 threatens the health, safety, or welfare of an 27 individual. 28 Each day a violation continues shall constitute a 29 separate offense. These rules shall include an opportunity 30 for a hearing in accordance with the Illinois Administrative 31 Procedure Act. All final decisions of the Department shall 32 be reviewable under the Administrative Review Law. 33 (e) Notwithstanding the existence or pursuit of any 34 other remedy, the Director may, through the Attorney General, HB0626 Engrossed -48- LRB9100964JSpc 1 seek an injunction to restrain or prevent any person or 2 entity from functioning or operating in violation of this Act 3 or rule. 4 Section 115. Emergency services prior to stabilization. 5 (a) A managed care plan subject to this Act that 6 provides or that is required by law to provide coverage for 7 emergency services shall provide coverage such that payment 8 under this coverage is not dependent upon whether the 9 services are performed by a plan or non-plan physician or 10 health care provider and without regard to prior 11 authorization. This coverage shall be at the same benefit 12 level as if the services or treatment had been rendered by 13 the managed care plan physician or health care provider. 14 (b) Prior authorization or approval by the plan shall 15 not be required for emergency services. 16 (c) Coverage and payment shall not be retrospectively 17 denied, with the following exceptions: 18 (1) upon reasonable determination that the 19 emergency services claimed were never performed; 20 (2) upon reasonable determination that the 21 emergency evaluation and treatment were rendered to an 22 enrollee who sought emergency services and whose 23 circumstance did not meet the definition of emergency 24 medical condition; 25 (3) upon determination that the patient receiving 26 such services was not an enrollee of the health insurance 27 plan; or 28 (4) upon material misrepresentation by the enrollee 29 or health care provider; "material" means a fact or 30 situation that is not merely technical in nature and 31 results or could result in a substantial change in the 32 situation. 33 (d) When an enrollee presents to a hospital seeking HB0626 Engrossed -49- LRB9100964JSpc 1 emergency services, the determination as to whether the need 2 for those services exists shall be made for purposes of 3 treatment by a physician licensed to practice medicine in all 4 its branches or, to the extent permitted by applicable law, 5 by other appropriately licensed personnel under the 6 supervision of or in collaboration with a physician licensed 7 to practice medicine in all its branches. The physician or 8 other appropriate personnel shall indicate in the patient's 9 chart the results of the emergency medical screening 10 examination. The managed care plan shall compensate the 11 health care professional or provider for the emergency 12 medical screening examination. 13 (e) The appropriate use of the 911 emergency telephone 14 system or its local equivalent shall not be discouraged or 15 penalized by the health insurance plan when an emergency 16 medical condition exists. This provision shall not imply that 17 the use of 911 or its local equivalent is a factor in 18 determining the existence of an emergency medical condition. 19 (f) Nothing in this Section alters the prohibition on 20 billing enrollees contained in the Health Maintenance 21 Organization Act. Nothing in this Section shall prohibit the 22 imposition of deductibles, co-payments, and co-insurance. 23 Section 120. Post-stabilization medical services. 24 (a) If prior authorization for covered post-stabilization 25 services is required by the managed care plan, the plan shall 26 provide access 24 hours a day, 7 days a week to persons 27 designated by the plan to make such determinations. 28 (b) The treating physician or health care provider shall 29 contact the managed care plan or delegated physician or 30 health care provider as designated on the enrollee's health 31 insurance card to obtain authorization, denial, or 32 arrangements for an alternate plan of treatment or transfer 33 of the enrollee. HB0626 Engrossed -50- LRB9100964JSpc 1 (c) The treating physician licensed to practice medicine 2 in all its branches or health care provider shall document in 3 the enrollee's medical record the enrollee's presenting 4 symptoms; emergency medical condition; and time, phone number 5 dialed, and result of the communication for request for 6 authorization of post stabilization medical services. The 7 managed care plan shall provide reimbursement for covered 8 post-stabilization medical services if: 9 (1) authorization to render them is received from 10 the managed care plan or its delegated physician or 11 health care provider; or 12 (2) after 2 documented good faith efforts, the 13 treating physician or health care provider has attempted 14 to contact the enrollee's managed care plan or its 15 delegated physician or health care provider, as 16 designated on the enrollee's health insurance card, for 17 prior authorization of post-stabilization medical 18 services and neither the plan nor designated persons were 19 accessible or the authorization was not denied within 60 20 minutes of the request. "Two documented good faith 21 efforts" means the physician or health care provider has 22 called the telephone number on the enrollee's health 23 insurance card or other available number either 2 times 24 or one time and made an additional call to any referral 25 number provided. "Good faith" means honesty of purpose, 26 freedom from intention to defraud, and being faithful to 27 one's duty or obligation. For the purpose of this Act, 28 good faith shall be presumed. 29 (d) After rendering any post-stabilization medical 30 services, the treating physician or health care provider 31 shall continue to make every reasonable effort to contact the 32 managed care plan or its delegated physician or health care 33 provider regarding authorization, denial, or arrangements for 34 an alternate plan of treatment or transfer of the enrollee HB0626 Engrossed -51- LRB9100964JSpc 1 until the treating physician or health care provider receives 2 instructions from the managed care plan or delegated 3 physician or health care provider for continued care or the 4 care is transferred to another physician or health care 5 provider or the patient is discharged. 6 (e) Payment for covered post-stabilization services may 7 be denied: 8 (1) if the treating physician or health care 9 provider does not meet the conditions outlined in 10 subsection (c); 11 (2) upon determination that the post-stabilization 12 services claimed were not performed; 13 (3) upon determination that the post-stabilization 14 services rendered were contrary to the instructions of 15 the managed care plan or its delegated physician or 16 health care provider if contact was made between those 17 parties prior to the service being rendered; 18 (4) upon determination that the patient receiving 19 such services was not an enrollee of the managed care 20 plan; or 21 (5) upon material misrepresentation by the enrollee 22 or health care provider; "material" means a fact or 23 situation that is not merely technical in nature and 24 results or could result in a substantial change in the 25 situation. 26 (f) Coverage and payment for post-stabilization medical 27 services for which prior authorization or deemed approval is 28 received shall not be retrospectively denied. 29 (g) Nothing in this Section prohibits a managed care 30 plan from delegating tasks associated with the 31 responsibilities enumerated in this Section to the managed 32 care plan's contracted health care providers or another 33 entity. However, the ultimate responsibility for coverage 34 and payment decisions may not be delegated. HB0626 Engrossed -52- LRB9100964JSpc 1 (h) Nothing in this Section shall prohibit the 2 imposition of deductibles, co-payments, and co-insurance. 3 Section 125. Prescription drugs. A managed care plan 4 that provides coverage for prescribed drugs approved by the 5 federal Food and Drug Administration shall not exclude 6 coverage of any drug on the basis that the drug has been 7 prescribed for the treatment of a particular indication for 8 which the drug has not been approved by the federal Food and 9 Drug Administration. The drug, however, must be approved by 10 the federal Food and Drug Administration and must be 11 recognized for the treatment of that particular indication 12 for which the drug has been prescribed in any one of the 13 following established reference compendia: 14 (1) the American Hospital Formulary Service Drug 15 Information; 16 (2) the United States Pharmacopoeia Drug 17 Information; or 18 (3) if not recognized by the authorities in item 19 (1) or (2), recommended for that particular indication in 20 formal clinical studies, the results of which have been 21 published in at least 2 peer reviewed professional 22 medical journals published in the United States or Great 23 Britain. 24 Any coverage required by this Section shall also include 25 those medically necessary services associated with the 26 administration of a drug. 27 Despite the provisions of this Section, coverage shall 28 not be required for any experimental or investigational drugs 29 or any drug that the federal Food and Drug Administration has 30 determined to be contraindicated for treatment of the 31 specific indication for which the drug has been prescribed. 32 Nothing in this Section shall be construed, expressly or by 33 implication, to create, impair, alter, limit, notify, HB0626 Engrossed -53- LRB9100964JSpc 1 enlarge, abrogate, or prohibit reimbursement for drugs used 2 in the treatment of any other disease or condition. 3 Section 130. Applicability and scope. This Act applies 4 to policies and contracts amended, delivered, issued, or 5 renewed on or after the effective date of this Act. This Act 6 does not diminish a managed care plan's duties and 7 responsibilities under other federal or State law or rules 8 promulgated thereunder. 9 Section 135. Effect on benefits under Workers' 10 Compensation Act and Workers' Occupational Diseases Act. 11 Nothing in this Act shall be construed to expand, modify, or 12 restrict the health care benefits provided to employees under 13 the Workers' Compensation Act and Workers' Occupational 14 Diseases Act. 15 Section 140. Conflicts with federal law. When health 16 care services are provided by a managed care plan subject to 17 this Act to a person who is a recipient of medical assistance 18 under Article V of the Illinois Public Aid Code, the rights, 19 benefits, requirements, and procedures available or 20 authorized under this Act shall not apply to the extent that 21 there are provisions of federal law that conflict. In the 22 event of a conflict, federal law shall prevail. 23 Section 145. Severability. The provisions of this Act 24 are severable under Section 1.31 of the Statute on Statutes. 25 Section 150. The State Employees Group Insurance Act of 26 1971 is amended by adding Section 6.12 as follows: 27 (5 ILCS 375/6.12 new) 28 Sec. 6.12. Managed Care Reform Act. The program of HB0626 Engrossed -54- LRB9100964JSpc 1 health benefits is subject to the provisions of the Managed 2 Care Reform Act. 3 Section 155. The Civil Administrative Code of Illinois 4 is amended by adding Sections 56.3 and 56.4 as follows: 5 (20 ILCS 1405/56.3 new) 6 Sec. 56.3. Office of Consumer Health Insurance. 7 (a) The Director of Insurance shall establish the Office 8 of Consumer Health Insurance within the Department of 9 Insurance to provide assistance, advocacy, and information to 10 all health care consumers within the State. The staff 11 responsible shall have direct line reporting responsibility 12 to the Director. Within the appropriation allocated, the 13 office shall provide information and assistance to all health 14 care consumers by: 15 (1) assisting consumers in understanding health 16 insurance marketing materials and the coverage provisions 17 of individual plans including, but not limited to, 18 advocacy for consumers before plans and governmental and 19 nongovernmental agencies; 20 (2) educating enrollees about their rights within 21 individual plans; 22 (3) assisting enrollees in filing formal grievances 23 and appeals; 24 (4) investigating enrollee complaints; 25 (5) establishing and operating an 800 telephone 26 line to handle consumer inquiries; 27 (6) making information available in languages other 28 than English that are spoken as a primary language by a 29 significant portion of the State's population, as 30 determined by the Department; 31 (7) analyzing, commenting on, monitoring, and 32 making publicly available reports on the development and HB0626 Engrossed -55- LRB9100964JSpc 1 implementation of federal, State and local laws, 2 regulations, and other governmental policies and actions 3 that pertain to the adequacy of managed care plans, 4 facilities, and services in the State; 5 (8) filing an annual report with the Director and 6 the General Assembly, which shall include recommendations 7 for improvement to the regulation of health insurance 8 plans; and 9 (9) performing all duties assigned to the Office by 10 the Director. 11 (b) Beginning March 1, 2000, the Office shall report, on 12 at least a quarterly basis, any patterns identified from the 13 consumer complaints addressed by the Office to the Director 14 and the Governor. By January 1, 2001, and each January 1 15 thereafter, the Director shall make an annual written report 16 to the General Assembly regarding activities of the Office, 17 including recommendations on improving health care consumer 18 assistance and complaint resolution processes. 19 (c) Nothing in this Section shall be interpreted to 20 authorize access to or disclosure of individual patient or 21 health professional or provider records. 22 (20 ILCS 1405/56.4 new) 23 Sec. 56.4. Retaliation. A managed care plan or health 24 care provider may not retaliate or take adverse action 25 against an enrollee or patient who, in good faith, makes a 26 complaint against a managed care plan, health plan company, 27 or health care provider. 28 Section 160. The State Finance Act is amended by adding 29 Section 5.490 as follows: 30 (30 ILCS 105/5.490 new) 31 Sec. 5.490. The Managed Care Reform Fund. HB0626 Engrossed -56- LRB9100964JSpc 1 Section 165. The State Mandates Act is amended by adding 2 Section 8.23 as follows: 3 (30 ILCS 805/8.23 new) 4 Sec. 8.23. Exempt mandate. Notwithstanding Sections 6 5 and 8 of this Act, no reimbursement by the State is required 6 for the implementation of any mandate created by this 7 amendatory Act of 1999. 8 Section 170. The Counties Code is amended by adding 9 Section 5-1069.8 as follows: 10 (55 ILCS 5/5-1069.8 new) 11 Sec. 5-1069.8. Managed Care Reform Act. All counties, 12 including home rule counties, are subject to the provisions 13 of the Managed Care Reform Act. The requirement under this 14 Section that health care benefits provided by counties comply 15 with the Managed Care Reform Act is an exclusive power and 16 function of the State and is a denial and limitation of home 17 rule county powers under Article VII, Section 6, subsection 18 (h) of the Illinois Constitution. 19 Section 175. The Illinois Municipal Code is amended by 20 adding Section 10-4-2.8 as follows: 21 (65 ILCS 5/10-4-2.8 new) 22 Sec. 10-4-2.8. Managed Care Reform Act. The corporate 23 authorities of all municipalities are subject to the 24 provisions of the Managed Care Reform Act. The requirement 25 under this Section that health care benefits provided by 26 municipalities comply with the Managed Care Reform Act is an 27 exclusive power and function of the State and is a denial and 28 limitation of home rule municipality powers under Article 29 VII, Section 6, subsection (h) of the Illinois Constitution. HB0626 Engrossed -57- LRB9100964JSpc 1 Section 180. The School Code is amended by adding 2 Section 10-22.3g as follows: 3 (105 ILCS 5/10-22.3g new) 4 Sec. 10-22.3g. Managed Care Reform Act. Insurance 5 protection and benefits for employees are subject to the 6 Managed Care Reform Act. 7 Section 185. The Illinois Insurance Code is amended by 8 changing Section 370g and adding Sections 155.36, 370s, and 9 511.118 as follows: 10 (215 ILCS 5/155.36 new) 11 Sec. 155.36. Managed Care Reform Act. Insurance 12 companies that transact the kinds of insurance authorized 13 under Class 1(b) or Class 2(a) of Section 4 of this Code 14 shall comply with Sections 25 and 75 and the definition of 15 the term "emergency medical condition" in Section 5 of the 16 Managed Care Reform Act. 17 (215 ILCS 5/370g) (from Ch. 73, par. 982g) 18 Sec. 370g. Definitions. As used in this Article, the 19 following definitions apply: 20 (a) "Health care services" means health care services or 21 products rendered or sold by a provider within the scope of 22 the provider's license or legal authorization. The term 23 includes, but is not limited to, hospital, medical, surgical, 24 dental, vision and pharmaceutical services or products. 25 (b) "Insurer" means an insurance company or a health 26 service corporation authorized in this State to issue 27 policies or subscriber contracts which reimburse for expenses 28 of health care services. 29 (c) "Insured" means an individual entitled to 30 reimbursement for expenses of health care services under a HB0626 Engrossed -58- LRB9100964JSpc 1 policy or subscriber contract issued or administered by an 2 insurer. 3 (d) "Provider" means an individual or entity duly 4 licensed or legally authorized to provide health care 5 services. 6 (e) "Noninstitutional provider" means any person 7 licensed under the Medical Practice Act of 1987, as now or 8 hereafter amended. 9 (f) "Beneficiary" means an individual entitled to 10 reimbursement for expenses of or the discount of provider 11 fees for health care services under a program where the 12 beneficiary has an incentive to utilize the services of a 13 provider which has entered into an agreement or arrangement 14 with an administrator. 15 (g) "Administrator" means any person, partnership or 16 corporation, other than an insurer or health maintenance 17 organization holding a certificate of authority under the 18 "Health Maintenance Organization Act", as now or hereafter 19 amended, that arranges, contracts with, or administers 20 contracts with a provider whereby beneficiaries are provided 21 an incentive to use the services of such provider. 22 (h) "Emergency medical condition" means a medical 23 condition manifesting itself by acute symptoms of sufficient 24 severity (including but not limited to severe pain) such that 25 a prudent layperson, who possesses an average knowledge of 26 health and medicine, could reasonably expect the absence of 27 immediate medical attention to result in: 28 (1) placing the health of the individual (or, with 29 respect to a pregnant woman, the health of the woman or 30 her unborn child) in serious jeopardy; 31 (2) serious impairment to bodily functions; or 32 (3) serious dysfunction of any bodily organ or 33 part."Emergency" means an accidental bodily injury or34emergency medical condition which reasonably requires theHB0626 Engrossed -59- LRB9100964JSpc 1beneficiary or insured to seek immediate medical care2under circumstances or at locations which reasonably3preclude the beneficiary or insured from obtaining needed4medical care from a preferred provider.5 (Source: P.A. 88-400.) 6 (215 ILCS 5/370s new) 7 Sec. 370s. Managed Care Reform Act. All administrators 8 shall comply with Sections 25 and 75 of the Managed Care 9 Reform Act. 10 (215 ILCS 5/511.118 new) 11 Sec. 511.118. Managed Care Reform Act. All 12 administrators are subject to the provisions of Sections 25 13 and 75 of the Managed Care Reform Act. 14 Section 190. The Comprehensive Health Insurance Plan Act 15 is amended by adding Section 8.6 as follows: 16 (215 ILCS 105/8.6 new) 17 Sec. 8.6. Managed Care Reform Act. The plan is subject 18 to the provisions of the Managed Care Reform Act. 19 Section 195. The Health Care Purchasing Group Act is 20 amended by changing Sections 15 and 20 as follows: 21 (215 ILCS 123/15) 22 Sec. 15. Health care purchasing groups; membership; 23 formation. 24 (a) An HPG may be an organization formed by 2 or more 25 employers with no more than 500 covered employees each2,50026covered individuals, an HPG sponsor or a risk-bearer for 27 purposes of contracting for health insurance under this Act 28 to cover employees and dependents of HPG members. An HPG HB0626 Engrossed -60- LRB9100964JSpc 1 shall not be prevented from supplementing health insurance 2 coverage purchased under this Act by contracting for services 3 from entities licensed and authorized in Illinois to provide 4 those services under the Dental Service Plan Act, the Limited 5 Health Service Organization Act, or Voluntary Health Services 6 Plans Act. An HPG may be a separate legal entity or simply a 7 group of 2 or more employers with no more than 500 covered 8 employees each2,500 covered individualsaggregated under 9 this Act by an HPG sponsor or risk-bearer for insurance 10 purposes. There shall be no limit as to the number of HPGs 11 that may operate in any geographic area of the State. No 12 insurance risk may be borne or retained by the HPG. All 13 health insurance contracts issued to the HPG must be 14 delivered or issued for delivery in Illinois. 15 (b) Members of an HPG must be Illinois domiciled 16 employers, except that an employer domiciled elsewhere may 17 become a member of an Illinois HPG for the sole purpose of 18 insuring its employees whose place of employment is located 19 within this State. HPG membership may include employers 20 having no more than 500 covered employees each2,500 covered21individuals. 22 (c) If an HPG is formed by any 2 or more employers with 23 no more than 500 covered employees each2,500 covered24individuals, it is authorized to negotiate, solicit, market, 25 obtain proposals for, and enter into group or master health 26 insurance contracts on behalf of its members and their 27 employees and employee dependents so long as it meets all of 28 the following requirements: 29 (1) The HPG must be an organization having the 30 legal capacity to contract and having its legal situs in 31 Illinois. 32 (2) The principal persons responsible for the 33 conduct of the HPG must perform their HPG related 34 functions in Illinois. HB0626 Engrossed -61- LRB9100964JSpc 1 (3) No HPG may collect premium in its name or hold 2 or manage premium or claim fund accounts unless duly 3 licensed and qualified as a managing general agent 4 pursuant to Section 141a of the Illinois Insurance Code 5 or a third party administrator pursuant to Section 6 511.105 of the Illinois Insurance Code. 7 (4) If the HPG gives an offer, application, notice, 8 or proposal of insurance to an employer, it must disclose 9 to that employer the total cost of the insurance. Dues, 10 fees, or charges to be paid to the HPG, HPG sponsor, or 11 any other entity as a condition to purchasing the 12 insurance must be itemized. The HPG shall also disclose 13 to its members the amount of any dividends, experience 14 refunds, or other such payments it receives from the 15 risk-bearer. 16 (5) An HPG must register with the Director before 17 entering into a group or master health insurance contract 18 on behalf of its members and must renew the registration 19 annually on forms and at times prescribed by the Director 20 in rules specifying, at minimum, (i) the identity of the 21 officers and directors, trustees, or attorney-in-fact of 22 the HPG; (ii) a certification that those persons have not 23 been convicted of any felony offense involving a breach 24 of fiduciary duty or improper manipulation of accounts; 25 and (iii) the number of employer members then enrolled in 26 the HPG, together with any other information that may be 27 needed to carry out the purposes of this Act. 28 (6) At the time of initial registration and each 29 renewal thereof an HPG shall pay a fee of $100 to the 30 Director. 31 (d) If an HPG is formed by an HPG sponsor or risk-bearer 32 and the HPG performs no marketing, negotiation, solicitation, 33 or proposing of insurance to HPG members, exclusive of 34 ministerial acts performed by individual employers to service HB0626 Engrossed -62- LRB9100964JSpc 1 their own employees, then a group or master health insurance 2 contract may be issued in the name of the HPG and held by an 3 HPG sponsor, risk-bearer, or designated employer member 4 within the State. In these cases the HPG requirements 5 specified in subsection (c) shall not be applicable, however: 6 (1) the group or master health insurance contract 7 must contain a provision permitting the contract to be 8 enforced through legal action initiated by any employer 9 member or by an employee of an HPG member who has paid 10 premium for the coverage provided; 11 (2) the group or master health insurance contract 12 must be available for inspection and copying by any HPG 13 member, employee, or insured dependent at a designated 14 location within the State at all normal business hours; 15 and 16 (3) any information concerning HPG membership 17 required by rule under item (5) of subsection (c) must be 18 provided by the HPG sponsor in its registration and 19 renewal forms or by the risk-bearer in its annual 20 reports. 21 (Source: P.A. 90-337, eff. 1-1-98; 90-655, eff. 7-30-98.) 22 (215 ILCS 123/20) 23 Sec. 20. HPG sponsors. Except as provided by Sections 15 24 and 25 of this Act, only a corporation authorized by the 25 Secretary of State to transact business in Illinois may 26 sponsor one or more HPGs with no more than 100,00010,00027 covered individuals by negotiating, soliciting, or servicing 28 health insurance contracts for HPGs and their members. Such a 29 corporation may assert and maintain authority to act as an 30 HPG sponsor by complying with all of the following 31 requirements: 32 (1) The principal officers and directors 33 responsible for the conduct of the HPG sponsor must HB0626 Engrossed -63- LRB9100964JSpc 1 perform their HPG sponsor related functions in Illinois. 2 (2) No insurance risk may be borne or retained by 3 the HPG sponsor; all health insurance contracts issued to 4 HPGs through the HPG sponsor must be delivered in 5 Illinois. 6 (3) No HPG sponsor may collect premium in its name 7 or hold or manage premium or claim fund accounts unless 8 duly qualified and licensed as a managing general agent 9 pursuant to Section 141a of the Illinois Insurance Code 10 or as a third party administrator pursuant to Section 11 511.105 of the Illinois Insurance Code. 12 (4) If the HPG gives an offer, application, notice, 13 or proposal of insurance to an employer, it must disclose 14 the total cost of the insurance. Dues, fees, or charges 15 to be paid to the HPG, HPG sponsor, or any other entity 16 as a condition to purchasing the insurance must be 17 itemized. The HPG shall also disclose to its members the 18 amount of any dividends, experience refunds, or other 19 such payments it receives from the risk-bearer. 20 (5) An HPG sponsor must register with the Director 21 before negotiating or soliciting any group or master 22 health insurance contract for any HPG and must renew the 23 registration annually on forms and at times prescribed by 24 the Director in rules specifying, at minimum, (i) the 25 identity of the officers and directors of the HPG sponsor 26 corporation; (ii) a certification that those persons have 27 not been convicted of any felony offense involving a 28 breach of fiduciary duty or improper manipulation of 29 accounts; (iii) the number of employer members then 30 enrolled in each HPG sponsored; (iv) the date on which 31 each HPG was issued a group or master health insurance 32 contract, if any; and (v) the date on which each such 33 contract, if any, was terminated. 34 (6) At the time of initial registration and each HB0626 Engrossed -64- LRB9100964JSpc 1 renewal thereof an HPG sponsor shall pay a fee of $100 to 2 the Director. 3 (Source: P.A. 90-337, eff. 1-1-98.) 4 Section 200. The Health Maintenance Organization Act is 5 amended by changing Sections 2-2 and 6-7 and adding Section 6 5-3.6 as follows: 7 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404) 8 Sec. 2-2. Determination by Director; Health Maintenance 9 Advisory Board. 10 (a) Upon receipt of an application for issuance of a 11 certificate of authority, the Director shall transmit copies 12 of such application and accompanying documents to the 13 Director of the Illinois Department of Public Health. The 14 Director of the Department of Public Health shall then 15 determine whether the applicant for certificate of authority, 16 with respect to health care services to be furnished: (1) has 17 demonstrated the willingness and potential ability to assure 18 that such health care service will be provided in a manner to 19 insure both availability and accessibility of adequate 20 personnel and facilities and in a manner enhancing 21 availability, accessibility, and continuity of service; and 22 (2) has arrangements, established in accordance with rules 23regulationspromulgated by the Department of Public Health 24 for an ongoing quality of health care assurance program 25 concerning health care processes and outcomes. Upon 26 investigation, the Director of the Department of Public 27 Health shall certify to the Director whether the proposed 28 Health Maintenance Organization meets the requirements of 29 this subsection (a). If the Director of the Department of 30 Public Health certifies that the Health Maintenance 31 Organization does not meet such requirements, he or she shall 32 specify in what respect it is deficient. HB0626 Engrossed -65- LRB9100964JSpc 1 There is created in the Department of Public Health a 2 Health Maintenance Advisory Board composed of 11 members. 3 Nine of the 119members shallwhohave practiced in the 4 health field and,4 of those 9whichshall have been or shall 5 bearecurrently affiliated with a Health Maintenance 6 Organization. Two of the members shall be members of the 7 general public, one of whom is over 65 years of age. Each 8 member shall be appointed by the Director of the Department 9 of Public Health and serve at the pleasure of that Director 10 and shall receive no compensation for services rendered other 11 than reimbursement for expenses. SixFivemembers of the 12 Board shall constitute a quorum. A vacancy in the membership 13 of the Advisory Board shall not impair the right of a quorum 14 to exercise all rights and perform all duties of the Board. 15 The Health Maintenance Advisory Board has the power to review 16 and comment on proposed rulesand regulationsto be 17 promulgated by the Director of the Department of Public 18 Health within 30 days after those proposed rulesand19regulationshave been submitted to the Advisory Board. 20 (b) Issuance of a certificate of authority shall be 21 granted if the following conditions are met: 22 (1) the requirements of subsection (c) of Section 23 2-1 have been fulfilled; 24 (2) the persons responsible for the conduct of the 25 affairs of the applicant are competent, trustworthy, and 26 possess good reputations, and have had appropriate 27 experience, training or education; 28 (3) the Director of the Department of Public Health 29 certifies that the Health Maintenance Organization's 30 proposed plan of operation meets the requirements of this 31 Act; 32 (4) the Health Care Plan furnishes basic health 33 care services on a prepaid basis, through insurance or 34 otherwise, except to the extent of reasonable HB0626 Engrossed -66- LRB9100964JSpc 1 requirements for co-payments or deductibles as authorized 2 by this Act; 3 (5) the Health Maintenance Organization is 4 financially responsible and may reasonably be expected to 5 meet its obligations to enrollees and prospective 6 enrollees; in making this determination, the Director 7 shall consider: 8 (A) the financial soundness of the applicant's 9 arrangements for health services and the minimum 10 standard rates, co-payments and other patient 11 charges used in connection therewith; 12 (B) the adequacy of working capital, other 13 sources of funding, and provisions for 14 contingencies; and 15 (C) that no certificate of authority shall be 16 issued if the initial minimum net worth of the 17 applicant is less than $2,000,000. The initial net 18 worth shall be provided in cash and securities in 19 combination and form acceptable to the Director; 20 (6) the agreements with providers for the provision 21 of health services contain the provisions required by 22 Section 2-8 of this Act; and 23 (7) any deficiencies identified by the Director 24 have been corrected. 25 (Source: P.A. 86-620; 86-1475.) 26 (215 ILCS 125/5-3.6 new) 27 Sec. 5-3.6. Managed Care Reform Act. Health 28 maintenance organizations are subject to the provisions of 29 the Managed Care Reform Act. 30 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7) 31 Sec. 6-7. Board of Directors. The board of directors of 32 the Association shall consistconsistsof not less than 75HB0626 Engrossed -67- LRB9100964JSpc 1 nor more than 119members serving terms as established in 2 the plan of operation. The members of the board are to be 3 selected by member organizations subject to the approval of 4 the Director provided, however, that 2 members shall be 5 enrollees, one of whom is over 65 years of age. Vacancies on 6 the board must be filled for the remaining period of the term 7 in the manner described in the plan of operation. To select 8 the initial board of directors, and initially organize the 9 Association, the Director must give notice to all member 10 organizations of the time and place of the organizational 11 meeting. In determining voting rights at the organizational 12 meeting each member organization is entitled to one vote in 13 person or by proxy. If the board of directors is not 14 selected at the organizational meeting, the Director may 15 appoint the initial members. 16 In approving selections or in appointing members to the 17 board, the Director must consider, whether all member 18 organizations are fairly represented. 19 Members of the board may be reimbursed from the assets of 20 the Association for expenses incurred by them as members of 21 the board of directors but members of the board may not 22 otherwise be compensated by the Association for their 23 services. 24 (Source: P.A. 85-20.) 25 Section 205. The Limited Health Service Organization Act 26 is amended by adding Section 4002.6 as follows: 27 (215 ILCS 130/4002.6 new) 28 Sec. 4002.6. Managed Care Reform Act. Except for health 29 care plans offering only dental services or only vision 30 services, limited health service organizations are subject to 31 the provisions of the Managed Care Reform Act. HB0626 Engrossed -68- LRB9100964JSpc 1 Section 210. The Voluntary Health Services Plans Act is 2 amended by adding Section 15.30 as follows: 3 (215 ILCS 165/15.30 new) 4 Sec. 15.30. Managed Care Reform Act. A health service 5 plan corporation is subject to the provisions of the Managed 6 Care Reform Act. 7 Section 215. The Illinois Public Aid Code is amended by 8 adding Section 5-16.12 as follows: 9 (305 ILCS 5/5-16.12 new) 10 Sec. 5-16.12. Managed Care Reform Act. The medical 11 assistance program and other programs administered by the 12 Department are subject to the provisions of the Managed Care 13 Reform Act. The Department may adopt rules to implement those 14 provisions. These rules shall require compliance with that 15 Act in the medical assistance managed care programs and other 16 programs administered by the Department. The medical 17 assistance fee-for-service program is not subject to the 18 provisions of the Managed Care Reform Act. 19 Section 250. Effective date. This Act takes effect 20 January 1, 2000.