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91_HB1277
LRB9102447JSpcB
1 AN ACT concerning regulation of health care plans.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Managed Care Reform Act of 1999.
6 Section 5. Purpose. This Act addresses changes in
7 managed care practice and operations in Illinois. The Act
8 enhances quality, affordable, and accessible health care
9 coverage for Illinois citizens, families and businesses.
10 Through the provisions of this Act, health care plan members
11 will be provided:
12 (1) Detailed information about health care plans,
13 the scope of coverage available, and physicians'
14 professional qualifications so that they can make
15 informed choices about their health care.
16 (2) Notification of termination or change in any
17 benefits, services or service delivery. This includes a
18 provision allowing enrollees to continue with a
19 non-network physician under certain specific
20 circumstances.
21 (3) A mechanism to apply for a standing referral to
22 a specialist physician when a condition requires ongoing
23 care from a specialist physician.
24 (4) Detailed grievance procedures and medical
25 necessity appeals procedures, which include an expedited
26 appeal process.
27 (5) Health care plan accountability for
28 accessibility of services and reimbursement for covered
29 emergency services.
30 Section 10. Definitions. As used in this Act:
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1 "Basic health care services" means emergency care, and
2 inpatient hospital and physician care, outpatient medical
3 services, mental health services and care for alcohol and
4 drug abuse, including any reasonable deductibles and
5 copayments, all of which are subject to such limitations as
6 are determined by the Director.
7 "Department" means the Department of Insurance.
8 "Director" means the Director of Insurance.
9 "Emergency medical condition" means a medical condition
10 manifesting itself by acute symptoms of sufficient severity
11 (including severe pain) such that a prudent layperson, who
12 possesses an average knowledge of health and medicine, could
13 reasonably expect the absence of immediate medical attention
14 to result in (i) placing the health of the individual (or,
15 with respect to a pregnant woman, the health of the woman or
16 her unborn child) in serious jeopardy, (ii) serious
17 impairment to bodily functions, or (iii) serious dysfunction
18 of any bodily organ or part.
19 "Emergency services" means, with respect to an individual
20 enrolled in a health care plan, covered inpatient and covered
21 outpatient services that are:
22 (1) furnished in a licensed hospital by a provider
23 that is qualified to furnish those services;
24 (2) needed to evaluate whether an emergency medical
25 condition exists; and
26 (3) needed for stabilization of an emergency
27 medical condition if one exists.
28 "Emergency services" does not refer to post-stabilization
29 medical services.
30 "Enrollee" means an individual enrolled in a health care
31 plan.
32 "Good faith" means honesty of purpose, freedom from
33 intention to defraud and being faithful to one's duty or
34 obligation. In addition the definition afforded this term by
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1 the courts of the State of Illinois shall apply.
2 "Governing body" means the board of trustees, or
3 directors, or if otherwise designated in the basic
4 organizational document bylaws, those individuals vested with
5 the ultimate responsibility for the management of the health
6 care plan.
7 "Grievance" means any written complaint submitted to the
8 health care plan by or on behalf of an enrollee regarding any
9 aspect of the plan relative to the enrollee, but shall not
10 include a complaint by or on behalf of a provider.
11 "Grievance committee" means individuals who have been
12 appointed by the health care plan to respond to grievances
13 which have been filed on appeal from the plan's simplified
14 complaint process. At least 50% of the individuals on this
15 committee shall be composed of enrollees who are consumers.
16 A grievance may not be heard or voted upon unless at least
17 50% of the voting individuals at the committee hearing are
18 enrollees.
19 "Health care plan" means any arrangement whereby an
20 organization undertakes to provide or arrange for and pay for
21 or reimburse the cost of basic health care services from
22 providers selected by the plan and such arrangement consists
23 of arranging for or the provision of such health care
24 services, as distinguished from mere indemnification against
25 the cost of such services, on a per capita prepaid basis,
26 through insurance or otherwise.
27 "Health care services" means any services included in the
28 furnishing to any individual of medical or dental care, or
29 the hospitalization or incident to the furnishing of such
30 care or hospitalization as well as the furnishing to any
31 person of any and all other services for the purpose of
32 preventing, alleviating, curing or healing human illness or
33 injury.
34 "Insurance company" means a company authorized to
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1 transact in this State the kind or kinds of business
2 enumerated in Class 1(a), Class 1(b), or Class 2(a) of
3 Section 4 of the Illinois Insurance Code.
4 "Insured" means an individual entitled to coverage of
5 expenses of health care services under a policy issued or
6 administered by an insurance company.
7 "Life threatening condition" means any condition, illness
8 or injury that (i) may directly lead to a patient's death,
9 (ii) results in a period of unconsciousness that is
10 indeterminate at the present, or (iii) imposes severe pain or
11 an inhumane burden on the patient.
12 "Medical director" means a physician licensed to practice
13 medicine in all its branches in Illinois who is employed by
14 or contracted with a health care plan and who is responsible
15 for final review when questions of medical practice arise in
16 the health care plan in order to assure the quality of health
17 care services provided.
18 "Patient" means any person who has received or is
19 receiving medical care, treatment, or services from an
20 individual or institution licensed to provide medical care or
21 treatment in this State.
22 "Post-stabilization medical services" means covered
23 health care services provided to an enrollee that are
24 furnished in a licensed hospital by a provider that is
25 qualified to furnish those services and determined to be
26 medically necessary and directly related to an emergency
27 medical condition following stabilization.
28 "Primary care physician" means a provider who has
29 contracted with a health care plan to provide primary care
30 services as defined by the contract and who is a physician
31 licensed to practice medicine in all of its branches who
32 spends a majority of clinical time engaged in general
33 practice or in the practice of internal medicine, pediatrics,
34 gynecology, obstetrics, or family practice.
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1 "Provider" means a physician, hospital facility, or other
2 person that is licensed or otherwise authorized to furnish
3 health care services.
4 "Stabilization" means, with respect to an emergency
5 medical condition, to provide such medical treatment of the
6 condition as may be necessary to assure, within reasonable
7 medical probability, that no material deterioration of the
8 condition is likely to result from the transfer of the
9 individual from a facility.
10 "Utilization review" means the study of the
11 appropriateness of the use of particular services and the
12 appropriateness of the volume of services used.
13 "Utilization review program" means an entity performing
14 utilization review, except an agency of the federal
15 government or its agent, but only to the extent that agent is
16 providing services to the federal government.
17 Section 15. Patient rights. The following rights are
18 hereby established:
19 (1) The right of each patient to be provided with
20 information about the health care plan and the providers
21 rendering care. For health care plans this right calls
22 for compliance with Section 20 of this Act.
23 (2) The right of each patient to a full disclosure
24 of the patient costs, benefits, risks, and alternatives
25 related to the treatment options and care, including
26 health care plan requirements, coverage, exclusions, or
27 limitations. For health care plans this right calls for
28 compliance with Section 25 of this Act. Insurance
29 companies and health care plans are prohibited from
30 terminating or suspending a provider from its network
31 because the provider advocated for what he or she
32 considered to be appropriate health care.
33 (3) The right of each patient to care consistent
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1 with nursing and medical practices, to be informed of the
2 name of the physician responsible for coordinating his or
3 her care, to receive information from his or her
4 physician concerning his or her condition and proposed
5 treatment, to refuse any treatment to the extent
6 permitted by law, and to privacy and confidentiality of
7 records as provided by law.
8 (4) The right of each patient, regardless of source
9 of payment, to examine and receive a reasonable
10 explanation of his or her total bill for services when a
11 bill is rendered by his or her physician or health care
12 provider, including the itemized charges for specific
13 services received. A provider shall be responsible for a
14 reasonable explanation of those specific services
15 provided or charges by the physician or health care
16 provider.
17 (5) In the event an insurance company or health
18 care plan cancels or refuses to renew an individual
19 policy or plan, the insured or enrollee shall be entitled
20 to timely, prior notice of the termination of the policy
21 or plan.
22 An insurance company or health care plan that
23 requires any insured, enrollee, or applicant for new or
24 continued insurance or coverage to be tested for
25 infection with HIV or any other identified causative
26 agent of AIDS shall (1) give the patient or applicant
27 prior written notice of such requirement, (2) proceed
28 with such testing only upon the written authorization of
29 the insured, enrollee, or applicant, and (3) keep the
30 results of the testing confidential. Notice of an
31 adverse underwriting or coverage decision may be given to
32 any appropriately interested party, but the insurance
33 company or health care plan may disclose the test result
34 itself only to a physician designated by the insured,
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1 enrollee, or applicant, and the disclosure shall be in a
2 manner that assures confidentiality.
3 (6) At the time of renewal, the right of a patient
4 to notification of termination or change in any benefits,
5 services or service delivery office or site.
6 (7) The right of a patient to privacy and
7 confidentiality in health care. A physician, health care
8 provider, health care plan, and insurance company may not
9 disclose the nature or details of services provided to
10 insureds and enrollees, except that such information may
11 be disclosed to the patient, the party making treatment
12 decisions if the patient is incapable of making decisions
13 regarding the health services provided, those parties
14 directly involved with providing treatment to the patient
15 or processing the payment for that treatment, those
16 parties responsible for peer review, utilization review
17 and quality assurance, and those parties required to be
18 notified under the Abused and Neglected Child Reporting
19 Act, the Illinois Sexually Transmissible Disease Control
20 Act, or where otherwise authorized or required by law.
21 This right may be waived in writing by the patient or the
22 patient's guardian, but a physician or other health care
23 provider may not condition the provision of services on
24 the patient's or guardian's agreement to sign such a
25 waiver.
26 Section 20. Provision of information.
27 (a) A health care plan shall provide to enrollees a list
28 of primary care physicians in the health care plan's service
29 area and an evidence of coverage that contains a description
30 of the following terms and conditions of coverage:
31 (1) The service area.
32 (2) Covered benefits, exclusions, or limitations.
33 (3) Registration and other utilization review
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1 procedures requirements.
2 (4) A description of the limitations on access to
3 specialist physicians.
4 (5) Emergency coverage and benefits both inside and
5 out of the plan service area.
6 (6) A description of post-stablization medical
7 service requirements.
8 (7) Out-of-area coverages and benefits, if any.
9 (8) The enrollee's financial responsibility for
10 copayments, deductibles, and any other out-of-pocket
11 expenses.
12 (9) Provisions for continuity of treatment in the
13 event a provider's participation terminates during the
14 course of an insured's or enrollee's treatment by that
15 provider.
16 (10) The grievance process, including the telephone
17 number to call to receive information concerning
18 grievance procedures.
19 (b) Upon written request, a health care plan shall
20 provide to enrollees a description of the financial
21 relationships between the health care plan and any provider,
22 except that no health care plan shall be required to disclose
23 specific reimbursement to providers.
24 (c) A participating provider shall provide to enrollees
25 upon request:
26 (1) information related to the health care
27 professional's educational background, experience,
28 training, specialty, and board certification, if
29 applicable;
30 (2) the names of licensed facilities on the
31 provider panel where the health professional presently
32 has privileges for the treatment, illness, or procedure
33 that is the subject of the request; and
34 (3) information regarding the health care
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1 professional's participation in continuing education
2 programs and compliance with any licensure,
3 certification, or registration requirements, if
4 applicable.
5 Section 25. Prohibited restraints on communication.
6 Nothing in a physician's contract with a health care plan
7 shall be construed to impair the physician's ethical and
8 legal duty to provide full informed consent and medical
9 counsel to enrollees, including full discussion of the costs,
10 benefits, risks, and alternatives related to the enrollee's
11 treatment options and care and the health care plan policies
12 related to those options, including health care plan
13 requirements, coverage, exclusions, or other policies or
14 practices that affect enrollees' access to coverage or
15 treatment options.
16 Section 30. Access to personnel and facilities.
17 (a) A health care plan shall include a sufficient number
18 and type of primary care physicians and specialist physicians
19 throughout the service area to meet the needs of enrollees
20 and to provide meaningful choice. A health care plan shall
21 offer:
22 (1) accessible acute care hospital services, within
23 a reasonable distance or travel time;
24 (2) primary care physicians, within a reasonable
25 distance or travel time; and
26 (3) specialist physicians within a reasonable
27 distance or travel time.
28 When the type of medical service needed for a specific
29 condition is not represented in the provider network, upon
30 request, the health care plan shall arrange for the enrollee
31 to have access to qualified non-participating health care
32 professionals as authorized by the primary care physician.
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1 (b) A health care plan shall provide telephone access to
2 the health care plan for sufficient time during business
3 hours to assure enrollee access for routine care and 24 hour
4 telephone access to the health care plan or, if so delegated
5 by the health care plan, a participating physician or group
6 for emergency care or authorization for care.
7 (c) A health care plan shall establish reasonable
8 standards for waiting times to obtain appointments, except as
9 provided below for emergency services. The standards shall
10 include appointment scheduling guidelines used for each type
11 of health care service, including prenatal care appointments,
12 well-child visits and immunizations, routine physicals,
13 follow-up appointments for chronic conditions, and urgent
14 care.
15 (d) A health care plan shall provide for continuity of
16 care for its enrollees as follows:
17 (1) If an enrollee's physician leaves the health
18 care plan's network of providers for reasons other than
19 termination with cause and the physician remains within
20 the health care plan's service area, the health care plan
21 shall permit the enrollee upon request to continue an
22 ongoing course of treatment with that physician during a
23 transitional period:
24 (A) of up to 60 days from the date of the
25 notice of physician's termination from the health
26 care plan network to the enrollee if the enrollee
27 has a life threatening disease or condition; or
28 (B) that includes the provision of post-partum
29 care directly related to the delivery, if the
30 enrollee has entered the third trimester of
31 pregnancy at the time of the physician's
32 disaffiliation.
33 (2) Notwithstanding the provisions in item (1),
34 care shall be authorized by the health care plan during
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1 the transitional period only if the physician agrees to:
2 (A) continue to accept reimbursement from the
3 health care plan at the rates applicable prior to
4 the start of the transitional period as payment in
5 full;
6 (B) adhere to the health care plan's quality
7 assurance requirements and provide to the health
8 care plan necessary medical information related to
9 the care; and
10 (C) otherwise adhere to the organization's
11 policies and procedures including, but not limited
12 to, procedures regarding referrals and obtaining
13 pre-authorizations and a treatment plan approved by
14 the health care plan.
15 (e) A health care plan shall provide for continuity of
16 care for new enrollees as follows:
17 (1) If a new enrollee whose physician is not a
18 member of the health care plan's provider network, but is
19 within the health care plan's service area, enrolls in
20 the health care plan, the health care plan shall, upon
21 request from the enrollee, provide benefits for otherwise
22 covered services provided by the enrollee's current
23 physician during a transitional period of up to 60 days
24 from the effective date of enrollment if:
25 (i) the enrollee has a life-threatening
26 disease or condition; or
27 (ii) the enrollee has entered the third
28 trimester of pregnancy at the effective date of
29 enrollment, in which case the transitional period
30 shall include the provision of post-partum care
31 directly related to the delivery.
32 (2) If an enrollee elects to continue to receive
33 care from a physician pursuant to item (1), benefits for
34 the care shall be authorized by the health care plan for
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1 the transitional period only if the physician agrees to:
2 (A) accept reimbursement from the health care
3 plan at rates established by the health care plan as
4 payment in full, such rates shall be no more than
5 the level of reimbursement applicable to similar
6 physicians within the health care plan's network for
7 such services;
8 (B) adhere to the health care plan's quality
9 assurance requirements and provide to the health
10 care plan necessary medical information related to
11 the care; and
12 (C) otherwise adhere to the health care plan's
13 policies and procedures including, but not limited
14 to, procedures regarding referrals and obtaining
15 pre-authorization and a treatment plan approved by
16 the health care plan.
17 In no event shall this Section be construed to require a
18 health care plan to provide coverage for benefits not
19 otherwise covered or to diminish or impair pre-existing
20 condition limitations contained in the subscriber's contract.
21 Section 35. Access to specialist physicians.
22 (a) A health care plan shall establish a procedure by
23 which an enrollee, who has a condition that requires ongoing
24 care from a specialist physician, may apply for a standing
25 referral to a specialist physician if a referral to a
26 specialist physician is required for coverage. The
27 application shall be made to the health care plan's medical
28 director. The health care plan, at its sole discretion, may
29 establish procedures whereby acceptance and review of the
30 application is delegated to the enrollee's primary care
31 physician, independent practice association or medical group.
32 This procedure for a standing referral must specify the
33 necessary criteria and conditions which must be met in order
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1 for an enrollee to obtain a standing referral.
2 (b) Unless waived by the health care plan, the plan at
3 its sole discretion may require an enrollee to seek care from
4 a specialist physician who is currently participating in the
5 health care plan's provider network and who is from the same
6 independent practice association or medical group as the
7 enrollee's primary care physician, if required by the health
8 care plan's procedure.
9 (c) When the type of specialist physician needed to
10 provide ongoing care for a specific condition is not
11 represented in the same independent practice association or
12 medical group as the enrollee's primary care physician, the
13 health care plan shall arrange for the enrollee to have
14 access to a specialist physician participating in the health
15 care plan's provider network.
16 (d) When the type of specialist physician is needed to
17 provide ongoing care for a specific condition is not
18 represented in the health care plan's provider network, the
19 health care plan shall arrange for the enrollee to have
20 access to a qualified non-participating health care
21 professional.
22 (e) The enrollee's primary care physician shall remain
23 responsible for coordinating the care of the enrollee who has
24 received a standing referral to a specialist physician.
25 Health care plans may require the specialist physician to
26 obtain a prior approval for secondary referrals from the
27 primary care physician. The health care plan or its delegate
28 may in providing the standing referral limit the number of
29 visits or the period during which the standing referral is
30 authorized. In addition, the health care plan or its
31 delegate may require the specialist physician to provide
32 regular updates to the enrollee's primary care physician.
33 (f) If an enrollee's application for a standing referral
34 is denied, an enrollee may appeal the decision through the
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1 health care plan's grievance process required under Section
2 50.
3 Section 40. Emergency services prior to stabilization.
4 (a) Except as provided for in subsection (c), a health
5 care plan shall cover emergency services without regard to
6 prior authorization or the treating provider's contractual
7 relationship with the organization.
8 (b) Reimbursement shall be provided by the health care
9 plan at the same rate as if the service or treatment had been
10 rendered by similar provider contracting with a health care
11 plan.
12 (c) Payment for covered emergency services may be
13 denied:
14 (1) upon determination that the emergency
15 services claimed were not performed;
16 (2) upon determination that emergency
17 evaluation and treatment were rendered to an
18 enrollee who sought emergency services and whose
19 circumstance did not meet the definition of
20 emergency medical condition;
21 (3) upon determination that the patient
22 receiving the services was not a covered enrollee of
23 the health care plan; or
24 (4) upon material misrepresentation by an
25 enrollee or provider.
26 (d) The appropriate use of 911 telephone systems or its
27 local equivalent shall not be discouraged or penalized when
28 an emergency medical condition exists. This provision shall
29 not imply that the use of 911 or its local equivalent is a
30 factor in determining the existence of an emergency medical
31 condition.
32 (e) For purposes of coverage, the medical director's or
33 his or her designee's determination of whether an enrollee
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1 meets the standard of an emergency medical condition shall be
2 based primarily upon the presenting symptoms documented in
3 the medical record at the time care was sought and the
4 circumstances that led an enrollee to believe that he or she
5 had an emergency medical condition.
6 (f) For emergency medical service claims reviewed for
7 reimbursement, the emergency department shall provide upon
8 request of the health care plan, at no charge, a copy of the
9 medical record documenting the presenting symptoms of the
10 enrollee at the time care was sought and the objective
11 findings of the medical examination.
12 (g) Nothing in this Section prohibits a health care plan
13 from imposing deductibles, coinsurance, or copayments in
14 covering emergency medical services. Copayments may vary
15 from those copayments charged for other covered services.
16 Section 45. Post-stabilization medical services.
17 (a) If prior benefit authorization for
18 post-stabilization medical services is required, the treating
19 provider shall contact the health care plan or delegated
20 provider as designated on the covered enrollee's health
21 insurance card to obtain benefit authorization or denial or
22 benefit authorization for an alternate plan of treatment or
23 transfer of the covered enrollee.
24 (b) The treating provider shall document in an
25 enrollee's medical record the enrollee's presenting symptoms,
26 emergency medical condition, the time, phone number or
27 numbers dialed, and result of the communication efforts to
28 request benefit authorization of post-stabilization medical
29 services. The health care plan shall provide reimbursement
30 as required under subsection (b) of Section 40 of this Act
31 for covered post-stabilization medical services if any of the
32 following apply:
33 (1) Benefit authorization for covered
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1 post-stabilization medical services is received from
2 the health care plan or its delegated provider.
3 (2) After at least 2 documented good faith
4 efforts over the course of 60 minutes, but each
5 effort being at least 10 minutes apart, the treating
6 health care provider has attempted without success
7 to contact an enrollee's health care plan or its
8 delegated health care provider, as designated on an
9 enrollee's health insurance card, for prior benefit
10 authorization of post-stabilization medical
11 services. A "documented good faith effort" means
12 contacting the health care plan or delegated
13 provider and any subsequent parties to whom the
14 calls are being forwarded in good faith.
15 (3) The treating health care provider has
16 contacted the plan or designated persons with a
17 request for prior benefit authorization of
18 post-stabilization services in one of its 2
19 documented good faith efforts as defined in item (2)
20 and the plan or designated persons did not deny the
21 request within 60 minutes of receiving the request.
22 (c) If rendering post-stabilization medical services
23 pursuant to item (2) or (3) of subsection (b), the treating
24 provider shall continue to make every reasonable effort to
25 contact the health care plan or the delegated provider
26 regarding benefit authorization or denial or benefit
27 authorization for an alternate plan of treatment or transfer
28 of the covered enrollee until the treating provider receives
29 benefit authorization from the health care plan or delegated
30 provider for continued care or the care is transferred to
31 another health care provider or the patient is discharged.
32 (d) Payment for covered post-stabilization medical
33 services may be denied:
34 (1) if the treating provider does not meet the
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1 conditions outlined in subsections (b) and (c);
2 (2) upon determination that the post-stabilization
3 medical services claimed were not performed;
4 (3) upon determination that the post-stabilization
5 medical services rendered were denied or were contrary to
6 the instructions of the health care plan or delegated
7 provider if contact was made between these parties prior
8 to the service being rendered;
9 (4) upon determination that the patient receiving
10 the services was not a covered enrollee of the health
11 care plan; or
12 (5) upon material misrepresentation by an enrollee
13 or provider.
14 (e) Nothing in this Section prohibits a health care plan
15 from delegating the responsibilities enumerated in this
16 Section to the health care plan's contracted medical
17 providers.
18 (f) For post-stabilization medical services claims
19 reviewed for reimbursement, the emergency department shall
20 provide upon request of the health care plan, at no charge, a
21 copy of the medical record.
22 (g) Nothing in this Section prohibits a health care plan
23 from imposing deductibles, coinsurance, or copayments in
24 covering post-stabilization medical services. Copayments may
25 vary from those copayments charged for other covered
26 services.
27 Section 50. Grievance procedures.
28 (a) A health care plan shall submit for the Director's
29 approval, and thereafter maintain, a system for the
30 resolution of grievances concerning the provision of health
31 care services or other matters concerning operation of the
32 health care plan as provided in this Section. A health care
33 plan shall:
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1 (1) submit to the Director for prior approval any
2 proposed changes to the system by which grievances may be
3 filed and reviewed;
4 (2) maintain records on each grievance filed with
5 the health care plan until the grievance is resolved and
6 for a period of at least 3 years including:
7 (A) a copy of the grievance and the date of
8 its filing;
9 (B) the date and outcome of all consultations,
10 hearings and hearing findings;
11 (C) the date and decisions of any appeal
12 proceedings; and
13 (D) the date and proceeding of any litigation;
14 and
15 (3) submit to the Director, in a form prescribed by
16 the Director, a report by March 1 for the previous
17 calendar year which shall include at least the following:
18 (A) the total number of grievances handled;
19 (B) a compilation of causes underlying the
20 grievances;
21 (C) the outcomes of the grievances;
22 (D) the elapsed time from receipt of the
23 grievance by the health care plan until its
24 conclusion; and
25 (E) the number of malpractice claims filed,
26 and if those claims have been completely
27 adjudicated, a compilation of causes, disposition,
28 form, and amount of any settlements.
29 (b) A health care plan shall have a grievance committee
30 that has the authority to hear and resolve by majority vote
31 grievances submitted to it as provided in subsection (a).
32 (1) Notwithstanding any other provisions of this
33 Section, the grievance committee may, but is not required
34 to, hear any grievance that alleges or indicates possible
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1 professional liability, commonly known as "malpractice."
2 (2) The committee is not empowered to resolve
3 grievances in any manner that is, or prescribe any
4 actions that are, in conflict with written policies of
5 the health care plan's governing body, but the committee
6 may hear those grievances for the purpose of providing
7 input to the governing body.
8 (3) The grievance committee shall meet at the main
9 office of the health care plan or another office
10 designated by the health care plan when the main office
11 is not within 50 miles of the grievant's home address.
12 Consideration shall be given to the enrollee's request
13 pertaining to the time and date of the meeting. The
14 enrollee shall have the right to attend and participate
15 in the formal grievance proceedings. The enrollee shall
16 have the right to be accompanied by a designated
17 representative of his or her choice.
18 (4) The filing of a grievance shall not preclude
19 the enrollee from filing a complaint with the Department
20 nor shall it preclude the Department from investigating a
21 complaint pursuant to its authority under Section 4-6 of
22 the Health Maintenance Organization Act.
23 (c) The grievance procedures must be fully and clearly
24 communicated to all enrollees and information concerning the
25 procedures shall be readily available to the enrollee.
26 (d) A health care plan shall have simplified procedures
27 for resolving complaints. These procedures do not require
28 review of the complaint by the grievance committee, but a
29 log, file, or other similar records must be maintained to
30 identify the general nature of the complaints. Resolution of
31 the complaints shall not preclude the enrollees' rightful
32 access to review by the grievance committee of a grievance.
33 (e) The health care plan shall institute procedures that
34 require grievances to have a determination made by the
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1 grievance committee within 60 days after the date the
2 grievance is received by the health care plan. A grievance
3 may not be heard or voted upon unless 50% of the voting
4 individuals of the committee present at the hearing are
5 enrollees. The determination by the grievance committee may
6 be extended for a period not to exceed 30 days in the event
7 of delay in obtaining documents or records necessary for the
8 resolution of the grievance. All requests for documents or
9 records necessary for the resolution of the grievance shall
10 be maintained in the health care plan's grievance file.
11 (f) The grievance procedure shall provide the enrollee
12 with a written acknowledgment of their grievance within 10
13 business days after receipt by the health care plan.
14 (g) The enrollee shall be notified at the time of the
15 hearing of the name and affiliation of those grievance
16 committee members who are representatives of the health care
17 plan.
18 (h) The health care plan shall institute procedures
19 whereby any document furnished to the members of the
20 grievance committee shall also be made available to the
21 enrollee not less than 5 business days prior to the hearing
22 of their grievance. The health care plan shall not present
23 any evidence without the enrollee having been given the
24 opportunity to be present.
25 (i) Notice in writing of the determination of the
26 grievance committee shall be mailed to the enrollee within 5
27 business days after the determination. Notice of the
28 determination made at the final appeal step of the health
29 care plan's grievance process shall include a "Notice of
30 Availability of the Department" to receive complaints as
31 provided in Section 4-6 of the Health Maintenance
32 Organization Act.
33 (j) Prior to the resolution of a grievance filed by a
34 subscriber or enrollee, coverage shall not be terminated for
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1 any reason that is the subject of the written grievance,
2 except where the health care plan has, in good faith, made a
3 reasonable effort to resolve the written grievance through
4 its grievance procedure and coverage is being terminated as a
5 result of good cause.
6 Section 55. Review of medical necessity. A health care
7 plan shall provide a mechanism for the timely review by a
8 physician holding the same class of license as the primary
9 care physician, who is unaffiliated with health care plan,
10 jointly selected by the patient (or the patient's next of kin
11 or legal representative if the patient is unable to act for
12 himself), and the patient's primary care physician and the
13 health care plan in the event of a dispute between the
14 primary care physician and the health care plan regarding the
15 medical necessity of a covered service proposed by the
16 primary care physician. In the event that the reviewing
17 physician determines the covered service to be medically
18 necessary, the health care plan shall provide the covered
19 service. Future contractual or employment action by the
20 health care plan regarding the primary care physician shall
21 not be based solely on the physician's participation in this
22 procedure.
23 Section 60. Expedited review of medical necessity.
24 (a) A health care plan shall have an expedited review
25 procedure whereby an enrollee with a life-threatening
26 condition, or physician authorized in writing to act on
27 behalf of the enrollee with a life-threatening condition, may
28 appeal a health care plan's decision of medical necessity of
29 a covered service.
30 (b) The expedited review procedure shall provide that an
31 initial determination of the review will be made by the
32 health care plan not later than 3 business days after receipt
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1 of all necessary information to complete the review process.
2 (c) After the initial adverse determination by the
3 health care plan, the enrollee, or physician authorized in
4 writing to act on behalf of the enrollee, may request further
5 review by the health care plan. If further review is
6 requested, a final determination by the health care plan
7 shall be made not later than 30 days after receipt of all
8 necessary information to complete further review. Upon
9 notification to the enrollee of the health care plan's final
10 determination resulting from the expedited review process,
11 the plan shall provide the enrollee a "Notice of Availability
12 of the Department" to receive complaints as provided in
13 Section 4-6 of the Health Maintenance Organization Act.
14 (d) A request for an expedited review under this Section
15 must contain a statement submitted by the physician, orally
16 or in writing, substantiating that the enrollee has a
17 life-threatening condition. This Section does not apply to a
18 provider's complaint concerning claims payment, handling, or
19 reimbursement for health care services.
20 (e) If the expedited review process is invoked it shall
21 be in place of and not in addition to the regular review
22 process.
23 Section 65. Registration of utilization review programs.
24 (a) All utilization review programs shall register
25 annually with the Department.
26 (b) The utilization review program shall submit all of
27 the following:
28 (1) The name, address, and telephone of the
29 registrant.
30 (2) The organization and governing structure of the
31 registrant.
32 (3) List of insurance companies and health care
33 plans for which the utilization review program performs
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1 utilization review in this State and the number of lives
2 for which utilization review is conducted.
3 (4) Hours of operation.
4 (5) Description of the grievance process.
5 (6) Number of covered lives for which utilization
6 review was conducted for the previous calendar year.
7 (7) Written policies and procedures for protecting
8 confidential information according to applicable State
9 and federal laws.
10 (c) If the Director determines that an insurance company
11 or health care plan licensed by the Department meets the
12 provisions of the requirements of this Section under its
13 licensing process, he or she may exempt the insurance company
14 or health care plan from providing duplicate information.
15 Section 70. Managed care community networks. Managed
16 care community networks providing or arranging health care
17 services under contract with the State exclusively to persons
18 who are enrolled in the integrated health care program
19 established under Section 5-16.3 of the Illinois Public Aid
20 Code or a managed care community network owned, operated, or
21 governed by a county provider as defined in Section 15-1 of
22 that Code are required to comply with Sections 15, 20, and 25
23 of this Act and are exempt from all other Sections of this
24 Act. The Illinois Department of Public Aid shall adopt rules
25 to implement these provisions.
26 Section 75. Penalties.
27 (a) Any organization that violates Section 20, 25, 30,
28 35, 40, 45, 50, 55, or 60 of this Act shall be guilty of a
29 Class B misdemeanor.
30 (b) The Director may issue to any organization subject
31 to this Act, a cease and desist order as provided in Article
32 XXIV, Section 401.1 of the Illinois Insurance Code.
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1 Section 90. Severability. The provisions of this Act are
2 severable under Section 1.31 of the Statute on Statutes.
3 Section 95. Applicability of Act. A health care plan
4 coverage amended, delivered, issued, or renewed in this State
5 after the effective date of this Act must comply with the
6 terms of this Act.
7 Section 99. Effective date. This Act takes effect
8 January 1, 2000.