Section 5420.40  Provision of Information

a)         Description of Coverage

1)         So that a person can  compare the attributes of various health care plans, both a description of coverage  cover page and worksheet must be completed by the health care plan.  The cover page and worksheet shall follow substantially the same format as prescribed in Exhibits A and B respectively of this Part.  Each shall be printed in no less than 12 point type.

A)        Copayments and/or deductibles which vary within a specific benefit category must be listed individually for each item (e.g., copayments for prescription drugs should be listed separately based upon the drug being brand name or generic equivalent).

B)        The category entitled "Other Services" may be modified to include additional headings as may be appropriate.  If the contract does not provide coverage for listed "Other Services", the description of coverage worksheet should so indicate by stating "Not Applicable" for each such item.

C)        A health care plan specific description of coverage worksheet shall contain financial information specific to the enrollee's plan.  A generic description of coverage worksheet will be applicable to all of the health care plan's plans and include a general description of financial information.

D)        All description of coverage worksheets shall include a notice of the enrollee's right to request a description of the financial relationships between the health care plan and any health care provider, the percent of copayments, deductibles and total premiums spent on health care related and administrative expenses, as well as a notice of the enrollee's right to request health care provider information from their provider as set forth in Section 15(c) of the Managed Care Reform and Patient Rights Act.

E)         All description of coverage worksheets shall clearly disclose that referral arrangements through the enrollee's  participating primary care physician may limit the enrollee's ability to seek services from certain participating specialist physicians or participating health care providers.  To obtain clarification on such referral arrangements, the enrollees must be instructed to contact their participating primary care physician's office.   If a referral arrangement does not exist between the enrollee's participating primary care physician and the desired participating specialist physician or participating health care provider, then the enrollees must be informed of their ability to designate a new participating primary care physician with whom such referral arrangement does exist.

F)         The description of coverage worksheet for point of service products, defined within 50 Ill. Adm. Code 5421.20, must include a specific description of coverages, limitations, exclusions, deductibles and copayments specific to the indemnity contract.

2)         A plan specific description of coverage cover page, worksheet and a list of participating health care providers shall be given to all new enrollees. Annually thereafter, a generic description of coverage cover page and worksheet must be mailed to enrollees. Only one enrollee per household must be furnished this material unless otherwise requested by the enrollee.  For group contracts, the plan may satisfy this requirement by giving the required material to the contract holder, for distribution to their members.

3)         Enrollees must be advised annually of their right to request a plan specific description of coverage cover page, worksheet and an updated list of participating health care providers.   The enrollee shall be given the choice of requesting this information through a local telephone number or long distance toll-free telephone number and a prepaid postcard.

4)         The plan specific description of coverage cover page, worksheet and list of participating health care providers shall be given to all prospective enrollees upon request.  Availability of this information shall be prominently communicated within the health care plan's marketing materials.  Prospective enrollees shall be able to request this information through a local telephone number or a long distance toll-free telephone number.

5)         Health care plans are encouraged to make a generic description of coverage cover page, worksheet and list of participating health care providers available on their web sites. This will not act as a substitute for other forms of required disclosure.

6)         Health care plans issuing contracts or evidences of coverage for delivery in this State shall not issue such contract or evidence of coverage unless a specific description of coverage cover page and worksheet are provided.

7)         All health care plans must clearly communicate their procedure for the filing of complaints pursuant to Section 45 of the Act.  When a health care plan is permitted by statute to require complaints be filed in writing, the appropriate complaint form must be made available to the enrollee.

b)         Within the group contract, evidence of coverage, individual contract and enrollee handbook, the health care plan shall provide a notice of the enrollees' right to request a description of the financial relationships between the health care plan and any health care provider, the percent of copayments, deductibles and total premiums spent on health care related and administrative expenses as well as the right to obtain health care provider information from their provider as set forth in Section 15(c) of the Managed Care Reform and Patient Rights Act.

c)         Each health care plan shall clearly disclose, within the group contract, evidence of coverage, individual contract, enrollee handbook and provider directory that referral arrangements through the enrollee's participating primary care physician may limit the enrollee's ability to seek services from certain participating specialist physicians or participating health care providers.  To obtain clarification on such referral arrangements, the enrollees must be instructed to contact their participating primary care physician's office.  If a referral arrangement does not exist between the enrollee's participating primary care physician and the desired participating specialist physician or participating health care provider, then the enrollee must be informed of his ability  to designate a new participating primary care physician with whom such referral arrangement does exist.

d)         Within the group contract, evidence of coverage, individual contract and enrollee handbook, all health care plans must clearly communicate their procedure for the filing of complaints pursuant to Section 45 of the Act. When a health care plan is permitted by statute to require complaints be filed in writing, the appropriate complaint form must be made available to the enrollee.