98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB1273

 

Introduced 1/31/2013, by Sen. Antonio Muņoz

 

SYNOPSIS AS INTRODUCED:
 
New Act
5 ILCS 140/7.5

    Creates the Exclusive Provider Benefit Plan Act. Provides that an exclusive provider benefit plan that meets the requirements of the Act shall be permitted. Provides that to the extent of any conflict between the provision permitting exclusive provider benefit plans and any other statutory provision, the provision permitting exclusive provider benefit plans prevails over the conflicting provision. Provides that an insurer duly licensed under the laws of this State may offer exclusive provider benefit plans to individuals and group health plans in conformity with the terms set forth in the provision concerning the applicability of the Act. Provides that an insurer shall not be required to be licensed as an HMO under the Health Maintenance Organization Act in order to offer exclusive provider benefit plans under the provision concerning the applicability of the Act. Sets forth provisions concerning the applicability of the Health Carrier External Review Act; the construction of the Exclusive Provider Benefit Plan Act; providing information to enrollees and prospective enrollees; the availability of exclusive providers; notice of nonrenewal or termination; transitions of service and continuity of care; prohibitions; exclusive provider benefit plan's access to specialists; health care services appeals, complaints, and external independent reviews; emergency services prior to stabilization; post-stabilization medical services; quality assessment programs; utilization review; and qualifying examinations of insurers and fees. Amends the Freedom of Information Act to establish an exemption for all identified or deidentified health information due to the Department's administration of the Exclusive Provider Benefit Plan Act. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be cited as the
5Exclusive Provider Benefit Plan Act.
 
6    Section 5. For the purposes of this Act:
7    "Clinical peer" means a health care professional who is in
8the same profession and the same or similar specialty as the
9health care provider who typically manages the medical
10condition, procedures, or treatment under review.
11    "Department" means the Department of Insurance.
12    "Director" means the Director of Insurance.
13    "Emergency medical condition" means a medical condition
14manifesting itself by acute symptoms of sufficient severity
15(including severe pain) such that a prudent layperson, who
16possesses an average knowledge of health and medicine, could
17reasonably expect the absence of immediate medical attention to
18result in:
19        (1) placing the health of the individual (or, with
20    respect to a pregnant woman, the health of the woman or her
21    unborn child) in serious jeopardy;
22        (2) serious impairment to bodily functions; or
23        (3) serious dysfunction of any bodily organ or part.

 

 

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1    "Emergency services" means, with respect to an enrollee of
2a health care plan, transportation services, including, but not
3limited to, ambulance services, and covered inpatient and
4outpatient hospital services furnished by a provider qualified
5to furnish those services that are needed to evaluate or
6stabilize an emergency medical condition. "Emergency services"
7does not include post-stabilization medical services.
8    "Enrollee" means any person and his or her dependents
9enrolled in or covered by an exclusive provider benefit plan.
10    "Exclusive provider" means a provider or health care
11provider, or an organization of providers or health care
12providers, who contracts with an insurer to provide medical
13care or health care to insureds covered by a health insurance
14policy.
15    "Exclusive provider benefit plan" means a benefit plan in
16which an insurer contracts with a provider to provide some
17services to an insured, not including emergency care services
18required under Section 65 of the Managed Care Reform and
19Patients Right Act, provided by a health care provider who is a
20non-exclusive provider.
21    "Health care provider" means a provider, institutional
22provider, or other person or organization that furnishes health
23care services and that is licensed or otherwise authorized to
24practice in this State.
25    "Health care services" means any services included in the
26furnishing of medical care to any individual, or the

 

 

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1hospitalization incident to the furnishing of such care, as
2well as the furnishing to any person of any and all other
3services for the purpose of preventing, alleviating, curing, or
4healing human illness or injury.
5    "Health insurance policy" means a group or individual
6insurance policy, certificate, or contract providing benefits
7for medical or surgical expenses incurred as a result of an
8accident or sickness.
9    "Hospital" means an institution licensed under the
10Hospital Licensing Act, an institution that meets all
11comparable conditions and requirements in effect in the state
12in which it is located, or the University of Illinois Hospital
13as defined in the University of Illinois Hospital Act.
14    "Institutional provider" means a hospital, nursing home,
15or other medical or health-related service facility that
16provides care for the sick or injured or other care that may be
17covered in a health insurance policy.
18    "Insurer" means an insurance company or a health service
19corporation authorized in this State to issue policies or
20subscriber contracts that reimburse for expense of health care
21services.
22    "Post-stabilization medical services" means health care
23services provided to an enrollee that are furnished in a
24licensed hospital by a provider that is qualified to furnish
25such services, and determined to be medically necessary and
26directly related to the emergency medical condition following

 

 

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1stabilization.
2    "Preauthorization" means a determination by an insurer
3that medical care or health care services proposed to be
4provided to a patient are medically necessary and appropriate.
5    "Provider" means an individual or entity duly licensed or
6legally authorized to provide health care services.
7    "Service area" means a geographic area or areas specified
8in an exclusive provider benefit contract in which a network of
9exclusive providers is offered and available.
10    "Stabilization" means, with respect to an emergency
11medical condition, to provide such medical treatment of the
12condition as may be necessary to ensure, within reasonable
13medical probability, that no material deterioration of the
14condition is likely to result.
 
15    Section 10. Exclusive provider benefit plans permitted. An
16exclusive provider benefit plan that meets the requirements of
17this Act shall be permitted. To the extent of any conflict
18between this Section and any other statutory provision, this
19Section prevails over the conflicting provision. The Director
20of Insurance may adopt rules necessary to implement the
21Department's responsibilities under this Act.
 
22    Section 15. Applicability of this Act.
23    (a) Except as otherwise specifically provided by this
24Section, this Section applies to each individual or group

 

 

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1exclusive provider benefit plan in which an insurer provides,
2through the insurer's health insurance policy, for the payment
3of coverage only for the use of an exclusive provider network,
4other than the use of a non-exclusive provider for emergency
5care services.
6    (b) Unless otherwise specified, an exclusive provider
7benefit plan is subject to this Section.
8    (c) This Act does not apply to:
9        (1) the Children's Health Insurance Program under the
10    Children's Health Insurance Program Act;
11        (2) a Medicaid managed care program under Article V of
12    the Illinois Public Aid Code; or
13        (3) an HMO under Article I of the Health Maintenance
14    Organization Act.
15    (d) An insurer duly licensed under the laws of this State
16may offer exclusive provider benefit plans to individuals and
17group health plans in conformity with the terms set forth in
18this Section. An insurer shall not be required to be licensed
19as an HMO under the Health Maintenance Organization Act in
20order to offer exclusive provider benefit plans under this
21Section.
 
22    Section 20. Applicability of Health Carrier External
23Review Act. The Health Carrier External Review Act shall apply
24to an exclusive provider benefit plan, except to the extent
25that the Director determines the provision to be inconsistent

 

 

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1with the function and purpose of an exclusive provider benefit
2plan.
 
3    Section 25. Construction of Act.
4    (a) This Act may not be construed to limit the level of
5reimbursement or the level of coverage, including deductibles,
6copayments, coinsurance, or other cost-sharing provisions,
7that are applicable to exclusive providers.
8    (b) Except as specifically provided for in this Act, this
9Act may not be construed to require an exclusive provider
10benefit plan to compensate a non-exclusive provider for
11services provided to an insured.
 
12    Section 30. Provision of information.
13    (a) An exclusive provider benefit plan shall provide
14annually to enrollees and prospective enrollees, upon request,
15a complete list of exclusive providers in the exclusive
16provider benefit plan service area and a description of the
17following terms of coverage:
18        (1) the service area;
19        (2) the covered benefits and services with all
20    exclusions, exceptions, and limitations;
21        (3) the pre-certification and other utilization
22    review, if applicable, procedures and requirements;
23        (4) a description of any limitation on access to
24    specialists, and the plan's standing referral policy;

 

 

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1        (5) the emergency coverage and benefits, including any
2    restrictions on emergency care services;
3        (6) the out-of-area coverage and benefits, if any;
4        (7) the enrollee's financial responsibility for
5    copayments, deductibles, premiums, and any other
6    out-of-pocket expenses;
7        (8) the provisions for continuity of treatment in the
8    event an exclusive provider's participation terminates
9    during the course of an enrollee's treatment by that
10    exclusive provider;
11        (9) the appeals process, forms, and time frames for
12    health care services appeals, complaints, and external
13    independent reviews, administrative complaints, and
14    utilization review complaints, if applicable, including a
15    phone number to call to receive more information from the
16    exclusive provider benefits plan concerning the appeals
17    process; and
18        (10) a statement of all basic health care services and
19    all specific benefits and services mandated to be provided
20    to enrollees by any State law or administrative rule.
21    In the event of an inconsistency between any separate
22written disclosure statement and the enrollee contract or
23certificate, the terms of the enrollee contract or certificate
24shall control.
25    (b) Upon written request, an exclusive provider benefit
26plan shall provide to enrollees a description of the financial

 

 

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1relationships between the exclusive provider benefit plan and
2any health care provider and, if requested, the percentage of
3copayments, deductibles, and total premiums spent on
4healthcare related expenses and the percentage of copayments,
5deductibles, and total premiums spent on other expenses,
6including administrative expenses, except that no exclusive
7provider benefit plan shall be required to disclose specific
8provider reimbursement.
9    (c) An exclusive provider shall provide all of the
10following, where applicable, to enrollees upon request:
11        (1) Information related to the exclusive provider's
12    educational background, experience, training, specialty,
13    and board certification, if applicable.
14        (2) The names of licensed facilities on the provider
15    panel where the exclusive provider presently has
16    privileges for the treatment, illness, or procedure that is
17    the subject of the request.
18        (3) Information regarding the exclusive provider's
19    participation in continuing education programs and
20    compliance with any licensure, certification, or
21    registration requirements, if applicable.
22    (d) An exclusive provider benefit plan shall provide the
23information required to be disclosed under this Act upon
24enrollment and annually thereafter in a legible and
25understandable format. The Department of Insurance shall adopt
26rules to establish the format based, to the extent practical,

 

 

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1on the standards developed for supplemental insurance coverage
2under Title XVIII of the federal Social Security Act as a
3guide, so that a person can compare the attributes of the
4various health care plans.
5    (e) An identification card or similar document issued by an
6insurer to an insured in an exclusive provider benefit plan
7must display:
8        (1) a toll-free number that a physician or health care
9    provider may use to obtain the date on which the insured
10    became insured under the plan; and
11        (2) the acronym "EPO" or the phrase "Exclusive Provider
12    Organization" on the card in a location of the insurer's
13    choice.
14    (f) The written disclosure requirements of this Section may
15be met by disclosure to one enrollee in a household.
 
16    Section 35. Availability of exclusive providers.
17    (a) An insurer offering an exclusive provider benefit plan
18shall ensure that the exclusive provider benefits are
19reasonably available to all insureds within a designated
20service area.
21    (b) If services are not available through an exclusive
22provider within a designated service area under an exclusive
23provider benefit plan, an insurer shall reimburse a physician
24or health care provider who is a non-exclusive provider at the
25same percentage level of benefit as an exclusive provider would

 

 

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1have been reimbursed had the insured been treated by an
2exclusive provider.
 
3    Section 40. Notice of nonrenewal or termination. An
4exclusive provider benefit plan must give at least 60 days
5notice of nonrenewal or termination of an exclusive provider to
6the exclusive provider and to the enrollees served by the
7exclusive provider. The notice shall include a name and address
8to which an enrollee or exclusive provider may direct comments
9and concerns regarding the nonrenewal or termination.
10Immediate written notice may be provided without 60 days notice
11when a health care provider's license has been disciplined by a
12state licensing board.
 
13    Section 45. Transition of service.
14    (a) An exclusive provider benefit plan shall provide for
15continuity of care for its enrollees as follows:
16        (1) If an enrollee's physician leaves the exclusive
17    provider benefit plan's network of health care providers
18    for reasons other than termination of a contract in
19    situations involving imminent harm to a patient or a final
20    disciplinary action by a state licensing board and the
21    physician remains within the exclusive provider benefit
22    plan's service area, the exclusive provider benefit plan
23    shall permit the enrollee to continue an ongoing course of
24    treatment with that physician during a transitional

 

 

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1    period:
2            (A) of 90 days after the date of the notice of the
3        physician's termination from the health care plan to
4        the enrollee of the physician's disaffiliation from
5        the health care plan if the enrollee has an ongoing
6        course of treatment; or
7            (B) that includes the provision of post-partum
8        care directly related to the delivery, if the enrollee
9        has entered the third trimester of pregnancy at the
10        time of the physician's disaffiliation.
11        (2) Notwithstanding the provisions in paragraph (1) of
12    this subsection (a), such care shall be authorized by the
13    exclusive provider benefit plan during the transitional
14    period only if the physician agrees:
15            (A) to continue to accept reimbursement from the
16        exclusive provider benefit plan at the rates
17        applicable prior to the start of the transitional
18        period;
19            (B) to adhere to the exclusive provider benefit
20        plan's quality assurance requirements and to provide
21        to the exclusive provider benefit plan necessary
22        medical information related to such care; and
23            (C) to otherwise adhere to the exclusive provider
24        benefit plan's policies and procedures, including, but
25        not limited to, procedures regarding referrals and
26        obtaining preauthorizations for treatment.

 

 

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1    (b) An exclusive provider benefit plan shall provide for
2continuity of care for new enrollees as follows:
3        (1) If a new enrollee whose physician is not a member
4    of the exclusive provider benefit plan's provider network,
5    but is within the exclusive provider benefit plan's service
6    area, enrolls in the exclusive provider benefit plan, the
7    exclusive provider benefit plan shall permit the enrollee
8    to continue an ongoing course of treatment with the
9    enrollee's current physician during a transitional period:
10            (A) of 90 days after the effective date of
11        enrollment if the enrollee has an ongoing course of
12        treatment; or
13            (B) that includes the provision of post-partum
14        care directly related to the delivery, if the enrollee
15        has entered the third trimester of pregnancy at the
16        effective date of enrollment.
17        (2) If an enrollee elects to continue to receive care
18    from such physician pursuant to paragraph (1) of this
19    subsection (a), such care shall be authorized by the
20    exclusive provider benefit plan for the transitional
21    period only if the physician agrees:
22            (A) to accept reimbursement from the exclusive
23        provider benefit plan at rates established by the
24        exclusive provider benefit plan; such rates shall be
25        the level of reimbursement applicable to similar
26        physicians within the exclusive provider benefit plan

 

 

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1        for such services;
2            (B) to adhere to the exclusive provider benefit
3        plan's quality assurance requirements and to provide
4        to the exclusive provider benefit plan necessary
5        medical information related to such care; and
6            (C) to otherwise adhere to the exclusive provider
7        benefit plan's policies and procedures, including, but
8        not limited to, procedures regarding referrals and
9        obtaining preauthorization for treatment.
10    (c) In no event shall this Section be construed to require
11an exclusive provider benefit plan to provide coverage for
12benefits not otherwise covered or to diminish or impair
13preexisting condition limitations contained in the enrollee's
14contract.
 
15    Section 50. Prohibitions.
16    (a) No exclusive provider benefit plan or its
17subcontractors may prohibit or discourage health care
18providers by contract or policy from discussing any health care
19services and health care providers, utilization review, if
20applicable, and quality assurance policies, terms, and
21conditions of plans, and plan policy with enrollees,
22prospective enrollees, providers, or the public.
23    (b) No exclusive provider benefit plan by contract, written
24policy, or procedure may permit or allow an individual or
25entity to dispense a different drug in place of the drug or

 

 

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1brand of drug ordered or prescribed without the express
2permission of the person ordering or prescribing the drug,
3except as provided under Section 3.14 of the Illinois Food,
4Drug and Cosmetic Act.
 
5    Section 55. Exclusive provider benefit plans; access to
6specialists.
7    (a) When the type of specialist physician or other health
8care provider needed to provide care for a specific condition
9is not represented in the exclusive provider benefit plan's
10network, the exclusive provider benefit plan shall allow for
11the enrollee to have access to a non-exclusive provider within
12a reasonable distance and travel time at no additional cost
13beyond what the enrollee would otherwise pay for services
14received within the network if it is determined by a licensed
15clinical peer that the service or treatment of the specific
16condition is medically necessary and such services or
17treatments are not available through the exclusive provider
18benefit plan network. Coverage for all services performed in
19accordance with this Section shall be at the same benefit level
20as if the service or treatment had been rendered by an
21exclusive provider.
22    (b) If an exclusive provider benefit plan denies an
23enrollee's request for a specialist physician or other health
24care provider that is not represented in the exclusive provider
25benefit plan's network, an enrollee may appeal the decision

 

 

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1through the exclusive provider benefit plan's external
2independent review process as provided by the Health Carrier
3External Review Act.
 
4    Section 60. Health care services appeals, complaints, and
5external independent reviews.
6    (a) An exclusive provider benefit plan shall establish and
7maintain an appeals procedure as outlined in this Act.
8Compliance with this Act's appeals procedures shall satisfy an
9exclusive provider benefit plan's obligation to provide appeal
10procedures under any other State law or rules.
11    (b) When an appeal concerns a decision or action by an
12exclusive provider benefit plan, its employees, or its
13subcontractors that relates to (i) health care services,
14including, but not limited to, procedures or treatments, for an
15enrollee with an ongoing course of treatment ordered by a
16health care provider, the denial of which could significantly
17increase the risk to an enrollee's health or (ii) a treatment
18referral, service, procedure, or other health care service, the
19denial of which could significantly increase the risk to an
20enrollee's health, the exclusive provider benefit plan must
21allow for the filing of an appeal either orally or in writing.
22Upon submission of the appeal, an exclusive provider benefit
23plan must notify the party filing the appeal as soon as
24possible, but in no event more than 24 hours after the
25submission of the appeal, of all information that the exclusive

 

 

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1provider benefit plan requires to evaluate the appeal. The
2exclusive provider benefit plan shall render a decision on the
3appeal within 24 hours after receipt of the required
4information. The exclusive provider benefit plan shall notify
5the party filing the appeal and the enrollee and any health
6care provider who recommended the health care service involved
7in the appeal of its decision orally, followed up by a written
8notice of the determination.
9    (c) For all appeals related to health care services,
10including, but not limited to, procedures or treatments for an
11enrollee, not covered by subsection (b) of this Section, the
12exclusive provider benefit plan shall establish a procedure for
13the filing of such appeals. Upon submission of an appeal under
14this subsection (c), an exclusive provider benefit plan must
15notify the party filing an appeal, within 3 business days after
16the submission, of all information that the plan requires to
17evaluate the appeal. The exclusive provider benefit plan shall
18render a decision on the appeal within 15 business days after
19receipt of the required information. The health care plan shall
20notify the party filing the appeal, the enrollee, and any
21health care provider who recommended the health care service
22involved in the appeal orally of its decision, followed up by a
23written notice of the determination.
24    (d) An appeal under subsections (b) or (c) of this Section
25may be filed by the enrollee, the enrollee's designee or
26guardian, or the enrollee's health care provider. An exclusive

 

 

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1provider benefit plan shall designate a clinical peer to review
2appeals, because these appeals pertain to medical or clinical
3matters and such an appeal must be reviewed by an appropriate
4health care professional. No one reviewing an appeal may have
5had any involvement in the initial determination that is the
6subject of the appeal. The written notice of determination
7required under subsections (b) and (c) shall include (i) clear
8and detailed reasons for the determination, (ii) the medical or
9clinical criteria for the determination, which shall be based
10upon sound clinical evidence and reviewed on a periodic basis,
11and (iii) in the case of an adverse determination, the
12procedures for requesting an external independent review as
13provided by the Health Carrier External Review Act.
14    (e) If an appeal filed under subsections (b) or (c) is
15denied for a reason, including, but not limited to, the
16service, procedure, or treatment is not viewed as medically
17necessary, denial of specific tests or procedures, denial of
18referral to specialist physicians or denial of hospitalization
19requests or length of stay requests, any involved party may
20request an external independent review as provided by the
21Health Carrier External Review Act.
22    (f) Future contractual or employment action by the
23exclusive provider benefit plan regarding the patient's
24physician or other health care provider shall not be based
25solely on the physician's or other health care provider's
26participation in health care services appeals, complaints, or

 

 

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1external independent reviews under the Health Carrier External
2Review Act.
3    (g) Nothing in this Section shall be construed to require
4an exclusive provider benefit plan to pay for a health care
5service not covered under the enrollee's certificate of
6coverage or policy.
 
7    Section 65. Emergency services prior to stabilization.
8    (a) An exclusive provider benefit plan that provides or
9that is required by law to provide coverage for emergency
10services shall provide coverage such that payment under this
11coverage is not dependent upon whether the services are
12performed by a plan or non-plan health care provider and
13without regard to prior authorization. This coverage shall be
14at the same benefit level as if the services or treatment had
15been rendered by the health care plan physician licensed to
16practice medicine in all its branches or health care provider.
17    (b) Prior authorization or approval by the plan shall not
18be required for emergency services.
19    (c) Coverage and payment shall only be retrospectively
20denied under the following circumstances:
21        (1) upon reasonable determination that the emergency
22    services claimed were never performed;
23        (2) upon timely determination that the emergency
24    evaluation and treatment were rendered to an enrollee who
25    sought emergency services and whose circumstance did not

 

 

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1    meet the definition of emergency medical condition;
2        (3) upon determination that the patient receiving such
3    services was not an enrollee of the health care plan; or
4        (4) upon material misrepresentation by the enrollee or
5    health care provider.
6    For the purposes of this subsection (c), "material" means a
7fact or situation that is not merely technical in nature and
8results or could result in a substantial change in the
9situation.
10    (d) When an enrollee presents to a hospital seeking
11emergency services, the determination as to whether the need
12for those services exists shall be made for purposes of
13treatment by a physician licensed to practice medicine in all
14its branches or, to the extent permitted by applicable law, by
15other appropriately licensed personnel under the supervision
16of or in collaboration with a physician licensed to practice
17medicine in all its branches. The physician or other
18appropriate personnel shall indicate in the patient's chart the
19results of the emergency medical screening examination.
20    (e) The appropriate use of the 9-1-1 emergency telephone
21system or its local equivalent shall not be discouraged or
22penalized by the exclusive provider benefit plan when an
23emergency medical condition exists. This provision shall not
24imply that the use of the 9-1-1 emergency telephone system or
25its local equivalent is a factor in determining the existence
26of an emergency medical condition.

 

 

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1    (f) The medical director's or his or her designee's
2determination of whether the enrollee meets the standard of an
3emergency medical condition shall be based solely upon the
4presenting symptoms documented in the medical record at the
5time care was sought. Only a clinical peer may make an adverse
6determination.
7    (g) Nothing in this Section shall prohibit the imposition
8of deductibles, copayments, and co-insurance.
 
9    Section 70. Post-stabilization medical services.
10    (a) If prior authorization for covered post-stabilization
11services is required by the exclusive provider benefit plan,
12the plan shall provide access 24 hours a day, 7 days a week to
13persons designated by the plan to make such determinations,
14provided that any determination made under this Section must be
15made by a health care professional.
16    (b) The treating physician licensed to practice medicine in
17all its branches or health care provider shall contact the
18exclusive provider benefit plan or delegated health care
19provider as designated on the enrollee's health insurance card
20to obtain authorization, denial, or arrangements for an
21alternate plan of treatment or transfer of the enrollee.
22    (c) The treating physician licensed to practice medicine in
23all its branches or health care provider shall document in the
24enrollee's medical record the enrollee's presenting symptoms;
25emergency medical condition; and time, phone number dialed, and

 

 

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1result of the communication for request for authorization of
2post-stabilization medical services. The exclusive provider
3benefit plan shall provide reimbursement for covered
4post-stabilization medical services if:
5        (1) authorization to render them is received from the
6    exclusive provider benefit plan or its delegated health
7    care provider; or
8        (2) after 2 documented good faith efforts, the treating
9    health care provider has attempted to contact the
10    enrollee's exclusive provider benefit plan or its
11    delegated health care provider, as designated on the
12    enrollee's health insurance card, for prior authorization
13    of post-stabilization medical services and neither the
14    plan nor designated persons were accessible or the
15    authorization was not denied within 60 minutes of the
16    request.
17    For the purposes of this subsection (c), "2 documented good
18faith efforts" means the health care provider has called the
19telephone number on the enrollee's health insurance card or
20other available number either 2 times or one time and an
21additional call to any referral number provided.
22    (d) After rendering any post-stabilization medical
23services, the treating physician licensed to practice medicine
24in all its branches or health care provider shall continue to
25make every reasonable effort to contact the exclusive provider
26benefit plan or its delegated health care provider regarding

 

 

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1authorization, denial, or arrangements for an alternate plan of
2treatment or transfer of the enrollee until the treating health
3care provider receives instructions from the exclusive
4provider benefit plan or delegated health care provider for
5continued care or the care is transferred to another health
6care provider or the patient is discharged.
7    (e) Payment for covered post-stabilization services may be
8denied:
9        (1) if the treating health care provider does not meet
10    the conditions outlined in subsection (c) of this Section;
11        (2) upon determination that the post-stabilization
12    services claimed were not performed;
13        (3) upon timely determination that the
14    post-stabilization services rendered were contrary to the
15    instructions of the exclusive provider benefit plan or its
16    delegated health care provider if contact was made between
17    those parties prior to the service being rendered;
18        (4) upon determination that the patient receiving such
19    services was not an enrollee of the exclusive provider
20    benefit plan; or
21        (5) upon material misrepresentation by the enrollee or
22    health care provider.
23    For the purposes of this subsection (e), "material" means a
24fact or situation that is not merely technical in nature and
25results or could result in a substantial change in the
26situation.

 

 

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1    (f) Nothing in this Section prohibits an exclusive provider
2benefit plan from delegating tasks associated with the
3responsibilities enumerated in this Section to the exclusive
4provider benefit plan's contracted health care providers or
5another entity. Only a clinical peer may make an adverse
6determination. However, the ultimate responsibility for
7coverage and payment decisions may not be delegated.
8    (g) Coverage and payment for post-stabilization medical
9services for which prior authorization or deemed approval is
10received shall not be retrospectively denied.
11    (h) Nothing in this Section shall prohibit the imposition
12of deductibles, copayments, and co-insurance.
 
13    Section 75. Quality assessment program.
14    (a) An exclusive provider benefit plan shall develop and
15implement a quality assessment and improvement strategy
16designed to identify and evaluate accessibility, continuity,
17and quality of care. The exclusive provider benefit plan shall
18have:
19        (1) an ongoing, written, internal quality assessment
20    program;
21        (2) specific written guidelines for monitoring and
22    evaluating the quality and appropriateness of care and
23    services provided to enrollees requiring the exclusive
24    provider benefit plan to assess:
25            (A) the accessibility to health care providers;

 

 

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1            (B) appropriateness of utilization;
2            (C) concerns identified by the exclusive provider
3        benefit plan's medical or administrative staff and
4        enrollees; and
5            (D) other aspects of care and service directly
6        related to the improvement of quality of care;
7        (3) a procedure for remedial action to correct quality
8    problems that have been verified in accordance with the
9    written plan's methodology and criteria, including written
10    procedures for taking appropriate corrective action; and
11        (4) follow-up measures implemented to evaluate the
12    effectiveness of the action plan.
13    (b) The exclusive provider benefit plan shall establish a
14committee that oversees the quality assessment and improvement
15strategy that includes physician and enrollee participation.
16    (c) Reports on quality assessment and improvement
17activities shall be made to the governing body of the exclusive
18provider benefit plan not less than quarterly.
19    (d) The exclusive provider benefit plan shall make
20available its written description of the quality assessment
21program to the Department of Public Health.
22    (e) With the exception of subsection (d), the Department of
23Public Health shall accept evidence of accreditation with
24regard to the health care network quality management and
25performance improvement standards of:
26        (1) the National Commission on Quality Assurance

 

 

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1    (NCQA);
2        (2) the American Accreditation Healthcare Commission
3    (URAC);
4        (3) the Joint Commission on Accreditation of
5    Healthcare Organizations (JCAHO); or
6        (4) any other entity that the Director of Public Health
7    deems has substantially similar or more stringent
8    standards than provided for in this Section.
9    (f) If the Department of Public Health determines that an
10exclusive provider benefit plan is not in compliance with the
11terms of this Section, it shall certify the finding to the
12Department of Insurance. The Department of Insurance may
13subject the exclusive provider benefit plan to penalties, as
14provided in this Act, for such non-compliance.
 
15    Section 80. Utilization review. If an exclusive provider
16benefit plan conducts a utilization review program in this
17State, then the exclusive provider benefit plan shall do so in
18accordance with Section 85 of the Managed Care Reform and
19Patient Rights Act.
 
20    Section 85. Examinations and fees. The Director may examine
21an insurer to determine the quality and adequacy of a network
22used by an exclusive provider benefit plan offered by the
23insurer under this Act. An insurer is subject to a qualifying
24examination of the insurer's exclusive provider benefit plans

 

 

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1and subsequent quality of care examinations by the Director at
2least once every 5 years. Documentation provided to the
3Director during an examination conducted under this Section is
4confidential and is not subject to disclosure as public
5information under the Freedom of Information Act.
 
6    Section 900. The Freedom of Information Act is amended by
7changing Section 7.5 as follows:
 
8    (5 ILCS 140/7.5)
9    Sec. 7.5. Statutory Exemptions. To the extent provided for
10by the statutes referenced below, the following shall be exempt
11from inspection and copying:
12    (a) All information determined to be confidential under
13Section 4002 of the Technology Advancement and Development Act.
14    (b) Library circulation and order records identifying
15library users with specific materials under the Library Records
16Confidentiality Act.
17    (c) Applications, related documents, and medical records
18received by the Experimental Organ Transplantation Procedures
19Board and any and all documents or other records prepared by
20the Experimental Organ Transplantation Procedures Board or its
21staff relating to applications it has received.
22    (d) Information and records held by the Department of
23Public Health and its authorized representatives relating to
24known or suspected cases of sexually transmissible disease or

 

 

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1any information the disclosure of which is restricted under the
2Illinois Sexually Transmissible Disease Control Act.
3    (e) Information the disclosure of which is exempted under
4Section 30 of the Radon Industry Licensing Act.
5    (f) Firm performance evaluations under Section 55 of the
6Architectural, Engineering, and Land Surveying Qualifications
7Based Selection Act.
8    (g) Information the disclosure of which is restricted and
9exempted under Section 50 of the Illinois Prepaid Tuition Act.
10    (h) Information the disclosure of which is exempted under
11the State Officials and Employees Ethics Act, and records of
12any lawfully created State or local inspector general's office
13that would be exempt if created or obtained by an Executive
14Inspector General's office under that Act.
15    (i) Information contained in a local emergency energy plan
16submitted to a municipality in accordance with a local
17emergency energy plan ordinance that is adopted under Section
1811-21.5-5 of the Illinois Municipal Code.
19    (j) Information and data concerning the distribution of
20surcharge moneys collected and remitted by wireless carriers
21under the Wireless Emergency Telephone Safety Act.
22    (k) Law enforcement officer identification information or
23driver identification information compiled by a law
24enforcement agency or the Department of Transportation under
25Section 11-212 of the Illinois Vehicle Code.
26    (l) Records and information provided to a residential

 

 

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1health care facility resident sexual assault and death review
2team or the Executive Council under the Abuse Prevention Review
3Team Act.
4    (m) Information provided to the predatory lending database
5created pursuant to Article 3 of the Residential Real Property
6Disclosure Act, except to the extent authorized under that
7Article.
8    (n) Defense budgets and petitions for certification of
9compensation and expenses for court appointed trial counsel as
10provided under Sections 10 and 15 of the Capital Crimes
11Litigation Act. This subsection (n) shall apply until the
12conclusion of the trial of the case, even if the prosecution
13chooses not to pursue the death penalty prior to trial or
14sentencing.
15    (o) Information that is prohibited from being disclosed
16under Section 4 of the Illinois Health and Hazardous Substances
17Registry Act.
18    (p) Security portions of system safety program plans,
19investigation reports, surveys, schedules, lists, data, or
20information compiled, collected, or prepared by or for the
21Regional Transportation Authority under Section 2.11 of the
22Regional Transportation Authority Act or the St. Clair County
23Transit District under the Bi-State Transit Safety Act.
24    (q) Information prohibited from being disclosed by the
25Personnel Records Review Act.
26    (r) Information prohibited from being disclosed by the

 

 

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1Illinois School Student Records Act.
2    (s) Information the disclosure of which is restricted under
3Section 5-108 of the Public Utilities Act.
4    (t) All identified or deidentified health information in
5the form of health data or medical records contained in, stored
6in, submitted to, transferred by, or released from the Illinois
7Health Information Exchange, and identified or deidentified
8health information in the form of health data and medical
9records of the Illinois Health Information Exchange in the
10possession of the Illinois Health Information Exchange
11Authority due to its administration of the Illinois Health
12Information Exchange. The terms "identified" and
13"deidentified" shall be given the same meaning as in the Health
14Insurance Accountability and Portability Act of 1996, Public
15Law 104-191, or any subsequent amendments thereto, and any
16regulations promulgated thereunder.
17    (u) Records and information provided to an independent team
18of experts under Brian's Law.
19    (v) Names and information of people who have applied for or
20received Firearm Owner's Identification Cards under the
21Firearm Owners Identification Card Act.
22    (w) Personally identifiable information which is exempted
23from disclosure under subsection (g) of Section 19.1 of the
24Toll Highway Act.
25    (x) Information which is exempted from disclosure under
26Section 5-1014.3 of the Counties Code or Section 8-11-21 of the

 

 

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1Illinois Municipal Code.
2    (y) All identified or deidentified health information in
3the form of health data or medical records in possession of the
4Department of Insurance due to the Department's administration
5of the Exclusive Provider Benefit Plan Act.
6(Source: P.A. 96-542, eff. 1-1-10; 96-1235, eff. 1-1-11;
796-1331, eff. 7-27-10; 97-80, eff. 7-5-11; 97-333, eff.
88-12-11; 97-342, eff. 8-12-11; 97-813, eff. 7-13-12; 97-976,
9eff. 1-1-13.)
 
10    Section 999. Effective date. This Act takes effect upon
11becoming law.