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91_HB0579
LRB9100767JSpcA
1 AN ACT concerning the delivery of health care services.
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 Patient Rights Act.
6 Section 5. Health care patient rights.
7 (a) A patient has the right to care consistent with
8 professional standards of practice to assure quality nursing
9 and medical practices, to choose the participating physician
10 responsible for coordinating his or her care, to receive
11 information concerning his or her condition and proposed
12 treatment, to refuse any treatment to the extent permitted by
13 law, and to privacy and confidentiality of records except as
14 otherwise provided by law.
15 (b) A patient has the right, regardless of source of
16 payment, to examine and to receive a reasonable explanation
17 of his or her total bill for health care services rendered by
18 his or her physician or health care provider, including the
19 itemized charges for specific health care services received.
20 A physician or health care provider shall be responsible only
21 for a reasonable explanation of those specific health care
22 services provided by the physician or health care provider.
23 (c) A patient has the right to timely prior notice of
24 the termination in the event a health care plan cancels or
25 refuses to renew an enrollee's participation in the plan.
26 (d) A patient has the right to privacy and
27 confidentiality in health care. This right may be expressly
28 waived in writing by the patient or the patient's guardian.
29 (e) An individual has the right to purchase any health
30 care services with that individual's own funds.
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1 Section 10. Definitions:
2 "Department" means the Department of Insurance.
3 "Emergency medical condition" means a medical condition
4 manifesting itself by acute symptoms of sufficient severity
5 (including severe pain) such that a prudent layperson, who
6 possesses an average knowledge of health and medicine, could
7 reasonably expect the absence of immediate medical attention
8 to result in:
9 (1) placing the health of the individual (or, with
10 respect to a pregnant woman, the health of the woman or
11 her unborn child) in serious jeopardy;
12 (2) serious impairment to bodily functions; or
13 (3) serious dysfunction of any bodily organ or
14 part.
15 "Emergency services" means, with respect to an enrollee
16 of a health plan, transportation services and covered
17 inpatient and outpatient hospital services furnished by a
18 provider qualified to furnish those services that are needed
19 to evaluate or stabilize an emergency medical condition.
20 "Emergency services" does not refer to post-stabilization
21 medical services.
22 "Enrollee" means any person and his or her dependents
23 enrolled in or covered by a health care plan.
24 "Health care plan" means a plan that establishes,
25 operates, or maintains a network of health care providers
26 that have entered into agreements with the plan to provide
27 health care services to enrollees to whom the plan has the
28 ultimate obligation to arrange for the provision of or
29 payment for services through organizational arrangements for
30 ongoing quality assurance, utilization review programs, or
31 dispute resolution.
32 For purposes of this definition, "health care plan" shall
33 not include the following:
34 (1) indemnity health insurance policies including
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1 those using a contracted provider network;
2 (2) health care plans that offer only dental or
3 only vision coverage;
4 (3) preferred provider administrators, as defined
5 in Section 370g(g) of the Illinois Insurance Code;
6 (4) employee or employer self-insured health
7 benefit plans under the federal Employee Retirement
8 Income Security Act of 1974; and
9 (5) health care provided pursuant to the Workers'
10 Compensation Act or the Workers' Occupational Diseases
11 Act.
12 "Health care provider" means any hospital facility or
13 other person that is licensed or otherwise authorized to
14 deliver health care services.
15 "Health care services" means any services included in the
16 furnishing to any individual of medical care, or the
17 hospitalization or incident to the furnishing of such care or
18 hospitalization as well as the furnishing to any person of
19 any and all other services for the purpose of preventing,
20 alleviating, curing, or healing human illness or injury
21 including home health and pharmaceutical services and
22 products.
23 "Medical director" means a physician licensed in any
24 state to practice medicine in all its branches appointed by a
25 health care plan.
26 "Person" means a corporation, association, partnership,
27 limited liability company, sole proprietorship, or any other
28 legal entity.
29 "Physician" means a person licensed under the Medical
30 Practice Act of 1987.
31 "Post-stabilization medical services" means health care
32 services provided to an enrollee that are furnished in a
33 licensed hospital by a physician or health care provider that
34 is qualified to furnish such services, and determined to be
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1 medically necessary and directly related to the emergency
2 medical condition following stabilization.
3 "Primary care" means the provision of a broad range of
4 personal health care services (preventive, diagnostic,
5 curative, counseling, or rehabilitative) in a manner that is
6 accessible and comprehensive and coordinated by a physician
7 licensed to practice medicine in all its branches.
8 "Primary care physician" means a physician who has
9 contracted with a health care plan to provide primary care
10 services as defined by the contract and who is a physician
11 licensed to practice medicine in all of its branches. Nothing
12 in this definition shall be construed to prohibit a health
13 care plan from requiring a physician to meet a health care
14 plan's criteria in order to coordinate access to health care.
15 "Stabilization" means, with respect to an emergency
16 medical condition, to provide such medical treatment of the
17 condition as may be necessary to assure, within reasonable
18 medical probability, that no material deterioration of the
19 condition is likely to result.
20 "Utilization review" means the evaluation of the medical
21 necessity, appropriateness, and efficiency of the use of
22 health care services, procedures, and facilities.
23 "Utilization review program" means a program established
24 by a person to perform utilization review.
25 Section 15. Provision of information.
26 (a) A health care plan shall provide to enrollees and,
27 upon request, to prospective enrollees a list of
28 participating physicians and health care providers in the
29 health care plan's service area and an evidence of coverage
30 that contains a description of the following terms of
31 coverage:
32 (1) the service area;
33 (2) covered benefits, exclusions or limitations;
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1 (3) precertification and other utilization review
2 procedures and requirements;
3 (4) a description of the limitations on access to
4 specialists;
5 (5) emergency coverage and benefits;
6 (6) out-of-area coverages and benefits, if any;
7 (7) the enrollee's financial responsibility for
8 copayments, deductibles, and any other out-of-pocket
9 expenses;
10 (8) provisions for continuity of treatment in the
11 event a physician's or health care provider's
12 participation terminates during the course of an
13 enrollee's treatment by that physician or health care
14 provider; and
15 (9) the grievance process, including the telephone
16 number to call to receive information concerning
17 grievance procedures.
18 (b) Upon written request, a health care plan shall
19 provide to enrollees a description of the financial
20 relationships between the health care plan and any physician
21 or health care provider, except that no health care plan
22 shall be required to disclose specific reimbursement to
23 physicians or health care providers.
24 (c) A participating physician or health care provider
25 shall provide all of the following, where applicable, to
26 enrollees upon request:
27 (1) Information related to the physician's or
28 health care provider's educational background,
29 experience, training, specialty, and board certification,
30 if applicable.
31 (2) The names of licensed facilities on the health
32 care provider panel where the physician or health care
33 provider presently has privileges for the treatment,
34 illness, or procedure that is the subject of the request.
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1 (3) Information regarding the physician's or health
2 care provider's participation in continuing education
3 programs and compliance with any licensure,
4 certification, or registration requirements, if
5 applicable.
6 (d) A health care plan shall provide the information
7 required to be disclosed under this Act in a legible and
8 understandable format consistent with the standards developed
9 for supplemental insurance coverage under Title XVIII of the
10 federal Social Security Act.
11 Section 20. Notice of nonrenewal or termination. A
12 health care plan must give at least 60 days notice of
13 nonrenewal or termination of a physician or health care
14 provider to the physician or health care provider and to the
15 enrollees served by the physician or health care provider.
16 The notice shall include a name and address to which an
17 enrollee, physician, or health care provider may direct
18 comments and concerns regarding the nonrenewal or
19 termination. Immediate written notice may be provided without
20 60 days notice when a physician's or health care provider's
21 license has been disciplined by a state licensing board.
22 Section 25. Transition of services.
23 (a) A health care plan shall provide for continuity of
24 care for its enrollees as follows:
25 (1) If an enrollee's physician leaves the health
26 care plan's network of physicians or health care
27 providers for reasons other than termination of a
28 contract in situations involving imminent harm to a
29 patient or a final disciplinary action by a State
30 licensing board and the physician remains within the
31 health care plan's service area, the health care plan
32 shall permit the enrollee to continue an ongoing course
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1 of treatment with that physician during a transitional
2 period:
3 (A) of at least 90 days from the date of the
4 notice of physician's termination from the health
5 care plan to the enrollee of the physician's
6 disaffiliation from the health care plan if the
7 enrollee has an ongoing course of treatment; or
8 (B) if the enrollee has entered the third
9 trimester of pregnancy at the time of the
10 physician's disaffiliation, that includes the
11 provision of post-partum care directly related to
12 the delivery.
13 (2) Notwithstanding the provisions in item (1) of
14 this subsection, such care shall be authorized by the
15 health care plan during the transitional period only if
16 the physician agrees:
17 (A) to continue to accept reimbursement from
18 the health care plan at the rates applicable prior
19 to the start of the transitional period;
20 (B) to adhere to the health care plan's
21 quality assurance requirements and to provide to the
22 health care plan necessary medical information
23 related to such care; and
24 (C) to otherwise adhere to the health care
25 plan's policies and procedures, including but not
26 limited to procedures regarding referrals and
27 obtaining preauthorizations for treatment.
28 (b) A health care plan shall provide for continuity of
29 care for new enrollees as follows:
30 (1) If a new enrollee whose physician is not a
31 member of the health care plan's physician or provider
32 network, but is within the health care plan's service
33 area, enrolls in the health care plan, the health care
34 plan shall permit the enrollee to continue an ongoing
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1 course of treatment with the enrollee's current physician
2 during a transitional period:
3 (A) of at least 90 days from the effective
4 date of enrollment if the enrollee has an ongoing
5 course of treatment; or
6 (B) if the enrollee has entered the third
7 trimester of pregnancy at the effective date of
8 enrollment, that includes the provision of
9 post-partum care directly related to the delivery.
10 (2) If an enrollee elects to continue to receive
11 care from such physician pursuant to item (1) of this
12 subsection, such care shall be authorized by the health
13 care plan for the transitional period only if the
14 physician agrees:
15 (A) to accept reimbursement from the health
16 care plan at rates established by the health care
17 plan; such rates shall be the level of reimbursement
18 applicable to similar physicians within the health
19 care plan for such services;
20 (B) to adhere to the health care plan's
21 quality assurance requirements and to provide to the
22 health care plan necessary medical information
23 related to such care; and
24 (C) to otherwise adhere to the health care
25 plan's policies and procedures including, but not
26 limited to procedures regarding referrals and
27 obtaining preauthorization for treatment.
28 (c) In no event shall this Section be construed to
29 require a health care plan to provide coverage for benefits
30 not otherwise covered or to diminish or impair preexisting
31 condition limitations contained in the enrollee's contract.
32 Section 30. Restraints on communications prohibited.
33 (a) No health care plan or its subcontractors may
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1 prohibit or discourage physicians or health care providers
2 from discussing any health care services, physicians and
3 health care providers, utilization review and quality
4 assurance policies, terms and conditions of plans and plan
5 policy with enrollees, prospective enrollees, other
6 physicians, other health care providers, or the public.
7 (b) No health care plan or its subcontractors shall by
8 contract, policy, or procedure impose any restrictions on the
9 physicians or health care providers who treat its enrollees
10 as to recommended health care services. Restrictions with
11 respect to the services for which the plan or its
12 subcontractors will pay may be imposed. These restrictions
13 shall not affect the ability of a physician or health care
14 provider to provide services to an enrollee.
15 (c) Any violation of this Section shall be subject to
16 the penalties under this Act.
17 Section 35. Medically appropriate health care
18 protection.
19 (a) No health care plan shall retaliate against a
20 physician or health care provider who advocates for
21 appropriate health care services for patients.
22 (b) It is the public policy of the State of Illinois
23 that a physician or health care provider be encouraged to
24 advocate for medically appropriate health care services for
25 his or her patients. For purposes of this Section, "to
26 advocate for medically appropriate health care services"
27 means to appeal a decision to deny payment for a health care
28 service pursuant to the reasonable grievance or appeal
29 procedure established by a health care plan or to protest a
30 decision, policy, or practice that the physician or health
31 care provider, consistent with that degree of learning and
32 skill ordinarily possessed by physicians or health care
33 providers practicing in the same or a similar locality and
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1 under similar circumstances, reasonably believes impairs the
2 physician's or health care provider's ability to provide
3 appropriate health care services to his or her patients.
4 (c) This Section shall not be construed to prohibit a
5 health care plan from making a determination not to pay for a
6 particular health care service or to prohibit a medical
7 group, independent practice association, preferred provider
8 organization, foundation, hospital medical staff, hospital
9 governing body or health care plan from enforcing reasonable
10 peer review or utilization review protocols or determining
11 whether a physician or health care provider has complied with
12 those protocols.
13 (d) Nothing in this Section shall be construed to
14 prohibit the governing body of a hospital or the hospital
15 medical staff from taking disciplinary actions against a
16 physician as authorized by law.
17 (e) Nothing in this Section shall be construed to
18 prohibit the Department of Professional Regulation from
19 taking disciplinary actions against a physician or health
20 care provider under the appropriate licensing Act.
21 Section 40. Access to specialists.
22 (a) All health care plans that require each enrollee to
23 select a health care provider for any purpose including
24 coordination of care shall allow all enrollees to choose any
25 primary care physician licensed to practice medicine in all
26 its branches or any health care provider participating in the
27 health care plan for that purpose. The health care plan shall
28 provide the enrollee with a choice of licensed health care
29 providers who are accessible and qualified.
30 (b) A health care plan shall establish a procedure by
31 which an enrollee who has a condition that requires ongoing
32 care from a specialist physician or health care provider may
33 apply for a standing referral to a specialist physician or
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1 health care provider if a referral to a specialist physician
2 or health care provider is required for coverage. The
3 application shall be made to the enrollee's primary care
4 physician. This procedure for a standing referral must
5 specify the necessary criteria and conditions that must be
6 met in order for an enrollee to obtain a standing referral. A
7 standing referral shall be effective for the period necessary
8 to provide the referred services or one year. A primary care
9 physician may renew a standing referral.
10 (c) The enrollee may be required by the health care plan
11 to select a specialist physician or health care provider who
12 has a referral arrangement with the enrollee's primary care
13 physician or to select a new primary care physician who has a
14 referral arrangement with the specialist physician or health
15 care provider chosen by the enrollee. If a health care plan
16 requires an enrollee to select a new physician under this
17 subsection, the health care plan must provide the enrollee
18 with both options provided in this subsection.
19 (d) When the type of specialist physician or health care
20 provider needed to provide ongoing care for a specific
21 condition is not represented in the health care plan's
22 network of physicians or health care providers, the primary
23 care physician shall arrange for the enrollee to have access
24 to a qualified non-participating physician or health care
25 provider within a reasonable distance and travel time.
26 (e) The enrollee's primary care physician shall remain
27 responsible for coordinating the care of an enrollee who has
28 received a standing referral to a specialist physician or
29 health care provider. If a secondary referral is necessary,
30 the specialist physician or health care provider shall advise
31 the primary care physician. The primary care physician shall
32 be responsible for making the secondary referral. In
33 addition, the health care plan shall require the specialist
34 physician or health care provider to provide regular updates
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1 to the enrollee's primary care physician.
2 (f) If an enrollee's application for any referral is
3 denied, an enrollee may appeal the decision through the
4 health care plan's medical necessity second opinion process
5 in accordance with Section 45 of this Act.
6 Section 45. Medical necessity; second opinion. A health
7 care plan shall provide a mechanism for the timely review by
8 a physician or health care provider holding the same class of
9 license as the patient's physician or health care provider,
10 who is unaffiliated with the health care plan, jointly
11 selected by the patient (or the patient's next of kin or
12 legal representative if the patient is unable to act for
13 himself), the patient's physician or health care provider,
14 and the health care plan in the event of a dispute between
15 the patient's physician or health care provider and the
16 health care plan regarding the medical necessity of a service
17 or a referral. If the reviewing physician or health care
18 provider determines the service to be medically necessary or
19 the referral to be appropriate, the health care plan shall
20 pay for the service. Future contractual or employment action
21 by the health care plan regarding the patient's physician or
22 health care provider shall not be based solely on the
23 physician's or health care provider's participation in this
24 procedure.
25 Section 50. Choosing a physician.
26 (a) A health care plan may also offer other arrangements
27 under which enrollees may access health care services from
28 contracted physicians or health care providers without a
29 referral or authorization.
30 (b) The enrollee may be required by the health care plan
31 to select a specialist physician or health care provider who
32 has a referral arrangement with the enrollee's primary care
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1 physician or to select a new primary care physician who has a
2 referral arrangement with the specialist physician or health
3 care provider chosen by the enrollee. If a health care plan
4 requires an enrollee to select a new physician under this
5 subsection, the health care plan must provide the enrollee
6 with both options provided in this subsection.
7 (c) The Director of Insurance and the Department of
8 Public Health each may promulgate rules to ensure appropriate
9 access to and quality of care for enrollees in any plan that
10 allows enrollees to access health care services from
11 contracted physicians and health care providers without a
12 referral or authorization from the primary care physician.
13 The rules may include, but shall not be limited to, a system
14 for the retrieval and compilation of enrollees' medical
15 records.
16 Section 55. Emergency services prior to stabilization.
17 (a) A health care plan that provides or that is required
18 by law to provide coverage for emergency services shall
19 provide coverage such that payment under this coverage is not
20 dependent upon whether the services are performed by a plan
21 or non-plan physician or health care provider and without
22 regard to prior authorization. This coverage shall be at the
23 same benefit level as if the services or treatment had been
24 rendered by the health care plan physician or health care
25 provider.
26 (b) Prior authorization or approval by the plan shall
27 not be required for emergency services.
28 (c) Payment shall not be retrospectively denied, with
29 the following exceptions:
30 (1) upon reasonable determination that the
31 emergency services claimed were never performed;
32 (2) upon determination that the emergency
33 evaluation and treatment were rendered to an enrollee who
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1 sought emergency services and whose circumstance did not
2 meet the definition of emergency medical condition;
3 (3) upon determination that the patient receiving
4 such services was not an enrollee of the health care
5 plan; or
6 (4) upon material misrepresentation by the enrollee
7 or health care provider; "material" means a fact or
8 situation that is not merely technical in nature and
9 results or could result in a substantial change in the
10 situation.
11 (d) When an enrollee presents to a hospital seeking
12 emergency services, the determination as to whether the need
13 for those services exists shall be made for purposes of
14 treatment by a physician licensed to practice medicine in all
15 its branches or, to the extent permitted by applicable law,
16 by other appropriately licensed personnel under the
17 supervision of a physician licensed to practice medicine in
18 all its branches. The physician or other appropriate
19 personnel shall indicate in the patient's chart the results
20 of the emergency medical screening examination.
21 (e) The appropriate use of the 911 emergency telephone
22 system or its local equivalent shall not be discouraged or
23 penalized by the health care plan when an emergency medical
24 condition exists. This provision shall not imply that the use
25 of 911 or its local equivalent is a factor in determining the
26 existence of an emergency medical condition.
27 (f) The medical director's or his or her designee's
28 determination of whether the enrollee meets the standard of
29 an emergency medical condition shall be based solely upon the
30 presenting symptoms documented in the medical record at the
31 time care was sought.
32 (g) Nothing in this Section shall prohibit the
33 imposition of deductibles, co-payments, and co-insurance.
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1 Section 60. Post-stabilization medical services.
2 (a) If prior authorization for covered post-stabilization
3 services is required by the health care plan, the plan shall
4 provide access 24 hours a day, 7 days a week to persons
5 designated by the plan to make such determinations.
6 (b) The treating physician or health care provider shall
7 contact the health care plan or delegated physician or health
8 care provider as designated on the enrollee's health
9 insurance card to obtain authorization, denial, or
10 arrangements for an alternate plan of treatment or transfer
11 of the enrollee.
12 (c) The treating physician licensed to practice medicine
13 in all its branches or health care provider shall document in
14 the enrollee's medical record the enrollee's presenting
15 symptoms; emergency medical condition; and time, phone number
16 dialed, and result of the communication for request for
17 authorization of post stabilization medical services. The
18 health care plan shall provide reimbursement for covered
19 post-stabilization medical services if:
20 (1) authorization to render them is received from
21 the health care plan or its delegated physician or health
22 care provider; or
23 (2) after 2 documented good faith efforts, the
24 treating physician or health care provider has attempted
25 to contact the enrollee's health care plan or its
26 delegated physician or health care provider, as
27 designated on the enrollee's health insurance card, for
28 prior authorization of post-stabilization medical
29 services and neither the plan nor designated persons were
30 accessible or the authorization was not denied within 60
31 minutes of the request. "Two documented good faith
32 efforts" means the physician or health care provider has
33 called the telephone number on the enrollee's health
34 insurance card or other available number either 2 times
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1 or one time and an additional call to any referral number
2 provided. "Good faith" means honesty of purpose, freedom
3 from intention to defraud, and being faithful to one's
4 duty or obligation. For the purpose of this Act, good
5 faith shall be presumed.
6 (d) After rendering any post-stabilization medical
7 services, the treating physician or health care provider
8 shall continue to make every reasonable effort to contact the
9 health care plan or its delegated physician or health care
10 provider regarding authorization, denial, or arrangements for
11 an alternate plan of treatment or transfer of the enrollee
12 until the treating physician or health care provider receives
13 instructions from the health care plan or delegated physician
14 or health care provider for continued care or the care is
15 transferred to another physician or health care provider or
16 the patient is discharged.
17 (e) Payment for covered post-stabilization services may
18 be denied:
19 (1) if the treating physician or health care
20 provider does not meet the conditions outlined in
21 subsection (c);
22 (2) upon determination that the post-stabilization
23 services claimed were not performed;
24 (3) upon determination that the post-stabilization
25 services rendered were contrary to the instructions of
26 the health care plan or its delegated physician or health
27 care provider if contact was made between those parties
28 prior to the service being rendered;
29 (4) upon determination that the patient receiving
30 such services was not an enrollee of the health care
31 plan; or
32 (5) upon material misrepresentation by the enrollee
33 or health care provider; "material" means a fact or
34 situation that is not merely technical in nature and
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1 results or could result in a substantial change in the
2 situation.
3 (f) Nothing in this Section prohibits a health care plan
4 from delegating tasks associated with the responsibilities
5 enumerated in this Section to the health care plan's
6 contracted physicians or health care providers or an other
7 entity.
8 (g) Coverage and payment for post-stabilization medical
9 services for which prior authorization or deemed approval is
10 received shall not be retrospectively denied.
11 (h) Nothing in this Section shall prohibit the
12 imposition of deductibles, co-payments, and co-insurance.
13 Section 65. Consumer advisory committee.
14 (a) A health care plan shall establish a consumer
15 advisory committee. The consumer advisory committee shall
16 have the authority to identify and review consumer concerns
17 and make advisory recommendations to the health care plan.
18 The health care plan may also make requests of the consumer
19 advisory committee to provide feedback to proposed changes in
20 plan policies and procedures which will affect enrollees.
21 However, the consumer advisory committee shall not have the
22 authority to hear or resolve specific complaints or
23 grievances, but instead shall refer such complaints or
24 grievances to the health care plan's grievance committee.
25 (b) The health care plan shall randomly select 8
26 enrollees meeting the requirements of this Section to serve
27 on the consumer advisory committee. Upon initial formation
28 of the consumer advisory committee, the health care plan
29 shall appoint 4 enrollees to a 2 year term and 4 enrollees to
30 a one year term. Thereafter, as an enrollee's term expires,
31 the health care plan shall re-appoint or appoint an enrollee
32 to serve on the consumer advisory committee for a 2 year
33 term. Members of the consumer advisory committee shall by
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1 majority vote elect a member of the committee to serve as
2 chair of the committee.
3 (c) An enrollee may not serve on the consumer advisory
4 committee if during the 2 years preceding service the
5 enrollee:
6 (1) has been an employee, officer, or director of
7 the plan, an affiliate of the plan, or a provider or
8 affiliate of a provider that furnishes health care
9 services to the plan or affiliate of the plan; or
10 (2) is a relative of a person specified in item
11 (1).
12 (d) A health care plan's consumer advisory committee
13 shall meet not less than quarterly.
14 (e) All meetings shall be held within the State of
15 Illinois. The costs of the meetings shall be borne by the
16 health care plan.
17 Section 70. Quality assessment program.
18 (a) A health care plan shall develop and implement a
19 quality assessment and improvement strategy designed to
20 identify and evaluate accessibility, continuity, and quality
21 of care. The health care plan shall have:
22 (1) an ongoing, written, internal quality
23 assessment program;
24 (2) specific written guidelines for monitoring and
25 evaluating the quality and appropriateness of care and
26 services provided to enrollees requiring the health care
27 plan to assess:
28 (A) the accessibility to physicians and health
29 care providers;
30 (B) appropriateness of utilization;
31 (C) concerns identified by the health care
32 plan's medical or administrative staff and
33 enrollees; and
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1 (D) other aspects of care and service directly
2 related to the improvement of quality of care;
3 (3) a procedure for remedial action to correct
4 quality problems that have been verified in accordance
5 with the written plan's methodology and criteria,
6 including written procedures for taking appropriate
7 corrective action;
8 (4) follow-up measures implemented to evaluate the
9 effectiveness of the action plan.
10 (b) The health care plan shall establish a committee
11 that oversees the quality assessment and improvement strategy
12 which includes physician and enrollee participation.
13 (c) Reports on quality assessment and improvement
14 activities shall be made to the governing body of the health
15 care plan not less than quarterly.
16 (d) The health care plan shall make available its
17 written description of the quality assessment program to the
18 Department of Public Health.
19 (e) With the exception of subsection (d), the Department
20 of Public Health shall accept evidence of accreditation with
21 regard to the health care network quality management and
22 performance improvement standards of:
23 (1) the National Commission on Quality Assurance
24 (NCQA);
25 (2) the American Accreditation Healthcare
26 Commission (URAC);
27 (3) the Joint Commission on Accreditation of
28 Healthcare Organizations (JCAHO); or
29 (4) any other entity that the Director of Public
30 Health deems has substantially similar or more stringent
31 standards than provided for in this Section.
32 Section 75. Complaints.
33 (a) A health care plan shall establish and maintain a
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1 complaint system providing reasonable procedures for
2 resolving complaints initiated by enrollees (complainant)
3 which shall provide for an expedited review of cases
4 involving imminent threat to the health of an enrollee.
5 Nothing in this Act shall be construed to preclude an
6 enrollee from filing a complaint with the Department or as
7 limiting the Department's ability to investigate complaints.
8 In addition, any enrollee not satisfied with the plan's
9 resolution of any complaint may appeal that final plan
10 decision to the Department.
11 (b) When a complaint against a health care plan
12 (respondent) is received by the Department, the respondent
13 shall be notified of the complaint. The Department shall, in
14 its notification, specify the date when a report is to be
15 received from the respondent, which shall be no later than 21
16 days after notification is sent to the respondent. A failure
17 to reply by the date specified may be followed by a collect
18 telephone call or collect telegram. Repeated instances of
19 failing to reply by the date specified may result in further
20 regulatory action.
21 (c) The respondent's report shall supply adequate
22 documentation that explains all actions taken or not taken
23 and that were the basis for the complaint. The report shall
24 include documents necessary to support the respondent's
25 position and any information requested by the Department. The
26 respondent's reply shall be in duplicate, but duplicate
27 copies of supporting documents shall not be required. The
28 respondent's reply shall include the name, telephone number,
29 and address of the individual assigned to investigate or
30 process the complaint. The Department shall respect the
31 confidentiality of medical reports and other documents that
32 by law are confidential. Any other information furnished by
33 a respondent shall be marked "confidential" if the respondent
34 does not wish it to be released to the complainant.
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1 (d) The Department shall review the plan decision to
2 determine whether it is consistent with the plan and Illinois
3 law and rules.
4 (e) Upon receipt of the respondent's report, the
5 Department shall evaluate the material submitted; and
6 (1) advise the complainant of the action taken and
7 disposition of its complaint;
8 (2) pursue further investigation with respondent or
9 complainant; or
10 (3) refer the investigation report to the
11 appropriate branch within the Department for further
12 regulatory action.
13 (f) The Department of Insurance and the Department of
14 Public Health shall coordinate the complaint review and
15 investigation process. The Department of Insurance and the
16 Department of Public Health shall jointly establish rules
17 under the Illinois Administrative Procedure Act implementing
18 this complaint process.
19 Section 80. Record of complaints.
20 (a) The Department shall maintain records concerning the
21 complaints filed against health care plans with the
22 Department and shall require health care plans to annually
23 report complaints made to and resolutions by health care
24 plans in a manner determined by rule. The Department shall
25 make a summary of all data collected available upon request
26 and publish the summary on the World Wide Web.
27 (b) The Department shall maintain records on the number
28 of complaints filed against each health care plan.
29 (c) The Department shall maintain records classifying
30 each complaint by whether the complaint was filed by:
31 (1) a consumer or enrollee;
32 (2) a physician or health care provider; or
33 (3) any other individual.
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1 (d) The Department shall maintain records classifying
2 each complaint according to the nature of the complaint as it
3 pertains to a specific function of the health care plan. The
4 complaints shall be classified under the following
5 categories:
6 (1) denial of care or treatment;
7 (2) denial of a diagnostic procedure;
8 (3) denial of a referral request;
9 (4) sufficient choice and accessibility of health
10 care providers;
11 (5) underwriting;
12 (6) marketing and sales;
13 (7) claims and utilization review;
14 (8) member services;
15 (9) provider relations; and
16 (10) miscellaneous.
17 (e) The Department shall maintain records classifying
18 the disposition of each complaint. The disposition of the
19 complaint shall be classified in one of the following
20 categories:
21 (1) complaint referred to the health care plan and
22 no further action necessary by the Department;
23 (2) no corrective action deemed necessary by the
24 Department; or
25 (3) corrective action taken by the Department.
26 (f) No Department publication or release of information
27 shall identify any enrollee, physician, health care provider,
28 or individual complainant.
29 Section 85. Utilization review program registration.
30 (a) No person may conduct a utilization review program
31 in this State unless once every 2 years the person registers
32 the utilization review program with the Department and
33 certifies compliance with all of the Health Utilization
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1 Management Standards of the American Accreditation Healthcare
2 Commission (URAC) or submits evidence of accreditation by the
3 American Accreditation Healthcare Commission (URAC) for its
4 Health Utilization Management Standards.
5 (b) In addition, the Director of the Department, in
6 consultation with the Director of the Department of Public
7 Health, may certify alternative utilization review standards
8 of national accreditation organizations or entities in order
9 for plans to comply with this Section. Any alternative
10 utilization review standards shall meet or exceed those
11 standards required under subsection (a).
12 (c) The provisions of this Section do not apply to:
13 (1) persons providing utilization review program
14 services only to the federal government;
15 (2) self-insured health plans under the federal
16 Employee Retirement Income Security Act of 1974, however,
17 this Section does apply to persons conducting a
18 utilization review program on behalf of these health
19 plans;
20 (3) hospitals and medical groups performing
21 utilization review activities for internal purposes
22 unless the utilization review program is conducted for
23 another person.
24 Nothing in this Act prohibits a health care plan or other
25 entity from contractually requiring an entity designated in
26 item (3) of this subsection to adhere to the utilization
27 review program requirements of this Act.
28 (d) This registration shall include submission of all of
29 the following information regarding utilization review
30 program activities:
31 (1) The name, address, and telephone of the
32 utilization review programs.
33 (2) The organization and governing structure of the
34 utilization review programs.
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1 (3) The number of lives for which utilization
2 review is conducted by each utilization review program.
3 (4) Hours of operation of each utilization review
4 program.
5 (5) Description of the grievance process for each
6 utilization review program.
7 (6) Number of covered lives for which utilization
8 review was conducted for the previous calendar year for
9 each utilization review program.
10 (7) Written policies and procedures for protecting
11 confidential information according to applicable State
12 and federal laws for each utilization review program.
13 (e) If the Department finds that a utilization review
14 program is not in compliance with this Section, the
15 Department shall issue a corrective action plan and allow a
16 reasonable amount of time for compliance with the plan. If
17 the utilization review program does not come into compliance,
18 the Department may issue a cease and desist order. Before
19 issuing a cease and desist order under this Section, the
20 Department shall provide the utilization review program with
21 a written notice of the reasons for the order and allow a
22 reasonable amount of time to supply additional information
23 demonstrating compliance with requirements of this Section
24 and to request a hearing. The hearing notice shall be sent
25 by certified mail, return receipt requested, and the hearing
26 shall be conducted in accordance with the Illinois
27 Administrative Procedure Act.
28 (f) A utilization review program subject to a corrective
29 action may continue to conduct business until a final
30 decision has been issued by the Department.
31 Section 90. Prohibited activity. No health care plan or
32 its subcontractors by contract, written policy, or procedure
33 shall contain any clause attempting to transfer or
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1 transferring to a physician or health care provider by
2 indemnification or otherwise, any civil or professional
3 liability relating to activities, actions, or omissions of
4 the health care plan or its officers, employees, or agents as
5 opposed to those of the health care provider. A health care
6 plan shall be responsible for any civil or professional
7 liability relating to activities, actions, or omissions of
8 the plan or its officers, employees, or agents. If a
9 physician or health care provider performs activities on
10 behalf of the plan or its subcontractors, then the physician
11 or health care provider is acting as agent of the plan.
12 Section 95. Prohibition of waiver of rights. No health
13 care plan or contract shall contain any provision, policy, or
14 procedure that limits, restricts, or waives any of the rights
15 set forth in this Act. Any such policy or procedure shall be
16 void and unenforceable.
17 Section 100. Administration and enforcement. The
18 Director of Insurance may adopt rules necessary to implement
19 the Department's responsibilities under this Act.
20 To enforce the provisions of this Act, the Director may
21 issue a cease and desist order or require a health care plan
22 to submit a plan of correction for violations of this Act, or
23 both. Subject to the provisions of the Illinois
24 Administrative Procedure Act, the Director may impose an
25 administrative fine on a health care plan or a utilization
26 review program of up to $5,000 for failure to submit a
27 requested plan of correction, failure to comply with its plan
28 of correction, or repeated violations of the Act.
29 Section 105. Applicability and scope. This Act applies
30 to policies and contracts amended, delivered, issued, or
31 renewed on or after the effective date of this Act. This Act
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1 does not diminish a health care plan's duties and
2 responsibilities under other federal or State law or rules
3 promulgated thereunder.
4 Section 110. Effect on benefits under Workers'
5 Compensation Act and Workers' Occupational Diseases Act.
6 Nothing in this Act shall be construed to expand, modify, or
7 restrict the health care benefits provided to employees under
8 the Workers' Compensation Act and Workers' Occupational
9 Diseases Act.
10 Section 115. Severability. The provisions of this Act
11 are severable under Section 1.31 of the Statute on Statutes.
12 Section 200. The State Employees Group Insurance Act of
13 1971 is amended by adding Section 6.12 as follows:
14 (5 ILCS 375/6.12 new)
15 Sec. 6.12. Managed Care Patient Rights Act. The program
16 of health benefits is subject to the provisions of the
17 Managed Care Patient Rights Act.
18 Section 205. The State Mandates Act is amended by adding
19 Section 8.23 as follows:
20 (30 ILCS 805/8.23 new)
21 Sec. 8.23. Exempt mandate. Notwithstanding Sections 6
22 and 8 of this Act, no reimbursement by the State is required
23 for the implementation of any mandate created by this
24 amendatory Act of 1999.
25 Section 210. The Counties Code is amended by adding
26 Section 5-1069.8 as follows:
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1 (55 ILCS 5/5-1069.8 new)
2 Sec. 5-1069.8. Managed Care Patient Rights Act. All
3 counties, including home rule counties, are subject to the
4 provisions of the Managed Care Patient Rights Act. The
5 requirement under this Section that health care benefits
6 provided by counties comply with the Managed Care Patient
7 Rights Act is an exclusive power and function of the State
8 and is a denial and limitation of home rule county powers
9 under Article VII, Section 6, subsection (h) of the Illinois
10 Constitution.
11 Section 215. The Illinois Municipal Code is amended by
12 adding 10-4-2.8 as follows:
13 (65 ILCS 5/10-4-2.8 new)
14 Sec. 10-4-2.8. Managed Care Patient Rights Act. The
15 corporate authorities of all municipalities are subject to
16 the provisions of the Managed Care Patients Rights Act. The
17 requirement under this Section that health care benefits
18 provided by municipalities comply with the Managed Care
19 Patient Rights Act is an exclusive power and function of the
20 State and is a denial and limitation of home rule
21 municipality powers under Article VII, Section 6, subsection
22 (h) of the Illinois Constitution.
23 Section 220. The Illinois Insurance Code is amended by
24 changing Sections 155.36 and 370g and adding Sections 370s
25 and 511.118 as follows:
26 (215 ILCS 5/155.36 new)
27 Sec. 155.36. Managed Care Patient Rights Act. Insurance
28 companies that transact the kinds of insurance authorized
29 under Class 1(b) or Class 2(a) of Section 4 of this Code
30 shall comply with Sections 80 and 85 and the definition of
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1 the term "emergency medical condition" in Section 10 of the
2 Managed Care Patients Rights Act.
3 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
4 Sec. 370g. Definitions. As used in this Article, the
5 following definitions apply:
6 (a) "Health care services" means health care services or
7 products rendered or sold by a provider within the scope of
8 the provider's license or legal authorization. The term
9 includes, but is not limited to, hospital, medical, surgical,
10 dental, vision and pharmaceutical services or products.
11 (b) "Insurer" means an insurance company or a health
12 service corporation authorized in this State to issue
13 policies or subscriber contracts which reimburse for expenses
14 of health care services.
15 (c) "Insured" means an individual entitled to
16 reimbursement for expenses of health care services under a
17 policy or subscriber contract issued or administered by an
18 insurer.
19 (d) "Provider" means an individual or entity duly
20 licensed or legally authorized to provide health care
21 services.
22 (e) "Noninstitutional provider" means any person
23 licensed under the Medical Practice Act of 1987, as now or
24 hereafter amended.
25 (f) "Beneficiary" means an individual entitled to
26 reimbursement for expenses of or the discount of provider
27 fees for health care services under a program where the
28 beneficiary has an incentive to utilize the services of a
29 provider which has entered into an agreement or arrangement
30 with an administrator.
31 (g) "Administrator" means any person, partnership or
32 corporation, other than an insurer or health maintenance
33 organization holding a certificate of authority under the
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1 "Health Maintenance Organization Act", as now or hereafter
2 amended, that arranges, contracts with, or administers
3 contracts with a provider whereby beneficiaries are provided
4 an incentive to use the services of such provider.
5 (h) "Emergency medical condition" means a medical
6 condition manifesting itself by acute symptoms of sufficient
7 severity (including severe pain) such that a prudent
8 layperson, who possesses an average knowledge of health and
9 medicine, could reasonably expect the absence of immediate
10 medical attention to result in:
11 (1) placing the health of the individual (or, with
12 respect to a pregnant woman, the health of the woman or
13 her unborn child) in serious jeopardy;
14 (2) serious impairment to bodily functions; or
15 (3) serious dysfunction of any bodily organ or
16 part. "Emergency" means an accidental bodily injury or
17 emergency medical condition which reasonably requires the
18 beneficiary or insured to seek immediate medical care
19 under circumstances or at locations which reasonably
20 preclude the beneficiary or insured from obtaining needed
21 medical care from a preferred provider.
22 (Source: P.A. 88-400.)
23 (215 ILCS 5/370s new)
24 Sec. 370s. Managed Care Patients Rights Act. All
25 administrators shall comply with Sections 80 and 85 of the
26 Managed Care Patients Rights Act.
27 (215 ILCS 5/511.118 new)
28 Sec. 511.118. Managed Care Patients Rights Act. All
29 administrators are subject to the provisions of Sections 80
30 and 85 of the Managed Care Patients Act.
31 Section 225. The Comprehensive Health Insurance Plan Act
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1 is amended by adding Section 8.6 as follows:
2 (215 ILCS 105/8.6 new)
3 Sec. 8.6. Managed Care Patient Rights Act. The plan is
4 subject to the provisions of the Managed Care Patient Rights
5 Act.
6 Section 230. The Health Care Purchasing Group Act is
7 amended by changing Sections 15 and 20 as follows:
8 (215 ILCS 123/15)
9 Sec. 15. Health care purchasing groups; membership;
10 formation.
11 (a) An HPG may be an organization formed by 2 or more
12 employers with no more than 500 covered employees each 2,500
13 covered individuals, an HPG sponsor or a risk-bearer for
14 purposes of contracting for health insurance under this Act
15 to cover employees and dependents of HPG members. An HPG
16 shall not be prevented from supplementing health insurance
17 coverage purchased under this Act by contracting for services
18 from entities licensed and authorized in Illinois to provide
19 those services under the Dental Service Plan Act, the Limited
20 Health Service Organization Act, or Voluntary Health Services
21 Plans Act. An HPG may be a separate legal entity or simply a
22 group of 2 or more employers with no more than 500 covered
23 employees each 2,500 covered individuals aggregated under
24 this Act by an HPG sponsor or risk-bearer for insurance
25 purposes. There shall be no limit as to the number of HPGs
26 that may operate in any geographic area of the State. No
27 insurance risk may be borne or retained by the HPG. All
28 health insurance contracts issued to the HPG must be
29 delivered or issued for delivery in Illinois.
30 (b) Members of an HPG must be Illinois domiciled
31 employers, except that an employer domiciled elsewhere may
-31- LRB9100767JSpcA
1 become a member of an Illinois HPG for the sole purpose of
2 insuring its employees whose place of employment is located
3 within this State. HPG membership may include employers
4 having no more than 500 covered employees each 2,500 covered
5 individuals.
6 (c) If an HPG is formed by any 2 or more employers with
7 no more than 500 covered employees each 2,500 covered
8 individuals, it is authorized to negotiate, solicit, market,
9 obtain proposals for, and enter into group or master health
10 insurance contracts on behalf of its members and their
11 employees and employee dependents so long as it meets all of
12 the following requirements:
13 (1) The HPG must be an organization having the
14 legal capacity to contract and having its legal situs in
15 Illinois.
16 (2) The principal persons responsible for the
17 conduct of the HPG must perform their HPG related
18 functions in Illinois.
19 (3) No HPG may collect premium in its name or hold
20 or manage premium or claim fund accounts unless duly
21 licensed and qualified as a managing general agent
22 pursuant to Section 141a of the Illinois Insurance Code
23 or a third party administrator pursuant to Section
24 511.105 of the Illinois Insurance Code.
25 (4) If the HPG gives an offer, application, notice,
26 or proposal of insurance to an employer, it must disclose
27 to that employer the total cost of the insurance. Dues,
28 fees, or charges to be paid to the HPG, HPG sponsor, or
29 any other entity as a condition to purchasing the
30 insurance must be itemized. The HPG shall also disclose
31 to its members the amount of any dividends, experience
32 refunds, or other such payments it receives from the
33 risk-bearer.
34 (5) An HPG must register with the Director before
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1 entering into a group or master health insurance contract
2 on behalf of its members and must renew the registration
3 annually on forms and at times prescribed by the Director
4 in rules specifying, at minimum, (i) the identity of the
5 officers and directors, trustees, or attorney-in-fact of
6 the HPG; (ii) a certification that those persons have not
7 been convicted of any felony offense involving a breach
8 of fiduciary duty or improper manipulation of accounts;
9 and (iii) the number of employer members then enrolled in
10 the HPG, together with any other information that may be
11 needed to carry out the purposes of this Act.
12 (6) At the time of initial registration and each
13 renewal thereof an HPG shall pay a fee of $100 to the
14 Director.
15 (d) If an HPG is formed by an HPG sponsor or risk-bearer
16 and the HPG performs no marketing, negotiation, solicitation,
17 or proposing of insurance to HPG members, exclusive of
18 ministerial acts performed by individual employers to service
19 their own employees, then a group or master health insurance
20 contract may be issued in the name of the HPG and held by an
21 HPG sponsor, risk-bearer, or designated employer member
22 within the State. In these cases the HPG requirements
23 specified in subsection (c) shall not be applicable, however:
24 (1) the group or master health insurance contract
25 must contain a provision permitting the contract to be
26 enforced through legal action initiated by any employer
27 member or by an employee of an HPG member who has paid
28 premium for the coverage provided;
29 (2) the group or master health insurance contract
30 must be available for inspection and copying by any HPG
31 member, employee, or insured dependent at a designated
32 location within the State at all normal business hours;
33 and
34 (3) any information concerning HPG membership
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1 required by rule under item (5) of subsection (c) must be
2 provided by the HPG sponsor in its registration and
3 renewal forms or by the risk-bearer in its annual
4 reports.
5 (Source: P.A. 90-337, eff. 1-1-98; 90-655, eff. 7-30-98.)
6 (215 ILCS 123/20)
7 Sec. 20. HPG sponsors. Except as provided by Sections 15
8 and 25 of this Act, only a corporation authorized by the
9 Secretary of State to transact business in Illinois may
10 sponsor one or more HPGs with no more than 100,000 10,000
11 covered individuals by negotiating, soliciting, or servicing
12 health insurance contracts for HPGs and their members. Such a
13 corporation may assert and maintain authority to act as an
14 HPG sponsor by complying with all of the following
15 requirements:
16 (1) The principal officers and directors
17 responsible for the conduct of the HPG sponsor must
18 perform their HPG sponsor related functions in Illinois.
19 (2) No insurance risk may be borne or retained by
20 the HPG sponsor; all health insurance contracts issued to
21 HPGs through the HPG sponsor must be delivered in
22 Illinois.
23 (3) No HPG sponsor may collect premium in its name
24 or hold or manage premium or claim fund accounts unless
25 duly qualified and licensed as a managing general agent
26 pursuant to Section 141a of the Illinois Insurance Code
27 or as a third party administrator pursuant to Section
28 511.105 of the Illinois Insurance Code.
29 (4) If the HPG gives an offer, application, notice,
30 or proposal of insurance to an employer, it must disclose
31 the total cost of the insurance. Dues, fees, or charges
32 to be paid to the HPG, HPG sponsor, or any other entity
33 as a condition to purchasing the insurance must be
-34- LRB9100767JSpcA
1 itemized. The HPG shall also disclose to its members the
2 amount of any dividends, experience refunds, or other
3 such payments it receives from the risk-bearer.
4 (5) An HPG sponsor must register with the Director
5 before negotiating or soliciting any group or master
6 health insurance contract for any HPG and must renew the
7 registration annually on forms and at times prescribed by
8 the Director in rules specifying, at minimum, (i) the
9 identity of the officers and directors of the HPG sponsor
10 corporation; (ii) a certification that those persons have
11 not been convicted of any felony offense involving a
12 breach of fiduciary duty or improper manipulation of
13 accounts; (iii) the number of employer members then
14 enrolled in each HPG sponsored; (iv) the date on which
15 each HPG was issued a group or master health insurance
16 contract, if any; and (v) the date on which each such
17 contract, if any, was terminated.
18 (6) At the time of initial registration and each
19 renewal thereof an HPG sponsor shall pay a fee of $100 to
20 the Director.
21 (Source: P.A. 90-337, eff. 1-1-98.)
22 Section 235. The Health Maintenance Organization Act is
23 amended by changing Sections 2-2 and 6-7 and adding Section
24 5-3.6 as follows:
25 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
26 Sec. 2-2. Determination by Director; Health Maintenance
27 Advisory Board.
28 (a) Upon receipt of an application for issuance of a
29 certificate of authority, the Director shall transmit copies
30 of such application and accompanying documents to the
31 Director of the Illinois Department of Public Health. The
32 Director of the Department of Public Health shall then
-35- LRB9100767JSpcA
1 determine whether the applicant for certificate of authority,
2 with respect to health care services to be furnished: (1) has
3 demonstrated the willingness and potential ability to assure
4 that such health care service will be provided in a manner to
5 insure both availability and accessibility of adequate
6 personnel and facilities and in a manner enhancing
7 availability, accessibility, and continuity of service; and
8 (2) has arrangements, established in accordance with
9 regulations promulgated by the Department of Public Health
10 for an ongoing quality of health care assurance program
11 concerning health care processes and outcomes. Upon
12 investigation, the Director of the Department of Public
13 Health shall certify to the Director whether the proposed
14 Health Maintenance Organization meets the requirements of
15 this subsection (a). If the Director of the Department of
16 Public Health certifies that the Health Maintenance
17 Organization does not meet such requirements, he shall
18 specify in what respect it is deficient.
19 There is created in the Department of Public Health a
20 Health Maintenance Advisory Board composed of 11 members.
21 Nine 9 members shall who have practiced in the health field,
22 4 of which shall have been or are currently affiliated with a
23 Health Maintenance Organization. Two of the members shall be
24 members of the general public, one of whom is over 50 years
25 of age. Each member shall be appointed by the Director of
26 the Department of Public Health and serve at the pleasure of
27 that Director and shall receive no compensation for services
28 rendered other than reimbursement for expenses. Six Five
29 members of the Board shall constitute a quorum. A vacancy in
30 the membership of the Advisory Board shall not impair the
31 right of a quorum to exercise all rights and perform all
32 duties of the Board. The Health Maintenance Advisory Board
33 has the power to review and comment on proposed rules and
34 regulations to be promulgated by the Director of the
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1 Department of Public Health within 30 days after those
2 proposed rules and regulations have been submitted to the
3 Advisory Board.
4 (b) Issuance of a certificate of authority shall be
5 granted if the following conditions are met:
6 (1) the requirements of subsection (c) of Section
7 2-1 have been fulfilled;
8 (2) the persons responsible for the conduct of the
9 affairs of the applicant are competent, trustworthy, and
10 possess good reputations, and have had appropriate
11 experience, training or education;
12 (3) the Director of the Department of Public Health
13 certifies that the Health Maintenance Organization's
14 proposed plan of operation meets the requirements of this
15 Act;
16 (4) the Health Care Plan furnishes basic health
17 care services on a prepaid basis, through insurance or
18 otherwise, except to the extent of reasonable
19 requirements for co-payments or deductibles as authorized
20 by this Act;
21 (5) the Health Maintenance Organization is
22 financially responsible and may reasonably be expected to
23 meet its obligations to enrollees and prospective
24 enrollees; in making this determination, the Director
25 shall consider:
26 (A) the financial soundness of the applicant's
27 arrangements for health services and the minimum
28 standard rates, co-payments and other patient
29 charges used in connection therewith;
30 (B) the adequacy of working capital, other
31 sources of funding, and provisions for
32 contingencies; and
33 (C) that no certificate of authority shall be
34 issued if the initial minimum net worth of the
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1 applicant is less than $2,000,000. The initial net
2 worth shall be provided in cash and securities in
3 combination and form acceptable to the Director;
4 (6) the agreements with providers for the provision
5 of health services contain the provisions required by
6 Section 2-8 of this Act; and
7 (7) any deficiencies identified by the Director
8 have been corrected.
9 (Source: P.A. 86-620; 86-1475.)
10 (215 ILCS 125/5-3.6 new)
11 Sec. 5-3.6. Managed Care Patient Rights Act. Health
12 maintenance organizations are subject to the provisions of
13 the Managed Care Patient Rights Act.
14 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
15 Sec. 6-7. Board of Directors. The board of directors of
16 the Association consists of not less than 7 5 nor more than
17 11 9 members serving terms as established in the plan of
18 operation. The members of the board are to be selected by
19 member organizations subject to the approval of the Director,
20 except the Director shall name 2 members who are current
21 enrollees, one of whom is over 50 years of age. Vacancies on
22 the board must be filled for the remaining period of the term
23 in the manner described in the plan of operation. To select
24 the initial board of directors, and initially organize the
25 Association, the Director must give notice to all member
26 organizations of the time and place of the organizational
27 meeting. In determining voting rights at the organizational
28 meeting each member organization is entitled to one vote in
29 person or by proxy. If the board of directors is not
30 selected at the organizational meeting, the Director may
31 appoint the initial members.
32 In approving selections or in appointing members to the
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1 board, the Director must consider, whether all member
2 organizations are fairly represented.
3 Members of the board may be reimbursed from the assets of
4 the Association for expenses incurred by them as members of
5 the board of directors but members of the board may not
6 otherwise be compensated by the Association for their
7 services.
8 (Source: P.A. 85-20.)
9 Section 240. The Limited Health Service Organization Act
10 is amended by adding Section 4002.6 as follows:
11 (215 ILCS 130/4002.6 new)
12 Sec. 4002.6. Managed Care Patient Rights Act. Except
13 for health care plans offering only dental services or only
14 vision services, limited health service organizations are
15 subject to the provisions of the Managed Care Patient Rights
16 Act.
17 Section 245. The Voluntary Health Services Plans Act is
18 amended by adding Section 15.30 as follows:
19 (215 ILCS 165/15.30 new)
20 Sec. 15.30. Managed Care Patient Rights Act. A health
21 service plan corporation is subject to the provisions of the
22 Managed Care Patient Rights Act.
23 Section 250. The Illinois Public Aid Code is amended by
24 adding Section 5-16.12 as follows:
25 (305 ILCS 5/5-16.12 new)
26 Sec. 5-16.12. Managed Care Patient Rights Act. The
27 medical assistance program and other programs administered by
28 the Department are subject to the provisions of the Managed
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1 Care Patient Rights Act. The Department may adopt rules to
2 implement those provisions. These rules shall require
3 compliance with that Act in the medical assistance managed
4 care programs and other programs administered by the
5 Department. The medical assistance fee-for-service program
6 is not subject to the provisions of the Managed Care Patient
7 Rights Act.
8 Section 299. Effective date. This Act takes effect
9 January 1, 2000.
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1 INDEX
2 Statutes amended in order of appearance
3 New Act
4 5 ILCS 375/6.12 new
5 30 ILCS 805/8.23 new
6 55 ILCS 5/5-1069.8 new
7 65 ILCS 5/10-4-2.8 new
8 215 ILCS 5/155.36 new
9 215 ILCS 5/370g from Ch. 73, par. 982g
10 215 ILCS 5/370s new
11 215 ILCS 5/511.118 new
12 215 ILCS 105/8.6 new
13 215 ILCS 123/15
14 215 ILCS 123/20
15 215 ILCS 125/2-2 from Ch. 111 1/2, par. 1404
16 215 ILCS 125/5-3.6 new
17 215 ILCS 125/6-7 from Ch. 111 1/2, par. 1418.7
18 215 ILCS 130/4002.6 new
19 215 ILCS 165/15.30 new
20 305 ILCS 5/5-16.12 new