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91_HB1150
LRB9101093JSpcA
1 AN ACT concerning managed care arrangements.
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 Responsibility to Members Act.
6 Section 5. Purpose. This Act addresses changes in managed
7 care practice and operations in Illinois. This Act enhances
8 quality, affordable, and accessible health care coverage for
9 Illinois citizens, families, and businesses. Through the
10 provisions of this Act, health care plan members will be
11 provided:
12 (1) Detailed information about health care plans, the
13 scope of coverage available, and the physicians' professional
14 qualifications so that they can make informed choices about
15 their health care.
16 (2) Notification of termination or change in any
17 benefits, services, or service delivery. This includes a
18 provision allowing enrollees to continue with a nonnetwork
19 physician under certain specific circumstances.
20 (3) Detailed grievance procedures and medical necessity
21 appeals procedures, which include an expedited appeal
22 process.
23 (4) Health care plan accountability for accessible
24 hospital and physician services and reimbursement for covered
25 emergency services.
26 Section 10. Definitions. As used in this Act:
27 "Basic health care services" means emergency care, and
28 inpatient hospital and physician care, outpatient medical
29 services, mental health services and care for alcohol and
30 drug abuse, including any reasonable deductibles and
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1 copayments, all of which are subject to such limitations as
2 are determined by the Director.
3 "Department" means the Department of Insurance.
4 "Director" means the Director of Insurance.
5 "Emergency medical condition" means a medical condition
6 manifesting itself by acute symptoms of sufficient severity
7 (including severe pain) such that a prudent layperson, who
8 possesses an average knowledge of health and medicine, could
9 reasonably expect the absence of immediate medical attention
10 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.
17 "Emergency services" means, with respect to an individual
18 enrolled in a health care plan, covered inpatient and covered
19 outpatient services that are:
20 (1) furnished in a licensed hospital by a provider
21 that is qualified to furnish those services;
22 (2) needed to evaluate whether an emergency medical
23 condition exists; and
24 (3) needed for stabilization of an emergency
25 medical condition if one exists.
26 "Emergency services" does not refer to post-stabilization
27 medical services.
28 "Enrollee" means an individual enrolled in a health care
29 plan.
30 "Governing body" means the board of trustees, or
31 directors, or if otherwise designated in the basic
32 organizational document bylaws, those individuals vested with
33 the ultimate responsibility for the management of the health
34 care plan.
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1 "Grievance" means any written complaint submitted to the
2 health care plan by or on behalf of an enrollee regarding any
3 aspect of the plan relative to the enrollee, but shall not
4 include a complaint by or on behalf of a provider.
5 "Grievance committee" means individuals who have been
6 appointed by the health care plan to respond to grievances
7 which have been filed on appeal from the plan's simplified
8 complaint process. At least 50% of the individuals on this
9 committee shall be composed of enrollees who are consumers.
10 A grievance may not be heard or voted upon unless at least
11 50% of the voting individuals at the committee hearing are
12 enrollees.
13 "Health care plan" means any arrangement whereby an
14 organization undertakes to provide or arrange for and pay for
15 or reimburse the cost of basic health care services from
16 providers selected by the plan and the arrangement consists
17 of arranging for or the provision of health care services, as
18 distinguished from mere indemnification against the cost of
19 those services, on a per capita prepaid basis, through
20 insurance or otherwise.
21 For purposes of this definition, "health care plan" shall
22 not include the following:
23 (1) indemnity health insurance policies including
24 those using a contracted provider network;
25 (2) health care plans that offer only dental or
26 only vision coverage;
27 (3) preferred provider administrators, as defined
28 in Section 370g(g) of the Illinois Insurance Code;
29 (4) employee or employer self-insured health
30 benefit plans under the federal Employee Retirement
31 Income Security Act of 1974; and
32 (5) health care provided pursuant to the Worker's
33 Compensation Act or the Workers' Occupational Diseases
34 Act.
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1 "Health care services" means any services included in the
2 furnishing to any individual of medical or dental care, or
3 the hospitalization incident to the furnishing of such care,
4 and the furnishing to any person of any and all other
5 services for the purpose of preventing, alleviating, curing,
6 or healing human illness or injury.
7 "Insurance company" means companies in this State
8 authorized to transact the kind or kinds of business
9 enumerated in Class 1(a), Class 1(b) or Class 2(a) of Section
10 4 of the Illinois Insurance Code.
11 "Insured" means an individual entitled to coverage of
12 expenses of health care services under a policy issued or
13 administered by an insurance company.
14 "Life threatening condition" means any condition, illness
15 or injury which (i) may directly lead to a patient's death,
16 (ii) results in a period of unconsciousness which is
17 indeterminate at the present, or (iii) imposes severe pain or
18 an inhumane burden on the patient.
19 "Medical director" means a physician licensed to practice
20 medicine in all its branches in Illinois who is employed by
21 or contracted with a health care plan and who shall be
22 responsible for final review when questions of medical
23 practice arise in the health care plan in order to assure the
24 quality of health care services provided.
25 "Patient" means any person who has received or is
26 receiving medical care, treatment, or services from an
27 individual or institution licensed to provide medical care or
28 treatment in this State.
29 "Post-stabilization medical services" means covered
30 health care services provided to an enrollee that are
31 furnished in a licensed hospital by a provider that is
32 qualified to furnish those services and determined to be
33 medically necessary and directly related to an emergency
34 medical condition following stabilization.
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1 "Primary care physician" means a provider who has
2 contracted with a health care plan to provide primary care
3 services as defined by the contract and who is (1) a
4 physician licensed to practice medicine in all of its
5 branches who spends a majority of clinical time engaged in
6 general practice or in the practice of internal medicine,
7 pediatrics, gynecology, obstetrics, or family practice or (2)
8 a chiropractic physician licensed to treat human ailments
9 without the use of drugs or operative surgery.
10 "Provider" means any physician, hospital facility, or
11 other person which is licensed or otherwise authorized to
12 furnish health care services.
13 "Stabilization" means, with respect to an emergency
14 medical condition, the provision of medical treatment of the
15 condition as may be necessary to assure within reasonable
16 medical probability that no material deterioration of the
17 condition is likely to result from the transfer of the
18 individual from a facility.
19 "Utilization review" means the study of the
20 appropriateness of the use of particular services and the
21 appropriateness of the volume of services used.
22 "Utilization review program" means an entity performing
23 utilization review, except an agency of the federal
24 government or its agent, but only to the extent that agent is
25 providing services to the federal government.
26 Section 15. Patient rights. The following rights are
27 hereby established:
28 (1) The right of each patient to be provided with
29 information about the health care plan and the providers
30 rendering care. For health care plans this right calls for
31 compliance with Section 20 of this Act.
32 (2) The right of each patient to a full disclosure of
33 the patient costs, benefits, risks, and alternatives related
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1 to the treatment options and care, including health care plan
2 requirements, coverage, exclusions, or limitations. For
3 health care plans this right calls for compliance with
4 Section 25 of this Act. Insurance companies and health care
5 plans are prohibited from terminating or suspending a
6 provider from its network for advocating appropriate health
7 care services because the provider advocated for what he or
8 she considered to be appropriate health care.
9 (3) The right of each patient to care, consistent with
10 nursing and medical practices, to be informed of the name of
11 the physician responsible for coordinating his or her care,
12 to receive information from his or her physician concerning
13 his or her condition and proposed treatment, to refuse any
14 treatment to the extent permitted by law, and to privacy and
15 confidentiality of records except as otherwise provided by
16 law.
17 (4) The right of each patient, regardless of source of
18 payment, to examine and receive a reasonable explanation of
19 his or her total bill for services where such a bill is
20 rendered by his or her physician or health care provider,
21 including the itemized charges for specific services
22 received. Each provider shall be responsible for a reasonable
23 explanation of those specific services provided by such
24 physician or health care provider.
25 (5) In the event an insurance company or health care
26 plan cancels or refuses to renew an individual policy or
27 plan, the insured or enrollee shall be entitled to timely,
28 prior notice of the termination of such policy or plan.
29 An insurance company or health care plan that requires
30 any insured, enrollee, or applicant for new or continued
31 insurance or coverage to be tested for infection with HIV or
32 any other identified causative agent of AIDS shall (i) give
33 the patient or applicant prior written notice of such
34 requirement, (ii) proceed with such testing only upon the
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1 written authorization of the insured, enrollee, or applicant,
2 and (iii) keep the results of such testing confidential.
3 Notice of an adverse underwriting or coverage decision may be
4 given to any appropriately interested party, but the
5 insurance company or health care plan may only disclose the
6 test result itself to a physician designated by the insured,
7 enrollee or applicant, and any such disclosure shall be in a
8 manner that assures confidentiality.
9 (6) At the time of renewal, the right of each patient to
10 notification of termination or change in any benefits,
11 services, or service delivery location.
12 (7) The right of each patient to privacy and
13 confidentiality in health care. Each physician, health care
14 provider, health care plan and insurance company shall not
15 disclose the nature or details of services provided to
16 insureds and enrollees, except that such information may be
17 disclosed to the patient, the party making treatment
18 decisions if the patient is incapable of making decisions
19 regarding the health services provided, those parties
20 directly involved with providing treatment to the patient or
21 processing the payment for that treatment, those parties
22 responsible for peer review, utilization review and quality
23 assurance, and those parties required to be notified under
24 the Abused and Neglected Child Reporting Act, the Illinois
25 Sexually Transmissible Disease Control Act or where otherwise
26 authorized or required by law. This right may be waived in
27 writing by the patient or the patient's guardian, but a
28 physician or other health care provider may not condition the
29 provision of services on the patient's or guardian's
30 agreement to sign such a waiver.
31 Section 20. Provision of information.
32 (a) A health care plan shall provide to enrollees a
33 description of the terms and conditions of the evidence of
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1 coverage. The form shall provide a description of all of the
2 following:
3 (1) The service area.
4 (2) Covered benefits, exclusions or limitations.
5 (3) Registration and other utilization review
6 procedures requirements.
7 (4) A list of primary care physicians in the health
8 care plan's service area and a description of the
9 limitations to access specialists.
10 (5) Emergency coverage and benefits, both inside
11 and outside of the plan's service area.
12 (6) Out-of-area coverages and benefits, if any.
13 (7) The enrollee's financial responsibility for
14 copayments, deductibles, and any other out-of-pocket
15 expenses.
16 (8) Provisions for continuity of treatment in the
17 event a provider's participation terminates during the
18 course of an insured's or enrollee's treatment by that
19 provider.
20 (9) The grievance process, including the telephone
21 number to call to receive information concerning
22 grievance procedures.
23 (b) Upon written request, a health care plan shall
24 provide to applicants and enrollees a description of the
25 financial relationships between the health care plan and any
26 provider, except that no health care plan shall be required
27 to disclose specific reimbursement to providers.
28 (c) A participating provider shall provide all of the
29 following to enrollees upon request:
30 (1) Information related to the health care
31 professional's educational background, experience,
32 training, specialty, and board certification, if
33 applicable.
34 (2) The names of licensed facilities on the
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1 provider panel where the health professional presently
2 has privileges for the treatment, illness, or procedure
3 that is the subject of the request.
4 (3) Information regarding the health care
5 professional's participation in continuing education
6 programs and compliance with any licensure,
7 certification, or registration requirements, if
8 applicable.
9 Section 25. Prohibited restraints on communication.
10 Nothing in a physician's contract with a health care plan
11 shall be construed to impair the physician's ethical and
12 legal duty to provide full informed consent and medical
13 counsel to enrollees, including full discussion of the costs,
14 benefits, risks, and alternatives related to the enrollee's
15 treatment options and care and health care plan policies
16 related to those options, including health care plan
17 requirements, coverage, exclusions, or other policies or
18 practices that affect enrollees' access to coverage or
19 treatment options.
20 Section 30. Access to personnel and facilities.
21 (a) A health care plan shall include a sufficient number
22 and type of primary care physicians and specialists,
23 throughout the service area, to meet the needs of enrollees
24 and to provide meaningful choice. A health care plan shall
25 offer:
26 (1) accessible acute care hospital services, within
27 a reasonable distance or travel time;
28 (2) primary care physicians, within a reasonable
29 distance or travel time; and
30 (3) specialists within a reasonable distance or
31 travel time.
32 When the type of medical service needed for a specific
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1 condition is not represented in the provider network, the
2 health care plan shall arrange for the enrollee to have
3 access to qualified nonparticipating health care
4 professionals as authorized by the primary care physician.
5 (b) A health care plan shall provide telephone access to
6 the health care plan for sufficient time during business
7 hours to assure enrollee access for routine care, and 24 hour
8 telephone access to the health care plan or, if so delegated
9 by the health care plan, a participating physician or group
10 for emergency care or authorization for care.
11 (c) A health care plan shall establish reasonable
12 standards for waiting times to obtain appointments, except as
13 provided below for emergency services.
14 Such standards shall include appointment scheduling
15 guidelines used for each type of health care service,
16 including prenatal care appointments, well-child visits and
17 immunizations, routine physicals, follow-up appointments for
18 chronic conditions, and urgent care.
19 (d) A health care plan shall provide for continuity of
20 care for its enrollees as follows:
21 (1) If an enrollee's physician leaves the health
22 care plan's network of providers for reasons other than
23 termination with cause and the physician remains within
24 the health care plan's service area, the health care plan
25 shall permit the enrollee to continue an ongoing course
26 of treatment with that physician during a transitional
27 period of:
28 (A) up to 60 days from the date of the notice
29 of physician's termination from the health care plan
30 network to the enrollee of the physician's
31 disaffiliation from the health care plan's network
32 if the enrollee has a life threatening disease or
33 condition; or
34 (B) if the enrollee has entered the third
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1 trimester of pregnancy at the time of the
2 physician's disaffiliation, for a transitional
3 period that includes the provision of post-partum
4 care directly related to the delivery.
5 (2) Notwithstanding the provisions in item (1) of
6 this subsection, such care shall be authorized by the
7 health care plan during the transitional period only if
8 the physician agrees:
9 (A) to continue to accept reimbursement from
10 the health care plan at the rates applicable prior
11 to the start of the transitional period as payment
12 in full;
13 (B) to adhere to the health care plan's
14 quality assurance requirements and to provide to the
15 health care plan necessary medical information
16 related to such care; and
17 (C) to otherwise adhere to the organization's
18 policies and procedures, including but not limited
19 to procedures regarding referrals and obtaining
20 preauthorizations and a treatment plan approved by
21 the health care plan.
22 (e) A health care plan shall provide for continuity of
23 care for new enrollees as follows:
24 (1) If a new enrollee whose physician is not a
25 member of the health care plan's provider network, but is
26 within the health care plan's service area, enrolls in
27 the health care plan, the health care plan shall, upon
28 request from the enrollee, provide benefits for otherwise
29 covered services provided by the enrollee's current
30 physician during a transitional period of up to 60 days
31 from the effective date of enrollment, if:
32 (A) the enrollee has a life-threatening
33 disease or condition; or
34 (B) the enrollee has entered the third
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1 trimester of pregnancy at the effective date of
2 enrollment, in which case the transitional period
3 shall include the provision of post-partum care
4 directly related to the delivery.
5 (2) If an enrollee elects to continue to receive
6 care from such physician pursuant to item (1) of this
7 subsection, such care shall be authorized by the health
8 care plan for the transitional period only if the
9 physician agrees:
10 (A) to accept reimbursement from the health
11 care plan at rates established by the health care
12 plan as payment in full, such rates shall be no more
13 than the level of reimbursement applicable to
14 similar physicians within the health care plan's
15 network for such services;
16 (B) to adhere to the health care plan's
17 quality assurance requirements and agrees to
18 provide to the health care plan necessary medical
19 information related to such care; and
20 (C) to otherwise adhere to the health care
21 plan's policies and procedures including, but not
22 limited to procedures regarding referrals and
23 obtaining preauthorization and a treatment plan
24 approved by the health care plan. In no event
25 shall this section be construed to require a health
26 care plan to provide coverage for benefits not
27 otherwise covered or to diminish or impair
28 preexisting condition limitations contained in the
29 subscriber's contract.
30 Section 35. Emergency services prior to stabilization.
31 (a) Except as provided for in subsection (c), a health
32 care plan shall cover emergency services without regard to
33 prior authorization or the treating provider's contractual
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1 relationship with the organization.
2 (b) Reimbursement shall be provided by the health care
3 plan at the same rate as if the service or treatment had been
4 rendered by similar provider contracting with a health care
5 plan.
6 (c) Payment for covered emergency services may be
7 denied:
8 (1) upon determination that the emergency
9 services claimed were not performed;
10 (2) upon determination that emergency
11 evaluation and treatment were rendered to an
12 enrollee who sought emergency services and whose
13 circumstance did not meet the definition of
14 emergency medical condition;
15 (3) upon determination that the patient
16 receiving the services was not a covered enrollee of
17 the health care plan; or
18 (4) upon material misrepresentation by an
19 enrollee or provider.
20 (d) The appropriate use of 911 telephone systems or its
21 local equivalent shall not be discouraged or penalized when
22 an emergency medical condition exists. This provision shall
23 not imply that the use of 911 or its local equivalent is a
24 factor in determining the existence of an emergency medical
25 condition.
26 (e) For purposes of coverage, the medical director's or
27 his or her designee's determination of whether an enrollee
28 meets the standard of an emergency medical condition shall be
29 based primarily upon the presenting symptoms documented in
30 the medical record at the time care was sought and the
31 circumstances that led an enrollee to believe that he or she
32 had an emergency medical condition.
33 (f) For emergency medical service claims reviewed for
34 reimbursement, the emergency department shall provide upon
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1 request of the health care plan, at no charge, a copy of the
2 medical record documenting the presenting symptoms of the
3 enrollee at the time care was sought and the objective
4 findings of the medical examination.
5 (g) Nothing in this Section prohibits a health care plan
6 from imposing deductibles, coinsurance, or copayments in
7 covering emergency medical services. Copayments may vary
8 from those copayments charged for other covered services.
9 Section 40. Post-stabilization medical services.
10 (a) If prior benefit authorization for
11 post-stabilization medical services is required by the health
12 care plan:
13 (1) the plan shall provide access 24 hours a day, 7
14 days a week to persons designated by the plan to make
15 benefit determinations; and
16 (2) the treating health care provider shall contact
17 the health care plan or delegated provider as designated
18 on the enrollee's health insurance card to obtain benefit
19 authorization or denial or obtain benefit authorization
20 for an alternate plan of treatment or transfer of the
21 covered enrollee.
22 (b) The treating provider shall document in an
23 enrollee's medical record the enrollee's presenting symptoms,
24 emergency medical condition, the time, phone number or
25 numbers dialed, and result of the communication efforts to
26 request benefit authorization of post-stabilization medical
27 services. The health care plan shall provide reimbursement
28 for covered post-stabilization medical services if any of the
29 following apply:
30 (1) Benefit authorization for covered
31 post-stabilization medical services is received from
32 the health care plan or its delegated health care
33 provider.
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1 (2) After at least 2 documented good faith
2 efforts over the course of 60 minutes, each effort
3 being at least 10 minutes apart, the treating health
4 care provider has attempted to contact the
5 enrollee's health care plan or its delegated health
6 care provider, as designated on the enrollee's
7 health insurance card, for prior benefit
8 authorization of post-stabilization medical
9 services. "Two documented good faith efforts" means
10 the health care provider has called the telephone
11 number on the enrollee's health insurance card or
12 other available number either 2 times or one time
13 and made an additional call to any referral number
14 provided. "Good faith" means honesty of purpose,
15 freedom from intent to defraud, and being faithful
16 to one's duty or obligation.
17 (3) The treating health care provider has
18 contacted the plan or designated persons with a
19 request for prior benefit authorization of
20 post-stabilization medical services in one of its 2
21 documented good faith efforts and the plan or
22 designated persons did not deny the request within
23 60 minutes of receiving the request.
24 (c) If rendering post-stabilization medical services
25 pursuant to item (2) or (3) of subsection (b), the treating
26 health care provider shall continue to make every reasonable
27 effort to contact the health care plan or its delegated
28 health care provider regarding benefit authorization or
29 denial or benefit authorization for an alternate plan of
30 treatment or transfer of the covered enrollee until the
31 treating provider receives benefit authorization from the
32 health care plan or delegated health care provider for
33 continued care or the care is transferred to another health
34 care provider or the patient is discharged.
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1 (d) Payment for covered post-stabilization medical
2 services may be denied:
3 (1) if the treating provider does not meet the
4 conditions outlined in subsections (b) and (c);
5 (2) upon determination that the post-stabilization
6 medical services claimed were not performed or were found
7 not to be medically necessary or not covered under the
8 enrollee's health care plan;
9 (3) upon determination that the post-stabilization
10 medical services rendered were denied or were contrary to
11 the benefit authorization of the health care plan or its
12 delegated health care provider if contact was made
13 between those parties prior to the service being
14 rendered;
15 (4) upon determination that the patient receiving
16 the services was not an enrollee of the health care plan;
17 or
18 (5) upon material misrepresentation by an enrollee
19 or provider; "material" means a fact or situation that is
20 not merely technical in nature and results or could
21 result in a substantial change in the situation.
22 (e) Nothing in this Section limits a health care plan
23 from delegating the responsibilities enumerated in this
24 Section to the health care plan's contracted medical
25 providers.
26 (f) Coverage and payment for post-stabilization medical
27 services for which prior authorization or deemed approval is
28 received shall not be retrospectively denied, except as
29 provided in subsection (d) of this Section.
30 (g) Payment for post-stabilization services shall be
31 provided by the health care plan at the contractual rate when
32 there is a contractual agreement in effect with the provider
33 or, in the absence of a contractual agreement with the health
34 care plan, at the usual and customary rate.
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1 (h) Nothing in this Section prohibits a health care plan
2 from imposing deductibles, coinsurance, or copayments in
3 covering post-stabilization medical services that may vary
4 from those copayments charged for other covered services.
5 Section 45. Provision of medical records for review.
6 For services provided under Sections 35 and 40 of this Act,
7 the provider shall provide upon request of the health care
8 plan, at no charge, a copy of the medical record.
9 Section 50. Consumer advisory committee.
10 (a) A health care plan shall establish a consumer
11 advisory committee. The consumer advisory committee shall
12 have the authority to review consumer concerns and make
13 advisory recommendations to the health care plan. The health
14 care plan may also make requests of the consumer advisory
15 committee to provide feedback to proposed changes in plan
16 policies and procedures which will affect enrollees.
17 However, the consumer advisory committee shall not have the
18 authority to hear or resolve specific complaints or
19 grievances, but instead shall refer such complaints or
20 grievances to the health care plan's grievance committee.
21 (b) The health care plan shall randomly select 8
22 enrollees meeting the requirements of this Section to serve
23 on the consumer advisory committee. Upon initial formation
24 of the consumer advisory committee, the health care plan
25 shall appoint 4 enrollees to a 2 year term and 4 enrollees to
26 a one year term. Thereafter, as an enrollee's term expires,
27 the health care plan shall re-appoint or appoint an enrollee
28 to serve on the consumer advisory committee for a 2 year
29 term. Members of the consumer advisory committee shall by
30 majority vote elect a member of the committee to serve as
31 chair of the committee.
32 (c) An enrollee may not serve on the consumer advisory
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1 committee if during the 2 years preceding service the
2 enrollee:
3 (1) has been an employee, officer, or director of
4 the plan, an affiliate of the plan, or a provider or
5 affiliate of a provider that furnishes health care
6 services to the plan or affiliate of the plan; or
7 (2) is a relative of a person specified in item
8 (1).
9 (d) A health care plan's consumer advisory committee
10 shall meet not less than quarterly.
11 (e) All meetings shall be held within the State of
12 Illinois. The costs of the meetings shall be borne by the
13 health care plan.
14 Section 55. Grievance procedures.
15 (a) Every health care plan shall submit for the
16 Director's approval, and thereafter maintain, a system for
17 the resolution of grievances concerning the provision of
18 health care services or other matters concerning operation
19 of the health care plan as follows. A health care plan shall
20 do all of the following:
21 (1) Submit to the Director for prior approval any
22 proposed changes to the system by which grievances may be
23 filed and reviewed;
24 (2) Maintain records on each grievance filed with
25 the health care plan until the grievance is resolved and
26 for a period of at least 3 years to include:
27 (A) a copy of the grievance and the date of
28 its filing;
29 (B) the date and outcome of all consultations,
30 hearings and hearing findings;
31 (C) the date and decisions of any appeal
32 proceedings; and
33 (D) the date and proceeding of any litigation.
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1 (3) Submit to the Director in a form prescribed by
2 the Director, a report by March 1 for the previous
3 calendar year which shall include at least the following:
4 (A) the total number of grievances handled;
5 (B) a compilation of causes underlying the
6 grievances;
7 (C) the outcomes of the grievances;
8 (D) the elapsed time from receipt of the
9 grievance by the health care plan until its
10 conclusion; and
11 (E) the number of malpractice claims filed and
12 if such claims have been completely adjudicated, a
13 compilation of causes, disposition, form, and amount
14 of any settlements.
15 (b) A health care plan shall have a grievance committee
16 which shall have the authority to hear and resolve by
17 majority vote grievances submitted to it as provided in
18 subsection (a).
19 Notwithstanding any other provisions of this Section, the
20 grievance committee may, but is not required to, hear any
21 grievance which alleges or indicates possible professional
22 liability, commonly known as "malpractice."
23 The committee is not empowered to resolve grievances in
24 any manner which, or prescribe any actions, that are in
25 conflict with written policies of the health care plan's
26 governing body, but the committee may hear such grievances
27 for the purpose of providing input to the governing body.
28 The grievance committee shall meet at the main office of
29 the health care plan, or such other office designated by the
30 health care plan where the main office is not within 50 miles
31 of the grievant's home address. Consideration shall be given
32 to the enrollee's request pertaining to the time and date of
33 such meeting. The enrollee shall have the right to attend
34 and participate in the formal grievance proceedings. The
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1 enrollee shall have the right to be accompanied by a
2 designated representative of his or her choice.
3 The filing of a grievance shall not preclude the enrollee
4 from filing a complaint with the Department nor shall it
5 preclude the Department from investigating a complaint
6 pursuant to its authority under Section 4-6 of the Health
7 Maintenance Organization Act.
8 (c) The grievance procedures must be fully and clearly
9 communicated to all enrollees and information concerning such
10 procedures shall be readily available to the enrollee.
11 (d) A health care plan shall have simplified procedure
12 for resolving complaints. Such procedures do not require
13 review of the complaint by the grievance committee, but a
14 log, file, or other similar records must be maintained to
15 identify the general nature of such complaints. Resolution
16 of such complaints shall not preclude the enrollees' rightful
17 access to review by the grievance committee of a grievance.
18 (e) The health care plan shall institute procedures
19 which would require grievances to have a determination made
20 by the grievance committee within 60 days from the date the
21 grievance is received by the health care plan. A grievance
22 may not be heard or voted upon unless 50% of the voting
23 individuals of the committee present at the hearing are
24 enrollees. The determination by the grievance committee may
25 be extended for a period not to exceed 30 days in the event
26 of delay in obtaining documents or records necessary for the
27 resolution of the grievance. All requests for documents or
28 records necessary for the resolution of the grievance shall
29 be maintained in the health care plan's grievance file.
30 (f) The grievance procedure shall provide the enrollee
31 with a written acknowledgment of their grievance within 10
32 business days after receipt by the health care plan.
33 (g) The enrollee shall be notified at the time of the
34 hearing of the name and affiliation of those grievance
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1 committee members who are representatives of the health care
2 plan.
3 (h) The health care plan shall institute procedures
4 whereby any document furnished to the members of the
5 grievance committee shall also be made available to the
6 enrollee not less than 5 business days prior to the hearing
7 of their grievance. The health care plan shall not present
8 any evidence without the enrollee having been given the
9 opportunity to be present.
10 (i) Notice in writing of the determination of the
11 grievance committee shall be mailed to the enrollee within 5
12 business days of such determination. Notice of the
13 determination made at the final appeal step of the health
14 care plan's grievance process shall include a notice of the
15 availability of the Department to receive complaints under
16 Section 4-6 of the Health Maintenance Organization Act.
17 (j) Prior to the resolution of a grievance filed by a
18 subscriber or enrollee, coverage shall not be terminated for
19 any reason which is the subject of the written grievance,
20 except where the health care plan has, in good faith, made a
21 reasonable effort to resolve the written grievance through
22 its grievance procedure and coverage is being terminated as a
23 result of good cause.
24 Section 60. Review of medical necessity. A health care
25 plan shall provide a mechanism for the timely review by a
26 physician holding the same class of license as the primary
27 care physician, who is unaffiliated with health care plan,
28 jointly selected by the patient (or the patient's next of kin
29 or legal representative if the patient is unable to act for
30 himself or herself), the patient's primary care physician and
31 the health care plan in the event of a dispute between the
32 primary care physician and the health care plan regarding the
33 medical necessity of a covered service proposed by the
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1 primary care physician. In the event that the reviewing
2 physician determines the covered service to be medically
3 necessary, the health care plan shall provide the covered
4 service. Future contractual or employment action by the
5 health care plan regarding the primary care physician shall
6 not be based solely on the physician's participation in this
7 procedure.
8 Section 65. Expedited review of medical necessity.
9 (a) A health care plan shall have an expedited review
10 procedure whereby an enrollee with a life-threatening
11 condition, or physician authorized in writing to act on
12 behalf of the enrollee with a life-threatening condition, may
13 appeal a health care plan's decision of medical necessity of
14 a covered service.
15 (b) The expedited review procedure shall provide that an
16 initial determination of the review will be made by the
17 health care plan not later than 3 business days after
18 receipt of all necessary information to complete the review
19 process.
20 (c) After the initial adverse determination by the
21 health care plan, the enrollee, or physician authorized in
22 writing to act on behalf of the enrollee, may request further
23 review by the health care plan. If further review is
24 requested, a final determination by the health care plan
25 shall be made not later than 30 days after receipt of all
26 necessary information to complete further review. Upon
27 notification to the enrollee of the health care plan's final
28 determination resulting from the expedited review process,
29 the plan shall provide the enrollee a notice of the
30 availability of the Department to receive complaints as
31 provided in Section 4-6 of the Health Maintenance
32 Organization Act.
33 (d) A request for an expedited review under this Section
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1 must contain a statement submitted by the physician, orally
2 or in writing, substantiating that the enrollee has a
3 life-threatening condition. This subsection does not apply to
4 a provider's complaint concerning claims payment, handling,
5 or reimbursement for health care services.
6 (e) If the expedited review process is invoked it shall
7 be in place of and not in addition to the regular review
8 process.
9 Section 70. Utilization review program registration.
10 (a) No person may conduct a utilization review program
11 in this State unless once every 2 years the person registers
12 the utilization review program with the Department and
13 certifies compliance with all of the Health Utilization
14 Management Standards of the American Accreditation Healthcare
15 Commission (URAC), the National Commission on Quality
16 Assurance (NCQA), or the Joint Committee on Accreditation of
17 Healthcare Organizations or submits evidence of accreditation
18 by the American Accreditation Healthcare Commission (URAC)
19 for its Health Utilization Management Standards, the National
20 Commission on Quality Assurance (NCQA), or the Joint
21 Committee on Accreditation of Healthcare Organizations.
22 (b) In addition, the Director of the Department, in
23 consultation with the Director of the Department of Public
24 Health, may certify alternative utilization review standards
25 of national accreditation organizations or entities in order
26 for plans to comply with this Section. Any alternative
27 utilization review standards shall meet or exceed those
28 standards required under subsection (a).
29 (c) The provisions of this Section do not apply to:
30 (1) persons providing utilization review program
31 services only to the federal government;
32 (2) self-insured health plans under the federal
33 Employee Retirement Income Security Act of 1974, however,
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1 this Section does apply to persons conducting a
2 utilization review program on behalf of these health
3 plans;
4 (3) hospitals and medical groups performing
5 utilization review activities for internal purposes
6 unless the utilization on review program is conducted for
7 another person.
8 Nothing in this Act prohibits a health care plan or other
9 entity from contractually requiring an entity designated in
10 item (3) of this subsection to adhere to the utilization
11 review program requirements of this Act.
12 (d) This registration shall include submission of all of
13 the following information regarding utilization review
14 program activities:
15 (1) The name, address, and telephone of the
16 utilization review programs.
17 (2) The organization and governing structure of the
18 utilization review programs.
19 (3) The number of lives for which utilization
20 review is conducted by each utilization review program.
21 (4) Hours of operation of each utilization review
22 program.
23 (5) Description of the grievance process for each
24 utilization review program.
25 (6) Number of covered lives for which utilization
26 review was conducted for the previous calendar year for
27 each utilization review program.
28 (7) Written policies and procedures for protecting
29 confidential information according to applicable State
30 and federal laws for each utilization review program.
31 (e) If the Department finds that a utilization review
32 program is not in compliance with this Section, the
33 Department shall issue a corrective action plan and allow a
34 reasonable amount of time for compliance with the plan. If
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1 the utilization review program does not come into compliance,
2 the Department may issue a cease and desist order. Before
3 issuing a cease and desist order under this Section, the
4 Department shall provide the utilization review program with
5 a written notice of the reasons for the order and allow a
6 reasonable amount of time to supply additional information
7 demonstrating compliance with requirements of this Section
8 and to request a hearing. The hearing notice shall be sent
9 by certified mail, return receipt requested, and the hearing
10 shall be conducted in accordance with the Illinois
11 Administrative Procedure Act.
12 (f) A utilization review program subject to a corrective
13 action may continue to conduct business until a final
14 decision has been issued by the Department.
15 Section 75. Collection rights.
16 (a) Providers and their assignees or subcontractors
17 shall not seek any type of payment from, bill, charge,
18 collect a deposit from, or have any recourse against an
19 enrollee, persons acting on an enrollee's behalf (other than
20 the health care plan), the employer, or group contract holder
21 for emergency services or post-stabilization medical services
22 provided, except for the payment of applicable copayments or
23 deductibles for services covered by the health care plan or
24 fees for services not covered under an enrollee's evidence of
25 coverage.
26 (b) Any collection or attempt to collect moneys or
27 maintain action against any subscriber or enrollee as
28 prohibited in subsection (a) may be reported to the Director
29 by any person. Any person making such a report shall be
30 immune from liability for doing so.
31 (c) The Director shall investigate such reports.
32 (d) If the Director finds that providers and their
33 assignees or subcontractors are not in compliance with this
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1 Section, he or she shall provide the person attempting to
2 bill, charge, collect a deposit from, or institute recourse
3 against an enrollee with a written notice of the reasons for
4 the finding and shall allow 14 days to supply additional
5 information demonstrating compliance with the requirements of
6 this Section and the opportunity to request a hearing. The
7 Director shall send a hearing notice by certified mail,
8 return receipt requested, and conduct a hearing in accordance
9 with the Illinois Administrative Procedure Act.
10 (e) Within 14 days after the final decision is rendered
11 under subsection (d), the Director shall provide a written
12 notice of the report to the reported provider's licensing or
13 disciplinary board or committee and require that the provider
14 reimburse, with interest at the rate of 8% per year, the
15 subscriber or enrollee any moneys found to be collected in
16 violation of this Section.
17 (f) The Director shall maintain a record of all notices
18 to licensing or disciplinary boards or committees pursuant to
19 this Section. This record shall be provided to any person
20 within 14 days of the Director's receipt of a written request
21 for the record.
22 (g) The Department, any enrollee, subscriber, or health
23 care plan may pursue injunctive relief to ensure compliance
24 with this Section.
25 Section 80. Penalties.
26 (a) Any organization that violates Section 20, 25, 30,
27 35, 40, 45, 50, 55, 60, or 65 of this Act shall be guilty of
28 a Class B misdemeanor.
29 (b) The Director may issue to any organization subject
30 to this Act a cease and desist order as provided in Article
31 XXIV, Section 401.1 of the Illinois Insurance Code.
32 Section 85. Severability. The provisions of this Act are
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1 severable under Section 1.31 of the Statute on Statutes.
2 Section 90. Applicability of Act. A health care plan
3 amended, delivered, issued, or renewed in this State after
4 the effective date of this Act must comply with the terms of
5 this Act.
6 Section 99. Effective date. This Act takes effect
7 January 1, 2000.