State of Illinois
91st General Assembly
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91_HB1331

 
                                               LRB9102355JSpc

 1        AN  ACT  concerning external appeal procedures concerning
 2    health care determinations, amending named Acts.

 3        Be it enacted by the People of  the  State  of  Illinois,
 4    represented in the General Assembly:

 5        Section  5.   The  State Employees Group Insurance Act of
 6    1971 is amended by changing Section 6.11 as follows:

 7        (5 ILCS 375/6.11)
 8        Sec. 6.11.  Required health  benefits.   The  program  of
 9    health   benefits  shall  provide  the  post-mastectomy  care
10    benefits required to be covered by a policy of  accident  and
11    health insurance under Section 356t of the Illinois Insurance
12    Code.   The  program  of  health  benefits  shall provide the
13    coverage required under Sections 356u, 356w, and 356x of  the
14    Illinois  Insurance  Code  and comply with Article VII of the
15    Health Maintenance Organization Act.
16    (Source: P.A.  90-7,  eff.  6-10-97;  90-655,  eff.  7-30-98;
17    90-741, eff. 1-1-99.)

18        Section 10.  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 the 91st General Assembly.

25        Section  15.   The  Counties  Code is amended by changing
26    Section 5-1069.3 as follows:

27        (55 ILCS 5/5-1069.3)
 
                            -2-                LRB9102355JSpc
 1        Sec. 5-1069.3.  Required health benefits.  If  a  county,
 2    including  a home rule county, is a self-insurer for purposes
 3    of providing health insurance coverage for its employees, the
 4    coverage shall include coverage for the post-mastectomy  care
 5    benefits  required  to be covered by a policy of accident and
 6    health insurance under Section 356t and the coverage required
 7    under Sections 356u, 356w, and 356x of the Illinois Insurance
 8    Code and comply with Article VII of  the  Health  Maintenance
 9    Organization  Act.   The  requirement that health benefits be
10    covered as provided in this Section is an exclusive power and
11    function of the State and is a denial  and  limitation  under
12    Article  VII,  Section  6,  subsection  (h)  of  the Illinois
13    Constitution.  A home  rule  county  to  which  this  Section
14    applies must comply with every provision of this Section.
15    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

16        Section  20.   The  Illinois Municipal Code is amended by
17    changing Section 10-4-2.3 as follows:

18        (65 ILCS 5/10-4-2.3)
19        Sec.  10-4-2.3.   Required   health   benefits.    If   a
20    municipality,  including  a  home  rule  municipality,  is  a
21    self-insurer  for  purposes  of  providing  health  insurance
22    coverage  for  its  employees,  the  coverage  shall  include
23    coverage for the post-mastectomy care benefits required to be
24    covered  by  a  policy of accident and health insurance under
25    Section 356t and the coverage required under  Sections  356u,
26    356w, and 356x of the Illinois Insurance Code and comply with
27    Article  VII of the Health Maintenance Organization Act.  The
28    requirement that health benefits be covered  as  provided  in
29    this is an exclusive power and function of the State and is a
30    denial   and   limitation   under  Article  VII,  Section  6,
31    subsection (h) of the Illinois  Constitution.   A  home  rule
32    municipality  to  which this Section applies must comply with
 
                            -3-                LRB9102355JSpc
 1    every provision of this Section.
 2    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

 3        Section 25.  The  School  Code  is  amended  by  changing
 4    Section 10-22.3f as follows:

 5        (105 ILCS 5/10-22.3f)
 6        Sec.   10-22.3f.  Required  health  benefits.   Insurance
 7    protection and  benefits  for  employees  shall  provide  the
 8    post-mastectomy  care  benefits  required  to be covered by a
 9    policy of accident and health insurance  under  Section  356t
10    and the coverage required under Sections 356u, 356w, and 356x
11    of the Illinois Insurance Code and comply with Article VII of
12    the Health Maintenance Organization Act.
13    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

14        Section  30.  The  Illinois  Insurance Code is amended by
15    adding Sections 155.36, 370s, and 511.114 as follows:

16        (215 ILCS 5/155.36 new)
17        Sec.   155.36.  Health   care   determination    appeals.
18    Insurance  companies  that  transact  the  kinds of insurance
19    authorized under Class 1(a) or Class 2(a)  of  Section  4  of
20    this  Code  shall comply with the requirements of Article VII
21    of the Health Maintenance Organization Act.

22        (215 ILCS 5/370s new)
23        Sec.   370s.   Health   care    determination    appeals.
24    Administrators  shall comply with the requirements of Article
25    VII of the Health Maintenance Organization Act.

26        (215 ILCS 5/511.114 new)
27        Sec.  511.114.   Health   care   determination   appeals.
28    Administrators  shall comply with the requirements of Article
 
                            -4-                LRB9102355JSpc
 1    VII of the Health Maintenance Organization Act.

 2        Section 35. The Health Maintenance  Organization  Act  is
 3    amended by adding Article VII as follows:

 4        (215 ILCS 5/Art. VII heading new)
 5        ARTICLE VII. EXTERNAL MEDICAL DETERMINATIONS APPEALS

 6        (215 ILCS 125/7-105 new)
 7        Sec. 7-105.  Right to external appeal established.
 8        (a)  There  is  hereby established an enrollee's right to
 9    an external appeal of a  final  adverse  determination  by  a
10    health care plan.
11        (b)  An   enrollee,   the  enrollee's  designee  and,  in
12    connection  with  retrospective  adverse  determinations,  an
13    enrollee's health care provider,  shall  have  the  right  to
14    request an external appeal when:
15             (1)  the  enrollee has had coverage of a health care
16        service that would otherwise be a covered benefit under a
17        subscriber contract  denied on appeal,  in  whole  or  in
18        part,  on the grounds that the health care service is not
19        medically necessary and the health care plan has rendered
20        a final adverse determination with respect to the  health
21        care  service  or  both  the  plan  and the enrollee have
22        jointly agreed to waive any internal appeal; or
23             (2)  the enrollee has had coverage of a health  care
24        service   denied   on  the  basis  that  the  service  is
25        experimental or investigational; both the  plan  and  the
26        enrollee  have  jointly  agreed  to  waive  any  internal
27        appeal; the  enrollee's attending physician has certified
28        that  the  enrollee  has  a life-threatening or disabling
29        condition  or  disease  (a)  for  which  standard  health
30        services or procedures have been ineffective or would  be
31        medically  inappropriate, or (b) for which there does not
 
                            -5-                LRB9102355JSpc
 1        exist  a  more  beneficial  standard  health  service  or
 2        procedure covered by the health care  plan,  or  (c)  for
 3        which  there  exists  a  clinical  trial;  the enrollee's
 4        attending   physician,   who   must   be   a    licensed,
 5        board-certified  or board-eligible physician qualified to
 6        practice in the area of practice appropriate to treat the
 7        enrollee's life threatening  or  disabling  condition  or
 8        disease,  has  recommended either (A) a health service or
 9        procedure  (including  a  pharmaceutical  product)  that,
10        based on 2  documents  from  the  available  medical  and
11        scientific  evidence,  is likely to be more beneficial to
12        the enrollee than any covered standard health service  or
13        procedure  or (B) a clinical trial for which the enrollee
14        is eligible; and the specific health service or procedure
15        recommended by the attending physician would otherwise be
16        covered under the  policy  except  for  the  health  care
17        plan's determination that the health service or procedure
18        is experimental or investigational.
19        Any   physician   certification   provided   under   this
20    subsection  shall  include a statement of the evidence relied
21    upon  by   the   physician   in   certifying   his   or   her
22    recommendation.
23        (c)  The  health  care plan may charge the enrollee a fee
24    of up to $50 per external appeal, provided that, in the event
25    the  external  appeal  agent  overturns  the  final   adverse
26    determination  of  the plan, the fee shall be refunded to the
27    enrollee. Notwithstanding  the  foregoing,  the  health  plan
28    shall  not  require the enrollee to pay a fee if the enrollee
29    is a recipient of medical assistance or  if  such  fee  shall
30    pose a hardship to the enrollee as determined by the plan.

31        (215 ILCS 125/7-110 new)
32        Sec. 7-110.  Powers of the Director.
33        (a)  The  Director  shall  have  the  power  to grant and
 
                            -6-                LRB9102355JSpc
 1    revoke certifications of external appeal  agents  to  conduct
 2    external appeals requested pursuant to Section 7-105.
 3        (b)  If,  after  reviewing  the application authorized by
 4    Section 7-115, the Director is satisfied that  the  applicant
 5    meets  the  requirements  of this Section, the Director shall
 6    issue a certificate to the applicant.  A  certificate  issued
 7    under  this  Section  shall be valid for a period of not more
 8    than 2 years.
 9        (c)  In order to be recertified, an external appeal agent
10    must demonstrate to the Director on forms prescribed  by  the
11    Director  that  it continues to meet all applicable standards
12    required by this Article. Recertification under this  Section
13    shall be valid for a period of not more than 2 years.

14        (215 ILCS 125/7-115 new)
15        Sec. 7-115.  Standards for certification.
16        (a)  The   Director  shall  develop  an  application  for
17    certification. At a minimum, applicants shall provide:
18             (1)  a description  of  the  qualifications  of  the
19        clinical  peer  reviewers  retained  to  conduct external
20        appeals of final adverse  determinations,  including  the
21        reviewers'   current  and  past  employment  history  and
22        practice affiliations;
23             (2)  a description of  the  procedures  employed  to
24        ensure  that  clinical peer reviewers conducting external
25        appeals are:
26                  (A)  appropriately  licensed,  registered,   or
27             certified;
28                  (B)  trained in the principles, procedures, and
29             standards of the external appeal agent; and
30                  (C)  knowledgeable   about   the   health  care
31             service that is the subject  of  the  final  adverse
32             determination under appeal;
33             (3)  a  description of the methods of recruiting and
 
                            -7-                LRB9102355JSpc
 1        selecting impartial clinical peer reviewers and  matching
 2        reviewers to specific cases;
 3             (4)  the  number of clinical peer reviewers retained
 4        by the external appeal agent, and a  description  of  the
 5        areas  of  expertise available from the reviewers and the
 6        types of cases the reviewers are qualified to review;
 7             (5)  a description of the  policies  and  procedures
 8        employed  to  protect  the  confidentiality of individual
 9        medical  and  treatment  records   in   accordance   with
10        applicable State and federal laws;
11             (6)  a  description of the quality assurance program
12        established by the external appeal agent pursuant to item
13        (3);
14             (7)  the names of all corporations and organizations
15        owned  or controlled by the external appeal agent or that
16        owns or controls such agent, and the nature and extent of
17        any such ownership or control;
18             (8)  the names and  biographies  of  all  directors,
19        officers, and executives of the external appeal agent;
20             (9)  an  experimental  and investigational treatment
21        review plan to conduct appeals pursuant to subsection (b)
22        of Section 7-125; and
23             (10)  a description of the fees  to  be  charged  by
24        agents for external appeals.
25        (b)  The   Director  shall,  at  a  minimum,  require  an
26    external appeal agent to:
27             (1)  appoint a medical director who is  a  physician
28        in  possession  of  a  current  and  valid non-restricted
29        license to practice medicine and who shall be responsible
30        for the supervision and oversight of the external  appeal
31        process;
32             (2)  develop   written   policies   and   procedures
33        governing  all  aspects of the appeal process, including,
34        at a minimum:
 
                            -8-                LRB9102355JSpc
 1                  (A)  procedures  to  ensure  that  appeals  are
 2             conducted  within  the  time  frames  specified   in
 3             Section  7-125 and any required notices are provided
 4             in a timely manner;
 5                  (B)  procedures  to  ensure  the  selection  of
 6             qualified and impartial clinical peer reviewers that
 7             are qualified to render determinations  relating  to
 8             the  health  care service that is the subject of the
 9             final adverse determination under appeal;
10                  (C)  procedures to ensure  the  confidentiality
11             of   medical   and   treatment  records  and  review
12             materials; and
13                  (D)  procedures  to  ensure  adherence  to  the
14             requirements of  this  Article  by  any  contractor,
15             subcontractor,   subvendor,   agent,   or   employee
16             affiliated   by   contract  or  otherwise  with  the
17             external appeal agent;
18             (3)  establish  a  quality  assurance  program  that
19        includes written descriptions,  to  be  provided  to  all
20        individuals    involved    in   the   program,   of   the
21        organizational arrangements and  ongoing  procedures  for
22        the identification, evaluation, resolution, and follow-up
23        of  potential  and  actual  problems  in external appeals
24        performed by the external appeal agent and to ensure  the
25        maintenance   of   program  standards  pursuant  to  this
26        Section;
27             (4)  establish  a  toll-free  telephone  service  to
28        receive information relating to  external  appeals  on  a
29        24-hour-a-day,  7-day-a-week  basis  that  is  capable of
30        accepting,  recording,  or   providing   instruction   to
31        incoming   telephone   calls  during  other  than  normal
32        business hours; and
33             (5)  develop procedures to ensure that:
34                  (A)  appropriate   personnel   are   reasonably
 
                            -9-                LRB9102355JSpc
 1             accessible not less than 40 hours  per  week  during
 2             normal business hours to discuss patient care and to
 3             allow response to telephone requests; and
 4                  (B)  response  to accepted or recorded messages
 5             will be made not less than one  business  day  after
 6             the date on which the call was received.
 7        (c)  No entity shall be qualified to submit a request for
 8    application  if  it  owns or controls, is owned or controlled
 9    by, or exercises common control with, any of the following:
10             (1)  a national, state,  or  local  illness,  health
11        benefit, or public advocacy group;
12             (2)  a   national,   state,   or  local  society  or
13        association of hospitals, physicians, or other  providers
14        of health care services; or
15             (3)  a  national,  state,  or  local  association of
16        health care plans.
17        (d)  A health care plan shall transmit, and  an  external
18    appeal  agent  shall  be authorized to receive and review, an
19    enrollee's medical and treatment records in order to  conduct
20    an external appeal pursuant to this Article.
21        (e)  An  external appeal agent shall provide ready access
22    to  the  Director  to  all  data,  records,  and  information
23    collected and  maintained  concerning  the  agent's  external
24    appeal activities.
25        (f)  An  external appeal agent shall agree to provide the
26    Director such data, information, and reports as the  Director
27    determines  necessary to evaluate the external appeal process
28    established pursuant to this Article.
29        (g)  The Director shall provide, upon the request of  any
30    interested  person,  a copy of all nonproprietary information
31    filed with the Director by the  external  appeal  agent.  The
32    Director may charge a reasonable fee to the interested person
33    for reproducing the requested information.
 
                            -10-               LRB9102355JSpc
 1        (215 ILCS 125/7-120 new)
 2        Sec. 7-120.  Conflict of interest.
 3        (a)  No  external  appeal  agent or officer, director, or
 4    management employee thereof and  no  clinical  peer  reviewer
 5    employed  or  engaged  thereby to conduct any external appeal
 6    pursuant to this Article shall have any material professional
 7    affiliation,   material   familial   affiliation,    material
 8    financial   affiliation,   or  other  affiliation  prescribed
 9    pursuant to rule, with any of the following:
10             (1)  the health care plan;
11             (2)  an officer, director, or management employee of
12        the health care plan;
13             (3)  a health  care  provider,  physician's  medical
14        group,  independent  practice association, or provider of
15        pharmaceutical products or services  or  durable  medical
16        equipment,  proposing  to  provide  or  supply the health
17        service;
18             (4)  the facility at which the health service  would
19        be provided;
20             (5)  the  developer or manufacturer of the principal
21        health service that is the subject of the appeal; or
22             (6)  the enrollee whose health care service  is  the
23        subject of the appeal, or the enrollee's designee.
24        (b)  Notwithstanding  the  provisions  of subsection (a),
25    the Director shall promulgate rules to minimize any  conflict
26    of interest when a conflict may be unavoidable.

27        (215 ILCS 125/7-125 new)
28        Sec.  7-125.  Procedures  for external appeals of adverse
29    determinations.
30        (a)  The Director shall establish procedures by  rule  to
31    randomly  assign  an  external  appeal  agent  to  conduct an
32    external appeal, provided that the Director may  establish  a
33    maximum  fee that may be charged for any external appeal, but
 
                            -11-               LRB9102355JSpc
 1    the Director may exclude from random assignment any  external
 2    appeal  agent  that  charges  a  fee  that  he  deems  to  be
 3    unreasonable.
 4        (b)  The  enrollee  shall  have  45  days  to initiate an
 5    external appeal after the enrollee receives notice  from  the
 6    health  care  plan, or the plan's utilization review agent if
 7    applicable, of a final adverse  determination  or  denial  or
 8    after  both  the plan and the enrollee have jointly agreed to
 9    waive any internal appeal. The request shall be in writing in
10    accordance with the instructions and in the  form  prescribed
11    by  subsection  (e)  of  this  Section. The enrollee, and the
12    enrollee's health care provider when applicable,  shall  have
13    the  opportunity  to  submit  additional  documentation  with
14    respect to the appeal to the external appeal agent within the
15    45-day  period,  however, when the documentation represents a
16    material  change  from  the  documentation  upon  which   the
17    utilization  review  agent based its adverse determination or
18    upon which the health plan based its denial, the health  plan
19    shall  have 3 business days to consider the documentation and
20    amend or confirm the adverse determination.
21        (c)  The external appeal agent shall make a determination
22    with respect to the appeal within 30 days after  the  receipt
23    of  the  enrollee's request therefor, submitted in accordance
24    with the Director's instructions. The external  appeal  agent
25    shall  have the opportunity to request additional information
26    from the enrollee, the enrollee's health care  provider,  and
27    the  enrollee's health care plan within the 30-day period, in
28    which case the agent shall have up to 5  additional  business
29    days  if  necessary  to  make  a  determination. The external
30    appeal agent shall notify the enrollee and  the  health  care
31    plan,  in  writing,  of  the  appeal  determination  within 2
32    business days after the rendering the determination.
33        (d)  Notwithstanding the provisions  of  subsections  (b)
34    and   (c)  of  this  Section,  if  the  enrollee's  attending
 
                            -12-               LRB9102355JSpc
 1    physician states that a delay in providing  the  health  care
 2    service  would  pose  an  imminent  or  serious threat to the
 3    health  of  the  enrollee,  the  external  appeal  shall   be
 4    completed  within  3  days  of  the request therefor, and the
 5    external appeal agent shall make every reasonable attempt  to
 6    immediately  notify  the  enrollee and the health plan of its
 7    determination by telephone or facsimile, followed immediately
 8    by written notification of the determination.
 9        (e)  For external appeals requested pursuant to paragraph
10    (1) of subsection (b) of Section 7-105, the  external  appeal
11    agent  shall  review  the  utilization  review  agent's final
12    adverse determination and, in accordance with the  provisions
13    of this Article, shall make a determination as to whether the
14    health  care  plan  acted  reasonably  and with sound medical
15    judgment and in the best interest of the  patient.  When  the
16    external  appeal  agent  makes  its  determination,  it shall
17    consider the clinical standards of the plan, the  information
18    provided  concerning  the  patient, the attending physician's
19    recommendation, and applicable  generally  accepted  practice
20    guidelines  developed  by the federal government and national
21    or professional medical societies, boards, and  associations.
22    The determination shall be:
23             (1)  conducted  only  by one or a greater odd number
24        of clinical peer reviewers;
25             (2)  accompanied by a notice of appeal determination
26        that includes the reasons for the determination, however,
27        when the final adverse determination is upheld on appeal,
28        the notice shall include the clinical rationale, if  any,
29        for the determination;
30             (3)  subject  to  the terms and conditions generally
31        applicable to benefits under  the  evidence  of  coverage
32        under the health care plan;
33             (4)  binding on the plan and the enrollee; and
34             (5)  admissible in any court proceeding.
 
                            -13-               LRB9102355JSpc
 1        (f)  For external appeals requested pursuant to paragraph
 2    (2)  of  subsection (b) of Section 7-105, the external appeal
 3    agent shall review the proposed health service  or  procedure
 4    for  which  coverage  has been denied and, in accordance with
 5    the provisions of  this  Article  and  the  external  agent's
 6    experimental  and investigational treatment review plan, make
 7    a determination as to whether the patient costs of the health
 8    service or procedure shall be  covered  by  the  health  care
 9    plan.  The determination shall:
10             (1)  be  conducted  by a panel of 3 or a greater odd
11        number of clinical peer reviewers;
12             (2)  be accompanied by a written statement:
13                  (A)  that the patient  costs  of  the  proposed
14             health  service or procedure shall be covered by the
15             health care plan either when a majority of the panel
16             of  reviewers  determines   upon   review   of   the
17             applicable  medical and scientific evidence (or upon
18             confirmation that the  recommended  treatment  is  a
19             clinical  trial), the enrollee's medical record, and
20             any other pertinent information  that  the  proposed
21             health    service    or   treatment   (including   a
22             pharmaceutical  product)  is  likely  to   be   more
23             beneficial than any standard treatment or treatments
24             for  the  enrollee's  life-threatening  or disabling
25             condition or disease (or, in the case of a  clinical
26             trial,  is  likely  to  benefit  the enrollee in the
27             treatment of the enrollee's condition or disease) or
28             when a reviewing panel is evenly  divided  as  to  a
29             determination  concerning  coverage  of  the  health
30             service or procedure; or
31                  (B)  upholding  the  health  plan's  denial  of
32             coverage;
33             (3)  be   subject   to   the  terms  and  conditions
34        generally applicable to benefits under  the  evidence  of
 
                            -14-               LRB9102355JSpc
 1        coverage under the health care plan;
 2             (4)  be binding on the plan and the enrollee; and
 3             (5)  be admissible in any court proceeding.
 4        As used in this subsection (f) with respect to a clinical
 5    trial,  patient  costs  shall  include  all  costs  of health
 6    services  required  to  provide  treatment  to  the  enrollee
 7    according to the design of the trial. Such  costs  shall  not
 8    include  the  costs  of  any investigational drugs or devices
 9    themselves, the cost of any nonhealth services that might  be
10    required for the enrollee to receive the treatment, the costs
11    of  managing the research, or costs that would not be covered
12    under the policy for noninvestigational treatments.
13        (g)  No external appeal agent or clinical  peer  reviewer
14    conducting  an  external appeal shall be liable in damages to
15    any person for any opinions rendered by the  external  appeal
16    agent  or  clinical  peer  reviewer  upon  completion  of  an
17    external  appeal  conducted  pursuant to this Section, unless
18    the opinion was rendered  in  bad  faith  or  involved  gross
19    negligence.
20        (h)  Payment   for   an  external  appeal  shall  be  the
21    responsibility of the health care plan. The health care  plan
22    shall  make  payment  to  the external appeal agent within 45
23    days after the date the appeal determination is  received  by
24    the  health  care  plan,  and  the  health care plan shall be
25    obligated to pay the amount together  with  interest  thereon
26    calculated  at  a rate 12% per annum, to be computed from the
27    date the bill was required to be  paid,  in  the  event  that
28    payment is not made within such 45 days.
29        (i)  The  Director  shall  promulgate  by rule a standard
30    description of the external appeal process established  under
31    this  Section,  which  shall  provide  a  standard  form  and
32    instructions  for  the initiation of an external appeal by an
33    enrollee.
 
                            -15-               LRB9102355JSpc
 1        (215 ILCS 125/7-130 new)
 2        Sec. 7-130.  Prohibited  practices.  An  external  appeal
 3    agent  shall not, with respect to external appeal activities,
 4    permit or provide compensation or anything of  value  to  its
 5    employees, agents, or contractors based on:
 6             (1)  either  a  percentage  of the amount by which a
 7        claim is reduced for payment or the number of  claims  or
 8        the  cost  of  services  for  which the person has denied
 9        authorization or payment; or
10             (2)  any other method that encourages the  upholding
11        of an adverse determination.

12        (215 ILCS 125/7-135 new)
13        Sec.  7-135.  Oversight  and surveillance of the external
14    appeal process.
15        (a)  The Director shall have the power to:
16             (1)  review the activities of the health care  plans
17        and  external  appeal  agents  pursuant  to this Article,
18        including the extent to which the plans and agents adhere
19        to the standards and time  frames  required  pursuant  to
20        this Article;
21             (2)  investigate  complaints  by enrollees regarding
22        requests for and processing of external appeals; and
23             (3)  conduct random audits of health care plans  and
24        external  appeal  agents to determine compliance with the
25        provisions of this Article.
26        (b)  A health care plan and external appeal  agent  shall
27    annually,  in such form as the Director shall require, report
28    the number of external appeals requested by enrollees and the
29    outcomes of any external appeals.
30        (c)  The Director shall  annually  report,  by  plan  and
31    agent,  such  information  to  the  Governor  and the General
32    Assembly, provided that no information shall be included that
33    would otherwise be deemed confidential information within the
 
                            -16-               LRB9102355JSpc
 1    meaning of this Act.

 2        Section 40.  The Voluntary Health Services Plans  Act  is
 3    amended by adding Section 15.30 as follows:

 4        (215 ILCS 165/15.30 new)
 5        Sec. 15.30.  Health care determination appeals.  A health
 6    services  plan is subject to the provisions of Article VII of
 7    the Health Maintenance Organization Act.

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