TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.10 AUTHORITY, SCOPE AND PURPOSE
Section 240.10 Authority,
Scope and Purpose
a) This Part is promulgated pursuant to the authority granted the
Department of Public Health in Sections 2-2(a), 2-2(b) 5-4, 5-5(d) and 5-8 of
the Health Maintenance Organization Act (Ill. Rev. Stat. 1987, ch. 111½, pars.
1404(a), 1404(b), 1412, 1413(d) and 1416) for the purpose of regulation and
enhancement of Health Maintenance Organizations in Illinois. These regulations
apply to certified Health Maintenance Organizations, as well as to applicants
for an HMO Certificate of Authority, and are promulgated to carry out the
Health Maintenance Organization Act and to facilitate the full and uniform
implementation, enforcement and intent of the Act.
b) Pursuant to the Act the Illinois Department of Public Health
and the Illinois Department of Insurance have joint responsibility for the
regulation of Health Maintenance Organizations (HMOs) in Illinois. All
applicants and certified programs are therefore bound by the Health Maintenance
Organization rules of the Department of Insurance located at 50 Ill. Adm. Code
6101 as well as this Part. No person shall establish or operate a Health
Maintenance Organization without obtaining a Certificate of Authority from the
Department of Insurance.
c) These regulations explain the requirements an HMO applicant
must satisfy in order for the Department of Public Health to certify to the
Department of Insurance that the applicant's proposed plan of operation meets
the Department of Public Health requirements. Also included in this Part are
the operational, recordkeeping and fee requirements applicable to HMOs.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.20 DEFINITIONS
Section 240.20 Definitions
"Act" means the Health Maintenance Organization Act
(Ill. Rev. Stat. 1987, ch. 111½, pars. 1401 et seq.).
"Basic health care services" means emergency
care, and inpatient hospital and physician care, outpatient medical services,
mental health services and care for alcohol and drug abuse, including any
reasonable deductibles and co-payments. (See also the Department of
Insurance regulations located at 50 Ill. Adm. Code 6101.130.) (Section 1-2 of
the Act)
"Director of Department of Public Health" means the
Director of the Illinois Department of Public Health, or such person or office
as designated by the Director of the Department of Public Health to act in the
Director's behalf.
"Encounter" means a face to face contact between an
enrollee and a basic health care service provider who has primary
responsibility for assessing and treating the condition of the patient at a
given contact and exercises independent judgement in the care of the enrollee.
"Enrollee" or "member" means an
individual who has been enrolled as a subscriber or as an eligible dependent of
a subscriber and for whom the HMO has accepted the contractual responsibility
for providing or arranging for at least, health care services and basic health
care services.
"Evidence of Coverage" means any certificate,
agreement, or contract issued to an enrollee setting out the coverage to which
he is entitled in exchange for a per capita prepaid sum. (Section 1-2 of
the Act)
"Grievance" means any written complaint by an
enrollee regarding any aspect of the HMO relative to the enrollee. (See also
the Department of Insurance regulations on HMO's, 50 Ill. Adm. Code 6101.40 for
clarification.)
"Health Care Plan" means any arrangement whereby
any organization undertakes to provide, arrange for and pay for or reimburse
the cost of basic health care services and at least part of such arrangement
consists of arranging for or the provision of health care services, as
distinguished from mere indemnification against the cost of such services, on a
prepaid basis, through insurance or otherwise. (Section 1-2 of the Act)
"Health Care Services" means any services
included in the furnishing to any individual of medical or dental care, or the
hospitalization or incident to the furnishing of such care or hospitalization
as well as the furnishing to any person of any and all other services for the
purpose of preventing, alleviating, curing or healing human illness or injury.
(Section 1-2 of the Act)
"Health Maintenance Organization" or "HMO"
means any organization formed under the laws of this or another state to
provide or arrange for one or more health care plans under a system which
causes any part of the risk of health care delivery to be borne by the
organization or its providers. (Section 1-2 of the Act)
"Medical Director" means a physician licensed to
practice medicine in all its branches in Illinois and who shall be responsible
for final review when questions of medical practice arise in the HMO in order to
assure the quality of health care services provided.
"Peer Review" means the evaluation
by similarly licensed practicing physicians of the
effectiveness and efficiency of services ordered or performed by other
similarly licensed practicing physicians, or
by other professionals of the effectiveness and efficiency of
services ordered or performed by other members of the profession whose work is
being reviewed.
"Plan Service Area" means the geographic territory
to be served by the HMO.
"Primary Care Physician" means a provider who has
contracted with a Health Maintenance Organization to provide primary care
services as defined by the contract and who is
a physician licensed to practice medicine in all of its
branches who spends a majority of clinical time engaged in general practice or
in the practice of internal medicine, pediatrics, gynecology, obstetrics or
family practice, or
a chiropractic physician licensed to treat human ailments
without the use of drugs or operative surgery.
"Provider" means any physician, hospital
facility, or other person which is licensed by state law or otherwise
authorized by state, federal, or local law to furnish health care
services. (Section 1-2 of the Act)
"Quality Assessment Monitoring" means the planned,
systematic, and routine collection of information by the HMO according to
previously determined indicators of quality and appropriateness of patient care
and clinical performance encompassing basic and supplemental health care
services and providers. After periodic assessment and evaluation by the HMO,
quality assessment monitoring can detect trends and identify opportunities for
improving enrollees' care.
"Supplemental Benefits" or "Selective
Benefits" means any services or benefits provided by the HMO over and
above those required as basic health care services.
"Utilization Review" means the study of the
appropriateness of the use of particular services and the appropriateness of
the volume of services used.
(Source: Amended at 14 Ill. Reg. 2403, effective February 15, 1990)
SUBPART B: APPLICATION FOR HMO CERTIFICATE OF AUTHORITY
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.30 SUBMISSION OF APPLICATION FOR HMO CERTIFICATE OF AUTHORITY
Section 240.30 Submission of
Application for HMO Certificate of Authority
The HMO application shall be
submitted in triplicate (one original and two copies) to the Department of
Insurance in a loose-leaf three-ring binder, indexed with the sections tabbed.
The application requirements pertaining to information required by the Department
of Public Health are described in Sections 240.40, 240.50, and 240.60 of this
Part.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.40 PERSONNEL, ORGANIZATION AND PROVIDER REQUIREMENTS
Section 240.40 Personnel,
Organization and Provider Requirements
The application for an HMO
Certificate of Authority shall contain the following information about the
applicant's personnel, organization and providers:
a) Organization charts which include descriptions of the
administrative structure of the HMO and the HMO's relationship with the medical
group, individual practice associations, or other provider arrangements, such
as home health agencies, durable medical suppliers, nursing homes and
laboratories.
b) A flow of care chart or narrative which illustrates the
movement and contacts of the enrollees through the primary and specialty care
physicians of the HMO care system.
c) A legible map or maps of the plan service areas by Zip Code to
be served by the HMO showing the location of its offices and ambulatory health
care facilities.
d) A general description of any facilities to be used. An HMO
that utilizes the services of physicians in their individual offices or
contracts with groups of five or less participating physicians shall submit a
map or maps of the locations of all such individual offices for such
practitioners. All other HMOs shall submit a floor plan identifying the square
footage available and a projection of the number of enrollees to be served in
each ambulatory care facility.
e) In addition to the Biographical Affidavit required by the
Department of Insurance, the name, medical license number, resume and address
of the medical director of the HMO.
f) The name, resume and address of the chief administrative
officer of the HMO.
g) Job descriptions for the chief administrative officer and
medical director positions.
h) The name, medical license number and any Drug Enforcement
Administration number issued to each physician with whom the HMO has
agreements.
i) Certification that each contract with providers requires the
providers to assure that all nurses and other ancillary and paramedic personnel
are licensed, certified or registered, as required to perform their duties.
j) A list of each participating physician's name, medical
license number, hospitals where the physician has admitting or staff
privileges, each physician's specialty, and office address. The HMO shall
provide evidence that the variety and composition of specialty participating
plan physicians reflects the medical needs and characteristics of the enrollees
in the plan service area. Such evidence may include historical data on the
service needs experienced by the projected HMO population, survey data, or any
other data concerning an assessment of the needs and characteristics of the
projected HMO population.
k) An explanation of how the HMO will make medically necessary
services available twenty-four hours a day, seven days a week.
l) The standards and procedures the HMO has developed for the
selection of providers.
m) Projections by the HMO for a two-year period that include
projected enrollment levels, primary care physician to enrollee ratios, and
plans for providing specialty care, laboratory, X-ray and hospital services.
The HMO must provide evidence that the ratio and the projected ratios are
consistent with its assessment and projection of enrollee needs and insure the
availability and accessibility of health care services.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.50 PROVISION OF CARE REQUIREMENTS
Section 240.50 Provision of
Care Requirements
The application for an HMO
Certificate of Authority shall contain the following information about the
provision of health care services by the HMO:
a) A copy of the evidence of coverage that will be issued to
enrollees.
b) A description of the HMO's referral system that will be used
when an enrollee is in need of a health care service covered by the HMO plan,
but not available through the participating plan physicians. The referral
mechanism shall require that the provider make any appointments, hospitalization,
surgical procedures and any other health services available to enrollees within
a medically appropriate timeframe. This policy shall not be construed so as to
relieve an enrollee of any financial obligation incurred when that enrollee
fails or refuses to utilize the HMO referral system.
c) A description of the medical record system of the HMO or HMO
providers. The HMO and its providers shall meet the following medical record
system requirements:
1) Clinical records shall be maintained on each enrollee who
receives health care services through the HMO. The medical records system shall
be organized to facilitate retrieval and compilation of medical records
information necessary to provide continuity of care among various member and
nonmember providers who are directly involved in the care of the enrollee.
2) There shall be a policy regarding the retention and retirement
of enrollees' medical records.
3) There shall be a policy regarding confidentiality, security
and release of enrollees' medical records.
d) Sample copies of all types of contracts entered into with
providers. Copies of portions of actual contracts that pertain to the scope of
services to be provided by the HMO shall be made available for review by the
Department.
1) The HMO's contracts shall contain the following:
A) Descriptions of the arrangements for the provision of each of
the types of services included in the evidence of coverage,
B) Descriptions of how the providers will ensure that the HMO's
enrollees will receive health care services at all times, and
C) The provider's responsibilities within the HMO self-evaluation
structure and activities described in Section 240.60 of this Part.
2) Services which are to be provided by participating plan
primary care physicians shall be covered by a written contract with the HMO.
3) The HMO is not required to execute contracts for emergency and
highly specialized services, such as pediatric cardiology, when the HMO
provides the Department with documentation describing the mechanism for the
provision of such services and the utilization review of such services.
Emergency treatment shall include responses to emergency health problems as
defined in the Department of Insurance Health Maintenance Organization rules
located at 50 Ill. Adm. Code 6101.130 (d).
4) If providers will be serving both HMO patients and
fee-for-service clients, there shall be a statement in each HMO provider
contract assuring no discrimination in the provision of health care services
toward patients due to payment source.
e) A description of the HMO's program of health education which
shall relate to preventive health care and be oriented toward reducing health
risks. This program can be provided by the HMO, or the HMO can choose to
utilize health education programs currently being offered by entities other
than the HMO.
f) A plan for the implementation of an enrollee education program
which shall relate to the use of the HMO system. Such a program shall describe
the sources and types of care accessible and available within the HMO. The HMO
shall include information on procedures for the coverage of emergency services
both inside and out of the plan service area and within the terms of the
enrollee certificate. When the scope of health care services available through
the HMO changes, the enrollee education program shall be modified to
communicate the changes in services available to enrollees.
g) A description of how the HMO proposes to ensure the continued
provision of health care services to enrollees in the event of the insolvency
or unexpected closures of provider sites. Specific information shall be
provided regarding hospitals and primary care provider sites.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.60 HMO SELF-EVALUATION STRUCTURE
Section 240.60 HMO
Self-Evaluation Structure
a) The application for an HMO Certificate of Authority shall
contain a description of the actions that will be taken by the HMO to:
1) Monitor, on an ongoing basis, the quality, availability and
accessibility of care delivered under the auspices of the HMO, and
2) Implement change, where necessary, based on problem
identification, analysis and identification of corrective action.
b) The application for an HMO Certificate of Authority shall
contain a description of the quality assessment program adopted by the HMO,
which shall meet the following requirements:
1) The quality assessment program shall address both the medical
and administrative aspects of the provision and delivery of health care
services, such as availability, accessibility and continuity of care.
2) The HMO shall have a written quality assessment plan that:
A) Establishes goals, timeframes and objectives for the quality
assessment program;
B) Outlines the organizational structure that will be utilized in
implementing the quality assessment monitoring activities and the
recommendations that result from the quality assessment monitoring activities;
and
C) Describes the methodology and criteria that will be used to
evaluate the health care services provided under the auspices of the HMO.
3) Quality assessment monitoring activities shall include the
following:
A) Problems or concerns relative to the care rendered to enrollees
shall be identified. Enrollees' accessibility to health care providers,
appropriateness of utilization, and concerns identified by the HMO's medical or
administrative staff and enrollees shall be considered.
B) Problems or concerns identified by the quality assessment
activities shall be evaluated in accordance with the written plan's methodology
and criteria to determine whether problems or concerns do indeed exist, and
what the causes of the problems or concerns are.
C) An action plan shall be developed and implemented to correct
the problems or concerns that have been verified. The action plan shall include
an educational component for providers included in the action plan.
D) Follow-up measures shall be implemented to evaluate the
effectiveness of the action plan.
E) The HMO shall have an ongoing process for monitoring the
continued effectiveness of action plans in preventing problems from
reoccurring, and in preventing problems from developing.
4) The quality assessment program shall include physician
participation, and all medical decisions shall be made by the medical director
or the HMO's peer review body.
5) Reports of quality assessment activities shall be made to the
governing board of the HMO on a quarterly basis, at a minimum.
A) Records and minutes shall be kept on meetings that pertain to
quality assessment activities.
B) Copies of reports of quality assessment activities shall be
forwarded to the administrators of the HMO.
C) The HMO shall make records and reports of quality assessment
activities available for review by the Department, and the HMO shall submit the
records to the Department upon request. In accordance with Sections 8-2101 and
8-2102 of the Code of Civil Procedure [735 ILCS 5], these records and reports
shall be used solely for the purpose of evaluating and improving the quality of
care rendered to enrollees through the HMO, and shall therefore not be
admissible as evidence, nor discoverable in any action of any kind in any court
or before any tribunal, board, agency or person. (Section 8-2102 of the
Code of Civil Procedure)
c) The application for an HMO Certificate of Authority shall
contain a description of the medical record review program adopted by the HMO,
which shall meet the following requirements:
1) A written medical record review program shall:
A) Establish minimum chart standards that shall be consistent with
the medical record standards contained in this Part (see Section 240.90);
B) Provide for a review and evaluation of the medical record
documentation of primary care physicians pursuant to the HMO medical record
review program, demonstrating that the HMO has assessed medical record
practices; and
C) Include a program of correction and education that will be
implemented when deficiencies relative to chart documentation are found. Such a
program shall include a means for the follow-up and correction of deficiencies.
2) Reports of medical record review activities shall be made, at
a minimum, on a quarterly basis.
A) Records and minutes shall be kept on meetings that pertain to
medical record review activities.
B) Copies of reports of medical record review activities shall be
forwarded to the administrators of the HMO.
C) The HMO shall make records and reports of medical record review
activities available for review by the Department, and the HMO shall submit the
records to the Department upon request. In accordance with Sections 8-2101 and
8-2102 of the Code of Civil Procedure, these records and reports shall be used
solely for the purpose of evaluating and improving the quality of care rendered
to enrollees through the HMO, and shall therefore not be admissible as
evidence, nor discoverable in any action of any kind in any court or before any
tribunal, board, agency or person. (Section 8-2102 of the Code of
Civil Procedure)
3) The HMO shall provide an outline of the organizational
structure that will be used in implementing the medical record review
activities and the recommendations that result from the medical record review
activities.
d) The application for an HMO Certificate of Authority shall
contain a description of the utilization review program adopted by the HMO,
which shall meet the following requirements:
1) The utilization review program shall include procedures for
the compilation of statistics that relate to health services information.
2) The utilization review program shall review and evaluate
health related statistical information, such as hospital admissions, ambulatory
encounters, and the level of care utilized.
3) The HMO shall outline the organizational structure that will
be used in implementing the utilization review program activities and the
recommendations that result from the utilization review activities.
4) Reports of utilization review activities shall be made to the
governing board of the HMO at a minimum, on a quarterly basis.
A) Records and minutes shall be kept on meetings that pertain to
utilization review activities.
B) Copies of reports of utilization review activities shall be
forwarded to the administrators of the HMO.
C) The HMO shall make records and reports of utilization review
activities available for review by the Department, and the HMO shall submit the
records to the Department upon request. In accordance with Sections 8-2101 and
8-2102 of the Code of Civil Procedure, these records and reports shall be used
solely for the purpose of evaluating and improving the quality of care rendered
to enrollees through the HMO, and shall therefore not be admissible as
evidence, nor discoverable in any action of any kind in any court or before any
tribunal, board, agency or person. (Section 8-2102 of the Code of Civil
Procedure)
(Source: Amended at 34 Ill.
Reg. 8104, effective June 2, 2010)
SUBPART C: HMO OPERATING REQUIREMENTS
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.80 GENERAL OPERATING REQUIREMENTS
Section 240.80 General
Operating Requirements
a) The HMO operations shall be consistent with the information
provided to the Department in the application.
b) The HMO shall appoint a medical director prior to commencing
operations. The medical director's credentials shall be submitted to the
Department.
c) The HMO shall develop and implement a process which will
enable the HMO to maintain current information regarding each provider site
under contract with the HMO, including the following:
1) Attestation of the presence of valid certifications, registrations
and licenses as required for physicians, nurses, and other ancillary and
paramedic personnel who render care to enrollees at the provider site.
2) The hours the provider site is open,
3) The hours each physician is routinely available at the provider
site,
4) The extent to which twenty-four (24) hour a day, seven (7) day
a week coverage is provided through the provider site,
5) The number of HMO enrollees the provider site serves as well
as the total number of patients served by the provider site.
d) The HMO shall maintain a log that summarizes enrollee
grievances and evidences HMO response to those grievances.
e) The HMO's participating physicians, other than those whose
scope of practice is limited to radiology, anesthesiology, pathology, or
emergency medical services, shall have one of the following:
1) admitting or staff privileges in at least one hospital within
the plan service area, or
2) documentation of an arrangement with a physician or physician
group who has admitting or staff privileges within the plan service area to
provide access to required hospital services. This documentation shall be
maintained by the HMO.
f) Within six (6) months of commencement of operation, the HMO
shall establish operational medical records, quality assessment and utilization
review programs as described in Section 240.60 of this Part.
g) The HMO shall inform the Department of the procedure to be
used in responding to an enrollee's need for an urgent appointment at a
provider site.
h) The HMO shall not cancel an enrollee's membership unless the
HMO can present documentation verifying that:
1) fraud or material misrepresentation in enrollment or in the
use of services or facilities;
2) material violation of the terms of the contract or evidence of
coverage;
3) termination of the group or individual contract under which
the enrollee was covered, pursuant to the terms of the contract;
4) failure of the enrollee and the primary care physician to
establish a satisfactory patient-physician relationship if it is shown that:
i) the HMO has, in good faith, provided the enrollee with the
opportunity to select an alternative primary care physician; or
ii) the enrollee has repeatedly refused to follow the plan of
treatment ordered by the physician.
i) In order to exercise the provisions of subsection (h) (4) of
this Section, the HMO must notify the enrollee in writing at least 31 days in
advance that the HMO considers the physician-patient relationship to be
unsatisfactory and has outlined specific changes required to avoid termination.
j) For purposes of subsection (h) of this Section,
"material" means a fact or situation which is not merely technical in
nature and results or could result in a substantive change in the situation. In
addition, the definitions afforded this term by the courts of the State of
Illinois shall apply when appropriate to the situation.
k) For purposes of subsection (h) of this Section, "good
faith" means honesty of purpose, freedom from intention to defraud and
being faithful to one's duty or obligation. In addition, the definitions
afforded this term by the courts of the State of Illinois shall apply when
appropriate to the situation.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.90 HMO PROVIDER SITE MEDICAL RECORD REQUIREMENTS
Section 240.90 HMO Provider
Site Medical Record Requirements
a) The HMO shall require each provider to maintain an active
record for each enrollee who receives health care services. This record shall
be kept current, complete, legible and available to the medical and
administrative staff of the HMO and to the Department's representatives.
b) The HMO shall require that each entry be indelibly added to
the enrollee's record, dated and signed or initialed by the person making the
entry. The HMO shall require each provider site to have a means of identifying
the name and professional title of the individual who makes each entry.
c) The medical record for each enrollee who has had a routine,
scheduled appointment with one of the HMO's primary care physicians shall
include the following information:
1) identification,
2) patient history,
3) known past surgical procedures,
4) known past and current diagnoses and problems, and
5) known allergies and untoward reactions to drugs.
d) The basic information collected pursuant to subsection (c)
above shall be made available to each HMO provider with whom the enrollee has a
scheduled encounter.
e) The HMO provider site shall not be expected to have the basic
information described in subsection (c) above for an enrollee whose only
encounters with the HMO are unscheduled or of an emergency nature.
f) The HMO shall require that the medical records for each
enrollee who receives health care services contain the following information
regarding each episode of care.
1) reason for the encounter,
2) evidence fo the provider's assessment of the enrollee's health
problems,
3) current diagnosis of the enrollee, including the results of
any diagnostic tests,
4) plan of treatment, including any therapies and health
education, and
5) if the basic information outlined in subsection (c) above is
not available, any medical history relevant to the current episode of care.
g) The HMO shall require each provider site to document that all
outcomes of ancillary reports, such as laboratory tests and x-rays have been
reviewed by the provider who ordered the reports. The HMO shall require each
provider site to document that follow up actions have been taken regarding
report results that are deemed significant by the provider who ordered the
report.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.100 REQUIRED INFORMATION AND REPORTS
Section 240.100 Required
Information and Reports
a) The HMO shall maintain a membership file that identifies the
name, date of enrollment, date of birth, sex, and address for each enrollee.
b) The following material changes to an Application for a
Certificate of Authority shall be submitted to the Department:
1) Changes in medical group, hospital, skilled nursing home or
other medically related agreements which may affect the availability and
accessibility of health care services to enrollees shall be communicated in
writing to the Department no later than thirty days after the execution of such
changes or termination of such agreements.
2) Personnel changes in the Chief Administrative Officer or
Medical Director positions shall be reported to the Department in writing upon
the termination and commencement of such employment. A resume for the new
appointees shall accompany each notice of appointment.
3) Termination of any benefit or service by the HMO shall be
reported to the Department within 48 hours by telephone and confirmed in
writing within five working days.
4) Changes in the HMO's medical record, quality assessment and
utilization review plans shall be submitted no later than thirty days after the
adoption of the new plan.
5) Changes in the contracts concerning the information required
in Section 240.50 (d) of this Part shall be filed with the Department at least
thirty (30) days prior to entering into the revised Contracts.
c) The HMO shall report to the Department semi-annually on or
before the first day of September and the first day of March the results of the
self evaluation activities regarding medical record review, quality assessment
monitoring and utilization review. In accordance with Sections 8-2101 and
8-2102 of the Code of Civil Procedure (Ill. Rev. Stat. 1985, ch. 110, pars. 8-2101
and 8-2102), these records and reports shall be used solely for the purpose of
evaluating and improving the quality of care rendered to enrollees through the
HMO, and shall therefore not be admissible as evidence, nor discoverable in
any action of any kind in any court or before any tribunal, board, agency or
person.
d) The HMO shall protect the confidentiality of its members from
public disclosure of confidential medical information; however, the Department
shall not be precluded from completing medical record reviews or obtaining
information as allowed in this Part and the Act. The HMO and all contracted
providers shall make available to the Department books, records and information
regarding the provision of health care services to enrollees. In accordance
with Sections 8-2101 and 8-2102 of the Code of Civil Procedure (Ill. Rev. Stat.
1985, ch. 110, pars. 8-2101 and 8-2102), these books, records and information
shall be used solely for the purpose of evaluating and improving the quality of
care rendered to enrollees through the HMO, and shall not be admissible as
evidence, nor discoverable in any action of any kind in any court or before any
tribunal, board, agency or person.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HEALTH CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.110 DEPARTMENT INTERVENTIONS
Section 240.110 Department
Interventions
a) The Department of Public Health shall make an examination
concerning the quality of health care services of any health maintenance
organization and providers with whom such organization has contracts,
agreements, or other arrangements, pursuant to its health care plan as often as
they deem it necessary for the protection of the interest of the people
of this state, but not less frequently than once every three years (Section
5-4 of the Act). In determining whether an examination is necessary, the
Department will consider whether health care services are being made available
and accessible and will determine what constitutes a material
violation of a contract or evidence of coverage, or what constitutes good faith
regarding certification (Section 5-5(d) of the Act) as evidenced by the
following factors:
1) The number and nature of grievances received by the HMO;
2) The number of enrollees in the plan service area relative to
the number participating health care providers in the plan service area;
3) The distribution of the enrollees and the providers throughout
the plan service area;
4) The hours providers are available;
5) The method by which after hours service is provided;
6) The HMO's ability to meet its obligations to provide coverage
to its enrollees;
7) The HMO's ability to provide for or arrange for basic health
services; and
8) The HMO's ability to meet its obligations outlined in the
contractual agreement with providers.
b) Upon completion of the Department's inspection of an HMO
provider site, the Department will provide verbal notification to the provider
site of areas of provider site operations and records found during the
inspection that fail to comply with this Part. HMO representatives may also be
present at this conference.
c) Upon completion of the Department's inspection of an HMO or
HMO provider, the Department will provide the HMO written notification of
findings of noncompliance with this Part.
d) The HMO shall respond to the Department's inspection findings
of noncompliance within ten working days of receipt of the findings. The HMO's
response shall indicate the actions to be taken by the HMO to remedy the
noncompliance noted by the Department. When the HMO's response does not remedy
the noncompliance, the Department will provide the HMO a written explanation of
the reasons the response is unsatisfactory.
e) When the Department determines that the HMO has failed to
secure a provider's compliance with this Part, the Department will recommend to
the Department of Insurance that the HMO be prohibited from adding more
enrollees who would be provided health care services at the noncompliant site. This
recommendation shall be made only when the noncompliance adversely affects the
enrollees' availability and accessibility to health care services described in
the evidence of coverage, and the HMO has demonstrated repeated inability to
correct the deficiencies.
f) When the Department determines that an HMO does not meet the
minimum standards contained in this Part, and has repeatedly failed to remedy
the noncompliance, the Department will certify the following to the Director
of The Department of Insurance:
1) That the Health Maintenance Organization does not meet the
requirements of the Act and this Part; or
2) That the Health Maintenance Organization is unable to
fulfill its obligations to furnish health care services as required under its
health care plan. This certification will inform the Department of
Insurance that administrative review is warranted to consider suspension or
revocation of the HMO's Certificate of Authority pursuant to Section 5-5 of the
Act. (Section 5-5(d) of the Act)
(Source: Amended at 49 Ill. Reg. 7969, effective May 21, 2025)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITAL AND AMBULATORY CARE FACILITIES
PART 240
HEALTH MAINTENANCE ORGANIZATIONS CODE
SECTION 240.120 FEES
Section 240.120 Fees
a) The expenses of examining Health Maintenance Organizations
shall be assessed against the organization being examined. (Section 5-4 of
the Act)
b) The annual fee for each health maintenance organization, which
is based on the Department's estimate of cost for staff and other Department
expenses to provide the examinations, shall be as follows:
1) A fixed annual fee of $1200, plus
2) An additional fee based on the individual HMO's enrollment in
Illinois as follows:
A) For the first 50,000 enrollees, the HMO shall pay $.03 per
enrollee,
B) For additional enrollees between 50,000 and 100,000, the HMO
shall pay $.02 per enrollee, and
C) The HMO shall pay $.01 for each enrollee in excess of 100,000.
c) In computing the amount of the additional fee, the HMO shall
use data from its most recent financial report filed with the Illinois
Department of Insurance on or before March 1 of the year as based on enrollment
as of December 31 of the previous year.
d) The HMO shall pay the fees, which will be billed by the
Department, no later than June 30 of the year in which the fees are billed.
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