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Rep. Mary E. Flowers
Filed: 3/26/2008
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09500HB4223ham003 |
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| AMENDMENT TO HOUSE BILL 4223
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| AMENDMENT NO. ______. Amend House Bill 4223, AS AMENDED, by |
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| replacing everything after the enacting clause with the |
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| following:
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| "Section 5. The State Employees Group Insurance Act of 1971 |
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| is amended by changing Section 6.11 as follows:
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| (5 ILCS 375/6.11)
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| Sec. 6.11. Required health benefits; Illinois Insurance |
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| Code
requirements. The program of health
benefits shall provide |
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| the post-mastectomy care benefits required to be covered
by a |
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| policy of accident and health insurance under Section 356t of |
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| the Illinois
Insurance Code. The program of health benefits |
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| shall provide the coverage
required under Sections 356f.1, |
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| 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, |
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| and 356z.10
356z.9 of the
Illinois Insurance Code.
The program |
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| of health benefits must comply with Section 155.37 of the
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| Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 10. The Counties Code is amended by changing |
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| Section 5-1069.3 as follows: |
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| (55 ILCS 5/5-1069.3)
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| Sec. 5-1069.3. Required health benefits. If a county, |
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| including a home
rule
county, is a self-insurer for purposes of |
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| providing health insurance coverage
for its employees, the |
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| coverage shall include coverage for the post-mastectomy
care |
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| benefits required to be covered by a policy of accident and |
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| health
insurance under Section 356t and the coverage required |
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| under Sections 356f.1, 356g.5, 356u,
356w, 356x, 356z.6, and |
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| 356z.9, and 356z.10
356z.9 of
the Illinois Insurance Code. The |
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| requirement that health benefits be covered
as provided in this |
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| Section is an
exclusive power and function of the State and is |
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| a denial and limitation under
Article VII, Section 6, |
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| subsection (h) of the Illinois Constitution. A home
rule county |
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| to which this Section applies must comply with every provision |
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| of
this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 15. The Illinois Municipal Code is amended by |
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| changing Section 10-4-2.3 as follows: |
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| (65 ILCS 5/10-4-2.3)
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| Sec. 10-4-2.3. Required health benefits. If a |
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| municipality, including a
home rule municipality, is a |
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| self-insurer for purposes of providing health
insurance |
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| coverage for its employees, the coverage shall include coverage |
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| for
the post-mastectomy care benefits required to be covered by |
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| a policy of
accident and health insurance under Section 356t |
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| and the coverage required
under Sections 356f.1, 356g.5, 356u, |
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| 356w, 356x, 356z.6, and 356z.9, and 356z.10
356z.9 of the |
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| Illinois
Insurance
Code. The requirement that health
benefits |
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| be covered as provided in this is an exclusive power and |
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| function of
the State and is a denial and limitation under |
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| Article VII, Section 6,
subsection (h) of the Illinois |
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| Constitution. A home rule municipality to which
this Section |
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| applies must comply with every provision of this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 20. The School Code is amended by changing Section |
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| 10-22.3f as follows: |
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| (105 ILCS 5/10-22.3f)
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| Sec. 10-22.3f. Required health benefits. Insurance |
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| protection and
benefits
for employees shall provide the |
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09500HB4223ham003 |
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| post-mastectomy care benefits required to be
covered by a |
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| policy of accident and health insurance under Section 356t and |
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| the
coverage required under Sections 356f.1, 356g.5, 356u, |
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| 356w, 356x,
356z.6, and 356z.9 of
the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| revised 12-4-07.)
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| Section 25. The Illinois Insurance Code is amended by |
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| adding Section 356f.1 as follows: |
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| (215 ILCS 5/356f.1 new) |
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| Sec. 356f.1. Health care services appeals,
complaints, and
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| external independent reviews. |
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| (a) A policy of accident or health insurance or managed |
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| care plan shall establish and maintain an appeals procedure as
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| outlined in this Section. Compliance with this Section's |
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| appeals procedures shall
satisfy a policy or plan's obligation |
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| to provide appeal procedures under any
other State law or |
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| rules. |
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| (b) When an appeal concerns a decision or action by a |
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| policy of accident or health insurance or managed care plan,
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| its
employees, or its subcontractors that relates to (i) health |
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| care services,
including, but not limited to, procedures or
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| treatments
for an enrollee with an ongoing course of treatment |
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| ordered
by a health care provider,
the denial of which could |
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| significantly
increase the risk to an
enrollee's health,
(ii) a |
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| treatment referral, service,
procedure, or other health care |
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| service,
the denial of which could significantly
increase the |
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| risk to an
enrollee's health, or (iii) nonrenewal or |
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| termination of a policy or plan,
the policy or plan must allow |
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| for the filing of an appeal
either orally or in writing. Upon |
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| submission of the appeal, a policy or plan
must notify the |
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| party filing the appeal, as soon as possible, but in no event
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| more than 24 hours after the submission of the appeal, of all |
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| information
that the plan requires to evaluate the appeal.
The |
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| policy or plan shall render a decision on the appeal within
24 |
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| hours after receipt of the required information. The policy or |
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| plan shall
notify the party filing the
appeal and the enrollee, |
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| enrollee's primary care physician, and any health care
provider |
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| who recommended the health care service involved in the appeal |
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| of its
decision orally
followed-up by a written notice of the |
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| determination. |
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| (c) For all appeals related to health care services |
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| including, but not
limited to, procedures or treatments for an |
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| enrollee and not covered by
subsection (b) above, the policy or |
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| plan shall establish a procedure for the filing of such |
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| appeals. Upon
submission of an appeal under this subsection, a |
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| policy or plan must notify
the party filing an appeal, within 3 |
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| business days, of all information that the
policy or plan |
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| requires to evaluate the appeal.
The policy or plan shall |
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| render a decision on the appeal within 15 business
days after |
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| receipt of the required information. The policy or plan shall
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| notify the party filing the appeal,
the enrollee, the |
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| enrollee's primary care physician, and any health care
provider
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| who recommended the health care service involved in the appeal |
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| orally of its
decision followed-up by a written notice of the |
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| determination. |
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| (d) An appeal under subsection (b) or (c) may be filed by |
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| the
enrollee, the enrollee's designee or guardian, the |
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| enrollee's primary care
physician, or the enrollee's health |
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| care provider. A policy or plan shall
designate a clinical peer |
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| to review
appeals, because these appeals pertain to medical or |
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| clinical matters
and such an appeal must be reviewed by an |
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| appropriate
health care professional. No one reviewing an |
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| appeal may have had any
involvement
in the initial |
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| determination that is the subject of the appeal. The written
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| notice of determination required under subsections (b) and (c) |
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| shall
include (i) clear and detailed reasons for the |
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| determination, (ii)
the medical or
clinical criteria for the |
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| determination, which shall be based upon sound
clinical |
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| evidence and reviewed on a periodic basis, and (iii) in the |
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| case of an
adverse determination, the
procedures for requesting |
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| an external independent review under subsection (f). |
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| (e) If an appeal filed under subsection (b) or (c) is |
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| denied for a reason
including, but not limited to, the
service, |
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| procedure, or treatment is not viewed as medically necessary,
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| denial of specific tests or procedures, denial of referral
to |
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| specialist physicians or denial of hospitalization requests or |
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| length of
stay requests, any involved party may request an |
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| external independent review
under subsection (f) of the adverse |
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| determination. |
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| (f) The party seeking an external independent review shall |
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| so notify the
policy or plan.
The policy or plan shall seek to |
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| resolve all
external independent
reviews in the most |
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| expeditious manner and shall make a determination and
provide |
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| notice of the determination no more
than 24 hours after the |
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| receipt of all necessary information when a delay would
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| significantly increase
the risk to an enrollee's health or when |
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| extended health care services for an
enrollee undergoing a
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| course of treatment prescribed by a health care provider are at |
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| issue. |
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| (1) Within 30 days after the enrollee receives written |
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| notice of an
adverse
determination,
if the enrollee decides |
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| to initiate an external independent review, the
enrollee |
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| shall send to the policy or plan a written request for an |
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| external independent review, including any
information or
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| documentation to support the enrollee's request for the |
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| covered service or
claim for a covered
service. |
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| (2) Within 30 days after the policy or plan receives a |
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| request for an
external
independent review from an enrollee |
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| or, within 24 hours after the receipt of a request if a |
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| delay would significantly increase the risk to the |
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| enrollee's health, the policy or plan shall: |
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| (A) select an external independent reviewer as |
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| provided in subsection (h) of this Section; and |
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| (B) forward to the independent reviewer all |
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| medical records and
supporting
documentation |
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| pertaining to the case, a summary description of the |
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| applicable
issues including a
statement of the |
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| decision made by, the criteria used, and the
medical |
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| and clinical reasons
for that decision. |
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| (3) Within 5 days after receipt of all necessary |
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| information or within 24 hours when a delay would
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| significantly increase
the risk to an enrollee's health, |
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| the
independent
reviewer
shall evaluate and analyze the |
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| case and render a decision that is based on
whether or not |
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| the health
care service or claim for the health care |
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| service is medically appropriate. The
decision by the
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| independent reviewer is final. If the external independent |
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| reviewer determines
the health care
service to be medically
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| appropriate, the policy or plan shall pay for the health |
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| care service. |
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| (4) The policy or plan shall be solely responsible for |
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| paying the fees
of the external
independent reviewer who is |
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| selected to perform the review. |
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| (5) An external independent reviewer who acts in good |
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| faith shall have
immunity
from any civil or criminal |
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| liability or professional discipline as a result of
acts or |
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| omissions with
respect to any external independent review, |
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| unless the acts or omissions
constitute wilful and wanton
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| misconduct. For purposes of any proceeding, the good faith |
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| of the person
participating shall be
presumed. |
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| (6) Future contractual or employment action by the |
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| policy or plan
regarding the
patient's physician or other |
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| health care provider shall not be based solely on
the |
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| physician's or other
health care provider's participation |
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| in this procedure. |
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| (7) For the purposes of this Section, an external |
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| independent reviewer
shall: |
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| (A) be a clinical peer; |
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| (B) have no direct financial interest in |
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| connection with the case; and |
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| (C) have not been informed of the specific identity |
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| of the enrollee. |
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| (g) The external independent reviewer and the medical |
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| review professional conducting the external review under this |
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| Section may not have a material professional, familial, |
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| financial, or other affiliation with any of the following: |
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| (1) The insurer. |
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| (2) Any officer, director, or management employee of |
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| the insurer. |
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| (3) The health care provider or the health care |
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| provider's medical group that is proposing the service. |
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| (4) The facility at which the service would be |
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| provided. |
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| (5) The development or manufacture of the principal |
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| drug, device, procedure, or other therapy that is proposed |
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| for use by the treating health care provider. |
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| (6) The covered individual requesting the external |
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| grievance review. |
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| However, the medical review professional may have an |
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| affiliation under which the medical review professional |
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| provides health care services to covered individuals of the |
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| insurer and may have an affiliation that is limited to staff |
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| privileges at the health facility, if the affiliation is |
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| disclosed to the covered individual and the insurer before |
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| commencing the review and neither the covered individual nor |
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| the insurer objects. |
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| A covered individual shall not pay any of the costs |
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| associated with the services of an external independent |
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| reviewer under this Section. All costs must be paid by the |
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| insurer. |
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| (h) When a request for appeal is filed, the insurer shall: |
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| (1) select a different external independent reviewer |
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| for each external independent review requested under this |
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| Section from the list of external independent reviewers |
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| that are certified by the Division under subsection (i) of |
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| this Section; and |
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| (2) rotate the choice of an external independent |
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| reviewer among all certified external independent |
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| reviewers before repeating a selection. |
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| (i) The Division of Insurance of the Department of |
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| Financial and Professional Regulation shall establish and |
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| maintain a process for annual certification of external |
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| independent reviewers. The Division shall certify a number of |
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| external independent reviewers determined by the Division to be |
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| sufficient to fulfill the purposes of this Section. An external |
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| independent reviewer must meet the following minimum |
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| requirements for certification by the Division: |
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| (1) Medical review professionals assigned by the |
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| external independent reviewer to perform external |
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| grievance reviews under this Section must: |
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| (A) be board certified in the specialty in which a |
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| covered individual's proposed service would be |
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| provided; |
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| (B) be knowledgeable about a proposed service |
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| through actual clinical experience; |
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| (C) hold an unlimited license to practice in a |
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| state of the United States; and |
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| (D) not have any history of disciplinary actions or |
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| sanctions, including: |
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| (i) loss of staff privileges; or |
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| (ii) restriction on participation; |
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| taken or pending by any hospital, government, or |
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| regulatory body. |
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| (2) The external independent reviewer must have a |
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| quality assurance mechanism to ensure: |
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| (A) the timeliness and quality of reviews; |
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| (B) the qualifications and independence of medical |
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| review professionals; |
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| (C) the confidentiality of medical records and |
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| other review materials; and |
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| (D) the satisfaction of covered individuals with |
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| the procedures utilized by the external independent |
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| reviewer, including the use of covered individual |
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| satisfaction surveys. |
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| (3) The external independent reviewer must file with |
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| the Division all of the following information on or before |
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| March 1 of each year: |
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| (A) The number and percentage of determinations |
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| made in favor of covered individuals. |
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| (B) The number and percentage of determinations |
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| made in favor of insurers. |
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| (C) The average time to process a determination. |
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| (D) Any other information required by the |
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| Division. |
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| The information required under this item (3) must be |
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| specified for each insurer for which the external |
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| independent reviewer performed reviews during the |
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| reporting year. |
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| (4) The external independent reviewer must meet any |
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| additional requirements established by the Division. |
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| The Division may not certify an external independent |
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| reviewer that is either (i) a professional or trade association |
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| of health care providers or a subsidiary or an affiliate of a |
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| professional or trade association of health care providers or |
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| (ii) an insurer, a health maintenance organization, or a health |
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| plan association or a subsidiary or an affiliate of an insurer, |
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| health maintenance organization, or health plan association. |
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| The Division may suspend or revoke an external independent |
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| reviewer's certification if the Division finds that the |
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| external independent reviewer is not in substantial compliance |
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| with the certification requirements under this subsection (i). |
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| The Division shall make available to insurers a list of all |
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| certified external independent reviewers. |
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| (j) The Division shall make the information provided to the |
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| Division under item (3) of subsection (i) available to the |
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| public in a format that does not identify individual covered |
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| individuals. |
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| (k) An insurer shall each year file with the Division a |
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| description of the external independent review procedure |
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| established by the insurer under this Section, including the |
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| following for each external independent reviewer used by the |
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| insurer during the reporting year: |
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| (1) the total number of external independent reviews |
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| handled through the procedure during the preceding |
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| calendar year; |
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| (2) a compilation of the causes underlying those |
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| reviews; and |
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| (3) a summary of the final disposition of those |
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| reviews. |
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| The information required by this subsection (k) must be |
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| filed with the Division on or before March 1 of each year. |
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| The Division shall make the information required to be |
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| filed under this subsection (k) available to the public and |
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| prepare an annual compilation of the data that allows for |
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| comparative analysis.
The Division may require any additional |
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| reports that are necessary and appropriate for the Division to |
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| carry out its duties under this Section. |
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| (l) Nothing in this Section shall be construed to require a |
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| policy or
plan to pay for a health care service not covered |
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| under the enrollee's
certificate of coverage or policy. |
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| (m) Notwithstanding any other rulemaking authority that |
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| may exist, neither the Governor nor any agency or agency head |
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| under the jurisdiction of the Governor has any authority to |
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| make or promulgate rules to implement or enforce the provisions |
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| of this amendatory Act of the 95th General Assembly. If, |
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| however, the Governor believes that rules are necessary to |
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| implement or enforce the provisions of this amendatory Act of |
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| the 95th General Assembly, the Governor may suggest rules to |
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| the General Assembly by filing them with the Clerk of the House |
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| and the Secretary of the Senate and by requesting that the |
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| General Assembly authorize such rulemaking by law, enact those |
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| suggested rules into law, or take any other appropriate action |
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| in the General Assembly's discretion. Nothing contained in this |
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| amendatory Act of the 95th General Assembly shall be |
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| interpreted to grant rulemaking authority under any other |
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| Illinois statute where such authority is not otherwise |
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| explicitly given. For the purposes of this subsection, "rules" |
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| is given the meaning contained in Section 1-70 of the Illinois |
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| Administrative Procedure Act, and "agency" and "agency head" |
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| are given the meanings contained in Sections 1-20 and 1-25 of |
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| the Illinois Administrative Procedure Act to the extent that |
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| such definitions apply to agencies or agency heads under the |
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| jurisdiction of the Governor.
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| Section 30. The Health Maintenance Organization Act is |
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| amended by changing Section 5-3 as follows:
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| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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| Sec. 5-3. Insurance Code provisions.
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| (a) Health Maintenance Organizations
shall be subject to |
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| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
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| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
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| 154.6,
154.7, 154.8, 155.04, 355.2, 356f.1, 356m, 356v, 356w, |
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| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
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| 356z.10
356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, |
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| 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, |
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| 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section |
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| 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, |
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| XXV, and XXVI of the Illinois Insurance Code.
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| (b) For purposes of the Illinois Insurance Code, except for |
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| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
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| Maintenance Organizations in
the following categories are |
3 |
| deemed to be "domestic companies":
|
4 |
| (1) a corporation authorized under the
Dental Service |
5 |
| Plan Act or the Voluntary Health Services Plans Act;
|
6 |
| (2) a corporation organized under the laws of this |
7 |
| State; or
|
8 |
| (3) a corporation organized under the laws of another |
9 |
| state, 30% or more
of the enrollees of which are residents |
10 |
| of this State, except a
corporation subject to |
11 |
| substantially the same requirements in its state of
|
12 |
| organization as is a "domestic company" under Article VIII |
13 |
| 1/2 of the
Illinois Insurance Code.
|
14 |
| (c) In considering the merger, consolidation, or other |
15 |
| acquisition of
control of a Health Maintenance Organization |
16 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
17 |
| (1) the Director shall give primary consideration to |
18 |
| the continuation of
benefits to enrollees and the financial |
19 |
| conditions of the acquired Health
Maintenance Organization |
20 |
| after the merger, consolidation, or other
acquisition of |
21 |
| control takes effect;
|
22 |
| (2)(i) the criteria specified in subsection (1)(b) of |
23 |
| Section 131.8 of
the Illinois Insurance Code shall not |
24 |
| apply and (ii) the Director, in making
his determination |
25 |
| with respect to the merger, consolidation, or other
|
26 |
| acquisition of control, need not take into account the |
|
|
|
09500HB4223ham003 |
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|
1 |
| effect on
competition of the merger, consolidation, or |
2 |
| other acquisition of control;
|
3 |
| (3) the Director shall have the power to require the |
4 |
| following
information:
|
5 |
| (A) certification by an independent actuary of the |
6 |
| adequacy
of the reserves of the Health Maintenance |
7 |
| Organization sought to be acquired;
|
8 |
| (B) pro forma financial statements reflecting the |
9 |
| combined balance
sheets of the acquiring company and |
10 |
| the Health Maintenance Organization sought
to be |
11 |
| acquired as of the end of the preceding year and as of |
12 |
| a date 90 days
prior to the acquisition, as well as pro |
13 |
| forma financial statements
reflecting projected |
14 |
| combined operation for a period of 2 years;
|
15 |
| (C) a pro forma business plan detailing an |
16 |
| acquiring party's plans with
respect to the operation |
17 |
| of the Health Maintenance Organization sought to
be |
18 |
| acquired for a period of not less than 3 years; and
|
19 |
| (D) such other information as the Director shall |
20 |
| require.
|
21 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
22 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
23 |
| any health maintenance
organization of greater than 10% of its
|
24 |
| enrollee population (including without limitation the health |
25 |
| maintenance
organization's right, title, and interest in and to |
26 |
| its health care
certificates).
|
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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1 |
| (e) In considering any management contract or service |
2 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
3 |
| Code, the Director (i) shall, in
addition to the criteria |
4 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
5 |
| into account the effect of the management contract or
service |
6 |
| agreement on the continuation of benefits to enrollees and the
|
7 |
| financial condition of the health maintenance organization to |
8 |
| be managed or
serviced, and (ii) need not take into account the |
9 |
| effect of the management
contract or service agreement on |
10 |
| competition.
|
11 |
| (f) Except for small employer groups as defined in the |
12 |
| Small Employer
Rating, Renewability and Portability Health |
13 |
| Insurance Act and except for
medicare supplement policies as |
14 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
15 |
| Maintenance Organization may by contract agree with a
group or |
16 |
| other enrollment unit to effect refunds or charge additional |
17 |
| premiums
under the following terms and conditions:
|
18 |
| (i) the amount of, and other terms and conditions with |
19 |
| respect to, the
refund or additional premium are set forth |
20 |
| in the group or enrollment unit
contract agreed in advance |
21 |
| of the period for which a refund is to be paid or
|
22 |
| additional premium is to be charged (which period shall not |
23 |
| be less than one
year); and
|
24 |
| (ii) the amount of the refund or additional premium |
25 |
| shall not exceed 20%
of the Health Maintenance |
26 |
| Organization's profitable or unprofitable experience
with |
|
|
|
09500HB4223ham003 |
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1 |
| respect to the group or other enrollment unit for the |
2 |
| period (and, for
purposes of a refund or additional |
3 |
| premium, the profitable or unprofitable
experience shall |
4 |
| be calculated taking into account a pro rata share of the
|
5 |
| Health Maintenance Organization's administrative and |
6 |
| marketing expenses, but
shall not include any refund to be |
7 |
| made or additional premium to be paid
pursuant to this |
8 |
| subsection (f)). The Health Maintenance Organization and |
9 |
| the
group or enrollment unit may agree that the profitable |
10 |
| or unprofitable
experience may be calculated taking into |
11 |
| account the refund period and the
immediately preceding 2 |
12 |
| plan years.
|
13 |
| The Health Maintenance Organization shall include a |
14 |
| statement in the
evidence of coverage issued to each enrollee |
15 |
| describing the possibility of a
refund or additional premium, |
16 |
| and upon request of any group or enrollment unit,
provide to |
17 |
| the group or enrollment unit a description of the method used |
18 |
| to
calculate (1) the Health Maintenance Organization's |
19 |
| profitable experience with
respect to the group or enrollment |
20 |
| unit and the resulting refund to the group
or enrollment unit |
21 |
| or (2) the Health Maintenance Organization's unprofitable
|
22 |
| experience with respect to the group or enrollment unit and the |
23 |
| resulting
additional premium to be paid by the group or |
24 |
| enrollment unit.
|
25 |
| In no event shall the Illinois Health Maintenance |
26 |
| Organization
Guaranty Association be liable to pay any |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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1 |
| contractual obligation of an
insolvent organization to pay any |
2 |
| refund authorized under this Section.
|
3 |
| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; |
4 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
|
5 |
| Section 35. The Limited Health Service Organization Act is |
6 |
| amended by changing Section 4003 as follows:
|
7 |
| (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
|
8 |
| Sec. 4003. Illinois Insurance Code provisions. Limited |
9 |
| health service
organizations shall be subject to the provisions |
10 |
| of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, |
11 |
| 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, |
12 |
| 155.04, 155.37, 355.2, 356f.1, 356v, 356z.10
356z.9 , 368a, 401, |
13 |
| 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and |
14 |
| Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and |
15 |
| XXVI of the Illinois Insurance Code. For purposes of the
|
16 |
| Illinois Insurance Code, except for Sections 444 and 444.1 and |
17 |
| Articles XIII
and XIII 1/2, limited health service |
18 |
| organizations in the following categories
are deemed to be |
19 |
| domestic companies:
|
20 |
| (1) a corporation under the laws of this State; or
|
21 |
| (2) a corporation organized under the laws of another |
22 |
| state, 30% of more
of the enrollees of which are residents |
23 |
| of this State, except a corporation
subject to |
24 |
| substantially the same requirements in its state of |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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|
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| organization as
is a domestic company under Article VIII |
2 |
| 1/2 of the Illinois Insurance Code.
|
3 |
| (Source: P.A. 95-520, eff. 8-28-07; revised 12-5-07.)
|
4 |
| Section 37. The Managed Care Reform and Patient Rights Act |
5 |
| is amended by changing Section 45 as follows:
|
6 |
| (215 ILCS 134/45)
|
7 |
| Sec. 45. Health care services appeals,
complaints, and
|
8 |
| external independent reviews.
|
9 |
| (a) A health care plan shall establish and maintain an |
10 |
| appeals procedure as
outlined in this Act. Compliance with this |
11 |
| Act's appeals procedures shall
satisfy a health care plan's |
12 |
| obligation to provide appeal procedures under any
other State |
13 |
| law or rules.
All appeals of a health care plan's |
14 |
| administrative determinations and
complaints regarding its |
15 |
| administrative decisions shall be handled as required
under |
16 |
| Section 50.
|
17 |
| (b) When an appeal concerns a decision or action by a |
18 |
| health care plan,
its
employees, or its subcontractors that |
19 |
| relates to (i) health care services,
including, but not limited |
20 |
| to, procedures or
treatments,
for an enrollee with an ongoing |
21 |
| course of treatment ordered
by a health care provider,
the |
22 |
| denial of which could significantly
increase the risk to an
|
23 |
| enrollee's health,
or (ii) a treatment referral, service,
|
24 |
| procedure, or other health care service,
the denial of which |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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|
1 |
| could significantly
increase the risk to an
enrollee's health , |
2 |
| or (iii) nonrenewal or termination of a plan ,
the health care |
3 |
| plan must allow for the filing of an appeal
either orally or in |
4 |
| writing. Upon submission of the appeal, a health care plan
must |
5 |
| notify the party filing the appeal, as soon as possible, but in |
6 |
| no event
more than 24 hours after the submission of the appeal, |
7 |
| of all information
that the plan requires to evaluate the |
8 |
| appeal.
The health care plan shall render a decision on the |
9 |
| appeal within
24 hours after receipt of the required |
10 |
| information. The health care plan shall
notify the party filing |
11 |
| the
appeal and the enrollee, enrollee's primary care physician, |
12 |
| and any health care
provider who recommended the health care |
13 |
| service involved in the appeal of its
decision orally
|
14 |
| followed-up by a written notice of the determination.
|
15 |
| (c) For all appeals related to health care services |
16 |
| including, but not
limited to, procedures or treatments for an |
17 |
| enrollee and not covered by
subsection (b) above, the health |
18 |
| care
plan shall establish a procedure for the filing of such |
19 |
| appeals. Upon
submission of an appeal under this subsection, a |
20 |
| health care plan must notify
the party filing an appeal, within |
21 |
| 3 business days, of all information that the
plan requires to |
22 |
| evaluate the appeal.
The health care plan shall render a |
23 |
| decision on the appeal within 15 business
days after receipt of |
24 |
| the required information. The health care plan shall
notify the |
25 |
| party filing the appeal,
the enrollee, the enrollee's primary |
26 |
| care physician, and any health care
provider
who recommended |
|
|
|
09500HB4223ham003 |
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1 |
| the health care service involved in the appeal orally of its
|
2 |
| decision followed-up by a written notice of the determination.
|
3 |
| (d) An appeal under subsection (b) or (c) may be filed by |
4 |
| the
enrollee, the enrollee's designee or guardian, the |
5 |
| enrollee's primary care
physician, or the enrollee's health |
6 |
| care provider. A health care plan shall
designate a clinical |
7 |
| peer to review
appeals, because these appeals pertain to |
8 |
| medical or clinical matters
and such an appeal must be reviewed |
9 |
| by an appropriate
health care professional. No one reviewing an |
10 |
| appeal may have had any
involvement
in the initial |
11 |
| determination that is the subject of the appeal. The written
|
12 |
| notice of determination required under subsections (b) and (c) |
13 |
| shall
include (i) clear and detailed reasons for the |
14 |
| determination, (ii)
the medical or
clinical criteria for the |
15 |
| determination, which shall be based upon sound
clinical |
16 |
| evidence and reviewed on a periodic basis, and (iii) in the |
17 |
| case of an
adverse determination, the
procedures for requesting |
18 |
| an external independent review under subsection (f).
|
19 |
| (e) If an appeal filed under subsection (b) or (c) is |
20 |
| denied for a reason
including, but not limited to, the
service, |
21 |
| procedure, or treatment is not viewed as medically necessary,
|
22 |
| denial of specific tests or procedures, denial of referral
to |
23 |
| specialist physicians or denial of hospitalization requests or |
24 |
| length of
stay requests, any involved party may request an |
25 |
| external independent review
under subsection (f) of the adverse |
26 |
| determination.
|
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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|
1 |
| (f) External independent review.
|
2 |
| (1) The party seeking an external independent review |
3 |
| shall so notify the
health care plan.
The health care plan |
4 |
| shall seek to resolve all
external independent
reviews in |
5 |
| the most expeditious manner and shall make a determination |
6 |
| and
provide notice of the determination no more
than 24 |
7 |
| hours after the receipt of all necessary information when a |
8 |
| delay would
significantly increase
the risk to an |
9 |
| enrollee's health or when extended health care services for |
10 |
| an
enrollee undergoing a
course of treatment prescribed by |
11 |
| a health care provider are at issue.
|
12 |
| (2) Within 30 days after the enrollee receives written |
13 |
| notice of an
adverse
determination,
if the enrollee decides |
14 |
| to initiate an external independent review, the
enrollee |
15 |
| shall send to the health
care plan a written request for an |
16 |
| external independent review, including any
information or
|
17 |
| documentation to support the enrollee's request for the |
18 |
| covered service or
claim for a covered
service.
|
19 |
| (3) Within 30 days after the health care plan receives |
20 |
| a request for an
external
independent review from an |
21 |
| enrollee, the health care plan shall:
|
22 |
| (A) select an external independent reviewer as |
23 |
| provided in subsection (h) of this Section; and provide |
24 |
| a mechanism for joint selection of an external |
25 |
| independent
reviewer by the enrollee, the enrollee's |
26 |
| physician or other health care
provider,
and the health |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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|
1 |
| care plan; and
|
2 |
| (B) forward to the independent reviewer all |
3 |
| medical records and
supporting
documentation |
4 |
| pertaining to the case, a summary description of the |
5 |
| applicable
issues including a
statement of the health |
6 |
| care plan's decision, the criteria used, and the
|
7 |
| medical and clinical reasons
for that decision.
|
8 |
| (4) Within 5 days after receipt of all necessary |
9 |
| information, the
independent
reviewer
shall evaluate and |
10 |
| analyze the case and render a decision that is based on
|
11 |
| whether or not the health
care service or claim for the |
12 |
| health care service is medically appropriate. The
decision |
13 |
| by the
independent reviewer is final. If the external |
14 |
| independent reviewer determines
the health care
service to |
15 |
| be medically
appropriate, the health
care plan shall pay |
16 |
| for the health care service.
|
17 |
| (5) The health care plan shall be solely responsible |
18 |
| for paying the fees
of the external
independent reviewer |
19 |
| who is selected to perform the review.
|
20 |
| (6) An external independent reviewer who acts in good |
21 |
| faith shall have
immunity
from any civil or criminal |
22 |
| liability or professional discipline as a result of
acts or |
23 |
| omissions with
respect to any external independent review, |
24 |
| unless the acts or omissions
constitute wilful and wanton
|
25 |
| misconduct. For purposes of any proceeding, the good faith |
26 |
| of the person
participating shall be
presumed.
|
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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| (7) Future contractual or employment action by the |
2 |
| health care plan
regarding the
patient's physician or other |
3 |
| health care provider shall not be based solely on
the |
4 |
| physician's or other
health care provider's participation |
5 |
| in this procedure.
|
6 |
| (8) For the purposes of this Section, an external |
7 |
| independent reviewer
shall:
|
8 |
| (A) be a clinical peer;
|
9 |
| (B) have no direct financial interest in |
10 |
| connection with the case; and
|
11 |
| (C) have not been informed of the specific identity |
12 |
| of the enrollee.
|
13 |
| (g) The external independent reviewer and the medical |
14 |
| review professional conducting the external review under this |
15 |
| Section may not have a material professional, familial, |
16 |
| financial, or other affiliation with any of the following: |
17 |
| (1) The insurer. |
18 |
| (2) Any officer, director, or management employee of |
19 |
| the insurer. |
20 |
| (3) The health care provider or the health care |
21 |
| provider's medical group that is proposing the service. |
22 |
| (4) The facility at which the service would be |
23 |
| provided. |
24 |
| (5) The development or manufacture of the principal |
25 |
| drug, device, procedure, or other therapy that is proposed |
26 |
| for use by the treating health care provider. |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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| (6) The covered individual requesting the external |
2 |
| grievance review.
|
3 |
| However, the medical review professional may have an |
4 |
| affiliation under which the medical review professional |
5 |
| provides health care services to covered individuals of the |
6 |
| insurer and may have an affiliation that is limited to staff |
7 |
| privileges at the health facility, if the affiliation is |
8 |
| disclosed to the covered individual and the insurer before |
9 |
| commencing the review and neither the covered individual nor |
10 |
| the insurer objects. |
11 |
| A covered individual shall not pay any of the costs |
12 |
| associated with the services of an external independent |
13 |
| reviewer under this Section. All costs must be paid by the |
14 |
| insurer. |
15 |
| (h) When a request for appeal is filed, the insurer shall: |
16 |
| (1) select a different external independent reviewer |
17 |
| for each external independent review requested under this |
18 |
| Section from the list of external independent reviewers |
19 |
| that are certified by the Division under subsection (i) of |
20 |
| this Section; and |
21 |
| (2) rotate the choice of an external independent |
22 |
| reviewer among all certified external independent |
23 |
| reviewers before repeating a selection. |
24 |
| (i) The Division of Insurance of the Department of |
25 |
| Financial and Professional Regulation shall establish and |
26 |
| maintain a process for annual certification of external |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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|
1 |
| independent reviewers. The Division shall certify a number of |
2 |
| external independent reviewers determined by the Division to be |
3 |
| sufficient to fulfill the purposes of this Section. An external |
4 |
| independent reviewer must meet the following minimum |
5 |
| requirements for certification by the Division: |
6 |
| (1) Medical review professionals assigned by the |
7 |
| external independent reviewer to perform external |
8 |
| grievance reviews under this Section must: |
9 |
| (A) be board certified in the specialty in which a |
10 |
| covered individual's proposed service would be |
11 |
| provided; |
12 |
| (B) be knowledgeable about a proposed service |
13 |
| through actual clinical experience; |
14 |
| (C) hold an unlimited license to practice in a |
15 |
| state of the United States; and |
16 |
| (D) not have any history of disciplinary actions or |
17 |
| sanctions, including: |
18 |
| (i) loss of staff privileges; or |
19 |
| (ii) restriction on participation; |
20 |
| taken or pending by any hospital, government, or |
21 |
| regulatory body. |
22 |
| (2) The external independent reviewer must have a |
23 |
| quality assurance mechanism to ensure: |
24 |
| (A) the timeliness and quality of reviews; |
25 |
| (B) the qualifications and independence of medical |
26 |
| review professionals; |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
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|
1 |
| (C) the confidentiality of medical records and |
2 |
| other review materials; and |
3 |
| (D) the satisfaction of covered individuals with |
4 |
| the procedures utilized by the external independent |
5 |
| reviewer, including the use of covered individual |
6 |
| satisfaction surveys. |
7 |
| (3) The external independent reviewer must file with |
8 |
| the Division all of the following information on or before |
9 |
| March 1 of each year: |
10 |
| (A) The number and percentage of determinations |
11 |
| made in favor of covered individuals. |
12 |
| (B) The number and percentage of determinations |
13 |
| made in favor of insurers. |
14 |
| (C) The average time to process a determination. |
15 |
| (D) Any other information required by the |
16 |
| Division. |
17 |
| The information required under this item (3) must be |
18 |
| specified for each insurer for which the external |
19 |
| independent reviewer performed reviews during the |
20 |
| reporting year. |
21 |
| (4) The external independent reviewer must meet any |
22 |
| additional requirements established by the Division. |
23 |
| The Division may not certify an external independent |
24 |
| reviewer that is either (i) a professional or trade association |
25 |
| of health care providers or a subsidiary or an affiliate of a |
26 |
| professional or trade association of health care providers or |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
|
|
1 |
| (ii) an insurer, a health maintenance organization, or a health |
2 |
| plan association or a subsidiary or an affiliate of an insurer, |
3 |
| health maintenance organization, or health plan association. |
4 |
| The Division may suspend or revoke an external independent |
5 |
| reviewer's certification if the Division finds that the |
6 |
| external independent reviewer is not in substantial compliance |
7 |
| with the certification requirements under this subsection (i). |
8 |
| The Division shall make available to insurers a list of all |
9 |
| certified external independent reviewers. |
10 |
| (j) The Division shall make the information provided to the |
11 |
| Division under item (3) of subsection (i) available to the |
12 |
| public in a format that does not identify individual covered |
13 |
| individuals. |
14 |
| (k) An insurer shall each year file with the Division a |
15 |
| description of the external independent review procedure |
16 |
| established by the insurer under this Section, including the |
17 |
| following for each external independent reviewer used by the |
18 |
| insurer during the reporting year: |
19 |
| (1) the total number of external independent reviews |
20 |
| handled through the procedure during the preceding |
21 |
| calendar year; |
22 |
| (2) a compilation of the causes underlying those |
23 |
| reviews; and |
24 |
| (3) a summary of the final disposition of those |
25 |
| reviews. |
26 |
| The information required by this subsection (k) must be |
|
|
|
09500HB4223ham003 |
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LRB095 15305 RPM 48567 a |
|
|
1 |
| filed with the Division on or before March 1 of each year. |
2 |
| The Division shall make the information required to be |
3 |
| filed under this subsection (k) available to the public and |
4 |
| prepare an annual compilation of the data that allows for |
5 |
| comparative analysis.
The Division may require any additional |
6 |
| reports that are necessary and appropriate for the Division to |
7 |
| carry out its duties under this Section. |
8 |
| (l) (g) Nothing in this Section shall be construed to |
9 |
| require a health care
plan to pay for a health care service not |
10 |
| covered under the enrollee's
certificate of coverage or policy.
|
11 |
| (m) Notwithstanding any other rulemaking authority that |
12 |
| may exist, neither the Governor nor any agency or agency head |
13 |
| under the jurisdiction of the Governor has any authority to |
14 |
| make or promulgate rules to implement or enforce the provisions |
15 |
| of this amendatory Act of the 95th General Assembly. If, |
16 |
| however, the Governor believes that rules are necessary to |
17 |
| implement or enforce the provisions of this amendatory Act of |
18 |
| the 95th General Assembly, the Governor may suggest rules to |
19 |
| the General Assembly by filing them with the Clerk of the House |
20 |
| and the Secretary of the Senate and by requesting that the |
21 |
| General Assembly authorize such rulemaking by law, enact those |
22 |
| suggested rules into law, or take any other appropriate action |
23 |
| in the General Assembly's discretion. Nothing contained in this |
24 |
| amendatory Act of the 95th General Assembly shall be |
25 |
| interpreted to grant rulemaking authority under any other |
26 |
| Illinois statute where such authority is not otherwise |
|
|
|
09500HB4223ham003 |
- 32 - |
LRB095 15305 RPM 48567 a |
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|
1 |
| explicitly given. For the purposes of this amendatory Act of |
2 |
| the 95th General Assembly, "rules" is given the meaning |
3 |
| contained in Section 1-70 of the Illinois Administrative |
4 |
| Procedure Act, and "agency" and "agency head" are given the |
5 |
| meanings contained in Sections 1-20 and 1-25 of the Illinois |
6 |
| Administrative Procedure Act to the extent that such |
7 |
| definitions apply to agencies or agency heads under the |
8 |
| jurisdiction of the Governor. |
9 |
| (Source: P.A. 91-617, eff. 1-1-00.)
|
10 |
| Section 40. The Voluntary Health Services Plans Act is |
11 |
| amended by changing Section 10 as follows:
|
12 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
|
13 |
| Sec. 10. Application of Insurance Code provisions. Health |
14 |
| services
plan corporations and all persons interested therein |
15 |
| or dealing therewith
shall be subject to the provisions of |
16 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
17 |
| 149, 155.37, 354, 355.2, 356f.1, 356g.5, 356r, 356t, 356u, |
18 |
| 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, |
19 |
| 356z.8, 356z.9,
356z.10
356z.9 , 364.01, 367.2, 368a, 401, |
20 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
21 |
| and (15) of Section 367 of the Illinois
Insurance Code.
|
22 |
| (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; |
23 |
| 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. |
24 |
| 8-28-07; revised 12-5-07.)".
|