Illinois General Assembly - Full Text of HB2065
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Full Text of HB2065  97th General Assembly

HB2065sam002 97TH GENERAL ASSEMBLY

Sen. William R. Haine

Filed: 12/4/2012

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 2065

2    AMENDMENT NO. ______. Amend House Bill 2065, AS AMENDED, by
3replacing everything after the enacting clause with the
4following:
 
5    "Section 1. Short title. This Act may be cited as the
6Exclusive Provider Benefit Plan Act.
 
7    Section 5. For the purposes of this Act:
8    "Clinical peer" means a health care professional who is in
9the same profession and the same or similar specialty as the
10health care provider who typically manages the medical
11condition, procedures, or treatment under review.
12    "Department" means the Department of Insurance.
13    "Director" means the Director of Insurance.
14    "Emergency medical condition" means a medical condition
15manifesting itself by acute symptoms of sufficient severity
16(including severe pain) such that a prudent layperson, who

 

 

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1possesses an average knowledge of health and medicine, could
2reasonably expect the absence of immediate medical attention to
3result in:
4        (1) placing the health of the individual (or, with
5    respect to a pregnant woman, the health of the woman or her
6    unborn child) in serious jeopardy;
7        (2) serious impairment to bodily functions; or
8        (3) serious dysfunction of any bodily organ or part.
9    "Emergency services" means, with respect to an enrollee of
10a health care plan, transportation services, including, but not
11limited to, ambulance services, and covered inpatient and
12outpatient hospital services furnished by a provider qualified
13to furnish those services that are needed to evaluate or
14stabilize an emergency medical condition. "Emergency services"
15does not include post-stabilization medical services.
16    "Enrollee" means any person and his or her dependents
17enrolled in or covered by an exclusive provider benefit plan.
18    "Exclusive provider" means a provider or health care
19provider, or an organization of providers or health care
20providers, who contracts with an insurer to provide medical
21care or health care to insureds covered by a health insurance
22policy.
23    "Exclusive provider benefit plan" means a benefit plan in
24which an insurer contracts with a provider to provide some
25services to an insured, not including emergency care services
26required under Section 65 of the Managed Care Reform and

 

 

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1Patients Right Act, provided by a health care provider who is a
2non-exclusive provider.
3    "Health care provider" means a provider, institutional
4provider, or other person or organization that furnishes health
5care services and that is licensed or otherwise authorized to
6practice in this State.
7    "Health care services" means any services included in the
8furnishing of medical care to any individual, or the
9hospitalization incident to the furnishing of such care, as
10well as the furnishing to any person of any and all other
11services for the purpose of preventing, alleviating, curing, or
12healing human illness or injury.
13    "Health insurance policy" means a group or individual
14insurance policy, certificate, or contract providing benefits
15for medical or surgical expenses incurred as a result of an
16accident or sickness.
17    "Hospital" means an institution licensed under the
18Hospital Licensing Act, an institution that meets all
19comparable conditions and requirements in effect in the state
20in which it is located, or the University of Illinois Hospital
21as defined in the University of Illinois Hospital Act.
22    "Institutional provider" means a hospital, nursing home,
23or other medical or health-related service facility that
24provides care for the sick or injured or other care that may be
25covered in a health insurance policy.
26    "Insurer" means an insurance company or a health service

 

 

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1corporation authorized in this State to issue policies or
2subscriber contracts that reimburse for expense of health care
3services.
4    "Post-stabilization medical services" means health care
5services provided to an enrollee that are furnished in a
6licensed hospital by a provider that is qualified to furnish
7such services, and determined to be medically necessary and
8directly related to the emergency medical condition following
9stabilization.
10    "Preauthorization" means a determination by an insurer
11that medical care or health care services proposed to be
12provided to a patient are medically necessary and appropriate.
13    "Provider" means an individual or entity duly licensed or
14legally authorized to provide health care services.
15    "Service area" means a geographic area or areas specified
16in an exclusive provider benefit contract in which a network of
17exclusive providers is offered and available.
18    "Stabilization" means, with respect to an emergency
19medical condition, to provide such medical treatment of the
20condition as may be necessary to ensure, within reasonable
21medical probability, that no material deterioration of the
22condition is likely to result.
 
23    Section 10. Exclusive provider benefit plans permitted. An
24exclusive provider benefit plan that meets the requirements of
25this Act shall be permitted. To the extent of any conflict

 

 

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1between this Section and any other statutory provision, this
2Section prevails over the conflicting provision. The Director
3of Insurance may adopt rules necessary to implement the
4Department's responsibilities under this Act.
 
5    Section 15. Applicability of this Act.
6    (a) Except as otherwise specifically provided by this
7Section, this Section applies to each individual or group
8exclusive provider benefit plan in which an insurer provides,
9through the insurer's health insurance policy, for the payment
10of coverage only for the use of an exclusive provider network,
11other than the use of a non-exclusive provider for emergency
12care services.
13    (b) Unless otherwise specified, an exclusive provider
14benefit plan is subject to this Section.
15    (c) This Act does not apply to:
16        (1) the Children's Health Insurance Program under the
17    Children's Health Insurance Program Act;
18        (2) a Medicaid managed care program under Article V of
19    the Illinois Public Aid Code; or
20        (3) an HMO under Article I of the Health Maintenance
21    Organization Act.
22    (d) An insurer duly licensed under the laws of this State
23may offer exclusive provider benefit plans to individuals and
24group health plans in conformity with the terms set forth in
25this Section. An insurer shall not be required to be licensed

 

 

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1as an HMO under the Health Maintenance Organization Act in
2order to offer exclusive provider benefit plans under this
3Section.
 
4    Section 20. Applicability of Health Carrier External
5Review Act. The Health Carrier External Review Act shall apply
6to an exclusive provider benefit plan, except to the extent
7that the Director determines the provision to be inconsistent
8with the function and purpose of an exclusive provider benefit
9plan.
 
10    Section 25. Construction of Act.
11    (a) This Act may not be construed to limit the level of
12reimbursement or the level of coverage, including deductibles,
13copayments, coinsurance, or other cost-sharing provisions,
14that are applicable to exclusive providers.
15    (b) Except as specifically provided for in this Act, this
16Act may not be construed to require an exclusive provider
17benefit plan to compensate a non-exclusive provider for
18services provided to an insured.
 
19    Section 30. Provision of information.
20    (a) An exclusive provider benefit plan shall provide
21annually to enrollees and prospective enrollees, upon request,
22a complete list of exclusive providers in the exclusive
23provider benefit plan service area and a description of the

 

 

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1following terms of coverage:
2        (1) the service area;
3        (2) the covered benefits and services with all
4    exclusions, exceptions, and limitations;
5        (3) the pre-certification and other utilization
6    review, if applicable, procedures and requirements;
7        (4) a description of any limitation on access to
8    specialists, and the plan's standing referral policy;
9        (5) the emergency coverage and benefits, including any
10    restrictions on emergency care services;
11        (6) the out-of-area coverage and benefits, if any;
12        (7) the enrollee's financial responsibility for
13    copayments, deductibles, premiums, and any other
14    out-of-pocket expenses;
15        (8) the provisions for continuity of treatment in the
16    event an exclusive provider's participation terminates
17    during the course of an enrollee's treatment by that
18    exclusive provider;
19        (9) the appeals process, forms, and time frames for
20    health care services appeals, complaints, and external
21    independent reviews, administrative complaints, and
22    utilization review complaints, if applicable, including a
23    phone number to call to receive more information from the
24    exclusive provider benefits plan concerning the appeals
25    process; and
26        (10) a statement of all basic health care services and

 

 

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1    all specific benefits and services mandated to be provided
2    to enrollees by any State law or administrative rule.
3    In the event of an inconsistency between any separate
4written disclosure statement and the enrollee contract or
5certificate, the terms of the enrollee contract or certificate
6shall control.
7    (b) Upon written request, an exclusive provider benefit
8plan shall provide to enrollees a description of the financial
9relationships between the exclusive provider benefit plan and
10any health care provider and, if requested, the percentage of
11copayments, deductibles, and total premiums spent on
12healthcare related expenses and the percentage of copayments,
13deductibles, and total premiums spent on other expenses,
14including administrative expenses, except that no exclusive
15provider benefit plan shall be required to disclose specific
16provider reimbursement.
17    (c) An exclusive provider shall provide all of the
18following, where applicable, to enrollees upon request:
19        (1) Information related to the exclusive provider's
20    educational background, experience, training, specialty,
21    and board certification, if applicable.
22        (2) The names of licensed facilities on the provider
23    panel where the exclusive provider presently has
24    privileges for the treatment, illness, or procedure that is
25    the subject of the request.
26        (3) Information regarding the exclusive provider's

 

 

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1    participation in continuing education programs and
2    compliance with any licensure, certification, or
3    registration requirements, if applicable.
4    (d) An exclusive provider benefit plan shall provide the
5information required to be disclosed under this Act upon
6enrollment and annually thereafter in a legible and
7understandable format. The Department of Insurance shall adopt
8rules to establish the format based, to the extent practical,
9on the standards developed for supplemental insurance coverage
10under Title XVIII of the federal Social Security Act as a
11guide, so that a person can compare the attributes of the
12various health care plans.
13    (e) An identification card or similar document issued by an
14insurer to an insured in an exclusive provider benefit plan
15must display:
16        (1) a toll-free number that a physician or health care
17    provider may use to obtain the date on which the insured
18    became insured under the plan; and
19        (2) the acronym "EPO" or the phrase "Exclusive Provider
20    Organization" on the card in a location of the insurer's
21    choice.
22    (f) The written disclosure requirements of this Section may
23be met by disclosure to one enrollee in a household.
 
24    Section 35. Availability of exclusive providers.
25    (a) An insurer offering an exclusive provider benefit plan

 

 

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1shall ensure that the exclusive provider benefits are
2reasonably available to all insureds within a designated
3service area.
4    (b) If services are not available through an exclusive
5provider within a designated service area under an exclusive
6provider benefit plan, an insurer shall reimburse a physician
7or health care provider who is a non-exclusive provider at the
8same percentage level of benefit as an exclusive provider would
9have been reimbursed had the insured been treated by an
10exclusive provider.
 
11    Section 40. Notice of nonrenewal or termination. An
12exclusive provider benefit plan must give at least 60 days
13notice of nonrenewal or termination of an exclusive provider to
14the exclusive provider and to the enrollees served by the
15exclusive provider. The notice shall include a name and address
16to which an enrollee or exclusive provider may direct comments
17and concerns regarding the nonrenewal or termination.
18Immediate written notice may be provided without 60 days notice
19when a health care provider's license has been disciplined by a
20state licensing board.
 
21    Section 45. Transition of service.
22    (a) An exclusive provider benefit plan shall provide for
23continuity of care for its enrollees as follows:
24        (1) If an enrollee's physician leaves the exclusive

 

 

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1    provider benefit plan's network of health care providers
2    for reasons other than termination of a contract in
3    situations involving imminent harm to a patient or a final
4    disciplinary action by a state licensing board and the
5    physician remains within the exclusive provider benefit
6    plan's service area, the exclusive provider benefit plan
7    shall permit the enrollee to continue an ongoing course of
8    treatment with that physician during a transitional
9    period:
10            (A) of 90 days after the date of the notice of the
11        physician's termination from the health care plan to
12        the enrollee of the physician's disaffiliation from
13        the health care plan if the enrollee has an ongoing
14        course of treatment; or
15            (B) that includes the provision of post-partum
16        care directly related to the delivery, if the enrollee
17        has entered the third trimester of pregnancy at the
18        time of the physician's disaffiliation.
19        (2) Notwithstanding the provisions in paragraph (1) of
20    this subsection (a), such care shall be authorized by the
21    exclusive provider benefit plan during the transitional
22    period only if the physician agrees:
23            (A) to continue to accept reimbursement from the
24        exclusive provider benefit plan at the rates
25        applicable prior to the start of the transitional
26        period;

 

 

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1            (B) to adhere to the exclusive provider benefit
2        plan's quality assurance requirements and to provide
3        to the exclusive provider benefit plan necessary
4        medical information related to such care; and
5            (C) to otherwise adhere to the exclusive provider
6        benefit plan's policies and procedures, including, but
7        not limited to, procedures regarding referrals and
8        obtaining preauthorizations for treatment.
9    (b) An exclusive provider benefit plan shall provide for
10continuity of care for new enrollees as follows:
11        (1) If a new enrollee whose physician is not a member
12    of the exclusive provider benefit plan's provider network,
13    but is within the exclusive provider benefit plan's service
14    area, enrolls in the exclusive provider benefit plan, the
15    exclusive provider benefit plan shall permit the enrollee
16    to continue an ongoing course of treatment with the
17    enrollee's current physician during a transitional period:
18            (A) of 90 days after the effective date of
19        enrollment if the enrollee has an ongoing course of
20        treatment; or
21            (B) that includes the provision of post-partum
22        care directly related to the delivery, if the enrollee
23        has entered the third trimester of pregnancy at the
24        effective date of enrollment.
25        (2) If an enrollee elects to continue to receive care
26    from such physician pursuant to paragraph (1) of this

 

 

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1    subsection (a), such care shall be authorized by the
2    exclusive provider benefit plan for the transitional
3    period only if the physician agrees:
4            (A) to accept reimbursement from the exclusive
5        provider benefit plan at rates established by the
6        exclusive provider benefit plan; such rates shall be
7        the level of reimbursement applicable to similar
8        physicians within the exclusive provider benefit plan
9        for such services;
10            (B) to adhere to the exclusive provider benefit
11        plan's quality assurance requirements and to provide
12        to the exclusive provider benefit plan necessary
13        medical information related to such care; and
14            (C) to otherwise adhere to the exclusive provider
15        benefit plan's policies and procedures, including, but
16        not limited to, procedures regarding referrals and
17        obtaining preauthorization for treatment.
18    (c) In no event shall this Section be construed to require
19an exclusive provider benefit plan to provide coverage for
20benefits not otherwise covered or to diminish or impair
21preexisting condition limitations contained in the enrollee's
22contract.
 
23    Section 50. Prohibitions.
24    (a) No exclusive provider benefit plan or its
25subcontractors may prohibit or discourage health care

 

 

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1providers by contract or policy from discussing any health care
2services and health care providers, utilization review, if
3applicable, and quality assurance policies, terms, and
4conditions of plans, and plan policy with enrollees,
5prospective enrollees, providers, or the public.
6    (b) No exclusive provider benefit plan by contract, written
7policy, or procedure may permit or allow an individual or
8entity to dispense a different drug in place of the drug or
9brand of drug ordered or prescribed without the express
10permission of the person ordering or prescribing the drug,
11except as provided under Section 3.14 of the Illinois Food,
12Drug and Cosmetic Act.
 
13    Section 55. Exclusive provider benefit plans; access to
14specialists.
15    (a) When the type of specialist physician or other health
16care provider needed to provide care for a specific condition
17is not represented in the exclusive provider benefit plan's
18network, the exclusive provider benefit plan shall allow for
19the enrollee to have access to a non-exclusive provider within
20a reasonable distance and travel time at no additional cost
21beyond what the enrollee would otherwise pay for services
22received within the network if it is determined by a licensed
23clinical peer that the service or treatment of the specific
24condition is medically necessary and such services or
25treatments are not available through the exclusive provider

 

 

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1benefit plan network. Coverage for all services performed in
2accordance with this Section shall be at the same benefit level
3as if the service or treatment had been rendered by an
4exclusive provider.
5    (b) If an exclusive provider benefit plan denies an
6enrollee's request for a specialist physician or other health
7care provider that is not represented in the exclusive provider
8benefit plan's network, an enrollee may appeal the decision
9through the exclusive provider benefit plan's external
10independent review process as provided by the Health Carrier
11External Review Act.
 
12    Section 60. Health care services appeals, complaints, and
13external independent reviews.
14    (a) An exclusive provider benefit plan shall establish and
15maintain an appeals procedure as outlined in this Act.
16Compliance with this Act's appeals procedures shall satisfy an
17exclusive provider benefit plan's obligation to provide appeal
18procedures under any other State law or rules.
19    (b) When an appeal concerns a decision or action by an
20exclusive provider benefit plan, its employees, or its
21subcontractors that relates to (i) health care services,
22including, but not limited to, procedures or treatments, for an
23enrollee with an ongoing course of treatment ordered by a
24health care provider, the denial of which could significantly
25increase the risk to an enrollee's health or (ii) a treatment

 

 

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1referral, service, procedure, or other health care service, the
2denial of which could significantly increase the risk to an
3enrollee's health, the exclusive provider benefit plan must
4allow for the filing of an appeal either orally or in writing.
5Upon submission of the appeal, an exclusive provider benefit
6plan must notify the party filing the appeal as soon as
7possible, but in no event more than 24 hours after the
8submission of the appeal, of all information that the exclusive
9provider benefit plan requires to evaluate the appeal. The
10exclusive provider benefit plan shall render a decision on the
11appeal within 24 hours after receipt of the required
12information. The exclusive provider benefit plan shall notify
13the party filing the appeal and the enrollee and any health
14care provider who recommended the health care service involved
15in the appeal of its decision orally, followed up by a written
16notice of the determination.
17    (c) For all appeals related to health care services,
18including, but not limited to, procedures or treatments for an
19enrollee, not covered by subsection (b) of this Section, the
20exclusive provider benefit plan shall establish a procedure for
21the filing of such appeals. Upon submission of an appeal under
22this subsection (c), an exclusive provider benefit plan must
23notify the party filing an appeal, within 3 business days after
24the submission, of all information that the plan requires to
25evaluate the appeal. The exclusive provider benefit plan shall
26render a decision on the appeal within 15 business days after

 

 

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1receipt of the required information. The health care plan shall
2notify the party filing the appeal, the enrollee, and any
3health care provider who recommended the health care service
4involved in the appeal orally of its decision, followed up by a
5written notice of the determination.
6    (d) An appeal under subsections (b) or (c) of this Section
7may be filed by the enrollee, the enrollee's designee or
8guardian, or the enrollee's health care provider. An exclusive
9provider benefit plan shall designate a clinical peer to review
10appeals, because these appeals pertain to medical or clinical
11matters and such an appeal must be reviewed by an appropriate
12health care professional. No one reviewing an appeal may have
13had any involvement in the initial determination that is the
14subject of the appeal. The written notice of determination
15required under subsections (b) and (c) shall include (i) clear
16and detailed reasons for the determination, (ii) the medical or
17clinical criteria for the determination, which shall be based
18upon sound clinical evidence and reviewed on a periodic basis,
19and (iii) in the case of an adverse determination, the
20procedures for requesting an external independent review as
21provided by the Health Carrier External Review Act.
22    (e) If an appeal filed under subsections (b) or (c) is
23denied for a reason, including, but not limited to, the
24service, procedure, or treatment is not viewed as medically
25necessary, denial of specific tests or procedures, denial of
26referral to specialist physicians or denial of hospitalization

 

 

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1requests or length of stay requests, any involved party may
2request an external independent review as provided by the
3Health Carrier External Review Act.
4    (f) Future contractual or employment action by the
5exclusive provider benefit plan regarding the patient's
6physician or other health care provider shall not be based
7solely on the physician's or other health care provider's
8participation in health care services appeals, complaints, or
9external independent reviews under the Health Carrier External
10Review Act.
11    (g) Nothing in this Section shall be construed to require
12an exclusive provider benefit plan to pay for a health care
13service not covered under the enrollee's certificate of
14coverage or policy.
 
15    Section 65. Emergency services prior to stabilization.
16    (a) An exclusive provider benefit plan that provides or
17that is required by law to provide coverage for emergency
18services shall provide coverage such that payment under this
19coverage is not dependent upon whether the services are
20performed by a plan or non-plan health care provider and
21without regard to prior authorization. This coverage shall be
22at the same benefit level as if the services or treatment had
23been rendered by the health care plan physician licensed to
24practice medicine in all its branches or health care provider.
25    (b) Prior authorization or approval by the plan shall not

 

 

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1be required for emergency services.
2    (c) Coverage and payment shall only be retrospectively
3denied under the following circumstances:
4        (1) upon reasonable determination that the emergency
5    services claimed were never performed;
6        (2) upon timely determination that the emergency
7    evaluation and treatment were rendered to an enrollee who
8    sought emergency services and whose circumstance did not
9    meet the definition of emergency medical condition;
10        (3) upon determination that the patient receiving such
11    services was not an enrollee of the health care plan; or
12        (4) upon material misrepresentation by the enrollee or
13    health care provider.
14    For the purposes of this subsection (c), "material" means a
15fact or situation that is not merely technical in nature and
16results or could result in a substantial change in the
17situation.
18    (d) When an enrollee presents to a hospital seeking
19emergency services, the determination as to whether the need
20for those services exists shall be made for purposes of
21treatment by a physician licensed to practice medicine in all
22its branches or, to the extent permitted by applicable law, by
23other appropriately licensed personnel under the supervision
24of or in collaboration with a physician licensed to practice
25medicine in all its branches. The physician or other
26appropriate personnel shall indicate in the patient's chart the

 

 

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1results of the emergency medical screening examination.
2    (e) The appropriate use of the 9-1-1 emergency telephone
3system or its local equivalent shall not be discouraged or
4penalized by the exclusive provider benefit plan when an
5emergency medical condition exists. This provision shall not
6imply that the use of the 9-1-1 emergency telephone system or
7its local equivalent is a factor in determining the existence
8of an emergency medical condition.
9    (f) The medical director's or his or her designee's
10determination of whether the enrollee meets the standard of an
11emergency medical condition shall be based solely upon the
12presenting symptoms documented in the medical record at the
13time care was sought. Only a clinical peer may make an adverse
14determination.
15    (g) Nothing in this Section shall prohibit the imposition
16of deductibles, copayments, and co-insurance.
 
17    Section 70. Post-stabilization medical services.
18    (a) If prior authorization for covered post-stabilization
19services is required by the exclusive provider benefit plan,
20the plan shall provide access 24 hours a day, 7 days a week to
21persons designated by the plan to make such determinations,
22provided that any determination made under this Section must be
23made by a health care professional.
24    (b) The treating physician licensed to practice medicine in
25all its branches or health care provider shall contact the

 

 

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1exclusive provider benefit plan or delegated health care
2provider as designated on the enrollee's health insurance card
3to obtain authorization, denial, or arrangements for an
4alternate plan of treatment or transfer of the enrollee.
5    (c) The treating physician licensed to practice medicine in
6all its branches or health care provider shall document in the
7enrollee's medical record the enrollee's presenting symptoms;
8emergency medical condition; and time, phone number dialed, and
9result of the communication for request for authorization of
10post-stabilization medical services. The exclusive provider
11benefit plan shall provide reimbursement for covered
12post-stabilization medical services if:
13        (1) authorization to render them is received from the
14    exclusive provider benefit plan or its delegated health
15    care provider; or
16        (2) after 2 documented good faith efforts, the treating
17    health care provider has attempted to contact the
18    enrollee's exclusive provider benefit plan or its
19    delegated health care provider, as designated on the
20    enrollee's health insurance card, for prior authorization
21    of post-stabilization medical services and neither the
22    plan nor designated persons were accessible or the
23    authorization was not denied within 60 minutes of the
24    request.
25    For the purposes of this subsection (c), "2 documented good
26faith efforts" means the health care provider has called the

 

 

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1telephone number on the enrollee's health insurance card or
2other available number either 2 times or one time and an
3additional call to any referral number provided.
4    (d) After rendering any post-stabilization medical
5services, the treating physician licensed to practice medicine
6in all its branches or health care provider shall continue to
7make every reasonable effort to contact the exclusive provider
8benefit plan or its delegated health care provider regarding
9authorization, denial, or arrangements for an alternate plan of
10treatment or transfer of the enrollee until the treating health
11care provider receives instructions from the exclusive
12provider benefit plan or delegated health care provider for
13continued care or the care is transferred to another health
14care provider or the patient is discharged.
15    (e) Payment for covered post-stabilization services may be
16denied:
17        (1) if the treating health care provider does not meet
18    the conditions outlined in subsection (c) of this Section;
19        (2) upon determination that the post-stabilization
20    services claimed were not performed;
21        (3) upon timely determination that the
22    post-stabilization services rendered were contrary to the
23    instructions of the exclusive provider benefit plan or its
24    delegated health care provider if contact was made between
25    those parties prior to the service being rendered;
26        (4) upon determination that the patient receiving such

 

 

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1    services was not an enrollee of the exclusive provider
2    benefit plan; or
3        (5) upon material misrepresentation by the enrollee or
4    health care provider.
5    For the purposes of this subsection (e), "material" means a
6fact or situation that is not merely technical in nature and
7results or could result in a substantial change in the
8situation.
9    (f) Nothing in this Section prohibits an exclusive provider
10benefit plan from delegating tasks associated with the
11responsibilities enumerated in this Section to the exclusive
12provider benefit plan's contracted health care providers or
13another entity. Only a clinical peer may make an adverse
14determination. However, the ultimate responsibility for
15coverage and payment decisions may not be delegated.
16    (g) Coverage and payment for post-stabilization medical
17services for which prior authorization or deemed approval is
18received shall not be retrospectively denied.
19    (h) Nothing in this Section shall prohibit the imposition
20of deductibles, copayments, and co-insurance.
 
21    Section 75. Quality assessment program.
22    (a) An exclusive provider benefit plan shall develop and
23implement a quality assessment and improvement strategy
24designed to identify and evaluate accessibility, continuity,
25and quality of care. The exclusive provider benefit plan shall

 

 

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1have:
2        (1) an ongoing, written, internal quality assessment
3    program;
4        (2) specific written guidelines for monitoring and
5    evaluating the quality and appropriateness of care and
6    services provided to enrollees requiring the exclusive
7    provider benefit plan to assess:
8            (A) the accessibility to health care providers;
9            (B) appropriateness of utilization;
10            (C) concerns identified by the exclusive provider
11        benefit plan's medical or administrative staff and
12        enrollees; and
13            (D) other aspects of care and service directly
14        related to the improvement of quality of care;
15        (3) a procedure for remedial action to correct quality
16    problems that have been verified in accordance with the
17    written plan's methodology and criteria, including written
18    procedures for taking appropriate corrective action; and
19        (4) follow-up measures implemented to evaluate the
20    effectiveness of the action plan.
21    (b) The exclusive provider benefit plan shall establish a
22committee that oversees the quality assessment and improvement
23strategy that includes physician and enrollee participation.
24    (c) Reports on quality assessment and improvement
25activities shall be made to the governing body of the exclusive
26provider benefit plan not less than quarterly.

 

 

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1    (d) The exclusive provider benefit plan shall make
2available its written description of the quality assessment
3program to the Department of Public Health.
4    (e) With the exception of subsection (d), the Department of
5Public Health shall accept evidence of accreditation with
6regard to the health care network quality management and
7performance improvement standards of:
8        (1) the National Commission on Quality Assurance
9    (NCQA);
10        (2) the American Accreditation Healthcare Commission
11    (URAC);
12        (3) the Joint Commission on Accreditation of
13    Healthcare Organizations (JCAHO); or
14        (4) any other entity that the Director of Public Health
15    deems has substantially similar or more stringent
16    standards than provided for in this Section.
17    (f) If the Department of Public Health determines that an
18exclusive provider benefit plan is not in compliance with the
19terms of this Section, it shall certify the finding to the
20Department of Insurance. The Department of Insurance may
21subject the exclusive provider benefit plan to penalties, as
22provided in this Act, for such non-compliance.
 
23    Section 80. Utilization review. If an exclusive provider
24benefit plan conducts a utilization review program in this
25State, then the exclusive provider benefit plan shall do so in

 

 

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1accordance with Section 85 of the Managed Care Reform and
2Patient Rights Act.
 
3    Section 85. Examinations and fees. The Director may examine
4an insurer to determine the quality and adequacy of a network
5used by an exclusive provider benefit plan offered by the
6insurer under this Act. An insurer is subject to a qualifying
7examination of the insurer's exclusive provider benefit plans
8and subsequent quality of care examinations by the Director at
9least once every 5 years. Documentation provided to the
10Director during an examination conducted under this Section is
11confidential and is not subject to disclosure as public
12information under the Freedom of Information Act.
 
13    Section 900. The Freedom of Information Act is amended by
14changing Section 7.5 as follows:
 
15    (5 ILCS 140/7.5)
16    Sec. 7.5. Statutory Exemptions. To the extent provided for
17by the statutes referenced below, the following shall be exempt
18from inspection and copying:
19    (a) All information determined to be confidential under
20Section 4002 of the Technology Advancement and Development Act.
21    (b) Library circulation and order records identifying
22library users with specific materials under the Library Records
23Confidentiality Act.

 

 

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1    (c) Applications, related documents, and medical records
2received by the Experimental Organ Transplantation Procedures
3Board and any and all documents or other records prepared by
4the Experimental Organ Transplantation Procedures Board or its
5staff relating to applications it has received.
6    (d) Information and records held by the Department of
7Public Health and its authorized representatives relating to
8known or suspected cases of sexually transmissible disease or
9any information the disclosure of which is restricted under the
10Illinois Sexually Transmissible Disease Control Act.
11    (e) Information the disclosure of which is exempted under
12Section 30 of the Radon Industry Licensing Act.
13    (f) Firm performance evaluations under Section 55 of the
14Architectural, Engineering, and Land Surveying Qualifications
15Based Selection Act.
16    (g) Information the disclosure of which is restricted and
17exempted under Section 50 of the Illinois Prepaid Tuition Act.
18    (h) Information the disclosure of which is exempted under
19the State Officials and Employees Ethics Act, and records of
20any lawfully created State or local inspector general's office
21that would be exempt if created or obtained by an Executive
22Inspector General's office under that Act.
23    (i) Information contained in a local emergency energy plan
24submitted to a municipality in accordance with a local
25emergency energy plan ordinance that is adopted under Section
2611-21.5-5 of the Illinois Municipal Code.

 

 

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1    (j) Information and data concerning the distribution of
2surcharge moneys collected and remitted by wireless carriers
3under the Wireless Emergency Telephone Safety Act.
4    (k) Law enforcement officer identification information or
5driver identification information compiled by a law
6enforcement agency or the Department of Transportation under
7Section 11-212 of the Illinois Vehicle Code.
8    (l) Records and information provided to a residential
9health care facility resident sexual assault and death review
10team or the Executive Council under the Abuse Prevention Review
11Team Act.
12    (m) Information provided to the predatory lending database
13created pursuant to Article 3 of the Residential Real Property
14Disclosure Act, except to the extent authorized under that
15Article.
16    (n) Defense budgets and petitions for certification of
17compensation and expenses for court appointed trial counsel as
18provided under Sections 10 and 15 of the Capital Crimes
19Litigation Act. This subsection (n) shall apply until the
20conclusion of the trial of the case, even if the prosecution
21chooses not to pursue the death penalty prior to trial or
22sentencing.
23    (o) Information that is prohibited from being disclosed
24under Section 4 of the Illinois Health and Hazardous Substances
25Registry Act.
26    (p) Security portions of system safety program plans,

 

 

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1investigation reports, surveys, schedules, lists, data, or
2information compiled, collected, or prepared by or for the
3Regional Transportation Authority under Section 2.11 of the
4Regional Transportation Authority Act or the St. Clair County
5Transit District under the Bi-State Transit Safety Act.
6    (q) Information prohibited from being disclosed by the
7Personnel Records Review Act.
8    (r) Information prohibited from being disclosed by the
9Illinois School Student Records Act.
10    (s) Information the disclosure of which is restricted under
11Section 5-108 of the Public Utilities Act.
12    (t) All identified or deidentified health information in
13the form of health data or medical records contained in, stored
14in, submitted to, transferred by, or released from the Illinois
15Health Information Exchange, and identified or deidentified
16health information in the form of health data and medical
17records of the Illinois Health Information Exchange in the
18possession of the Illinois Health Information Exchange
19Authority due to its administration of the Illinois Health
20Information Exchange. The terms "identified" and
21"deidentified" shall be given the same meaning as in the Health
22Insurance Accountability and Portability Act of 1996, Public
23Law 104-191, or any subsequent amendments thereto, and any
24regulations promulgated thereunder.
25    (u) Records and information provided to an independent team
26of experts under Brian's Law.

 

 

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1    (v) Names and information of people who have applied for or
2received Firearm Owner's Identification Cards under the
3Firearm Owners Identification Card Act.
4    (w) Personally identifiable information which is exempted
5from disclosure under subsection (g) of Section 19.1 of the
6Toll Highway Act.
7    (x) Information which is exempted from disclosure under
8Section 5-1014.3 of the Counties Code or Section 8-11-21 of the
9Illinois Municipal Code.
10    (y) All identified or deidentified health information in
11the form of health data or medical records in possession of the
12Department of Insurance due to the Department's administration
13of the Exclusive Provider Benefit Plan Act.
14(Source: P.A. 96-542, eff. 1-1-10; 96-1235, eff. 1-1-11;
1596-1331, eff. 7-27-10; 97-80, eff. 7-5-11; 97-333, eff.
168-12-11; 97-342, eff. 8-12-11; 97-813, eff. 7-13-12; 97-976,
17eff. 1-1-13.)
 
18    Section 999. Effective date. This Act takes effect upon
19becoming law.".