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90_HB0974sam001
LRB9002705JSdvam01
1 AMENDMENT TO HOUSE BILL 974
2 AMENDMENT NO. . Amend House Bill 974 by replacing
3 the title with the following:
4 "AN ACT concerning the delivery of health care
5 services."; and
6 by replacing everything after the enacting clause with the
7 following:
8 "Section 1. Short title. This Act may be cited as the
9 Managed Care Patient Rights Act.
10 Section 5. Health care patient rights.
11 (a) A patient has the right to care consistent with
12 professional standards of practice to assure quality nursing
13 and medical practices, to choose the participating physician
14 responsible for coordinating his or her care, to receive
15 information concerning his or her condition and proposed
16 treatment, to refuse any treatment to the extent permitted by
17 law, and to privacy and confidentiality of records except as
18 otherwise provided by law.
19 (b) A patient has the right, regardless of source of
20 payment, to examine and to receive a reasonable explanation
21 of his or her total bill for health care services rendered by
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1 his or her physician or other health care provider, including
2 the itemized charges for specific health care services
3 received. A physician or other health care provider shall be
4 responsible only for a reasonable explanation of those
5 specific health care services provided by the health care
6 provider.
7 (c) A patient has the right to timely prior notice of
8 the termination in the event a health care plan cancels or
9 refuses to renew an enrollee's participation in the plan.
10 (d) A patient has the right to privacy and
11 confidentiality in health care. This right may be expressly
12 waived in writing by the patient or the patient's guardian.
13 (e) An individual has the right to purchase any health
14 care services with that individual's own funds.
15 Section 10. Definitions:
16 "Department" means the Department of Insurance.
17 "Emergency medical condition" means a medical condition
18 manifesting itself by acute symptoms of sufficient severity
19 (including severe pain) such that a prudent layperson, who
20 possesses an average knowledge of health and medicine, could
21 reasonably expect the absence of immediate medical attention
22 to result in:
23 (1) placing the health of the individual (or, with
24 respect to a pregnant woman, the health of the woman or
25 her unborn child) in serious jeopardy;
26 (2) serious impairment to bodily functions; or
27 (3) serious dysfunction of any bodily organ or
28 part.
29 "Emergency services" means, with respect to an enrollee
30 of a health plan, transportation services and covered
31 inpatient and outpatient hospital services furnished by a
32 provider qualified to furnish those services that are needed
33 to evaluate or stabilize an emergency medical condition.
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1 "Emergency services" does not refer to post-stabilization
2 medical services.
3 "Enrollee" means any person and his or her dependents
4 enrolled in or covered by a health care plan.
5 "Health care plan" means a plan that establishes,
6 operates, or maintains a network of health care providers
7 that have entered into agreements with the plan to provide
8 health care services to enrollees to whom the plan has the
9 obligation to arrange for the provision of or payment for
10 services through organizational arrangements for ongoing
11 quality assurance, utilization review programs, or dispute
12 resolution.
13 For purposes of this definition, "health care plan" shall
14 not include the following:
15 (1) indemnity health insurance policies including
16 those using a contracted provider network;
17 (2) health care plans that offer only dental or
18 only vision coverage;
19 (3) preferred provider administrators, as defined
20 in Section 370g(g) of the Illinois Insurance Code;
21 (4) employee or employer self-insured health
22 benefit plans under the federal Employee Retirement
23 Income Security Act of 1974; and
24 (5) health care provided pursuant to the Workers'
25 Compensation Act or the Workers' Occupational Diseases
26 Act.
27 "Health care provider" means any physician, hospital
28 facility, or other person that is licensed or otherwise
29 authorized to deliver health care services.
30 "Health care services" means any services included in the
31 furnishing to any individual of medical care, or the
32 hospitalization or incident to the furnishing of such care or
33 hospitalization as well as the furnishing to any person of
34 any and all other services for the purpose of preventing,
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1 alleviating, curing, or healing human illness or injury
2 including home health and pharmaceutical services and
3 products.
4 "Medical director" means a physician licensed in any
5 state to practice medicine in all its branches appointed by a
6 health care plan.
7 "Person" means a corporation, association, partnership,
8 limited liability company, sole proprietorship, or any other
9 legal entity.
10 "Physician" means a person licensed to practice medicine
11 in all its branches under the Medical Practice Act of 1987.
12 "Post-stabilization medical services" means health care
13 services provided to an enrollee that are furnished in a
14 licensed hospital by a provider that is qualified to furnish
15 such services, and determined to be medically necessary and
16 directly related to the emergency medical condition following
17 stabilization.
18 "Primary care" means the provision of a broad range of
19 personal health care services (preventive, diagnostic,
20 curative, counseling, or rehabilitative) in a manner that is
21 accessible and comprehensive and coordinated by a physician
22 licensed to practice medicine in all its branches.
23 "Primary care physician" means a physician who has
24 contracted with a health care plan to provide primary care
25 services as defined by the contract and who is a physician
26 licensed to practice medicine in all of its branches. Nothing
27 in this definition shall be construed to prohibit a health
28 care plan from requiring a physician to meet a health care
29 plan's criteria in order to coordinate access to health care.
30 "Stabilization" means, with respect to an emergency
31 medical condition, to provide such medical treatment of the
32 condition as may be necessary to assure, within reasonable
33 medical probability, that no material deterioration of the
34 condition is likely to result.
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1 "Utilization review" means the evaluation of the medical
2 necessity, appropriateness, and efficiency of the use of
3 health care services, procedures, and facilities.
4 "Utilization review program" means a program established
5 by a person to perform utilization review.
6 Section 15. Provision of information.
7 (a) A health care plan shall provide to enrollees and,
8 upon request, to prospective enrollees a list of
9 participating health care providers in the health care plan's
10 service area and an evidence of coverage that contains a
11 description of the following terms of coverage:
12 (1) the service area;
13 (2) covered benefits, exclusions or limitations;
14 (3) precertification and other utilization review
15 procedures and requirements;
16 (4) a description of the limitations on access to
17 specialists;
18 (5) emergency coverage and benefits;
19 (6) out-of-area coverages and benefits, if any;
20 (7) the enrollee's financial responsibility for
21 copayments, deductibles, and any other out-of-pocket
22 expenses;
23 (8) provisions for continuity of treatment in the
24 event a provider's participation terminates during the
25 course of an enrollee's treatment by that provider; and
26 (9) the grievance process, including the telephone
27 number to call to receive information concerning
28 grievance procedures.
29 (b) Upon written request, a health care plan shall
30 provide to enrollees a description of the financial
31 relationships between the health care plan and any provider,
32 except that no health care plan shall be required to disclose
33 specific reimbursement to providers.
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1 (c) A participating health care provider shall provide
2 all of the following, where applicable, to enrollees upon
3 request:
4 (1) Information related to the health care
5 provider's educational background, experience, training,
6 specialty, and board certification, if applicable.
7 (2) The names of licensed facilities on the
8 provider panel where the health provider presently has
9 privileges for the treatment, illness, or procedure that
10 is the subject of the request.
11 (3) Information regarding the health care
12 provider's participation in continuing education programs
13 and compliance with any licensure, certification, or
14 registration requirements, if applicable.
15 (d) A health care plan shall provide the information
16 required to be disclosed under this Act in a legible and
17 understandable format consistent with the standards developed
18 for supplemental insurance coverage under Title XVIII of the
19 federal Social Security Act.
20 Section 20. Notice of nonrenewal or termination. A
21 health care plan must give at least 60 days notice of
22 nonrenewal or termination of a health care provider to the
23 health care provider and to the enrollees served by the
24 health care provider. The notice shall include a name and
25 address to which an enrollee or health care provider may
26 direct comments and concerns regarding the nonrenewal or
27 termination. Immediate written notice may be provided without
28 60 days notice when a health care provider's license has been
29 disciplined by a state licensing board.
30 Section 25. Transition of services.
31 (a) A health care plan shall provide for continuity of
32 care for its enrollees as follows:
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1 (1) If an enrollee's physician leaves the health
2 care plan's network of providers for reasons other than
3 termination of a contract in situations involving
4 imminent harm to a patient or a final disciplinary action
5 by a State licensing board and the physician remains
6 within the health care plan's service area, the health
7 care plan shall permit the enrollee to continue an
8 ongoing course of treatment with that physician during a
9 transitional period:
10 (A) of 90 days from the date of the notice of
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) if the enrollee has entered the third
16 trimester of pregnancy at the time of the
17 physician's disaffiliation, that includes the
18 provision of post-partum care directly related to
19 the delivery.
20 (2) Notwithstanding the provisions in item (1) of
21 this subsection, such care shall be authorized by the
22 health care plan during the transitional period only if
23 the physician agrees:
24 (A) to continue to accept reimbursement from
25 the health care plan at the rates applicable prior
26 to the start of the transitional period;
27 (B) to adhere to the health care plan's
28 quality assurance requirements and to provide to the
29 health care plan necessary medical information
30 related to such care; and
31 (C) to otherwise adhere to the health care
32 plan's policies and procedures, including but not
33 limited to procedures regarding referrals and
34 obtaining preauthorizations for treatment.
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1 (b) A health care plan shall provide for continuity of
2 care for new enrollees as follows:
3 (1) If a new enrollee whose physician is not a
4 member of the health care plan's provider network, but is
5 within the health care plan's service area, enrolls in
6 the health care plan, the health care plan shall permit
7 the enrollee to continue an ongoing course of treatment
8 with the enrollee's current physician during a
9 transitional period:
10 (A) of at least 90 days from the effective
11 date of enrollment if the enrollee has an ongoing
12 course of treatment; or
13 (B) if the enrollee has entered the third
14 trimester of pregnancy at the effective date of
15 enrollment, that includes the provision of
16 post-partum care directly related to the delivery.
17 (2) If an enrollee elects to continue to receive
18 care from such physician pursuant to item (1) of this
19 subsection, such care shall be authorized by the health
20 care plan for the transitional period only if the
21 physician agrees:
22 (A) to accept reimbursement from the health
23 care plan at rates established by the health care
24 plan; such rates shall be the level of reimbursement
25 applicable to similar physicians within the health
26 care plan for such services;
27 (B) to adhere to the health care plan's
28 quality assurance requirements and to provide to the
29 health care plan necessary medical information
30 related to such care; and
31 (C) to otherwise adhere to the health care
32 plan's policies and procedures including, but not
33 limited to procedures regarding referrals and
34 obtaining preauthorization for treatment.
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1 (c) In no event shall this Section be construed to
2 require a health care plan to provide coverage for benefits
3 not otherwise covered or to diminish or impair preexisting
4 condition limitations contained in the enrollee's contract.
5 Section 30. Restraints on communications prohibited.
6 (a) No health care plan or its subcontractors may
7 prohibit or discourage health care providers from discussing
8 any alternative health care services and providers,
9 utilization review and quality assurance policies, terms and
10 conditions of plans and plan policy with enrollees,
11 prospective enrollees, providers, or the public.
12 (b) No health care plan or its subcontractors shall by
13 contract, policy, or procedure impose any restrictions on the
14 physicians or other health care providers who treat its
15 enrollees as to recommended health care services.
16 (c) Any violation of this Section shall be subject to
17 the penalties under this Act.
18 Section 35. Medically appropriate health care
19 protection.
20 (a) No health care plan shall retaliate against a
21 physician or other health care provider who advocates for
22 appropriate health care services for patients.
23 (b) It is the public policy of the State of Illinois
24 that a physician or any other health care provider be
25 encouraged to advocate for medically appropriate health care
26 services for his or her patients. For purposes of this
27 Section, "to advocate for medically appropriate health care
28 services" means to appeal a decision to deny payment for a
29 health care service pursuant to the reasonable grievance or
30 appeal procedure established by a health care plan or to
31 protest a decision, policy, or practice that the physician or
32 other health care provider, consistent with that degree of
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1 learning and skill ordinarily possessed by physicians or
2 other health care providers practicing in the same or a
3 similar locality and under similar circumstances, reasonably
4 believes impairs the physician's or other health care
5 provider's ability to provide appropriate health care
6 services to his or her patients.
7 (c) This Section shall not be construed to prohibit a
8 health care plan from making a determination not to pay for a
9 particular health care service or to prohibit a medical
10 group, independent practice association, preferred provider
11 organization, foundation, hospital medical staff, hospital
12 governing body or health care plan from enforcing reasonable
13 peer review or utilization review protocols or determining
14 whether a physician or other health care provider has
15 complied with those protocols.
16 (d) Nothing in this Section shall be construed to
17 prohibit the governing body of a hospital or the hospital
18 medical staff from taking disciplinary actions against a
19 physician as authorized by law.
20 (e) Nothing in this Section shall be construed to
21 prohibit the Department of Professional Regulation from
22 taking disciplinary actions against a physician or other
23 health care provider under the appropriate licensing Act.
24 Section 40. Access to specialists.
25 (a) All health care plans that require each enrollee to
26 select a health care provider for any purpose including
27 coordination of care shall allow all enrollees to choose any
28 primary care physician licensed to practice medicine in all
29 its branches or any other health care provider participating
30 in the health care plan for that purpose. The health care
31 plan shall provide the enrollee with a choice of licensed
32 health care providers who are accessible and qualified.
33 (b) A health care plan shall establish a procedure by
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1 which an enrollee who has a condition that requires ongoing
2 care from a specialist physician or other health care
3 provider may apply for a standing referral to a specialist
4 physician or other health care provider if a referral to a
5 specialist physician or other health care provider is
6 required for coverage. The application shall be made to the
7 enrollee's primary care physician. This procedure for a
8 standing referral must specify the necessary criteria and
9 conditions that must be met in order for an enrollee to
10 obtain a standing referral. A standing referral shall be
11 effective for a period of up to one year. A primary care
12 physician may renew a standing referral.
13 (c) The enrollee may be required by the health care plan
14 to select a specialist physician or other health care
15 provider who has a referral arrangement with the enrollee's
16 primary care physician or to select a new primary care
17 physician who has a referral arrangement with the specialist
18 physician or other health care provider chosen by the
19 enrollee. If a health care plan requires an enrollee to
20 select a new physician under this subsection, the health care
21 plan must provide the enrollee with both options provided in
22 this subsection.
23 (d) When the type of specialist physician or other
24 health care provider needed to provide ongoing care for a
25 specific condition is not represented in the health care
26 plan's provider network, the primary care physician shall
27 arrange for the enrollee to have access to a qualified
28 non-participating health care provider within a reasonable
29 distance and travel time.
30 (e) The enrollee's primary care physician shall remain
31 responsible for coordinating the care of an enrollee who has
32 received a standing referral to a specialist physician or
33 other health care provider. If a secondary referral is
34 necessary, the specialist physician or other health care
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1 provider shall advise the primary care physician. The
2 primary care physician shall be responsible for making the
3 secondary referral. In addition, the health care plan shall
4 require the specialist physician or other health care
5 provider to provide regular updates to the enrollee's primary
6 care physician.
7 (f) If an enrollee's application for any referral is
8 denied, an enrollee may appeal the decision through the
9 health care plan's medical necessity second opinion process
10 in accordance with Section 45 of this Act.
11 Section 45. Medical necessity; second opinion. A health
12 care plan shall provide a mechanism for the timely review by
13 a physician or other health care provider holding the same
14 class of license as the patient's physician or other health
15 care provider, who is unaffiliated with the health care plan,
16 jointly selected by the patient (or the patient's next of kin
17 or legal representative if the patient is unable to act for
18 himself), the patient's physician or other health care
19 provider, and the health care plan in the event of a dispute
20 between the patient's physician or other health care provider
21 and the health care plan regarding the medical necessity of a
22 service or a referral. If the reviewing physician or other
23 health care provider determines the service to be medically
24 necessary or the referral to be appropriate, the health care
25 plan shall pay for the service. Future contractual or
26 employment action by the health care plan regarding the
27 patient's physician or other health care provider shall not
28 be based solely on the physician's or other health care
29 provider's participation in this procedure.
30 Section 50. Choosing a physician.
31 (a) A health care plan may also offer other arrangements
32 under which enrollees may access health care services from
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1 contracted providers without a referral or authorization from
2 their primary care physician.
3 (b) The enrollee may be required by the health care plan
4 to select a specialist physician or other health care
5 provider who has a referral arrangement with the enrollee's
6 primary care physician or to select a new primary care
7 physician who has a referral arrangement with the specialist
8 physician or other health care provider chosen by the
9 enrollee. If a health care plan requires an enrollee to
10 select a new physician under this subsection, the health care
11 plan must provide the enrollee with both options provided in
12 this subsection.
13 (c) The Director of Insurance and the Department of
14 Public Health each may promulgate rules to ensure appropriate
15 access to and quality of care for enrollees in any plan that
16 allows enrollees to access health care services from
17 contractual providers without a referral or authorization
18 from the primary care physician. The rules may include, but
19 shall not be limited to, a system for the retrieval and
20 compilation of enrollees' medical records.
21 Section 55. Emergency services prior to stabilization.
22 (a) A health care plan that provides or that is required
23 by law to provide coverage for emergency services shall
24 provide coverage such that payment under this coverage is not
25 dependent upon whether the services are performed by a plan
26 or non-plan health care provider and without regard to prior
27 authorization. This coverage shall be at the same benefit
28 level as if the services or treatment had been rendered by
29 the health care plan provider.
30 (b) Prior authorization or approval by the plan shall
31 not be required for emergency services.
32 (c) Payment shall not be retrospectively denied, with
33 the following exceptions:
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1 (1) upon reasonable determination that the
2 emergency services claimed were never performed;
3 (2) upon determination that the emergency
4 evaluation and treatment were rendered to an enrollee who
5 sought emergency services and whose circumstance did not
6 meet the definition of emergency medical condition;
7 (3) upon determination that the patient receiving
8 such services was not an enrollee of the health care
9 plan; or
10 (4) upon material misrepresentation by the enrollee
11 or health care provider; "material" means a fact or
12 situation that is not merely technical in nature and
13 results or could result in a substantial change in the
14 situation.
15 (d) When an enrollee presents to a hospital seeking
16 emergency services, the determination as to whether the need
17 for those services exists shall be made for purposes of
18 treatment by a physician or, to the extent permitted by
19 applicable law, by other appropriately licensed personnel
20 under the supervision of a physician. The physician or other
21 appropriate personnel shall indicate in the patient's chart
22 the results of the emergency medical screening examination.
23 (e) The appropriate use of the 911 emergency telephone
24 system or its local equivalent shall not be discouraged or
25 penalized by the health care plan when an emergency medical
26 condition exists. This provision shall not imply that the use
27 of 911 or its local equivalent is a factor in determining the
28 existence of an emergency medical condition.
29 (f) The medical director's or his or her designee's
30 determination of whether the enrollee meets the standard of
31 an emergency medical condition shall be based solely upon the
32 presenting symptoms documented in the medical record at the
33 time care was sought.
34 (g) Nothing in this Section shall prohibit the
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1 imposition of deductibles, co-payments, and co-insurance.
2 Section 60. Post-stabilization medical services.
3 (a) If prior authorization for covered post-stabilization
4 services is required by the health care plan, the plan shall
5 provide access 24 hours a day, 7 days a week to persons
6 designated by the plan to make such determinations.
7 (b) The treating health care provider shall contact the
8 health care plan or delegated provider as designated on the
9 enrollee's health insurance card to obtain authorization,
10 denial, or arrangements for an alternate plan of treatment or
11 transfer of the enrollee.
12 (c) The treating health care provider shall document in
13 the enrollee's medical record the enrollee's presenting
14 symptoms; emergency medical condition; and time, phone number
15 dialed, and result of the communication for request for
16 authorization of post stabilization medical services. The
17 health care plan shall provide reimbursement for covered
18 post-stabilization medical services if:
19 (1) authorization to render them is received from
20 the health care plan or its delegated health care
21 provider, or
22 (2) after 2 documented good faith efforts, the
23 treating health care provider has attempted to contact
24 the enrollee's health care plan or its delegated health
25 care provider, as designated on the enrollee's health
26 insurance card, for prior authorization of
27 post-stabilization medical services and neither the plan
28 nor designated persons were accessible or the
29 authorization was not denied within 60 minutes of the
30 request. Two documented good faith efforts means the
31 health care provider has called the telephone number on
32 the enrollee's health insurance card or other available
33 number either 2 times or one time and an additional call
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1 to any referral number provided. Good faith means honesty
2 of purpose, freedom from intention to defraud, and being
3 faithful to one's duty or obligation. For the purpose of
4 this Act, good faith shall be presumed.
5 (d) After rendering any post-stabilization medical
6 services, the treating health care provider shall continue to
7 make every reasonable effort to contact the health care plan
8 or its delegated health care provider regarding
9 authorization, denial, or arrangements for an alternate plan
10 of treatment or transfer of the enrollee until the treating
11 health care provider receives instructions from the health
12 care plan or delegated health care provider for continued
13 care or the care is transferred to another health care
14 provider or the patient is discharged.
15 (e) Payment for covered post-stabilization services may
16 be denied:
17 (1) if the treating health care provider does not
18 meet the conditions outlined in subsection (c);
19 (2) upon determination that the post-stabilization
20 services claimed were not performed;
21 (3) upon determination that the post-stabilization
22 services rendered were contrary to the instructions of
23 the health care plan or its delegated health care
24 provider if contact was made between those parties prior
25 to the service being rendered;
26 (4) upon determination that the patient receiving
27 such services was not an enrollee of the health care
28 plan; or
29 (5) upon material misrepresentation by the enrollee
30 or health care provider; "material" means a fact or
31 situation that is not merely technical in nature and
32 results or could result in a substantial change in the
33 situation.
34 (f) Nothing in this Section prohibits a health care plan
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1 from delegating tasks associated with the responsibilities
2 enumerated in this Section to the health care plan's
3 contracted health care providers or an other entity.
4 (g) Coverage and payment for post-stabilization medical
5 services for which prior authorization or deemed approval is
6 received shall not be retrospectively denied.
7 (h) Nothing in this Section shall prohibit the
8 imposition of deductibles, co-payments, and co-insurance.
9 Section 65. Consumer advisory committee.
10 (a) A health care plan shall establish a consumer
11 advisory committee. The consumer advisory committee shall
12 have the authority to identify and review consumer concerns
13 and make advisory recommendations to the health care plan.
14 The health care plan may also make requests of the consumer
15 advisory committee to provide feedback to proposed changes in
16 plan policies and procedures which will affect enrollees.
17 However, the consumer advisory committee shall not have the
18 authority to hear or resolve specific complaints or
19 grievances, but instead shall refer such complaints or
20 grievances to the health care plan's grievance committee.
21 (b) The health care plan shall randomly select 8
22 enrollees meeting the requirements of this Section to serve
23 on the consumer advisory committee. Upon initial formation
24 of the consumer advisory committee, the health care plan
25 shall appoint 4 enrollees to a 2 year term and 4 enrollees to
26 a one year term. Thereafter, as an enrollee's term expires,
27 the health care plan shall re-appoint or appoint an enrollee
28 to serve on the consumer advisory committee for a 2 year
29 term. Members of the consumer advisory committee shall by
30 majority vote elect a member of the committee to serve as
31 chair of the committee.
32 (c) An enrollee may not serve on the consumer advisory
33 committee if during the 2 years preceding service the
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1 enrollee:
2 (1) has been an employee, officer, or director of
3 the plan, an affiliate of the plan, or a provider or
4 affiliate of a provider that furnishes health care
5 services to the plan or affiliate of the plan; or
6 (2) is a relative of a person specified in item
7 (1).
8 (d) A health care plan's consumer advisory committee
9 shall meet not less than quarterly.
10 (e) All meetings shall be held within the State of
11 Illinois. The costs of the meetings shall be borne by the
12 health care plan.
13 Section 70. Quality assessment program.
14 (a) A health care plan shall develop and implement a
15 quality assessment and improvement strategy designed to
16 identify and evaluate accessibility, continuity, and quality
17 of care. The health care plan shall have:
18 (1) an ongoing, written, internal quality
19 assessment program;
20 (2) specific written guidelines for monitoring and
21 evaluating the quality and appropriateness of care and
22 services provided to enrollees requiring the health care
23 plan to assess:
24 (A) the accessibility to health care
25 providers;
26 (B) appropriateness of utilization;
27 (C) concerns identified by the health care
28 plan's medical or administrative staff and
29 enrollees; and
30 (D) other aspects of care and service directly
31 related to the improvement of quality of care;
32 (3) a procedure for remedial action to correct
33 quality problems that have been verified in accordance
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1 with the written plan's methodology and criteria,
2 including written procedures for taking appropriate
3 corrective action;
4 (4) follow-up measures implemented to evaluate the
5 effectiveness of the action plan.
6 (b) The health care plan shall establish a committee
7 that oversees the quality assessment and improvement strategy
8 which includes physician and enrollee participation.
9 (c) Reports on quality assessment and improvement
10 activities shall be made to the governing body of the health
11 care plan not less than quarterly.
12 (d) The health care plan shall make available its
13 written description of the quality assessment program to the
14 Department of Public Health.
15 (e) With the exception of subsection (d), the Department
16 of Public Health shall accept evidence of accreditation with
17 regard to the health care network quality management and
18 performance improvement standards of:
19 (1) the National Commission on Quality Assurance
20 (NCQA);
21 (2) the American Accreditation Healthcare
22 Commission (URAC);
23 (3) the Joint Commission on Accreditation of
24 Healthcare Organizations (JCAHO); or
25 (4) any other entity that the Director of Public
26 Health deems has substantially similar or more stringent
27 standards than provided for in this Section.
28 Section 75. Complaints.
29 (a) A health care plan shall establish and maintain a
30 complaint system providing reasonable procedures for
31 resolving complaints initiated by enrollees (complainant)
32 which shall provide for an expedited review of cases
33 involving imminent threat to the health of an enrollee.
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1 Nothing in this Act shall be construed to preclude an
2 enrollee from filing a complaint with the Department or as
3 limiting the Department's ability to investigate complaints.
4 In addition, any enrollee not satisfied with the plan's
5 resolution of any complaint may appeal that final plan
6 decision to the Department.
7 (b) When a complaint against a health care plan
8 (respondent) is received by the Department, the respondent
9 shall be notified of the complaint. The Department shall, in
10 its notification, specify the date when a report is to be
11 received from the respondent, which shall be no later than 21
12 days after notification is sent to the respondent. A failure
13 to reply by the date specified may be followed by a collect
14 telephone call or collect telegram. Repeated instances of
15 failing to reply by the date specified may result in further
16 regulatory action.
17 (c) The respondent's report shall supply adequate
18 documentation that explains all actions taken or not taken
19 and that were the basis for the complaint. The report shall
20 include documents necessary to support the respondent's
21 position and any information requested by the Department. The
22 respondent's reply shall be in duplicate, but duplicate
23 copies of supporting documents shall not be required. The
24 respondent's reply shall include the name, telephone number,
25 and address of the individual assigned to investigate or
26 process the complaint. The Department shall respect the
27 confidentiality of medical reports and other documents that
28 by law are confidential. Any other information furnished by
29 a respondent shall be marked "confidential" if the respondent
30 does not wish it to be released to the complainant.
31 (d) The Department shall review the plan decision to
32 determine whether it is consistent with the plan and Illinois
33 law and rules.
34 (e) Upon receipt of the respondent's report, the
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1 Department shall evaluate the material submitted; and
2 (1) advise the complainant of the action taken and
3 disposition of its complaint;
4 (2) pursue further investigation with respondent or
5 complainant; or
6 (3) refer the investigation report to the
7 appropriate branch within the Department for further
8 regulatory action.
9 (f) The Department of Insurance and the Department of
10 Public Health shall coordinate the complaint review and
11 investigation process. The Department of Insurance and the
12 Department of Public Health shall jointly establish rules
13 under the Illinois Administrative Procedure Act implementing
14 this complaint process.
15 Section 80. Record of complaints.
16 (a) The Department shall maintain records concerning the
17 complaints filed against health care plans with the
18 Department and shall require health care plans to annually
19 report complaints made to and resolutions by health care
20 plans in a manner determined by rule. The Department shall
21 make a summary of all data collected available upon request
22 and publish the summary on the World Wide Web.
23 (b) The Department shall maintain records on the number
24 of complaints filed against each health care plan.
25 (c) The Department shall maintain records classifying
26 each complaint by whether the complaint was filed by:
27 (1) a consumer or enrollee;
28 (2) a provider; or
29 (3) any other individual.
30 (d) The Department shall maintain records classifying
31 each complaint according to the nature of the complaint as it
32 pertains to a specific function of the health care plan. The
33 complaints shall be classified under the following
-22- LRB9002705JSdvam01
1 categories:
2 (1) denial of care or treatment;
3 (2) denial of a diagnostic procedure;
4 (3) denial of a referral request;
5 (4) sufficient choice and accessibility of health
6 care providers;
7 (5) underwriting;
8 (6) marketing and sales;
9 (7) claims and utilization review;
10 (8) member services;
11 (9) provider relations; and
12 (10) miscellaneous.
13 (e) The Department shall maintain records classifying
14 the disposition of each complaint. The disposition of the
15 complaint shall be classified in one of the following
16 categories:
17 (1) complaint referred to the health care plan and
18 no further action necessary by the Department;
19 (2) no corrective action deemed necessary by the
20 Department; or
21 (3) corrective action taken by the Department.
22 (f) No Department publication or release of information
23 shall identify any enrollee, health care provider, or
24 individual complainant.
25 Section 85. Utilization review program registration.
26 (a) No person may conduct a utilization review program
27 in this State unless once every 2 years the person registers
28 the utilization review program with the Department and
29 certifies compliance with all of the Health Utilization
30 Management Standards of the American Accreditation Healthcare
31 Commission (URAC) or submits evidence of accreditation by the
32 American Accreditation Healthcare Commission (URAC) for its
33 Health Utilization Management Standards.
-23- LRB9002705JSdvam01
1 (b) In addition, the Director of the Department, in
2 consultation with the Director of the Department of Public
3 Health, may certify alternative utilization review standards
4 of national accreditation organizations or entities in order
5 for plans to comply with this Section. Any alternative
6 utilization review standards shall meet or exceed those
7 standards required under subsection (a).
8 (c) The provisions of this Section do not apply to:
9 (1) persons providing utilization review program
10 services only to the federal government;
11 (2) self-insured health plans under the federal
12 Employee Retirement Income Security Act of 1974, however,
13 this Section does apply to persons conducting a
14 utilization review program on behalf of these health
15 plans;
16 (3) hospitals and medical groups performing
17 utilization review activities for internal purposes
18 unless the utilization on review program is conducted for
19 another person.
20 Nothing in this Act prohibits a health care plan or other
21 entity from contractually requiring an entity designated in
22 item (3) of this subsection to adhere to the utilization
23 review program requirements of this Act.
24 (d) This registration shall include submission of all of
25 the following information regarding utilization review
26 program activities:
27 (1) The name, address, and telephone of the
28 utilization review programs.
29 (2) The organization and governing structure of the
30 utilization review programs.
31 (3) The number of lives for which utilization
32 review is conducted by each utilization review program.
33 (4) Hours of operation of each utilization review
34 program.
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1 (5) Description of the grievance process for each
2 utilization review program.
3 (6) Number of covered lives for which utilization
4 review was conducted for the previous calendar year for
5 each utilization review program.
6 (7) Written policies and procedures for protecting
7 confidential information according to applicable State
8 and federal laws for each utilization review program.
9 (e) If the Department finds that a utilization review
10 program is not in compliance with this Section, the
11 Department shall issue a corrective action plan and allow a
12 reasonable amount of time for compliance with the plan. If
13 the utilization review program does not come into compliance,
14 the Department may issue a cease and desist order. Before
15 issuing a cease and desist order under this Section, the
16 Department shall provide the utilization review program with
17 a written notice of the reasons for the order and allow a
18 reasonable amount of time to supply additional information
19 demonstrating compliance with requirements of this Section
20 and to request a hearing. The hearing notice shall be sent
21 by certified mail, return receipt requested, and the hearing
22 shall be conducted in accordance with the Illinois
23 Administrative Procedure Act.
24 (f) A utilization review program subject to a corrective
25 action may continue to conduct business until a final
26 decision has been issued by the Department.
27 Section 90. Prohibited activity. No health care plan by
28 contract, written policy, or procedure shall contain any
29 clause attempting to transfer or transferring to a health
30 care provider by indemnification or otherwise, any liability
31 relating to activities, actions, or omissions of the health
32 care plan or its officers, employees, or agents as opposed to
33 those of the health care provider.
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1 Section 95. Prohibition of waiver of rights. No health
2 care plan or contract shall contain any provision, policy, or
3 procedure that limits, restricts, or waives any of the rights
4 set forth in this Act. Any such policy or procedure shall be
5 void and unenforceable.
6 Section 100. Administration and enforcement. The
7 Director of Insurance may adopt rules necessary to implement
8 the Department's responsibilities under this Act.
9 To enforce the provisions of this Act, the Director may
10 issue a cease and desist order or require a health care plan
11 to submit a plan of correction for violations of this Act, or
12 both. Subject to the provisions of the Illinois
13 Administrative Procedure Act, the Director may impose an
14 administrative fine on a health care plan of up to $5,000 for
15 failure to submit a requested plan of correction, failure to
16 comply with its plan of correction, or repeated violations of
17 the Act.
18 Section 105. Applicability and scope. This Act applies
19 to policies and contracts amended, delivered, issued, or
20 renewed on or after the effective date of this Act. This Act
21 does not diminish a health care plan's duties and
22 responsibilities under other federal or State law or rules
23 promulgated thereunder.
24 Section 110. Effect on benefits under Workers'
25 Compensation Act and Workers' Occupational Diseases Act.
26 Nothing in this Act shall be construed to expand, modify, or
27 restrict the health care benefits provided to employees under
28 the Workers' Compensation Act and Workers' Occupational
29 Diseases Act.
30 Section 115. Severability. The provisions of this Act
-26- LRB9002705JSdvam01
1 are severable under Section 1.31 of the Statute on Statutes.
2 Section 200. The State Employees Group Insurance Act of
3 1971 is amended by adding Section 6.12 as follows:
4 (5 ILCS 375/6.12 new)
5 Sec. 6.12. Managed Care Patient Rights Act. The program
6 of health benefits is subject to the provisions of the
7 Managed Care Patient Rights Act.
8 Section 205. The State Mandates Act is amended by adding
9 Section 8.22 as follows:
10 (30 ILCS 805/8.22 new)
11 Sec. 8.22. Exempt mandate. Notwithstanding Sections 6
12 and 8 of this Act, no reimbursement by the State is required
13 for the implementation of any mandate created by this
14 amendatory Act of 1998.
15 Section 210. The Counties Code is amended by adding
16 Section 5-1069.8 as follows:
17 (55 ILCS 5/5-1069.8 new)
18 Sec. 5-1069.8. Managed Care Patient Rights Act. All
19 counties, including home rule counties, are subject to the
20 provisions of the Managed Care Patient Rights Act. The
21 requirement under this Section that health care benefits
22 provided by counties comply with the Managed Care Patient
23 Rights Act is an exclusive power and function of the State
24 and is a denial and limitation of home rule county powers
25 under Article VII, Section 6, subsection (h) of the Illinois
26 Constitution.
27 Section 215. The Illinois Municipal Code is amended by
-27- LRB9002705JSdvam01
1 adding 10-4-2.8 as follows:
2 (65 ILCS 5/10-4-2.8 new)
3 Sec. 10-4-2.8. Managed Care Patient Rights Act. The
4 corporate authorities of all municipalities are subject to
5 the provisions of the Managed Care Patients Rights Act. The
6 requirement under this Section that health care benefits
7 provided by municipalities comply with the Managed Care
8 Patient Rights Act is an exclusive power and function of the
9 State and is a denial and limitation of home rule
10 municipality powers under Article VII, Section 6, subsection
11 (h) of the Illinois Constitution.
12 Section 220. The Illinois Insurance Code is amended by
13 changing Sections 155.36 and 370g and adding Sections 370s
14 and 511.118 as follows:
15 (215 ILCS 5/155.36 new)
16 Sec. 155.36. Managed Care Patient Rights Act. Insurance
17 companies that transact the kinds of insurance authorized
18 under Class 1(b) or Class 2(a) of Section 4 of this Code
19 shall comply with Sections 80 and 85 and the definition of
20 the term "emergency medical condition" in Section 10 of the
21 Managed Care Patients Rights Act.
22 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
23 Sec. 370g. Definitions. As used in this Article, the
24 following definitions apply:
25 (a) "Health care services" means health care services or
26 products rendered or sold by a provider within the scope of
27 the provider's license or legal authorization. The term
28 includes, but is not limited to, hospital, medical, surgical,
29 dental, vision and pharmaceutical services or products.
30 (b) "Insurer" means an insurance company or a health
-28- LRB9002705JSdvam01
1 service corporation authorized in this State to issue
2 policies or subscriber contracts which reimburse for expenses
3 of health care services.
4 (c) "Insured" means an individual entitled to
5 reimbursement for expenses of health care services under a
6 policy or subscriber contract issued or administered by an
7 insurer.
8 (d) "Provider" means an individual or entity duly
9 licensed or legally authorized to provide health care
10 services.
11 (e) "Noninstitutional provider" means any person
12 licensed under the Medical Practice Act of 1987, as now or
13 hereafter amended.
14 (f) "Beneficiary" means an individual entitled to
15 reimbursement for expenses of or the discount of provider
16 fees for health care services under a program where the
17 beneficiary has an incentive to utilize the services of a
18 provider which has entered into an agreement or arrangement
19 with an administrator.
20 (g) "Administrator" means any person, partnership or
21 corporation, other than an insurer or health maintenance
22 organization holding a certificate of authority under the
23 "Health Maintenance Organization Act", as now or hereafter
24 amended, that arranges, contracts with, or administers
25 contracts with a provider whereby beneficiaries are provided
26 an incentive to use the services of such provider.
27 (h) "Emergency medical condition" means a medical
28 condition manifesting itself by acute symptoms of sufficient
29 severity (including severe pain) such that a prudent
30 layperson, who possesses an average knowledge of health and
31 medicine, could reasonably expect the absence of immediate
32 medical attention to result in:
33 (1) placing the health of the individual (or, with
34 respect to a pregnant woman, the health of the woman or
-29- LRB9002705JSdvam01
1 her unborn child) in serious jeopardy;
2 (2) serious impairment to bodily functions; or
3 (3) serious dysfunction of any bodily organ or
4 part. "Emergency" means an accidental bodily injury or
5 emergency medical condition which reasonably requires the
6 beneficiary or insured to seek immediate medical care
7 under circumstances or at locations which reasonably
8 preclude the beneficiary or insured from obtaining needed
9 medical care from a preferred provider.
10 (Source: P.A. 88-400.)
11 (215 ILCS 5/370s new)
12 Sec. 370s. Managed Care Patients Rights Act. All
13 administrators shall comply with Sections 80 and 85 of the
14 Managed Care Patients Rights Act.
15 (215 ILCS 5/511.118 new)
16 Sec. 511.118. Managed Care Patients Rights Act. All
17 administrators are subject to the provisions of Sections 80
18 and 85 of the Managed Care Patients Act.
19 Section 225. The Comprehensive Health Insurance Plan Act
20 is amended by adding Section 8.6 as follows:
21 (215 ILCS 105/8.6 new)
22 Sec. 8.6. Managed Care Patient Rights Act. The plan is
23 subject to the provisions of the Managed Care Patient Rights
24 Act.
25 Section 230. The Health Care Purchasing Group Act is
26 amended by changing Sections 15 and 20 as follows:
27 (215 ILCS 123/15)
28 Sec. 15. Health care purchasing groups; membership;
-30- LRB9002705JSdvam01
1 formation.
2 (a) An HPG may be an organization formed by 2 or more
3 employers with no more than 500 covered employees each 2,500
4 covered individuals, an HPG sponsor or a risk-bearer for
5 purposes of contracting for health insurance under this Act
6 to cover employees and dependents of HPG members. An HPG
7 shall not be prevented from supplementing health insurance
8 coverage purchased under this Act by contracting for services
9 from entities licensed and authorized in Illinois to provide
10 those services under the Dental Service Plan Act, the Limited
11 Health Service Organization Act, Vision Service Plan Act, or
12 Voluntary Health Services Plans Act. An HPG may be a
13 separate legal entity or simply a group of 2 or more
14 employers with no more than 500 covered employees each 2,500
15 covered individuals aggregated under this Act by an HPG
16 sponsor or risk-bearer for insurance purposes. There shall
17 be no limit as to the number of HPGs that may operate in any
18 geographic area of the State. No insurance risk may be borne
19 or retained by the HPG. All health insurance contracts
20 issued to the HPG must be delivered or issued for delivery in
21 Illinois.
22 (b) Members of an HPG must be Illinois domiciled
23 employers, except that an employer domiciled elsewhere may
24 become a member of an Illinois HPG for the sole purpose of
25 insuring its employees whose place of employment is located
26 within this State. HPG membership may include employers
27 having no more than 500 covered employees each 2,500 covered
28 individuals.
29 (c) If an HPG is formed by any 2 or more employers with
30 no more than 500 covered employees each 2,500 covered
31 individuals, it is authorized to negotiate, solicit, market,
32 obtain proposals for, and enter into group or master health
33 insurance contracts on behalf of its members and their
34 employees and employee dependents so long as it meets all of
-31- LRB9002705JSdvam01
1 the following requirements:
2 (1) The HPG must be an organization having the
3 legal capacity to contract and having its legal situs in
4 Illinois.
5 (2) The principal persons responsible for the
6 conduct of the HPG must perform their HPG related
7 functions in Illinois.
8 (3) No HPG may collect premium in its name or hold
9 or manage premium or claim fund accounts unless duly
10 licensed and qualified as a managing general agent
11 pursuant to Section 141a of the Illinois Insurance Code
12 or a third party administrator pursuant to Section
13 511.105 of the Illinois Insurance Code.
14 (4) If the HPG gives an offer, application, notice,
15 or proposal of insurance to an employer, it must disclose
16 to that employer the total cost of the insurance. Dues,
17 fees, or charges to be paid to the HPG, HPG sponsor, or
18 any other entity as a condition to purchasing the
19 insurance must be itemized. The HPG shall also disclose
20 to its members the amount of any dividends, experience
21 refunds, or other such payments it receives from the
22 risk-bearer.
23 (5) An HPG must register with the Director before
24 entering into a group or master health insurance contract
25 on behalf of its members and must renew the registration
26 annually on forms and at times prescribed by the Director
27 in rules specifying, at minimum, (i) the identity of the
28 officers and directors, trustees, or attorney-in-fact of
29 the HPG; (ii) a certification that those persons have not
30 been convicted of any felony offense involving a breach
31 of fiduciary duty or improper manipulation of accounts;
32 and (iii) the number of employer members then enrolled in
33 the HPG, together with any other information that may be
34 needed to carry out the purposes of this Act.
-32- LRB9002705JSdvam01
1 (6) At the time of initial registration and each
2 renewal thereof an HPG shall pay a fee of $100 to the
3 Director.
4 (d) If an HPG is formed by an HPG sponsor or risk-bearer
5 and the HPG performs no marketing, negotiation, solicitation,
6 or proposing of insurance to HPG members, exclusive of
7 ministerial acts performed by individual employers to service
8 their own employees, then a group or master health insurance
9 contract may be issued in the name of the HPG and held by an
10 HPG sponsor, risk-bearer, or designated employer member
11 within the State. In these cases the HPG requirements
12 specified in subsection (c) shall not be applicable, however:
13 (1) the group or master health insurance contract
14 must contain a provision permitting the contract to be
15 enforced through legal action initiated by any employer
16 member or by an employee of an HPG member who has paid
17 premium for the coverage provided;
18 (2) the group or master health insurance contract
19 must be available for inspection and copying by any HPG
20 member, employee, or insured dependent at a designated
21 location within the State at all normal business hours;
22 and
23 (3) any information concerning HPG membership
24 required by rule under item (5) of subsection (c) must be
25 provided by the HPG sponsor in its registration and
26 renewal forms or by the risk-bearer in its annual
27 reports.
28 (Source: P.A. 90-337, eff. 1-1-98; revised 1-21-98.)
29 (215 ILCS 123/20)
30 Sec. 20. HPG sponsors. Except as provided by Sections 15
31 and 25 of this Act, only a corporation authorized by the
32 Secretary of State to transact business in Illinois may
33 sponsor one or more HPGs with no more than 100,000 10,000
-33- LRB9002705JSdvam01
1 covered individuals by negotiating, soliciting, or servicing
2 health insurance contracts for HPGs and their members. Such a
3 corporation may assert and maintain authority to act as an
4 HPG sponsor by complying with all of the following
5 requirements:
6 (1) The principal officers and directors
7 responsible for the conduct of the HPG sponsor must
8 perform their HPG sponsor related functions in Illinois.
9 (2) No insurance risk may be borne or retained by
10 the HPG sponsor; all health insurance contracts issued to
11 HPGs through the HPG sponsor must be delivered in
12 Illinois.
13 (3) No HPG sponsor may collect premium in its name
14 or hold or manage premium or claim fund accounts unless
15 duly qualified and licensed as a managing general agent
16 pursuant to Section 141a of the Illinois Insurance Code
17 or as a third party administrator pursuant to Section
18 511.105 of the Illinois Insurance Code.
19 (4) If the HPG gives an offer, application, notice,
20 or proposal of insurance to an employer, it must disclose
21 the total cost of the insurance. Dues, fees, or charges
22 to be paid to the HPG, HPG sponsor, or any other entity
23 as a condition to purchasing the insurance must be
24 itemized. The HPG shall also disclose to its members the
25 amount of any dividends, experience refunds, or other
26 such payments it receives from the risk-bearer.
27 (5) An HPG sponsor must register with the Director
28 before negotiating or soliciting any group or master
29 health insurance contract for any HPG and must renew the
30 registration annually on forms and at times prescribed by
31 the Director in rules specifying, at minimum, (i) the
32 identity of the officers and directors of the HPG sponsor
33 corporation; (ii) a certification that those persons have
34 not been convicted of any felony offense involving a
-34- LRB9002705JSdvam01
1 breach of fiduciary duty or improper manipulation of
2 accounts; (iii) the number of employer members then
3 enrolled in each HPG sponsored; (iv) the date on which
4 each HPG was issued a group or master health insurance
5 contract, if any; and (v) the date on which each such
6 contract, if any, was terminated.
7 (6) At the time of initial registration and each
8 renewal thereof an HPG sponsor shall pay a fee of $100 to
9 the Director.
10 (Source: P.A. 90-337, eff. 1-1-98.)
11 Section 235. The Health Maintenance Organization Act is
12 amended by changing Sections 2-2 and 6-7 and adding Section
13 5-3.6 as follows:
14 (215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
15 Sec. 2-2. Determination by Director; Health Maintenance
16 Advisory Board.
17 (a) Upon receipt of an application for issuance of a
18 certificate of authority, the Director shall transmit copies
19 of such application and accompanying documents to the
20 Director of the Illinois Department of Public Health. The
21 Director of the Department of Public Health shall then
22 determine whether the applicant for certificate of authority,
23 with respect to health care services to be furnished: (1) has
24 demonstrated the willingness and potential ability to assure
25 that such health care service will be provided in a manner to
26 insure both availability and accessibility of adequate
27 personnel and facilities and in a manner enhancing
28 availability, accessibility, and continuity of service; and
29 (2) has arrangements, established in accordance with
30 regulations promulgated by the Department of Public Health
31 for an ongoing quality of health care assurance program
32 concerning health care processes and outcomes. Upon
-35- LRB9002705JSdvam01
1 investigation, the Director of the Department of Public
2 Health shall certify to the Director whether the proposed
3 Health Maintenance Organization meets the requirements of
4 this subsection (a). If the Director of the Department of
5 Public Health certifies that the Health Maintenance
6 Organization does not meet such requirements, he shall
7 specify in what respect it is deficient.
8 There is created in the Department of Public Health a
9 Health Maintenance Advisory Board composed of 11 members.
10 Nine 9 members shall who have practiced in the health field,
11 4 of which shall have been or are currently affiliated with a
12 Health Maintenance Organization. Two of the members shall be
13 members of the general public, one of whom is over 50 years
14 of age. Each member shall be appointed by the Director of
15 the Department of Public Health and serve at the pleasure of
16 that Director and shall receive no compensation for services
17 rendered other than reimbursement for expenses. Six Five
18 members of the Board shall constitute a quorum. A vacancy in
19 the membership of the Advisory Board shall not impair the
20 right of a quorum to exercise all rights and perform all
21 duties of the Board. The Health Maintenance Advisory Board
22 has the power to review and comment on proposed rules and
23 regulations to be promulgated by the Director of the
24 Department of Public Health within 30 days after those
25 proposed rules and regulations have been submitted to the
26 Advisory Board.
27 (b) Issuance of a certificate of authority shall be
28 granted if the following conditions are met:
29 (1) the requirements of subsection (c) of Section
30 2-1 have been fulfilled;
31 (2) the persons responsible for the conduct of the
32 affairs of the applicant are competent, trustworthy, and
33 possess good reputations, and have had appropriate
34 experience, training or education;
-36- LRB9002705JSdvam01
1 (3) the Director of the Department of Public Health
2 certifies that the Health Maintenance Organization's
3 proposed plan of operation meets the requirements of this
4 Act;
5 (4) the Health Care Plan furnishes basic health
6 care services on a prepaid basis, through insurance or
7 otherwise, except to the extent of reasonable
8 requirements for co-payments or deductibles as authorized
9 by this Act;
10 (5) the Health Maintenance Organization is
11 financially responsible and may reasonably be expected to
12 meet its obligations to enrollees and prospective
13 enrollees; in making this determination, the Director
14 shall consider:
15 (A) the financial soundness of the applicant's
16 arrangements for health services and the minimum
17 standard rates, co-payments and other patient
18 charges used in connection therewith;
19 (B) the adequacy of working capital, other
20 sources of funding, and provisions for
21 contingencies; and
22 (C) that no certificate of authority shall be
23 issued if the initial minimum net worth of the
24 applicant is less than $2,000,000. The initial net
25 worth shall be provided in cash and securities in
26 combination and form acceptable to the Director;
27 (6) the agreements with providers for the provision
28 of health services contain the provisions required by
29 Section 2-8 of this Act; and
30 (7) any deficiencies identified by the Director
31 have been corrected.
32 (Source: P.A. 86-620; 86-1475.)
33 (215 ILCS 125/5-3.6 new)
-37- LRB9002705JSdvam01
1 Sec. 5-3.6. Managed Care Patient Rights Act. Health
2 maintenance organizations are subject to the provisions of
3 the Managed Care Patient Rights Act.
4 (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
5 Sec. 6-7. Board of Directors. The board of directors of
6 the Association consists of not less than 7 5 nor more than
7 11 9 members serving terms as established in the plan of
8 operation. The members of the board are to be selected by
9 member organizations subject to the approval of the Director,
10 except the Director shall name 2 members who are current
11 enrollees, one of whom is over 50 years of age. Vacancies on
12 the board must be filled for the remaining period of the term
13 in the manner described in the plan of operation. To select
14 the initial board of directors, and initially organize the
15 Association, the Director must give notice to all member
16 organizations of the time and place of the organizational
17 meeting. In determining voting rights at the organizational
18 meeting each member organization is entitled to one vote in
19 person or by proxy. If the board of directors is not
20 selected at the organizational meeting, the Director may
21 appoint the initial members.
22 In approving selections or in appointing members to the
23 board, the Director must consider, whether all member
24 organizations are fairly represented.
25 Members of the board may be reimbursed from the assets of
26 the Association for expenses incurred by them as members of
27 the board of directors but members of the board may not
28 otherwise be compensated by the Association for their
29 services.
30 (Source: P.A. 85-20.)
31 Section 240. The Limited Health Service Organization Act
32 is amended by adding Section 4002.6 as follows:
-38- LRB9002705JSdvam01
1 (215 ILCS 130/4002.6 new)
2 Sec. 4002.6. Managed Care Patient Rights Act. Except
3 for health care plans offering only dental services or only
4 vision services, limited health service organizations are
5 subject to the provisions of the Managed Care Patient Rights
6 Act.
7 Section 245. The Voluntary Health Services Plans Act is
8 amended by adding Section 15.30 as follows:
9 (215 ILCS 165/15.30 new)
10 Sec. 15.30. Managed Care Patient Rights Act. A health
11 service plan corporation is subject to the provisions of the
12 Managed Care Patient Rights Act.
13 Section 250. The Illinois Public Aid Code is amended by
14 adding Section 5-16.12 as follows:
15 (305 ILCS 5/5-16.12 new)
16 Sec. 5-16.12. Managed Care Patient Rights Act. The
17 medical assistance program and other programs administered by
18 the Department are subject to the provisions of the Managed
19 Care Patient Rights Act. The Department may adopt rules to
20 implement those provisions. These rules shall require
21 compliance with that Act in the medical assistance managed
22 care programs and other programs administered by the
23 Department. The medical assistance fee-for-service program
24 is not subject to the provisions of the Managed Care Patient
25 Rights Act.
26 Section 299. Effective date. This Act takes effect
27 January 1, 1999.".