State of Illinois
91st General Assembly
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[ Engrossed ][ House Amendment 001 ]

91_HB0626

 
                                               LRB9100964JSpc

 1        AN  ACT  concerning the delivery of health care services,
 2    amending named Acts.

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

 5        Section  1.  Short  title.   This Act may be cited as the
 6    Managed Care Reform Act.

 7        Section 5. Definitions. For purposes  of  this  Act,  the
 8    following  words  shall  have  the  meanings provided in this
 9    Section, unless otherwise indicated:
10        "Adverse determination" means  a   determination   by   a
11    utilization  review  agent  that an admission, extension of a
12    stay, or other health care service  has  been  reviewed  and,
13    based   on   the   information  provided,  is  not  medically
14    necessary.
15        "Clinical peer reviewer" or "clinical personnel" means:
16             (1)  in the case of  physician  reviewers,  a  State
17        licensed  physician  who  is  of the same category in the
18        same or similar specialty as the health care provider who
19        typically manages the  medical  condition,  procedure  or
20        treatment under review; or
21             (2)  in the case of non-physician reviewers, a State
22        licensed  or  registered  health care professional who is
23        in  the  same  profession  and same or similar  specialty
24        as  the  health  care  provider who typically manages the
25        medical condition, procedure, or treatment under review.
26        Nothing  herein  shall  be  construed   to   change   any
27    statutorily defined scope of practice.
28        "Culturally and linguistically competent care" means that
29    a  managed  care  plan  has  staff and procedures in place to
30    provide  all  covered  services  and  policy  procedures   in
31    English,  Spanish, and any other language spoken as a primary
 
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 1    language by 5% or more of its enrollees.
 2        "Degenerative or disabling condition or disease" means  a
 3    condition  or  disease  that  is  permanent  or of indefinite
 4    duration, that is likely to become  worse  or  more  advanced
 5    over  time,  and  that  substantially  impairs  a  major life
 6    function.
 7        "Department" means the Department of Public Health.
 8        "Director" means the Director of Public Health.
 9        "Emergency medical screening examination" means a medical
10    screening examination and evaluation by a  physician  or,  to
11    the extent permitted by applicable laws, by other appropriate
12    personnel  under  the supervision of a physician to determine
13    whether the need for emergency  services exists.
14        "Emergency services" means the provision of  health  care
15    services  for  sudden and, at the time, unexpected onset of a
16    health condition that  would  lead  a  prudent  layperson  to
17    believe  that  failure to receive immediate medical attention
18    would result in serious  impairment  to  bodily  function  or
19    serious  dysfunction of any body organ or part or would place
20    the person's health in serious jeopardy.
21        "Enrollee" means a person  enrolled  in  a  managed  care
22    plan.
23        "Health care professional" means a physician,  registered
24    professional nurse, or other person appropriately licensed or
25    registered  pursuant  to  the  laws  of this State to provide
26    health care services.
27        "Health care provider" means a health care  professional,
28    hospital, facility, or other person appropriately licensed or
29    otherwise  authorized  to  furnish  health  care  services or
30    arrange for the delivery of  health  care  services  in  this
31    State.
32        "Health care services" means services included in the (i)
33    furnishing  of medical care, (ii) hospitalization incident to
34    the furnishing of  medical  care,  and  (iii)  furnishing  of
 
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 1    services,  including  pharmaceuticals,  for  the  purpose  of
 2    preventing,  alleviating, curing, or healing human illness or
 3    injury to an individual.
 4        "Informal policy or procedure" means a nonwritten  policy
 5    or  procedure,  the  existence  of  which may be proven by an
 6    admission of an authorized agent of a managed  care  plan  or
 7    statistical evidence supported by anecdotal evidence.
 8        "Life   threatening   condition  or  disease"  means  any
 9    condition, illness, or injury  that,  in  the  opinion  of  a
10    licensed  physician,  (i)  may  directly  lead to a patient's
11    death, (ii) results in a period of unconsciousness  which  is
12    indeterminate at the present, or (iii) imposes severe pain or
13    an inhumane burden on the patient.
14        "Managed  care  plan"  means  a  plan  that  establishes,
15    operates,  or  maintains  a  network of health care providers
16    that have entered into agreements with the  plan  to  provide
17    health  care  services  to  enrollees  where the plan has the
18    obligation to the enrollee to arrange for the provision of or
19    pay for services through:
20             (1)  organizational arrangements for ongoing quality
21        assurance,  utilization  review  programs,   or   dispute
22        resolution; or
23             (2)  financial  incentives  for  persons enrolled in
24        the  plan  to  use  the   participating   providers   and
25        procedures covered by the plan.
26        A managed care plan may be established or operated by any
27    entity  including, but not necessarily limited to, a licensed
28    insurance company, hospital or medical service  plan,  health
29    maintenance     organization,    limited    health    service
30    organization, preferred provider  organization,  third  party
31    administrator,  independent practice association, or employer
32    or employee organization.
33        For purposes of  this  definition,  "managed  care  plan"
34    shall not include the following:
 
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 1             (1)  strict  indemnity  health insurance policies or
 2        plans issued by an insurer that does not require approval
 3        of a primary care provider or other  similar  coordinator
 4        to access health care services; and
 5             (2)  managed  care  plans  that offer only dental or
 6        vision coverage.
 7        "Post-stabilization services"  means  those  health  care
 8    services determined by a treating provider to be promptly and
 9    medically  necessary  following stabilization of an emergency
10    condition.
11        "Primary care provider" means  a  physician  licensed  to
12    practice  medicine  in  all its branches who provides a broad
13    range  of  personal  medical  care  (preventive,  diagnostic,
14    curative, counseling, or rehabilitative) in a   comprehensive
15    and coordinated manner over time for a managed care plan.
16        "Specialist"   means   a  health  care  professional  who
17    concentrates practice in  a  recognized  specialty  field  of
18    care.
19        "Speciality  care  center"  means  only  a center that is
20    accredited by an agency of the State or federal government or
21    by a voluntary national health organization as having special
22    expertise  in  treating  the  life-threatening   disease   or
23    condition  or  degenerative or disabling disease or condition
24    for which it is accredited.
25        "Utilization  review" means the review, undertaken  by  a
26    entity  other than the managed care plan itself, to determine
27    whether health care services that  have  been  provided,  are
28    being  provided  or  are proposed  to  be  provided   to   an
29    individual  by  a managed care plan, whether undertaken prior
30    to, concurrent with, or  subsequent  to   the   delivery   of
31    such  services  are medically  necessary.  For  the  purposes
32    of   this   Act,  none  of  the following shall be considered
33    utilization review:
34             (1)  denials based on failure to obtain health  care
 
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 1        services  from  a designated  or  approved  health   care
 2        provider  as  required  under  an enrollee's contract;
 3             (2)  the   review  of  the  appropriateness  of  the
 4        application  of  a  particular  coding  to   a   patient,
 5        including  the  assignment  of  diagnosis  and procedure;
 6             (3)  any   issues  relating  to the determination of
 7        the amount or extent of payment other than determinations
 8        to deny payment based on an adverse determination; and
 9             (4)  any determination of any coverage issues  other
10        than  whether  health care services are or were medically
11        necessary.
12        "Utilization   review   agent"   means    any    company,
13    organization,  or other entity performing utilization review,
14    except:
15             (1)  an agency of the State or federal government;
16             (2)  an  agent  acting  on  behalf  of  the  federal
17        government, but  only  to the  extent  that the agent  is
18        providing services to the federal government;
19             (3)  an  agent  acting  on  behalf  of the State and
20        local  government  for services   provided   pursuant  to
21        Title XIX of the federal Social Security Act, but only to
22        the  extent  that  the agent is providing services to the
23        State or local government;
24             (4)  a hospital's internal quality assurance program
25        except  if   associated  with  a  health  care  financing
26        mechanism.
27        "Utilization review plan" means:
28             (1)  a description of the process for developing the
29        written  clinical review criteria;
30             (2)  a  description of the types of written clinical
31        information which the plan might consider in its clinical
32        review including, but not limited to, a set  of  specific
33        written clinical review criteria;
34             (3)  a   description   of  practice  guidelines  and
 
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 1        standards used by a utilization review agent in making  a
 2        determination  of  medical necessity;
 3             (4)  the  procedures  for   scheduled   review   and
 4        evaluation of the written clinical review criteria; and
 5             (5)  a   description   of   the  qualifications  and
 6        experience  of   the   health  care   professionals   who
 7        developed the criteria, who are responsible for  periodic
 8        evaluation  of  the  criteria  and  of  the  health  care
 9        professionals  or  others  who  use  the written clinical
10        review criteria in the process of utilization review.

11        Section 10.  Disclosure  of  information.
12        (a)  An enrollee, and upon request a prospective enrollee
13    prior to  enrollment,   shall   be  supplied   with   written
14    disclosure  information,  containing at least the information
15    specified in  this  Section,  if  applicable,  which  may  be
16    incorporated  into  the  member  handbook   or  the  enrollee
17    contract  or  certificate. All written descriptions shall  be
18    in   readable  and  understandable  format,  consistent  with
19    standards developed for supplemental insurance coverage under
20    Title XVIII of the Social Security Act.  The Department shall
21    promulgate rules to standardize this format so that potential
22    members can compare the attributes  of  the  various  managed
23    care  entities. In the event of any inconsistency between any
24    separate written  disclosure  statement   and  the   enrollee
25    contract    or   certificate,   the  terms  of  the  enrollee
26    contract  or  certificate   shall   be    controlling.    The
27    information   to   be  disclosed shall include, at a minimum,
28    all of the following:
29             (1)  A description of  coverage  provisions,  health
30        care   benefits,   benefit  maximums,  including  benefit
31        limitations, and exclusions of  coverage,  including  the
32        definition  of  medical  necessity  used  in  determining
33        whether benefits will be covered.
 
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 1             (2)  A  description  of  all  prior authorization or
 2        other requirements for treatments,  pharmaceuticals,  and
 3        services.
 4             (3)  A  description  of  utilization review policies
 5        and   procedures   used  by   the   managed  care   plan,
 6        including   the  circumstances  under  which  utilization
 7        review will  be  undertaken,  the   toll-free   telephone
 8        number  of  the  utilization review agent, the timeframes
 9        under which utilization review decisions must be made for
10        prospective, retrospective,  and   concurrent  decisions,
11        the  right  to  reconsideration,  the right to an appeal,
12        including the expedited and  standard  appeals  processes
13        and   the  timeframes   for  those  appeals, the right to
14        designate a representative, a notice that all denials  of
15        claims  will  be   made  by  clinical personnel, and that
16        all notices of denials will include information about the
17        basis of the decision and further appeal rights, if any.
18             (4)  A description prepared annually of the types of
19        methodologies the managed care  plan  uses  to  reimburse
20        providers   specifying the  type  of  methodology that is
21        used to  reimburse  particular  types  of  providers   or
22        reimburse  for  the  provision  of  particular  types  of
23        services,  provided,  however,  that nothing in this item
24        should be construed to require disclosure  of  individual
25        contracts  or  the   specific  details  of  any financial
26        arrangement between a managed care plan and a health care
27        provider.
28             (5)  An  explanation  of   a   enrollee's  financial
29        responsibility  for  payment  of  premiums,  coinsurance,
30        co-payments,  deductibles,  and any other charges, annual
31        limits on an enrollee's financial  responsibility,   caps
32        on   payments   for   covered   services   and  financial
33        responsibility for non-covered health  care   procedures,
34        treatments,   or   services   provided within the managed
 
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 1        care plan.
 2             (6)  An  explanation  of  an   enrollee's  financial
 3        responsibility  for payment when services are provided by
 4        a health care provider who is  not part  of  the  managed
 5        care   plan   or   by   any   provider  without  required
 6        authorization or when a procedure, treatment, or  service
 7        is  not a covered health care benefit.
 8             (7)  A   description  of the grievance procedures to
 9        be used to resolve disputes between a managed  care  plan
10        and   an   enrollee,  including   the   right  to  file a
11        grievance regarding any dispute between an enrollee and a
12        managed care  plan,  the  right  to   file   a  grievance
13        orally   when   the dispute is about referrals or covered
14        benefits, the toll-free telephone number  that  enrollees
15        may  use  to  file  an oral grievance, the timeframes and
16        circumstances for expedited and standard  grievances, the
17        right  to  appeal  a  grievance  determination  and   the
18        procedures  for  filing  the  appeal, the timeframes  and
19        circumstances for  expedited  and standard  appeals,  the
20        right  to  designate  a representative, a notice that all
21        disputes involving clinical decisions will  be  made   by
22        clinical personnel, and that all notices of determination
23        will  include  information  about  the   basis   of   the
24        decision  and further appeal rights, if any.
25             (8)  A  description  of  the procedure for providing
26        care  and coverage 24 hours a day for emergency services.
27        The   description   shall  include   the  definition   of
28        emergency  services, notice  that emergency services  are
29        not  subject  to   prior  approval, and an explanation of
30        the  enrollee's  financial  and  other   responsibilities
31        regarding   obtaining  those  services,  including   when
32        those services are  received  outside  the  managed  care
33        plan's service area.
34             (9)  A  description  of  procedures for enrollees to
 
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 1        select and access the managed  care  plan's  primary  and
 2        specialty  care   providers,  including  notice of how to
 3        determine whether a participating provider  is  accepting
 4        new patients.
 5             (10)  A  description  of the procedures for changing
 6        primary and specialty care providers within  the  managed
 7        care plan.
 8             (11)  Notice  that an enrollee may obtain a referral
 9        to  a  health  care  provider outside of the managed care
10        plan's  network  or panel  when  the  managed  care  plan
11        does  not  have  a  health care provider with appropriate
12        training and experience in the network or panel  to  meet
13        the  particular  health  care  needs of the enrollee  and
14        the procedure  by  which  the  enrollee  can  obtain  the
15        referral.
16             (12)  Notice   that   an  enrollee  with a condition
17        that  requires  ongoing  care  from  a  specialist    may
18        request   a   standing  referral  to  the specialist  and
19        the procedure for requesting  and  obtaining  a  standing
20        referral.
21             (13)  Notice    that   an   enrollee  with    (i)  a
22        life-threatening  condition  or   disease   or   (ii)   a
23        degenerative or disabling condition or disease, either of
24        which  requires specialized medical care over a prolonged
25        period  of time, may request a specialist responsible for
26        providing or coordinating the enrollee's medical care and
27        the  procedure   for   requesting   and   obtaining   the
28        specialist.
29             (14)  A  description  of  the  mechanisms  by  which
30        enrollees  may  participate  in  the  development  of the
31        policies of the managed care plan.
32             (15)  A description of how  the  managed  care  plan
33        addresses the needs of non-English speaking enrollees.
34             (16)  Notice  of  all  appropriate mailing addresses
 
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 1        and  telephone   numbers  to  be  utilized  by  enrollees
 2        seeking information or authorization.
 3             (17)  A listing by specialty,  which  may  be  in  a
 4        separate  document that is updated annually, of the name,
 5        address, and telephone   number   of   all  participating
 6        providers, including facilities, and, in addition, in the
 7        case   of  physicians,  category  of  license  and  board
 8        certification, if applicable.
 9        (b)  Upon request of an enrollee or prospective enrollee,
10    a managed care plan shall do all of the following:
11             (1)  Provide  a  list   of   the   names,   business
12        addresses,  and  official positions of the members of the
13        board  of  directors,  officers,   controlling   persons,
14        owners, and partners of the managed care plan.
15             (2)  Provide   a   copy  of  the  most recent annual
16        certified financial statement of the managed  care  plan,
17        including   a  balance  sheet and summary of receipts and
18        disbursements and the ratio of (i) premium dollars  going
19        to  administrative expenses to (ii) premium dollars going
20        to  direct  care,  prepared   by   a   certified   public
21        accountant.  The  Department  shall  promulgate  rules to
22        standardize the information that must be contained in the
23        statement and the statement's format.
24             (3)  Provide  information   relating   to   consumer
25        complaints  compiled in accordance with subsection (b) of
26        Section  30  of  this Act and the rules promulgated under
27        this Act.
28             (4)  Provide  the  procedures  for  protecting   the
29        confidentiality  of  medical  records  and other enrollee
30        information.
31             (5)  Allow enrollees and  prospective  enrollees  to
32        inspect  drug  formularies  used by the managed care plan
33        and  disclose  whether  individual  drugs are included or
34        excluded from coverage and whether a drug requires  prior
 
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 1        authorization.   An  enrollee or prospective enrollee may
 2        seek information as to the inclusion or  exclusion  of  a
 3        specific drug.  A managed care plan need only release the
 4        information  if  the  enrollee or prospective enrollee or
 5        his or her dependent needs, used, or may need or use  the
 6        drug.
 7             (6)  Provide    a   written   description   of   the
 8        organizational  arrangements and  ongoing  procedures  of
 9        the managed care plan's quality assurance program.
10             (7)  Provide   a   description   of  the  procedures
11        followed  by  the managed care plan in  making  decisions
12        about  the  experimental  or  investigational  nature  of
13        individual  drugs,  medical   devices,  or  treatments in
14        clinical trials.
15             (8)  Provide  individual  health  care  professional
16        affiliations with participating hospitals, if any.
17             (9)  Upon   written   request,   provide    specific
18        written   clinical   review  criteria   relating   to   a
19        particular  condition  or disease and, where appropriate,
20        other clinical information that  the  managed  care  plan
21        might  consider in  its  utilization  review; the managed
22        care plan may include with the information a  description
23        of  how  it  will   be  used  in  the  utilization review
24        process.  An enrollee or prospective  enrollee  may  seek
25        information  as  to specific clinical review criteria.  A
26        managed care plan need only release  the  information  if
27        the  enrollee  or  prospective  enrollee  or  his  or her
28        dependent has, may have, or is at risk of  contracting  a
29        particular condition or disease.
30             (10)  Provide the written application procedures and
31        minimum   qualification   requirements  for  health  care
32        providers  to  be  considered  by  the managed care plan.
33             (11)  Disclose  other  information  as  required  by
34        the Director.
 
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 1             (12)  To the extent the information  provided  under
 2        item  (5) or (9) of this subsection is proprietary to the
 3        managed care plan, the enrollee or  prospective  enrollee
 4        shall  only  use  the  information  for  the  purposes of
 5        assisting  the  enrollee  or  prospective   enrollee   in
 6        evaluating  the covered services  provided by the managed
 7        care plan. Any misuse of proprietary data is  prohibited,
 8        provided  that  the  managed  care  plan  has  labeled or
 9        identified the data as proprietary.
10        (c)  Nothing in this Section shall prevent a managed care
11    plan from changing or updating the materials  that  are  made
12    available to enrollees or prospective enrollees.
13        (d)  If  a  primary care provider ceases participation in
14    the managed care plan, the  managed care plan  shall  provide
15    written notice within 15 business days from the date that the
16    managed  care  plan  becomes aware of the change in status to
17    each of the enrollees who have  chosen   the   provider    as
18    their   primary   care  provider.  If  an  enrollee  is in an
19    ongoing course of  treatment  with  any  other  participating
20    provider  who  becomes   unavailable  to  continue to provide
21    services to the enrollee and the managed care plan  is  aware
22    of the ongoing  course  of  treatment,  the managed care plan
23    shall   provide   written notice within 15 business days from
24    the date that the managed care  plan  becomes  aware  of  the
25    unavailability   to  the  enrollee.  The  notice  shall  also
26    describe the procedures for continuing care.
27        (e)  A managed care plan offering to indemnify  enrollees
28    for  non-participating  provider services shall file a report
29    with the Director  twice  a  year  showing   the   percentage
30    utilization    for    the   preceding    6  month  period  of
31    non-participating  provider  services  in   such   form   and
32    providing   such   other  information  as  the Director shall
33    prescribe.
34        (f)  The written information disclosure  requirements  of
 
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 1    this  Section  may  be met by disclosure to one enrollee in a
 2    household.

 3        Section 15.  General grievance procedure.
 4        (a)  A managed care plan shall establish and  maintain  a
 5    grievance  procedure,  as  described in this Act.  Compliance
 6    with this Act's grievance procedures shall satisfy a  managed
 7    care  plan's obligation to provide grievance procedures under
 8    any other State law or rules.
 9        A copy of the grievance procedures, including  all  forms
10    used  to  process  a  grievance,  shall  be  filed  with  the
11    Director.   Any  subsequent  material  modifications  to  the
12    documents  also  shall be filed.  In addition, a managed care
13    plan shall file annually with the Director a  certificate  of
14    compliance stating that the managed care plan has established
15    and  maintains,  for  each of its plans, grievance procedures
16    that fully comply with  the  provisions  of  this  Act.   The
17    Director  has  authority to disapprove a filing that fails to
18    comply with this Act or applicable rules.
19        (b)  A managed care plan shall provide written notice  of
20    the  grievance  procedure  to  all  enrollees  in  the member
21    handbook and to an enrollee at any time that the managed care
22    plan denies  access  to  a  referral  or  determines  that  a
23    requested benefit is not covered pursuant to the terms of the
24    contract.  In  the  event  that  a managed care plan denies a
25    service as an adverse determination, the  managed  care  plan
26    shall  inform the enrollee  or  the  enrollee's  designee  of
27    the appeal rights under this Act.
28        The  notice  to  an  enrollee  describing  the  grievance
29    process  shall explain the process  for  filing  a  grievance
30    with  the  managed  care  plan, the timeframes within which a
31    grievance determination must be made, and  the  right  of  an
32    enrollee to designate a representative to file a grievance on
33    behalf  of the enrollee. Information required to be disclosed
 
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 1    or  provided  under  this  Section  must  be  provided  in  a
 2    reasonable and understandable format.
 3        The managed care plan shall assure  that  the   grievance
 4    procedure  is reasonably accessible to those who do not speak
 5    English.
 6        (c)  A  managed  care  plan shall not retaliate  or  take
 7    any  discriminatory action  against an  enrollee  because  an
 8    enrollee has filed a grievance or appeal.

 9        Section 20.  First level grievance review.
10        (a)  The  managed  care  plan  may require an enrollee to
11    file a grievance in writing,  by letter  or  by  a  grievance
12    form  which shall be made available by the managed care plan,
13    however, an enrollee  must  be  allowed  to  submit  an  oral
14    grievance  in  connection with (i) a denial of, or failure to
15    pay for, a referral or service or (ii) a determination as  to
16    whether  a  benefit  is  covered pursuant to the terms of the
17    enrollee's contract.  In  connection  with  the submission of
18    an oral grievance, a  managed  care  plan  shall,  within  24
19    hours,  reduce the complaint to writing and give the enrollee
20    written acknowledgment  of  the  grievance  prepared  by  the
21    managed  care  plan summarizing the nature  of the  grievance
22    and requesting any information that  the  enrollee  needs  to
23    provide   before   the   grievance  can  be  processed.   The
24    acknowledgment  shall  be  mailed within the  24-hour  period
25    to   the   enrollee,   who   shall   sign   and   return  the
26    acknowledgment,   with   any    amendments   and    requested
27    information,    in  order  to  initiate  the  grievance.  The
28    grievance  acknowledgment  shall  prominently  state that the
29    enrollee  must  sign  and   return   the  acknowledgment   to
30    initiate  the grievance. A managed care plan may elect not to
31    require   a   signed   acknowledgment   when   no  additional
32    information is necessary to process  the  grievance,  and  an
33    oral  grievance  shall  be   initiated  at  the  time  of the
 
                            -15-               LRB9100964JSpc
 1    telephone call.
 2        Except as authorized in this subsection, a  managed  care
 3    plan  shall  designate  personnel  to accept the filing of an
 4    enrollee's grievance by toll-free telephone  no   less   than
 5    40  hours   per  week  during normal business hours and shall
 6    have a telephone system available to take calls during  other
 7    than  normal  business  hours and  shall  respond to all such
 8    calls no later than the next business day after the call  was
 9    recorded.  In  the  case of grievances subject to item (i) of
10    subsection  (b)  of this Section, telephone  access  must  be
11    available on a 24 hour a day, 7 day a week basis.
12        (b)  Within  48 hours of  receipt of a written grievance,
13    the managed care plan shall provide  written   acknowledgment
14    of    the    grievance,   including    the   name,   address,
15    qualifying  credentials,  and   telephone   number   of   the
16    individuals or department designated by the managed care plan
17    to  respond  to   the   grievance. All  grievances  shall  be
18    resolved in an expeditious manner, and in any event, no  more
19    than  (i)  24  hours   after  the  receipt  of  all necessary
20    information when a delay  would  significantly  increase  the
21    risk  to  an  enrollee's  health or when extended health care
22    services,  procedures,  or   treatments   for   an   enrollee
23    undergoing  a course of treatment prescribed by a health care
24    provider are at issue, (ii) 15 days after the receipt of  all
25    necessary  information  in the case of requests for referrals
26    or  determinations  concerning  whether  a requested  benefit
27    is  covered pursuant to the contract, and (iii) 30 days after
28    the receipt  of  all   necessary  information  in  all  other
29    instances.
30        (c)  The  managed  care  plan shall designate one or more
31    qualified  personnel  to  review  the  grievance.   When  the
32    grievance pertains to clinical matters, the  personnel  shall
33    include,  but  not  be  limited to, one or more appropriately
34    licensed or registered health care professionals.
 
                            -16-               LRB9100964JSpc
 1        (d)  The  notice  of  a determination  of  the  grievance
 2    shall be made in writing to the enrollee or to the enrollee's
 3    designee.  In the case of a determination made in conformance
 4    with  item  (i)   of   subsection (b) of this Section, notice
 5    shall be made by telephone  directly  to  the  enrollee  with
 6    written notice to follow within 2 business days.
 7        (e)  The  notice of a  determination  shall  include  (i)
 8    clear and detailed reasons for the  determination,  including
 9    any  contract  basis  for the determination, and the evidence
10    relied upon in making that determination, (ii) in cases where
11    the determination has  a   clinical   basis,   the   clinical
12    rationale for the determination, and (iii) the procedures for
13    the  filing  of an appeal of  the  determination, including a
14    form for the filing of an appeal.

15        Section 25.  Second level grievance review.
16        (a)  A managed care plan shall establish a  second  level
17    grievance  review  process  to  give  those enrollees who are
18    dissatisfied with the first level grievance  review  decision
19    the  option  to  request  a second level review, at which the
20    enrollee shall have the right  to  appear  in  person  before
21    authorized individuals designated to respond to the appeal.
22        (b)    An   enrollee   or   an  enrollee's designee shall
23    have not less than 60 days after receipt of  notice  of   the
24    grievance  determination  to file a written appeal, which may
25    be  submitted  by letter or by a form supplied by the managed
26    care plan. The enrollee shall indicate in his or her  written
27    appeal  whether he or she wants the right to appear in person
28    before the person or  panel  designated  to  respond  to  the
29    appeal.
30        (c)  Within  48  hours  of  receipt  of  the second level
31    grievance review, the managed care plan shall provide written
32    acknowledgment of the appeal, including  the  name,  address,
33    qualifying   credentials,   and   telephone   number  of  the
 
                            -17-               LRB9100964JSpc
 1    individual  designated  by the managed care plan  to  respond
 2    to  the  appeal and what additional information, if any, must
 3    be provided in order for the managed care plan  to  render  a
 4    decision.
 5        (d)  The determination of a second level grievance review
 6    on  a  clinical matter must  be  made by  personnel qualified
 7    to review the appeal,  including  appropriately  licensed  or
 8    registered  health   care  professionals  who  did  not  make
 9    the initial   determination,  a  majority  of  whom  must  be
10    clinical  peer  reviewers.  The   determination   of a second
11    level grievance review on a matter that is not clinical shall
12    be made by qualified personnel at a  higher  level  than  the
13    personnel  who  made  the initial grievance determination.
14        (e)  The  managed  care  plan  shall  seek to resolve all
15    second level grievance reviews in the most expeditious manner
16    and shall make a determination and provide  notice   no  more
17    than  (i)  24  hours  after  the  receipt  of  all  necessary
18    information  when  a  delay would significantly increase  the
19    risk  to  an  enrollee's health or when extended health  care
20    services,   procedures,   or   treatments   for  an  enrollee
21    undergoing a course of treatment prescribed by a health  care
22    provider  are  at  issue  and (ii) 30 business days after the
23    receipt of all necessary information in all other instances.
24        (f)  The notice of a  determination  on  a  second  level
25    grievance  review  shall include (i) the detailed reasons for
26    the determination,  including  any  contract  basis  for  the
27    determination  and  the  evidence  relied  upon in making the
28    determination and (ii) in cases where the determination has a
29    clinical   basis,   the    clinical   rationale    for    the
30    determination.
31        (g)  If  an  enrollee  has  requested  the opportunity to
32    appear in person before the authorized representatives of the
33    managed care plan designated to respond to  the  appeal,  the
34    review  panel shall schedule and hold a review meeting within
 
                            -18-               LRB9100964JSpc
 1    30 days of receiving a request from an enrollee for a  second
 2    level  review  with  a  right  to appear.  The review meeting
 3    shall be held during regular business  hours  at  a  location
 4    reasonably  accessible to the enrollee. The enrollee shall be
 5    notified in writing at least 14 days in advance of the review
 6    date.
 7        Upon the request of an  enrollee,  a  managed  care  plan
 8    shall  provide  to the enrollee all relevant information that
 9    is not confidential or privileged.
10        An enrollee has the right to:
11             (1)  attend the second level review;
12             (2)  present his or her case to the review panel;
13             (3)  submit supporting material both before  and  at
14        the review meeting;
15             (4)  ask  questions  of  any  representative  of the
16        managed care plan; and
17             (5)  be assisted or represented by persons of his or
18        her choice.
19        The notice  shall  advise  the  enrollee  of  the  rights
20    specified in this subsection.
21        If  the  managed  care  plan  desires to have an attorney
22    present to represent  its  interests,  it  shall  notify  the
23    enrollee  at  least 14  days in advance of the review that an
24    attorney will be present and that the enrollee  may  wish  to
25    obtain legal representation of his or her own.

26        Section    30.  Grievance    register    and    reporting
27    requirements.
28        (a)  A  managed  care  plan  shall  maintain  a  register
29    consisting  of  a  written record of all complaints initiated
30    during the past 3 years.  The register shall be maintained in
31    a manner that is  reasonably  clear  and  accessible  to  the
32    Director.   The  register  shall  include  at  a  minimum the
33    following:
 
                            -19-               LRB9100964JSpc
 1             (1)  the name of the enrollee;
 2             (2)  a description of the reason for the complaint;
 3             (3)  the dates when first  level  and  second  level
 4        review were requested and completed;
 5             (4)  a copy of the written decision rendered at each
 6        level of review;
 7             (5)  if  required  time  limits  were  exceeded,  an
 8        explanation  of  why they were exceeded and a copy of the
 9        enrollee's consent to an extension of time;
10             (6)  whether expedited review was requested and  the
11        response to the request;
12             (7)  whether  the  complaint  resulted in litigation
13        and the result of the litigation.
14        (b)  A managed care plan shall  report  annually  to  the
15    Department   the   numbers,  and  related  information  where
16    indicated, for the following:
17             (1)  covered lives;
18             (2)  total complaints initiated;
19             (3)  total complaints involving medical necessity or
20        appropriateness;
21             (4)  complaints involving termination  or  reduction
22        of inpatient hospital services;
23             (5)  complaints  involving  termination or reduction
24        of other health care services;
25             (6)  complaints  involving  denial  of  health  care
26        services where the enrollee had not received the services
27        at the time the complaint was initiated;
28             (7)  complaints involving payment  for  health  care
29        services  that  the  enrollee had already received at the
30        time of initiating the complaint;
31             (8)  complaints resolved at each level of review and
32        how they were resolved;
33             (9)  complaints where expedited review was  provided
34        because  adherence  to  regular  time  limits  would have
 
                            -20-               LRB9100964JSpc
 1        jeopardized the enrollee's life, health,  or  ability  to
 2        regain maximum function; and
 3             (10)  complaints that resulted in litigation and the
 4        outcome of the litigation.
 5        The  Department  shall  promulgate  rules  regarding  the
 6    format  of  the  report,  the timing of the report, and other
 7    matters related to the report.

 8        Section 35.  External independent review.
 9        (a)  If an enrollee's or  enrollee's  designee's  request
10    for  a  covered  service  or  claim  for a covered service is
11    denied under the grievance review under  Section  25  because
12    the  service  is  not  viewed  as  medically  necessary,  the
13    enrollee may initiate an external independent review.
14        (b)  Within  30  days after the enrollee receives written
15    notice of such an adverse  decision  made  under  the  second
16    level  grievance  review  procedures  of  Section  25, if the
17    enrollee decides to initiate an external independent  review,
18    the  enrollee  shall  send to the managed care plan a written
19    request for an external  independent  review,  including  any
20    material   justification  or  documentation  to  support  the
21    enrollee's request for the covered service  or  claim  for  a
22    covered service.
23        (c)  Within  30 days after the managed care plan receives
24    a  request  for  an  external  independent  review  from   an
25    enrollee, the managed care plan shall:
26             (1)  provide  a  mechanism  for jointly selecting an
27        external independent reviewer by  the  enrollee,  primary
28        care physician, and managed care plan; and
29             (2)  forward to the independent reviewer all medical
30        records  and  supporting  documentation pertaining to the
31        case, a summary  description  of  the  applicable  issues
32        including   a   statement  of  the  managed  care  plan's
33        decision, and the criteria used and the clinical  reasons
 
                            -21-               LRB9100964JSpc
 1        for that decision.
 2        (d)  Within   5   days   of   receipt  of  all  necessary
 3    information, the  independent  reviewer  or  reviewers  shall
 4    evaluate  and  analyze the case and render a decision that is
 5    based on whether or not the service or claim for the  service
 6    is  medically  necessary.   The  decision  by the independent
 7    reviewer or reviewers is final.
 8        (e)  Pursuant to  subsection  (c)  of  this  Section,  an
 9    external independent reviewer shall:
10             (1)  have   no   direct  financial  interest  in  or
11        connection to the case;
12             (2)  be State licensed  physicians,  who  are  board
13        certified  or  board eligible by the appropriate American
14        Medical Specialty Board, if applicable, and  who  are  in
15        the  same or similar scope of practice as a physician who
16        typically manages the medical  condition,  procedure,  or
17        treatment under review; and
18             (3)  have not been informed of the specific identity
19        of the enrollee or the enrollee's treating provider.
20        (f)  If  an  appropriate  reviewer pursuant to subsection
21    (e) of this Section for a particular case is not on the  list
22    established  by  the  Director,  the  parties  shall choose a
23    reviewer who is mutually acceptable.

24        Section 40.  Independent reviewers.
25        (a)  From information  filed  with  the  Director  on  or
26    before  March  1  of  each year, the Director shall compile a
27    list of external independent reviewers and organizations that
28    represent external independent reviewers from lists  provided
29    by  managed  care  plans  and  by any State and county public
30    health department and State medical associations that wish to
31    submit a list to the Director.  The Director may consult with
32    other persons about the suitability of any  reviewer  or  any
33    potential  reviewer.   The Director shall annually review the
 
                            -22-               LRB9100964JSpc
 1    list and add and remove names as appropriate.  On  or  before
 2    June  1  of each year, the Director shall publish the list in
 3    the Illinois Register.
 4        (b)  The managed care plan shall  be  solely  responsible
 5    for  paying the fees of the external independent reviewer who
 6    is selected to perform the review.
 7        (c)  An external independent reviewer who  acts  in  good
 8    faith   shall  have  immunity  from  any  civil  or  criminal
 9    liability or professional discipline as a result of  acts  or
10    omissions  with  respect  to any external independent review,
11    unless the acts or omissions  constitute  wilful  and  wanton
12    misconduct.   For  purposes of any proceeding, the good faith
13    of the person participating shall be presumed.
14        (d)  The Director's decision to add a name to or remove a
15    name from the  list  of  independent  reviewers  pursuant  to
16    subsection  (a)  is  not  subject to administrative appeal or
17    judicial review.

18        Section 45.  Health care  professional  applications  and
19    terminations.
20        (a)  A  managed  care  plan  shall,  upon  request,  make
21    available  and  disclose to health care professionals written
22    application    procedures    and     minimum    qualification
23    requirements  that  a  health  care professional must meet in
24    order  to  be  considered  by  the  managed  care  plan.  The
25    managed  care plan shall consult with appropriately qualified
26    health care professionals  in  developing  its  qualification
27    requirements.
28        (b)  A managed care plan may not terminate a contract of
29    employment  or refuse to renew a contract on the basis of any
30    action protected under Section  50  of  this  Act  or  solely
31    because a health care professional has:
32             (1)  filed  a  complaint  against  the  managed care
33        plan;
 
                            -23-               LRB9100964JSpc
 1             (2)  appealed a decision of the managed  care  plan;
 2        or
 3             (3)  requested a hearing pursuant to this Section.
 4        (c)  A  managed  care plan shall provide to a health care
 5    professional,  in  writing,  the  reasons  for  the  contract
 6    termination or non-renewal.
 7        (d)  A managed care plan shall   provide  an  opportunity
 8    for  a  hearing to any health care professional terminated by
 9    the managed care plan, or  non-renewed  if  the  health  care
10    professional has had a contract or contracts with the managed
11    care plan for at least 24 of the past 36 months.
12        (e)  After  the  notice  provided  pursuant to subsection
13    (c), the health care  professional  shall  have  21  days  to
14    request  a  hearing,  and  the hearing must be held within 15
15    days after receipt of the request for a hearing.  The hearing
16    shall be held before a panel appointed by  the  managed  care
17    plan.
18        The hearing panel shall be composed of 5 individuals, the
19    majority of whom shall be clinical peer reviewers and, to the
20    extent  possible,  in  the  same  discipline  and the same or
21    similar  specialty  as the  health  care  professional  under
22    review.
23        The  hearing panel shall render a written decision on the
24    proposed  action within 14 business days.  The decision shall
25    be one of the following:
26             (1)  reinstatement of the health  care  professional
27        by the managed care  plan;
28             (2)  provisional    reinstatement     subject     to
29        conditions  set forth by the panel; or
30             (3)  termination of the health care  professional.
31        The decision of the hearing panel shall be final.
32        A  decision  by  the  hearing panel to terminate a health
33    care professional shall be effective not less  than  15  days
34    after  the  receipt  by  the  health care professional of the
 
                            -24-               LRB9100964JSpc
 1    hearing panel's decision.
 2        A hearing under this subsection shall provide the  health
 3    care  professional  in  question  with  the  right to examine
 4    pertinent information,  to  present  witnesses,  and  to  ask
 5    questions of an authorized representative of the plan.
 6        (f)  A  managed  care  plan  may  terminate or decline to
 7    renew a health care professional, without a prior hearing, in
 8    cases  involving   imminent   harm   to   patient   care,   a
 9    determination  of intentional falsification of reports to the
10    plan or a final disciplinary  action  by  a  state  licensing
11    board  or  other  governmental agency that impairs the health
12    care professional's  ability  to  practice.   A  professional
13    terminated  for  one  of  the  these  reasons  shall be given
14    written notice to that effect.   Within  21  days  after  the
15    termination, a health care professional terminated because of
16    imminent   harm   to  patient  care  or  a  determination  of
17    intentional  falsification  of  reports  to  the  plan  shall
18    receive a hearing.  The hearing shall be held before a  panel
19    appointed  by  the  managed  care  plan.   The panel shall be
20    composed of 5 individuals  the  majority  of  whom  shall  be
21    clinical  peer  reviewers and, to the extent possible, in the
22    same discipline and the same  or  similar  specialty  as  the
23    health  care  professional  under  review.  The hearing panel
24    shall render a decision on  the  proposed  action  within  14
25    days.   The  panel  shall  issue  a  written  decision either
26    supporting  the  termination  or  ordering  the  health  care
27    professional's reinstatement.  The decision  of  the  hearing
28    panel shall be final.
29        If  the  hearing  panel  upholds  the managed care plan's
30    termination  of  the  health  care  professional  under  this
31    subsection, the managed care plan shall forward the  decision
32    to   the  appropriate  professional  disciplinary  agency  in
33    accordance with subsection (b) of Section 60.
34        Any hearing  under  this  subsection  shall  provide  the
 
                            -25-               LRB9100964JSpc
 1    health  care  professional  in  question  with  the  right to
 2    examine pertinent information, to present witnesses,  and  to
 3    ask questions of an authorized representative of the plan.
 4        For  any  hearing  under this Section, because the candid
 5    and  conscientious  evaluation  of  clinical   practices   is
 6    essential  to  the provision of health care, it is the policy
 7    of this  State  to  encourage  peer  review  by  health  care
 8    professionals.   Therefore,  no  managed  care  plan  and  no
 9    individual  who participates in a hearing or who is a member,
10    agent, or employee of a managed care plan shall be liable for
11    criminal or civil damages or  professional  discipline  as  a
12    result  of  the  acts,  omissions,  decisions,  or  any other
13    conduct, direct or indirect, associated with a hearing panel,
14    except for wilful and wanton  misconduct.   Nothing  in  this
15    Section  shall  relieve  any  person,  health  care provider,
16    health  care   professional,   facility,   organization,   or
17    corporation   from   liability  for  his,  her,  or  its  own
18    negligence in the performance of his, her, or its  duties  or
19    arising  from  treatment  of  a  patient.   The hearing panel
20    information shall not be subject to inspection or  disclosure
21    except   upon   formal   written  request  by  an  authorized
22    representative of a duly authorized State agency or  pursuant
23    to a court order issued in a pending action or proceeding.
24        (g)  A  managed  care  plan  shall  develop and implement
25    policies  and  procedures  to   ensure   that   health   care
26    professionals  are  at least annually informed of information
27    maintained  by  the  managed  care  plan  to   evaluate   the
28    performance  or practice of the health care professional. The
29    managed   care   plan   shall   consult   with   health  care
30    professionals in  developing  methodologies  to  collect  and
31    analyze  health  care  professional data.  Managed care plans
32    shall provide the information and data and analysis to health
33    care  professionals.  The  information,  data,  or   analysis
34    shall be provided on at least an annual  basis  in  a  format
 
                            -26-               LRB9100964JSpc
 1    appropriate  to  the nature and amount of data and the volume
 2    and scope of services provided.  Any data  used  to  evaluate
 3    the  performance  or  practice  of a health care professional
 4    shall be measured against stated criteria  and  a  comparable
 5    group  of health care professionals who use similar treatment
 6    modalities and serve a comparable patient  population.   Upon
 7    receipt   of   the   information   or  data,  a  health  care
 8    professional shall be given the  opportunity to  explain  the
 9    unique  nature  of  the  health  care  professional's patient
10    population that  may  have  a  bearing  on  the  health  care
11    professional's  data  and  to  work  cooperatively  with  the
12    managed care plan to improve performance.
13        (h)  Any  contract  provision  or  procedure  or informal
14    policy or procedure in violation of this Section violates the
15    public policy of the  State  of  Illinois  and  is  void  and
16    unenforceable.

17        Section 50.  Prohibitions.
18        (a)  No  managed  care  plan  shall  by contract, written
19    policy or written procedure, or informal policy or  procedure
20    prohibit   or   restrict   any   health  care  provider  from
21    disclosing   to    any    enrollee,    patient,    designated
22    representative    or,    where    appropriate,    prospective
23    enrollee,   (hereinafter    collectively   referred   to   as
24    enrollee) any information that the provider deems appropriate
25    regarding:
26             (1)  a  condition   or a course of treatment with an
27        enrollee including the availability of  other  therapies,
28        consultations, or tests; or
29             (2)  the  provisions,  terms, or requirements of the
30        managed care  plan's  products  as  they  relate  to  the
31        enrollee, where applicable.
32        (b)  No  managed  care  plan  shall  by contract, written
33    policy or procedure, or informal policy or procedure prohibit
 
                            -27-               LRB9100964JSpc
 1    or  restrict  any  health  care  provider   from   filing   a
 2    complaint,  making a report, or commenting to an  appropriate
 3    governmental  body regarding the policies or practices of the
 4    managed  care  plan  that  the    provider    believes    may
 5    negatively  impact upon the quality of, or access to, patient
 6    care.
 7        (c)  No  managed  care  plan  shall  by contract, written
 8    policy or procedure, or informal policy or procedure prohibit
 9    or restrict any health care provider from advocating  to  the
10    managed  care  plan on behalf of the enrollee for approval or
11    coverage of a particular  course  of  treatment  or  for  the
12    provision  of  health care services.
13        (d)    No   contract  or agreement between a managed care
14    plan and a health care  provider  shall  contain  any  clause
15    purporting   to   transfer   to  the health  care provider by
16    indemnification  or  otherwise  any  liability  relating   to
17    activities,  actions,  or omissions  of the managed care plan
18    as opposed to those of the health care provider.
19        (e)  No contract between a managed care plan and a health
20    care provider shall contain any incentive plan that  includes
21    specific payment made directly, in any form, to a health care
22    provider  as  an  inducement to deny, reduce, limit, or delay
23    specific,  medically  necessary  and   appropriate   services
24    provided  with  respect  to  a specific enrollee or groups of
25    enrollees with similar medical conditions.  Nothing  in  this
26    Section shall be construed to prohibit contracts that contain
27    incentive  plans  that  involve  general  payments,  such  as
28    capitation payments or shared-risk arrangements, that are not
29    tied   to   specific  medical  decisions  involving  specific
30    enrollees  or  groups  of  enrollees  with  similar   medical
31    conditions.   The  payments  rendered  or  to  be rendered to
32    health care provider under these arrangements shall be deemed
33    confidential information.
34        (f)  No managed care  plan  shall  by  contract,  written
 
                            -28-               LRB9100964JSpc
 1    policy  or procedure, or informal policy or procedure permit,
 2    allow, or encourage an individual or  entity  to  dispense  a
 3    different  drug in place of the drug or brand of drug ordered
 4    or prescribed without the express permission  of  the  person
 5    ordering  or  prescribing,  except  this prohibition does not
 6    prohibit the interchange of  different  brands  of  the  same
 7    generically   equivalent  drug  product,  as  provided  under
 8    Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
 9        (g)  Any   contract   provision,    written   policy   or
10    procedure,  or  informal  policy or procedure in violation of
11    this Section violates the  public  policy  of  the  State  of
12    Illinois and is void and unenforceable.

13        Section 55.  Network of providers.
14        (a)  At  least  once  every 3 years, and upon application
15    for expansion of service area,  a  managed  care  plan  shall
16    obtain  certification from the Director of Public Health that
17    the managed care plan maintains  a  network  of  health  care
18    providers  and  facilities adequate to meet the comprehensive
19    health needs of its enrollees and to provide  an  appropriate
20    choice  of  providers  sufficient  to  provide  the  services
21    covered under its enrollee's contracts by determining that:
22             (1) there are a  sufficient number of geographically
23        accessible participating providers and facilities;
24             (2)  there are opportunities to select from at least
25        3 primary  care   providers  pursuant   to   travel   and
26        distance   time standards, providing that these standards
27        account for the conditions of  accessing   providers   in
28        rural areas; and
29             (3)   there  are sufficient providers in all covered
30        areas of specialty practice to  meet  the  needs  of  the
31        enrollment population.
32        (b)  The  following  criteria  shall be considered by the
33    Director of Public Health at the  time  of  a  review:
 
                            -29-               LRB9100964JSpc
 1             (1)  provider-enrollee ratios by specialty;
 2             (2)  primary care provider-enrollee ratios;
 3             (3)  safe  and  adequate  staffing  of  health  care
 4        providers in all participating facilities based on:
 5                  (A)  severity of patient illness and functional
 6             capacity;
 7                  (B)  factors affecting the period  and  quality
 8             of patient recovery; and
 9                  (C)  any  other factor substantially related to
10             the condition and health care needs of patients;
11             (4)  geographic accessibility;
12             (5)  the number of  grievances  filed  by  enrollees
13        relating    to    waiting    times    for   appointments,
14        appropriateness of referrals, and other indicators  of  a
15        managed care plan's capacity;
16             (6)  hours of operation;
17             (7)  the  managed  care  plan's  ability  to provide
18        culturally and linguistically competent care to meet  the
19        needs of its enrollee population; and
20             (8)  the  volume  of  technological  and  speciality
21        services  available  to  serve  the  needs  of  enrollees
22        requiring technologically advanced or specialty care.
23        (c)  A  managed care plan shall report on an annual basis
24    the number of  enrollees  and  the  number  of  participating
25    providers in the managed care plan.
26        (d)  If  a  managed care plan determines that it does not
27    have a health care provider  with  appropriate  training  and
28    experience  in  its  panel  or network to meet the particular
29    health care needs  of  an enrollee,  the  managed  care  plan
30    shall make a referral to an appropriate provider, pursuant to
31    a  treatment  plan  approved by the primary care provider, in
32    consultation   with    the    managed    care    plan,    the
33    non-participating  provider,  and the enrollee or  enrollee's
34    designee, at no additional cost to the enrollee  beyond  what
 
                            -30-               LRB9100964JSpc
 1    the enrollee would otherwise pay for services received within
 2    the network.
 3        (e)  A  managed care plan shall have a procedure by which
 4    an  enrollee  who  needs    ongoing  health  care   services,
 5    provided or coordinated by a specialist focused on a specific
 6    organ  system, disease or condition, shall receive a referral
 7    to the  specialist.  If  the  primary  care  provider,  after
 8    consultation   with      the    medical   director  or  other
 9    contractually authorized representative of the  managed  care
10    plan,  determines that a referral is appropriate, the primary
11    care provider shall make such a referral to a specialist.  In
12    no  event  shall a managed care plan be  required  to  permit
13    an   enrollee   to  elect   to   have   a   non-participating
14    specialist,  except  pursuant to the provisions of subsection
15    (d).  The  referral  made  under  this  subsection  shall  be
16    pursuant to a  treatment plan  approved by  the  enrollee  or
17    enrollee's  designee,  the  primary  care  provider,  and the
18    specialist in consultation  with the managed care plan.   The
19    treatment  plan  shall  authorize the specialist to treat the
20    ongoing injury, disease, or condition. It also may limit  the
21    number  of  visits  or  the  period  during  which visits are
22    authorized and may require the  specialists  to  provide  the
23    primary  care  provider with regular updates on the specialty
24    care provided, as well as all necessary medical information.
25        (f)  A managed care plan shall have a procedure by  which
26    a  new  enrollee,  upon  enrollment,  or  an  enrollee,  upon
27    diagnosis,  with  (i) a life-threatening condition or disease
28    or (ii) a degenerative or  disabling  condition  or  disease,
29    either  of  which  requires  specialized  medical care over a
30    prolonged period of time shall receive a standing referral to
31    a specialist with expertise in treating the  life-threatening
32    condition  or  disease or degenerative or disabling condition
33    or disease who shall  be  responsible  for  and  capable   of
34    providing   and   coordinating  the  enrollee's  primary  and
 
                            -31-               LRB9100964JSpc
 1    specialty   care.  If  the  primary  care   provider,   after
 2    consultation  with  the  enrollee  or enrollee's designee and
 3    medical   director   or   other   contractually    authorized
 4    representative of the managed care plan, determines that the
 5    enrollee's   care  would  most appropriately  be  coordinated
 6    by a specialist, the primary care provider shall refer, on  a
 7    standing  basis,  the  enrollee  to a specialist. In no event
 8    shall a managed care plan be required to permit  an  enrollee
 9    to  elect  to  have  a  non-participating  specialist, except
10    pursuant  to   the   provisions  of   subsection   (d).   The
11    specialist   shall  be   permitted   to  treat  the  enrollee
12    without  a   referral   from   the  enrollee's  primary  care
13    provider   and   shall  be authorized to make such referrals,
14    procedures,   tests,   and  other  medical  services  as  the
15    enrollee's  primary  care   provider   would   otherwise   be
16    permitted    to    provide    or    authorize  including,  if
17    appropriate, referral  to  a  specialty  care  center.  If  a
18    primary    care   provider   refers   an   enrollee    to   a
19    non-participating provider  pursuant  to  the  provisions  of
20    subsection  (d), the standing referral shall be pursuant to a
21    treatment  plan  approved  by  the  enrollee  or   enrollee's
22    designee  and  specialist,  in consultation with  the managed
23    care  plan.   Services  provided  pursuant  to  the  approved
24    treatment plan shall be provided at no additional   cost   to
25    the   enrollee   beyond what the enrollee would otherwise pay
26    for services received within the network.
27        (g)  If an enrollee's health  care  provider  leaves  the
28    managed  care  plan's  network of providers for reasons other
29    than those for which the provider would not  be  eligible  to
30    receive  a pre-termination hearing pursuant to subsection (f)
31    of Section  45,  the  managed  care  plan  shall  permit  the
32    enrollee  to   continue   an   ongoing  course  of  treatment
33    with  the enrollee's  current health care provider  during  a
34    transitional period of:
 
                            -32-               LRB9100964JSpc
 1             (1)  up  to  90 days from the date of notice to  the
 2        enrollee  of  the provider's  disaffiliation   from   the
 3        managed care plan's network; or
 4             (2) if the enrollee has entered the second trimester
 5        of   pregnancy   at    the    time  of   the   provider's
 6        disaffiliation,   for   a   transitional   period    that
 7        includes  the  provision  of  post-partum  care  directly
 8        related  to  the delivery.
 9        Transitional care, however, shall be  authorized  by  the
10    managed care plan during the transitional period only if  the
11    health   care   provider  agrees   (i)  to continue to accept
12    reimbursement  from  the  managed  care  plan  at  the  rates
13    applicable prior to  the  start  of  the transitional  period
14    as payment in full, (ii) to adhere to the managed care plan's
15    quality assurance requirements and to provide to the  managed
16    care  plan necessary medical information related to the care,
17    (iii)  to   otherwise  adhere  to  the  managed  care  plan's
18    policies  and  procedures  including,  but  not  limited  to,
19    procedures     regarding     referrals     and      obtaining
20    pre-authorization  and  a  treatment  plan  approved  by  the
21    primary  care provider or specialist in consultation with the
22    managed care plan, and (iv) if the enrollee is a recipient of
23    services under Article V of the Illinois Public Aid Code, the
24    health  care  provider  has  not  been  subject  to  a  final
25    disciplinary  action  by  a  state  or  federal  agency   for
26    violations of the Medicaid or Medicare program.
27        (h)  If  a new enrollee whose health care provider is not
28    a member of the managed care plan's provider network  enrolls
29    in  the managed care plan, the managed care plan shall permit
30    the enrollee to continue an ongoing course of treatment  with
31    the    enrollee's  current  health  care  provider  during  a
32    transitional period of up to 90 days   from   the   effective
33    date   of   enrollment,   if   (i)   the   enrollee   has   a
34    life-threatening  disease  or  condition or a degenerative or
 
                            -33-               LRB9100964JSpc
 1    disabling disease or  condition  or  (ii)  the  enrollee  has
 2    entered  the  second trimester  of pregnancy at the effective
 3    date of enrollment, in which  case  the  transitional  period
 4    shall include  the  provision  of  post-partum  care directly
 5    related  to  the delivery.  If an enrollee elects to continue
 6    to receive payment for  care  from  a  health  care  provider
 7    pursuant to this  subsection, the care shall be authorized by
 8    the  managed  care plan for the  transitional  period only if
 9    the health care provider agrees (i) to  accept  reimbursement
10    from  the  managed  care  plan  at rates established  by  the
11    managed care plan as payment in full, which rates shall be no
12    more than the level of reimbursement  applicable to   similar
13    providers   within   the   managed  care  plan's network  for
14    those services, (ii) to adhere to  the  managed  care  plan's
15    quality  assurance  requirements and agrees to provide to the
16    managed care plan necessary medical  information  related  to
17    the care, (iii) to  otherwise  adhere  to  the  managed  care
18    plan's  policies  and  procedures including, but  not limited
19    to,    procedures   regarding   referrals    and    obtaining
20    pre-authorization  and  a  treatment  plan  approved  by  the
21    primary care provider or specialist, in consultation with the
22    managed care plan, and (iv) if the enrollee is a recipient of
23    services under Article V of the Illinois Public Aid Code, the
24    health  care  provider  has  not  been  subject  to  a  final
25    disciplinary   action  by  a  state  or  federal  agency  for
26    violations of the Medicaid or  Medicare  program.     In   no
27    event shall this subsection be construed to require a managed
28    care  plan  to  provide  coverage  for benefits not otherwise
29    covered or  to  diminish  or  impair  pre-existing  condition
30    limitations  contained  within the enrollee's contract.

31        Section 60.  Duty to report.
32        (a)    A   managed   care  plan  shall  report   to   the
33    appropriate   professional   disciplinary    agency,    after
 
                            -34-               LRB9100964JSpc
 1    compliance  and  in  accordance  with  the provisions of this
 2    Section:
 3             (1)  termination of a health care provider  contract
 4        for  commission  of  an  act  or  acts  that may directly
 5        threaten patient  care,  and  not  of  an  administrative
 6        nature,  or  that  a person may be mentally or physically
 7        disabled in such a manner as to endanger a patient  under
 8        that person's care;
 9             (2)  voluntary   or  involuntary  termination  of  a
10        contract or employment  or  other  affiliation  with  the
11        managed care plan to avoid the imposition of disciplinary
12        measures.
13        The managed care plan shall only make the report after it
14    has  provided  the health care professional with a hearing on
15    the matter.  (This hearing shall  not  impair  or  limit  the
16    managed  care  plan's  ability to terminate the professional.
17    Its purpose is solely  to  ensure  that  a  sufficient  basis
18    exists  for  making  the  report.)  The hearing shall be held
19    before a panel appointed  by  the  managed  care  plan.   The
20    hearing panel shall be composed of 5 persons appointed by the
21    plan,  the majority of whom shall be clinical peer reviewers,
22    to the extent possible, in the same discipline and  the  same
23    specialty  as the health care professional under review.  The
24    hearing panel shall determine whether the proposed basis  for
25    the  report  is supported by a preponderance of the evidence.
26    The panel shall render its determination within 14 days.   If
27    a  majority  of  the  panel  finds the proposed basis for the
28    report is supported by a preponderance of the  evidence,  the
29    managed  care  plan  shall make the required report within 21
30    days.
31        Any hearing under this Section shall provide  the  health
32    care  professional  in  question  with  the  right to examine
33    pertinent information,  to  present  witnesses,  and  to  ask
34    questions of an authorized representative of the plan.
 
                            -35-               LRB9100964JSpc
 1        If  a hearing has been held pursuant to subsection (f) of
 2    Section  45  and  the  hearing  panel  sustained   a   plan's
 3    termination  of  a  health  care  professional, no additional
 4    hearing is required, and  the  plan  shall  make  the  report
 5    required under this Section.
 6        (b)  Reports  made pursuant to this Section shall be made
 7    in writing  to  the  appropriate  professional   disciplinary
 8    agency.  Written  reports  shall  include  the name, address,
 9    profession, and  license  number  of  the  individual  and  a
10    description  of  the  action  taken by the managed care plan,
11    including the reason  for the action and the date thereof, or
12    the  nature  of  the  action  or  conduct  that  led  to  the
13    resignation, termination of contract, or withdrawal, and  the
14    date thereof.
15        For  any  hearing  under this Section, because the candid
16    and  conscientious  evaluation  of  clinical   practices   is
17    essential  to  the provision of health care, it is the policy
18    of this  State  to  encourage  peer  review  by  health  care
19    professionals.   Therefore,  no  managed  care  plan  and  no
20    individual  who participates in a hearing or who is a member,
21    agent, or employee of a managed care plan shall be liable for
22    criminal or civil damages or  professional  discipline  as  a
23    result  of  the  acts,  omissions,  decisions,  or  any other
24    conduct, direct or indirect, associated with a hearing panel,
25    except for wilful and wanton  misconduct.   Nothing  in  this
26    Section  shall  relieve  any  person,  health  care provider,
27    health  care   professional,   facility,   organization,   or
28    corporation   from   liability  for  his,  her,  or  its  own
29    negligence in the performance of his, her, or its  duties  or
30    arising  from  treatment  of  a  patient.   The hearing panel
31    information shall not be subject to inspection or  disclosure
32    except   upon   formal   written  request  by  an  authorized
33    representative of a duly authorized State agency or  pursuant
34    to a court order issued in a pending action or proceeding.
 
                            -36-               LRB9100964JSpc
 1        Section 65.  Disclosure of information.
 2        (a)  A  health   care    professional  affiliated  with a
 3    managed care plan shall make available, in  written  form  at
 4    his  or  her  office,  to his or her patients or  prospective
 5    patients the following:
 6             (1)  information  related   to   the   health   care
 7        professional's    educational   background,   experience,
 8        training,   specialty   and   board   certification,   if
 9        applicable, number of years in  practice,  and  hospitals
10        where he or she has privileges;
11             (2)  information    regarding    the   health   care
12        professional's participation  in   continuing   education
13        programs     and     compliance   with   any   licensure,
14        certification,   or   registration    requirements,    if
15        applicable;
16             (3)  information    regarding    the   health   care
17        professional's  participation  in  clinical   performance
18        reviews conducted by the Department, where applicable and
19        available; and
20             (4)  the  location of the health care professional's
21        primary practice setting and the  identification  of  any
22        translation services available.

23        Section 70.  Registration of utilization review agents.
24        (a)  A utilization review agent who conducts the practice
25    of  utilization review  shall biennially  register  with  the
26    Director and report, in a statement subscribed  and  affirmed
27    as  true under  the  penalties  of  perjury,  the information
28    required pursuant to subsection (b) of this Section.
29        (b)  The  report  shall  contain  a  description  of  the
30    following:
31             (1)  the utilization review plan;
32             (2)  a description of the  grievance  procedures  by
33        which an enrollee, the enrollee's designee, or his or her
 
                            -37-               LRB9100964JSpc
 1        health  care provider may seek reconsideration of adverse
 2        determinations  by  the  utilization  review   agent   in
 3        accordance with this Act;
 4             (3)  procedures by which a decision on a request for
 5        utilization     review     for     services     requiring
 6        pre-authorization    shall   comply    with    timeframes
 7        established pursuant to this Act;
 8             (4)  a  description  of  an  emergency  care policy,
 9        consistent with this Act.
10             (5)  a description of personnel utilized to  conduct
11        utilization   review,  including  a  description  of  the
12        circumstances  under  which  utilization  review  may  be
13        conducted by:
14                  (A)  administrative personnel,
15                  (B)  health  care  professionals  who  are  not
16             clinical peer reviewers, and
17                  (C) clinical peer reviewers;
18             (6)  a  description  of  the  mechanisms employed to
19        assure  that  administrative personnel are trained in the
20        principles and procedures of intake screening  and   data
21        collection    and   are   appropriately  monitored  by  a
22        licensed health care professional  while  performing   an
23        administrative review;
24             (7)  a   description  of  the mechanisms employed to
25        assure  that   health   care   professionals   conducting
26        utilization review are:
27                  (A)  appropriately licensed or registered; and
28                  (B)  trained  in  the  principles,  procedures,
29             and  standards  of  the utilization review agent;
30             (8)  a  description  of  the mechanisms employed  to
31        assure that only a clinical peer reviewer shall render an
32        adverse determination;
33             (9)  provisions to ensure that appropriate personnel
34        of the utilization review agent are reasonably accessible
 
                            -38-               LRB9100964JSpc
 1        by toll-free telephone:
 2                  (A)  not   less  than  40 hours per week during
 3             normal business hours, to discuss patient  care  and
 4             allow  response to telephone requests, and to ensure
 5             that the utilization review agent  has  a  telephone
 6             system capable of accepting, recording, or providing
 7             instruction  to   incoming   telephone calls  during
 8             other than  normal  business  hours  and  to  ensure
 9             response  to accepted or recorded messages not later
10             than the next business day after the date  on  which
11             the call was received; or
12                  (B) notwithstanding the provisions of item (A),
13             in  the  case  of  a  request  submitted pursuant to
14             subsection (c) of Section  80 or an expedited appeal
15             filed pursuant to subsection (b) of  Section  85,  a
16             response is provided within 24 hours;
17             (10)  the  policies  and  procedures  to ensure that
18        all  applicable State and  federal  laws  to protect  the
19        confidentiality   of  individual  medical  and  treatment
20        records are followed;
21             (11)  a copy of the materials to be disclosed to  an
22        enrollee or prospective enrollee pursuant to this Act;
23             (12)  a  description  of  the mechanisms employed by
24        the  utilization  review  agent  to   assure   that   all
25        contractors,   subcontractors,  subvendors,  agents,  and
26        employees affiliated by contract or otherwise  with  such
27        utilization review agent will adhere to the standards and
28        requirements of this Act; and
29             (13)  a   list   of   the   payors   for  which  the
30        utilization  review   agent   is  performing  utilization
31        review in this State.
32        (c)    Upon   receipt   of   the   report,  the  Director
33    shall issue an acknowledgment of the filing.
34        (d)  A registration issued under this Act shall be  valid
 
                            -39-               LRB9100964JSpc
 1    for a period of not more than 2 years, and may be renewed for
 2    additional periods of not more than 2 years each.

 3        Section 75.  Utilization  review  program  standards.
 4        (a)  A   utilization  review  agent   shall   adhere   to
 5    utilization  review  program  standards consistent  with  the
 6    provisions of this Act, which shall, at a minimum, include:
 7             (1)  appointment of a medical director,  who  is   a
 8        licensed    physician;   provided,   however,   that  the
 9        utilization review agent may appoint a clinical  director
10        when  the utilization review performed is for a  discrete
11        category of health care service and provided further that
12        the   clinical  director   is   a   licensed  health care
13        professional  who  typically  manages  the  category   of
14        service;  responsibilities of the medical  director,  or,
15        where   appropriate,   the   clinical   director,   shall
16        include, but not be limited  to,  the   supervision   and
17        oversight of the utilization review process;
18             (2)  development of written policies and  procedures
19        that   govern   all aspects  of  the  utilization  review
20        process  and a  requirement  that  a  utilization  review
21        agent shall maintain and make available to  enrollees and
22        health   care   providers  a  written  description of the
23        procedures, including the procedures to appeal an adverse
24        determination;
25             (3)  utilization of written clinical review criteria
26        developed pursuant to a utilization review plan;
27             (4)  consistent with the applicable Sections of this
28        Act, establishment of a process for rendering utilization
29        review  determinations,  which  shall,  at  a    minimum,
30        include  written  procedures  to assure  that utilization
31        reviews  and  determinations  are  conducted  within  the
32        required  timeframes,  procedures  to notify an enrollee,
33        an enrollee's designee, and  an  enrollee's  health  care
 
                            -40-               LRB9100964JSpc
 1        provider  of  adverse  determinations, and the procedures
 2        for  appeal  of  adverse  determinations,  including  the
 3        establishment   of   an  expedited  appeals  process  for
 4        denials of continued inpatient care or when  delay  would
 5        significantly increase the risk to an enrollee's health;
 6             (5)  establishment     of    a    requirement   that
 7        appropriate personnel of the utilization review agent are
 8        reasonably accessible  by  toll-free  telephone:
 9                  (A)  not less than 40  hours  per  week  during
10             normal business hours to discuss  patient  care  and
11             allow  response to telephone requests, and to ensure
12             that the utilization review agent  has  a  telephone
13             system  capable of accepting, recording or providing
14             instruction to  incoming   telephone  calls   during
15             other  than  normal  business  hours  and  to ensure
16             response to accepted or recorded messages  not  less
17             than  one business day  after  the date on which the
18             call was received; or
19                  (B)  in  the  case  of  a   request   submitted
20             pursuant  to  subsection  (c)  of  Section 80 or  an
21             expedited  appeal  filed   pursuant   to  subsection
22             (b)  of Section 85, a response is provided within 24
23             hours;
24             (6)  establishment  of   appropriate   policies  and
25        procedures  to  ensure  that  all  applicable  State  and
26        federal laws to protect the confidentiality of individual
27        medical records are followed;
28             (7)  establishment  of  a requirement that emergency
29        services, as defined in this Act, rendered to an enrollee
30        shall not  be  subject   to   prior   authorization   nor
31        shall reimbursement  for  those  services  be  denied  on
32        retrospective review, except as authorized in this Act.
33        (b)  A utilization review agent shall assure adherence to
34    the  requirements stated in subsection (a) of this Section by
 
                            -41-               LRB9100964JSpc
 1    all  contractors,  subcontractors,  subvendors,  agents,  and
 2    employees  affiliated  by  contract  or  otherwise  with  the
 3    utilization review agent.

 4        Section 80.  Utilization review determinations.
 5        (a)  Utilization review shall be conducted by:
 6             (1)  administrative   personnel   trained   in   the
 7        principles and procedures of intake  screening  and  data
 8        collection,   provided,  however,  that    administrative
 9        personnel  shall  only  perform  intake  screening,  data
10        collection, and  non-clinical review functions and  shall
11        be supervised by a licensed health care professional;
12             (2)  a    health    care    professional    who   is
13        appropriately  trained  in  the  principles,  procedures,
14        and  standards of the utilization review agent; provided,
15        however, that a health care professional  who  is  not  a
16        clinical   peer   reviewer  may  not  render  an  adverse
17        determination; and
18             (3)  a clinical peer  reviewer  where   the   review
19        involves  an  adverse determination.
20        (b)  A  utilization review agent shall make a utilization
21    review determination involving  health   care  services  that
22    require   pre-authorization   and   provide   notice  of  the
23    determination, as soon as possible,  to  the   enrollee    or
24    enrollee's designee and the  enrollee's  health care provider
25    by  telephone  upon, and in writing within 2 business days of
26    receipt of the necessary  information.
27        (c)  A  utilization    review    agent   shall   make   a
28    determination  involving  continued  or  extended health care
29    services  or   additional    services    for   an    enrollee
30    undergoing  a  course  of continued treatment prescribed by a
31    health care provider and provide notice of the  determination
32    to  the  enrollee or the enrollee's designee by notice within
33    24 hours to the enrollee's health care provider by  telephone
 
                            -42-               LRB9100964JSpc
 1    upon,  and in writing within 2 business days after receipt of
 2    the necessary information.  Notification  of   continued   or
 3    extended  services  shall  include  the  number  of  extended
 4    services  approved,  the  new total of approved services, the
 5    date of onset of services, and the next review date.
 6        (d)  A utilization review agent shall make a  utilization
 7    review determination involving health care services that have
 8    already  been  delivered,  within  30  days of receipt of the
 9    necessary information.
10        (e)   Notice  of  an  adverse  determination  made  by  a
11    utilization  review  agent  shall  be  given  in  writing  in
12    accordance  with  the  grievance  procedures of this Act. The
13    notice  shall  also  specify  what,  if    any,    additional
14    necessary   information  must be provided to, or obtained by,
15    the utilization review agent in order to render a decision on
16    the appeal.
17        (f)  In  the  event  that  a  utilization  review   agent
18    renders  an  adverse determination  without   attempting   to
19    discuss   the   matter   with   the  enrollee's  health  care
20    provider   who  specifically  recommended  the   health  care
21    service,  procedure,  or  treatment  under review, the health
22    care provider  shall  have  the  opportunity  to  request  an
23    immediate  reconsideration  of    the adverse  determination.
24    Except    in   cases   of    retrospective    reviews,    the
25    reconsideration  shall  occur    in  a  prompt manner, not to
26    exceed 24 hours after receipt of the  necessary  information,
27    and   shall   be  conducted  by  the  enrollee's  health care
28    provider and the clinical peer reviewer making  the   initial
29    determination  or  a designated clinical peer reviewer if the
30    original  clinical  peer  reviewer cannot  be  available.  In
31    the  event that the adverse  determination  is  upheld  after
32    reconsideration,  the  utilization review agent shall provide
33    notice  as  required  pursuant  to  subsection  (e)  of  this
34    Section. Nothing in this Section shall preclude the  enrollee
 
                            -43-               LRB9100964JSpc
 1    from  initiating  an  appeal from an adverse determination.

 2        Section   85.  Appeal   of   adverse   determinations  by
 3    utilization review agents.
 4        (a)  An   enrollee,  the  enrollee's  designee,  and,  in
 5    connection with  retrospective  adverse  determinations,  the
 6    enrollee's   health  care  provider  may  appeal  an  adverse
 7    determination rendered by a utilization review agent pursuant
 8    to Sections 15, 20, 25, and 35.
 9        (b)  A   utilization   review   agent   shall   establish
10    mechanisms  that  facilitate   resolution   of   the   appeal
11    including,  but  not  limited  to, the sharing of information
12    from the enrollee's health care provider and the  utilization
13    review  agent  by  telephonic  means  or  by  facsimile.  The
14    utilization review agent shall provide reasonable  access  to
15    its clinical peer reviewer in a prompt manner.
16        (c)  Appeals   shall  be  reviewed  by  a  clinical  peer
17    reviewer   other   than   the  clinical  peer  reviewer   who
18    rendered the adverse determination.

19        Section 90.  Required and prohibited practices.
20        (a)  A  utilization   review  agent   shall  have written
21    procedures for  assuring  that  patient-specific  information
22    obtained during the process of utilization review will be:
23             (1)  kept confidential in accordance with applicable
24        State and  federal laws; and
25             (2)  shared    only    with    the   enrollee,   the
26        enrollee's designee, the enrollee's health care provider,
27        and those who are authorized  by   law   to  receive  the
28        information.
29        (b)   Summary  data  shall not be considered confidential
30    if it does not provide information to allow identification of
31    individual patients.
32        (c)  Any    health    care    professional    who   makes
 
                            -44-               LRB9100964JSpc
 1    determinations regarding the medical necessity of health care
 2    services during the course of  utilization  review  shall  be
 3    appropriately licensed or registered.
 4        (d)  A  utilization  review agent shall not, with respect
 5    to  utilization  review   activities,   permit   or   provide
 6    compensation or anything  of  value to its employees, agents,
 7    or contractors based on:
 8             (1)  either  a  percentage  of the amount by which a
 9        claim is reduced for payment or the number of  claims  or
10        the  cost  of services  for  which  the person has denied
11        authorization or payment; or
12             (2)  any   other   method   that   encourages    the
13        rendering of an adverse determination.
14        (e)  If  a  health  care  service  has been  specifically
15    pre-authorized   or  approved   for   an    enrollee   by   a
16    utilization  review  agent,  a utilization review agent shall
17    not, pursuant  to  retrospective  review,  revise  or  modify
18    the  specific  standards,  criteria,  or  procedures used for
19    the   utilization   review  for  procedures,  treatment,  and
20    services  delivered  to the enrollee during the  same  course
21    of treatment.
22        (f)    Utilization   review  shall  not be conducted more
23    frequently than is reasonably required to assess whether  the
24    health  care  services  under review are medically necessary.
25    The  Department  may promulgate rules governing the frequency
26    of utilization reviews for managed care  plans  of  differing
27    size and geographic location.
28        (g)     When    making    prospective,   concurrent,  and
29    retrospective determinations, utilization review agents shall
30    collect only  information  that  is  necessary  to  make  the
31    determination  and  shall  not  routinely require health care
32    providers to numerically code  diagnoses  or  procedures   to
33    be  considered for certification, unless required under State
34    or federal Medicare or  Medicaid  rules  or  regulations,  or
 
                            -45-               LRB9100964JSpc
 1    routinely  request  copies of medical records of all patients
 2    reviewed. During prospective or  concurrent  review,   copies
 3    of   medical   records  shall only be required when necessary
 4    to verify that the health care services subject to the review
 5    are medically necessary. In these cases, only  the  necessary
 6    or   relevant  sections   of   the  medical  record  shall be
 7    required. A utilization review agent may  request  copies  of
 8    partial or complete medical records  retrospectively.
 9        (h)  In  no  event  shall  information be  obtained  from
10    health  care providers   for   the  use  of  the  utilization
11    review agent by persons other than health care professionals,
12    medical record technologists, or administrative personnel who
13    have received appropriate training.
14        (i)  The  utilization  review  agent  shall not undertake
15    utilization review at the site of  the  provision  of  health
16    care services unless the utilization review agent:
17             (1)  identifies  himself  or herself by name and the
18        name of his  or  her organization,  including  displaying
19        photographic  identification that includes  the  name  of
20        the  utilization  review agent and clearly identifies the
21        individual as representative of  the  utilization  review
22        agent;
23             (2)  whenever  possible,  schedules  review at least
24        one business  day  in advance with the appropriate health
25        care provider;
26             (3)  if   requested  by  a  health  care   provider,
27        assures  that  the on-site review staff register with the
28        appropriate  contact  person,  if  available,  prior   to
29        requesting  any  clinical   information   or   assistance
30        from  the health care provider; and
31             (4)  obtains   consent   from  the  enrollee  or the
32        enrollee's designee  before  interviewing  the  patient's
33        family  or  observing  any   health   care  service being
34        provided to the enrollee.
 
                            -46-               LRB9100964JSpc
 1        This   subsection   does   not   apply  to  health   care
 2    professionals  engaged in providing care, case management, or
 3    making  on-site  discharge decisions.
 4        (j)  A utilization review agent shall not base an adverse
 5    determination on a refusal to consent to observing any health
 6    care service.
 7        (k)  A utilization review agent shall not base an adverse
 8    determination on  lack  of  reasonable  access  to  a  health
 9    care  provider's  medical  or  treatment  records unless  the
10    utilization  review  agent  has  provided reasonable   notice
11    to   both  the   enrollee  or the enrollee's designee and the
12    enrollee's health care provider and  has  complied  with  all
13    provisions  of subsection (i) of this Section. The Department
14    may promulgate rules defining reasonable notice and the  time
15    period  within  which  medical  and treatment records must be
16    turned over.
17        (l)  Neither the utilization review agent nor the  entity
18    for  which  the agent  provides utilization review shall take
19    any action with  respect  to  a  patient  or  a  health  care
20    provider  that  is  intended  to  penalize  the enrollee, the
21    enrollee's designee, or the enrollee's health  care  provider
22    for,  or to discourage the enrollee, the enrollee's designee,
23    or the enrollee's health care provider from, undertaking   an
24    appeal,  dispute resolution, or judicial review of an adverse
25    determination.
26        (m)   In  no  event  shall  an  enrollee,  an  enrollee's
27    designee,  an  enrollee's  health  care  provider,  any other
28    health care provider, or   any  other  person  or  entity  be
29    required  to  inform or contact the utilization review  agent
30    prior to the provision of emergency services  as  defined  in
31    this Act.
32        (n)  No  contract  or  agreement  between  a  utilization
33    review  agent  and  a health  care provider shall contain any
34    clause purporting to transfer to the health care provider  by
 
                            -47-               LRB9100964JSpc
 1    indemnification  or  otherwise   any   liability relating  to
 2    activities, actions, or omissions of the  utilization  review
 3    agent.
 4        (o)    A  health  care professional providing health care
 5    services  to  an enrollee  shall be prohibited  from  serving
 6    as the clinical peer reviewer for that enrollee in connection
 7    with   the   health   care   services   being provided to the
 8    enrollee.

 9        Section 95.  Annual consumer  satisfaction  survey.   The
10    Director shall develop and administer a survey of persons who
11    have  been enrolled in a managed care plan in the most recent
12    calendar  year  to  collect  information  on  relative   plan
13    performance.  This survey shall:
14             (1)  be administered annually by the Director, or by
15        an  independent  agency  or  organization selected by the
16        Director;
17             (2)  be administered to  a  scientifically  selected
18        representative  sample  of  current  enrollees  from each
19        plan, as well as persons who have disenrolled from a plan
20        in the last calendar year; and
21             (3)  emphasize the collection  of  information  from
22        persons  who  have  used  the  managed  care  plan  to  a
23        significant degree, as defined by rule.
24        Selected  data  from  the  annual  survey  shall  be made
25    available to current and prospective enrollees as part  of  a
26    consumer  guidebook  of  health  plan  performance, which the
27    Department shall develop and publish.   The  elements  to  be
28    included  in  the guidebook shall be reassessed on an ongoing
29    basis by the Department.  The  consumer  guidebook  shall  be
30    updated at least annually.

31        Section  100.   Managed care patient rights.  In addition
32    to all other requirements of this Act, a  managed  care  plan
 
                            -48-               LRB9100964JSpc
 1    shall ensure that an enrollee has the following rights:
 2        (1)  A  patient  has  the  right  to care consistent with
 3    professional standards of practice to assure quality  nursing
 4    and  medical  practices,  to  be  informed of the name of the
 5    participating physician responsible for coordinating  his  or
 6    her  care,  to  receive  information  concerning  his  or her
 7    condition and proposed treatment, to refuse any treatment  to
 8    the   extent   permitted   by   law,   and   to  privacy  and
 9    confidentiality of records except as  otherwise  provided  by
10    law.
11        (2)  A  patient  has  the  right, regardless of source of
12    payment, to examine and to receive a  reasonable  explanation
13    of his or her total bill for health care services rendered by
14    his or her physician or other health care provider, including
15    the  itemized  charges  for  specific  health  care  services
16    received.  A physician or other health care provider shall be
17    responsible  only  for  a  reasonable  explanation  of  these
18    specific  health  care  services  provided by the health care
19    provider.
20        (3)  A   patient   has   the   right   to   privacy   and
21    confidentiality in health care.  A  physician,  other  health
22    care  provider,  managed  care  plan,  and utilization review
23    agent shall refrain from disclosing the nature or details  of
24    health  care  services  provided to patients, except that the
25    information may be disclosed to the patient, the party making
26    treatment decisions if the patient  is  incapable  of  making
27    decisions  regarding the health care services provided, those
28    parties directly involved with  providing  treatment  to  the
29    patient  or  processing  the payment for the treatment, those
30    parties responsible for peer review, utilization review,  and
31    quality  assurance, and those parties required to be notified
32    under the Abused  and  Neglected  Child  Reporting  Act,  the
33    Illinois Sexually Transmissible Disease Control Act, or where
34    otherwise  authorized  or required by law.  This right may be
 
                            -49-               LRB9100964JSpc
 1    expressly waived in writing by the patient or  the  patient's
 2    guardian,  but  a  managed  care  plan, a physician, or other
 3    health care provider  may  not  condition  the  provision  of
 4    health care services on the patient's or guardian's agreement
 5    to sign the waiver.

 6        Section 105.  Health care entity liability.
 7        (a)  In this Section:
 8        "Appropriate  and medically necessary" means the standard
 9    for health care services  as  determined  by  physicians  and
10    health  care  providers  in  accordance  with  the prevailing
11    practices  and  standards  of  the  medical  profession   and
12    community.
13        "Enrollee"  means  an  individual  who  is  enrolled in a
14    health care plan, including covered dependents.
15        "Health care plan" means  any  plan  whereby  any  person
16    undertakes to provide, arrange for, pay for, or reimburse any
17    part of the cost of any health care services.
18        "Health  care  provider"  means  a  person  or  entity as
19    defined in Section 2-1003 of the Code of Civil Procedure.
20        "Health care treatment decision"  means  a  determination
21    made  when  medical  services  are  actually  provided by the
22    health care plan and a decision that affects the  quality  of
23    the  diagnosis,  care,  or  treatment  provided to the plan's
24    insureds or enrollees.
25        "Health insurance carrier" means an authorized  insurance
26    company that issues policies of accident and health insurance
27    under the Illinois Insurance Code.
28        "Health  maintenance  organization" means an organization
29    licensed under the Health Maintenance Organization Act.
30        "Managed care entity" means  any  entity  that  delivers,
31    administers,  or  assumes  risk for health care services with
32    systems or techniques to control or  influence  the  quality,
33    accessibility,  utilization,  or  costs  and  prices of those
 
                            -50-               LRB9100964JSpc
 1    services to a  defined  enrollee  population,  but  does  not
 2    include  an  employer purchasing coverage or acting on behalf
 3    of its employees or the employees of one or more subsidiaries
 4    or affiliated corporations of the employer.
 5        "Physician" means: (1) an individual licensed to practice
 6    medicine in  this  State;  (2)  a  professional  association,
 7    professional   service   corporation,   partnership,  medical
 8    corporation,  or  limited  liability  company,  entitled   to
 9    lawfully  engage  in the practice of medicine; or (3) another
10    person wholly owned by physicians.
11        "Ordinary care" means, in the case of a health  insurance
12    carrier,  health  maintenance  organization,  or managed care
13    entity, that degree of care that a health insurance  carrier,
14    health  maintenance  organization,  or managed care entity of
15    ordinary  prudence  would  use  under  the  same  or  similar
16    circumstances.  In the case of a person who is  an  employee,
17    agent,  ostensible  agent,  or  representative  of  a  health
18    insurance   carrier,   health  maintenance  organization,  or
19    managed care entity, "ordinary care"  means  that  degree  of
20    care   that  a  person  of  ordinary  prudence  in  the  same
21    profession, specialty, or area of  practice  as  such  person
22    would use in the same or similar circumstances.
23        (b)  A   health  insurance  carrier,  health  maintenance
24    organization, or other managed care entity for a health  care
25    plan  has  the  duty  to  exercise  ordinary care when making
26    health care treatment decisions and is liable for damages for
27    harm to an insured or  enrollee  proximately  caused  by  its
28    failure to exercise such ordinary care.
29        (c)  A   health  insurance  carrier,  health  maintenance
30    organization, or other managed care entity for a health  care
31    plan  is  also  liable  for damages for harm to an insured or
32    enrollee proximately caused  by  the  health  care  treatment
33    decisions made by its:
34             (1)  employees;
 
                            -51-               LRB9100964JSpc
 1             (2)  agents;
 2             (3)  ostensible agents; or
 3             (4)  representatives  who  are  acting on its behalf
 4        and over whom it has the right to exercise  influence  or
 5        control  or  has  actually exercised influence or control
 6        that results in the failure to exercise ordinary care.
 7        (d)  The standards in subsections (b) and (c)  create  no
 8    obligation  on  the  part  of  the  health insurance carrier,
 9    health maintenance organization, or other managed care entity
10    to provide to an insured or enrollee treatment  that  is  not
11    covered by the health care plan of the entity.
12        (e)  A   health  insurance  carrier,  health  maintenance
13    organization,  or  managed  care  entity  may  not  remove  a
14    physician or health care provider from its plan or refuse  to
15    renew the physician or health care provider with its plan for
16    advocating  on  behalf  of  an  enrollee  for appropriate and
17    medically necessary health care for the enrollee.
18        (f)  A  health  insurance  carrier,  health   maintenance
19    organization, or other managed care entity may not enter into
20    a  contract  with a physician, hospital, or other health care
21    provider  or  pharmaceutical  company   which   includes   an
22    indemnification  or  hold  harmless  clause  for  the acts or
23    conduct of the health insurance carrier,  health  maintenance
24    organization,   or  other  managed  care  entity.   Any  such
25    indemnification  or  hold  harmless  clause  in  an  existing
26    contract is hereby declared void.
27        (g)  Nothing in any  law  of  this  State  prohibiting  a
28    health insurance carrier, health maintenance organization, or
29    other  managed  care entity from practicing medicine or being
30    licensed to practice medicine may be asserted as a defense by
31    the   health   insurance    carrier,    health    maintenance
32    organization,  or  other  managed  care  entity  in an action
33    brought against it pursuant to this Section or any other law.
34        (h)  In an action against  a  health  insurance  carrier,
 
                            -52-               LRB9100964JSpc
 1    health  maintenance  organization,  or managed care entity, a
 2    finding that a physician or other health care provider is  an
 3    employee,  agent,  ostensible agent, or representative of the
 4    health insurance carrier, health maintenance organization, or
 5    managed care entity shall not be based solely on  proof  that
 6    the person's name appears in a listing of approved physicians
 7    or  health  care  providers  made  available  to  insureds or
 8    enrollees under a health care plan.
 9        (i)  This Section does not apply to workers' compensation
10    insurance coverage subject to the Workers' Compensation Act.
11        (j)  This Section does not apply to actions seeking  only
12    a  review  of  an  adverse  utilization review determination.
13    This Section applies only to causes of action that accrue  on
14    or  after  the  effective  date  of  this  Act. An insured or
15    enrollee seeking damages under this Section has the right and
16    duty to submit the claim to arbitration  in  accordance  with
17    the  Uniform  Arbitration  Act.   No  agreement  between  the
18    parties  to  submit the claim to arbitration is necessary.  A
19    health insurance carrier, health maintenance organization, or
20    managed care  entity  shall  have  no  liability  under  this
21    Section unless the claim is first submitted to arbitration in
22    accordance  with  the  Uniform Arbitration Act.  The award in
23    matters arbitrated pursuant to this  Section  shall  be  made
24    within  30  days  after  notification  of  the arbitration is
25    provided to all parties.
26        (k)  The  determination  of  whether   a   procedure   or
27    treatment is medically necessary must be made by a physician.
28        (l)  If  the  physician  determines  that  a procedure or
29    treatment is medically necessary, the health care  plan  must
30    pay for the procedure or treatment.

31        Section  110.  Waiver.   Any  agreement  that purports to
32    waive, limit, disclaim or in any way diminish the rights  set
33    forth in  this Act is void as contrary to public policy.
 
                            -53-               LRB9100964JSpc
 1        Section 115.  Administration of Act.
 2        (a)  The Department shall administer this Act.
 3        (b)  All managed care plans and utilization review agents
 4    providing  or  reviewing  services in Illinois shall annually
 5    certify compliance with this Act and rules adopted under this
 6    Act to the Department in  addition  to  any  other  licensure
 7    required  by  law.   The  Director  shall establish by rule a
 8    process for this certification including fees  to  cover  the
 9    costs  associated  with  implementing this Act.  All fees and
10    fines assessed under this  Act  shall  be  deposited  in  the
11    Managed  Care  Reform  Fund, a special fund hereby created in
12    the State treasury.  Moneys in the Fund shall be used by  the
13    Department  only  to  enforce  and  administer this Act.  The
14    certification requirements of this Act shall be  incorporated
15    into program requirements of the Department of Public Aid and
16    Department  of  Human  Services  and no further certification
17    under this Act is required.
18        (c)  The Director shall  take  enforcement  action  under
19    this  Act  including,  but  not limited to, the assessment of
20    civil fines and injunctive relief for any failure  to  comply
21    with  this  Act  or  any  violation  of the Act or rules by a
22    managed care plan or any utilization review agent.
23        (d)  The Department shall have the  authority  to  impose
24    fines  on  any  managed  care  plan or any utilization review
25    agent.  The Department shall adopt rules pursuant to this Act
26    that establish a system of fines  related  to  the  type  and
27    level  of  violation  or  repeat violation, including but not
28    limited to:
29             (1)  A fine not exceeding $10,000  for  a  violation
30        that  created  a  condition  or  occurrence  presenting a
31        substantial probability that death or serious harm to  an
32        individual will or did result therefrom; and
33             (2)   A  fine  not  exceeding $5,000 for a violation
34        that creates or created a condition  or  occurrence  that
 
                            -54-               LRB9100964JSpc
 1        threatens   the   health,   safety,   or  welfare  of  an
 2        individual.
 3        Each  day  a  violation  continues  shall  constitute   a
 4    separate  offense.   These rules shall include an opportunity
 5    for a hearing in accordance with the Illinois  Administrative
 6    Procedure  Act.   All final decisions of the Department shall
 7    be reviewable under the Administrative Review Law.
 8        (e)  Notwithstanding the  existence  or  pursuit  of  any
 9    other remedy, the Director may, through the Attorney General,
10    seek  an  injunction  to  restrain  or  prevent any person or
11    entity from functioning or operating in violation of this Act
12    or rule.

13        Section 120.  Emergency services.
14        (a)  Any managed care plan  subject  to  this  Act  shall
15    provide  the  enrollee  emergency services coverage such that
16    payment for this coverage is not dependent upon whether  such
17    services are performed by a participating or nonparticipating
18    provider,  and  such  coverage  shall  be at the same benefit
19    level as if the service or treatment had been rendered  by  a
20    plan  provider.   Nothing  in  this  Section  is  intended to
21    prohibit a  plan  from  imposing  its  customary  and  normal
22    co-payments,   deductibles,   co-insurance,  and  other  like
23    charges for emergency services.
24        (b)  Prior authorization or approval by  the  plan  shall
25    not  be  required  for emergency services rendered under this
26    Section.
27        (c)  Coverage and payment shall  not  be  retrospectively
28    denied, with the following exceptions:
29             (1)  upon    reasonable   determination   that   the
30        emergency services claimed were never performed; or
31             (2)  upon reasonable determination that an emergency
32        medical screening examination was performed on a  patient
33        who  personally sought emergency services knowing that he
 
                            -55-               LRB9100964JSpc
 1        or she did not have an emergency condition or  necessity,
 2        and who did not in fact require emergency services.
 3        (d)  When  an  enrollee  presents  to  a hospital seeking
 4    emergency services, as defined in this Act, the determination
 5    as to whether the need for those  services  exists  shall  be
 6    made  for  purposes  of  treatment  by a physician or, to the
 7    extent permitted by  applicable  law,  by  other  appropriate
 8    licensed personnel under the supervision of a physician.  The
 9    physician  or  other  appropriate personnel shall indicate in
10    the patient's chart the  results  of  the  emergency  medical
11    screening   examination.    The  plan  shall  compensate  the
12    provider for an emergency medical screening examination  that
13    is  reasonably  calculated to assist the health care provider
14    in  determining  whether  the  patient's  condition  requires
15    emergency services. A plan shall have  no  duty  to  pay  for
16    services   rendered  after  an  emergency  medical  screening
17    examination determines the  lack  of  a  need  for  emergency
18    services.
19        (e)  The  appropriate  use of the 911 emergency telephone
20    number shall not be discouraged or penalized, and coverage or
21    payment shall not be denied solely  on  the  basis  that  the
22    insured  used  the  911  emergency telephone number to summon
23    emergency services.
24        (f)  If  prior   authorization   for   post-stabilization
25    services,  as  defined  in this Act, is required, the managed
26    care plan shall provide access 24 hours a day, 7 days a  week
27    to  persons  designated  by plan to make such determinations.
28    If a provider has attempted to contact such person for  prior
29    authorization  and  no  designated persons were accessible or
30    the authorization was not  denied  within  one  hour  of  the
31    request,  the plan is deemed to have approved the request for
32    prior authorization.
33        (g)  Coverage and payment for post-stabilization services
34    which received prior authorization or deemed  approval  shall
 
                            -56-               LRB9100964JSpc
 1    not  be  retrospectively  denied.  Nothing in this Section is
 2    intended to prohibit a plan from imposing its  customary  and
 3    normal co-payments, deductibles, co-insurance, and other like
 4    changes for post-stabilization services.

 5        Section  125.  Prescription  drugs.  A  managed care plan
 6    that provides coverage for prescribed drugs approved  by  the
 7    federal  Food  and  Drug  Administration  shall  not  exclude
 8    coverage  of  any  drug  on  the basis that the drug has been
 9    prescribed for the treatment of a particular  indication  for
10    which  the drug has not been approved by the federal Food and
11    Drug Administration.  The drug, however, must be approved  by
12    the   federal  Food  and  Drug  Administration  and  must  be
13    recognized for the treatment of  that  particular  indication
14    for  which  the  drug  has  been prescribed in any one of the
15    following established reference compendia:
16             (1)  the American Hospital  Formulary  Service  Drug
17        Information;
18             (2)  the    United    States    Pharmacopoeia   Drug
19        Information; or
20             (3)  if not recognized by the  authorities  in  item
21        (1) or (2), recommended for that particular indication in
22        formal  clinical  studies, the results of which have been
23        published  in  at  least  2  peer  reviewed  professional
24        medical journals published in the United States or  Great
25        Britain.
26        Any  coverage required by this Section shall also include
27    those  medically  necessary  services  associated  with   the
28    administration of a drug.
29        Despite  the  provisions  of this Section, coverage shall
30    not be required for any experimental or investigational drugs
31    or any drug that the federal Food and Drug Administration has
32    determined  to  be  contraindicated  for  treatment  of   the
33    specific  indication  for which the drug has been prescribed.
 
                            -57-               LRB9100964JSpc
 1    Nothing in this Section shall be construed, expressly  or  by
 2    implication,   to   create,  impair,  alter,  limit,  notify,
 3    enlarge, abrogate, or prohibit reimbursement for  drugs  used
 4    in the treatment of any other disease or condition.

 5        Section 130.  Health Care Service Delivery Review Board.
 6        (a)  A  managed  care  plan  shall organize a Health Care
 7    Service Delivery Review Board from participants in the  plan.
 8    The  Board  shall  consist  of  17  members:  5 participating
 9    physicians  elected  by  participating  physicians,  5  other
10    participating providers elected  by  the  other  health  care
11    providers,  5  enrollees  elected  by  the  enrollees,  and 2
12    representatives of the  plan  appointed  by  the  plan.   The
13    representatives  of  the  plan  shall  not have a vote on the
14    Board, but shall have  all  other  rights  granted  to  Board
15    members.   The plan shall devise a mechanism for the election
16    of the Board's  members,  subject  to  the  approval  of  the
17    Department.   The  Department shall not unreasonably withhold
18    its approval of a mechanism.
19        (b)  The  Health  Care  Service  Delivery   Board   shall
20    establish   written   rules  and  regulations  governing  its
21    operation.  The managed care plan shall  approve  the  rules,
22    but  may  not  unilaterally  amend  them.   A  plan  may  not
23    unreasonably   withhold   approval   of  proposed  rules  and
24    regulations.
25        (c)  The Health Care Service Delivery Board  shall,  from
26    time to time, issue nonbinding reports and reviews concerning
27    the  plan's  health  care  delivery policy, quality assurance
28    procedures, utilization review criteria and  procedures,  and
29    medical  management  procedures.   The Board shall select the
30    aspects of the plan that it wishes to study or review and may
31    undertake a study or review at the request of the plan.   The
32    Board  shall  issue  its  report directly to the managed care
33    plan's governing board.
 
                            -58-               LRB9100964JSpc
 1        Section 135.  Conflicts with federal  law.   When  health
 2    care  services are provided by a managed care plan subject to
 3    this Act to a person who is a recipient of medical assistance
 4    under Article V of the Illinois Public Aid Code, the  rights,
 5    benefits,   requirements,   and   procedures   available   or
 6    authorized  under this Act shall not apply to the extent that
 7    there are provisions of federal law that  conflict.   In  the
 8    event of a conflict, federal law shall prevail.

 9        Section  140.  Severability.   The provisions of this Act
10    are severable under Section 1.31 of the Statute on Statutes.

11        Section 145.  The State Employees Group Insurance Act  of
12    1971 is amended by adding Section 6.12 as follows:

13        (5 ILCS 375/6.12 new)
14        Sec.  6.12.   Managed  Care  Reform  Act.  The program of
15    health benefits is subject to the provisions of  the  Managed
16    Care Reform Act.

17        Section  150.  The  Civil Administrative Code of Illinois
18    is amended by adding Sections 56.3,  56.4,  56.5,  56.6,  and
19    56.7 as follows:

20        (20 ILCS 1405/56.3 new)
21        Sec.  56.3.  Office  of  Health Care Consumer Assistance,
22    Advocacy, and Information.
23        (a)  The  Office  of  Health  Care  Consumer  Assistance,
24    Advocacy,  and  Information   is   established   within   the
25    Department  of Insurance to provide assistance, advocacy, and
26    information to all health care consumers  within  the  State.
27    The  office  shall  have no regulatory power or authority and
28    shall not provide legal representation in a court of law.
29        (b)  An executive director  shall  be  appointed  by  the
 
                            -59-               LRB9100964JSpc
 1    governor  for  a 3-year term and may be removed only for just
 2    cause.
 3        (c)  The executive director must:
 4             (1)  be  selected  without   regard   to   political
 5        affiliation;
 6             (2)  have  knowledge  and  experience concerning the
 7        needs and rights of health care consumers; and
 8             (3)  be  qualified  to  analyze  questions  of  law,
 9        administrative functions, and public policy.
10        (d)  No person may  serve  as  executive  director  while
11    holding another public office.
12        (e)  The Department shall provide office space, equipment
13    and  supplies,  and technical support to the Office of Health
14    Care Consumer Assistance, Advocacy, and Information.

15        (20 ILCS 1405/56.4 new)
16        Sec. 56.4.  Duties and powers of  the  Office  of  Health
17    Care Consumer Assistance, Advocacy, and Information.
18        (a)  Within  the  appropriation  allocated, the executive
19    director shall provide  information  and  assistance  to  all
20    health care consumers by:
21             (1)  assisting    patients    and    enrollees    in
22        understanding  and  asserting their contractual and legal
23        rights, including the rights under an alternative dispute
24        resolution process; this assistance may include  advocacy
25        for  enrollees  in  administrative  proceedings  or other
26        formal or informal dispute resolution processes;
27             (2)  assisting enrollees  in  obtaining  appropriate
28        health  care  referrals  under their health plan company,
29        health insurance, or health coverage plan;
30             (3)  assisting patients and enrollees  in  accessing
31        the  services  of  governmental  agencies  or  regulatory
32        boards  or  other  State consumer assistance programs, or
33        advocacy  services  whenever  appropriate  so  that   the
 
                            -60-               LRB9100964JSpc
 1        patient  or  enrollee can take full advantage of existing
 2        mechanisms for resolving complaints;
 3             (4)  referring    patients    and    enrollees    to
 4        governmental  agencies  and  regulatory  boards  for  the
 5        investigation  of  health   care   complaints   and   for
 6        enforcement action;
 7             (5)  educating  and  training  enrollees about their
 8        health plan company, health insurance, or health coverage
 9        plan to  enable  them  to  assert  their  rights  and  to
10        understand their responsibilities;
11             (6)  assisting   enrollees  in  receiving  a  timely
12        resolution of their complaints;
13             (7)  monitoring  health  care  consumer   complaints
14        addressed   by   the   Office  of  Health  Care  Consumer
15        Assistance,  Advocacy,  and   Information   to   identify
16        specific   complaint   patterns  or  areas  of  potential
17        improvement;
18             (8)  collecting  public  information   on   consumer
19        satisfaction and outcomes data on health plan company and
20        health  care  provider  performances  from  organizations
21        conducting surveys; and
22             (9)  recommending  to  health plan companies ways to
23        identify and remove any  barriers  that  might  delay  or
24        impede  the  health  plan  company's  effort  to  resolve
25        consumer complaints.

26        (20 ILCS 1405/56.5 new)
27        Sec. 56.5.  Reports by executive director.
28        (a) Beginning March 1, 2000, the executive director shall
29    report,   on   at  least  a  quarterly  basis,  any  patterns
30    identified from the  consumer  complaints  addressed  by  the
31    office to the Director and the Governor.
32        (b)  By  January  1, 2001, and each January 1 thereafter,
33    the executive director shall make an annual written report to
 
                            -61-               LRB9100964JSpc
 1    the General Assembly  regarding  activities  of  the  office,
 2    including  recommendations  on improving health care consumer
 3    assistance and complaint resolution  processes.   Before  any
 4    recommendations   are  made  to  the  General  Assembly,  the
 5    executive director  must  consult  with  the  Public  Service
 6    Division and other interested parties.

 7        (20 ILCS 1405/56.6 new)
 8        Sec. 56.6.  Managed Care Ombudsman Program.
 9        (a)  The   Department  shall  establish  a  Managed  Care
10    Ombudsman Program (MCOP) within the  Office  of  Health  Care
11    Consumer  Assistance, Advocacy, and Information.  The purpose
12    of the MCOP is to assist consumers to:
13             (1)  navigate the managed care system;
14             (2)  select an appropriate managed care plan; and
15             (3)  understand  and   assert   their   rights   and
16        responsibilities as managed care plan enrollees.
17        (b)  The  Department  shall  contract with an independent
18    organization or organizations to perform the  following  MCOP
19    functions:
20             (1)  Assist   consumers   with   managed  care  plan
21        selection  by  providing   information,   referral,   and
22        assistance to individuals about means of obtaining health
23        coverage and services, including, but not limited to:
24                  (A)  access   through   a  toll-free  telephone
25             number; and
26                  (B)  availability of information  in  languages
27             other  than  English  that  are  spoken as a primary
28             language by a significant  portion  of  the  State's
29             population, as determined by the Department.
30             (2)  Educate  and  train consumers in the use of the
31        Department's annual Consumer  Guidebook  of  Health  Plan
32        Performance, compiled in accordance with Section 95.
33             (3)  Analyze, comment on, monitor, and make publicly
 
                            -62-               LRB9100964JSpc
 1        available  reports  on the development and implementation
 2        of federal, State and local laws, regulations, and  other
 3        governmental  policies  and  actions  that pertain to the
 4        adequacy of managed care plans, facilities, and  services
 5        in the State.
 6             (4)  Ensure  that  individuals have timely access to
 7        the services provided through the MCOP.
 8             (5)  Submit an annual report to the  Department  and
 9        General Assembly:
10                  (A)  describing  the  activities carried out by
11             the MCOP  in  the  year  for  which  the  report  is
12             prepared;
13                  (B)  containing    and   analyzing   the   data
14             collected by the MCOP; and
15                  (C)  evaluating  the  problems  experienced  by
16             managed care plan enrollees.
17             (6)  Exercise such other powers and functions as the
18        Department determines to be appropriate.
19        (c)  The  Department   shall   establish   criteria   for
20    selection  of an independent organization or organizations to
21    perform the functions of the MCOP, including, but not limited
22    to, the following:
23             (1)  Preference   shall   be   given   to   private,
24        not-for-profit  organizations  governed  by  boards  with
25        consumer members in the majority that represent  a  broad
26        spectrum of the diverse consumer interests in the State.
27             (2)  No individual or organization under contract to
28        perform functions of the MCOP may:
29                  (A)  have   a   direct   involvement   in   the
30             licensing,  certification,  or  accreditation  of  a
31             health  care  facility,  a  managed  care plan, or a
32             provider of a managed care plan, or  have  a  direct
33             involvement   with  a  provider  of  a  health  care
34             service;
 
                            -63-               LRB9100964JSpc
 1                  (B)  have  a  direct  ownership  or  investment
 2             interest in a health care facility, a  managed  care
 3             plan, or a health care service;
 4                  (C)  be  employed  by,  or  participate  in the
 5             management of, a health care service or facility  or
 6             a managed care plan; or
 7                  (D)  receive,  or  have  the  right to receive,
 8             directly or indirectly, remuneration (in cash or  in
 9             kind) under a compensation arrangement with an owner
10             or  operator of a health care service or facility or
11             managed care plan.
12        The Department shall contract  with  an  organization  or
13    organizations qualified under criteria established under this
14    Section for an initial term of 3 years.  The initial contract
15    shall  be  renewable  thereafter  for additional 3 year terms
16    without reopening the competitive  selection  process  unless
17    there  has been an unfavorable written performance evaluation
18    conducted by the Department.
19        (d)  The Department shall establish,  by  rule,  policies
20    and procedures for the operation of MCOP sufficient to ensure
21    that  the  MCOP  can  perform all functions specified in this
22    Section.
23        (e)  Nothing in this  Section  shall  be  interpreted  to
24    authorize  access  to  or disclosure of individual patient or
25    provider records.

26        (20 ILCS 1405/56.7 new)
27        Sec. 56.7.  Retaliation. A health plan company or  health
28    care  provider  may  not  retaliate  or  take  adverse action
29    against an enrollee or patient who, in good  faith,  makes  a
30    complaint  against  a  health  plan  company  or  health care
31    provider.

32        Section 155.  The State Finance Act is amended by  adding
 
                            -64-               LRB9100964JSpc
 1    Section 5.490 as follows:

 2        (30 ILCS 105/5.490 new)
 3        Sec. 5.490.  The Managed Care Reform Fund.

 4        Section 160.  The State Mandates Act is amended by adding
 5    Section 8.23 as follows:

 6        (30 ILCS 805/8.23 new)
 7        Sec.  8.23.  Exempt  mandate.  Notwithstanding Sections 6
 8    and 8 of this Act, no reimbursement by the State is  required
 9    for  the  implementation  of  any  mandate  created  by  this
10    amendatory Act of 1999.

11        Section  165.  The  Counties  Code  is  amended by adding
12    Section 5-1069.8 as follows:

13        (55 ILCS 5/5-1069.8 new)
14        Sec. 5-1069.8.  Managed Care Reform Act.   All  counties,
15    including  home  rule counties, are subject to the provisions
16    of the Managed Care Reform Act. The  requirement  under  this
17    Section that health care benefits provided by counties comply
18    with  the  Managed  Care Reform Act is an exclusive power and
19    function of the State and is a denial and limitation of  home
20    rule  county  powers under Article VII, Section 6, subsection
21    (h) of the Illinois Constitution.

22        Section 170.  The Illinois Municipal Code is  amended  by
23    adding 10-4-2.8 as follows:

24        (65 ILCS 5/10-4-2.8 new)
25        Sec.  10-4-2.8.   Managed Care Reform Act.  The corporate
26    authorities  of  all  municipalities  are  subject   to   the
27    provisions  of  the Managed Care Reform Act.  The requirement
 
                            -65-               LRB9100964JSpc
 1    under this Section that  health  care  benefits  provided  by
 2    municipalities  comply with the Managed Care Reform Act is an
 3    exclusive power and function of the State and is a denial and
 4    limitation of home rule  municipality  powers  under  Article
 5    VII, Section 6, subsection (h) of the Illinois Constitution.

 6        Section  175.  The  School  Code  is  amended  by  adding
 7    Section 10-22.3g as follows:

 8        (105 ILCS 5/10-22.3g new)
 9        Sec.   10-22.3g.  Managed   Care  Reform  Act.  Insurance
10    protection and benefits for  employees  are  subject  to  the
11    Managed Care Reform Act.

12        Section  180.  The Health Maintenance Organization Act is
13    amended by changing Sections 2-2 and 6-7 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  rules
30    regulations  promulgated  by  the Department of Public Health
 
                            -66-               LRB9100964JSpc
 1    for an ongoing  quality  of  health  care  assurance  program
 2    concerning   health   care   processes   and  outcomes.  Upon
 3    investigation, the  Director  of  the  Department  of  Public
 4    Health  shall  certify  to  the Director whether the proposed
 5    Health Maintenance Organization  meets  the  requirements  of
 6    this  subsection  (a).  If  the Director of the Department of
 7    Public  Health  certifies   that   the   Health   Maintenance
 8    Organization does not meet such requirements, he or she shall
 9    specify in what respect it is deficient.
10        There  is  created  in  the Department of Public Health a
11    Health Maintenance Advisory Board  composed  of  11  members.
12    Nine  of  the  11  9  members shall who have practiced in the
13    health field and, 4 of those 9 which shall have been or shall
14    be  are  currently  affiliated  with  a  Health   Maintenance
15    Organization.   Two  of  the  members shall be members of the
16    general public, one of whom is over 65  years  of  age.  Each
17    member  shall  be appointed by the Director of the Department
18    of Public Health and serve at the pleasure of  that  Director
19    and shall receive no compensation for services rendered other
20    than  reimbursement  for  expenses.  Six  Five members of the
21    Board shall constitute a quorum. A vacancy in the  membership
22    of  the Advisory Board shall not impair the right of a quorum
23    to exercise all rights and perform all duties of  the  Board.
24    The Health Maintenance Advisory Board has the power to review
25    and   comment   on  proposed  rules  and  regulations  to  be
26    promulgated by the  Director  of  the  Department  of  Public
27    Health   within  30  days  after  those  proposed  rules  and
28    regulations have been submitted to the Advisory Board.
29        (b)  Issuance of a  certificate  of  authority  shall  be
30    granted if the following conditions are met:
31             (1)  the  requirements  of subsection (c) of Section
32        2-1 have been fulfilled;
33             (2)  the persons responsible for the conduct of  the
34        affairs  of the applicant are competent, trustworthy, and
 
                            -67-               LRB9100964JSpc
 1        possess  good  reputations,  and  have  had   appropriate
 2        experience, training or education;
 3             (3)  the Director of the Department of Public Health
 4        certifies  that  the  Health  Maintenance  Organization's
 5        proposed plan of operation meets the requirements of this
 6        Act;
 7             (4)  the  Health  Care  Plan  furnishes basic health
 8        care services on a prepaid basis,  through  insurance  or
 9        otherwise,   except   to   the   extent   of   reasonable
10        requirements for co-payments or deductibles as authorized
11        by this Act;
12             (5)  the    Health   Maintenance   Organization   is
13        financially responsible and may reasonably be expected to
14        meet  its  obligations  to  enrollees   and   prospective
15        enrollees;  in  making  this  determination, the Director
16        shall consider:
17                  (A)  the financial soundness of the applicant's
18             arrangements for health  services  and  the  minimum
19             standard   rates,   co-payments  and  other  patient
20             charges used in connection therewith;
21                  (B)  the adequacy  of  working  capital,  other
22             sources    of    funding,    and    provisions   for
23             contingencies; and
24                  (C)  that no certificate of authority shall  be
25             issued  if  the  initial  minimum  net  worth of the
26             applicant is less than $2,000,000. The  initial  net
27             worth  shall  be  provided in cash and securities in
28             combination and form acceptable to the Director;
29             (6)  the agreements with providers for the provision
30        of health services contain  the  provisions  required  by
31        Section 2-8 of this Act; and
32             (7)  any  deficiencies  identified  by  the Director
33        have been corrected.
34    (Source: P.A. 86-620; 86-1475.)
 
                            -68-               LRB9100964JSpc
 1        (215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
 2        Sec. 6-7.  Board of Directors.  The board of directors of
 3    the Association shall consist consists of not less than  7  5
 4    nor  more  than  11 9 members serving terms as established in
 5    the plan of operation.  The members of the board  are  to  be
 6    selected  by  member organizations subject to the approval of
 7    the Director provided,  however,  that  2  members  shall  be
 8    enrollees, one of whom is over 65 years of age.  Vacancies on
 9    the board must be filled for the remaining period of the term
10    in  the manner described in the plan of operation.  To select
11    the initial board of directors, and  initially  organize  the
12    Association,  the  Director  must  give  notice to all member
13    organizations of the time and  place  of  the  organizational
14    meeting.   In determining voting rights at the organizational
15    meeting each member organization is entitled to one  vote  in
16    person  or  by  proxy.   If  the  board  of  directors is not
17    selected at the  organizational  meeting,  the  Director  may
18    appoint the initial members.
19        In  approving  selections or in appointing members to the
20    board,  the  Director  must  consider,  whether  all   member
21    organizations are fairly represented.
22        Members of the board may be reimbursed from the assets of
23    the  Association  for expenses incurred by them as members of
24    the board of directors but  members  of  the  board  may  not
25    otherwise   be  compensated  by  the  Association  for  their
26    services.
27    (Source: P.A. 85-20.)

28        Section  199.  Effective  date.  This  Act  takes  effect
29    January 1, 2000.
 
                            -69-               LRB9100964JSpc
 1                                INDEX
 2               Statutes amended in order of appearance
 3    New Act
 4    5 ILCS 375/6.12 new
 5    20 ILCS 1405/56.3 new
 6    20 ILCS 1405/56.4 new
 7    20 ILCS 1405/56.5 new
 8    20 ILCS 1405/56.6 new
 9    20 ILCS 1405/56.7 new
10    30 ILCS 105/5.490 new
11    30 ILCS 805/8.23 new
12    55 ILCS 5/5-1069.8 new
13    65 ILCS 5/10-4-2.8 new
14    105 ILCS 5/10-22.3g new
15    215 ILCS 125/2-2          from Ch. 111 1/2, par. 1404
16    215 ILCS 125/6-7          from Ch. 111 1/2, par. 1418.7

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