State of Illinois
91st General Assembly

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 1        AN ACT concerning regulation of health care plans.

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

 4        Section  1.  Short  title.   This Act may be cited as the
 5    Managed Care Reform Act of 1999.

 6        Section  5.  Purpose.   This  Act  addresses  changes  in
 7    managed care practice and operations in  Illinois.   The  Act
 8    enhances  quality,  affordable,  and  accessible  health care
 9    coverage for  Illinois  citizens,  families  and  businesses.
10    Through  the provisions of this Act, health care plan members
11    will be provided:
12             (1)  Detailed information about health  care  plans,
13        the   scope   of   coverage  available,  and  physicians'
14        professional  qualifications  so  that  they   can   make
15        informed choices about their health care.
16             (2)  Notification  of  termination  or change in any
17        benefits, services or service delivery.  This includes  a
18        provision   allowing   enrollees   to   continue  with  a
19        non-network    physician    under    certain     specific
20        circumstances.
21             (3)  A mechanism to apply for a standing referral to
22        a specialist physician when a  condition requires ongoing
23        care from a specialist physician.
24             (4)  Detailed   grievance   procedures  and  medical
25        necessity appeals procedures, which include an  expedited
26        appeal process.
27             (5)  Health    care    plan    accountability    for
28        accessibility  of  services and reimbursement for covered
29        emergency services.

30        Section 10.  Definitions.  As used in this Act:
                            -2-               LRB9102446JSpcA
 1        "Basic health care services" means  emergency  care,  and
 2    inpatient  hospital  and  physician  care, outpatient medical
 3    services, mental health services and  care  for  alcohol  and
 4    drug   abuse,   including   any  reasonable  deductibles  and
 5    copayments, all of which are subject to such  limitations  as
 6    are determined by the Director.
 7        "Department" means the Department of Insurance.
 8        "Director" means the Director of Insurance.
 9        "Emergency  medical  condition" means a medical condition
10    manifesting itself by acute symptoms of  sufficient  severity
11    (including  severe  pain)  such that a prudent layperson, who
12    possesses an average knowledge of health and medicine,  could
13    reasonably  expect the absence of immediate medical attention
14    to result in (i) placing the health of  the  individual  (or,
15    with  respect to a pregnant woman, the health of the woman or
16    her  unborn  child)  in  serious   jeopardy,   (ii)   serious
17    impairment  to bodily functions, or (iii) serious dysfunction
18    of any bodily organ or part.
19        "Emergency services" means, with respect to an individual
20    enrolled in a health care plan, covered inpatient and covered
21    outpatient services that are:
22             (1)  furnished in a licensed hospital by a  provider
23        that is qualified to furnish those services;
24             (2)  needed to evaluate whether an emergency medical
25        condition exists; and
26             (3)  needed   for   stabilization  of  an  emergency
27        medical condition if one exists.
28        "Emergency services" does not refer to post-stabilization
29    medical services.
30        "Enrollee" means an individual enrolled in a health  care
31    plan.
32        "Good  faith"  means  honesty  of  purpose,  freedom from
33    intention to defraud and being  faithful  to  one's  duty  or
34    obligation.  In addition the definition afforded this term by
                            -3-               LRB9102446JSpcA
 1    the courts of the State of Illinois shall apply.
 2        "Governing   body"   means  the  board  of  trustees,  or
 3    directors,  or  if  otherwise   designated   in   the   basic
 4    organizational document bylaws, those individuals vested with
 5    the  ultimate responsibility for the management of the health
 6    care plan.
 7        "Grievance" means any written complaint submitted to  the
 8    health care plan by or on behalf of an enrollee regarding any
 9    aspect  of  the  plan relative to the enrollee, but shall not
10    include a complaint by or on behalf of a provider.
11        "Grievance committee" means  individuals  who  have  been
12    appointed  by  the  health care plan to respond to grievances
13    which have been filed on appeal from  the  plan's  simplified
14    complaint  process.   At least 50% of the individuals on this
15    committee shall be composed of enrollees who  are  consumers.
16    A  grievance  may  not be heard or voted upon unless at least
17    50% of the voting individuals at the  committee  hearing  are
18    enrollees.
19        "Health  care  plan"  means  any  arrangement  whereby an
20    organization undertakes to provide or arrange for and pay for
21    or reimburse the cost of  basic  health  care  services  from
22    providers  selected by the plan and such arrangement consists
23    of arranging  for  or  the  provision  of  such  health  care
24    services,  as distinguished from mere indemnification against
25    the cost of such services, on a  per  capita  prepaid  basis,
26    through insurance or otherwise.
27        "Health care services" means any services included in the
28    furnishing  to  any  individual of medical or dental care, or
29    the hospitalization or incident to  the  furnishing  of  such
30    care  or  hospitalization  as  well  as the furnishing to any
31    person of any and all  other  services  for  the  purpose  of
32    preventing,  alleviating,  curing or healing human illness or
33    injury.
34        "Insurance  company"  means  a  company   authorized   to
                            -4-               LRB9102446JSpcA
 1    transact  in  this  State  the  kind  or  kinds  of  business
 2    enumerated  in  Class  1(a),  Class  1(b),  or  Class 2(a) of
 3    Section 4 of the Illinois Insurance Code.
 4        "Insured" means an individual  entitled  to  coverage  of
 5    expenses  of  health  care  services under a policy issued or
 6    administered by an insurance company.
 7        "Life threatening condition" means any condition, illness
 8    or injury that (i) may directly lead to  a  patient's  death,
 9    (ii)   results   in  a  period  of  unconsciousness  that  is
10    indeterminate at the present, or (iii) imposes severe pain or
11    an inhumane burden on the patient.
12        "Medical director" means a physician licensed to practice
13    medicine in all its branches in Illinois who is  employed  by
14    or  contracted with a health care plan and who is responsible
15    for final review when questions of medical practice arise  in
16    the health care plan in order to assure the quality of health
17    care services provided.
18        "Patient"  means  any  person  who  has  received  or  is
19    receiving  medical  care,  treatment,  or  services  from  an
20    individual or institution licensed to provide medical care or
21    treatment in this State.
22        "Post-stabilization   medical   services"  means  covered
23    health  care  services  provided  to  an  enrollee  that  are
24    furnished in a  licensed  hospital  by  a  provider  that  is
25    qualified  to  furnish  those  services  and determined to be
26    medically necessary and  directly  related  to  an  emergency
27    medical condition following stabilization.
28        "Primary   care  physician"  means  a  provider  who  has
29    contracted with a health care plan to  provide  primary  care
30    services  as  defined  by the contract and who is a physician
31    licensed to practice medicine in  all  of  its  branches  who
32    spends  a  majority  of  clinical  time  engaged  in  general
33    practice or in the practice of internal medicine, pediatrics,
34    gynecology, obstetrics, or family practice.
                            -5-               LRB9102446JSpcA
 1        "Provider" means a physician, hospital facility, or other
 2    person  that  is  licensed or otherwise authorized to furnish
 3    health care services.
 4        "Stabilization"  means,  with  respect  to  an  emergency
 5    medical condition, to provide such medical treatment  of  the
 6    condition  as  may  be necessary to assure, within reasonable
 7    medical probability, that no material  deterioration  of  the
 8    condition  is  likely  to  result  from  the  transfer of the
 9    individual from a facility.
10        "Utilization   review"   means   the   study    of    the
11    appropriateness  of  the  use  of particular services and the
12    appropriateness of the volume of services used.
13        "Utilization review program" means an  entity  performing
14    utilization   review,   except   an  agency  of  the  federal
15    government or its agent, but only to the extent that agent is
16    providing services to the federal government.

17        Section 15.  Patient rights.  The  following  rights  are
18    hereby established:
19             (1)  The  right  of each patient to be provided with
20        information about the health care plan and the  providers
21        rendering  care.   For health care plans this right calls
22        for compliance with Section 20 of this Act.
23             (2)  The right of each patient to a full  disclosure
24        of  the  patient costs, benefits, risks, and alternatives
25        related to the  treatment  options  and  care,  including
26        health  care  plan requirements, coverage, exclusions, or
27        limitations.  For health care plans this right calls  for
28        compliance  with  Section  25  of  this  Act.   Insurance
29        companies  and  health  care  plans  are  prohibited from
30        terminating or suspending a  provider  from  its  network
31        because  the  provider  advocated  for  what  he  or  she
32        considered to be appropriate health care.
33             (3)  The  right  of  each patient to care consistent
                            -6-               LRB9102446JSpcA
 1        with nursing and medical practices, to be informed of the
 2        name of the physician responsible for coordinating his or
 3        her  care,  to  receive  information  from  his  or   her
 4        physician  concerning  his  or her condition and proposed
 5        treatment,  to  refuse  any  treatment  to   the   extent
 6        permitted  by  law, and to privacy and confidentiality of
 7        records as provided by law.
 8             (4)  The right of each patient, regardless of source
 9        of  payment,  to  examine  and   receive   a   reasonable
10        explanation  of his or her total bill for services when a
11        bill is rendered by his or her physician or  health  care
12        provider,  including  the  itemized  charges for specific
13        services received. A provider shall be responsible for  a
14        reasonable   explanation   of   those  specific  services
15        provided or charges  by  the  physician  or  health  care
16        provider.
17             (5)  In  the  event  an  insurance company or health
18        care plan cancels  or  refuses  to  renew  an  individual
19        policy or plan, the insured or enrollee shall be entitled
20        to  timely, prior notice of the termination of the policy
21        or plan.
22             An  insurance  company  or  health  care  plan  that
23        requires any insured, enrollee, or applicant for  new  or
24        continued   insurance   or  coverage  to  be  tested  for
25        infection with HIV  or  any  other  identified  causative
26        agent  of  AIDS  shall  (1) give the patient or applicant
27        prior written notice of  such  requirement,  (2)  proceed
28        with  such testing only upon the written authorization of
29        the insured, enrollee, or applicant,  and  (3)  keep  the
30        results  of  the  testing  confidential.   Notice  of  an
31        adverse underwriting or coverage decision may be given to
32        any  appropriately  interested  party,  but the insurance
33        company or health care plan may disclose the test  result
34        itself  only  to  a  physician designated by the insured,
                            -7-               LRB9102446JSpcA
 1        enrollee, or applicant, and the disclosure shall be in  a
 2        manner that assures confidentiality.
 3             (6)  At  the time of renewal, the right of a patient
 4        to notification of termination or change in any benefits,
 5        services or service delivery office or site.
 6             (7)  The  right  of  a  patient   to   privacy   and
 7        confidentiality in health care.  A physician, health care
 8        provider, health care plan, and insurance company may not
 9        disclose  the  nature  or details of services provided to
10        insureds and enrollees, except that such information  may
11        be  disclosed  to the patient, the party making treatment
12        decisions if the patient is incapable of making decisions
13        regarding the health  services  provided,  those  parties
14        directly involved with providing treatment to the patient
15        or  processing  the  payment  for  that  treatment, those
16        parties responsible for peer review,  utilization  review
17        and  quality  assurance, and those parties required to be
18        notified under the Abused and Neglected  Child  Reporting
19        Act,  the Illinois Sexually Transmissible Disease Control
20        Act, or where otherwise authorized or  required  by  law.
21        This right may be waived in writing by the patient or the
22        patient's  guardian, but a physician or other health care
23        provider may not condition the provision of  services  on
24        the  patient's  or  guardian's  agreement  to sign such a
25        waiver.

26        Section 20.  Provision of information.
27        (a)  A health care plan shall provide to enrollees a list
28    of primary care physicians in the health care plan's  service
29    area  and an evidence of coverage that contains a description
30    of the following terms and conditions of coverage:
31             (1)  The service area.
32             (2)  Covered benefits, exclusions, or limitations.
33             (3)  Registration  and  other   utilization   review
                            -8-               LRB9102446JSpcA
 1        procedures requirements.
 2             (4)  A  description  of the limitations on access to
 3        specialist physicians.
 4             (5)  Emergency coverage and benefits both inside and
 5        out of the plan service area.
 6             (6)  A  description  of  post-stablization   medical
 7        service requirements.
 8             (7)  Out-of-area coverages and benefits, if any.
 9             (8)  The  enrollee's  financial  responsibility  for
10        copayments,  deductibles,  and  any  other  out-of-pocket
11        expenses.
12             (9)  Provisions  for  continuity of treatment in the
13        event a provider's participation  terminates  during  the
14        course  of  an  insured's or enrollee's treatment by that
15        provider.
16             (10)  The grievance process, including the telephone
17        number  to  call  to   receive   information   concerning
18        grievance procedures.
19        (b)  Upon  written  request,  a  health  care  plan shall
20    provide  to  enrollees  a  description   of   the   financial
21    relationships  between the health care plan and any provider,
22    except that no health care plan shall be required to disclose
23    specific reimbursement to  providers.
24        (c)  A participating provider shall provide to  enrollees
25    upon request:
26             (1)  information   related   to   the   health  care
27        professional's   educational   background,    experience,
28        training,   specialty,   and   board   certification,  if
29        applicable;
30             (2)  the  names  of  licensed  facilities   on   the
31        provider  panel  where  the health professional presently
32        has privileges for the treatment, illness,  or  procedure
33        that is the subject of the request; and
34             (3)  information    regarding    the   health   care
                            -9-               LRB9102446JSpcA
 1        professional's  participation  in  continuing   education
 2        programs    and    compliance    with    any   licensure,
 3        certification,   or   registration    requirements,    if
 4        applicable.

 5        Section   25.  Prohibited  restraints  on  communication.
 6    Nothing in a physician's contract with  a  health  care  plan
 7    shall  be  construed  to  impair  the physician's ethical and
 8    legal duty to  provide  full  informed  consent  and  medical
 9    counsel to enrollees, including full discussion of the costs,
10    benefits,  risks,  and alternatives related to the enrollee's
11    treatment options and care and the health care plan  policies
12    related   to   those  options,  including  health  care  plan
13    requirements, coverage,  exclusions,  or  other  policies  or
14    practices  that  affect  enrollees'  access  to  coverage  or
15    treatment options.

16        Section 30.  Access to personnel and facilities.
17        (a)  A health care plan shall include a sufficient number
18    and type of primary care physicians and specialist physicians
19    throughout  the  service  area to meet the needs of enrollees
20    and to provide meaningful choice.  A health care  plan  shall
21    offer:
22             (1)  accessible acute care hospital services, within
23        a reasonable distance or travel time;
24             (2)  primary  care  physicians,  within a reasonable
25        distance or travel time; and
26             (3)  specialist  physicians  within   a   reasonable
27        distance or travel time.
28        When  the  type  of medical service needed for a specific
29    condition is not represented in the  provider  network,  upon
30    request,  the health care plan shall arrange for the enrollee
31    to have access to  qualified  non-participating  health  care
32    professionals as authorized by the primary care physician.
                            -10-              LRB9102446JSpcA
 1        (b)  A health care plan shall provide telephone access to
 2    the  health  care  plan  for  sufficient time during business
 3    hours to assure enrollee access for routine care and 24  hour
 4    telephone  access to the health care plan or, if so delegated
 5    by the health care plan, a participating physician  or  group
 6    for emergency care or authorization for care.
 7        (c)  A   health  care  plan  shall  establish  reasonable
 8    standards for waiting times to obtain appointments, except as
 9    provided below for emergency services.  The  standards  shall
10    include  appointment scheduling guidelines used for each type
11    of health care service, including prenatal care appointments,
12    well-child  visits  and  immunizations,  routine   physicals,
13    follow-up  appointments  for  chronic  conditions, and urgent
14    care.
15        (d)  A health care plan shall provide for  continuity  of
16    care for its enrollees as follows:
17             (1)  If  an  enrollee's  physician leaves the health
18        care plan's network of providers for reasons  other  than
19        termination  with  cause and the physician remains within
20        the health care plan's service area, the health care plan
21        shall permit the enrollee upon  request  to  continue  an
22        ongoing  course of treatment with that physician during a
23        transitional period:
24                  (A)  of up to 60 days  from  the  date  of  the
25             notice  of  physician's  termination from the health
26             care plan network to the enrollee  if  the  enrollee
27             has a life threatening disease or condition; or
28                  (B)  that includes the provision of post-partum
29             care  directly  related  to  the  delivery,  if  the
30             enrollee   has   entered   the  third  trimester  of
31             pregnancy   at   the   time   of   the   physician's
32             disaffiliation.
33             (2)  Notwithstanding the  provisions  in  item  (1),
34        care  shall  be authorized by the health care plan during
                            -11-              LRB9102446JSpcA
 1        the transitional period only if the physician agrees to:
 2                  (A)  continue to accept reimbursement from  the
 3             health  care  plan  at the rates applicable prior to
 4             the start of the transitional period as  payment  in
 5             full;
 6                  (B)  adhere  to  the health care plan's quality
 7             assurance requirements and  provide  to  the  health
 8             care  plan  necessary medical information related to
 9             the care; and
10                  (C)  otherwise  adhere  to  the  organization's
11             policies and procedures including, but  not  limited
12             to,  procedures  regarding  referrals  and obtaining
13             pre-authorizations and a treatment plan approved  by
14             the health care plan.
15        (e)  A  health  care plan shall provide for continuity of
16    care for new enrollees as follows:
17             (1)  If a new enrollee  whose  physician  is  not  a
18        member of the health care plan's provider network, but is
19        within  the  health  care plan's service area, enrolls in
20        the health care plan, the health care  plan  shall,  upon
21        request from the enrollee, provide benefits for otherwise
22        covered  services  provided  by  the  enrollee's  current
23        physician  during  a transitional period of up to 60 days
24        from the effective date of enrollment if:
25                  (i)  the  enrollee   has   a   life-threatening
26             disease or condition; or
27                  (ii)  the   enrollee   has  entered  the  third
28             trimester of pregnancy  at  the  effective  date  of
29             enrollment,  in  which  case the transitional period
30             shall include  the  provision  of  post-partum  care
31             directly related to the delivery.
32             (2)  If  an  enrollee  elects to continue to receive
33        care from a physician pursuant to item (1), benefits  for
34        the  care shall be authorized by the health care plan for
                            -12-              LRB9102446JSpcA
 1        the transitional period only if the physician agrees to:
 2                  (A)  accept reimbursement from the health  care
 3             plan at rates established by the health care plan as
 4             payment  in  full,  such rates shall be no more than
 5             the level of  reimbursement  applicable  to  similar
 6             physicians within the health care plan's network for
 7             such services;
 8                  (B)  adhere  to  the health care plan's quality
 9             assurance requirements and  provide  to  the  health
10             care  plan  necessary medical information related to
11             the care; and
12                  (C)  otherwise adhere to the health care plan's
13             policies and procedures including, but  not  limited
14             to,  procedures  regarding  referrals  and obtaining
15             pre-authorization and a treatment plan  approved  by
16             the health care plan.
17        In  no event shall this Section be construed to require a
18    health  care  plan  to  provide  coverage  for  benefits  not
19    otherwise covered  or  to  diminish  or  impair  pre-existing
20    condition limitations contained in the subscriber's contract.

21        Section 35.  Access to specialist physicians.
22        (a)  A  health  care  plan shall establish a procedure by
23    which an enrollee, who has a condition that requires  ongoing
24    care  from  a  specialist physician, may apply for a standing
25    referral to  a  specialist  physician  if  a  referral  to  a
26    specialist   physician   is   required   for   coverage.  The
27    application shall be made to the health care  plan's  medical
28    director.  The  health care plan, at its sole discretion, may
29    establish procedures whereby acceptance  and  review  of  the
30    application  is  delegated  to  the  enrollee's  primary care
31    physician, independent practice association or medical group.
32    This procedure for  a  standing  referral  must  specify  the
33    necessary  criteria and conditions which must be met in order
                            -13-              LRB9102446JSpcA
 1    for an enrollee to obtain a standing referral.
 2        (b)  Unless waived by the health care plan, the  plan  at
 3    its sole discretion may require an enrollee to seek care from
 4    a  specialist physician who is currently participating in the
 5    health care plan's provider network and who is from the  same
 6    independent  practice  association  or  medical  group as the
 7    enrollee's primary care physician, if required by the  health
 8    care plan's procedure.
 9        (c)  When  the  type  of  specialist  physician needed to
10    provide  ongoing  care  for  a  specific  condition  is   not
11    represented  in  the same independent practice association or
12    medical group as the enrollee's primary care  physician,  the
13    health  care  plan  shall  arrange  for  the enrollee to have
14    access to a specialist physician participating in the  health
15    care plan's provider network.
16        (d)  When  the  type of specialist physician is needed to
17    provide  ongoing  care  for  a  specific  condition  is   not
18    represented  in  the health care plan's provider network, the
19    health care plan shall  arrange  for  the  enrollee  to  have
20    access   to   a   qualified   non-participating  health  care
21    professional.
22        (e)  The enrollee's primary care physician  shall  remain
23    responsible for coordinating the care of the enrollee who has
24    received  a  standing  referral  to  a  specialist physician.
25    Health care plans may require  the  specialist  physician  to
26    obtain  a  prior  approval  for  secondary referrals from the
27    primary care physician.  The health care plan or its delegate
28    may in providing the standing referral limit  the  number  of
29    visits  or  the  period during which the standing referral is
30    authorized.   In  addition,  the  health  care  plan  or  its
31    delegate  may  require  the  specialist  physician to provide
32    regular updates to the enrollee's primary care physician.
33        (f)  If an enrollee's application for a standing referral
34    is denied, an enrollee may appeal the  decision  through  the
                            -14-              LRB9102446JSpcA
 1    health  care  plan's grievance process required under Section
 2    50.

 3        Section 40.  Emergency services prior to stabilization.
 4        (a)  Except as provided for in subsection (c),  a  health
 5    care  plan  shall  cover emergency services without regard to
 6    prior authorization or the  treating  provider's  contractual
 7    relationship with the organization.
 8        (b)  Reimbursement  shall  be provided by the health care
 9    plan at the same rate as if the service or treatment had been
10    rendered by similar provider contracting with a  health  care
11    plan.
12        (c)  Payment   for  covered  emergency  services  may  be
13    denied:
14                  (1)  upon  determination  that  the   emergency
15             services claimed were not performed;
16                  (2)  upon    determination    that    emergency
17             evaluation   and  treatment  were  rendered   to  an
18             enrollee who sought  emergency  services  and  whose
19             circumstance   did   not   meet  the  definition  of
20             emergency medical condition;
21                  (3)  upon  determination   that   the   patient
22             receiving the services was not a covered enrollee of
23             the health care plan; or
24                  (4)  upon   material  misrepresentation  by  an
25             enrollee or provider.
26        (d)  The appropriate use of 911 telephone systems or  its
27    local  equivalent  shall not be discouraged or penalized when
28    an emergency medical condition exists.  This provision  shall
29    not  imply  that  the use of 911 or its local equivalent is a
30    factor in determining the existence of an  emergency  medical
31    condition.
32        (e)  For  purposes of coverage, the medical director's or
33    his or her designee's determination of  whether  an  enrollee
                            -15-              LRB9102446JSpcA
 1    meets the standard of an emergency medical condition shall be
 2    based  primarily  upon  the presenting symptoms documented in
 3    the medical record at  the  time  care  was  sought  and  the
 4    circumstances  that led an enrollee to believe that he or she
 5    had an emergency medical condition.
 6        (f)  For emergency medical service  claims  reviewed  for
 7    reimbursement,  the  emergency  department shall provide upon
 8    request of the health care plan, at no charge, a copy of  the
 9    medical  record  documenting  the  presenting symptoms of the
10    enrollee at the  time  care  was  sought  and  the  objective
11    findings of the medical examination.
12        (g)  Nothing in this Section prohibits a health care plan
13    from  imposing  deductibles,  coinsurance,  or  copayments in
14    covering emergency medical  services.   Copayments  may  vary
15    from those copayments charged for other covered services.

16        Section 45.  Post-stabilization medical services.
17        (a)  If      prior      benefit     authorization     for
18    post-stabilization medical services is required, the treating
19    provider shall contact the  health  care  plan  or  delegated
20    provider  as  designated  on  the  covered  enrollee's health
21    insurance card to obtain benefit authorization or  denial  or
22    benefit  authorization  for an alternate plan of treatment or
23    transfer of the covered enrollee.
24        (b)  The  treating  provider   shall   document   in   an
25    enrollee's medical record the enrollee's presenting symptoms,
26    emergency  medical  condition,  the  time,  phone  number  or
27    numbers  dialed,  and  result of the communication efforts to
28    request benefit authorization of  post-stabilization  medical
29    services.   The  health care plan shall provide reimbursement
30    as required under subsection (b) of Section 40  of  this  Act
31    for covered post-stabilization medical services if any of the
32    following apply:
33                  (1)  Benefit    authorization    for    covered
                            -16-              LRB9102446JSpcA
 1             post-stabilization medical services is received from
 2             the health care plan or its delegated provider.
 3                  (2)  After  at  least  2  documented good faith
 4             efforts over the course  of  60  minutes,  but  each
 5             effort being at least 10 minutes apart, the treating
 6             health  care  provider has attempted without success
 7             to contact an enrollee's health  care  plan  or  its
 8             delegated  health care provider, as designated on an
 9             enrollee's health insurance card, for prior  benefit
10             authorization    of    post-stabilization    medical
11             services.  A  "documented  good  faith effort" means
12             contacting  the  health  care  plan   or   delegated
13             provider  and  any  subsequent  parties  to whom the
14             calls are being forwarded in good faith.
15                  (3)  The  treating  health  care  provider  has
16             contacted the plan  or  designated  persons  with  a
17             request   for   prior   benefit   authorization   of
18             post-stabilization   services   in   one  of  its  2
19             documented good faith efforts as defined in item (2)
20             and the plan or designated persons did not deny  the
21             request within 60 minutes of receiving the request.
22        (c)  If  rendering  post-stabilization  medical  services
23    pursuant  to  item (2) or (3) of subsection (b), the treating
24    provider shall continue to make every  reasonable  effort  to
25    contact  the  health  care  plan  or  the  delegated provider
26    regarding  benefit  authorization  or   denial   or   benefit
27    authorization  for an alternate plan of treatment or transfer
28    of the covered enrollee until the treating provider  receives
29    benefit  authorization from the health care plan or delegated
30    provider for continued care or the  care  is  transferred  to
31    another health care provider or the patient is discharged.
32        (d)  Payment   for   covered  post-stabilization  medical
33    services may be denied:
34             (1)  if the treating  provider  does  not  meet  the
                            -17-              LRB9102446JSpcA
 1        conditions outlined in subsections (b) and (c);
 2             (2)  upon  determination that the post-stabilization
 3        medical services claimed were not performed;
 4             (3)  upon determination that the  post-stabilization
 5        medical services rendered were denied or were contrary to
 6        the  instructions  of  the  health care plan or delegated
 7        provider if contact was made between these parties  prior
 8        to the service being rendered;
 9             (4)  upon  determination  that the patient receiving
10        the services was not a covered  enrollee  of  the  health
11        care plan; or
12             (5)  upon  material misrepresentation by an enrollee
13        or provider.
14        (e)  Nothing in this Section prohibits a health care plan
15    from  delegating  the  responsibilities  enumerated  in  this
16    Section  to  the  health  care  plan's   contracted   medical
17    providers.
18        (f)  For   post-stabilization   medical  services  claims
19    reviewed for reimbursement, the  emergency  department  shall
20    provide upon request of the health care plan, at no charge, a
21    copy of the medical record.
22        (g)  Nothing in this Section prohibits a health care plan
23    from  imposing  deductibles,  coinsurance,  or  copayments in
24    covering post-stabilization medical services.  Copayments may
25    vary  from  those  copayments  charged  for   other   covered
26    services.

27        Section 50.  Grievance procedures.
28        (a)  A  health  care plan shall submit for the Director's
29    approval,  and  thereafter  maintain,  a   system   for   the
30    resolution  of  grievances concerning the provision of health
31    care services or other matters concerning  operation  of  the
32    health  care plan as provided in this Section.  A health care
33    plan shall:
                            -18-              LRB9102446JSpcA
 1             (1)  submit to the Director for prior  approval  any
 2        proposed changes to the system by which grievances may be
 3        filed and reviewed;
 4             (2)  maintain  records  on each grievance filed with
 5        the health care plan until the grievance is resolved  and
 6        for a period of at least 3 years including:
 7                  (A)  a  copy  of  the grievance and the date of
 8             its filing;
 9                  (B)  the date and outcome of all consultations,
10             hearings and hearing findings;
11                  (C)  the  date  and  decisions  of  any  appeal
12             proceedings; and
13                  (D)  the date and proceeding of any litigation;
14             and
15             (3)  submit to the Director, in a form prescribed by
16        the Director, a  report  by  March  1  for  the  previous
17        calendar year which shall include at least the following:
18                  (A)  the total number of grievances handled;
19                  (B)  a  compilation  of  causes  underlying the
20             grievances;
21                  (C)  the outcomes of the grievances;
22                  (D)  the  elapsed  time  from  receipt  of  the
23             grievance  by  the  health  care  plan   until   its
24             conclusion; and
25                  (E)  the  number  of  malpractice claims filed,
26             and   if   those   claims   have   been   completely
27             adjudicated, a compilation of  causes,  disposition,
28             form, and amount of any settlements.
29        (b)  A  health care plan shall have a grievance committee
30    that has the authority to hear and resolve by  majority  vote
31    grievances submitted to it as provided in subsection (a).
32             (1)  Notwithstanding  any  other  provisions of this
33        Section, the grievance committee may, but is not required
34        to, hear any grievance that alleges or indicates possible
                            -19-              LRB9102446JSpcA
 1        professional liability, commonly known as "malpractice."
 2             (2)  The  committee  is  not  empowered  to  resolve
 3        grievances in  any  manner  that  is,  or  prescribe  any
 4        actions  that  are,  in conflict with written policies of
 5        the health care plan's governing body, but the  committee
 6        may  hear  those  grievances for the purpose of providing
 7        input to the governing body.
 8             (3)  The grievance committee shall meet at the  main
 9        office   of  the  health  care  plan  or  another  office
10        designated by the health care plan when the  main  office
11        is  not  within  50 miles of the grievant's home address.
12        Consideration shall be given to  the  enrollee's  request
13        pertaining  to  the  time  and  date of the meeting.  The
14        enrollee shall have the right to attend  and  participate
15        in  the formal grievance proceedings.  The enrollee shall
16        have  the  right  to  be  accompanied  by  a   designated
17        representative of his or her choice.
18             (4)  The  filing  of  a grievance shall not preclude
19        the enrollee from filing a complaint with the  Department
20        nor shall it preclude the Department from investigating a
21        complaint  pursuant to its authority under Section 4-6 of
22        the Health Maintenance Organization Act.
23        (c)  The grievance procedures must be fully  and  clearly
24    communicated  to all enrollees and information concerning the
25    procedures shall be readily available to the enrollee.
26        (d)  A health care plan shall have simplified  procedures
27    for  resolving  complaints.   These procedures do not require
28    review of the complaint by the  grievance  committee,  but  a
29    log,  file,  or  other  similar records must be maintained to
30    identify the general nature of the complaints.  Resolution of
31    the complaints shall not  preclude  the  enrollees'  rightful
32    access to review by the grievance committee of a grievance.
33        (e)  The health care plan shall institute procedures that
34    require  grievances  to  have  a  determination  made  by the
                            -20-              LRB9102446JSpcA
 1    grievance  committee  within  60  days  after  the  date  the
 2    grievance is received by the health care plan.   A  grievance
 3    may  not  be  heard  or  voted  upon unless 50% of the voting
 4    individuals of the  committee  present  at  the  hearing  are
 5    enrollees.   The determination by the grievance committee may
 6    be extended for a period not to exceed 30 days in  the  event
 7    of  delay in obtaining documents or records necessary for the
 8    resolution of the grievance.  All requests for  documents  or
 9    records  necessary  for the resolution of the grievance shall
10    be maintained in the health care plan's grievance file.
11        (f)  The grievance procedure shall provide  the  enrollee
12    with  a  written  acknowledgment of their grievance within 10
13    business days after receipt by the health care plan.
14        (g)  The enrollee shall be notified at the  time  of  the
15    hearing  of  the  name  and  affiliation  of  those grievance
16    committee members who are representatives of the health  care
17    plan.
18        (h)  The  health  care  plan  shall  institute procedures
19    whereby  any  document  furnished  to  the  members  of   the
20    grievance  committee  shall  also  be  made  available to the
21    enrollee not less than 5 business days prior to  the  hearing
22    of  their  grievance.  The health care plan shall not present
23    any evidence without  the  enrollee  having  been  given  the
24    opportunity to be present.
25        (i)  Notice  in  writing  of  the  determination  of  the
26    grievance  committee shall be mailed to the enrollee within 5
27    business  days  after  the  determination.   Notice  of   the
28    determination  made  at  the  final appeal step of the health
29    care plan's grievance process  shall  include  a  "Notice  of
30    Availability  of  the  Department"  to  receive complaints as
31    provided  in  Section   4-6   of   the   Health   Maintenance
32    Organization Act.
33        (j)  Prior  to  the  resolution of a grievance filed by a
34    subscriber or enrollee, coverage shall not be terminated  for
                            -21-              LRB9102446JSpcA
 1    any  reason  that  is  the  subject of the written grievance,
 2    except where the health care plan has, in good faith, made  a
 3    reasonable  effort  to  resolve the written grievance through
 4    its grievance procedure and coverage is being terminated as a
 5    result of good cause.

 6        Section 55.  Review of medical necessity.  A health  care
 7    plan  shall  provide  a  mechanism for the timely review by a
 8    physician holding the same class of license  as  the  primary
 9    care  physician,  who  is unaffiliated with health care plan,
10    jointly selected by the patient (or the patient's next of kin
11    or legal representative if the patient is unable to  act  for
12    himself),  and  the  patient's primary care physician and the
13    health care plan in  the  event  of  a  dispute  between  the
14    primary care physician and the health care plan regarding the
15    medical  necessity  of  a  covered  service  proposed  by the
16    primary care physician.  In  the  event  that  the  reviewing
17    physician  determines  the  covered  service  to be medically
18    necessary, the health care plan  shall  provide  the  covered
19    service.   Future  contractual  or  employment  action by the
20    health care plan regarding the primary care  physician  shall
21    not  be based solely on the physician's participation in this
22    procedure.

23        Section 60.  Expedited review of medical necessity.
24        (a)  A health care plan shall have  an  expedited  review
25    procedure   whereby   an  enrollee  with  a  life-threatening
26    condition, or physician  authorized  in  writing  to  act  on
27    behalf of the enrollee with a life-threatening condition, may
28    appeal  a health care plan's decision of medical necessity of
29    a covered service.
30        (b)  The expedited review procedure shall provide that an
31    initial determination of the  review  will  be  made  by  the
32    health care plan not later than 3 business days after receipt
                            -22-              LRB9102446JSpcA
 1    of all necessary information to complete the review process.
 2        (c)  After  the  initial  adverse  determination  by  the
 3    health  care  plan,  the enrollee, or physician authorized in
 4    writing to act on behalf of the enrollee, may request further
 5    review by  the  health  care  plan.   If  further  review  is
 6    requested,  a  final  determination  by  the health care plan
 7    shall be made not later than 30 days  after  receipt  of  all
 8    necessary  information  to  complete  further  review.   Upon
 9    notification  to the enrollee of the health care plan's final
10    determination resulting from the  expedited  review  process,
11    the plan shall provide the enrollee a "Notice of Availability
12    of  the  Department"  to  receive  complaints  as provided in
13    Section 4-6 of the Health Maintenance Organization Act.
14        (d)  A request for an expedited review under this Section
15    must contain a statement submitted by the  physician,  orally
16    or  in  writing,  substantiating  that  the  enrollee  has  a
17    life-threatening  condition. This Section does not apply to a
18    provider's complaint concerning claims payment, handling,  or
19    reimbursement for health care services.
20        (e)  If  the expedited review process is invoked it shall
21    be in place of and not in  addition  to  the  regular  review
22    process.

23        Section 65.  Registration of utilization review programs.
24        (a)  All   utilization  review  programs  shall  register
25    annually with the Department.
26        (b)  The utilization review program shall submit  all  of
27    the following:
28             (1)  The   name,   address,  and  telephone  of  the
29        registrant.
30             (2)  The organization and governing structure of the
31        registrant.
32             (3)  List of insurance  companies  and  health  care
33        plans  for  which the utilization review program performs
                            -23-              LRB9102446JSpcA
 1        utilization review in this State and the number of  lives
 2        for which utilization review is conducted.
 3             (4)  Hours of operation.
 4             (5)  Description of the grievance process.
 5             (6)  Number  of  covered lives for which utilization
 6        review was conducted for the previous calendar year.
 7             (7)  Written policies and procedures for  protecting
 8        confidential  information  according  to applicable State
 9        and federal laws.
10        (c)  If the Director determines that an insurance company
11    or health care plan licensed  by  the  Department  meets  the
12    provisions  of  the  requirements  of  this Section under its
13    licensing process, he or she may exempt the insurance company
14    or health care plan from providing duplicate information.

15        Section 70.  Managed care  community  networks.   Managed
16    care  community  networks  providing or arranging health care
17    services under contract with the State exclusively to persons
18    who are  enrolled  in  the  integrated  health  care  program
19    established  under  Section 5-16.3 of the Illinois Public Aid
20    Code or a managed care community network owned, operated,  or
21    governed  by  a county provider as defined in Section 15-1 of
22    that Code are required to comply with Sections 15, 20, and 25
23    of this Act and are exempt from all other  Sections  of  this
24    Act.  The Illinois Department of Public Aid shall adopt rules
25    to implement these provisions.

26        Section 75.  Collection rights.
27        (a)  Providers  and  their  assignees  or  subcontractors
28    shall  not  seek  any  type  of  payment  from, bill, charge,
29    collect a deposit from,  or  have  any  recourse  against  an
30    enrollee,  persons acting on an enrollee's behalf (other than
31    the health care plan), the employer, or group contract holder
32    for emergency services or post-stabilization medical services
                            -24-              LRB9102446JSpcA
 1    provided, except for the payment of applicable copayments  or
 2    deductibles  for  services covered by the health care plan or
 3    fees for services not covered under an enrollee's evidence of
 4    coverage.
 5        (b)  Any collection  or  attempt  to  collect  moneys  or
 6    maintain   action  against  any  subscriber  or  enrollee  as
 7    prohibited in subsection (a) may be reported to the  Director
 8    by  any  person.   Any  person  making such a report shall be
 9    immune from liability for doing so.
10        (c)  The Director  shall investigate such reports.
11        (d)  If the  Director  finds  that  providers  and  their
12    assignees  or  subcontractors are not in compliance with this
13    Section, he or she shall provide  the  person  attempting  to
14    bill,  charge,  collect a deposit from, or institute recourse
15    against an enrollee with a written notice of the reasons  for
16    the  finding  and  shall  allow  14 days to supply additional
17    information demonstrating compliance with the requirements of
18    this Section and the opportunity to request a  hearing.   The
19    Director  shall  send  a  hearing  notice  by certified mail,
20    return receipt requested, and conduct a hearing in accordance
21    with the Illinois Administrative Procedure Act.
22        (e)  Within 14 days after the final decision is  rendered
23    under  subsection  (d),  the Director shall provide a written
24    notice of the report to the reported provider's licensing  or
25    disciplinary board or committee and require that the provider
26    reimburse,  with  interest  at  the  rate of 8% per year, the
27    subscriber or enrollee any moneys found to  be  collected  in
28    violation of this Section.
29        (f)  The  Director shall maintain a record of all notices
30    to licensing or disciplinary boards or committees pursuant to
31    this Section.  This record shall be provided  to  any  person
32    within 14 days of the Director's receipt of a written request
33    for the record.
34        (g)  The  Department, any enrollee, subscriber, or health
                            -25-              LRB9102446JSpcA
 1    care plan may pursue injunctive relief to  ensure  compliance
 2    with this Section.

 3        Section 80.  Penalties.
 4        (a)  Any  organization  that violates Section 20, 25, 30,
 5    35, 40, 45, 50, 55, or 60 of this Act shall be  guilty  of  a
 6    Class B misdemeanor.
 7        (b)  The  Director  may issue to any organization subject
 8    to this Act, a cease and desist order as provided in  Article
 9    XXIV, Section 401.1 of the Illinois Insurance Code.

10        Section 85.  Severability. The provisions of this Act are
11    severable under Section 1.31 of the Statute on Statutes.

12        Section  90.  Applicability  of  Act.  A health care plan
13    coverage amended, delivered, issued, or renewed in this State
14    after the effective date of this Act  must  comply  with  the
15    terms of this Act.

16        Section  99.  Effective  date.   This  Act  takes  effect
17    January 1, 2000.

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