Rep. Mary E. Flowers
Filed: 5/21/2008
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1 | AMENDMENT TO HOUSE BILL 2286
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2 | AMENDMENT NO. ______. Amend House Bill 2286 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The State Employees Group Insurance Act of 1971 | ||||||
5 | is amended by changing Section 6.11 as follows:
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6 | (5 ILCS 375/6.11)
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7 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
8 | Code
requirements. The program of health
benefits shall provide | ||||||
9 | the post-mastectomy care benefits required to be covered
by a | ||||||
10 | policy of accident and health insurance under Section 356t of | ||||||
11 | the Illinois
Insurance Code. The program of health benefits | ||||||
12 | shall provide the coverage
required under Sections 356f.1, | ||||||
13 | 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, | ||||||
14 | and 356z.10
356z.9 of the
Illinois Insurance Code.
The program | ||||||
15 | of health benefits must comply with Section 155.37 of the
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16 | Illinois Insurance Code.
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1 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
2 | 95-520, eff. 8-28-07; revised 12-4-07.)
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3 | Section 10. The Counties Code is amended by changing | ||||||
4 | Section 5-1069.3 as follows: | ||||||
5 | (55 ILCS 5/5-1069.3)
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6 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
7 | including a home
rule
county, is a self-insurer for purposes of | ||||||
8 | providing health insurance coverage
for its employees, the | ||||||
9 | coverage shall include coverage for the post-mastectomy
care | ||||||
10 | benefits required to be covered by a policy of accident and | ||||||
11 | health
insurance under Section 356t and the coverage required | ||||||
12 | under Sections 356f.1, 356g.5, 356u,
356w, 356x, 356z.6, and | ||||||
13 | 356z.9, and 356z.10
356z.9 of
the Illinois Insurance Code. The | ||||||
14 | requirement that health benefits be covered
as provided in this | ||||||
15 | Section is an
exclusive power and function of the State and is | ||||||
16 | a denial and limitation under
Article VII, Section 6, | ||||||
17 | subsection (h) of the Illinois Constitution. A home
rule county | ||||||
18 | to which this Section applies must comply with every provision | ||||||
19 | of
this Section.
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20 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
21 | 95-520, eff. 8-28-07; revised 12-4-07.)
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22 | Section 15. The Illinois Municipal Code is amended by | ||||||
23 | changing Section 10-4-2.3 as follows: |
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1 | (65 ILCS 5/10-4-2.3)
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2 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
3 | municipality, including a
home rule municipality, is a | ||||||
4 | self-insurer for purposes of providing health
insurance | ||||||
5 | coverage for its employees, the coverage shall include coverage | ||||||
6 | for
the post-mastectomy care benefits required to be covered by | ||||||
7 | a policy of
accident and health insurance under Section 356t | ||||||
8 | and the coverage required
under Sections 356f.1, 356g.5, 356u, | ||||||
9 | 356w, 356x, 356z.6, and 356z.9, and 356z.10
356z.9 of the | ||||||
10 | Illinois
Insurance
Code. The requirement that health
benefits | ||||||
11 | be covered as provided in this is an exclusive power and | ||||||
12 | function of
the State and is a denial and limitation under | ||||||
13 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
14 | Constitution. A home rule municipality to which
this Section | ||||||
15 | applies must comply with every provision of this Section.
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16 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
17 | 95-520, eff. 8-28-07; revised 12-4-07.)
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18 | Section 20. The School Code is amended by changing Section | ||||||
19 | 10-22.3f as follows: | ||||||
20 | (105 ILCS 5/10-22.3f)
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21 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
22 | protection and
benefits
for employees shall provide the | ||||||
23 | post-mastectomy care benefits required to be
covered by a |
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1 | policy of accident and health insurance under Section 356t and | ||||||
2 | the
coverage required under Sections 356f.1, 356g.5, 356u, | ||||||
3 | 356w, 356x,
356z.6, and 356z.9 of
the
Illinois Insurance Code.
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4 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
5 | revised 12-4-07.)
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6 | Section 25. The Illinois Insurance Code is amended by | ||||||
7 | adding Section 356f.1 as follows: | ||||||
8 | (215 ILCS 5/356f.1 new) | ||||||
9 | Sec. 356f.1. Third-party review. | ||||||
10 | (a) Definitions. For purposes of this Section, the | ||||||
11 | following definitions shall apply: | ||||||
12 | "Authorized representative" means: | ||||||
13 | (1) a person to whom a covered person has given express | ||||||
14 | written consent to represent the covered person in a | ||||||
15 | third-party review; | ||||||
16 | (2) a person authorized by law to provide substituted | ||||||
17 | consent for a covered person; or | ||||||
18 | (3) a family member of the covered person or the | ||||||
19 | covered person's treating health care professional only | ||||||
20 | when the covered person is unable to provide consent. | ||||||
21 | "Director" means the Director of the Division of Insurance | ||||||
22 | of the Department of Financial and Professional Regulation. | ||||||
23 | "Covered person" means an individual whose coverage under | ||||||
24 | an individual health insurance plan has been rescinded. |
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1 | "Division" means the Division of Insurance of the | ||||||
2 | Department of Financial and Professional Regulation. | ||||||
3 | "Disclose" means to release, transfer, or otherwise | ||||||
4 | divulge protected health information to any person other than | ||||||
5 | the individual who is the subject of the protected health | ||||||
6 | information. | ||||||
7 | "Health insurance plan" means a policy, contract, | ||||||
8 | certificate, or agreement issued by a
health carrier to | ||||||
9 | provide, deliver, arrange for, pay, or reimburse any of the | ||||||
10 | costs of health
care services. For the purposes of this | ||||||
11 | definition, "health insurance plan" does not include one or | ||||||
12 | more, or any combination of, the following: coverage only for | ||||||
13 | accident or disability income insurance; coverage issued as
a | ||||||
14 | supplement to liability insurance; liability insurance, | ||||||
15 | including general liability
insurance and automobile liability | ||||||
16 | insurance; workers' compensation or similar
insurance; | ||||||
17 | automobile medical payment insurance; credit-only insurance; | ||||||
18 | coverage for
on-site medical clinics; coverage similar to the | ||||||
19 | foregoing as specified in federal
regulations issued pursuant | ||||||
20 | to Public Law 104-191, under which benefits for medical
care | ||||||
21 | are secondary or incidental to other insurance benefits; dental | ||||||
22 | or vision benefits;
benefits for long-term care, nursing home | ||||||
23 | care, home health care, or community-based
care; specified | ||||||
24 | disease or illness coverage, hospital indemnity or other fixed | ||||||
25 | indemnity
insurance, or such other similar, limited benefits as | ||||||
26 | are specified in rules; Medicare
supplemental health insurance |
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1 | as defined under Section 1882(g)(1) of the Social Security
Act; | ||||||
2 | coverage supplemental to the coverage provided under Chapter 55 | ||||||
3 | of Title 10 of the
United States Code; or other similar limited | ||||||
4 | benefit supplemental coverages. | ||||||
5 | "Health care professional" means a physician or other | ||||||
6 | health care practitioner licensed,
accredited, or certified in | ||||||
7 | any state to perform specified health care services. | ||||||
8 | "Health care services" means services for the diagnosis, | ||||||
9 | prevention, treatment, or cure of a health condition, illness, | ||||||
10 | injury, or disease. | ||||||
11 | "Health carrier" means an entity subject to the insurance | ||||||
12 | laws and rules of this State or subject to the jurisdiction of | ||||||
13 | the Division that issues individual health insurance plans | ||||||
14 | covering one or more residents of this State, including a | ||||||
15 | sickness and accident insurance
company, a health maintenance | ||||||
16 | organization, a nonprofit hospital and health corporation, or | ||||||
17 | any other entity providing or issuing an individual health | ||||||
18 | insurance plan. | ||||||
19 | "Health maintenance organization" means an organization | ||||||
20 | licensed under the Health Maintenance Organization Act. | ||||||
21 | "Medicare" means coverage under both Parts A and B of Title | ||||||
22 | XVIII of the Social Security Act. | ||||||
23 | "Person" means an individual, a corporation, a | ||||||
24 | partnership, an association, a joint venture, a joint stock | ||||||
25 | company, a trust, an unincorporated organization, any similar | ||||||
26 | entity, or any combination of the foregoing. |
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1 | "Protected health information" means health information | ||||||
2 | that identifies an individual who is the subject of the | ||||||
3 | information or with respect to which there is a reasonable | ||||||
4 | basis to believe that the information could be used to identify | ||||||
5 | the individual. | ||||||
6 | "Rescission" means the process of voiding an individual | ||||||
7 | health insurance plan, from its
inception, on the grounds of | ||||||
8 | material misrepresentation or omission on the application for
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9 | insurance that would have resulted in a different decision by | ||||||
10 | the health carrier with respect to
issuing coverage. | ||||||
11 | "Review criteria" means the written screening procedures, | ||||||
12 | decision abstracts, clinical protocols, the health carrier's | ||||||
13 | underwriting manual, and practice guidelines used by a health | ||||||
14 | carrier in making its rescission determination. | ||||||
15 | "Third-party review organization" means an entity that | ||||||
16 | conducts independent third-party reviews of rescission | ||||||
17 | decisions made by health carriers that are based on medical | ||||||
18 | issues for health insurance plan coverage. | ||||||
19 | (b) Purpose, applicability, and scope. The purpose of this | ||||||
20 | Section is to provide uniform standards for the establishment | ||||||
21 | and maintenance of third-party review procedures to ensure that | ||||||
22 | covered persons have the opportunity for an independent review | ||||||
23 | of medical issues related to health carrier rescission | ||||||
24 | decisions. This Section shall apply to rescission decisions | ||||||
25 | made by health carriers that are based on medical issues for | ||||||
26 | health insurance plan coverage. This Section does not extend to |
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1 | allegations related to agent conduct or decisions not based on | ||||||
2 | medical issues, such as residency and marital status. | ||||||
3 | (c) Notice of right to third-party review. A health carrier | ||||||
4 | shall notify the covered person in writing of the covered | ||||||
5 | person's right to request a third-party review to be conducted | ||||||
6 | pursuant to subsection (f) of this Section and include the | ||||||
7 | appropriate statements and information set forth in this | ||||||
8 | subsection (c) at the same time the health carrier sends | ||||||
9 | written notice of the rescission of the individual health | ||||||
10 | insurance plan. As part of the written notice required under | ||||||
11 | this subsection (c), a health carrier shall include the | ||||||
12 | following, or substantially equivalent, language: | ||||||
13 | "We have rescinded your coverage with us based on a | ||||||
14 | material
misrepresentation contained in your application. | ||||||
15 | After you have followed the
procedures for our internal | ||||||
16 | grievance process for this rescission decision (if
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17 | applicable), you may have the right to have our decision | ||||||
18 | reviewed by health care and
legal professionals who have no | ||||||
19 | association with us if our decision was based on a
medical | ||||||
20 | issue by submitting a request for third-party review to the | ||||||
21 | Director at
the following address: (insert address where | ||||||
22 | covered persons are to submit requests
for third-party | ||||||
23 | review)." | ||||||
24 | The health carrier shall include the following information | ||||||
25 | in or attached to the notice required under this subsection | ||||||
26 | (c): |
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1 | (1) a description of the standard and expedited | ||||||
2 | third-party review procedures required under this Section, | ||||||
3 | highlighting the provisions that give the covered person or | ||||||
4 | the covered person's authorized representative the right | ||||||
5 | to file a request for an expedited third-party review if | ||||||
6 | the covered person has a medical condition where the | ||||||
7 | timeframe for completion of an expedited review of the | ||||||
8 | grievance or a standard third-party review under this | ||||||
9 | Section would seriously jeopardize the life or health of | ||||||
10 | the covered person or would jeopardize the covered person's | ||||||
11 | ability to regain maximum function; and | ||||||
12 | (2) an authorization form or other document approved by | ||||||
13 | the Director that complies with the requirements of 45 | ||||||
14 | C.F.R. 164.508 by which the covered person, for purposes of | ||||||
15 | conducting a third-party review under this Section, | ||||||
16 | authorizes the health carrier and the covered person's | ||||||
17 | treating provider to disclose protected health | ||||||
18 | information, including medical records, concerning the | ||||||
19 | covered person that are pertinent to the third-party | ||||||
20 | review, as provided under State medical record privacy laws | ||||||
21 | and Article XL of this Code. | ||||||
22 | (d) Third-party review requests. All requests for | ||||||
23 | third-party review shall be made in writing to the Director. | ||||||
24 | An expedited third-party review process shall be made | ||||||
25 | available for the
review of health carrier rescission | ||||||
26 | decisions. For expedited third-party review of a rescission |
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1 | decision, a covered person or the covered person's authorized | ||||||
2 | representative may file a written request for an expedited | ||||||
3 | third-party review with the Director after the exhaustion of | ||||||
4 | the health carrier's internal grievance process in accordance | ||||||
5 | with the requirements of
subsection (e) of this Section or | ||||||
6 | after the receipt of the written notice of the right to | ||||||
7 | third-party review pursuant to subsection (c) of this Section, | ||||||
8 | whichever is later. | ||||||
9 | (e) Exhaustion of internal grievance process. A | ||||||
10 | third-party review cannot commence until the covered person has | ||||||
11 | exhausted the health carrier's internal grievance process in | ||||||
12 | accordance with the requirements of this subsection (e). | ||||||
13 | For rescission decisions, a covered person shall be | ||||||
14 | considered to have exhausted the health
carrier's internal | ||||||
15 | grievance process for purposes of this Section if: | ||||||
16 | (1) the health carrier has an internal grievance | ||||||
17 | process for rescission decisions and the covered
person or | ||||||
18 | the covered person's authorized representative has | ||||||
19 | complied with all of the
steps required in the health | ||||||
20 | carrier's internal grievance process that is established
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21 | pursuant to this Section and, except to the extent
the | ||||||
22 | covered person or the covered person's authorized | ||||||
23 | representative requested or agreed
to a delay, has not | ||||||
24 | received a written decision on the grievance from the | ||||||
25 | health carrier
within 30 days after the date the covered | ||||||
26 | person or the covered person's
authorized representative |
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1 | filed the grievance with the health carrier or the date the | ||||||
2 | health
carrier receives any requested information, | ||||||
3 | whichever is later; | ||||||
4 | (2) the grievance concerns a rescission decision and | ||||||
5 | the covered person (i) is subject to procedures, | ||||||
6 | treatments, or an ongoing course of treatment ordered by a | ||||||
7 | health care provider, the suspension or termination of | ||||||
8 | which could significantly increase the risk to the person's | ||||||
9 | health or (ii) has received a treatment referral for a | ||||||
10 | service, procedure, or other health care service, the | ||||||
11 | denial of which could significantly increase the risk to | ||||||
12 | the person's health, the policy or plan must allow for the | ||||||
13 | filing of an expedited internal grievance either orally or | ||||||
14 | in writing; upon submission of the expedited internal | ||||||
15 | grievance, a policy or plan must notify the party filing | ||||||
16 | the expedited internal grievance as soon as possible, but | ||||||
17 | in no event more than 24 hours after the submission of the | ||||||
18 | expedited internal grievance, of all information that the | ||||||
19 | plan requires to evaluate the expedited internal | ||||||
20 | grievance; the policy or plan shall render a decision on | ||||||
21 | the expedited internal grievance within 24 hours after | ||||||
22 | receipt of the required information; the policy or plan | ||||||
23 | shall notify the party filing the expedited internal | ||||||
24 | grievance and the person, the person's primary care | ||||||
25 | physician, and any health care provider who recommended the | ||||||
26 | health care service involved in the expedited internal |
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1 | grievance of its decision orally followed by a written | ||||||
2 | notice of the determination; or | ||||||
3 | (3) the health carrier waives the exhaustion | ||||||
4 | requirement in writing. | ||||||
5 | (f) Third-party review process - standard and expedited. | ||||||
6 | Immediately following receipt of a request for an expedited | ||||||
7 | third-party review, or within one business day after the date | ||||||
8 | of receipt of a request for a standard third-party review, the | ||||||
9 | Director shall do the following: | ||||||
10 | (1) send a copy of the request to the health carrier; | ||||||
11 | and | ||||||
12 | (2) send written notice to the covered person or the | ||||||
13 | covered person's authorized
representative informing him | ||||||
14 | or her of the right to submit additional information to the
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15 | Director that the covered person or the covered person's | ||||||
16 | authorized
representative would like considered by the | ||||||
17 | health carrier. These materials must
be submitted to the | ||||||
18 | Director within 3 business days after receipt of
the | ||||||
19 | Director's written notice provided under this subsection | ||||||
20 | (f). | ||||||
21 | Within one business day after receipt of any information | ||||||
22 | submitted by the covered
person or the covered person's | ||||||
23 | authorized representative pursuant to this subsection
(f), the | ||||||
24 | Director shall forward the information to the health carrier. | ||||||
25 | Upon receipt of the information, if any, required to be | ||||||
26 | forwarded pursuant to this subsection (f), the health carrier |
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1 | may reconsider its determination that is the subject of the | ||||||
2 | third-party review. Reconsideration by the health carrier of | ||||||
3 | its determination pursuant to this subsection (f) shall not | ||||||
4 | delay or terminate the third-party review. The third-party | ||||||
5 | review may only be terminated if the health carrier decides, | ||||||
6 | upon completion of its reconsideration, to reverse its
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7 | determination and provide coverage for the health care service | ||||||
8 | or reinstate the health insurance plan. Within one business day | ||||||
9 | after making the decision to reverse its determination
pursuant | ||||||
10 | to this subsection (f), the health carrier shall notify the | ||||||
11 | covered person, the covered person's authorized | ||||||
12 | representative, the assigned third-party review organization, | ||||||
13 | and the Director in writing of its decision. The assigned | ||||||
14 | third-party review organization shall terminate the | ||||||
15 | third-party review upon receipt of the notice from the health | ||||||
16 | carrier sent pursuant to this subsection (f). | ||||||
17 | Immediately following receipt of a request for an expedited | ||||||
18 | third-party review or within 5 business days after the date of | ||||||
19 | receipt of a standard third-party review request, the Director | ||||||
20 | shall complete a preliminary review of the request to determine | ||||||
21 | the following concerning rescission third-party reviews: | ||||||
22 | (i) the individual's coverage under an individual | ||||||
23 | health insurance plan has been rescinded; | ||||||
24 | (ii) the rescission decision made by the health carrier | ||||||
25 | is based on a medical issue; | ||||||
26 | (iii) if the health carrier has an internal grievance |
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1 | process for rescission decisions, the
covered person has | ||||||
2 | exhausted the health carrier's internal grievance process | ||||||
3 | as set
forth in this Section, unless the covered
person is | ||||||
4 | exempt under subsection (e) of this Section; and | ||||||
5 | (iv) the covered person has provided all the | ||||||
6 | information and forms required to proceed
with the | ||||||
7 | third-party review. | ||||||
8 | The Director shall notify the covered person, the covered | ||||||
9 | person's authorized
representative, and the health carrier in | ||||||
10 | writing whether the request is complete and
eligible for | ||||||
11 | third-party review immediately after completion of the | ||||||
12 | preliminary review under this subsection (f) for an expedited | ||||||
13 | third-party review request or within one business day after | ||||||
14 | completion of the preliminary review under this subsection (f) | ||||||
15 | for a standard third-party review request. If the request is | ||||||
16 | not complete, the Director shall include a statement in the | ||||||
17 | notice required under this subsection (f) informing the covered | ||||||
18 | person, the covered person's
authorized representative, and | ||||||
19 | the health carrier in writing and include in the notice what
| ||||||
20 | information or materials are needed to make the request | ||||||
21 | complete. If the request is not eligible for third-party | ||||||
22 | review, the Director shall include a statement in the notice | ||||||
23 | required under this subsection (f) informing the covered | ||||||
24 | person, the covered person's authorized representative, and | ||||||
25 | the health carrier in writing and include in the notice the | ||||||
26 | reasons for its ineligibility. If the request is complete and |
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1 | eligible for third-party review, the Director shall
| ||||||
2 | immediately randomly assign a third-party review organization | ||||||
3 | from the list of approved
third-party review organizations | ||||||
4 | compiled and maintained pursuant to subsection (j) of this | ||||||
5 | Section to conduct the third-party review and shall notify the | ||||||
6 | third-party review organization and the health carrier of the | ||||||
7 | assignment. | ||||||
8 | The health carrier shall provide to the assigned | ||||||
9 | third-party review organization the
documents and any | ||||||
10 | information considered in making its determination within one | ||||||
11 | business day after the date of receipt of the notice provided | ||||||
12 | pursuant to this subsection (f) for expedited third-party | ||||||
13 | review or within 5 business days after the date of receipt of | ||||||
14 | the notice provided
pursuant to this subsection (f) for | ||||||
15 | standard third-party reviews. Failure by the health carrier to | ||||||
16 | provide the documents and information within the time specified | ||||||
17 | in this subsection (f) shall not delay the conduct of the | ||||||
18 | third-party review. If the health carrier fails to provide the | ||||||
19 | documents and information within the time specified in this | ||||||
20 | subsection (f), the assigned third-party review organization | ||||||
21 | may terminate the third-party review and make a decision to | ||||||
22 | reverse the health carrier's determination. Within one | ||||||
23 | business day after making the decision under this subsection | ||||||
24 | (f), the third-party review organization shall notify the | ||||||
25 | covered person,
the covered person's authorized | ||||||
26 | representative, if applicable, the health carrier,
and the |
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1 | Director. | ||||||
2 | (g) Third-party review process - health care review panel. | ||||||
3 | The assigned third-party review organization shall select a | ||||||
4 | panel of health care professional reviewers and legal reviewers | ||||||
5 | to conduct the third-party review in accordance with subsection | ||||||
6 | (f) of this Section immediately after being assigned by the | ||||||
7 | Director to conduct an expedited
third-party review or within | ||||||
8 | one business day after being assigned by the Director to | ||||||
9 | conduct
a standard third-party review. | ||||||
10 | For third-party reviews of rescission decisions, the panel | ||||||
11 | shall consist of one health care professional reviewer and 2 | ||||||
12 | legal reviewers and must include individuals with expertise and | ||||||
13 | knowledge of the individual health insurance market, including | ||||||
14 | the underwriting process. In selecting the third-party review | ||||||
15 | panel, the assigned third-party review
organization shall | ||||||
16 | select physicians, health care professionals, and attorneys | ||||||
17 | who
meet the minimum qualifications described in subsections | ||||||
18 | (k) and (l) of this Section. Neither the covered person, the | ||||||
19 | covered person's authorized representative, the health | ||||||
20 | carrier, nor the Director shall choose or control the choice of | ||||||
21 | the physicians, health care professionals, or attorneys | ||||||
22 | selected to conduct the third-party review. | ||||||
23 | The third-party review panel shall provide an opinion to | ||||||
24 | the assigned third-party review
organization on whether the | ||||||
25 | medical condition should be covered or whether the health
| ||||||
26 | insurance plan should be reinstated as expeditiously as the |
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1 | covered person's medical condition or circumstances require, | ||||||
2 | but in no event more than 2 business days after being selected | ||||||
3 | to conduct the expedited third-party review or within 20 days | ||||||
4 | after being selected to conduct the standard third-party | ||||||
5 | review. | ||||||
6 | Each third-party review panel opinion shall be in writing | ||||||
7 | and include the following information: | ||||||
8 | (1) a description of the covered person's medical | ||||||
9 | condition; | ||||||
10 | (2) a description of the relevant information from the | ||||||
11 | individual's application; | ||||||
12 | (3) a description and analysis of any medical or | ||||||
13 | scientific evidence considered in
reaching the opinion; | ||||||
14 | (4) a description and analysis of any applicable legal | ||||||
15 | standard or requirement; | ||||||
16 | (5) an identification of the applicable terms of the | ||||||
17 | health insurance plan; and | ||||||
18 | (6) an explanation of the panel's rationale for the | ||||||
19 | opinion. | ||||||
20 | In rendering its decision, neither the third-party review | ||||||
21 | panel nor the third-party review
organization is bound by any | ||||||
22 | decisions or conclusions reached during the health carrier's
| ||||||
23 | initial determination or the health carrier's internal | ||||||
24 | grievance process, if applicable, as set
forth in this Section; | ||||||
25 | however, the third-party review panel and the third-party | ||||||
26 | review organization must use the health carrier's underwriting |
| |||||||
| |||||||
1 | guidelines that were in effect at the time the person was first | ||||||
2 | issued the health insurance plan. | ||||||
3 | The assigned third-party review organization shall make a | ||||||
4 | decision and provide written
notice of the decision, in | ||||||
5 | accordance with this subsection (g), to the covered person, the | ||||||
6 | covered person's authorized representative, the health | ||||||
7 | carrier, and the Director immediately upon receipt of the | ||||||
8 | third-party review panel opinion, but in no event
more than 3 | ||||||
9 | business days after being selected to conduct the expedited | ||||||
10 | third-party review or within 20 days after receipt of the | ||||||
11 | third-party review panel opinion, but in no event more than 45 | ||||||
12 | days after being selected to conduct the standard third-party | ||||||
13 | review. | ||||||
14 | The third-party review organization shall include the | ||||||
15 | following information in the notice
sent pursuant to this | ||||||
16 | subsection (g): | ||||||
17 | (i) a general description of the reason for the request | ||||||
18 | for third-party review; | ||||||
19 | (ii) the date the third-party review organization | ||||||
20 | received the assignment to conduct
the third-party review; | ||||||
21 | (iii) the written opinion of the third-party review | ||||||
22 | panel, including the recommendation
of the panel as to | ||||||
23 | whether the medical condition should be covered or the | ||||||
24 | health
insurance plan reinstated; | ||||||
25 | (iv) the date the third-party review was conducted, if | ||||||
26 | appropriate; |
| |||||||
| |||||||
1 | (v) the date of its decision; | ||||||
2 | (vi) the principal reason or reasons for its decision; | ||||||
3 | (vii) the rationale for its decision; and | ||||||
4 | (viii) references to the evidence or documentation | ||||||
5 | considered in reaching its decision,
including the | ||||||
6 | relevant portions of the covered person's application, the | ||||||
7 | terms of
the health insurance plan, any medical and | ||||||
8 | scientific evidence, and the applicable
legal | ||||||
9 | requirements. | ||||||
10 | Upon receipt of a notice of the third-party review | ||||||
11 | organization's decision pursuant to this subsection (g) that | ||||||
12 | reverses the health carrier's determination, the health | ||||||
13 | carrier immediately shall reinstate the health insurance plan | ||||||
14 | that was the subject of the third-party review. | ||||||
15 | (h) Binding nature of third-party review decision. A | ||||||
16 | third-party review decision is binding on the health carrier | ||||||
17 | except to the extent the health carrier has other remedies | ||||||
18 | available under applicable federal or State law. | ||||||
19 | A covered person or the covered person's authorized | ||||||
20 | representative may not file a subsequent request for | ||||||
21 | third-party review involving the same medical condition that | ||||||
22 | was the subject of the rescission decision or health carrier | ||||||
23 | determination for which the covered person has already received | ||||||
24 | a third-party review decision pursuant to this Section. | ||||||
25 | (i) Exhaustion of third-party review process. A covered | ||||||
26 | person or the covered person's authorized representative may |
| |||||||
| |||||||
1 | not pursue litigation of a health carrier's decisions based on | ||||||
2 | medical issues involved in a denial of a claim based on the | ||||||
3 | determination to rescind a policy until the covered person has | ||||||
4 | exhausted the third-party review process as set forth in this | ||||||
5 | Section. | ||||||
6 | (j) Approval of third-party review organizations. The | ||||||
7 | Director shall approve third-party review organizations | ||||||
8 | eligible to be assigned to conduct third-party reviews under | ||||||
9 | this Section. In order to be eligible for approval by the | ||||||
10 | Director under this Section to conduct third-party reviews | ||||||
11 | under this Section, a third-party review organization shall | ||||||
12 | submit an application for approval pursuant to this subsection | ||||||
13 | (j). The Director shall develop an application form for | ||||||
14 | initially approving and for re-approving third-party review | ||||||
15 | organizations to conduct third-party reviews. | ||||||
16 | Any third-party review organization wishing to be approved | ||||||
17 | to conduct third-party
reviews under this Section shall submit | ||||||
18 | the application form and include with the form all
| ||||||
19 | documentation and information necessary for the Director to | ||||||
20 | determine if the third-party review organization satisfies the | ||||||
21 | minimum qualifications established under subsections (k) and | ||||||
22 | (l) of this Section. The Director may charge an application fee | ||||||
23 | that third-party review organizations
shall submit to the | ||||||
24 | Director with an application for approval or re-approval. A | ||||||
25 | third-party review organization shall be deemed approved 90 | ||||||
26 | days after the date of receipt of a complete application |
| |||||||
| |||||||
1 | submitted under this subsection (j), unless the Director | ||||||
2 | disapproves the application within that period or the Director | ||||||
3 | extends the timeframe for an additional 90 days. If the | ||||||
4 | Director extends the timeframe for an additional 90 days, the | ||||||
5 | third-party review organization shall be deemed approved at the | ||||||
6 | end of that additional period, unless the Director disapproves
| ||||||
7 | the application within the extended 90-day period. | ||||||
8 | An approval is effective for 2 years, unless the Director | ||||||
9 | determines before its expiration that the third-party review | ||||||
10 | organization is not satisfying the minimum qualifications | ||||||
11 | established under subsections (k) and (l) of this Section. | ||||||
12 | Whenever the Director determines that a third-party review | ||||||
13 | organization no longer satisfies the minimum requirements | ||||||
14 | established under subsections (k) and (l) of this Section, the | ||||||
15 | Director shall terminate the approval of the third-party review | ||||||
16 | organization and remove the third-party review organization | ||||||
17 | from the list of third-party review organizations approved to | ||||||
18 | conduct third-party reviews under this Section that is | ||||||
19 | maintained by the Director. The Director shall maintain and | ||||||
20 | periodically update a list of approved third-party review | ||||||
21 | organizations. | ||||||
22 | (k) Minimum qualifications for third-party review | ||||||
23 | organizations' written policies and procedures. To be approved | ||||||
24 | under subsection (j) of this Section to conduct third-party | ||||||
25 | reviews, a third-party review organization shall have and | ||||||
26 | maintain written policies and procedures that govern all |
| |||||||
| |||||||
1 | aspects of both the standard third-party review process and the | ||||||
2 | expedited third-party review process set forth in this Section, | ||||||
3 | which include, at a minimum, the following: | ||||||
4 | (1) a quality assurance mechanism in place that | ||||||
5 | ensures: | ||||||
6 | (A) that third-party reviews are conducted within | ||||||
7 | the specified time frames and required notices are | ||||||
8 | provided in a timely manner; | ||||||
9 | (B) the selection of qualified and impartial | ||||||
10 | health care professional reviewers and legal reviewers | ||||||
11 | with expertise and knowledge about the individual | ||||||
12 | health insurance market, including the underwriting | ||||||
13 | process, to conduct each third-party review on behalf | ||||||
14 | of the third-party review organization, suitable | ||||||
15 | matching of reviewers to specific cases, and that the | ||||||
16 | third-party review organization employs or contracts | ||||||
17 | with an adequate number of health care professional | ||||||
18 | reviewers and legal reviewers to meet this objective; | ||||||
19 | (C) the confidentiality of medical and treatment | ||||||
20 | records and review criteria; and | ||||||
21 | (D) that any person employed by or under contract | ||||||
22 | with the third-party review organization adheres to | ||||||
23 | the requirements of this Section; | ||||||
24 | (2) a toll-free telephone service to receive | ||||||
25 | information on a 24-hour-a-day, 7-day-a-week basis related | ||||||
26 | to third-party reviews that is capable of accepting, |
| |||||||
| |||||||
1 | recording, or providing appropriate instruction to | ||||||
2 | incoming telephone callers during other than normal | ||||||
3 | business hours; and | ||||||
4 | (3) agreement to maintain and provide to the Director | ||||||
5 | the information set out in subsection (n) of this Section. | ||||||
6 | (l) Minimum qualifications for third-party review | ||||||
7 | organizations. All legal reviewers assigned by a third-party | ||||||
8 | review organization to conduct third-party reviews shall be | ||||||
9 | licensed attorneys who meet the following minimum | ||||||
10 | qualifications: | ||||||
11 | (1) possess demonstrated expertise in contract and | ||||||
12 | insurance law with knowledge of the
individual health | ||||||
13 | insurance market, including the underwriting process; | ||||||
14 | (2) hold a non-restricted license to practice law in | ||||||
15 | any state or the District of
Columbia; and | ||||||
16 | (3) have no history of disciplinary actions or | ||||||
17 | sanctions that have been taken or are
pending by any state | ||||||
18 | bar association, regulatory body, or court of law that | ||||||
19 | raise a
substantial question as to the legal reviewer's | ||||||
20 | physical, mental, or professional
competence or moral | ||||||
21 | character. | ||||||
22 | All health care professional reviewers assigned by a | ||||||
23 | third-party review organization to
conduct third-party reviews | ||||||
24 | shall be physicians or other appropriate health care providers
| ||||||
25 | who meet the following minimum qualifications: | ||||||
26 | (A) be knowledgeable about the relevant health care |
| |||||||
| |||||||
1 | service or treatment through
recent or current actual | ||||||
2 | clinical experience treating patients with the same or
| ||||||
3 | similar medical condition of the covered person; | ||||||
4 | (B) hold a non-restricted license in any state or the | ||||||
5 | District of Columbia and, for
physicians, a current | ||||||
6 | certification by a recognized American medical specialty
| ||||||
7 | board in the area or areas appropriate to the subject of | ||||||
8 | the third-party review; and | ||||||
9 | (C) have no history of disciplinary actions or | ||||||
10 | sanctions, including loss of staff
privileges or | ||||||
11 | participation restrictions, that have been taken or are | ||||||
12 | pending by any
hospital, governmental agency or unit, or | ||||||
13 | regulatory body that raise a substantial
question as to the | ||||||
14 | health care professional reviewer's physical, mental, or
| ||||||
15 | professional competence or moral character. | ||||||
16 | In addition to the requirements set forth in subsection (k) | ||||||
17 | of this Section, the third-party review organization selected | ||||||
18 | to conduct the third-party review and any health care | ||||||
19 | professional reviewer or legal reviewer assigned by the | ||||||
20 | third-party review organization to conduct the third-party | ||||||
21 | review may not own or control, be a subsidiary of, or in any | ||||||
22 | way be owned or controlled by or exercise control with a health | ||||||
23 | carrier; a national, state, or local trade association of | ||||||
24 | health carriers; or a national, state, or local trade | ||||||
25 | association of health care
providers. The third-party review | ||||||
26 | organization shall be unbiased. A third-party review |
| |||||||
| |||||||
1 | organization shall establish and maintain written procedures | ||||||
2 | to ensure that it is unbiased in addition to any other | ||||||
3 | procedures required under this Section. | ||||||
4 | In addition to the requirements set forth in this | ||||||
5 | subsection and subsection (k) of this Section, to be approved | ||||||
6 | pursuant to subsection (j) of this Section to conduct a | ||||||
7 | third-party review of a specified case, neither the third-party | ||||||
8 | review organization selected to conduct the third-party review | ||||||
9 | nor any health care professional reviewer or legal reviewer | ||||||
10 | assigned by the third-party review organization to conduct the | ||||||
11 | third-party review may have a material professional, familial, | ||||||
12 | or financial conflict of interest with any of the following: | ||||||
13 | (i) the health carrier that is the subject of the | ||||||
14 | third-party review; | ||||||
15 | (ii) the covered person whose treatment is the subject | ||||||
16 | of the third-party review or the
covered person's | ||||||
17 | authorized representative; | ||||||
18 | (iii) any officer, director, or management employee of | ||||||
19 | the health carrier that is the
subject of the third-party | ||||||
20 | review; | ||||||
21 | (iv) the health care provider or the health care | ||||||
22 | provider's medical group or
independent practice | ||||||
23 | association recommending the health care service or
| ||||||
24 | treatment that is the subject of the third-party review; | ||||||
25 | (v) the facility at which the recommended health care | ||||||
26 | service or treatment would be
provided; or |
| |||||||
| |||||||
1 | (vi) the developer or manufacturer of the principal | ||||||
2 | drug, device, procedure, or other
therapy being | ||||||
3 | recommended for the covered person whose treatment is the | ||||||
4 | subject
of the third-party review. | ||||||
5 | In determining whether a material professional, familial, or | ||||||
6 | financial conflict of interest
exists for purposes of this | ||||||
7 | subsection (l), the Director shall take into consideration
| ||||||
8 | situations where the third-party review organization, the | ||||||
9 | health care professional
reviewer, or legal reviewer may have | ||||||
10 | an apparent professional, familial, or financial
relationship | ||||||
11 | or connection with a person described in this subsection (l), | ||||||
12 | but the
characteristics of that relationship or connection are | ||||||
13 | such that they do not create a
material professional, familial, | ||||||
14 | or financial conflict of interest. | ||||||
15 | (m) Hold harmless for third-party review organizations. No | ||||||
16 | third-party review organization; health care professional | ||||||
17 | reviewer or legal reviewer working on behalf of a third-party | ||||||
18 | review organization; or an employee, agent, or contractor of a | ||||||
19 | third-party review organization shall be liable in damages to | ||||||
20 | any person for any opinions rendered or acts or omissions | ||||||
21 | performed within the scope of the organization's or person's | ||||||
22 | duties under the law during or upon completion of a third-party | ||||||
23 | review conducted pursuant to this Section, unless the opinion | ||||||
24 | was rendered or act or omission performed in bad faith or | ||||||
25 | involved gross negligence. | ||||||
26 | (n) Third-party review reporting requirements. A |
| |||||||
| |||||||
1 | third-party review organization assigned to conduct a | ||||||
2 | third-party review shall maintain written records in the | ||||||
3 | aggregate, by state, and by health carrier on all requests for | ||||||
4 | which it received a request to conduct a third-party review | ||||||
5 | during a calendar year. The third-party review organization | ||||||
6 | shall retain the written records required pursuant to this | ||||||
7 | subsection (n) for at least 3 years. | ||||||
8 | Each third-party review organization shall submit to the | ||||||
9 | Director, upon request, a report in the format specified by the | ||||||
10 | Director. The report shall include, at a minimum, the following | ||||||
11 | information in the aggregate, by state, and for each health | ||||||
12 | carrier: | ||||||
13 | (1) the total number of assigned third-party review | ||||||
14 | requests; | ||||||
15 | (2) the number of third-party review requests resolved | ||||||
16 | by the third-party review
organization and, of those | ||||||
17 | resolved, the number resolved upholding the
health | ||||||
18 | carrier's determination and the number resolved reversing | ||||||
19 | the health
carrier's determination; | ||||||
20 | (3) the average length of time for resolution; | ||||||
21 | (4) a summary of the types of coverages or cases for | ||||||
22 | which a third-party review
was sought, as provided in the | ||||||
23 | format required by the Director; | ||||||
24 | (5) the number of third-party reviews that were | ||||||
25 | terminated as the result of a
reconsideration by the health | ||||||
26 | carrier of its determination after the receipt of
|
| |||||||
| |||||||
1 | additional information from the covered person or the | ||||||
2 | covered person's
authorized representative pursuant to | ||||||
3 | subsection (f) of this Section; and | ||||||
4 | (6) any other information the Director may request or | ||||||
5 | require. | ||||||
6 | Each health carrier shall maintain written records in the | ||||||
7 | aggregate, by state, and for each
type of health insurance plan | ||||||
8 | offered by the health carrier for all third-party review | ||||||
9 | requests received by the health carrier pursuant to subsection | ||||||
10 | (f) of this Section. The health carrier
shall retain the | ||||||
11 | written records required pursuant to this subsection (n) for at | ||||||
12 | least 3 years. Each health carrier shall submit to the | ||||||
13 | Director, upon request, a report on all third-party review | ||||||
14 | requests received by the health carrier pursuant to subsection | ||||||
15 | (f) of this Section in the format specified by the Director. | ||||||
16 | The Director shall annually collect data on the third-party | ||||||
17 | reviews conducted in this State and issue a report that | ||||||
18 | includes the information reported by third-party review | ||||||
19 | organizations and health carriers under this subsection (n), | ||||||
20 | along with the total number of written third-party review | ||||||
21 | requests received by the Director. | ||||||
22 | (o) Funding of third-party review process. The health | ||||||
23 | carrier against which a third-party review request is filed | ||||||
24 | shall pay the reasonable and necessary costs associated with | ||||||
25 | the review process. The Director shall maintain active | ||||||
26 | management and oversight of the third-party review process, |
| |||||||
| |||||||
1 | including, but not limited to, the administrative costs | ||||||
2 | associated with the process, and the fees associated with the | ||||||
3 | use of health care professional reviewers and legal reviewers. | ||||||
4 | The Director shall review and affirmatively endorse detailed | ||||||
5 | billings from the third-party review organization before the | ||||||
6 | detailed billings are sent to the health carrier. | ||||||
7 | (p) Health carrier disclosure requirements. Each health | ||||||
8 | carrier shall include a description of the third-party review | ||||||
9 | procedures in or attached to the policy, certificate, | ||||||
10 | membership booklet, outline of coverage, or other evidence of | ||||||
11 | coverage it provides to covered persons that includes, at a | ||||||
12 | minimum, the following information: | ||||||
13 | (1) a statement that informs the covered person of the | ||||||
14 | right to file a request for a third-party review of | ||||||
15 | rescission decisions made by the health carrier are based | ||||||
16 | on medical issues for health insurance plan coverage. The | ||||||
17 | statement shall explain that third-party review is only | ||||||
18 | available when the rescission decisions made by the health | ||||||
19 | carrier are based on medical issues for health insurance | ||||||
20 | plan coverage and include the telephone number and address | ||||||
21 | of the Director where the policy is issued and delivered; | ||||||
22 | and | ||||||
23 | (2) a statement that informs the covered person that, | ||||||
24 | when filing a request for a third-party review, the covered | ||||||
25 | person will be required to authorize the release of any
| ||||||
26 | medical records of the covered person that may be required |
| |||||||
| |||||||
1 | to be reviewed for the
purpose of reaching a decision on | ||||||
2 | the third-party review. | ||||||
3 | The disclosure required by this subsection (p) shall be in | ||||||
4 | a format prescribed by the Director. | ||||||
5 | (q) Third-party review panel confidentiality. A | ||||||
6 | third-party review organization shall not disclose the | ||||||
7 | identity of the health care professional reviewers or legal | ||||||
8 | reviewers involved in the third-party review process, unless | ||||||
9 | otherwise directed to divulge this information by a federal or | ||||||
10 | State court of law. | ||||||
11 | (r) Notwithstanding any other rulemaking authority that | ||||||
12 | may exist, neither the Governor nor any agency or agency head | ||||||
13 | under the jurisdiction of the Governor has any authority to | ||||||
14 | make or promulgate rules to implement or enforce the provisions | ||||||
15 | of this amendatory Act of the 95th General Assembly. If, | ||||||
16 | however, the Governor believes that rules are necessary to | ||||||
17 | implement or enforce the provisions of this amendatory Act of | ||||||
18 | the 95th General Assembly, the Governor may suggest rules to | ||||||
19 | the General Assembly by filing them with the Clerk of the House | ||||||
20 | and the Secretary of the Senate and by requesting that the | ||||||
21 | General Assembly authorize such rulemaking by law, enact those | ||||||
22 | suggested rules into law, or take any other appropriate action | ||||||
23 | in the General Assembly's discretion. Nothing contained in this | ||||||
24 | amendatory Act of the 95th General Assembly shall be | ||||||
25 | interpreted to grant rulemaking authority under any other | ||||||
26 | Illinois statute where such authority is not otherwise |
| |||||||
| |||||||
1 | explicitly given. For the purposes of this amendatory Act of | ||||||
2 | the 95th General Assembly, "rules" is given the meaning | ||||||
3 | contained in Section 1-70 of the Illinois Administrative | ||||||
4 | Procedure Act, and "agency" and "agency head" are given the | ||||||
5 | meanings contained in Sections 1-20 and 1-25 of the Illinois | ||||||
6 | Administrative Procedure Act to the extent that such | ||||||
7 | definitions apply to agencies or agency heads under the | ||||||
8 | jurisdiction of the Governor.
| ||||||
9 | Section 30. The Health Maintenance Organization Act is | ||||||
10 | amended by changing Section 5-3 as follows:
| ||||||
11 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
12 | Sec. 5-3. Insurance Code provisions.
| ||||||
13 | (a) Health Maintenance Organizations
shall be subject to | ||||||
14 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
15 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
16 | 154.6,
154.7, 154.8, 155.04, 355.2, 356f.1, 356m, 356v, 356w, | ||||||
17 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
18 | 356z.10
356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | ||||||
19 | 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, | ||||||
20 | 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section | ||||||
21 | 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, | ||||||
22 | XXV, and XXVI of the Illinois Insurance Code.
| ||||||
23 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
24 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
| |||||||
| |||||||
1 | Maintenance Organizations in
the following categories are | ||||||
2 | deemed to be "domestic companies":
| ||||||
3 | (1) a corporation authorized under the
Dental Service | ||||||
4 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
5 | (2) a corporation organized under the laws of this | ||||||
6 | State; or
| ||||||
7 | (3) a corporation organized under the laws of another | ||||||
8 | state, 30% or more
of the enrollees of which are residents | ||||||
9 | of this State, except a
corporation subject to | ||||||
10 | substantially the same requirements in its state of
| ||||||
11 | organization as is a "domestic company" under Article VIII | ||||||
12 | 1/2 of the
Illinois Insurance Code.
| ||||||
13 | (c) In considering the merger, consolidation, or other | ||||||
14 | acquisition of
control of a Health Maintenance Organization | ||||||
15 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
16 | (1) the Director shall give primary consideration to | ||||||
17 | the continuation of
benefits to enrollees and the financial | ||||||
18 | conditions of the acquired Health
Maintenance Organization | ||||||
19 | after the merger, consolidation, or other
acquisition of | ||||||
20 | control takes effect;
| ||||||
21 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
22 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
23 | apply and (ii) the Director, in making
his determination | ||||||
24 | with respect to the merger, consolidation, or other
| ||||||
25 | acquisition of control, need not take into account the | ||||||
26 | effect on
competition of the merger, consolidation, or |
| |||||||
| |||||||
1 | other acquisition of control;
| ||||||
2 | (3) the Director shall have the power to require the | ||||||
3 | following
information:
| ||||||
4 | (A) certification by an independent actuary of the | ||||||
5 | adequacy
of the reserves of the Health Maintenance | ||||||
6 | Organization sought to be acquired;
| ||||||
7 | (B) pro forma financial statements reflecting the | ||||||
8 | combined balance
sheets of the acquiring company and | ||||||
9 | the Health Maintenance Organization sought
to be | ||||||
10 | acquired as of the end of the preceding year and as of | ||||||
11 | a date 90 days
prior to the acquisition, as well as pro | ||||||
12 | forma financial statements
reflecting projected | ||||||
13 | combined operation for a period of 2 years;
| ||||||
14 | (C) a pro forma business plan detailing an | ||||||
15 | acquiring party's plans with
respect to the operation | ||||||
16 | of the Health Maintenance Organization sought to
be | ||||||
17 | acquired for a period of not less than 3 years; and
| ||||||
18 | (D) such other information as the Director shall | ||||||
19 | require.
| ||||||
20 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
21 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
22 | any health maintenance
organization of greater than 10% of its
| ||||||
23 | enrollee population (including without limitation the health | ||||||
24 | maintenance
organization's right, title, and interest in and to | ||||||
25 | its health care
certificates).
| ||||||
26 | (e) In considering any management contract or service |
| |||||||
| |||||||
1 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
2 | Code, the Director (i) shall, in
addition to the criteria | ||||||
3 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
4 | into account the effect of the management contract or
service | ||||||
5 | agreement on the continuation of benefits to enrollees and the
| ||||||
6 | financial condition of the health maintenance organization to | ||||||
7 | be managed or
serviced, and (ii) need not take into account the | ||||||
8 | effect of the management
contract or service agreement on | ||||||
9 | competition.
| ||||||
10 | (f) Except for small employer groups as defined in the | ||||||
11 | Small Employer
Rating, Renewability and Portability Health | ||||||
12 | Insurance Act and except for
medicare supplement policies as | ||||||
13 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
14 | Maintenance Organization may by contract agree with a
group or | ||||||
15 | other enrollment unit to effect refunds or charge additional | ||||||
16 | premiums
under the following terms and conditions:
| ||||||
17 | (i) the amount of, and other terms and conditions with | ||||||
18 | respect to, the
refund or additional premium are set forth | ||||||
19 | in the group or enrollment unit
contract agreed in advance | ||||||
20 | of the period for which a refund is to be paid or
| ||||||
21 | additional premium is to be charged (which period shall not | ||||||
22 | be less than one
year); and
| ||||||
23 | (ii) the amount of the refund or additional premium | ||||||
24 | shall not exceed 20%
of the Health Maintenance | ||||||
25 | Organization's profitable or unprofitable experience
with | ||||||
26 | respect to the group or other enrollment unit for the |
| |||||||
| |||||||
1 | period (and, for
purposes of a refund or additional | ||||||
2 | premium, the profitable or unprofitable
experience shall | ||||||
3 | be calculated taking into account a pro rata share of the
| ||||||
4 | Health Maintenance Organization's administrative and | ||||||
5 | marketing expenses, but
shall not include any refund to be | ||||||
6 | made or additional premium to be paid
pursuant to this | ||||||
7 | subsection (f)). The Health Maintenance Organization and | ||||||
8 | the
group or enrollment unit may agree that the profitable | ||||||
9 | or unprofitable
experience may be calculated taking into | ||||||
10 | account the refund period and the
immediately preceding 2 | ||||||
11 | plan years.
| ||||||
12 | The Health Maintenance Organization shall include a | ||||||
13 | statement in the
evidence of coverage issued to each enrollee | ||||||
14 | describing the possibility of a
refund or additional premium, | ||||||
15 | and upon request of any group or enrollment unit,
provide to | ||||||
16 | the group or enrollment unit a description of the method used | ||||||
17 | to
calculate (1) the Health Maintenance Organization's | ||||||
18 | profitable experience with
respect to the group or enrollment | ||||||
19 | unit and the resulting refund to the group
or enrollment unit | ||||||
20 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
21 | experience with respect to the group or enrollment unit and the | ||||||
22 | resulting
additional premium to be paid by the group or | ||||||
23 | enrollment unit.
| ||||||
24 | In no event shall the Illinois Health Maintenance | ||||||
25 | Organization
Guaranty Association be liable to pay any | ||||||
26 | contractual obligation of an
insolvent organization to pay any |
| |||||||
| |||||||
1 | refund authorized under this Section.
| ||||||
2 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
3 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
4 | Section 35. The Limited Health Service Organization Act is | ||||||
5 | amended by changing Section 4003 as follows:
| ||||||
6 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| ||||||
7 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
8 | health service
organizations shall be subject to the provisions | ||||||
9 | of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | ||||||
10 | 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | ||||||
11 | 155.04, 155.37, 355.2, 356f.1, 356v, 356z.10
356z.9 , 368a, 401, | ||||||
12 | 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and | ||||||
13 | Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and | ||||||
14 | XXVI of the Illinois Insurance Code. For purposes of the
| ||||||
15 | Illinois Insurance Code, except for Sections 444 and 444.1 and | ||||||
16 | Articles XIII
and XIII 1/2, limited health service | ||||||
17 | organizations in the following categories
are deemed to be | ||||||
18 | domestic companies:
| ||||||
19 | (1) a corporation under the laws of this State; or
| ||||||
20 | (2) a corporation organized under the laws of another | ||||||
21 | state, 30% of more
of the enrollees of which are residents | ||||||
22 | of this State, except a corporation
subject to | ||||||
23 | substantially the same requirements in its state of | ||||||
24 | organization as
is a domestic company under Article VIII |
| |||||||
| |||||||
1 | 1/2 of the Illinois Insurance Code.
| ||||||
2 | (Source: P.A. 95-520, eff. 8-28-07; revised 12-5-07.)
| ||||||
3 | Section 40. The Voluntary Health Services Plans Act is | ||||||
4 | amended by changing Section 10 as follows:
| ||||||
5 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
6 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
7 | services
plan corporations and all persons interested therein | ||||||
8 | or dealing therewith
shall be subject to the provisions of | ||||||
9 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
10 | 149, 155.37, 354, 355.2, 356f.1, 356g.5, 356r, 356t, 356u, | ||||||
11 | 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||||||
12 | 356z.8, 356z.9,
356z.10
356z.9 , 364.01, 367.2, 368a, 401, | ||||||
13 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
14 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
15 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
16 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
17 | 8-28-07; revised 12-5-07.)".
|