State of Illinois
2015 and 2016


Introduced , by Rep. Laura Fine


215 ILCS 134/80
215 ILCS 134/85

    Amends the Managed Care Reform and Patient Rights Act. Provides that the Department of Public Health shall accept evidence of accreditation with regard to the health care network quality management and performance improvement standards of the Accreditation Association for Ambulatory Health Care. Provides that the Department of Insurance shall recognize the Accreditation Association for Ambulatory Health Care among the list of accreditors from which utilization organizations may receive accreditation and qualify for reduced registration and renewal fees.

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HB2788LRB099 08001 MLM 28141 b

1    AN ACT concerning insurance.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Managed Care Reform and Patient Rights Act
5is amended by changing Sections 80 and 85 as follows:
6    (215 ILCS 134/80)
7    Sec. 80. Quality assessment program.
8    (a) A health care plan shall develop and implement a
9quality assessment and improvement strategy designed to
10identify and evaluate accessibility, continuity, and quality
11of care. The health care plan shall have:
12        (1) an ongoing, written, internal quality assessment
13    program;
14        (2) specific written guidelines for monitoring and
15    evaluating the quality and appropriateness of care and
16    services provided to enrollees requiring the health care
17    plan to assess:
18            (A) the accessibility to health care providers;
19            (B) appropriateness of utilization;
20            (C) concerns identified by the health care plan's
21        medical or administrative staff and enrollees; and
22            (D) other aspects of care and service directly
23        related to the improvement of quality of care;



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1        (3) a procedure for remedial action to correct quality
2    problems that have been verified in accordance with the
3    written plan's methodology and criteria, including written
4    procedures for taking appropriate corrective action;
5        (4) follow-up measures implemented to evaluate the
6    effectiveness of the action plan.
7    (b) The health care plan shall establish a committee that
8oversees the quality assessment and improvement strategy which
9includes physician and enrollee participation.
10    (c) Reports on quality assessment and improvement
11activities shall be made to the governing body of the health
12care plan not less than quarterly.
13    (d) The health care plan shall make available its written
14description of the quality assessment program to the Department
15of Public Health.
16    (e) With the exception of subsection (d), the Department of
17Public Health shall accept evidence of accreditation with
18regard to the health care network quality management and
19performance improvement standards of:
20        (1) the National Commission on Quality Assurance
21    (NCQA);
22        (2) the American Accreditation Healthcare Commission
23    (URAC);
24        (3) the Joint Commission on Accreditation of
25    Healthcare Organizations (JCAHO); or
26        (4) the Accreditation Association for Ambulatory



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1    Health Care (AAAHC); or
2        (5) (4) any other entity that the Director of Public
3    Health deems has substantially similar or more stringent
4    standards than provided for in this Section.
5    (f) If the Department of Public Health determines that a
6health care plan is not in compliance with the terms of this
7Section, it shall certify the finding to the Department of
8Insurance. The Department of Insurance shall subject a health
9care plan to penalties, as provided in this Act, for such
11(Source: P.A. 91-617, eff. 1-1-00.)
12    (215 ILCS 134/85)
13    Sec. 85. Utilization review program registration.
14    (a) No person may conduct a utilization review program in
15this State unless once every 2 years the person registers the
16utilization review program with the Department and certifies
17compliance with the Health Utilization Management Standards of
18the American Accreditation Healthcare Commission (URAC)
19sufficient to achieve American Accreditation Healthcare
20Commission (URAC) accreditation or submits evidence of
21accreditation by the American Accreditation Healthcare
22Commission (URAC) for its Health Utilization Management
23Standards. Nothing in this Act shall be construed to require a
24health care plan or its subcontractors to become American
25Accreditation Healthcare Commission (URAC) accredited.



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1    (b) In addition, the Director of the Department, in
2consultation with the Director of the Department of Public
3Health, may certify alternative utilization review standards
4of national accreditation organizations or entities in order
5for plans to comply with this Section. Any alternative
6utilization review standards shall meet or exceed those
7standards required under subsection (a).
8    (b-5) The Department shall recognize the Accreditation
9Association for Ambulatory Health Care among the list of
10accreditors from which utilization organizations may receive
11accreditation and qualify for reduced registration and renewal
13    (c) The provisions of this Section do not apply to:
14        (1) persons providing utilization review program
15    services only to the federal government;
16        (2) self-insured health plans under the federal
17    Employee Retirement Income Security Act of 1974, however,
18    this Section does apply to persons conducting a utilization
19    review program on behalf of these health plans;
20        (3) hospitals and medical groups performing
21    utilization review activities for internal purposes unless
22    the utilization review program is conducted for another
23    person.
24    Nothing in this Act prohibits a health care plan or other
25entity from contractually requiring an entity designated in
26item (3) of this subsection to adhere to the utilization review



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1program requirements of this Act.
2    (d) This registration shall include submission of all of
3the following information regarding utilization review program
5        (1) The name, address, and telephone number of the
6    utilization review programs.
7        (2) The organization and governing structure of the
8    utilization review programs.
9        (3) The number of lives for which utilization review is
10    conducted by each utilization review program.
11        (4) Hours of operation of each utilization review
12    program.
13        (5) Description of the grievance process for each
14    utilization review program.
15        (6) Number of covered lives for which utilization
16    review was conducted for the previous calendar year for
17    each utilization review program.
18        (7) Written policies and procedures for protecting
19    confidential information according to applicable State and
20    federal laws for each utilization review program.
21    (e) (1) A utilization review program shall have written
22procedures for assuring that patient-specific information
23obtained during the process of utilization review will be:
24        (A) kept confidential in accordance with applicable
25    State and federal laws; and
26        (B) shared only with the enrollee, the enrollee's



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1    designee, the enrollee's health care provider, and those
2    who are authorized by law to receive the information.
3    Summary data shall not be considered confidential if it
4does not provide information to allow identification of
5individual patients or health care providers.
6        (2) Only a health care professional may make
7    determinations regarding the medical necessity of health
8    care services during the course of utilization review.
9        (3) When making retrospective reviews, utilization
10    review programs shall base reviews solely on the medical
11    information available to the attending physician or
12    ordering provider at the time the health care services were
13    provided.
14        (4) When making prospective, concurrent, and
15    retrospective determinations, utilization review programs
16    shall collect only information that is necessary to make
17    the determination and shall not routinely require health
18    care providers to numerically code diagnoses or procedures
19    to be considered for certification, unless required under
20    State or federal Medicare or Medicaid rules or regulations,
21    but may request such code if available, or routinely
22    request copies of medical records of all enrollees
23    reviewed. During prospective or concurrent review, copies
24    of medical records shall only be required when necessary to
25    verify that the health care services subject to review are
26    medically necessary. In these cases, only the necessary or



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1    relevant sections of the medical record shall be required.
2    (f) If the Department finds that a utilization review
3program is not in compliance with this Section, the Department
4shall issue a corrective action plan and allow a reasonable
5amount of time for compliance with the plan. If the utilization
6review program does not come into compliance, the Department
7may issue a cease and desist order. Before issuing a cease and
8desist order under this Section, the Department shall provide
9the utilization review program with a written notice of the
10reasons for the order and allow a reasonable amount of time to
11supply additional information demonstrating compliance with
12requirements of this Section and to request a hearing. The
13hearing notice shall be sent by certified mail, return receipt
14requested, and the hearing shall be conducted in accordance
15with the Illinois Administrative Procedure Act.
16    (g) A utilization review program subject to a corrective
17action may continue to conduct business until a final decision
18has been issued by the Department.
19    (h) Any adverse determination made by a health care plan or
20its subcontractors may be appealed in accordance with
21subsection (f) of Section 45.
22    (i) The Director may by rule establish a registration fee
23for each person conducting a utilization review program. All
24fees paid to and collected by the Director under this Section
25shall be deposited into the Insurance Producer Administration



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1(Source: P.A. 91-617, eff. 7-1-00.)