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| | HB2788 Enrolled | | LRB099 08001 MLM 28141 b |
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1 | | AN ACT concerning insurance.
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2 | | Be it enacted by the People of the State of Illinois,
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3 | | represented in the General Assembly:
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4 | | Section 5. The Managed Care Reform and Patient Rights Act |
5 | | is amended by changing Sections 80 and 85 as follows:
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6 | | (215 ILCS 134/80)
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7 | | Sec. 80. Quality assessment program.
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8 | | (a) A health care plan shall develop and implement a |
9 | | quality assessment and
improvement strategy designed to |
10 | | identify and evaluate accessibility,
continuity, and quality |
11 | | of care. The health care plan shall have:
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12 | | (1) an ongoing, written, internal quality assessment |
13 | | program;
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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:
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18 | | (A) the accessibility to health care providers;
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19 | | (B) appropriateness of utilization;
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20 | | (C) concerns identified by the health care plan's |
21 | | medical or
administrative staff and enrollees; and
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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;
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5 | | (4) follow-up measures implemented to evaluate the |
6 | | effectiveness of the
action plan.
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7 | | (b) The health care plan shall establish a committee that |
8 | | oversees the
quality assessment and improvement strategy which |
9 | | includes physician
and enrollee participation.
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10 | | (c) Reports on quality assessment and improvement |
11 | | activities shall be made
to the governing body of the health |
12 | | care plan not less than quarterly.
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13 | | (d) The health care plan shall make available its written |
14 | | description of
the quality assessment program to the Department |
15 | | of
Public Health.
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16 | | (e) With the exception of subsection (d), the Department of |
17 | | Public Health
shall accept evidence of accreditation with |
18 | | regard to the health care network
quality management and |
19 | | performance improvement standards of:
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20 | | (1) the National Commission on Quality Assurance |
21 | | (NCQA);
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22 | | (2) the American Accreditation Healthcare Commission |
23 | | (URAC);
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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
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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.
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5 | | (f) If the Department of Public Health determines that a |
6 | | health care plan
is not in compliance with the terms of this |
7 | | Section, it shall certify the
finding to the Department of |
8 | | Insurance. The Department of Insurance shall
subject a health |
9 | | care plan to penalties, as provided in this Act, for such
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10 | | non-compliance.
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11 | | (Source: P.A. 91-617, eff. 1-1-00.)
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12 | | (215 ILCS 134/85)
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13 | | Sec. 85. Utilization review program registration.
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14 | | (a) No person may conduct a utilization review program in |
15 | | this State unless
once every 2 years the person
registers the |
16 | | utilization review program with the Department and certifies
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17 | | compliance with the Health
Utilization Management Standards of |
18 | | the American Accreditation Healthcare
Commission (URAC) |
19 | | sufficient to achieve American Accreditation Healthcare
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20 | | Commission (URAC) accreditation or submits evidence of |
21 | | accreditation by the
American
Accreditation Healthcare |
22 | | Commission (URAC) for its Health Utilization
Management |
23 | | Standards.
Nothing in this Act shall be construed to require a |
24 | | health care plan or its
subcontractors to become American |
25 | | Accreditation Healthcare Commission (URAC)
accredited.
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1 | | (b) In addition, the Director of the Department, in |
2 | | consultation with the
Director of the Department of Public |
3 | | Health, may certify alternative
utilization review standards |
4 | | of national accreditation organizations or
entities in order |
5 | | for plans to comply with this Section. Any alternative
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6 | | utilization review standards shall meet or exceed those |
7 | | standards required
under subsection (a).
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8 | | (b-5) The Department shall recognize the Accreditation |
9 | | Association for Ambulatory Health Care among the list of |
10 | | accreditors from which utilization organizations may receive |
11 | | accreditation and qualify for reduced registration and renewal |
12 | | fees. |
13 | | (c) The provisions of this Section do not apply to:
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14 | | (1) persons providing utilization review program |
15 | | services only to the
federal
government;
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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;
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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.
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24 | | Nothing in this Act prohibits a health care plan or other |
25 | | entity from
contractually requiring an entity designated in |
26 | | item (3) of this subsection
to adhere to
the
utilization review |
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1 | | program requirements of
this Act.
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2 | | (d) This registration shall include submission of all of |
3 | | the following
information
regarding utilization review program |
4 | | activities:
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5 | | (1) The name, address, and telephone number of the |
6 | | utilization review
programs.
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7 | | (2) The organization and governing structure of the |
8 | | utilization review
programs.
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9 | | (3) The
number of lives for which utilization review is |
10 | | conducted by each utilization
review program.
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11 | | (4) Hours of operation of each utilization review |
12 | | program.
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13 | | (5) Description of the grievance process for each |
14 | | utilization review
program.
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15 | | (6) Number of covered lives for which utilization |
16 | | review was conducted for
the previous calendar year for |
17 | | each utilization review program.
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18 | | (7) Written policies and procedures for protecting |
19 | | confidential
information
according to applicable State and |
20 | | federal laws for each utilization review
program.
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21 | | (e) (1) A utilization review program shall have written |
22 | | procedures for
assuring that patient-specific information |
23 | | obtained during the process of
utilization review will be:
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24 | | (A) kept confidential in accordance with applicable |
25 | | State and
federal laws; and
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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.
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3 | | Summary data shall not be considered confidential if it |
4 | | does not provide
information to allow identification of |
5 | | individual patients or health care
providers.
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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.
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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.
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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
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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.
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2 | | (f) If the Department finds that a utilization review |
3 | | program is
not in compliance with this Section, the Department |
4 | | shall issue a corrective
action plan and allow a reasonable |
5 | | amount of time for compliance with the plan.
If the utilization |
6 | | review program does not come into compliance, the
Department |
7 | | may issue a cease and desist order. Before issuing a cease and
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8 | | desist order under this Section, the Department shall provide |
9 | | the
utilization review program with a written notice of the |
10 | | reasons for the
order and allow a reasonable amount of time to |
11 | | supply additional information
demonstrating compliance with |
12 | | requirements of this Section and to request a
hearing. The |
13 | | hearing notice shall be sent by certified mail, return receipt
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14 | | requested, and the hearing shall be conducted in accordance |
15 | | with the Illinois
Administrative Procedure Act.
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16 | | (g) A utilization review program subject to a corrective |
17 | | action may continue
to conduct business
until a final decision |
18 | | has been issued by the Department.
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19 | | (h) Any adverse determination made by a health care plan or |
20 | | its
subcontractors may be appealed
in accordance with |
21 | | subsection (f) of Section 45.
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22 | | (i) The Director may by rule establish a registration fee |
23 | | for each person
conducting a utilization review program. All |
24 | | fees paid to and collected by the
Director under this Section |
25 | | shall be deposited into
the Insurance Producer Administration |
26 | | Fund.
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