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(215 ILCS 134/80)
Quality assessment program.
(a) A health care plan shall develop and implement a quality assessment and
improvement strategy designed to identify and evaluate accessibility,
continuity, and quality of care. The health care plan shall have:
(1) an ongoing, written, internal quality assessment
(2) specific written guidelines for monitoring and
evaluating the quality and appropriateness of care and services provided to enrollees requiring the health care plan to assess:
(A) the accessibility to health care providers;
(B) appropriateness of utilization;
(C) concerns identified by the health care plan's
medical or administrative staff and enrollees; and
(D) other aspects of care and service directly
related to the improvement of quality of care;
(3) a procedure for remedial action to correct
quality problems that have been verified in accordance with the written plan's methodology and criteria, including written procedures for taking appropriate corrective action;
(4) follow-up measures implemented to evaluate the
effectiveness of the action plan.
(b) The health care plan shall establish a committee that oversees the
quality assessment and improvement strategy which includes physician
and enrollee participation.
(c) Reports on quality assessment and improvement activities shall be made
to the governing body of the health care plan not less than quarterly.
(d) The health care plan shall make available its written description of
the quality assessment program to the Department of
(e) With the exception of subsection (d), the Department of Public Health
shall accept evidence of accreditation with regard to the health care network
quality management and performance improvement standards of:
(1) the National Commission on Quality Assurance
(2) the American Accreditation Healthcare Commission
(3) the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO);
(4) the Accreditation Association for Ambulatory
(5) any other entity that the Director of Public
Health deems has substantially similar or more stringent standards than provided for in this Section.
(f) If the Department of Public Health determines that a health care plan
is not in compliance with the terms of this Section, it shall certify the
finding to the Department of Insurance. The Department of Insurance shall
subject a health care plan to penalties, as provided in this Act, for such
(Source: P.A. 99-111, eff. 1-1-16