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90_HB3431sam001
LRB9010626DJpcam
1 AMENDMENT TO HOUSE BILL 3431
2 AMENDMENT NO. . Amend House Bill 3431 as follows:
3 on page 2, by replacing lines 11 through 18 with the
4 following:
5 "Department of Public Aid pursuant to that Section."; and
6 on page 7, after line 34, by inserting the following:
7 "A managed care community network that contracts with the
8 Illinois Department to furnish health care services to or
9 arrange those services for enrollees participating in
10 programs administered by the Illinois Department shall do all
11 of the following:
12 (1) Provide that any provider affiliated with the
13 managed care community network may also provide services
14 on a fee-for-service basis to Illinois Department clients
15 not enrolled in such managed care entities.
16 (2) Provide client education services as determined
17 and approved by the Illinois Department, including but
18 not limited to (i) education regarding appropriate
19 utilization of health care services in a managed care
20 system, (ii) written disclosure of treatment policies and
21 restrictions or limitations on health services,
22 including, but not limited to, physical services,
-2- LRB9010626DJpcam
1 clinical laboratory tests, hospital and surgical
2 procedures, prescription drugs and biologics, and
3 radiological examinations, and (iii) written notice that
4 the enrollee may receive from another provider those
5 covered services that are not provided by the managed
6 care community network.
7 (3) Provide that enrollees within the system may
8 choose the site for provision of services and the panel
9 of health care providers.
10 (4) Not discriminate in enrollment or disenrollment
11 practices among recipients of medical services or
12 enrollees based on health status.
13 (5) Provide a quality assurance and utilization
14 review program that meets the requirements established by
15 the Illinois Department in rules that incorporate those
16 standards set forth in the Health Maintenance
17 Organization Act.
18 (6) Issue a managed care community network
19 identification card to each enrollee upon enrollment.
20 The card must contain all of the following:
21 (A) The enrollee's health plan.
22 (B) The name and telephone number of the
23 enrollee's primary care physician or the site for
24 receiving primary care services.
25 (C) A telephone number to be used to confirm
26 eligibility for benefits and authorization for
27 services that is available 24 hours per day, 7 days
28 per week.
29 (7) Ensure that every primary care physician and
30 pharmacy in the managed care community network meets the
31 standards established by the Illinois Department for
32 accessibility and quality of care. The Illinois
33 Department shall arrange for and oversee an evaluation of
34 the standards established under this paragraph (7) and
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1 may recommend any necessary changes to these standards.
2 (8) Provide a procedure for handling complaints
3 that meets the requirements established by the Illinois
4 Department in rules that incorporate those standards set
5 forth in the Health Maintenance Organization Act.
6 (9) Maintain, retain, and make available to the
7 Illinois Department records, data, and information, in a
8 uniform manner determined by the Illinois Department,
9 sufficient for the Illinois Department to monitor
10 utilization, accessibility, and quality of care.
11 (10) Provide that the pharmacy formulary used by
12 the managed care community network and its contract
13 providers be no more restrictive than the Illinois
14 Department's pharmaceutical program on the effective date
15 of this amendatory Act of 1998 and as amended after that
16 date.
17 The Illinois Department shall contract with an entity or
18 entities to provide external peer-based quality assurance
19 review for the managed health care programs administered by
20 the Illinois Department. The entity shall be representative
21 of Illinois physicians licensed to practice medicine in all
22 its branches and have statewide geographic representation in
23 all specialities of medical care that are provided in managed
24 health care programs administered by the Illinois Department.
25 The entity may not be a third party payer and shall maintain
26 offices in locations around the State in order to provide
27 service and continuing medical education to physician
28 participants within those managed health care programs
29 administered by the Illinois Department. The review process
30 shall be developed and conducted by Illinois physicians
31 licensed to practice medicine in all its branches. In
32 consultation with the entity, the Illinois Department may
33 contract with other entities for professional peer-based
34 quality assurance review of individual categories of services
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1 other than services provided, supervised, or coordinated by
2 physicians licensed to practice medicine in all its branches.
3 The Illinois Department shall establish, by rule, criteria to
4 avoid conflicts of interest in the conduct of quality
5 assurance activities consistent with professional peer-review
6 standards. All quality assurance activities shall be
7 coordinated by the Illinois Department.".