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90_HB3530
5 ILCS 375/6.12 new
55 ILCS 5/5-1069.8 new
65 ILCS 5/10-4-2.8 new
215 ILCS 5/155.36 new
215 ILCS 5/356w new
215 ILCS 5/370s new
215 ILCS 5/511.118 new
215 ILCS 105/8.6 new
215 ILCS 125/5-3.6 new
215 ILCS 130/4002.6 new
215 ILCS 110/48 new
215 ILCS 165/15.30 new
305 ILCS 5/5-16.12 new
30 ILCS 105/5.480 new
Creates the Managed Care Patient Rights Act. Provides
that patients who receive health care under a managed care
program have rights to certain coverage and service standards
including, but not limited to, quality health care service,
privacy and confidentiality, freedom of choice of physician,
explanation of bills, and protection from revocation of prior
authorization. Provides for the Illinois Department of
Public Health to establish standards to ensure patient
protection, quality of care, fairness to physicians, and
utilization review safeguards. Requires utilization review
plans to be licensed by the Department of Public Health.
Amends various Acts to require compliance by health care
providers under the Illinois Insurance Code, Comprehensive
Health Insurance Plan Act, Health Maintenance Organization
Act, Limited Health Service Organization Act, Dental Service
Plan Act, Voluntary Health Services Plans Act, State
Employees Group Insurance Act of 1971, Counties Code,
Illinois Municipal Code, and Illinois Public Aid Code.
Effective immediately.
LRB9011344JSgc
LRB9011344JSgc
1 AN ACT to create the Managed Care Patient Rights Act and
2 amend various named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 ARTICLE 1. SHORT TITLE, LEGISLATIVE PURPOSE, DEFINITIONS
6 Section 1-1. Short title. This Act may be cited as the
7 Managed Care Patient Rights Act.
8 Section 1-5. Legislative purpose. The legislature
9 hereby finds and declares that:
10 (a) Managed care consists of systems or techniques that
11 are used to affect access to and control payments for health
12 care services. Managed care plans can be organized in a vast
13 number of structures, including licensed and unlicensed
14 components that can restrict access to health care services.
15 As this State's health care market becomes increasingly
16 dominated by managed care plans that utilize various managed
17 care techniques that include decisions regarding coverage and
18 the appropriateness of health care, it is a vital state
19 governmental function to protect patients and ensure fair and
20 equitable managed care practices.
21 (b) Managed care plans, including insurance companies,
22 are responsible for making coverage decisions that have a
23 direct effect on the health of patients. Some of these
24 managed care plans make decisions concerning the medical
25 necessity, appropriateness of alternative treatments and
26 length of hospital stays. Further, these managed care plans
27 can restrict patients' ability to make choices about their
28 health care providers. Strong provider-patient
29 relationships, particularly for patients with acute or
30 chronic medical conditions, enhances the curative process.
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1 Maintaining continuity of care as patients change providers
2 and health plans is essential to the health and well-being of
3 the patients enrolled in the managed care plans. It is in
4 the interest of the health of the public to insure that
5 decisions about the availability of health care providers and
6 the willingness of payors to pay for medically necessary care
7 are made in an appropriate manner.
8 (c) This legislation establishes a managed care patient's
9 right to, at a minimum, all of the following:
10 (1) Quality health care services.
11 (2) Identification of his or her participating
12 providers.
13 (3) Reasonable explanation of the patient's plan of
14 care.
15 (4) A reasonable explanation of bills for health
16 care services.
17 (5) Clear and understandable explanation of the
18 terms and conditions of coverage.
19 (6) Timely notification of individual coverage
20 termination.
21 (7) Privacy and confidentiality in health care
22 services.
23 (8) Freedom to purchase necessary health care
24 services.
25 (9) Freedom of choice of physician to coordinate
26 health care, and a prohibition of retaliation against
27 health care providers who advocate medically necessary
28 health care for their patients.
29 (10) Protection from revocation of prior
30 authorization.
31 (11) Prohibition of prior authorization for
32 emergency care.
33 (12) Timely and clear notification of provider
34 termination.
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1 These rights are implemented through the regulation of
2 managed care plans and utilization review programs.
3 (d) Licensed insurance companies, health maintenance
4 organizations, self-insured employer or employee
5 organizations, and other managed care plans are required to
6 certify compliance with this Act to the Department of Public
7 Health. Certification of compliance is required to ensure
8 patient protection, quality of care, fairness to physician
9 and other health care providers, utilization review
10 safeguards, and coverage options for all patients, including
11 the ability to enroll in a point of service plan.
12 Section 1-10. Definitions. As used in this Act:
13 "Department" means the Department of Public Health.
14 "Director" means the Director of the Public Health.
15 "Enrollee" means an individual and his or her dependents
16 who are enrolled in a managed care plan.
17 "Emergency condition" means a medical condition of recent
18 onset and severity that would lead a prudent layperson,
19 possessing an average knowledge of medicine and health, to
20 believe that urgent or unscheduled health care services are
21 required.
22 "Emergency medical screening examination" means a medical
23 screening examination and evaluation by a physician or, to
24 the extent permitted by applicable laws, by other appropriate
25 personnel under the supervision of a physician to determine
26 whether the need for emergency services exists.
27 "Emergency services" means those health care services
28 provided to evaluate and treat medical conditions of recent
29 onset and severity that would lead a prudent layperson,
30 possessing an average knowledge of medicine and health, to
31 believe that urgent or unscheduled health care services are
32 required.
33 "Health care provider" means a physician, dentist,
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1 podiatrist, registered professional nurse, clinic, hospital,
2 federally qualified health center, rural health clinic,
3 ambulatory surgical treatment center, pharmacy, laboratory,
4 or other appropriately licensed provider of health care
5 services.
6 "Health care services" means services, supplies or
7 products rendered or sold by a health care provider within
8 the scope of the provider's license. The term includes, but
9 is not limited to, hospital, medical, surgical, dental,
10 podiatric, pharmacy, vision, home health and pharmaceutical
11 services and products.
12 "Managed care plan" means a plan that establishes,
13 operates or maintains a network of health care providers
14 that have entered into agreements with the plan to provide
15 health care services to enrollees where the plan has the
16 ultimate and direct contractual obligation to the enrollee to
17 arrange for the provision of or pay for services through:
18 (1) organizational arrangements for ongoing quality
19 assurance, utilization review programs, or dispute
20 resolution; or
21 (2) financial incentives for enrollees enrolled in
22 the plan to use the participating providers and
23 procedures covered by the plan.
24 A managed care plan may be established or operated by any
25 entity including a licensed insurance company, hospital or
26 medical service plan, health maintenance organization,
27 limited health services organization, preferred provider
28 organization, third party administrator, or an employer or
29 employee organization.
30 "Participating provider" means a health care provider
31 that has entered into an agreement with a managed care plan
32 to provide health care services to an enrollee.
33 "Patient" means any person who has received or is
34 receiving health care services from a health care provider.
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1 "Post-stabilization services" means those health care
2 services determined by a health care provider to be promptly
3 and medically necessary following stabilization of an
4 emergency condition.
5 "Primary care" means the provision of a broad range of
6 personal health care services (preventive, diagnostic,
7 curative, counseling, or rehabilitative) in a manner that is
8 accessible, comprehensive and coordinated by a physician
9 licensed to practice medicine in all its branches over time.
10 "Principal care" means the provision of ongoing
11 preventive, diagnostic, curative, counseling, or
12 rehabilitative care, provided or coordinated by a physician
13 licensed to practice medicine in all its branches, that is
14 focused on a specific organ system, disease or condition.
15 Principal care may be provided concurrently with or apart
16 from primary care.
17 "Utilization review program" means a system operated by
18 or on behalf of a managed care plan for the purpose of
19 reviewing the medical necessity or appropriateness of health
20 care services provided or proposed to be provided to
21 enrollees of the managed care plan using specified
22 guidelines. The system may include preadmission
23 certification, the application of appropriately developed
24 clinically based guidelines, length of stay review, discharge
25 planning, preauthorization of ambulatory procedures, and
26 retrospective review.
27 ARTICLE 5. ENUMERATED PATIENT RIGHTS
28 Section 5-5. Managed care patient rights.
29 (a) A patient has the right to care consistent with
30 professional standards of practice to assure quality nursing
31 and medical practices, to be informed of the name of the
32 participating physician responsible for coordinating his or
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1 her care, to receive information concerning his or her
2 condition and proposed treatment, to refuse any treatment to
3 the extent permitted by law, and to privacy and
4 confidentiality of records except as otherwise provided by
5 law.
6 (b) A patient has the right, regardless of source of
7 payment, to examine and to receive a reasonable explanation
8 of his or her total bill for health care services rendered by
9 his or her physician or other health care provider, including
10 the itemized charges for specific health care services
11 received. A physician or other health care provider shall be
12 responsible only for a reasonable explanation of those
13 specific health care services provided by the health care
14 provider.
15 (c) A patient has the right to timely prior notice of the
16 termination in the event a managed care plan cancels or
17 refuses to renew an enrollee's participation in the plan.
18 (d) A patient has the right to privacy and
19 confidentiality in health care. A physician, other health
20 care provider, managed care plan, and utilization review
21 program shall refrain from disclosing the nature or details
22 of health care services provided to patients, except that the
23 information may be disclosed to the patient, the party making
24 treatment decisions if the patient is incapable of making
25 decisions regarding the health care services provided, those
26 parties directly involved with providing treatment to the
27 patient or processing the payment for that treatment only in
28 accordance with Section 5-35, those parties responsible for
29 peer review, utilization review, and quality assurance, and
30 those parties required to be notified under the Abused and
31 Neglected Child Reporting Act, the Illinois Sexually
32 Transmissible Disease Control Act, or where otherwise
33 authorized or required by law. This right may be expressly
34 waived in writing by the patient or the patient's guardian,
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1 but a managed care plan, a physician, or other health care
2 provider may not condition the provision of health care
3 services on the patient's or guardian's agreement to sign
4 such a waiver.
5 (e) An individual has the right to purchase any health
6 care services with that individual's own funds, whether the
7 health care services are covered within the individual's
8 basic benefit package or from any health care provider or
9 plan received as a benefit of employment or from another
10 source. Employers shall not be prohibited from providing
11 coverage for benefits in addition those mandated by law.
12 Section 5-10. Medically appropriate health care
13 protection.
14 (a) No managed care plan shall retaliate against a
15 physician or other health care provider who advocates for
16 appropriate health care services for their patients.
17 (b) It is the public policy of the State of Illinois
18 that a physician or any other health care provider be
19 encouraged to advocate for medically appropriate health care
20 services for his or her patients. For purposes of this
21 Section, "to advocate for medically appropriate health care
22 services" means to appeal a decision to deny payment for a
23 health care service pursuant to the reasonable grievance or
24 appeal procedure established by a managed care plan or to
25 protest a decision, policy, or practice that the physician or
26 other health care provider, consistent with that degree of
27 learning and skill ordinarily possessed by physicians or
28 other health care providers practicing in the same or a
29 similar locality and under similar circumstances, reasonably
30 believes impairs the physician's or other health care
31 provider's ability to provide appropriate health care
32 services to his or her patients.
33 (c) The application and rendering by any person of a
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1 decision to terminate an employment or other contractual
2 relationship with or otherwise penalize a physician or other
3 health care provider for advocating for appropriate health
4 care services consistent with the degree of learning and
5 skill ordinarily possessed by physicians or other health care
6 providers practicing in the same or a similar locality and
7 under similar circumstances violates the public policy of
8 this State and constitutes a business offense subject to the
9 penalty under this Act.
10 (d) This Section shall not be construed to prohibit a
11 managed care plan from making a determination not to pay for
12 a particular health care service or to prohibit a medical
13 group, independent practice association, preferred provider
14 organization, foundation, hospital medical staff, hospital
15 governing body or managed care plan from enforcing reasonable
16 peer review or utilization review protocols or determining
17 whether a physician or other health care provider has
18 complied with those protocols.
19 (e) Nothing in this Section shall be construed to
20 prohibit the governing body of a hospital or the hospital
21 medical staff from taking disciplinary actions against a
22 physician as authorized by law.
23 (f) Nothing in this Section shall be construed to
24 prohibit the Department of Professional Regulation from
25 taking disciplinary actions against a physician or other
26 health care provider under the appropriate licensing Act.
27 Section 5-15. Choice of physician.
28 (a) All managed care plans that require each enrollee to
29 select a participating provider for any purpose including
30 coordination of care shall allow all enrollees to choose any
31 primary care physician licensed to practice medicine in all
32 its branches participating in the managed care plan for that
33 purpose.
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1 (b) In addition, all enrollees with an ongoing,
2 recurring or chronic disease or condition shall be allowed to
3 choose any participating physician licensed to practice
4 medicine in all its branches to provide principal care,
5 without referral from the provider coordinating care. The
6 decision regarding selection of any physician for any purpose
7 must be made by the enrollee and the physician. The managed
8 care plan's Health Care Delivery Policy Advisory Board shall
9 recommend definitions for those diseases and conditions which
10 shall be considered ongoing, recurring, or chronic diseases
11 or conditions for the managed care plan's governing body.
12 Any definitions adopted for the plan shall be mutually agreed
13 upon between the Board and the governing body. Neither may
14 unilaterally adopt definitions.
15 (c) The enrollee may be required by the managed care plan
16 to select a principal care physician who has a referral
17 arrangement with the enrollee's primary care physician or to
18 select a new primary care physician who has a referral
19 arrangement with the principal care physician chosen by the
20 enrollee. If a managed care plan requires an enrollee to
21 select a new physician under this subsection (c), the managed
22 care plan must provide the enrollee with both options
23 provided in this subsection (c).
24 (d) Nothing shall prohibit the managed care plan from
25 requiring prior authorization or approval from either a
26 primary care physician or a principal care physician for
27 referrals for additional health care services. Nothing shall
28 prohibit the managed care plan from requiring the principal
29 care physician to coordinate referrals for additional health
30 care services with the primary care physician.
31 Section 5-20. Prohibited restraints on communication or
32 practice.
33 (a) No managed care plan may prohibit or discourage
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1 health care providers from discussing any alternative health
2 care services and providers, utilization review and quality
3 assurance policies, terms and conditions of plans and plan
4 policy with enrollees, prospective enrollees, providers, or
5 the public.
6 (b) No managed care plan shall by contract, written
7 policy or written procedure, or informal policy or procedure
8 impose any restrictions on the physicians or other health
9 care providers who treat its enrollees as to recommended
10 health care services except as approved by the Health Care
11 Delivery Policy Advisory Board.
12 (c) Any violation of this Section shall be subject to
13 the penalties under this Act.
14 Section 5-25. Prohibited activity. No managed care plan
15 by contract, written policy or procedure, or informal policy
16 or procedure shall contain any clause attempting to transfer
17 or transferring to a health care provider, by indemnification
18 or otherwise, any liability relating to activities, actions,
19 or omissions of the managed care plan or its officers,
20 employees, or agents as opposed to those of the health care
21 provider.
22 Section 5-30. Procedure authorization. A managed care
23 plan that authorizes a specific type of treatment by a health
24 care provider shall not rescind or modify the authorization
25 after the health care provider renders the health care
26 service in good faith and pursuant to the authorization.
27 This Section shall not be construed to expand or alter the
28 benefits available to the enrollee under a managed care plan.
29 Section 5-35. Patient confidential records. A managed
30 care plan shall not release any information to an employer or
31 anyone else, except as specifically authorized by law, that
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1 would directly or indirectly indicate to the employer or
2 anyone else that an enrollee is receiving or has received
3 health care services from a health care provider unless
4 expressly authorized to do so in writing by the enrollee.
5 Section 5-40. Emergency services.
6 (a) All managed care plans shall provide the enrollee
7 emergency services coverage providing that payment for this
8 coverage is not dependent upon whether the services are
9 performed by a participating or nonparticipating provider.
10 This coverage shall be at the same benefit level as if the
11 service or treatment had been rendered by a participating
12 provider.
13 (b) Prior authorization or approval by the managed care
14 plan shall not be required.
15 (c) Coverage and payment shall not be retrospectively
16 denied, with the following exceptions:
17 (1) upon reasonable determination that the
18 emergency services claimed were never performed; or
19 (2) upon reasonable determination that an emergency
20 medical screening examination was performed on a patient
21 who personally sought emergency services knowing that he
22 or she did not have an emergency condition and who did
23 not in fact require emergency services.
24 (d) When an enrollee presents to a hospital seeking
25 emergency services, the determination as to whether the need
26 for those services exists shall be made for purposes of
27 treatment by a physician or, to the extent permitted by
28 applicable law, by other appropriate licensed personnel under
29 the supervision of a physician. The physician or other
30 appropriate personnel shall indicate in the patient's chart
31 the results of the emergency medical screening examination.
32 (e) The appropriate use of the 911 emergency telephone
33 number shall not be discouraged or penalized, and coverage or
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1 payment shall not be denied solely on the basis that the
2 enrollee used the 911 emergency telephone number to summon
3 emergency services.
4 Section 5-45. Post-stabilization services.
5 (a) If prior authorization for post-stabilization
6 services is required, the managed care plan shall provide
7 access 24 hours a day, 7 days a week to persons designated by
8 the plan to make those determinations. If a health care
9 provider has attempted to contact a person for prior
10 authorization and no designated persons were accessible or
11 the authorization was not denied within 30 minutes of the
12 request, the managed care plan is deemed to have approved the
13 request for prior authorization.
14 (b) Coverage and payment for post-stabilization services
15 that received prior authorization or deemed approval shall
16 not be retrospectively denied.
17 Section 5-50. Notices of payment denial. All managed
18 care plans shall provide enrollees with detailed notices of
19 payment denial. The notices of denial shall be signed by the
20 individual responsible for denying payment and include the
21 name, an address and accessible phone number and facsimile
22 number of the individual responsible for denying payment.
23 Further, the notice of denial shall clearly state the
24 procedures for appealing the denial. The enrollee shall be
25 given the opportunity to respond to any denial and explain
26 any discrepancies.
27 Section 5-55. Managed care plan information.
28 (a) Prospective enrollees in managed care plans must be
29 provided written information disclosing the terms and
30 conditions of the managed care plans so that they can make
31 informed decisions about accepting a certain system of health
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1 care delivery. Where the managed care plan is described
2 orally to prospective enrollees, this oral description must
3 be easily understood, truthful, and objective in the terms
4 used.
5 (b) All managed care plans must be described in writing
6 in a legible and understandable format, consistent with
7 standards developed for supplemental insurance coverage under
8 Title XVIII of the Social Security Act. This format must be
9 standardized so that prospective enrollees can compare the
10 attributes of the managed care plans. Specific items that
11 must be included are:
12 (1) coverage provisions, benefits, and any
13 exclusions or limitations of: (i) health care services
14 or (ii) physicians or other providers;
15 (2) any and all prior authorization or other review
16 requirements including preauthorization review,
17 concurrent review, post-service review, post payment
18 review and any procedures that may lead the patient to be
19 denied coverage for or not be provided a particular
20 health care service and an explanation of the registry of
21 review decisions and how it can be reviewed;
22 (3) a detailed explanation of the managed care plan
23 policy describing how the managed care plan shall
24 facilitate the continuity of care for enrollees receiving
25 health care services from non-participating providers;
26 (4) a detailed explanation of how managed care plan
27 limitations impact enrollees, including information on
28 enrollee financial responsibility for payment of
29 co-payments, deductibles, coinsurance and non-covered or
30 out-of-plan health care services;
31 (5) a detailed explanation of the percent of premium
32 going to pay for care and percent of premium going to pay
33 for administration;
34 (6) educational materials explaining the proper
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1 utilization of emergency services in accordance with
2 Section 5-40 prepared by the Department of Public Health;
3 (7) enrollee satisfaction statistics, including, but
4 not limited to, reenrollment, and reasons for leaving a
5 managed care plan; and
6 (8) explanation of how the managed care plan
7 compensates health care providers and how those
8 compensation arrangements may impact the provision of
9 health care services.
10 Section 5-60. Access to providers. Managed care plans
11 must demonstrate that they have adequate access to physicians
12 in appropriate medical specialties and other health care
13 providers, so that all covered health care services will be
14 provided in a timely fashion. This requirement cannot be
15 waived and must be met in all geographic areas where the
16 managed care plan has enrollees, including rural areas.
17 Section 5-65. Fairness in contracting. All managed care
18 plans must provide that any individual physician, any
19 pharmacy, any federally qualified health center, any dentist,
20 and any podiatrist, that consistently meets the reasonable
21 terms and conditions established by a managed care plan
22 including, but not limited to credentialing standards,
23 adherence to quality assurance program requirements,
24 utilization management guidelines, contract procedures, and
25 provider network size and accessibility requirements must be
26 accepted by the managed care plan. Any physician or any
27 other health care provider who is either terminated from or
28 denied inclusion in the provider network of the managed care
29 plan shall be given, within 10 business days after that
30 determination, a written explanation of the reasons for his
31 or her exclusion or termination from the provider network and
32 an opportunity to appeal.
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1 Section 5-70. Managed care plan health care delivery
2 policy advisory system.
3 (a) The managed care plan shall organize its network of
4 providers for the purpose of electing a Health Care Delivery
5 Policy Advisory Board from participants in the plan. The
6 Health Care Delivery Policy Advisory Board shall be
7 representative of the health care providers in the network
8 providing health care services to enrollees with at least
9 one-third participating physicians, one-third other
10 participating providers and one-third enrollees. This Board
11 shall establish written rules and regulations for its
12 deliberations. The managed care plan must approve the rules
13 and may not unilaterally amend the rules. The managed care
14 plan shall grant the Board defined rights under which the
15 Board collaborates with the managed care plan to establish
16 the plan's health care delivery policy (including, but not
17 limited to, delivery of any covered: (i) health care
18 services, (ii) pharmaceuticals, (iii) procedures and (iv)
19 technology), utilization review criteria and procedures,
20 quality assurance procedures used by plan or any utilization
21 review programs employed by the plan, credentialing criteria,
22 and medical management procedures. The Board may make
23 recommendations on health care delivery policies, but shall
24 not determine the managed care plan's covered services. The
25 Board shall report directly to the managed care plan's
26 governing body.
27 (b) The Board's rules and regulations shall provide due
28 process procedures for all actions granting, reducing,
29 restricting, suspending, revoking, denying or not renewing
30 provider network membership and privileges. The managed care
31 plan's governing body shall not control evaluation of
32 credentials of applicants for provider network membership and
33 privileges or the exercise of professional judgment. The
34 managed care plan's governing body shall make all final
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1 provider network membership and privilege decisions. The
2 Department shall develop standardized application forms for
3 credentialing. This information shall be verified by the
4 managed care plans from primary sources.
5 Section 5-75. Credentialing.
6 (a) A managed care plan shall allow all physicians
7 within the managed care plans' geographic service area to
8 apply for a contract and clinical privileges or credentials
9 to provide services to the managed care plan under rules
10 established by the Health Care Delivery Policy Advisory Board
11 and approved by the managed care plan's governing body. This
12 process is referred to as credentialing. All physicians
13 within the managed care plan shall be recredentialed no more
14 often than once every 2 years. The Health Care Delivery
15 Policy Advisory Board shall at a minimum establish the
16 following:
17 (1) Written procedures relating to the acceptance
18 and processing of initial applicants for contracts and
19 written procedures for making renewal and adverse
20 decisions concerning health care providers who have a
21 contract with the managed care plan.
22 (2) Written procedures to be followed in determining
23 an applicant's qualifications for being granted a
24 contract.
25 (3) Written criteria to be followed in evaluating
26 qualifications. Credentialing shall be based on objective
27 standards of quality with input from physicians
28 credentialed in the managed care plan. The standards
29 shall be available to applicants and physicians
30 credentialed in the managed care plan. Any profiling of
31 physicians must be adjusted to recognize case mix,
32 severity of illness, age of patients and other features
33 of a physician's practice including all economic factors
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1 that may account for higher than or lower than expected
2 costs. Profiles must be made available to those so
3 profiled. When graduate medical education is a
4 consideration in credentialing, equal recognition shall
5 be given to training programs accredited by the
6 Accrediting Council on Graduate Medical Education and by
7 the American Osteopathic Association. The lack of board
8 certification may not be the single or exclusive criteria
9 for denial of participation.
10 (4) An evaluation of an applicant's or contractee's
11 current health status and current license status in
12 Illinois.
13 (5) A written notice to each applicant and
14 contractee that explains the reason or reasons for any
15 adverse decision, including all reasons based in whole or
16 in part on the applicant's or contractee's medical
17 qualification or any other basis including economic
18 factors.
19 (b) In accordance with the criteria in this subsection
20 and subsection (c), credentialing shall be performed in a
21 timely manner by a credentialing committee established by the
22 Health Care Delivery Policy Advisory Board directly or
23 through a contract with a physician organization approved by
24 Health Care Delivery Policy Advisory Board and managed care
25 plan's governing body. The credentialing Committee shall have
26 representation of the applicant's medical speciality. The
27 credentialing process shall be completed in a timely manner
28 not to exceed 3 months. The managed care plan shall inform
29 physicians and other health care providers of credentialing
30 decisions within 3 months of receiving a completed
31 application. Failure to provide this notice shall result in
32 a fine under this Act. For purposes of credentialing:
33 "Adverse decision" means a decision reducing, restricting,
34 suspending, revoking, denying, or not renewing medical staff
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1 membership including, but not limited to, limitations on
2 access to institutional equipment, facilities and personnel.
3 "Economic factor" means any information or reasons for
4 decisions unrelated to quality of care or professional
5 competency.
6 (1) A managed care plan is prohibited from excluding
7 health care providers solely because those health care
8 providers treat a substantial number of patients with
9 conditions or illnesses that may require costly care or
10 treatment.
11 (2) The Health Care Delivery Policy Advisory Board
12 shall make credentialing recommendations to the managed
13 care plan's governing body. All governing body
14 credentialing decisions shall be made on the record, and
15 the applicant shall be provided with all reasons used if
16 the application is denied or the credentials not renewed.
17 (c)(1) A managed care plan may not make an adverse
18 credentialing decision including termination of a
19 contract of employment or refuse to renew a contract on
20 the basis of any action protected under this Act or
21 solely because a health care provider has:
22 (A) filed a complaint against the managed care
23 plan;
24 (B) appealed a decision of the managed care
25 plan; or
26 (C) requested a hearing pursuant to this
27 Section.
28 (2) A managed care plan shall provide to a health
29 care provider, in writing, notice of and the reasons for
30 any adverse decision.
31 (3) A managed care plan shall provide an opportunity
32 for a hearing to any health care provider prior to
33 implementation of any adverse decision, if the health
34 care provider has had a contract or contracts with the
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1 managed care plan for at least 12 of the past 18 months.
2 (4) After the notice provided pursuant to item (2),
3 the health care provider shall have 21 days to request a
4 hearing, and the hearing must be held within 15 days
5 after receipt of the request for a hearing. The hearing
6 shall be held before a panel appointed pursuant to the
7 requirements of this Section. The hearing panel shall be
8 composed of 3 individuals, all of whom shall be in the
9 same licensed discipline and, to the extent possible, in
10 the same or similar specialty as the health care provider
11 under review. One member shall be chosen by the managed
12 care plan, one member shall be chosen by the health care
13 provider and one shall be chosen by the plan and health
14 care provider from a list approved by the Health Care
15 Delivery Policy Advisory Board and approved by the
16 managed care plan's governing body. The hearing panel
17 shall render a written decision on the proposed action
18 within 14 business days. The decision shall be one of
19 the following:
20 (A) reinstatement of the health care provider
21 by the managed care plan;
22 (B) provisional reinstatement subject to
23 conditions set forth by the panel; or
24 (C) termination of the health care provider.
25 The decision of the hearing panel shall be final.
26 A decision by the hearing panel to terminate a
27 health care provider shall be effective not less than 60
28 days after the receipt by the health care provider of the
29 hearing panel's decision.
30 A hearing under this subsection shall provide the
31 health care provider in question with the right to
32 examine pertinent information, to present witnesses, to
33 receive a copy of all plan records related to the matter
34 free of charge, and to ask questions of authorized
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1 representatives of the plan.
2 (5) A managed care plan may terminate or decline to
3 renew a health care provider, without a prior hearing, in
4 cases involving imminent harm to patient care, or a final
5 disciplinary action by a state licensing board or other
6 governmental agency that impairs the health care
7 provider's ability to practice. A health care provider
8 terminated for one of these reasons shall be given
9 written notice to that effect. Within 15 days after the
10 termination, a health care provider shall receive a
11 hearing which shall completed without delay. The hearing
12 shall be held before a panel chosen in the same manner as
13 a panel under item (4). The hearing panel shall issue a
14 written decision as required under item (4).
15 The decision of the hearing panel shall be final.
16 Any hearing under this subsection shall provide the
17 health care provider in question with the right to examine
18 pertinent information, to present witnesses, to receive a
19 copy of all plan records related to the matter free of
20 charge, and to ask questions of an authorized representative
21 of the plan.
22 For any hearing under this Section 5-75, because the
23 candid and conscientious evaluation of clinical practices is
24 essential to the provision of health care, it is the policy
25 of this State to encourage peer review by health care
26 providers. Therefore, no managed care plan and no individual
27 who participates in a hearing or who is a member, agent, or
28 employee of a managed care plan shall be liable for criminal
29 or civil damages or professional discipline as a result of
30 the acts, omissions, decisions, or any other conduct, direct
31 or indirect, associated with a hearing panel, except for
32 wilful and wanton misconduct. Nothing in this Section shall
33 relieve any person, health care provider, health care
34 professional, facility, organization, or corporation from
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1 liability for his, her, or its own negligence in the
2 performance of his, her, or its duties or arising from
3 treatment of a patient. The hearing panel information shall
4 not be subject to inspection or disclosure and shall be
5 afforded the same status as is provided information
6 concerning medical studies in Part 21 of Article VIII of the
7 Code of Civil Procedure.
8 (d) Every adverse credentialing decision based
9 substantially on economic factors shall be reported by the
10 managed care plan's governing body to the Board of Health
11 before the decision takes effect. These reports shall not be
12 disclosed in any form that reveals the identity of any health
13 care providers. These reports shall be utilized to study the
14 effects that credentialing decisions based upon economic
15 factors have on access to care and the availability of health
16 care services. The Board of Health shall submit an initial
17 study to the Governor and the General Assembly by July 1,
18 1999, and subsequent reports shall be submitted periodically
19 thereafter.
20 Section 5-80. Records. Procedures shall be established
21 to ensure that all applicable federal and State laws designed
22 to protect the confidentiality of health care provider
23 records and individual medical records are followed. These
24 records shall be afforded the protections of Section 8-2101
25 through 8-2105 of the Code of Civil Procedure and may not be
26 disclosed to any court, tribunal or board except in
27 accordance with this provision.
28 Section 5-85. Health care provider termination.
29 (a) The Director shall adopt rules requiring that all
30 participating provider agreements contain provisions
31 concerning timely and reasonable notices to be given between
32 the parties and for the managed care plan to provide timely
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1 and reasonable notice to its enrollees. In order to
2 facilitate transfer of health care services, reasonable
3 advance notice of health care provider termination shall be
4 given to the health care provider and enrollees. Notice
5 shall be given for events including, but not limited to,
6 termination of health care provider agreements or managed
7 care plan services. Notice of provider termination to
8 enrollees shall be in a form approved by the Director.
9 (b) When a managed care plan terminates a contract with
10 an entire medical group, physician organization, or other
11 health care provider organization, the managed care plan
12 shall notify enrollees who have selected that medical group,
13 physician organization or other health care provider
14 organization of the termination.
15 (c) When a managed care plan terminates a contractual
16 arrangement with an individual health care provider within a
17 medical group, physician organization, or other health care
18 provider organization, the managed care plan may request that
19 medical group, physician organization or other health care
20 provider organization to notify the enrollees who are
21 patients of that health care provider of the termination.
22 Section 5-90. Complaint handling procedure.
23 (a) A managed care plan and utilization review program
24 shall establish and maintain a complaint system providing
25 reasonable procedures for resolving complaints initiated by
26 enrollees or health care providers (complainant). Nothing
27 herein shall be construed to preclude an enrollee or a health
28 care provider from filing a complaint with the Director or as
29 limiting the Director's ability to investigate complaints.
30 In addition, any enrollee or health care provider not
31 satisfied with the plan's resolution of any complaint may
32 appeal that final plan or utilization program decision to the
33 Department for review.
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1 (b) When a complaint is received by the Department
2 against a managed care plan (respondent), the respondent
3 shall be notified of the complaint. The Department shall, in
4 its notification, specify the date when a report is to be
5 received from the respondent, which shall be no later than 21
6 days after notification is sent to the respondent. A failure
7 to reply by the date specified may be followed by a collect
8 telephone call or collect telegram. Repeated instances of
9 failing to reply by the date specified may result in further
10 regulatory action.
11 (c) Contents of Response or Report.
12 (1) The respondent shall supply adequate
13 documentation that explains all actions taken or not
14 taken and that were the basis for the complaint.
15 (2) Documents necessary to support the respondent's
16 position and information requested by the Department
17 shall be furnished with the respondent's reply.
18 (3) The respondent's reply shall be in duplicate,
19 but duplicate copies of supporting documents shall not be
20 required.
21 (4) The respondent's reply shall include the name,
22 telephone number and address of the individual assigned
23 to investigate or process the complaint.
24 (5) The Department shall respect the confidentiality
25 of medical reports and other documents that by law are
26 confidential. Any other information furnished by a
27 respondent shall be marked "confidential" if the
28 respondent does not wish it to be released to the
29 complainant.
30 (d) The Director shall review the plan decision to
31 determine whether it is consistent with the plan and Illinois
32 law and rules. The Director may contract with individual
33 licensed health care providers for an impartial review of
34 complaints concerning plan decisions. These individuals
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1 shall be licensed in the same discipline and, to the extent
2 possible, in the same or similar specialty as the health care
3 provider involved in the action under review. Any licensed
4 professional providing impartial review for the Director who
5 acts in good faith shall have immunity for any civil or
6 criminal liability or professional discipline as a result of
7 acts or omissions with respect to any impartial review,
8 except for wilful and wanton misconduct. For purposes of any
9 proceeding, the good faith of the individual participant is
10 presumed.
11 (e) Follow-up conclusion. Upon receipt of the
12 respondent's report, the Department shall evaluate the
13 material submitted; and
14 (1) advise the complainant of the action taken and
15 disposition of its complaint;
16 (2) pursue further investigation with respondent or
17 complainant; or
18 (3) refer the investigation report to the
19 appropriate branch within the Department for further
20 regulatory action.
21 (f) The Department of Public Health and Department of
22 Insurance shall coordinate the complaint review and
23 investigation and establish joint rules under the Illinois
24 Administrative Procedure Act implementing this coordinated
25 complaint process.
26 Section 5-95. Quality assurance requirements.
27 (a) A managed care plan shall have a Quality Assurance
28 Plan approved by the Health Care Delivery Policy Advisory
29 Board through a designated Quality Assurance Committee or
30 through a contract with a physician organization for
31 measuring, assessing and improving quality. The managed care
32 plan must:
33 (1) Have a written quality assurance plan that sets
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1 standards and evaluates, at a minimum:
2 (A) Provider availability and accessibility.
3 (B) Appropriateness of care, including the
4 provision of all medically necessary care.
5 (C) Coordination and continuity of care.
6 (D) Patient satisfaction.
7 (2) Assess quality using:
8 (A) Enrollee and provider quality assessment
9 surveys to be conducted at least annually.
10 (B) A log maintained by the managed care plan
11 including utilization review functions identifying
12 the number and types of patient and provider
13 grievances with the resolutions to those issues.
14 (C) Utilization and outcome reports and studies
15 whereby relevant case mix and patient demographic
16 information are taken into account.
17 (3) Establish mechanisms for quality improvement,
18 which include implementation of corrective action plans
19 in response to confirmed quality of care or quality of
20 service identified problems.
21 The Department shall require managed care plans to
22 prepare and submit quarterly aggregate quality assurance
23 reports. These reports shall include, but not be limited to,
24 provider availability and accessibility and patient
25 satisfaction information compiled in aggregate, by diagnosis
26 and by participating provider category. Quality reports must
27 be made available, when requested, to prospective enrollees,
28 enrollees, health care providers and the public. The quality
29 assurance information or data may not be released in any
30 manner that tends to identify any enrollee, patient, or
31 health care provider. This information or data shall be
32 afforded the protections of Section 8-2101 through 8-2105 of
33 the Code of Civil Procedure.
34 (b) A managed care plan shall implement procedures for
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1 ensuring that all applicable federal and State laws designed
2 to protect the confidentiality of health care provider and
3 individual medical records are followed.
4 Section 5-100. Prohibition of waiver of rights. No
5 managed care plan or contract shall contain any provision in
6 procedure or informal policy or procedure that limits,
7 restricts or waives any of the rights set forth in this Act.
8 Any such policy or procedure shall be void and unenforceable.
9 Section 5-105. Transition of services.
10 (a) If an enrollee's health care provider leaves the
11 managed care plan's network of providers for reasons other
12 than those for which the provider would not be eligible to
13 receive a pretermination hearing pursuant to subsection (b)
14 of Section 5-75, the managed care plan shall permit the
15 enrollee to continue an ongoing course of treatment with the
16 enrollee's current health care provider during a transitional
17 period of:
18 (1) at least 90 days from the date of notice to the
19 enrollee of the provider's disaffiliation from the
20 managed care plan's network; or
21 (2) if the enrollee has entered the third trimester
22 of pregnancy at the time of the provider's
23 disaffiliation, for a transitional period that extends
24 through the provision of post-partum health care services
25 directly related to the delivery.
26 Transitional care, however, shall be authorized by the
27 managed care plan during the transitional period only if the
28 health care provider agrees (i) to continue to accept
29 reimbursement from the managed care plan at the rates
30 applicable prior to the start of the transitional period as
31 payment in full, (ii) to adhere to the managed care plan's
32 quality assurance requirements and to provide to the managed
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1 care plan necessary medical information related to the care,
2 (iii) to otherwise adhere to the managed care plan's policies
3 and procedures including, but not limited to, procedures
4 regarding referrals and obtaining preauthorization and a
5 treatment plan approved by the primary care provider or
6 specialist in consultation with the managed care plan, and
7 (iv) if the enrollee is a recipient of services under Article
8 V of the Illinois Public Aid Code, the health care provider
9 has not been subject to a final disciplinary action by a
10 state or federal agency for violations of the Medicaid or
11 Medicare program. In no event shall this subsection be
12 construed to require a managed care plan to provide coverage
13 for benefits not otherwise covered.
14 (b) If a new enrollee whose health care provider is not a
15 member of the managed care plan's provider network enrolls in
16 the managed care plan, the managed care plan shall permit the
17 enrollee to continue an ongoing course of treatment with the
18 enrollee's current health care provider during a transitional
19 period of at least 90 days from the effective date of
20 enrollment, if (i) the enrollee has an ongoing, recurring or
21 chronic disease or condition or (ii) the enrollee has entered
22 the third trimester of pregnancy at the effect date of
23 enrollment, in which case the transitional period shall
24 extend through the provision of post-partum health care
25 services directly related to the delivery. If an enrollee
26 elects to continue to receive payment for care from a health
27 care provider pursuant to this subsection, the payment for
28 the health care services shall be authorized by the managed
29 care plan for the transitional period if the health care
30 provider agrees (i) to accept reimbursement from the managed
31 care plan at rates established by the managed care plan as
32 payment in full, which rates shall be no less than the level
33 of reimbursement applicable to participating providers in the
34 managed care plan's network for those services, (ii) to
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1 adhere to the managed care plan's quality assurance
2 requirements and to provide to the managed care plan
3 necessary medical information related to the care, (iii) to
4 otherwise adhere to the managed care plan's policies and
5 procedures including, but not limited to, procedures
6 regarding referrals and obtaining preauthorization and a
7 treatment plan approved by the primary care provider or
8 specialist in consultation with the managed care plan, and
9 (iv) if the enrollee is a recipient of services under Article
10 V of the Illinois Public Aid Code, the health care provider
11 has not been subject to a final disciplinary action by a
12 state or federal agency for violations of the Medicaid or
13 Medicare program. In no event shall this subsection be
14 construed to require a managed care plan to provide coverage
15 for benefits not otherwise covered.
16 (c) If no participating provider can be engaged to care
17 for the covered health care needs of an enrollee, the managed
18 care plan shall make arrangements for these needs to be met
19 by a non-participating provider with no expense to the
20 enrollee over the expense the enrollee would have incurred
21 had the needs been met by a participating provider.
22 Section 5-110. Grievance procedures. A managed care
23 plan shall establish at least 2 levels of appeal for any
24 enrollee or health care provider grievances. Any grievances
25 concerning an adverse claim decision based on medical
26 necessity shall be heard by a panel of health care providers
27 in the same licensed discipline and, to the extent possible,
28 in the same or similar specialty as the health care provider
29 who made the decision under review. The panel shall be
30 established by the managed care plan in consultation with the
31 Health Care Delivery Policy Advisory Board.
32 Section 5-115. Registry of complaints, grievances,
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1 appeals and reviews. A managed care plan shall create a
2 registry that coordinates information concerning enrollee and
3 health care provider complaints, grievances and requests for
4 appeals and reviews. This information shall be made
5 available to enrollees and health care providers upon request
6 without personal identifying information. All information
7 contained in and related to this registry shall be expunged
8 after 5 years.
9 ARTICLE 10. LICENSURE OF UTILIZATION REVIEW PROGRAMS
10 Section 10-5. Licensed utilization review programs.
11 (a) The Director shall establish standards for the
12 licensure of utilization review programs.
13 (b) All programs must have a medical director, who is a
14 physician licensed to practice medicine in all its branches,
15 responsible for all decisions by the program and who shall
16 assure that the medical necessity review practices they use,
17 and the medical necessity review of payors or reviewers with
18 whom they contract, comply with the following requirements:
19 (1) Screening criteria, weighting elements, and
20 computer algorithms utilized in the medical necessity
21 review process and their method of development, must be
22 released to participating providers and be made
23 available to the public.
24 (2) The medical necessity criteria including, but
25 not limited to, preadmission, appropriateness review,
26 length of stay, discharge planning, follow-up care, and
27 medically acceptable treatment alternatives must be
28 based on sound scientific principles and developed in
29 cooperation with practicing physicians, other affected
30 health care providers, and consumer representatives. A
31 managed care plan's Health Care Delivery Policy Advisory
32 Board may be utilized for this purpose.
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1 (3) Any person who recommends denial of coverage
2 or payment, or determines that a service shall not be
3 provided, based on medical necessity, must be licensed in
4 Illinois and of the same licensed profession as the
5 health care provider who provided, ordered, or proposed
6 the services. The basis for any denial and the name,
7 address, telephone and facsimile number, licensure, and
8 qualifications of the person making any denials shall be
9 provided in writing.
10 (4) An enrollee or provider (upon assignment of an
11 enrollee) who has had a claim denied as not medically
12 necessary must be provided an opportunity for a due
13 process appeal to a qualified physician consultant or
14 qualified provider peer review group not involved in the
15 initial review.
16 (5) Upon request, physicians and other affected
17 health care providers shall be provided the names and
18 credentials of all individuals conducting medical
19 necessity review, subject to reasonable safeguards and
20 standards.
21 (6) In accordance with Section 5-40, prior
22 authorization shall not be required for care for an
23 emergency condition, and patient or health care provider
24 requests for prior authorization of a non-emergency
25 health care service must be answered within 24 hours of
26 the request.
27 (7) Qualified personnel with the minimum licensure
28 status of registered professional nurse must be available
29 for same-day telephone responses to inquiries about
30 medical necessity, including certification of continued
31 length of stay.
32 (8) Programs and managed care plans must ensure
33 that enrollees, in managed care plans where prior
34 authorization is a condition to coverage of a service,
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1 are informed in writing of the reasons medical
2 information is needed and provide appropriate medical
3 information release consent forms for use where services
4 requiring prior authorization are recommended or
5 proposed by their participating providers.
6 (9) When prior approval for a service or other
7 covered item is obtained, it shall be considered approval
8 for the purpose requested, and the service shall be
9 considered to be covered, in accordance with Section
10 5-30.
11 (10) Programs and managed care plans shall disclose
12 to the enrollees, prospective enrollees, and health care
13 providers, in writing, any financial incentives or other
14 inducements to individuals performing medical necessity
15 reviews and their qualifications.
16 Section 10-10. Application of licensure standards.
17 (a) Standards shall first be established, under this
18 Article, by no later than 18 months after the date of the
19 enactment of this Act. In developing standards under this
20 Article, the Director shall:
21 (1) review standards in use by national private
22 accreditation organizations;
23 (2) recognize, to the extent appropriate,
24 differences in the organizational structure and operation
25 of utilization review programs;
26 (3) establish procedures for the timely
27 consideration of applications for licensure of
28 utilization review programs; and
29 (4) establish grievance procedures for enrollees
30 and participating providers to appeal utilization review
31 program decisions.
32 (b) The Director shall periodically review the standards
33 established under this Article, and may revise the standards
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1 from time to time to assure that the standards continue to
2 reflect appropriate policies and practices for the
3 cost-effective and medically appropriate use of health care
4 services within utilization review programs.
5 ARTICLE 20. ADMINISTRATION AND ENFORCEMENT
6 Section 20-5. Responsibilities of the Department.
7 (a) All managed care plans shall bi-annually certify
8 compliance with this Act and utilization review programs
9 providing or reviewing services in Illinois shall be licensed
10 by the Department under rules adopted under this Act. The
11 Director shall establish by rule a process for this
12 certification and licensure including fees to cover the costs
13 associated with implementing the Act. All fees and fines
14 assessed under the Act shall be deposited in Managed Care
15 Entity Responsibility and Patient Rights Fund hereby created
16 as a special fund in the State treasury. For health
17 maintenance organizations, the certification requirements of
18 this Act shall be incorporated into the licensure
19 requirements under the Health Maintenance Organization Act.
20 In addition, the certification requirements of this Act shall
21 be incorporated into the program requirements of the
22 Department of Public Aid and Department of Human Services and
23 no further certification under this Act is required.
24 (b) The Director shall take any appropriate enforcement
25 action under this Act including, but not limited to, the
26 assessment of civil fines and seeking injunctive relief for
27 any failure to certify compliance with this Act or obtain a
28 license under this Act or any violation of the Act or rules
29 by a managed care plan or any utilization review program.
30 (c) The Department shall have the authority to impose
31 fines on any managed care plan or any utilization review
32 program. The Department shall adopt rules pursuant to this
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1 Act which establish a system of fines related to the type and
2 level of violation or repeat violation, including but not
3 limited to:
4 (1) A fine not exceeding $10,000 for a violation
5 that created a condition or occurrence presenting a
6 substantial probability that death or serious harm to an
7 individual will or did result therefrom; and
8 (2) A fine not exceeding $5,000 for a violation
9 that creates or created a condition or occurrence that
10 threatens the health, safety or welfare of an individual.
11 These rules shall include an opportunity for a hearing in
12 accordance with the Illinois Administrative Procedure
13 Act. All final decisions of the Department shall be
14 reviewable under the Administrative Review Law.
15 (d) Notwithstanding the existence or pursuit of any
16 other remedy, the Director may, through the Attorney General,
17 seek an injunction to restrain or prevent any person or
18 entity from functioning, or operating in violation of this
19 Act or rules adopted under this Act.
20 (e) The Department shall adopt rules for managed care
21 plan certification and utilization review program licensure
22 under this Act that shall include, but not be limited to, the
23 following:
24 (1) Further definition of managed care plans and
25 utilization review programs.
26 (2) Information required by the Department.
27 (3) Certification requirements for managed care
28 plans and utilization review programs.
29 (4) Certification and licensure programs and renewal
30 fees which may cover the cost of administering the
31 programs.
32 (5) Information including mandated reports that may
33 be necessary for the Department to monitor and evaluate,
34 managed care plans and utilization review programs.
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1 These reports shall include but not be limited to
2 coverage decisions, credentialing decisions,
3 participating provider capacity and any other necessary
4 information.
5 (6) Administrative fines that may be assessed
6 against managed care plans or utilization review programs
7 by the Department for violations of this Act or the rules
8 adopted under this Act.
9 (f) The Department shall perform inspections of managed
10 care plans and utilization review programs as deemed
11 necessary by the Department to ensure compliance with this
12 Act or the rules adopted under this Act.
13 (g) The Department shall deposit application fees,
14 renewal fees, and fines into the Managed Care Entity
15 Responsibility and Patient Rights Fund.
16 (h) All managed care plan and utilization review program
17 records including any patient records reviewed by the
18 Department shall be afforded the protections of Sections
19 8-2101 through 8-2105 of the Code of Civil Procedure.
20 Section 20-10. Conflicts. To the extent of any conflict
21 between this Act and any other Act, this Act prevails over
22 the conflicting provision.
23 Section 20-15. Illinois Administrative Procedure Act.
24 The Illinois Administrative Procedure Act is hereby expressly
25 adopted and incorporated herein and shall apply to the
26 Department as if all of the provisions of that Act were
27 included in this Act; except that in case of a conflict
28 between the Illinois Administrative Procedure Act and this
29 Act, the provisions of this Act shall control.
30 ARTICLE 90. AMENDATORY PROVISIONS
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1 Section 90-5. The State Employees Group Insurance Act of
2 1971 is amended by adding Section 6.12 as follows:
3 (5 ILCS 375/6.12 new)
4 Sec. 6.12. Managed Care Patient Rights Act. The program
5 of health benefits is subject to the provisions of the
6 Managed Care Patient Rights Act and Section 356w of the
7 Illinois Insurance Code.
8 Section 90-10. The Counties Code is amended by adding
9 Section 5-1069.8 as follows:
10 (55 ILCS 5/5-1069.8 new)
11 Sec. 5-1069.8. Managed Care Patient Rights Act. All
12 counties, including home rule counties, are subject to the
13 provisions of the Managed Care Patient Rights Act and Section
14 356w of the Illinois Insurance Code. The requirement under
15 this Section that health care benefits provided by counties
16 comply with the Managed Care Patient Rights Act is an
17 exclusive power and function of the State and is a denial and
18 limitation of home rule county powers under Article VII,
19 Section 6, subsection (h) of the Illinois Constitution.
20 Section 90-15. The Illinois Municipal Code is amended by
21 adding 10-4-2.8 as follows:
22 (65 ILCS 5/10-4-2.8 new)
23 Sec. 10-4-2.8. Managed Care Patient Rights Act. The
24 corporate authorities of all municipalities are subject to
25 the provisions of the Managed Care Patient Rights Act and
26 Section 356w of the Illinois Insurance Code. The requirement
27 under this Section that health care benefits provided by
28 municipalities comply with the Managed Care Patient Rights
29 Act is an exclusive power and function of the State and is a
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1 denial and limitation of home rule municipality powers under
2 Article VII, Section 6, subsection (h) of the Illinois
3 Constitution.
4 Section 90-20. The Illinois Insurance Code is changed by
5 adding Sections 155.36, 356w, 370s, and 511.118 as follows:
6 (215 ILCS 5/155.36 new)
7 Sec. 155.36. Managed Care Patient Rights Act provisions.
8 Insurance companies providing coverage for health care
9 services are subject to the provisions of the Managed Care
10 Patient Rights Act. The provisions of Article 10 shall be
11 implemented through existing Department of Public Health
12 certification procedures.
13 (215 ILCS 5/356w new)
14 Sec. 356w. Choice requirements for point of service
15 plans.
16 (a) An employer, self-insured entity, labor union,
17 association, or other person providing, offering, or making
18 available to employees or individuals a managed care plan,
19 as defined in the Managed Care Patient Rights Act, shall
20 offer to all enrollees the opportunity to obtain coverage
21 through a "point of service" plan at the time of enrollment
22 and once annually thereafter. The "point of service" plan
23 shall provide coverage for health care services when the
24 health care services are provided by any health care provider
25 without the necessary referrals, prior authorization, or
26 other utilization review requirements of the managed care
27 plan.
28 (b) A point of service plan may charge an enrollee who
29 opts to obtain point of service coverage an alternative
30 premium that takes into account the actuarial value of the
31 coverage.
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1 (c) A point of service plan may require reasonable
2 payment of coinsurance, co-payments, or deductibles. The
3 co-insurance rate on the point of service plan shall not be
4 greater than 20 percentage points more than the co-insurance
5 rate on the underlying plan. The maximum out-of-pocket
6 amount shall not exceed $5,000 for an individual and $7,500
7 for family coverage.
8 (215 ILCS 5/370s new)
9 Sec. 370s. Managed Care Patient Rights Act. All
10 insurers and administrators are subject to the provisions of
11 the Managed Care Patient Rights Act and Section 356w of this
12 Code.
13 (215 ILCS 5/511.118 new)
14 Sec. 511.118. Managed Care Patient Rights Act. All
15 administrators are subject to the provisions of the Managed
16 Care Patient Rights Act and Section 356w of this Code.
17 Section 90-25. The Comprehensive Health Insurance Plan
18 Act is amended by adding Section 8.6 as follows:
19 (215 ILCS 105/8.6 new)
20 Sec. 8.6. Managed Care Patient Rights Act. The plan
21 shall be subject to the provisions of the Managed Care
22 Patient Rights Act and Section 356w of the Illinois Insurance
23 Code.
24 Section 90-30. The Health Maintenance Organization Act
25 is amended by adding Section 5-3.6 as follows:
26 (215 ILCS 125/5-3.6 new)
27 Sec. 5-3.6. Managed Care Patient Rights Act provisions.
28 Health maintenance organizations are subject to the
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1 provisions of the Managed Care Patient Rights Act and Section
2 356w of the Illinois Insurance Code.
3 Section 90-35. The Limited Health Services Organization
4 Act is amended by adding Section 4002.6 as follows:
5 (215 ILCS 130/4002.6 new)
6 Sec. 4002.6. Managed Care Patient Rights Act
7 provisions. Limited health service organizations are subject
8 to the provisions of the Managed Care Patient Rights Act and
9 Section 356w of the Illinois Insurance Code.
10 Section 90-40. The Dental Service Plan Act is amended by
11 adding Section 48 as follows:
12 (215 ILCS 110/48 new)
13 Sec. 48. Managed Care Patient Rights Act provisions.
14 Dental Service Plans are subject to the provisions of the
15 Managed Care Patient Rights Act and Section 356w of the
16 Illinois Insurance Code. For purposes of the Dental Service
17 Plan Act the term physician as used in the Managed Care
18 Patient Rights Act shall mean dentist.
19 Section 90-45. The Voluntary Health Services Plans Act
20 is amended by adding Section 15.30 as follows:
21 (215 ILCS 165/15.30 new)
22 Sec. 15.30. Managed Care Patient Rights Act. A health
23 service plan corporation is subject to the provisions of the
24 Managed Care Patient Rights Act and Section 356w of the
25 Illinois Insurance Code.
26 Section 90-50. The Illinois Public Aid Code is amended
27 by adding Section 5-16.12 as follows:
-39- LRB9011344JSgc
1 (305 ILCS 5/5-16.12 new)
2 Sec. 5-16.12. Managed Care Patient Rights Act. The
3 medical assistance program is subject to the provisions of
4 the Managed Care Patient Rights Act and Section 356w of the
5 Illinois Insurance Code. The Department shall adopt rules to
6 implement these provisions. These rules shall require
7 compliance with Article 5, and Section 10-5(b) of Article 10
8 of the Managed Care Patient Rights Act in the medical
9 assistance managed care programs. The medical assistance
10 fee-for-service program is not subject to the provisions of
11 the Managed Care Patient Rights Act.
12 Section 400. The State Finance Act is amended by adding
13 Section 5.480 as follows:
14 (30 ILCS 105/5.480 new)
15 Sec. 5.480. The Managed Care Entity Responsibility and
16 Patient Rights Fund.
17 ARTICLE 99. EFFECTIVE DATE
18 Section 99-1. Effective date. This Act takes effect
19 upon becoming law.