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90_SB0705
New Act
5 ILCS 375/6.9 new
55 ILCS 5/5-1069.8 new
65 ILCS 5/10-4-2.8 new
215 ILCS 5/155.31 new
215 ILCS 5/356t new
215 ILCS 5/370s new
215 ILCS 5/511.118 new
215 ILCS 105/8.6 new
215 ILCS 125/5-3.5 new
215 ILCS 130/4002.5 new
215 ILCS 110/48 new
215 ILCS 165/15.25 new
305 ILCS 5/5-16.8 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 managed care plans
and utilization review plans to be certified 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, Voluntary Health Services Plans Act, State
Employees Group Insurance Act of 1971, Counties Code,
Illinois Municipal Code, and Illinois Public Aid Code.
Effective immediately.
LRB9001044JSgcB
LRB9001044JSgcB
1 AN ACT to create the Managed Care Patient Rights Act,
2 amending 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
9 patient's 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, including a prohibition of retaliation
27 against physicians 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 shall be implemented through the regulation of
2 managed care plans and utilization review programs.
3 (d) The Department of Public Health is required to
4 establish standards for the certification of certain
5 functions common to licensed insurance companies, health
6 maintenance organizations, self-insured employer or employee
7 organizations, and other managed care plans. These functions
8 shall be certified as qualified managed care plans or
9 qualified utilization review programs. Standards are
10 required to ensure patient protection, quality of care,
11 fairness to physician and other health care providers,
12 utilization review safeguards, and coverage options for all
13 patients, including the ability to enroll in a point of
14 service plan.
15 Section 1-10. Definitions. As used in this Act:
16 "Board" means the State Board of Health.
17 "Department" means the Department of Public Health.
18 "Director" means the Director of Public Health.
19 "Enrollee" means an individual and his or her dependents
20 who are enrolled in a managed care plan.
21 "Health care provider" means a physician, dentist,
22 podiatrist, registered professional nurse, clinic, hospital,
23 federally qualified health center, rural health clinic,
24 ambulatory surgical treatment center, pharmacy, laboratory,
25 physician organization, preferred provider organization,
26 independent practice association, or other appropriately
27 licensed provider of health care services.
28 "Health care services" means services, supplies, or
29 products rendered or sold by a health care provider within
30 the scope of the provider's license. The term includes, but
31 is not limited to, hospital, medical, surgical, dental,
32 podiatric, pharmacy, vision, home health, and pharmaceutical
33 products.
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1 "Managed care plan" means a plan that establishes,
2 operates, or maintains a network of health care providers
3 that have entered into agreements with the plan to provide
4 health care services to enrollees where the plan has the
5 ultimate and direct contractual obligation to the enrollee to
6 arrange for the provision of or pay for health care services
7 through:
8 (1) organizational arrangements for ongoing
9 quality assurance, utilization review programs, or
10 dispute resolution; or
11 (2) financial incentives for persons enrolled
12 in the plan to use the participating providers and
13 procedures covered by the plan.
14 A managed care plan may be established or operated
15 by any entity including a licensed insurance company,
16 hospital or medical service plan, health maintenance
17 organization, limited health service organization,
18 preferred provider organization, third party
19 administrator, or an employer or employee organization.
20 "Participating provider" means a health care provider
21 that has entered into an agreement with a managed care plan
22 to provide health care services to a patient enrolled in the
23 managed care plan.
24 "Patient" means any person who has received or is
25 receiving health care services from a health care provider.
26 "Primary care" means the provision of a broad range of
27 personal medical care (preventive, diagnostic, curative,
28 counseling, or rehabilitative) in a manner that is
29 accessible, comprehensive, and coordinated over time by a
30 physician licensed to practice medicine in all its branches.
31 "Principal care" means the provision of ongoing
32 preventive, diagnostic, curative, counseling, or
33 rehabilitative care, provided or coordinated by a physician
34 licensed to practice medicine in all its branches, that is
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1 focused on a specific organ system, disease, or condition.
2 Principal care may be provided concurrently with or apart
3 from primary care.
4 "Qualified managed care plan" means a managed care plan
5 that the Director certifies upon application by the plan as
6 meeting the requirements of this Act.
7 "Qualified utilization review program" means a
8 utilization review program that the Director certifies upon
9 application by the program as meeting the requirements of
10 this Act.
11 "Utilization review program" means a system operated by
12 or on behalf of a managed care plan for the purpose of
13 reviewing the medical necessity, appropriateness, or quality
14 of health care services and supplies provided or proposed to
15 be provided by the managed care plan using specified
16 guidelines. The system may include pre-admission
17 certification, the application of appropriately developed
18 clinically-based guidelines, length of stay review, discharge
19 planning, preauthorization of ambulatory procedures, and
20 retrospective review.
21 ARTICLE 5. ENUMERATED PATIENT RIGHTS
22 Section 5-5. Managed care patient rights.
23 (a) A patient has the right to care consistent with
24 professional standards of practice to assure quality nursing
25 and medical practices, to be informed of the name of the
26 participating physician responsible for coordinating his or
27 her care, to receive information concerning his or her
28 condition and proposed treatment, to refuse any treatment to
29 the extent permitted by law, and to privacy and
30 confidentiality of records except as otherwise provided by
31 law.
32 (b) A patient has the right, regardless of source of
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1 payment, to examine and to receive a reasonable explanation
2 of his or her total bill for health care services rendered by
3 his or her physician or other health care provider, including
4 the itemized charges for specific health care services
5 received. A physician or other health care provider shall be
6 responsible only for a reasonable explanation of these
7 specific health care services provided by the health care
8 provider.
9 (c) A patient has the right to timely prior notice of
10 the termination in the event a managed care plan cancels or
11 refuses to renew an individual's participation in the plan.
12 (d) A patient has the right to privacy and
13 confidentiality in health care. A physician, other health
14 care provider, managed care plan, and utilization review
15 program shall refrain from disclosing the nature or details
16 of health care services provided to patients, except that the
17 information may be disclosed to the patient, the party making
18 treatment decisions if the patient is incapable of making
19 decisions regarding the health care services provided, those
20 parties directly involved with providing treatment to the
21 patient or processing the payment for the treatment only in
22 accordance with Section 5-40, those parties responsible for
23 peer review, utilization review, and quality assurance, and
24 those parties required to be notified under the Abused and
25 Neglected Child Reporting Act, the Illinois Sexually
26 Transmissible Disease Control Act, or where otherwise
27 authorized or required by law. This right may be expressly
28 waived in writing by the patient or the patient's guardian,
29 but a managed care plan, a physician, or other health care
30 provider may not condition the provision of health care
31 services on the patient's or guardian's agreement to sign
32 such a waiver.
33 (e) An individual has the right to purchase any health
34 care services with that individual's own funds, whether the
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1 health care services are covered within the individual's
2 basic benefit package or from any health care provider or
3 plan received as a benefit of employment or from another
4 source. Employers shall not be prohibited from providing
5 coverage for benefits in addition those mandated by law.
6 Section 5-10. Medically appropriate health care
7 protection.
8 (a) No managed care plan shall retaliate against a
9 physician or other health care provider who advocates for
10 appropriate health care for their patients.
11 (b) It is the public policy of the State of Illinois
12 that a physician or any other health care provider be
13 encouraged to advocate for medically appropriate health care
14 for his or her patients. For purposes of this Section, "to
15 advocate for medically appropriate health care" means to
16 appeal a payor's decision to deny payment for a service
17 pursuant to the reasonable grievance or appeal procedure
18 established by a managed care plan or third-party payor, or
19 to protest a decision, policy, or practice that the physician
20 or another health care provider, consistent with that degree
21 of learning and skill ordinarily possessed by physicians or
22 other health care providers practicing in the same or a
23 similar locality and under similar circumstances, reasonably
24 believes impairs the physician's or other health care
25 provider's ability to provide appropriate health care to his
26 or her patients.
27 (c) The application and rendering by any person of a
28 decision to terminate an employment or other contractual
29 relationship with or otherwise penalize a physician or other
30 health care provider for advocating for appropriate health
31 care consistent with the degree of learning and skill
32 ordinarily possessed by physicians or other health care
33 providers practicing in the same or a similar locality and
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1 under similar circumstances violates the public policy of
2 this State and constitutes a business offense subject to the
3 penalty under Section 20-15.
4 (d) This Section shall not be construed to prohibit a
5 payor from making a determination not to pay for a particular
6 health care service or to prohibit a medical group,
7 independent practice association, preferred provider
8 organization, foundation, hospital medical staff, hospital
9 governing body, or payor from enforcing reasonable peer
10 review or utilization review protocols or determining whether
11 a physician or other health care provider has complied with
12 those protocols.
13 (e) Nothing in this Section shall be construed to
14 prohibit the governing body of a hospital or the hospital
15 medical staff from taking disciplinary action against a
16 physician as authorized by law.
17 (f) Nothing in this Section shall be construed to
18 prohibit the Department of Professional Regulation from
19 taking disciplinary action against a physician or other
20 health care provider under the appropriate licensing Act.
21 Section 5-20. Choice of physician.
22 (a) All managed care plans that require each enrollee to
23 select a participating provider for any purpose including
24 coordination of care shall allow all enrollees to choose any
25 primary care physician licensed to practice medicine in all
26 its branches participating in the managed care plan for that
27 purpose.
28 (b) In addition, all enrollees with an ongoing,
29 recurring, or chronic disease or condition shall be allowed
30 to choose any participating physician licensed to practice
31 medicine in all its branches to provide principal care,
32 without referral from the provider coordinating care. The
33 decision regarding selection of any physician for any purpose
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1 must be made by the enrollee and the physician. The managed
2 care plan's Medical Review Board shall define those diseases
3 and conditions that shall be considered ongoing, recurring,
4 or chronic diseases and conditions for the managed care plan.
5 (c) The enrollee may be required by the managed care
6 plan to select a principal care physician who has a referral
7 arrangement with the enrollee's primary care physician or to
8 select a new primary care physician who has a referral
9 arrangement with the principal care physician chosen by the
10 enrollee. If a managed care plan requires an enrollee to
11 select a new physician under this subsection (c), the managed
12 care plan must provide the enrollee with both options
13 provided in this subsection (c).
14 (d) Nothing shall prohibit the managed care plan from
15 requiring prior authorization or approval from either a
16 primary care physician or a principal care physician for
17 referrals for additional health care services. Nothing shall
18 prohibit the managed care plan from requiring the principal
19 care physician to coordinate referrals for additional health
20 care services with the primary care physician.
21 Section 5-25. Prohibited restraints on communication.
22 No managed care plan may prohibit or discourage health care
23 providers from discussing any alternative health care
24 services and providers, utilization review and quality
25 assurance policies, terms and conditions of plans and plan
26 policies with enrollees, prospective enrollees, providers, or
27 the public. Any violation of this Section shall be subject
28 to the penalties set forth in Sections 20-15 and 20-55.
29 Section 5-30. Procedure authorization. A managed care
30 plan that authorizes a specific type of treatment by a
31 provider shall not rescind or modify the authorization after
32 the provider renders the health care service in good faith
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1 and pursuant to the authorization. This Section shall not be
2 construed to expand or alter the benefits available to the
3 enrollee under a managed care plan.
4 Section 5-40. Patient confidential records. A managed
5 care plan shall not release any information to an employer or
6 anyone else, except as specifically authorized by law, that
7 would directly or indirectly indicate to the employer or
8 anyone else that an enrollee is receiving or has received
9 health care services from a health care provider covered by
10 the managed care plan, unless expressly authorized to do so
11 in writing by the enrollee.
12 Section 5-45. Emergency care. All managed care plans
13 shall provide care for an emergency, as defined in Section
14 3.5 of the Emergency Medical Services (EMS) Systems Act, such
15 that payment for this coverage is not dependent upon whether
16 or not the health care services are performed by a
17 participating provider. The managed care plan shall be
18 notified, after the patient is stabilized, of any nonemergent
19 health care services needed by the patient. The managed care
20 plan must respond to the request for authorization for any
21 needed health care services within 30 minutes of
22 notification. In the absence of a response, the health care
23 services shall be deemed approved.
24 Section 5-50. Notices of payment or denial. All managed
25 care plans shall provide enrollees with detailed notices of
26 payment and denial. The notices of denial shall be signed by
27 the individual responsible for denying payment and include an
28 address and accessible phone number of the individual
29 responsible for denying payment. Further, the notice of
30 denial shall clearly state the procedures for appealing the
31 denial. The enrollee shall be given the opportunity to
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1 respond to any denial and explain any discrepancies.
2 Section 5-55. Prohibition of waiver of rights. No
3 managed care plan or contract shall contain any provision
4 which limits, restricts or waives any of the rights set forth
5 in this Act.
6 ARTICLE 10. CERTIFICATION OF MANAGED CARE PLANS AND UTILIZATION
7 REVIEW PROGRAMS
8 Section 10-5. Certification of managed care plans and
9 utilization review programs.
10 (a) Certification. All managed care plans with
11 enrollees in Illinois and utilization review programs
12 reviewing health care services provided in Illinois must be
13 certified by the Department in addition to any other
14 licensure required by law in order to do business in
15 Illinois. The Director shall establish a process for
16 certification of managed care plans and of utilization review
17 programs. Certification of managed care plans shall be
18 supplemental to the existing regulation of managed care plans
19 by the Department of Insurance. The certification
20 requirements of Sections 10-15, 10-20, 10-25, 10-30, 10-35,
21 10-40, 10-45, and 10-60 shall be incorporated into the
22 licensure requirements under the Health Maintenance
23 Organization Act and the program requirements of the
24 Department of Public Aid and the Department of Human
25 Services, and no further certification under this Article is
26 required. With respect to all other managed care plans, the
27 Department of Insurance shall transmit copies of any
28 application for issuance of a certificate of authority to the
29 Director of the Department of Public Health. The Director of
30 the Department of Public Health shall then determine whether
31 the applicant for the certificate of authority, with respect
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1 to the delivery of health care services: (1) has
2 demonstrated the willingness and potential ability to assure
3 that such health care services will be provided in a manner
4 to insure both availability, accessibility, and continuity of
5 health care services with adequate personnel and facilities
6 and (2) has arrangements, established in accordance with
7 regulations adopted by the Department of Public Health, for
8 continuing compliance with the requirements of the Act. Upon
9 investigation, the Director of the Department of Public
10 Health shall certify to the Director of the Department of
11 Insurance whether the proposed managed care plan or
12 utilization review program meets the requirements of this
13 Act. If the Director of the Department of Public Health
14 certifies that the managed care plan or utilization review
15 program does not meet the requirements, he shall specify in
16 writing the deficiencies. The Director of the Department of
17 Insurance shall not issue a certificate of authority, unless
18 the Director of the Department of Public Health certifies
19 that the managed care plan's or utilization review program's
20 proposed plan of operation meets the requirements of this
21 Act.
22 (b) Review and recertification. The Director shall
23 establish procedures for the periodic review and
24 recertification of qualified managed care plans and qualified
25 utilization review programs.
26 (c) Termination of certification. The Director shall
27 terminate the certification of a previously qualified managed
28 care plan or a qualified utilization review program if the
29 Director determines that the plan or program no longer meets
30 the applicable requirements for certification. Before
31 effecting a termination, the Director shall provide the plan
32 or program notice and opportunity for a hearing on the
33 proposed termination in accordance with Sections 20-35,
34 20-40, and 20-45 of this Act.
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1 (d) Recognition of accreditation. If the Director finds
2 that a national accreditation body establishes a requirement
3 or requirements for accreditation of a managed care plan or
4 utilization review program that are at least equivalent to a
5 requirement established under Article 10, the Director may,
6 to the extent appropriate, treat a managed care plan or a
7 utilization review program thus accredited as meeting the
8 requirements of Article 10. The requirements of Sections
9 10-25, 10-30, 10-35, and 10-60(b)(3) and (6), however, must
10 be adhered to by all certified entities.
11 Section 10-10. Managed care plan. Requirements for
12 certification. The Director shall establish standards for the
13 certification of qualified managed care plans that conduct
14 business in this State, including standards set forth in
15 Sections 10-15 through 10-50.
16 Section 10-15. Managed care plan information.
17 (a) Prospective enrollees in managed care plans must be
18 provided written information disclosing the terms and
19 conditions of the managed care plans so that they can make
20 informed decisions about accepting a certain system of health
21 care delivery. Where the managed care plan is described
22 orally to prospective enrollees, the oral description must be
23 easily understood, truthful, and objective in the terms used.
24 (b) All managed care plans must be described in writing
25 in a legible and understandable format, consistent with
26 standards developed for supplemental insurance coverage under
27 Title XVIII of the Social Security Act. This format must be
28 standardized so that prospective enrollees can compare the
29 attributes of the managed care plans. Specific items that
30 must be included are:
31 (1) coverage provisions, benefits, and any
32 exclusions or limitations of: (i) health care services
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1 or (ii) physicians or other providers;
2 (2) any and all prior authorization or other review
3 requirements including preauthorization review,
4 concurrent review, post-service review, post-payment
5 review, and any procedures that may lead the patient to
6 be denied coverage for or not be provided a particular
7 health care service;
8 (3) a detailed explanation of the managed care plan
9 policy describing how the managed care plan shall
10 facilitate the continuity of care for enrollees receiving
11 health care services from non-participating providers;
12 (4) a detailed explanation of how managed care plan
13 limitations affect enrollees, including information on
14 enrollee financial responsibility for payment of
15 co-payments, deductibles, coinsurance, and non-covered or
16 out-of-plan health care services;
17 (5) a detailed explanation of the percent of
18 premium going to pay for care and percent of premium
19 going to pay for administration;
20 (6) educational materials explaining the proper
21 utilization of emergency care in accordance with Section
22 5-45 prepared by the Department of Public Health;
23 (7) enrollee satisfaction statistics, including,
24 but not limited to, reenrollment, and reasons for
25 leaving a managed care plan; and
26 (8) explanation of how the managed care plan
27 compensates health care providers and how those
28 compensation arrangements may impact the provision of
29 health care services.
30 Section 10-20. Access to providers. Managed care plans
31 must demonstrate that they have adequate access to physicians
32 in appropriate medical specialties and other health care
33 providers, so that all covered health care services will be
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1 provided in a timely fashion. This requirement cannot be
2 waived and must be met in all geographic areas where the
3 managed care plan has enrollees, including rural areas.
4 Section 10-25. Fairness in contracting. All managed
5 care plans must provide that any individual physician
6 licensed to practice medicine in all its branches, any
7 pharmacy, any federally qualified health center, any dentist,
8 and any podiatrist, that consistently meets the reasonable
9 terms and conditions established by a managed care plan
10 including, but not limited to, credentialing standards,
11 adherence to quality assurance program requirements,
12 utilization management guidelines, contract procedures, and
13 provider network size and accessibility requirements must be
14 accepted by the managed care plan. Any physician or any
15 other health care provider who is either terminated from or
16 denied inclusion in the medical staff or provider network of
17 the managed care plan shall be given, within 10 business days
18 after that determination, a written explanation of the
19 reasons for his or her exclusion or termination from the
20 medical staff or provider network and an opportunity to
21 appeal.
22 Section 10-30. Managed care plan medical staff.
23 (a) Within 12 months after the effective date of this
24 Act, all managed care plans shall be required to establish an
25 independent medical staff comprised of all participating
26 physicians licensed to practice medicine in all its branches.
27 The medical staff must be organized and operated in
28 accordance with written rules and regulations. These rules
29 and regulations must be written and approved by the medical
30 staff and the managed care plan's governing body. Neither
31 the medical staff nor the managed care plan's governing body
32 may unilaterally amend the rules and regulations. The
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1 medical staff must elect from its members a Medical Review
2 Board representative by medical specialty and geographic area
3 of the medical staff. The Medical Review Board shall be
4 established in the medical staff rules and regulations and
5 shall be comprised of a minimum of 25 physicians with no more
6 than 20% of the physicians being from any one medical
7 specialty. The managed care plans must grant the Medical
8 Review Board defined rights under which physicians
9 participating in the managed care plan collaborate with the
10 managed care plan to establish the plan's medical policy
11 (including, but not limited to, delivery of any covered: (i)
12 health care services, (ii) pharmaceuticals, (iii) procedures
13 and (iv) technology), utilization review criteria and
14 procedures, quality assurance procedures, credentialing
15 criteria, and medical management procedures. The Medical
16 Review Board may make recommendations, but shall not
17 determine the managed care plan's covered services. The
18 medical staff and Medical Review Board must report directly
19 to the managed care plan's governing body.
20 (b) The medical staff rules and regulations shall
21 provide due process procedures for all actions granting,
22 reducing, restricting, suspending, revoking, denying, or not
23 renewing medical staff membership and privileges. The
24 managed care plan's governing body shall not control
25 evaluation of credentials of applicants for medical staff
26 membership and privileges or the exercise of professional
27 judgment. The managed care plan's governing body shall make
28 all final medical staff membership and privilege decisions.
29 The Department shall develop standardized application forms
30 for credentialing. This information shall be verified by the
31 managed care plans from primary sources.
32 Section 10-35. Credentialing.
33 (a) A managed care plan shall allow all physicians
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1 within the managed care plan's geographic service area to
2 apply for medical staff membership and clinical privileges
3 under established medical staff rules and regulations. All
4 physicians within the managed care plan shall be
5 recredentialed no more often than once every 2 years.
6 (1) In accordance with the criteria in this item,
7 items (2) and (3), and subsection (b), credentialing
8 shall be performed in a timely manner by the medical
9 staff directly or through a contract with a physician
10 organization approved by the medical staff. The
11 credentialing process shall be completed in a timely
12 manner not to exceed 6 months. For purposes of
13 credentialing: "Adverse decision" means a decision
14 reducing, restricting, suspending, revoking, denying, or
15 not renewing medical staff membership including, but not
16 limited to, limitations on access to institutional
17 equipment, facilities and personnel. "Economic factor"
18 means any information or reasons for decisions unrelated
19 to quality of care or professional competency.
20 (A) The credentialing process shall begin upon
21 application of a physician to the managed care plan
22 for inclusion.
23 (B) An application shall be reviewed by a
24 credentialing committee with representation of the
25 applicant's medical specialty.
26 (C) Credentialing shall be based on objective
27 standards of quality with input from physicians
28 credentialed in the managed care plan, and the
29 standards shall be available to applicants and
30 medical staff members. Any profiling of physicians
31 must be adjusted to recognize case mix, severity of
32 illness, age of patients, and other features of a
33 physician's practice including all economic factors
34 that may account for higher than or lower than
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1 expected costs. Profiles must be made available to
2 those so profiled. When graduate medical education
3 is a consideration in credentialing, equal
4 recognition shall be given to training programs
5 accredited by the Accrediting Council on Graduate
6 Medical Education or by the American Osteopathic
7 Association. The lack of board certification may
8 not be the single or exclusive criteria for denial
9 of participation.
10 (D) A managed care plan is prohibited from
11 excluding health care providers solely because those
12 health care providers treat a substantial number of
13 patients with conditions or illnesses which may
14 require costly care or treatment.
15 (E) The medical staff shall make credentialing
16 recommendations to the managed care plan's governing
17 body. All governing body credentialing decisions
18 shall be made on the record, and the applicant shall
19 be provided with all reasons used if the application
20 is denied or the credentials not renewed.
21 (F) Prior to initiation of a proceeding
22 leading to termination of a contract, the physician
23 shall be provided notice, an opportunity for
24 discussion, and an opportunity to enter into and
25 complete a corrective action plan, except in cases
26 where there is imminent harm to patient health or a
27 license probation, suspension, or revocation action
28 by the Department of Professional Regulation.
29 (2) Minimum procedures for initial applicants for
30 medical staff membership and privileges shall include the
31 following:
32 (A) Written procedures relating to the
33 acceptance and processing of initial applicants for
34 medical staff membership.
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1 (B) Written procedures to be followed in
2 determining an applicant's qualifications for being
3 granted medical staff membership and privileges.
4 (C) Written criteria to be followed in
5 evaluating an applicant's qualifications.
6 (D) An evaluation of an applicant's current
7 health status and current license status in
8 Illinois.
9 (E) A written response to each applicant that
10 explains the reason or reasons for any adverse
11 decision, including all reasons based in whole or in
12 part on the applicant's medical qualifications or
13 any other basis, including economic factors.
14 (3) Minimum procedures with respect to medical
15 staff membership and privilege determinations concerning
16 current members of the medical staff shall include the
17 following:
18 (A) A written notice of an adverse decision by
19 the governing body of the managed care plan.
20 (B) An explanation of the reasons for an
21 adverse decision including all reasons based on the
22 quality of medical care or any other basis,
23 including economic factors.
24 (C) A statement of the medical staff member's
25 right to request a fair hearing on the adverse
26 decision before a hearing panel whose membership is
27 mutually agreed upon by the medical staff and the
28 governing body of the managed care plan. The
29 hearing panel shall have independent authority to
30 recommend action to the governing body of the
31 managed care plan. Upon the request of the medical
32 staff member or the governing body of the managed
33 care plan, the hearing panel shall make findings
34 concerning the nature of each basis for any adverse
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1 decision recommended to and accepted by the
2 governing body of the managed care plan. Nothing in
3 this item (C) limits a managed care plan's or
4 medical staff's right to summarily suspend, without
5 a prior hearing, a person's medical staff membership
6 or privileges if the continuation of practice of a
7 medical staff member constitutes an immediate danger
8 to the public. A fair hearing shall be commenced
9 within 15 days after the suspension and completed
10 without delay. Nothing in this item (C) limits a
11 medical staff's right to permit, in the medical
12 staff rules and regulations, summary suspension of
13 membership or privileges in designated
14 administrative circumstances as specifically
15 approved by the medical staff. This provision must
16 specifically describe both the administrative
17 circumstances that can result in a summary
18 suspension and the length of the summary suspension.
19 The opportunity for a fair hearing is required for
20 any administrative summary suspension. Any
21 requested hearing must be commenced within 15 days
22 after the summary suspension and completed without
23 delay. Adverse decisions other than suspension or
24 other restrictions on the treatment or admission of
25 patients may be imposed summarily and without a
26 hearing under designated administrative
27 circumstances as specifically provided for in the
28 medical staff rules and regulations as approved by
29 the medical staff.
30 (D) A statement of the member's right to
31 inspect all pertinent information in the managed
32 care plan's possession with respect to the decision.
33 (E) A statement of the member's right to
34 present witnesses and other evidence at the hearing
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1 on the decision.
2 (F) A written notice and written explanation
3 of the decision resulting from the hearing.
4 (G) Notice shall be given 15 days before
5 implementation of an adverse medical staff
6 membership or privileges decision based
7 substantially on economic factors. This notice
8 shall be given after the medical staff member
9 exhausts all applicable procedures under this
10 Section, including item (C) of this item (3), and
11 under the medical staff rules and regulations in
12 order to allow sufficient time for the orderly
13 provision of patient care.
14 (H) Nothing in this item (3) limits a medical
15 staff member's right to waive, in writing, the
16 rights provided in items (A) through (H) of this
17 item (3) upon being granted the written exclusive
18 right to provide particular health care services for
19 a managed care plan, either individually or as a
20 member of a group.
21 (b) Every adverse medical staff membership and
22 privileges decision based substantially on economic factors
23 shall be reported by the managed care plan's governing body
24 to the Board of Health before the decision takes effect.
25 These reports shall not be disclosed in any form that reveals
26 the identity of any physician. These reports shall be
27 utilized to study the effects that medical staff membership
28 decisions based upon economic factors have on access to care
29 and the availability of physician services. The Board shall
30 submit an initial study to the Governor and the General
31 Assembly by July 1, 1998, and subsequent reports shall be
32 submitted periodically thereafter.
33 (c) All other participating providers shall be provided
34 a due process appeal from all adverse participation decisions
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1 by the managed care plan's governing body. The providers
2 shall be provided notice, an opportunity for discussion, and
3 an opportunity to enter into and complete a corrective action
4 plan, except in cases where there is imminent harm to patient
5 health or license probation, suspension or revocation action
6 by the applicable licensing agency.
7 Section 10-40. Records. Procedures shall be
8 established to ensure that all applicable federal and State
9 laws designed to protect the confidentiality of health care
10 provider records and individual medical records are followed.
11 These records shall be afforded the protections of Section
12 8-2101 through 8-2105 of the Code of Civil Procedure and may
13 not be disclosed to any court, tribunal or board except in
14 accordance with this provision.
15 Section 10-45. Provider termination.
16 (a) The Director shall adopt rules requiring that all
17 participating provider agreements contain provisions
18 concerning timely and reasonable notices to be given between
19 the parties and for the managed care plan to provide timely
20 and reasonable notice to its enrollees. In order to
21 facilitate transfer of health care services, reasonable
22 advance notice of provider termination shall be given to the
23 provider and enrollees. Notice shall be given for events
24 including, but not limited to, termination of provider
25 agreements or managed care plan services. Notice of provider
26 termination to enrollees shall be in a form approved by the
27 Director.
28 (b) When a managed care plan terminates a contract with
29 an entire medical group, physician organization, or other
30 health care provider organization, the managed care plan
31 shall notify enrollees who have selected that medical group,
32 physician organization, or other health care provider
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1 organization of the termination.
2 (c) When a managed care plan terminates a contractual
3 arrangement with an individual health care provider within a
4 medical group, physician organization, or other health care
5 provider organization, the managed care plan may request that
6 medical group, physician organization, or other health care
7 provider organization to notify the enrollees who are
8 patients of that health care provider of the termination.
9 (d) Whenever a managed care plan indicates that a
10 provider's contract is being terminated for any reason, it
11 shall provide a detailed written statement to the health care
12 provider of the reasons for termination.
13 Section 10-50. Complaint handling procedure.
14 (a) Every managed care plan and utilization review
15 program shall establish and maintain a complaint system
16 providing reasonable procedures for resolving complaints
17 initiated by enrollees or health care providers
18 (complainant). Nothing herein shall be construed to preclude
19 an enrollee or a health care provider from filing a complaint
20 with the Director or as limiting the Director's ability to
21 investigate complaints.
22 (b) When a complaint is received by the Department
23 against a managed care plan (respondent), the respondent
24 shall be notified of the complaint. The Department shall, in
25 its notification, specify the date when a report is to be
26 received from the respondent, which shall be no later than 21
27 days after notification is sent to the respondent. A failure
28 to reply by the date specified may be followed by a collect
29 telephone call or collect telegram. Repeated instances of
30 failing to reply by the date specified may result in further
31 regulatory action.
32 (c) Contents of response or report.
33 (1) The respondent shall supply adequate
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1 documentation which explains all actions taken or not
2 taken and which were the basis for the complaint.
3 (2) Documents necessary to support the respondent's
4 position and information requested by the Department,
5 shall be furnished with the respondent's reply.
6 (3) The respondent's reply shall be in duplicate,
7 but duplicate copies of supporting documents shall not be
8 required.
9 (4) The respondent's reply shall include the name,
10 telephone number, and address of the individual assigned
11 to the complaint.
12 (5) The Department shall respect the
13 confidentiality of medical reports and other documents
14 which by law are confidential. Any other information
15 furnished by a respondent shall be marked "confidential"
16 if the respondent does not wish it to be released to the
17 complainant.
18 (d) Follow-up conclusion. Upon receipt of the
19 respondent's report, the Department shall evaluate the
20 material submitted; and
21 (1) advise the complainant of the action taken and
22 disposition of its complaint;
23 (2) pursue further investigation with respondent or
24 complainant; or
25 (3) refer the investigation report to the
26 appropriate branch within the Department for further
27 regulatory action.
28 (e) The Department of Public Health and Department of
29 Insurance shall coordinate the complaint review and
30 investigation and establish joint rules under the Illinois
31 Administrative Procedure Act implementing this coordinated
32 complaint process.
33 Section 10-60. Qualified utilization review programs.
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1 (a) The Director shall establish standards for the
2 certification of qualified utilization review programs.
3 (b) All programs must have a medical director, who is a
4 physician licensed to practice medicine in all its branches,
5 responsible for all clinical decisions by the program and who
6 shall assure that the medical review or utilization practices
7 they use, and the medical review or utilization practices of
8 payors or reviewers with whom they contract, comply with the
9 following requirements:
10 (1) Screening criteria, weighing elements, and
11 computer algorithms utilized in the review process and
12 their method of development, must be released to
13 applicable participating providers and be made available
14 to the public.
15 (2) The criteria including, but not limited to,
16 pre-admission, medical necessity, length of stay,
17 discharge planning, follow-up care, and medically
18 acceptable treatment alternatives must be based on sound
19 scientific principles and developed in cooperation with
20 practicing physicians, other affected health care
21 providers, and consumer representatives.
22 (3) Any person who recommends denial of coverage or
23 payment or determines that a service shall not be
24 provided based on medical necessity standards, must be
25 licensed in Illinois and of the same licensed profession
26 as the provider who provided, ordered or proposed the
27 services.
28 (4) An enrollee or provider (upon assignment of an
29 enrollee) who has had a claim denied as not medically
30 necessary must be provided an opportunity for a due
31 process appeal to a qualified physician consultant or
32 qualified provider peer review group not involved in the
33 initial review.
34 (5) Upon request, physicians and other affected
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1 health care providers shall be provided the names and
2 credentials of all individuals conducting medical
3 necessity or appropriateness review, subject to
4 reasonable safeguards and standards.
5 (6) In accordance with Section 5-45, prior
6 authorization shall not be required for care for an
7 emergency, as defined in Section 3.5 of the Emergency
8 Medical Services (EMS) Systems Act, and patient or
9 participating provider requests for prior authorization
10 of nonemergent health care services must be answered the
11 same day as the request.
12 (7) Qualified personnel with the minimum licensure
13 status of registered professional nurse must be available
14 for same-day telephone responses to inquiries about
15 medical necessity, including certification of continued
16 length of stay.
17 (8) Programs and managed care plans must ensure
18 that enrollees, in managed care plans where prior
19 authorization is a condition to coverage of a service,
20 are informed in writing of the reasons medical
21 information is needed and provided with appropriate
22 medical information release consent forms for use where
23 services requiring prior authorization are recommended or
24 proposed by their participating providers.
25 (9) When prior approval for a service or other
26 covered item is obtained, it shall be considered approval
27 for the purpose requested, and the service shall be
28 considered to be covered, in accordance with Section
29 5-30.
30 Section 10-65. Quality assurance requirements.
31 (a) Every managed care plan shall have a Quality
32 Assurance Plan developed by the Medical Review Board through
33 a designated Quality Assurance Committee or through a
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1 contract with a physician organization for measuring,
2 assessing and improving quality. The managed care plan must:
3 (1) Have a written quality assurance plan which
4 sets standards and evaluates, at a minimum:
5 (A) Provider availability and accessibility.
6 (B) Appropriateness of care, including the
7 provision of all medically necessary care.
8 (C) Coordination and continuity of care.
9 (D) Patient satisfaction.
10 (2) Assess quality using:
11 (A) Enrollee and provider quality assessment
12 surveys to be conducted at least annually.
13 (B) A log maintained by the managed care plan
14 including utilization review functions identifying
15 the number and types of patient and provider
16 grievances with the resolutions to those issues.
17 (C) Utilization and outcome reports and
18 studies whereby relevant case mix and patient
19 demographic information are taken into account.
20 (3) Establish mechanisms for quality improvement,
21 which include implementation of corrective action plans
22 in response to confirmed quality of care or quality of
23 service identified problems.
24 The Department shall require managed care plans to
25 prepare and submit quarterly aggregate quality assurance
26 reports. These reports shall include, but not be limited to,
27 provider availability and accessibility and patient
28 satisfaction information compiled in aggregate by diagnosis
29 and by participating provider category. Quality reports must
30 be made available, when requested, to prospective enrollees,
31 enrollees, health care providers and the public. The quality
32 assurance information or data may not be released in any
33 manner which tends to identify any enrollee or health care
34 provider. This information or data shall be afforded the
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1 protections of Section 8-2101 through 8-2105 of the Code of
2 Civil Procedure.
3 (b) Every managed care plan shall implement procedures
4 for ensuring that all applicable federal and State laws
5 designed to protect the confidentiality of provider and
6 individual medical records are followed.
7 Section 10-70. Application of certification standards.
8 (a) In general. Standards shall first be established,
9 under this Article, by no later than 18 months after the
10 effective date of this Act. In developing standards under
11 this Article, the Director shall:
12 (1) review standards in use by national private
13 accreditation organizations;
14 (2) recognize, to the extent appropriate,
15 differences in the organizational structure and operation
16 of managed care plans, and utilization review programs;
17 (3) establish procedures for the timely
18 consideration of applications for certification by
19 managed care plans and utilization review programs; and
20 (4) establish grievance procedures for enrollees
21 and participating providers to appeal managed care plan
22 and utilization review program decisions.
23 (b) Revision of standards. The Director shall
24 periodically review the standards established under this
25 Article, and may revise the standards from time to time to
26 assure that such standards continue to reflect appropriate
27 policies and practices for the cost-effective and medically
28 appropriate use of health care services within managed care
29 plans and utilization review programs.
30 ARTICLE 20. ADMINISTRATION AND ENFORCEMENT
31 Section 20-5. Responsibilities of the State Board of
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1 Health.
2 (a) The Board shall advise the Director regarding public
3 health policy and managed care.
4 (b) The Board shall review the final draft of all
5 proposed administrative rules under this Act within 90 days
6 of submission by the Department. The Department shall take
7 into consideration any comments and recommendations of the
8 Board regarding the proposed rules prior to submission to the
9 Secretary of State for initial publication. If the
10 Department disagrees with the recommendations of the Board,
11 it shall submit a written response outlining the reasons for
12 not accepting the recommendations.
13 (c) The Board shall receive and report in aggregate
14 information from all reports mandated by law or rule. These
15 reports shall be made to the Illinois General Assembly and
16 the Governor.
17 (d) The Board shall monitor and otherwise advise the
18 Department on the administration and enforcement of the Act
19 as the Board deems appropriate.
20 Section 20-10. Responsibilities of the Department.
21 (a) The Department shall, after review by the Board,
22 adopt rules for managed care plan and utilization review
23 program certification under this Act that shall include, but
24 not be limited to, the following:
25 (1) Further definition of managed care plans and
26 utilization review programs.
27 (2) License application information required by the
28 Department.
29 (3) Certification requirements for managed care
30 plans and utilization review programs.
31 (4) License application and renewal fees which may
32 cover the cost of administering the certification
33 program.
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1 (5) Information including mandated reports that may
2 be necessary for the Department and Board to monitor and
3 evaluate the certified entities. These reports shall
4 include but not be limited to coverage decisions,
5 credentialing decisions, participating provider capacity
6 and any other necessary information.
7 (6) Administrative fines that may be assessed
8 against managed care plans or utilization review programs
9 by the Department for violations of this Act or the rules
10 adopted under this Act.
11 (b) The Department shall issue, renew, deny, suspend, or
12 revoke licenses for certification.
13 (c) The Department shall perform inspections of managed
14 care plans and utilization review programs as deemed
15 necessary by the Department to ensure compliance with this
16 Act or rules.
17 (d) The Department shall deposit application fees,
18 renewal fees, and fines into the Regulatory Evaluation and
19 Basic Enforcement Fund.
20 (e) All managed care plan and utilization review program
21 records including any patient records reviewed by the
22 Department shall be afforded the protections of Sections
23 8-2101 through 8-2105 of the Code of Civil Procedure.
24 Section 20-15. Violations; penalties.
25 (a) After July 1, 1998, any person opening, operating or
26 maintaining a managed care plan or utilization review program
27 without a certificate issued under this Act and any person
28 who violates Sections 5-10 or 5-55 of this Act shall be
29 guilty of a business offense punishable upon conviction by a
30 fine of $10,000. Each day a violation continues shall
31 constitute a separate offense.
32 Section 20-20. Conflicts. To the extent of any conflict
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1 between this Act and any other Act, this Act prevails over
2 the conflicting provision.
3 Section 20-25. Illinois Administrative Procedure Act.
4 The Illinois Administrative Procedure Act is hereby expressly
5 adopted and incorporated herein and shall apply to the
6 Department as if all of the provisions of such Act were
7 included in this Act; except that in case of a conflict
8 between the Illinois Administrative Procedure Act and this
9 Act, the provisions of this Act shall control.
10 Section 20-30. Certificate denial, suspension, or
11 revocation and fine assessment. A certificate may be denied,
12 suspended, or revoked, the renewal of a certificate may be
13 denied, or an administrative fee may be assessed for any of
14 the following reasons:
15 (1) Violation of any provision of this Act or the rules
16 adopted by the Department under this Act.
17 (2) Conviction of the owner or operator of the certified
18 entity (i) of a felony or (ii) of any other crime under the
19 laws of any state or of the United States arising out of or
20 in connection with the operation of a health care facility.
21 An owner shall be defined as any person with at least a 5
22 percent ownership interest in the entity. The record of
23 conviction or a certified copy of it shall be conclusive
24 evidence of conviction.
25 (3) An encumbrance on a health care license issued in
26 Illinois or any other state to the owner or operator of the
27 certified entity.
28 (4) Revocation of any facility license issued by the
29 Department during the previous 5 years or surrender or
30 expiration of the license during the pendency of action by
31 the Department to revoke or suspend the license during the
32 previous 5 years, if (i) the prior license was issued to the
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1 individual applicant or an owner of the applicant or (ii)
2 any affiliate of the individual applicant or owner of the
3 applicant or affiliate of the applicant was a owner of the
4 prior license.
5 Section 20-35. Investigation of applicant or certificate
6 holder; notice. The Department may on its own motion, and
7 shall on the verified complaint in writing of any person
8 setting forth facts which if proven would constitute grounds
9 for the denial of an application for a certificate, refusal
10 to renew a certificate, suspension of a certificate, or
11 revocation of a certificate, investigate the applicant or
12 certificate holder. The Department, after notice and an
13 opportunity for a hearing, may deny an application for a
14 certificate, revoke a certificate, refuse to renew a
15 certificate or assess an administrative fine under Section
16 20-30 of this Act. Before denying a certificate
17 application, refusing to renew a certificate, suspending a
18 certificate, revoking a certificate, or assessing a fine, the
19 Department shall notify the applicant or certificate holder
20 in writing. The notice shall specify the charges or reasons
21 for the Department's contemplated action. If the applicant
22 or certificate holder desires a hearing on the Department's
23 contemplated action, he or she must request a hearing within
24 10 days after receiving the notice. A failure to request a
25 hearing within 10 days shall constitute a waiver of the
26 applicant's or certificate holder's right to a hearing.
27 Section 20-40. Hearings. The hearing requested under
28 Section 20-35 shall be conducted by the Director or an
29 individual designated in writing by the Director as a hearing
30 officer. The Director or hearing officer may compel, by
31 subpoena or subpoena duces tecum, the attendance and
32 testimony of witnesses and the production of books and
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1 papers. The Director or hearing officer may administer oaths
2 to witnesses. The hearing shall be conducted at a place
3 designated by the Department. The procedures governing
4 hearings and the issuance of final orders under this Act
5 shall be according to rules adopted by the Department. All
6 subpoenas issued by the Director or hearing officer may be
7 served as in civil actions. The fees of witnesses for
8 attendance and travel shall be the same as the fees for
9 witnesses before the circuit court and shall be paid by the
10 party to the proceedings at whose request the subpoena is
11 issued. If a subpoena is issued at the request of the
12 Department, the witness fee shall be paid by the Department
13 as an administrative expense. If a witness refuses to attend
14 or testify, or to produce books or papers, concerning any
15 matter on which he or she might be lawfully examined, the
16 circuit court of the county in which the hearing is held, on
17 application of any party to the proceeding, may compel
18 obedience by a proceeding for contempt as in cases of a
19 refusal to obey a similar order of the court.
20 Section 20-45. Final orders. The Director or hearing
21 officer shall make findings of fact and conclusions of law in
22 the matters that are the subject of the hearing, and the
23 Director shall render a decision, or the hearing officer a
24 proposal for decision, within 45 days after the termination
25 of the hearing unless additional time is required by the
26 Director or hearing officer for a proper disposition of the
27 matter. A copy of the final decision of the Director shall
28 be served on the applicant or certificate holder in person or
29 by certified mail.
30 Section 20-50. Judicial review; deposit for costs.
31 (a) All final administrative decisions of the Department
32 under this Act shall be subject to judicial review under the
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1 provisions of the Administrative Review Law and the rules
2 adopted under that Law. "Administrative decision" is defined
3 as in Section 3-101 of the Code of Civil Procedure.
4 Proceedings for judicial review shall be commenced in the
5 circuit court of the county in which the party applying for
6 review resides. If that party is not a resident of this
7 State, however, the venue shall be in Sangamon County.
8 (b) The Department shall not be required to certify any
9 record or file any answer or otherwise appear in any
10 proceeding for judicial review unless the party filing the
11 complaint deposits with the clerk of the circuit court the
12 sum of $0.95 per page for the costs of certification.
13 Failure by the plaintiff to make the deposit shall be grounds
14 for dismissing the action.
15 Section 20-55. Injunction. The operation or maintenance
16 of a managed care plan or utilization review program in
17 violation of this Act or the rules adopted under this Act
18 including, but not limited to, retaliation against a
19 physician or other health care provider is declared to be
20 inimical to the public welfare. The Director, in addition to
21 other remedies provided in this Act, may bring an action in
22 the name of the People of the State, through the Attorney
23 General, for an injunction to restrain a violation of this
24 Act or the rules or to enjoin the future operation or
25 maintenance of the managed care plan or utilization review
26 program.
27 Section 20-60. Managed care malpractice. In any action,
28 whether in tort, contract, or otherwise, all managed care
29 plans and utilization review programs shall be held liable to
30 enrollees for any injuries incurred due to decisions of the
31 managed care plan or utilization review program that result
32 in unreasonable delay, reduction or denial of medically
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1 necessary health care services, care or treatment, covered by
2 the enrollee's plan as recommended by a health care provider.
3 Section 20-65. Severability. If any provision of this
4 Act is held by a court to be invalid, such invalidity shall
5 not affect the remaining provisions of this Act, and to this
6 end the provisions of this Act are hereby declared severable.
7 ARTICLE 90. AMENDATORY PROVISIONS
8 Section 90-5. The State Employees Group Insurance Act of
9 1971 is amended by adding Section 6.9 as follows:
10 (5 ILCS 375/6.9 new)
11 Sec. 6.9. Managed Care Patient Rights Act. The program
12 of health benefits is subject to the provisions of the
13 Managed Care Patient Rights Act and Section 356t of the
14 Illinois Insurance Code.
15 Section 90-10. The Counties Code is amended by adding
16 Section 5-1069.8 as follows:
17 (55 ILCS 5/5-1069.8 new)
18 Sec. 5-1069.8. Managed Care Patient Rights Act. All
19 counties, including home rule counties, are subject to the
20 provisions of the Managed Care Patient Rights Act and Section
21 356t of the Illinois Insurance Code. The requirement under
22 this Section that health care benefits provided by counties
23 comply with the Managed Care Patient Rights Act is an
24 exclusive power and function of the State and is a denial and
25 limitation of home rule county powers under Article VII,
26 Section 6, subsection (h) of the Illinois Constitution.
27 Section 90-15. The Illinois Municipal Code is amended by
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1 adding 10-4-2.8 as follows:
2 (65 ILCS 5/10-4-2.8 new)
3 Sec. 10-4-2.8. Managed Care Patient Rights Act. The
4 corporate authorities of all municipalities are subject to
5 the provisions of the Managed Care Patient Rights Act and
6 Section 356t of the Illinois Insurance Code. The requirement
7 under this Section that health care benefits provided by
8 municipalities comply with the Managed Care Patient Rights
9 Act is an exclusive power and function of the State and is a
10 denial and limitation of home rule municipality powers under
11 Article VII, Section 6, subsection (h) of the Illinois
12 Constitution.
13 Section 90-20. The Illinois Insurance Code is changed by
14 adding Sections 155.31, 356t, 370s, and 511.118 as follows:
15 (215 ILCS 5/155.31 new)
16 Sec. 155.31. Managed Care Patient Rights Act provisions.
17 Insurance companies providing coverage for health care
18 services are subject to the provisions of the Managed Care
19 Patient Rights Act. The provisions of Article 10 shall be
20 implemented through existing Department of Public Health
21 certification procedures.
22 (215 ILCS 5/356t new)
23 Sec. 356t. Choice requirements for point of service
24 plans.
25 (a) An employer, self-insured employer or employee
26 organization, labor union, association or other person
27 providing, offering, or making available to employees or
28 individuals a managed care plan, as defined in the Managed
29 Care Patient Rights Act, shall offer to all enrollees the
30 opportunity to obtain coverage through a "point of service"
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1 plan, at the time of enrollment and once annually thereafter.
2 The "point of service" plan shall provide coverage for health
3 care services when such health care services are provided by
4 any health care provider without the necessary referrals,
5 prior authorization, or other utilization review requirements
6 of the managed care plan.
7 (b) A point of service plan may charge an enrollee who
8 opts to obtain point of service coverage an alternative
9 premium that takes into account the actuarial value of such
10 coverage.
11 (c) A point of service plan may require reasonable
12 payment of coinsurance, co-payments or deductibles. The
13 co-insurance rate on the point of service plan shall not be
14 greater than 20 percentage points more than the co-insurance
15 rate on the underlying plan. The maximum out-of-pocket
16 amount shall not exceed $5,000 for an individual and $7,500
17 for family coverage.
18 (215 ILCS 5/370s new)
19 Sec. 370s. Managed Care Patient Rights Act. All
20 insurers and administrators are subject to the provisions of
21 the Managed Care Patient Rights Act and Section 356t of this
22 Code.
23 (215 ILCS 5/511.118 new)
24 Sec. 511.118. Managed Care Patient Rights Act. All
25 administrators are subject to the provisions of the Managed
26 Care Patient Rights Act and Section 356t of this Code.
27 Section 90-25. The Comprehensive Health Insurance Plan
28 Act is amended by adding Section 8.6 as follows:
29 (215 ILCS 105/8.6 new)
30 Sec. 8.6. Managed Care Patient Rights Act. The plan
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1 shall be subject to the provisions of the Managed Care
2 Patient Rights Act and Section 356t of the Illinois Insurance
3 Code.
4 Section 90-30. The Health Maintenance Organization Act
5 is amended by adding Section 5-3.5 as follows:
6 (215 ILCS 125/5-3.5 new)
7 Sec. 5-3.5. Managed Care Patient Rights Act provisions.
8 Health maintenance organizations are subject to the
9 provisions Article 5, Sections 10-15, 10-20, 10-25, 10-30,
10 10-35, 10-40, 10-50, and 10-60 of Article 10 and Article 20
11 of the Managed Care Patient Rights Act and Section 356t of
12 the Illinois Insurance Code.
13 Section 90-35. The Limited Health Service Organization
14 Act is amended by adding Section 4002.5 as follows:
15 (215 ILCS 130/4002.5 new)
16 Sec. 4002.5. Managed Care Patient Rights Act
17 provisions. Limited health service organizations are subject
18 to the provisions of the Managed Care Patient Rights Act and
19 Section 356t of the Illinois Insurance Code.
20 Section 90-40. The Dental Service Plan Act is amended by
21 adding Section 48 as follows:
22 (215 ILCS 110/48 new)
23 Sec. 48. Managed Care Patient Rights Act provisions.
24 Dental Service Plans are subject to the provisions of the
25 Managed Care Patient Rights Act and Section 356t of the
26 Illinois Insurance Code. For purposes of the Dental Service
27 Plan Act the term physician as used in the Managed Care
28 Patient Rights Act shall mean dentist.
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1 Section 90-45. The Voluntary Health Services Plans Act
2 is amended by adding Section 15.25 as follows:
3 (215 ILCS 165/15.25 new)
4 Sec. 15.25. Managed Care Patient Rights Act. A health
5 service plan corporation is subject to the provisions of the
6 Managed Care Patient Rights Act and Section 356t of the
7 Illinois Insurance Code.
8 Section 90-50. The Illinois Public Aid Code is amended
9 by adding Section 5-16.8 as follows:
10 (305 ILCS 5/5-16.8 new)
11 Sec. 5-16.8. Managed Care Patient Rights Act. The
12 medical assistance program is subject to the provisions of
13 the Managed Care Patient Rights Act and Section 356t of the
14 Illinois Insurance Code. The Illinois Department shall adopt
15 rules to implement these provisions. These rules shall
16 require compliance with Article 5, and Section 10-15, 10-20,
17 10-25, 10-30, 10-35, 10-40, 10-50 and 10-60 of Article 10 of
18 the Managed Care Patient Rights Act in the medical assistance
19 program including managed care components defined in Section
20 5-16.3.
21 ARTICLE 99. EFFECTIVE DATE.
22 Section 99-1. Effective date. This Act takes effect upon
23 becoming law.