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Public Act 099-0111
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| HB2788 Enrolled | LRB099 08001 MLM 28141 b |
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Managed Care Reform and Patient Rights Act |
is amended by changing Sections 80 and 85 as follows:
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(215 ILCS 134/80)
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Sec. 80. Quality assessment program.
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(a) A health care plan shall develop and implement a |
quality assessment and
improvement strategy designed to |
identify and evaluate accessibility,
continuity, and quality |
of care. The health care plan shall have:
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(1) an ongoing, written, internal quality assessment |
program;
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(2) specific written guidelines for monitoring and |
evaluating the quality
and appropriateness of care and |
services provided to enrollees requiring the
health care |
plan to assess:
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(A) the accessibility to health care providers;
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(B) appropriateness of utilization;
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(C) concerns identified by the health care plan's |
medical or
administrative staff and enrollees; and
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(D) other aspects of care and service directly |
related to the
improvement of quality of care;
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(3) a procedure for remedial action to correct quality |
problems that have
been verified in accordance with the |
written plan's methodology and criteria,
including written |
procedures for taking appropriate corrective action;
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(4) follow-up measures implemented to evaluate the |
effectiveness of the
action plan.
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(b) The health care plan shall establish a committee that |
oversees the
quality assessment and improvement strategy which |
includes physician
and enrollee participation.
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(c) Reports on quality assessment and improvement |
activities shall be made
to the governing body of the health |
care plan not less than quarterly.
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(d) The health care plan shall make available its written |
description of
the quality assessment program to the Department |
of
Public Health.
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(e) With the exception of subsection (d), the Department of |
Public Health
shall accept evidence of accreditation with |
regard to the health care network
quality management and |
performance improvement standards of:
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(1) the National Commission on Quality Assurance |
(NCQA);
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(2) the American Accreditation Healthcare Commission |
(URAC);
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(3) the Joint Commission on Accreditation of |
Healthcare Organizations
(JCAHO); or |
(4) the Accreditation Association for Ambulatory |
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Health Care (AAAHC); or
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(5) (4) any other entity that the Director of Public |
Health deems has
substantially similar or
more stringent |
standards than provided for in this Section.
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(f) If the Department of Public Health determines that a |
health care plan
is not in compliance with the terms of this |
Section, it shall certify the
finding to the Department of |
Insurance. The Department of Insurance shall
subject a health |
care plan to penalties, as provided in this Act, for such
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non-compliance.
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(Source: P.A. 91-617, eff. 1-1-00.)
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(215 ILCS 134/85)
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Sec. 85. Utilization review program registration.
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(a) No person may conduct a utilization review program in |
this State unless
once every 2 years the person
registers the |
utilization review program with the Department and certifies
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compliance with the Health
Utilization Management Standards of |
the American Accreditation Healthcare
Commission (URAC) |
sufficient to achieve American Accreditation Healthcare
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Commission (URAC) accreditation or submits evidence of |
accreditation by the
American
Accreditation Healthcare |
Commission (URAC) for its Health Utilization
Management |
Standards.
Nothing in this Act shall be construed to require a |
health care plan or its
subcontractors to become American |
Accreditation Healthcare Commission (URAC)
accredited.
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(b) In addition, the Director of the Department, in |
consultation with the
Director of the Department of Public |
Health, may certify alternative
utilization review standards |
of national accreditation organizations or
entities in order |
for plans to comply with this Section. Any alternative
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utilization review standards shall meet or exceed those |
standards required
under subsection (a).
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(b-5) The Department shall recognize the Accreditation |
Association for Ambulatory Health Care among the list of |
accreditors from which utilization organizations may receive |
accreditation and qualify for reduced registration and renewal |
fees. |
(c) The provisions of this Section do not apply to:
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(1) persons providing utilization review program |
services only to the
federal
government;
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(2) self-insured health plans under the federal |
Employee Retirement Income
Security Act of 1974, however, |
this Section does apply to persons conducting
a utilization |
review program on behalf of these health plans;
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(3) hospitals and medical groups performing |
utilization review activities
for
internal purposes unless |
the utilization review program is conducted for
another |
person.
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Nothing in this Act prohibits a health care plan or other |
entity from
contractually requiring an entity designated in |
item (3) of this subsection
to adhere to
the
utilization review |
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program requirements of
this Act.
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(d) This registration shall include submission of all of |
the following
information
regarding utilization review program |
activities:
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(1) The name, address, and telephone number of the |
utilization review
programs.
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(2) The organization and governing structure of the |
utilization review
programs.
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(3) The
number of lives for which utilization review is |
conducted by each utilization
review program.
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(4) Hours of operation of each utilization review |
program.
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(5) Description of the grievance process for each |
utilization review
program.
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(6) Number of covered lives for which utilization |
review was conducted for
the previous calendar year for |
each utilization review program.
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(7) Written policies and procedures for protecting |
confidential
information
according to applicable State and |
federal laws for each utilization review
program.
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(e) (1) A utilization review program shall have written |
procedures for
assuring that patient-specific information |
obtained during the process of
utilization review will be:
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(A) kept confidential in accordance with applicable |
State and
federal laws; and
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(B) shared only with the enrollee, the enrollee's |
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designee, the
enrollee's health
care provider, and those |
who are authorized by law to receive the information.
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Summary data shall not be considered confidential if it |
does not provide
information to allow identification of |
individual patients or health care
providers.
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(2) Only a health care professional may make |
determinations regarding
the medical
necessity of health |
care services during the course of utilization review.
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(3) When making retrospective reviews, utilization |
review programs shall
base
reviews solely on the medical |
information available to the attending physician
or |
ordering provider at the time the health care services were |
provided.
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(4) When making prospective, concurrent, and |
retrospective determinations,
utilization review programs |
shall collect only information that is necessary to
make |
the determination and shall not routinely require health |
care providers to
numerically code diagnoses or procedures |
to be considered for certification,
unless required under |
State or federal Medicare or Medicaid rules or
regulations, |
but may request such code if available, or routinely |
request
copies
of medical records of all enrollees
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reviewed. During prospective or concurrent review, copies |
of medical records
shall only be required when necessary to |
verify that the health care services
subject to review are |
medically necessary. In these cases, only the necessary
or
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relevant sections of the medical record shall be required.
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(f) If the Department finds that a utilization review |
program is
not in compliance with this Section, the Department |
shall issue a corrective
action plan and allow a reasonable |
amount of time for compliance with the plan.
If the utilization |
review program does not come into compliance, the
Department |
may issue a cease and desist order. Before issuing a cease and
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desist order under this Section, the Department shall provide |
the
utilization review program with a written notice of the |
reasons for the
order and allow a reasonable amount of time to |
supply additional information
demonstrating compliance with |
requirements of this Section and to request a
hearing. The |
hearing notice shall be sent by certified mail, return receipt
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requested, and the hearing shall be conducted in accordance |
with the Illinois
Administrative Procedure Act.
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(g) A utilization review program subject to a corrective |
action may continue
to conduct business
until a final decision |
has been issued by the Department.
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(h) Any adverse determination made by a health care plan or |
its
subcontractors may be appealed
in accordance with |
subsection (f) of Section 45.
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(i) The Director may by rule establish a registration fee |
for each person
conducting a utilization review program. All |
fees paid to and collected by the
Director under this Section |
shall be deposited into
the Insurance Producer Administration |
Fund.
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