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Public Act 91-0617
SB251 Enrolled LRB9102764EGfg
AN ACT concerning the delivery of health care services,
amending named Acts.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. Short title. This Act may be cited as the
Managed Care Reform and Patient Rights Act.
Section 5. Health care patient rights.
(a) The General Assembly finds that:
(1) A patient has the right to care consistent with
professional standards of practice to assure quality
nursing and medical practices, to choose the
participating physician responsible for coordinating his
or her care, to receive information concerning his or her
condition and proposed treatment, to refuse any treatment
to the extent permitted by law, and to privacy and
confidentiality of records except as otherwise provided
by law.
(2) A patient has the right, regardless of source
of payment, to examine and to receive a reasonable
explanation of his or her total bill for health care
services rendered by his or her physician or other health
care provider, including the itemized charges for
specific health care services received. A physician or
other health care provider has responsibility only for a
reasonable explanation of those specific health care
services provided by the health care provider.
(3) A patient has the right to timely prior notice
of the termination whenever a health care plan cancels or
refuses to renew an enrollee's participation in the plan.
(4) A patient has the right to privacy and
confidentiality in health care. This right may be
expressly waived in writing by the patient or the
patient's guardian.
(5) An individual has the right to purchase any
health care services with that individual's own funds.
(b) Nothing in this Section shall preclude the health
care plan from sharing information for plan quality
assessment and improvement purposes as required by Section
80.
Section 10. Definitions:
"Adverse determination" means a determination by a health
care plan under Section 45 or by a utilization review program
under Section 85 that a health care service is not medically
necessary.
"Clinical peer" means a health care professional who is
in the same profession and the same or similar specialty as
the health care provider who typically manages the medical
condition, procedures, or treatment under review.
"Department" means the Department of Insurance.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including, but not limited to, severe pain) such that a
prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of
immediate medical attention to result in:
(1) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or
her unborn child) in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or
part.
"Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed
to practice medicine in all its branches, or to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches
to determine whether the need for emergency services exists.
"Emergency services" means, with respect to an enrollee
of a health care plan, transportation services, including but
not limited to ambulance services, and covered inpatient and
outpatient hospital services furnished by a provider
qualified to furnish those services that are needed to
evaluate or stabilize an emergency medical condition.
"Emergency services" does not refer to post-stabilization
medical services.
"Enrollee" means any person and his or her dependents
enrolled in or covered by a health care plan.
"Health care plan" means a plan that establishes,
operates, or maintains a network of health care providers
that has entered into an agreement with the plan to provide
health care services to enrollees to whom the plan has the
ultimate obligation to arrange for the provision of or
payment for services through organizational arrangements for
ongoing quality assurance, utilization review programs, or
dispute resolution. Nothing in this definition shall be
construed to mean that an independent practice association or
a physician hospital organization that subcontracts with a
health care plan is, for purposes of that subcontract, a
health care plan.
For purposes of this definition, "health care plan" shall
not include the following:
(1) indemnity health insurance policies including
those using a contracted provider network;
(2) health care plans that offer only dental or
only vision coverage;
(3) preferred provider administrators, as defined
in Section 370g(g) of the Illinois Insurance Code;
(4) employee or employer self-insured health
benefit plans under the federal Employee Retirement
Income Security Act of 1974;
(5) health care provided pursuant to the Workers'
Compensation Act or the Workers' Occupational Diseases
Act; and
(6) not-for-profit voluntary health services plans
with health maintenance organization authority in
existence as of January 1, 1999 that are affiliated with
a union and that only extend coverage to union members
and their dependents.
"Health care professional" means a physician, a
registered professional nurse, or other individual
appropriately licensed or registered to provide health care
services.
"Health care provider" means any physician, hospital
facility, or other person that is licensed or otherwise
authorized to deliver health care services. Nothing in this
Act shall be construed to define Independent Practice
Associations or Physician-Hospital Organizations as health
care providers.
"Health care services" means any services included in the
furnishing to any individual of medical care, or the
hospitalization incident to the furnishing of such care, as
well as the furnishing to any person of any and all other
services for the purpose of preventing, alleviating, curing,
or healing human illness or injury including home health and
pharmaceutical services and products.
"Medical director" means a physician licensed in any
state to practice medicine in all its branches appointed by a
health care plan.
"Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
"Physician" means a person licensed under the Medical
Practice Act of 1987.
"Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
licensed hospital by a provider that is qualified to furnish
such services, and determined to be medically necessary and
directly related to the emergency medical condition following
stabilization.
"Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to assure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
"Utilization review" means the evaluation of the medical
necessity, appropriateness, and efficiency of the use of
health care services, procedures, and facilities.
"Utilization review program" means a program established
by a person to perform utilization review.
Section 15. Provision of information.
(a) A health care plan shall provide annually to
enrollees and prospective enrollees, upon request, a complete
list of participating health care providers in the health
care plan's service area and a description of the following
terms of coverage:
(1) the service area;
(2) the covered benefits and services with all
exclusions, exceptions, and limitations;
(3) the pre-certification and other utilization
review procedures and requirements;
(4) a description of the process for the selection
of a primary care physician, any limitation on access to
specialists, and the plan's standing referral policy;
(5) the emergency coverage and benefits, including
any restrictions on emergency care services;
(6) the out-of-area coverage and benefits, if any;
(7) the enrollee's financial responsibility for
copayments, deductibles, premiums, and any other
out-of-pocket expenses;
(8) the provisions for continuity of treatment in
the event a health care provider's participation
terminates during the course of an enrollee's treatment
by that provider;
(9) the appeals process, forms, and time frames for
health care services appeals, complaints, and external
independent reviews, administrative complaints, and
utilization review complaints, including a phone number
to call to receive more information from the health care
plan concerning the appeals process; and
(10) a statement of all basic health care services
and all specific benefits and services mandated to be
provided to enrollees by any State law or administrative
rule.
In the event of an inconsistency between any separate
written disclosure statement and the enrollee contract or
certificate, the terms of the enrollee contract or
certificate shall control.
(b) Upon written request, a health care plan shall
provide to enrollees a description of the financial
relationships between the health care plan and any health
care provider and, if requested, the percentage of
copayments, deductibles, and total premiums spent on
healthcare related expenses and the percentage of copayments,
deductibles, and total premiums spent on other expenses,
including administrative expenses, except that no health care
plan shall be required to disclose specific provider
reimbursement.
(c) A participating health care provider shall provide
all of the following, where applicable, to enrollees upon
request:
(1) Information related to the health care
provider's educational background, experience, training,
specialty, and board certification, if applicable.
(2) The names of licensed facilities on the
provider panel where the health care provider presently
has privileges for the treatment, illness, or procedure
that is the subject of the request.
(3) Information regarding the health care
provider's participation in continuing education
programs and compliance with any licensure,
certification, or registration requirements, if
applicable.
(d) A health care plan shall provide the information
required to be disclosed under this Act upon enrollment and
annually thereafter in a legible and understandable format.
The Department shall promulgate rules to establish the format
based, to the extent practical, on the standards developed
for supplemental insurance coverage under Title XVIII of the
federal Social Security Act as a guide, so that a person can
compare the attributes of the various health care plans.
(e) The written disclosure requirements of this Section
may be met by disclosure to one enrollee in a household.
Section 20. Notice of nonrenewal or termination. A
health care plan must give at least 60 days notice of
nonrenewal or termination of a health care provider to the
health care provider and to the enrollees served by the
health care provider. The notice shall include a name and
address to which an enrollee or health care provider may
direct comments and concerns regarding the nonrenewal or
termination. Immediate written notice may be provided without
60 days notice when a health care provider's license has been
disciplined by a State licensing board.
Section 25. Transition of services.
(a) A health care plan shall provide for continuity of
care for its enrollees as follows:
(1) If an enrollee's physician leaves the health
care plan's network of health care providers for reasons
other than termination of a contract in situations
involving imminent harm to a patient or a final
disciplinary action by a State licensing board and the
physician remains within the health care plan's service
area, the health care plan shall permit the enrollee to
continue an ongoing course of treatment with that
physician during a transitional period:
(A) of 90 days from the date of the notice of
physician's termination from the health care plan to
the enrollee of the physician's disaffiliation from
the health care plan if the enrollee has an ongoing
course of treatment; or
(B) if the enrollee has entered the third
trimester of pregnancy at the time of the
physician's disaffiliation, that includes the
provision of post-partum care directly related to
the delivery.
(2) Notwithstanding the provisions in item (1) of
this subsection, such care shall be authorized by the
health care plan during the transitional period only if
the physician agrees:
(A) to continue to accept reimbursement from
the health care plan at the rates applicable prior
to the start of the transitional period;
(B) to adhere to the health care plan's
quality assurance requirements and to provide to the
health care plan necessary medical information
related to such care; and
(C) to otherwise adhere to the health care
plan's policies and procedures, including but not
limited to procedures regarding referrals and
obtaining preauthorizations for treatment.
(b) A health care plan shall provide for continuity of
care for new enrollees as follows:
(1) If a new enrollee whose physician is not a
member of the health care plan's provider network, but is
within the health care plan's service area, enrolls in
the health care plan, the health care plan shall permit
the enrollee to continue an ongoing course of treatment
with the enrollee's current physician during a
transitional period:
(A) of 90 days from the effective date of
enrollment if the enrollee has an ongoing course of
treatment; or
(B) if the enrollee has entered the third
trimester of pregnancy at the effective date of
enrollment, that includes the provision of
post-partum care directly related to the delivery.
(2) If an enrollee elects to continue to receive
care from such physician pursuant to item (1) of this
subsection, such care shall be authorized by the health
care plan for the transitional period only if the
physician agrees:
(A) to accept reimbursement from the health
care plan at rates established by the health care
plan; such rates shall be the level of reimbursement
applicable to similar physicians within the health
care plan for such services;
(B) to adhere to the health care plan's
quality assurance requirements and to provide to the
health care plan necessary medical information
related to such care; and
(C) to otherwise adhere to the health care
plan's policies and procedures including, but not
limited to procedures regarding referrals and
obtaining preauthorization for treatment.
(c) In no event shall this Section be construed to
require a health care plan to provide coverage for benefits
not otherwise covered or to diminish or impair preexisting
condition limitations contained in the enrollee's contract.
Section 30. Prohibitions.
(a) No health care plan or its subcontractors may
prohibit or discourage health care providers by contract or
policy from discussing any health care services and health
care providers, utilization review and quality assurance
policies, terms and conditions of plans and plan policy with
enrollees, prospective enrollees, providers, or the public.
(b) No health care plan by contract, written policy, or
procedure may permit or allow an individual or entity to
dispense a different drug in place of the drug or brand of
drug ordered or prescribed without the express permission of
the person ordering or prescribing the drug, except as
provided under Section 3.14 of the Illinois Food, Drug and
Cosmetic Act.
(c) Any violation of this Section shall be subject to
the penalties under this Act.
Section 35. Medically appropriate health care
protection.
(a) No health care plan or its subcontractors shall
retaliate against a physician or other health care provider
who advocates for appropriate health care services for
patients.
(b) It is the public policy of the State of Illinois
that a physician or any other health care provider be
encouraged to advocate for medically appropriate health care
services for his or her patients. For purposes of this
Section, "to advocate for medically appropriate health care
services" means to appeal a decision to deny payment for a
health care service pursuant to the reasonable grievance or
appeal procedure established by a health care plan or to
protest a decision, policy, or practice that the physician or
other health care provider, consistent with that degree of
learning and skill ordinarily possessed by physicians or
other health care providers practicing in the same or a
similar locality and under similar circumstances, reasonably
believes impairs the physician's or other health care
provider's ability to provide appropriate health care
services to his or her patients.
(c) This Section shall not be construed to prohibit a
health care plan or its subcontractors from making a
determination not to pay for a particular health care service
or to prohibit a medical group, independent practice
association, preferred provider organization, foundation,
hospital medical staff, hospital governing body or health
care plan from enforcing reasonable peer review or
utilization review protocols or determining whether a
physician or other health care provider has complied with
those protocols.
(d) Nothing in this Section shall be construed to
prohibit the governing body of a hospital or the hospital
medical staff from taking disciplinary actions against a
physician as authorized by law.
(e) Nothing in this Section shall be construed to
prohibit the Department of Professional Regulation from
taking disciplinary actions against a physician or other
health care provider under the appropriate licensing Act.
(f) Any violation of this Section shall be subject to
the penalties under this Act.
Section 40. Access to specialists.
(a) All health care plans that require each enrollee to
select a health care provider for any purpose including
coordination of care shall permit an enrollee to choose any
available primary care physician licensed to practice
medicine in all its branches participating in the health care
plan for that purpose. The health care plan shall provide the
enrollee with a choice of licensed health care providers who
are accessible and qualified. Nothing in this Act shall be
construed to prohibit a health care plan from requiring a
health care provider to meet the health care plan's criteria
in order to coordinate access to health care.
(b) A health care plan shall establish a procedure by
which an enrollee who has a condition that requires ongoing
care from a specialist physician or other health care
provider may apply for a standing referral to a specialist
physician or other health care provider if a referral to a
specialist physician or other health care provider is
required for coverage. The application shall be made to the
enrollee's primary care physician. This procedure for a
standing referral must specify the necessary criteria and
conditions that must be met in order for an enrollee to
obtain a standing referral. A standing referral shall be
effective for the period necessary to provide the referred
services or one year, except in the event of termination of a
contract or policy in which case Section 25 on transition of
services shall apply, if applicable. A primary care physician
may renew and re-renew a standing referral.
(c) The enrollee may be required by the health care plan
to select a specialist physician or other health care
provider who has a referral arrangement with the enrollee's
primary care physician or to select a new primary care
physician who has a referral arrangement with the specialist
physician or other health care provider chosen by the
enrollee. If a health care plan requires an enrollee to
select a new physician under this subsection, the health care
plan must provide the enrollee with both options provided in
this subsection. When a participating specialist with a
referral arrangement is not available, the primary care
physician, in consultation with the enrollee, shall arrange
for the enrollee to have access to a qualified participating
health care provider, and the enrollee shall be allowed to
stay with his or her primary care physician. If a secondary
referral is necessary, the specialist physician or other
health care provider shall advise the primary care physician.
The primary care physician shall be responsible for making
the secondary referral. In addition, the health care plan
shall require the specialist physician or other health care
provider to provide regular updates to the enrollee's primary
care physician.
(d) When the type of specialist physician or other
health care provider needed to provide ongoing care for a
specific condition is not represented in the health care
plan's provider network, the primary care physician shall
arrange for the enrollee to have access to a qualified
non-participating health care provider within a reasonable
distance and travel time at no additional cost beyond what
the enrollee would otherwise pay for services received within
the network. The referring physician shall notify the plan
when a referral is made outside the network.
(e) The enrollee's primary care physician shall remain
responsible for coordinating the care of an enrollee who has
received a standing referral to a specialist physician or
other health care provider. If a secondary referral is
necessary, the specialist physician or other health care
provider shall advise the primary care physician. The
primary care physician shall be responsible for making the
secondary referral. In addition, the health care plan shall
require the specialist physician or other health care
provider to provide regular updates to the enrollee's primary
care physician.
(f) If an enrollee's application for any referral is
denied, an enrollee may appeal the decision through the
health care plan's external independent review process in
accordance with subsection (f) of Section 45 of this Act.
(g) Nothing in this Act shall be construed to require an
enrollee to select a new primary care physician when no
referral arrangement exists between the enrollee's primary
care physician and the specialist selected by the enrollee
and when the enrollee has a long-standing relationship with
his or her primary care physician.
(h) In promulgating rules to implement this Act, the
Department shall define "standing referral" and "ongoing
course of treatment".
Section 45. Health care services appeals, complaints,
and external independent reviews.
(a) A health care plan shall establish and maintain an
appeals procedure as outlined in this Act. Compliance with
this Act's appeals procedures shall satisfy a health care
plan's obligation to provide appeal procedures under any
other State law or rules. All appeals of a health care plan's
administrative determinations and complaints regarding its
administrative decisions shall be handled as required under
Section 50.
(b) When an appeal concerns a decision or action by a
health care plan, its employees, or its subcontractors that
relates to (i) health care services, including, but not
limited to, procedures or treatments, for an enrollee with an
ongoing course of treatment ordered by a health care
provider, the denial of which could significantly increase
the risk to an enrollee's health, or (ii) a treatment
referral, service, procedure, or other health care service,
the denial of which could significantly increase the risk to
an enrollee's health, the health care plan must allow for the
filing of an appeal either orally or in writing. Upon
submission of the appeal, a health care plan must notify the
party filing the appeal, as soon as possible, but in no event
more than 24 hours after the submission of the appeal, of all
information that the plan requires to evaluate the appeal.
The health care plan shall render a decision on the appeal
within 24 hours after receipt of the required information.
The health care plan shall notify the party filing the appeal
and the enrollee, enrollee's primary care physician, and any
health care provider who recommended the health care service
involved in the appeal of its decision orally followed-up by
a written notice of the determination.
(c) For all appeals related to health care services
including, but not limited to, procedures or treatments for
an enrollee and not covered by subsection (b) above, the
health care plan shall establish a procedure for the filing
of such appeals. Upon submission of an appeal under this
subsection, a health care plan must notify the party filing
an appeal, within 3 business days, of all information that
the plan requires to evaluate the appeal. The health care
plan shall render a decision on the appeal within 15 business
days after receipt of the required information. The health
care plan shall notify the party filing the appeal, the
enrollee, the enrollee's primary care physician, and any
health care provider who recommended the health care service
involved in the appeal orally of its decision followed-up by
a written notice of the determination.
(d) An appeal under subsection (b) or (c) may be filed
by the enrollee, the enrollee's designee or guardian, the
enrollee's primary care physician, or the enrollee's health
care provider. A health care plan shall designate a clinical
peer to review appeals, because these appeals pertain to
medical or clinical matters and such an appeal must be
reviewed by an appropriate health care professional. No one
reviewing an appeal may have had any involvement in the
initial determination that is the subject of the appeal. The
written notice of determination required under subsections
(b) and (c) shall include (i) clear and detailed reasons for
the determination, (ii) the medical or clinical criteria for
the determination, which shall be based upon sound clinical
evidence and reviewed on a periodic basis, and (iii) in the
case of an adverse determination, the procedures for
requesting an external independent review under subsection
(f).
(e) If an appeal filed under subsection (b) or (c) is
denied for a reason including, but not limited to, the
service, procedure, or treatment is not viewed as medically
necessary, denial of specific tests or procedures, denial of
referral to specialist physicians or denial of
hospitalization requests or length of stay requests, any
involved party may request an external independent review
under subsection (f) of the adverse determination.
(f) External independent review.
(1) The party seeking an external independent
review shall so notify the health care plan. The health
care plan shall seek to resolve all external independent
reviews in the most expeditious manner and shall make a
determination and provide notice of the determination no
more than 24 hours after the receipt of all necessary
information when a delay would significantly increase the
risk to an enrollee's health or when extended health care
services for an enrollee undergoing a course of treatment
prescribed by a health care provider are at issue.
(2) Within 30 days after the enrollee receives
written notice of an adverse determination, if the
enrollee decides to initiate an external independent
review, the enrollee shall send to the health care plan a
written request for an external independent review,
including any information or documentation to support the
enrollee's request for the covered service or claim for a
covered service.
(3) Within 30 days after the health care plan
receives a request for an external independent review
from an enrollee, the health care plan shall:
(A) provide a mechanism for joint selection of
an external independent reviewer by the enrollee,
the enrollee's physician or other health care
provider, and the health care plan; and
(B) forward to the independent reviewer all
medical records and supporting documentation
pertaining to the case, a summary description of the
applicable issues including a statement of the
health care plan's decision, the criteria used, and
the medical and clinical reasons for that decision.
(4) Within 5 days after receipt of all necessary
information, the independent reviewer shall evaluate and
analyze the case and render a decision that is based on
whether or not the health care service or claim for the
health care service is medically appropriate. The
decision by the independent reviewer is final. If the
external independent reviewer determines the health care
service to be medically appropriate, the health care plan
shall pay for the health care service.
(5) The health care plan shall be solely
responsible for paying the fees of the external
independent reviewer who is selected to perform the
review.
(6) An external independent reviewer who acts in
good faith shall have immunity from any civil or criminal
liability or professional discipline as a result of acts
or omissions with respect to any external independent
review, unless the acts or omissions constitute wilful
and wanton misconduct. For purposes of any proceeding,
the good faith of the person participating shall be
presumed.
(7) Future contractual or employment action by the
health care plan regarding the patient's physician or
other health care provider shall not be based solely on
the physician's or other health care provider's
participation in this procedure.
(8) For the purposes of this Section, an external
independent reviewer shall:
(A) be a clinical peer;
(B) have no direct financial interest in
connection with the case; and
(C) have not been informed of the specific
identity of the enrollee.
(g) Nothing in this Section shall be construed to
require a health care plan to pay for a health care service
not covered under the enrollee's certificate of coverage or
policy.
Section 50. Administrative complaints and Departmental
review.
(a) Administrative complaint process.
(1) A health care plan shall accept and review
appeals of its determinations and complaints related to
administrative issues initiated by enrollees or their
health care providers (complainant). All appeals of a
health care plan's determinations and complaints related
to health care services shall be handled as required
under Section 45. Nothing in this Act shall be construed
to preclude an enrollee from filing a complaint with the
Department or as limiting the Department's ability to
investigate complaints. In addition, any enrollee not
satisfied with the plan's resolution of any complaint may
appeal that final plan decision to the Department.
(2) When a complaint against a health care plan
(respondent) is received by the Department, the
respondent shall be notified of the complaint. The
Department shall, in its notification, specify the date
when a report is to be received from the respondent,
which shall be no later than 21 days after notification
is sent to the respondent. A failure to reply by the date
specified may be followed by a collect telephone call or
collect telegram. Repeated instances of failing to reply
by the date specified may result in further regulatory
action.
(3) The respondent's report shall supply adequate
documentation that explains all actions taken or not
taken and that were the basis for the complaint. The
report shall include documents necessary to support the
respondent's position and any information requested by
the Department. The respondent's reply shall be in
duplicate, but duplicate copies of supporting documents
shall not be required. The respondent's reply shall
include the name, telephone number, and address of the
individual assigned to investigate or process the
complaint. The Department shall respect the
confidentiality of medical reports and other documents
that by law are confidential. Any other information
furnished by a respondent shall be marked "confidential"
if the respondent does not wish it to be released to the
complainant.
(b) Departmental review. The Department shall review
the plan decision to determine whether it is consistent with
the plan and Illinois law and rules. Upon receipt of the
respondent's report, the Department shall evaluate the
material submitted and:
(1) advise the complainant of the action taken and
disposition of the complaint;
(2) pursue further investigation with the
respondent or complainant; or
(3) refer the investigation report to the
appropriate branch within the Department for further
regulatory action.
(c) The Department of Insurance and the Department of
Public Health shall coordinate the complaint review and
investigation process. The Department of Insurance and the
Department of Public Health shall jointly establish rules
under the Illinois Administrative Procedure Act implementing
this complaint process.
Section 55. Record of complaints.
(a) The Department shall maintain records concerning the
complaints filed against health care plans. To that end, the
Department shall require health care plans to annually report
complaints made to and resolutions by health care plans in a
manner determined by rule. The Department shall make a
summary of all data collected available upon request and
publish the summary on the World Wide Web.
(b) The Department shall maintain records on the number
of complaints filed against each health care plan.
(c) The Department shall maintain records classifying
each complaint by whether the complaint was filed by:
(1) a consumer or enrollee;
(2) a provider; or
(3) any other individual.
(d) The Department shall maintain records classifying
each complaint according to the nature of the complaint as it
pertains to a specific function of the health care plan. The
complaints shall be classified under the following
categories:
(1) denial of care or treatment;
(2) denial of a diagnostic procedure;
(3) denial of a referral request;
(4) sufficient choice and accessibility of health
care providers;
(5) underwriting;
(6) marketing and sales;
(7) claims and utilization review;
(8) member services;
(9) provider relations; and
(10) miscellaneous.
(e) The Department shall maintain records classifying
the disposition of each complaint. The disposition of the
complaint shall be classified in one of the following
categories:
(1) complaint referred to the health care plan and
no further action necessary by the Department;
(2) no corrective action deemed necessary by the
Department; or
(3) corrective action taken by the Department.
(f) No Department publication or release of information
shall identify any enrollee, health care provider, or
individual complainant.
Section 60. Choosing a physician.
(a) A health care plan may also offer other arrangements
under which enrollees may access health care services from
contracted providers without a referral or authorization from
their primary care physician.
(b) The enrollee may be required by the health care plan
to select a specialist physician or other health care
provider who has a referral arrangement with the enrollee's
primary care physician or to select a new primary care
physician who has a referral arrangement with the specialist
physician or other health care provider chosen by the
enrollee. If a health care plan requires an enrollee to
select a new physician under this subsection, the health care
plan must provide the enrollee with both options provided in
this subsection.
(c) The Director of Insurance and the Department of
Public Health each may promulgate rules to ensure appropriate
access to and quality of care for enrollees in any plan that
allows enrollees to access health care services from
contractual providers without a referral or authorization
from the primary care physician. The rules may include, but
shall not be limited to, a system for the retrieval and
compilation of enrollees' medical records.
Section 65. Emergency services prior to stabilization.
(a) A health care plan that provides or that is required
by law to provide coverage for emergency services shall
provide coverage such that payment under this coverage is not
dependent upon whether the services are performed by a plan
or non-plan health care provider and without regard to prior
authorization. This coverage shall be at the same benefit
level as if the services or treatment had been rendered by
the health care plan physician licensed to practice medicine
in all its branches or health care provider.
(b) Prior authorization or approval by the plan shall
not be required for emergency services.
(c) Coverage and payment shall only be retrospectively
denied under the following circumstances:
(1) upon reasonable determination that the
emergency services claimed were never performed;
(2) upon timely determination that the emergency
evaluation and treatment were rendered to an enrollee who
sought emergency services and whose circumstance did not
meet the definition of emergency medical condition;
(3) upon determination that the patient receiving
such services was not an enrollee of the health care
plan; or
(4) upon material misrepresentation by the enrollee
or health care provider; "material" means a fact or
situation that is not merely technical in nature and
results or could result in a substantial change in the
situation.
(d) When an enrollee presents to a hospital seeking
emergency services, the determination as to whether the need
for those services exists shall be made for purposes of
treatment by a physician licensed to practice medicine in
all its branches or, to the extent permitted by applicable
law, by other appropriately licensed personnel under the
supervision of or in collaboration with a physician licensed
to practice medicine in all its branches. The physician or
other appropriate personnel shall indicate in the patient's
chart the results of the emergency medical screening
examination.
(e) The appropriate use of the 911 emergency telephone
system or its local equivalent shall not be discouraged or
penalized by the health care plan when an emergency medical
condition exists. This provision shall not imply that the use
of 911 or its local equivalent is a factor in determining the
existence of an emergency medical condition.
(f) The medical director's or his or her designee's
determination of whether the enrollee meets the standard of
an emergency medical condition shall be based solely upon the
presenting symptoms documented in the medical record at the
time care was sought. Only a clinical peer may make an
adverse determination.
(g) Nothing in this Section shall prohibit the
imposition of deductibles, copayments, and co-insurance.
Nothing in this Section alters the prohibition on billing
enrollees contained in the Health Maintenance Organization
Act.
Section 70. Post-stabilization medical services.
(a) If prior authorization for covered post-stabilization
services is required by the health care plan, the plan shall
provide access 24 hours a day, 7 days a week to persons
designated by the plan to make such determinations, provided
that any determination made under this Section must be made
by a health care professional. The review shall be resolved
in accordance with the provisions of Section 85 and the time
requirements of this Section.
(b) The treating physician licensed to practice medicine
in all its branches or health care provider shall contact
the health care plan or delegated health care provider as
designated on the enrollee's health insurance card to obtain
authorization, denial, or arrangements for an alternate plan
of treatment or transfer of the enrollee.
(c) The treating physician licensed to practice
medicine in all its branches or health care provider shall
document in the enrollee's medical record the enrollee's
presenting symptoms; emergency medical condition; and time,
phone number dialed, and result of the communication for
request for authorization of post-stabilization medical
services. The health care plan shall provide reimbursement
for covered post-stabilization medical services if:
(1) authorization to render them is received from
the health care plan or its delegated health care
provider, or
(2) after 2 documented good faith efforts, the
treating health care provider has attempted to contact
the enrollee's health care plan or its delegated health
care provider, as designated on the enrollee's health
insurance card, for prior authorization of
post-stabilization medical services and neither the plan
nor designated persons were accessible or the
authorization was not denied within 60 minutes of the
request. "Two documented good faith efforts" means the
health care provider has called the telephone number on
the enrollee's health insurance card or other available
number either 2 times or one time and an additional call
to any referral number provided. "Good faith" means
honesty of purpose, freedom from intention to defraud,
and being faithful to one's duty or obligation. For the
purpose of this Act, good faith shall be presumed.
(d) After rendering any post-stabilization medical
services, the treating physician licensed to practice
medicine in all its branches or health care provider shall
continue to make every reasonable effort to contact the
health care plan or its delegated health care provider
regarding authorization, denial, or arrangements for an
alternate plan of treatment or transfer of the enrollee until
the treating health care provider receives instructions from
the health care plan or delegated health care provider for
continued care or the care is transferred to another health
care provider or the patient is discharged.
(e) Payment for covered post-stabilization services may
be denied:
(1) if the treating health care provider does not
meet the conditions outlined in subsection (c);
(2) upon determination that the post-stabilization
services claimed were not performed;
(3) upon timely determination that the
post-stabilization services rendered were contrary to the
instructions of the health care plan or its delegated
health care provider if contact was made between those
parties prior to the service being rendered;
(4) upon determination that the patient receiving
such services was not an enrollee of the health care
plan; or
(5) upon material misrepresentation by the enrollee
or health care provider; "material" means a fact or
situation that is not merely technical in nature and
results or could result in a substantial change in the
situation.
(f) Nothing in this Section prohibits a health care plan
from delegating tasks associated with the responsibilities
enumerated in this Section to the health care plan's
contracted health care providers or another entity. Only a
clinical peer may make an adverse determination. However,
the ultimate responsibility for coverage and payment
decisions may not be delegated.
(g) Coverage and payment for post-stabilization medical
services for which prior authorization or deemed approval is
received shall not be retrospectively denied.
(h) Nothing in this Section shall prohibit the
imposition of deductibles, copayments, and co-insurance.
Nothing in this Section alters the prohibition on billing
enrollees contained in the Health Maintenance Organization
Act.
Section 72. Pharmacy providers.
(a) Before entering into an agreement with pharmacy
providers, a health care plan must establish terms and
conditions that must be met by pharmacy providers desiring to
contract with the health care plan. The terms and conditions
shall not discriminate against a pharmacy provider. A health
care plan may not refuse to contract with a pharmacy provider
that meets the terms and conditions established by the health
care plan. If a pharmacy provider rejects the terms and
conditions established, the health care plan may offer other
terms and conditions necessary to comply with network
adequacy requirements.
(b) A health care plan shall apply the same co-insurance,
copayment, and deductible factors to all drug prescriptions
filled by a pharmacy provider that participates in the health
care plan's network. Nothing in this subsection, however,
prohibits a health care plan from applying different
co-insurance, copayment, and deductible factors between brand
name drugs and generic drugs when a generic equivalent exists
for the brand name drug.
(c) A health care plan may not set a limit on the
quantity of drugs that an enrollee may obtain at one time
with a prescription unless the limit is applied uniformly to
all pharmacy providers in the health care plan's network.
Section 75. Consumer advisory committee.
(a) A health care plan shall establish a consumer
advisory committee. The consumer advisory committee shall
have the authority to identify and review consumer concerns
and make advisory recommendations to the health care plan.
The health care plan may also make requests of the consumer
advisory committee to provide feedback to proposed changes in
plan policies and procedures which will affect enrollees.
However, the consumer advisory committee shall not have the
authority to hear or resolve specific complaints or
grievances, but instead shall refer such complaints or
grievances to the health care plan's grievance committee.
(b) The health care plan shall randomly select 8
enrollees meeting the requirements of this Section to serve
on the consumer advisory committee. The health care plan must
continue to randomly select enrollees until 8 enrollees have
agreed to serve on the consumer advisory committee. Upon
initial formation of the consumer advisory committee, the
health care plan shall appoint 4 enrollees to a 2 year term
and 4 enrollees to a one year term. Thereafter, as an
enrollee's term expires, the health care plan shall
re-appoint or appoint an enrollee to serve on the consumer
advisory committee for a 2 year term. Members of the consumer
advisory committee shall by majority vote elect a member of
the committee to serve as chair of the committee.
(c) An enrollee may not serve on the consumer advisory
committee if during the 2 years preceding service the
enrollee:
(1) has been an employee, officer, or director of
the plan, an affiliate of the plan, or a provider or
affiliate of a provider that furnishes health care
services to the plan or affiliate of the plan; or
(2) is a relative of a person specified in item
(1).
(d) A health care plan's consumer advisory committee
shall meet not less than quarterly.
(e) All meetings shall be held within the State of
Illinois. The costs of the meetings shall be borne by the
health care plan.
Section 80. Quality assessment program.
(a) A health care plan shall develop and implement a
quality assessment and improvement strategy designed to
identify and evaluate accessibility, continuity, and quality
of care. The health care plan shall have:
(1) an ongoing, written, internal quality
assessment program;
(2) specific written guidelines for monitoring and
evaluating the quality and appropriateness of care and
services provided to enrollees requiring the health care
plan to assess:
(A) the accessibility to health care
providers;
(B) appropriateness of utilization;
(C) concerns identified by the health care
plan's medical or administrative staff and
enrollees; and
(D) other aspects of care and service directly
related to the improvement of quality of care;
(3) a procedure for remedial action to correct
quality problems that have been verified in accordance
with the written plan's methodology and criteria,
including written procedures for taking appropriate
corrective action;
(4) follow-up measures implemented to evaluate the
effectiveness of the action plan.
(b) The health care plan shall establish a committee
that oversees the quality assessment and improvement strategy
which includes physician and enrollee participation.
(c) Reports on quality assessment and improvement
activities shall be made to the governing body of the health
care plan not less than quarterly.
(d) The health care plan shall make available its
written description of the quality assessment program to the
Department of Public Health.
(e) With the exception of subsection (d), the Department
of Public Health shall accept evidence of accreditation with
regard to the health care network quality management and
performance improvement standards of:
(1) the National Commission on Quality Assurance
(NCQA);
(2) the American Accreditation Healthcare
Commission (URAC);
(3) the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO); or
(4) any other entity that the Director of Public
Health deems has substantially similar or more stringent
standards than provided for in this Section.
(f) If the Department of Public Health determines that a
health care plan is not in compliance with the terms of this
Section, it shall certify the finding to the Department of
Insurance. The Department of Insurance shall subject a health
care plan to penalties, as provided in this Act, for such
non-compliance.
Section 85. Utilization review program registration.
(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 compliance with the Health Utilization Management
Standards of the American Accreditation Healthcare Commission
(URAC) sufficient to achieve American Accreditation
Healthcare 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.
(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
utilization review standards shall meet or exceed those
standards required under subsection (a).
(c) The provisions of this Section do not apply to:
(1) persons providing utilization review program
services only to the federal government;
(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;
(3) hospitals and medical groups performing
utilization review activities for internal purposes
unless the utilization review program is conducted for
another person.
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 program requirements of this Act.
(d) This registration shall include submission of all of
the following information regarding utilization review
program activities:
(1) The name, address, and telephone number of the
utilization review programs.
(2) The organization and governing structure of the
utilization review programs.
(3) The number of lives for which utilization
review is conducted by each utilization review program.
(4) Hours of operation of each utilization review
program.
(5) Description of the grievance process for each
utilization review program.
(6) Number of covered lives for which utilization
review was conducted for the previous calendar year for
each utilization review program.
(7) Written policies and procedures for protecting
confidential information according to applicable State
and federal laws for each utilization review program.
(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:
(A) kept confidential in accordance with applicable
State and federal laws; and
(B) shared only with the enrollee, the enrollee's
designee, the enrollee's health care provider, and those
who are authorized by law to receive the information.
Summary data shall not be considered confidential if it
does not provide information to allow identification of
individual patients or health care providers.
(2) Only a health care professional may make
determinations regarding the medical necessity of health
care services during the course of utilization review.
(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.
(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 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 relevant sections of
the medical record shall be required.
(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 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 requested, and the hearing
shall be conducted in accordance with the Illinois
Administrative Procedure Act.
(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.
(h) Any adverse determination made by a health care plan
or its subcontractors may be appealed in accordance with
subsection (f) of Section 45.
(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.
Section 90. Office of Consumer Health Insurance.
(a) The Director of Insurance shall establish the Office
of Consumer Health Insurance within the Department of
Insurance to provide assistance and information to all health
care consumers within the State. Within the appropriation
allocated, the Office shall provide information and
assistance to all health care consumers by:
(1) assisting consumers in understanding health
insurance marketing materials and the coverage provisions
of individual plans;
(2) educating enrollees about their rights within
individual plans;
(3) assisting enrollees with the process of filing
formal grievances and appeals;
(4) establishing and operating a toll-free "800"
telephone number line to handle consumer inquiries;
(5) making related information available in
languages other than English that are spoken as a primary
language by a significant portion of the State's
population, as determined by the Department;
(6) analyzing, commenting on, monitoring, and
making publicly available reports on the development and
implementation of federal, State, and local laws,
regulations, and other governmental policies and actions
that pertain to the adequacy of health care plans,
facilities, and services in the State;
(7) filing an annual report with the Governor, the
Director, and the General Assembly, which shall contain
recommendations for improvement of the regulation of
health insurance plans, including recommendations on
improving health care consumer assistance and patterns,
abuses, and progress that it has identified from its
interaction with health care consumers; and
(8) performing all duties assigned to the Office by
the Director.
(b) The report required under subsection (a)(7) shall be
filed by January 31, 2001 and each January 31 thereafter.
(c) Nothing in this Section shall be interpreted to
authorize access to or disclosure of individual patient or
health care professional or provider records.
Section 95. Prohibited activity. No health care plan or
its subcontractors by contract, written policy, or procedure
shall contain any clause attempting to transfer or
transferring to a health care provider by indemnification,
hold harmless, or contribution requirements concerning any
liability relating to activities, actions, or omissions of
the health care plan or its officers, employees, or agents.
Nothing in this Section shall relieve any person or health
care provider from liability for his, her, or its own
negligence in the performance of his, her, or its duties
arising from treatment of a patient. The Illinois General
Assembly finds it to be against public policy for a person to
transfer liability in such a manner.
Section 100. Prohibition of waiver of rights. No health
care plan or contract shall contain any provision, policy, or
procedure that limits, restricts, or waives any of the rights
set forth in this Act. Any such policy or procedure shall be
void and unenforceable.
Section 105. Administration and enforcement. The
Director of Insurance may adopt rules necessary to implement
the Department's responsibilities under this Act.
To enforce the provisions of this Act, the Director may
issue a cease and desist order or require a health care plan
to submit a plan of correction for violations of this Act, or
both. Subject to the provisions of the Illinois
Administrative Procedure Act, the Director may, pursuant to
Section 403A of the Illinois Insurance Code, impose upon a
health care plan an administrative fine not to exceed
$250,000 for failure to submit a requested plan of
correction, failure to comply with its plan of correction, or
repeated violations of the Act.
Any person who believes that his or her health care plan
is in violation of the provisions of this Act may file a
complaint with the Department. The Department shall review
all complaints received and investigate all of those
complaints that it deems to state a potential violation. The
Department shall establish rules to fairly, efficiently, and
timely review and investigate complaints. Health care plans
found to be in violation of this Act shall be penalized in
accordance with this Section.
Section 110. Applicability and scope. This Act applies
to policies and contracts amended, delivered, issued, or
renewed on or after the effective date of this Act. This Act
does not diminish a health care plan's duties and
responsibilities under other federal or State law or rules
promulgated thereunder.
Section 115. Effect on benefits under Workers'
Compensation Act and Workers' Occupational Diseases Act.
Nothing in this Act shall be construed to expand, modify, or
restrict the health care benefits provided to employees under
the Workers' Compensation Act and Workers' Occupational
Diseases Act.
Section 120. Severability. The provisions of this Act
are severable under Section 1.31 of the Statute on Statutes.
Section 200. The State Employees Group Insurance Act of
1971 is amended by changing Sections 3 and 10 and adding
Section 6.12 as follows:
(5 ILCS 375/3) (from Ch. 127, par. 523)
Sec. 3. Definitions. Unless the context otherwise
requires, the following words and phrases as used in this Act
shall have the following meanings. The Department may define
these and other words and phrases separately for the purpose
of implementing specific programs providing benefits under
this Act.
(a) "Administrative service organization" means any
person, firm or corporation experienced in the handling of
claims which is fully qualified, financially sound and
capable of meeting the service requirements of a contract of
administration executed with the Department.
(b) "Annuitant" means (1) an employee who retires, or
has retired, on or after January 1, 1966 on an immediate
annuity under the provisions of Articles 2, 14, 15 (including
an employee who has retired under the optional retirement
program established under Section 15-158.2), paragraphs (2),
(3), or (5) of Section 16-106, or Article 18 of the Illinois
Pension Code; (2) any person who was receiving group
insurance coverage under this Act as of March 31, 1978 by
reason of his status as an annuitant, even though the annuity
in relation to which such coverage was provided is a
proportional annuity based on less than the minimum period of
service required for a retirement annuity in the system
involved; (3) any person not otherwise covered by this Act
who has retired as a participating member under Article 2 of
the Illinois Pension Code but is ineligible for the
retirement annuity under Section 2-119 of the Illinois
Pension Code; (4) the spouse of any person who is receiving a
retirement annuity under Article 18 of the Illinois Pension
Code and who is covered under a group health insurance
program sponsored by a governmental employer other than the
State of Illinois and who has irrevocably elected to waive
his or her coverage under this Act and to have his or her
spouse considered as the "annuitant" under this Act and not
as a "dependent"; or (5) an employee who retires, or has
retired, from a qualified position, as determined according
to rules promulgated by the Director, under a qualified local
government or a qualified rehabilitation facility or a
qualified domestic violence shelter or service. (For
definition of "retired employee", see (p) post).
(b-5) "New SERS annuitant" means a person who, on or
after January 1, 1998, becomes an annuitant, as defined in
subsection (b), by virtue of beginning to receive a
retirement annuity under Article 14 of the Illinois Pension
Code, and is eligible to participate in the basic program of
group health benefits provided for annuitants under this Act.
(b-6) "New SURS annuitant" means a person who, on or
after January 1, 1998, becomes an annuitant, as defined in
subsection (b), by virtue of beginning to receive a
retirement annuity under Article 15 of the Illinois Pension
Code, and is eligible to participate in the basic program of
group health benefits provided for annuitants under this Act.
(b-7) "New TRS State annuitant" means a person who, on
or after July 1, 1998, becomes an annuitant, as defined in
subsection (b), by virtue of beginning to receive a
retirement annuity under Article 16 of the Illinois Pension
Code based on service as a teacher as defined in paragraph
(2), (3), or (5) of Section 16-106 of that Code, and is
eligible to participate in the basic program of group health
benefits provided for annuitants under this Act.
(c) "Carrier" means (1) an insurance company, a
corporation organized under the Limited Health Service
Organization Act or the Voluntary Health Services Plan Act, a
partnership, or other nongovernmental organization, which is
authorized to do group life or group health insurance
business in Illinois, or (2) the State of Illinois as a
self-insurer.
(d) "Compensation" means salary or wages payable on a
regular payroll by the State Treasurer on a warrant of the
State Comptroller out of any State, trust or federal fund, or
by the Governor of the State through a disbursing officer of
the State out of a trust or out of federal funds, or by any
Department out of State, trust, federal or other funds held
by the State Treasurer or the Department, to any person for
personal services currently performed, and ordinary or
accidental disability benefits under Articles 2, 14, 15
(including ordinary or accidental disability benefits under
the optional retirement program established under Section
15-158.2), paragraphs (2), (3), or (5) of Section 16-106, or
Article 18 of the Illinois Pension Code, for disability
incurred after January 1, 1966, or benefits payable under the
Workers' Compensation or Occupational Diseases Act or
benefits payable under a sick pay plan established in
accordance with Section 36 of the State Finance Act.
"Compensation" also means salary or wages paid to an employee
of any qualified local government or qualified rehabilitation
facility or a qualified domestic violence shelter or service.
(e) "Commission" means the State Employees Group
Insurance Advisory Commission authorized by this Act.
Commencing July 1, 1984, "Commission" as used in this Act
means the Illinois Economic and Fiscal Commission as
established by the Legislative Commission Reorganization Act
of 1984.
(f) "Contributory", when referred to as contributory
coverage, shall mean optional coverages or benefits elected
by the member toward the cost of which such member makes
contribution, or which are funded in whole or in part through
the acceptance of a reduction in earnings or the foregoing of
an increase in earnings by an employee, as distinguished from
noncontributory coverage or benefits which are paid entirely
by the State of Illinois without reduction of the member's
salary.
(g) "Department" means any department, institution,
board, commission, officer, court or any agency of the State
government receiving appropriations and having power to
certify payrolls to the Comptroller authorizing payments of
salary and wages against such appropriations as are made by
the General Assembly from any State fund, or against trust
funds held by the State Treasurer and includes boards of
trustees of the retirement systems created by Articles 2, 14,
15, 16 and 18 of the Illinois Pension Code. "Department"
also includes the Illinois Comprehensive Health Insurance
Board, the Board of Examiners established under the Illinois
Public Accounting Act, and the Illinois Rural Bond Bank.
(h) "Dependent", when the term is used in the context of
the health and life plan, means a member's spouse and any
unmarried child (1) from birth to age 19 including an adopted
child, a child who lives with the member from the time of the
filing of a petition for adoption until entry of an order of
adoption, a stepchild or recognized child who lives with the
member in a parent-child relationship, or a child who lives
with the member if such member is a court appointed guardian
of the child, or (2) age 19 to 23 enrolled as a full-time
student in any accredited school, financially dependent upon
the member, and eligible as a dependent for Illinois State
income tax purposes, or (3) age 19 or over who is mentally or
physically handicapped as defined in the Illinois Insurance
Code. For the health plan only, the term "dependent" also
includes any person enrolled prior to the effective date of
this Section who is dependent upon the member to the extent
that the member may claim such person as a dependent for
Illinois State income tax deduction purposes; no other such
person may be enrolled.
(i) "Director" means the Director of the Illinois
Department of Central Management Services.
(j) "Eligibility period" means the period of time a
member has to elect enrollment in programs or to select
benefits without regard to age, sex or health.
(k) "Employee" means and includes each officer or
employee in the service of a department who (1) receives his
compensation for service rendered to the department on a
warrant issued pursuant to a payroll certified by a
department or on a warrant or check issued and drawn by a
department upon a trust, federal or other fund or on a
warrant issued pursuant to a payroll certified by an elected
or duly appointed officer of the State or who receives
payment of the performance of personal services on a warrant
issued pursuant to a payroll certified by a Department and
drawn by the Comptroller upon the State Treasurer against
appropriations made by the General Assembly from any fund or
against trust funds held by the State Treasurer, and (2) is
employed full-time or part-time in a position normally
requiring actual performance of duty during not less than 1/2
of a normal work period, as established by the Director in
cooperation with each department, except that persons elected
by popular vote will be considered employees during the
entire term for which they are elected regardless of hours
devoted to the service of the State, and (3) except that
"employee" does not include any person who is not eligible by
reason of such person's employment to participate in one of
the State retirement systems under Articles 2, 14, 15 (either
the regular Article 15 system or the optional retirement
program established under Section 15-158.2) or 18, or under
paragraph (2), (3), or (5) of Section 16-106, of the Illinois
Pension Code, but such term does include persons who are
employed during the 6 month qualifying period under Article
14 of the Illinois Pension Code. Such term also includes any
person who (1) after January 1, 1966, is receiving ordinary
or accidental disability benefits under Articles 2, 14, 15
(including ordinary or accidental disability benefits under
the optional retirement program established under Section
15-158.2), paragraphs (2), (3), or (5) of Section 16-106, or
Article 18 of the Illinois Pension Code, for disability
incurred after January 1, 1966, (2) receives total permanent
or total temporary disability under the Workers' Compensation
Act or Occupational Disease Act as a result of injuries
sustained or illness contracted in the course of employment
with the State of Illinois, or (3) is not otherwise covered
under this Act and has retired as a participating member
under Article 2 of the Illinois Pension Code but is
ineligible for the retirement annuity under Section 2-119 of
the Illinois Pension Code. However, a person who satisfies
the criteria of the foregoing definition of "employee" except
that such person is made ineligible to participate in the
State Universities Retirement System by clause (4) of
subsection (a) of Section 15-107 of the Illinois Pension Code
is also an "employee" for the purposes of this Act.
"Employee" also includes any person receiving or eligible for
benefits under a sick pay plan established in accordance with
Section 36 of the State Finance Act. "Employee" also includes
each officer or employee in the service of a qualified local
government, including persons appointed as trustees of
sanitary districts regardless of hours devoted to the service
of the sanitary district, and each employee in the service of
a qualified rehabilitation facility and each full-time
employee in the service of a qualified domestic violence
shelter or service, as determined according to rules
promulgated by the Director.
(l) "Member" means an employee, annuitant, retired
employee or survivor.
(m) "Optional coverages or benefits" means those
coverages or benefits available to the member on his or her
voluntary election, and at his or her own expense.
(n) "Program" means the group life insurance, health
benefits and other employee benefits designed and contracted
for by the Director under this Act.
(o) "Health plan" means a self-insured health insurance
program offered by the State of Illinois for the purposes of
benefiting employees by means of providing, among others,
wellness programs, utilization reviews, second opinions and
medical fee reviews, as well as for paying for hospital and
medical care up to the maximum coverage provided by the plan,
to its members and their dependents.
(p) "Retired employee" means any person who would be an
annuitant as that term is defined herein but for the fact
that such person retired prior to January 1, 1966. Such term
also includes any person formerly employed by the University
of Illinois in the Cooperative Extension Service who would be
an annuitant but for the fact that such person was made
ineligible to participate in the State Universities
Retirement System by clause (4) of subsection (a) of Section
15-107 of the Illinois Pension Code.
(p-6) "New SURS retired employee" means a person who, on
or after January 1, 1998, becomes a retired employee, as
defined in subsection (p), by virtue of being a person
formerly employed by the University of Illinois in the
Cooperative Extension Service who would be an annuitant but
for the fact that he or she was made ineligible to
participate in the State Universities Retirement System by
clause (4) of subsection (a) of Section 15-107 of the
Illinois Pension Code, and who is eligible to participate in
the basic program of group health benefits provided for
retired employees under this Act.
(q) "Survivor" means a person receiving an annuity as a
survivor of an employee or of an annuitant. "Survivor" also
includes: (1) the surviving dependent of a person who
satisfies the definition of "employee" except that such
person is made ineligible to participate in the State
Universities Retirement System by clause (4) of subsection
(a) of Section 15-107 of the Illinois Pension Code; and (2)
the surviving dependent of any person formerly employed by
the University of Illinois in the Cooperative Extension
Service who would be an annuitant except for the fact that
such person was made ineligible to participate in the State
Universities Retirement System by clause (4) of subsection
(a) of Section 15-107 of the Illinois Pension Code.
(q-5) "New SERS survivor" means a survivor, as defined
in subsection (q), whose annuity is paid under Article 14 of
the Illinois Pension Code and is based on the death of (i) an
employee whose death occurs on or after January 1, 1998, or
(ii) a new SERS annuitant as defined in subsection (b-5).
(q-6) "New SURS survivor" means a survivor, as defined
in subsection (q), whose annuity is paid under Article 15 of
the Illinois Pension Code and is based on the death of (i) an
employee whose death occurs on or after January 1, 1998, (ii)
a new SURS annuitant as defined in subsection (b-6), or (iii)
a new SURS retired employee as defined in subsection (p-6).
(q-7) "New TRS State survivor" means a survivor, as
defined in subsection (q), whose annuity is paid under
Article 16 of the Illinois Pension Code and is based on the
death of (i) an employee who is a teacher as defined in
paragraph (2), (3), or (5) of Section 16-106 of that Code and
whose death occurs on or after July 1, 1998, or (ii) a new
TRS State annuitant as defined in subsection (b-7).
(r) "Medical services" means the services provided
within the scope of their licenses by practitioners in all
categories licensed under the Medical Practice Act of 1987.
(s) "Unit of local government" means any county,
municipality, township, school district, special district or
other unit, designated as a unit of local government by law,
which exercises limited governmental powers or powers in
respect to limited governmental subjects, any not-for-profit
association with a membership that primarily includes
townships and township officials, that has duties that
include provision of research service, dissemination of
information, and other acts for the purpose of improving
township government, and that is funded wholly or partly in
accordance with Section 85-15 of the Township Code; any
not-for-profit corporation or association, with a membership
consisting primarily of municipalities, that operates its own
utility system, and provides research, training,
dissemination of information, or other acts to promote
cooperation between and among municipalities that provide
utility services and for the advancement of the goals and
purposes of its membership; the Southern Illinois Collegiate
Common Market, which is a consortium of higher education
institutions in Southern Illinois; and the Illinois
Association of Park Districts. "Qualified local government"
means a unit of local government approved by the Director and
participating in a program created under subsection (i) of
Section 10 of this Act.
(t) "Qualified rehabilitation facility" means any
not-for-profit organization that is accredited by the
Commission on Accreditation of Rehabilitation Facilities or
certified by the Department of Human Services (as successor
to the Department of Mental Health and Developmental
Disabilities) to provide services to persons with
disabilities and which receives funds from the State of
Illinois for providing those services, approved by the
Director and participating in a program created under
subsection (j) of Section 10 of this Act.
(u) "Qualified domestic violence shelter or service"
means any Illinois domestic violence shelter or service and
its administrative offices funded by the Department of Human
Services (as successor to the Illinois Department of Public
Aid), approved by the Director and participating in a program
created under subsection (k) of Section 10.
(v) "TRS benefit recipient" means a person who:
(1) is not a "member" as defined in this Section;
and
(2) is receiving a monthly benefit or retirement
annuity under Article 16 of the Illinois Pension Code;
and
(3) either (i) has at least 8 years of creditable
service under Article 16 of the Illinois Pension Code, or
(ii) was enrolled in the health insurance program offered
under that Article on January 1, 1996, or (iii) is the
survivor of a benefit recipient who had at least 8 years
of creditable service under Article 16 of the Illinois
Pension Code or was enrolled in the health insurance
program offered under that Article on the effective date
of this amendatory Act of 1995, or (iv) is a recipient or
survivor of a recipient of a disability benefit under
Article 16 of the Illinois Pension Code.
(w) "TRS dependent beneficiary" means a person who:
(1) is not a "member" or "dependent" as defined in
this Section; and
(2) is a TRS benefit recipient's: (A) spouse, (B)
dependent parent who is receiving at least half of his or
her support from the TRS benefit recipient, or (C)
unmarried natural or adopted child who is (i) under age
19, or (ii) enrolled as a full-time student in an
accredited school, financially dependent upon the TRS
benefit recipient, eligible as a dependent for Illinois
State income tax purposes, and either is under age 24 or
was, on January 1, 1996, participating as a dependent
beneficiary in the health insurance program offered under
Article 16 of the Illinois Pension Code, or (iii) age 19
or over who is mentally or physically handicapped as
defined in the Illinois Insurance Code.
(x) "Military leave with pay and benefits" refers to
individuals in basic training for reserves, special/advanced
training, annual training, emergency call up, or activation
by the President of the United States with approved pay and
benefits.
(y) "Military leave without pay and benefits" refers to
individuals who enlist for active duty in a regular component
of the U.S. Armed Forces or other duty not specified or
authorized under military leave with pay and benefits.
(z) "Community college benefit recipient" means a person
who:
(1) is not a "member" as defined in this Section;
and
(2) is receiving a monthly survivor's annuity or
retirement annuity under Article 15 of the Illinois
Pension Code; and
(3) either (i) was a full-time employee of a
community college district or an association of community
college boards created under the Public Community College
Act (other than an employee whose last employer under
Article 15 of the Illinois Pension Code was a community
college district subject to Article VII of the Public
Community College Act) and was eligible to participate in
a group health benefit plan as an employee during the
time of employment with a community college district
(other than a community college district subject to
Article VII of the Public Community College Act) or an
association of community college boards, or (ii) is the
survivor of a person described in item (i).
(aa) "Community college dependent beneficiary" means a
person who:
(1) is not a "member" or "dependent" as defined in
this Section; and
(2) is a community college benefit recipient's: (A)
spouse, (B) dependent parent who is receiving at least
half of his or her support from the community college
benefit recipient, or (C) unmarried natural or adopted
child who is (i) under age 19, or (ii) enrolled as a
full-time student in an accredited school, financially
dependent upon the community college benefit recipient,
eligible as a dependent for Illinois State income tax
purposes and under age 23, or (iii) age 19 or over and
mentally or physically handicapped as defined in the
Illinois Insurance Code.
(Source: P.A. 89-21, eff. 6-21-95; 89-25, eff. 6-21-95;
89-76, eff. 7-1-95; 89-324, eff. 8-13-95; 89-430, eff.
12-15-95; 89-502, eff. 7-1-96; 89-507, eff. 7-1-97; 89-628,
eff. 8-9-96; 90-14, eff. 7-1-97; 90-65, eff. 7-7-97; 90-448,
eff. 8-16-97; 90-497, eff. 8-18-97; 90-511, eff. 8-22-97;
90-582, eff. 5-27-98; 90-655, eff. 7-30-98.)
(5 ILCS 375/6.12 new)
Sec. 6.12. Managed Care Reform and Patient Rights Act.
The program of health benefits is subject to the provisions
of the Managed Care Reform and Patient Rights Act, except the
fee for service program shall only be required to comply with
Section 85 and the definition of "emergency medical
condition" in Section 10 of the Managed Care Reform and
Patient Rights Act.
(5 ILCS 375/10) (from Ch. 127, par. 530)
Sec. 10. Payments by State; premiums.
(a) The State shall pay the cost of basic
non-contributory group life insurance and, subject to member
paid contributions set by the Department or required by this
Section, the basic program of group health benefits on each
eligible member, except a member, not otherwise covered by
this Act, who has retired as a participating member under
Article 2 of the Illinois Pension Code but is ineligible for
the retirement annuity under Section 2-119 of the Illinois
Pension Code, and part of each eligible member's and retired
member's premiums for health insurance coverage for enrolled
dependents as provided by Section 9. The State shall pay the
cost of the basic program of group health benefits only after
benefits are reduced by the amount of benefits covered by
Medicare for all retired members and retired dependents aged
65 years or older who are entitled to benefits under Social
Security or the Railroad Retirement system or who had
sufficient Medicare-covered government employment except that
such reduction in benefits shall apply only to those retired
members or retired dependents who (1) first become eligible
for such Medicare coverage on or after July 1, 1992; or (2)
remain eligible for, but no longer receive Medicare coverage
which they had been receiving on or after July 1, 1992. The
Department may determine the aggregate level of the State's
contribution on the basis of actual cost of medical services
adjusted for age, sex or geographic or other demographic
characteristics which affect the costs of such programs.
The cost of participation in the basic program of group
health benefits for the dependent or survivor of a living or
deceased retired employee who was formerly employed by the
University of Illinois in the Cooperative Extension Service
and would be an annuitant but for the fact that he or she was
made ineligible to participate in the State Universities
Retirement System by clause (4) of subsection (a) of Section
15-107 of the Illinois Pension Code shall not be greater than
the cost of participation that would otherwise apply to that
dependent or survivor if he or she were the dependent or
survivor of an annuitant under the State Universities
Retirement System.
(a-1) Beginning January 1, 1998, for each person who
becomes a new SERS annuitant and participates in the basic
program of group health benefits, the State shall contribute
toward the cost of the annuitant's coverage under the basic
program of group health benefits an amount equal to 5% of
that cost for each full year of creditable service upon which
the annuitant's retirement annuity is based, up to a maximum
of 100% for an annuitant with 20 or more years of creditable
service. The remainder of the cost of a new SERS annuitant's
coverage under the basic program of group health benefits
shall be the responsibility of the annuitant.
(a-2) Beginning January 1, 1998, for each person who
becomes a new SERS survivor and participates in the basic
program of group health benefits, the State shall contribute
toward the cost of the survivor's coverage under the basic
program of group health benefits an amount equal to 5% of
that cost for each full year of the deceased employee's or
deceased annuitant's creditable service in the State
Employees' Retirement System of Illinois on the date of
death, up to a maximum of 100% for a survivor of an employee
or annuitant with 20 or more years of creditable service.
The remainder of the cost of the new SERS survivor's coverage
under the basic program of group health benefits shall be the
responsibility of the survivor.
(a-3) Beginning January 1, 1998, for each person who
becomes a new SURS annuitant and participates in the basic
program of group health benefits, the State shall contribute
toward the cost of the annuitant's coverage under the basic
program of group health benefits an amount equal to 5% of
that cost for each full year of creditable service upon which
the annuitant's retirement annuity is based, up to a maximum
of 100% for an annuitant with 20 or more years of creditable
service. The remainder of the cost of a new SURS annuitant's
coverage under the basic program of group health benefits
shall be the responsibility of the annuitant.
(a-4) Beginning January 1, 1998, for each person who
becomes a new SURS retired employee and participates in the
basic program of group health benefits, the State shall
contribute toward the cost of the retired employee's coverage
under the basic program of group health benefits an amount
equal to 5% of that cost for each full year that the retired
employee was an employee as defined in Section 3, up to a
maximum of 100% for a retired employee who was an employee
for 20 or more years. The remainder of the cost of a new
SURS retired employee's coverage under the basic program of
group health benefits shall be the responsibility of the
retired employee.
(a-5) Beginning January 1, 1998, for each person who
becomes a new SURS survivor and participates in the basic
program of group health benefits, the State shall contribute
toward the cost of the survivor's coverage under the basic
program of group health benefits an amount equal to 5% of
that cost for each full year of the deceased employee's or
deceased annuitant's creditable service in the State
Universities Retirement System on the date of death, up to a
maximum of 100% for a survivor of an employee or annuitant
with 20 or more years of creditable service. The remainder
of the cost of the new SURS survivor's coverage under the
basic program of group health benefits shall be the
responsibility of the survivor.
(a-6) Beginning July 1, 1998, for each person who
becomes a new TRS State annuitant and participates in the
basic program of group health benefits, the State shall
contribute toward the cost of the annuitant's coverage under
the basic program of group health benefits an amount equal to
5% of that cost for each full year of creditable service as a
teacher as defined in paragraph (2), (3), or (5) of Section
16-106 of the Illinois Pension Code upon which the
annuitant's retirement annuity is based, up to a maximum of
100% for an annuitant with 20 or more years of such
creditable service. The remainder of the cost of a new TRS
State annuitant's coverage under the basic program of group
health benefits shall be the responsibility of the annuitant.
(a-7) Beginning July 1, 1998, for each person who
becomes a new TRS State survivor and participates in the
basic program of group health benefits, the State shall
contribute toward the cost of the survivor's coverage under
the basic program of group health benefits an amount equal to
5% of that cost for each full year of the deceased employee's
or deceased annuitant's creditable service as a teacher as
defined in paragraph (2), (3), or (5) of Section 16-106 of
the Illinois Pension Code on the date of death, up to a
maximum of 100% for a survivor of an employee or annuitant
with 20 or more years of such creditable service. The
remainder of the cost of the new TRS State survivor's
coverage under the basic program of group health benefits
shall be the responsibility of the survivor.
(a-8) A new SERS annuitant, new SERS survivor, new SURS
annuitant, new SURS retired employee, new SURS survivor, new
TRS State annuitant, or new TRS State survivor may waive or
terminate coverage in the program of group health benefits.
Any such annuitant, survivor, or retired employee who has
waived or terminated coverage may enroll or re-enroll in the
program of group health benefits only during the annual
benefit choice period, as determined by the Director; except
that in the event of termination of coverage due to
nonpayment of premiums, the annuitant, survivor, or retired
employee may not re-enroll in the program.
(a-9) No later than May 1 of each calendar year, the
Director of Central Management Services shall certify in
writing to the Executive Secretary of the State Employees'
Retirement System of Illinois the amounts of the Medicare
supplement health care premiums and the amounts of the health
care premiums for all other retirees who are not Medicare
eligible.
A separate calculation of the premiums based upon the
actual cost of each health care plan shall be so certified.
The Director of Central Management Services shall provide
to the Executive Secretary of the State Employees' Retirement
System of Illinois such information, statistics, and other
data as he or she may require to review the premium amounts
certified by the Director of Central Management Services.
(b) State employees who become eligible for this program
on or after January 1, 1980 in positions normally requiring
actual performance of duty not less than 1/2 of a normal work
period but not equal to that of a normal work period, shall
be given the option of participating in the available
program. If the employee elects coverage, the State shall
contribute on behalf of such employee to the cost of the
employee's benefit and any applicable dependent supplement,
that sum which bears the same percentage as that percentage
of time the employee regularly works when compared to normal
work period.
(c) The basic non-contributory coverage from the basic
program of group health benefits shall be continued for each
employee not in pay status or on active service by reason of
(1) leave of absence due to illness or injury, (2) authorized
educational leave of absence or sabbatical leave, or (3)
military leave with pay and benefits. This coverage shall
continue until expiration of authorized leave and return to
active service, but not to exceed 24 months for leaves under
item (1) or (2). This 24-month limitation and the requirement
of returning to active service shall not apply to persons
receiving ordinary or accidental disability benefits or
retirement benefits through the appropriate State retirement
system or benefits under the Workers' Compensation or
Occupational Disease Act.
(d) The basic group life insurance coverage shall
continue, with full State contribution, where such person is
(1) absent from active service by reason of disability
arising from any cause other than self-inflicted, (2) on
authorized educational leave of absence or sabbatical leave,
or (3) on military leave with pay and benefits.
(e) Where the person is in non-pay status for a period
in excess of 30 days or on leave of absence, other than by
reason of disability, educational or sabbatical leave, or
military leave with pay and benefits, such person may
continue coverage only by making personal payment equal to
the amount normally contributed by the State on such person's
behalf. Such payments and coverage may be continued: (1)
until such time as the person returns to a status eligible
for coverage at State expense, but not to exceed 24 months,
(2) until such person's employment or annuitant status with
the State is terminated, or (3) for a maximum period of 4
years for members on military leave with pay and benefits and
military leave without pay and benefits (exclusive of any
additional service imposed pursuant to law).
(f) The Department shall establish by rule the extent
to which other employee benefits will continue for persons in
non-pay status or who are not in active service.
(g) The State shall not pay the cost of the basic
non-contributory group life insurance, program of health
benefits and other employee benefits for members who are
survivors as defined by paragraphs (1) and (2) of subsection
(q) of Section 3 of this Act. The costs of benefits for
these survivors shall be paid by the survivors or by the
University of Illinois Cooperative Extension Service, or any
combination thereof. However, the State shall pay the amount
of the reduction in the cost of participation, if any,
resulting from the amendment to subsection (a) made by this
amendatory Act of the 91st General Assembly.
(h) Those persons occupying positions with any
department as a result of emergency appointments pursuant to
Section 8b.8 of the Personnel Code who are not considered
employees under this Act shall be given the option of
participating in the programs of group life insurance, health
benefits and other employee benefits. Such persons electing
coverage may participate only by making payment equal to the
amount normally contributed by the State for similarly
situated employees. Such amounts shall be determined by the
Director. Such payments and coverage may be continued until
such time as the person becomes an employee pursuant to this
Act or such person's appointment is terminated.
(i) Any unit of local government within the State of
Illinois may apply to the Director to have its employees,
annuitants, and their dependents provided group health
coverage under this Act on a non-insured basis. To
participate, a unit of local government must agree to enroll
all of its employees, who may select coverage under either
the State group health insurance plan or a health maintenance
organization that has contracted with the State to be
available as a health care provider for employees as defined
in this Act. A unit of local government must remit the
entire cost of providing coverage under the State group
health insurance plan or, for coverage under a health
maintenance organization, an amount determined by the
Director based on an analysis of the sex, age, geographic
location, or other relevant demographic variables for its
employees, except that the unit of local government shall not
be required to enroll those of its employees who are covered
spouses or dependents under this plan or another group policy
or plan providing health benefits as long as (1) an
appropriate official from the unit of local government
attests that each employee not enrolled is a covered spouse
or dependent under this plan or another group policy or plan,
and (2) at least 85% of the employees are enrolled and the
unit of local government remits the entire cost of providing
coverage to those employees. Employees of a participating
unit of local government who are not enrolled due to coverage
under another group health policy or plan may enroll at a
later date subject to submission of satisfactory evidence of
insurability and provided that no benefits shall be payable
for services incurred during the first 6 months of coverage
to the extent the services are in connection with any
pre-existing condition. A participating unit of local
government may also elect to cover its annuitants. Dependent
coverage shall be offered on an optional basis, with the
costs paid by the unit of local government, its employees, or
some combination of the two as determined by the unit of
local government. The unit of local government shall be
responsible for timely collection and transmission of
dependent premiums.
The Director shall annually determine monthly rates of
payment, subject to the following constraints:
(1) In the first year of coverage, the rates shall
be equal to the amount normally charged to State
employees for elected optional coverages or for enrolled
dependents coverages or other contributory coverages, or
contributed by the State for basic insurance coverages on
behalf of its employees, adjusted for differences between
State employees and employees of the local government in
age, sex, geographic location or other relevant
demographic variables, plus an amount sufficient to pay
for the additional administrative costs of providing
coverage to employees of the unit of local government and
their dependents.
(2) In subsequent years, a further adjustment shall
be made to reflect the actual prior years' claims
experience of the employees of the unit of local
government.
In the case of coverage of local government employees
under a health maintenance organization, the Director shall
annually determine for each participating unit of local
government the maximum monthly amount the unit may contribute
toward that coverage, based on an analysis of (i) the age,
sex, geographic location, and other relevant demographic
variables of the unit's employees and (ii) the cost to cover
those employees under the State group health insurance plan.
The Director may similarly determine the maximum monthly
amount each unit of local government may contribute toward
coverage of its employees' dependents under a health
maintenance organization.
Monthly payments by the unit of local government or its
employees for group health insurance or health maintenance
organization coverage shall be deposited in the Local
Government Health Insurance Reserve Fund. The Local
Government Health Insurance Reserve Fund shall be a
continuing fund not subject to fiscal year limitations. All
expenditures from this fund shall be used for payments for
health care benefits for local government and rehabilitation
facility employees, annuitants, and dependents, and to
reimburse the Department or its administrative service
organization for all expenses incurred in the administration
of benefits. No other State funds may be used for these
purposes.
A local government employer's participation or desire to
participate in a program created under this subsection shall
not limit that employer's duty to bargain with the
representative of any collective bargaining unit of its
employees.
(j) Any rehabilitation facility within the State of
Illinois may apply to the Director to have its employees,
annuitants, and their dependents provided group health
coverage under this Act on a non-insured basis. To
participate, a rehabilitation facility must agree to enroll
all of its employees and remit the entire cost of providing
such coverage for its employees, except that the
rehabilitation facility shall not be required to enroll those
of its employees who are covered spouses or dependents under
this plan or another group policy or plan providing health
benefits as long as (1) an appropriate official from the
rehabilitation facility attests that each employee not
enrolled is a covered spouse or dependent under this plan or
another group policy or plan, and (2) at least 85% of the
employees are enrolled and the rehabilitation facility remits
the entire cost of providing coverage to those employees.
Employees of a participating rehabilitation facility who are
not enrolled due to coverage under another group health
policy or plan may enroll at a later date subject to
submission of satisfactory evidence of insurability and
provided that no benefits shall be payable for services
incurred during the first 6 months of coverage to the extent
the services are in connection with any pre-existing
condition. A participating rehabilitation facility may also
elect to cover its annuitants. Dependent coverage shall be
offered on an optional basis, with the costs paid by the
rehabilitation facility, its employees, or some combination
of the 2 as determined by the rehabilitation facility. The
rehabilitation facility shall be responsible for timely
collection and transmission of dependent premiums.
The Director shall annually determine quarterly rates of
payment, subject to the following constraints:
(1) In the first year of coverage, the rates shall
be equal to the amount normally charged to State
employees for elected optional coverages or for enrolled
dependents coverages or other contributory coverages on
behalf of its employees, adjusted for differences between
State employees and employees of the rehabilitation
facility in age, sex, geographic location or other
relevant demographic variables, plus an amount sufficient
to pay for the additional administrative costs of
providing coverage to employees of the rehabilitation
facility and their dependents.
(2) In subsequent years, a further adjustment shall
be made to reflect the actual prior years' claims
experience of the employees of the rehabilitation
facility.
Monthly payments by the rehabilitation facility or its
employees for group health insurance shall be deposited in
the Local Government Health Insurance Reserve Fund.
(k) Any domestic violence shelter or service within the
State of Illinois may apply to the Director to have its
employees, annuitants, and their dependents provided group
health coverage under this Act on a non-insured basis. To
participate, a domestic violence shelter or service must
agree to enroll all of its employees and pay the entire cost
of providing such coverage for its employees. A
participating domestic violence shelter may also elect to
cover its annuitants. Dependent coverage shall be offered on
an optional basis, with employees, or some combination of the
2 as determined by the domestic violence shelter or service.
The domestic violence shelter or service shall be responsible
for timely collection and transmission of dependent premiums.
The Director shall annually determine quarterly rates of
payment, subject to the following constraints:
(1) In the first year of coverage, the rates shall
be equal to the amount normally charged to State
employees for elected optional coverages or for enrolled
dependents coverages or other contributory coverages on
behalf of its employees, adjusted for differences between
State employees and employees of the domestic violence
shelter or service in age, sex, geographic location or
other relevant demographic variables, plus an amount
sufficient to pay for the additional administrative costs
of providing coverage to employees of the domestic
violence shelter or service and their dependents.
(2) In subsequent years, a further adjustment shall
be made to reflect the actual prior years' claims
experience of the employees of the domestic violence
shelter or service.
(3) In no case shall the rate be less than the
amount normally charged to State employees or contributed
by the State on behalf of its employees.
Monthly payments by the domestic violence shelter or
service or its employees for group health insurance shall be
deposited in the Local Government Health Insurance Reserve
Fund.
(l) A public community college or entity organized
pursuant to the Public Community College Act may apply to the
Director initially to have only annuitants not covered prior
to July 1, 1992 by the district's health plan provided health
coverage under this Act on a non-insured basis. The
community college must execute a 2-year contract to
participate in the Local Government Health Plan. Those
annuitants enrolled initially under this contract shall have
no benefits payable for services incurred during the first 6
months of coverage to the extent the services are in
connection with any pre-existing condition. Any annuitant
who may enroll after this initial enrollment period shall be
subject to submission of satisfactory evidence of
insurability and to the pre-existing conditions limitation.
The Director shall annually determine monthly rates of
payment subject to the following constraints: for those
community colleges with annuitants only enrolled, first year
rates shall be equal to the average cost to cover claims for
a State member adjusted for demographics, Medicare
participation, and other factors; and in the second year, a
further adjustment of rates shall be made to reflect the
actual first year's claims experience of the covered
annuitants.
(m) The Director shall adopt any rules deemed necessary
for implementation of this amendatory Act of 1989 (Public Act
86-978).
(Source: P.A. 89-53, eff. 7-1-95; 89-236, eff. 8-4-95;
89-324, eff. 8-13-95; 89-626, eff. 8-9-96; 90-65, eff.
7-7-97; 90-582, eff. 5-27-98; 90-655, eff. 7-30-98; revised
8-3-98.)
Section 205. The State Mandates Act is amended by adding
Section 8.23 as follows:
(30 ILCS 805/8.23 new)
Sec. 8.23. Exempt mandate. Notwithstanding Sections 6
and 8 of this Act, no reimbursement by the State is required
for the implementation of any mandate created by this
amendatory Act of the 91st General Assembly.
Section 210. The Counties Code is amended by adding
Section 5-1069.8 as follows:
(55 ILCS 5/5-1069.8 new)
Sec. 5-1069.8. Managed Care Reform and Patient Rights
Act. All counties, including home rule counties, are subject
to the provisions of the Managed Care Reform and Patient
Rights Act. The requirement under this Section that health
care benefits provided by counties comply with the Managed
Care Reform and Patient Rights Act is an exclusive power and
function of the State and is a denial and limitation of home
rule county powers under Article VII, Section 6, subsection
(h) of the Illinois Constitution.
Section 215. The Illinois Municipal Code is amended by
adding Section 10-4-2.8 as follows:
(65 ILCS 5/10-4-2.8 new)
Sec. 10-4-2.8. Managed Care Reform and Patient Rights
Act. The corporate authorities of all municipalities are
subject to the provisions of the Managed Care Reform and
Patient Rights Act. The requirement under this Section that
health care benefits provided by municipalities comply with
the Managed Care Reform and Patient Rights Act is an
exclusive power and function of the State and is a denial and
limitation of home rule municipality powers under Article
VII, Section 6, subsection (h) of the Illinois Constitution.
Section 220. The Illinois Insurance Code is amended by
changing Section 370g and adding Sections 155.36, 370s, and
511.118 as follows:
(215 ILCS 5/155.36 new)
Sec. 155.36. Managed Care Reform and Patient Rights Act.
Insurance companies that transact the kinds of insurance
authorized under Class 1(b) or Class 2(a) of Section 4 of
this Code shall comply with Section 85 and the definition of
the term "emergency medical condition" in Section 10 of the
Managed Care Reform and Patient Rights Act.
(215 ILCS 5/370g) (from Ch. 73, par. 982g)
Sec. 370g. Definitions. As used in this Article, the
following definitions apply:
(a) "Health care services" means health care services or
products rendered or sold by a provider within the scope of
the provider's license or legal authorization. The term
includes, but is not limited to, hospital, medical, surgical,
dental, vision and pharmaceutical services or products.
(b) "Insurer" means an insurance company or a health
service corporation authorized in this State to issue
policies or subscriber contracts which reimburse for expenses
of health care services.
(c) "Insured" means an individual entitled to
reimbursement for expenses of health care services under a
policy or subscriber contract issued or administered by an
insurer.
(d) "Provider" means an individual or entity duly
licensed or legally authorized to provide health care
services.
(e) "Noninstitutional provider" means any person
licensed under the Medical Practice Act of 1987, as now or
hereafter amended.
(f) "Beneficiary" means an individual entitled to
reimbursement for expenses of or the discount of provider
fees for health care services under a program where the
beneficiary has an incentive to utilize the services of a
provider which has entered into an agreement or arrangement
with an administrator.
(g) "Administrator" means any person, partnership or
corporation, other than an insurer or health maintenance
organization holding a certificate of authority under the
"Health Maintenance Organization Act", as now or hereafter
amended, that arranges, contracts with, or administers
contracts with a provider whereby beneficiaries are provided
an incentive to use the services of such provider.
(h) "Emergency medical condition" means a medical
condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate
medical attention to result in:
(1) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or
her unborn child) in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or
part. "Emergency" means an accidental bodily injury or
emergency medical condition which reasonably requires the
beneficiary or insured to seek immediate medical care
under circumstances or at locations which reasonably
preclude the beneficiary or insured from obtaining needed
medical care from a preferred provider.
(Source: P.A. 88-400.)
(215 ILCS 5/370s new)
Sec. 370s. Managed Care Reform and Patient Rights Act.
All administrators shall comply with Sections 55 and 85 of
the Managed Care Reform and Patient Rights Act.
(215 ILCS 5/511.118 new)
Sec. 511.118. Managed Care Reform and Patient Rights
Act. All administrators are subject to the provisions of
Sections 55 and 85 of the Managed Care Reform and Patient
Rights Act.
Section 225. The Comprehensive Health Insurance Plan Act
is amended by adding Section 8.6 as follows:
(215 ILCS 105/8.6 new)
Sec. 8.6. Managed Care Reform and Patient Rights Act.
The plan is subject to the provisions of the Managed Care
Reform and Patient Rights Act.
Section 230. The Health Care Purchasing Group Act is
amended by changing Sections 15 and 20 as follows:
(215 ILCS 123/15)
Sec. 15. Health care purchasing groups; membership;
formation.
(a) An HPG may be an organization formed by 2 or more
employers with no more than 500 covered employees each 2,500
covered individuals, an HPG sponsor or a risk-bearer for
purposes of contracting for health insurance under this Act
to cover employees and dependents of HPG members. An HPG
shall not be prevented from supplementing health insurance
coverage purchased under this Act by contracting for services
from entities licensed and authorized in Illinois to provide
those services under the Dental Service Plan Act, the Limited
Health Service Organization Act, or Voluntary Health Services
Plans Act. An HPG may be a separate legal entity or simply a
group of 2 or more employers with no more than 500 covered
employees each 2,500 covered individuals aggregated under
this Act by an HPG sponsor or risk-bearer for insurance
purposes. There shall be no limit as to the number of HPGs
that may operate in any geographic area of the State. No
insurance risk may be borne or retained by the HPG. All
health insurance contracts issued to the HPG must be
delivered or issued for delivery in Illinois.
(b) Members of an HPG must be Illinois domiciled
employers, except that an employer domiciled elsewhere may
become a member of an Illinois HPG for the sole purpose of
insuring its employees whose place of employment is located
within this State. HPG membership may include employers
having no more than 500 covered employees each 2,500 covered
individuals.
(c) If an HPG is formed by any 2 or more employers with
no more than 500 covered employees each 2,500 covered
individuals, it is authorized to negotiate, solicit, market,
obtain proposals for, and enter into group or master health
insurance contracts on behalf of its members and their
employees and employee dependents so long as it meets all of
the following requirements:
(1) The HPG must be an organization having the
legal capacity to contract and having its legal situs in
Illinois.
(2) The principal persons responsible for the
conduct of the HPG must perform their HPG related
functions in Illinois.
(3) No HPG may collect premium in its name or hold
or manage premium or claim fund accounts unless duly
licensed and qualified as a managing general agent
pursuant to Section 141a of the Illinois Insurance Code
or a third party administrator pursuant to Section
511.105 of the Illinois Insurance Code.
(4) If the HPG gives an offer, application, notice,
or proposal of insurance to an employer, it must disclose
to that employer the total cost of the insurance. Dues,
fees, or charges to be paid to the HPG, HPG sponsor, or
any other entity as a condition to purchasing the
insurance must be itemized. The HPG shall also disclose
to its members the amount of any dividends, experience
refunds, or other such payments it receives from the
risk-bearer.
(5) An HPG must register with the Director before
entering into a group or master health insurance contract
on behalf of its members and must renew the registration
annually on forms and at times prescribed by the Director
in rules specifying, at minimum, (i) the identity of the
officers and directors, trustees, or attorney-in-fact of
the HPG; (ii) a certification that those persons have not
been convicted of any felony offense involving a breach
of fiduciary duty or improper manipulation of accounts;
and (iii) the number of employer members then enrolled in
the HPG, together with any other information that may be
needed to carry out the purposes of this Act.
(6) At the time of initial registration and each
renewal thereof an HPG shall pay a fee of $100 to the
Director.
(d) If an HPG is formed by an HPG sponsor or risk-bearer
and the HPG performs no marketing, negotiation, solicitation,
or proposing of insurance to HPG members, exclusive of
ministerial acts performed by individual employers to service
their own employees, then a group or master health insurance
contract may be issued in the name of the HPG and held by an
HPG sponsor, risk-bearer, or designated employer member
within the State. In these cases the HPG requirements
specified in subsection (c) shall not be applicable, however:
(1) the group or master health insurance contract
must contain a provision permitting the contract to be
enforced through legal action initiated by any employer
member or by an employee of an HPG member who has paid
premium for the coverage provided;
(2) the group or master health insurance contract
must be available for inspection and copying by any HPG
member, employee, or insured dependent at a designated
location within the State at all normal business hours;
and
(3) any information concerning HPG membership
required by rule under item (5) of subsection (c) must be
provided by the HPG sponsor in its registration and
renewal forms or by the risk-bearer in its annual
reports.
(Source: P.A. 90-337, eff. 1-1-98; 90-655, eff. 7-30-98.)
(215 ILCS 123/20)
Sec. 20. HPG sponsors. Except as provided by Sections 15
and 25 of this Act, only a corporation authorized by the
Secretary of State to transact business in Illinois may
sponsor one or more HPGs with no more than 100,000 10,000
covered individuals by negotiating, soliciting, or servicing
health insurance contracts for HPGs and their members. Such a
corporation may assert and maintain authority to act as an
HPG sponsor by complying with all of the following
requirements:
(1) The principal officers and directors
responsible for the conduct of the HPG sponsor must
perform their HPG sponsor related functions in Illinois.
(2) No insurance risk may be borne or retained by
the HPG sponsor; all health insurance contracts issued to
HPGs through the HPG sponsor must be delivered in
Illinois.
(3) No HPG sponsor may collect premium in its name
or hold or manage premium or claim fund accounts unless
duly qualified and licensed as a managing general agent
pursuant to Section 141a of the Illinois Insurance Code
or as a third party administrator pursuant to Section
511.105 of the Illinois Insurance Code.
(4) If the HPG gives an offer, application, notice,
or proposal of insurance to an employer, it must disclose
the total cost of the insurance. Dues, fees, or charges
to be paid to the HPG, HPG sponsor, or any other entity
as a condition to purchasing the insurance must be
itemized. The HPG shall also disclose to its members the
amount of any dividends, experience refunds, or other
such payments it receives from the risk-bearer.
(5) An HPG sponsor must register with the Director
before negotiating or soliciting any group or master
health insurance contract for any HPG and must renew the
registration annually on forms and at times prescribed by
the Director in rules specifying, at minimum, (i) the
identity of the officers and directors of the HPG sponsor
corporation; (ii) a certification that those persons have
not been convicted of any felony offense involving a
breach of fiduciary duty or improper manipulation of
accounts; (iii) the number of employer members then
enrolled in each HPG sponsored; (iv) the date on which
each HPG was issued a group or master health insurance
contract, if any; and (v) the date on which each such
contract, if any, was terminated.
(6) At the time of initial registration and each
renewal thereof an HPG sponsor shall pay a fee of $100 to
the Director.
(Source: P.A. 90-337, eff. 1-1-98.)
Section 235. The Health Maintenance Organization Act is
amended by changing Sections 2-2 and 6-7 and adding Section
5-3.6 as follows:
(215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404)
Sec. 2-2. Determination by Director; Health Maintenance
Advisory Board.
(a) Upon receipt of an application for issuance of a
certificate of authority, the Director shall transmit copies
of such application and accompanying documents to the
Director of the Illinois Department of Public Health. The
Director of the Department of Public Health shall then
determine whether the applicant for certificate of authority,
with respect to health care services to be furnished: (1) has
demonstrated the willingness and potential ability to assure
that such health care service will be provided in a manner to
insure both availability and accessibility of adequate
personnel and facilities and in a manner enhancing
availability, accessibility, and continuity of service; and
(2) has arrangements, established in accordance with
regulations promulgated by the Department of Public Health
for an ongoing quality of health care assurance program
concerning health care processes and outcomes. Upon
investigation, the Director of the Department of Public
Health shall certify to the Director whether the proposed
Health Maintenance Organization meets the requirements of
this subsection (a). If the Director of the Department of
Public Health certifies that the Health Maintenance
Organization does not meet such requirements, he shall
specify in what respect it is deficient.
There is created in the Department of Public Health a
Health Maintenance Advisory Board composed of 11 members.
Nine 9 members shall who have practiced in the health field,
4 of which shall have been or are currently affiliated with a
Health Maintenance Organization. Two of the members shall be
members of the general public, one of whom is over 50 years
of age. Each member shall be appointed by the Director of
the Department of Public Health and serve at the pleasure of
that Director and shall receive no compensation for services
rendered other than reimbursement for expenses. Six Five
members of the Board shall constitute a quorum. A vacancy in
the membership of the Advisory Board shall not impair the
right of a quorum to exercise all rights and perform all
duties of the Board. The Health Maintenance Advisory Board
has the power to review and comment on proposed rules and
regulations to be promulgated by the Director of the
Department of Public Health within 30 days after those
proposed rules and regulations have been submitted to the
Advisory Board.
(b) Issuance of a certificate of authority shall be
granted if the following conditions are met:
(1) the requirements of subsection (c) of Section
2-1 have been fulfilled;
(2) the persons responsible for the conduct of the
affairs of the applicant are competent, trustworthy, and
possess good reputations, and have had appropriate
experience, training or education;
(3) the Director of the Department of Public Health
certifies that the Health Maintenance Organization's
proposed plan of operation meets the requirements of this
Act;
(4) the Health Care Plan furnishes basic health
care services on a prepaid basis, through insurance or
otherwise, except to the extent of reasonable
requirements for co-payments or deductibles as authorized
by this Act;
(5) the Health Maintenance Organization is
financially responsible and may reasonably be expected to
meet its obligations to enrollees and prospective
enrollees; in making this determination, the Director
shall consider:
(A) the financial soundness of the applicant's
arrangements for health services and the minimum
standard rates, co-payments and other patient
charges used in connection therewith;
(B) the adequacy of working capital, other
sources of funding, and provisions for
contingencies; and
(C) that no certificate of authority shall be
issued if the initial minimum net worth of the
applicant is less than $2,000,000. The initial net
worth shall be provided in cash and securities in
combination and form acceptable to the Director;
(6) the agreements with providers for the provision
of health services contain the provisions required by
Section 2-8 of this Act; and
(7) any deficiencies identified by the Director
have been corrected.
(Source: P.A. 86-620; 86-1475.)
(215 ILCS 125/5-3.6 new)
Sec. 5-3.6. Managed Care Reform and Patient Rights Act.
Health maintenance organizations are subject to the
provisions of the Managed Care Reform and Patient Rights Act.
(215 ILCS 125/6-7) (from Ch. 111 1/2, par. 1418.7)
Sec. 6-7. Board of Directors. The board of directors of
the Association consists of not less than 7 5 nor more than
11 9 members serving terms as established in the plan of
operation. The members of the board are to be selected by
member organizations subject to the approval of the Director,
except the Director shall name 2 members who are current
enrollees, one of whom is over 50 years of age. Vacancies on
the board must be filled for the remaining period of the term
in the manner described in the plan of operation. To select
the initial board of directors, and initially organize the
Association, the Director must give notice to all member
organizations of the time and place of the organizational
meeting. In determining voting rights at the organizational
meeting each member organization is entitled to one vote in
person or by proxy. If the board of directors is not
selected at the organizational meeting, the Director may
appoint the initial members.
In approving selections or in appointing members to the
board, the Director must consider, whether all member
organizations are fairly represented.
Members of the board may be reimbursed from the assets of
the Association for expenses incurred by them as members of
the board of directors but members of the board may not
otherwise be compensated by the Association for their
services.
(Source: P.A. 85-20.)
Section 240. The Limited Health Service Organization Act
is amended by adding Section 4002.6 as follows:
(215 ILCS 130/4002.6 new)
Sec. 4002.6. Managed Care Reform and Patient Rights Act.
Except for health care plans offering only dental services or
only vision services, limited health service organizations
are subject to the provisions of the Managed Care Reform and
Patient Rights Act.
Section 245. The Voluntary Health Services Plans Act is
amended by adding Section 15.30 as follows:
(215 ILCS 165/15.30 new)
Sec. 15.30. Managed Care Reform and Patient Rights Act.
A health service plan corporation is subject to the
provisions of the Managed Care Reform and Patient Rights Act.
Section 250. The Illinois Public Aid Code is amended by
adding Section 5-16.12 as follows:
(305 ILCS 5/5-16.12 new)
Sec. 5-16.12. Managed Care Reform and Patient Rights
Act. The medical assistance program and other programs
administered by the Department are subject to the provisions
of the Managed Care Reform and Patient Rights Act. The
Department may adopt rules to implement those provisions.
These rules shall require compliance with that Act in the
medical assistance managed care programs and other programs
administered by the Department. The medical assistance
fee-for-service program is not subject to the provisions of
the Managed Care Reform and Patient Rights Act.
Nothing in the Managed Care Reform and Patient Rights Act
shall be construed to mean that the Department is a health
care plan as defined in that Act simply because the
Department enters into contractual relationships with health
care plans.
Section 299. Effective date. This Section and Section
200 of this Act take effect upon becoming law; Sections 25
and 85 take effect July 1, 2000; and the remaining Sections
of this Act take effect January 1, 2000.
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