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| | 97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
HB1479 Introduced , by Rep. Mary E. Flowers SYNOPSIS AS INTRODUCED:
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Amends the Illinois Insurance Code to provide that accident and health insurance policies and managed care plans must provide coverage for intravenous feeding, prescription nutritional supplements, and hospital patient assessments.
Makes corresponding changes in the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Health Maintenance Organization Act, Voluntary Health Services Plans Act, and Illinois Public Aid Code. Amends the Emergency Medical Treatment Act to provide that every hospital licensed under the Hospital Licensing Act shall comply with the Hospital Emergency Service Act. Amends the Hospital Emergency Service Act to provide that every hospital required to be licensed by the Department of Public Health shall provide a hospital emergency service in accordance with rules and regulations adopted by the Department which shall be consistent with the federal Emergency Medical Treatment and Active Labor Act. Amends the Health Carrier External Review Act. Sets forth provisions concerning standard
information for application forms; medical underwriting; the requirement to send to the applicant a copy of the health care service plan contract along with a notice; rescission and cancellation; postcontract investigation; and continuation. Makes changes in the provision concerning standard external review.
Amends the Medical Patient Rights Act. Provides that each patient has a right to be informed of his or her inpatient or outpatient status. Provides that the statement of a hospital patient's rights shall include the right not to be discriminated against by the hospital and shall provide notice of how to initiate and lodge a grievance regarding improper discrimination. Sets forth provisions concerning discrimination grievance procedures and emergency room antidiscrimination notice.
Amends the State Mandates Act to require implementation without reimbursement by the State. Effective immediately.
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| | A BILL FOR |
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| | HB1479 | | LRB097 06668 RPM 46754 b |
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| 1 | | AN ACT concerning insurance.
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| 2 | | Be it enacted by the People of the State of Illinois,
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| 3 | | represented in the General Assembly:
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| 4 | | Section 5. The State Employees Group Insurance Act of 1971 |
| 5 | | is amended by
changing Section 6.11 as follows:
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| 6 | | (5 ILCS 375/6.11)
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| 7 | | Sec. 6.11. Required health benefits; Illinois Insurance |
| 8 | | Code
requirements. The program of health
benefits shall provide |
| 9 | | the post-mastectomy care benefits required to be covered
by a |
| 10 | | policy of accident and health insurance under Section 356t of |
| 11 | | the Illinois
Insurance Code. The program of health benefits |
| 12 | | shall provide the coverage
required under Sections 356g, |
| 13 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
| 14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
| 15 | | 356z.14, 356z.15, and 356z.17, 356z.19, 356z.20, and 356z.21 of |
| 16 | | the
Illinois Insurance Code.
The program of health benefits |
| 17 | | must comply with Section 155.37 of the
Illinois Insurance Code.
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| 18 | | Rulemaking authority to implement Public Act 95-1045, if |
| 19 | | any, is conditioned on the rules being adopted in accordance |
| 20 | | with all provisions of the Illinois Administrative Procedure |
| 21 | | Act and all rules and procedures of the Joint Committee on |
| 22 | | Administrative Rules; any purported rule not so adopted, for |
| 23 | | whatever reason, is unauthorized. |
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| 1 | | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
| 2 | | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
| 3 | | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, |
| 4 | | eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
| 5 | | 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; |
| 6 | | 96-1000, eff. 7-2-10.)
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| 7 | | Section 10. The Counties Code is amended by changing |
| 8 | | Section 5-1069.3 as
follows:
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| 9 | | (55 ILCS 5/5-1069.3)
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| 10 | | Sec. 5-1069.3. Required health benefits. If a county, |
| 11 | | including a home
rule
county, is a self-insurer for purposes of |
| 12 | | providing health insurance coverage
for its employees, the |
| 13 | | coverage shall include coverage for the post-mastectomy
care |
| 14 | | benefits required to be covered by a policy of accident and |
| 15 | | health
insurance under Section 356t and the coverage required |
| 16 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
| 17 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
| 18 | | 356z.14, and 356z.15, 356z.19, 356z.20, and 356z.21 of
the |
| 19 | | Illinois Insurance Code. The requirement that health benefits |
| 20 | | be covered
as provided in this Section is an
exclusive power |
| 21 | | and function of the State and is a denial and limitation under
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| 22 | | Article VII, Section 6, subsection (h) of the Illinois |
| 23 | | Constitution. A home
rule county to which this Section applies |
| 24 | | must comply with every provision of
this Section.
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| 1 | | Rulemaking authority to implement Public Act 95-1045, if |
| 2 | | any, is conditioned on the rules being adopted in accordance |
| 3 | | with all provisions of the Illinois Administrative Procedure |
| 4 | | Act and all rules and procedures of the Joint Committee on |
| 5 | | Administrative Rules; any purported rule not so adopted, for |
| 6 | | whatever reason, is unauthorized. |
| 7 | | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
| 8 | | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
| 9 | | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
| 10 | | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
| 11 | | 96-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
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| 12 | | Section 15. The Illinois Municipal Code is amended by |
| 13 | | changing Section
10-4-2.3 as follows:
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| 14 | | (65 ILCS 5/10-4-2.3)
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| 15 | | Sec. 10-4-2.3. Required health benefits. If a |
| 16 | | municipality, including a
home rule municipality, is a |
| 17 | | self-insurer for purposes of providing health
insurance |
| 18 | | coverage for its employees, the coverage shall include coverage |
| 19 | | for
the post-mastectomy care benefits required to be covered by |
| 20 | | a policy of
accident and health insurance under Section 356t |
| 21 | | and the coverage required
under Sections 356g, 356g.5, |
| 22 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
| 23 | | 356z.11, 356z.12, 356z.13, 356z.14, and 356z.15 356z.19, |
| 24 | | 356z.20, and 356z.21 of the Illinois
Insurance
Code. The |
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| 1 | | requirement that health
benefits be covered as provided in this |
| 2 | | is an exclusive power and function of
the State and is a denial |
| 3 | | and limitation under Article VII, Section 6,
subsection (h) of |
| 4 | | the Illinois Constitution. A home rule municipality to which
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| 5 | | this Section applies must comply with every provision of this |
| 6 | | Section.
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| 7 | | Rulemaking authority to implement Public Act 95-1045, if |
| 8 | | any, is conditioned on the rules being adopted in accordance |
| 9 | | with all provisions of the Illinois Administrative Procedure |
| 10 | | Act and all rules and procedures of the Joint Committee on |
| 11 | | Administrative Rules; any purported rule not so adopted, for |
| 12 | | whatever reason, is unauthorized. |
| 13 | | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
| 14 | | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
| 15 | | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
| 16 | | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
| 17 | | 96-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
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| 18 | | Section 20. The School Code is amended by changing Section |
| 19 | | 10-22.3f as
follows:
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| 20 | | (105 ILCS 5/10-22.3f)
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| 21 | | Sec. 10-22.3f. Required health benefits. Insurance |
| 22 | | protection and
benefits
for employees shall provide the |
| 23 | | post-mastectomy care benefits required to be
covered by a |
| 24 | | policy of accident and health insurance under Section 356t and |
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| 1 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
| 2 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
| 3 | | 356z.13, 356z.14, and 356z.15, 356z.19, and 356z.20 of
the
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| 4 | | Illinois Insurance Code.
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| 5 | | Rulemaking authority to implement Public Act 95-1045, if |
| 6 | | any, is conditioned on the rules being adopted in accordance |
| 7 | | with all provisions of the Illinois Administrative Procedure |
| 8 | | Act and all rules and procedures of the Joint Committee on |
| 9 | | Administrative Rules; any purported rule not so adopted, for |
| 10 | | whatever reason, is unauthorized. |
| 11 | | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
| 12 | | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
| 13 | | 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
| 14 | | 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-1000, |
| 15 | | eff. 7-2-10.)
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| 16 | | Section 25. The Emergency Medical Treatment Act is amended |
| 17 | | by changing Section 1 as follows:
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| 18 | | (210 ILCS 70/1) (from Ch. 111 1/2, par. 6151)
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| 19 | | Sec. 1.
No hospital, physician, dentist or other provider |
| 20 | | of professional
health care licensed under the laws of this |
| 21 | | State may refuse to provide
needed emergency treatment to any |
| 22 | | person whose life would be threatened
in the absence of such |
| 23 | | treatment, because of that person's inability to
pay therefor, |
| 24 | | nor because of the source of any payment promised therefor. |
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| 1 | | Every hospital licensed under the Hospital Licensing Act shall |
| 2 | | comply with the Hospital Emergency Service Act.
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| 3 | | (Source: P.A. 83-723.)
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| 4 | | Section 30. The Hospital Emergency Service Act is amended |
| 5 | | by changing Section 1 as follows:
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| 6 | | (210 ILCS 80/1) (from Ch. 111 1/2, par. 86)
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| 7 | | Sec. 1.
Every hospital required to be licensed by the |
| 8 | | Department of Public
Health pursuant to the Hospital Licensing |
| 9 | | Act which provides general medical
and surgical
hospital |
| 10 | | services shall provide a hospital emergency service in |
| 11 | | accordance
with rules and regulations adopted by the Department |
| 12 | | of Public Health which shall be consistent with the federal |
| 13 | | Emergency Medical Treatment and Active Labor Act (42 U.S.C. |
| 14 | | 1395dd) and
shall furnish such hospital emergency services to |
| 15 | | any applicant who applies
for the same in case of injury or |
| 16 | | acute medical condition where the same is
liable to cause death |
| 17 | | or severe injury or serious illness.
For purposes of this Act, |
| 18 | | "applicant" includes any person who is brought
to a hospital by |
| 19 | | ambulance or specialized emergency medical services
vehicle as |
| 20 | | defined in the Emergency Medical Services (EMS) Systems Act.
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| 21 | | (Source: P.A. 86-1461.)
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| 22 | | Section 35. The Illinois Insurance Code is amended by |
| 23 | | adding Sections
356z.19, 356z.20, and
356z.21
as
follows:
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| 1 | | (215 ILCS 5/356z.19 new)
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| 2 | | Sec. 356z.19. Intravenous feeding. A group or individual |
| 3 | | policy of
accident and health insurance or managed care plan |
| 4 | | amended, delivered, issued,
or renewed after the effective date |
| 5 | | of this amendatory Act of the 97th General
Assembly must |
| 6 | | provide coverage for intravenous feeding. The benefits under
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| 7 | | this Section shall be at least as favorable as for other |
| 8 | | coverages under the
policy and may be subject to the same |
| 9 | | dollar amount limits, deductibles, and
co-insurance |
| 10 | | requirements applicable generally to other coverages under the
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| 11 | | policy.
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| 12 | | (215 ILCS 5/356z.20 new)
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| 13 | | Sec. 356z.20. Prescription nutritional supplements. A |
| 14 | | group or individual
policy of
accident and health insurance or |
| 15 | | managed care plan amended, delivered, issued,
or renewed
after |
| 16 | | the effective date of this amendatory Act of the 97th General |
| 17 | | Assembly
that provides
coverage for prescription drugs must |
| 18 | | provide coverage for reimbursement for
medically
appropriate |
| 19 | | prescription nutritional supplements when ordered by a |
| 20 | | physician
licensed to
practice medicine in all its branches and |
| 21 | | the insured suffers from a condition
that prevents
him or her |
| 22 | | from taking sufficient oral nourishment to sustain life.
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| 23 | | (215 ILCS 5/356z.21 new) |
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| 1 | | Sec. 356z.21. Hospital patient assessments. A group or |
| 2 | | individual policy of accident and health insurance or managed |
| 3 | | care plan amended, delivered, issued, or renewed after the |
| 4 | | effective date of this amendatory Act of the 97th General |
| 5 | | Assembly that provides coverage for hospital care shall include |
| 6 | | in that coverage all services ordered by a physician and |
| 7 | | provided in the hospital that are considered medically |
| 8 | | necessary for the evaluation, assessment, and diagnosis of the |
| 9 | | illness or condition that resulted in the hospital stay of the |
| 10 | | enrollee or recipient. Such services are subject to reasonable |
| 11 | | review and utilization standards required by the policy or plan |
| 12 | | for all hospital services, as defined by the Department of |
| 13 | | Insurance or its successor agency.
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| 14 | | Section 40. The Health Maintenance Organization Act is |
| 15 | | amended by changing
Section 5-3 as follows:
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| 16 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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| 17 | | Sec. 5-3. Insurance Code provisions.
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| 18 | | (a) Health Maintenance Organizations
shall be subject to |
| 19 | | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
| 20 | | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
| 21 | | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
| 22 | | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
| 23 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, |
| 24 | | 356z.18, 356z.19, 356z.20, 364.01, 367.2, 367.2-5, 367i, 368a, |
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| 1 | | 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, |
| 2 | | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection |
| 3 | | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, |
| 4 | | XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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| 5 | | (b) For purposes of the Illinois Insurance Code, except for |
| 6 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
| 7 | | Maintenance Organizations in
the following categories are |
| 8 | | deemed to be "domestic companies":
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| 9 | | (1) a corporation authorized under the
Dental Service |
| 10 | | Plan Act or the Voluntary Health Services Plans Act;
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| 11 | | (2) a corporation organized under the laws of this |
| 12 | | State; or
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| 13 | | (3) a corporation organized under the laws of another |
| 14 | | state, 30% or more
of the enrollees of which are residents |
| 15 | | of this State, except a
corporation subject to |
| 16 | | substantially the same requirements in its state of
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| 17 | | organization as is a "domestic company" under Article VIII |
| 18 | | 1/2 of the
Illinois Insurance Code.
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| 19 | | (c) In considering the merger, consolidation, or other |
| 20 | | acquisition of
control of a Health Maintenance Organization |
| 21 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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| 22 | | (1) the Director shall give primary consideration to |
| 23 | | the continuation of
benefits to enrollees and the financial |
| 24 | | conditions of the acquired Health
Maintenance Organization |
| 25 | | after the merger, consolidation, or other
acquisition of |
| 26 | | control takes effect;
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| 1 | | (2)(i) the criteria specified in subsection (1)(b) of |
| 2 | | Section 131.8 of
the Illinois Insurance Code shall not |
| 3 | | apply and (ii) the Director, in making
his determination |
| 4 | | with respect to the merger, consolidation, or other
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| 5 | | acquisition of control, need not take into account the |
| 6 | | effect on
competition of the merger, consolidation, or |
| 7 | | other acquisition of control;
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| 8 | | (3) the Director shall have the power to require the |
| 9 | | following
information:
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| 10 | | (A) certification by an independent actuary of the |
| 11 | | adequacy
of the reserves of the Health Maintenance |
| 12 | | Organization sought to be acquired;
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| 13 | | (B) pro forma financial statements reflecting the |
| 14 | | combined balance
sheets of the acquiring company and |
| 15 | | the Health Maintenance Organization sought
to be |
| 16 | | acquired as of the end of the preceding year and as of |
| 17 | | a date 90 days
prior to the acquisition, as well as pro |
| 18 | | forma financial statements
reflecting projected |
| 19 | | combined operation for a period of 2 years;
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| 20 | | (C) a pro forma business plan detailing an |
| 21 | | acquiring party's plans with
respect to the operation |
| 22 | | of the Health Maintenance Organization sought to
be |
| 23 | | acquired for a period of not less than 3 years; and
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| 24 | | (D) such other information as the Director shall |
| 25 | | require.
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| 26 | | (d) The provisions of Article VIII 1/2 of the Illinois |
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| 1 | | Insurance Code
and this Section 5-3 shall apply to the sale by |
| 2 | | any health maintenance
organization of greater than 10% of its
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| 3 | | enrollee population (including without limitation the health |
| 4 | | maintenance
organization's right, title, and interest in and to |
| 5 | | its health care
certificates).
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| 6 | | (e) In considering any management contract or service |
| 7 | | agreement subject
to Section 141.1 of the Illinois Insurance |
| 8 | | Code, the Director (i) shall, in
addition to the criteria |
| 9 | | specified in Section 141.2 of the Illinois
Insurance Code, take |
| 10 | | into account the effect of the management contract or
service |
| 11 | | agreement on the continuation of benefits to enrollees and the
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| 12 | | financial condition of the health maintenance organization to |
| 13 | | be managed or
serviced, and (ii) need not take into account the |
| 14 | | effect of the management
contract or service agreement on |
| 15 | | competition.
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| 16 | | (f) Except for small employer groups as defined in the |
| 17 | | Small Employer
Rating, Renewability and Portability Health |
| 18 | | Insurance Act and except for
medicare supplement policies as |
| 19 | | defined in Section 363 of the Illinois
Insurance Code, a Health |
| 20 | | Maintenance Organization may by contract agree with a
group or |
| 21 | | other enrollment unit to effect refunds or charge additional |
| 22 | | premiums
under the following terms and conditions:
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| 23 | | (i) the amount of, and other terms and conditions with |
| 24 | | respect to, the
refund or additional premium are set forth |
| 25 | | in the group or enrollment unit
contract agreed in advance |
| 26 | | of the period for which a refund is to be paid or
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| 1 | | additional premium is to be charged (which period shall not |
| 2 | | be less than one
year); and
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| 3 | | (ii) the amount of the refund or additional premium |
| 4 | | shall not exceed 20%
of the Health Maintenance |
| 5 | | Organization's profitable or unprofitable experience
with |
| 6 | | respect to the group or other enrollment unit for the |
| 7 | | period (and, for
purposes of a refund or additional |
| 8 | | premium, the profitable or unprofitable
experience shall |
| 9 | | be calculated taking into account a pro rata share of the
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| 10 | | Health Maintenance Organization's administrative and |
| 11 | | marketing expenses, but
shall not include any refund to be |
| 12 | | made or additional premium to be paid
pursuant to this |
| 13 | | subsection (f)). The Health Maintenance Organization and |
| 14 | | the
group or enrollment unit may agree that the profitable |
| 15 | | or unprofitable
experience may be calculated taking into |
| 16 | | account the refund period and the
immediately preceding 2 |
| 17 | | plan years.
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| 18 | | The Health Maintenance Organization shall include a |
| 19 | | statement in the
evidence of coverage issued to each enrollee |
| 20 | | describing the possibility of a
refund or additional premium, |
| 21 | | and upon request of any group or enrollment unit,
provide to |
| 22 | | the group or enrollment unit a description of the method used |
| 23 | | to
calculate (1) the Health Maintenance Organization's |
| 24 | | profitable experience with
respect to the group or enrollment |
| 25 | | unit and the resulting refund to the group
or enrollment unit |
| 26 | | or (2) the Health Maintenance Organization's unprofitable
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| 1 | | experience with respect to the group or enrollment unit and the |
| 2 | | resulting
additional premium to be paid by the group or |
| 3 | | enrollment unit.
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| 4 | | In no event shall the Illinois Health Maintenance |
| 5 | | Organization
Guaranty Association be liable to pay any |
| 6 | | contractual obligation of an
insolvent organization to pay any |
| 7 | | refund authorized under this Section.
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| 8 | | (g) Rulemaking authority to implement Public Act 95-1045, |
| 9 | | if any, is conditioned on the rules being adopted in accordance |
| 10 | | with all provisions of the Illinois Administrative Procedure |
| 11 | | Act and all rules and procedures of the Joint Committee on |
| 12 | | Administrative Rules; any purported rule not so adopted, for |
| 13 | | whatever reason, is unauthorized. |
| 14 | | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
| 15 | | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
| 16 | | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
| 17 | | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. |
| 18 | | 6-1-10; 96-1000, eff. 7-2-10.)
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| 19 | | Section 45. The Voluntary Health Services Plans Act is |
| 20 | | amended by changing
Section 10 as follows:
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| 21 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
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| 22 | | Sec. 10. Application of Insurance Code provisions. Health |
| 23 | | services
plan corporations and all persons interested therein |
| 24 | | or dealing therewith
shall be subject to the provisions of |
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| 1 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
| 2 | | 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
| 3 | | 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, |
| 4 | | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, |
| 5 | | 356z.14, 356z.15, 356z.18, 356z.19, 356z.20, 364.01, 367.2, |
| 6 | | 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and |
| 7 | | paragraphs (7) and (15) of Section 367 of the Illinois
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| 8 | | Insurance Code.
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| 9 | | Rulemaking authority to implement Public Act 95-1045, if |
| 10 | | any, is conditioned on the rules being adopted in accordance |
| 11 | | with all provisions of the Illinois Administrative Procedure |
| 12 | | Act and all rules and procedures of the Joint Committee on |
| 13 | | Administrative Rules; any purported rule not so adopted, for |
| 14 | | whatever reason, is unauthorized. |
| 15 | | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
| 16 | | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
| 17 | | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, |
| 18 | | eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
| 19 | | 96-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff. |
| 20 | | 7-2-10.)
|
| 21 | | Section 50. The Health Carrier External Review Act is |
| 22 | | amended by changing Section 35 and by adding Sections 25.1, |
| 23 | | 25.2, 25.3, 25.4, 25.5, and 25.6 as follows:
|
| 24 | | (215 ILCS 180/25.1 new) |
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| 1 | | Sec. 25.1. Standard
information for application forms. |
| 2 | | (a) The Director shall establish standard
information and |
| 3 | | health history questions that shall be used by all
health care |
| 4 | | service plans for their individual health care coverage
|
| 5 | | application forms for individual health plan contracts and
|
| 6 | | individual health insurance policies. The health care service |
| 7 | | plan
and health insurance application forms for individual |
| 8 | | health plan
contracts and health insurance policies may only |
| 9 | | contain questions
approved by the Director. |
| 10 | | (b) The standard information and health history questions
|
| 11 | | developed by the Director shall contain clear and unambiguous
|
| 12 | | information and questions designed to ascertain the health |
| 13 | | history of
the applicant and shall be based on the medical |
| 14 | | information that is
reasonable and necessary for medical |
| 15 | | underwriting purposes. |
| 16 | | (c) The application form shall include a prominently |
| 17 | | displayed
notice that shall read:
"Illinois law prohibits an |
| 18 | | HIV test from being required or used
by health care service |
| 19 | | plans as a condition of obtaining coverage.". |
| 20 | | (d) No later than 6 months after the adoption of the |
| 21 | | regulation
under subsection (a) of this Section, all individual |
| 22 | | health care service plan
application forms shall utilize only |
| 23 | | the pool of approved questions
and the standardized information |
| 24 | | established pursuant to subsection (a). |
| 25 | | (e) On and after January 1, 2011, all individual health |
| 26 | | care
service plan applications shall be reviewed and approved |
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| 1 | | by the
Director before they may be used by a health care |
| 2 | | service plan.
|
| 3 | | (215 ILCS 180/25.2 new) |
| 4 | | Sec. 25.2. Medical
underwriting. |
| 5 | | (a) "Medical underwriting" means the completion of a |
| 6 | | reasonable
investigation of the applicant's health history |
| 7 | | information, which
includes, but is not limited to, the |
| 8 | | following: |
| 9 | | (1) Ensuring that the information submitted on the |
| 10 | | application
form and the material submitted with the |
| 11 | | application form are
complete and accurate. |
| 12 | | (2) Resolving all reasonable questions arising from |
| 13 | | the
application form or any materials submitted with the |
| 14 | | application form or
any information obtained by the health |
| 15 | | care service plan as part of
its verification of the |
| 16 | | accuracy and completeness of the application
form. |
| 17 | | (b) A health care service plan shall complete medical
|
| 18 | | underwriting prior to issuing an enrollee or subscriber health |
| 19 | | care
service plan contract. |
| 20 | | (c) A health care service plan shall adopt and implement |
| 21 | | written
medical underwriting policies and procedures to ensure |
| 22 | | that the
health care service plan does all of the following |
| 23 | | with respect to an
application for health care coverage: |
| 24 | | (1) Reviews all of the following:
|
| 25 | | (A) Information on the application and any |
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| 1 | | materials submitted
with the application form for |
| 2 | | accuracy and completeness.
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| 3 | | (B) Claims information about the applicant that is |
| 4 | | within the
health care service plan's own claims |
| 5 | | information.
|
| 6 | | (C) At least one commercially available |
| 7 | | prescription drug database
for information about the |
| 8 | | applicant.
|
| 9 | | (2) Identifies and makes inquiries, including |
| 10 | | contacting the
applicant about any questions raised by |
| 11 | | omissions, ambiguities, or
inconsistencies based upon the |
| 12 | | information collected pursuant to
item (1) of this |
| 13 | | subsection (c).
|
| 14 | | (d) The plan shall document all information collected |
| 15 | | during the
underwriting review process.
|
| 16 | | (e) On or before January 1, 2011, a health care service |
| 17 | | plan shall
file its medical underwriting policies and |
| 18 | | procedures with the
Department.
|
| 19 | | (215 ILCS 180/25.3 new) |
| 20 | | Sec. 25.3. Copies of application and contract; notice. |
| 21 | | (a) Within 10 business days after issuing a health care
|
| 22 | | service plan contract, the health care service plan shall send |
| 23 | | a copy
of the completed written application to the applicant |
| 24 | | with a copy of
the health care service plan contract issued by |
| 25 | | the health care
service plan, along with a notice that states |
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| 1 | | all of the following:
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| 2 | | (1) The applicant should review the completed |
| 3 | | application
carefully and notify the health care service |
| 4 | | plan within 30 days of
any inaccuracy in the application.
|
| 5 | | (2) Any intentional material misrepresentation or |
| 6 | | intentional
material omission in the information submitted |
| 7 | | in the application may
result in the cancellation or |
| 8 | | rescission of the plan contract.
|
| 9 | | (3) The applicant should retain a copy of the completed |
| 10 | | written
application for the applicant's records.
|
| 11 | | (b) If new information is provided by the applicant within |
| 12 | | the
30-day period permitted by subsection (a), then the |
| 13 | | provisions concerning medical underwriting shall apply to the |
| 14 | | new information.
|
| 15 | | (215 ILCS 180/25.4 new) |
| 16 | | Sec. 25.4. Rescission; cancellation. |
| 17 | | (a) Once a plan has issued an individual health care
|
| 18 | | service plan contract, the health care service plan shall not |
| 19 | | rescind
or cancel the health care service plan contract unless |
| 20 | | all of the
following apply:
|
| 21 | | (1) There was a material misrepresentation or material |
| 22 | | omission in
the information submitted by the applicant in |
| 23 | | the written
application to the health care service plan |
| 24 | | prior to the issuance of
the health care service plan |
| 25 | | contract that would have prevented the
contract from being |
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| 1 | | entered into.
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| 2 | | (2) The health care service plan completed medical |
| 3 | | underwriting before issuing the plan contract.
|
| 4 | | (3) The health care service plan demonstrates that the |
| 5 | | applicant
intentionally misrepresented or intentionally |
| 6 | | omitted material
information on the application prior to |
| 7 | | the issuance of the plan
contract with the purpose of |
| 8 | | misrepresenting his or her health
history in order to |
| 9 | | obtain health care coverage.
|
| 10 | | (4) The application form was approved by the |
| 11 | | Department.
|
| 12 | | (5) The health care service plan sent a copy of the |
| 13 | | completed
written application to the applicant with a copy |
| 14 | | of the health care
service plan contract issued by the |
| 15 | | health care service plan.
|
| 16 | | (b) Notwithstanding subsection (a) of this Section, an |
| 17 | | enrollment or subscription
may be canceled or not renewed for |
| 18 | | failure to pay the fees for
that coverage.
|
| 19 | | (215 ILCS 180/25.5 new) |
| 20 | | Sec. 25.5. Postcontract investigation. |
| 21 | | (a) If a health care service plan obtains information
after |
| 22 | | issuing an individual health care service plan contract that
|
| 23 | | the subscriber or enrollee may have intentionally omitted or
|
| 24 | | intentionally misrepresented material information during the
|
| 25 | | application for coverage process, then the health care service |
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| 1 | | plan may
investigate the potential omissions or |
| 2 | | misrepresentations in order to
determine whether the |
| 3 | | subscriber's or enrollee's health care service
plan contract |
| 4 | | may be rescinded or canceled.
|
| 5 | | (b) The following provisions shall apply to a postcontract |
| 6 | | issuance investigation: |
| 7 | | (1) Upon initiating a postcontract issuance |
| 8 | | investigation for
potential rescission or cancellation of |
| 9 | | health care coverage, the
plan shall provide a written |
| 10 | | notice to the enrollee or subscriber by
regular and |
| 11 | | certified mail that it has initiated an investigation of
|
| 12 | | intentional material misrepresentation or intentional |
| 13 | | material
omission on the part of the enrollee or subscriber |
| 14 | | and that the
investigation could lead to the rescission or |
| 15 | | cancellation of the
enrollee's or subscriber's health care |
| 16 | | service plan contract. The
notice shall be provided by the |
| 17 | | health care service plan within 5
days of the initiation of |
| 18 | | the investigation.
|
| 19 | | (2) The written notice required under item (1) of this |
| 20 | | subsection (b) shall include
full disclosure of the |
| 21 | | allegedly intentional material omission or
|
| 22 | | misrepresentation and a clear and concise explanation of |
| 23 | | why the
information has resulted in the health care service |
| 24 | | plan's initiation
of an investigation to determine whether |
| 25 | | rescission or cancellation
is warranted. The notice shall |
| 26 | | invite the enrollee or subscriber to
provide any evidence |
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| 1 | | or information within 45 business days to negate
the plan's |
| 2 | | reasons for initiating the postissuance investigation.
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| 3 | | (3) The plan shall complete its investigation no later |
| 4 | | than 90
days after the date that the notice is sent to the |
| 5 | | enrollee or subscriber
pursuant to item (1) of this |
| 6 | | subsection (b).
|
| 7 | | (4) Upon completion of its postissuance investigation, |
| 8 | | the plan
shall provide written notice by regular and |
| 9 | | certified mail to the
subscriber or enrollee that it has |
| 10 | | concluded its investigation and
has made one of the |
| 11 | | following determinations:
|
| 12 | | (A) The plan has determined that the enrollee or |
| 13 | | subscriber did
not intentionally misrepresent or |
| 14 | | intentionally omit material
information during the |
| 15 | | application process and that the subscriber's
or |
| 16 | | enrollee's health care coverage will not be canceled or |
| 17 | | rescinded.
|
| 18 | | (B) The plan intends to seek approval from the |
| 19 | | Director to cancel
or rescind the enrollee's or |
| 20 | | subscriber's health care service plan
contract for |
| 21 | | intentional misrepresentation or intentional omission |
| 22 | | of
material information during the application for |
| 23 | | coverage process.
|
| 24 | | (5) The written notice required under paragraph (B) of
|
| 25 | | item (4) of this subsection (b) shall do all of the |
| 26 | | following:
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| 1 | | (A) Include full disclosure of the nature and |
| 2 | | substance of any
information that led to the plan's |
| 3 | | determination that the enrollee or
subscriber |
| 4 | | intentionally misrepresented or intentionally omitted
|
| 5 | | material information on the application form.
|
| 6 | | (B) Provide the enrollee or subscriber with |
| 7 | | information indicating
that the health plan's |
| 8 | | determination shall not become final until it
is |
| 9 | | reviewed and approved by the Department's independent |
| 10 | | review
process.
|
| 11 | | (C) Provide the enrollee or subscriber with |
| 12 | | information regarding
the Department's independent |
| 13 | | review process and the right of the
enrollee or |
| 14 | | subscriber to opt out of that review process within 45
|
| 15 | | days of the date upon which an independent review |
| 16 | | organization
receives a request for independent |
| 17 | | review.
|
| 18 | | (D) Provide a statement that the health care |
| 19 | | service plan's
proposed decision to cancel or rescind |
| 20 | | the health care service plan
contract shall not become |
| 21 | | effective unless the Department's
independent review |
| 22 | | organization upholds the health care service plan'
s |
| 23 | | decision or unless the enrollee or subscriber has opted |
| 24 | | out of the
independent review.
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| 25 | | (215 ILCS 180/25.6 new) |
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| 1 | | Sec. 25.6. Continuation. |
| 2 | | (a) A health care service plan shall continue to
authorize |
| 3 | | and provide all medically necessary health care services
|
| 4 | | required to be covered under an enrollee's or subscriber's |
| 5 | | health
care service plan contract until the effective date of |
| 6 | | cancellation
or rescission.
|
| 7 | | (b) The effective date of the health care service plan's
|
| 8 | | cancellation or the date upon which the plan may initiate a
|
| 9 | | rescission shall be no earlier than the date that the enrollee |
| 10 | | or
subscriber receives notification via regular and certified |
| 11 | | mail that
the independent review organization has made a |
| 12 | | determination
upholding the health care service plan's |
| 13 | | decision to rescind or
cancel.
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| 14 | | (215 ILCS 180/35)
|
| 15 | | Sec. 35. Standard external review. |
| 16 | | (a) Within 4 months after the date of receipt of a notice |
| 17 | | of an adverse determination or final adverse determination, a |
| 18 | | covered person or the covered person's authorized |
| 19 | | representative may file a request for an external review with |
| 20 | | the health carrier. |
| 21 | | (b) Within 5 business days following the date of receipt of |
| 22 | | the external review request, the health carrier shall complete |
| 23 | | a preliminary review of the request to determine whether:
|
| 24 | | (1) the individual is or was a covered person in the |
| 25 | | health benefit plan at the time the health care service was |
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| 1 | | requested or at the time the health care service was |
| 2 | | provided; |
| 3 | | (2) the health care service that is the subject of the |
| 4 | | adverse determination or the final adverse determination |
| 5 | | is a covered service under the covered person's health |
| 6 | | benefit plan, but the health carrier has determined that |
| 7 | | the health care service is not covered because it does not |
| 8 | | meet the health carrier's requirements for medical |
| 9 | | necessity, appropriateness, health care setting, level of |
| 10 | | care, or effectiveness; |
| 11 | | (3) the covered person has exhausted the health |
| 12 | | carrier's internal grievance process as set forth in this |
| 13 | | Act; |
| 14 | | (4) for appeals relating to a determination based on |
| 15 | | treatment being experimental or investigational, the |
| 16 | | requested health care service or treatment that is the |
| 17 | | subject of the adverse determination or final adverse |
| 18 | | determination is a covered benefit under the covered |
| 19 | | person's health benefit plan except for the health |
| 20 | | carrier's determination that the service or treatment is |
| 21 | | experimental or investigational for a particular medical |
| 22 | | condition and is not explicitly listed as an excluded |
| 23 | | benefit under the covered person's health benefit plan with |
| 24 | | the health carrier and that the covered person's health |
| 25 | | care provider, who ordered or provided the services in |
| 26 | | question and who is licensed under the
Medical Practice Act |
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| 1 | | of 1987, has certified that one of the following situations |
| 2 | | is applicable: |
| 3 | | (A) standard health care services or treatments |
| 4 | | have not been effective in improving the condition of |
| 5 | | the covered person; |
| 6 | | (B) standard health care services or treatments |
| 7 | | are not medically appropriate for the covered person; |
| 8 | | (C) there is no available standard health care |
| 9 | | service or treatment covered by the health carrier that |
| 10 | | is more beneficial than the recommended or requested |
| 11 | | health care service or treatment;
|
| 12 | | (D) the health care service or treatment is likely |
| 13 | | to be more beneficial to the covered person, in the |
| 14 | | health care provider's opinion, than any available |
| 15 | | standard health care services or treatments; or |
| 16 | | (E) that scientifically valid studies using |
| 17 | | accepted protocols demonstrate that the health care |
| 18 | | service or treatment requested is likely to be more |
| 19 | | beneficial to the covered person than any available |
| 20 | | standard health care services or treatments; and |
| 21 | | (5) the covered person has provided all the information |
| 22 | | and forms required to process an external review, as |
| 23 | | specified in this Act. |
| 24 | | (c) Within one business day after completion of the |
| 25 | | preliminary review, the health carrier shall notify the covered |
| 26 | | person and, if applicable, the covered person's authorized |
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| 1 | | representative in writing whether the request is complete and |
| 2 | | eligible for external review. If the request: |
| 3 | | (1) is not complete, the health carrier shall inform |
| 4 | | the covered person and, if applicable, the covered person's |
| 5 | | authorized representative in writing and include in the |
| 6 | | notice what information or materials are required by this |
| 7 | | Act to make the request complete; or |
| 8 | | (2) is not eligible for external review, the health |
| 9 | | carrier shall inform the covered person and, if applicable, |
| 10 | | the covered person's authorized representative in writing |
| 11 | | and include in the notice the reasons for its |
| 12 | | ineligibility.
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| 13 | | The notice of initial determination of ineligibility shall |
| 14 | | include a statement informing the covered person and, if |
| 15 | | applicable, the covered person's authorized representative |
| 16 | | that a health carrier's initial determination that the external |
| 17 | | review request is ineligible for review may be appealed to the |
| 18 | | Director by filing a complaint with the Director. |
| 19 | | Notwithstanding a health carrier's initial determination |
| 20 | | that the request is ineligible for external review, the |
| 21 | | Director may determine that a request is eligible for external |
| 22 | | review and require that it be referred for external review. In |
| 23 | | making such determination, the Director's decision shall be in |
| 24 | | accordance with the terms of the covered person's health |
| 25 | | benefit plan and shall be subject to all applicable provisions |
| 26 | | of this Act. |
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| 1 | | (d) Whenever a request is eligible for external review the |
| 2 | | health carrier shall, within 5 business days: |
| 3 | | (1) assign an independent review organization from the |
| 4 | | list of approved independent review organizations compiled |
| 5 | | and maintained by the Director; and |
| 6 | | (2) notify in writing the covered person and, if |
| 7 | | applicable, the covered person's authorized representative |
| 8 | | of the request's eligibility and acceptance for external |
| 9 | | review and the name of the independent review organization. |
| 10 | | The health carrier shall include in the notice provided to |
| 11 | | the covered person and, if applicable, the covered person's |
| 12 | | authorized representative a statement that the covered person |
| 13 | | or the covered person's authorized representative may, within 5 |
| 14 | | business days following the date of receipt of the notice |
| 15 | | provided pursuant to item (2) of this subsection (d), submit in |
| 16 | | writing to the assigned independent review organization |
| 17 | | additional information that the independent review |
| 18 | | organization shall consider when conducting the external |
| 19 | | review. The independent review organization is not required to, |
| 20 | | but may, accept and consider additional information submitted |
| 21 | | after 5 business days. |
| 22 | | (e) The assignment of an approved independent review |
| 23 | | organization to conduct an external review in accordance with |
| 24 | | this Section shall be made from those approved independent |
| 25 | | review organizations qualified to conduct external review as |
| 26 | | required by Sections 50 and 55 of this Act. |
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| 1 | | (f) Upon assignment of an independent review organization, |
| 2 | | the health carrier or its designee utilization review |
| 3 | | organization shall, within 5 business days, provide to the |
| 4 | | assigned independent review organization the documents and any |
| 5 | | information considered in making the adverse determination or |
| 6 | | final adverse determination; in such cases, the following |
| 7 | | provisions shall apply: |
| 8 | | (1) Except as provided in item (2) of this subsection |
| 9 | | (f), failure by the health carrier or its utilization |
| 10 | | review organization to provide the documents and |
| 11 | | information within the specified time frame shall not delay |
| 12 | | the conduct of the external review. |
| 13 | | (2) If the health carrier or its utilization review |
| 14 | | organization fails to provide the documents and |
| 15 | | information within the specified time frame, the assigned |
| 16 | | independent review organization may terminate the external |
| 17 | | review and make a decision to reverse the adverse |
| 18 | | determination or final adverse determination. |
| 19 | | (3) Within one business day after making the decision |
| 20 | | to terminate the external review and make a decision to |
| 21 | | reverse the adverse determination or final adverse |
| 22 | | determination under item (2) of this subsection (f), the |
| 23 | | independent review organization shall notify the health |
| 24 | | carrier, the covered person and, if applicable, the covered |
| 25 | | person's authorized representative, of its decision to |
| 26 | | reverse the adverse determination. |
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| 1 | | (g) Upon receipt of the information from the health carrier |
| 2 | | or its utilization review organization, the assigned |
| 3 | | independent review organization shall review all of the |
| 4 | | information and documents and any other information submitted |
| 5 | | in writing to the independent review organization by the |
| 6 | | covered person and the covered person's authorized |
| 7 | | representative. |
| 8 | | (h) Upon receipt of any information submitted by the |
| 9 | | covered person or the covered person's authorized |
| 10 | | representative, the independent review organization shall |
| 11 | | forward the information to the health carrier within 1 business |
| 12 | | day. |
| 13 | | (1) Upon receipt of the information, if any, the health |
| 14 | | carrier may reconsider its adverse determination or final |
| 15 | | adverse determination that is the subject of the external |
| 16 | | review.
|
| 17 | | (2) Reconsideration by the health carrier of its |
| 18 | | adverse determination or final adverse determination shall |
| 19 | | not delay or terminate the external review.
|
| 20 | | (3) The external review may only be terminated if the |
| 21 | | health carrier decides, upon completion of its |
| 22 | | reconsideration, to reverse its adverse determination or |
| 23 | | final adverse determination and provide coverage or |
| 24 | | payment for the health care service that is the subject of |
| 25 | | the adverse determination or final adverse determination. |
| 26 | | In such cases, the following provisions shall apply: |
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| 1 | | (A) Within one business day after making the |
| 2 | | decision to reverse its adverse determination or final |
| 3 | | adverse determination, the health carrier shall notify |
| 4 | | the covered person and if applicable, the covered |
| 5 | | person's authorized representative, and the assigned |
| 6 | | independent review organization in writing of its |
| 7 | | decision. |
| 8 | | (B) Upon notice from the health carrier that the |
| 9 | | health carrier has made a decision to reverse its |
| 10 | | adverse determination or final adverse determination, |
| 11 | | the assigned independent review organization shall |
| 12 | | terminate the external review. |
| 13 | | (i) In addition to the documents and information provided |
| 14 | | by the health carrier or its utilization review organization |
| 15 | | and the covered person and the covered person's authorized |
| 16 | | representative, if any, the independent review organization, |
| 17 | | to the extent the information or documents are available and |
| 18 | | the independent review organization considers them |
| 19 | | appropriate, shall consider the following in reaching a |
| 20 | | decision: |
| 21 | | (1) the covered person's pertinent medical records; |
| 22 | | (2) the covered person's health care provider's |
| 23 | | recommendation; |
| 24 | | (3) consulting reports from appropriate health care |
| 25 | | providers and other documents submitted by the health |
| 26 | | carrier, the covered person, the covered person's |
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| 1 | | authorized representative, or the covered person's |
| 2 | | treating provider; |
| 3 | | (4) the terms of coverage under the covered person's |
| 4 | | health benefit plan with the health carrier to ensure that |
| 5 | | the independent review organization's decision is not |
| 6 | | contrary to the terms of coverage under the covered |
| 7 | | person's health benefit plan with the health carrier; |
| 8 | | (5) the most appropriate practice guidelines, which |
| 9 | | shall include applicable evidence-based standards and may |
| 10 | | include any other practice guidelines developed by the |
| 11 | | federal government, national or professional medical |
| 12 | | societies, boards, and associations; |
| 13 | | (6) any applicable clinical review criteria developed |
| 14 | | and used by the health carrier or its designee utilization |
| 15 | | review organization; and |
| 16 | | (7) the opinion of the independent review |
| 17 | | organization's clinical reviewer or reviewers after |
| 18 | | considering items (1) through (6) of this subsection (i) to |
| 19 | | the extent the information or documents are available and |
| 20 | | the clinical reviewer or reviewers considers the |
| 21 | | information or documents appropriate; and |
| 22 | | (8) for a denial of coverage based on a determination |
| 23 | | that the health care service or treatment recommended or |
| 24 | | requested is experimental or investigational, whether and |
| 25 | | to what extent: |
| 26 | | (A) the recommended or requested health care |
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| 1 | | service or treatment has been approved by the federal |
| 2 | | Food and Drug Administration, if applicable, for the |
| 3 | | condition; |
| 4 | | (B) medical or scientific evidence or |
| 5 | | evidence-based standards demonstrate that the expected |
| 6 | | benefits of the recommended or requested health care |
| 7 | | service or treatment is more likely than not to be |
| 8 | | beneficial to the covered person than any available |
| 9 | | standard health care service or treatment and the |
| 10 | | adverse risks of the recommended or requested health |
| 11 | | care service or treatment would not be substantially |
| 12 | | increased over those of available standard health care |
| 13 | | services or treatments; or |
| 14 | | (C) the terms of coverage under the covered |
| 15 | | person's health benefit plan with the health carrier to |
| 16 | | ensure that the health care service or treatment that |
| 17 | | is the subject of the opinion is experimental or |
| 18 | | investigational would otherwise be covered under the |
| 19 | | terms of coverage of the covered person's health |
| 20 | | benefit plan with the health carrier. |
| 21 | | (j) Within 5 days after the date of receipt of all |
| 22 | | necessary information, the assigned independent review |
| 23 | | organization shall provide written notice of its decision to |
| 24 | | uphold or reverse the adverse determination or the final |
| 25 | | adverse determination to the health carrier, the covered person |
| 26 | | and, if applicable, the covered person's authorized |
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| 1 | | representative. In reaching a decision, the assigned |
| 2 | | independent review organization is not bound by any claim |
| 3 | | determinations reached prior to the submission of information |
| 4 | | to the independent review organization. The assigned |
| 5 | | independent review organization shall independently determine |
| 6 | | if the health care services under review are the medically |
| 7 | | necessary health care services that a physician, exercising |
| 8 | | prudent clinical judgment, would provide to a patient for the |
| 9 | | purpose of preventing, evaluating, diagnosing, or treating an |
| 10 | | illness, injury, disease, or its symptoms and are: (i) in |
| 11 | | accordance with generally accepted standards of medical |
| 12 | | practice; (ii) clinically appropriate, in terms of type, |
| 13 | | frequency, extent, site, and duration and considered effective |
| 14 | | for the patient's illness, injury, or disease; and (iii) not |
| 15 | | primarily for the convenience of the patient, physician, or |
| 16 | | other health care provider. For the purposes of this subsection |
| 17 | | (j), "generally accepted standards of medical practice" means |
| 18 | | standards that are based on credible scientific evidence |
| 19 | | published in peer-reviewed medical literature generally |
| 20 | | recognized by the relevant medical community, physician |
| 21 | | specialty society recommendations, and the views of physicians |
| 22 | | practicing in relevant clinical areas and any other relevant |
| 23 | | factors. In such cases, the following provisions shall apply: |
| 24 | | (1) The independent review organization shall include |
| 25 | | in the notice: |
| 26 | | (A) a general description of the reason for the |
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| 1 | | request for external review; |
| 2 | | (B) the date the independent review organization |
| 3 | | received the assignment from the health carrier to |
| 4 | | conduct the external review; |
| 5 | | (C) the time period during which the external |
| 6 | | review was conducted; |
| 7 | | (D) references to the evidence or documentation, |
| 8 | | including the evidence-based standards, considered in |
| 9 | | reaching its decision; |
| 10 | | (E) the date of its decision; and |
| 11 | | (F) the principal reason or reasons for its |
| 12 | | decision, including what applicable, if any, |
| 13 | | evidence-based standards that were a basis for its |
| 14 | | decision.
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| 15 | | (2) For reviews of experimental or investigational |
| 16 | | treatments, the notice shall include the following |
| 17 | | information: |
| 18 | | (A) a description of the covered person's medical |
| 19 | | condition; |
| 20 | | (B) a description of the indicators relevant to |
| 21 | | whether there is sufficient evidence to demonstrate |
| 22 | | that the recommended or requested health care service |
| 23 | | or treatment is more likely than not to be more |
| 24 | | beneficial to the covered person than any available |
| 25 | | standard health care services or treatments and the |
| 26 | | adverse risks of the recommended or requested health |
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| 1 | | care service or treatment would not be substantially |
| 2 | | increased over those of available standard health care |
| 3 | | services or treatments; |
| 4 | | (C) a description and analysis of any medical or |
| 5 | | scientific evidence considered in reaching the |
| 6 | | opinion; |
| 7 | | (D) a description and analysis of any |
| 8 | | evidence-based standards; |
| 9 | | (E) whether the recommended or requested health |
| 10 | | care service or treatment has been approved by the |
| 11 | | federal Food and Drug Administration, for the |
| 12 | | condition; |
| 13 | | (F) whether medical or scientific evidence or |
| 14 | | evidence-based standards demonstrate that the expected |
| 15 | | benefits of the recommended or requested health care |
| 16 | | service or treatment is more likely than not to be more |
| 17 | | beneficial to the covered person than any available |
| 18 | | standard health care service or treatment and the |
| 19 | | adverse risks of the recommended or requested health |
| 20 | | care service or treatment would not be substantially |
| 21 | | increased over those of available standard health care |
| 22 | | services or treatments; and |
| 23 | | (G) the written opinion of the clinical reviewer, |
| 24 | | including the reviewer's recommendation as to whether |
| 25 | | the recommended or requested health care service or |
| 26 | | treatment should be covered and the rationale for the |
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| 1 | | reviewer's recommendation. |
| 2 | | (3) In reaching a decision, the assigned independent |
| 3 | | review organization is not bound by any decisions or |
| 4 | | conclusions reached during the health carrier's |
| 5 | | utilization review process or the health carrier's |
| 6 | | internal grievance or appeals process. |
| 7 | | (4) Upon receipt of a notice of a decision reversing |
| 8 | | the adverse determination or final adverse determination, |
| 9 | | the health carrier immediately shall approve the coverage |
| 10 | | that was the subject of the adverse determination or final |
| 11 | | adverse determination.
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| 12 | | (Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11.)
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| 13 | | Section 55. The Illinois Public Aid Code is amended by |
| 14 | | changing Section 5-16.8 as follows:
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| 15 | | (305 ILCS 5/5-16.8)
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| 16 | | Sec. 5-16.8. Required health benefits. The medical |
| 17 | | assistance program
shall
(i) provide the post-mastectomy care |
| 18 | | benefits required to be covered by a policy of
accident and |
| 19 | | health insurance under Section 356t and the coverage required
|
| 20 | | under Sections 356g.5, 356u, 356w, 356x, and 356z.6, and |
| 21 | | 356z.21 of the Illinois
Insurance Code and (ii) be subject to |
| 22 | | the provisions of Section 364.01 of the Illinois
Insurance |
| 23 | | Code.
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| 24 | | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07.)
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| 1 | | Section 60. The Medical Patient Rights Act is amended by |
| 2 | | changing Sections 2.04, 3, and 5 and adding Sections 2.06, 5.1, |
| 3 | | and 5.2 as follows:
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| 4 | | (410 ILCS 50/2.04) (from Ch. 111 1/2, par. 5402.04)
|
| 5 | | Sec. 2.04.
"Insurance company" means (1) an insurance |
| 6 | | company, fraternal
benefit society, and any other insurer |
| 7 | | subject to regulation under the
Illinois Insurance Code; or (2) |
| 8 | | a health maintenance organization, a limited health service |
| 9 | | organization under the Limited Health Service Organization |
| 10 | | Act, or a voluntary health services plan under the Voluntary |
| 11 | | Health Services Plans Act.
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| 12 | | (Source: P.A. 85-677; 85-679.)
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| 13 | | (410 ILCS 50/2.06 new) |
| 14 | | Sec. 2.06. Health insurance policy or health care plan. |
| 15 | | "Health insurance policy or health care plan" means any policy |
| 16 | | of health or accident insurance provided by a health insurance |
| 17 | | company or under the Counties Code, the Municipal Code, the |
| 18 | | State Employees Group Insurance Act or Medical Assistance |
| 19 | | provided under the Public Aid Code.
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| 20 | | (410 ILCS 50/3) (from Ch. 111 1/2, par. 5403)
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| 21 | | Sec. 3. The following rights are hereby established:
|
| 22 | | (a) The right of each patient to care consistent with sound |
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| 1 | | nursing and
medical practices, to be informed of the name of |
| 2 | | the physician responsible
for coordinating his or her care, to |
| 3 | | receive information concerning his or
her condition and |
| 4 | | proposed treatment, to refuse any treatment to the extent
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| 5 | | permitted by law, and to privacy and confidentiality of records |
| 6 | | except as
otherwise provided by law. Each patient has a right |
| 7 | | to be informed of his or her inpatient or outpatient status |
| 8 | | while undergoing evaluation, assessment, diagnosis, treatment, |
| 9 | | or observation in a hospital. The patient must be informed of |
| 10 | | this status and put on notice that this admission status may |
| 11 | | affect coverage by his or her health insurance policy or health |
| 12 | | care plan or his or her personal responsibility for payment.
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| 13 | | (b) The right of each patient, regardless of source of |
| 14 | | payment, to examine
and receive a reasonable explanation of his |
| 15 | | total bill for services rendered
by his physician or health |
| 16 | | care provider, including the itemized charges
for specific |
| 17 | | services received. Each physician or health care provider
shall |
| 18 | | be responsible only for a reasonable explanation of those |
| 19 | | specific
services provided by such physician or health care |
| 20 | | provider.
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| 21 | | (c) In the event an insurance company or health services |
| 22 | | corporation cancels
or refuses to renew an individual policy or |
| 23 | | plan, the insured patient shall
be entitled to timely, prior |
| 24 | | notice of the termination of such policy or plan.
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| 25 | | An insurance company or health services corporation that |
| 26 | | requires any
insured patient or applicant for new or continued |
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| 1 | | insurance or coverage to
be tested for infection with human |
| 2 | | immunodeficiency virus (HIV) or any
other identified causative |
| 3 | | agent of acquired immunodeficiency syndrome
(AIDS) shall (1) |
| 4 | | give the patient or applicant prior written notice of such
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| 5 | | requirement, (2) proceed with such testing only upon the |
| 6 | | written
authorization of the applicant or patient, and (3) keep |
| 7 | | the results of such
testing confidential. Notice of an adverse |
| 8 | | underwriting or coverage
decision may be given to any |
| 9 | | appropriately interested party, but the
insurer may only |
| 10 | | disclose the test result itself to a physician designated
by |
| 11 | | the applicant or patient, and any such disclosure shall be in a |
| 12 | | manner
that assures confidentiality.
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| 13 | | The Department of Insurance shall enforce the provisions of |
| 14 | | this subsection.
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| 15 | | (d) The right of each patient to privacy and |
| 16 | | confidentiality in health
care. Each physician, health care |
| 17 | | provider, health services corporation and
insurance company |
| 18 | | shall refrain from disclosing the nature or details of
services |
| 19 | | provided to patients, except that such information may be |
| 20 | | disclosed to the
patient, the party making treatment decisions |
| 21 | | if the patient is incapable
of making decisions regarding the |
| 22 | | health services provided, those parties
directly involved with |
| 23 | | providing treatment to the patient or processing the
payment |
| 24 | | for that treatment, those parties responsible for peer review,
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| 25 | | utilization review and quality assurance, and those parties |
| 26 | | required to
be notified under the Abused and Neglected Child |
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| 1 | | Reporting Act, the
Illinois Sexually Transmissible Disease |
| 2 | | Control Act or where otherwise
authorized or required by law. |
| 3 | | This right may be waived in writing by the
patient or the |
| 4 | | patient's guardian, but a physician or other health care
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| 5 | | provider may not condition the provision of services on the |
| 6 | | patient's or
guardian's agreement to sign such a waiver.
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| 7 | | (Source: P.A. 86-895; 86-902; 86-1028; 87-334.)
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| 8 | | (410 ILCS 50/5)
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| 9 | | Sec. 5. Statement of hospital patient's rights.
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| 10 | | (a) Each patient admitted to a hospital, and the guardian |
| 11 | | or authorized
representative or parent of a minor patient, |
| 12 | | shall be given a written
statement of all the rights enumerated |
| 13 | | in this Act, or a similar statement of
patients' rights |
| 14 | | required of the hospital by the Joint Commission on
|
| 15 | | Accreditation of Healthcare Organizations or a similar |
| 16 | | accrediting
organization. The statement shall be given at the |
| 17 | | time of admission or as soon
thereafter as the condition of the |
| 18 | | patient permits.
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| 19 | | (b) If a patient is unable to read the written statement, a |
| 20 | | hospital
shall make a reasonable effort to provide it to the |
| 21 | | guardian or authorized
representative of the patient.
|
| 22 | | (c) The statement shall also include the right not to be |
| 23 | | discriminated against by the hospital due to the patient's |
| 24 | | race, color, or national origin where such characteristics are |
| 25 | | not relevant to the patient's medical diagnosis and treatment. |
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| 1 | | The statement shall further provide each admitted patient or |
| 2 | | the patient's representative or guardian with notice of how to |
| 3 | | initiate a grievance regarding improper discrimination with |
| 4 | | the hospital and how the patient may lodge a grievance with the |
| 5 | | Illinois Department of Public Health regardless of whether the |
| 6 | | patient has first used the hospital's grievance process. |
| 7 | | (Source: P.A. 88-56; 88-670, eff. 12-2-94.)
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| 8 | | (410 ILCS 50/5.1 new)
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| 9 | | Sec. 5.1. Discrimination grievance procedures. Upon |
| 10 | | receipt of a grievance alleging unlawful discrimination on the |
| 11 | | basis of race, color, or national origin, the hospital must |
| 12 | | investigate the claim and work with the patient to address |
| 13 | | valid or proven concerns in accordance with the hospital's |
| 14 | | grievance process. At the conclusion of the hospital's |
| 15 | | grievance process, the hospital shall inform the patient that |
| 16 | | such grievances may be reported to the Illinois Department of |
| 17 | | Public Health if not resolved to the patient's satisfaction at |
| 18 | | the hospital level.
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| 19 | | (410 ILCS 50/5.2 new)
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| 20 | | Sec. 5.2. Emergency room antidiscrimination notice. Every |
| 21 | | hospital shall post a sign next to or in close proximity of its |
| 22 | | sign required by Section 489.20 (q)(1) of Title 42 of the Code |
| 23 | | of Federal Regulations stating the following: |
| 24 | | "You have the right not to be discriminated against by the |
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| 1 | | hospital due to your race, color, or national origin if these |
| 2 | | characteristics are unrelated to your diagnosis or treatment. |
| 3 | | If you believe this right has been violated, please call |
| 4 | | (insert number for hospital grievance officer).".
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| 5 | | Section 90. The State Mandates Act is amended by adding |
| 6 | | Section 8.35 as follows:
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| 7 | | (30 ILCS 805/8.35 new) |
| 8 | | Sec. 8.35. Exempt mandate. Notwithstanding Sections 6 and 8 |
| 9 | | of this Act, no reimbursement by the State is required for the |
| 10 | | implementation of any mandate created by this amendatory Act of |
| 11 | | the 97th General Assembly.
|
| 12 | | Section 99. Effective date. This Act takes effect upon |
| 13 | | becoming law. |
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| | 1 | |
INDEX
| | 2 | |
Statutes amended in order of appearance
| | | 3 | | 5 ILCS 375/6.11 | | | | 4 | | 55 ILCS 5/5-1069.3 | | | | 5 | | 65 ILCS 5/10-4-2.3 | | | | 6 | | 105 ILCS 5/10-22.3f | | | | 7 | | 210 ILCS 70/1 | from Ch. 111 1/2, par. 6151 | | | 8 | | 210 ILCS 80/1 | from Ch. 111 1/2, par. 86 | | | 9 | | 215 ILCS 5/356z.19 new | | | | 10 | | 215 ILCS 5/356z.20 new | | | | 11 | | 215 ILCS 5/356z.21 new | | | | 12 | | 215 ILCS 125/5-3 | from Ch. 111 1/2, par. 1411.2 | | | 13 | | 215 ILCS 165/10 | from Ch. 32, par. 604 | | | 14 | | 215 ILCS 180/25.1 new | | | | 15 | | 215 ILCS 180/25.2 new | | | | 16 | | 215 ILCS 180/25.3 new | | | | 17 | | 215 ILCS 180/25.4 new | | | | 18 | | 215 ILCS 180/25.5 new | | | | 19 | | 215 ILCS 180/25.6 new | | | | 20 | | 215 ILCS 180/35 | | | | 21 | | 305 ILCS 5/5-16.8 | | | | 22 | | 410 ILCS 50/2.04 | from Ch. 111 1/2, par. 5402.04 | | | 23 | | 410 ILCS 50/2.06 new | | | | 24 | | 410 ILCS 50/3 | from Ch. 111 1/2, par. 5403 | | | 25 | | 410 ILCS 50/5 | | |
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