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2010 Illinois Code
CHAPTER 215 INSURANCE
215 ILCS 134/ Managed Care Reform and Patient Rights Act.

    (215 ILCS 134/1)
    Sec. 1. Short title. This Act may be cited as the Managed Care Reform and Patient Rights Act.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/5)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/10)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/15)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/20)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/25)
    Sec. 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.
(Source: P.A. 91‑617, eff. 7‑1‑00.)

    (215 ILCS 134/30)
    Sec. 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) No health care plan or its subcontractors may by contract, written policy, procedure, or otherwise mandate or require an enrollee to substitute his or her participating primary care physician under the plan during inpatient hospitalization, such as with a hospitalist physician licensed to practice medicine in all its branches, without the agreement of that enrollee's participating primary care physician. "Participating primary care physician" for health care plans and subcontractors that do not require coordination of care by a primary care physician means the participating physician treating the patient. All health care plans shall inform enrollees of any policies, recommendations, or guidelines concerning the substitution of the enrollee's primary care physician when hospitalization is necessary in the manner set forth in subsections (d) and (e) of Section 15.
    (d) Any violation of this Section shall be subject to the penalties under this Act.
(Source: P.A. 94‑866, eff. 6‑16‑06.)

    (215 ILCS 134/35)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/40)
    (Text of Section before amendment by P.A. 96‑857)
    Sec. 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".
(Source: P.A. 91‑617, eff. 1‑1‑00.)
 
    (Text of Section after amendment by P.A. 96‑857)
    Sec. 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 as provided by the Illinois Health Carrier External Review 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".
(Source: P.A. 96‑857, eff. 7‑1‑10.)

    (215 ILCS 134/43)
    Sec. 43. Utilization of health care facilities.
    (a) A health care plan must provide its enrollees with a description of their rights and responsibilities in obtaining referrals to and making appropriate use of health care facilities when access to their primary care physician is not readily available.
    (b) Nothing in this Section is intended to affect the rights of enrollees or relieve a health care plan of its responsibilities with respect to the provision of and coverage of emergency services or treatment of an emergency medical condition, as those terms are defined by this Act, and as those responsibilities and rights are otherwise provided under this Act, especially Section 65 of this Act.
(Source: P.A. 93‑540, eff. 8‑18‑03.)

    (215 ILCS 134/45)
    (Text of Section before amendment by P.A. 96‑857)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)
 
    (Text of Section after amendment by P.A. 96‑857)
    Sec. 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 as provided by the Illinois Health Carrier External Review Act.
    (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 as provided by the Illinois Health Carrier External Review Act.
    (f) Until July 1, 2013, if an external independent review decision made pursuant to the Illinois Health Carrier External Review Act upholds a determination adverse to the covered person, the covered person has the right to appeal the final decision to the Department; if the external review decision is found by the Director to have been arbitrary and capricious, then the Director, with consultation from a licensed medical professional, may overturn the external review decision and require the health carrier to pay for the health care service or treatment; such decision, if any, shall be made solely on the legal or medical merits of the claim. If an external review decision is overturned by the Director pursuant to this Section and the health carrier so requests, then the Director shall assign a new independent review organization to reconsider the overturned decision. The new independent review organization shall follow subsection (d) of Section 40 of the Health Carrier External Review Act in rendering a decision.
        (g) 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 health care services appeals, complaints, or external independent reviews under the Illinois Health Carrier External Review Act.
    (h) 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.
(Source: P.A. 96‑857, eff. 7‑1‑10.)

    (215 ILCS 134/50)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/55)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/60)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/65)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/70)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/72)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/75)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/80)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/85)
    Sec. 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.
(Source: P.A. 91‑617, eff. 7‑1‑00.)

    (215 ILCS 134/90)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/95)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/100)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/105)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/110)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/115)
    Sec. 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.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/120)
    Sec. 120. Severability. The provisions of this Act are severable under Section 1.31 of the Statute on Statutes.
(Source: P.A. 91‑617, eff. 1‑1‑00.)

    (215 ILCS 134/200)
    Sec. 200. (Amendatory provisions; text omitted).
(Source: P.A. 91‑617, eff. 8‑19‑99; text omitted.)

    (215 ILCS 134/205)
    Sec. 205. (Amendatory provisions; text omitted).
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/210)
    Sec. 210. (Amendatory provisions; text omitted).
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/215)
    Sec. 215. (Amendatory provisions, text omitted).
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/220)
    Sec. 220. (Amendatory provisions; text omitted.)
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/225)
    Sec. 225. (Amendatory provisions; text omitted.)
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/230)
    Sec. 230. (Amendatory provisions; text omitted).
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/235)
    Sec. 235. (Amendatory provisions; text omitted).
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/240)
    Sec. 240. (Amendatory provisions; text omitted).
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/245)
    Sec. 245. (Amendatory provisions; text omitted).
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/250)
    Sec. 250. (Amendatory provisions; text omitted.)
(Source: P.A. 91‑617, eff. 1‑1‑00; text omitted.)

    (215 ILCS 134/299)
    Sec. 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.
(Source: P.A. 91‑617, eff. 8‑19‑99.)

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