Bill Text: IL HB3923 | 2009-2010 | 96th General Assembly | Engrossed
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Creates the Individual Market Fairness Reform Law. Provides that a managed care entity shall (1) fairly and affirmatively offer all of its managed care plans that are sold to all individuals in each service area in which the managed care entity provides or arranges for the provision of health care services and (2) may not reject an application for an individual managed care plan if certain requirements are met. Provides that the Division of Insurance of the Department of Financial and Professional Regulation shall develop a system to categorize all managed care plans offered and sold to individuals pursuant to this Law into 5 coverage choice categories. Creates the Minimum Medical Loss Ratio Law. Provides that any company selling a health benefit plan in the individual or small group market shall expend in the form of health care benefits no less than 85 percent of the aggregate dues, fees, and premiums received by the company. Creates the Health Sure Illinois Law to establish a program for the purpose of making managed care plans affordable and accessible to small employers and individuals. Provides that the program is limited to active managed care entities. Amends the Illinois Insurance Code. Creates new Articles in the Code establishing the Office of Patient Protection and the Illinois Health Carrier External Review Law. Amends the Small Employer Health Insurance Rating Act, Illinois Health Insurance Portability and Accountability Act, and Managed Care Reform and Patient Rights Act in provisions concerning small employers, individuals, review, and rates. Repeals a provision of the Small Employer Health Insurance Rating Act concerning establishment of a class of business. Makes other changes.
Spectrum: Partisan Bill (Democrat 34-0)
Status: (Passed) 2010-01-05 - Public Act . . . . . . . . . 96-0857 [HB3923 Detail]
Download: Illinois-2009-HB3923-Engrossed.html
Bill Title: Creates the Individual Market Fairness Reform Law. Provides that a managed care entity shall (1) fairly and affirmatively offer all of its managed care plans that are sold to all individuals in each service area in which the managed care entity provides or arranges for the provision of health care services and (2) may not reject an application for an individual managed care plan if certain requirements are met. Provides that the Division of Insurance of the Department of Financial and Professional Regulation shall develop a system to categorize all managed care plans offered and sold to individuals pursuant to this Law into 5 coverage choice categories. Creates the Minimum Medical Loss Ratio Law. Provides that any company selling a health benefit plan in the individual or small group market shall expend in the form of health care benefits no less than 85 percent of the aggregate dues, fees, and premiums received by the company. Creates the Health Sure Illinois Law to establish a program for the purpose of making managed care plans affordable and accessible to small employers and individuals. Provides that the program is limited to active managed care entities. Amends the Illinois Insurance Code. Creates new Articles in the Code establishing the Office of Patient Protection and the Illinois Health Carrier External Review Law. Amends the Small Employer Health Insurance Rating Act, Illinois Health Insurance Portability and Accountability Act, and Managed Care Reform and Patient Rights Act in provisions concerning small employers, individuals, review, and rates. Repeals a provision of the Small Employer Health Insurance Rating Act concerning establishment of a class of business. Makes other changes.
Spectrum: Partisan Bill (Democrat 34-0)
Status: (Passed) 2010-01-05 - Public Act . . . . . . . . . 96-0857 [HB3923 Detail]
Download: Illinois-2009-HB3923-Engrossed.html
|
|||||||
| |||||||
| |||||||
1 | AN ACT concerning insurance.
| ||||||
2 | Be it enacted by the People of the State of Illinois,
| ||||||
3 | represented in the General Assembly:
| ||||||
4 | Section 5. The Illinois Insurance Code is amended by adding | ||||||
5 | Sections 359a.1 and 359a.2 and Article XLV and by changing | ||||||
6 | Section 370c as follows:
| ||||||
7 | (215 ILCS 5/359a.1 new) | ||||||
8 | Sec. 359a.1. Standard small group applications. The | ||||||
9 | Director shall develop, by rule, a standard application form | ||||||
10 | for use by small employers applying for coverage under a health | ||||||
11 | benefit plan offered by small employer carriers. Small employer | ||||||
12 | carriers shall be required to use the standard application form | ||||||
13 | not less than 6 months after the rules developing the form | ||||||
14 | become effective. The Director shall revise the standard | ||||||
15 | application form at least every 3 years. For purposes of this | ||||||
16 | Section, "health benefit plan", "small employer", and "small | ||||||
17 | employer carrier" shall have the meaning given those terms in | ||||||
18 | the Small Employer Health Insurance Rating Act.
| ||||||
19 | (215 ILCS 5/359a.2 new) | ||||||
20 | Sec. 359a.2. Standard individual market health statements. | ||||||
21 | The Director shall develop, by rule, a standard health | ||||||
22 | statement for use by individuals applying for a health benefit |
| |||||||
| |||||||
1 | plan in the individual market. All carriers who offer health | ||||||
2 | benefit plans in the individual market and evaluate the health | ||||||
3 | status of individuals shall be required to use the standard | ||||||
4 | health statement not less than 6 months after the statement | ||||||
5 | becomes effective and thereafter may not use any other method | ||||||
6 | to determine the health status of an individual. Nothing in | ||||||
7 | this Section shall prevent a carrier from using health | ||||||
8 | information after enrollment for the purpose of providing | ||||||
9 | services or arranging for the provision of services under a | ||||||
10 | health benefit plan. For purposes of this Section, "health | ||||||
11 | benefit plan" shall have the meaning given the term in the | ||||||
12 | Small Employer Health Insurance Rating Act and "individual | ||||||
13 | market" shall have meaning given the term in the Illinois | ||||||
14 | Health Insurance Portability and Accountability Act.
| ||||||
15 | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| ||||||
16 | Sec. 370c. Mental and emotional disorders.
| ||||||
17 | (a) (1) On and after the effective date of this Section,
| ||||||
18 | every insurer which delivers, issues for delivery or renews or | ||||||
19 | modifies
group A&H policies providing coverage for hospital or | ||||||
20 | medical treatment or
services for illness on an | ||||||
21 | expense-incurred basis shall offer to the
applicant or group | ||||||
22 | policyholder subject to the insurers standards of
| ||||||
23 | insurability, coverage for reasonable and necessary treatment | ||||||
24 | and services
for mental, emotional or nervous disorders or | ||||||
25 | conditions, other than serious
mental illnesses as defined in |
| |||||||
| |||||||
1 | item (2) of subsection (b), up to the limits
provided in the | ||||||
2 | policy for other disorders or conditions, except (i) the
| ||||||
3 | insured may be required to pay up to 50% of expenses incurred | ||||||
4 | as a result
of the treatment or services, and (ii) the annual | ||||||
5 | benefit limit may be
limited to the lesser of $10,000 or 25% of | ||||||
6 | the lifetime policy limit.
| ||||||
7 | (2) Each insured that is covered for mental, emotional or | ||||||
8 | nervous
disorders or conditions shall be free to select the | ||||||
9 | physician licensed to
practice medicine in all its branches, | ||||||
10 | licensed clinical psychologist,
licensed clinical social | ||||||
11 | worker, licensed clinical professional counselor, or licensed | ||||||
12 | marriage and family therapist of
his choice to treat such | ||||||
13 | disorders, and
the insurer shall pay the covered charges of | ||||||
14 | such physician licensed to
practice medicine in all its | ||||||
15 | branches, licensed clinical psychologist,
licensed clinical | ||||||
16 | social worker, licensed clinical professional counselor, or | ||||||
17 | licensed marriage and family therapist up
to the limits of | ||||||
18 | coverage, provided (i)
the disorder or condition treated is | ||||||
19 | covered by the policy, and (ii) the
physician, licensed | ||||||
20 | psychologist, licensed clinical social worker, licensed
| ||||||
21 | clinical professional counselor, or licensed marriage and | ||||||
22 | family therapist is
authorized to provide said services under | ||||||
23 | the statutes of this State and in
accordance with accepted | ||||||
24 | principles of his profession.
| ||||||
25 | (3) Insofar as this Section applies solely to licensed | ||||||
26 | clinical social
workers, licensed clinical professional |
| |||||||
| |||||||
1 | counselors, and licensed marriage and family therapists, those | ||||||
2 | persons who may
provide services to individuals shall do so
| ||||||
3 | after the licensed clinical social worker, licensed clinical | ||||||
4 | professional
counselor, or licensed marriage and family | ||||||
5 | therapist has informed the patient of the
desirability of the | ||||||
6 | patient conferring with the patient's primary care
physician | ||||||
7 | and the licensed clinical social worker, licensed clinical
| ||||||
8 | professional counselor, or licensed marriage and family | ||||||
9 | therapist has
provided written
notification to the patient's | ||||||
10 | primary care physician, if any, that services
are being | ||||||
11 | provided to the patient. That notification may, however, be
| ||||||
12 | waived by the patient on a written form. Those forms shall be | ||||||
13 | retained by
the licensed clinical social worker, licensed | ||||||
14 | clinical professional counselor, or licensed marriage and | ||||||
15 | family therapist
for a period of not less than 5 years.
| ||||||
16 | (b) (1) An insurer that provides coverage for hospital or | ||||||
17 | medical
expenses under a group policy of accident and health | ||||||
18 | insurance or
health care plan amended, delivered, issued, or | ||||||
19 | renewed after the effective
date of this amendatory Act of the | ||||||
20 | 92nd General Assembly shall provide coverage
under the policy | ||||||
21 | for treatment of serious mental illness under the same terms
| ||||||
22 | and conditions as coverage for hospital or medical expenses | ||||||
23 | related to other
illnesses and diseases. The coverage required | ||||||
24 | under this Section must provide
for same durational limits, | ||||||
25 | amount limits, deductibles, and co-insurance
requirements for | ||||||
26 | serious mental illness as are provided for other illnesses
and |
| |||||||
| |||||||
1 | diseases. This subsection does not apply to coverage provided | ||||||
2 | to
employees by employers who have 50 or fewer employees.
| ||||||
3 | (2) "Serious mental illness" means the following | ||||||
4 | psychiatric illnesses as
defined in the most current edition of | ||||||
5 | the Diagnostic and Statistical Manual
(DSM) published by the | ||||||
6 | American Psychiatric Association:
| ||||||
7 | (A) schizophrenia;
| ||||||
8 | (B) paranoid and other psychotic disorders;
| ||||||
9 | (C) bipolar disorders (hypomanic, manic, depressive, | ||||||
10 | and mixed);
| ||||||
11 | (D) major depressive disorders (single episode or | ||||||
12 | recurrent);
| ||||||
13 | (E) schizoaffective disorders (bipolar or depressive);
| ||||||
14 | (F) pervasive developmental disorders;
| ||||||
15 | (G) obsessive-compulsive disorders;
| ||||||
16 | (H) depression in childhood and adolescence;
| ||||||
17 | (I) panic disorder; | ||||||
18 | (J) post-traumatic stress disorders (acute, chronic, | ||||||
19 | or with delayed onset); and
| ||||||
20 | (K) anorexia nervosa and bulimia nervosa. | ||||||
21 | (3) (Blank). Upon request of the reimbursing insurer, a | ||||||
22 | provider of treatment of
serious mental illness shall furnish | ||||||
23 | medical records or other necessary data
that substantiate that | ||||||
24 | initial or continued treatment is at all times medically
| ||||||
25 | necessary. An insurer shall provide a mechanism for the timely | ||||||
26 | review by a
provider holding the same license and practicing in |
| |||||||
| |||||||
1 | the same specialty as the
patient's provider, who is | ||||||
2 | unaffiliated with the insurer, jointly selected by
the patient | ||||||
3 | (or the patient's next of kin or legal representative if the
| ||||||
4 | patient is unable to act for himself or herself), the patient's | ||||||
5 | provider, and
the insurer in the event of a dispute between the | ||||||
6 | insurer and patient's
provider regarding the medical necessity | ||||||
7 | of a treatment proposed by a patient's
provider. If the | ||||||
8 | reviewing provider determines the treatment to be medically
| ||||||
9 | necessary, the insurer shall provide reimbursement for the | ||||||
10 | treatment. Future
contractual or employment actions by the | ||||||
11 | insurer regarding the patient's
provider may not be based on | ||||||
12 | the provider's participation in this procedure.
Nothing | ||||||
13 | prevents
the insured from agreeing in writing to continue | ||||||
14 | treatment at his or her
expense. When making a determination of | ||||||
15 | the medical necessity for a treatment
modality for serous | ||||||
16 | mental illness, an insurer must make the determination in a
| ||||||
17 | manner that is consistent with the manner used to make that | ||||||
18 | determination with
respect to other diseases or illnesses | ||||||
19 | covered under the policy, including an
appeals process.
| ||||||
20 | (4) A group health benefit plan:
| ||||||
21 | (A) shall provide coverage based upon medical | ||||||
22 | necessity for the following
treatment of mental illness in | ||||||
23 | each calendar year:
| ||||||
24 | (i) 45 days of inpatient treatment; and
| ||||||
25 | (ii) beginning on June 26, 2006 (the effective date | ||||||
26 | of Public Act 94-921), 60 visits for outpatient |
| |||||||
| |||||||
1 | treatment including group and individual
outpatient | ||||||
2 | treatment; and | ||||||
3 | (iii) for plans or policies delivered, issued for | ||||||
4 | delivery, renewed, or modified after January 1, 2007 | ||||||
5 | (the effective date of Public Act 94-906),
20 | ||||||
6 | additional outpatient visits for speech therapy for | ||||||
7 | treatment of pervasive developmental disorders that | ||||||
8 | will be in addition to speech therapy provided pursuant | ||||||
9 | to item (ii) of this subparagraph (A);
| ||||||
10 | (B) may not include a lifetime limit on the number of | ||||||
11 | days of inpatient
treatment or the number of outpatient | ||||||
12 | visits covered under the plan; and
| ||||||
13 | (C) shall include the same amount limits, deductibles, | ||||||
14 | copayments, and
coinsurance factors for serious mental | ||||||
15 | illness as for physical illness.
| ||||||
16 | (5) An issuer of a group health benefit plan may not count | ||||||
17 | toward the number
of outpatient visits required to be covered | ||||||
18 | under this Section an outpatient
visit for the purpose of | ||||||
19 | medication management and shall cover the outpatient
visits | ||||||
20 | under the same terms and conditions as it covers outpatient | ||||||
21 | visits for
the treatment of physical illness.
| ||||||
22 | (6) An issuer of a group health benefit
plan may provide or | ||||||
23 | offer coverage required under this Section through a
managed | ||||||
24 | care plan.
| ||||||
25 | (7) This Section shall not be interpreted to require a | ||||||
26 | group health benefit
plan to provide coverage for treatment of:
|
| |||||||
| |||||||
1 | (A) an addiction to a controlled substance or cannabis | ||||||
2 | that is used in
violation of law; or
| ||||||
3 | (B) mental illness resulting from the use of a | ||||||
4 | controlled substance or
cannabis in violation of law.
| ||||||
5 | (8)
(Blank).
| ||||||
6 | (9) On and after June 1, 2010, coverage for the treatment | ||||||
7 | of mental and emotional disorders as provided by subsections | ||||||
8 | (a) and (b) of this Section shall not be denied under the | ||||||
9 | policy, provided that services are medically necessary as | ||||||
10 | determined by the insured's treating physician. For purposes of | ||||||
11 | this Section, "medically necessary" means health care services | ||||||
12 | appropriate, in terms of type, frequency, level, setting, and | ||||||
13 | duration, to the enrollee's diagnosis or condition, and | ||||||
14 | diagnostic testing and preventive services. Medically | ||||||
15 | necessary care must be consistent with generally accepted | ||||||
16 | practice parameters as determined by health care providers in | ||||||
17 | the same or similar general specialty as typically manages the | ||||||
18 | condition, procedure, or treatment at issue and must be | ||||||
19 | intended to either help restore or maintain the enrollee's | ||||||
20 | health or prevent deterioration of the enrollee's condition. | ||||||
21 | Upon request of the reimbursing insurer, a provider of | ||||||
22 | treatment of serious mental illness shall furnish medical | ||||||
23 | records or other necessary data that substantiate that initial | ||||||
24 | or continued treatment is at all times medically necessary. | ||||||
25 | (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; | ||||||
26 | 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff. |
| |||||||
| |||||||
1 | 8-21-07; 95-972, eff. 9-22-08; 95-973, eff. 1-1-09; revised | ||||||
2 | 10-14-08.)
| ||||||
3 | (215 ILCS 5/Art. XLV heading new) | ||||||
4 | ARTICLE XLV. MINIMUM MEDICAL LOSS RATIO LAW | ||||||
5 | (215 ILCS 5/1501 new) | ||||||
6 | Sec. 1501. Short title. This Law may be cited as the | ||||||
7 | Minimum Medical Loss Ratio Law.
| ||||||
8 | (215 ILCS 5/1505 new)
| ||||||
9 | Sec. 1505. Purpose. The General Assembly recognizes that a | ||||||
10 | significant share of the premium dollars paid by individuals | ||||||
11 | and small employers to health insurers and health maintenance | ||||||
12 | organizations is directed toward administrative and marketing | ||||||
13 | activities and profit. It is the intent of this Law to ensure | ||||||
14 | that premium costs for consumers more accurately reflect the | ||||||
15 | value of health care they receive by increasing the portion of | ||||||
16 | premium dollars dedicated to medical services.
| ||||||
17 | (215 ILCS 5/1510 new)
| ||||||
18 | Sec. 1510. Definitions. In this Law: | ||||||
19 | "Company" means any entity that provides health insurance | ||||||
20 | in this State. For the purposes of this Law, company includes a | ||||||
21 | licensed insurance company, a health maintenance organization, | ||||||
22 | or any other entity providing a plan of health insurance or |
| |||||||
| |||||||
1 | health benefits subject to State insurance regulation. | ||||||
2 | "Division" means the Division of Insurance within the | ||||||
3 | Illinois Department of Financial and Professional Regulation. | ||||||
4 | "Health benefit plan" means any hospital or medical | ||||||
5 | expense-incurred policy, hospital or medical service plan | ||||||
6 | contract, or health maintenance organization subscriber | ||||||
7 | contract. "Health benefit plan" shall not include | ||||||
8 | accident-only, credit, dental, vision, Medicare supplement, | ||||||
9 | hospital indemnity, long term care, specific disease, stop loss | ||||||
10 | or disability income insurance, coverage issued as a supplement | ||||||
11 | to liability insurance, workers' compensation or similar | ||||||
12 | insurance, or automobile medical payment insurance. | ||||||
13 | "Health care benefits" means health care services that are | ||||||
14 | either provided or reimbursed by a managed care entity or its | ||||||
15 | contracted providers as benefits to its policyholders and | ||||||
16 | insurers. Health care benefits shall include: | ||||||
17 | (A) The costs of programs or activities, including | ||||||
18 | training and the provision of informational materials that | ||||||
19 | are determined as part of the regulation to improve the | ||||||
20 | provision of quality care, improve health care outcomes, or | ||||||
21 | encourage the use of evidence-based medicine. | ||||||
22 | (B) Disease management expenses using cost-effective | ||||||
23 | evidence-based guidelines. | ||||||
24 | (C) Plan medical advice by telephone. | ||||||
25 | (D) Payments to providers as risk pool payments of | ||||||
26 | pay-for-performance initiatives. |
| |||||||
| |||||||
1 | "Health care benefits" shall not include administrative | ||||||
2 | costs as determined by the Division. | ||||||
3 | "Individual market" means the individual market as defined | ||||||
4 | by the Illinois Health Insurance Portability and | ||||||
5 | Accountability Act. | ||||||
6 | "Small group market" means small group market as defined by | ||||||
7 | the Illinois Health Insurance Portability and Accountability | ||||||
8 | Act.
| ||||||
9 | (215 ILCS 5/1515 new)
| ||||||
10 | Sec. 1515. Minimum medical loss requirement for companies | ||||||
11 | offering coverage in the individual and small group market. | ||||||
12 | (a) Any company selling a health benefit plan in the | ||||||
13 | individual or small group market shall, on and after June 1, | ||||||
14 | 2011, expend in the form of health care benefits no less than | ||||||
15 | 75% of the aggregate dues, fees, premiums, or other periodic | ||||||
16 | payments received by the company. For purposes of this Section, | ||||||
17 | the company may deduct from the aggregate dues, fees, premiums, | ||||||
18 | or other periodic payments received by the company the amount | ||||||
19 | of income taxes or other taxes that the company expensed. | ||||||
20 | (b) To assess compliance with this Section, a company with | ||||||
21 | a valid certificate of authority may average its total costs | ||||||
22 | across all health benefit plans issued, amended, or renewed in | ||||||
23 | Illinois, and all health benefit plans issued, amended, or | ||||||
24 | renewed by its affiliated companies that are licensed to | ||||||
25 | operate in Illinois. |
| |||||||
| |||||||
1 | (c) The Division shall adopt rules to implement this | ||||||
2 | Section and to establish uniform reporting by companies of the | ||||||
3 | information necessary to determine compliance with this | ||||||
4 | Section. | ||||||
5 | (d) The Division may exclude from the determination of | ||||||
6 | compliance with the requirement of subsection (a) of this | ||||||
7 | Section any new health benefit plans for up to the first 2 | ||||||
8 | years that these health benefit plans are offered for sale in | ||||||
9 | Illinois, provided that the Division determines that the new | ||||||
10 | health benefit plans are substantially different from the | ||||||
11 | existing health benefit plans being issued, amended, or renewed | ||||||
12 | by the company seeking the exclusion.
| ||||||
13 | Section 10. The Managed Care Reform and Patient Rights Act | ||||||
14 | is amended by changing Section 90 as follows:
| ||||||
15 | (215 ILCS 134/90)
| ||||||
16 | Sec. 90. Office of Consumer Health Insurance.
| ||||||
17 | (a) The Director of Insurance shall establish the Office of | ||||||
18 | Consumer
Health Insurance within the Department of Insurance to | ||||||
19 | provide assistance and
information to all health care consumers | ||||||
20 | within the State and to ensure that persons covered by health | ||||||
21 | insurance companies or health care plans are provided benefits | ||||||
22 | due under the Illinois Insurance Code and related statutes and | ||||||
23 | are protected from health insurance company and health care | ||||||
24 | plan actions or policy provisions that are unjust, unfair, |
| |||||||
| |||||||
1 | inequitable, ambiguous, misleading, inconsistent, deceptive, | ||||||
2 | or contrary to the law or to the public policy of this State or | ||||||
3 | that unreasonably or deceptively affect the risk purposed to be | ||||||
4 | assumed . Within the
appropriation allocated, the Office shall | ||||||
5 | provide information and assistance to
all health care | ||||||
6 | consumers . by The responsibilities of the Office shall include, | ||||||
7 | but not be limited to, the following :
| ||||||
8 | (1) assisting consumers in understanding health | ||||||
9 | insurance marketing
materials and
the coverage provisions | ||||||
10 | of individual plans;
| ||||||
11 | (2) educating enrollees about their rights within | ||||||
12 | individual plans;
| ||||||
13 | (3) assisting enrollees with the process of filing | ||||||
14 | formal
grievances and appeals;
| ||||||
15 | (4) establishing and operating a toll-free "800" | ||||||
16 | telephone number
line to handle
consumer inquiries;
| ||||||
17 | (5) making related information available in languages | ||||||
18 | other than English
that
are spoken as a primary language by | ||||||
19 | a significant portion of the State's
population, as | ||||||
20 | determined by the Department;
| ||||||
21 | (6) analyzing, commenting on, monitoring, and making | ||||||
22 | publicly available
reports
on the development and | ||||||
23 | implementation of federal, State, and local laws,
| ||||||
24 | regulations, and other governmental policies and actions | ||||||
25 | that pertain to the
adequacy of health care plans, | ||||||
26 | facilities, and services in the State;
|
| |||||||
| |||||||
1 | (7) filing an annual report with the Governor, the | ||||||
2 | Director, and the
General
Assembly, which shall contain | ||||||
3 | recommendations for improvement of the regulation
of | ||||||
4 | health insurance plans, including recommendations on | ||||||
5 | improving health care
consumer assistance and patterns, | ||||||
6 | abuses, and progress that it has identified
from its | ||||||
7 | interaction with health care consumers; and
| ||||||
8 | (8) performing oversight of health insurance companies | ||||||
9 | and health care plans with respect to: | ||||||
10 | (A) improper claims practices as set forth in | ||||||
11 | Sections 154.5 and 154.6 of the Illinois Insurance | ||||||
12 | Code; | ||||||
13 | (B) emergency services; | ||||||
14 | (C) compliance with this Act; | ||||||
15 | (D) ensuring proper coverage for mental health | ||||||
16 | treatment; | ||||||
17 | (E) reviewing insurance company and health care | ||||||
18 | plan underwriting, rating, and rescission practices; | ||||||
19 | and | ||||||
20 | (F) reviewing insurance company and health care | ||||||
21 | plan billing practices, including, but not limited to, | ||||||
22 | consumer cost-sharing that results from co-pay, | ||||||
23 | deductible, and provider network provisions; | ||||||
24 | (9) assisting health insurance companies and health | ||||||
25 | care plan consumers with respect to the exercise of the | ||||||
26 | grievance and appeals rights established in the Illinois |
| |||||||
| |||||||
1 | Insurance Code; | ||||||
2 | (10) if an external independent review decision | ||||||
3 | upholds a determination adverse to the patient, the patient | ||||||
4 | has the right to appeal the final decision to the Office; | ||||||
5 | if the external review decision is found by the Director | ||||||
6 | through the Office to have been arbitrary and capricious, | ||||||
7 | then the Director, with consultation from a licensed | ||||||
8 | medical professional, may overturn the external review | ||||||
9 | decision and require the health insurance company or health | ||||||
10 | care plan to pay for the health care service or treatment; | ||||||
11 | such decision, if any, shall be made solely on the legal or | ||||||
12 | medical merits of the claim; and
| ||||||
13 | (11) (8) performing all duties assigned to the Office | ||||||
14 | by the Director.
| ||||||
15 | (b) The report required under subsection (a)(7) shall be | ||||||
16 | filed by January
31, 2001 and each January 31 thereafter.
| ||||||
17 | (c) Nothing in this Section shall be interpreted to | ||||||
18 | authorize access to or
disclosure of individual patient or | ||||||
19 | health care professional or provider
records.
| ||||||
20 | (d) The Director, in his or her discretion, may issue a | ||||||
21 | Notice of Hearing requiring a health insurance company or | ||||||
22 | health care plan to appear at a hearing for the purpose of | ||||||
23 | determining the health insurance company or health care plan's | ||||||
24 | compliance with the duties and responsibilities listed in this | ||||||
25 | Act and in the Illinois Insurance Code. | ||||||
26 | (e) Nothing in this Section shall diminish or affect the |
| |||||||
| |||||||
1 | powers and authority of the Director of Insurance otherwise set | ||||||
2 | forth in this Act and in the Illinois Insurance Code. | ||||||
3 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
4 | Section 99. Effective date. This Act takes effect January | ||||||
5 |