Bill Text: IL SB2721 | 2011-2012 | 97th General Assembly | Amended

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Bill Title: Amends the Illinois Savings and Loan Act of 1985. Makes a technical change in a Section concerning the short title.

Sponsorship: Partisan Bill (Democrat 1)

Status: (Failed) 2013-01-08 - Session Sine Die [SB2721 Detail]

Download: Illinois-2011-SB2721-Amended.html

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Sen. William R. Haine

Filed: 4/25/2012

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AMENDMENT TO SENATE BILL 2721
AMENDMENT NO. ______. Amend Senate Bill 2721 by replacing
everything after the enacting clause with the following:
"Section 1. Short title. This Act may be cited as the
Exclusive Provider Benefit Plan Act.
Section 5. For the purposes of this Act:
"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.
"Director" means the Director of Insurance.
"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

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to furnish those services that are needed to evaluate or
stabilize an emergency medical condition. "Emergency services"
does not include post-stabilization medical services.
"Enrollee" means any person and his or her dependents
enrolled in or covered by an exclusive provider benefit plan.
"Exclusive provider" means a provider or health care
provider, or an organization of providers or health care
providers, who contracts with an insurer to provide medical
care or health care to insureds covered by a health insurance
policy.
"Exclusive provider benefit plan" means a benefit plan in
which an insurer contracts with a provider to provide some
services to an insured, not including emergency care services
required under Section 65 of the Managed Care Reform and
Patients Right Act, provided by a health care provider who is a
non-exclusive provider.
"Health care provider" means a provider, institutional
provider, or other person or organization that furnishes health
care services and that is licensed or otherwise authorized to
practice in this State.
"Health care services" means any services included in the
furnishing of medical care to any individual, 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.

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"Health insurance policy" means a group or individual
insurance policy, certificate, or contract providing benefits
for medical or surgical expenses incurred as a result of an
accident or sickness.
"Hospital" means an institution licensed under the
Hospital Licensing Act, an institution that meets all
comparable conditions and requirements in effect in the state
in which it is located, or the University of Illinois Hospital
as defined in the University of Illinois Hospital Act.
"Institutional provider" means a hospital, nursing home,
or other medical or health-related service facility that
provides care for the sick or injured or other care that may be
covered in a health insurance policy.
"Insurer" means an insurance company or a health service
corporation authorized in this State to issue policies or
subscriber contracts that reimburse for expense of health care
services.
"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.
"Preauthorization" means a determination by an insurer
that medical care or health care services proposed to be
provided to a patient are medically necessary and appropriate.

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"Provider" means an individual or entity duly licensed or
legally authorized to provide health care services.
"Service area" means a geographic area or areas specified
in an exclusive provider benefit contract in which a network of
exclusive providers is offered and available.
"Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to ensure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
Section 10. Exclusive provider benefit plans permitted. An
exclusive provider benefit plan that meets the requirements of
this Act shall be permitted. To the extent of any conflict
between this Section and any other statutory provision, this
Section prevails over the conflicting provision. The Director
of Insurance may adopt rules necessary to implement the
Department's responsibilities under this Act.
Section 15. Applicability of this Act.
(a) Except as otherwise specifically provided by this
Section, this Section applies to each individual or group
exclusive provider benefit plan in which an insurer provides,
through the insurer's health insurance policy, for the payment
of coverage only for the use of an exclusive provider network,
other than the use of a non-exclusive provider for emergency

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care services.
(b) Unless otherwise specified, an exclusive provider
benefit plan is subject to this Section.
(c) This Act does not apply to:
(1) the Children's Health Insurance Program under the
Children's Health Insurance Program Act;
(2) a Medicaid managed care program under Article V of
the Illinois Public Aid Code; or
(3) an HMO under Article I of the Health Maintenance
Organization Act.
(d) An insurer duly licensed under the laws of this State
may offer exclusive provider benefit plans to individuals and
group health plans in conformity with the terms set forth in
this Section. An insurer shall not be required to be licensed
as an HMO under the Health Maintenance Organization Act in
order to offer exclusive provider benefit plans under this
Section.
Section 20. Applicability of Health Carrier External
Review Act. The Health Carrier External Review Act shall apply
to an exclusive provider benefit plan, except to the extent
that the Director determines the provision to be inconsistent
with the function and purpose of an exclusive provider benefit
plan.
Section 25. Construction of Act.

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(a) This Act may not be construed to limit the level of
reimbursement or the level of coverage, including deductibles,
copayments, coinsurance, or other cost-sharing provisions,
that are applicable to exclusive providers.
(b) Except as specifically provided for in this Act, this
Act may not be construed to require an exclusive provider
benefit plan to compensate a non-exclusive provider for
services provided to an insured.
Section 30. Provision of information.
(a) An exclusive provider benefit plan shall provide
annually to enrollees and prospective enrollees, upon request,
a complete list of exclusive providers in the exclusive
provider benefit plan 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, if applicable, procedures and requirements;
(4) a description of 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

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copayments, deductibles, premiums, and any other
out-of-pocket expenses;
(8) the provisions for continuity of treatment in the
event an exclusive provider's participation terminates
during the course of an enrollee's treatment by that
exclusive 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, if applicable, including a
phone number to call to receive more information from the
exclusive provider benefits 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, an exclusive provider benefit
plan shall provide to enrollees a description of the financial
relationships between the exclusive provider benefit 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,

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deductibles, and total premiums spent on other expenses,
including administrative expenses, except that no exclusive
provider benefit plan shall be required to disclose specific
provider reimbursement.
(c) An exclusive provider shall provide all of the
following, where applicable, to enrollees upon request:
(1) Information related to the exclusive provider's
educational background, experience, training, specialty,
and board certification, if applicable.
(2) The names of licensed facilities on the provider
panel where the exclusive provider presently has
privileges for the treatment, illness, or procedure that is
the subject of the request.
(3) Information regarding the exclusive provider's
participation in continuing education programs and
compliance with any licensure, certification, or
registration requirements, if applicable.
(d) An exclusive provider benefit 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 of Insurance shall adopt
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.

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(e) An identification card or similar document issued by an
insurer to an insured in an exclusive provider benefit plan
must display:
(1) a toll-free number that a physician or health care
provider may use to obtain the date on which the insured
became insured under the plan; and
(2) the acronym "EPO" or the phrase "Exclusive Provider
Organization" on the card in a location of the insurer's
choice.
(f) The written disclosure requirements of this Section may
be met by disclosure to one enrollee in a household.
Section 35. Availability of exclusive providers.
(a) An insurer offering an exclusive provider benefit plan
shall ensure that the exclusive provider benefits are
reasonably available to all insureds within a designated
service area.
(b) If services are not available through an exclusive
provider within a designated service area under an exclusive
provider benefit plan, an insurer shall reimburse a physician
or health care provider who is a non-exclusive provider at the
same percentage level of benefit as an exclusive provider would
have been reimbursed had the insured been treated by an
exclusive provider.
Section 40. Notice of nonrenewal or termination. An

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exclusive provider benefit plan must give at least 60 days
notice of nonrenewal or termination of an exclusive provider to
the exclusive provider and to the enrollees served by the
exclusive provider. The notice shall include a name and address
to which an enrollee or exclusive provider may direct comments
and concerns regarding the nonrenewal or termination.
Immediate written notice may be provided without 60 days notice
when a health care provider's license has been disciplined by a
state licensing board.
Section 45. Transition of service.
(a) An exclusive provider benefit plan shall provide for
continuity of care for its enrollees as follows:
(1) If an enrollee's physician leaves the exclusive
provider benefit 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 exclusive provider benefit
plan's service area, the exclusive provider benefit plan
shall permit the enrollee to continue an ongoing course of
treatment with that physician during a transitional
period:
(A) of 90 days after the date of the notice of the
physician's termination from the health care plan to
the enrollee of the physician's disaffiliation from

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the health care plan if the enrollee has an ongoing
course of treatment; or
(B) that includes the provision of post-partum
care directly related to the delivery, if the enrollee
has entered the third trimester of pregnancy at the
time of the physician's disaffiliation.
(2) Notwithstanding the provisions in paragraph (1) of
this subsection (a), such care shall be authorized by the
exclusive provider benefit plan during the transitional
period only if the physician agrees:
(A) to continue to accept reimbursement from the
exclusive provider benefit plan at the rates
applicable prior to the start of the transitional
period;
(B) to adhere to the exclusive provider benefit
plan's quality assurance requirements and to provide
to the exclusive provider benefit plan necessary
medical information related to such care; and
(C) to otherwise adhere to the exclusive provider
benefit plan's policies and procedures, including, but
not limited to, procedures regarding referrals and
obtaining preauthorizations for treatment.
(b) An exclusive provider benefit 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 exclusive provider benefit plan's provider network,

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but is within the exclusive provider benefit plan's service
area, enrolls in the exclusive provider benefit plan, the
exclusive provider benefit 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 after the effective date of
enrollment if the enrollee has an ongoing course of
treatment; or
(B) that includes the provision of post-partum
care directly related to the delivery, if the enrollee
has entered the third trimester of pregnancy at the
effective date of enrollment.
(2) If an enrollee elects to continue to receive care
from such physician pursuant to paragraph (1) of this
subsection (a), such care shall be authorized by the
exclusive provider benefit plan for the transitional
period only if the physician agrees:
(A) to accept reimbursement from the exclusive
provider benefit plan at rates established by the
exclusive provider benefit plan; such rates shall be
the level of reimbursement applicable to similar
physicians within the exclusive provider benefit plan
for such services;
(B) to adhere to the exclusive provider benefit
plan's quality assurance requirements and to provide
to the exclusive provider benefit plan necessary

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medical information related to such care; and
(C) to otherwise adhere to the exclusive provider
benefit 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
an exclusive provider benefit plan to provide coverage for
benefits not otherwise covered or to diminish or impair
preexisting condition limitations contained in the enrollee's
contract.
Section 50. Prohibitions.
(a) No exclusive provider benefit 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, if
applicable, and quality assurance policies, terms, and
conditions of plans, and plan policy with enrollees,
prospective enrollees, providers, or the public.
(b) No exclusive provider benefit 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.

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Section 55. Exclusive provider benefit plans; access to
specialists.
(a) When the type of specialist physician or other health
care provider needed to provide care for a specific condition
is not represented in the exclusive provider benefit plan's
network, the exclusive provider benefit plan shall allow for
the enrollee to have access to a non-exclusive 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 if it is determined by a licensed
clinical peer that the service or treatment of the specific
condition is medically necessary and such services or
treatments are not available through the exclusive provider
benefit plan network. Coverage for all services performed in
accordance with this Section shall be at the same benefit level
as if the service or treatment had been rendered by an
exclusive provider.
(b) If an exclusive provider benefit plan denies an
enrollee's request for a specialist physician or other health
care provider that is not represented in the exclusive provider
benefit plan's network, an enrollee may appeal the decision
through the exclusive provider benefit plan's external
independent review process as provided by the Health Carrier
External Review Act.

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Section 60. Health care services appeals, complaints, and
external independent reviews.
(a) An exclusive provider benefit plan shall establish and
maintain an appeals procedure as outlined in this Act.
Compliance with this Act's appeals procedures shall satisfy an
exclusive provider benefit plan's obligation to provide appeal
procedures under any other State law or rules.
(b) When an appeal concerns a decision or action by an
exclusive provider benefit 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 exclusive provider benefit plan must
allow for the filing of an appeal either orally or in writing.
Upon submission of the appeal, an exclusive provider benefit
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 exclusive
provider benefit plan requires to evaluate the appeal. The
exclusive provider benefit plan shall render a decision on the
appeal within 24 hours after receipt of the required
information. The exclusive provider benefit plan shall notify

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the party filing the appeal and the enrollee 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, not covered by subsection (b) of this Section, the
exclusive provider benefit plan shall establish a procedure for
the filing of such appeals. Upon submission of an appeal under
this subsection (c), an exclusive provider benefit plan must
notify the party filing an appeal, within 3 business days after
the submission, of all information that the plan requires to
evaluate the appeal. The exclusive provider benefit 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, 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 subsections (b) or (c) of this Section
may be filed by the enrollee, the enrollee's designee or
guardian, or the enrollee's health care provider. An exclusive
provider benefit 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

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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 Health Carrier External Review Act.
(e) If an appeal filed under subsections (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
Health Carrier External Review Act.
(f) Future contractual or employment action by the
exclusive provider benefit 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 Health Carrier External
Review Act.
(g) Nothing in this Section shall be construed to require
an exclusive provider benefit plan to pay for a health care

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service not covered under the enrollee's certificate of
coverage or policy.
Section 65. Emergency services prior to stabilization.
(a) An exclusive provider benefit 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

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health care provider.
For the purposes of this subsection (c), "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 9-1-1 emergency telephone
system or its local equivalent shall not be discouraged or
penalized by the exclusive provider benefit plan when an
emergency medical condition exists. This provision shall not
imply that the use of the 9-1-1 emergency telephone system 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

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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.
Section 70. Post-stabilization medical services.
(a) If prior authorization for covered post-stabilization
services is required by the exclusive provider benefit 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.
(b) The treating physician licensed to practice medicine in
all its branches or health care provider shall contact the
exclusive provider benefit 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 exclusive provider
benefit plan shall provide reimbursement for covered
post-stabilization medical services if:

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(1) authorization to render them is received from the
exclusive provider benefit 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 exclusive provider benefit 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.
For the purposes of this subsection (c), "2 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.
(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 exclusive provider
benefit 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 exclusive
provider benefit plan or delegated health care provider for

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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) of this Section;
(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 exclusive provider benefit 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 exclusive provider
benefit plan; or
(5) upon material misrepresentation by the enrollee or
health care provider.
For the purposes of this subsection (e), "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 an exclusive provider
benefit plan from delegating tasks associated with the
responsibilities enumerated in this Section to the exclusive
provider benefit plan's contracted health care providers or

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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.
Section 75. Quality assessment program.
(a) An exclusive provider benefit plan shall develop and
implement a quality assessment and improvement strategy
designed to identify and evaluate accessibility, continuity,
and quality of care. The exclusive provider benefit 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 exclusive
provider benefit plan to assess:
(A) the accessibility to health care providers;
(B) appropriateness of utilization;
(C) concerns identified by the exclusive provider
benefit plan's medical or administrative staff and
enrollees; and

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(D) other aspects of care and service directly
related to the improvement of quality of care;
(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; and
(4) follow-up measures implemented to evaluate the
effectiveness of the action plan.
(b) The exclusive provider benefit plan shall establish a
committee that oversees the quality assessment and improvement
strategy that includes physician and enrollee participation.
(c) Reports on quality assessment and improvement
activities shall be made to the governing body of the exclusive
provider benefit plan not less than quarterly.
(d) The exclusive provider benefit 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

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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 an
exclusive provider benefit 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 may
subject the exclusive provider benefit plan to penalties, as
provided in this Act, for such non-compliance.
Section 80. Utilization review. If an exclusive provider
benefit plan conducts a utilization review program in this
State, then the exclusive provider benefit plan shall do so in
accordance with Section 85 of the Managed Care Reform and
Patient Rights Act.
Section 85. Examinations and fees. The Director may examine
an insurer to determine the quality and adequacy of a network
used by an exclusive provider benefit plan offered by the
insurer under this Act. An insurer is subject to a qualifying
examination of the insurer's exclusive provider benefit plans
and subsequent quality of care examinations by the Director at
least once every 5 years. Documentation provided to the
Director during an examination conducted under this Section is
confidential and is not subject to disclosure as public

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information under the Freedom of Information Act.
Section 900. The Freedom of Information Act is amended by
changing Section 7.5 as follows:
(5 ILCS 140/7.5)
Sec. 7.5. Statutory Exemptions. To the extent provided for
by the statutes referenced below, the following shall be exempt
from inspection and copying:
(a) All information determined to be confidential under
Section 4002 of the Technology Advancement and Development Act.
(b) Library circulation and order records identifying
library users with specific materials under the Library Records
Confidentiality Act.
(c) Applications, related documents, and medical records
received by the Experimental Organ Transplantation Procedures
Board and any and all documents or other records prepared by
the Experimental Organ Transplantation Procedures Board or its
staff relating to applications it has received.
(d) Information and records held by the Department of
Public Health and its authorized representatives relating to
known or suspected cases of sexually transmissible disease or
any information the disclosure of which is restricted under the
Illinois Sexually Transmissible Disease Control Act.
(e) Information the disclosure of which is exempted under
Section 30 of the Radon Industry Licensing Act.

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(f) Firm performance evaluations under Section 55 of the
Architectural, Engineering, and Land Surveying Qualifications
Based Selection Act.
(g) Information the disclosure of which is restricted and
exempted under Section 50 of the Illinois Prepaid Tuition Act.
(h) Information the disclosure of which is exempted under
the State Officials and Employees Ethics Act, and records of
any lawfully created State or local inspector general's office
that would be exempt if created or obtained by an Executive
Inspector General's office under that Act.
(i) Information contained in a local emergency energy plan
submitted to a municipality in accordance with a local
emergency energy plan ordinance that is adopted under Section
11-21.5-5 of the Illinois Municipal Code.
(j) Information and data concerning the distribution of
surcharge moneys collected and remitted by wireless carriers
under the Wireless Emergency Telephone Safety Act.
(k) Law enforcement officer identification information or
driver identification information compiled by a law
enforcement agency or the Department of Transportation under
Section 11-212 of the Illinois Vehicle Code.
(l) Records and information provided to a residential
health care facility resident sexual assault and death review
team or the Executive Council under the Abuse Prevention Review
Team Act.
(m) Information provided to the predatory lending database

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created pursuant to Article 3 of the Residential Real Property
Disclosure Act, except to the extent authorized under that
Article.
(n) Defense budgets and petitions for certification of
compensation and expenses for court appointed trial counsel as
provided under Sections 10 and 15 of the Capital Crimes
Litigation Act. This subsection (n) shall apply until the
conclusion of the trial of the case, even if the prosecution
chooses not to pursue the death penalty prior to trial or
sentencing.
(o) Information that is prohibited from being disclosed
under Section 4 of the Illinois Health and Hazardous Substances
Registry Act.
(p) Security portions of system safety program plans,
investigation reports, surveys, schedules, lists, data, or
information compiled, collected, or prepared by or for the
Regional Transportation Authority under Section 2.11 of the
Regional Transportation Authority Act or the St. Clair County
Transit District under the Bi-State Transit Safety Act.
(q) Information prohibited from being disclosed by the
Personnel Records Review Act.
(r) Information prohibited from being disclosed by the
Illinois School Student Records Act.
(s) Information the disclosure of which is restricted under
Section 5-108 of the Public Utilities Act.
(t) All identified or deidentified health information in

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the form of health data or medical records contained in, stored
in, submitted to, transferred by, or released from the Illinois
Health Information Exchange, and identified or deidentified
health information in the form of health data and medical
records of the Illinois Health Information Exchange in the
possession of the Illinois Health Information Exchange
Authority due to its administration of the Illinois Health
Information Exchange. The terms "identified" and
"deidentified" shall be given the same meaning as in the Health
Insurance Accountability and Portability Act of 1996, Public
Law 104-191, or any subsequent amendments thereto, and any
regulations promulgated thereunder.
(u) Records and information provided to an independent team
of experts under Brian's Law.
(v) Names and information of people who have applied for or
received Firearm Owner's Identification Cards under the
Firearm Owners Identification Card Act.
(w) (v) Personally identifiable information which is
exempted from disclosure under subsection (g) of Section 19.1
of the Toll Highway Act.
(x) All identified or deidentified health information in
the form of health data or medical records in possession of the
Department of Insurance due to the Department's administration
of the Exclusive Provider Benefit Plan Act.
(Source: P.A. 96-542, eff. 1-1-10; 96-1235, eff. 1-1-11;
96-1331, eff. 7-27-10; 97-80, eff. 7-5-11; 97-333, eff.

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8-12-11; 97-342, eff. 8-12-11; revised 9-2-11.)
Section 999. Effective date. This Act takes effect upon
becoming law.".