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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

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