reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Section 4520.60 - Transition of Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Health care
			 plans shall notify new enrollees and current enrollees of the availability of
			 transitional services for conditions that require ongoing course of
			 treatment.
b) New enrollees must
			 request the option of transitional services in writing, within 15 days after
			 receiving notification of the availability of transitional services, through a
			 mechanism established by the health care plan.
c) Enrollees whose physician leaves the
			 health care plan's network of health care providers shall request the option of
			 transitional services in writing within 30 days after receipt of notification
			 of termination of the physician.
d)
			 Within 15 days after receiving such notification from the enrollee, the health
			 care plan shall notify the enrollee if a denial is issued for the enrollee's
			 request of transitional services based on the enrollee's physician refusing to
			 agree to accept the health care plan's reimbursement rates, adhere to the
			 health care plan's quality assurance requirements, provide the health care plan
			 with necessary medical information related to the enrollee's care, or otherwise
			 adhere to the health care plan's policies and procedures. The notification
			 shall be in writing and include the specific reason for such denial.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Section 4520.70 - Health Care Services, Appeals, Complaints and External Independent Reviews

Current through Register Vol. 48, No. 28, July 12, 2024
a) A plan shall
			 implement an effective appeals process for appeals of coverage determinations
			 and claims, under which the health care plan shall, at a minimum:
1) have in effect an internal claims appeal
			 process;
2) provide notice to
			 enrollees, in a culturally and linguistically appropriate manner, of available
			 internal and external appeals processes, and the availability of Department
			 consumer assistance to assist enrollees with the appeals processes;
			 and
3) allow an enrollee to review
			 his or her file, to present evidence and testimony as part of the appeals
			 process, and to receive continued coverage pending the outcome of the appeals
			 process. (Section 2719 of the Public Health Service Act;
			 42
			 USC 201 et seq.)
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Section 4520.80 - Joint Resolution of Complaints - Department of Insurance and Department of Public Health - Notification and Resolution Process

Current through Register Vol. 48, No. 28, July 12, 2024
a) Complaints against health care plans
			 participating in programs administered by the Department of Healthcare and
			 Family Services (HFS) pursuant to the Public Aid Code shall be resolved under
			 rules published by HFS. Any complaints against such plans received by the
			 Department of Insurance or the Department of Public Health shall be referred to
			 HFS.
b) Any enrollee or health care
			 provider, on behalf of the enrollee, may file a written complaint against the
			 health care plan through the Department of Insurance. Complaints received by
			 the Department of Public Health shall be referred to the Department of
			 Insurance for processing prior to investigation.
c) The health care plan response shall
			 include documentation and an explanation of all actions taken or not taken that
			 were the basis for the complaint. The respondent shall include documents
			 necessary to support the respondent's position and any additional information
			 requested by the Department of Insurance and/or the Department of Public
			 Health. Both the Department of Insurance and the Department of Public Health
			 shall maintain confidentiality of medical records and other pertinent
			 documents.
d) Quality of care
			 complaints may be referred to the Department of Public Health for
			 investigation.
1) The Department of Public
			 Health shall determine if an on-site investigation is warranted and may request
			 additional information from the complainant, health care provider, or health
			 care plan if the information provided is determined to be incomplete or if
			 additional information is needed to make a determination regarding the
			 complaint.
2) If an investigation
			 is warranted, the Department of Public Health shall make available the name,
			 address and telephone number where an enrollee may obtain the status of the
			 complaint.
3) The Department of
			 Public Health shall forward the findings of the investigation to the Department
			 for final disposition and record keeping.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Section 4520.90 - Record of Complaints

Current through Register Vol. 48, No. 28, July 12, 2024
a)
			 Complaint, as used in this Section, means any communication primarily
			 expressing a grievance to the health care plan by, or on behalf of, the
			 enrollee, or by the health care provider. For purposes of this definition,
			 "communication" shall include the following:
1) A written notice relating to the health
			 care plan's determinations, procedures and administration as stated in Sections
			 45 and 50 of the Act; and
2)
			 Written or oral notice filed under the expedited health care services appeal
			 process or under the utilization review process.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Section 4520.100 - Access and Quality of Care from Providers Without Primary Care Physician Referral or Authorization

Current through Register Vol. 48, No. 28, July 12, 2024
a)
			 Health care plans that allow enrollees to access health care services from
			 contractual providers without a referral or authorization from the primary care
			 physician (PCP) shall have in place a system for centralized record keeping to
			 track and monitor the provider/enrollee encounters to assure that enrollees are
			 receiving needed services.
b) The
			 health care plan's centralized record keeping system for access and quality of
			 care shall be described in detail, filed with and deemed acceptable by the
			 Director of Public Health. The Director of Public Health shall forward a copy
			 of the approved system for record keeping and the notice of his or her final
			 action with the Department of Insurance.
c) The health care plan shall be able to
			 retrieve an enrollee's centralized record of the provider/enrollee encounters
			 for review by the Department and/or Department of Public Health as part of a
			 complaint investigation or inquiry.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Section 4520.110 - Emergency Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) For purposes
			 of determining compliance with Section 65 of the Act, timely determination
			 shall mean a determination is made within 30 days after the health care plan
			 receives a claim for emergency services if no additional information is needed
			 to determine the emergency services meet the definition of an emergency medical
			 condition. In the event additional information is necessary to make the
			 determination, the health care plan shall request the medical record
			 documenting the presenting symptoms at the time care was sought within 15 days
			 after receipt of the emergency services claim and make a determination within
			 30 days after its receipt.
b) If a
			 group health care plan offering group or individual health insurance, provides
			 or covers any benefits with respect to services in an emergency department of a
			 hospital, the plan shall cover emergency services in a manner that those
			 services will be provided without imposing a requirement under the plan for
			 prior authorization of services or any limitation on coverage when the provider
			 of services does not have a contractual relationship with the plan for the
			 providing of services that is more restrictive than the requirements or
			 limitations that apply to emergency department services received from providers
			 who do have such a contractual relationship with the plan.
c) In addition to complying with the coverage
			 requirements provided in 50 Ill. Adm. Code
			 2051.310(a)(6)(J),
			 if emergency services are provided out-of-network, the cost-sharing requirement
			 (expressed as a copayment amount or coinsurance rate) is the same requirement
			 that would apply if the services were provided in-network. (Section 2719A(b)
			 and (c)(ii) of the Public Health Service Act (
			 42 USC
			 300 gg-19(1)))
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Section 4520.120 - Post Stabilization Services

Current through Register Vol. 48, No. 28, July 12, 2024
For purposes of determining compliance with Section 70 of the
				Act, timely determination shall mean a determination is made within 30 days
				after the health care plan receives a claim for post stabilization services if
				no additional information is needed to determine that services rendered were
				not contrary to the instructions of the health care plan or its delegated
				health care provider if the contact was made between those parties and the
				treating health care provider prior to the services being rendered. In the
				event additional information is necessary to make such a determination, the
				health care plan shall request the medical record documenting the time, phone
				number dialed, and the result of the communication for request for
				authorization of post stabilization medical services as well as the post
				stabilization medical services rendered within 15 days after receipt of the
				post stabilization services claim and make a determination within 30 days after
				its receipt.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Section 4520.140 - Operational Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
A URO shall comply with all URAC standards except when
				specifically addressed by Sections 45 and 50 of the Act for health care plans.
				The terms in Sections 45 and 50 of the Act shall have the meaning assigned by
				the Act. Utilization review decisions shall be issued pursuant to the Managed
				Care Reform and Patient Rights Act [ 215 ILCS 134 ].
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Exhibit A - Complaint Record and Column Descriptions

Current through Register Vol. 48, No. 28, July 12, 2024
1.
			 Column A. Health Care Plan Identification Number - This is the identification
			 number used by the health care plan to identify the complaint internally. The
			 identification number must be unique for each complaint.
2. Column B. Complaint Origin - complaint was
			 filed by:
a) Consumer or enrollee;
b) Provider;
c) Any other individual.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4520 - MANAGED CARE REFORM & PATIENT RIGHTS › Exhibit D - NAIC Utilization Review Organization Officers and Directors Biographical Affidavit (Repealed)

Current through Register Vol. 48, No. 28, July 12, 2024
If an affiant has any doubt about the accuracy of an answer,
				  the question should be answered in the positive and an explanation
				  provided.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.30 - Valuation of Investments

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
			 "Purposes and Procedures Manual of the NAIC Investment Analysis Office", as of
			 December 31, 2022 (National Association of Insurance Commissioners, One New
			 York Plaza, Ste. 4210, New York NY 10004) (no later editions or amendments),
			 available at
https://www.naic.org
,
			 shall be used for valuing securities for which valuations are not otherwise
			 defined by statute or rule. The Director shall disallow any procedure
			 prescribed by that manual if the Director deems it necessary to ascertain the
			 condition and affairs of the company. In making this determination, the
			 Director shall consider such factors as:
1)
			 the nature of the investment (stocks or bonds);
2) the financial condition of the issuing
			 company;
3) the applicability of
			 other standardized accounting procedures; and
4) other factors affecting the accuracy of
			 the valuation.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.40 - Grievance Procedure

Current through Register Vol. 48, No. 28, July 12, 2024
a) Every
			 HMO shall submit for the Director's approval, and maintain, a system for the
			 resolution of grievances concerning the provision of health care services or
			 other matters concerning operation of the HMO as follows. Each HMO shall:
1) Submit to the Director for prior approval
			 any proposed changes to the system by which grievances may be filed and
			 reviewed;
2) Maintain records of
			 each grievance, filed with the HMO until the grievance is resolved and for a
			 period of at least 3 years, that includes:
A)
			 A copy of the grievance, the date of its filing;
B) The date and outcome of all consultations,
			 hearings and hearing findings;
C)
			 The date and decisions of any appeal proceedings; and
D) The date and proceedings of any
			 litigation;
3) Submit to
			 the Director, in a form prescribed by the Director, a report by March 1 for the
			 previous calendar year that includes at least the following:
A) the total number of grievances
			 handled;
B) a compilation of causes
			 underlying the grievances;
C) the
			 outcomes of the grievances;
D) the
			 elapsed time from receipt of the grievance by the HMO until its conclusion;
			 and
E) the number of malpractice
			 claims filed and, if those claims have been completely adjudicated, a
			 compilation of causes, disposition, form and amount of any
			 settlements.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.60 - Rates

Current through Register Vol. 48, No. 28, July 12, 2024
a) Subject to the
			 requirements of 50 Ill. Adm. Code 2026, the HMO shall file all schedules of
			 base rates to be used in conjunction with enrollee certificates. The schedules
			 shall be filed with the Director prior to the effective date and will be
			 maintained as a public document by the Department.
b) When the schedules of base rates are
			 filed, percentage change from the previous filing for the schedules of base
			 rates shall be included.
c) Upon
			 the request of the Director, the HMO shall submit actuarial documentation for
			 any submitted rates, which shall be stamped "confidential" by the HMO.
			 Documentation shall include, but not be limited to, the major cost components,
			 experience, assumptions and procedures used to develop the submitted rates. The
			 actuarial documentation shall be deemed confidential and proprietary by the
			 Department unless specific authorization is given by the HMO.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.70 - Subordinated Indebtedness

Current through Register Vol. 48, No. 28, July 12, 2024
Subordinated indebtedness agreements (debenture) shall be
				submitted for the approval of the Director as required by Section 2-9 of the
				Act.
a) The agreement must state that:
1) All payments of principal and/or interest
			 may be made only after the HMO has obtained approval from the
			 Director;
2) The obligation of the
			 HMO under the debenture may not be offset or be subject to recoupment with
			 respect to any liability or obligation owed to the HMO; and
3) No agreement or interest securing the
			 debentures, whether existing on the date of the debenture or subsequently
			 entered, applies to the obligation under the debenture.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.90 - Conflict of Interest and Required Disclosure

Current through Register Vol. 48, No. 28, July 12, 2024
Each applicant for a Certificate of Authority shall file with
				the application, and shall immediately file any changes thereafter, disclosure
				of the following:
a) Any contractual
			 or financial arrangements between members of the Board of Directors/principal
			 officers and the HMO, including:
1) A
			 description of any obligation, specified by contract or otherwise, to be met by
			 each party in accordance with any such arrangements; and
2) A listing of the dollar amounts of any
			 consideration to be paid each party in accordance with any such
			 arrangements.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.100 - Solicitation

Current through Register Vol. 48, No. 28, July 12, 2024
a) No HMO, or
			 representative of the HMO, may cause or knowingly permit the use of
			 advertising, solicitation, or any form of evidence of coverage that is untrue,
			 misleading or deceptive.
1) All information
			 required to be disclosed pursuant to this Part shall set out conspicuously and
			 in close conjunction with the statements to which the information relates under
			 appropriate captions of the prominence that it shall not be minimized, rendered
			 obscure or presented in an ambiguous fashion or intermingled with the context
			 of the solicitation as to be confusing or misleading.
2) The format and context of a solicitation
			 of any HMO's plan or program shall be sufficiently complete and clear to avoid
			 deception or the capacity or tendency to mislead or deceive. Whether an
			 advertisement has a capacity or tendency to mislead or deceive shall be
			 determined by the Director from the overall impression that the advertisement
			 may be reasonably expected to create upon a person of average education or
			 intelligence within the segment of the public to which it is
			 directed.
3) Solicitations shall be
			 truthful and not misleading in fact or implication. Words or phrases, the
			 meaning of which is clear only by employment or by familiarity with insurance,
			 medical terminology or health care plans, shall not be used unless those words
			 or phrases are otherwise explained in the solicitation.
4) No solicitation shall omit information or
			 use words, phrases, statements, references, or illustrations if an omission of
			 the information or use of the words, phrases, statements, references or
			 illustrations has the capacity, tendency or effect of misleading or deceiving
			 prospective enrollees as to the nature or extent of any benefit payable, loss
			 covered, premium payable or health care service provided.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.111 - Cancellation

Current through Register Vol. 48, No. 28, July 12, 2024
a) No HMO shall
			 cancel a group or individual contract or evidence of coverage except for one or
			 more of the following reasons:
1) Failure of
			 the enrollee to pay the amount due under the contract or evidence of coverage,
			 for which the enrollee is legally responsible;
2) Fraud or material misrepresentation in
			 enrollment or in the use of services or facilities;
3) Material violation of the terms of the
			 contract or evidence of coverage;
4) Failure of the enrollee and the primary
			 care physician to establish a satisfactory patient-physician relationship if
			 the enrollee has repeatedly refused to follow the plan of treatment ordered by
			 the physician; it is shown that the HMO has in good faith provided the enrollee
			 with the opportunity to select an alternative primary care physician; and the
			 enrollee has been notified in writing at least 31 days in advance that the HMO
			 considers such patient-physician relationship to be unsatisfactory;
5) Under the Basic Outpatient Preventive and
			 Primary Care Services for Children Program, failure to meet or continue to meet
			 eligibility requirements as required by Section
			 5421.131
			 of this Part; or
6) Other good
			 cause agreed upon in the contract and approved by the Director pursuant to
			 Section 4-13 of the Act.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.112 - Form Filing Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
Group contracts, evidences of coverage, individual contracts,
				enrollment applications or other forms that affect the terms and conditions
				applicable to the enrollee in the provision of health care services must be
				filed with the Department pursuant to 50 Ill. Adm. Code 916. If the form is a
				revised version of a previously approved form, the HMO must provide the number
				of the previously approved form and the date it was approved by the Department,
				and highlight all changes from the previously approved form. Any changes not
				highlighted will not be deemed to be approved.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.113 - Point of Service Plan Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a) The filing as described in this subsection
			 shall be comprised of an HMO filing and an indemnity filing. The filing shall
			 be coordinated by the HMO. The filing must contain reasonable financial
			 incentives for point of service members to utilize HMO services provided or
			 arranged by the designated HMO primary care physician and shall include:
1) Copies of all policy forms necessary to
			 implement the point of service product, including the member handbook used to
			 integrate the services provided by the HMO and the benefits provided by the
			 indemnity carrier.
2) Enrollment
			 application and member identification card disclosing the names of both the HMO
			 and indemnity carrier.
3)
			 Solicitation material.
4) Copies of
			 all contracts required by Section
			 5421.50
			 between the HMO and affiliated indemnity carrier detailing their respective
			 responsibilities and obligations in offering a point of service
			 product.
5) The HMO shall include
			 in its rate filing the rate level justification and a demonstration of how the
			 out-of-network indemnity benefits to be provided by the affiliated indemnity
			 carrier will impact on the HMO's rates and underlying utilization assumptions.
			 The documentation shall be deemed confidential by the Department unless
			 specific authorization is given by the HMO.
6) Written descriptions and illustrative flow
			 charts of how the premium is received and distributed in a timely fashion and
			 how claims will be handled for payment.
7) A comparison of benefits offered by the
			 HMO carrier and the indemnity carrier.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.120 - Internal Security Standards and Fidelity Bonds

Current through Register Vol. 48, No. 28, July 12, 2024
The standards and provisions set forth in 50 Ill. Adm. Code 904
				(Internal Security Standard and Fidelity Bonds) shall apply to
				HMOs.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.131 - Basic Outpatient Preventive and Primary Health Care Services for Children

Current through Register Vol. 48, No. 28, July 12, 2024
a)
			 Eligibility.
1) A health maintenance
			 organization may undertake to provide or arrange for and to pay for or
			 reimburse the cost of basic outpatient preventive and primary health care
			 services for children in Illinois who:
A) are
			 without health care coverage:
i) through a
			 parent's employment;
ii) through
			 failure to qualify for medical assistance under the Illinois Public Aid Code or
			 failure to qualify for coverage under the State Children's Health Insurance
			 Program of the Social Security Act as amended by the Balanced Budget Act of
			 1997, P.L.
			 105-33;
iii) through any other health plan. For
			 purposes of this Section, health plan means a policy, contract, certificate or
			 agreement offered by a carrier to provide, deliver, arrange for, pay for or
			 reimburse any of the costs of health care services. Health plan does not
			 include accident-only, credit, dental, vision, Medicare supplement, partnership
			 or traditional long-term care, or disability income insurance coverage issued
			 as a supplement to liability insurance, worker's compensation or similar
			 insurance, or automobile medical payment insurance or short-term and
			 catastrophic health insurance policies, or a policy that pays on a
			 cost-incurred basis, or student insurance;
iv) due to a loss of medical assistance when
			 a parent has moved from welfare to work and does not find employment that
			 offers health care coverage;
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.132 - Required Coverage for Reconstructive Surgery Following Mastectomies

Current through Register Vol. 48, No. 28, July 12, 2024
a) As required by
			 the Federal Women's Health and Cancer Rights Act of 1998 (WHCRA) (
			 42 USC
			 300gg-6,
			 300gg-52,
			 incorporating
			 29 USC
			 1185(b) ), every individual
			 and group contract or evidence of coverage issued by a health maintenance
			 organization that provides medical and surgical benefits with respect to a
			 mastectomy shall provide, in a case of an enrollee who is receiving benefits in
			 connection with a mastectomy and who elects breast reconstruction in connection
			 with a mastectomy, coverage in a manner determined in consultation with the
			 attending physician and the patient for:
1)
			 Reconstruction for the breast on which the mastectomy has been
			 performed;
2) Surgery and
			 reconstruction of the other breast to produce a symmetrical appearance;
			 and
3) Prostheses and physical
			 complications for all stages of mastectomy, including lymphedemas.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.140 - General Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
Every HMO, having been declared to be an entity to be regulated
				for the public good, shall take care to conduct all of its affairs within the
				declared Public Policy on Fair Employment. The Congress of the United States
				and the General Assembly of Illinois have stated that discrimination in
				employment based upon race, color, religion, sex or national origin is illegal.
				Every HMO will handle all matters relating to employment in the manner required
				by Section 2-102 of the Illinois Human Rights Act [
				775 ILCS
				5/2-102 ] and Title VII of the Civil Rights Act of
				1964 (
				42
				USC 2000d et seq.) or any rule or regulation
				promulgated pursuant to either.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.141 - Producer Licensing Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a) HMO producer means an individual who
			 solicits, negotiates, effects, procures, renews or continues enrollment in an
			 HMO. The term HMO "producer" shall not include:
1) any regular salaried officer or employee
			 of an HMO or of a licensed HMO producer who devotes substantially all of his or
			 her time to activities other than the solicitation of applications for HMO
			 membership and receives no commission or other compensation directly dependent
			 upon the business obtained and who does not solicit or accept from the public
			 applications for membership;
2)
			 employers or their officers or employees or the trustees of any employee
			 benefit plan to the extent that such employers, officers, employees, or
			 trustees are engaged in the administration or operation of any program of
			 employee benefits involving the use of membership in an HMO; provided that the
			 employers, officers, employees, or trustees are not in any manner compensated
			 directly or indirectly by the HMO issuing the HMO membership;
3) banks or their officers and employees, to
			 the extent that the banks, officers, and employees collect and remit charges by
			 charging same against accounts of depositors on the orders of
			 depositors.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.142 - Limited Insurance Representative Requirements - Public Aid and Medicare Enrollers

Current through Register Vol. 48, No. 28, July 12, 2024
a) No
			 person may enroll recipients of Public Aid or Medicare in an HMO, either
			 personally or by mail, unless the person is duly licensed by the Director
			 pursuant to this Part.
b) The
			 provisions of Article XXXI of the Illinois Insurance Code [ 215 ILCS 5 /Art.
			 XXXI.] and the regulations promulgated under that statute (50 Ill. Adm. Code:
			 Chapter I, Subchapter ii) shall be applicable to all HMO limited insurance
			 representatives and HMO producers.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.150 - Severability

Current through Register Vol. 48, No. 28, July 12, 2024
If any Section, term or provision of this Part is adjudged
				invalid for any reason, that judgment shall not affect, impair or invalidate
				any other Section, term or provision of this Part and the remaining Sections,
				terms and provisions shall be and remain in full force and
				effect.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4525 - MANAGED CARE DENTAL PLANS › Section 4525.10 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
The purpose of this Part is to implement the Dental Care
				Patient Protection Act. This Part will set forth guidelines for the formation
				of an advisory committee; require the filing and approval of a summary
				description and grievance procedure for managed care dental plans; also
				identify the point of service plan filing requirements.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4525 - MANAGED CARE DENTAL PLANS › Section 4525.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
Act means the Dental Care Patient Protection Act [ 215 ILCS 109
				].
Code means the Illinois Insurance Code [ 215 ILCS 5 ].
Dental Director means the dental director of the Illinois
				Department of Public Health.
Dentist means a person licensed to practice dentistry in any
				state.
Department means the Illinois Department of Insurance.
Director means the Director of the Illinois Department of
				Insurance.
Enrollee means an individual and his or her dependents who are
				enrolled in a managed care dental plan.
Grievance means a written notice relating to the managed care
				dental plan determinations, procedures, and administration primarily expressing
				a complaint to the managed care dental plan by, or on behalf of, the enrollee,
				or by the dental care provider.
Managed Care Dental Plan or Plan means a plan that establishes,
				operates, or maintains a network of dentists that have entered into agreements
				with the plan to provide dental care services to enrollees to whom the plan has
				the obligation to arrange for the provision of or payment for services through
				organizational arrangements for ongoing quality assurance, utilization review
				programs, or dispute resolution. Managed care dental plans do not include
				employee or employer self-insured dental benefit plans under the federal ERISA
				Act of 1974.
Reasonable Travel Distance means a normal commute of no more
				than 30 miles or 30 minutes from the residence or place of employment of the
				enrollee.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4525 - MANAGED CARE DENTAL PLANS › Section 4525.40 - Dental Managed Care Advisory Committee

Current through Register Vol. 48, No. 28, July 12, 2024
Pursuant to Section 15 of the Act [
				215 ILCS 109/15 ] the
				Director is authorized to convene an advisory committee for the purpose of
				providing counsel and gathering clinical advice concerning dental managed care
				issues.
a) Such advisory committee
			 shall be comprised as follows:
1) There will
			 be a total of 5 members all of whom shall be dentists licensed to practice
			 dentistry in this State pursuant to Section 15 of the Act [
			 215 ILCS 109/15 ];
			 and
2) Two of the 5 members shall
			 be dental directors from a managed care dental plan, or be a dentist designee
			 on behalf of a plan, that is subject to the requirements of this Part and the
			 Act; and
3) Two of the remaining 3
			 members shall be general dentists; and
4) The 1 remaining member shall be the dental
			 director as defined in Section
			 5425.30
			 of this Part.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4525 - MANAGED CARE DENTAL PLANS › Section 4525.50 - Filing and Approval of Summary Description

Current through Register Vol. 48, No. 28, July 12, 2024
Pursuant to Section 143 of the Code a managed care dental plan
				shall file a summary description of coverage for approval by the Department,
				prior to its use, for each plan it establishes, operates, or maintains. The
				summary description shall contain all terms of coverage required by Section 25
				of the Dental Care Patient Protection Act [
				215 ILCS
				109/25 ]. In addition, each managed care dental plan
				is required to file a list of all participating dentists for informational
				purposes in accordance with the filing requirements of 50 Ill. Adm. Code 916.
				Subsequent filings of the summary description will only be required pursuant to
				Section
				5425.80
				of this Part, if material modifications occur and are to be submitted to the
				Life, Accident and Health Compliance Unit of the Department in accordance with
				the filing requirements of 50 Ill. Adm. Code 916.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4525 - MANAGED CARE DENTAL PLANS › Section 4525.60 - Filing and Approval of Grievance Procedure

Current through Register Vol. 48, No. 28, July 12, 2024
Every managed care dental plan shall submit for the Director's
				approval, and thereafter maintain, a system for the resolution of grievances
				pursuant to Section 35(n) of the Act [
				215 ILCS
				109/35(n) ]. The initial grievance
				procedure shall be filed with the annual financial statement by March 1 of the
				year after the managed care dental plan is formed. Subsequent filings of the
				grievance procedure will only be required, pursuant to Section
				5425.80
				of this Part, if material modifications occur and are to be submitted to the
				Life, Accident and Health Compliance Unit of the Department in accordance with
				the filing requirements of 50 Ill. Adm. Code 916.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4525 - MANAGED CARE DENTAL PLANS › Section 4525.70 - Filing and Approval of Point of Service Plan Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
Every managed care dental plan that is required to offer a
				point of service plan pursuant to the Act, except those plans that are licensed
				pursuant to Section 1001 of the Limited Health Service Organization Act [
				215 ILCS 130/1001 ],
				shall be required to file a description of its point of service plan for
				approval to the Life, Accident and Health Compliance Unit of the Department in
				accordance with the filing requirements of 50 Ill. Adm. Code 916.
a) The filing shall be comprised of:
1) A managed care dental plan filing and an
			 indemnity filing. Such filing shall be coordinated by the managed care dental
			 plan. The filing must contain reasonable financial incentives for the point of
			 service member to utilize dental services provided or arranged by the
			 designated managed care dental plan primary care provider and shall include:
A) Copies of all policy forms necessary to
			 implement the point of service plan, including the member handbook used to
			 integrate the services provided by the managed care dental plan and the
			 benefits provided by the indemnity carrier; and
B) Enrollment application and member
			 identification card disclosing the name of both the managed care dental plan
			 and the indemnity carrier; and
C)
			 Solicitation material; and
D)
			 Copies of all administrative service contracts between the managed care dental
			 plan and indemnity carrier detailing their respective responsibilities and
			 obligations in offering a point of service plan; and
E) The managed care dental plan shall include
			 in its rate filing the rate level justification and a demonstration of how the
			 out-of-network indemnity benefits to be provided by the indemnity carrier will
			 impact on the managed care dental plan's rates and underlying utilization
			 assumptions. Such documentation shall be deemed confidential by the Department
			 unless specific authorization for disclosure is given by the managed care
			 dental plan; and
F) Written
			 descriptions and illustrative flow charts of how the premium is received and
			 distributed in a timely fashion and how claims will be handled for payment;
			 and
G) A comparison of benefits
			 offered by the managed care dental plan and the indemnity carrier.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4525 - MANAGED CARE DENTAL PLANS › Section 4525.80 - Material Modifications to Summary Description, Grievance Procedure or Point of Service Plan

Current through Register Vol. 48, No. 28, July 12, 2024
A managed care dental plan shall file for approval with the
				Director, prior to use, any change in the summary description, grievance
				procedure, or point of service plan. In addition, each managed care dental plan
				shall keep current the list of participating dentists required to be filed
				pursuant to Section
				5425.50
				of this Part. Any changes or additions to the list shall be filed with the
				Department for informational purposes within 30 days after such
				change.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4525 - MANAGED CARE DENTAL PLANS › Section 4525.90 - Enforcement and Penalties

Current through Register Vol. 48, No. 28, July 12, 2024
a) To
			 enforce the provisions of this Part, the Director may issue a Cease and Desist
			 Order and/or require a managed care dental plan to submit a plan of correction
			 for violations of this Part or the Act.
b) The Director may also impose an
			 administrative fine, pursuant to Section 65 of the Act [
			 215 ILCS
			 109/65 ], not to exceed $1000, for failure to submit a
			 requested plan of correction, failure to comply with its plan of correction, or
			 repeated violations of this Part or the Act.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Section 4530.10 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
This Part will implement the Health Carrier External Review Act
				[ 215 ILCS 180 ] in order to assure uniform standards for the establishment and
				maintenance of external review procedures, to assure that covered persons have
				the opportunity for an independent review of an adverse determination or final
				adverse determination and provide appropriate registration standards and
				oversight of health care plans by the Department of Insurance for the review of
				adverse and final adverse determinations.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Section 4530.20 - Applicability and Scope

Current through Register Vol. 48, No. 28, July 12, 2024
a) Except
			 as provided in subsection (b), the requirements of this Part are applicable to
			 all health carriers.
b) The
			 provisions of this Part shall not apply to:
1) A policy or certificate that provides
			 coverage only for a specified disease, specified accident or accident-only
			 coverage, credit, dental, disability income, hospital indemnity, long-term care
			 insurance as defined by Article XIXA of the Illinois Insurance Code, vision
			 care, or any other limited supplemental benefit;
2) A Medicare supplement policy of insurance
			 as defined by the Director in 50 Ill. Adm. Code
			 2008.40;
3) Coverage under a plan through Medicare,
			 Medicaid, or the federal employees health benefits program;
4) Any coverage issued under 10 USC 55 and
			 any coverage issued as supplement to that coverage;
5) Any coverage issued as supplemental to
			 liability insurance, workers' compensation, or similar insurance; or
6) Automobile medical-payment insurance or
			 any insurance under which benefits are payable with or without regard to fault,
			 whether written on a group blanket or individual basis.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Section 4530.50 - Independent Review Organization Obligations

Current through Register Vol. 48, No. 28, July 12, 2024
a) An independent review organization may not
			 conduct external independent reviews of adverse determinations for persons
			 subject to Section 15 of the Act unless the independent review organization has
			 first registered with the Director. An application for registration shall be in
			 the format set forth in Appendix D.
b) An independent review organization must
			 secure and maintain a current certificate of accreditation by the American
			 Accreditation Healthcare Commission (URAC) under applicable standards for
			 Independent Review Organizations.
c) Each independent review organization shall
			 provide a written notice as set forth in Appendix B and Appendix C, explaining
			 its decision to uphold or reverse adverse or final adverse determinations to
			 the health carrier, the covered person, and, if applicable, the covered
			 person's authorized representative.
d) Each independent review organization shall
			 maintain written records in the aggregate, by state, and by health carrier on
			 all requests for external review for which it conducted an external review
			 during a calendar year and submit, electronically, a report in the format
			 specified by the Director by March 1 of each year. The independent review
			 organization shall retain the written records required under the Act for at
			 least three years.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Section 4530.60 - Registration of Independent Review Organizations

Current through Register Vol. 48, No. 28, July 12, 2024
a) On or after July 1, 2010, an independent
			 review organization may not conduct external reviews for persons subject to
			 Section 15 of the Act unless the independent review organization has registered
			 with the Director. An application for registration shall be in the format set
			 forth in Appendix D and must be signed by an officer or director of the
			 independent review organization. Initial registration applications shall be
			 deemed approved unless the Director finds an application to be noncompliant
			 with either the standards set forth in Section 55 of the Act or this
			 Part.
b) An independent review
			 organization must register with the Director every 2 years. A fee of $1,000
			 must be submitted with each application or renewal. If the Director determines
			 that there are no acceptable nationally recognized private accrediting entities
			 providing independent review organization accreditation, he or she may then
			 approve independent review organizations that are not accredited by a
			 nationally recognized private accrediting entity, in which case the fee for
			 each application or renewal shall be $1,500.
c) Any material changes in the information
			 filed pursuant to this Part shall be filed with the Director within 30 days
			 after the change. Loss of accreditation status will require re-registration and
			 payment of the appropriate fee pursuant to subsection (b).
d) Renewals and Appeals
1) A registered independent review
			 organization may continue to operate, if a renewal application as specified in
			 Appendix E and fee have been filed 30 days prior to the renewal date, until the
			 renewal is denied or issued by the Director.
2) If the renewal application and fee are not
			 received prior to the renewal date, the registration will automatically expire
			 and the independent review organization must re-register and pay a fee pursuant
			 to subsection (b).
3) If an
			 application for registration or renewal is denied under this Part, the
			 applicant may appeal the denial by requesting a hearing under the terms of
			 Article 10 of the Illinois Administrative Procedure Act [ 5 ILCS 100 /Art. 10]
			 and 50 Ill. Adm. Code 2402. A petition for hearing must be postmarked no later
			 than 30 days from the date of initial denial. A hearing shall be scheduled
			 within 45 days after the petition is filed with the Director. A decision by the
			 Director shall be rendered within 60 days after the close of the
			 hearing.
Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Section 4530.70 - Operational Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
An independent review organization shall secure and maintain a
				current certificate of accreditation by the American Accreditation Healthcare
				Commission (URAC) under applicable standards for Independent Review
				Organizations except when the Director determines that there are no acceptable
				nationally recognized private accrediting entities providing independent review
				organization accreditation. Independent review decisions shall be issued
				pursuant to the Act.