Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.50 - Contracts, Administrative Arrangements and Material Modifications

Current through Register Vol. 48, No. 28, July 12, 2024
a) Agreements or
			 Contracts
1) All sample agreements or
			 contracts, with variable language bracketed, under which any person is
			 delegated management duties or control of the HMO or that transfer a
			 substantial part of any major function of the HMO, including but not limited to
			 all reinsurance treaties, all agreements with providers, and all administrative
			 service contracts, must be submitted to the Department of Insurance. The HMO
			 must file with the Department any contract amendments, renewals, addenda, or
			 any other changes from those originally submitted. The HMO must also file any
			 material modifications to the application submitted pursuant to Section 2-1 of
			 the Act including, but not limited to, extension of service area.
2) The HMO must file with the Department of
			 Public Health copies of all sample agreements with providers, as well as any
			 amendments, addenda, or any other changes from the agreements originally
			 submitted.
3) On a quarterly basis,
			 each HMO must submit a list identifying any MCO with which the HMO has a
			 current contract. The list must contain the name, address, and telephone number
			 of the MCO, as well as the name of its Administrator, and must identify the
			 bond or letter of credit issuer as required by subsection (d)(2), along with
			 the expiration date and principal dollar amount for the instrument. The
			 quarterly report shall be due at the Department within 10 days following the
			 end of each quarter.
4) All types
			 of written health care provider agreements must contain provisions under which
			 the provider shall provide, arrange for, or participate in the quality
			 assurance programs mandated by Section 2-8(b) of the Act, unless the Illinois
			 Department of Public Health certifies that those programs will be fully
			 implemented without any participation or action from the contracting
			 provider.
5) All provider
			 agreements shall provide for at least 60 days' notice by the provider for
			 termination with cause, as defined in the provider agreement, and at least 90
			 days' notice by the provider for termination without cause. The HMO must inform
			 the Department immediately of any known or intended termination, with or
			 without cause, of an MCO.
6)
			 Subscribers must receive notice from the HMO at least 60 days in advance of any
			 termination that would curtail or eliminate services to subscribers. However,
			 in the event that the HMO receives notice of less than 60 days from any
			 provider for termination of any contract that would curtail or eliminate
			 services to subscribers, the HMO must provide immediate notice to the
			 subscribers. The Notice shall include instructions regarding referrals which
			 have been issued and appointments which may be pending.
7) The contractual agreement between the
			 provider and the HMO must contain evidence that the provider has professional
			 liability insurance and that such insurance coverage is effective as of the
			 effective date of such contract. Furthermore, the contract must set forth that
			 the Provider will give at least 15 days' advance notice of cancellation of such
			 insurance. In instances in which the HMO will provide physician services
			 directly through employed physicians and not through a contractual arrangement
			 with a provider, the HMO shall provide evidence to the Department that each
			 individual physician has professional liability insurance or that the HMO has
			 coverage on behalf of the employed physicians.