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State of Illinois Division of Insurance - DOC

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State of Illinois Division of Insurance - DOC Powered By Docstoc
					                                                                                                            320 West Washington
Cont act Person:                            Illinois Division of Insurance
                                                                                                            Street
David Grant                                 Review Requirements Checklist                                   Springfield, IL 62767-0001
217-782-6369
david_grant@ins.state.il.us                                                                                 Effective 10/20/10
Line(s) of                                 Line(s) of
Business                                   Insuranc e
Individual Health Maintenance Organization Individual HMO Policies (Includes Point of Service Products)
Illinois Insurance Code Link                Illinois Compiled Statutes Online
Illinois Admini strative Code Link          Administrative Regulations Online
Product Coding Matrix                       Product Coding Matrix



       REVIEW
                                                                       DESCRIPTION OF REVIEW                                      LOCATION OF
                                 REFERENCE
    REQUIREMENTS                                                                                                               STANDARD IN FILING
                                                                       STANDARDS REQUIREMENTS
                                                   NOTE: These brief summaries do not include all requirements of all
                                                   laws, regulations, bulletins, or requirements, so review actual law,
                                                   regulation, bulletin, or requirement for details to ensure that forms are
                                                   fully compliant before filing with the Department of Insurance.
     FORM FILING                                                                                                                  LOCATION OF
                                 REFERENCE          DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS
    REQUIREMENTS                                                                                                               STANDARD IN FILING
                                                   Form filings must now be submitted either by SERFF or CD-ROM.
                                                   Please visit the Division's web site for the Universal Transmittal
Uniform Transmittal            50 IL Adm. Code
                                                   Document (Etrans) at:
Document (Etrans)              916
                                                   http://insurance.illinois.gov/Regulatory_Filings/regulatory_filings.asp.
                                                   Scroll down to "Universal Transmittal Document Software (Etrans)"
                               Go to Review        Each filing must include a completed Review Requirements Checklist
Review Requirements            Requirements        that must contain a completed “Location of Standard in Filing”
Checklist                      Checklists.         column for each required element of the filing. Please indicate the
                               See next column     proper page # and form # for each entry.
                               50 IL Adm. Code     In addition to referencing any previously approved form number(s) as
                               1405.20 (e)         required by 50 IL Adm. Code 1405.20(e), those references must also
Cover Letter and Letter of
                               50 IL Adm. Code     include the filing number and SERFF tracking number (if applicable
Submission
                               2001.30 (a) (3)     and available) for the referenced forms.
                               50 IL Adm. Code
                           916.40 (b)        Letters of submission must generally describe the intent and use of the
                                             form being filed and, if applicable, how it will be used with any
                                             previously approved form(s).
Filing of Marketing and    50 IL Admin. Code All brochures, media scripts, marketing and advertising material must
Advertising Materials      5421.100 c)       be filed with the Division of Insurance prior to use.
        GENERAL
                                                                                                                            LOCATION OF
 REQUIREMENTS FOR            REFERENCE         DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS
                                                                                                                         STANDARD IN FILING
      ALL FILINGS
                                               The individual contract, including the application and any
                           50 IL Adm. Code
Entire Contract                                amendments and riders, constitutes the entire contract between the
                           5421.110 d)
                                               parties.
                                               Periodic payments must be made within 60 days of an enrollee's
                                               selection of a provider, or effective date of selection, whichever is
                                               later. In case of retrospective enrollment only 30 days after notice by
Timely Payment of Health                       the employer to the insurer. Subsequent payments must be in monthly
                           215 ILCS 5/368a
Care Services                                  periodic cycle. Penalty payment of 9% per year.

                                               Payments other than periodic must be made within 30 days after
                                               receipt of due proof of loss. Same penalty provisions.
                           50 IL Adm. Code     An individual contract must provide for a grace period of no less than
Grace Period
                           5421.110 m)         31 days.
                           50 IL Adm. Code     There is a 10-day free look requirement with the exception of an
Free Look
                           5421.110 o)         individual HMO Medicare contract.
                                               The individual contract must contain eligibility requirements that
                                               explain the conditions that must be met to enroll in the plan, the
                           50 IL Adm. Code
Eligibility Requirements                       limiting age for enrollees and eligible dependents, including the
                           5421.110 e)
                                               effects of Medicare eligibility, and a clear statement regarding
                                               newborn coverage.
                                               No HMO may cancel an individual contract except for one or more of
                                               the following reasons:
                           50 IL Adm. Code
                           5421.110 k)                Failure to pay the premium;
Cancellation
                           50 IL Adm. Code            Fraud or material misrepresentation;
                           5421.111 a)                Material violation of the terms of the contract or evidence of
                                                       coverage;
                                                      Failure to establish a satisfactory patient-physician
                                                     relationship;
                                                    Failure to meet or continue to meet eligibility requirements
                                                     under the Basic Outpatient Preventive and Primary Care
                                                     Services for Children Program offered by 50 IL Adm. Code
                                                     5421.131; or,
                                                    Such other good cause as appears in the contract.

                                              Spousal and dependent continuation rights in case of death, divorce or
Spousal continuation     215 ILCS 5/367.2
                                              retirement.
                                            Continuation rights for an insured's dependent child in the event of the
Dependent continuation   215 ILCS 5/367.2-5 death of the insured and the child is not eligible for coverage as a
                                            dependent under 215 ILCS 5/367.2.
                                            Effective June 1, 2009 a policy that includes dependent coverage must
                                            allow unmarried dependents under the age of 26 to apply for
                                            coverage.

                                              Additionally, polices must allow military veteran dependents under
                                              the age of 30 to apply for coverage if the veteran is an Illinois
                                              resident, not married; has served in the active or a reserve components
                                              of the U.S. Armed Forces (including the National Guard) and has
                                              received a release or discharge other than dishonorable.

                         215 ILCS             Policies in force as of June 1, 2009 must provide for a 90 day open
Extended age dependent   5/356z.12            enrollment period for all dependents that meet the criteria described
continuation             215 ILCS 125/5-      above beginning on the policy renewal date, but no later than May 31,
                         3(a)                 2010.

                                              Insurers may not apply requirements for creditable coverage,
                                              continuous coverage or breaks in coverage during the initial
                                              enrollment period. However, preexisting condition limitations may be
                                              applied if creditable coverage has not been established.

                                              Policies issued on or after June 1, 2009 must also provide for a 90 day
                                              open enrollment applicable to policies issued on or before May 31,
                                              2010.
                                              Insurers must provide an annual 30 day open enrollment period.
                                               The law does not change HIPAA special enrollment requirements.

                                               The attached link provides FAQ information from our web site.
                                               Effective June 1, 2009 a policy must continue to provide coverage for
                                               a dependent college student who has taken a medical leave of absence
                                               or reduced hours to part-time status due to a catastrophic illness or
                           215 ILCS            injury. Continuation is subject to all of the policy’s terms and
Dependent students;
                           5/356z.11           conditions applicable to that form of insurance and shall terminate 12
medical leave of absence
                           215 ILCS 125/5-     months after the notice of the illness or injury or until coverage would
continuation
                           3(a)                have otherwise lapsed.

                                               This coverage mirrors the requirements of H.R. 285, known as
                                               Michelle’s Law, signed by the President on October 9, 2008.
                           50 IL Adm. Code
                                               HMOs are permitted, but not required, to adopt coordination of
                           5421.110 t)
Coordination of Benefits                       benefits (COB) provisions. An HMO electing to include COB must be
                           50 IL Adm. Code
                                               consistent with the requirements of 50 IL Adm. Code 2009.
                           2009
                           215 ILCS 5/367i
                                               A contract shall provide a reasonable extension of benefits (up to 12
                           50 IL Adm. Code
Discontinuance and                             months) in the event of total disability on the date the policy is
                           2013.20
replacement of coverage                        discontinued. In case of discontinuance the prior plan shall be liable
                           215 ILCS 125/5-
                                               only to the extent of its accrued liabilities and extension of benefits.
                           3(a)
                                               The individual contract must state newborns are covered from the
Newborn Coverage           215 ILCS 125/4-8    moment of birth. If additional premium is required the insurer may
                                               require notification within 31 days in order to have coverage continue.
                                               No contract that covers the insured's immediate family or children
                                               may exclude or limit coverage of an adopted child or a child not
Pending & Adopted                              residing with the insured (foster child). A child residing with an
                           215 ILCS 125/4-9
Children                                       enrollee pursuant to an interim court order of adoption is considered
                                               an adopted child. Grandchildren are considered dependents if
                                               appropriate documentation of dependency can be provided.
                           50 IL Adm. Code     The individual contract must contain the conditions of the enrollee's
Reinstatement
                           5421.110 l)         right to reinstatement.
                           215 ILCS 125/4-9.1
                                              Provides continuation for handicapped dependent that has attained the
Disabled Dependents        50 IL Adm. Code
                                              limiting age of the contract.
                           5421.110 u)
                                               An HMO may require copayments, but not to exceed 50% of the usual
                                               and customary fee of the service.
Deductibles and              50 IL Adm. Code
Copayments                   5421.110 i)
                                               Maximum copays per calendar year are $3,000 per enrollee and
                                               $6,000 per family.
Out of Area Benefits and     50 IL Adm. Code   The individual contract must contain a specific description of the
Services                     5421.110 h)       benefits and services that are available out of the HMO's service area.
Benefits and Services        50 IL Adm. Code   The individual contract must contain a specific description of the
Within the Service Area      5421.110 f)       benefits and services that are available in the HMO's service area.
                             50 IL Adm.        The individual contract must provide a full description of the HMO's
Grievance Procedure
                             5421.110 x)       grievance procedure.
                           215 ILCS 125/4-
                                               There must be a detailed statement in the individual contract that
                           14(3)
Limitations and Exclusions                     describes the limitations and exclusions expressed with the same
                           50 IL Adm. Code
                                               prominence as the description of the benefits.
                           5421.110 b)
                                               No individual contract may be issued without notice of the complaint
Notice of Address of         50 IL Adm. Code
                                               department of the HMO and the address of the Managed Care Unit of
Division of Insurance        5421.110 n)
                                               the Division of Insurance.
  REQUIREMENTS
                                                                                                                            LOCATION OF
RELATING TO POLICY             REFERENCE       DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS
                                                                                                                         STANDARD IN FILING
   FORM REVIEW
                                               This section contains the minimum standards that must be met for
                                               basic health care services provided those services are determined to be
                             50 IL Adm. Code
Basic Health Care Services                     medically necessary by the enrollee's primary care physician (PCP).
                             5421.130
                                               Some of these services are outlined in more detail in this section of
                                               the checklist.
Description of in-plan and   50 IL Adm. Code   The individual contract must contain a specific description of benefits
out-of-plan Benefits         5421.110 f) h)    and services available both in-plan and out-of plan.
                             50 IL Adm. Code
                                               The individual contract must include a specific description of benefits
                             5421.110 g)
                                               available for emergencies 24 hours a day, 7 days a week.
                             50 IL Adm. Code
Emergency Care Services
                             5421.130 d)
                                               No HMO may limit emergency services within the service area to
                             215 ILCS 134/10
                                               contracted providers.
                             215 ILCS 134/65
Alcoholism and Drug          50 IL Adm. Code   Coverage must include diagnosis, detoxification and treatment of
Abuse                     5421.130 i)          medical complications of the abuse of or addiction to alcohol or drugs
                                               on either an inpatient or outpatient basis.

                                               Rehabilitation services must be included.
                                               Coverage for criminal sexual assault must be at the same benefit
Criminal Sexual Assault   215 ILCS 125/4-4
                                               levels as any other emergency or accident care situation.
                                               Coverage of screening by low-dose mammography for all women
                                               over 35;

                                               Coverage requires baseline mammogram for women 35-39 and annual
                                               mammogram for women 40 years of age and older.

                                               For women under 40 with a family history of breast cancer or other
                          215 ILCS 125/4-      risk factors mammograms must be provided at an age and intervals
Mammography
                          6.1(a)               considered medically necessary.

                                               Coverage includes a comprehensive ultrasound screening of an entire
                                               breast or breasts when a mammogram demonstrates medical necessity
                                               as described.

                                               Coverage must be provided at no cost to the insured and shall not be
                                               applied to an annual or lifetime maximum benefit.
                                               Clinical breast examinations must be covered:
                          215 ILCS 5/356g.5
                                                  1. at a minimum every three years for women over 20 years of
                          215 ILCS 125/4-6.5
Clinical Breast Exam                                 age but less than 40; and,
                                                  2. annually for women 40 years of age and older.


                                               Coverage requirements include reconstruction of the breast upon
                                               which the mastectomy is performed, surgery and reconstruction of the
                          215 ILCS 125/4-      other breast to produce a symmetrical appearance and prostheses and
Reconstructive Breast     6.1(b)               treatment for physical complications at all stages of mastectomy,
Surgery                   50 IL Adm. Code      including lymphdemas.
                          5421.132
                                               Written notice of the availability of this coverage must be delivered to
                                               the enrollee upon enrollment and annually thereafter.
                            215 ILCS 5/356g.5-    Coverage must include all medically necessary pain medication and
Breast Cancer Pain          1                     pain therapy related to the treatment of breast cancer under the same
Medication and Therapy      215 ILCS 125/5-       terms and condition applicable to treatment of other conditions. The
                            3(a)                  term “pain therapy” is defined.
                                                  No HMO contract may deny medically necessary breast implant
                                                  removal for a sickness or injury.
Breast Implant Removal      215 ILCS 125/4-6.2
                                                  This provision does not apply to the removal of breast implants that
                                                  were done solely for cosmetic purposes.
                                              No individual contract may deny or exclude coverage for fibrocystic
                                              breast condition in the absence of a breast biopsy demonstrating an
Fibrocystic Breast
                            215 ILCS 125/4-16 increased disposition to the development of breast cancer unless the
Condition
                                              enrollee's medical history is able to confirm a chronic, relapsing,
                                              symptomatic breast condition.
                                               Coverage must provide inpatient treatment following mastectomy for
                            215 ILCS 5/356t    a length of time to be determined by attending physician; must also
Post Mastectomy Care
                            215 ILCS 125/4-6.5 provide for availability of post-discharge physician office visit or in-
                                               home nurse visit within 48 hours of discharge.
                                               No individual contract may deny reimbursement for an organ
Organ Transplant            215 ILCS 125/4-5 transplant as experimental or investigational unless supported by
                                               appropriate, required documentation.
                                              No HMO that provides prescription drug coverage for certain types of
                                              cancer may exclude coverage of any drug on the basis that the drug
                                              has not been FDA approved for that particular type of cancer if
                                              documentation is provided in certain medical reference compendia as
Prescription Drugs, Cancer
                           215 ILCS 125/4-6.3 to the efficacy of that drug for the form of cancer in question, or if the
Treatment: Off- Label Use
                                              drug has been recommended for that particular type of cancer in
                                              formal clinical studies, the results of which have been published in at
                                              least two peer reviewed professional medical journals here or in Great
                                              Britain.
Mental, Emotional or       50 IL Adm. Code An individual contract must provide 10 days of inpatient care and 20
Nervous Disorders          5421.130 h)        visits for outpatient care per year.
                           215 ILCS 5/356(s) Coverage must include prenatal and post-natal care and complications
Maternity and Post-        215 ILCS 125/4-6.4 of pregnancy for mother as well as care of newborn.
Parturition Care           50 IL Adm. Code
                           5421.130 e)        Coverage must provide minimum of 48 hours inpatient care for
                          50 IL Adm. Code      normal delivery and 96 hours for caesarian section. Shorter lengths of
                          2603.30 a) 11)       stays are permitted based on decision of the PCP.
                                               Coverage must include annual cervical smear or Pap smear test for
                                               female insureds, including surveillance tests for ovarian cancer for
                                               female insureds who are at risk for ovarian cancer; and,
                          215 ILCS 5/356u
Pap and Prostate tests
                          215 ILCS 125/4-6.5 Annual digital rectal examination and prostate-specific antigen test for
                                             males upon recommendation of the PCP. Must include asymptomatic
                                             men age 50 and over; African-American men age 40 and over; and
                                             men age 40 and over with family history of prostate cancer.
                          215 ILCS 5/356x    Must cover all colorectal cancer exams and lab tests for colorectal
Colorectal Cancer
                          215 ILCS 125/5-    cancer as prescribed by the PCP according to stated guidelines; may
Screening
                          3(a)               not impose greater copays, ded or waiting periods.
                          215 ILCS 5/356w
Diabetes Supplies and                        Coverage must be provided for outpatient self- management training
                          215 ILCS 125/5-
Testing                                      and education, equipment and supplies. Guidelines are provided.
                          3(a)
                          215 ILCS 5/356z.1
Prenatal HIV testing                         Must be provided if coverage includes maternity benefit.
                          215 ILCS 125/4-6.5
Emergency Ambulance                          An individual contract must include coverage for emergency
                          215 ILCS 125/4-15
Transportation                               transportation by ground or air ambulance.
                          215 ILCS 5/356z.2 This coverage is limited to children age 6 or under; to individuals with
Adjunctive Services in
                          215 ILCS 125/5-    medical conditions that require hospitalization and general anesthesia
Dental Care
                          3(a)               for dental care; and for disabled individuals.
                                             If the individual contract provides RX coverage it may not deny or
                          215 ILCS 5/356z.5
                                             limit coverage for prescription inhalants when diagnosis is asthma or
Prescription Inhalants    215 ILCS 125/5-
                                             other life-threatening bronchial ailments; additional guidelines
                          3(a)
                                             provided.
                                             If the individual contract provides coverage for OP services and RX
                          215 ILCS 5/356z.4
Coverage for                                 or devices it must provide enrollee and dependent coverage for all OP
                          215 ILCS 125/5-
contraceptives                               and contraceptive drugs and devices approved by the FDA; may not
                          3(a)
                                             impose greater copays, ded or waiting periods.
                         215 ILCS 5/356z.6 Coverage must include medically necessary bone mass measurement
Bone Mass
                         215 ILCS 125/5-   and diagnosis and treatment of osteoporosis the same as any other
Measurement/Osteoporosis
                         3(a)              illness.
Multiple Sclerosis        215 ILCS 5/356z.8 Coverage must provide for medically necessary preventative physical
Preventative Physical       215 ILCS 125/5-    therapy for insureds diagnosed with this disease. A definition of
Therapy                     3(a)               “preventative physical therapy” is included. Coverage limitations,
                                               deductibles, coinsurance features, etc. must be provided the same as
                                               any other illness.
                          215 ILCS
                                               Coverage must include reimbursement for amino acid-based
Amino acid-based          5/356z.10
                                               elemental formulas, regardless of delivery method, for diagnosis and
elemental formulas        215 ILCS 125/5-
                                               treatment of conditions described herein.
                          3(a)
                          215 ILCS 5/356z.9
Coverage for Human                             Coverage must include benefit for FDA approved human
                          215 ILCS 125/5-
Papillomavirus Vaccine                         papillomarivus vaccine (HPV).
                          3(a)
                          215 ILCS
                                               Coverage must include a vaccine for shingles that is approved by the
                          5/356z.13
Shingles Vaccine                               federal Food and Drug Administration if it is ordered by a physician
                          215 ILCS 125/5-
                                               for an insured/enrollee who is 60 years of age or older.
                          3(a)
                          215 ILCS
                          5/356z.14
                                               Coverage must be provided for individuals under age 21 for the
                          215 ILCS 125/5-
Autism Spectrum Disorders                      diagnosis and treatment of autism spectrum disorders to the extent that
                          3(a)
                                               such care is not already covered by the policy.


                                               A group or individual policy of accident and health or a managed care
                            215 ILCS
Habilitative Services for                      plan must provide coverage for habilitative services for children less
                            5/356z.15
Children                                       than 19 years of age with congenital, genetic, or early acquired
                            215 ILCS 125/5-3
                                               disorders as described.
                            215 ILCS           A group or individual major medical policy of accident or health
Prosthetic and customized   5/356z.18          insurance or a managed care plan must provide coverage for
orthotic devices            215 ILCS 125/5-    prosthetic and orthotic devices subject to other general exclusions,
                            3(a)               limitations and financial requirements of the policy.
Outpatient Rehabilitative   50 IL Adm. Code    Coverage must include, but is not limited to, speech, physical and
Therapy                     5421.130 j)        occupational therapy for up to 60 treatments per year.
                            215 ILCS 180/      The Act provides uniform standards for the establishment and
Health Care External                           maintenance of external review procedures.
Review Act                  50 IL. Adm. Code
                            5430.40            The Rule provides insurer reporting requirements.
  REQUIREMENTS                                                                                                             LOCATION OF
                             REFERENCE         DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS
 SPECIFIC TO HIPPA                                                                                                      STANDARD IN FILING
                                               Except as provided, an insurer in the individual market must continue
                                               coverage except for:

                                                      Nonpayment of premium;
                           215 ILCS
Guaranteed Renewability                               Fraud;
                           97/50(A)(B)
                                                      Termination of the plan;
                                                      Movement outside of the service area; or,
                                                      Membership in the association ceases.

                                              Insurers must comply with the uniform notification requirements for
Uniform Termination of
                                              discontinuing a particular type of coverage and discontinuing all
Coverage Notification      215 ILCS 97/50 (C)
                                              coverage in the state. Notification requirements must appear in the
Requirements
                                              certificate.
                                               An insurer electing to uniformly modify, terminate or discontinue
Notice Requirement         215 ILCS 97/60      coverage in accordance with Section 30 or 50 of Act 97 (HIPAA)
                                               must provide 90 days advance notice to the Division by certified mail.
  MANAGED CARE
   REFORM AND                                                                                                              LOCATION OF
                             REFERENCE         DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS
PATIENT RIGHTS ACT                                                                                                      STANDARD IN FILING
    PROVISIONS
                                             A health care plan must provide for continuity of care for an ongoing
                           215 ILCS 134/25   course of treatment for its enrollees in circumstances in which the
Transition of Services     50 IL Adm. Code   enrollee's PCP leaves the network as described. Treatment is available
                           5420.60           for 90 days from the date of the notice of the physician's termination
                                             or if the enrollee has entered the third trimester of a pregnancy.
Definition of Emergency    215 ILCS 5/155.36 A health care plan must use this definition that includes “prudent lay
Medical Condition          215 ILCS 134/10   person” language.
                                             A health care plan that provides, or is required to provide, coverage
                           215 ILCS 134/65
Emergency Services Prior                     for emergency services may not make payments contingent upon
                           50 IL Adm. Code
to Stabilization                             whether the provider is in or out-of plan, or whether prior
                           5420.110
                                             authorization is obtained.
                           215 ILCS 134/70     The health care plan will be responsible for providing post-
Post-Stabilization Medical
                           50 IL Adm. Code     stabilization medical services if authorization is received from the
Services
                           5420.120            health care plan, or one of its delegated providers, or after 2
                                                    documented good faith efforts by the treating health care provider as
                                                    described.
                                                    A health care plan shall establish a procedure by which an enrollee
                                                    who requires the treatment of a specialist physician or other health
Standing Referral to         215 ILCS
                                                    care provider may obtain a standing referral to that individual. Such a
Specialist                   134/40(b)
                                                    referral may be effective for up to one year and may be renewed and
                                                    re-renewed.
                                                    A health care plan must provide its enrollees with a description of
Utilization of Health Care                          their rights and responsibilities for obtaining referrals and for making
                             215 ILCS 134/43
Facilities                                          appropriate use of health care facilities when their PCP is not
                                                    available.
                                                    An HMO is required to establish a procedure to handle complaints
                             215 ILCS 134/50        regarding administrative issues and procedures, but nothing in these
Administrative Appeals:      215 ILCS 134/55        requirements prevents an enrollee from filing a complaint with the
Complaint Handling           215 ILCS 125/4-6       Division.
Procedures                   50 IL Adm. Code
                             5420.90                An HMO is required to respond to a complaint received from the
                                                    Division of Insurance within 21 days of such notification.
                                                    An HMO must establish procedures for both expedited appeals of
                                                    health care services and other appeals for health care services that
Appeals and Grievances
                             215 ILCS               meet the minimum requirements outlined herein.
Relating to Health Care
                             134/45(a)(b)(c), (d)
Services
                                                If the case involves an adverse determination the HMO must provide
                                                the procedures for requesting an external independent review.
                                                A health care plan is required to submit for the Division's review a
                             215 ILCS 134/45(e) mechanism for the joint selection of an independent external reviewer
External Independent         and (f)            under the conditions described in 215 ILCS 134/45(f).
Review                       50 IL Adm. Code
                             5420.70            Any proposed changes to the mechanism must be filed for review
                                                with the Division's Managed Care unit.
                                                    A health care plan is required to provide 60 days notice of nonrenewal
Notice of Nonrenewal or
                             215 ILCS 134/20        or termination of a health care provider to both the provider and to
Termination
                                                    his/her enrollees.
  POINT OF SERVICE
                                                                                                                                  LOCATION OF
     (POS) PLAN                REFERENCE            DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS
                                                                                                                               STANDARD IN FILING
   REQUIREMENTS
                                                The filing must include an HMO portion (base) and an indemnity
                                                portion. The HMO filing must be filed with the HMO unit and the
                             215 ILCS 125/4.5-1
                                                indemnity portion must be filed with the LAH unit.
Filing of POS Product        50 IL Adm. Code
                             5421.113
                                                Illinois does not permit a POS plan with a preferred provider
                                                organization (PPO) base and an HMO "tail" (out-of-network piece).
      GENERAL                                                                                                               LOCATION OF
                               REFERENCE          DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS
    INFORMATION                                                                                                          STANDARD IN FILING
                             50 IL Adm. Code
                                               An HMO must file its rates with the Division's actuarial unit prior to
Rate Filing Required         5421.60
                                               use. The Division may require additional actuarial documentation.
                             215 ILCS 125/4-12
                             215 ILCS 125/5-3  An HMO may effect refunds or charge additional premium under the
Retrospective Rate Filings
                             (f)               circumstances described.
                                               Each HMO must establish a dispute resolution process in which a
                                               physician, holding the same class of license as the PCP and not
                                               affiliated with the HMO, is jointly selected by the patient and the
Medically Necessary
                             215 ILCS 125/4-10 HMO in the event of a dispute regarding medical necessity of a
Dispute Resolution
                                               covered service proposed by the patient's PCP. In the event the
                                               reviewing physician determines the covered service is medically
                                               necessary the HMO will be required to provide the service.
                                               An HMO must provide to each enrollee information regarding its
                                               functions, organization, and related institutions and describe the
                             50 IL Adm. Code appropriate use of its services. This material must also include a
                             5421.110(q)       description of the grievance procedure, directions on filing a
Provision of Information
                             50 IL Adm. Code grievance and "Notice of Availability of the Division".
                             5420.40
                                               HMOs must provide description of coverage worksheets as detailed in
                                               50 IL Adm. Code 5420.40.
                                                 HMOs must provide ID cards to their enrollees. Mandatory data
                                                 elements for the card or other technology include:
                             50 IL Adm. Code
ID Card Required             5421.110(r)                Processor control number if required for claims adjudication;
                             215 ILCS 139/15            Group number;
                                                        Card issuer identifier;
                                                        Cardholder ID number; and
                                                       Cardholder name.

                                                 The back of the card or other technology is to include the claims
                                                 submission names and addresses and the help desk telephone numbers
                                                 and names.

                                                 Cards must be issued upon enrollment and reissued upon any change
                                                 in the enrollee's coverage that affects any of the required elements.
                                                 The focus of HB 4712 is on any card required for an individual to
                                                 access products or services, while SB 2545 is more limited in that it
                                                 just focuses on insurance cards.

                                                 HB 4712 prevents a person from:

                                                       Publicly posting or displaying an individual's SSN;
                                                       Printing an individual's SSN on any card required for the
                                                        individual to access products or services, however, an entity
                                                        providing an insurance card must print on the card a unique
                            815 ILCS 505 2QQ
Use of SSN on ID Cards                                  identification number as required by 215 ILCS 138/15.
                            215 ILCS 138/15
                                                       Being required to transmit an SSN over the Internet to access a
                                                        web site unless the connection is secure or the SSN is
                                                        encrypted;
                                                       Requiring the individual to use his/her SSN to access a web
                                                        site unless a PIN number or other authentication device is also
                                                        used; and,
                                                       Printing an individual's SSN on any materials mailed to an
                                                        individual unless required by state or federal law.

                                                 Insurers must comply with both provisions.
                                               An HMO that requires enrollees to select a PCP must allow female
Women's Principal           215 ILCS 125/5-3.1
                                               enrollees the right to select a participating woman's principal health
HealthCare Provider         215 ILCS 5/356r
                                               care provider. Notification is required.
                                               Guidelines for Unfair Discrimination based on sex, sexual preference
                            50 IL Adm Code
Discrimination                                 or marital status. Forbids excluding coverage for dependent child
                            2603
                                               maternity.
Basic Outpatient Preventive 215 ILCS 125/4-17 An HMO may choose to provide or arrange to pay for or reimburse
and Primary Health Care     50 IL Adm. Code the cost of basic outpatient preventive and primary health care
Services for Children         5421.131            services for children who are without health care coverage.
                                                  An HMO Medicare contract must be delivered to the enrollee at least
                              50 IL Adm. Code     15 days prior to the effective date of coverage and the enrollee will
HMO Medicare Contract
                              5421.110 p)         have the option to return the contract prior to the effective date with a
                                                  full refund of coverage.
No Medicaid Limitation or 215 ILCS 125/4-         No individual contract may limit or exclude coverage because an
Exclusion                 2(b)                    enrollee or dependent is receiving Medicaid benefits.
                              215 ILCS 5/355.2  No individual contract that also includes dental and bases
Dental Coverage
                              215 ILCS 125/5-   reimbursement on usual and customary fees must disclose specific
Reimbursement Rates
                              3(a)              information.
                                                Questions designed to elicit information regarding AIDS, ARC and
HIV/AIDS Questions on                           HIV must be specifically related to the testing, diagnosis or treatment
                              215 ILCS 5/143(1)
Application                                     done by a physician or an appropriately licensed clinical professional
                                                acting within the scope of his/her license.
                              215 ILCS 5/364.01 Insurers may not cancel or nonrenew any individual's coverage due to
Cancer Clinical Trials        215 ILCS 125/5-   participation in a qualified cancer clinical trial. Guidelines are
                              3(a)              provided.
                                                  No health care plan, or one of its subcontractors, may require an
Prohibition against           215 ILCS
                                                  enrollee who is hospital confined to substitute his/her primary care
Substitution of Hospitalist   5/134/30(c)
                                                  physician for a hospitalist who is under the control of that entity.
                              215 ILCS
                              5/356z.17           Individual and group accident and health insurers and HMOs may
Wellness Coverage
                              215 ILCS 125/5-     offer reasonably designed programs for wellness coverage.
                              3(a)
Organ Transplant
                                                  Provides guidelines for health insurance policies and health care
Medication Notification       215 ILCS 175
                                                  service plans that cover immunosuppressant drugs.
Act
     DEPARTMENT                                                                                                                  LOCATION OF
                                REFERENCE          DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS
      POSITIONS                                                                                                               STANDARD IN FILING
                                                The definition of hospital must allow for those hospitals providing
Hospital Definition           215 ILCS 5/143(1)
                                                surgery, etc., on a formal arrangement basis with another institution.
                                                The Division will permit a failure to precertify a hospital admission
Precertification penalties    215 ILCS 5/143(1) penalty of the lesser of up to $1,000 or 50% of the billed charge. The
                                                penalty may be no more frequent than a per confinement basis.

				
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