Frequently Asked Questions on P.A. 90-0741 (HR 3427) Revised April 2001

Public Act (P.A.) 90-0741 provides that if a managed care plan requires an enrollee to choose an individual to coordinate care, then the managed care plan is required to also allow female enrollees to select a woman's principle health care provider (WPHCP). Managed care entities are required by P.A. 90-0741 to provide notice to all such female plan members regarding their right to select a WPHCP. (The terms "managed care entity" and "managed care plan" are defined in 215 ILCS 5/356r, reprinted below.)

(2) "Managed care entity" means any entity including a licensed insurance company, hospital or medical service plan, health maintenance organization, limited health service organization, preferred provider organization, third party administrator, an employer or employee organization, or any person or entity that establishes, operates, or maintains a network of participating providers.
(3) "Managed care plan" means a plan operated by a managed care entity that provides for the financing of health care services to persons enrolled in the plan through:

1. organizational arrangements for ongoing quality assurance, utilization review programs, or dispute resolution; or
2. financial incentives for persons enrolled in the plan to use the participating providers and procedures covered by the plan.

The following are frequently asked questions and the Department's responses thereto:

For all managed care plans:

1. Question: Who can be a WPHCP?

Answer: A WPHCP is a physician licensed to practice medicine in all of its branches specializing in obstetrics or gynecology or specializing in family practice who is a part of the member's plan. A participating physician licensed to practice medicine in all of its branches specializing in obstetrics or gynecology or specializing in family practice may elect not to be a WPHCP.

2. Question: Does P.A. 90-0741 mandate that a managed care entity make available to female enrollees all WPHCPs contracted with that managed care entity?

Answer: No. For insurers, WPHCP availability may be limited to specific contractual areas established by the female enrollee's managed care plan. In the case of an HMO, WPHCP availability may be limited by the service area established by the female enrollee's HMO. A service area is a geographic boundary defined by the HMO and approved by the Division of Insurance in consultation with the Department of Public Health. Service areas must be explicitly outlined in the HMO enrollees' certificate and/or member handbook.

3. Question: Does P.A. 90-0741 require the disclosure of financial incentives between the Primary Care Physician and the WPHCP?

Answer: No.

For managed care plans which do not require the member's primary care physician and the WPHCP to have a referral arrangement with one another:

4. Question: Which WPHCPs must appear upon the list of participating providers?

Answer: Upon request, female enrollees are entitled to receive a list of their plan's participating obstetricians, gynecologists and family practice specialists. For HMOs, the list may be limited to participating providers in the HMO's service area.

For managed care plans which require the member's primary care physician and WPHCP to have a referral arrangement with one another:

5. Question: Which WPHCPs must appear upon the list of participating providers?

Answer: Upon request, female enrollees are entitled to receive a list of their plan's participating obstetricians, gynecologists and family practice specialists. For HMOs, the list may be limited to participating providers in the HMO's service area. Such list must identify any referral arrangements between such providers and plan primary care physicians authorized to coordinate care.

6. Question: Can a referral arrangement exist between the primary care physician and the WPHCP if it is not on the list of participating providers?

Answer: Yes. In addition to those referral arrangements provided on the list to each woman, a referral arrangement exists between a participating primary care physician and a participating WPHCP, for purposes of that referral arrangement, when a participating primary care physician acknowledges that a referral arrangement to a participating WPHCP exists for a specific enrollee.

If there is no referral arrangement between the participating primary care physician and a selected participating WPHCP, the enrollee may select a new participating primary care physician or a new participating WPHCP. Such choices may be made at any time in order to comply with the referral arrangement requirement, but must be made in accordance with the managed care plan's administrative procedures.

For Primary Care Physicians in relation to their provider agreements:

7. Question: Does P.A. 90-0741 require a primary care physician to join a payment center, e.g., an IPA or referral group?

Answer: No. Nothing in this bulletin changes or mandates any contractual payment arrangements between any persons or entities described in or impacted by this bulletin.