Office of Consumer Health Insurance Illinois Department of Financial and Professional Regulation Division of Insurance

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What is the Office of Consumer Health Insurance?

The Office of Consumer Health Insurance is a consumer assistance office that helps you with your health insurance problems and questions.

The office was established by the Illinois Department (now Division) of Insurance on January 1, 2000, as part of the new Managed Care Reform and Patient Rights Act.

The Office of Consumer Health Insurance can:

• Explain your rights as a health care consumer;
• Answer your questions about health insurance;
• Help you understand the coverage provisions of your specific health care plan; and
• Assist you when you have a problem or complaint.

To contact the Office of Consumer Health Insurance,
call toll free at (877) 527-9431.

What is the Managed Care Reform and Patient Rights Act?

Governor George H. Ryan signed the Managed Care Reform and Patient Rights Act (Public Act 91-617) on August 19, 1999. This new law gives Illinois insurance consumers more control of their health care through tighter requirements on health maintenance organizations (HMOs), insurance companies, doctors, and other health care providers.

The Act generally applies to state regulated managed care plans, including all state regulated HMOs. The Act only partially applies to other insurers. The Act does not apply to self-funded plans regulated by the U.S. Department of Labor.

To find out how the Act applies to your health care plan, call the Office of Consumer Health Insurance toll free at (877) 527-9431.

What Are My Rights Under the New Act?

You have the right to receive detailed information from your HMO about your coverage, including information on:

• the areas of the state served by the plan;
• exclusions and limitations;
• pre-certification and utilization review requirements;
• emergency room coverage and requirements;
• selection of primary care physicians;
• access to specialty care;
• benefits available for out-of-area coverage;
• out-of-pocket expenses;
• provisions for continuity of care; and
• an explanation of the appeals process.

You have the right to receive coverage for emergency services when a "prudent person" would reasonably believe that your condition is serious enough to require emergency medical attention.

You have the right to apply for a standing referral from your primary care physician when you have a condition that requires ongoing care from a specialist. In some cases, your HMO may be required to provide access to such specialty care outside the network

You have the right to appeal decisions made by your HMO.

If you have questions about your rights under the new Act,
contact the Office of Consumer Health Insurance
toll free at (877) 527-9431.

How Do I File a Complaint against My Health Plan?

If you are insured through an HMO and have a complaint, you should file an appeal directly with your HMO.

If your HMO appeal for medical services is denied, you can request an external independent review. Your request should be made in writing unless your situation requires an urgent decision. You have the right to approve the doctor making the independent review. If you are unsure about the independent reviewer's qualifications, you should consult with your own physician.

If you are unable to resolve a problem with your HMO or any other health care plan, you may file a complaint at any time with the Illinois Division of Insurance.

To obtain a complaint form or receive help in completing the form,
call the Office of Consumer Health Insurance
toll free at (877) 527-9431.

You can also file a complaint electronically from the Division of Insurance web site.

Important Health Insurance Telephone Numbers

State Resources:

Uninsured Ombudsman Program