Managed Care Reform Rule Filed

SPRINGFIELD --Director of Insurance Nat Shapo announced today that an emergency rule (50 Ill. Adm. Code Part 5420) is in effect to implement the provisions of the new Managed Care Reform and Patient Rights Act (PA 91-617) signed by Gov. George Ryan on August 19, 1999. The rule has been posted on the Department's web site at http://www.ins.state.il.us/legal/Part5420.pdf.     Available on the Illinois Legislative Website at http://www.ilga.gov/commission/jcar/admincode/050/05005420sections.html .

"Over 99 percent of the approximately 2.4 million Illinoisans enrolled in health maintenance organizations are covered under group policies, many of which will be up for renewal on January 1, 2000, when the majority of the law's provisions become effective," Shapo said. "Because the Act will enhance the way enrollees receive health care benefits, adopting the rule on an emergency basis provides the best consumer safeguards.

"Allowing health care plans almost three months to revise their marketing materials and operating procedures will eliminate unnecessary confusion and disruption in the health care market. Health care plans will be better able to assess costs and properly price their products so that enrollees will have the comparison information they need to choose the health care plan that best suits their family needs," Shapo said.

Among the issues addressed in the rule are: type of information health care plans must furnish their enrollees; external independent review of complaints; reporting complaints to the Department of Insurance; referral procedures; and emergency services.

The rule requires health care plans to furnish consumers a description of coverage that sets forth: 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.

The rule defines emergency services as "medical conditions of sufficient severity such that a prudent lay person could reasonably expect the absence of immediate medical attention to result in serious jeopardy of the person's health, serious impairment to bodily functions or serious dysfunction of any bodily organ or part."

The Managed Care Reform Act enables enrollees who have a condition that requires ongoing care from a specialist to apply for a standing referral from their primary care physician and, if necessary, to access such specialty care outside the network. The rule requires health care plans to clearly spell out the procedures for those referral arrangements with specialists, as well as any limitations on access to specialists.

By March 1, health care plans are required to submit to the Department of Insurance a report on all complaints received for the previous calendar year that shows: who filed the complaint; nature of the complaint; dates the complaint was received and closed; whether the complaint was processed through an external review procedure; and how the complaint was resolved.

The emergency rule is effective for 150 days beginning September 27, and will be published in the October 8 issue of the Illinois Register published by the Secretary of State. The Department of Insurance has also initiated rulemaking for a proposed rule identical to the emergency regulation. Written public comments on the proposed rule may be submitted to the Department of Insurance until November 22, 1999. Once the proposed rule has been adopted as final, the emergency rule will automatically expire.

In addition to being posted on the Department of Insurance web site, an official paper copy of the rule can be obtained for a $10 fee from the Secretary of State's Office at (217) 782-0630.