215 ILCS 134/1
Short title
Short title. This Act may be cited as the Managed Care Reform and Patient Rights Act. (Source: P.A. 91-617, eff. 1-1-00.)
Illinois Compiled Statutes 215 ILCS 134 — Managed Care Reform and Patient Rights Act.
Illinois · statute · 215 ILCS 134 · 43 active provisions
Provisions
215 ILCS 134/5
Health care patient rights
Health care patient rights. (a) The General Assembly finds that: (1) A patient has the right to care consistent with professional standards of practice to assure quality nursing and medical practices, to choose the participating physician responsible for coordinating his or her care, to receive information concerning h…
215 ILCS 134/10
Definitions
Definitions. In this Act: For a health care plan under Section 45 or for a utilization review program under Section 85, "adverse determination" has the meaning given to that term in Section 10 of the Health Carrier External Review Act. "Clinical peer" means a health care professional who is in the same profession and t…
215 ILCS 134/15
Provision of information
Provision of information. (a) A health care plan shall provide annually to enrollees and prospective enrollees, upon request, a complete list of participating health care providers in the health care plan's service area and a description of the following terms of coverage: (1) the service area; (2) the covered benefits…
215 ILCS 134/20
Notice of nonrenewal or termination
Notice of nonrenewal or termination. A health care plan must give at least 60 days notice of nonrenewal or termination of a health care provider to the health care provider and to the enrollees served by the health care provider. The notice shall include a name and address to which an enrollee or health care provider m…
215 ILCS 134/25
Transition of services
Transition of services. (a) A health care plan shall provide for continuity of care for its enrollees as follows: (1) If an enrollee's health care provider leaves the health care plan's network of health care providers for reasons other than termination of a contract in situations involving imminent harm to a patient o…
215 ILCS 134/30
Prohibitions
Prohibitions. (a) No health care plan or its subcontractors may prohibit or discourage health care providers by contract or policy from discussing any health care services and health care providers, utilization review and quality assurance policies, terms and conditions of plans and plan policy with enrollees, prospect…
215 ILCS 134/35
Medically appropriate health care protection
Medically appropriate health care protection. (a) No health care plan or its subcontractors shall retaliate against a physician or other health care provider who advocates for appropriate health care services for patients. (b) It is the public policy of the State of Illinois that a physician or any other health care pr…
215 ILCS 134/40
Access to specialists
Access to specialists. (a) All health care plans that require each enrollee to select a health care provider for any purpose including coordination of care shall permit an enrollee to choose any available primary care physician licensed to practice medicine in all its branches participating in the health care plan for…
215 ILCS 134/43
Utilization of health care facilities
Utilization of health care facilities. (a) A health care plan must provide its enrollees with a description of their rights and responsibilities in obtaining referrals to and making appropriate use of health care facilities when access to their primary care physician is not readily available. (b) Nothing in this Sectio…
215 ILCS 134/45
Health care services appeals, complaints, and external independent reviews
Health care services appeals, complaints, and external independent reviews. (a) A health care plan shall establish and maintain an appeals procedure as outlined in this Act. Compliance with this Act's appeals procedures shall satisfy a health care plan's obligation to provide appeal procedures under any other State law…
215 ILCS 134/45.1
Medical exceptions procedures required
Medical exceptions procedures required. (a) Notwithstanding any other provision of law, on or after January 1, 2018 (the effective date of Public Act 99-761), every insurer licensed in this State to sell a policy of group or individual accident and health insurance or a health benefits plan shall establish and maintain…
215 ILCS 134/45.2
Prior authorization form; prescription benefits
Prior authorization form; prescription benefits. (a) Notwithstanding any other provision of law, on and after January 1, 2015, a health insurer that provides prescription drug benefits must, within 72 hours after receipt of a paper or electronic prior authorization form from a prescribing provider or pharmacist, either…
215 ILCS 134/45.3
Prescription drug benefits; plan choice
Prescription drug benefits; plan choice. (a) Notwithstanding any other provision of law, beginning January 1, 2023, every health insurance carrier that offers an individual health plan that provides coverage for prescription drugs shall ensure that at least 10% of individual health care plans offered in each applicable…
215 ILCS 134/50
Administrative complaints and Departmental review
Administrative complaints and Departmental review. (a) Administrative complaint process. (1) A health care plan shall accept and review appeals of its determinations and complaints related to administrative issues initiated by enrollees or their health care providers (complainant). All appeals of a health care plan's d…
215 ILCS 134/55
Record of complaints
Record of complaints. (a) The Department shall maintain records concerning the complaints filed against health care plans. To that end, the Department shall require health care plans to annually report complaints made to and resolutions by health care plans in a manner determined by rule. The Department shall make a su…
215 ILCS 134/60
Choosing a physician
Choosing a physician. (a) A health care plan may also offer other arrangements under which enrollees may access health care services from contracted providers without a referral or authorization from their primary care physician. (b) The enrollee may be required by the health care plan to select a specialist physician…
215 ILCS 134/65
Emergency services prior to stabilization
Emergency services prior to stabilization. (a) A health care plan that provides or that is required by law to provide coverage for emergency services shall provide coverage such that payment under this coverage is not dependent upon whether the services are performed by a plan or non-plan health care provider and witho…
215 ILCS 134/70
Post-stabilization medical services
Post-stabilization medical services. (a) If prior authorization for covered post-stabilization services is required by the health care plan, the plan shall provide access 24 hours a day, 7 days a week to persons designated by the plan to make such determinations, provided that any determination made under this Section…
215 ILCS 134/72
Pharmacy providers
Pharmacy providers. (a) Before entering into an agreement with pharmacy providers, a health care plan must establish terms and conditions that must be met by pharmacy providers desiring to contract with the health care plan. The terms and conditions shall not discriminate against a pharmacy provider. A health care plan…
215 ILCS 134/75
Consumer advisory committee
Consumer advisory committee. (a) A health care plan shall establish a consumer advisory committee. The consumer advisory committee shall have the authority to identify and review consumer concerns and make advisory recommendations to the health care plan. The health care plan may also make requests of the consumer advi…
215 ILCS 134/80
Quality assessment program
Quality assessment program. (a) A health care plan shall develop and implement a quality assessment and improvement strategy designed to identify and evaluate accessibility, continuity, and quality of care. The health care plan shall have: (1) an ongoing, written, internal quality assessment program; (2) specific writt…
215 ILCS 134/85
Utilization review program registration
Utilization review program registration. (a) No person may conduct a utilization review program in this State unless once every 2 years the person registers the utilization review program with the Department and provides proof of current accreditation for itself and its subcontractors with the Health Utilization Manage…
215 ILCS 134/87
General standards for use of utilization review criteria
General standards for use of utilization review criteria. (a) Beginning January 1, 2026, all utilization review programs shall make medical necessity determinations in accordance with the requirements of this Section. No policy, contract, certificate, formulary, or evidence of coverage issued to any enrollee may contai…
215 ILCS 134/90
Office of Consumer Health Insurance
Office of Consumer Health Insurance. (a) The Director of Insurance shall establish the Office of Consumer Health Insurance within the Department of Insurance to provide assistance and information to all health care consumers within the State. Within the appropriation allocated, the Office shall provide information and…
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