Managed Care Reform and Patient Rights Act
Revised June 2009
Note: This information was developed to provide consumers with general information and guidance about insurance coverages and laws. It is not intended to provide a formal, definitive description or interpretation of Department policy. For specific Department policy on any issue, regulated entities (insurance industry) and interested parties should contact the Department.
What is the Managed Care Reform and Patient Rights Act?
The Managed Care Reform and Patient Rights Act, effective January 1, 2000, gives Illinois 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 HMO plans. The Act only partially applies to other insurance plans, including PPO plans. With the exception of utilization review processes, the Act does not apply to self-insured plans regulated by the U.S. Department of Labor.
To determine 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 Managed Care Reform and Patient Rights Act?
You have the right to receive detailed information from your HMO about your coverage, including information on:
- 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 and women’s principal health care providers
- Access to specialty care
- Benefits available for out-of-area coverage
- Out-of-pocket expenses
- Provisions for continuity of care
- Description of the appeals process
- Rights to an external independent review of claims denied for medical necessity
Basic Rights Under the Managed Care Reform and Patient Rights Act
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 and a right to an external independent review of any claim denied for not being medically necessary or appropriate.
You have a right to be given information about health care plans in a format that will allow you to compare benefits, exclusions and limitations as well as basic information about the health care plan, its financial condition and its financial relationships with providers.
How Do I File a Complaint Against My Health Plan?
If you are covered by an HMO and have a complaint, you should file an appeal directly with the HMO. If your HMO appeal for medical services is denied, you, your designee, your primary care physician or other health care provider can request an external independent review through the HMO. Your request should be made in writing unless your situation is urgent and requires an expedited decision. You have the right to jointly approve the doctor who will conduct the external independent review. If you are unsure about the external independent reviewer’s qualifications, you should consult with your 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 Department of Insurance. Complaints may be submitted in the following ways:
- On-line at http://insurance.illinois.gov and by following the instructions posted there
- By email at consumer_complaints@ins.state.il.us.
- By fax to (217) 558-2083
- By mail to 320 W. Washington Street, Springfield, IL 62767
Keep your originals and send only copies of information. For a printed copy of the Department’s complaint form, contact our toll-free Consumer Assistance Hotline at (866) 445-5364.
The Office of Consumer Health Insurance (OCHI)
The Office of Consumer Health Insurance, established within the Department of Insurance on January 1, 2000 by the Managed Care Reform and Patient Rights Act, is a consumer assistance office that can assist you with your health insurance problems and questions by:
- Explaining your rights as a health care consumer
- Answering your questions about health insurance
- Helping you understand the coverage provisions of your specific health care plan
- Assisting you when you have a problem or complaint.
You may contact the Office of Consumer Health Insurance toll-free at (877) 527-9431.
Other Important Health Insurance Telephone Numbers
| State | |
|---|---|
| Senior Health Insurance Program (SHIP) | (800) 548-9034 |
| Comprehensive Health Insurance Plan (CHIP) | (866) 851-2751 IL only (217) 782-6333 |
| Attorney General's Hotline | (877) 305-5145 |
| All Kids | (866) 255-5437 |
| State Employees Group Insurance | (800) 442-1300 |
| Federal | |
| ERISA/COBRA - U.S. Department of Labor | (866) 444-3272 |
| Medicare Hotline | (800) 633-4227 |
For More Information
Call our Consumer Services Section at (312) 814-2427 or our Office of Consumer Health Insurance toll free at (877) 527-9431 or visit us on our website at http://insurance.illinois.gov