DOI Pat Quinn Governor Andrew Boron, Director

Office of Consumer Health Insurance (OCHI)

OCHI Annual Report - 2012  2011  2010  2009  2008  2007  2006  2005  2004  2003  2002  2001  2000


What is the Office of Consumer Health Insurance?

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

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

OCHI 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 OCHI, call toll free at (877) 527-9431.


What is the Managed Care Reform and Patient Rights Act?

The Managed Care Reform and Patient Rights Act is the hyper link), 215 ILCS 134,  gives Illinois consumers more control of their health care through tighter requirements on health maintenance organizations, insurance companies, doctors and other health care providers. 

The Act does not apply to self-funded plans regulated by the U.S. Department of Labor.

To find out more about the Act, call OCHI toll free at (877) 527-9431.


What Are My Rights Under the Act?

You have the right to receive detailed information from your insurance company or 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
  • 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.

If you are in an HMO, 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 insurance company or HMO.

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


How Do I File a Complaint against My Health Plan?

You should first file an appeal directly with your insurance company or HMO.

If your appeal is denied, for the following reasons:

  • Medical necessity including appropriateness, healthcare setting, level of care or effectiveness
  • Experimental/Investigational
  • Pre-existing condition
  • Rescission of coverage

You can request an external independent review.

Information about the external review process and required forms are located at http://insurance.illinois.gov/ExternalReview/default.asp.

The completed forms may be submitted by:

  • email: doi.externalreview@illinois.gov
  • fax: (217) 557-8495
  • By US Mail: Illinois Department of Insurance, External Review, 320 W. Washington St., Springfield, IL 62767

You may contact the External Review Unit within OCHI toll-free at (877) 850-4740.

If you are unable to resolve problems other than those listed above, you may file a complaint at any time with the Illinois Department 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 Department of Insurance web site at: https://mc.insurance.illinois.gov/messagecenter.nsf.


Important Health Insurance Telephone Numbers

State Resources:

Department of Insurance
Springfield Office 217-782-4515
Chicago Office 312-814-2420
External Review Hot-Line 877-850-4740
   
Office of Consumer Health Insurance 877-527-9431
Senior Health Insurance Program (SHIP) within the Illinois Department on Aging 800-548-9034 or 800-252-8966
Comprehensive Health Insurance Plan (CHIP) 866-851-2751
Attorney General's Hotline 877-305-5145
All Kids/Family Care/Adult Medicaid 800-226-0768
State Employees Group Insurance 217-782-2548
   
Federal Resources:
ERISA/COBRA Department of Labor 866-444-3272
Medicare Hotline 800-633-4227

Uninsured Ombudsman Program