Current through Register Vol. 48, No. 12, March 22, 2024
Each applicant for registration shall file the following
information and documents with the Director in the format provided in the
Health Care Preferred Provider Program Administrator Checklist. DHCSP
administrators who only administer DHCSPs shall instead file in the format
provided in the Discounted Health Care Services Plan Only Registration
Checklist. WC PPP administrators shall instead file in the format provided in
the Workers' Compensation Preferred Provider Program Administrator Registration
Checklist. All of these checklists are located under "Managed Care
License/Registration Information" on the Department's website at
http://insurance.illinois.gov/company/companyMain.html.
a) Organizational requirements identified in
Section
2051.270;
b) Sample copies of all payor and provider
agreements identified in Sections
2051.280
and
2051.290,
when applicable. If the terms and conditions in an agreement include
significant, substantial or material change or additions, the filing of one
complete sample of each type of agreement, together with a description of all
variable terms and conditions, will satisfy this requirement;
c) Signed copies of all current
administrative agreements with any entity with which the applicant contracts to
provide services or to meet the requirements of the Act. Examples of these
contracts may include, but are not necessarily limited to, agreements with
other administrators, utilization review organizations, third party
administrators, third party prescription program administrators, risk-bearing
entities, and employers or employer groups for the purposes of WC PPPs.
Agreements at a minimum shall contain the following provisions:
1) Network availability and adequacy
requirements identified in Section
2051.310
or
2051.315;
2) If applicable, any DHCSP beneficiary
agreement requirements identified in Section
2051.320;
3) Copies of the preferred provider program
disclosure statements required to be furnished to beneficiaries by Section 370m
of the Act and illustrative advertising material to be used by the
applicant;
4) A description of
programs for utilization review, including procedures for timely investigation,
resolution of questions concerning medical necessity and appropriateness of
medical services and supplies and appeals from beneficiaries and providers as
provided by Section 370s of the Act and Section 85 of the Managed Care Reform
and Patient Rights Act [
215 ILCS
134/85 ] or, for the purposes of WC PPP, Section 8.7
of the Workers' Compensation Act. Administrators who administer only DHCSPs
need not comply with this subsection;
5) A description of any fiduciary account
established by the administrator, including the location and identification
number of the account, established and maintained pursuant to Section 370l of
the Act and Section
2051.340
of this Part; and/or a bond in compliance with Section 370l of the Act and
Section
2051.340
of this Part. If a bond is submitted, the administrator shall also furnish a
certification of the total estimated annual reimbursements under the preferred
provider program, supported by the methodology used to arrive at that
figure;
6) Administrators may not
participate in an exclusive provider organization in this State, except when
such an arrangement is shown to be in the best interest of the beneficiaries
and has been expressly approved by the Director in writing. This subsection
(c)(6) does not apply to administrators offering only DHCSPs.
7) WC PPP administrators that utilize
economic evaluation of their providers shall file a description of any policies
and procedures related to the economic evaluation utilized by the program. The
filing shall describe how these policies and procedures are used in utilization
review, peer review, incentive and penalty programs, and in provider retention
and termination decisions.
8) WC
PPP administrators shall provide those policies and procedures instituted to
insure the employer is providing proper notification to the covered employee in
accordance with the form promulgated by the Workers' Compensation
Commission.
d) A listing
containing the name, address and FEIN of all entities that private label a
DHCSP of the administrator, including:
1) The
name of the private label marketer;
2) Any DBA used by the private label
marketer; and
3) All product names
used by the private label marketer.