a)
Administrators and insurers must file a description of the services to be
offered through the preferred provider program. WC PPPs are exempt from the
requirements of this Section, but must instead comply with the requirements of
Section
2051.315.
The description shall include:
2) A
geographic map of the area proposed to be served by the program by county and
zip code, including marked locations for preferred providers;
3) The names, addresses and specialties of
the providers who have entered into preferred provider agreements under the
program;
4) The number of
beneficiaries anticipated to be covered by the providers listed in subsection
(a)(3);
5) An Internet website and
toll-free telephone number for beneficiaries and prospective beneficiaries to
access regarding up-to-date lists of preferred providers, additional
information about the DHCSP, as well as any other information necessary to
conform to this Part. A plan shall identify specific providers in a
beneficiary's area, confirm specific provider participation or provide a
listing of preferred providers by mail. Preferred provider lists requested by
phone must be sent within 3 working days. The up-to-date provider list applies
to all providers that have entered arrangements to provide services under the
program either directly, or indirectly through another administrator.
Administrators' and insurers' Internet website addresses shall be prominently
displayed on all advertisements, marketing materials, brochures, benefit cards
and identification cards; and
6) A
description of how health care services to be rendered under the preferred
provider program are reasonably accessible and available to beneficiaries.
Standards shall address:
A) The type of
health care services to be provided by the administrator;
B) The ratio of providers to beneficiaries,
by specialty and including primary care physicians when applicable under the
contract, necessary to meet the health care needs and service demands of the
currently enrolled population;
C)
The greatest distance or time that the beneficiary may be required to travel to
access:
i) Preferred provider hospital
services when applicable under the contract;
ii) Primary care physician and woman's
principal health care provider services when applicable under the
contract;
iii) Any applicable
health care service providers;
D) Written policies and procedures for
determining when the program is closed to new providers desiring to enter into
preferred provider arrangements;
E)
Written policies and procedures for adding providers to meet patient needs
based on increases in the number of beneficiaries, changes in the patient to
provider ratio, changes in medical and health care capabilities, and increased
demand for services;
F) The
provision of 24 hour, 7 day per week access to network affiliated primary care
and woman's principal health care providers. This subsection (a)(6)(F) does not
apply to administrators offering only a DHCSP;
G) The procedures for making referrals within
and outside the network. This subsection (a)(6)(G) does not apply to
administrators offering only a DHCSP;
H) A provision ensuring that whenever a
beneficiary has made a good faith effort to utilize preferred providers for a
covered service and it is determined the administrator does not have the
appropriate preferred providers due to insufficient number, type or distance,
the administrator shall ensure, directly or indirectly, by terms contained in
the payor contract, that the beneficiary will be provided the covered service
at no greater cost to the beneficiary than if the service had been provided by
a preferred provider. This subsection (a)(6)(H) does not apply to a beneficiary
who willfully chooses to access a non-preferred provider for health care
services available through the administrator's panel of participating
providers. In these circumstances, the contractual requirements for
non-preferred provider reimbursements will apply. This subsection (a)(6)(H)
does not apply to administrators offering only a DHCSP;
I) The procedures for paying benefits when
particular physician specialties are not represented within the provider
network, or the services of such providers are not available at the time care
is sought. In any case in which a beneficiary has made a good faith effort to
utilize network providers, by satisfying contractual obligation specified in
the benefit contract or certificate, for a covered service and the
administrator does not have the appropriate preferred specialty providers
(including but not limited to radiologists, anesthesiologists, pathologists and
emergency room physicians) under contract due to the inability of the
administrator to contract with the specialists, or due to the insufficient
number or type of, or travel distance to, specialists, the administrator shall
ensure that the beneficiary will be provided the covered service at no greater
cost to the beneficiary than if the service had been provided by a preferred
provider. This subsection (a)(6)(I) does not apply to a beneficiary who
willfully chooses to access a non-preferred provider for health care services
available through the administrator's panel of participating providers. In
these circumstances, the contractual requirements for non-preferred provider
reimbursements will apply. This subsection (a)(6)(I) does not apply to
administrators offering only a DHCSP;
J) A provision that the beneficiary shall
receive emergency care coverage such that payment for this coverage is not
dependent upon whether the services are performed by a preferred or
non-preferred provider and the coverage shall be at the same benefit level as
if the service or treatment had been rendered by a preferred provider. For
purposes of this subsection (a)(6)(J), "the same benefit level" means that the
beneficiary will be provided the covered service at no greater cost to the
beneficiary than if the service had been provided by a preferred provider. This
subsection (a)(6)(J) does not apply to administrators offering only a
DHCSP;
K) A limitation that, if the
plan provides that the beneficiary will incur a penalty for failing to
pre-certify inpatient hospital treatment, the penalty may not exceed $1,000 per
occurrence;
L) Efforts to address
the needs of beneficiaries with limited English proficiency and literacy and/or
diverse cultural and ethnic backgrounds, and to comply with the Americans With
Disabilities Act of 1990;
M) A
sample beneficiary identification card in conformity with the Uniform Health
Care Service Benefits Information Card Act [215 ILCS 139 ], and the Uniform
Prescription Drug Information Card Act [215 ILCS 138 ] when pharmaceutical
services are provided as part of the program's health care services;
N) When a gatekeeper option is included as
part of the program, a requirement that the administrator make a good faith
effort to provide written notice of termination of the gatekeeper to all
beneficiaries who are patients seen on a regular basis by the gatekeeper whose
contract is terminating. In a gatekeeper option, when a contract termination
involves a primary care physician, all beneficiaries who are patients of that
primary care physician shall also be notified. This subsection (a)(6)(N) does
not apply to administrators offering only a DHCSP.