215 Ill. Comp. Stat. §§ 125/4-10 through 125/4-20: Health Maintenance Organization Act — Delivery of Services – Required Provisions and Marketing – Illinois

Status: Enacted
Year Enacted: 1987
Year Amended: 2017
File: Download

Statutes lay out indepenent review process for what constitutes “medically necessary” for a certain patient. Statutes require a health maintenance organization to file with the Director, prior to use, a notice of any change in rate methodology, or benefits and of any material modification of any matter or document and require all policy forms going to enrollees be approved by the director. All subscribers shall be provided a clear and concise statement of limitation of services and benefits to be provided, including reasonable cost sharing charges. Statutes prohibit providers of emergency transport to balance bill an enrollee after payment from HMO. HMOs may require copayments and deductibles of enrollees.

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