Under the Illinois Managed Care Reform and Patient Rights Act, individuals who receive health care benefits through a managed care plan such as an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization), have certain rights and remedies.

Individuals have the right to choose any available doctor who is participating in the health care plan to act as a primary care physician. The managed care organization must provide a list of licensed and qualified physicians from which to choose a doctor.

The standing referral process described in the Act enables patients with an ongoing medical condition to go directly to a specialist for care. For other types of referrals, the Act dictates that access to specialty care must be determined in conjunction with a primary care physician in a way that ensures a close coordination of care between health care providers.

Usually, health care plans will provide treatment only for medically necessary care. The Act requires that determinations regarding medical necessity be made only by health care professionals. Furthermore, the plan's review of a physician's treatment choices must be based solely on the medical information that was available to the physician at the time the services were performed.

If a managed health care organization declines to authorize payment for care recommended by a physician because it concludes that the care is not medically necessary, the patient and the health care provider may want to challenge this adverse determination.

The Act provides that individuals may seek both an internal and external review of adverse determinations. In an internal review, the patient must notify the managed care organization and request that it reconsider its decision. The patient must then submit the necessary information from the attending physician. The health care organization is required to make a decision within 15 days (or 24 hours for urgent cases).

While the Act applies to HMOs and many other health care plans purchased by an employer, it does not apply to self-insured health care benefit plans in which the employer bears the financial risk of providing health care benefits to its employees.

Those who participate in a self-insured plan, which is governed by a federal law called ERISA (the "Employee Retirement Income Security Act"), still have rights under the law. For more information about this topic as it relates to the Managed Care Reform and Patients Rights Act, you can contact an attorney, the Illinois Department of Insurance, or your plan's benefit coordinator.

Note: This information was prepared as a public service by the Illinois State Bar Association and is a joint project with the Illinois Press Association. Its purpose is to inform citizens of their legal rights and obligations.