Managed health care: what you should know
If you receive your health care benefits through a managed care plan such as an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization), you may benefit from an Illinois law designed to expand the rights, remedies and information available to both you and your health care providers.
Under the Illinois Managed Care Reform and Patients Rights Act, you may choose any available doctor who is participating in your health care plan to act as your primary care physician. Your managed care organization must provide you with a list of licensed and qualified physicians from which you may choose a doctor.
If you have an ongoing medical condition, a standing referral process described in the Act will enable you to go directly to a specialist for care. For other types of referrals, the Act provides that access to specialty care must be determined in conjunction with your primary care physician in a way that ensures a close coordination of care between your 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 your physician's treatment choices must be based solely on the medical information that was available to your physician at the time the services were performed.
If your managed health care organization declines to authorize payment for care recommended by your physician because it concludes that the care is not medically necessary, you and your 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, you notify your managed care organization and request that it reconsider its decision. It will then ask you to submit the necessary information from your physician. Once you have done so, your plan is required to make a decision within 15 days (or 24 hours for urgent cases).
While the Act applies to HMOs and many health care plans purchased by an employer from an independent insurer, 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.
Your participation in a self-insured plan, which is governed by a federal law called ERISA (the "Employee Retirement Income Security Act"), does not mean that you are without legal rights, however. To learn whether your benefit plan is subject 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.
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If you have questions about the application of the law in a particular case, consult your lawyer. The law is constantly changing. Information on this site or any site to which we link does not constitute legal advice.