INS - APPEALS

Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Illinois Insurance Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, and the Voluntary Health Services Plans Act. Provides that a policy of accident or health insurance or managed care plan shall establish and maintain an appeals procedure related to the denial of health care benefits. Sets forth guidelines for maintaining an appeals procedure, including an expedited process for an enrollee with (1) an ongoing course of treatment ordered by a health care provider, the denial of which could significantly increase the risk to an enrollee's health, (2) a treatment referral, service, procedure, or other health care service, the denial of which could significantly increase the risk to an enrollee's health, or (3) nonrenewal or termination of a plan. Provides that if an initial appeal is denied by the policy or plan, an enrollee is entitled to seek external independent review of the decision made by the policy or plan. Sets forth guidelines and requirements for the external independent review process. Provides that nothing in the provision shall be construed to require a policy or plan to pay for a health care service not covered under the enrollee's certificate of coverage or policy. Provides that a policy or plan shall provide each enrollee, prospective enrollee, and enrollee representative with written notification of the policy's or plan's appeal processes. Amends the Managed Care Reform and Patient Rights Act to provide that when an appeal concerns a decision or action by a health care plan, its employees, or its subcontractors that relates to the nonrenewal or termination of a plan, the health care plan must allow for the filing of an appeal either orally or in writing. Makes other changes.