(215 ILCS 134/25)
Sec. 25. Transition of services.
(a) A health care plan shall provide for continuity of care for its enrollees as follows:
(1) If an enrollee's physician leaves the health care
plan's network of health care providers for reasons other than termination of a contract in situations involving imminent harm to a patient or a final disciplinary action by a State licensing board and the physician remains within the health care plan's service area, the health care plan shall permit the enrollee to continue an ongoing course of treatment with that physician during a transitional period:
(A) of 90 days from the date of the notice of
physician's termination from the health care plan to the enrollee of the physician's disaffiliation from the health care plan if the enrollee has an ongoing course of treatment; or
(B) if the enrollee has entered the third
trimester of pregnancy at the time of the physician's disaffiliation, that includes the provision of post-partum care directly related to the delivery.
(2) Notwithstanding the provisions in item (1) of
this subsection, such care shall be authorized by the health care plan during the transitional period only if the physician agrees:
(A) to continue to accept reimbursement from the
health care plan at the rates applicable prior to the start of the transitional period;
(B) to adhere to the health care plan's quality
assurance requirements and to provide to the health care plan necessary medical information related to such care; and
(C) to otherwise adhere to the health care plan's
policies and procedures, including but not limited to procedures regarding referrals and obtaining preauthorizations for treatment.
(b) A health care plan shall provide for continuity of care for new enrollees as follows:
(1) If a new enrollee whose physician is not a member
of the health care plan's provider network, but is within the health care plan's service area, enrolls in the health care plan, the health care plan shall permit the enrollee to continue an ongoing course of treatment with the enrollee's current physician during a transitional period:
(A) of 90 days from the effective date of
enrollment if the enrollee has an ongoing course of treatment; or
(B) if the enrollee has entered the third
trimester of pregnancy at the effective date of enrollment, that includes the provision of post-partum care directly related to the delivery.
(2) If an enrollee elects to continue to receive care
from such physician pursuant to item (1) of this subsection, such care shall be authorized by the health care plan for the transitional period only if the physician agrees:
(A) to accept reimbursement from the health care
plan at rates established by the health care plan; such rates shall be the level of reimbursement applicable to similar physicians within the health care plan for such services;
(B) to adhere to the health care plan's quality
assurance requirements and to provide to the health care plan necessary medical information related to such care; and
(C) to otherwise adhere to the health care plan's
policies and procedures including, but not limited to procedures regarding referrals and obtaining preauthorization for treatment.
(c) In no event shall this Section be construed to require a health care plan to provide coverage for benefits not otherwise covered or to diminish or impair preexisting condition limitations contained in the enrollee's contract.
(Source: P.A. 91-617, eff. 7-1-00.)
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Last modified: February 18, 2015