Illinois Compiled Statutes 215 ILCS 125 Health Maintenance Organization Act. Section 5-5

    (215 ILCS 125/5-5) (from Ch. 111 1/2, par. 1413)

    Sec. 5-5. Suspension, revocation or denial of certification of authority. The Director may suspend or revoke any certificate of authority issued to a health maintenance organization under this Act or deny an application for a certificate of authority if he finds any of the following:

    (a) The health maintenance organization is operating significantly in contravention of its basic organizational document, its health care plan, or in a manner contrary to that described in any information submitted under Section 2-1 or 4-12.

    (b) The health maintenance organization issues contracts or evidences of coverage or uses a schedule of charges for health care services that do not comply with the requirement of Section 2-1 or 4-12.

    (c) The health care plan does not provide or arrange for basic health care services, except as provided in Section 4-13 concerning mental health services for clients of the Department of Children and Family Services.

    (d) The Director of Public Health certifies to the Director that (1) the health maintenance organization does not meet the requirements of Section 2-2 or (2) the health maintenance organization is unable to fulfill its obligations to furnish health care services as required under its health care plan. The Department of Public Health shall promulgate by rule, pursuant to the Illinois Administrative Procedure Act, the precise standards used for determining what constitutes a material misrepresentation, what constitutes a material violation of a contract or evidence of coverage, or what constitutes good faith with regard to certification under this paragraph.

    (e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees.

    (f) The health maintenance organization, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner.

    (g) The continued operation of the health maintenance organization would be hazardous to its enrollees.

    (h) The health maintenance organization has neglected to correct, within the time prescribed by subsection (c) of Section 2-4, any deficiency occurring due to the organization's prescribed minimum net worth or special contingent reserve being impaired.

    (i) The health maintenance organization has otherwise failed to substantially comply with this Act.

    (j) The health maintenance organization has failed to meet the requirements for issuance of a certificate of authority set forth in Section 2-2.

    When the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. The Director may permit further operation of the organization that he finds to be in the best interest of enrollees to the end that the enrollees will be afforded the greatest practical opportunity to obtain health care services.

(Source: P.A. 88-487.)

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Last modified: February 18, 2015