Customers of Illinois HMOs can expect quality, affordable, and accessible health care plans under a state law passed in 2000.

The Managed Care Responsibility to Members Act spells out several requirements for managed care organizations, including patient rights to confidentiality of sensitive medical information (such as HIV status), the prohibition of "gag rules" on their doctors, and the establishment of grievance and review panels.

The HMO reform bill, which took effect Jan. 1, 2000, was passed unanimously by both the Illinois House and Senate, although many legislators had criticized it as being "antibusiness." The law does stop short of allowing consumers to sue their HMOs for medical malpractice.

Provisions of the reform law

• Prohibits restraints on communication. HMOs cannot impose gag orders on doctors that prevent them from "fully discussing" with patients their treatment costs, benefits, risks, plan exclusions, or other policy practices that affect patient access to coverage or treatment options.

• Provides greater continuity of care. Under certain circumstances, patients can continue to see their doctor for up to 60 days after the doctor leaves a health care plan. The provision applies to pregnant women in their third trimester and patients who have a life-threatening disease. It also allows new enrollees to continue to see their former doctors if the doctors are within the health plan's service area.

• Removes restrictions on emergency care. Patients will no longer have to seek prior approval for treatment in an ER. The HMO must also pay the ER costs even if the hospital is not in its network.

• Establishes a consumer advisory committee. HMOs must randomly select eight customers to sit on a consumer advisory committee. The committee will have the authority to review consumer concerns and make recommendations to the health care plan.

• Creates a grievance procedure. Each health care plan must maintain a system for resolving grievances that concern the provision of health care services or other issues about the operation of the HMO. It must report to state insurance regulators the number of grievances handled, the reasons for the grievances, the outcome, and the time it takes to resolve the dispute.

• Mandates a medical review procedure. In the event of a dispute between a patient's doctor and the HMO about the medical necessity of treatment, the health care plan must have a procedure in place to review the case. A doctor unaffiliated with the HMO and who is jointly selected by the patient, the doctor, and the HMO, will oversee the review. A decision must be rendered in 60 days, or three days if the patient's health is at stake.