Sec. 80. Quality assessment program.

368 words·~2 min read·/il/chapter-215/act-134/80

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(a)A health care plan shall develop and implement a quality assessment and improvement strategy designed to identify and evaluate accessibility, continuity, and quality of care. The health care plan shall have:

(1)an ongoing, written, internal quality assessment program;

(2)specific written guidelines for monitoring and evaluating the quality and

appropriateness of care and services provided to enrollees requiring the health care plan to assess:

(A)the accessibility to health care providers;

(B)appropriateness of utilization;

(C)concerns identified by the health care plan's medical or administrative staff

and enrollees; and

(D)other aspects of care and service directly related to the improvement of quality

of care;

(3)a procedure for remedial action to correct quality problems that have been verified

in accordance with the written plan's methodology and criteria, including written procedures for taking appropriate corrective action;

(4)follow-up measures implemented to evaluate the effectiveness of the action plan.

(b)The health care plan shall establish a committee that oversees the quality assessment and improvement strategy which includes physician and enrollee participation.

(c)Reports on quality assessment and improvement activities shall be made to the governing body of the health care plan not less than quarterly.

(d)The health care plan shall make available its written description of the quality assessment program to the Department of Public Health.

(e)With the exception of subsection (d), the Department of Public Health shall accept evidence of accreditation with regard to the health care network quality management and performance improvement standards of:

(1)the National Commission on Quality Assurance (NCQA);

(2)the American Accreditation Healthcare Commission (URAC);

(3)the Joint Commission on Accreditation of Healthcare Organizations (JCAHO);

(4)the Accreditation Association for Ambulatory Health Care (AAAHC); or

(5)any other entity that the Director of Public Health deems has substantially similar

or more stringent standards than provided for in this Section.

(f)If the Department of Public Health determines that a health care plan is not in compliance with the terms of this Section, it shall certify the finding to the Department of Insurance. The Department of Insurance shall subject a health care plan to penalties, as provided in this Act, for such non-compliance.