Illinois Department of InsuranceBy Jim Norris, Outreach Officer

Overview of the IL Dept. of Insurance presented to:The Arc of Illinois Health Seminar

October 20, 2015

Illinois Department of InsuranceGoals

Our Mission:

“To protect consumers by providing assistance and information, by efficiently regulating the insurance industry’s market behavior and financial solvency, and by fostering a competitive insurance marketplace.”

Illinois Department of Insurance(also known as IDOI or DOI)

• Total number of employees = 260– Consumer Divisions = 102 employees• Includes Life, Accident, Health, and Property and

Casualty Analysts– Financial/Corporate Divisions = 111 employees– Pension = 13 employees– Legal = 22 employees– Workers’ Compensation Fraud Unit =7 employees

Office of Consumer Health Insurance (OCHI)

The Office of Consumer Health Insurance (OCHI), a Division of the Department of Insurance, is a consumer assistance office created under the Managed Care Reform and Patient Rights Act (215 ILCS

134/). OCHI can help you with your health insurance problems and questions. OCHI can:

• Explain your rights as a health care consumer; • Answer your questions about health insurance;

• Help you understand the coverage provisions of your specific health care plan; and

• Assist you when you have a problem or complaint.

To contact the Office of Consumer Health Insurance, call toll-free at (877) 527-9431.

What Are Your “Rights” Under the Act?

• You have the right to receive detailed information from your health insurance company about your coverage including the following information:

• the areas of the state served by the plan;• exclusions and limitations;• pre-certification & utilization review requirements;• emergency room coverage and requirements;• selection of primary care physicians;• access to specialty care;• benefits available for out-of-area coverage;• out-of-pocket expenses;• provisions for continuity of care; and lastly• the appeals process.

How To File a Complaint against Your Health Plan

• You have the right to appeal decisions made by your health insurance company;

• You should first file an appeal directly with your insurance company;

• You can request an external independent review, if your appeal is denied for the following reasons:

• Medical necessity including appropriateness, healthcare setting, level of care or effectiveness; • Experimental/Investigational; • Pre-existing condition; • Rescission of coverage;

External Review Process

More information about the External Review Process can be found at the following website: http://insurance.illinois.gov/ExternalReview/default.asp An accredited independent review organization will be randomly assigned by the Department of Insurance to review your appeal if it is eligible. The completed forms may be submitted by: • email: doi.externalreview@illinois.gov • fax: (217) 557-8495 • by US Mail: Illinois Department of Insurance, Externa Review, 320 W. Washington St., Springfield, IL 62767You may contact the External Review Unit within OCHI toll-free at (877) 850-4740. You may file a complaint at any time with the Illinois Department of Insurance.

Complaints

In 2014, DOI implemented the Message Center• 100% federally funded• Replaces fax, email, and paper complaints• Total Complaints = 10,137 in 2014• 4,609 Property and Casualty• 4,091 Health• 886 Life• 551 HMO

Consumer Outreach & Education 2015 Efforts

• Disaster Relief – provide on-site victim assistance working closely with the Red Cross, IEMA, & FEMA;

• State Fair – Staffing the Governor’s tent providing information to consumers on DOI services;

• Get Covered Illinois Outreach: - Help facilitate individuals and groups to purchase health insurance , which is required by law;

• Property and Casualty Outreach:- Implement opportunities to meet with community groups regarding fires, floods and storms;

• Make External Review educational materials available to interested parties.

Licensing• DOI issues licenses both insurance companies and

their producers (agents and brokers)• Insurance Companies – Total 2,235– 1,746 licensed Property and Casualty companies in

2014– 489 licensed Life, Accident, and Health companies in

2014• Producers – Total 194,302– 76,519 Active Resident Producers– 117,783 Active Non-Resident Producers

Financial• 15 Insurance Companies were newly admitted in 2014:– Property and Casualty:• 1 new domestic surplus lines company;• 11 new foreign companies;

– Life, Accident, & Health (LAH):• 1 new foreign LAH company;• 2 HMOs (1 domestic and 1 foreign );• 1 domestic LHSO (Limited Health Service

Organization).• Premium Reporting for 2014:– P&C reported $22,374,715,079 in Illinois premiums;– LAH reported $46,399,548,931 in Illinois premiums;– Farm Mutuals reported $109,573,205 in Illinois premiums

Public Pension Division

• Our Public Pension Division is responsible for overseeing all public pension funds within the state.

• 675 Funds:– 15 “Large” pension funds• SERS, TRS, IMRF, etc.;

– 660 municipality-specific downstate and suburban police and fire pension funds.

• 1 million pension annuitants are covered: – 599,000 active participants;– 452,000 retirees, surviving spouses, and other

beneficiaries.

Workers’ Compensation Fraud• The Illinois Workers’ Compensation Commission (IWCC)

administers statutory provisions in the Illinois Workers’ Compensation Act.

• The Department of Insurance investigates potential fraud in our Workers’ Compensation Fraud Unit (WCFU).

• In 2014, the Department received 100 complaints:– 42 of the complaints were deemed sufficient to warrant

further investigation• The Department also assists consumers with the following

items:– Audit disputes– Insurance company disputes

Market Conduct

• Completed 29 insurance company examinations in 2014– 17 Life and Health insurers and affiliates– 12 Property and Casualty insurers and affiliates

• 26 Stipulation and Consent Orders were issued

Important DOI Contact Information

• Illinois Department of Insurance http://insurance.illinois.gov – Springfield main number: 217.782.4515– Chicago main number: 312.814.2420

• Consumer Assistance Hotline: 866.445.5364• Office of Consumer Health Insurance (OCHI):

877.527.9431• Public Pension: 800.207.6958