Illinois Department of Insurance

Transcription

1 Illinois Department of Insurance By Jim Norris, Outreach Officer Overview of the IL Dept. of Insurance presented to: The Arc of Illinois Health Seminar October 20, 2015

2 Illinois Department of Insurance Goals 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.

3 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

4 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)

5 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.

6 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;

7 External Review Process More information about the External Review Process can be found at the following website: 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: fax: (217) by US Mail: Illinois Department of Insurance, Externa Review, 320 W. Washington St., Springfield, IL You may contact the External Review Unit within OCHI tollfree at (877) You may file a complaint at any time with the Illinois Department of Insurance.

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

9 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.

10 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 licensed Life, Accident, and Health companies in 2014 Producers Total 194,302 76,519 Active Resident Producers 117,783 Active Non-Resident Producers

11 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

12 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.

13 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

14 Market Conduct Completed 29 insurance company examinations in Life and Health insurers and affiliates 12 Property and Casualty insurers and affiliates 26 Stipulation and Consent Orders were issued

15 Important DOI Contact Information Illinois Department of Insurance insurance.illinois.gov Springfield main number: Chicago main number: Consumer Assistance Hotline: Office of Consumer Health Insurance (OCHI): Public Pension: