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
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.”
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 informationfrom 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
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;
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
62767
You 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
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
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
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
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
