Illinois Department of Insurance

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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

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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.”

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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

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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.

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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

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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;

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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.

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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

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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.

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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

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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

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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.

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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

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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

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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

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