Office of Consumer Health Insurance (OCHI)
What is the Office of Consumer Health Insurance?
The Office of Consumer Health Insurance (OCHI) is a consumer assistance office that helps you with your health insurance problems and questions.
The office was established by the Illinois Department of Insurance on January 1, 2000, as part of the Managed Care Reform and Patient Rights Act.
- 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 OCHI, call toll free at (877) 527-9431.
What is the Managed Care Reform and Patient Rights Act?
The Managed Care Reform and Patient Rights Act is the hyper link), 215 ILCS 134, gives Illinois consumers more control of their health care through tighter requirements on health maintenance organizations, insurance companies, doctors and other health care providers.
The Act does not apply to self-funded plans regulated by the U.S. Department of Labor.
To find out more about the Act, call OCHI toll free at (877) 527-9431.
What Are My Rights Under the Act?
You have the right to receive detailed information from your insurance company or HMO about your coverage, including information on:
- the areas of the state served by the plan;
- exclusions and limitations;
- pre-certification and 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
- the appeals process.
You have the right to receive coverage for emergency services when a "prudent person" would reasonably believe that your condition is serious enough to require emergency medical attention.
If you are in an HMO, you have the right to apply for a standing referral from your primary care physician when you have a condition that requires ongoing care from a specialist. In some cases, your HMO may be required to provide access to such specialty care outside the network
You have the right to appeal decisions made by your insurance company or HMO.
If you have questions about your rights under the Act,
contact the Office of Consumer Health Insurance
toll free at (877) 527-9431.
How Do I File a Complaint against My Health Plan?
You should first file an appeal directly with your insurance company or HMO.
If your appeal is denied, for the following reasons:
- Medical necessity including appropriateness, healthcare setting, level of care or effectiveness
- Pre-existing condition
- Rescission of coverage
You can request an external independent review.
Information about the external review process and required forms are located at http://insurance.illinois.gov/ExternalReview/default.asp.
The completed forms may be submitted by:
- email: firstname.lastname@example.org
- fax: (217) 557-8495
- By US Mail: Illinois Department of Insurance, External Review, 320 W. Washington St., Springfield, IL 62767
You may contact the External Review Unit within OCHI toll-free at (877) 850-4740.
If you are unable to resolve problems other than those listed above, you may file a complaint at any time with the Illinois Department of Insurance.
To obtain a complaint form or receive help in completing the form,
call the Office of Consumer Health Insurance
toll free at (877) 527-9431.
You can also file a complaint electronically from the Department of Insurance web site at: https://mc.insurance.illinois.gov/messagecenter.nsf.
Important Health Insurance Telephone Numbers
|Department of Insurance|
|External Review Hot-Line||877-850-4740|
|Office of Consumer Health Insurance||877-527-9431|
|Senior Health Insurance Program (SHIP) within the Illinois Department on Aging||800-548-9034 or 800-252-8966|
|Comprehensive Health Insurance Plan (CHIP)||866-851-2751|
|Attorney General's Hotline||877-305-5145|
|All Kids/Family Care/Adult Medicaid||800-226-0768|
|State Employees Group Insurance||217-782-2548|
|ERISA/COBRA Department of Labor||866-444-3272|