Bill Amendment: IL HB5395 | 2023-2024 | 103rd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: NETWORK ADEQUACY-STANDARDS
Status: 2024-05-25 - Passed Both Houses [HB5395 Detail]
Download: Illinois-2023-HB5395-House_Amendment_002.html
Bill Title: NETWORK ADEQUACY-STANDARDS
Status: 2024-05-25 - Passed Both Houses [HB5395 Detail]
Download: Illinois-2023-HB5395-House_Amendment_002.html
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1 | AMENDMENT TO HOUSE BILL 5395 | ||||||
2 | AMENDMENT NO. ______. Amend House Bill 5395, AS AMENDED, | ||||||
3 | by replacing everything after the enacting clause with the | ||||||
4 | following:
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5 | "Article 1. | ||||||
6 | Section 1-1. This Act may be referred to as the Health Care | ||||||
7 | Consumer Access and Protection Act.
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8 | Article 2. | ||||||
9 | Section 2-5. The Illinois Administrative Procedure Act is | ||||||
10 | amended by adding Section 5-45.55 as follows:
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11 | (5 ILCS 100/5-45.55 new) | ||||||
12 | Sec. 5-45.55. Emergency rulemaking; Network Adequacy and | ||||||
13 | Transparency Act. To provide for the expeditious and timely |
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1 | implementation of the Network Adequacy and Transparency Act, | ||||||
2 | emergency rules implementing federal standards for provider | ||||||
3 | ratios, travel time and distance, and appointment wait times | ||||||
4 | if such standards apply to health insurance coverage regulated | ||||||
5 | by the Department of Insurance and are more stringent than the | ||||||
6 | State standards extant at the time the final federal standards | ||||||
7 | are published may be adopted in accordance with Section 5-45 | ||||||
8 | by the Department of Insurance. The adoption of emergency | ||||||
9 | rules authorized by Section 5-45 and this Section is deemed to | ||||||
10 | be necessary for the public interest, safety, and welfare.
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11 | Section 2-10. The Network Adequacy and Transparency Act is | ||||||
12 | amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and | ||||||
13 | by adding Sections 35, 40, 50, and 55 as follows:
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14 | (215 ILCS 124/3) | ||||||
15 | Sec. 3. Applicability of Act. This Act applies to an | ||||||
16 | individual or group policy of accident and health insurance | ||||||
17 | coverage with a network plan amended, delivered, issued, or | ||||||
18 | renewed in this State on or after January 1, 2019. This Act | ||||||
19 | does not apply to an individual or group policy for excepted | ||||||
20 | benefits or short-term, limited-duration health insurance | ||||||
21 | coverage dental or vision insurance or a limited health | ||||||
22 | service organization with a network plan amended, delivered, | ||||||
23 | issued, or renewed in this State on or after January 1, 2019 , | ||||||
24 | except to the extent that federal law establishes network |
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1 | adequacy and transparency standards for stand-alone dental | ||||||
2 | plans, which the Department shall enforce for plans amended, | ||||||
3 | delivered, issued, or renewed on or after January 1, 2025 . | ||||||
4 | (Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
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5 | (215 ILCS 124/5) | ||||||
6 | Sec. 5. Definitions. In this Act: | ||||||
7 | "Authorized representative" means a person to whom a | ||||||
8 | beneficiary has given express written consent to represent the | ||||||
9 | beneficiary; a person authorized by law to provide substituted | ||||||
10 | consent for a beneficiary; or the beneficiary's treating | ||||||
11 | provider only when the beneficiary or his or her family member | ||||||
12 | is unable to provide consent. | ||||||
13 | "Beneficiary" means an individual, an enrollee, an | ||||||
14 | insured, a participant, or any other person entitled to | ||||||
15 | reimbursement for covered expenses of or the discounting of | ||||||
16 | provider fees for health care services under a program in | ||||||
17 | which the beneficiary has an incentive to utilize the services | ||||||
18 | of a provider that has entered into an agreement or | ||||||
19 | arrangement with an issuer insurer . | ||||||
20 | "Department" means the Department of Insurance. | ||||||
21 | "Essential community provider" has the meaning ascribed to | ||||||
22 | that term in 45 CFR 156.235. | ||||||
23 | "Excepted benefits" has the meaning ascribed to that term | ||||||
24 | in 42 U.S.C. 300gg-91(c). | ||||||
25 | "Exchange" has the meaning ascribed to that term in 45 CFR |
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1 | 155.20. | ||||||
2 | "Director" means the Director of Insurance. | ||||||
3 | "Family caregiver" means a relative, partner, friend, or | ||||||
4 | neighbor who has a significant relationship with the patient | ||||||
5 | and administers or assists the patient with activities of | ||||||
6 | daily living, instrumental activities of daily living, or | ||||||
7 | other medical or nursing tasks for the quality and welfare of | ||||||
8 | that patient. | ||||||
9 | "Group health plan" has the meaning ascribed to that term | ||||||
10 | in Section 5 of the Illinois Health Insurance Portability and | ||||||
11 | Accountability Act. | ||||||
12 | "Health insurance coverage" has the meaning ascribed to | ||||||
13 | that term in Section 5 of the Illinois Health Insurance | ||||||
14 | Portability and Accountability Act. "Health insurance | ||||||
15 | coverage" does not include any coverage or benefits under | ||||||
16 | Medicare or under the medical assistance program established | ||||||
17 | under Article V of the Illinois Public Aid Code. | ||||||
18 | "Issuer" means a "health insurance issuer" as defined in | ||||||
19 | Section 5 of the Illinois Health Insurance Portability and | ||||||
20 | Accountability Act. | ||||||
21 | "Insurer" means any entity that offers individual or group | ||||||
22 | accident and health insurance, including, but not limited to, | ||||||
23 | health maintenance organizations, preferred provider | ||||||
24 | organizations, exclusive provider organizations, and other | ||||||
25 | plan structures requiring network participation, excluding the | ||||||
26 | medical assistance program under the Illinois Public Aid Code, |
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1 | the State employees group health insurance program, workers | ||||||
2 | compensation insurance, and pharmacy benefit managers. | ||||||
3 | "Material change" means a significant reduction in the | ||||||
4 | number of providers available in a network plan, including, | ||||||
5 | but not limited to, a reduction of 10% or more in a specific | ||||||
6 | type of providers within any county , the removal of a major | ||||||
7 | health system that causes a network to be significantly | ||||||
8 | different within any county from the network when the | ||||||
9 | beneficiary purchased the network plan, or any change that | ||||||
10 | would cause the network to no longer satisfy the requirements | ||||||
11 | of this Act or the Department's rules for network adequacy and | ||||||
12 | transparency. | ||||||
13 | "Network" means the group or groups of preferred providers | ||||||
14 | providing services to a network plan. | ||||||
15 | "Network plan" means an individual or group policy of | ||||||
16 | accident and health insurance coverage that either requires a | ||||||
17 | covered person to use or creates incentives, including | ||||||
18 | financial incentives, for a covered person to use providers | ||||||
19 | managed, owned, under contract with, or employed by the issuer | ||||||
20 | or by a third party contracted to arrange, contract for, or | ||||||
21 | administer such provider-related incentives for the issuer | ||||||
22 | insurer . | ||||||
23 | "Ongoing course of treatment" means (1) treatment for a | ||||||
24 | life-threatening condition, which is a disease or condition | ||||||
25 | for which likelihood of death is probable unless the course of | ||||||
26 | the disease or condition is interrupted; (2) treatment for a |
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1 | serious acute condition, defined as a disease or condition | ||||||
2 | requiring complex ongoing care that the covered person is | ||||||
3 | currently receiving, such as chemotherapy, radiation therapy, | ||||||
4 | or post-operative visits , or a serious and complex condition | ||||||
5 | as defined under 42 U.S.C. 300gg-113(b)(2) ; (3) a course of | ||||||
6 | treatment for a health condition that a treating provider | ||||||
7 | attests that discontinuing care by that provider would worsen | ||||||
8 | the condition or interfere with anticipated outcomes; or (4) | ||||||
9 | the third trimester of pregnancy through the post-partum | ||||||
10 | period ; (5) undergoing a course of institutional or inpatient | ||||||
11 | care from the provider within the meaning of 42 U.S.C. | ||||||
12 | 300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective | ||||||
13 | surgery from the provider, including receipt of preoperative | ||||||
14 | or postoperative care from such provider with respect to such | ||||||
15 | a surgery; (7) being determined to be terminally ill, as | ||||||
16 | determined under 42 U.S.C. 1395x(dd)(3)(A), and receiving | ||||||
17 | treatment for such illness from such provider; or (8) any | ||||||
18 | other treatment of a condition or disease that requires | ||||||
19 | repeated health care services pursuant to a plan of treatment | ||||||
20 | by a provider because of the potential for changes in the | ||||||
21 | therapeutic regimen or because of the potential for a | ||||||
22 | recurrence of symptoms . | ||||||
23 | "Preferred provider" means any provider who has entered, | ||||||
24 | either directly or indirectly, into an agreement with an | ||||||
25 | employer or risk-bearing entity relating to health care | ||||||
26 | services that may be rendered to beneficiaries under a network |
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1 | plan. | ||||||
2 | "Providers" means physicians licensed to practice medicine | ||||||
3 | in all its branches, other health care professionals, | ||||||
4 | hospitals, or other health care institutions or facilities | ||||||
5 | that provide health care services. | ||||||
6 | "Short-term, limited-duration insurance" means any type of | ||||||
7 | accident and health insurance offered or provided within this | ||||||
8 | State pursuant to a group or individual policy or individual | ||||||
9 | certificate by a company, regardless of the situs state of the | ||||||
10 | delivery of the policy, that has an expiration date specified | ||||||
11 | in the contract that is fewer than 365 days after the original | ||||||
12 | effective date. Regardless of the duration of coverage, | ||||||
13 | "short-term, limited-duration insurance" does not include | ||||||
14 | excepted benefits or any student health insurance coverage. | ||||||
15 | "Stand-alone dental plan" has the meaning ascribed to that | ||||||
16 | term in 45 CFR 156.400. | ||||||
17 | "Telehealth" has the meaning given to that term in Section | ||||||
18 | 356z.22 of the Illinois Insurance Code. | ||||||
19 | "Telemedicine" has the meaning given to that term in | ||||||
20 | Section 49.5 of the Medical Practice Act of 1987. | ||||||
21 | "Tiered network" means a network that identifies and | ||||||
22 | groups some or all types of provider and facilities into | ||||||
23 | specific groups to which different provider reimbursement, | ||||||
24 | covered person cost-sharing or provider access requirements, | ||||||
25 | or any combination thereof, apply for the same services. | ||||||
26 | "Woman's principal health care provider" means a physician |
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1 | licensed to practice medicine in all of its branches | ||||||
2 | specializing in obstetrics, gynecology, or family practice. | ||||||
3 | (Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)
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4 | (215 ILCS 124/10) | ||||||
5 | Sec. 10. Network adequacy. | ||||||
6 | (a) Before issuing, delivering, or renewing a network | ||||||
7 | plan, an issuer An insurer providing a network plan shall file | ||||||
8 | a description of all of the following with the Director: | ||||||
9 | (1) The written policies and procedures for adding | ||||||
10 | providers to meet patient needs based on increases in the | ||||||
11 | number of beneficiaries, changes in the | ||||||
12 | patient-to-provider ratio, changes in medical and health | ||||||
13 | care capabilities, and increased demand for services. | ||||||
14 | (2) The written policies and procedures for making | ||||||
15 | referrals within and outside the network. | ||||||
16 | (3) The written policies and procedures on how the | ||||||
17 | network plan will provide 24-hour, 7-day per week access | ||||||
18 | to network-affiliated primary care, emergency services, | ||||||
19 | and women's principal health care providers. | ||||||
20 | An issuer insurer shall not prohibit a preferred provider | ||||||
21 | from discussing any specific or all treatment options with | ||||||
22 | beneficiaries irrespective of the insurer's position on those | ||||||
23 | treatment options or from advocating on behalf of | ||||||
24 | beneficiaries within the utilization review, grievance, or | ||||||
25 | appeals processes established by the issuer insurer in |
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1 | accordance with any rights or remedies available under | ||||||
2 | applicable State or federal law. | ||||||
3 | (b) Before issuing, delivering, or renewing a network | ||||||
4 | plan, an issuer Insurers must file for review a description of | ||||||
5 | the services to be offered through a network plan. The | ||||||
6 | description shall include all of the following: | ||||||
7 | (1) A geographic map of the area proposed to be served | ||||||
8 | by the plan by county service area and zip code, including | ||||||
9 | marked locations for preferred providers. | ||||||
10 | (2) As deemed necessary by the Department, the names, | ||||||
11 | addresses, phone numbers, and specialties of the providers | ||||||
12 | who have entered into preferred provider agreements under | ||||||
13 | the network plan. | ||||||
14 | (3) The number of beneficiaries anticipated to be | ||||||
15 | covered by the network plan. | ||||||
16 | (4) An Internet website and toll-free telephone number | ||||||
17 | for beneficiaries and prospective beneficiaries to access | ||||||
18 | current and accurate lists of preferred providers in each | ||||||
19 | plan , additional information about the plan, as well as | ||||||
20 | any other information required by Department rule. | ||||||
21 | (5) A description of how health care services to be | ||||||
22 | rendered under the network plan are reasonably accessible | ||||||
23 | and available to beneficiaries. The description shall | ||||||
24 | address all of the following: | ||||||
25 | (A) the type of health care services to be | ||||||
26 | provided by the network plan; |
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1 | (B) the ratio of physicians and other providers to | ||||||
2 | beneficiaries, by specialty and including primary care | ||||||
3 | physicians and facility-based physicians when | ||||||
4 | applicable under the contract, necessary to meet the | ||||||
5 | health care needs and service demands of the currently | ||||||
6 | enrolled population; | ||||||
7 | (C) the travel and distance standards for plan | ||||||
8 | beneficiaries in county service areas; and | ||||||
9 | (D) a description of how the use of telemedicine, | ||||||
10 | telehealth, or mobile care services may be used to | ||||||
11 | partially meet the network adequacy standards, if | ||||||
12 | applicable. | ||||||
13 | (6) A provision ensuring that whenever a beneficiary | ||||||
14 | has made a good faith effort, as evidenced by accessing | ||||||
15 | the provider directory, calling the network plan, and | ||||||
16 | calling the provider, to utilize preferred providers for a | ||||||
17 | covered service and it is determined the insurer does not | ||||||
18 | have the appropriate preferred providers due to | ||||||
19 | insufficient number, type, unreasonable travel distance or | ||||||
20 | delay, or preferred providers refusing to provide a | ||||||
21 | covered service because it is contrary to the conscience | ||||||
22 | of the preferred providers, as protected by the Health | ||||||
23 | Care Right of Conscience Act, the issuer insurer shall | ||||||
24 | ensure, directly or indirectly, by terms contained in the | ||||||
25 | payer contract, that the beneficiary will be provided the | ||||||
26 | covered service at no greater cost to the beneficiary than |
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1 | if the service had been provided by a preferred provider. | ||||||
2 | This paragraph (6) does not apply to: (A) a beneficiary | ||||||
3 | who willfully chooses to access a non-preferred provider | ||||||
4 | for health care services available through the panel of | ||||||
5 | preferred providers, or (B) a beneficiary enrolled in a | ||||||
6 | health maintenance organization. In these circumstances, | ||||||
7 | the contractual requirements for non-preferred provider | ||||||
8 | reimbursements shall apply unless Section 356z.3a of the | ||||||
9 | Illinois Insurance Code requires otherwise. In no event | ||||||
10 | shall a beneficiary who receives care at a participating | ||||||
11 | health care facility be required to search for | ||||||
12 | participating providers under the circumstances described | ||||||
13 | in subsection (b) or (b-5) of Section 356z.3a of the | ||||||
14 | Illinois Insurance Code except under the circumstances | ||||||
15 | described in paragraph (2) of subsection (b-5). | ||||||
16 | (7) A provision that the beneficiary shall receive | ||||||
17 | emergency care coverage such that payment for this | ||||||
18 | coverage is not dependent upon whether the emergency | ||||||
19 | services are performed by a preferred or non-preferred | ||||||
20 | provider and the coverage shall be at the same benefit | ||||||
21 | level as if the service or treatment had been rendered by a | ||||||
22 | preferred provider. For purposes of this paragraph (7), | ||||||
23 | "the same benefit level" means that the beneficiary is | ||||||
24 | provided the covered service at no greater cost to the | ||||||
25 | beneficiary than if the service had been provided by a | ||||||
26 | preferred provider. This provision shall be consistent |
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1 | with Section 356z.3a of the Illinois Insurance Code. | ||||||
2 | (8) A limitation that, if the plan provides that the | ||||||
3 | beneficiary will incur a penalty for failing to | ||||||
4 | pre-certify inpatient hospital treatment, the penalty may | ||||||
5 | not exceed $1,000 per occurrence in addition to the plan | ||||||
6 | cost sharing provisions. | ||||||
7 | (9) For a network plan to be offered through the | ||||||
8 | Exchange in the individual or small group market, as well | ||||||
9 | as any off-Exchange mirror of such a network plan, | ||||||
10 | evidence that the network plan includes essential | ||||||
11 | community providers in accordance with rules established | ||||||
12 | by the Exchange that will operate in this State for the | ||||||
13 | applicable plan year. | ||||||
14 | (c) The issuer network plan shall demonstrate to the | ||||||
15 | Director a minimum ratio of providers to plan beneficiaries as | ||||||
16 | required by the Department for each network plan . | ||||||
17 | (1) The minimum ratio of physicians or other providers | ||||||
18 | to plan beneficiaries shall be established annually by the | ||||||
19 | Department in consultation with the Department of Public | ||||||
20 | Health based upon the guidance from the federal Centers | ||||||
21 | for Medicare and Medicaid Services. The Department shall | ||||||
22 | not establish ratios for vision or dental providers who | ||||||
23 | provide services under dental-specific or vision-specific | ||||||
24 | benefits , except to the extent provided under federal law | ||||||
25 | for stand-alone dental plans . The Department shall | ||||||
26 | consider establishing ratios for the following physicians |
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1 | or other providers: | ||||||
2 | (A) Primary Care; | ||||||
3 | (B) Pediatrics; | ||||||
4 | (C) Cardiology; | ||||||
5 | (D) Gastroenterology; | ||||||
6 | (E) General Surgery; | ||||||
7 | (F) Neurology; | ||||||
8 | (G) OB/GYN; | ||||||
9 | (H) Oncology/Radiation; | ||||||
10 | (I) Ophthalmology; | ||||||
11 | (J) Urology; | ||||||
12 | (K) Behavioral Health; | ||||||
13 | (L) Allergy/Immunology; | ||||||
14 | (M) Chiropractic; | ||||||
15 | (N) Dermatology; | ||||||
16 | (O) Endocrinology; | ||||||
17 | (P) Ears, Nose, and Throat (ENT)/Otolaryngology; | ||||||
18 | (Q) Infectious Disease; | ||||||
19 | (R) Nephrology; | ||||||
20 | (S) Neurosurgery; | ||||||
21 | (T) Orthopedic Surgery; | ||||||
22 | (U) Physiatry/Rehabilitative; | ||||||
23 | (V) Plastic Surgery; | ||||||
24 | (W) Pulmonary; | ||||||
25 | (X) Rheumatology; | ||||||
26 | (Y) Anesthesiology; |
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1 | (Z) Pain Medicine; | ||||||
2 | (AA) Pediatric Specialty Services; | ||||||
3 | (BB) Outpatient Dialysis; and | ||||||
4 | (CC) HIV. | ||||||
5 | (2) The Director shall establish a process for the | ||||||
6 | review of the adequacy of these standards, along with an | ||||||
7 | assessment of additional specialties to be included in the | ||||||
8 | list under this subsection (c). | ||||||
9 | (3) Notwithstanding any other law or rule, the minimum | ||||||
10 | ratio for each provider type shall be no less than any such | ||||||
11 | ratio established for qualified health plans in | ||||||
12 | Federally-Facilitated Exchanges by federal law or by the | ||||||
13 | federal Centers for Medicare and Medicaid Services, even | ||||||
14 | if the network plan is issued in the large group market or | ||||||
15 | is otherwise not issued through an exchange. Federal | ||||||
16 | standards for stand-alone dental plans shall only apply to | ||||||
17 | such network plans. In the absence of an applicable | ||||||
18 | Department rule, the federal standards shall apply for the | ||||||
19 | time period specified in the federal law, regulation, or | ||||||
20 | guidance. If the Centers for Medicare and Medicaid | ||||||
21 | Services establish standards that are more stringent than | ||||||
22 | the standards in effect under any Department rule, the | ||||||
23 | Department may amend its rules to conform to the more | ||||||
24 | stringent federal standards. | ||||||
25 | (d) The network plan shall demonstrate to the Director | ||||||
26 | maximum travel and distance standards and appointment wait |
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1 | time standards for plan beneficiaries, which shall be | ||||||
2 | established annually by the Department in consultation with | ||||||
3 | the Department of Public Health based upon the guidance from | ||||||
4 | the federal Centers for Medicare and Medicaid Services. These | ||||||
5 | standards shall consist of the maximum minutes or miles to be | ||||||
6 | traveled by a plan beneficiary for each county type, such as | ||||||
7 | large counties, metro counties, or rural counties as defined | ||||||
8 | by Department rule. | ||||||
9 | The maximum travel time and distance standards must | ||||||
10 | include standards for each physician and other provider | ||||||
11 | category listed for which ratios have been established. | ||||||
12 | The Director shall establish a process for the review of | ||||||
13 | the adequacy of these standards along with an assessment of | ||||||
14 | additional specialties to be included in the list under this | ||||||
15 | subsection (d). | ||||||
16 | Notwithstanding any other law or Department rule, the | ||||||
17 | maximum travel time and distance standards and appointment | ||||||
18 | wait time standards shall be no greater than any such | ||||||
19 | standards established for qualified health plans in | ||||||
20 | Federally-Facilitated Exchanges by federal law or by the | ||||||
21 | federal Centers for Medicare and Medicaid Services, even if | ||||||
22 | the network plan is issued in the large group market or is | ||||||
23 | otherwise not issued through an exchange. Federal standards | ||||||
24 | for stand-alone dental plans shall only apply to such network | ||||||
25 | plans. In the absence of an applicable Department rule, the | ||||||
26 | federal standards shall apply for the time period specified in |
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1 | the federal law, regulation, or guidance. If the Centers for | ||||||
2 | Medicare and Medicaid Services establish standards that are | ||||||
3 | more stringent than the standards in effect under any | ||||||
4 | Department rule, the Department may amend its rules to conform | ||||||
5 | to the more stringent federal standards. | ||||||
6 | If the federal area designations for the maximum time or | ||||||
7 | distance or appointment wait time standards required are | ||||||
8 | changed by the most recent Letter to Issuers in the | ||||||
9 | Federally-facilitated Marketplaces, the Department shall post | ||||||
10 | on its website notice of such changes and may amend its rules | ||||||
11 | to conform to those designations if the Director deems | ||||||
12 | appropriate. | ||||||
13 | (d-5)(1) Every issuer insurer shall ensure that | ||||||
14 | beneficiaries have timely and proximate access to treatment | ||||||
15 | for mental, emotional, nervous, or substance use disorders or | ||||||
16 | conditions in accordance with the provisions of paragraph (4) | ||||||
17 | of subsection (a) of Section 370c of the Illinois Insurance | ||||||
18 | Code. Issuers Insurers shall use a comparable process, | ||||||
19 | strategy, evidentiary standard, and other factors in the | ||||||
20 | development and application of the network adequacy standards | ||||||
21 | for timely and proximate access to treatment for mental, | ||||||
22 | emotional, nervous, or substance use disorders or conditions | ||||||
23 | and those for the access to treatment for medical and surgical | ||||||
24 | conditions. As such, the network adequacy standards for timely | ||||||
25 | and proximate access shall equally be applied to treatment | ||||||
26 | facilities and providers for mental, emotional, nervous, or |
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1 | substance use disorders or conditions and specialists | ||||||
2 | providing medical or surgical benefits pursuant to the parity | ||||||
3 | requirements of Section 370c.1 of the Illinois Insurance Code | ||||||
4 | and the federal Paul Wellstone and Pete Domenici Mental Health | ||||||
5 | Parity and Addiction Equity Act of 2008. Notwithstanding the | ||||||
6 | foregoing, the network adequacy standards for timely and | ||||||
7 | proximate access to treatment for mental, emotional, nervous, | ||||||
8 | or substance use disorders or conditions shall, at a minimum, | ||||||
9 | satisfy the following requirements: | ||||||
10 | (A) For beneficiaries residing in the metropolitan | ||||||
11 | counties of Cook, DuPage, Kane, Lake, McHenry, and Will, | ||||||
12 | network adequacy standards for timely and proximate access | ||||||
13 | to treatment for mental, emotional, nervous, or substance | ||||||
14 | use disorders or conditions means a beneficiary shall not | ||||||
15 | have to travel longer than 30 minutes or 30 miles from the | ||||||
16 | beneficiary's residence to receive outpatient treatment | ||||||
17 | for mental, emotional, nervous, or substance use disorders | ||||||
18 | or conditions. Beneficiaries shall not be required to wait | ||||||
19 | longer than 10 business days between requesting an initial | ||||||
20 | appointment and being seen by the facility or provider of | ||||||
21 | mental, emotional, nervous, or substance use disorders or | ||||||
22 | conditions for outpatient treatment or to wait longer than | ||||||
23 | 20 business days between requesting a repeat or follow-up | ||||||
24 | appointment and being seen by the facility or provider of | ||||||
25 | mental, emotional, nervous, or substance use disorders or | ||||||
26 | conditions for outpatient treatment; however, subject to |
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1 | the protections of paragraph (3) of this subsection, a | ||||||
2 | network plan shall not be held responsible if the | ||||||
3 | beneficiary or provider voluntarily chooses to schedule an | ||||||
4 | appointment outside of these required time frames. | ||||||
5 | (B) For beneficiaries residing in Illinois counties | ||||||
6 | other than those counties listed in subparagraph (A) of | ||||||
7 | this paragraph, network adequacy standards for timely and | ||||||
8 | proximate access to treatment for mental, emotional, | ||||||
9 | nervous, or substance use disorders or conditions means a | ||||||
10 | beneficiary shall not have to travel longer than 60 | ||||||
11 | minutes or 60 miles from the beneficiary's residence to | ||||||
12 | receive outpatient treatment for mental, emotional, | ||||||
13 | nervous, or substance use disorders or conditions. | ||||||
14 | Beneficiaries shall not be required to wait longer than 10 | ||||||
15 | business days between requesting an initial appointment | ||||||
16 | and being seen by the facility or provider of mental, | ||||||
17 | emotional, nervous, or substance use disorders or | ||||||
18 | conditions for outpatient treatment or to wait longer than | ||||||
19 | 20 business days between requesting a repeat or follow-up | ||||||
20 | appointment and being seen by the facility or provider of | ||||||
21 | mental, emotional, nervous, or substance use disorders or | ||||||
22 | conditions for outpatient treatment; however, subject to | ||||||
23 | the protections of paragraph (3) of this subsection, a | ||||||
24 | network plan shall not be held responsible if the | ||||||
25 | beneficiary or provider voluntarily chooses to schedule an | ||||||
26 | appointment outside of these required time frames. |
| |||||||
| |||||||
1 | (2) For beneficiaries residing in all Illinois counties, | ||||||
2 | network adequacy standards for timely and proximate access to | ||||||
3 | treatment for mental, emotional, nervous, or substance use | ||||||
4 | disorders or conditions means a beneficiary shall not have to | ||||||
5 | travel longer than 60 minutes or 60 miles from the | ||||||
6 | beneficiary's residence to receive inpatient or residential | ||||||
7 | treatment for mental, emotional, nervous, or substance use | ||||||
8 | disorders or conditions. | ||||||
9 | (3) If there is no in-network facility or provider | ||||||
10 | available for a beneficiary to receive timely and proximate | ||||||
11 | access to treatment for mental, emotional, nervous, or | ||||||
12 | substance use disorders or conditions in accordance with the | ||||||
13 | network adequacy standards outlined in this subsection, the | ||||||
14 | issuer insurer shall provide necessary exceptions to its | ||||||
15 | network to ensure admission and treatment with a provider or | ||||||
16 | at a treatment facility in accordance with the network | ||||||
17 | adequacy standards in this subsection. | ||||||
18 | (4) If the federal Centers for Medicare and Medicaid | ||||||
19 | Services establishes or law requires more stringent standards | ||||||
20 | for qualified health plans in the Federally-Facilitated | ||||||
21 | Exchanges, the federal standards shall control for all network | ||||||
22 | plans for the time period specified in the federal law, | ||||||
23 | regulation, or guidance, even if the network plan is issued in | ||||||
24 | the large group market, is issued through a different type of | ||||||
25 | Exchange, or is otherwise not issued through an Exchange. | ||||||
26 | (e) Except for network plans solely offered as a group |
| |||||||
| |||||||
1 | health plan, these ratio and time and distance standards apply | ||||||
2 | to the lowest cost-sharing tier of any tiered network. | ||||||
3 | (f) The network plan may consider use of other health care | ||||||
4 | service delivery options, such as telemedicine or telehealth, | ||||||
5 | mobile clinics, and centers of excellence, or other ways of | ||||||
6 | delivering care to partially meet the requirements set under | ||||||
7 | this Section. | ||||||
8 | (g) Except for the requirements set forth in subsection | ||||||
9 | (d-5), issuers insurers who are not able to comply with the | ||||||
10 | provider ratios and time and distance or appointment wait time | ||||||
11 | standards established under this Act or federal law by the | ||||||
12 | Department may request an exception to these requirements from | ||||||
13 | the Department. The Department may grant an exception in the | ||||||
14 | following circumstances: | ||||||
15 | (1) if no providers or facilities meet the specific | ||||||
16 | time and distance standard in a specific service area and | ||||||
17 | the issuer insurer (i) discloses information on the | ||||||
18 | distance and travel time points that beneficiaries would | ||||||
19 | have to travel beyond the required criterion to reach the | ||||||
20 | next closest contracted provider outside of the service | ||||||
21 | area and (ii) provides contact information, including | ||||||
22 | names, addresses, and phone numbers for the next closest | ||||||
23 | contracted provider or facility; | ||||||
24 | (2) if patterns of care in the service area do not | ||||||
25 | support the need for the requested number of provider or | ||||||
26 | facility type and the issuer insurer provides data on |
| |||||||
| |||||||
1 | local patterns of care, such as claims data, referral | ||||||
2 | patterns, or local provider interviews, indicating where | ||||||
3 | the beneficiaries currently seek this type of care or | ||||||
4 | where the physicians currently refer beneficiaries, or | ||||||
5 | both; or | ||||||
6 | (3) other circumstances deemed appropriate by the | ||||||
7 | Department consistent with the requirements of this Act. | ||||||
8 | (h) Issuers Insurers are required to report to the | ||||||
9 | Director any material change to an approved network plan | ||||||
10 | within 15 business days after the change occurs and any change | ||||||
11 | that would result in failure to meet the requirements of this | ||||||
12 | Act. The issuer shall submit a revised version of the portions | ||||||
13 | of the network adequacy filing affected by the material | ||||||
14 | change, as determined by the Director by rule, and the issuer | ||||||
15 | shall attach versions with the changes indicated for each | ||||||
16 | document that was revised from the previous version of the | ||||||
17 | filing. Upon notice from the issuer insurer , the Director | ||||||
18 | shall reevaluate the network plan's compliance with the | ||||||
19 | network adequacy and transparency standards of this Act. For | ||||||
20 | every day past 15 business days that the issuer fails to submit | ||||||
21 | a revised network adequacy filing to the Director, the | ||||||
22 | Director may order a fine of $5,000 per day. | ||||||
23 | (i) If a network plan is inadequate under this Act with | ||||||
24 | respect to a provider type in a county, and if the network plan | ||||||
25 | does not have an approved exception for that provider type in | ||||||
26 | that county pursuant to subsection (g), an issuer shall cover |
| |||||||
| |||||||
1 | out-of-network claims for covered health care services | ||||||
2 | received from that provider type within that county at the | ||||||
3 | in-network benefit level and shall retroactively adjudicate | ||||||
4 | and reimburse beneficiaries to achieve that objective if their | ||||||
5 | claims were processed at the out-of-network level contrary to | ||||||
6 | this subsection. | ||||||
7 | (j) If the Director determines that a network is | ||||||
8 | inadequate in any county and no exception has been granted | ||||||
9 | under subsection (g) and the issuer does not have a process in | ||||||
10 | place to comply with subsection (d-5), the Director may | ||||||
11 | prohibit the network plan from being issued or renewed within | ||||||
12 | that county until the Director determines that the network is | ||||||
13 | adequate apart from processes and exceptions described in | ||||||
14 | subsections (d-5) and (g). Nothing in this subsection shall be | ||||||
15 | construed to terminate any beneficiary's health insurance | ||||||
16 | coverage under a network plan before the expiration of the | ||||||
17 | beneficiary's policy period if the Director makes a | ||||||
18 | determination under this subsection after the issuance or | ||||||
19 | renewal of the beneficiary's policy or certificate because of | ||||||
20 | a material change. Policies or certificates issued or renewed | ||||||
21 | in violation of this subsection may subject the issuer to a | ||||||
22 | civil penalty of $5,000 per policy. | ||||||
23 | (k) For the Department to enforce any new or modified | ||||||
24 | federal standard before the Department adopts the standard by | ||||||
25 | rule, the Department must, no later than May 15 before the | ||||||
26 | start of the plan year, give public notice to the affected |
| |||||||
| |||||||
1 | health insurance issuers through a bulletin. | ||||||
2 | (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; | ||||||
3 | 102-1117, eff. 1-13-23.)
| ||||||
4 | (215 ILCS 124/15) | ||||||
5 | Sec. 15. Notice of nonrenewal or termination. | ||||||
6 | (a) A network plan must give at least 60 days' notice of | ||||||
7 | nonrenewal or termination of a provider to the provider and to | ||||||
8 | the beneficiaries served by the provider. The notice shall | ||||||
9 | include a name and address to which a beneficiary or provider | ||||||
10 | may direct comments and concerns regarding the nonrenewal or | ||||||
11 | termination and the telephone number maintained by the | ||||||
12 | Department for consumer complaints. Immediate written notice | ||||||
13 | may be provided without 60 days' notice when a provider's | ||||||
14 | license has been disciplined by a State licensing board or | ||||||
15 | when the network plan reasonably believes direct imminent | ||||||
16 | physical harm to patients under the provider's providers care | ||||||
17 | may occur. The notice to the beneficiary shall provide the | ||||||
18 | individual with an opportunity to notify the issuer of the | ||||||
19 | individual's need for transitional care. | ||||||
20 | (b) Primary care providers must notify active affected | ||||||
21 | patients of nonrenewal or termination of the provider from the | ||||||
22 | network plan, except in the case of incapacitation. | ||||||
23 | (Source: P.A. 100-502, eff. 9-15-17.)
| ||||||
24 | (215 ILCS 124/20) |
| |||||||
| |||||||
1 | Sec. 20. Transition of services. | ||||||
2 | (a) A network plan shall provide for continuity of care | ||||||
3 | for its beneficiaries as follows: | ||||||
4 | (1) If a beneficiary's physician or hospital provider | ||||||
5 | leaves the network plan's network of providers for reasons | ||||||
6 | other than termination of a contract in situations | ||||||
7 | involving imminent harm to a patient or a final | ||||||
8 | disciplinary action by a State licensing board and the | ||||||
9 | provider remains within the network plan's service area, | ||||||
10 | if benefits provided under such network plan with respect | ||||||
11 | to such provider or facility are terminated because of a | ||||||
12 | change in the terms of the participation of such provider | ||||||
13 | or facility in such plan, or if a contract between a group | ||||||
14 | health plan and a health insurance issuer offering a | ||||||
15 | network plan in connection with the group health plan is | ||||||
16 | terminated and results in a loss of benefits provided | ||||||
17 | under such plan with respect to such provider, then the | ||||||
18 | network plan shall permit the beneficiary to continue an | ||||||
19 | ongoing course of treatment with that provider during a | ||||||
20 | transitional period for the following duration: | ||||||
21 | (A) 90 days from the date of the notice to the | ||||||
22 | beneficiary of the provider's disaffiliation from the | ||||||
23 | network plan if the beneficiary has an ongoing course | ||||||
24 | of treatment; or | ||||||
25 | (B) if the beneficiary has entered the third | ||||||
26 | trimester of pregnancy at the time of the provider's |
| |||||||
| |||||||
1 | disaffiliation, a period that includes the provision | ||||||
2 | of post-partum care directly related to the delivery. | ||||||
3 | (2) Notwithstanding the provisions of paragraph (1) of | ||||||
4 | this subsection (a), such care shall be authorized by the | ||||||
5 | network plan during the transitional period in accordance | ||||||
6 | with the following: | ||||||
7 | (A) the provider receives continued reimbursement | ||||||
8 | from the network plan at the rates and terms and | ||||||
9 | conditions applicable under the terminated contract | ||||||
10 | prior to the start of the transitional period; | ||||||
11 | (B) the provider adheres to the network plan's | ||||||
12 | quality assurance requirements, including provision to | ||||||
13 | the network plan of necessary medical information | ||||||
14 | related to such care; and | ||||||
15 | (C) the provider otherwise adheres to the network | ||||||
16 | plan's policies and procedures, including, but not | ||||||
17 | limited to, procedures regarding referrals and | ||||||
18 | obtaining preauthorizations for treatment. | ||||||
19 | (3) The provisions of this Section governing health | ||||||
20 | care provided during the transition period do not apply if | ||||||
21 | the beneficiary has successfully transitioned to another | ||||||
22 | provider participating in the network plan, if the | ||||||
23 | beneficiary has already met or exceeded the benefit | ||||||
24 | limitations of the plan, or if the care provided is not | ||||||
25 | medically necessary. | ||||||
26 | (b) A network plan shall provide for continuity of care |
| |||||||
| |||||||
1 | for new beneficiaries as follows: | ||||||
2 | (1) If a new beneficiary whose provider is not a | ||||||
3 | member of the network plan's provider network, but is | ||||||
4 | within the network plan's service area, enrolls in the | ||||||
5 | network plan, the network plan shall permit the | ||||||
6 | beneficiary to continue an ongoing course of treatment | ||||||
7 | with the beneficiary's current physician during a | ||||||
8 | transitional period: | ||||||
9 | (A) of 90 days from the effective date of | ||||||
10 | enrollment if the beneficiary has an ongoing course of | ||||||
11 | treatment; or | ||||||
12 | (B) if the beneficiary has entered the third | ||||||
13 | trimester of pregnancy at the effective date of | ||||||
14 | enrollment, that includes the provision of post-partum | ||||||
15 | care directly related to the delivery. | ||||||
16 | (2) If a beneficiary, or a beneficiary's authorized | ||||||
17 | representative, elects in writing to continue to receive | ||||||
18 | care from such provider pursuant to paragraph (1) of this | ||||||
19 | subsection (b), such care shall be authorized by the | ||||||
20 | network plan for the transitional period in accordance | ||||||
21 | with the following: | ||||||
22 | (A) the provider receives reimbursement from the | ||||||
23 | network plan at rates established by the network plan; | ||||||
24 | (B) the provider adheres to the network plan's | ||||||
25 | quality assurance requirements, including provision to | ||||||
26 | the network plan of necessary medical information |
| |||||||
| |||||||
1 | related to such care; and | ||||||
2 | (C) the provider otherwise adheres to the network | ||||||
3 | plan's policies and procedures, including, but not | ||||||
4 | limited to, procedures regarding referrals and | ||||||
5 | obtaining preauthorization for treatment. | ||||||
6 | (3) The provisions of this Section governing health | ||||||
7 | care provided during the transition period do not apply if | ||||||
8 | the beneficiary has successfully transitioned to another | ||||||
9 | provider participating in the network plan, if the | ||||||
10 | beneficiary has already met or exceeded the benefit | ||||||
11 | limitations of the plan, or if the care provided is not | ||||||
12 | medically necessary. | ||||||
13 | (c) In no event shall this Section be construed to require | ||||||
14 | a network plan to provide coverage for benefits not otherwise | ||||||
15 | covered or to diminish or impair preexisting condition | ||||||
16 | limitations contained in the beneficiary's contract. | ||||||
17 | (d) A provider shall comply with the requirements of 42 | ||||||
18 | U.S.C. 300gg-138. | ||||||
19 | (Source: P.A. 100-502, eff. 9-15-17.)
| ||||||
20 | (215 ILCS 124/25) | ||||||
21 | Sec. 25. Network transparency. | ||||||
22 | (a) A network plan shall post electronically an | ||||||
23 | up-to-date, accurate, and complete provider directory for each | ||||||
24 | of its network plans, with the information and search | ||||||
25 | functions, as described in this Section. |
| |||||||
| |||||||
1 | (1) In making the directory available electronically, | ||||||
2 | the network plans shall ensure that the general public is | ||||||
3 | able to view all of the current providers for a plan | ||||||
4 | through a clearly identifiable link or tab and without | ||||||
5 | creating or accessing an account or entering a policy or | ||||||
6 | contract number. | ||||||
7 | (2) An issuer's failure to update a network plan's | ||||||
8 | directory shall subject the issuer to a civil penalty of | ||||||
9 | $5,000 per month. The network plan shall update the online | ||||||
10 | provider directory at least monthly. Providers shall | ||||||
11 | notify the network plan electronically or in writing | ||||||
12 | within 10 business days of any changes to their | ||||||
13 | information as listed in the provider directory, including | ||||||
14 | the information required in subsections (b), (c), and (d) | ||||||
15 | subparagraph (K) of paragraph (1) of subsection (b) . With | ||||||
16 | regard to subparagraph (I) of paragraph (1) of subsection | ||||||
17 | (b), the provider must give notice to the issuer within 20 | ||||||
18 | business days of deciding to cease accepting new patients | ||||||
19 | covered by the plan if the new patient limitation is | ||||||
20 | expected to last 40 business days or longer. The network | ||||||
21 | plan shall update its online provider directory in a | ||||||
22 | manner consistent with the information provided by the | ||||||
23 | provider within 2 10 business days after being notified of | ||||||
24 | the change by the provider. Nothing in this paragraph (2) | ||||||
25 | shall void any contractual relationship between the | ||||||
26 | provider and the plan. |
| |||||||
| |||||||
1 | (3) At least once every 90 days, the issuer The | ||||||
2 | network plan shall audit each network plan's periodically | ||||||
3 | at least 25% of its provider directories for accuracy, | ||||||
4 | make any corrections necessary, and retain documentation | ||||||
5 | of the audit. The network plan shall submit the audit to | ||||||
6 | the Director upon request. As part of these audits, the | ||||||
7 | network plan shall contact any provider in its network | ||||||
8 | that has not submitted a claim to the plan or otherwise | ||||||
9 | communicated his or her intent to continue participation | ||||||
10 | in the plan's network. The audits shall comply with 42 | ||||||
11 | U.S.C. 300gg-115(a)(2), except that "provider directory | ||||||
12 | information" shall include all information required to be | ||||||
13 | included in a provider directory pursuant to this Act. | ||||||
14 | (4) A network plan shall provide a print copy of a | ||||||
15 | current provider directory or a print copy of the | ||||||
16 | requested directory information upon request of a | ||||||
17 | beneficiary or a prospective beneficiary. Except when an | ||||||
18 | issuer's print copies use the same provider information as | ||||||
19 | the electronic provider directory on each print copy's | ||||||
20 | date of printing, print Print copies must be updated at | ||||||
21 | least every 90 days quarterly and an errata that reflects | ||||||
22 | changes in the provider network must be included in each | ||||||
23 | update updated quarterly . | ||||||
24 | (5) For each network plan, a network plan shall | ||||||
25 | include, in plain language in both the electronic and | ||||||
26 | print directory, the following general information: |
| |||||||
| |||||||
1 | (A) in plain language, a description of the | ||||||
2 | criteria the plan has used to build its provider | ||||||
3 | network; | ||||||
4 | (B) if applicable, in plain language, a | ||||||
5 | description of the criteria the issuer insurer or | ||||||
6 | network plan has used to create tiered networks; | ||||||
7 | (C) if applicable, in plain language, how the | ||||||
8 | network plan designates the different provider tiers | ||||||
9 | or levels in the network and identifies for each | ||||||
10 | specific provider, hospital, or other type of facility | ||||||
11 | in the network which tier each is placed, for example, | ||||||
12 | by name, symbols, or grouping, in order for a | ||||||
13 | beneficiary-covered person or a prospective | ||||||
14 | beneficiary-covered person to be able to identify the | ||||||
15 | provider tier; and | ||||||
16 | (D) if applicable, a notation that authorization | ||||||
17 | or referral may be required to access some providers. | ||||||
18 | (6) A network plan shall make it clear for both its | ||||||
19 | electronic and print directories what provider directory | ||||||
20 | applies to which network plan, such as including the | ||||||
21 | specific name of the network plan as marketed and issued | ||||||
22 | in this State. The network plan shall include in both its | ||||||
23 | electronic and print directories a customer service email | ||||||
24 | address and telephone number or electronic link that | ||||||
25 | beneficiaries or the general public may use to notify the | ||||||
26 | network plan of inaccurate provider directory information |
| |||||||
| |||||||
1 | and contact information for the Department's Office of | ||||||
2 | Consumer Health Insurance. | ||||||
3 | (7) A provider directory, whether in electronic or | ||||||
4 | print format, shall accommodate the communication needs of | ||||||
5 | individuals with disabilities, and include a link to or | ||||||
6 | information regarding available assistance for persons | ||||||
7 | with limited English proficiency. | ||||||
8 | (b) For each network plan, a network plan shall make | ||||||
9 | available through an electronic provider directory the | ||||||
10 | following information in a searchable format: | ||||||
11 | (1) for health care professionals: | ||||||
12 | (A) name; | ||||||
13 | (B) gender; | ||||||
14 | (C) participating office locations; | ||||||
15 | (D) specialty, if applicable; | ||||||
16 | (E) medical group affiliations, if applicable; | ||||||
17 | (F) facility affiliations, if applicable; | ||||||
18 | (G) participating facility affiliations, if | ||||||
19 | applicable; | ||||||
20 | (H) languages spoken other than English, if | ||||||
21 | applicable; | ||||||
22 | (I) whether accepting new patients; | ||||||
23 | (J) board certifications, if applicable; and | ||||||
24 | (K) use of telehealth or telemedicine, including, | ||||||
25 | but not limited to: | ||||||
26 | (i) whether the provider offers the use of |
| |||||||
| |||||||
1 | telehealth or telemedicine to deliver services to | ||||||
2 | patients for whom it would be clinically | ||||||
3 | appropriate; | ||||||
4 | (ii) what modalities are used and what types | ||||||
5 | of services may be provided via telehealth or | ||||||
6 | telemedicine; and | ||||||
7 | (iii) whether the provider has the ability and | ||||||
8 | willingness to include in a telehealth or | ||||||
9 | telemedicine encounter a family caregiver who is | ||||||
10 | in a separate location than the patient if the | ||||||
11 | patient wishes and provides his or her consent; | ||||||
12 | and | ||||||
13 | (L) whether the health care professional accepts | ||||||
14 | appointment requests from patients. | ||||||
15 | (2) for hospitals: | ||||||
16 | (A) hospital name; | ||||||
17 | (B) hospital type (such as acute, rehabilitation, | ||||||
18 | children's, or cancer); | ||||||
19 | (C) participating hospital location; and | ||||||
20 | (D) hospital accreditation status; and | ||||||
21 | (3) for facilities, other than hospitals, by type: | ||||||
22 | (A) facility name; | ||||||
23 | (B) facility type; | ||||||
24 | (C) types of services performed; and | ||||||
25 | (D) participating facility location or locations. | ||||||
26 | (c) For the electronic provider directories, for each |
| |||||||
| |||||||
1 | network plan, a network plan shall make available all of the | ||||||
2 | following information in addition to the searchable | ||||||
3 | information required in this Section: | ||||||
4 | (1) for health care professionals: | ||||||
5 | (A) contact information , including both a | ||||||
6 | telephone number and digital contact information if | ||||||
7 | the provider has supplied digital contact information ; | ||||||
8 | and | ||||||
9 | (B) languages spoken other than English by | ||||||
10 | clinical staff, if applicable; | ||||||
11 | (2) for hospitals, telephone number and digital | ||||||
12 | contact information ; and | ||||||
13 | (3) for facilities other than hospitals, telephone | ||||||
14 | number. | ||||||
15 | (d) The issuer insurer or network plan shall make | ||||||
16 | available in print, upon request, the following provider | ||||||
17 | directory information for the applicable network plan: | ||||||
18 | (1) for health care professionals: | ||||||
19 | (A) name; | ||||||
20 | (B) contact information , including a telephone | ||||||
21 | number and digital contact information if the provider | ||||||
22 | has supplied digital contact information ; | ||||||
23 | (C) participating office location or locations; | ||||||
24 | (D) specialty, if applicable; | ||||||
25 | (E) languages spoken other than English, if | ||||||
26 | applicable; |
| |||||||
| |||||||
1 | (F) whether accepting new patients; and | ||||||
2 | (G) use of telehealth or telemedicine, including, | ||||||
3 | but not limited to: | ||||||
4 | (i) whether the provider offers the use of | ||||||
5 | telehealth or telemedicine to deliver services to | ||||||
6 | patients for whom it would be clinically | ||||||
7 | appropriate; | ||||||
8 | (ii) what modalities are used and what types | ||||||
9 | of services may be provided via telehealth or | ||||||
10 | telemedicine; and | ||||||
11 | (iii) whether the provider has the ability and | ||||||
12 | willingness to include in a telehealth or | ||||||
13 | telemedicine encounter a family caregiver who is | ||||||
14 | in a separate location than the patient if the | ||||||
15 | patient wishes and provides his or her consent; | ||||||
16 | and | ||||||
17 | (H) whether the health care professional accepts | ||||||
18 | appointment requests from patients. | ||||||
19 | (2) for hospitals: | ||||||
20 | (A) hospital name; | ||||||
21 | (B) hospital type (such as acute, rehabilitation, | ||||||
22 | children's, or cancer); and | ||||||
23 | (C) participating hospital location , and telephone | ||||||
24 | number , and digital contact information ; and | ||||||
25 | (3) for facilities, other than hospitals, by type: | ||||||
26 | (A) facility name; |
| |||||||
| |||||||
1 | (B) facility type; | ||||||
2 | (C) types of services performed; and | ||||||
3 | (D) participating facility location or locations , | ||||||
4 | and telephone numbers , and digital contact information | ||||||
5 | for each location . | ||||||
6 | (e) The network plan shall include a disclosure in the | ||||||
7 | print format provider directory that the information included | ||||||
8 | in the directory is accurate as of the date of printing and | ||||||
9 | that beneficiaries or prospective beneficiaries should consult | ||||||
10 | the issuer's insurer's electronic provider directory on its | ||||||
11 | website and contact the provider. The network plan shall also | ||||||
12 | include a telephone number in the print format provider | ||||||
13 | directory for a customer service representative where the | ||||||
14 | beneficiary can obtain current provider directory information. | ||||||
15 | (f) The Director may conduct periodic audits of the | ||||||
16 | accuracy of provider directories. A network plan shall not be | ||||||
17 | subject to any fines or penalties for information required in | ||||||
18 | this Section that a provider submits that is inaccurate or | ||||||
19 | incomplete. | ||||||
20 | (g) To the extent not otherwise provided in this Act, an | ||||||
21 | issuer shall comply with the requirements of 42 U.S.C. | ||||||
22 | 300gg-115, except that "provider directory information" shall | ||||||
23 | include all information required to be included in a provider | ||||||
24 | directory pursuant to this Section. | ||||||
25 | (h) This Section applies to network plans not otherwise | ||||||
26 | exempt under Section 3, including stand-alone dental plans. |
| |||||||
| |||||||
1 | (Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
| ||||||
2 | (215 ILCS 124/30) | ||||||
3 | Sec. 30. Administration and enforcement. | ||||||
4 | (a) Issuers Insurers , as defined in this Act, have a | ||||||
5 | continuing obligation to comply with the requirements of this | ||||||
6 | Act. Other than the duties specifically created in this Act, | ||||||
7 | nothing in this Act is intended to preclude, prevent, or | ||||||
8 | require the adoption, modification, or termination of any | ||||||
9 | utilization management, quality management, or claims | ||||||
10 | processing methodologies of an issuer insurer . | ||||||
11 | (b) Nothing in this Act precludes, prevents, or requires | ||||||
12 | the adoption, modification, or termination of any network plan | ||||||
13 | term, benefit, coverage or eligibility provision, or payment | ||||||
14 | methodology. | ||||||
15 | (c) The Director shall enforce the provisions of this Act | ||||||
16 | pursuant to the enforcement powers granted to it by law. | ||||||
17 | (d) The Department shall adopt rules to enforce compliance | ||||||
18 | with this Act to the extent necessary. | ||||||
19 | (e) In accordance with Section 5-45 of the Illinois | ||||||
20 | Administrative Procedure Act, the Department may adopt | ||||||
21 | emergency rules to implement federal standards for provider | ||||||
22 | ratios, travel time and distance, and appointment wait times | ||||||
23 | if such standards apply to health insurance coverage regulated | ||||||
24 | by the Department and are more stringent than the State | ||||||
25 | standards extant at the time the final federal standards are |
| |||||||
| |||||||
1 | published. | ||||||
2 | (Source: P.A. 100-502, eff. 9-15-17.)
| ||||||
3 | (215 ILCS 124/35 new) | ||||||
4 | Sec. 35. Provider requirements. Providers shall comply | ||||||
5 | with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations | ||||||
6 | promulgated thereunder, as well as Section 20 and paragraph | ||||||
7 | (2) of subsection (a) of Section 25 of this Act, except that | ||||||
8 | "provider directory information" includes all information | ||||||
9 | required to be included in a provider directory pursuant to | ||||||
10 | Section 25 of this Act.
| ||||||
11 | (215 ILCS 124/40 new) | ||||||
12 | Sec. 40. Confidentiality. | ||||||
13 | (a) All records in the custody or possession of the | ||||||
14 | Department are presumed to be open to public inspection or | ||||||
15 | copying unless exempt from disclosure by Section 7 or 7.5 of | ||||||
16 | the Freedom of Information Act. Except as otherwise provided | ||||||
17 | in this Section or other applicable law, the filings required | ||||||
18 | under this Act shall be open to public inspection or copying. | ||||||
19 | (b) The following information shall not be deemed | ||||||
20 | confidential: | ||||||
21 | (1) actual or projected ratios of providers to | ||||||
22 | beneficiaries; | ||||||
23 | (2) actual or projected time and distance between | ||||||
24 | network providers and beneficiaries or actual or projected |
| |||||||
| |||||||
1 | waiting times for a beneficiary to see a network provider; | ||||||
2 | (3) geographic maps of network providers; | ||||||
3 | (4) requests for exceptions under subsection (g) of | ||||||
4 | Section 10, except with respect to any discussion of | ||||||
5 | ongoing or planned contractual negotiations with providers | ||||||
6 | that the issuer requests to be treated as confidential; | ||||||
7 | (5) provider directories and provider lists; and | ||||||
8 | (6) insurer or Department statements of determination | ||||||
9 | as to whether a network plan has satisfied this Act's | ||||||
10 | requirements regarding the information described in this | ||||||
11 | subsection. | ||||||
12 | (c) An issuer's work papers and reports on the results of a | ||||||
13 | self-audit of its provider directories, including any | ||||||
14 | communications between the issuer and the Department, shall | ||||||
15 | remain confidential unless expressly waived by the issuer or | ||||||
16 | unless deemed public information under federal law. | ||||||
17 | (d) The filings required under Section 10 of this Act | ||||||
18 | shall be confidential while they remain under the Department's | ||||||
19 | review but shall become open to public inspection and copying | ||||||
20 | upon completion of the review, except as provided in this | ||||||
21 | Section or under other applicable law. | ||||||
22 | (e) Nothing in this Section shall supersede the statutory | ||||||
23 | requirement that work papers obtained during a market conduct | ||||||
24 | examination be deemed confidential.
| ||||||
25 | (215 ILCS 124/50 new) |
| |||||||
| |||||||
1 | Sec. 50. Funds for enforcement. Moneys from fines and | ||||||
2 | penalties collected from issuers for violations of this Act | ||||||
3 | shall be deposited into the Insurance Producer Administration | ||||||
4 | Fund for appropriation by the General Assembly to the | ||||||
5 | Department to be used for providing financial support of the | ||||||
6 | Department's enforcement of this Act.
| ||||||
7 | (215 ILCS 124/55 new) | ||||||
8 | Sec. 55. Uniform electronic provider directory information | ||||||
9 | notification forms. | ||||||
10 | (a) On or before January 1, 2029, the Department shall | ||||||
11 | develop and publish a uniform electronic provider directory | ||||||
12 | information form that issuers shall make available to | ||||||
13 | onboarding, current, and former preferred providers to notify | ||||||
14 | the issuer of the provider's currently accurate provider | ||||||
15 | directory information under Section 25 of this Act and 42 | ||||||
16 | U.S.C. 300gg-139. The form shall address information needed | ||||||
17 | from newly onboarding preferred providers, updates to | ||||||
18 | previously supplied provider directory information, reporting | ||||||
19 | an inaccurate directory entry of previously supplied | ||||||
20 | information, contract terminations, and differences in | ||||||
21 | information for specific network plans offered by an issuer, | ||||||
22 | such as whether the provider is a preferred provider for the | ||||||
23 | network plan or is accepting new patients under that plan. The | ||||||
24 | Department shall allow issuers to implement this form through | ||||||
25 | either a PDF or a web portal that requests the same |
| |||||||
| |||||||
1 | information. | ||||||
2 | (b) Notwithstanding any other provision of law to the | ||||||
3 | contrary, beginning 6 months after the Department publishes | ||||||
4 | the uniform electronic provider directory information form and | ||||||
5 | no later than July 1, 2029, every provider must use the uniform | ||||||
6 | electronic provider directory information form to notify | ||||||
7 | issuers of their provider directory information as required | ||||||
8 | under Section 25 of this Act and 42 U.S.C. 300gg-139. Issuers | ||||||
9 | shall accept this form as sufficient to update their provider | ||||||
10 | directories. Issuers shall not accept paper or fax submissions | ||||||
11 | of provider directory information from providers. | ||||||
12 | (c) The Department shall develop the form required under | ||||||
13 | this Section with input from a working group including, but | ||||||
14 | not limited to, the following individuals: | ||||||
15 | (1) the Director of Insurance or a designee, as chair; | ||||||
16 | (2) the Marketplace Director or a designee; | ||||||
17 | (3) the Director of the Division of Professional | ||||||
18 | Regulation or a designee; | ||||||
19 | (4) the Director of Public Health or a designee; | ||||||
20 | (5) the Secretary of Innovation and Technology or a | ||||||
21 | designee; | ||||||
22 | (6) the Director of Healthcare and Family Services or | ||||||
23 | a designee; | ||||||
24 | (7) the following individuals appointed by the | ||||||
25 | Director: | ||||||
26 | (A) one representative of a statewide association |
| |||||||
| |||||||
1 | representing physicians; | ||||||
2 | (B) one representative of a statewide association | ||||||
3 | representing nurses; | ||||||
4 | (C) one representative of a statewide organization | ||||||
5 | representing a majority of Illinois hospitals; | ||||||
6 | (D) one representative of a statewide organization | ||||||
7 | representing Illinois pharmacies; | ||||||
8 | (E) one representative of a statewide organization | ||||||
9 | representing mental health care providers; | ||||||
10 | (F) one representative of a statewide organization | ||||||
11 | representing substance use disorder health care | ||||||
12 | providers; | ||||||
13 | (G) 2 representatives of health insurance issuers | ||||||
14 | doing business in this State or issuer trade | ||||||
15 | associations, at least one of which represents a | ||||||
16 | State-domiciled mutual health insurance company, with | ||||||
17 | a demonstrated expertise in the business of health | ||||||
18 | insurance or health benefits administration; and | ||||||
19 | (H) 2 representatives of a health insurance | ||||||
20 | consumer advocacy group. | ||||||
21 | (d) The Department shall convene the working group | ||||||
22 | described in this Section no later than April 1, 2025 and at | ||||||
23 | least annually thereafter until the Department publishes the | ||||||
24 | uniform electronic provider directory information form. | ||||||
25 | (e) The Department, in development of the uniform | ||||||
26 | electronic provider directory information form, and the |
| |||||||
| |||||||
1 | working group, in offering input, shall take into | ||||||
2 | consideration the following: | ||||||
3 | (1) readability and user experience; | ||||||
4 | (2) interoperability; | ||||||
5 | (3) existing regulations established by the federal | ||||||
6 | Centers for Medicare and Medicaid Services, the Department | ||||||
7 | of Insurance, the Department of Healthcare and Family | ||||||
8 | Service, the Department of Financial and Professional | ||||||
9 | Regulation, and the Department of Public Health; | ||||||
10 | (4) potential opportunities to avoid duplication of | ||||||
11 | data collection efforts, including, but not limited to, | ||||||
12 | opportunities related to: | ||||||
13 | (A) integrating any provider reporting required | ||||||
14 | under Section 25 of this Act and 42 U.S.C. 300gg-139 | ||||||
15 | with the provider reporting required under the Health | ||||||
16 | Care Professional Credentials Data Collection Act; | ||||||
17 | (B) furnishing information to any national | ||||||
18 | provider directory established by the federal Centers | ||||||
19 | for Medicare and Medicaid Services or another federal | ||||||
20 | agency with jurisdiction over health care providers; | ||||||
21 | and | ||||||
22 | (C) furnishing information in compliance with the | ||||||
23 | Patients' Right to Know Act; | ||||||
24 | (5) compatibility with the Illinois Health Benefits | ||||||
25 | Exchange; | ||||||
26 | (6) provider licensing requirements and forms; and |
| |||||||
| |||||||
1 | (7) information needed to classify a provider under | ||||||
2 | any specialty type for which a network adequacy standard | ||||||
3 | may be established under this Act when a specialty board | ||||||
4 | certification or State license does not currently exist.
| ||||||
5 | Section 2-15. The Managed Care Reform and Patient Rights | ||||||
6 | Act is amended by changing Sections 20 and 25 as follows:
| ||||||
7 | (215 ILCS 134/20) | ||||||
8 | Sec. 20. Notice of nonrenewal or termination. A health | ||||||
9 | care plan must give at least 60 days notice of nonrenewal or | ||||||
10 | termination of a health care provider to the health care | ||||||
11 | provider and to the enrollees served by the health care | ||||||
12 | provider. The notice shall include a name and address to which | ||||||
13 | an enrollee or health care provider may direct comments and | ||||||
14 | concerns regarding the nonrenewal or termination. Immediate | ||||||
15 | written notice may be provided without 60 days notice when a | ||||||
16 | health care provider's license has been disciplined by a State | ||||||
17 | licensing board. The notice to the enrollee shall provide the | ||||||
18 | individual with an opportunity to notify the health care plan | ||||||
19 | of the individual's need for transitional care. | ||||||
20 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
21 | (215 ILCS 134/25) | ||||||
22 | Sec. 25. Transition of services. | ||||||
23 | (a) A health care plan shall provide for continuity of |
| |||||||
| |||||||
1 | care for its enrollees as follows: | ||||||
2 | (1) If an enrollee's health care provider physician | ||||||
3 | leaves the health care plan's network of health care | ||||||
4 | providers for reasons other than termination of a contract | ||||||
5 | in situations involving imminent harm to a patient or a | ||||||
6 | final disciplinary action by a State licensing board and | ||||||
7 | the provider physician remains within the health care | ||||||
8 | plan's service area, or if benefits provided under such | ||||||
9 | health care plan with respect to such provider are | ||||||
10 | terminated because of a change in the terms of the | ||||||
11 | participation of such provider in such plan, or if a | ||||||
12 | contract between a group health plan, as defined in | ||||||
13 | Section 5 of the Illinois Health Insurance Portability and | ||||||
14 | Accountability Act, and a health care plan offered in | ||||||
15 | connection with the group health plan is terminated and | ||||||
16 | results in a loss of benefits provided under such plan | ||||||
17 | with respect to such provider, the health care plan shall | ||||||
18 | permit the enrollee to continue an ongoing course of | ||||||
19 | treatment with that provider physician during a | ||||||
20 | transitional period: | ||||||
21 | (A) of 90 days from the date of the notice of | ||||||
22 | provider's physician's termination from the health | ||||||
23 | care plan to the enrollee of the provider's | ||||||
24 | physician's disaffiliation from the health care plan | ||||||
25 | if the enrollee has an ongoing course of treatment; or | ||||||
26 | (B) if the enrollee has entered the third |
| |||||||
| |||||||
1 | trimester of pregnancy at the time of the provider's | ||||||
2 | physician's disaffiliation, that includes the | ||||||
3 | provision of post-partum care directly related to the | ||||||
4 | delivery. | ||||||
5 | (2) Notwithstanding the provisions in item (1) of this | ||||||
6 | subsection, such care shall be authorized by the health | ||||||
7 | care plan during the transitional period only if the | ||||||
8 | provider physician agrees: | ||||||
9 | (A) to continue to accept reimbursement from the | ||||||
10 | health care plan at the rates applicable prior to the | ||||||
11 | start of the transitional period; | ||||||
12 | (B) to adhere to the health care plan's quality | ||||||
13 | assurance requirements and to provide to the health | ||||||
14 | care plan necessary medical information related to | ||||||
15 | such care; and | ||||||
16 | (C) to otherwise adhere to the health care plan's | ||||||
17 | policies and procedures, including but not limited to | ||||||
18 | procedures regarding referrals and obtaining | ||||||
19 | preauthorizations for treatment. | ||||||
20 | (3) During an enrollee's plan year, a health care plan | ||||||
21 | shall not remove a drug from its formulary or negatively | ||||||
22 | change its preferred or cost-tier sharing unless, at least | ||||||
23 | 60 days before making the formulary change, the health | ||||||
24 | care plan: | ||||||
25 | (A) provides general notification of the change in | ||||||
26 | its formulary to current and prospective enrollees; |
| |||||||
| |||||||
1 | (B) directly notifies enrollees currently | ||||||
2 | receiving coverage for the drug, including information | ||||||
3 | on the specific drugs involved and the steps they may | ||||||
4 | take to request coverage determinations and | ||||||
5 | exceptions, including a statement that a certification | ||||||
6 | of medical necessity by the enrollee's prescribing | ||||||
7 | provider will result in continuation of coverage at | ||||||
8 | the existing level; and | ||||||
9 | (C) directly notifies in writing by first class | ||||||
10 | mail and through an electronic transmission, if | ||||||
11 | available, the prescribing provider of all health care | ||||||
12 | plan enrollees currently prescribed the drug affected | ||||||
13 | by the proposed change; the notice shall include a | ||||||
14 | one-page form by which the prescribing provider can | ||||||
15 | notify the health care plan in writing or | ||||||
16 | electronically by first class mail that coverage of | ||||||
17 | the drug for the enrollee is medically necessary. | ||||||
18 | The notification in paragraph (C) may direct the | ||||||
19 | prescribing provider to an electronic portal through which | ||||||
20 | the prescribing provider may electronically file a | ||||||
21 | certification to the health care plan that coverage of the | ||||||
22 | drug for the enrollee is medically necessary. The | ||||||
23 | prescribing provider may make a secure electronic | ||||||
24 | signature beside the words "certification of medical | ||||||
25 | necessity", and this certification shall authorize | ||||||
26 | continuation of coverage for the drug. |
| |||||||
| |||||||
1 | If the prescribing provider certifies to the health | ||||||
2 | care plan either in writing or electronically that the | ||||||
3 | drug is medically necessary for the enrollee as provided | ||||||
4 | in paragraph (C), a health care plan shall authorize | ||||||
5 | coverage for the drug prescribed based solely on the | ||||||
6 | prescribing provider's assertion that coverage is | ||||||
7 | medically necessary, and the health care plan is | ||||||
8 | prohibited from making modifications to the coverage | ||||||
9 | related to the covered drug, including, but not limited | ||||||
10 | to: | ||||||
11 | (i) increasing the out-of-pocket costs for the | ||||||
12 | covered drug; | ||||||
13 | (ii) moving the covered drug to a more restrictive | ||||||
14 | tier; or | ||||||
15 | (iii) denying an enrollee coverage of the drug for | ||||||
16 | which the enrollee has been previously approved for | ||||||
17 | coverage by the health care plan. | ||||||
18 | Nothing in this item (3) prevents a health care plan | ||||||
19 | from removing a drug from its formulary or denying an | ||||||
20 | enrollee coverage if the United States Food and Drug | ||||||
21 | Administration has issued a statement about the drug that | ||||||
22 | calls into question the clinical safety of the drug, the | ||||||
23 | drug manufacturer has notified the United States Food and | ||||||
24 | Drug Administration of a manufacturing discontinuance or | ||||||
25 | potential discontinuance of the drug as required by | ||||||
26 | Section 506C of the Federal Food, Drug, and Cosmetic Act, |
| |||||||
| |||||||
1 | as codified in 21 U.S.C. 356c, or the drug manufacturer | ||||||
2 | has removed the drug from the market. | ||||||
3 | Nothing in this item (3) prohibits a health care plan, | ||||||
4 | by contract, written policy or procedure, or any other | ||||||
5 | agreement or course of conduct, from requiring a | ||||||
6 | pharmacist to effect substitutions of prescription drugs | ||||||
7 | consistent with Section 19.5 of the Pharmacy Practice Act, | ||||||
8 | under which a pharmacist may substitute an interchangeable | ||||||
9 | biologic for a prescribed biologic product, and Section 25 | ||||||
10 | of the Pharmacy Practice Act, under which a pharmacist may | ||||||
11 | select a generic drug determined to be therapeutically | ||||||
12 | equivalent by the United States Food and Drug | ||||||
13 | Administration and in accordance with the Illinois Food, | ||||||
14 | Drug and Cosmetic Act. | ||||||
15 | This item (3) applies to a policy or contract that is | ||||||
16 | amended, delivered, issued, or renewed on or after January | ||||||
17 | 1, 2019. This item (3) does not apply to a health plan as | ||||||
18 | defined in the State Employees Group Insurance Act of 1971 | ||||||
19 | or medical assistance under Article V of the Illinois | ||||||
20 | Public Aid Code. | ||||||
21 | (b) A health care plan shall provide for continuity of | ||||||
22 | care for new enrollees as follows: | ||||||
23 | (1) If a new enrollee whose physician is not a member | ||||||
24 | of the health care plan's provider network, but is within | ||||||
25 | the health care plan's service area, enrolls in the health | ||||||
26 | care plan, the health care plan shall permit the enrollee |
| |||||||
| |||||||
1 | to continue an ongoing course of treatment with the | ||||||
2 | enrollee's current physician during a transitional period: | ||||||
3 | (A) of 90 days from the effective date of | ||||||
4 | enrollment if the enrollee has an ongoing course of | ||||||
5 | treatment; or | ||||||
6 | (B) if the enrollee has entered the third | ||||||
7 | trimester of pregnancy at the effective date of | ||||||
8 | enrollment, that includes the provision of post-partum | ||||||
9 | care directly related to the delivery. | ||||||
10 | (2) If an enrollee elects to continue to receive care | ||||||
11 | from such physician pursuant to item (1) of this | ||||||
12 | subsection, such care shall be authorized by the health | ||||||
13 | care plan for the transitional period only if the | ||||||
14 | physician agrees: | ||||||
15 | (A) to accept reimbursement from the health care | ||||||
16 | plan at rates established by the health care plan; | ||||||
17 | such rates shall be the level of reimbursement | ||||||
18 | applicable to similar physicians within the health | ||||||
19 | care plan for such services; | ||||||
20 | (B) to adhere to the health care plan's quality | ||||||
21 | assurance requirements and to provide to the health | ||||||
22 | care plan necessary medical information related to | ||||||
23 | such care; and | ||||||
24 | (C) to otherwise adhere to the health care plan's | ||||||
25 | policies and procedures including, but not limited to | ||||||
26 | procedures regarding referrals and obtaining |
| |||||||
| |||||||
1 | preauthorization for treatment. | ||||||
2 | (c) In no event shall this Section be construed to require | ||||||
3 | a health care plan to provide coverage for benefits not | ||||||
4 | otherwise covered or to diminish or impair preexisting | ||||||
5 | condition limitations contained in the enrollee's contract. In | ||||||
6 | no event shall this Section be construed to prohibit the | ||||||
7 | addition of prescription drugs to a health care plan's list of | ||||||
8 | covered drugs during the coverage year. | ||||||
9 | (d) In this Section, "ongoing course of treatment" has the | ||||||
10 | meaning ascribed to that term in Section 5 of the Network | ||||||
11 | Adequacy and Transparency Act. | ||||||
12 | (Source: P.A. 100-1052, eff. 8-24-18.)
| ||||||
13 | Article 3. | ||||||
14 | Section 3-5. The Illinois Insurance Code is amended by | ||||||
15 | changing Section 355 as follows:
| ||||||
16 | (215 ILCS 5/355) (from Ch. 73, par. 967) | ||||||
17 | Sec. 355. Accident and health policies; provisions. | ||||||
18 | (a) As used in this Section: | ||||||
19 | "Inadequate rate" means a rate: | ||||||
20 | (1) that is insufficient to sustain projected losses | ||||||
21 | and expenses to which the rate applies; and | ||||||
22 | (2) the continued use of which endangers the solvency | ||||||
23 | of an insurer using that rate. |
| |||||||
| |||||||
1 | "Large employer" has the meaning provided in the Illinois | ||||||
2 | Health Insurance Portability and Accountability Act. | ||||||
3 | "Plain language" has the meaning provided in the federal | ||||||
4 | Plain Writing Act of 2010 and subsequent guidance documents, | ||||||
5 | including the Federal Plain Language Guidelines. | ||||||
6 | "Unreasonable rate increase" means a rate increase that | ||||||
7 | the Director determines to be excessive, unjustified, or | ||||||
8 | unfairly discriminatory in accordance with 45 CFR 154.205. | ||||||
9 | (b) No policy of insurance against loss or damage from the | ||||||
10 | sickness, or from the bodily injury or death of the insured by | ||||||
11 | accident shall be issued or delivered to any person in this | ||||||
12 | State until a copy of the form thereof and of the | ||||||
13 | classification of risks and the premium rates pertaining | ||||||
14 | thereto have been filed with the Director; nor shall it be so | ||||||
15 | issued or delivered until the Director shall have approved | ||||||
16 | such policy pursuant to the provisions of Section 143. If the | ||||||
17 | Director disapproves the policy form, he or she shall make a | ||||||
18 | written decision stating the respects in which such form does | ||||||
19 | not comply with the requirements of law and shall deliver a | ||||||
20 | copy thereof to the company and it shall be unlawful | ||||||
21 | thereafter for any such company to issue any policy in such | ||||||
22 | form. On and after January 1, 2025, any form filing submitted | ||||||
23 | for large employer group accident and health insurance shall | ||||||
24 | be automatically deemed approved within 90 days of the | ||||||
25 | submission date unless the Director extends by not more than | ||||||
26 | an additional 30 days the period within which the form shall be |
| |||||||
| |||||||
1 | approved or disapproved by giving written notice to the | ||||||
2 | insurer of such extension before the expiration of the 90 | ||||||
3 | days. Any form in receipt of such an extension shall be | ||||||
4 | automatically deemed approved within 120 days of the | ||||||
5 | submission date. The Director may toll the filing due to a | ||||||
6 | conflict in legal interpretation of federal or State law as | ||||||
7 | long as the tolling is applied uniformly to all applicable | ||||||
8 | forms, written notification is provided to the insurer prior | ||||||
9 | to the tolling, the duration of the tolling is provided within | ||||||
10 | the notice to the insurer, and justification for the tolling | ||||||
11 | is posted to the Department's website. The Director may | ||||||
12 | disapprove the filing if the insurer fails to respond to an | ||||||
13 | objection or request for additional information within the | ||||||
14 | timeframe identified for response. As used in this subsection, | ||||||
15 | "large employer" has the meaning given in Section 5 of the | ||||||
16 | federal Health Insurance Portability and Accountability Act. | ||||||
17 | (c) For plan year 2026 and thereafter, premium rates for | ||||||
18 | all individual and small group accident and health insurance | ||||||
19 | policies must be filed with the Department for approval. | ||||||
20 | Unreasonable rate increases or inadequate rates shall be | ||||||
21 | modified or disapproved. For any plan year during which the | ||||||
22 | Illinois Health Benefits Exchange operates as a full | ||||||
23 | State-based exchange, the Department shall provide insurers at | ||||||
24 | least 30 days' notice of the deadline to submit rate filings. | ||||||
25 | (c-5) Unless prohibited under federal law, for plan year | ||||||
26 | 2026 and thereafter, each insurer proposing to offer a |
| |||||||
| |||||||
1 | qualified health plan issued in the individual market through | ||||||
2 | the Illinois Health Benefits Exchange must incorporate the | ||||||
3 | following approach in its rate filing under this Section: | ||||||
4 | (1) The rate filing must apply a cost-sharing | ||||||
5 | reduction defunding adjustment factor within a range that: | ||||||
6 | (A) is uniform across all insurers; | ||||||
7 | (B) is consistent with the total adjustment | ||||||
8 | expected to be needed to cover actual cost-sharing | ||||||
9 | reduction costs across all silver plans on the | ||||||
10 | Illinois Health Benefits Exchange statewide; and | ||||||
11 | (C) assumes that the only enrollees who will | ||||||
12 | purchase silver plans on the Illinois Health Benefits | ||||||
13 | Exchange are those individuals who are eligible for | ||||||
14 | 87% and 94% cost-sharing reduction plans. | ||||||
15 | (2) The rate filing must apply an induced demand | ||||||
16 | factor based on the following formula: (Plan Actuarial | ||||||
17 | Value) 2 - (Plan Actuarial Value) + 1.24. | ||||||
18 | In the annual notice to insurers described in subsection | ||||||
19 | (c), the Department must include the specific numerical range | ||||||
20 | calculated for the applicable plan year under paragraph (1) of | ||||||
21 | this subsection (c-5) and the formula in paragraph (2) of this | ||||||
22 | subsection (c-5). | ||||||
23 | (d) For plan year 2025 and thereafter, the Department | ||||||
24 | shall post all insurers' rate filings and summaries on the | ||||||
25 | Department's website 5 business days after the rate filing | ||||||
26 | deadline set by the Department in annual guidance. The rate |
| |||||||
| |||||||
1 | filings and summaries posted to the Department's website shall | ||||||
2 | exclude information that is proprietary or trade secret | ||||||
3 | information protected under paragraph (g) of subsection (1) of | ||||||
4 | Section 7 of the Freedom of Information Act or confidential or | ||||||
5 | privileged under any applicable insurance law or rule. All | ||||||
6 | summaries shall include a brief justification of any rate | ||||||
7 | increase or decrease requested, including the number of | ||||||
8 | individual members, the medical loss ratio, medical trend, | ||||||
9 | administrative costs, and any other information required by | ||||||
10 | rule. The plain writing summary shall include notification of | ||||||
11 | the public comment period established in subsection (e). | ||||||
12 | (e) The Department shall open a 30-day public comment | ||||||
13 | period on the rate filings beginning on the date that all of | ||||||
14 | the rate filings are posted on the Department's website. The | ||||||
15 | Department shall post all of the comments received to the | ||||||
16 | Department's website within 5 business days after the comment | ||||||
17 | period ends. | ||||||
18 | (f) After the close of the public comment period described | ||||||
19 | in subsection (e), the Department, beginning for plan year | ||||||
20 | 2026, shall issue a decision to approve, disapprove, or modify | ||||||
21 | a rate filing within 60 days. Any rate filing or any rates | ||||||
22 | within a filing on which the Director does not issue a decision | ||||||
23 | within 60 days shall automatically be deemed approved. The | ||||||
24 | Director's decision shall take into account the actuarial | ||||||
25 | justifications and public comments. The Department shall | ||||||
26 | notify the insurer of the decision, make the decision |
| |||||||
| |||||||
1 | available to the public by posting it on the Department's | ||||||
2 | website, and include an explanation of the findings, actuarial | ||||||
3 | justifications, and rationale that are the basis for the | ||||||
4 | decision. Any company whose rate has been modified or | ||||||
5 | disapproved shall be allowed to request a hearing within 10 | ||||||
6 | days after the action taken. The action of the Director in | ||||||
7 | disapproving a rate shall be subject to judicial review under | ||||||
8 | the Administrative Review Law. | ||||||
9 | (g) If, following the issuance of a decision but before | ||||||
10 | the effective date of the premium rates approved by the | ||||||
11 | decision, an event occurs that materially affects the | ||||||
12 | Director's decision to approve, deny, or modify the rates, the | ||||||
13 | Director may consider supplemental facts or data reasonably | ||||||
14 | related to the event. | ||||||
15 | (h) The Department shall adopt rules implementing the | ||||||
16 | procedures described in subsections (d) through (g) by March | ||||||
17 | 31, 2024. | ||||||
18 | (i) Subsection (a) and subsections (c) through (h) of this | ||||||
19 | Section do not apply to grandfathered health plans as defined | ||||||
20 | in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C. | ||||||
21 | 300gg-91; student health insurance coverage as defined in 45 | ||||||
22 | CFR 147.145; the large group market as defined in Section 5 of | ||||||
23 | the Illinois Health Insurance Portability and Accountability | ||||||
24 | Act; or short-term, limited-duration health insurance coverage | ||||||
25 | as defined in Section 5 of the Short-Term, Limited-Duration | ||||||
26 | Health Insurance Coverage Act. For a filing of premium rates |
| |||||||
| |||||||
1 | or classifications of risk for any of these types of coverage, | ||||||
2 | the Director's initial review period shall not exceed 60 days | ||||||
3 | to issue informal objections to the company that request | ||||||
4 | additional clarification, explanation, substantiating | ||||||
5 | documentation, or correction of concerns identified in the | ||||||
6 | filing before the company implements the premium rates, | ||||||
7 | classifications, or related rate-setting methodologies | ||||||
8 | described in the filing, except that the Director may extend | ||||||
9 | by not more than an additional 30 days the period of initial | ||||||
10 | review by giving written notice to the company of such | ||||||
11 | extension before the expiration of the initial 60-day period. | ||||||
12 | Nothing in this subsection shall confer authority upon the | ||||||
13 | Director to approve, modify, or disapprove rates where that | ||||||
14 | authority is not provided by other law. Nothing in this | ||||||
15 | subsection shall prohibit the Director from conducting any | ||||||
16 | investigation, examination, hearing, or other formal | ||||||
17 | administrative or enforcement proceeding with respect to a | ||||||
18 | company's rate filing or implementation thereof under | ||||||
19 | applicable law at any time, including after the period of | ||||||
20 | initial review. | ||||||
21 | (Source: P.A. 103-106, eff. 1-1-24 .)
| ||||||
22 | Article 4. | ||||||
23 | Section 4-5. The Illinois Insurance Code is amended by | ||||||
24 | changing Section 355 as follows:
|
| |||||||
| |||||||
1 | (215 ILCS 5/355) (from Ch. 73, par. 967) | ||||||
2 | Sec. 355. Accident and health policies; provisions. | ||||||
3 | (a) As used in this Section: | ||||||
4 | "Inadequate rate" means a rate: | ||||||
5 | (1) that is insufficient to sustain projected losses | ||||||
6 | and expenses to which the rate applies; and | ||||||
7 | (2) the continued use of which endangers the solvency | ||||||
8 | of an insurer using that rate. | ||||||
9 | "Large employer" has the meaning provided in the Illinois | ||||||
10 | Health Insurance Portability and Accountability Act. | ||||||
11 | "Plain language" has the meaning provided in the federal | ||||||
12 | Plain Writing Act of 2010 and subsequent guidance documents, | ||||||
13 | including the Federal Plain Language Guidelines. | ||||||
14 | "Unreasonable rate increase" means a rate increase that | ||||||
15 | the Director determines to be excessive, unjustified, or | ||||||
16 | unfairly discriminatory in accordance with 45 CFR 154.205. | ||||||
17 | (b) No policy of insurance against loss or damage from the | ||||||
18 | sickness, or from the bodily injury or death of the insured by | ||||||
19 | accident shall be issued or delivered to any person in this | ||||||
20 | State until a copy of the form thereof and of the | ||||||
21 | classification of risks and the premium rates pertaining | ||||||
22 | thereto have been filed with the Director; nor shall it be so | ||||||
23 | issued or delivered until the Director shall have approved | ||||||
24 | such policy pursuant to the provisions of Section 143. If the | ||||||
25 | Director disapproves the policy form, he or she shall make a |
| |||||||
| |||||||
1 | written decision stating the respects in which such form does | ||||||
2 | not comply with the requirements of law and shall deliver a | ||||||
3 | copy thereof to the company and it shall be unlawful | ||||||
4 | thereafter for any such company to issue any policy in such | ||||||
5 | form. On and after January 1, 2025, any form filing submitted | ||||||
6 | for large employer group accident and health insurance shall | ||||||
7 | be automatically deemed approved within 90 days of the | ||||||
8 | submission date unless the Director extends by not more than | ||||||
9 | an additional 30 days the period within which the form shall be | ||||||
10 | approved or disapproved by giving written notice to the | ||||||
11 | insurer of such extension before the expiration of the 90 | ||||||
12 | days. Any form in receipt of such an extension shall be | ||||||
13 | automatically deemed approved within 120 days of the | ||||||
14 | submission date. The Director may toll the filing due to a | ||||||
15 | conflict in legal interpretation of federal or State law as | ||||||
16 | long as the tolling is applied uniformly to all applicable | ||||||
17 | forms, written notification is provided to the insurer prior | ||||||
18 | to the tolling, the duration of the tolling is provided within | ||||||
19 | the notice to the insurer, and justification for the tolling | ||||||
20 | is posted to the Department's website. The Director may | ||||||
21 | disapprove the filing if the insurer fails to respond to an | ||||||
22 | objection or request for additional information within the | ||||||
23 | timeframe identified for response. As used in this subsection, | ||||||
24 | "large employer" has the meaning given in Section 5 of the | ||||||
25 | federal Health Insurance Portability and Accountability Act. | ||||||
26 | (c) For plan year 2026 and thereafter, premium rates for |
| |||||||
| |||||||
1 | all individual and small group accident and health insurance | ||||||
2 | policies must be filed with the Department for approval. | ||||||
3 | Unreasonable rate increases or inadequate rates shall be | ||||||
4 | modified or disapproved. For any plan year during which the | ||||||
5 | Illinois Health Benefits Exchange operates as a full | ||||||
6 | State-based exchange, the Department shall provide insurers at | ||||||
7 | least 30 days' notice of the deadline to submit rate filings. | ||||||
8 | (d) For plan year 2025 and thereafter, the Department | ||||||
9 | shall post all insurers' rate filings and summaries on the | ||||||
10 | Department's website 5 business days after the rate filing | ||||||
11 | deadline set by the Department in annual guidance. The rate | ||||||
12 | filings and summaries posted to the Department's website shall | ||||||
13 | exclude information that is proprietary or trade secret | ||||||
14 | information protected under paragraph (g) of subsection (1) of | ||||||
15 | Section 7 of the Freedom of Information Act or confidential or | ||||||
16 | privileged under any applicable insurance law or rule. All | ||||||
17 | summaries shall include a brief justification of any rate | ||||||
18 | increase or decrease requested, including the number of | ||||||
19 | individual members, the medical loss ratio, medical trend, | ||||||
20 | administrative costs, and any other information required by | ||||||
21 | rule. The plain writing summary shall include notification of | ||||||
22 | the public comment period established in subsection (e). | ||||||
23 | (e) The Department shall open a 30-day public comment | ||||||
24 | period on the rate filings beginning on the date that all of | ||||||
25 | the rate filings are posted on the Department's website. The | ||||||
26 | Department shall post all of the comments received to the |
| |||||||
| |||||||
1 | Department's website within 5 business days after the comment | ||||||
2 | period ends. | ||||||
3 | (f) After the close of the public comment period described | ||||||
4 | in subsection (e), the Department, beginning for plan year | ||||||
5 | 2026, shall issue a decision to approve, disapprove, or modify | ||||||
6 | a rate filing within 60 days. Any rate filing or any rates | ||||||
7 | within a filing on which the Director does not issue a decision | ||||||
8 | within 60 days shall automatically be deemed approved. The | ||||||
9 | Director's decision shall take into account the actuarial | ||||||
10 | justifications and public comments. The Department shall | ||||||
11 | notify the insurer of the decision, make the decision | ||||||
12 | available to the public by posting it on the Department's | ||||||
13 | website, and include an explanation of the findings, actuarial | ||||||
14 | justifications, and rationale that are the basis for the | ||||||
15 | decision. Any company whose rate has been modified or | ||||||
16 | disapproved shall be allowed to request a hearing within 10 | ||||||
17 | days after the action taken. The action of the Director in | ||||||
18 | disapproving a rate shall be subject to judicial review under | ||||||
19 | the Administrative Review Law. | ||||||
20 | (g) If, following the issuance of a decision but before | ||||||
21 | the effective date of the premium rates approved by the | ||||||
22 | decision, an event occurs that materially affects the | ||||||
23 | Director's decision to approve, deny, or modify the rates, the | ||||||
24 | Director may consider supplemental facts or data reasonably | ||||||
25 | related to the event. | ||||||
26 | (h) The Department shall adopt rules implementing the |
| |||||||
| |||||||
1 | procedures described in subsections (d) through (g) by March | ||||||
2 | 31, 2024. | ||||||
3 | (i) Subsection (a) , and subsections (c) through (h) , and | ||||||
4 | subsection (j) of this Section do not apply to grandfathered | ||||||
5 | health plans as defined in 45 CFR 147.140; excepted benefits | ||||||
6 | as defined in 42 U.S.C. 300gg-91; student health insurance | ||||||
7 | coverage as defined in 45 CFR 147.145; the large group market | ||||||
8 | as defined in Section 5 of the Illinois Health Insurance | ||||||
9 | Portability and Accountability Act; or short-term, | ||||||
10 | limited-duration health insurance coverage as defined in | ||||||
11 | Section 5 of the Short-Term, Limited-Duration Health Insurance | ||||||
12 | Coverage Act. For a filing of premium rates or classifications | ||||||
13 | of risk for any of these types of coverage, the Director's | ||||||
14 | initial review period shall not exceed 60 days to issue | ||||||
15 | informal objections to the company that request additional | ||||||
16 | clarification, explanation, substantiating documentation, or | ||||||
17 | correction of concerns identified in the filing before the | ||||||
18 | company implements the premium rates, classifications, or | ||||||
19 | related rate-setting methodologies described in the filing, | ||||||
20 | except that the Director may extend by not more than an | ||||||
21 | additional 30 days the period of initial review by giving | ||||||
22 | written notice to the company of such extension before the | ||||||
23 | expiration of the initial 60-day period. Nothing in this | ||||||
24 | subsection shall confer authority upon the Director to | ||||||
25 | approve, modify, or disapprove rates where that authority is | ||||||
26 | not provided by other law. Nothing in this subsection shall |
| |||||||
| |||||||
1 | prohibit the Director from conducting any investigation, | ||||||
2 | examination, hearing, or other formal administrative or | ||||||
3 | enforcement proceeding with respect to a company's rate filing | ||||||
4 | or implementation thereof under applicable law at any time, | ||||||
5 | including after the period of initial review. | ||||||
6 | (j) Subsections (c) through (h) do not apply to group | ||||||
7 | policies issued to large employers. For large employer group | ||||||
8 | policies issued, delivered, amended, or renewed on or after | ||||||
9 | January 1, 2026 that are not described in subsection (i), the | ||||||
10 | premium rates and risk classifications, including any rate | ||||||
11 | manuals and rules used to arrive at the rates, must be filed | ||||||
12 | with the Department annually for approval at least 120 days | ||||||
13 | before the rates are intended to take effect. | ||||||
14 | (1) A rate filing shall be modified or disapproved if | ||||||
15 | rates will be unreasonable in relation to the benefits, | ||||||
16 | unjustified, or unfairly discriminatory, or otherwise in | ||||||
17 | violation of applicable State or federal law. | ||||||
18 | (2) Within 60 days of receipt of the rate filing, the | ||||||
19 | Director shall issue a decision to approve, disapprove, or | ||||||
20 | modify the filing along with the reasons and actuarial | ||||||
21 | justification for the decision. Any rate filing or rates | ||||||
22 | within a filing on which the Director does not issue a | ||||||
23 | decision within 60 days shall be automatically deemed | ||||||
24 | approved. | ||||||
25 | (3) Any company whose rate or rate filing has been | ||||||
26 | modified or disapproved shall be allowed to request a |
| |||||||
| |||||||
1 | hearing within 10 days after the action taken. The action | ||||||
2 | of the Director in disapproving a rate or rate filing | ||||||
3 | shall be subject to judicial review under the | ||||||
4 | Administrative Review Law. | ||||||
5 | (4) Nothing in this subsection requires a company to | ||||||
6 | file a large employer group policy's final premium rates | ||||||
7 | for prior approval if the company negotiates the final | ||||||
8 | rates or rate adjustments with the large employer in | ||||||
9 | accordance with the rate manual and rules of the currently | ||||||
10 | approved rate filing for the policy. | ||||||
11 | (Source: P.A. 103-106, eff. 1-1-24 .)
| ||||||
12 | Section 4-10. The Health Maintenance Organization Act is | ||||||
13 | amended by changing Section 4-12 as follows:
| ||||||
14 | (215 ILCS 125/4-12) (from Ch. 111 1/2, par. 1409.5) | ||||||
15 | Sec. 4-12. Changes in rate methodology and benefits, | ||||||
16 | material modifications. A health maintenance organization | ||||||
17 | shall file with the Director, prior to use, a notice of any | ||||||
18 | change in rate methodology, or benefits and of any material | ||||||
19 | modification of any matter or document furnished pursuant to | ||||||
20 | Section 2-1, together with such supporting documents as are | ||||||
21 | necessary to fully explain the change or modification. | ||||||
22 | (a) Contract modifications described in subsections | ||||||
23 | (c)(5), (c)(6) and (c)(7) of Section 2-1 shall include all | ||||||
24 | form agreements between the organization and enrollees, |
| |||||||
| |||||||
1 | providers, administrators of services and insurers of health | ||||||
2 | maintenance organizations. | ||||||
3 | (b) Material transactions or series of transactions other | ||||||
4 | than those described in subsection (a) of this Section, the | ||||||
5 | total annual value of which exceeds the greater of $100,000 or | ||||||
6 | 5% of net earned subscription revenue for the most current | ||||||
7 | 12-month period as determined from filed financial statements. | ||||||
8 | (c) Any agreement between the organization and an insurer | ||||||
9 | shall be subject to the provisions of the laws of this State | ||||||
10 | regarding reinsurance as provided in Article XI of the | ||||||
11 | Illinois Insurance Code. All reinsurance agreements must be | ||||||
12 | filed. Approval of the Director is required for all agreements | ||||||
13 | except the following: individual stop loss, aggregate excess, | ||||||
14 | hospitalization benefits or out-of-area of the participating | ||||||
15 | providers unless 20% or more of the organization's total risk | ||||||
16 | is reinsured, in which case all reinsurance agreements require | ||||||
17 | approval. | ||||||
18 | (d) In addition to any applicable provisions of this Act, | ||||||
19 | premium rate filings shall be subject to subsections (a) and | ||||||
20 | (c) through (j) (i) of Section 355 of the Illinois Insurance | ||||||
21 | Code. | ||||||
22 | (Source: P.A. 103-106, eff. 1-1-24 .)
| ||||||
23 | Section 4-15. The Limited Health Service Organization Act | ||||||
24 | is amended by changing Section 3006 as follows:
|
| |||||||
| |||||||
1 | (215 ILCS 130/3006) (from Ch. 73, par. 1503-6) | ||||||
2 | Sec. 3006. Changes in rate methodology and benefits; | ||||||
3 | material modifications; addition of limited health services. | ||||||
4 | (a) A limited health service organization shall file with | ||||||
5 | the Director prior to use, a notice of any change in rate | ||||||
6 | methodology, charges , or benefits and of any material | ||||||
7 | modification of any matter or document furnished pursuant to | ||||||
8 | Section 2001, together with such supporting documents as are | ||||||
9 | necessary to fully explain the change or modification. | ||||||
10 | (1) Contract modifications described in paragraphs (5) | ||||||
11 | and (6) of subsection (c) of Section 2001 shall include | ||||||
12 | all agreements between the organization and enrollees, | ||||||
13 | providers, administrators of services , and insurers of | ||||||
14 | limited health services; also other material transactions | ||||||
15 | or series of transactions, the total annual value of which | ||||||
16 | exceeds the greater of $100,000 or 5% of net earned | ||||||
17 | subscription revenue for the most current 12-month 12 | ||||||
18 | month period as determined from filed financial | ||||||
19 | statements. | ||||||
20 | (2) Contract modification for reinsurance. Any | ||||||
21 | agreement between the organization and an insurer shall be | ||||||
22 | subject to the provisions of Article XI of the Illinois | ||||||
23 | Insurance Code, as now or hereafter amended. All | ||||||
24 | reinsurance agreements must be filed with the Director. | ||||||
25 | Approval of the Director in required agreements must be | ||||||
26 | filed. Approval of the director is required for all |
| |||||||
| |||||||
1 | agreements except individual stop loss, aggregate excess, | ||||||
2 | hospitalization benefits , or out-of-area of the | ||||||
3 | participating providers, unless 20% or more of the | ||||||
4 | organization's total risk is reinsured, in which case all | ||||||
5 | reinsurance agreements shall require approval. | ||||||
6 | (b) If a limited health service organization desires to | ||||||
7 | add one or more additional limited health services, it shall | ||||||
8 | file a notice with the Director and, at the same time, submit | ||||||
9 | the information required by Section 2001 if different from | ||||||
10 | that filed with the prepaid limited health service | ||||||
11 | organization's application. Issuance of such an amended | ||||||
12 | certificate of authority shall be subject to the conditions of | ||||||
13 | Section 2002 of this Act. | ||||||
14 | (c) In addition to any applicable provisions of this Act, | ||||||
15 | premium rate filings shall be subject to subsection (i) and, | ||||||
16 | for pharmaceutical policies, subsection (j) of Section 355 of | ||||||
17 | the Illinois Insurance Code. | ||||||
18 | (Source: P.A. 103-106, eff. 1-1-24; revised 1-2-24.)
| ||||||
19 | Article 5. | ||||||
20 | Section 5-5. The Illinois Insurance Code is amended by | ||||||
21 | changing Sections 121-2.05, 356z.18, 367.3, 367a, and 368f and | ||||||
22 | by adding Section 352c as follows:
| ||||||
23 | (215 ILCS 5/121-2.05) (from Ch. 73, par. 733-2.05) |
| |||||||
| |||||||
1 | Sec. 121-2.05. Group insurance policies issued and | ||||||
2 | delivered in other State-Transactions in this State. With the | ||||||
3 | exception of insurance transactions authorized under Sections | ||||||
4 | 230.2 or 367.3 of this Code or transactions described under | ||||||
5 | Section 352c , transactions in this State involving group | ||||||
6 | legal, group life and group accident and health or blanket | ||||||
7 | accident and health insurance or group annuities where the | ||||||
8 | master policy of such groups was lawfully issued and delivered | ||||||
9 | in, and under the laws of, a State in which the insurer was | ||||||
10 | authorized to do an insurance business, to a group properly | ||||||
11 | established pursuant to law or regulation, and where the | ||||||
12 | policyholder is domiciled or otherwise has a bona fide situs. | ||||||
13 | (Source: P.A. 86-753.)
| ||||||
14 | (215 ILCS 5/352c new) | ||||||
15 | Sec. 352c. Short-term, limited-duration insurance | ||||||
16 | prohibited; rules for excepted benefits. | ||||||
17 | (a) Definitions. As used in this Section: | ||||||
18 | "Excepted benefits" has the meaning given to that term in | ||||||
19 | 42 U.S.C. 300gg-91 and implementing regulations. "Excepted | ||||||
20 | benefits" includes individual, group, or blanket coverage. | ||||||
21 | "Short-term, limited-duration insurance" means any type of | ||||||
22 | accident and health insurance offered or provided within this | ||||||
23 | State pursuant to a group or individual policy or individual | ||||||
24 | certificate by a company, regardless of the situs state of the | ||||||
25 | delivery of the policy, that has an expiration date specified |
| |||||||
| |||||||
1 | in the contract that is fewer than 365 days after the original | ||||||
2 | effective date. Regardless of the duration of coverage, | ||||||
3 | "short-term, limited-duration insurance" does not include | ||||||
4 | excepted benefits or any student health insurance coverage. | ||||||
5 | "Student health insurance coverage" has the meaning given | ||||||
6 | to that term in 45 CFR 147.145. | ||||||
7 | (b) On and after January 1, 2025, no company shall issue, | ||||||
8 | deliver, amend, or renew short-term, limited-duration | ||||||
9 | insurance to any natural or legal person that is a resident or | ||||||
10 | domiciled in this State. | ||||||
11 | (c) To prevent the use, design, and combination of | ||||||
12 | excepted benefits to circumvent State or federal requirements | ||||||
13 | for comprehensive forms of health insurance coverage, to | ||||||
14 | prevent confusion or misinformation of insureds about | ||||||
15 | duplicate or distinct types of coverage, and to ensure a | ||||||
16 | measure of consistency within product lines across the | ||||||
17 | individual, group, and blanket markets, the Department may | ||||||
18 | adopt rules as deemed necessary that prescribe specific | ||||||
19 | standards for or restrictions on policy provisions, benefit | ||||||
20 | design, disclosures, and sales and marketing practices for | ||||||
21 | excepted benefits. For purposes of these rules, the Director's | ||||||
22 | authority under subsections (3) and (4) of Section 355a is | ||||||
23 | extended to group and blanket excepted benefits. To ensure | ||||||
24 | compliance with these rules, the Director may require policy | ||||||
25 | forms and rates to be filed as provided in Sections 143 and 355 | ||||||
26 | and rules thereunder with respect to excepted benefits |
| |||||||
| |||||||
1 | coverage intended to be issued to residents of this State | ||||||
2 | under a master contract issued to a group domiciled or | ||||||
3 | otherwise with bona fide situs outside of this State. This | ||||||
4 | subsection does not apply to limited-scope dental, | ||||||
5 | limited-scope vision, long-term care, Medicare supplement, | ||||||
6 | credit life, credit health, or any excepted benefits that are | ||||||
7 | filed under subsections (b) through (l) of Class 2 or under | ||||||
8 | Class 3 of Section 4. Nothing in this subsection shall be | ||||||
9 | construed to limit the Director's authority under other | ||||||
10 | statutes.
| ||||||
11 | (215 ILCS 5/356z.18) | ||||||
12 | (Text of Section before amendment by P.A. 103-512 ) | ||||||
13 | Sec. 356z.18. Prosthetic and customized orthotic devices. | ||||||
14 | (a) For the purposes of this Section: | ||||||
15 | "Customized orthotic device" means a supportive device for | ||||||
16 | the body or a part of the body, the head, neck, or extremities, | ||||||
17 | and includes the replacement or repair of the device based on | ||||||
18 | the patient's physical condition as medically necessary, | ||||||
19 | excluding foot orthotics defined as an in-shoe device designed | ||||||
20 | to support the structural components of the foot during | ||||||
21 | weight-bearing activities. | ||||||
22 | "Licensed provider" means a prosthetist, orthotist, or | ||||||
23 | pedorthist licensed to practice in this State. | ||||||
24 | "Prosthetic device" means an artificial device to replace, | ||||||
25 | in whole or in part, an arm or leg and includes accessories |
| |||||||
| |||||||
1 | essential to the effective use of the device and the | ||||||
2 | replacement or repair of the device based on the patient's | ||||||
3 | physical condition as medically necessary. | ||||||
4 | (b) This amendatory Act of the 96th General Assembly shall | ||||||
5 | provide benefits to any person covered thereunder for expenses | ||||||
6 | incurred in obtaining a prosthetic or custom orthotic device | ||||||
7 | from any Illinois licensed prosthetist, licensed orthotist, or | ||||||
8 | licensed pedorthist as required under the Orthotics, | ||||||
9 | Prosthetics, and Pedorthics Practice Act. | ||||||
10 | (c) A group or individual major medical policy of accident | ||||||
11 | or health insurance or managed care plan or medical, health, | ||||||
12 | or hospital service corporation contract that provides | ||||||
13 | coverage for prosthetic or custom orthotic care and is | ||||||
14 | amended, delivered, issued, or renewed 6 months after the | ||||||
15 | effective date of this amendatory Act of the 96th General | ||||||
16 | Assembly must provide coverage for prosthetic and orthotic | ||||||
17 | devices in accordance with this subsection (c). The coverage | ||||||
18 | required under this Section shall be subject to the other | ||||||
19 | general exclusions, limitations, and financial requirements of | ||||||
20 | the policy, including coordination of benefits, participating | ||||||
21 | provider requirements, utilization review of health care | ||||||
22 | services, including review of medical necessity, case | ||||||
23 | management, and experimental and investigational treatments, | ||||||
24 | and other managed care provisions under terms and conditions | ||||||
25 | that are no less favorable than the terms and conditions that | ||||||
26 | apply to substantially all medical and surgical benefits |
| |||||||
| |||||||
1 | provided under the plan or coverage. | ||||||
2 | (d) The policy or plan or contract may require prior | ||||||
3 | authorization for the prosthetic or orthotic devices in the | ||||||
4 | same manner that prior authorization is required for any other | ||||||
5 | covered benefit. | ||||||
6 | (e) Repairs and replacements of prosthetic and orthotic | ||||||
7 | devices are also covered, subject to the co-payments and | ||||||
8 | deductibles, unless necessitated by misuse or loss. | ||||||
9 | (f) A policy or plan or contract may require that, if | ||||||
10 | coverage is provided through a managed care plan, the benefits | ||||||
11 | mandated pursuant to this Section shall be covered benefits | ||||||
12 | only if the prosthetic or orthotic devices are provided by a | ||||||
13 | licensed provider employed by a provider service who contracts | ||||||
14 | with or is designated by the carrier, to the extent that the | ||||||
15 | carrier provides in-network and out-of-network service, the | ||||||
16 | coverage for the prosthetic or orthotic device shall be | ||||||
17 | offered no less extensively. | ||||||
18 | (g) The policy or plan or contract shall also meet | ||||||
19 | adequacy requirements as established by the Health Care | ||||||
20 | Reimbursement Reform Act of 1985 of the Illinois Insurance | ||||||
21 | Code. | ||||||
22 | (h) This Section shall not apply to accident only, | ||||||
23 | specified disease, short-term travel hospital or medical , | ||||||
24 | hospital confinement indemnity or other fixed indemnity , | ||||||
25 | credit, dental, vision, Medicare supplement, long-term care, | ||||||
26 | basic hospital and medical-surgical expense coverage, |
| |||||||
| |||||||
1 | disability income insurance coverage, coverage issued as a | ||||||
2 | supplement to liability insurance, workers' compensation | ||||||
3 | insurance, or automobile medical payment insurance. | ||||||
4 | (Source: P.A. 96-833, eff. 6-1-10 .)
| ||||||
5 | (Text of Section after amendment by P.A. 103-512 ) | ||||||
6 | Sec. 356z.18. Prosthetic and customized orthotic devices. | ||||||
7 | (a) For the purposes of this Section: | ||||||
8 | "Customized orthotic device" means a supportive device for | ||||||
9 | the body or a part of the body, the head, neck, or extremities, | ||||||
10 | and includes the replacement or repair of the device based on | ||||||
11 | the patient's physical condition as medically necessary, | ||||||
12 | excluding foot orthotics defined as an in-shoe device designed | ||||||
13 | to support the structural components of the foot during | ||||||
14 | weight-bearing activities. | ||||||
15 | "Licensed provider" means a prosthetist, orthotist, or | ||||||
16 | pedorthist licensed to practice in this State. | ||||||
17 | "Prosthetic device" means an artificial device to replace, | ||||||
18 | in whole or in part, an arm or leg and includes accessories | ||||||
19 | essential to the effective use of the device and the | ||||||
20 | replacement or repair of the device based on the patient's | ||||||
21 | physical condition as medically necessary. | ||||||
22 | (b) This amendatory Act of the 96th General Assembly shall | ||||||
23 | provide benefits to any person covered thereunder for expenses | ||||||
24 | incurred in obtaining a prosthetic or custom orthotic device | ||||||
25 | from any Illinois licensed prosthetist, licensed orthotist, or |
| |||||||
| |||||||
1 | licensed pedorthist as required under the Orthotics, | ||||||
2 | Prosthetics, and Pedorthics Practice Act. | ||||||
3 | (c) A group or individual major medical policy of accident | ||||||
4 | or health insurance or managed care plan or medical, health, | ||||||
5 | or hospital service corporation contract that provides | ||||||
6 | coverage for prosthetic or custom orthotic care and is | ||||||
7 | amended, delivered, issued, or renewed 6 months after the | ||||||
8 | effective date of this amendatory Act of the 96th General | ||||||
9 | Assembly must provide coverage for prosthetic and orthotic | ||||||
10 | devices in accordance with this subsection (c). The coverage | ||||||
11 | required under this Section shall be subject to the other | ||||||
12 | general exclusions, limitations, and financial requirements of | ||||||
13 | the policy, including coordination of benefits, participating | ||||||
14 | provider requirements, utilization review of health care | ||||||
15 | services, including review of medical necessity, case | ||||||
16 | management, and experimental and investigational treatments, | ||||||
17 | and other managed care provisions under terms and conditions | ||||||
18 | that are no less favorable than the terms and conditions that | ||||||
19 | apply to substantially all medical and surgical benefits | ||||||
20 | provided under the plan or coverage. | ||||||
21 | (d) With respect to an enrollee at any age, in addition to | ||||||
22 | coverage of a prosthetic or custom orthotic device required by | ||||||
23 | this Section, benefits shall be provided for a prosthetic or | ||||||
24 | custom orthotic device determined by the enrollee's provider | ||||||
25 | to be the most appropriate model that is medically necessary | ||||||
26 | for the enrollee to perform physical activities, as |
| |||||||
| |||||||
1 | applicable, such as running, biking, swimming, and lifting | ||||||
2 | weights, and to maximize the enrollee's whole body health and | ||||||
3 | strengthen the lower and upper limb function. | ||||||
4 | (e) The requirements of this Section do not constitute an | ||||||
5 | addition to this State's essential health benefits that | ||||||
6 | requires defrayal of costs by this State pursuant to 42 U.S.C. | ||||||
7 | 18031(d)(3)(B). | ||||||
8 | (f) The policy or plan or contract may require prior | ||||||
9 | authorization for the prosthetic or orthotic devices in the | ||||||
10 | same manner that prior authorization is required for any other | ||||||
11 | covered benefit. | ||||||
12 | (g) Repairs and replacements of prosthetic and orthotic | ||||||
13 | devices are also covered, subject to the co-payments and | ||||||
14 | deductibles, unless necessitated by misuse or loss. | ||||||
15 | (h) A policy or plan or contract may require that, if | ||||||
16 | coverage is provided through a managed care plan, the benefits | ||||||
17 | mandated pursuant to this Section shall be covered benefits | ||||||
18 | only if the prosthetic or orthotic devices are provided by a | ||||||
19 | licensed provider employed by a provider service who contracts | ||||||
20 | with or is designated by the carrier, to the extent that the | ||||||
21 | carrier provides in-network and out-of-network service, the | ||||||
22 | coverage for the prosthetic or orthotic device shall be | ||||||
23 | offered no less extensively. | ||||||
24 | (i) The policy or plan or contract shall also meet | ||||||
25 | adequacy requirements as established by the Health Care | ||||||
26 | Reimbursement Reform Act of 1985 of the Illinois Insurance |
| |||||||
| |||||||
1 | Code. | ||||||
2 | (j) This Section shall not apply to accident only, | ||||||
3 | specified disease, short-term travel hospital or medical , | ||||||
4 | hospital confinement indemnity or other fixed indemnity , | ||||||
5 | credit, dental, vision, Medicare supplement, long-term care, | ||||||
6 | basic hospital and medical-surgical expense coverage, | ||||||
7 | disability income insurance coverage, coverage issued as a | ||||||
8 | supplement to liability insurance, workers' compensation | ||||||
9 | insurance, or automobile medical payment insurance. | ||||||
10 | (Source: P.A. 103-512, eff. 1-1-25.)
| ||||||
11 | (215 ILCS 5/367.3) (from Ch. 73, par. 979.3) | ||||||
12 | Sec. 367.3. Group accident and health insurance; | ||||||
13 | discretionary groups. | ||||||
14 | (a) No group health insurance offered to a resident of | ||||||
15 | this State under a policy issued to a group, other than one | ||||||
16 | specifically described in Section 367(1), shall be delivered | ||||||
17 | or issued for delivery in this State unless the Director | ||||||
18 | determines that: | ||||||
19 | (1) the issuance of the policy is not contrary to the | ||||||
20 | public interest; | ||||||
21 | (2) the issuance of the policy will result in | ||||||
22 | economies of acquisition and administration; and | ||||||
23 | (3) the benefits under the policy are reasonable in | ||||||
24 | relation to the premium charged. | ||||||
25 | (b) No such group health insurance may be offered in this |
| |||||||
| |||||||
1 | State under a policy issued in another state unless this State | ||||||
2 | or the state in which the group policy is issued has made a | ||||||
3 | determination that the requirements of subsection (a) have | ||||||
4 | been met. | ||||||
5 | Where insurance is to be offered in this State under a | ||||||
6 | policy described in this subsection, the insurer shall file | ||||||
7 | for informational review purposes: | ||||||
8 | (1) a copy of the group master contract; | ||||||
9 | (2) a copy of the statute authorizing the issuance of | ||||||
10 | the group policy in the state of situs, which statute has | ||||||
11 | the same or similar requirements as this State, or in the | ||||||
12 | absence of such statute, a certification by an officer of | ||||||
13 | the company that the policy meets the Illinois minimum | ||||||
14 | standards required for individual accident and health | ||||||
15 | policies under authority of Section 401 of this Code, as | ||||||
16 | now or hereafter amended, as promulgated by rule at 50 | ||||||
17 | Illinois Administrative Code, Ch. I, Sec. 2007, et seq., | ||||||
18 | as now or hereafter amended, or by a successor rule; | ||||||
19 | (3) evidence of approval by the state of situs of the | ||||||
20 | group master policy; and | ||||||
21 | (4) copies of all supportive material furnished to the | ||||||
22 | state of situs to satisfy the criteria for approval. | ||||||
23 | (c) The Director may, at any time after receipt of the | ||||||
24 | information required under subsection (b) and after finding | ||||||
25 | that the standards of subsection (a) have not been met, order | ||||||
26 | the insurer to cease the issuance or marketing of that |
| |||||||
| |||||||
1 | coverage in this State. | ||||||
2 | (d) Notwithstanding subsections (a) and (b), group Group | ||||||
3 | accident and health insurance subject to the provisions of | ||||||
4 | this Section is also subject to the provisions of Sections | ||||||
5 | 352c and Section 367i of this Code and rules thereunder . | ||||||
6 | (Source: P.A. 90-655, eff. 7-30-98.)
| ||||||
7 | (215 ILCS 5/367a) (from Ch. 73, par. 979a) | ||||||
8 | Sec. 367a. Blanket accident and health insurance. | ||||||
9 | (1) Blanket accident and health insurance is the that form | ||||||
10 | of accident and health insurance providing excepted benefits, | ||||||
11 | as defined in Section 352c, that covers covering special | ||||||
12 | groups of persons as enumerated in one of the following | ||||||
13 | paragraphs (a) to (g), inclusive: | ||||||
14 | (a) Under a policy or contract issued to any carrier for | ||||||
15 | hire, which shall be deemed the policyholder, covering a group | ||||||
16 | defined as all persons who may become passengers on such | ||||||
17 | carrier. | ||||||
18 | (b) Under a policy or contract issued to an employer, who | ||||||
19 | shall be deemed the policyholder, covering all employees or | ||||||
20 | any group of employees defined by reference to exceptional | ||||||
21 | hazards incident to such employment. | ||||||
22 | (c) Under a policy or contract issued to a college, | ||||||
23 | school, or other institution of learning or to the head or | ||||||
24 | principal thereof, who or which shall be deemed the | ||||||
25 | policyholder, covering students or teachers. However, except |
| |||||||
| |||||||
1 | where inconsistent with 45 CFR 147.145, student health | ||||||
2 | insurance coverage other than excepted benefits that is | ||||||
3 | provided pursuant to a written agreement with an institution | ||||||
4 | of higher education for the benefit of its enrolled students | ||||||
5 | and their dependents shall remain subject to the standards and | ||||||
6 | requirements for individual coverage. | ||||||
7 | (d) Under a policy or contract issued in the name of any | ||||||
8 | volunteer fire department, first aid, or other such volunteer | ||||||
9 | group, which shall be deemed the policyholder, covering all of | ||||||
10 | the members of such department or group. | ||||||
11 | (e) Under a policy or contract issued to a creditor, who | ||||||
12 | shall be deemed the policyholder, to insure debtors of the | ||||||
13 | creditors; Provided, however, that in the case of a loan which | ||||||
14 | is subject to the Small Loans Act, no insurance premium or | ||||||
15 | other cost shall be directly or indirectly charged or assessed | ||||||
16 | against, or collected or received from the borrower. | ||||||
17 | (f) Under a policy or contract issued to a sports team or | ||||||
18 | to a camp, which team or camp sponsor shall be deemed the | ||||||
19 | policyholder, covering members or campers. | ||||||
20 | (g) Under a policy or contract issued to any other | ||||||
21 | substantially similar group which, in the discretion of the | ||||||
22 | Director, may be subject to the issuance of a blanket accident | ||||||
23 | and health policy or contract. | ||||||
24 | (2) Any insurance company authorized to write accident and | ||||||
25 | health insurance in this state shall have the power to issue | ||||||
26 | blanket accident and health insurance. No such blanket policy |
| |||||||
| |||||||
1 | may be issued or delivered in this State unless a copy of the | ||||||
2 | form thereof shall have been filed in accordance with Section | ||||||
3 | 355, and it contains in substance such of those provisions | ||||||
4 | contained in Sections 357.1 through 357.30 as may be | ||||||
5 | applicable to blanket accident and health insurance and the | ||||||
6 | following provisions: | ||||||
7 | (a) A provision that the policy and the application shall | ||||||
8 | constitute the entire contract between the parties, and that | ||||||
9 | all statements made by the policyholder shall, in absence of | ||||||
10 | fraud, be deemed representations and not warranties, and that | ||||||
11 | no such statements shall be used in defense to a claim under | ||||||
12 | the policy, unless it is contained in a written application. | ||||||
13 | (b) A provision that to the group or class thereof | ||||||
14 | originally insured shall be added from time to time all new | ||||||
15 | persons or individuals eligible for coverage. | ||||||
16 | (3) An individual application shall not be required from a | ||||||
17 | person covered under a blanket accident or health policy or | ||||||
18 | contract, nor shall it be necessary for the insurer to furnish | ||||||
19 | each person a certificate. | ||||||
20 | (4) All benefits under any blanket accident and health | ||||||
21 | policy shall be payable to the person insured, or to his | ||||||
22 | designated beneficiary or beneficiaries, or to his or her | ||||||
23 | estate, except that if the person insured be a minor or person | ||||||
24 | under legal disability, such benefits may be made payable to | ||||||
25 | his or her parent, guardian, or other person actually | ||||||
26 | supporting him or her. Provided further, however, that the |
| |||||||
| |||||||
1 | policy may provide that all or any portion of any indemnities | ||||||
2 | provided by any such policy on account of hospital, nursing, | ||||||
3 | medical or surgical services may, at the insurer's option, be | ||||||
4 | paid directly to the hospital or person rendering such | ||||||
5 | services; but the policy may not require that the service be | ||||||
6 | rendered by a particular hospital or person. Payment so made | ||||||
7 | shall discharge the insurer's obligation with respect to the | ||||||
8 | amount of insurance so paid. | ||||||
9 | (5) Nothing contained in this section shall be deemed to | ||||||
10 | affect the legal liability of policyholders for the death of | ||||||
11 | or injury to, any such member of such group. | ||||||
12 | (Source: P.A. 83-1362.)
| ||||||
13 | (215 ILCS 5/368f) | ||||||
14 | Sec. 368f. Military service member insurance | ||||||
15 | reinstatement. | ||||||
16 | (a) No Illinois resident activated for military service | ||||||
17 | and no spouse or dependent of the resident who becomes | ||||||
18 | eligible for a federal government-sponsored health insurance | ||||||
19 | program, including the TriCare program providing coverage for | ||||||
20 | civilian dependents of military personnel, as a result of the | ||||||
21 | activation shall be denied reinstatement into the same | ||||||
22 | individual health insurance coverage with the health insurer | ||||||
23 | that the resident lapsed as a result of activation or becoming | ||||||
24 | covered by the federal government-sponsored health insurance | ||||||
25 | program. The resident shall have the right to reinstatement in |
| |||||||
| |||||||
1 | the same individual health insurance coverage without medical | ||||||
2 | underwriting, subject to payment of the current premium | ||||||
3 | charged to other persons of the same age and gender that are | ||||||
4 | covered under the same individual health coverage. Except in | ||||||
5 | the case of birth or adoption that occurs during the period of | ||||||
6 | activation, reinstatement must be into the same coverage type | ||||||
7 | as the resident held prior to lapsing the individual health | ||||||
8 | insurance coverage and at the same or, at the option of the | ||||||
9 | resident, higher deductible level. The reinstatement rights | ||||||
10 | provided under this subsection (a) are not available to a | ||||||
11 | resident or dependents if the activated person is discharged | ||||||
12 | from the military under other than honorable conditions. | ||||||
13 | (b) The health insurer with which the reinstatement is | ||||||
14 | being requested must receive a request for reinstatement no | ||||||
15 | later than 63 days following the later of (i) deactivation or | ||||||
16 | (ii) loss of coverage under the federal government-sponsored | ||||||
17 | health insurance program. The health insurer may request proof | ||||||
18 | of loss of coverage and the timing of the loss of coverage of | ||||||
19 | the government-sponsored coverage in order to determine | ||||||
20 | eligibility for reinstatement into the individual coverage. | ||||||
21 | The effective date of the reinstatement of individual health | ||||||
22 | coverage shall be the first of the month following receipt of | ||||||
23 | the notice requesting reinstatement. | ||||||
24 | (c) All insurers must provide written notice to the | ||||||
25 | policyholder of individual health coverage of the rights | ||||||
26 | described in subsection (a) of this Section. In lieu of the |
| |||||||
| |||||||
1 | inclusion of the notice in the individual health insurance | ||||||
2 | policy, an insurance company may satisfy the notification | ||||||
3 | requirement by providing a single written notice: | ||||||
4 | (1) in conjunction with the enrollment process for a | ||||||
5 | policyholder initially enrolling in the individual | ||||||
6 | coverage on or after the effective date of this amendatory | ||||||
7 | Act of the 94th General Assembly; or | ||||||
8 | (2) by mailing written notice to policyholders whose | ||||||
9 | coverage was effective prior to the effective date of this | ||||||
10 | amendatory Act of the 94th General Assembly no later than | ||||||
11 | 90 days following the effective date of this amendatory | ||||||
12 | Act of the 94th General Assembly. | ||||||
13 | (d) The provisions of subsection (a) of this Section do | ||||||
14 | not apply to any policy or certificate providing coverage for | ||||||
15 | any specified disease, specified accident or accident-only | ||||||
16 | coverage, credit, dental, disability income, hospital | ||||||
17 | indemnity or other fixed indemnity , long-term care, Medicare | ||||||
18 | supplement, vision care, or short-term travel nonrenewable | ||||||
19 | health policy or other limited-benefit supplemental insurance, | ||||||
20 | or any coverage issued as a supplement to any liability | ||||||
21 | insurance, workers' compensation or similar insurance, or any | ||||||
22 | insurance under which benefits are payable with or without | ||||||
23 | regard to fault, whether written on a group, blanket, or | ||||||
24 | individual basis. | ||||||
25 | (e) Nothing in this Section shall require an insurer to | ||||||
26 | reinstate the resident if the insurer requires residency in an |
| |||||||
| |||||||
1 | enrollment area and those residency requirements are not met | ||||||
2 | after deactivation or loss of coverage under the | ||||||
3 | government-sponsored health insurance program. | ||||||
4 | (f) All terms, conditions, and limitations of the | ||||||
5 | individual coverage into which reinstatement is made apply | ||||||
6 | equally to all insureds enrolled in the coverage. | ||||||
7 | (g) The Secretary may adopt rules as may be necessary to | ||||||
8 | carry out the provisions of this Section. | ||||||
9 | (Source: P.A. 94-1037, eff. 7-20-06.)
| ||||||
10 | Section 5-10. The Health Maintenance Organization Act is | ||||||
11 | amended by changing Section 5-3 as follows:
| ||||||
12 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | ||||||
13 | Sec. 5-3. Insurance Code provisions. | ||||||
14 | (a) Health Maintenance Organizations shall be subject to | ||||||
15 | the provisions of Sections 133, 134, 136, 137, 139, 140, | ||||||
16 | 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | ||||||
17 | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | ||||||
18 | 352c, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, | ||||||
19 | 356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | ||||||
20 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||
21 | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | ||||||
22 | 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, | ||||||
23 | 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | ||||||
24 | 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, |
| |||||||
| |||||||
1 | 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | ||||||
2 | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | ||||||
3 | 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | ||||||
4 | 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
5 | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||||||
6 | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | ||||||
7 | subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||||||
8 | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||||||
9 | Illinois Insurance Code. | ||||||
10 | (b) For purposes of the Illinois Insurance Code, except | ||||||
11 | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||||||
12 | Health Maintenance Organizations in the following categories | ||||||
13 | are deemed to be "domestic companies": | ||||||
14 | (1) a corporation authorized under the Dental Service | ||||||
15 | Plan Act or the Voluntary Health Services Plans Act; | ||||||
16 | (2) a corporation organized under the laws of this | ||||||
17 | State; or | ||||||
18 | (3) a corporation organized under the laws of another | ||||||
19 | state, 30% or more of the enrollees of which are residents | ||||||
20 | of this State, except a corporation subject to | ||||||
21 | substantially the same requirements in its state of | ||||||
22 | organization as is a "domestic company" under Article VIII | ||||||
23 | 1/2 of the Illinois Insurance Code. | ||||||
24 | (c) In considering the merger, consolidation, or other | ||||||
25 | acquisition of control of a Health Maintenance Organization | ||||||
26 | pursuant to Article VIII 1/2 of the Illinois Insurance Code, |
| |||||||
| |||||||
1 | (1) the Director shall give primary consideration to | ||||||
2 | the continuation of benefits to enrollees and the | ||||||
3 | financial conditions of the acquired Health Maintenance | ||||||
4 | Organization after the merger, consolidation, or other | ||||||
5 | acquisition of control takes effect; | ||||||
6 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
7 | Section 131.8 of the Illinois Insurance Code shall not | ||||||
8 | apply and (ii) the Director, in making his determination | ||||||
9 | with respect to the merger, consolidation, or other | ||||||
10 | acquisition of control, need not take into account the | ||||||
11 | effect on competition of the merger, consolidation, or | ||||||
12 | other acquisition of control; | ||||||
13 | (3) the Director shall have the power to require the | ||||||
14 | following information: | ||||||
15 | (A) certification by an independent actuary of the | ||||||
16 | adequacy of the reserves of the Health Maintenance | ||||||
17 | Organization sought to be acquired; | ||||||
18 | (B) pro forma financial statements reflecting the | ||||||
19 | combined balance sheets of the acquiring company and | ||||||
20 | the Health Maintenance Organization sought to be | ||||||
21 | acquired as of the end of the preceding year and as of | ||||||
22 | a date 90 days prior to the acquisition, as well as pro | ||||||
23 | forma financial statements reflecting projected | ||||||
24 | combined operation for a period of 2 years; | ||||||
25 | (C) a pro forma business plan detailing an | ||||||
26 | acquiring party's plans with respect to the operation |
| |||||||
| |||||||
1 | of the Health Maintenance Organization sought to be | ||||||
2 | acquired for a period of not less than 3 years; and | ||||||
3 | (D) such other information as the Director shall | ||||||
4 | require. | ||||||
5 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
6 | Insurance Code and this Section 5-3 shall apply to the sale by | ||||||
7 | any health maintenance organization of greater than 10% of its | ||||||
8 | enrollee population (including , without limitation , the health | ||||||
9 | maintenance organization's right, title, and interest in and | ||||||
10 | to its health care certificates). | ||||||
11 | (e) In considering any management contract or service | ||||||
12 | agreement subject to Section 141.1 of the Illinois Insurance | ||||||
13 | Code, the Director (i) shall, in addition to the criteria | ||||||
14 | specified in Section 141.2 of the Illinois Insurance Code, | ||||||
15 | take into account the effect of the management contract or | ||||||
16 | service agreement on the continuation of benefits to enrollees | ||||||
17 | and the financial condition of the health maintenance | ||||||
18 | organization to be managed or serviced, and (ii) need not take | ||||||
19 | into account the effect of the management contract or service | ||||||
20 | agreement on competition. | ||||||
21 | (f) Except for small employer groups as defined in the | ||||||
22 | Small Employer Rating, Renewability and Portability Health | ||||||
23 | Insurance Act and except for medicare supplement policies as | ||||||
24 | defined in Section 363 of the Illinois Insurance Code, a | ||||||
25 | Health Maintenance Organization may by contract agree with a | ||||||
26 | group or other enrollment unit to effect refunds or charge |
| |||||||
| |||||||
1 | additional premiums under the following terms and conditions: | ||||||
2 | (i) the amount of, and other terms and conditions with | ||||||
3 | respect to, the refund or additional premium are set forth | ||||||
4 | in the group or enrollment unit contract agreed in advance | ||||||
5 | of the period for which a refund is to be paid or | ||||||
6 | additional premium is to be charged (which period shall | ||||||
7 | not be less than one year); and | ||||||
8 | (ii) the amount of the refund or additional premium | ||||||
9 | shall not exceed 20% of the Health Maintenance | ||||||
10 | Organization's profitable or unprofitable experience with | ||||||
11 | respect to the group or other enrollment unit for the | ||||||
12 | period (and, for purposes of a refund or additional | ||||||
13 | premium, the profitable or unprofitable experience shall | ||||||
14 | be calculated taking into account a pro rata share of the | ||||||
15 | Health Maintenance Organization's administrative and | ||||||
16 | marketing expenses, but shall not include any refund to be | ||||||
17 | made or additional premium to be paid pursuant to this | ||||||
18 | subsection (f)). The Health Maintenance Organization and | ||||||
19 | the group or enrollment unit may agree that the profitable | ||||||
20 | or unprofitable experience may be calculated taking into | ||||||
21 | account the refund period and the immediately preceding 2 | ||||||
22 | plan years. | ||||||
23 | The Health Maintenance Organization shall include a | ||||||
24 | statement in the evidence of coverage issued to each enrollee | ||||||
25 | describing the possibility of a refund or additional premium, | ||||||
26 | and upon request of any group or enrollment unit, provide to |
| |||||||
| |||||||
1 | the group or enrollment unit a description of the method used | ||||||
2 | to calculate (1) the Health Maintenance Organization's | ||||||
3 | profitable experience with respect to the group or enrollment | ||||||
4 | unit and the resulting refund to the group or enrollment unit | ||||||
5 | or (2) the Health Maintenance Organization's unprofitable | ||||||
6 | experience with respect to the group or enrollment unit and | ||||||
7 | the resulting additional premium to be paid by the group or | ||||||
8 | enrollment unit. | ||||||
9 | In no event shall the Illinois Health Maintenance | ||||||
10 | Organization Guaranty Association be liable to pay any | ||||||
11 | contractual obligation of an insolvent organization to pay any | ||||||
12 | refund authorized under this Section. | ||||||
13 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
14 | if any, is conditioned on the rules being adopted in | ||||||
15 | accordance with all provisions of the Illinois Administrative | ||||||
16 | Procedure Act and all rules and procedures of the Joint | ||||||
17 | Committee on Administrative Rules; any purported rule not so | ||||||
18 | adopted, for whatever reason, is unauthorized. | ||||||
19 | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||||||
20 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
21 | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||||||
22 | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||||||
23 | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||||||
24 | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||||||
25 | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||||||
26 | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. |
| |||||||
| |||||||
1 | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
2 | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
| ||||||
3 | Section 5-15. The Limited Health Service Organization Act | ||||||
4 | is amended by changing Section 4003 as follows:
| ||||||
5 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) | ||||||
6 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
7 | health service organizations shall be subject to the | ||||||
8 | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | ||||||
9 | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, | ||||||
10 | 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c, | ||||||
11 | 355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, | ||||||
12 | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | ||||||
13 | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | ||||||
14 | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | ||||||
15 | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, | ||||||
16 | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, | ||||||
17 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. | ||||||
18 | Nothing in this Section shall require a limited health care | ||||||
19 | plan to cover any service that is not a limited health service. | ||||||
20 | For purposes of the Illinois Insurance Code, except for | ||||||
21 | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited | ||||||
22 | health service organizations in the following categories are | ||||||
23 | deemed to be domestic companies: | ||||||
24 | (1) a corporation under the laws of this State; or |
| |||||||
| |||||||
1 | (2) a corporation organized under the laws of another | ||||||
2 | state, 30% or more of the enrollees of which are residents | ||||||
3 | of this State, except a corporation subject to | ||||||
4 | substantially the same requirements in its state of | ||||||
5 | organization as is a domestic company under Article VIII | ||||||
6 | 1/2 of the Illinois Insurance Code. | ||||||
7 | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||||||
8 | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | ||||||
9 | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | ||||||
10 | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | ||||||
11 | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | ||||||
12 | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
13 | eff. 1-1-24; revised 8-29-23.)
| ||||||
14 | (215 ILCS 190/Act rep.) | ||||||
15 | Section 5-20. The Short-Term, Limited-Duration Health | ||||||
16 | Insurance Coverage Act is repealed.
| ||||||
17 | Article 6. | ||||||
18 | Section 6-5. The Illinois Insurance Code is amended by | ||||||
19 | changing Sections 155.36, 155.37, 356z.40, and 370c as | ||||||
20 | follows:
| ||||||
21 | (215 ILCS 5/155.36) | ||||||
22 | Sec. 155.36. Managed Care Reform and Patient Rights Act. |
| |||||||
| |||||||
1 | Insurance companies that transact the kinds of insurance | ||||||
2 | authorized under Class 1(b) or Class 2(a) of Section 4 of this | ||||||
3 | Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65, | ||||||
4 | 70, and 85, and 87, subsection (d) of Section 30, and the | ||||||
5 | definitions definition of the term "emergency medical | ||||||
6 | condition" and any other term in Section 10 of the Managed Care | ||||||
7 | Reform and Patient Rights Act that is used in the other | ||||||
8 | Sections listed in this Section . | ||||||
9 | (Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
| ||||||
10 | (215 ILCS 5/155.37) | ||||||
11 | Sec. 155.37. Drug formulary; notice. | ||||||
12 | (a) Insurance companies that transact the kinds of | ||||||
13 | insurance authorized under Class 1(b) or Class 2(a) of Section | ||||||
14 | 4 of this Code and provide coverage for prescription drugs | ||||||
15 | through the use of a drug formulary must notify insureds of any | ||||||
16 | change in the formulary. A company may comply with this | ||||||
17 | Section by posting changes in the formulary on its website. | ||||||
18 | (b) No later than July 1, 2025, insurance companies that | ||||||
19 | use a drug formulary shall post the formulary on their | ||||||
20 | websites in a manner that is searchable and accessible to the | ||||||
21 | general public without requiring an individual to create any | ||||||
22 | account. This formulary shall adhere to a template developed | ||||||
23 | by the Department by March 31, 2025, which shall take into | ||||||
24 | consideration existing requirements for reporting of | ||||||
25 | information established by the federal Centers for Medicare |
| |||||||
| |||||||
1 | and Medicaid Services as well as display of cost-sharing | ||||||
2 | information. This template and all formularies also shall do | ||||||
3 | all the following: | ||||||
4 | (1) include information on cost-sharing tiers and | ||||||
5 | utilization controls, such as prior authorization, for | ||||||
6 | each covered drug; | ||||||
7 | (2) indicate any drugs on the formulary that are | ||||||
8 | preferred over other drugs on the formulary; | ||||||
9 | (3) include information to educate insureds about the | ||||||
10 | differences between drugs administered or provided under a | ||||||
11 | policy's medical benefit and drugs covered under a drug | ||||||
12 | benefit and how to obtain coverage information about drugs | ||||||
13 | that are not covered under the drug benefit; | ||||||
14 | (4) include information to educate insureds that | ||||||
15 | policies that provide drug benefits are required to have a | ||||||
16 | method for enrollees to obtain drugs not listed in the | ||||||
17 | formulary if they are deemed medically necessary by a | ||||||
18 | clinician under Section 45.1 of the Managed Care Reform | ||||||
19 | and Patient Rights Act; | ||||||
20 | (5) include information on which medications are | ||||||
21 | covered, including both generic and brand name; and | ||||||
22 | (6) include information on what tier of the plan's | ||||||
23 | drug formulary each medication is in. | ||||||
24 | (c) No formulary may establish a step therapy requirement | ||||||
25 | for any formulary drug or any drug covered as a result of a | ||||||
26 | medical exceptions procedure. |
| |||||||
| |||||||
1 | (Source: P.A. 92-440, eff. 8-17-01; 92-651, eff. 7-11-02.)
| ||||||
2 | (215 ILCS 5/356z.40) | ||||||
3 | Sec. 356z.40. Pregnancy and postpartum coverage. | ||||||
4 | (a) An individual or group policy of accident and health | ||||||
5 | insurance or managed care plan amended, delivered, issued, or | ||||||
6 | renewed on or after the effective date of this amendatory Act | ||||||
7 | of the 102nd General Assembly shall provide coverage for | ||||||
8 | pregnancy and newborn care in accordance with 42 U.S.C. | ||||||
9 | 18022(b) regarding essential health benefits. | ||||||
10 | (b) Benefits under this Section shall be as follows: | ||||||
11 | (1) An individual who has been identified as | ||||||
12 | experiencing a high-risk pregnancy by the individual's | ||||||
13 | treating provider shall have access to clinically | ||||||
14 | appropriate case management programs. As used in this | ||||||
15 | subsection, "case management" means a mechanism to | ||||||
16 | coordinate and assure continuity of services, including, | ||||||
17 | but not limited to, health services, social services, and | ||||||
18 | educational services necessary for the individual. "Case | ||||||
19 | management" involves individualized assessment of needs, | ||||||
20 | planning of services, referral, monitoring, and advocacy | ||||||
21 | to assist an individual in gaining access to appropriate | ||||||
22 | services and closure when services are no longer required. | ||||||
23 | "Case management" is an active and collaborative process | ||||||
24 | involving a single qualified case manager, the individual, | ||||||
25 | the individual's family, the providers, and the community. |
| |||||||
| |||||||
1 | This includes close coordination and involvement with all | ||||||
2 | service providers in the management plan for that | ||||||
3 | individual or family, including assuring that the | ||||||
4 | individual receives the services. As used in this | ||||||
5 | subsection, "high-risk pregnancy" means a pregnancy in | ||||||
6 | which the pregnant or postpartum individual or baby is at | ||||||
7 | an increased risk for poor health or complications during | ||||||
8 | pregnancy or childbirth, including, but not limited to, | ||||||
9 | hypertension disorders, gestational diabetes, and | ||||||
10 | hemorrhage. | ||||||
11 | (2) An individual shall have access to medically | ||||||
12 | necessary treatment of a mental, emotional, nervous, or | ||||||
13 | substance use disorder or condition consistent with the | ||||||
14 | requirements set forth in this Section and in Sections | ||||||
15 | 370c and 370c.1 of this Code. | ||||||
16 | (3) The benefits provided for inpatient and outpatient | ||||||
17 | services for the treatment of a mental, emotional, | ||||||
18 | nervous, or substance use disorder or condition related to | ||||||
19 | pregnancy or postpartum complications shall be provided if | ||||||
20 | determined to be medically necessary, consistent with the | ||||||
21 | requirements of Sections 370c and 370c.1 of this Code. The | ||||||
22 | facility or provider shall notify the insurer of both the | ||||||
23 | admission and the initial treatment plan within 48 hours | ||||||
24 | after admission or initiation of treatment. Subject to the | ||||||
25 | requirements of Sections 370c and 370c.1 of this Code, | ||||||
26 | nothing Nothing in this paragraph shall prevent an insurer |
| |||||||
| |||||||
1 | from applying concurrent and post-service utilization | ||||||
2 | review of health care services, including review of | ||||||
3 | medical necessity, case management, experimental and | ||||||
4 | investigational treatments, managed care provisions, and | ||||||
5 | other terms and conditions of the insurance policy. | ||||||
6 | (4) The benefits for the first 48 hours of initiation | ||||||
7 | of services for an inpatient admission, detoxification or | ||||||
8 | withdrawal management program, or partial hospitalization | ||||||
9 | admission for the treatment of a mental, emotional, | ||||||
10 | nervous, or substance use disorder or condition related to | ||||||
11 | pregnancy or postpartum complications shall be provided | ||||||
12 | without post-service or concurrent review of medical | ||||||
13 | necessity, as the medical necessity for the first 48 hours | ||||||
14 | of such services shall be determined solely by the covered | ||||||
15 | pregnant or postpartum individual's provider. Subject to | ||||||
16 | Section 370c and 370c.1 of this Code, nothing Nothing in | ||||||
17 | this paragraph shall prevent an insurer from applying | ||||||
18 | concurrent and post-service utilization review, including | ||||||
19 | the review of medical necessity, case management, | ||||||
20 | experimental and investigational treatments, managed care | ||||||
21 | provisions, and other terms and conditions of the | ||||||
22 | insurance policy, of any inpatient admission, | ||||||
23 | detoxification or withdrawal management program admission, | ||||||
24 | or partial hospitalization admission services for the | ||||||
25 | treatment of a mental, emotional, nervous, or substance | ||||||
26 | use disorder or condition related to pregnancy or |
| |||||||
| |||||||
1 | postpartum complications received 48 hours after the | ||||||
2 | initiation of such services. If an insurer determines that | ||||||
3 | the services are no longer medically necessary, then the | ||||||
4 | covered person shall have the right to external review | ||||||
5 | pursuant to the requirements of the Health Carrier | ||||||
6 | External Review Act. | ||||||
7 | (5) If an insurer determines that continued inpatient | ||||||
8 | care, detoxification or withdrawal management, partial | ||||||
9 | hospitalization, intensive outpatient treatment, or | ||||||
10 | outpatient treatment in a facility is no longer medically | ||||||
11 | necessary, the insurer shall, within 24 hours, provide | ||||||
12 | written notice to the covered pregnant or postpartum | ||||||
13 | individual and the covered pregnant or postpartum | ||||||
14 | individual's provider of its decision and the right to | ||||||
15 | file an expedited internal appeal of the determination. | ||||||
16 | The insurer shall review and make a determination with | ||||||
17 | respect to the internal appeal within 24 hours and | ||||||
18 | communicate such determination to the covered pregnant or | ||||||
19 | postpartum individual and the covered pregnant or | ||||||
20 | postpartum individual's provider. If the determination is | ||||||
21 | to uphold the denial, the covered pregnant or postpartum | ||||||
22 | individual and the covered pregnant or postpartum | ||||||
23 | individual's provider have the right to file an expedited | ||||||
24 | external appeal. An independent utilization review | ||||||
25 | organization shall make a determination within 72 hours. | ||||||
26 | If the insurer's determination is upheld and it is |
| |||||||
| |||||||
1 | determined that continued inpatient care, detoxification | ||||||
2 | or withdrawal management, partial hospitalization, | ||||||
3 | intensive outpatient treatment, or outpatient treatment is | ||||||
4 | not medically necessary, the insurer shall remain | ||||||
5 | responsible for providing benefits for the inpatient care, | ||||||
6 | detoxification or withdrawal management, partial | ||||||
7 | hospitalization, intensive outpatient treatment, or | ||||||
8 | outpatient treatment through the day following the date | ||||||
9 | the determination is made, and the covered pregnant or | ||||||
10 | postpartum individual shall only be responsible for any | ||||||
11 | applicable copayment, deductible, and coinsurance for the | ||||||
12 | stay through that date as applicable under the policy. The | ||||||
13 | covered pregnant or postpartum individual shall not be | ||||||
14 | discharged or released from the inpatient facility, | ||||||
15 | detoxification or withdrawal management, partial | ||||||
16 | hospitalization, intensive outpatient treatment, or | ||||||
17 | outpatient treatment until all internal appeals and | ||||||
18 | independent utilization review organization appeals are | ||||||
19 | exhausted. A decision to reverse an adverse determination | ||||||
20 | shall comply with the Health Carrier External Review Act. | ||||||
21 | (6) Except as otherwise stated in this subsection (b), | ||||||
22 | the benefits and cost-sharing shall be provided to the | ||||||
23 | same extent as for any other medical condition covered | ||||||
24 | under the policy. | ||||||
25 | (7) The benefits required by paragraphs (2) and (6) of | ||||||
26 | this subsection (b) are to be provided to all covered |
| |||||||
| |||||||
1 | pregnant or postpartum individuals with a diagnosis of a | ||||||
2 | mental, emotional, nervous, or substance use disorder or | ||||||
3 | condition. The presence of additional related or unrelated | ||||||
4 | diagnoses shall not be a basis to reduce or deny the | ||||||
5 | benefits required by this subsection (b). | ||||||
6 | (Source: P.A. 102-665, eff. 10-8-21.)
| ||||||
7 | (215 ILCS 5/370c) (from Ch. 73, par. 982c) | ||||||
8 | Sec. 370c. Mental and emotional disorders. | ||||||
9 | (a)(1) On and after January 1, 2022 (the effective date of | ||||||
10 | Public Act 102-579), every insurer that amends, delivers, | ||||||
11 | issues, or renews group accident and health policies providing | ||||||
12 | coverage for hospital or medical treatment or services for | ||||||
13 | illness on an expense-incurred basis shall provide coverage | ||||||
14 | for the medically necessary treatment of mental, emotional, | ||||||
15 | nervous, or substance use disorders or conditions consistent | ||||||
16 | with the parity requirements of Section 370c.1 of this Code. | ||||||
17 | (2) Each insured that is covered for mental, emotional, | ||||||
18 | nervous, or substance use disorders or conditions shall be | ||||||
19 | free to select the physician licensed to practice medicine in | ||||||
20 | all its branches, licensed clinical psychologist, licensed | ||||||
21 | clinical social worker, licensed clinical professional | ||||||
22 | counselor, licensed marriage and family therapist, licensed | ||||||
23 | speech-language pathologist, or other licensed or certified | ||||||
24 | professional at a program licensed pursuant to the Substance | ||||||
25 | Use Disorder Act of his or her choice to treat such disorders, |
| |||||||
| |||||||
1 | and the insurer shall pay the covered charges of such | ||||||
2 | physician licensed to practice medicine in all its branches, | ||||||
3 | licensed clinical psychologist, licensed clinical social | ||||||
4 | worker, licensed clinical professional counselor, licensed | ||||||
5 | marriage and family therapist, licensed speech-language | ||||||
6 | pathologist, or other licensed or certified professional at a | ||||||
7 | program licensed pursuant to the Substance Use Disorder Act up | ||||||
8 | to the limits of coverage, provided (i) the disorder or | ||||||
9 | condition treated is covered by the policy, and (ii) the | ||||||
10 | physician, licensed psychologist, licensed clinical social | ||||||
11 | worker, licensed clinical professional counselor, licensed | ||||||
12 | marriage and family therapist, licensed speech-language | ||||||
13 | pathologist, or other licensed or certified professional at a | ||||||
14 | program licensed pursuant to the Substance Use Disorder Act is | ||||||
15 | authorized to provide said services under the statutes of this | ||||||
16 | State and in accordance with accepted principles of his or her | ||||||
17 | profession. | ||||||
18 | (3) Insofar as this Section applies solely to licensed | ||||||
19 | clinical social workers, licensed clinical professional | ||||||
20 | counselors, licensed marriage and family therapists, licensed | ||||||
21 | speech-language pathologists, and other licensed or certified | ||||||
22 | professionals at programs licensed pursuant to the Substance | ||||||
23 | Use Disorder Act, those persons who may provide services to | ||||||
24 | individuals shall do so after the licensed clinical social | ||||||
25 | worker, licensed clinical professional counselor, licensed | ||||||
26 | marriage and family therapist, licensed speech-language |
| |||||||
| |||||||
1 | pathologist, or other licensed or certified professional at a | ||||||
2 | program licensed pursuant to the Substance Use Disorder Act | ||||||
3 | has informed the patient of the desirability of the patient | ||||||
4 | conferring with the patient's primary care physician. | ||||||
5 | (4) "Mental, emotional, nervous, or substance use disorder | ||||||
6 | or condition" means a condition or disorder that involves a | ||||||
7 | mental health condition or substance use disorder that falls | ||||||
8 | under any of the diagnostic categories listed in the mental | ||||||
9 | and behavioral disorders chapter of the current edition of the | ||||||
10 | World Health Organization's International Classification of | ||||||
11 | Disease or that is listed in the most recent version of the | ||||||
12 | American Psychiatric Association's Diagnostic and Statistical | ||||||
13 | Manual of Mental Disorders. "Mental, emotional, nervous, or | ||||||
14 | substance use disorder or condition" includes any mental | ||||||
15 | health condition that occurs during pregnancy or during the | ||||||
16 | postpartum period and includes, but is not limited to, | ||||||
17 | postpartum depression. | ||||||
18 | (5) Medically necessary treatment and medical necessity | ||||||
19 | determinations shall be interpreted and made in a manner that | ||||||
20 | is consistent with and pursuant to subsections (h) through | ||||||
21 | (t). | ||||||
22 | (b)(1) (Blank). | ||||||
23 | (2) (Blank). | ||||||
24 | (2.5) (Blank). | ||||||
25 | (3) Unless otherwise prohibited by federal law and | ||||||
26 | consistent with the parity requirements of Section 370c.1 of |
| |||||||
| |||||||
1 | this Code, the reimbursing insurer that amends, delivers, | ||||||
2 | issues, or renews a group or individual policy of accident and | ||||||
3 | health insurance, a qualified health plan offered through the | ||||||
4 | health insurance marketplace, or a provider of treatment of | ||||||
5 | mental, emotional, nervous, or substance use disorders or | ||||||
6 | conditions shall furnish medical records or other necessary | ||||||
7 | data that substantiate that initial or continued treatment is | ||||||
8 | at all times medically necessary. An insurer shall provide a | ||||||
9 | mechanism for the timely review by a provider holding the same | ||||||
10 | license and practicing in the same specialty as the patient's | ||||||
11 | provider, who is unaffiliated with the insurer, jointly | ||||||
12 | selected by the patient (or the patient's next of kin or legal | ||||||
13 | representative if the patient is unable to act for himself or | ||||||
14 | herself), the patient's provider, and the insurer in the event | ||||||
15 | of a dispute between the insurer and patient's provider | ||||||
16 | regarding the medical necessity of a treatment proposed by a | ||||||
17 | patient's provider. If the reviewing provider determines the | ||||||
18 | treatment to be medically necessary, the insurer shall provide | ||||||
19 | reimbursement for the treatment. Future contractual or | ||||||
20 | employment actions by the insurer regarding the patient's | ||||||
21 | provider may not be based on the provider's participation in | ||||||
22 | this procedure. Nothing prevents the insured from agreeing in | ||||||
23 | writing to continue treatment at his or her expense. When | ||||||
24 | making a determination of the medical necessity for a | ||||||
25 | treatment modality for mental, emotional, nervous, or | ||||||
26 | substance use disorders or conditions, an insurer must make |
| |||||||
| |||||||
1 | the determination in a manner that is consistent with the | ||||||
2 | manner used to make that determination with respect to other | ||||||
3 | diseases or illnesses covered under the policy, including an | ||||||
4 | appeals process. Medical necessity determinations for | ||||||
5 | substance use disorders shall be made in accordance with | ||||||
6 | appropriate patient placement criteria established by the | ||||||
7 | American Society of Addiction Medicine. No additional criteria | ||||||
8 | may be used to make medical necessity determinations for | ||||||
9 | substance use disorders. | ||||||
10 | (4) A group health benefit plan amended, delivered, | ||||||
11 | issued, or renewed on or after January 1, 2019 (the effective | ||||||
12 | date of Public Act 100-1024) or an individual policy of | ||||||
13 | accident and health insurance or a qualified health plan | ||||||
14 | offered through the health insurance marketplace amended, | ||||||
15 | delivered, issued, or renewed on or after January 1, 2019 (the | ||||||
16 | effective date of Public Act 100-1024): | ||||||
17 | (A) shall provide coverage based upon medical | ||||||
18 | necessity for the treatment of a mental, emotional, | ||||||
19 | nervous, or substance use disorder or condition consistent | ||||||
20 | with the parity requirements of Section 370c.1 of this | ||||||
21 | Code; provided, however, that in each calendar year | ||||||
22 | coverage shall not be less than the following: | ||||||
23 | (i) 45 days of inpatient treatment; and | ||||||
24 | (ii) beginning on June 26, 2006 (the effective | ||||||
25 | date of Public Act 94-921), 60 visits for outpatient | ||||||
26 | treatment including group and individual outpatient |
| |||||||
| |||||||
1 | treatment; and | ||||||
2 | (iii) for plans or policies delivered, issued for | ||||||
3 | delivery, renewed, or modified after January 1, 2007 | ||||||
4 | (the effective date of Public Act 94-906), 20 | ||||||
5 | additional outpatient visits for speech therapy for | ||||||
6 | treatment of pervasive developmental disorders that | ||||||
7 | will be in addition to speech therapy provided | ||||||
8 | pursuant to item (ii) of this subparagraph (A); and | ||||||
9 | (B) may not include a lifetime limit on the number of | ||||||
10 | days of inpatient treatment or the number of outpatient | ||||||
11 | visits covered under the plan. | ||||||
12 | (C) (Blank). | ||||||
13 | (5) An issuer of a group health benefit plan or an | ||||||
14 | individual policy of accident and health insurance or a | ||||||
15 | qualified health plan offered through the health insurance | ||||||
16 | marketplace may not count toward the number of outpatient | ||||||
17 | visits required to be covered under this Section an outpatient | ||||||
18 | visit for the purpose of medication management and shall cover | ||||||
19 | the outpatient visits under the same terms and conditions as | ||||||
20 | it covers outpatient visits for the treatment of physical | ||||||
21 | illness. | ||||||
22 | (5.5) An individual or group health benefit plan amended, | ||||||
23 | delivered, issued, or renewed on or after September 9, 2015 | ||||||
24 | (the effective date of Public Act 99-480) shall offer coverage | ||||||
25 | for medically necessary acute treatment services and medically | ||||||
26 | necessary clinical stabilization services. The treating |
| |||||||
| |||||||
1 | provider shall base all treatment recommendations and the | ||||||
2 | health benefit plan shall base all medical necessity | ||||||
3 | determinations for substance use disorders in accordance with | ||||||
4 | the most current edition of the Treatment Criteria for | ||||||
5 | Addictive, Substance-Related, and Co-Occurring Conditions | ||||||
6 | established by the American Society of Addiction Medicine. The | ||||||
7 | treating provider shall base all treatment recommendations and | ||||||
8 | the health benefit plan shall base all medical necessity | ||||||
9 | determinations for medication-assisted treatment in accordance | ||||||
10 | with the most current Treatment Criteria for Addictive, | ||||||
11 | Substance-Related, and Co-Occurring Conditions established by | ||||||
12 | the American Society of Addiction Medicine. | ||||||
13 | As used in this subsection: | ||||||
14 | "Acute treatment services" means 24-hour medically | ||||||
15 | supervised addiction treatment that provides evaluation and | ||||||
16 | withdrawal management and may include biopsychosocial | ||||||
17 | assessment, individual and group counseling, psychoeducational | ||||||
18 | groups, and discharge planning. | ||||||
19 | "Clinical stabilization services" means 24-hour treatment, | ||||||
20 | usually following acute treatment services for substance | ||||||
21 | abuse, which may include intensive education and counseling | ||||||
22 | regarding the nature of addiction and its consequences, | ||||||
23 | relapse prevention, outreach to families and significant | ||||||
24 | others, and aftercare planning for individuals beginning to | ||||||
25 | engage in recovery from addiction. | ||||||
26 | (6) An issuer of a group health benefit plan may provide or |
| |||||||
| |||||||
1 | offer coverage required under this Section through a managed | ||||||
2 | care plan. | ||||||
3 | (6.5) An individual or group health benefit plan amended, | ||||||
4 | delivered, issued, or renewed on or after January 1, 2019 (the | ||||||
5 | effective date of Public Act 100-1024): | ||||||
6 | (A) shall not impose prior authorization requirements, | ||||||
7 | other than those established under the Treatment Criteria | ||||||
8 | for Addictive, Substance-Related, and Co-Occurring | ||||||
9 | Conditions established by the American Society of | ||||||
10 | Addiction Medicine, on a prescription medication approved | ||||||
11 | by the United States Food and Drug Administration that is | ||||||
12 | prescribed or administered for the treatment of substance | ||||||
13 | use disorders; | ||||||
14 | (B) shall not impose any step therapy requirements , | ||||||
15 | other than those established under the Treatment Criteria | ||||||
16 | for Addictive, Substance-Related, and Co-Occurring | ||||||
17 | Conditions established by the American Society of | ||||||
18 | Addiction Medicine, before authorizing coverage for a | ||||||
19 | prescription medication approved by the United States Food | ||||||
20 | and Drug Administration that is prescribed or administered | ||||||
21 | for the treatment of substance use disorders ; | ||||||
22 | (C) shall place all prescription medications approved | ||||||
23 | by the United States Food and Drug Administration | ||||||
24 | prescribed or administered for the treatment of substance | ||||||
25 | use disorders on, for brand medications, the lowest tier | ||||||
26 | of the drug formulary developed and maintained by the |
| |||||||
| |||||||
1 | individual or group health benefit plan that covers brand | ||||||
2 | medications and, for generic medications, the lowest tier | ||||||
3 | of the drug formulary developed and maintained by the | ||||||
4 | individual or group health benefit plan that covers | ||||||
5 | generic medications; and | ||||||
6 | (D) shall not exclude coverage for a prescription | ||||||
7 | medication approved by the United States Food and Drug | ||||||
8 | Administration for the treatment of substance use | ||||||
9 | disorders and any associated counseling or wraparound | ||||||
10 | services on the grounds that such medications and services | ||||||
11 | were court ordered. | ||||||
12 | (7) (Blank). | ||||||
13 | (8) (Blank). | ||||||
14 | (9) With respect to all mental, emotional, nervous, or | ||||||
15 | substance use disorders or conditions, coverage for inpatient | ||||||
16 | treatment shall include coverage for treatment in a | ||||||
17 | residential treatment center certified or licensed by the | ||||||
18 | Department of Public Health or the Department of Human | ||||||
19 | Services. | ||||||
20 | (c) This Section shall not be interpreted to require | ||||||
21 | coverage for speech therapy or other habilitative services for | ||||||
22 | those individuals covered under Section 356z.15 of this Code. | ||||||
23 | (d) With respect to a group or individual policy of | ||||||
24 | accident and health insurance or a qualified health plan | ||||||
25 | offered through the health insurance marketplace, the | ||||||
26 | Department and, with respect to medical assistance, the |
| |||||||
| |||||||
1 | Department of Healthcare and Family Services shall each | ||||||
2 | enforce the requirements of this Section and Sections 356z.23 | ||||||
3 | and 370c.1 of this Code, the Paul Wellstone and Pete Domenici | ||||||
4 | Mental Health Parity and Addiction Equity Act of 2008, 42 | ||||||
5 | U.S.C. 18031(j), and any amendments to, and federal guidance | ||||||
6 | or regulations issued under, those Acts, including, but not | ||||||
7 | limited to, final regulations issued under the Paul Wellstone | ||||||
8 | and Pete Domenici Mental Health Parity and Addiction Equity | ||||||
9 | Act of 2008 and final regulations applying the Paul Wellstone | ||||||
10 | and Pete Domenici Mental Health Parity and Addiction Equity | ||||||
11 | Act of 2008 to Medicaid managed care organizations, the | ||||||
12 | Children's Health Insurance Program, and alternative benefit | ||||||
13 | plans. Specifically, the Department and the Department of | ||||||
14 | Healthcare and Family Services shall take action: | ||||||
15 | (1) proactively ensuring compliance by individual and | ||||||
16 | group policies, including by requiring that insurers | ||||||
17 | submit comparative analyses, as set forth in paragraph (6) | ||||||
18 | of subsection (k) of Section 370c.1, demonstrating how | ||||||
19 | they design and apply nonquantitative treatment | ||||||
20 | limitations, both as written and in operation, for mental, | ||||||
21 | emotional, nervous, or substance use disorder or condition | ||||||
22 | benefits as compared to how they design and apply | ||||||
23 | nonquantitative treatment limitations, as written and in | ||||||
24 | operation, for medical and surgical benefits; | ||||||
25 | (2) evaluating all consumer or provider complaints | ||||||
26 | regarding mental, emotional, nervous, or substance use |
| |||||||
| |||||||
1 | disorder or condition coverage for possible parity | ||||||
2 | violations; | ||||||
3 | (3) performing parity compliance market conduct | ||||||
4 | examinations or, in the case of the Department of | ||||||
5 | Healthcare and Family Services, parity compliance audits | ||||||
6 | of individual and group plans and policies, including, but | ||||||
7 | not limited to, reviews of: | ||||||
8 | (A) nonquantitative treatment limitations, | ||||||
9 | including, but not limited to, prior authorization | ||||||
10 | requirements, concurrent review, retrospective review, | ||||||
11 | step therapy, network admission standards, | ||||||
12 | reimbursement rates, and geographic restrictions; | ||||||
13 | (B) denials of authorization, payment, and | ||||||
14 | coverage; and | ||||||
15 | (C) other specific criteria as may be determined | ||||||
16 | by the Department. | ||||||
17 | The findings and the conclusions of the parity compliance | ||||||
18 | market conduct examinations and audits shall be made public. | ||||||
19 | The Director may adopt rules to effectuate any provisions | ||||||
20 | of the Paul Wellstone and Pete Domenici Mental Health Parity | ||||||
21 | and Addiction Equity Act of 2008 that relate to the business of | ||||||
22 | insurance. | ||||||
23 | (e) Availability of plan information. | ||||||
24 | (1) The criteria for medical necessity determinations | ||||||
25 | made under a group health plan, an individual policy of | ||||||
26 | accident and health insurance, or a qualified health plan |
| |||||||
| |||||||
1 | offered through the health insurance marketplace with | ||||||
2 | respect to mental health or substance use disorder | ||||||
3 | benefits (or health insurance coverage offered in | ||||||
4 | connection with the plan with respect to such benefits) | ||||||
5 | must be made available by the plan administrator (or the | ||||||
6 | health insurance issuer offering such coverage) to any | ||||||
7 | current or potential participant, beneficiary, or | ||||||
8 | contracting provider upon request. | ||||||
9 | (2) The reason for any denial under a group health | ||||||
10 | benefit plan, an individual policy of accident and health | ||||||
11 | insurance, or a qualified health plan offered through the | ||||||
12 | health insurance marketplace (or health insurance coverage | ||||||
13 | offered in connection with such plan or policy) of | ||||||
14 | reimbursement or payment for services with respect to | ||||||
15 | mental, emotional, nervous, or substance use disorders or | ||||||
16 | conditions benefits in the case of any participant or | ||||||
17 | beneficiary must be made available within a reasonable | ||||||
18 | time and in a reasonable manner and in readily | ||||||
19 | understandable language by the plan administrator (or the | ||||||
20 | health insurance issuer offering such coverage) to the | ||||||
21 | participant or beneficiary upon request. | ||||||
22 | (f) As used in this Section, "group policy of accident and | ||||||
23 | health insurance" and "group health benefit plan" includes (1) | ||||||
24 | State-regulated employer-sponsored group health insurance | ||||||
25 | plans written in Illinois or which purport to provide coverage | ||||||
26 | for a resident of this State; and (2) State employee health |
| |||||||
| |||||||
1 | plans. | ||||||
2 | (g) (1) As used in this subsection: | ||||||
3 | "Benefits", with respect to insurers, means the benefits | ||||||
4 | provided for treatment services for inpatient and outpatient | ||||||
5 | treatment of substance use disorders or conditions at American | ||||||
6 | Society of Addiction Medicine levels of treatment 2.1 | ||||||
7 | (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 | ||||||
8 | (Clinically Managed Low-Intensity Residential), 3.3 | ||||||
9 | (Clinically Managed Population-Specific High-Intensity | ||||||
10 | Residential), 3.5 (Clinically Managed High-Intensity | ||||||
11 | Residential), and 3.7 (Medically Monitored Intensive | ||||||
12 | Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||||||
13 | "Benefits", with respect to managed care organizations, | ||||||
14 | means the benefits provided for treatment services for | ||||||
15 | inpatient and outpatient treatment of substance use disorders | ||||||
16 | or conditions at American Society of Addiction Medicine levels | ||||||
17 | of treatment 2.1 (Intensive Outpatient), 2.5 (Partial | ||||||
18 | Hospitalization), 3.5 (Clinically Managed High-Intensity | ||||||
19 | Residential), and 3.7 (Medically Monitored Intensive | ||||||
20 | Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||||||
21 | "Substance use disorder treatment provider or facility" | ||||||
22 | means a licensed physician, licensed psychologist, licensed | ||||||
23 | psychiatrist, licensed advanced practice registered nurse, or | ||||||
24 | licensed, certified, or otherwise State-approved facility or | ||||||
25 | provider of substance use disorder treatment. | ||||||
26 | (2) A group health insurance policy, an individual health |
| |||||||
| |||||||
1 | benefit plan, or qualified health plan that is offered through | ||||||
2 | the health insurance marketplace, small employer group health | ||||||
3 | plan, and large employer group health plan that is amended, | ||||||
4 | delivered, issued, executed, or renewed in this State, or | ||||||
5 | approved for issuance or renewal in this State, on or after | ||||||
6 | January 1, 2019 (the effective date of Public Act 100-1023) | ||||||
7 | shall comply with the requirements of this Section and Section | ||||||
8 | 370c.1. The services for the treatment and the ongoing | ||||||
9 | assessment of the patient's progress in treatment shall follow | ||||||
10 | the requirements of 77 Ill. Adm. Code 2060. | ||||||
11 | (3) Prior authorization shall not be utilized for the | ||||||
12 | benefits under this subsection. The substance use disorder | ||||||
13 | treatment provider or facility shall notify the insurer of the | ||||||
14 | initiation of treatment. For an insurer that is not a managed | ||||||
15 | care organization, the substance use disorder treatment | ||||||
16 | provider or facility notification shall occur for the | ||||||
17 | initiation of treatment of the covered person within 2 | ||||||
18 | business days. For managed care organizations, the substance | ||||||
19 | use disorder treatment provider or facility notification shall | ||||||
20 | occur in accordance with the protocol set forth in the | ||||||
21 | provider agreement for initiation of treatment within 24 | ||||||
22 | hours. If the managed care organization is not capable of | ||||||
23 | accepting the notification in accordance with the contractual | ||||||
24 | protocol during the 24-hour period following admission, the | ||||||
25 | substance use disorder treatment provider or facility shall | ||||||
26 | have one additional business day to provide the notification |
| |||||||
| |||||||
1 | to the appropriate managed care organization. Treatment plans | ||||||
2 | shall be developed in accordance with the requirements and | ||||||
3 | timeframes established in 77 Ill. Adm. Code 2060. If the | ||||||
4 | substance use disorder treatment provider or facility fails to | ||||||
5 | notify the insurer of the initiation of treatment in | ||||||
6 | accordance with these provisions, the insurer may follow its | ||||||
7 | normal prior authorization processes. | ||||||
8 | (4) For an insurer that is not a managed care | ||||||
9 | organization, if an insurer determines that benefits are no | ||||||
10 | longer medically necessary, the insurer shall notify the | ||||||
11 | covered person, the covered person's authorized | ||||||
12 | representative, if any, and the covered person's health care | ||||||
13 | provider in writing of the covered person's right to request | ||||||
14 | an external review pursuant to the Health Carrier External | ||||||
15 | Review Act. The notification shall occur within 24 hours | ||||||
16 | following the adverse determination. | ||||||
17 | Pursuant to the requirements of the Health Carrier | ||||||
18 | External Review Act, the covered person or the covered | ||||||
19 | person's authorized representative may request an expedited | ||||||
20 | external review. An expedited external review may not occur if | ||||||
21 | the substance use disorder treatment provider or facility | ||||||
22 | determines that continued treatment is no longer medically | ||||||
23 | necessary. | ||||||
24 | If an expedited external review request meets the criteria | ||||||
25 | of the Health Carrier External Review Act, an independent | ||||||
26 | review organization shall make a final determination of |
| |||||||
| |||||||
1 | medical necessity within 72 hours. If an independent review | ||||||
2 | organization upholds an adverse determination, an insurer | ||||||
3 | shall remain responsible to provide coverage of benefits | ||||||
4 | through the day following the determination of the independent | ||||||
5 | review organization. A decision to reverse an adverse | ||||||
6 | determination shall comply with the Health Carrier External | ||||||
7 | Review Act. | ||||||
8 | (5) The substance use disorder treatment provider or | ||||||
9 | facility shall provide the insurer with 7 business days' | ||||||
10 | advance notice of the planned discharge of the patient from | ||||||
11 | the substance use disorder treatment provider or facility and | ||||||
12 | notice on the day that the patient is discharged from the | ||||||
13 | substance use disorder treatment provider or facility. | ||||||
14 | (6) The benefits required by this subsection shall be | ||||||
15 | provided to all covered persons with a diagnosis of substance | ||||||
16 | use disorder or conditions. The presence of additional related | ||||||
17 | or unrelated diagnoses shall not be a basis to reduce or deny | ||||||
18 | the benefits required by this subsection. | ||||||
19 | (7) Nothing in this subsection shall be construed to | ||||||
20 | require an insurer to provide coverage for any of the benefits | ||||||
21 | in this subsection. | ||||||
22 | (h) As used in this Section: | ||||||
23 | "Generally accepted standards of mental, emotional, | ||||||
24 | nervous, or substance use disorder or condition care" means | ||||||
25 | standards of care and clinical practice that are generally | ||||||
26 | recognized by health care providers practicing in relevant |
| |||||||
| |||||||
1 | clinical specialties such as psychiatry, psychology, clinical | ||||||
2 | sociology, social work, addiction medicine and counseling, and | ||||||
3 | behavioral health treatment. Valid, evidence-based sources | ||||||
4 | reflecting generally accepted standards of mental, emotional, | ||||||
5 | nervous, or substance use disorder or condition care include | ||||||
6 | peer-reviewed scientific studies and medical literature, | ||||||
7 | recommendations of nonprofit health care provider professional | ||||||
8 | associations and specialty societies, including, but not | ||||||
9 | limited to, patient placement criteria and clinical practice | ||||||
10 | guidelines, recommendations of federal government agencies, | ||||||
11 | and drug labeling approved by the United States Food and Drug | ||||||
12 | Administration. | ||||||
13 | "Medically necessary treatment of mental, emotional, | ||||||
14 | nervous, or substance use disorders or conditions" means a | ||||||
15 | service or product addressing the specific needs of that | ||||||
16 | patient, for the purpose of screening, preventing, diagnosing, | ||||||
17 | managing, or treating an illness, injury, or condition or its | ||||||
18 | symptoms and comorbidities, including minimizing the | ||||||
19 | progression of an illness, injury, or condition or its | ||||||
20 | symptoms and comorbidities in a manner that is all of the | ||||||
21 | following: | ||||||
22 | (1) in accordance with the generally accepted | ||||||
23 | standards of mental, emotional, nervous, or substance use | ||||||
24 | disorder or condition care; | ||||||
25 | (2) clinically appropriate in terms of type, | ||||||
26 | frequency, extent, site, and duration; and |
| |||||||
| |||||||
1 | (3) not primarily for the economic benefit of the | ||||||
2 | insurer, purchaser, or for the convenience of the patient, | ||||||
3 | treating physician, or other health care provider. | ||||||
4 | "Utilization review" means either of the following: | ||||||
5 | (1) prospectively, retrospectively, or concurrently | ||||||
6 | reviewing and approving, modifying, delaying, or denying, | ||||||
7 | based in whole or in part on medical necessity, requests | ||||||
8 | by health care providers, insureds, or their authorized | ||||||
9 | representatives for coverage of health care services | ||||||
10 | before, retrospectively, or concurrently with the | ||||||
11 | provision of health care services to insureds. | ||||||
12 | (2) evaluating the medical necessity, appropriateness, | ||||||
13 | level of care, service intensity, efficacy, or efficiency | ||||||
14 | of health care services, benefits, procedures, or | ||||||
15 | settings, under any circumstances, to determine whether a | ||||||
16 | health care service or benefit subject to a medical | ||||||
17 | necessity coverage requirement in an insurance policy is | ||||||
18 | covered as medically necessary for an insured. | ||||||
19 | "Utilization review criteria" means patient placement | ||||||
20 | criteria or any criteria, standards, protocols, or guidelines | ||||||
21 | used by an insurer to conduct utilization review. | ||||||
22 | (i)(1) Every insurer that amends, delivers, issues, or | ||||||
23 | renews a group or individual policy of accident and health | ||||||
24 | insurance or a qualified health plan offered through the | ||||||
25 | health insurance marketplace in this State and Medicaid | ||||||
26 | managed care organizations providing coverage for hospital or |
| |||||||
| |||||||
1 | medical treatment on or after January 1, 2023 shall, pursuant | ||||||
2 | to subsections (h) through (s), provide coverage for medically | ||||||
3 | necessary treatment of mental, emotional, nervous, or | ||||||
4 | substance use disorders or conditions. | ||||||
5 | (2) An insurer shall not set a specific limit on the | ||||||
6 | duration of benefits or coverage of medically necessary | ||||||
7 | treatment of mental, emotional, nervous, or substance use | ||||||
8 | disorders or conditions or limit coverage only to alleviation | ||||||
9 | of the insured's current symptoms. | ||||||
10 | (3) All medical necessity determinations made by the | ||||||
11 | insurer concerning service intensity, level of care placement, | ||||||
12 | continued stay, and transfer or discharge of insureds | ||||||
13 | diagnosed with mental, emotional, nervous, or substance use | ||||||
14 | disorders or conditions shall be conducted in accordance with | ||||||
15 | the requirements of subsections (k) through (w) (u) . | ||||||
16 | (4) An insurer that authorizes a specific type of | ||||||
17 | treatment by a provider pursuant to this Section shall not | ||||||
18 | rescind or modify the authorization after that provider | ||||||
19 | renders the health care service in good faith and pursuant to | ||||||
20 | this authorization for any reason, including, but not limited | ||||||
21 | to, the insurer's subsequent cancellation or modification of | ||||||
22 | the insured's or policyholder's contract, or the insured's or | ||||||
23 | policyholder's eligibility. Nothing in this Section shall | ||||||
24 | require the insurer to cover a treatment when the | ||||||
25 | authorization was granted based on a material | ||||||
26 | misrepresentation by the insured, the policyholder, or the |
| |||||||
| |||||||
1 | provider. Nothing in this Section shall require Medicaid | ||||||
2 | managed care organizations to pay for services if the | ||||||
3 | individual was not eligible for Medicaid at the time the | ||||||
4 | service was rendered. Nothing in this Section shall require an | ||||||
5 | insurer to pay for services if the individual was not the | ||||||
6 | insurer's enrollee at the time services were rendered. As used | ||||||
7 | in this paragraph, "material" means a fact or situation that | ||||||
8 | is not merely technical in nature and results in or could | ||||||
9 | result in a substantial change in the situation. | ||||||
10 | (j) An insurer shall not limit benefits or coverage for | ||||||
11 | medically necessary services on the basis that those services | ||||||
12 | should be or could be covered by a public entitlement program, | ||||||
13 | including, but not limited to, special education or an | ||||||
14 | individualized education program, Medicaid, Medicare, | ||||||
15 | Supplemental Security Income, or Social Security Disability | ||||||
16 | Insurance, and shall not include or enforce a contract term | ||||||
17 | that excludes otherwise covered benefits on the basis that | ||||||
18 | those services should be or could be covered by a public | ||||||
19 | entitlement program. Nothing in this subsection shall be | ||||||
20 | construed to require an insurer to cover benefits that have | ||||||
21 | been authorized and provided for a covered person by a public | ||||||
22 | entitlement program. Medicaid managed care organizations are | ||||||
23 | not subject to this subsection. | ||||||
24 | (k) An insurer shall base any medical necessity | ||||||
25 | determination or the utilization review criteria that the | ||||||
26 | insurer, and any entity acting on the insurer's behalf, |
| |||||||
| |||||||
1 | applies to determine the medical necessity of health care | ||||||
2 | services and benefits for the diagnosis, prevention, and | ||||||
3 | treatment of mental, emotional, nervous, or substance use | ||||||
4 | disorders or conditions on current generally accepted | ||||||
5 | standards of mental, emotional, nervous, or substance use | ||||||
6 | disorder or condition care. All denials and appeals shall be | ||||||
7 | reviewed by a professional with experience or expertise | ||||||
8 | comparable to the provider requesting the authorization. | ||||||
9 | (l) For medical necessity determinations relating to level | ||||||
10 | of care placement, continued stay, and transfer or discharge | ||||||
11 | of insureds diagnosed with mental, emotional, and nervous | ||||||
12 | disorders or conditions, an insurer shall apply the patient | ||||||
13 | placement criteria set forth in the most recent version of the | ||||||
14 | treatment criteria developed by an unaffiliated nonprofit | ||||||
15 | professional association for the relevant clinical specialty | ||||||
16 | or, for Medicaid managed care organizations, patient placement | ||||||
17 | criteria determined by the Department of Healthcare and Family | ||||||
18 | Services that are consistent with generally accepted standards | ||||||
19 | of mental, emotional, nervous or substance use disorder or | ||||||
20 | condition care. Pursuant to subsection (b), in conducting | ||||||
21 | utilization review of all covered services and benefits for | ||||||
22 | the diagnosis, prevention, and treatment of substance use | ||||||
23 | disorders an insurer shall use the most recent edition of the | ||||||
24 | patient placement criteria established by the American Society | ||||||
25 | of Addiction Medicine. | ||||||
26 | (m) For medical necessity determinations relating to level |
| |||||||
| |||||||
1 | of care placement, continued stay, and transfer or discharge | ||||||
2 | that are within the scope of the sources specified in | ||||||
3 | subsection (l), an insurer shall not apply different, | ||||||
4 | additional, conflicting, or more restrictive utilization | ||||||
5 | review criteria than the criteria set forth in those sources. | ||||||
6 | For all level of care placement decisions, the insurer shall | ||||||
7 | authorize placement at the level of care consistent with the | ||||||
8 | assessment of the insured using the relevant patient placement | ||||||
9 | criteria as specified in subsection (l). If that level of | ||||||
10 | placement is not available, the insurer shall authorize the | ||||||
11 | next higher level of care. In the event of disagreement, the | ||||||
12 | insurer shall provide full detail of its assessment using the | ||||||
13 | relevant criteria as specified in subsection (l) to the | ||||||
14 | provider of the service and the patient. | ||||||
15 | Nothing in this subsection or subsection (l) prohibits an | ||||||
16 | insurer from applying utilization review criteria that were | ||||||
17 | developed in accordance with subsection (k) to health care | ||||||
18 | services and benefits for mental, emotional, and nervous | ||||||
19 | disorders or conditions that are not related to medical | ||||||
20 | necessity determinations for level of care placement, | ||||||
21 | continued stay, and transfer or discharge. If an insurer | ||||||
22 | purchases or licenses utilization review criteria pursuant to | ||||||
23 | this subsection, the insurer shall verify and document before | ||||||
24 | use that the criteria were developed in accordance with | ||||||
25 | subsection (k). | ||||||
26 | (n) In conducting utilization review that is outside the |
| |||||||
| |||||||
1 | scope of the criteria as specified in subsection (l) or | ||||||
2 | relates to the advancements in technology or in the types or | ||||||
3 | levels of care that are not addressed in the most recent | ||||||
4 | versions of the sources specified in subsection (l), an | ||||||
5 | insurer shall conduct utilization review in accordance with | ||||||
6 | subsection (k). | ||||||
7 | (o) This Section does not in any way limit the rights of a | ||||||
8 | patient under the Medical Patient Rights Act. | ||||||
9 | (p) This Section does not in any way limit early and | ||||||
10 | periodic screening, diagnostic, and treatment benefits as | ||||||
11 | defined under 42 U.S.C. 1396d(r). | ||||||
12 | (q) To ensure the proper use of the criteria described in | ||||||
13 | subsection (l), every insurer shall do all of the following: | ||||||
14 | (1) Educate the insurer's staff, including any third | ||||||
15 | parties contracted with the insurer to review claims, | ||||||
16 | conduct utilization reviews, or make medical necessity | ||||||
17 | determinations about the utilization review criteria. | ||||||
18 | (2) Make the educational program available to other | ||||||
19 | stakeholders, including the insurer's participating or | ||||||
20 | contracted providers and potential participants, | ||||||
21 | beneficiaries, or covered lives. The education program | ||||||
22 | must be provided at least once a year, in-person or | ||||||
23 | digitally, or recordings of the education program must be | ||||||
24 | made available to the aforementioned stakeholders. | ||||||
25 | (3) Provide, at no cost, the utilization review | ||||||
26 | criteria and any training material or resources to |
| |||||||
| |||||||
1 | providers and insured patients upon request. For | ||||||
2 | utilization review criteria not concerning level of care | ||||||
3 | placement, continued stay, and transfer or discharge used | ||||||
4 | by the insurer pursuant to subsection (m), the insurer may | ||||||
5 | place the criteria on a secure, password-protected website | ||||||
6 | so long as the access requirements of the website do not | ||||||
7 | unreasonably restrict access to insureds or their | ||||||
8 | providers. No restrictions shall be placed upon the | ||||||
9 | insured's or treating provider's access right to | ||||||
10 | utilization review criteria obtained under this paragraph | ||||||
11 | at any point in time, including before an initial request | ||||||
12 | for authorization. | ||||||
13 | (4) Track, identify, and analyze how the utilization | ||||||
14 | review criteria are used to certify care, deny care, and | ||||||
15 | support the appeals process. | ||||||
16 | (5) Conduct interrater reliability testing to ensure | ||||||
17 | consistency in utilization review decision making that | ||||||
18 | covers how medical necessity decisions are made; this | ||||||
19 | assessment shall cover all aspects of utilization review | ||||||
20 | as defined in subsection (h). | ||||||
21 | (6) Run interrater reliability reports about how the | ||||||
22 | clinical guidelines are used in conjunction with the | ||||||
23 | utilization review process and parity compliance | ||||||
24 | activities. | ||||||
25 | (7) Achieve interrater reliability pass rates of at | ||||||
26 | least 90% and, if this threshold is not met, immediately |
| |||||||
| |||||||
1 | provide for the remediation of poor interrater reliability | ||||||
2 | and interrater reliability testing for all new staff | ||||||
3 | before they can conduct utilization review without | ||||||
4 | supervision. | ||||||
5 | (8) Maintain documentation of interrater reliability | ||||||
6 | testing and the remediation actions taken for those with | ||||||
7 | pass rates lower than 90% and submit to the Department of | ||||||
8 | Insurance or, in the case of Medicaid managed care | ||||||
9 | organizations, the Department of Healthcare and Family | ||||||
10 | Services the testing results and a summary of remedial | ||||||
11 | actions as part of parity compliance reporting set forth | ||||||
12 | in subsection (k) of Section 370c.1. | ||||||
13 | (r) This Section applies to all health care services and | ||||||
14 | benefits for the diagnosis, prevention, and treatment of | ||||||
15 | mental, emotional, nervous, or substance use disorders or | ||||||
16 | conditions covered by an insurance policy, including | ||||||
17 | prescription drugs. | ||||||
18 | (s) This Section applies to an insurer that amends, | ||||||
19 | delivers, issues, or renews a group or individual policy of | ||||||
20 | accident and health insurance or a qualified health plan | ||||||
21 | offered through the health insurance marketplace in this State | ||||||
22 | providing coverage for hospital or medical treatment and | ||||||
23 | conducts utilization review as defined in this Section, | ||||||
24 | including Medicaid managed care organizations, and any entity | ||||||
25 | or contracting provider that performs utilization review or | ||||||
26 | utilization management functions on an insurer's behalf. |
| |||||||
| |||||||
1 | (t) If the Director determines that an insurer has | ||||||
2 | violated this Section, the Director may, after appropriate | ||||||
3 | notice and opportunity for hearing, by order, assess a civil | ||||||
4 | penalty between $1,000 and $5,000 for each violation. Moneys | ||||||
5 | collected from penalties shall be deposited into the Parity | ||||||
6 | Advancement Fund established in subsection (i) of Section | ||||||
7 | 370c.1. | ||||||
8 | (u) An insurer shall not adopt, impose, or enforce terms | ||||||
9 | in its policies or provider agreements, in writing or in | ||||||
10 | operation, that undermine, alter, or conflict with the | ||||||
11 | requirements of this Section. | ||||||
12 | (v) The provisions of this Section are severable. If any | ||||||
13 | provision of this Section or its application is held invalid, | ||||||
14 | that invalidity shall not affect other provisions or | ||||||
15 | applications that can be given effect without the invalid | ||||||
16 | provision or application. | ||||||
17 | (w) Beginning January 1, 2026, coverage for inpatient | ||||||
18 | mental health treatment at participating hospitals shall | ||||||
19 | comply with the following requirements: | ||||||
20 | (1) Subject to paragraphs (2) and (3) of this | ||||||
21 | subsection, no policy shall require prior authorization | ||||||
22 | for admission for such treatment at any participating | ||||||
23 | hospital. | ||||||
24 | (2) Coverage provided under this subsection also shall | ||||||
25 | not be subject to concurrent review for the first 72 | ||||||
26 | hours, provided that the hospital must notify the insurer |
| |||||||
| |||||||
1 | of both the admission and the initial treatment plan | ||||||
2 | within 48 hours of admission. A discharge plan must be | ||||||
3 | fully developed and continuity services prepared to meet | ||||||
4 | the patient's needs and the patient's community preference | ||||||
5 | upon release. Nothing in this paragraph supersedes a | ||||||
6 | health maintenance organization's referral requirement for | ||||||
7 | services from nonparticipating providers upon a patient's | ||||||
8 | discharge from a hospital. | ||||||
9 | (3) Treatment provided under this subsection may be | ||||||
10 | reviewed retrospectively. | ||||||
11 | If coverage is denied retrospectively, neither the insurer nor | ||||||
12 | the participating hospital shall bill, and the insured shall | ||||||
13 | not be liable, for any treatment under this subsection through | ||||||
14 | the date the adverse determination is issued, other than any | ||||||
15 | copayment, coinsurance, or deductible for the stay through | ||||||
16 | that date as applicable under the policy. Coverage shall not | ||||||
17 | be retrospectively denied for the first 72 hours of treatment | ||||||
18 | except: | ||||||
19 | (A) upon reasonable determination that the inpatient | ||||||
20 | mental health treatment was not provided; | ||||||
21 | (B) upon determination that the patient receiving the | ||||||
22 | treatment was not an insured, enrollee, or beneficiary | ||||||
23 | under the policy; or | ||||||
24 | (C) upon material misrepresentation by the patient or | ||||||
25 | health care provider. In this item (C), "material" means a | ||||||
26 | fact or situation that is not merely technical in nature |
| |||||||
| |||||||
1 | and results or could result in a substantial change in the | ||||||
2 | situation. | ||||||
3 | (x) Notwithstanding any provision of this Section, nothing | ||||||
4 | shall require the medical assistance program under Article V | ||||||
5 | of the Illinois Public Aid Code to violate any applicable | ||||||
6 | federal laws, regulations, or grant requirements or any State | ||||||
7 | or federal consent decrees. Nothing in subsection (w) shall | ||||||
8 | prevent the Department of Healthcare and Family Services from | ||||||
9 | requiring a health care provider to use specified level of | ||||||
10 | care, admission, continued stay, or discharge criteria, | ||||||
11 | including, but not limited to, those under Section 5-5.23 of | ||||||
12 | the Illinois Public Aid Code, as long as the Department of | ||||||
13 | Healthcare and Family Services does not require a health care | ||||||
14 | provider to seek prior authorization or concurrent review from | ||||||
15 | the Department of Healthcare and Family Services, a Medicaid | ||||||
16 | managed care organization, or a utilization review | ||||||
17 | organization under the circumstances expressly prohibited by | ||||||
18 | subsection (w). | ||||||
19 | (y) Children's Mental Health. Nothing in this Section | ||||||
20 | shall suspend the screening and assessment requirements for | ||||||
21 | mental health services for children participating in the | ||||||
22 | State's medical assistance program as required in Section | ||||||
23 | 5-5.23 of the Illinois Public Aid Code. | ||||||
24 | (Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22; | ||||||
25 | 102-813, eff. 5-13-22; 103-426, eff. 8-4-23.)
|
| |||||||
| |||||||
1 | Section 6-10. The Managed Care Reform and Patient Rights | ||||||
2 | Act is amended by changing Sections 10, 45.1, and 85 and by | ||||||
3 | adding Section 87 as follows:
| ||||||
4 | (215 ILCS 134/10) | ||||||
5 | Sec. 10. Definitions. In this Act: | ||||||
6 | "Adverse determination" means a determination by a health | ||||||
7 | care plan under Section 45 or by a utilization review program | ||||||
8 | under Section 85 that a health care service is not medically | ||||||
9 | necessary. | ||||||
10 | "Clinical peer" means a health care professional who is in | ||||||
11 | the same profession and the same or similar specialty as the | ||||||
12 | health care provider who typically manages the medical | ||||||
13 | condition, procedures, or treatment under review. | ||||||
14 | "Department" means the Department of Insurance. | ||||||
15 | "Emergency medical condition" means a medical condition | ||||||
16 | manifesting itself by acute symptoms of sufficient severity, | ||||||
17 | regardless of the final diagnosis given, such that a prudent | ||||||
18 | layperson, who possesses an average knowledge of health and | ||||||
19 | medicine, could reasonably expect the absence of immediate | ||||||
20 | medical attention to result in: | ||||||
21 | (1) placing the health of the individual (or, with | ||||||
22 | respect to a pregnant woman, the health of the woman or her | ||||||
23 | unborn child) in serious jeopardy; | ||||||
24 | (2) serious impairment to bodily functions; | ||||||
25 | (3) serious dysfunction of any bodily organ or part; |
| |||||||
| |||||||
1 | (4) inadequately controlled pain; or | ||||||
2 | (5) with respect to a pregnant woman who is having | ||||||
3 | contractions: | ||||||
4 | (A) inadequate time to complete a safe transfer to | ||||||
5 | another hospital before delivery; or | ||||||
6 | (B) a transfer to another hospital may pose a | ||||||
7 | threat to the health or safety of the woman or unborn | ||||||
8 | child. | ||||||
9 | "Emergency medical screening examination" means a medical | ||||||
10 | screening examination and evaluation by a physician licensed | ||||||
11 | to practice medicine in all its branches, or to the extent | ||||||
12 | permitted by applicable laws, by other appropriately licensed | ||||||
13 | personnel under the supervision of or in collaboration with a | ||||||
14 | physician licensed to practice medicine in all its branches to | ||||||
15 | determine whether the need for emergency services exists. | ||||||
16 | "Emergency services" means, with respect to an enrollee of | ||||||
17 | a health care plan, transportation services, including but not | ||||||
18 | limited to ambulance services, and covered inpatient and | ||||||
19 | outpatient hospital services furnished by a provider qualified | ||||||
20 | to furnish those services that are needed to evaluate or | ||||||
21 | stabilize an emergency medical condition. "Emergency services" | ||||||
22 | does not refer to post-stabilization medical services. | ||||||
23 | "Enrollee" means any person and his or her dependents | ||||||
24 | enrolled in or covered by a health care plan. | ||||||
25 | "Generally accepted standards of care" means standards of | ||||||
26 | care and clinical practice that are generally recognized by |
| |||||||
| |||||||
1 | health care providers practicing in relevant clinical | ||||||
2 | specialties for the illness, injury, or condition or its | ||||||
3 | symptoms and comorbidities. Valid, evidence-based sources | ||||||
4 | reflecting generally accepted standards of care include | ||||||
5 | peer-reviewed scientific studies and medical literature, | ||||||
6 | recommendations of nonprofit health care provider professional | ||||||
7 | associations and specialty societies, including, but not | ||||||
8 | limited to, patient placement criteria and clinical practice | ||||||
9 | guidelines, recommendations of federal government agencies, | ||||||
10 | and drug labeling approved by the United States Food and Drug | ||||||
11 | Administration. | ||||||
12 | "Health care plan" means a plan, including, but not | ||||||
13 | limited to, a health maintenance organization, a managed care | ||||||
14 | community network as defined in the Illinois Public Aid Code, | ||||||
15 | or an accountable care entity as defined in the Illinois | ||||||
16 | Public Aid Code that receives capitated payments to cover | ||||||
17 | medical services from the Department of Healthcare and Family | ||||||
18 | Services, that establishes, operates, or maintains a network | ||||||
19 | of health care providers that has entered into an agreement | ||||||
20 | with the plan to provide health care services to enrollees to | ||||||
21 | whom the plan has the ultimate obligation to arrange for the | ||||||
22 | provision of or payment for services through organizational | ||||||
23 | arrangements for ongoing quality assurance, utilization review | ||||||
24 | programs, or dispute resolution. Nothing in this definition | ||||||
25 | shall be construed to mean that an independent practice | ||||||
26 | association or a physician hospital organization that |
| |||||||
| |||||||
1 | subcontracts with a health care plan is, for purposes of that | ||||||
2 | subcontract, a health care plan. | ||||||
3 | For purposes of this definition, "health care plan" shall | ||||||
4 | not include the following: | ||||||
5 | (1) indemnity health insurance policies including | ||||||
6 | those using a contracted provider network; | ||||||
7 | (2) health care plans that offer only dental or only | ||||||
8 | vision coverage; | ||||||
9 | (3) preferred provider administrators, as defined in | ||||||
10 | Section 370g(g) of the Illinois Insurance Code; | ||||||
11 | (4) employee or employer self-insured health benefit | ||||||
12 | plans under the federal Employee Retirement Income | ||||||
13 | Security Act of 1974; | ||||||
14 | (5) health care provided pursuant to the Workers' | ||||||
15 | Compensation Act or the Workers' Occupational Diseases | ||||||
16 | Act; and | ||||||
17 | (6) except with respect to subsections (a) and (b) of | ||||||
18 | Section 65 and subsection (a-5) of Section 70, | ||||||
19 | not-for-profit voluntary health services plans with health | ||||||
20 | maintenance organization authority in existence as of | ||||||
21 | January 1, 1999 that are affiliated with a union and that | ||||||
22 | only extend coverage to union members and their | ||||||
23 | dependents. | ||||||
24 | "Health care professional" means a physician, a registered | ||||||
25 | professional nurse, or other individual appropriately licensed | ||||||
26 | or registered to provide health care services. |
| |||||||
| |||||||
1 | "Health care provider" means any physician, hospital | ||||||
2 | facility, facility licensed under the Nursing Home Care Act, | ||||||
3 | long-term care facility as defined in Section 1-113 of the | ||||||
4 | Nursing Home Care Act, or other person that is licensed or | ||||||
5 | otherwise authorized to deliver health care services. Nothing | ||||||
6 | in this Act shall be construed to define Independent Practice | ||||||
7 | Associations or Physician-Hospital Organizations as health | ||||||
8 | care providers. | ||||||
9 | "Health care services" means any services included in the | ||||||
10 | furnishing to any individual of medical care, or the | ||||||
11 | hospitalization incident to the furnishing of such care, as | ||||||
12 | well as the furnishing to any person of any and all other | ||||||
13 | services for the purpose of preventing, alleviating, curing, | ||||||
14 | or healing human illness or injury including behavioral | ||||||
15 | health, mental health, home health, and pharmaceutical | ||||||
16 | services and products. | ||||||
17 | "Medical director" means a physician licensed in any state | ||||||
18 | to practice medicine in all its branches appointed by a health | ||||||
19 | care plan. | ||||||
20 | "Medically necessary" means that a service or product | ||||||
21 | addresses the specific needs of a patient for the purpose of | ||||||
22 | screening, preventing, diagnosing, managing, or treating an | ||||||
23 | illness, injury, or condition or its symptoms and | ||||||
24 | comorbidities, including minimizing the progression of an | ||||||
25 | illness, injury, or condition or its symptoms and | ||||||
26 | comorbidities, in a manner that is all of the following: |
| |||||||
| |||||||
1 | (1) in accordance with generally accepted standards of | ||||||
2 | care; | ||||||
3 | (2) clinically appropriate in terms of type, | ||||||
4 | frequency, extent, site, and duration; and | ||||||
5 | (3) not primarily for the economic benefit of the | ||||||
6 | health care plan, purchaser, or utilization review | ||||||
7 | organization, or for the convenience of the patient, | ||||||
8 | treating physician, or other health care provider. | ||||||
9 | "Person" means a corporation, association, partnership, | ||||||
10 | limited liability company, sole proprietorship, or any other | ||||||
11 | legal entity. | ||||||
12 | "Physician" means a person licensed under the Medical | ||||||
13 | Practice Act of 1987. | ||||||
14 | "Post-stabilization medical services" means health care | ||||||
15 | services provided to an enrollee that are furnished in a | ||||||
16 | licensed hospital by a provider that is qualified to furnish | ||||||
17 | such services, and determined to be medically necessary and | ||||||
18 | directly related to the emergency medical condition following | ||||||
19 | stabilization. | ||||||
20 | "Stabilization" means, with respect to an emergency | ||||||
21 | medical condition, to provide such medical treatment of the | ||||||
22 | condition as may be necessary to assure, within reasonable | ||||||
23 | medical probability, that no material deterioration of the | ||||||
24 | condition is likely to result. | ||||||
25 | "Step therapy requirement" means a fail-first utilization | ||||||
26 | review or formulary requirement that specifies, as a condition |
| |||||||
| |||||||
1 | of coverage under a health care plan, the order in which | ||||||
2 | certain health care services must be used to treat or manage an | ||||||
3 | enrollee's health condition. | ||||||
4 | "Step therapy requirement" does not include: | ||||||
5 | (i) the use of utilization review to identify when a | ||||||
6 | treatment is contraindicated or to limit quantity or | ||||||
7 | dosage for an enrollee based on utilization review | ||||||
8 | criteria consistent with generally accepted standards of | ||||||
9 | care; | ||||||
10 | (ii) the removal of a drug from a formulary or | ||||||
11 | negatively changing a formulary drug's preferred or | ||||||
12 | cost-sharing tier; | ||||||
13 | (iii) the fact that an enrollee or the enrollee's | ||||||
14 | authorized representative must use the medical exceptions | ||||||
15 | process under Section 45.1 of this Act to obtain coverage | ||||||
16 | for a drug that is not concurrently listed on the | ||||||
17 | formulary for the enrollee's health care plan. However, if | ||||||
18 | a health care plan or utilization review program's medical | ||||||
19 | exceptions process requires an enrollee to fail first on a | ||||||
20 | formulary drug before approving coverage for an | ||||||
21 | off-formulary drug, that requirement is a step therapy | ||||||
22 | requirement; | ||||||
23 | (iv) a requirement that an enrollee or the enrollee's | ||||||
24 | authorized representative obtain prior authorization for | ||||||
25 | the requested treatment, unless the utilization review | ||||||
26 | criteria to authorize coverage for a requested treatment |
| |||||||
| |||||||
1 | condition authorization on the enrollee failing first with | ||||||
2 | another treatment; | ||||||
3 | (v) for health care plans operated or overseen by the | ||||||
4 | Department of Healthcare and Family Services, including | ||||||
5 | Medicaid managed care plans, any utilization controls | ||||||
6 | mandated by 42 CFR 456.703; or | ||||||
7 | (vi) the creation and maintenance by the Department of | ||||||
8 | Healthcare and Family Services of a Preferred Drug List, | ||||||
9 | and any requirement that Medicaid managed care | ||||||
10 | organizations comply with the Preferred Drug List | ||||||
11 | utilization control process, as described in Section | ||||||
12 | 5-30.14 of the Illinois Public Aid Code. | ||||||
13 | "Utilization review" means the evaluation of the medical | ||||||
14 | necessity, appropriateness, and efficiency of the use of | ||||||
15 | health care services, procedures, and facilities . | ||||||
16 | "Utilization review" includes either of the following: | ||||||
17 | (1) prospectively, retrospectively, or concurrently | ||||||
18 | reviewing and approving, modifying, delaying, or denying, | ||||||
19 | based, in whole or in part, on medical necessity, requests | ||||||
20 | by health care providers, enrollees, or their authorized | ||||||
21 | representatives for coverage of health care services | ||||||
22 | before, retrospectively, or concurrently with the | ||||||
23 | provision of health care services to enrollees; or | ||||||
24 | (2) evaluating the medical necessity, appropriateness, | ||||||
25 | level of care, service intensity, efficacy, or efficiency | ||||||
26 | of health care services, benefits, procedures, or |
| |||||||
| |||||||
1 | settings, under any circumstances, to determine whether a | ||||||
2 | health care service or benefit subject to a medical | ||||||
3 | necessity coverage requirement in a health care plan is | ||||||
4 | covered as medically necessary for an enrollee. | ||||||
5 | "Utilization review criteria" means criteria, standards, | ||||||
6 | protocols, or guidelines used by a utilization review program | ||||||
7 | to conduct utilization review to ensure that a patient's care | ||||||
8 | is aligned with generally accepted standards of care and | ||||||
9 | consistent with State law . | ||||||
10 | "Utilization review program" means a program established | ||||||
11 | by a person to perform utilization review. | ||||||
12 | (Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
| ||||||
13 | (215 ILCS 134/45.1) | ||||||
14 | Sec. 45.1. Medical exceptions procedures required. | ||||||
15 | (a) Notwithstanding any other provision of law, on or | ||||||
16 | after January 1, 2018 (the effective date of Public Act | ||||||
17 | 99-761), every insurer licensed in this State to sell a policy | ||||||
18 | of group or individual accident and health insurance or a | ||||||
19 | health benefits plan shall establish and maintain a medical | ||||||
20 | exceptions process that allows covered persons or their | ||||||
21 | authorized representatives to request any clinically | ||||||
22 | appropriate prescription drug when (1) the drug is not covered | ||||||
23 | based on the health benefit plan's formulary; (2) the health | ||||||
24 | benefit plan is discontinuing coverage of the drug on the | ||||||
25 | plan's formulary for reasons other than safety or other than |
| |||||||
| |||||||
1 | because the prescription drug has been withdrawn from the | ||||||
2 | market by the drug's manufacturer; (3) (blank) the | ||||||
3 | prescription drug alternatives required to be used in | ||||||
4 | accordance with a step therapy requirement (A) has been | ||||||
5 | ineffective in the treatment of the enrollee's disease or | ||||||
6 | medical condition or, based on both sound clinical evidence | ||||||
7 | and medical and scientific evidence, the known relevant | ||||||
8 | physical or mental characteristics of the enrollee, and the | ||||||
9 | known characteristics of the drug regimen, is likely to be | ||||||
10 | ineffective or adversely affect the drug's effectiveness or | ||||||
11 | patient compliance or (B) has caused or, based on sound | ||||||
12 | medical evidence, is likely to cause an adverse reaction or | ||||||
13 | harm to the enrollee ; or (4) the number of doses available | ||||||
14 | under a dose restriction for the prescription drug (A) has | ||||||
15 | been ineffective in the treatment of the enrollee's disease or | ||||||
16 | medical condition or (B) based on both sound clinical evidence | ||||||
17 | and medical and scientific evidence, the known relevant | ||||||
18 | physical and mental characteristics of the enrollee, and known | ||||||
19 | characteristics of the drug regimen, is likely to be | ||||||
20 | ineffective or adversely affect the drug's effective or | ||||||
21 | patient compliance. | ||||||
22 | (b) The health carrier's established medical exceptions | ||||||
23 | procedures must require, at a minimum, the following: | ||||||
24 | (1) Any request for approval of coverage made verbally | ||||||
25 | or in writing (regardless of whether made using a paper or | ||||||
26 | electronic form or some other writing) at any time shall |
| |||||||
| |||||||
1 | be reviewed by appropriate health care professionals. | ||||||
2 | (2) The health carrier must, within 72 hours after | ||||||
3 | receipt of a request made under subsection (a) of this | ||||||
4 | Section, either approve or deny the request. In the case | ||||||
5 | of a denial, the health carrier shall provide the covered | ||||||
6 | person or the covered person's authorized representative | ||||||
7 | and the covered person's prescribing provider with the | ||||||
8 | reason for the denial, an alternative covered medication, | ||||||
9 | if applicable, and information regarding the procedure for | ||||||
10 | submitting an appeal to the denial. A health carrier shall | ||||||
11 | not use the authorization of alternative covered | ||||||
12 | medications under this Section in a manner that | ||||||
13 | effectively creates a step therapy requirement. | ||||||
14 | (3) In the case of an expedited coverage | ||||||
15 | determination, the health carrier must either approve or | ||||||
16 | deny the request within 24 hours after receipt of the | ||||||
17 | request. In the case of a denial, the health carrier shall | ||||||
18 | provide the covered person or the covered person's | ||||||
19 | authorized representative and the covered person's | ||||||
20 | prescribing provider with the reason for the denial, an | ||||||
21 | alternative covered medication, if applicable, and | ||||||
22 | information regarding the procedure for submitting an | ||||||
23 | appeal to the denial. | ||||||
24 | (c) (Blank). A step therapy requirement exception request | ||||||
25 | shall be approved if: | ||||||
26 | (1) the required prescription drug is contraindicated; |
| |||||||
| |||||||
1 | (2) the patient has tried the required prescription | ||||||
2 | drug while under the patient's current or previous health | ||||||
3 | insurance or health benefit plan and the prescribing | ||||||
4 | provider submits evidence of failure or intolerance; or | ||||||
5 | (3) the patient is stable on a prescription drug | ||||||
6 | selected by his or her health care provider for the | ||||||
7 | medical condition under consideration while on a current | ||||||
8 | or previous health insurance or health benefit plan. | ||||||
9 | (d) Upon the granting of an exception request, the | ||||||
10 | insurer, health plan, utilization review organization, or | ||||||
11 | other entity shall authorize the coverage for the drug | ||||||
12 | prescribed by the enrollee's treating health care provider, to | ||||||
13 | the extent the prescribed drug is a covered drug under the | ||||||
14 | policy or contract up to the quantity covered. | ||||||
15 | (e) Any approval of a medical exception request made | ||||||
16 | pursuant to this Section shall be honored for 12 months | ||||||
17 | following the date of the approval or until renewal of the | ||||||
18 | plan. | ||||||
19 | (f) Notwithstanding any other provision of this Section, | ||||||
20 | nothing in this Section shall be interpreted or implemented in | ||||||
21 | a manner not consistent with the federal Patient Protection | ||||||
22 | and Affordable Care Act (Public Law 111-148), as amended by | ||||||
23 | the federal Health Care and Education Reconciliation Act of | ||||||
24 | 2010 (Public Law 111-152), and any amendments thereto, or | ||||||
25 | regulations or guidance issued under those Acts. | ||||||
26 | (g) Nothing in this Section shall require or authorize the |
| |||||||
| |||||||
1 | State agency responsible for the administration of the medical | ||||||
2 | assistance program established under the Illinois Public Aid | ||||||
3 | Code to approve, supply, or cover prescription drugs pursuant | ||||||
4 | to the procedure established in this Section. | ||||||
5 | (Source: P.A. 103-154, eff. 6-30-23.)
| ||||||
6 | (215 ILCS 134/85) | ||||||
7 | Sec. 85. Utilization review program registration. | ||||||
8 | (a) No person may conduct a utilization review program in | ||||||
9 | this State unless once every 2 years the person registers the | ||||||
10 | utilization review program with the Department and certifies | ||||||
11 | compliance with the Health Utilization Management Standards of | ||||||
12 | the American Accreditation Healthcare Commission (URAC) | ||||||
13 | sufficient to achieve American Accreditation Healthcare | ||||||
14 | Commission (URAC) accreditation or submits evidence of | ||||||
15 | accreditation by the American Accreditation Healthcare | ||||||
16 | Commission (URAC) for its Health Utilization Management | ||||||
17 | Standards. Nothing in this Act shall be construed to require a | ||||||
18 | health care plan or its subcontractors to become American | ||||||
19 | Accreditation Healthcare Commission (URAC) accredited. | ||||||
20 | (b) In addition, the Director of the Department, in | ||||||
21 | consultation with the Director of the Department of Public | ||||||
22 | Health, may certify alternative utilization review standards | ||||||
23 | of national accreditation organizations or entities in order | ||||||
24 | for plans to comply with this Section. Any alternative | ||||||
25 | utilization review standards shall meet or exceed those |
| |||||||
| |||||||
1 | standards required under subsection (a). | ||||||
2 | (b-5) The Department shall recognize the Accreditation | ||||||
3 | Association for Ambulatory Health Care among the list of | ||||||
4 | accreditors from which utilization organizations may receive | ||||||
5 | accreditation and qualify for reduced registration and renewal | ||||||
6 | fees. | ||||||
7 | (c) The provisions of this Section do not apply to: | ||||||
8 | (1) persons providing utilization review program | ||||||
9 | services only to the federal government; | ||||||
10 | (2) self-insured health plans under the federal | ||||||
11 | Employee Retirement Income Security Act of 1974, however, | ||||||
12 | this Section does apply to persons conducting a | ||||||
13 | utilization review program on behalf of these health | ||||||
14 | plans; | ||||||
15 | (3) hospitals and medical groups performing | ||||||
16 | utilization review activities for internal purposes unless | ||||||
17 | the utilization review program is conducted for another | ||||||
18 | person. | ||||||
19 | Nothing in this Act prohibits a health care plan or other | ||||||
20 | entity from contractually requiring an entity designated in | ||||||
21 | item (3) of this subsection to adhere to the utilization | ||||||
22 | review program requirements of this Act. | ||||||
23 | (d) This registration shall include submission of all of | ||||||
24 | the following information regarding utilization review program | ||||||
25 | activities: | ||||||
26 | (1) The name, address, and telephone number of the |
| |||||||
| |||||||
1 | utilization review programs. | ||||||
2 | (2) The organization and governing structure of the | ||||||
3 | utilization review programs. | ||||||
4 | (3) The number of lives for which utilization review | ||||||
5 | is conducted by each utilization review program. | ||||||
6 | (4) Hours of operation of each utilization review | ||||||
7 | program. | ||||||
8 | (5) Description of the grievance process for each | ||||||
9 | utilization review program. | ||||||
10 | (6) Number of covered lives for which utilization | ||||||
11 | review was conducted for the previous calendar year for | ||||||
12 | each utilization review program. | ||||||
13 | (7) Written policies and procedures for protecting | ||||||
14 | confidential information according to applicable State and | ||||||
15 | federal laws for each utilization review program. | ||||||
16 | (e) (1) A utilization review program shall have written | ||||||
17 | procedures for assuring that patient-specific information | ||||||
18 | obtained during the process of utilization review will be: | ||||||
19 | (A) kept confidential in accordance with applicable | ||||||
20 | State and federal laws; and | ||||||
21 | (B) shared only with the enrollee, the enrollee's | ||||||
22 | designee, the enrollee's health care provider, and those | ||||||
23 | who are authorized by law to receive the information. | ||||||
24 | Summary data shall not be considered confidential if it | ||||||
25 | does not provide information to allow identification of | ||||||
26 | individual patients or health care providers. |
| |||||||
| |||||||
1 | (2) Only a health care professional may make | ||||||
2 | determinations regarding the medical necessity of health | ||||||
3 | care services during the course of utilization review. | ||||||
4 | Only a clinical peer may make an adverse determination. | ||||||
5 | (3) When making retrospective reviews, utilization | ||||||
6 | review programs shall base reviews solely on the medical | ||||||
7 | information available to the attending physician or | ||||||
8 | ordering provider at the time the health care services | ||||||
9 | were provided. | ||||||
10 | (4) When making prospective, concurrent, and | ||||||
11 | retrospective determinations, utilization review programs | ||||||
12 | shall collect only information that is necessary to make | ||||||
13 | the determination and shall not routinely require health | ||||||
14 | care providers to numerically code diagnoses or procedures | ||||||
15 | to be considered for certification, unless required under | ||||||
16 | State or federal Medicare or Medicaid rules or | ||||||
17 | regulations, but may request such code if available, or | ||||||
18 | routinely request copies of medical records of all | ||||||
19 | enrollees reviewed. During prospective or concurrent | ||||||
20 | review, copies of medical records shall only be required | ||||||
21 | when necessary to verify that the health care services | ||||||
22 | subject to review are medically necessary. In these cases, | ||||||
23 | only the necessary or relevant sections of the medical | ||||||
24 | record shall be required. | ||||||
25 | (f) If the Department finds that a utilization review | ||||||
26 | program is not in compliance with this Section, the Department |
| |||||||
| |||||||
1 | shall issue a corrective action plan and allow a reasonable | ||||||
2 | amount of time for compliance with the plan. If the | ||||||
3 | utilization review program does not come into compliance, the | ||||||
4 | Department may issue a cease and desist order. Before issuing | ||||||
5 | a cease and desist order under this Section, the Department | ||||||
6 | shall provide the utilization review program with a written | ||||||
7 | notice of the reasons for the order and allow a reasonable | ||||||
8 | amount of time to supply additional information demonstrating | ||||||
9 | compliance with requirements of this Section and to request a | ||||||
10 | hearing. The hearing notice shall be sent by certified mail, | ||||||
11 | return receipt requested, and the hearing shall be conducted | ||||||
12 | in accordance with the Illinois Administrative Procedure Act. | ||||||
13 | (g) A utilization review program subject to a corrective | ||||||
14 | action may continue to conduct business until a final decision | ||||||
15 | has been issued by the Department. | ||||||
16 | (h) Any adverse determination made by a health care plan | ||||||
17 | or its subcontractors may be appealed in accordance with | ||||||
18 | subsection (f) of Section 45. | ||||||
19 | (i) The Director may by rule establish a registration fee | ||||||
20 | for each person conducting a utilization review program. All | ||||||
21 | fees paid to and collected by the Director under this Section | ||||||
22 | shall be deposited into the Insurance Producer Administration | ||||||
23 | Fund. | ||||||
24 | (Source: P.A. 99-111, eff. 1-1-16 .)
| ||||||
25 | (215 ILCS 134/87 new) |
| |||||||
| |||||||
1 | Sec. 87. General standards for use of utilization review | ||||||
2 | criteria. | ||||||
3 | (a) Except as provided in subsections (g) and (h), | ||||||
4 | beginning January 1, 2026, all medical necessity | ||||||
5 | determinations made by a utilization review program shall be | ||||||
6 | conducted in accordance with the requirements of this Section. | ||||||
7 | No policy, contract, certificate, or evidence of coverage | ||||||
8 | issued to any enrollee, nor any formulary, may contain terms | ||||||
9 | or conditions to the contrary. | ||||||
10 | (b) A utilization review program shall base any medical | ||||||
11 | necessity determination or the utilization review criteria | ||||||
12 | that the program applies to determine the medical necessity of | ||||||
13 | health care services and benefits on current generally | ||||||
14 | accepted standards of care. | ||||||
15 | (c) Subject to subsection (i), a utilization review | ||||||
16 | program shall apply the most recent version of the treatment | ||||||
17 | criteria developed by: | ||||||
18 | (1) an unaffiliated nonprofit professional association | ||||||
19 | for the relevant clinical specialty; | ||||||
20 | (2) nationally recognized, evidence-based treatment | ||||||
21 | criteria reflecting current generally accepted standards | ||||||
22 | of care when: | ||||||
23 | (A) such national criteria are developed and | ||||||
24 | updated annually by a third-party entity that does not | ||||||
25 | receive direct payments based on the outcome of the | ||||||
26 | clinical care decisions; |
| |||||||
| |||||||
1 | (B) such national criteria account for the most | ||||||
2 | recent treatment criteria described in paragraph (1) | ||||||
3 | of this subsection (c), peer-reviewed medical and | ||||||
4 | scientific literature, federal governmental agency | ||||||
5 | recommendations, and drug labeling approved by the | ||||||
6 | United States Food and Drug Administration; and | ||||||
7 | (C) for utilization review programs with respect | ||||||
8 | to health care plans subject to this Act, neither the | ||||||
9 | developing entity nor the utilization review program | ||||||
10 | customizes or adapts such national criteria, and the | ||||||
11 | developing entity does not offer the utilization | ||||||
12 | review program a choice the among more than one | ||||||
13 | distinct set of criteria for the same health care | ||||||
14 | service, except to the extent necessary for all | ||||||
15 | utilization review programs subject to this Section to | ||||||
16 | comply with State or federal requirements applicable | ||||||
17 | to each health care plan that they offer or administer | ||||||
18 | as provided in subsection (i); or | ||||||
19 | (3) for health care plans operated or overseen by the | ||||||
20 | Department of Healthcare and Family Services, including | ||||||
21 | Medicaid managed care plans, when neither of the preceding | ||||||
22 | types of sources offers treatment criteria for a covered | ||||||
23 | item or service, treatment criteria determined by the | ||||||
24 | Department of Healthcare and Family Services that are not | ||||||
25 | inconsistent with generally accepted standards of care. | ||||||
26 | (d) For medical necessity determinations that are within |
| |||||||
| |||||||
1 | the scope of the sources specified in subsection (c), a | ||||||
2 | utilization review program shall not apply different, | ||||||
3 | additional, conflicting, or more restrictive utilization | ||||||
4 | review criteria than the criteria set forth in those sources. | ||||||
5 | For all level of care placement decisions, the utilization | ||||||
6 | review program or health care plan shall authorize placement | ||||||
7 | at the level of care consistent with the assessment of the | ||||||
8 | enrollee using the relevant patient placement criteria as | ||||||
9 | specified in subsection (c). If that level of placement is not | ||||||
10 | available, the utilization review program or health care plan | ||||||
11 | shall authorize the next highest level of care. In the event of | ||||||
12 | disagreement, the utilization review program shall provide | ||||||
13 | full detail of its assessment using the relevant criteria as | ||||||
14 | specified in subsection (c) to the provider of the service and | ||||||
15 | the patient. | ||||||
16 | (e) In conducting utilization review that is outside the | ||||||
17 | scope of the criteria specified in subsection (c) or that | ||||||
18 | relates to the advancements in technology or in the types or | ||||||
19 | levels of care that are not addressed in the most recent | ||||||
20 | versions of the sources specified in subsection (c), a | ||||||
21 | utilization review program shall conduct utilization review in | ||||||
22 | accordance with subsection (b). If a utilization review | ||||||
23 | program purchases or licenses utilization review criteria | ||||||
24 | pursuant to this subsection, the utilization review program | ||||||
25 | shall verify and document before use that the criteria were | ||||||
26 | developed in accordance with subsection (b). |
| |||||||
| |||||||
1 | (f) To ensure the proper use of utilization review | ||||||
2 | criteria that were not developed under or that diverge from | ||||||
3 | those developed under subsection (c), every health care plan | ||||||
4 | shall do all of the following: | ||||||
5 | (1) Make an educational program available to the | ||||||
6 | health care plan's staff, as well as the staff of any other | ||||||
7 | utilization review program contracted to review claims, | ||||||
8 | conduct utilization reviews, or make medical necessity | ||||||
9 | determinations about the utilization review criteria. | ||||||
10 | (2) Make the educational program available, at no | ||||||
11 | cost, to other stakeholders, including the health care | ||||||
12 | plan's participating or contracted providers and potential | ||||||
13 | enrollees. The education program must be provided at least | ||||||
14 | once a year, in person or digitally, or recordings of the | ||||||
15 | education program must be made available to those | ||||||
16 | stakeholders. | ||||||
17 | (3) Provide, at no cost, the utilization review | ||||||
18 | criteria and any training material or resources to | ||||||
19 | providers and enrollees upon request. The health care plan | ||||||
20 | may place the criteria on a secure, password-protected | ||||||
21 | website so long as the access requirements of the website | ||||||
22 | do not unreasonably restrict access to enrollees or their | ||||||
23 | providers. No restrictions shall be placed upon the | ||||||
24 | enrollee's or treating provider's access right to | ||||||
25 | utilization review criteria obtained under this paragraph | ||||||
26 | at any point in time, including before an initial request |
| |||||||
| |||||||
1 | for authorization. | ||||||
2 | (4) Track, identify, and analyze how the utilization | ||||||
3 | review criteria are used to certify care, deny care, and | ||||||
4 | support the appeals process. | ||||||
5 | (5) Conduct interrater reliability testing to ensure | ||||||
6 | consistency in utilization review decision-making that | ||||||
7 | covers how medical necessity decisions are made. This | ||||||
8 | assessment shall cover all aspects of utilization review | ||||||
9 | as defined in Section 10. | ||||||
10 | (6) Run interrater reliability reports about how the | ||||||
11 | clinical guidelines are used in conjunction with the | ||||||
12 | utilization review process and parity compliance | ||||||
13 | activities. | ||||||
14 | (7) Achieve interrater reliability pass rates of at | ||||||
15 | least 90% and, if this threshold is not met, immediately | ||||||
16 | provide for the remediation of poor interrater reliability | ||||||
17 | and interrater reliability testing for all new staff | ||||||
18 | before they can conduct utilization review without | ||||||
19 | supervision. | ||||||
20 | (8) Maintain documentation of interrater reliability | ||||||
21 | testing and the remediation actions taken for those with | ||||||
22 | pass rates lower than 90% and submit to the Department of | ||||||
23 | Insurance or, in the case of Medicaid managed care | ||||||
24 | organizations, the Department of Healthcare and Family | ||||||
25 | Services the testing results and a summary of remedial | ||||||
26 | actions. |
| |||||||
| |||||||
1 | (g) Beginning January 1, 2025, except for Medicaid managed | ||||||
2 | care plans under contract with the Department of Healthcare | ||||||
3 | and Family Services, no utilization review program or any | ||||||
4 | policy, contract, certificate, evidence of coverage, or | ||||||
5 | formulary shall impose step therapy requirements for any | ||||||
6 | health care service, including prescription drugs. Nothing in | ||||||
7 | this subsection prohibits a health care plan, by contract, | ||||||
8 | written policy or procedure, or any other agreement or course | ||||||
9 | of conduct, from requiring a pharmacist to effect | ||||||
10 | substitutions of prescription drugs consistent with Section | ||||||
11 | 19.5 of the Pharmacy Practice Act, under which a pharmacist | ||||||
12 | may substitute an interchangeable biologic for a prescribed | ||||||
13 | biologic product, and Section 25 of the Pharmacy Practice Act, | ||||||
14 | under which a pharmacist may select a generic drug determined | ||||||
15 | to be therapeutically equivalent by the United States Food and | ||||||
16 | Drug Administration and in accordance with the Illinois Food, | ||||||
17 | Drug and Cosmetic Act. For health care plans operated or | ||||||
18 | overseen by the Department of Healthcare and Family Services, | ||||||
19 | including Medicaid managed care plans, the prohibition in this | ||||||
20 | subsection does not apply to step therapy requirements for | ||||||
21 | drugs that do not appear on the most recent Preferred Drug List | ||||||
22 | published by the Department of Healthcare and Family Services. | ||||||
23 | (h) Except for subsection (g), this Section does not apply | ||||||
24 | to medical necessity determinations concerning service | ||||||
25 | intensity, level of care placement, continued stay, or | ||||||
26 | transfer or discharge of enrollees diagnosed with mental, |
| |||||||
| |||||||
1 | emotional, nervous, or substance use disorders or conditions, | ||||||
2 | which shall be governed by Section 370c of the Illinois | ||||||
3 | Insurance Code. | ||||||
4 | (i) Nothing in this Section shall be construed to | ||||||
5 | supersede or waive requirements provided under any other State | ||||||
6 | or federal law or federal regulation that any coverage subject | ||||||
7 | to this Section comply with specific utilization review | ||||||
8 | criteria for a specific illness, level of care placement, | ||||||
9 | injury, or condition or its symptoms and comorbidities.
| ||||||
10 | Section 6-15. The Health Carrier External Review Act is | ||||||
11 | amended by changing Sections 10 as follows:
| ||||||
12 | (215 ILCS 180/10) | ||||||
13 | Sec. 10. Definitions. For the purposes of this Act: | ||||||
14 | "Adverse determination" means: | ||||||
15 | (1) a determination by a health carrier or its | ||||||
16 | designee utilization review organization that, based upon | ||||||
17 | the information provided, a request for a benefit under | ||||||
18 | the health carrier's health benefit plan upon application | ||||||
19 | of any utilization review technique does not meet the | ||||||
20 | health carrier's requirements for medical necessity, | ||||||
21 | appropriateness, health care setting, level of care, or | ||||||
22 | effectiveness or is determined to be experimental or | ||||||
23 | investigational and the requested benefit is therefore | ||||||
24 | denied, reduced, or terminated or payment is not provided |
| |||||||
| |||||||
1 | or made, in whole or in part, for the benefit; | ||||||
2 | (2) the denial, reduction, or termination of or | ||||||
3 | failure to provide or make payment, in whole or in part, | ||||||
4 | for a benefit based on a determination by a health carrier | ||||||
5 | or its designee utilization review organization that a | ||||||
6 | preexisting condition was present before the effective | ||||||
7 | date of coverage; or | ||||||
8 | (3) a rescission of coverage determination, which does | ||||||
9 | not include a cancellation or discontinuance of coverage | ||||||
10 | that is attributable to a failure to timely pay required | ||||||
11 | premiums or contributions towards the cost of coverage. | ||||||
12 | "Authorized representative" means: | ||||||
13 | (1) a person to whom a covered person has given | ||||||
14 | express written consent to represent the covered person | ||||||
15 | for purposes of this Law; | ||||||
16 | (2) a person authorized by law to provide substituted | ||||||
17 | consent for a covered person; | ||||||
18 | (3) a family member of the covered person or the | ||||||
19 | covered person's treating health care professional when | ||||||
20 | the covered person is unable to provide consent; | ||||||
21 | (4) a health care provider when the covered person's | ||||||
22 | health benefit plan requires that a request for a benefit | ||||||
23 | under the plan be initiated by the health care provider; | ||||||
24 | or | ||||||
25 | (5) in the case of an urgent care request, a health | ||||||
26 | care provider with knowledge of the covered person's |
| |||||||
| |||||||
1 | medical condition. | ||||||
2 | "Best evidence" means evidence based on: | ||||||
3 | (1) randomized clinical trials; | ||||||
4 | (2) if randomized clinical trials are not available, | ||||||
5 | then cohort studies or case-control studies; | ||||||
6 | (3) if items (1) and (2) are not available, then | ||||||
7 | case-series; or | ||||||
8 | (4) if items (1), (2), and (3) are not available, then | ||||||
9 | expert opinion. | ||||||
10 | "Case-series" means an evaluation of a series of patients | ||||||
11 | with a particular outcome, without the use of a control group. | ||||||
12 | "Clinical review criteria" means the written screening | ||||||
13 | procedures, decision abstracts, clinical protocols, and | ||||||
14 | practice guidelines used by a health carrier to determine the | ||||||
15 | necessity and appropriateness of health care services. | ||||||
16 | "Clinical review criteria" includes all utilization review | ||||||
17 | criteria as defined in Section 10 of the Managed Care Reform | ||||||
18 | and Patient Rights Act. | ||||||
19 | "Cohort study" means a prospective evaluation of 2 groups | ||||||
20 | of patients with only one group of patients receiving specific | ||||||
21 | intervention. | ||||||
22 | "Concurrent review" means a review conducted during a | ||||||
23 | patient's stay or course of treatment in a facility, the | ||||||
24 | office of a health care professional, or other inpatient or | ||||||
25 | outpatient health care setting. | ||||||
26 | "Covered benefits" or "benefits" means those health care |
| |||||||
| |||||||
1 | services to which a covered person is entitled under the terms | ||||||
2 | of a health benefit plan. | ||||||
3 | "Covered person" means a policyholder, subscriber, | ||||||
4 | enrollee, or other individual participating in a health | ||||||
5 | benefit plan. | ||||||
6 | "Director" means the Director of the Department of | ||||||
7 | Insurance. | ||||||
8 | "Emergency medical condition" means a medical condition | ||||||
9 | manifesting itself by acute symptoms of sufficient severity, | ||||||
10 | including, but not limited to, severe pain, such that a | ||||||
11 | prudent layperson who possesses an average knowledge of health | ||||||
12 | and medicine could reasonably expect the absence of immediate | ||||||
13 | medical attention to result in: | ||||||
14 | (1) placing the health of the individual or, with | ||||||
15 | respect to a pregnant woman, the health of the woman or her | ||||||
16 | unborn child, in serious jeopardy; | ||||||
17 | (2) serious impairment to bodily functions; or | ||||||
18 | (3) serious dysfunction of any bodily organ or part. | ||||||
19 | "Emergency services" means health care items and services | ||||||
20 | furnished or required to evaluate and treat an emergency | ||||||
21 | medical condition. | ||||||
22 | "Evidence-based standard" means the conscientious, | ||||||
23 | explicit, and judicious use of the current best evidence based | ||||||
24 | on an overall systematic review of the research in making | ||||||
25 | decisions about the care of individual patients. | ||||||
26 | "Expert opinion" means a belief or an interpretation by |
| |||||||
| |||||||
1 | specialists with experience in a specific area about the | ||||||
2 | scientific evidence pertaining to a particular service, | ||||||
3 | intervention, or therapy. | ||||||
4 | "Facility" means an institution providing health care | ||||||
5 | services or a health care setting. | ||||||
6 | "Final adverse determination" means an adverse | ||||||
7 | determination involving a covered benefit that has been upheld | ||||||
8 | by a health carrier, or its designee utilization review | ||||||
9 | organization, at the completion of the health carrier's | ||||||
10 | internal grievance process procedures as set forth by the | ||||||
11 | Managed Care Reform and Patient Rights Act. | ||||||
12 | "Health benefit plan" means a policy, contract, | ||||||
13 | certificate, plan, or agreement offered or issued by a health | ||||||
14 | carrier to provide, deliver, arrange for, pay for, or | ||||||
15 | reimburse any of the costs of health care services. | ||||||
16 | "Health care provider" or "provider" means a physician, | ||||||
17 | hospital facility, or other health care practitioner licensed, | ||||||
18 | accredited, or certified to perform specified health care | ||||||
19 | services consistent with State law, responsible for | ||||||
20 | recommending health care services on behalf of a covered | ||||||
21 | person. | ||||||
22 | "Health care services" means services for the diagnosis, | ||||||
23 | prevention, treatment, cure, or relief of a health condition, | ||||||
24 | illness, injury, or disease. | ||||||
25 | "Health carrier" means an entity subject to the insurance | ||||||
26 | laws and regulations of this State, or subject to the |
| |||||||
| |||||||
1 | jurisdiction of the Director, that contracts or offers to | ||||||
2 | contract to provide, deliver, arrange for, pay for, or | ||||||
3 | reimburse any of the costs of health care services, including | ||||||
4 | a sickness and accident insurance company, a health | ||||||
5 | maintenance organization, or any other entity providing a plan | ||||||
6 | of health insurance, health benefits, or health care services. | ||||||
7 | "Health carrier" also means Limited Health Service | ||||||
8 | Organizations (LHSO) and Voluntary Health Service Plans. | ||||||
9 | "Health information" means information or data, whether | ||||||
10 | oral or recorded in any form or medium, and personal facts or | ||||||
11 | information about events or relationships that relate to: | ||||||
12 | (1) the past, present, or future physical, mental, or | ||||||
13 | behavioral health or condition of an individual or a | ||||||
14 | member of the individual's family; | ||||||
15 | (2) the provision of health care services to an | ||||||
16 | individual; or | ||||||
17 | (3) payment for the provision of health care services | ||||||
18 | to an individual. | ||||||
19 | "Independent review organization" means an entity that | ||||||
20 | conducts independent external reviews of adverse | ||||||
21 | determinations and final adverse determinations. | ||||||
22 | "Medical or scientific evidence" means evidence found in | ||||||
23 | the following sources: | ||||||
24 | (1) peer-reviewed scientific studies published in or | ||||||
25 | accepted for publication by medical journals that meet | ||||||
26 | nationally recognized requirements for scientific |
| |||||||
| |||||||
1 | manuscripts and that submit most of their published | ||||||
2 | articles for review by experts who are not part of the | ||||||
3 | editorial staff; | ||||||
4 | (2) peer-reviewed medical literature, including | ||||||
5 | literature relating to therapies reviewed and approved by | ||||||
6 | a qualified institutional review board, biomedical | ||||||
7 | compendia, and other medical literature that meet the | ||||||
8 | criteria of the National Institutes of Health's Library of | ||||||
9 | Medicine for indexing in Index Medicus (Medline) and | ||||||
10 | Elsevier Science Ltd. for indexing in Excerpta Medicus | ||||||
11 | (EMBASE); | ||||||
12 | (3) medical journals recognized by the Secretary of | ||||||
13 | Health and Human Services under Section 1861(t)(2) of the | ||||||
14 | federal Social Security Act; | ||||||
15 | (4) the following standard reference compendia: | ||||||
16 | (a) The American Hospital Formulary Service-Drug | ||||||
17 | Information; | ||||||
18 | (b) Drug Facts and Comparisons; | ||||||
19 | (c) The American Dental Association Accepted | ||||||
20 | Dental Therapeutics; and | ||||||
21 | (d) The United States Pharmacopoeia-Drug | ||||||
22 | Information; | ||||||
23 | (5) findings, studies, or research conducted by or | ||||||
24 | under the auspices of federal government agencies and | ||||||
25 | nationally recognized federal research institutes, | ||||||
26 | including: |
| |||||||
| |||||||
1 | (a) the federal Agency for Healthcare Research and | ||||||
2 | Quality; | ||||||
3 | (b) the National Institutes of Health; | ||||||
4 | (c) the National Cancer Institute; | ||||||
5 | (d) the National Academy of Sciences; | ||||||
6 | (e) the Centers for Medicare & Medicaid Services; | ||||||
7 | (f) the federal Food and Drug Administration; and | ||||||
8 | (g) any national board recognized by the National | ||||||
9 | Institutes of Health for the purpose of evaluating the | ||||||
10 | medical value of health care services; or | ||||||
11 | (6) any other medical or scientific evidence that is | ||||||
12 | comparable to the sources listed in items (1) through (5). | ||||||
13 | "Person" means an individual, a corporation, a | ||||||
14 | partnership, an association, a joint venture, a joint stock | ||||||
15 | company, a trust, an unincorporated organization, any similar | ||||||
16 | entity, or any combination of the foregoing. | ||||||
17 | "Prospective review" means a review conducted prior to an | ||||||
18 | admission or the provision of a health care service or a course | ||||||
19 | of treatment in accordance with a health carrier's requirement | ||||||
20 | that the health care service or course of treatment, in whole | ||||||
21 | or in part, be approved prior to its provision. | ||||||
22 | "Protected health information" means health information | ||||||
23 | (i) that identifies an individual who is the subject of the | ||||||
24 | information; or (ii) with respect to which there is a | ||||||
25 | reasonable basis to believe that the information could be used | ||||||
26 | to identify an individual. |
| |||||||
| |||||||
1 | "Randomized clinical trial" means a controlled prospective | ||||||
2 | study of patients that have been randomized into an | ||||||
3 | experimental group and a control group at the beginning of the | ||||||
4 | study with only the experimental group of patients receiving a | ||||||
5 | specific intervention, which includes study of the groups for | ||||||
6 | variables and anticipated outcomes over time. | ||||||
7 | "Retrospective review" means any review of a request for a | ||||||
8 | benefit that is not a concurrent or prospective review | ||||||
9 | request. "Retrospective review" does not include the review of | ||||||
10 | a claim that is limited to veracity of documentation or | ||||||
11 | accuracy of coding. | ||||||
12 | "Utilization review" has the meaning provided by the | ||||||
13 | Managed Care Reform and Patient Rights Act. | ||||||
14 | "Utilization review organization" means a utilization | ||||||
15 | review program as defined in the Managed Care Reform and | ||||||
16 | Patient Rights Act. | ||||||
17 | (Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12; | ||||||
18 | 98-756, eff. 7-16-14.)
| ||||||
19 | Section 6-20. The Prior Authorization Reform Act is | ||||||
20 | amended by changing Sections 15 and 20 as follows:
| ||||||
21 | (215 ILCS 200/15) | ||||||
22 | Sec. 15. Definitions. As used in this Act: | ||||||
23 | "Adverse determination" has the meaning given to that term | ||||||
24 | in Section 10 of the Health Carrier External Review Act. |
| |||||||
| |||||||
1 | "Appeal" means a formal request, either orally or in | ||||||
2 | writing, to reconsider an adverse determination. | ||||||
3 | "Approval" means a determination by a health insurance | ||||||
4 | issuer or its contracted utilization review organization that | ||||||
5 | a health care service has been reviewed and, based on the | ||||||
6 | information provided, satisfies the health insurance issuer's | ||||||
7 | or its contracted utilization review organization's | ||||||
8 | requirements for medical necessity and appropriateness. | ||||||
9 | "Clinical review criteria" has the meaning given to that | ||||||
10 | term in Section 10 of the Health Carrier External Review Act. | ||||||
11 | "Department" means the Department of Insurance. | ||||||
12 | "Emergency medical condition" has the meaning given to | ||||||
13 | that term in Section 10 of the Managed Care Reform and Patient | ||||||
14 | Rights Act. | ||||||
15 | "Emergency services" has the meaning given to that term in | ||||||
16 | federal health insurance reform requirements for the group and | ||||||
17 | individual health insurance markets, 45 CFR 147.138. | ||||||
18 | "Enrollee" has the meaning given to that term in Section | ||||||
19 | 10 of the Managed Care Reform and Patient Rights Act. | ||||||
20 | "Health care professional" has the meaning given to that | ||||||
21 | term in Section 10 of the Managed Care Reform and Patient | ||||||
22 | Rights Act. | ||||||
23 | "Health care provider" has the meaning given to that term | ||||||
24 | in Section 10 of the Managed Care Reform and Patient Rights | ||||||
25 | Act, except that facilities licensed under the Nursing Home | ||||||
26 | Care Act and long-term care facilities as defined in Section |
| |||||||
| |||||||
1 | 1-113 of the Nursing Home Care Act are excluded from this Act. | ||||||
2 | "Health care service" means any services or level of | ||||||
3 | services included in the furnishing to an individual of | ||||||
4 | medical care or the hospitalization incident to the furnishing | ||||||
5 | of such care, as well as the furnishing to any person of any | ||||||
6 | other services for the purpose of preventing, alleviating, | ||||||
7 | curing, or healing human illness or injury, including | ||||||
8 | behavioral health, mental health, home health, and | ||||||
9 | pharmaceutical services and products. | ||||||
10 | "Health insurance issuer" has the meaning given to that | ||||||
11 | term in Section 5 of the Illinois Health Insurance Portability | ||||||
12 | and Accountability Act. | ||||||
13 | "Medically necessary" has the meaning given to that term | ||||||
14 | in Section 10 of the Managed Care Reform and Patient Rights | ||||||
15 | Act. means a health care professional exercising prudent | ||||||
16 | clinical judgment would provide care to a patient for the | ||||||
17 | purpose of preventing, diagnosing, or treating an illness, | ||||||
18 | injury, disease, or its symptoms and that are: (i) in | ||||||
19 | accordance with generally accepted standards of medical | ||||||
20 | practice; (ii) clinically appropriate in terms of type, | ||||||
21 | frequency, extent, site, and duration and are considered | ||||||
22 | effective for the patient's illness, injury, or disease; and | ||||||
23 | (iii) not primarily for the convenience of the patient, | ||||||
24 | treating physician, other health care professional, caregiver, | ||||||
25 | family member, or other interested party, but focused on what | ||||||
26 | is best for the patient's health outcome. |
| |||||||
| |||||||
1 | "Physician" means a person licensed under the Medical | ||||||
2 | Practice Act of 1987 or licensed under the laws of another | ||||||
3 | state to practice medicine in all its branches. | ||||||
4 | "Prior authorization" means the process by which health | ||||||
5 | insurance issuers or their contracted utilization review | ||||||
6 | organizations determine the medical necessity and medical | ||||||
7 | appropriateness of otherwise covered health care services | ||||||
8 | before the rendering of such health care services. "Prior | ||||||
9 | authorization" includes any health insurance issuer's or its | ||||||
10 | contracted utilization review organization's requirement that | ||||||
11 | an enrollee, health care professional, or health care provider | ||||||
12 | notify the health insurance issuer or its contracted | ||||||
13 | utilization review organization before, at the time of, or | ||||||
14 | concurrent to providing a health care service. | ||||||
15 | "Urgent health care service" means a health care service | ||||||
16 | with respect to which the application of the time periods for | ||||||
17 | making a non-expedited prior authorization that in the opinion | ||||||
18 | of a health care professional with knowledge of the enrollee's | ||||||
19 | medical condition: | ||||||
20 | (1) could seriously jeopardize the life or health of | ||||||
21 | the enrollee or the ability of the enrollee to regain | ||||||
22 | maximum function; or | ||||||
23 | (2) could subject the enrollee to severe pain that | ||||||
24 | cannot be adequately managed without the care or treatment | ||||||
25 | that is the subject of the utilization review. | ||||||
26 | "Urgent health care service" does not include emergency |
| |||||||
| |||||||
1 | services. | ||||||
2 | "Utilization review organization" has the meaning given to | ||||||
3 | that term in 50 Ill. Adm. Code 4520.30. | ||||||
4 | (Source: P.A. 102-409, eff. 1-1-22 .)
| ||||||
5 | (215 ILCS 200/20) | ||||||
6 | Sec. 20. Disclosure and review of prior authorization | ||||||
7 | requirements. | ||||||
8 | (a) A health insurance issuer shall maintain a complete | ||||||
9 | list of services for which prior authorization is required, | ||||||
10 | including for all services where prior authorization is | ||||||
11 | performed by an entity under contract with the health | ||||||
12 | insurance issuer. The health insurance issuer shall publish | ||||||
13 | this list on its public website without requiring a member of | ||||||
14 | the general public to create any account or enter any | ||||||
15 | credentials to access it. The list described in this | ||||||
16 | subsection is not required to contain the clinical review | ||||||
17 | criteria applicable to these services. | ||||||
18 | (b) A health insurance issuer shall make any current prior | ||||||
19 | authorization requirements and restrictions, including the | ||||||
20 | written clinical review criteria, readily accessible and | ||||||
21 | conspicuously posted on its website to enrollees, health care | ||||||
22 | professionals, and health care providers. Content published by | ||||||
23 | a third party and licensed for use by a health insurance issuer | ||||||
24 | or its contracted utilization review organization may be made | ||||||
25 | available through the health insurance issuer's or its |
| |||||||
| |||||||
1 | contracted utilization review organization's secure, | ||||||
2 | password-protected website so long as the access requirements | ||||||
3 | of the website do not unreasonably restrict access. | ||||||
4 | Requirements shall be described in detail, written in easily | ||||||
5 | understandable language, and readily available to the health | ||||||
6 | care professional and health care provider at the point of | ||||||
7 | care. The website shall indicate for each service subject to | ||||||
8 | prior authorization: | ||||||
9 | (1) when prior authorization became required for | ||||||
10 | policies issued or delivered in Illinois, including the | ||||||
11 | effective date or dates and the termination date or dates, | ||||||
12 | if applicable, in Illinois; | ||||||
13 | (2) the date the Illinois-specific requirement was | ||||||
14 | listed on the health insurance issuer's or its contracted | ||||||
15 | utilization review organization's website; | ||||||
16 | (3) where applicable, the date that prior | ||||||
17 | authorization was removed for Illinois; and | ||||||
18 | (4) where applicable, access to a standardized | ||||||
19 | electronic prior authorization request transaction | ||||||
20 | process. | ||||||
21 | (c) The clinical review criteria must: | ||||||
22 | (1) be based on nationally recognized, generally | ||||||
23 | accepted standards except where State law provides its own | ||||||
24 | standard; | ||||||
25 | (2) be developed in accordance with the current | ||||||
26 | standards of a national medical accreditation entity; |
| |||||||
| |||||||
1 | (3) ensure quality of care and access to needed health | ||||||
2 | care services; | ||||||
3 | (4) be evidence-based; | ||||||
4 | (5) be sufficiently flexible to allow deviations from | ||||||
5 | norms when justified on a case-by-case basis; and | ||||||
6 | (6) be evaluated and updated, if necessary, at least | ||||||
7 | annually. | ||||||
8 | (d) A health insurance issuer shall not deny a claim for | ||||||
9 | failure to obtain prior authorization if the prior | ||||||
10 | authorization requirement was not in effect on the date of | ||||||
11 | service on the claim. | ||||||
12 | (e) A health insurance issuer or its contracted | ||||||
13 | utilization review organization shall not deem as incidental | ||||||
14 | or deny supplies or health care services that are routinely | ||||||
15 | used as part of a health care service when: | ||||||
16 | (1) an associated health care service has received | ||||||
17 | prior authorization; or | ||||||
18 | (2) prior authorization for the health care service is | ||||||
19 | not required. | ||||||
20 | (f) If a health insurance issuer intends either to | ||||||
21 | implement a new prior authorization requirement or restriction | ||||||
22 | or amend an existing requirement or restriction, the health | ||||||
23 | insurance issuer shall provide contracted health care | ||||||
24 | professionals and contracted health care providers of | ||||||
25 | enrollees written notice of the new or amended requirement or | ||||||
26 | amendment no less than 60 days before the requirement or |
| |||||||
| |||||||
1 | restriction is implemented. The written notice may be provided | ||||||
2 | in an electronic format, including email or facsimile, if the | ||||||
3 | health care professional or health care provider has agreed in | ||||||
4 | advance to receive notices electronically. The health | ||||||
5 | insurance issuer shall ensure that the new or amended | ||||||
6 | requirement is not implemented unless the health insurance | ||||||
7 | issuer's or its contracted utilization review organization's | ||||||
8 | website has been updated to reflect the new or amended | ||||||
9 | requirement or restriction. | ||||||
10 | (g) Entities using prior authorization shall make | ||||||
11 | statistics available regarding prior authorization approvals | ||||||
12 | and denials on their website in a readily accessible format. | ||||||
13 | The statistics must be updated annually and include all of the | ||||||
14 | following information: | ||||||
15 | (1) a list of all health care services, including | ||||||
16 | medications, that are subject to prior authorization; | ||||||
17 | (2) the total number of prior authorization requests | ||||||
18 | received; | ||||||
19 | (3) the number of prior authorization requests denied | ||||||
20 | during the previous plan year by the health insurance | ||||||
21 | issuer or its contracted utilization review organization | ||||||
22 | with respect to each service described in paragraph (1) | ||||||
23 | and the top 5 reasons for denial; | ||||||
24 | (4) the number of requests described in paragraph (3) | ||||||
25 | that were appealed, the number of the appealed requests | ||||||
26 | that upheld the adverse determination, and the number of |
| |||||||
| |||||||
1 | appealed requests that reversed the adverse determination; | ||||||
2 | (5) the average time between submission and response; | ||||||
3 | and | ||||||
4 | (6) any other information as the Director determines | ||||||
5 | appropriate. | ||||||
6 | (Source: P.A. 102-409, eff. 1-1-22 .)
| ||||||
7 | Section 6-25. The Illinois Public Aid Code is amended by | ||||||
8 | changing Section 5-16.12 as follows:
| ||||||
9 | (305 ILCS 5/5-16.12) | ||||||
10 | Sec. 5-16.12. Managed Care Reform and Patient Rights Act. | ||||||
11 | The medical assistance program and other programs administered | ||||||
12 | by the Department are subject to the provisions of the Managed | ||||||
13 | Care Reform and Patient Rights Act. The Department may adopt | ||||||
14 | rules to implement those provisions. These rules shall require | ||||||
15 | compliance with that Act in the medical assistance managed | ||||||
16 | care programs and other programs administered by the | ||||||
17 | Department. The medical assistance fee-for-service program is | ||||||
18 | not subject to the provisions of the Managed Care Reform and | ||||||
19 | Patient Rights Act , except for Sections 85 and 87 of the | ||||||
20 | Managed Care Reform and Patient Rights Act and for any | ||||||
21 | definition in Section 10 of the Managed Care Reform and | ||||||
22 | Patient Rights Act that applies to Section 87 of the Managed | ||||||
23 | Care Reform and Patient Rights Act . | ||||||
24 | Nothing in the Managed Care Reform and Patient Rights Act |
| |||||||
| |||||||
1 | shall be construed to mean that the Department is a health care | ||||||
2 | plan as defined in that Act simply because the Department | ||||||
3 | enters into contractual relationships with health care plans ; | ||||||
4 | provided that this clause shall not defeat the applicability | ||||||
5 | of Sections 10, 85, and 87 of the Managed Care Reform and | ||||||
6 | Patient Rights Act to the fee-for-service program . | ||||||
7 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
8 | Article 99. | ||||||
9 | Section 99-95. No acceleration or delay. Where this Act | ||||||
10 | makes changes in a statute that is represented in this Act by | ||||||
11 | text that is not yet or no longer in effect (for example, a | ||||||
12 | Section represented by multiple versions), the use of that | ||||||
13 | text does not accelerate or delay the taking effect of (i) the | ||||||
14 | changes made by this Act or (ii) provisions derived from any | ||||||
15 | other Public Act.
|