HB3638 EnrolledLRB098 12067 KTG 45783 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This amendatory Act may be referred
5to as the Health Insurance Consumer Protection Act of 2014.
 
6    Section 3. Findings and purpose. The General Assembly
7finds that the federal Patient Protection and Affordable Care
8Act and the federal regulations implementing that Act give the
9State and its Department of Insurance primary responsibility
10for ensuring that all policies of health insurance and health
11care plans that are offered for sale directly to consumers in
12the State provide consumers with adequate information about the
13coverage offered to enable them to meaningfully compare plans
14and premiums and enroll in the appropriate policy or plan. The
15purpose of this amendatory Act of the 98th General Assembly is
16to build on the consumer protections provided in federal law
17for policies or qualified health plans offered for sale
18directly to consumers through the Health Insurance Marketplace
19in Illinois.
 
20    Section 5. The Illinois Insurance Code is amended by
21changing Sections 155.36 and 355a as follows:
 

 

 

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1    (215 ILCS 5/155.36)
2    Sec. 155.36. Managed Care Reform and Patient Rights Act.
3Insurance companies that transact the kinds of insurance
4authorized under Class 1(b) or Class 2(a) of Section 4 of this
5Code shall comply with Sections 45, 45.1, 45.2, and 85 and the
6definition of the term "emergency medical condition" in Section
710 of the Managed Care Reform and Patient Rights Act.
8(Source: P.A. 96-857, eff. 7-1-10.)
 
9    (215 ILCS 5/355a)  (from Ch. 73, par. 967a)
10    Sec. 355a. Standardization of terms and coverage.
11    (1) The purpose of this Section shall be (a) to provide
12reasonable standardization and simplification of terms and
13coverages of individual accident and health insurance policies
14to facilitate public understanding and comparisons; (b) to
15eliminate provisions contained in individual accident and
16health insurance policies which may be misleading or
17unreasonably confusing in connection either with the purchase
18of such coverages or with the settlement of claims; and (c) to
19provide for reasonable disclosure in the sale of accident and
20health coverages.
21    (2) Definitions applicable to this Section are as follows:
22        (a) "Policy" means all or any part of the forms
23    constituting the contract between the insurer and the
24    insured, including the policy, certificate, subscriber
25    contract, riders, endorsements, and the application if

 

 

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1    attached, which are subject to filing with and approval by
2    the Director.
3        (b) "Service corporations" means voluntary health and
4    dental corporations organized and operating respectively
5    under the Voluntary Health Services Plans Act and the
6    Dental Service Plan Act.
7        (c) "Accident and health insurance" means insurance
8    written under Article XX of the Insurance Code, other than
9    credit accident and health insurance, and coverages
10    provided in subscriber contracts issued by service
11    corporations. For purposes of this Section such service
12    corporations shall be deemed to be insurers engaged in the
13    business of insurance.
14    (3) The Director shall issue such rules as he shall deem
15necessary or desirable to establish specific standards,
16including standards of full and fair disclosure that set forth
17the form and content and required disclosure for sale, of
18individual policies of accident and health insurance, which
19rules and regulations shall be in addition to and in accordance
20with the applicable laws of this State, and which may cover but
21shall not be limited to: (a) terms of renewability; (b) initial
22and subsequent conditions of eligibility; (c) non-duplication
23of coverage provisions; (d) coverage of dependents; (e)
24pre-existing conditions; (f) termination of insurance; (g)
25probationary periods; (h) limitation, exceptions, and
26reductions; (i) elimination periods; (j) requirements

 

 

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1regarding replacements; (k) recurrent conditions; and (l) the
2definition of terms including but not limited to the following:
3hospital, accident, sickness, injury, physician, accidental
4means, total disability, partial disability, nervous disorder,
5guaranteed renewable, and non-cancellable.
6    The Director may issue rules that specify prohibited policy
7provisions not otherwise specifically authorized by statute
8which in the opinion of the Director are unjust, unfair or
9unfairly discriminatory to the policyholder, any person
10insured under the policy, or beneficiary.
11    (4) The Director shall issue such rules as he shall deem
12necessary or desirable to establish minimum standards for
13benefits under each category of coverage in individual accident
14and health policies, other than conversion policies issued
15pursuant to a contractual conversion privilege under a group
16policy, including but not limited to the following categories:
17(a) basic hospital expense coverage; (b) basic
18medical-surgical expense coverage; (c) hospital confinement
19indemnity coverage; (d) major medical expense coverage; (e)
20disability income protection coverage; (f) accident only
21coverage; and (g) specified disease or specified accident
22coverage.
23    Nothing in this subsection (4) shall preclude the issuance
24of any policy which combines two or more of the categories of
25coverage enumerated in subparagraphs (a) through (f) of this
26subsection.

 

 

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1    No policy shall be delivered or issued for delivery in this
2State which does not meet the prescribed minimum standards for
3the categories of coverage listed in this subsection unless the
4Director finds that such policy is necessary to meet specific
5needs of individuals or groups and such individuals or groups
6will be adequately informed that such policy does not meet the
7prescribed minimum standards, and such policy meets the
8requirement that the benefits provided therein are reasonable
9in relation to the premium charged. The standards and criteria
10to be used by the Director in approving such policies shall be
11included in the rules required under this Section with as much
12specificity as practicable.
13    The Director shall prescribe by rule the method of
14identification of policies based upon coverages provided.
15    (5) (a) In order to provide for full and fair disclosure in
16the sale of individual accident and health insurance policies,
17no such policy shall be delivered or issued for delivery in
18this State unless the outline of coverage described in
19paragraph (b) of this subsection either accompanies the policy,
20or is delivered to the applicant at the time the application is
21made, and an acknowledgment signed by the insured, of receipt
22of delivery of such outline, is provided to the insurer. In the
23event the policy is issued on a basis other than that applied
24for, the outline of coverage properly describing the policy
25must accompany the policy when it is delivered and such outline
26shall clearly state that the policy differs, and to what

 

 

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1extent, from that for which application was originally made.
2All policies, except single premium nonrenewal policies, shall
3have a notice prominently printed on the first page of the
4policy or attached thereto stating in substance, that the
5policyholder shall have the right to return the policy within
610 days of its delivery and to have the premium refunded if
7after examination of the policy the policyholder is not
8satisfied for any reason.
9    (b) The Director shall issue such rules as he shall deem
10necessary or desirable to prescribe the format and content of
11the outline of coverage required by paragraph (a) of this
12subsection. "Format" means style, arrangement, and overall
13appearance, including such items as the size, color, and
14prominence of type and the arrangement of text and captions.
15"Content" shall include without limitation thereto, statements
16relating to the particular policy as to the applicable category
17of coverage prescribed under subsection 4; principal benefits;
18exceptions, reductions and limitations; and renewal
19provisions, including any reservation by the insurer of a right
20to change premiums. Such outline of coverage shall clearly
21state that it constitutes a summary of the policy issued or
22applied for and that the policy should be consulted to
23determine governing contractual provisions.
24    (c) Without limiting the generality of paragraph (b) of
25this subsection (5), no qualified health plans shall be offered
26for sale directly to consumers through the health insurance

 

 

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1marketplace operating in the State in accordance with Sections
21311 and 1321 of the federal Patient Protection and Affordable
3Care Act of 2010 (Public Law 111-148), as amended by the
4federal Health Care and Education Reconciliation Act of 2010
5(Public Law 111-152), and any amendments thereto, or
6regulations or guidance issued thereunder (collectively, "the
7Federal Act"), unless the following information is made
8available to the consumer at the time he or she is comparing
9policies and their premiums:
10        (i) With respect to prescription drug benefits, the
11    most recently published formulary where a consumer can view
12    in one location covered prescription drugs; information on
13    tiering and the cost-sharing structure for each tier; and
14    information about how a consumer can obtain specific
15    copayment amounts or coinsurance percentages for a
16    specific qualified health plan before enrolling in that
17    plan. This information shall clearly identify the
18    qualified health plan to which it applies.
19        (ii) The most recently published provider directory
20    where a consumer can view the provider network that applies
21    to each qualified health plan and information about each
22    provider, including location, contact information,
23    specialty, medical group, if any, any institutional
24    affiliation, and whether the provider is accepting new
25    patients. The information shall clearly identify the
26    qualified health plan to which it applies.

 

 

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1    (d) Each company that offers qualified health plans for
2sale directly to consumers through the health insurance
3marketplace operating in the State shall make the information
4in paragraph (c) of this subsection (5), for each qualified
5health plan that it offers, available and accessible to the
6general public on the company's Internet website and through
7other means for individuals without access to the Internet.
8    (e) The Department shall ensure that State-operated
9Internet websites, in addition to the Internet website for the
10health insurance marketplace established in this State in
11accordance with the Federal Act, prominently provide links to
12Internet-based materials and tools to help consumers be
13informed purchasers of health insurance.
14    (f) Nothing in this Section shall be interpreted or
15implemented in a manner not consistent with the Federal Act.
16This Section shall apply to all qualified health plans offered
17for sale directly to consumers through the health insurance
18marketplace operating in this State for any coverage year
19beginning on or after January 1, 2015.
20    (6) Prior to the issuance of rules pursuant to this
21Section, the Director shall afford the public, including the
22companies affected thereby, reasonable opportunity for
23comment. Such rulemaking is subject to the provisions of the
24Illinois Administrative Procedure Act.
25    (7) When a rule has been adopted, pursuant to this Section,
26all policies of insurance or subscriber contracts which are not

 

 

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1in compliance with such rule shall, when so provided in such
2rule, be deemed to be disapproved as of a date specified in
3such rule not less than 120 days following its effective date,
4without any further or additional notice other than the
5adoption of the rule.
6    (8) When a rule adopted pursuant to this Section so
7provides, a policy of insurance or subscriber contract which
8does not comply with the rule shall not less than 120 days from
9the effective date of such rule, be construed, and the insurer
10or service corporation shall be liable, as if the policy or
11contract did comply with the rule.
12    (9) Violation of any rule adopted pursuant to this Section
13shall be a violation of the insurance law for purposes of
14Sections 370 and 446 of the Insurance Code.
15(Source: P.A. 90-177, eff. 7-23-97; 90-372, eff. 7-1-98;
1690-655, eff. 7-30-98.)
 
17    Section 10. The Managed Care Reform and Patient Rights Act
18is amended by changing Section 15 and by adding Sections 45.1
19and 45.2 as follows:
 
20    (215 ILCS 134/15)
21    Sec. 15. Provision of information.
22    (a) A health care plan shall provide annually to enrollees
23and prospective enrollees, upon request, a complete list of
24participating health care providers in the health care plan's

 

 

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1service area and a description of the following terms of
2coverage:
3        (1) the service area;
4        (2) the covered benefits and services with all
5    exclusions, exceptions, and limitations;
6        (3) the pre-certification and other utilization review
7    procedures and requirements;
8        (4) a description of the process for the selection of a
9    primary care physician, any limitation on access to
10    specialists, and the plan's standing referral policy;
11        (5) the emergency coverage and benefits, including any
12    restrictions on emergency care services;
13        (6) the out-of-area coverage and benefits, if any;
14        (7) the enrollee's financial responsibility for
15    copayments, deductibles, premiums, and any other
16    out-of-pocket expenses;
17        (8) the provisions for continuity of treatment in the
18    event a health care provider's participation terminates
19    during the course of an enrollee's treatment by that
20    provider;
21        (9) the appeals process, forms, and time frames for
22    health care services appeals, complaints, and external
23    independent reviews, administrative complaints, and
24    utilization review complaints, including a phone number to
25    call to receive more information from the health care plan
26    concerning the appeals process; and

 

 

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1        (10) a statement of all basic health care services and
2    all specific benefits and services mandated to be provided
3    to enrollees by any State law or administrative rule.
4    (a-5) Without limiting the generality of subsection (a) of
5this Section, no qualified health plans shall be offered for
6sale directly to consumers through the health insurance
7marketplace operating in the State in accordance with Sections
81311 and 1321 of the federal Patient Protection and Affordable
9Care Act of 2010 (Public Law 111-148), as amended by the
10federal Health Care and Education Reconciliation Act of 2010
11(Public Law 111-152), and any amendments thereto, or
12regulations or guidance issued thereunder (collectively, "the
13Federal Act"), unless, in addition to the information required
14under subsection (a) of this Section, the following information
15is available to the consumer at the time he or she is comparing
16health care plans and their premiums:
17        (1) With respect to prescription drug benefits, the
18    most recently published formulary where a consumer can view
19    in one location covered prescription drugs; information on
20    tiering and the cost-sharing structure for each tier; and
21    information about how a consumer can obtain specific
22    copayment amounts or coinsurance percentages for a
23    specific qualified health plan before enrolling in that
24    plan. This information shall clearly identify the
25    qualified health plan to which it applies.
26        (2) The most recently published provider directory

 

 

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1    where a consumer can view the provider network that applies
2    to each qualified health plan and information about each
3    provider, including location, contact information,
4    specialty, medical group, if any, any institutional
5    affiliation, and whether the provider is accepting new
6    patients. The information shall clearly identify the
7    qualified health plan to which it applies.
8    In the event of an inconsistency between any separate
9written disclosure statement and the enrollee contract or
10certificate, the terms of the enrollee contract or certificate
11shall control.
12    (b) Upon written request, a health care plan shall provide
13to enrollees a description of the financial relationships
14between the health care plan and any health care provider and,
15if requested, the percentage of copayments, deductibles, and
16total premiums spent on healthcare related expenses and the
17percentage of copayments, deductibles, and total premiums
18spent on other expenses, including administrative expenses,
19except that no health care plan shall be required to disclose
20specific provider reimbursement.
21    (c) A participating health care provider shall provide all
22of the following, where applicable, to enrollees upon request:
23        (1) Information related to the health care provider's
24    educational background, experience, training, specialty,
25    and board certification, if applicable.
26        (2) The names of licensed facilities on the provider

 

 

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1    panel where the health care provider presently has
2    privileges for the treatment, illness, or procedure that is
3    the subject of the request.
4        (3) Information regarding the health care provider's
5    participation in continuing education programs and
6    compliance with any licensure, certification, or
7    registration requirements, if applicable.
8    (d) A health care plan shall provide the information
9required to be disclosed under this Act upon enrollment and
10annually thereafter in a legible and understandable format. The
11Department shall promulgate rules to establish the format
12based, to the extent practical, on the standards developed for
13supplemental insurance coverage under Title XVIII of the
14federal Social Security Act as a guide, so that a person can
15compare the attributes of the various health care plans.
16    (e) The written disclosure requirements of this Section may
17be met by disclosure to one enrollee in a household.
18    (f) Each issuer of qualified health plans for sale directly
19to consumers through the health insurance marketplace
20operating in the State shall make the information described in
21subsection (a) of this Section, for each qualified health plan
22that it offers, available and accessible to the general public
23on the company's Internet website and through other means for
24individuals without access to the Internet.
25    (g) The Department shall ensure that State-operated
26Internet websites, in addition to the Internet website for the

 

 

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1health insurance marketplace established in this State in
2accordance with the Federal Act and its implementing
3regulations, prominently provide links to Internet-based
4materials and tools to help consumers be informed purchasers of
5health care plans.
6    (h) Nothing in this Section shall be interpreted or
7implemented in a manner not consistent with the Federal Act.
8This Section shall apply to all qualified health plans offered
9for sale directly to consumers through the health insurance
10marketplace operating in this State for any coverage year
11beginning on or after January 1, 2015.
12(Source: P.A. 91-617, eff. 1-1-00.)
 
13    (215 ILCS 134/45.1 new)
14    Sec. 45.1. Medical exceptions procedures required.
15    (a) Every health carrier that offers a qualified health
16plan, as defined in the federal Patient Protection and
17Affordable Care Act of 2010 (Public Law 111-148), as amended by
18the federal Health Care and Education Reconciliation Act of
192010 (Public Law 111-152), and any amendments thereto, or
20regulations or guidance issued under those Acts (collectively,
21"the Federal Act"), directly to consumers in this State shall
22establish and maintain a medical exceptions process that allows
23covered persons or their authorized representatives to request
24any clinically appropriate prescription drug when (1) the drug
25is not covered based on the health benefit plan's formulary;

 

 

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1(2) the health benefit plan is discontinuing coverage of the
2drug on the plan's formulary for reasons other than safety or
3other than because the prescription drug has been withdrawn
4from the market by the drug's manufacturer; (3) the
5prescription drug alternatives required to be used in
6accordance with a step therapy requirement (A) has been
7ineffective in the treatment of the enrollee's disease or
8medical condition or, based on both sound clinical evidence and
9medical and scientific evidence, the known relevant physical or
10mental characteristics of the enrollee, and the known
11characteristics of the drug regimen, is likely to be
12ineffective or adversely affect the drug's effectiveness or
13patient compliance or (B) has caused or, based on sound medical
14evidence, is likely to cause an adverse reaction or harm to the
15enrollee; or (4) the number of doses available under a dose
16restriction for the prescription drug (A) has been ineffective
17in the treatment of the enrollee's disease or medical condition
18or (B) based on both sound clinical evidence and medical and
19scientific evidence, the known relevant physical and mental
20characteristics of the enrollee, and known characteristics of
21the drug regimen, is likely to be ineffective or adversely
22affect the drug's effective or patient compliance.
23    (b) The health carrier's established medical exceptions
24procedures must require, at a minimum, the following:
25        (1) Any request for approval of coverage made verbally
26    or in writing (regardless of whether made using a paper or

 

 

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1    electronic form or some other writing) at any time shall be
2    reviewed by appropriate health care professionals.
3        (2) The health carrier must, within 72 hours after
4    receipt of a request made under subsection (a) of this
5    Section, either approve or deny the request. In the case of
6    a denial, the health carrier shall provide the covered
7    person or the covered person's authorized representative
8    and the covered person's prescribing provider with the
9    reason for the denial, an alternative covered medication,
10    if applicable, and information regarding the procedure for
11    submitting an appeal to the denial.
12        (3) In the case of an expedited coverage determination,
13    the health carrier must either approve or deny the request
14    within 24 hours after receipt of the request. In the case
15    of a denial, the health carrier shall provide the covered
16    person or the covered person's authorized representative
17    and the covered person's prescribing provider with the
18    reason for the denial, an alternative covered medication,
19    if applicable, and information regarding the procedure for
20    submitting an appeal to the denial.
21    (c) Notwithstanding any other provision of this Section,
22nothing in this Section shall be interpreted or implemented in
23a manner not consistent with the Federal Act.
 
24    (215 ILCS 134/45.2 new)
25    Sec. 45.2. Prior authorization form; prescription

 

 

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1benefits.
2    (a) Notwithstanding any other provision of law, on and
3after January 1, 2015, a health insurer that provides
4prescription drug benefits must, within 72 hours after receipt
5of a paper or electronic prior authorization form from a
6prescribing provider or pharmacist, either approve or deny the
7prior authorization. In the case of a denial, the insurer shall
8provide the prescriber with the reason for the denial, an
9alternative covered medication, if applicable, and information
10regarding the denial.
11    In the case of an expedited coverage determination, the
12health insurer must either approve or deny the prior
13authorization within 24 hours after receipt of the paper or
14electronic prior authorization form. In the case of a denial,
15the health insurer shall provide the prescriber with the reason
16for the denial, an alternative covered medication, if
17applicable, and information regarding the procedure for
18submitting an appeal to the denial.
19    (b) This Section does not apply to plans for beneficiaries
20of Medicare or Medicaid.
21    (c) For the purposes of this Section:
22    "Pharmacist" has the same meaning as set forth in the
23Pharmacy Practice Act.
24    "Prescribing provider" includes a provider authorized to
25write a prescription, as described in subsection (e) of Section
263 of the Pharmacy Practice Act, to treat a medical condition of

 

 

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1an insured.
 
2    Section 99. Effective date. This Act takes effect upon
3becoming law.