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Public Act 103-0656 | ||||
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AN ACT concerning regulation. | ||||
Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly: | ||||
Section 5. The Illinois Insurance Code is amended by | ||||
changing Sections 143.31, 155.36, 315.6, and 370s as follows: | ||||
(215 ILCS 5/143.31) | ||||
Sec. 143.31. Uniform medical claim and billing forms. | ||||
(a) The Director shall prescribe by rule, after | ||||
consultation with providers of health care or treatment, | ||||
insurers, hospital, medical, and dental service corporations, | ||||
and other prepayment organizations, insurance claim and | ||||
billing forms that the Director determines will provide for | ||||
uniformity and simplicity in insurance claims handling. The | ||||
claim forms shall include, but need not be limited to, | ||||
information regarding the medical diagnosis, treatment, and | ||||
prognosis of the patient, together with the details of charges | ||||
incident to the providing of care, treatment, or services, | ||||
sufficient for the purpose of meeting the proof requirements | ||||
of an insurance policy or a hospital, medical, or dental | ||||
service contract. | ||||
(b) An insurer or a provider of health care treatment may | ||||
not refuse to accept a claim or bill submitted on duly | ||||
promulgated uniform claim and billing forms. An insurer, |
however, may accept claims and bills submitted on any other | ||
form. | ||
(c) After receipt and adjudication or readjudication of | ||
any claim or bill with all required documentation from an | ||
insured or provider, or a notification under 42 U.S.C. | ||
300gg-136, an accident Accident and health insurer shall send | ||
explanation of benefits paid statements or claims summary | ||
statements sent to an insured by the accident and health | ||
insurer shall be in a format and written in a manner that | ||
promotes understanding by the insured by setting forth all of | ||
the following: | ||
(1) The total dollar amount submitted to the insurer | ||
for payment. | ||
(2) Any reduction in the amount paid due to the | ||
application of any co-payment , coinsurance, or deductible, | ||
along with an explanation of the amount of the co-payment , | ||
coinsurance, or deductible applied under the insured's | ||
policy. | ||
(3) Any reduction in the amount paid due to the | ||
application of any other policy limitation , penalty, or | ||
exclusion set forth in the insured's policy, along with an | ||
explanation thereof. | ||
(4) The total dollar amount paid. | ||
(5) The total dollar amount remaining unpaid. | ||
(6) If applicable under 42 U.S.C. 300gg-111 or 42 | ||
U.S.C. 300gg-115, other information required for any |
explanation of benefits described in either of those | ||
Sections. | ||
(d) The Director may issue an order directing an accident | ||
and health insurer to comply with subsection (c). | ||
(e) An accident and health insurer does not violate | ||
subsection (c) by using a document that the accident and | ||
health insurer is required to use by the federal government or | ||
the State. | ||
(f) The adoption of uniform claim forms and uniform | ||
billing forms by the Director under this Section does not | ||
preclude an insurer, hospital, medical, or dental service | ||
corporation, or other prepayment organization from obtaining | ||
any necessary additional information regarding a claim from | ||
the claimant, provider of health care or treatment, or | ||
certifier of coverage, as may be required. | ||
(g) On and after January 1, 1996 when billing insurers or | ||
otherwise filing insurance claims with insurers subject to | ||
this Section, providers of health care or treatment, medical | ||
services, dental services, pharmaceutical services, or medical | ||
equipment must use the uniform claim and billing forms adopted | ||
by the Director under this Section. | ||
(Source: P.A. 91-357, eff. 7-29-99.) | ||
(215 ILCS 5/155.36) | ||
Sec. 155.36. Managed Care Reform and Patient Rights Act. | ||
Insurance companies that transact the kinds of insurance |
authorized under Class 1(b) or Class 2(a) of Section 4 of this | ||
Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65, | ||
70, and 85, subsection (d) of Section 30, and the definition of | ||
the term "emergency medical condition" in Section 10 of the | ||
Managed Care Reform and Patient Rights Act. Except as provided | ||
by Section 85 of the Managed Care Reform and Patient Rights | ||
Act, no law or rule shall be construed to exempt any | ||
utilization review program from the requirements of Section 85 | ||
of the Managed Care Reform and Patient Rights Act with respect | ||
to any insurance described in this Section. | ||
(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.) | ||
(215 ILCS 5/315.6) (from Ch. 73, par. 927.6) | ||
(Section scheduled to be repealed on January 1, 2027) | ||
Sec. 315.6. Application of other Code provisions. Unless | ||
otherwise provided in this amendatory Act, every fraternal | ||
benefit society shall be governed by this amendatory Act and | ||
shall be exempt from all other provisions of the insurance | ||
laws of this State not only in governmental relations with the | ||
State but for every other purpose, except for those provisions | ||
specified in this amendatory Act and except as follows: | ||
(a) Sections 1, 2, 2.1, 3.1, 117, 118, 132, 132.1, | ||
132.2, 132.3, 132.4, 132.5, 132.6, 132.7, 133, 134, 136, | ||
138, 139, 140, 141, 141.01, 141.1, 141.2, 141.3, 143, | ||
143.31, 143c, 144.1, 147, 148, 149, 150, 151, 152, 153, | ||
154.5, 154.6, 154.7, 154.8, 155, 155.04, 155.05, 155.06, |
155.07, 155.08 and 408 of this Code; and | ||
(b) Articles VIII 1/2, XII, XII 1/2, XIII, XXIV, and | ||
XXVIII of this Code. | ||
(Source: P.A. 98-814, eff. 1-1-15 .) | ||
(215 ILCS 5/370s) | ||
Sec. 370s. Managed Care Reform and Patient Rights Act. All | ||
administrators shall comply with Sections 55 and 85 of the | ||
Managed Care Reform and Patient Rights Act. Except as provided | ||
by Section 85 of the Managed Care Reform and Patient Rights | ||
Act, no law or rule shall be construed to exempt any | ||
utilization review program from the requirements of Section 85 | ||
of the Managed Care Reform and Patient Rights Act with respect | ||
to any insured or beneficiary described in this Article. | ||
(Source: P.A. 91-617, eff. 1-1-00.) | ||
Section 10. The Dental Service Plan Act is amended by | ||
changing Section 25 as follows: | ||
(215 ILCS 110/25) (from Ch. 32, par. 690.25) | ||
Sec. 25. Application of Insurance Code provisions. Dental | ||
service plan corporations and all persons interested therein | ||
or dealing therewith shall be subject to the provisions of | ||
Articles IIA, XI, and XII 1/2 and Sections 3.1, 133, 136, 139, | ||
140, 143, 143.31, 143c, 149, 155.49, 355.2, 355.3, 367.2, 401, | ||
401.1, 402, 403, 403A, 408, 408.2, and 412, and subsection |
(15) of Section 367 of the Illinois Insurance Code. | ||
(Source: P.A. 103-426, eff. 8-4-23.) | ||
Section 15. The Network Adequacy and Transparency Act is | ||
amended by changing Section 10 as follows: | ||
(215 ILCS 124/10) | ||
Sec. 10. Network adequacy. | ||
(a) An insurer providing a network plan shall file a | ||
description of all of the following with the Director: | ||
(1) The written policies and procedures for adding | ||
providers to meet patient needs based on increases in the | ||
number of beneficiaries, changes in the | ||
patient-to-provider ratio, changes in medical and health | ||
care capabilities, and increased demand for services. | ||
(2) The written policies and procedures for making | ||
referrals within and outside the network. | ||
(3) The written policies and procedures on how the | ||
network plan will provide 24-hour, 7-day per week access | ||
to network-affiliated primary care, emergency services, | ||
and women's principal health care providers. | ||
An insurer shall not prohibit a preferred provider from | ||
discussing any specific or all treatment options with | ||
beneficiaries irrespective of the insurer's position on those | ||
treatment options or from advocating on behalf of | ||
beneficiaries within the utilization review, grievance, or |
appeals processes established by the insurer in accordance | ||
with any rights or remedies available under applicable State | ||
or federal law. | ||
(b) Insurers must file for review a description of the | ||
services to be offered through a network plan. The description | ||
shall include all of the following: | ||
(1) A geographic map of the area proposed to be served | ||
by the plan by county service area and zip code, including | ||
marked locations for preferred providers. | ||
(2) As deemed necessary by the Department, the names, | ||
addresses, phone numbers, and specialties of the providers | ||
who have entered into preferred provider agreements under | ||
the network plan. | ||
(3) The number of beneficiaries anticipated to be | ||
covered by the network plan. | ||
(4) An Internet website and toll-free telephone number | ||
for beneficiaries and prospective beneficiaries to access | ||
current and accurate lists of preferred providers, | ||
additional information about the plan, as well as any | ||
other information required by Department rule. | ||
(5) A description of how health care services to be | ||
rendered under the network plan are reasonably accessible | ||
and available to beneficiaries. The description shall | ||
address all of the following: | ||
(A) the type of health care services to be | ||
provided by the network plan; |
(B) the ratio of physicians and other providers to | ||
beneficiaries, by specialty and including primary care | ||
physicians and facility-based physicians when | ||
applicable under the contract, necessary to meet the | ||
health care needs and service demands of the currently | ||
enrolled population; | ||
(C) the travel and distance standards for plan | ||
beneficiaries in county service areas; and | ||
(D) a description of how the use of telemedicine, | ||
telehealth, or mobile care services may be used to | ||
partially meet the network adequacy standards, if | ||
applicable. | ||
(6) A provision ensuring that whenever a beneficiary | ||
has made a good faith effort, as evidenced by accessing | ||
the provider directory, calling the network plan, and | ||
calling the provider, to utilize preferred providers for a | ||
covered service and it is determined the insurer does not | ||
have the appropriate preferred providers due to | ||
insufficient number, type, unreasonable travel distance or | ||
delay, or preferred providers refusing to provide a | ||
covered service because it is contrary to the conscience | ||
of the preferred providers, as protected by the Health | ||
Care Right of Conscience Act, the insurer shall ensure, | ||
directly or indirectly, by terms contained in the payer | ||
contract, that the beneficiary will be provided the | ||
covered service at no greater cost to the beneficiary than |
if the service had been provided by a preferred provider. | ||
This paragraph (6) does not apply to: (A) a beneficiary | ||
who willfully chooses to access a non-preferred provider | ||
for health care services available through the panel of | ||
preferred providers, or (B) a beneficiary enrolled in a | ||
health maintenance organization. In these circumstances, | ||
the contractual requirements for non-preferred provider | ||
reimbursements shall apply unless Section 356z.3a of the | ||
Illinois Insurance Code requires otherwise. In no event | ||
shall a beneficiary who receives care at a participating | ||
health care facility be required to search for | ||
participating providers under the circumstances described | ||
in subsection (b) or (b-5) of Section 356z.3a of the | ||
Illinois Insurance Code except under the circumstances | ||
described in paragraph (2) of subsection (b-5). | ||
(7) A provision that the beneficiary shall receive | ||
emergency care coverage such that payment for this | ||
coverage is not dependent upon whether the emergency | ||
services are performed by a preferred or non-preferred | ||
provider and the coverage shall be at the same benefit | ||
level as if the service or treatment had been rendered by a | ||
preferred provider. For purposes of this paragraph (7), | ||
"the same benefit level" means that the beneficiary is | ||
provided the covered service at no greater cost to the | ||
beneficiary than if the service had been provided by a | ||
preferred provider. This provision shall be consistent |
with Section 356z.3a of the Illinois Insurance Code. | ||
(8) A limitation that complies with subsections (d) | ||
and (e) of Section 55 of the Prior Authorization Reform | ||
Act , if the plan provides that the beneficiary will incur | ||
a penalty for failing to pre-certify inpatient hospital | ||
treatment, the penalty may not exceed $1,000 per | ||
occurrence in addition to the plan cost sharing | ||
provisions . | ||
(c) The network plan shall demonstrate to the Director a | ||
minimum ratio of providers to plan beneficiaries as required | ||
by the Department. | ||
(1) The ratio of physicians or other providers to plan | ||
beneficiaries shall be established annually by the | ||
Department in consultation with the Department of Public | ||
Health based upon the guidance from the federal Centers | ||
for Medicare and Medicaid Services. The Department shall | ||
not establish ratios for vision or dental providers who | ||
provide services under dental-specific or vision-specific | ||
benefits. The Department shall consider establishing | ||
ratios for the following physicians or other providers: | ||
(A) Primary Care; | ||
(B) Pediatrics; | ||
(C) Cardiology; | ||
(D) Gastroenterology; | ||
(E) General Surgery; | ||
(F) Neurology; |
(G) OB/GYN; | ||
(H) Oncology/Radiation; | ||
(I) Ophthalmology; | ||
(J) Urology; | ||
(K) Behavioral Health; | ||
(L) Allergy/Immunology; | ||
(M) Chiropractic; | ||
(N) Dermatology; | ||
(O) Endocrinology; | ||
(P) Ears, Nose, and Throat (ENT)/Otolaryngology; | ||
(Q) Infectious Disease; | ||
(R) Nephrology; | ||
(S) Neurosurgery; | ||
(T) Orthopedic Surgery; | ||
(U) Physiatry/Rehabilitative; | ||
(V) Plastic Surgery; | ||
(W) Pulmonary; | ||
(X) Rheumatology; | ||
(Y) Anesthesiology; | ||
(Z) Pain Medicine; | ||
(AA) Pediatric Specialty Services; | ||
(BB) Outpatient Dialysis; and | ||
(CC) HIV. | ||
(2) The Director shall establish a process for the | ||
review of the adequacy of these standards, along with an | ||
assessment of additional specialties to be included in the |
list under this subsection (c). | ||
(d) The network plan shall demonstrate to the Director | ||
maximum travel and distance standards for plan beneficiaries, | ||
which shall be established annually by the Department in | ||
consultation with the Department of Public Health based upon | ||
the guidance from the federal Centers for Medicare and | ||
Medicaid Services. These standards shall consist of the | ||
maximum minutes or miles to be traveled by a plan beneficiary | ||
for each county type, such as large counties, metro counties, | ||
or rural counties as defined by Department rule. | ||
The maximum travel time and distance standards must | ||
include standards for each physician and other provider | ||
category listed for which ratios have been established. | ||
The Director shall establish a process for the review of | ||
the adequacy of these standards along with an assessment of | ||
additional specialties to be included in the list under this | ||
subsection (d). | ||
(d-5)(1) Every insurer shall ensure that beneficiaries | ||
have timely and proximate access to treatment for mental, | ||
emotional, nervous, or substance use disorders or conditions | ||
in accordance with the provisions of paragraph (4) of | ||
subsection (a) of Section 370c of the Illinois Insurance Code. | ||
Insurers shall use a comparable process, strategy, evidentiary | ||
standard, and other factors in the development and application | ||
of the network adequacy standards for timely and proximate | ||
access to treatment for mental, emotional, nervous, or |
substance use disorders or conditions and those for the access | ||
to treatment for medical and surgical conditions. As such, the | ||
network adequacy standards for timely and proximate access | ||
shall equally be applied to treatment facilities and providers | ||
for mental, emotional, nervous, or substance use disorders or | ||
conditions and specialists providing medical or surgical | ||
benefits pursuant to the parity requirements of Section 370c.1 | ||
of the Illinois Insurance Code and the federal Paul Wellstone | ||
and Pete Domenici Mental Health Parity and Addiction Equity | ||
Act of 2008. Notwithstanding the foregoing, the network | ||
adequacy standards for timely and proximate access to | ||
treatment for mental, emotional, nervous, or substance use | ||
disorders or conditions shall, at a minimum, satisfy the | ||
following requirements: | ||
(A) For beneficiaries residing in the metropolitan | ||
counties of Cook, DuPage, Kane, Lake, McHenry, and Will, | ||
network adequacy standards for timely and proximate access | ||
to treatment for mental, emotional, nervous, or substance | ||
use disorders or conditions means a beneficiary shall not | ||
have to travel longer than 30 minutes or 30 miles from the | ||
beneficiary's residence to receive outpatient treatment | ||
for mental, emotional, nervous, or substance use disorders | ||
or conditions. Beneficiaries shall not be required to wait | ||
longer than 10 business days between requesting an initial | ||
appointment and being seen by the facility or provider of | ||
mental, emotional, nervous, or substance use disorders or |
conditions for outpatient treatment or to wait longer than | ||
20 business days between requesting a repeat or follow-up | ||
appointment and being seen by the facility or provider of | ||
mental, emotional, nervous, or substance use disorders or | ||
conditions for outpatient treatment; however, subject to | ||
the protections of paragraph (3) of this subsection, a | ||
network plan shall not be held responsible if the | ||
beneficiary or provider voluntarily chooses to schedule an | ||
appointment outside of these required time frames. | ||
(B) For beneficiaries residing in Illinois counties | ||
other than those counties listed in subparagraph (A) of | ||
this paragraph, network adequacy standards for timely and | ||
proximate access to treatment for mental, emotional, | ||
nervous, or substance use disorders or conditions means a | ||
beneficiary shall not have to travel longer than 60 | ||
minutes or 60 miles from the beneficiary's residence to | ||
receive outpatient treatment for mental, emotional, | ||
nervous, or substance use disorders or conditions. | ||
Beneficiaries shall not be required to wait longer than 10 | ||
business days between requesting an initial appointment | ||
and being seen by the facility or provider of mental, | ||
emotional, nervous, or substance use disorders or | ||
conditions for outpatient treatment or to wait longer than | ||
20 business days between requesting a repeat or follow-up | ||
appointment and being seen by the facility or provider of | ||
mental, emotional, nervous, or substance use disorders or |
conditions for outpatient treatment; however, subject to | ||
the protections of paragraph (3) of this subsection, a | ||
network plan shall not be held responsible if the | ||
beneficiary or provider voluntarily chooses to schedule an | ||
appointment outside of these required time frames. | ||
(2) For beneficiaries residing in all Illinois counties, | ||
network adequacy standards for timely and proximate access to | ||
treatment for mental, emotional, nervous, or substance use | ||
disorders or conditions means a beneficiary shall not have to | ||
travel longer than 60 minutes or 60 miles from the | ||
beneficiary's residence to receive inpatient or residential | ||
treatment for mental, emotional, nervous, or substance use | ||
disorders or conditions. | ||
(3) If there is no in-network facility or provider | ||
available for a beneficiary to receive timely and proximate | ||
access to treatment for mental, emotional, nervous, or | ||
substance use disorders or conditions in accordance with the | ||
network adequacy standards outlined in this subsection, the | ||
insurer shall provide necessary exceptions to its network to | ||
ensure admission and treatment with a provider or at a | ||
treatment facility in accordance with the network adequacy | ||
standards in this subsection. | ||
(e) Except for network plans solely offered as a group | ||
health plan, these ratio and time and distance standards apply | ||
to the lowest cost-sharing tier of any tiered network. | ||
(f) The network plan may consider use of other health care |
service delivery options, such as telemedicine or telehealth, | ||
mobile clinics, and centers of excellence, or other ways of | ||
delivering care to partially meet the requirements set under | ||
this Section. | ||
(g) Except for the requirements set forth in subsection | ||
(d-5), insurers who are not able to comply with the provider | ||
ratios and time and distance standards established by the | ||
Department may request an exception to these requirements from | ||
the Department. The Department may grant an exception in the | ||
following circumstances: | ||
(1) if no providers or facilities meet the specific | ||
time and distance standard in a specific service area and | ||
the insurer (i) discloses information on the distance and | ||
travel time points that beneficiaries would have to travel | ||
beyond the required criterion to reach the next closest | ||
contracted provider outside of the service area and (ii) | ||
provides contact information, including names, addresses, | ||
and phone numbers for the next closest contracted provider | ||
or facility; | ||
(2) if patterns of care in the service area do not | ||
support the need for the requested number of provider or | ||
facility type and the insurer provides data on local | ||
patterns of care, such as claims data, referral patterns, | ||
or local provider interviews, indicating where the | ||
beneficiaries currently seek this type of care or where | ||
the physicians currently refer beneficiaries, or both; or |
(3) other circumstances deemed appropriate by the | ||
Department consistent with the requirements of this Act. | ||
(h) Insurers are required to report to the Director any | ||
material change to an approved network plan within 15 days | ||
after the change occurs and any change that would result in | ||
failure to meet the requirements of this Act. Upon notice from | ||
the insurer, the Director shall reevaluate the network plan's | ||
compliance with the network adequacy and transparency | ||
standards of this Act. | ||
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; | ||
102-1117, eff. 1-13-23.) | ||
Section 20. The Health Maintenance Organization Act is | ||
amended by changing Section 5-3 as follows: | ||
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | ||
Sec. 5-3. Insurance Code provisions. | ||
(a) Health Maintenance Organizations shall be subject to | ||
the provisions of Sections 133, 134, 136, 137, 139, 140, | ||
141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, | ||
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, | ||
155.49, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, | ||
356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | ||
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||
356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | ||
356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, |
356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | ||
356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, | ||
356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | ||
356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | ||
356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | ||
356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||
368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||
408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | ||
subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||
Illinois Insurance Code. | ||
(b) For purposes of the Illinois Insurance Code, except | ||
for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||
Health Maintenance Organizations in the following categories | ||
are deemed to be "domestic companies": | ||
(1) a corporation authorized under the Dental Service | ||
Plan Act or the Voluntary Health Services Plans Act; | ||
(2) a corporation organized under the laws of this | ||
State; or | ||
(3) a corporation organized under the laws of another | ||
state, 30% or more of the enrollees of which are residents | ||
of this State, except a corporation subject to | ||
substantially the same requirements in its state of | ||
organization as is a "domestic company" under Article VIII | ||
1/2 of the Illinois Insurance Code. | ||
(c) In considering the merger, consolidation, or other |
acquisition of control of a Health Maintenance Organization | ||
pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||
(1) the Director shall give primary consideration to | ||
the continuation of benefits to enrollees and the | ||
financial conditions of the acquired Health Maintenance | ||
Organization after the merger, consolidation, or other | ||
acquisition of control takes effect; | ||
(2)(i) the criteria specified in subsection (1)(b) of | ||
Section 131.8 of the Illinois Insurance Code shall not | ||
apply and (ii) the Director, in making his determination | ||
with respect to the merger, consolidation, or other | ||
acquisition of control, need not take into account the | ||
effect on competition of the merger, consolidation, or | ||
other acquisition of control; | ||
(3) the Director shall have the power to require the | ||
following information: | ||
(A) certification by an independent actuary of the | ||
adequacy of the reserves of the Health Maintenance | ||
Organization sought to be acquired; | ||
(B) pro forma financial statements reflecting the | ||
combined balance sheets of the acquiring company and | ||
the Health Maintenance Organization sought to be | ||
acquired as of the end of the preceding year and as of | ||
a date 90 days prior to the acquisition, as well as pro | ||
forma financial statements reflecting projected | ||
combined operation for a period of 2 years; |
(C) a pro forma business plan detailing an | ||
acquiring party's plans with respect to the operation | ||
of the Health Maintenance Organization sought to be | ||
acquired for a period of not less than 3 years; and | ||
(D) such other information as the Director shall | ||
require. | ||
(d) The provisions of Article VIII 1/2 of the Illinois | ||
Insurance Code and this Section 5-3 shall apply to the sale by | ||
any health maintenance organization of greater than 10% of its | ||
enrollee population (including , without limitation , the health | ||
maintenance organization's right, title, and interest in and | ||
to its health care certificates). | ||
(e) In considering any management contract or service | ||
agreement subject to Section 141.1 of the Illinois Insurance | ||
Code, the Director (i) shall, in addition to the criteria | ||
specified in Section 141.2 of the Illinois Insurance Code, | ||
take into account the effect of the management contract or | ||
service agreement on the continuation of benefits to enrollees | ||
and the financial condition of the health maintenance | ||
organization to be managed or serviced, and (ii) need not take | ||
into account the effect of the management contract or service | ||
agreement on competition. | ||
(f) Except for small employer groups as defined in the | ||
Small Employer Rating, Renewability and Portability Health | ||
Insurance Act and except for medicare supplement policies as | ||
defined in Section 363 of the Illinois Insurance Code, a |
Health Maintenance Organization may by contract agree with a | ||
group or other enrollment unit to effect refunds or charge | ||
additional premiums under the following terms and conditions: | ||
(i) the amount of, and other terms and conditions with | ||
respect to, the refund or additional premium are set forth | ||
in the group or enrollment unit contract agreed in advance | ||
of the period for which a refund is to be paid or | ||
additional premium is to be charged (which period shall | ||
not be less than one year); and | ||
(ii) the amount of the refund or additional premium | ||
shall not exceed 20% of the Health Maintenance | ||
Organization's profitable or unprofitable experience with | ||
respect to the group or other enrollment unit for the | ||
period (and, for purposes of a refund or additional | ||
premium, the profitable or unprofitable experience shall | ||
be calculated taking into account a pro rata share of the | ||
Health Maintenance Organization's administrative and | ||
marketing expenses, but shall not include any refund to be | ||
made or additional premium to be paid pursuant to this | ||
subsection (f)). The Health Maintenance Organization and | ||
the group or enrollment unit may agree that the profitable | ||
or unprofitable experience may be calculated taking into | ||
account the refund period and the immediately preceding 2 | ||
plan years. | ||
The Health Maintenance Organization shall include a | ||
statement in the evidence of coverage issued to each enrollee |
describing the possibility of a refund or additional premium, | ||
and upon request of any group or enrollment unit, provide to | ||
the group or enrollment unit a description of the method used | ||
to calculate (1) the Health Maintenance Organization's | ||
profitable experience with respect to the group or enrollment | ||
unit and the resulting refund to the group or enrollment unit | ||
or (2) the Health Maintenance Organization's unprofitable | ||
experience with respect to the group or enrollment unit and | ||
the resulting additional premium to be paid by the group or | ||
enrollment unit. | ||
In no event shall the Illinois Health Maintenance | ||
Organization Guaranty Association be liable to pay any | ||
contractual obligation of an insolvent organization to pay any | ||
refund authorized under this Section. | ||
(g) Rulemaking authority to implement Public Act 95-1045, | ||
if any, is conditioned on the rules being adopted in | ||
accordance with all provisions of the Illinois Administrative | ||
Procedure Act and all rules and procedures of the Joint | ||
Committee on Administrative Rules; any purported rule not so | ||
adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, |
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||
eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | ||
Section 25. The Limited Health Service Organization Act is | ||
amended by changing Section 4003 as follows: | ||
(215 ILCS 130/4003) (from Ch. 73, par. 1504-3) | ||
Sec. 4003. Illinois Insurance Code provisions. Limited | ||
health service organizations shall be subject to the | ||
provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | ||
141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153, | ||
154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, | ||
355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, | ||
356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | ||
356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | ||
356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | ||
364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, | ||
444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, | ||
XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. | ||
Nothing in this Section shall require a limited health care | ||
plan to cover any service that is not a limited health service. | ||
For purposes of the Illinois Insurance Code, except for | ||
Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited | ||
health service organizations in the following categories are |
deemed to be domestic companies: | ||
(1) a corporation under the laws of this State; or | ||
(2) a corporation organized under the laws of another | ||
state, 30% or more of the enrollees of which are residents | ||
of this State, except a corporation subject to | ||
substantially the same requirements in its state of | ||
organization as is a domestic company under Article VIII | ||
1/2 of the Illinois Insurance Code. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | ||
1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | ||
eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | ||
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | ||
1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||
eff. 1-1-24; revised 8-29-23.) | ||
Section 30. The Managed Care Reform and Patient Rights Act | ||
is amended by changing Sections 10, 45, and 85 as follows: | ||
(215 ILCS 134/10) | ||
Sec. 10. Definitions. In this Act: | ||
For a health care plan under Section 45 or for a | ||
utilization review program under Section 85, "adverse | ||
determination" has the meaning given to that term in Section | ||
10 of the Health Carrier External Review Act "Adverse | ||
determination" means a determination by a health care plan |
under Section 45 or by a utilization review program under | ||
Section 85 that a health care service is not medically | ||
necessary . | ||
"Clinical peer" means a health care professional who is in | ||
the same profession and the same or similar specialty as the | ||
health care provider who typically manages the medical | ||
condition, procedures, or treatment under review. | ||
"Department" means the Department of Insurance. | ||
"Emergency medical condition" means a medical condition | ||
manifesting itself by acute symptoms of sufficient severity, | ||
regardless of the final diagnosis given, such that a prudent | ||
layperson, who possesses an average knowledge of health and | ||
medicine, could reasonably expect the absence of immediate | ||
medical attention to result in: | ||
(1) placing the health of the individual (or, with | ||
respect to a pregnant woman, the health of the woman or her | ||
unborn child) in serious jeopardy; | ||
(2) serious impairment to bodily functions; | ||
(3) serious dysfunction of any bodily organ or part; | ||
(4) inadequately controlled pain; or | ||
(5) with respect to a pregnant woman who is having | ||
contractions: | ||
(A) inadequate time to complete a safe transfer to | ||
another hospital before delivery; or | ||
(B) a transfer to another hospital may pose a | ||
threat to the health or safety of the woman or unborn |
child. | ||
"Emergency medical screening examination" means a medical | ||
screening examination and evaluation by a physician licensed | ||
to practice medicine in all its branches, or to the extent | ||
permitted by applicable laws, by other appropriately licensed | ||
personnel under the supervision of or in collaboration with a | ||
physician licensed to practice medicine in all its branches to | ||
determine whether the need for emergency services exists. | ||
"Emergency services" means, with respect to an enrollee of | ||
a health care plan, transportation services, including but not | ||
limited to ambulance services, and covered inpatient and | ||
outpatient hospital services furnished by a provider qualified | ||
to furnish those services that are needed to evaluate or | ||
stabilize an emergency medical condition. "Emergency services" | ||
does not refer to post-stabilization medical services. | ||
"Enrollee" means any person and his or her dependents | ||
enrolled in or covered by a health care plan. | ||
"Health care plan" means a plan, including, but not | ||
limited to, a health maintenance organization, a managed care | ||
community network as defined in the Illinois Public Aid Code, | ||
or an accountable care entity as defined in the Illinois | ||
Public Aid Code that receives capitated payments to cover | ||
medical services from the Department of Healthcare and Family | ||
Services, that establishes, operates, or maintains a network | ||
of health care providers that has entered into an agreement | ||
with the plan to provide health care services to enrollees to |
whom the plan has the ultimate obligation to arrange for the | ||
provision of or payment for services through organizational | ||
arrangements for ongoing quality assurance, utilization review | ||
programs, or dispute resolution. Nothing in this definition | ||
shall be construed to mean that an independent practice | ||
association or a physician hospital organization that | ||
subcontracts with a health care plan is, for purposes of that | ||
subcontract, a health care plan. | ||
For purposes of this definition, "health care plan" shall | ||
not include the following: | ||
(1) indemnity health insurance policies including | ||
those using a contracted provider network; | ||
(2) health care plans that offer only dental or only | ||
vision coverage; | ||
(3) preferred provider administrators, as defined in | ||
Section 370g(g) of the Illinois Insurance Code; | ||
(4) employee or employer self-insured health benefit | ||
plans under the federal Employee Retirement Income | ||
Security Act of 1974; | ||
(5) health care provided pursuant to the Workers' | ||
Compensation Act or the Workers' Occupational Diseases | ||
Act; and | ||
(6) except with respect to subsections (a) and (b) of | ||
Section 65 and subsection (a-5) of Section 70, | ||
not-for-profit voluntary health services plans with health | ||
maintenance organization authority in existence as of |
January 1, 1999 that are affiliated with a union and that | ||
only extend coverage to union members and their | ||
dependents. | ||
"Health care professional" means a physician, a registered | ||
professional nurse, or other individual appropriately licensed | ||
or registered to provide health care services. | ||
"Health care provider" means any physician, hospital | ||
facility, facility licensed under the Nursing Home Care Act, | ||
long-term care facility as defined in Section 1-113 of the | ||
Nursing Home Care Act, or other person that is licensed or | ||
otherwise authorized to deliver health care services. Nothing | ||
in this Act shall be construed to define Independent Practice | ||
Associations or Physician-Hospital Organizations as health | ||
care providers. | ||
"Health care services" means any services included in the | ||
furnishing to any individual of medical care, or the | ||
hospitalization incident to the furnishing of such care, as | ||
well as the furnishing to any person of any and all other | ||
services for the purpose of preventing, alleviating, curing, | ||
or healing human illness or injury including behavioral | ||
health, mental health, home health, and pharmaceutical | ||
services and products. | ||
"Medical director" means a physician licensed in any state | ||
to practice medicine in all its branches appointed by a health | ||
care plan. | ||
"Person" means a corporation, association, partnership, |
limited liability company, sole proprietorship, or any other | ||
legal entity. | ||
"Physician" means a person licensed under the Medical | ||
Practice Act of 1987. | ||
"Post-stabilization medical services" means health care | ||
services provided to an enrollee that are furnished in a | ||
licensed hospital by a provider that is qualified to furnish | ||
such services, and determined to be medically necessary and | ||
directly related to the emergency medical condition following | ||
stabilization. | ||
"Stabilization" means, with respect to an emergency | ||
medical condition, to provide such medical treatment of the | ||
condition as may be necessary to assure, within reasonable | ||
medical probability, that no material deterioration of the | ||
condition is likely to result. | ||
"Utilization review" means the evaluation , including any | ||
evaluation based on an algorithmic automated process, of the | ||
medical necessity, appropriateness, and efficiency of the use | ||
of health care services, procedures, and facilities. | ||
"Utilization review program" means a program established | ||
by a person to perform utilization review. | ||
(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.) | ||
(215 ILCS 134/45) | ||
Sec. 45. Health care services appeals, complaints, and | ||
external independent reviews. |
(a) A health care plan shall establish and maintain an | ||
appeals procedure as outlined in this Act. Compliance with | ||
this Act's appeals procedures shall satisfy a health care | ||
plan's obligation to provide appeal procedures under any other | ||
State law or rules. All appeals of a health care plan's | ||
administrative determinations and complaints regarding its | ||
administrative decisions shall be handled as required under | ||
Section 50. | ||
(b) When an appeal concerns a decision or action by a | ||
health care plan, its employees, or its subcontractors that | ||
relates to (i) health care services, including, but not | ||
limited to, procedures or treatments, for an enrollee with an | ||
ongoing course of treatment ordered by a health care provider, | ||
the denial of which could significantly increase the risk to | ||
an enrollee's health, or (ii) a treatment referral, service, | ||
procedure, or other health care service, the denial of which | ||
could significantly increase the risk to an enrollee's health, | ||
the health care plan must allow for the filing of an appeal | ||
either orally or in writing. Upon submission of the appeal, a | ||
health care plan must notify the party filing the appeal, as | ||
soon as possible, but in no event more than 24 hours after the | ||
submission of the appeal, of all information that the plan | ||
requires to evaluate the appeal. The health care plan shall | ||
render a decision on the appeal within 24 hours after receipt | ||
of the required information. The health care plan shall notify | ||
the party filing the appeal and the enrollee, enrollee's |
primary care physician, and any health care provider who | ||
recommended the health care service involved in the appeal of | ||
its decision orally followed-up by a written notice of the | ||
determination. | ||
(c) For all appeals related to health care services | ||
including, but not limited to, procedures or treatments for an | ||
enrollee and not covered by subsection (b) above, the health | ||
care plan shall establish a procedure for the filing of such | ||
appeals. Upon submission of an appeal under this subsection, a | ||
health care plan must notify the party filing an appeal, | ||
within 3 business days, of all information that the plan | ||
requires to evaluate the appeal. The health care plan shall | ||
render a decision on the appeal within 15 business days after | ||
receipt of the required information. The health care plan | ||
shall notify the party filing the appeal, the enrollee, the | ||
enrollee's primary care physician, and any health care | ||
provider who recommended the health care service involved in | ||
the appeal orally of its decision followed-up by a written | ||
notice of the determination. | ||
(d) An appeal under subsection (b) or (c) may be filed by | ||
the enrollee, the enrollee's designee or guardian, the | ||
enrollee's primary care physician, or the enrollee's health | ||
care provider. A health care plan shall designate a clinical | ||
peer to review appeals, because these appeals pertain to | ||
medical or clinical matters and such an appeal must be | ||
reviewed by an appropriate health care professional. No one |
reviewing an appeal may have had any involvement in the | ||
initial determination that is the subject of the appeal. The | ||
written notice of determination required under subsections (b) | ||
and (c) shall include (i) clear and detailed reasons for the | ||
determination, (ii) the medical or clinical criteria for the | ||
determination, which shall be based upon sound clinical | ||
evidence and reviewed on a periodic basis, and (iii) in the | ||
case of an adverse determination, the procedures for | ||
requesting an external independent review as provided by the | ||
Illinois Health Carrier External Review Act. | ||
(e) If an appeal filed under subsection (b) or (c) is | ||
denied for a reason including, but not limited to, the | ||
service, procedure, or treatment is not viewed as medically | ||
necessary, denial of specific tests or procedures, denial of | ||
referral to specialist physicians or denial of hospitalization | ||
requests or length of stay requests, any involved party may | ||
request an external independent review as provided by the | ||
Illinois Health Carrier External Review Act. | ||
(f) Until July 1, 2013, if an external independent review | ||
decision made pursuant to the Illinois Health Carrier External | ||
Review Act upholds a determination adverse to the covered | ||
person, the covered person has the right to appeal the final | ||
decision to the Department; if the external review decision is | ||
found by the Director to have been arbitrary and capricious, | ||
then the Director, with consultation from a licensed medical | ||
professional, may overturn the external review decision and |
require the health carrier to pay for the health care service | ||
or treatment; such decision, if any, shall be made solely on | ||
the legal or medical merits of the claim. If an external review | ||
decision is overturned by the Director pursuant to this | ||
Section and the health carrier so requests, then the Director | ||
shall assign a new independent review organization to | ||
reconsider the overturned decision. The new independent review | ||
organization shall follow subsection (d) of Section 40 of the | ||
Health Carrier External Review Act in rendering a decision. | ||
(g) Future contractual or employment action by the health | ||
care plan regarding the patient's physician or other health | ||
care provider shall not be based solely on the physician's or | ||
other health care provider's participation in health care | ||
services appeals, complaints, or external independent reviews | ||
under the Illinois Health Carrier External Review Act. | ||
(h) Nothing in this Section shall be construed to require | ||
a health care plan to pay for a health care service not covered | ||
under the enrollee's certificate of coverage or policy. | ||
(i) Even if a health care plan or other utilization review | ||
program uses an algorithmic automated process in the course of | ||
utilization review for medical necessity, the health care plan | ||
or other utilization review program shall ensure that only a | ||
clinical peer makes any adverse determination based on medical | ||
necessity and that any subsequent appeal is processed as | ||
required by this Section, including the restriction that only | ||
a clinical peer may review an appeal. A health care plan or |
other utilization review program using an automated process | ||
shall have the accreditation and the policies and procedures | ||
required by subsection (b-10) of Section 85 of this Act. | ||
(Source: P.A. 96-857, eff. 7-1-10 .) | ||
(215 ILCS 134/85) | ||
Sec. 85. Utilization review program registration. | ||
(a) No person may conduct a utilization review program in | ||
this State unless once every 2 years the person registers the | ||
utilization review program with the Department and provides | ||
proof of current accreditation for itself and its | ||
subcontractors certifies compliance with the Health | ||
Utilization Management Standards of the Utilization Review | ||
Accreditation Commission, the National Committee for Quality | ||
Assurance, or another accreditation entity authorized under | ||
this Section Health Utilization Management Standards of the | ||
American Accreditation Healthcare Commission (URAC) sufficient | ||
to achieve American Accreditation Healthcare Commission (URAC) | ||
accreditation or submits evidence of accreditation by the | ||
American Accreditation Healthcare Commission (URAC) for its | ||
Health Utilization Management Standards. Nothing in this Act | ||
shall be construed to require a health care plan or its | ||
subcontractors to become American Accreditation Healthcare | ||
Commission (URAC) accredited . | ||
(b) In addition, the Director of the Department, in | ||
consultation with the Director of the Department of Public |
Health, may certify alternative utilization review standards | ||
of national accreditation organizations or entities in order | ||
for plans to comply with this Section. Any alternative | ||
utilization review standards shall meet or exceed those | ||
standards required under subsection (a). | ||
(b-5) The Department shall recognize the Accreditation | ||
Association for Ambulatory Health Care among the list of | ||
accreditors from which utilization organizations may receive | ||
accreditation and qualify for reduced registration and renewal | ||
fees. | ||
(b-10) Utilization review programs that use algorithmic | ||
automated processes to decide whether to render adverse | ||
determinations based on medical necessity in the course of | ||
utilization review shall use objective, evidence-based | ||
criteria compliant with the accreditation requirements of the | ||
Health Utilization Management Standards of the Utilization | ||
Review Accreditation Commission or the National Committee for | ||
Quality Assurance (NCQA) and shall provide proof of such | ||
compliance to the Department with the registration required | ||
under subsection (a), including any renewal registrations. | ||
Nothing in this subsection supersedes paragraph (2) of | ||
subsection (e). The utilization review program shall include, | ||
with its registration materials, attachments that contain | ||
policies and procedures: | ||
(1) to ensure that licensed physicians with relevant | ||
board certifications establish all criteria that the |
algorithmic automated process uses for utilization review; | ||
and | ||
(2) for a program integrity system that, both before | ||
new or revised criteria are used for utilization review | ||
and when implementation errors in the algorithmic | ||
automated process are identified after new or revised | ||
criteria go into effect, requires licensed physicians with | ||
relevant board certifications to verify that the | ||
algorithmic automated process and corrections to it yield | ||
results consistent with the criteria for their certified | ||
field. | ||
(c) The provisions of this Section do not apply to: | ||
(1) persons providing utilization review program | ||
services only to the federal government; | ||
(2) self-insured health plans under the federal | ||
Employee Retirement Income Security Act of 1974, however, | ||
this Section does apply to persons conducting a | ||
utilization review program on behalf of these health | ||
plans; | ||
(3) hospitals and medical groups performing | ||
utilization review activities for internal purposes unless | ||
the utilization review program is conducted for another | ||
person. | ||
Nothing in this Act prohibits a health care plan or other | ||
entity from contractually requiring an entity designated in | ||
item (3) of this subsection to adhere to the utilization |
review program requirements of this Act. | ||
(d) This registration shall include submission of all of | ||
the following information regarding utilization review program | ||
activities: | ||
(1) The name, address, and telephone number of the | ||
utilization review programs. | ||
(2) The organization and governing structure of the | ||
utilization review programs. | ||
(3) The number of lives for which utilization review | ||
is conducted by each utilization review program. | ||
(4) Hours of operation of each utilization review | ||
program. | ||
(5) Description of the grievance process for each | ||
utilization review program. | ||
(6) Number of covered lives for which utilization | ||
review was conducted for the previous calendar year for | ||
each utilization review program. | ||
(7) Written policies and procedures for protecting | ||
confidential information according to applicable State and | ||
federal laws for each utilization review program. | ||
(e) (1) A utilization review program shall have written | ||
procedures for assuring that patient-specific information | ||
obtained during the process of utilization review will be: | ||
(A) kept confidential in accordance with applicable | ||
State and federal laws; and | ||
(B) shared only with the enrollee, the enrollee's |
designee, the enrollee's health care provider, and those | ||
who are authorized by law to receive the information. | ||
Summary data shall not be considered confidential if it | ||
does not provide information to allow identification of | ||
individual patients or health care providers. | ||
(2) Only a clinical peer health care professional may | ||
make adverse determinations regarding the medical | ||
necessity of health care services during the course of | ||
utilization review. Either a health care professional or | ||
an accredited algorithmic automated process, or both in | ||
combination, may certify the medical necessity of a health | ||
care service in accordance with accreditation standards. | ||
Nothing in this subsection prohibits an accredited | ||
algorithmic automated process from being used to refer a | ||
case to a clinical peer for a potential adverse | ||
determination. | ||
(3) When making retrospective reviews, utilization | ||
review programs shall base reviews solely on the medical | ||
information available to the attending physician or | ||
ordering provider at the time the health care services | ||
were provided. This paragraph includes billing records and | ||
diagnosis or procedure codes that substantively contain | ||
the same medical information to an equal or lesser degree | ||
of specificity as the records the attending physician or | ||
ordering provider directly consulted at the time health | ||
care services were provided. |
(4) When making prospective, concurrent, and | ||
retrospective determinations, utilization review programs | ||
shall collect only information that is necessary to make | ||
the determination and shall not routinely require health | ||
care providers to numerically code diagnoses or procedures | ||
to be considered for certification, unless required under | ||
State or federal Medicare or Medicaid rules or | ||
regulations, but may request such code if available, or | ||
routinely request copies of medical records of all | ||
enrollees reviewed. During prospective or concurrent | ||
review, copies of medical records shall only be required | ||
when necessary to verify that the health care services | ||
subject to review are medically necessary. In these cases, | ||
only the necessary or relevant sections of the medical | ||
record shall be required. | ||
(f) If the Department finds that a utilization review | ||
program is not in compliance with this Section, the Department | ||
shall issue a corrective action plan and allow a reasonable | ||
amount of time for compliance with the plan. If the | ||
utilization review program does not come into compliance, the | ||
Department may issue a cease and desist order. Before issuing | ||
a cease and desist order under this Section, the Department | ||
shall provide the utilization review program with a written | ||
notice of the reasons for the order and allow a reasonable | ||
amount of time to supply additional information demonstrating | ||
compliance with requirements of this Section and to request a |
hearing. The hearing notice shall be sent by certified mail, | ||
return receipt requested, and the hearing shall be conducted | ||
in accordance with the Illinois Administrative Procedure Act. | ||
(g) A utilization review program subject to a corrective | ||
action may continue to conduct business until a final decision | ||
has been issued by the Department. | ||
(h) Any adverse determination made by a health care plan | ||
or its subcontractors may be appealed in accordance with | ||
subsection (f) of Section 45. | ||
(i) The Director may by rule establish a registration fee | ||
for each person conducting a utilization review program. All | ||
fees paid to and collected by the Director under this Section | ||
shall be deposited into the Insurance Producer Administration | ||
Fund. | ||
(Source: P.A. 99-111, eff. 1-1-16 .) | ||
Section 35. The Voluntary Health Services Plans Act is | ||
amended by changing Section 10 as follows: | ||
(215 ILCS 165/10) (from Ch. 32, par. 604) | ||
Sec. 10. Application of Insurance Code provisions. Health | ||
services plan corporations and all persons interested therein | ||
or dealing therewith shall be subject to the provisions of | ||
Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, | ||
143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, | ||
355b, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, |
356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, | ||
356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | ||
356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, | ||
356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, | ||
356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | ||
356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, | ||
356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401, | ||
401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) | ||
and (15) of Section 367 of the Illinois Insurance Code. | ||
Rulemaking authority to implement Public Act 95-1045, if | ||
any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for | ||
whatever reason, is unauthorized. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. | ||
10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, | ||
eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | ||
102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. | ||
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||
103-551, eff. 8-11-23; revised 8-29-23.) | ||
Section 40. The Health Carrier External Review Act is | ||
amended by changing Section 10 as follows: |
(215 ILCS 180/10) | ||
Sec. 10. Definitions. For the purposes of this Act: | ||
"Adverse determination" means: | ||
(1) a determination by a health carrier or its | ||
designee utilization review organization that, based upon | ||
the health information provided for a covered person , a | ||
request for a benefit , including any quantity, frequency, | ||
duration, or other measurement of a benefit, under the | ||
health carrier's health benefit plan upon application of | ||
any utilization review technique does not meet the health | ||
carrier's requirements for medical necessity, | ||
appropriateness, health care setting, level of care, or | ||
effectiveness or is determined to be experimental or | ||
investigational and the requested benefit is therefore | ||
denied, reduced, or terminated or payment is not provided | ||
or made, in whole or in part, for the benefit; | ||
(2) the denial, reduction, or termination of or | ||
failure to provide or make payment, in whole or in part, | ||
for a benefit based on a determination by a health carrier | ||
or its designee utilization review organization that a | ||
preexisting condition was present before the effective | ||
date of coverage; or | ||
(3) a rescission of coverage determination, which does | ||
not include a cancellation or discontinuance of coverage | ||
that is attributable to a failure to timely pay required |
premiums or contributions towards the cost of coverage. | ||
"Adverse determination" includes unilateral | ||
determinations that replace the requested health care service | ||
with an approval of an alternative health care service without | ||
the agreement of the covered person or the covered person's | ||
attending provider for the requested health care service, or | ||
that condition approval of the requested service on first | ||
trying an alternative health care service, either if the | ||
request was made under a medical exceptions procedure, or if | ||
all of the following are true: (1) the requested service was | ||
not excluded by name, description, or service category under | ||
the written terms of coverage, (2) the alternative health care | ||
service poses no greater risk to the patient based on | ||
generally accepted standards of care, and (3) the alternative | ||
health care service is at least as likely to produce the same | ||
or better effect on the covered person's health as the | ||
requested service based on generally accepted standards of | ||
care. "Adverse determination" includes determinations made | ||
based on any source of health information pertaining to the | ||
covered person that is used to deny, reduce, replace, | ||
condition, or terminate the benefit or payment. "Adverse | ||
determination" includes determinations made in response to a | ||
request for authorization when the request was submitted by | ||
the health care provider regardless of whether the provider | ||
gave notice to or obtained the consent of the covered person or | ||
authorized representative to file the request. "Adverse |
determination" does not include substitutions performed under | ||
Section 19.5 or 25 of the Pharmacy Practice Act. | ||
"Authorized representative" means: | ||
(1) a person to whom a covered person has given | ||
express written consent to represent the covered person | ||
for purposes of this Law; | ||
(2) a person authorized by law to provide substituted | ||
consent for a covered person; | ||
(3) a family member of the covered person or the | ||
covered person's treating health care professional when | ||
the covered person is unable to provide consent; | ||
(4) a health care provider when the covered person's | ||
health benefit plan requires that a request for a benefit | ||
under the plan be initiated by the health care provider; | ||
or | ||
(5) in the case of an urgent care request, a health | ||
care provider with knowledge of the covered person's | ||
medical condition. | ||
"Best evidence" means evidence based on: | ||
(1) randomized clinical trials; | ||
(2) if randomized clinical trials are not available, | ||
then cohort studies or case-control studies; | ||
(3) if items (1) and (2) are not available, then | ||
case-series; or | ||
(4) if items (1), (2), and (3) are not available, then | ||
expert opinion. |
"Case-series" means an evaluation of a series of patients | ||
with a particular outcome, without the use of a control group. | ||
"Clinical review criteria" means the written screening | ||
procedures, decision abstracts, clinical protocols, and | ||
practice guidelines used by a health carrier to determine the | ||
necessity and appropriateness of health care services. | ||
"Cohort study" means a prospective evaluation of 2 groups | ||
of patients with only one group of patients receiving specific | ||
intervention. | ||
"Concurrent review" means a review conducted during a | ||
patient's stay or course of treatment in a facility, the | ||
office of a health care professional, or other inpatient or | ||
outpatient health care setting. | ||
"Covered benefits" or "benefits" means those health care | ||
services to which a covered person is entitled under the terms | ||
of a health benefit plan. | ||
"Covered person" means a policyholder, subscriber, | ||
enrollee, or other individual participating in a health | ||
benefit plan. | ||
"Director" means the Director of the Department of | ||
Insurance. | ||
"Emergency medical condition" means a medical condition | ||
manifesting itself by acute symptoms of sufficient severity, | ||
including, but not limited to, severe pain, such that a | ||
prudent layperson who possesses an average knowledge of health | ||
and medicine could reasonably expect the absence of immediate |
medical attention to result in: | ||
(1) placing the health of the individual or, with | ||
respect to a pregnant woman, the health of the woman or her | ||
unborn child, in serious jeopardy; | ||
(2) serious impairment to bodily functions; or | ||
(3) serious dysfunction of any bodily organ or part. | ||
"Emergency services" means health care items and services | ||
furnished or required to evaluate and treat an emergency | ||
medical condition. | ||
"Evidence-based standard" means the conscientious, | ||
explicit, and judicious use of the current best evidence based | ||
on an overall systematic review of the research in making | ||
decisions about the care of individual patients. | ||
"Expert opinion" means a belief or an interpretation by | ||
specialists with experience in a specific area about the | ||
scientific evidence pertaining to a particular service, | ||
intervention, or therapy. | ||
"Facility" means an institution providing health care | ||
services or a health care setting. | ||
"Final adverse determination" means an adverse | ||
determination involving a covered benefit that has been upheld | ||
by a health carrier, or its designee utilization review | ||
organization, at the completion of the health carrier's | ||
internal grievance process procedures as set forth by the | ||
Managed Care Reform and Patient Rights Act or as set forth for | ||
any additional authorization or internal appeal process |
provided by contract between the health carrier and the | ||
provider. "Final adverse determination" includes | ||
determinations made in an appeal of a denial of prior | ||
authorization when the appeal was submitted by the health care | ||
provider regardless of whether the provider gave notice to or | ||
obtained the consent of the covered person or authorized | ||
representative to file an internal appeal . | ||
"Health benefit plan" means a policy, contract, | ||
certificate, plan, or agreement offered or issued by a health | ||
carrier to provide, deliver, arrange for, pay for, or | ||
reimburse any of the costs of health care services. | ||
"Health care provider" or "provider" means a physician, | ||
hospital facility, or other health care practitioner licensed, | ||
accredited, or certified to perform specified health care | ||
services consistent with State law, responsible for | ||
recommending health care services on behalf of a covered | ||
person. | ||
"Health care services" means services for the diagnosis, | ||
prevention, treatment, cure, or relief of a health condition, | ||
illness, injury, or disease. | ||
"Health carrier" means an entity subject to the insurance | ||
laws and regulations of this State, or subject to the | ||
jurisdiction of the Director, that contracts or offers to | ||
contract to provide, deliver, arrange for, pay for, or | ||
reimburse any of the costs of health care services, including | ||
a sickness and accident insurance company, a health |
maintenance organization, or any other entity providing a plan | ||
of health insurance, health benefits, or health care services. | ||
"Health carrier" also means Limited Health Service | ||
Organizations (LHSO) and Voluntary Health Service Plans. | ||
"Health information" means information or data, whether | ||
oral or recorded in any form or medium, and personal facts or | ||
information about events or relationships that relate to: | ||
(1) the past, present, or future physical, mental, or | ||
behavioral health or condition of an individual or a | ||
member of the individual's family; | ||
(2) the provision of health care services to an | ||
individual; or | ||
(3) payment for the provision of health care services | ||
to an individual. | ||
"Independent review organization" means an entity that | ||
conducts independent external reviews of adverse | ||
determinations and final adverse determinations. | ||
"Medical or scientific evidence" means evidence found in | ||
the following sources: | ||
(1) peer-reviewed scientific studies published in or | ||
accepted for publication by medical journals that meet | ||
nationally recognized requirements for scientific | ||
manuscripts and that submit most of their published | ||
articles for review by experts who are not part of the | ||
editorial staff; | ||
(2) peer-reviewed medical literature, including |
literature relating to therapies reviewed and approved by | ||
a qualified institutional review board, biomedical | ||
compendia, and other medical literature that meet the | ||
criteria of the National Institutes of Health's Library of | ||
Medicine for indexing in Index Medicus (Medline) and | ||
Elsevier Science Ltd. for indexing in Excerpta Medicus | ||
(EMBASE); | ||
(3) medical journals recognized by the Secretary of | ||
Health and Human Services under Section 1861(t)(2) of the | ||
federal Social Security Act; | ||
(4) the following standard reference compendia: | ||
(a) The American Hospital Formulary Service-Drug | ||
Information; | ||
(b) Drug Facts and Comparisons; | ||
(c) The American Dental Association Accepted | ||
Dental Therapeutics; and | ||
(d) The United States Pharmacopoeia-Drug | ||
Information; | ||
(5) findings, studies, or research conducted by or | ||
under the auspices of federal government agencies and | ||
nationally recognized federal research institutes, | ||
including: | ||
(a) the federal Agency for Healthcare Research and | ||
Quality; | ||
(b) the National Institutes of Health; | ||
(c) the National Cancer Institute; |
(d) the National Academy of Sciences; | ||
(e) the Centers for Medicare & Medicaid Services; | ||
(f) the federal Food and Drug Administration; and | ||
(g) any national board recognized by the National | ||
Institutes of Health for the purpose of evaluating the | ||
medical value of health care services; or | ||
(6) any other medical or scientific evidence that is | ||
comparable to the sources listed in items (1) through (5). | ||
"Person" means an individual, a corporation, a | ||
partnership, an association, a joint venture, a joint stock | ||
company, a trust, an unincorporated organization, any similar | ||
entity, or any combination of the foregoing. | ||
"Prospective review" means a review conducted prior to an | ||
admission or the provision of a health care service or a course | ||
of treatment in accordance with a health carrier's requirement | ||
that the health care service or course of treatment, in whole | ||
or in part, be approved prior to its provision. | ||
"Protected health information" means health information | ||
(i) that identifies an individual who is the subject of the | ||
information; or (ii) with respect to which there is a | ||
reasonable basis to believe that the information could be used | ||
to identify an individual. | ||
"Randomized clinical trial" means a controlled prospective | ||
study of patients that have been randomized into an | ||
experimental group and a control group at the beginning of the | ||
study with only the experimental group of patients receiving a |
specific intervention, which includes study of the groups for | ||
variables and anticipated outcomes over time. | ||
"Retrospective review" means any review of a request for a | ||
benefit that is not a concurrent or prospective review | ||
request. "Retrospective review" does not include the review of | ||
a claim that is limited to veracity of documentation or | ||
accuracy of coding. | ||
"Utilization review" has the meaning provided by the | ||
Managed Care Reform and Patient Rights Act. | ||
"Utilization review organization" means a utilization | ||
review program as defined in the Managed Care Reform and | ||
Patient Rights Act. | ||
(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12; | ||
98-756, eff. 7-16-14.) | ||
Section 45. The Prior Authorization Reform Act is amended | ||
by changing Section 55 as follows: | ||
(215 ILCS 200/55) | ||
Sec. 55. Denial or penalty . | ||
(a) The health insurance issuer or its contracted | ||
utilization review organization may not revoke or further | ||
limit, condition, or restrict a previously issued prior | ||
authorization approval while it remains valid under this Act. | ||
(b) Notwithstanding any other provision of law, if a claim | ||
is properly coded and submitted timely to a health insurance |
issuer, the health insurance issuer shall make payment | ||
according to the terms of coverage on claims for health care | ||
services for which prior authorization was required and | ||
approval received before the rendering of health care | ||
services, unless one of the following occurs: | ||
(1) it is timely determined that the enrollee's health | ||
care professional or health care provider knowingly | ||
provided health care services that required prior | ||
authorization from the health insurance issuer or its | ||
contracted utilization review organization without first | ||
obtaining prior authorization for those health care | ||
services; | ||
(2) it is timely determined that the health care | ||
services claimed were not performed; | ||
(3) it is timely determined that the health care | ||
services rendered were contrary to the instructions of the | ||
health insurance issuer or its contracted utilization | ||
review organization or delegated reviewer if contact was | ||
made between those parties before the service being | ||
rendered; | ||
(4) it is timely determined that the enrollee | ||
receiving such health care services was not an enrollee of | ||
the health care plan; or | ||
(5) the approval was based upon a material | ||
misrepresentation by the enrollee, health care | ||
professional, or health care provider; as used in this |
paragraph (5), "material" means a fact or situation that | ||
is not merely technical in nature and results or could | ||
result in a substantial change in the situation. | ||
(c) Nothing in this Section shall preclude a utilization | ||
review organization or a health insurance issuer from | ||
performing post-service reviews of health care claims for | ||
purposes of payment integrity or for the prevention of fraud, | ||
waste, or abuse. | ||
(d) If a health insurance issuer imposes a monetary | ||
penalty on the enrollee for the enrollee's, health care | ||
professional's, or health care provider's failure to obtain | ||
any form of prior authorization for a health care service, the | ||
penalty may not exceed the lesser of: | ||
(1) the actual cost of the health care service; or | ||
(2) $1,000 per occurrence in addition to the plan | ||
cost-sharing provisions. | ||
(e) A health insurance issuer may not require both the | ||
enrollee and the health care professional or health care | ||
provider to obtain any form of prior authorization for the | ||
same instance of a health care service, nor otherwise require | ||
more than one prior authorization for the same instance of a | ||
health care service. | ||
(Source: P.A. 102-409, eff. 1-1-22 .) | ||
Section 99. Effective date. This Act takes effect January | ||
1, 2025. |