SB2152 104TH GENERAL ASSEMBLY

LRB104 11051 BAB 21133 b

104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
SB2152

Introduced 2/7/2025, by Sen. Cristina Castro

SYNOPSIS AS INTRODUCED:

5 ILCS 375/6.11
215 ILCS 200/10
215 ILCS 200/50
215 ILCS 200/65

Amends the Prior Authorization Reform Act. Provides that the Act applies to policies issued or delivered to persons who are enrolled in the State Employee Group Health Insurance Program to the extent required under a provision of the State Employees Group Insurance Act of 1971 concerning required health benefits. Provides that a health insurance issuer shall not require prior authorization where a covered medication, with the exception of benzodiazepines or Schedule II narcotic drugs: (1) is prescribed for the management and treatment of multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, diabetes type 1, diabetes type 2, or pre-diabetes; and (2) is for a patient currently managed with an established treatment regimen for at least 12 months. Provides that nothing in the provision prevents a health care plan from denying an enrollee coverage or imposing a prior authorization requirement if the United States Food and Drug Administration has issued a statement about the drug that calls into question the clinical safety of the drug, the drug manufacturer has notified the United States Food and Drug Administration of a manufacturing discontinuance or potential discontinuance of the drug, or the drug manufacturer has removed the drug from the market. In a provision concerning the length of prior authorization approval for treatment of chronic or long-term condition, excludes a provision of the State Employees Group Insurance Act of 1971 concerning coverage for injectable medicines to improve glucose or weight loss. Effective January 1, 2027.

A BILL FOR

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The State Employees Group Insurance Act of 1971 is amended by changing Section 6.11 as follows:

(5 ILCS 375/6.11)

Sec. 6.11. Required health benefits; Illinois Insurance Code requirements. The program of health benefits shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.2, 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.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, 356z.76, and 356z.77 of the Illinois Insurance Code. The program of health benefits must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance Code, and the Prior Authorization Reform Act. The program of health benefits shall provide the coverage required under Section 356m of the Illinois Insurance Code and, for the employees of the State Employee Group Insurance Program only, the coverage as also provided in Section 6.11B of this Act. The Department of Insurance shall enforce the requirements of this Section with respect to Sections 370c and 370c.1 of the Illinois Insurance Code and the Prior Authorization Reform Act; all other requirements of this Section shall be enforced by the Department of Central Management Services.

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; 102-103, 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; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25; 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)

Section 10. The Prior Authorization Reform Act is amended by changing Sections 10, 50, and 65 as follows:

(215 ILCS 200/10)

Sec. 10. Applicability; scope. This Act applies to health insurance coverage as defined in the Illinois Health Insurance Portability and Accountability Act, policies issued or delivered to persons who are enrolled in the State Employees Group Health Insurance Program to the extent required under Section 6.11 of the State Employees Group Insurance Act of 1971, and policies issued or delivered in this State to the Department of Healthcare and Family Services and providing coverage to persons who are enrolled under Article V of the Illinois Public Aid Code or under the Children's Health Insurance Program Act, amended, delivered, issued, or renewed on or after the effective date of this Act, with the exception of employee or employer self-insured health benefit plans under the federal Employee Retirement Income Security Act of 1974, health care provided pursuant to the Workers' Compensation Act or the Workers' Occupational Diseases Act, county, municipal, and State, employee, unit of local government, or school district health plans. This Act does not diminish a health care plan's duties and responsibilities under other federal or State law or rules promulgated thereunder. This Act is not intended to alter or impede the provisions of any consent decree or judicial order to which the State or any of its agencies is a party.

(Source: P.A. 102-409, eff. 1-1-22.)

(215 ILCS 200/50)

Sec. 50. Limitations on Review of prior authorization requirements.

(a) A health insurance issuer shall not require periodically review its prior authorization requirements and consider removal of prior authorization where a covered medication, with the exception of benzodiazepines or Schedule II narcotic drugs requirements:

(1) is where a medication or procedure prescribed for the management and treatment of multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, diabetes type 1, diabetes type 2, or pre-diabetes is customary and properly indicated or is a treatment for the clinical indication as supported by peer-reviewed medical publications; and or

(2) is for a patient patients currently managed with an established treatment regimen for at least 12 months.

(b) Nothing in this Section prevents a health care plan from denying an enrollee coverage or imposing a prior authorization requirement if the United States Food and Drug Administration has issued a statement about the drug that calls into question the clinical safety of the drug, the drug manufacturer has notified the United States Food and Drug Administration of a manufacturing discontinuance or potential discontinuance of the drug as required by Section 506C of the Federal Food, Drug, and Cosmetic Act, as codified in 21 U.S.C. 356c, or the drug manufacturer has removed the drug from the market.

(c) Except to the extent required by medical exceptions processes for prescription drugs set forth in Section 45.1 of the Managed Care and Patient Rights Act, nothing in this Section shall require a policy to cover any care, treatment, or services for any health condition that the terms of coverage otherwise completely exclude from the policy's covered benefits without regard for whether the care, treatment, or services are medically necessary.

(Source: P.A. 102-409, eff. 1-1-22.)

(215 ILCS 200/65)

Sec. 65. Length of prior authorization approval for treatment for chronic or long-term conditions. If a health insurance issuer requires a prior authorization for a recurring health care service or maintenance medication for the treatment of a chronic or long-term condition other than those specified in Section 50, the approval shall remain valid for the lesser of 12 months from the date the health care professional or health care provider receives the prior authorization approval or the length of the treatment as determined by the patient's health care professional. This Section shall not apply to the prescription of benzodiazepines or Schedule II narcotic drugs, such as opioids. This Section does not apply to Section 6.11C of the State Employees Group Insurance Act of 1971. Except to the extent required by medical exceptions processes for prescription drugs set forth in Section 45.1 of the Managed Care Reform and Patient Rights Act, nothing in this Section shall require a policy to cover any care, treatment, or services for any health condition that the terms of coverage otherwise completely exclude from the policy's covered benefits without regard for whether the care, treatment, or services are medically necessary.

(Source: P.A. 102-409, eff. 1-1-22.)

Section 99. Effective date. This Act takes effect January 1, 2027.