Rep. Anna Moeller

Filed: 3/6/2024

 

 


 

 


 
10300HB5395ham001LRB103 37071 RPS 70534 a

1
AMENDMENT TO HOUSE BILL 5395

2    AMENDMENT NO. ______. Amend House Bill 5395 by replacing
3everything after the enacting clause with the following:
 
4
"Article 1.

 
5    Section 1-1. This Act may be referred to as the Health Care
6Consumer Access and Protection Act.
 
7
Article 2.

 
8    Section 2-5. The Illinois Administrative Procedure Act is
9amended by adding Section 5-45.55 as follows:
 
10    (5 ILCS 100/5-45.55 new)
11    Sec. 5-45.55. Emergency rulemaking; Network Adequacy and
12Transparency Act. To provide for the expeditious and timely
13implementation of the Network Adequacy and Transparency Act,

 

 

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1emergency rules implementing federal standards for provider
2ratios, travel time and distance, and appointment wait times
3if such standards apply to health insurance coverage regulated
4by the Department of Insurance and are more stringent than the
5State standards extant at the time the final federal standards
6are published may be adopted in accordance with Section 5-45
7by the Department of Insurance. The adoption of emergency
8rules authorized by Section 5-45 and this Section is deemed to
9be necessary for the public interest, safety, and welfare.
 
10    Section 2-10. The Network Adequacy and Transparency Act is
11amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and
12by adding Sections 35, 40, and 50 as follows:
 
13    (215 ILCS 124/3)
14    Sec. 3. Applicability of Act. This Act applies to an
15individual or group policy of accident and health insurance
16coverage with a network plan amended, delivered, issued, or
17renewed in this State on or after January 1, 2019. This Act
18does not apply to an individual or group policy for excepted
19benefits or short-term, limited-duration health insurance
20coverage dental or vision insurance or a limited health
21service organization with a network plan amended, delivered,
22issued, or renewed in this State on or after January 1, 2019,
23except to the extent that federal law establishes network
24adequacy and transparency standards for stand-alone dental

 

 

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1plans, which the Department shall enforce.
2(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
 
3    (215 ILCS 124/5)
4    Sec. 5. Definitions. In this Act:
5    "Authorized representative" means a person to whom a
6beneficiary has given express written consent to represent the
7beneficiary; a person authorized by law to provide substituted
8consent for a beneficiary; or the beneficiary's treating
9provider only when the beneficiary or his or her family member
10is unable to provide consent.
11    "Beneficiary" means an individual, an enrollee, an
12insured, a participant, or any other person entitled to
13reimbursement for covered expenses of or the discounting of
14provider fees for health care services under a program in
15which the beneficiary has an incentive to utilize the services
16of a provider that has entered into an agreement or
17arrangement with an issuer insurer.
18    "Department" means the Department of Insurance.
19    "Essential community provider" has the meaning ascribed to
20that term in 45 CFR 156.235.
21    "Excepted benefits" has the meaning ascribed to that term
22in 42 U.S.C. 300gg-91(c).
23    "Exchange" has the meaning ascribed to that term in 45 CFR
24155.20.
25    "Director" means the Director of Insurance.

 

 

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1    "Family caregiver" means a relative, partner, friend, or
2neighbor who has a significant relationship with the patient
3and administers or assists the patient with activities of
4daily living, instrumental activities of daily living, or
5other medical or nursing tasks for the quality and welfare of
6that patient.
7    "Group health plan" has the meaning ascribed to that term
8in Section 5 of the Illinois Health Insurance Portability and
9Accountability Act.
10    "Health insurance coverage" has the meaning ascribed to
11that term in Section 5 of the Illinois Health Insurance
12Portability and Accountability Act. "Health insurance
13coverage" does not include any coverage or benefits under
14Medicare or under the medical assistance program established
15under Article V of the Illinois Public Aid Code.
16    "Issuer" means a "health insurance issuer" as defined in
17Section 5 of the Illinois Health Insurance Portability and
18Accountability Act.
19    "Insurer" means any entity that offers individual or group
20accident and health insurance, including, but not limited to,
21health maintenance organizations, preferred provider
22organizations, exclusive provider organizations, and other
23plan structures requiring network participation, excluding the
24medical assistance program under the Illinois Public Aid Code,
25the State employees group health insurance program, workers
26compensation insurance, and pharmacy benefit managers.

 

 

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1    "Material change" means a significant reduction in the
2number of providers available in a network plan, including,
3but not limited to, a reduction of 10% or more in a specific
4type of providers within any county, the removal of a major
5health system that causes a network to be significantly
6different within any county from the network when the
7beneficiary purchased the network plan, or any change that
8would cause the network to no longer satisfy the requirements
9of this Act or the Department's rules for network adequacy and
10transparency.
11    "Network" means the group or groups of preferred providers
12providing services to a network plan.
13    "Network plan" means an individual or group policy of
14accident and health insurance coverage that either requires a
15covered person to use or creates incentives, including
16financial incentives, for a covered person to use providers
17managed, owned, under contract with, or employed by the issuer
18or by a third party contracted to arrange, contract for, or
19administer such provider-related incentives for the issuer
20insurer.
21    "Ongoing course of treatment" means (1) treatment for a
22life-threatening condition, which is a disease or condition
23for which likelihood of death is probable unless the course of
24the disease or condition is interrupted; (2) treatment for a
25serious acute condition, defined as a disease or condition
26requiring complex ongoing care that the covered person is

 

 

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1currently receiving, such as chemotherapy, radiation therapy,
2or post-operative visits, or a serious and complex condition
3as defined under 42 U.S.C. 300gg-113(b)(2); (3) a course of
4treatment for a health condition that a treating provider
5attests that discontinuing care by that provider would worsen
6the condition or interfere with anticipated outcomes; or (4)
7the third trimester of pregnancy through the post-partum
8period; (5) undergoing a course of institutional or inpatient
9care from the provider within the meaning of 42 U.S.C.
10300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective
11surgery from the provider, including receipt of preoperative
12or postoperative care from such provider with respect to such
13a surgery; (7) being determined to be terminally ill, as
14determined under 42 U.S.C. 1395x(dd)(3)(A), and receiving
15treatment for such illness from such provider; or (8) any
16other treatment of a condition or disease that requires
17repeated health care services pursuant to a plan of treatment
18by a provider because of the potential for changes in the
19therapeutic regimen or because of the potential for a
20recurrence of symptoms.
21    "Preferred provider" means any provider who has entered,
22either directly or indirectly, into an agreement with an
23employer or risk-bearing entity relating to health care
24services that may be rendered to beneficiaries under a network
25plan.
26    "Providers" means physicians licensed to practice medicine

 

 

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1in all its branches, other health care professionals,
2hospitals, or other health care institutions or facilities
3that provide health care services.
4    "Short-term, limited-duration insurance" means any type of
5accident and health insurance offered or provided within this
6State pursuant to a group or individual policy or individual
7certificate by a company, regardless of the situs state of the
8delivery of the policy, that has an expiration date specified
9in the contract that is fewer than 365 days after the original
10effective date. Regardless of the duration of coverage,
11"short-term, limited-duration insurance" does not include
12excepted benefits or any student health insurance coverage.
13    "Stand-alone dental plan" has the meaning ascribed to that
14term in 45 CFR 156.400.
15    "Telehealth" has the meaning given to that term in Section
16356z.22 of the Illinois Insurance Code.
17    "Telemedicine" has the meaning given to that term in
18Section 49.5 of the Medical Practice Act of 1987.
19    "Tiered network" means a network that identifies and
20groups some or all types of provider and facilities into
21specific groups to which different provider reimbursement,
22covered person cost-sharing or provider access requirements,
23or any combination thereof, apply for the same services.
24    "Woman's principal health care provider" means a physician
25licensed to practice medicine in all of its branches
26specializing in obstetrics, gynecology, or family practice.

 

 

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1(Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)
 
2    (215 ILCS 124/10)
3    Sec. 10. Network adequacy.
4    (a) Before issuing, delivering, or renewing a network
5plan, an issuer An insurer providing a network plan shall file
6a description of all of the following with the Director:
7        (1) The written policies and procedures for adding
8    providers to meet patient needs based on increases in the
9    number of beneficiaries, changes in the
10    patient-to-provider ratio, changes in medical and health
11    care capabilities, and increased demand for services.
12        (2) The written policies and procedures for making
13    referrals within and outside the network.
14        (3) The written policies and procedures on how the
15    network plan will provide 24-hour, 7-day per week access
16    to network-affiliated primary care, emergency services,
17    and women's principal health care providers.
18    An issuer insurer shall not prohibit a preferred provider
19from discussing any specific or all treatment options with
20beneficiaries irrespective of the insurer's position on those
21treatment options or from advocating on behalf of
22beneficiaries within the utilization review, grievance, or
23appeals processes established by the issuer insurer in
24accordance with any rights or remedies available under
25applicable State or federal law.

 

 

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1    (b) Before issuing, delivering, or renewing a network
2plan, an issuer Insurers must file for review a description of
3the services to be offered through a network plan. The
4description shall include all of the following:
5        (1) A geographic map of the area proposed to be served
6    by the plan by county service area and zip code, including
7    marked locations for preferred providers.
8        (2) As deemed necessary by the Department, the names,
9    addresses, phone numbers, and specialties of the providers
10    who have entered into preferred provider agreements under
11    the network plan.
12        (3) The number of beneficiaries anticipated to be
13    covered by the network plan.
14        (4) An Internet website and toll-free telephone number
15    for beneficiaries and prospective beneficiaries to access
16    current and accurate lists of preferred providers in each
17    plan, additional information about the plan, as well as
18    any other information required by Department rule.
19        (5) A description of how health care services to be
20    rendered under the network plan are reasonably accessible
21    and available to beneficiaries. The description shall
22    address all of the following:
23            (A) the type of health care services to be
24        provided by the network plan;
25            (B) the ratio of physicians and other providers to
26        beneficiaries, by specialty and including primary care

 

 

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1        physicians and facility-based physicians when
2        applicable under the contract, necessary to meet the
3        health care needs and service demands of the currently
4        enrolled population;
5            (C) the travel and distance standards for plan
6        beneficiaries in county service areas; and
7            (D) a description of how the use of telemedicine,
8        telehealth, or mobile care services may be used to
9        partially meet the network adequacy standards, if
10        applicable.
11        (6) A provision ensuring that whenever a beneficiary
12    has made a good faith effort, as evidenced by accessing
13    the provider directory, calling the network plan, and
14    calling the provider, to utilize preferred providers for a
15    covered service and it is determined the insurer does not
16    have the appropriate preferred providers due to
17    insufficient number, type, unreasonable travel distance or
18    delay, or preferred providers refusing to provide a
19    covered service because it is contrary to the conscience
20    of the preferred providers, as protected by the Health
21    Care Right of Conscience Act, the issuer insurer shall
22    ensure, directly or indirectly, by terms contained in the
23    payer contract, that the beneficiary will be provided the
24    covered service at no greater cost to the beneficiary than
25    if the service had been provided by a preferred provider.
26    This paragraph (6) does not apply to: (A) a beneficiary

 

 

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1    who willfully chooses to access a non-preferred provider
2    for health care services available through the panel of
3    preferred providers, or (B) a beneficiary enrolled in a
4    health maintenance organization. In these circumstances,
5    the contractual requirements for non-preferred provider
6    reimbursements shall apply unless Section 356z.3a of the
7    Illinois Insurance Code requires otherwise. In no event
8    shall a beneficiary who receives care at a participating
9    health care facility be required to search for
10    participating providers under the circumstances described
11    in subsection (b) or (b-5) of Section 356z.3a of the
12    Illinois Insurance Code except under the circumstances
13    described in paragraph (2) of subsection (b-5).
14        (7) A provision that the beneficiary shall receive
15    emergency care coverage such that payment for this
16    coverage is not dependent upon whether the emergency
17    services are performed by a preferred or non-preferred
18    provider and the coverage shall be at the same benefit
19    level as if the service or treatment had been rendered by a
20    preferred provider. For purposes of this paragraph (7),
21    "the same benefit level" means that the beneficiary is
22    provided the covered service at no greater cost to the
23    beneficiary than if the service had been provided by a
24    preferred provider. This provision shall be consistent
25    with Section 356z.3a of the Illinois Insurance Code.
26        (8) A limitation that, if the plan provides that the

 

 

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1    beneficiary will incur a penalty for failing to
2    pre-certify inpatient hospital treatment, the penalty may
3    not exceed $1,000 per occurrence in addition to the plan
4    cost sharing provisions.
5        (9) For a network plan to be offered through the
6    Exchange in the individual or small group market, as well
7    as any off-Exchange mirror of such a network plan,
8    evidence that the network plan includes essential
9    community providers in accordance with rules established
10    by the Exchange that will operate in this State for the
11    applicable plan year.
12    (c) The issuer network plan shall demonstrate to the
13Director a minimum ratio of providers to plan beneficiaries as
14required by the Department for each network plan.
15        (1) The minimum ratio of physicians or other providers
16    to plan beneficiaries shall be established annually by the
17    Department in consultation with the Department of Public
18    Health based upon the guidance from the federal Centers
19    for Medicare and Medicaid Services. The Department shall
20    not establish ratios for vision or dental providers who
21    provide services under dental-specific or vision-specific
22    benefits, except to the extent provided under federal law
23    for stand-alone dental plans. The Department shall
24    consider establishing ratios for the following physicians
25    or other providers:
26            (A) Primary Care;

 

 

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1            (B) Pediatrics;
2            (C) Cardiology;
3            (D) Gastroenterology;
4            (E) General Surgery;
5            (F) Neurology;
6            (G) OB/GYN;
7            (H) Oncology/Radiation;
8            (I) Ophthalmology;
9            (J) Urology;
10            (K) Behavioral Health;
11            (L) Allergy/Immunology;
12            (M) Chiropractic;
13            (N) Dermatology;
14            (O) Endocrinology;
15            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
16            (Q) Infectious Disease;
17            (R) Nephrology;
18            (S) Neurosurgery;
19            (T) Orthopedic Surgery;
20            (U) Physiatry/Rehabilitative;
21            (V) Plastic Surgery;
22            (W) Pulmonary;
23            (X) Rheumatology;
24            (Y) Anesthesiology;
25            (Z) Pain Medicine;
26            (AA) Pediatric Specialty Services;

 

 

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1            (BB) Outpatient Dialysis; and
2            (CC) HIV.
3        (2) The Director shall establish a process for the
4    review of the adequacy of these standards, along with an
5    assessment of additional specialties to be included in the
6    list under this subsection (c).
7        (3) Notwithstanding any other law or rule, the minimum
8    ratio for each provider type shall be no less than any such
9    ratio established for qualified health plans in
10    Federally-Facilitated Exchanges by federal law or by the
11    federal Centers for Medicare and Medicaid Services, even
12    if the network plan is issued in the large group market or
13    is otherwise not issued through an exchange. Federal
14    standards for stand-alone dental plans shall only apply to
15    such network plans. In the absence of an applicable
16    Department rule, the federal standards shall apply for the
17    time period specified in the federal law, regulation, or
18    guidance. If the Centers for Medicare and Medicaid
19    Services establish standards that are more stringent than
20    the standards in effect under any Department rule, the
21    Department may amend its rules to conform to the more
22    stringent federal standards.
23    (d) The network plan shall demonstrate to the Director
24maximum travel and distance standards and appointment wait
25time standards for plan beneficiaries, which shall be
26established annually by the Department in consultation with

 

 

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1the Department of Public Health based upon the guidance from
2the federal Centers for Medicare and Medicaid Services. These
3standards shall consist of the maximum minutes or miles to be
4traveled by a plan beneficiary for each county type, such as
5large counties, metro counties, or rural counties as defined
6by Department rule.
7    The maximum travel time and distance standards must
8include standards for each physician and other provider
9category listed for which ratios have been established.
10    The Director shall establish a process for the review of
11the adequacy of these standards along with an assessment of
12additional specialties to be included in the list under this
13subsection (d).
14    Notwithstanding any other law or Department rule, the
15maximum travel time and distance standards and appointment
16wait time standards shall be no greater than any such
17standards established for qualified health plans in
18Federally-Facilitated Exchanges by federal law or by the
19federal Centers for Medicare and Medicaid Services, even if
20the network plan is issued in the large group market or is
21otherwise not issued through an exchange. Federal standards
22for stand-alone dental plans shall only apply to such network
23plans. In the absence of an applicable Department rule, the
24federal standards shall apply for the time period specified in
25the federal law, regulation, or guidance. If the Centers for
26Medicare and Medicaid Services establish standards that are

 

 

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1more stringent than the standards in effect under any
2Department rule, the Department may amend its rules to conform
3to the more stringent federal standards.
4    If the federal area designations for the maximum time or
5distance or appointment wait time standards required are
6changed by the most recent Letter to Issuers in the
7Federally-facilitated Marketplaces, the Department shall post
8on its website notice of such changes and may amend its rules
9to conform to those designations if the Director deems
10appropriate.
11    (d-5)(1) Every issuer insurer shall ensure that
12beneficiaries have timely and proximate access to treatment
13for mental, emotional, nervous, or substance use disorders or
14conditions in accordance with the provisions of paragraph (4)
15of subsection (a) of Section 370c of the Illinois Insurance
16Code. Issuers Insurers shall use a comparable process,
17strategy, evidentiary standard, and other factors in the
18development and application of the network adequacy standards
19for timely and proximate access to treatment for mental,
20emotional, nervous, or substance use disorders or conditions
21and those for the access to treatment for medical and surgical
22conditions. As such, the network adequacy standards for timely
23and proximate access shall equally be applied to treatment
24facilities and providers for mental, emotional, nervous, or
25substance use disorders or conditions and specialists
26providing medical or surgical benefits pursuant to the parity

 

 

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1requirements of Section 370c.1 of the Illinois Insurance Code
2and the federal Paul Wellstone and Pete Domenici Mental Health
3Parity and Addiction Equity Act of 2008. Notwithstanding the
4foregoing, the network adequacy standards for timely and
5proximate access to treatment for mental, emotional, nervous,
6or substance use disorders or conditions shall, at a minimum,
7satisfy the following requirements:
8        (A) For beneficiaries residing in the metropolitan
9    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
10    network adequacy standards for timely and proximate access
11    to treatment for mental, emotional, nervous, or substance
12    use disorders or conditions means a beneficiary shall not
13    have to travel longer than 30 minutes or 30 miles from the
14    beneficiary's residence to receive outpatient treatment
15    for mental, emotional, nervous, or substance use disorders
16    or conditions. Beneficiaries shall not be required to wait
17    longer than 10 business days between requesting an initial
18    appointment and being seen by the facility or provider of
19    mental, emotional, nervous, or substance use disorders or
20    conditions for outpatient treatment or to wait longer than
21    20 business days between requesting a repeat or follow-up
22    appointment and being seen by the facility or provider of
23    mental, emotional, nervous, or substance use disorders or
24    conditions for outpatient treatment; however, subject to
25    the protections of paragraph (3) of this subsection, a
26    network plan shall not be held responsible if the

 

 

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1    beneficiary or provider voluntarily chooses to schedule an
2    appointment outside of these required time frames.
3        (B) For beneficiaries residing in Illinois counties
4    other than those counties listed in subparagraph (A) of
5    this paragraph, network adequacy standards for timely and
6    proximate access to treatment for mental, emotional,
7    nervous, or substance use disorders or conditions means a
8    beneficiary shall not have to travel longer than 60
9    minutes or 60 miles from the beneficiary's residence to
10    receive outpatient treatment for mental, emotional,
11    nervous, or substance use disorders or conditions.
12    Beneficiaries shall not be required to wait longer than 10
13    business days between requesting an initial appointment
14    and being seen by the facility or provider of mental,
15    emotional, nervous, or substance use disorders or
16    conditions for outpatient treatment or to wait longer than
17    20 business days between requesting a repeat or follow-up
18    appointment and being seen by the facility or provider of
19    mental, emotional, nervous, or substance use disorders or
20    conditions for outpatient treatment; however, subject to
21    the protections of paragraph (3) of this subsection, a
22    network plan shall not be held responsible if the
23    beneficiary or provider voluntarily chooses to schedule an
24    appointment outside of these required time frames.
25    (2) For beneficiaries residing in all Illinois counties,
26network adequacy standards for timely and proximate access to

 

 

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1treatment for mental, emotional, nervous, or substance use
2disorders or conditions means a beneficiary shall not have to
3travel longer than 60 minutes or 60 miles from the
4beneficiary's residence to receive inpatient or residential
5treatment for mental, emotional, nervous, or substance use
6disorders or conditions.
7    (3) If there is no in-network facility or provider
8available for a beneficiary to receive timely and proximate
9access to treatment for mental, emotional, nervous, or
10substance use disorders or conditions in accordance with the
11network adequacy standards outlined in this subsection, the
12issuer insurer shall provide necessary exceptions to its
13network to ensure admission and treatment with a provider or
14at a treatment facility in accordance with the network
15adequacy standards in this subsection.
16    (4) If the federal Centers for Medicare and Medicaid
17Services establishes or law requires more stringent standards
18for qualified health plans in the Federally-Facilitated
19Exchanges, the federal standards shall control for all network
20plans for the time period specified in the federal law,
21regulation, or guidance, even if the network plan is issued in
22the large group market, is issued through a different type of
23Exchange, or is otherwise not issued through an Exchange.
24    (e) Except for network plans solely offered as a group
25health plan, these ratio and time and distance standards apply
26to the lowest cost-sharing tier of any tiered network.

 

 

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1    (f) The network plan may consider use of other health care
2service delivery options, such as telemedicine or telehealth,
3mobile clinics, and centers of excellence, or other ways of
4delivering care to partially meet the requirements set under
5this Section.
6    (g) Except for the requirements set forth in subsection
7(d-5), issuers insurers who are not able to comply with the
8provider ratios and time and distance or appointment wait time
9standards established under this Act or federal law by the
10Department may request an exception to these requirements from
11the Department. The Department may grant an exception in the
12following circumstances:
13        (1) if no providers or facilities meet the specific
14    time and distance standard in a specific service area and
15    the issuer insurer (i) discloses information on the
16    distance and travel time points that beneficiaries would
17    have to travel beyond the required criterion to reach the
18    next closest contracted provider outside of the service
19    area and (ii) provides contact information, including
20    names, addresses, and phone numbers for the next closest
21    contracted provider or facility;
22        (2) if patterns of care in the service area do not
23    support the need for the requested number of provider or
24    facility type and the issuer insurer provides data on
25    local patterns of care, such as claims data, referral
26    patterns, or local provider interviews, indicating where

 

 

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1    the beneficiaries currently seek this type of care or
2    where the physicians currently refer beneficiaries, or
3    both; or
4        (3) other circumstances deemed appropriate by the
5    Department consistent with the requirements of this Act.
6    (h) Issuers Insurers are required to report to the
7Director any material change to an approved network plan
8within 15 days after the change occurs and any change that
9would result in failure to meet the requirements of this Act.
10The issuer shall submit a revised version of the portions of
11the network adequacy filing affected by the material change,
12as determined by the Director by rule, and the issuer shall
13attach versions with the changes indicated for each document
14that was revised from the previous version of the filing. Upon
15notice from the issuer insurer, the Director shall reevaluate
16the network plan's compliance with the network adequacy and
17transparency standards of this Act. For every day past 15 days
18that the issuer fails to submit a revised network adequacy
19filing to the Director, the Director may order a fine of $5,000
20per day.
21    (i) If a network plan is inadequate under this Act with
22respect to a provider type in a county, and if the network plan
23does not have an approved exception for that provider type in
24that county pursuant to subsection (g), an issuer shall
25process out-of-network claims for covered health care services
26received from that provider type within that county at the

 

 

10300HB5395ham001- 22 -LRB103 37071 RPS 70534 a

1in-network benefit level and shall retroactively adjudicate
2and reimburse beneficiaries to achieve that objective if their
3claims were processed at the out-of-network level contrary to
4this subsection.
5    (j) If the Director determines that a network is
6inadequate in any county and no exception has been granted
7under subsection (g) and the issuer does not have a process in
8place to comply with subsection (d-5), the Director may
9prohibit the network plan from being issued or renewed within
10that county until the Director determines that the network is
11adequate apart from processes and exceptions described in
12subsections (d-5) and (g). Nothing in this subsection shall be
13construed to terminate any beneficiary's health insurance
14coverage under a network plan before the expiration of the
15beneficiary's policy period if the Director makes a
16determination under this subsection after the issuance or
17renewal of the beneficiary's policy or certificate because of
18a material change. Policies or certificates issued or renewed
19in violation of this subsection may subject the issuer to a
20civil penalty of $5,000 per policy.
21(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
22102-1117, eff. 1-13-23.)
 
23    (215 ILCS 124/15)
24    Sec. 15. Notice of nonrenewal or termination.
25    (a) A network plan must give at least 60 days' notice of

 

 

10300HB5395ham001- 23 -LRB103 37071 RPS 70534 a

1nonrenewal or termination of a provider to the provider and to
2the beneficiaries served by the provider. The notice shall
3include a name and address to which a beneficiary or provider
4may direct comments and concerns regarding the nonrenewal or
5termination and the telephone number maintained by the
6Department for consumer complaints. Immediate written notice
7may be provided without 60 days' notice when a provider's
8license has been disciplined by a State licensing board or
9when the network plan reasonably believes direct imminent
10physical harm to patients under the provider's providers care
11may occur. The notice to the beneficiary shall provide the
12individual with an opportunity to notify the issuer of the
13individual's need for transitional care.
14    (b) Primary care providers must notify active affected
15patients of nonrenewal or termination of the provider from the
16network plan, except in the case of incapacitation.
17(Source: P.A. 100-502, eff. 9-15-17.)
 
18    (215 ILCS 124/20)
19    Sec. 20. Transition of services.
20    (a) A network plan shall provide for continuity of care
21for its beneficiaries as follows:
22        (1) If a beneficiary's physician or hospital provider
23    leaves the network plan's network of providers for reasons
24    other than termination of a contract in situations
25    involving imminent harm to a patient or a final

 

 

10300HB5395ham001- 24 -LRB103 37071 RPS 70534 a

1    disciplinary action by a State licensing board and the
2    provider remains within the network plan's service area,
3    if benefits provided under such network plan with respect
4    to such provider or facility are terminated because of a
5    change in the terms of the participation of such provider
6    or facility in such plan, or if a contract between a group
7    health plan and a health insurance issuer offering a
8    network plan in connection with the group health plan is
9    terminated and results in a loss of benefits provided
10    under such plan with respect to such provider, then the
11    network plan shall permit the beneficiary to continue an
12    ongoing course of treatment with that provider during a
13    transitional period for the following duration:
14            (A) 90 days from the date of the notice to the
15        beneficiary of the provider's disaffiliation from the
16        network plan if the beneficiary has an ongoing course
17        of treatment; or
18            (B) if the beneficiary has entered the third
19        trimester of pregnancy at the time of the provider's
20        disaffiliation, a period that includes the provision
21        of post-partum care directly related to the delivery.
22        (2) Notwithstanding the provisions of paragraph (1) of
23    this subsection (a), such care shall be authorized by the
24    network plan during the transitional period in accordance
25    with the following:
26            (A) the provider receives continued reimbursement

 

 

10300HB5395ham001- 25 -LRB103 37071 RPS 70534 a

1        from the network plan at the rates and terms and
2        conditions applicable under the terminated contract
3        prior to the start of the transitional period;
4            (B) the provider adheres to the network plan's
5        quality assurance requirements, including provision to
6        the network plan of necessary medical information
7        related to such care; and
8            (C) the provider otherwise adheres to the network
9        plan's policies and procedures, including, but not
10        limited to, procedures regarding referrals and
11        obtaining preauthorizations for treatment.
12        (3) The provisions of this Section governing health
13    care provided during the transition period do not apply if
14    the beneficiary has successfully transitioned to another
15    provider participating in the network plan, if the
16    beneficiary has already met or exceeded the benefit
17    limitations of the plan, or if the care provided is not
18    medically necessary.
19    (b) A network plan shall provide for continuity of care
20for new beneficiaries as follows:
21        (1) If a new beneficiary whose provider is not a
22    member of the network plan's provider network, but is
23    within the network plan's service area, enrolls in the
24    network plan, the network plan shall permit the
25    beneficiary to continue an ongoing course of treatment
26    with the beneficiary's current physician during a

 

 

10300HB5395ham001- 26 -LRB103 37071 RPS 70534 a

1    transitional period:
2            (A) of 90 days from the effective date of
3        enrollment if the beneficiary has an ongoing course of
4        treatment; or
5            (B) if the beneficiary has entered the third
6        trimester of pregnancy at the effective date of
7        enrollment, that includes the provision of post-partum
8        care directly related to the delivery.
9        (2) If a beneficiary, or a beneficiary's authorized
10    representative, elects in writing to continue to receive
11    care from such provider pursuant to paragraph (1) of this
12    subsection (b), such care shall be authorized by the
13    network plan for the transitional period in accordance
14    with the following:
15            (A) the provider receives reimbursement from the
16        network plan at rates established by the network plan;
17            (B) the provider adheres to the network plan's
18        quality assurance requirements, including provision to
19        the network plan of necessary medical information
20        related to such care; and
21            (C) the provider otherwise adheres to the network
22        plan's policies and procedures, including, but not
23        limited to, procedures regarding referrals and
24        obtaining preauthorization for treatment.
25        (3) The provisions of this Section governing health
26    care provided during the transition period do not apply if

 

 

10300HB5395ham001- 27 -LRB103 37071 RPS 70534 a

1    the beneficiary has successfully transitioned to another
2    provider participating in the network plan, if the
3    beneficiary has already met or exceeded the benefit
4    limitations of the plan, or if the care provided is not
5    medically necessary.
6    (c) In no event shall this Section be construed to require
7a network plan to provide coverage for benefits not otherwise
8covered or to diminish or impair preexisting condition
9limitations contained in the beneficiary's contract.
10    (d) A provider shall comply with the requirements of 42
11U.S.C. 300gg-138.
12(Source: P.A. 100-502, eff. 9-15-17.)
 
13    (215 ILCS 124/25)
14    Sec. 25. Network transparency.
15    (a) A network plan shall post electronically an
16up-to-date, accurate, and complete provider directory for each
17of its network plans, with the information and search
18functions, as described in this Section.
19        (1) In making the directory available electronically,
20    the network plans shall ensure that the general public is
21    able to view all of the current providers for a plan
22    through a clearly identifiable link or tab and without
23    creating or accessing an account or entering a policy or
24    contract number.
25        (2) The network plan shall update the online provider

 

 

10300HB5395ham001- 28 -LRB103 37071 RPS 70534 a

1    directory at least monthly. An issuer's failure to update
2    a network plan's directory shall subject the issuer to a
3    civil penalty of $5,000 per month. Providers shall notify
4    the network plan electronically or in writing of any
5    changes to their information as listed in the provider
6    directory, including the information required in
7    subparagraph (K) of paragraph (1) of subsection (b). With
8    regard to subparagraph (I) of paragraph (1) of subsection
9    (b), the provider must give notice to the issuer within 20
10    business days of deciding to cease accepting new patients
11    covered by the plan if the new patient limitation is
12    expected to last 40 business days or longer. The network
13    plan shall update its online provider directory in a
14    manner consistent with the information provided by the
15    provider within 2 10 business days after being notified of
16    the change by the provider. Nothing in this paragraph (2)
17    shall void any contractual relationship between the
18    provider and the plan.
19        (3) At least once every 90 days, the The network plan
20    shall audit each periodically at least 25% of its print
21    and online provider directories for accuracy, make any
22    corrections necessary, and retain documentation of the
23    audit. The network plan shall submit the audit to the
24    Director upon request. As part of these audits, the
25    network plan shall contact any provider in its network
26    that has not submitted a claim to the plan or otherwise

 

 

10300HB5395ham001- 29 -LRB103 37071 RPS 70534 a

1    communicated his or her intent to continue participation
2    in the plan's network. The audits shall comply with 42
3    U.S.C. 300gg-115(a)(2), except that "provider directory
4    information" shall include all information required to be
5    included in a provider directory pursuant to this Act.
6        (4) A network plan shall provide a print copy of a
7    current provider directory or a print copy of the
8    requested directory information upon request of a
9    beneficiary or a prospective beneficiary. Print copies
10    must be updated quarterly and an errata that reflects
11    changes in the provider network must be updated quarterly.
12        (5) For each network plan, a network plan shall
13    include, in plain language in both the electronic and
14    print directory, the following general information:
15            (A) in plain language, a description of the
16        criteria the plan has used to build its provider
17        network;
18            (B) if applicable, in plain language, a
19        description of the criteria the issuer insurer or
20        network plan has used to create tiered networks;
21            (C) if applicable, in plain language, how the
22        network plan designates the different provider tiers
23        or levels in the network and identifies for each
24        specific provider, hospital, or other type of facility
25        in the network which tier each is placed, for example,
26        by name, symbols, or grouping, in order for a

 

 

10300HB5395ham001- 30 -LRB103 37071 RPS 70534 a

1        beneficiary-covered person or a prospective
2        beneficiary-covered person to be able to identify the
3        provider tier; and
4            (D) if applicable, a notation that authorization
5        or referral may be required to access some providers.
6        (6) A network plan shall make it clear for both its
7    electronic and print directories what provider directory
8    applies to which network plan, such as including the
9    specific name of the network plan as marketed and issued
10    in this State. The network plan shall include in both its
11    electronic and print directories a customer service email
12    address and telephone number or electronic link that
13    beneficiaries or the general public may use to notify the
14    network plan of inaccurate provider directory information
15    and contact information for the Department's Office of
16    Consumer Health Insurance.
17        (7) A provider directory, whether in electronic or
18    print format, shall accommodate the communication needs of
19    individuals with disabilities, and include a link to or
20    information regarding available assistance for persons
21    with limited English proficiency.
22    (b) For each network plan, a network plan shall make
23available through an electronic provider directory the
24following information in a searchable format:
25        (1) for health care professionals:
26            (A) name;

 

 

10300HB5395ham001- 31 -LRB103 37071 RPS 70534 a

1            (B) gender;
2            (C) participating office locations;
3            (D) specialty, if applicable;
4            (E) medical group affiliations, if applicable;
5            (F) facility affiliations, if applicable;
6            (G) participating facility affiliations, if
7        applicable;
8            (H) languages spoken other than English, if
9        applicable;
10            (I) whether accepting new patients;
11            (J) board certifications, if applicable; and
12            (K) use of telehealth or telemedicine, including,
13        but not limited to:
14                (i) whether the provider offers the use of
15            telehealth or telemedicine to deliver services to
16            patients for whom it would be clinically
17            appropriate;
18                (ii) what modalities are used and what types
19            of services may be provided via telehealth or
20            telemedicine; and
21                (iii) whether the provider has the ability and
22            willingness to include in a telehealth or
23            telemedicine encounter a family caregiver who is
24            in a separate location than the patient if the
25            patient wishes and provides his or her consent;
26            and

 

 

10300HB5395ham001- 32 -LRB103 37071 RPS 70534 a

1            (L) whether patients can make an appointment to
2        visit the health care professional.
3        (2) for hospitals:
4            (A) hospital name;
5            (B) hospital type (such as acute, rehabilitation,
6        children's, or cancer);
7            (C) participating hospital location; and
8            (D) hospital accreditation status; and
9        (3) for facilities, other than hospitals, by type:
10            (A) facility name;
11            (B) facility type;
12            (C) types of services performed; and
13            (D) participating facility location or locations.
14    (c) For the electronic provider directories, for each
15network plan, a network plan shall make available all of the
16following information in addition to the searchable
17information required in this Section:
18        (1) for health care professionals:
19            (A) contact information, including both a
20        telephone number and digital contact information if
21        the provider has supplied digital contact information;
22        and
23            (B) languages spoken other than English by
24        clinical staff, if applicable;
25        (2) for hospitals, telephone number and digital
26    contact information; and

 

 

10300HB5395ham001- 33 -LRB103 37071 RPS 70534 a

1        (3) for facilities other than hospitals, telephone
2    number.
3    (d) The issuer insurer or network plan shall make
4available in print, upon request, the following provider
5directory information for the applicable network plan:
6        (1) for health care professionals:
7            (A) name;
8            (B) contact information, including a telephone
9        number and digital contact information if the provider
10        has supplied digital contact information;
11            (C) participating office location or locations;
12            (D) specialty, if applicable;
13            (E) languages spoken other than English, if
14        applicable;
15            (F) whether accepting new patients; and
16            (G) use of telehealth or telemedicine, including,
17        but not limited to:
18                (i) whether the provider offers the use of
19            telehealth or telemedicine to deliver services to
20            patients for whom it would be clinically
21            appropriate;
22                (ii) what modalities are used and what types
23            of services may be provided via telehealth or
24            telemedicine; and
25                (iii) whether the provider has the ability and
26            willingness to include in a telehealth or

 

 

10300HB5395ham001- 34 -LRB103 37071 RPS 70534 a

1            telemedicine encounter a family caregiver who is
2            in a separate location than the patient if the
3            patient wishes and provides his or her consent;
4            and
5            (H) whether patients can make an appointment to
6        visit the health care professional.
7        (2) for hospitals:
8            (A) hospital name;
9            (B) hospital type (such as acute, rehabilitation,
10        children's, or cancer); and
11            (C) participating hospital location, and telephone
12        number, and digital contact information; and
13        (3) for facilities, other than hospitals, by type:
14            (A) facility name;
15            (B) facility type;
16            (C) types of services performed; and
17            (D) participating facility location or locations,
18        and telephone numbers, and digital contact information
19        for each location.
20    (e) The network plan shall include a disclosure in the
21print format provider directory that the information included
22in the directory is accurate as of the date of printing and
23that beneficiaries or prospective beneficiaries should consult
24the issuer's insurer's electronic provider directory on its
25website and contact the provider. The network plan shall also
26include a telephone number in the print format provider

 

 

10300HB5395ham001- 35 -LRB103 37071 RPS 70534 a

1directory for a customer service representative where the
2beneficiary can obtain current provider directory information.
3    (f) The Director may conduct periodic audits of the
4accuracy of provider directories. A network plan shall not be
5subject to any fines or penalties for information required in
6this Section that a provider submits that is inaccurate or
7incomplete.
8    (g) To the extent not otherwise provided in this Act, an
9issuer shall comply with the requirements of 42 U.S.C.
10300gg-115, except that "provider directory information" shall
11include all information required to be included in a provider
12directory pursuant to this Section.
13    (h) This Section applies to network plans not otherwise
14exempt under Section 3, including stand-alone dental plans.
15(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
 
16    (215 ILCS 124/30)
17    Sec. 30. Administration and enforcement.
18    (a) Issuers Insurers, as defined in this Act, have a
19continuing obligation to comply with the requirements of this
20Act. Other than the duties specifically created in this Act,
21nothing in this Act is intended to preclude, prevent, or
22require the adoption, modification, or termination of any
23utilization management, quality management, or claims
24processing methodologies of an issuer insurer.
25    (b) Nothing in this Act precludes, prevents, or requires

 

 

10300HB5395ham001- 36 -LRB103 37071 RPS 70534 a

1the adoption, modification, or termination of any network plan
2term, benefit, coverage or eligibility provision, or payment
3methodology.
4    (c) The Director shall enforce the provisions of this Act
5pursuant to the enforcement powers granted to it by law.
6    (d) The Department shall adopt rules to enforce compliance
7with this Act to the extent necessary.
8    (e) In accordance with Section 5-45 of the Illinois
9Administrative Procedure Act, the Department may adopt
10emergency rules to implement federal standards for provider
11ratios, travel time and distance, and appointment wait times
12if such standards apply to health insurance coverage regulated
13by the Department and are more stringent than the State
14standards extant at the time the final federal standards are
15published.
16(Source: P.A. 100-502, eff. 9-15-17.)
 
17    (215 ILCS 124/35 new)
18    Sec. 35. Provider requirements. Providers shall comply
19with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations
20promulgated thereunder, as well as Section 20 and paragraph
21(2) of subsection (a) of Section 25 of this Act, except that
22"provider directory information" includes all information
23required to be included in a provider directory pursuant to
24Section 25 of this Act.
 

 

 

10300HB5395ham001- 37 -LRB103 37071 RPS 70534 a

1    (215 ILCS 124/40 new)
2    Sec. 40. Confidentiality.
3    (a) All records in the custody or possession of the
4Department are presumed to be open to public inspection or
5copying unless exempt from disclosure by Section 7 or 7.5 of
6the Freedom of Information Act. Except as otherwise provided
7in this Section or other applicable law, the filings required
8under this Act shall be open to public inspection or copying.
9    (b) The following information shall not be deemed
10confidential:
11        (1) actual or projected ratios of providers to
12    beneficiaries;
13        (2) actual or projected time and distance between
14    network providers and beneficiaries or actual or projected
15    waiting times for a beneficiary to see a network provider;
16        (3) geographic maps of network providers;
17        (4) requests for exceptions under subsection (g) of
18    Section 10, except with respect to any discussion of
19    ongoing or planned contractual negotiations with providers
20    that the issuer requests to be treated as confidential;
21        (5) provider directories and provider lists; and
22        (6) insurer or Department statements of determination
23    as to whether a network plan has satisfied the Act's
24    requirements regarding the information described in this
25    subsection.
26    (c) An issuer's work papers and reports on the results of a

 

 

10300HB5395ham001- 38 -LRB103 37071 RPS 70534 a

1self-audit of its provider directories shall remain
2confidential unless expressly waived by the insurer or unless
3deemed public information under federal law.
4    (d) The filings required under Section 10 of this Act
5shall be confidential while they remain under the Department's
6review but shall become open to public inspection and copying
7upon completion of the review, except as provided in this
8Section or under other applicable law.
9    (e) Nothing in this Section shall supersede the statutory
10requirement that work papers obtained during a market conduct
11examination be deemed confidential.
 
12    (215 ILCS 124/50 new)
13    Sec. 50. Funds for enforcement. Moneys from fines and
14penalties collected from issuers for violations of this Act
15shall be deposited into the Insurance Producer Administration
16Fund for appropriation by the General Assembly to the
17Department to be used for providing financial support of the
18Department's enforcement of this Act.
 
19    Section 2-15. The Managed Care Reform and Patient Rights
20Act is amended by changing Sections 20 and 25 as follows:
 
21    (215 ILCS 134/20)
22    Sec. 20. Notice of nonrenewal or termination. A health
23care plan must give at least 60 days notice of nonrenewal or

 

 

10300HB5395ham001- 39 -LRB103 37071 RPS 70534 a

1termination of a health care provider to the health care
2provider and to the enrollees served by the health care
3provider. The notice shall include a name and address to which
4an enrollee or health care provider may direct comments and
5concerns regarding the nonrenewal or termination. Immediate
6written notice may be provided without 60 days notice when a
7health care provider's license has been disciplined by a State
8licensing board. The notice to the enrollee shall provide the
9individual with an opportunity to notify the health care plan
10of the individual's need for transitional care.
11(Source: P.A. 91-617, eff. 1-1-00.)
 
12    (215 ILCS 134/25)
13    Sec. 25. Transition of services.
14    (a) A health care plan shall provide for continuity of
15care for its enrollees as follows:
16        (1) If an enrollee's health care provider physician
17    leaves the health care plan's network of health care
18    providers for reasons other than termination of a contract
19    in situations involving imminent harm to a patient or a
20    final disciplinary action by a State licensing board and
21    the provider physician remains within the health care
22    plan's service area, or if benefits provided under such
23    health care plan with respect to such provider are
24    terminated because of a change in the terms of the
25    participation of such provider in such plan, or if a

 

 

10300HB5395ham001- 40 -LRB103 37071 RPS 70534 a

1    contract between a group health plan, as defined in
2    Section 5 of the Illinois Health Insurance Portability and
3    Accountability Act, and a health care plan offered in
4    connection with the group health plan is terminated and
5    results in a loss of benefits provided under such plan
6    with respect to such provider, the health care plan shall
7    permit the enrollee to continue an ongoing course of
8    treatment with that provider physician during a
9    transitional period:
10            (A) of 90 days from the date of the notice of
11        provider's physician's termination from the health
12        care plan to the enrollee of the provider's
13        physician's disaffiliation from the health care plan
14        if the enrollee has an ongoing course of treatment; or
15            (B) if the enrollee has entered the third
16        trimester of pregnancy at the time of the provider's
17        physician's disaffiliation, that includes the
18        provision of post-partum care directly related to the
19        delivery.
20        (2) Notwithstanding the provisions in item (1) of this
21    subsection, such care shall be authorized by the health
22    care plan during the transitional period only if the
23    provider physician agrees:
24            (A) to continue to accept reimbursement from the
25        health care plan at the rates applicable prior to the
26        start of the transitional period;

 

 

10300HB5395ham001- 41 -LRB103 37071 RPS 70534 a

1            (B) to adhere to the health care plan's quality
2        assurance requirements and to provide to the health
3        care plan necessary medical information related to
4        such care; and
5            (C) to otherwise adhere to the health care plan's
6        policies and procedures, including but not limited to
7        procedures regarding referrals and obtaining
8        preauthorizations for treatment.
9        (3) During an enrollee's plan year, a health care plan
10    shall not remove a drug from its formulary or negatively
11    change its preferred or cost-tier sharing unless, at least
12    60 days before making the formulary change, the health
13    care plan:
14            (A) provides general notification of the change in
15        its formulary to current and prospective enrollees;
16            (B) directly notifies enrollees currently
17        receiving coverage for the drug, including information
18        on the specific drugs involved and the steps they may
19        take to request coverage determinations and
20        exceptions, including a statement that a certification
21        of medical necessity by the enrollee's prescribing
22        provider will result in continuation of coverage at
23        the existing level; and
24            (C) directly notifies by first class mail and
25        through an electronic transmission, if available, the
26        prescribing provider of all health care plan enrollees

 

 

10300HB5395ham001- 42 -LRB103 37071 RPS 70534 a

1        currently prescribed the drug affected by the proposed
2        change; the notice shall include a one-page form by
3        which the prescribing provider can notify the health
4        care plan by first class mail that coverage of the drug
5        for the enrollee is medically necessary.
6        The notification in paragraph (C) may direct the
7    prescribing provider to an electronic portal through which
8    the prescribing provider may electronically file a
9    certification to the health care plan that coverage of the
10    drug for the enrollee is medically necessary. The
11    prescribing provider may make a secure electronic
12    signature beside the words "certification of medical
13    necessity", and this certification shall authorize
14    continuation of coverage for the drug.
15        If the prescribing provider certifies to the health
16    care plan either in writing or electronically that the
17    drug is medically necessary for the enrollee as provided
18    in paragraph (C), a health care plan shall authorize
19    coverage for the drug prescribed based solely on the
20    prescribing provider's assertion that coverage is
21    medically necessary, and the health care plan is
22    prohibited from making modifications to the coverage
23    related to the covered drug, including, but not limited
24    to:
25            (i) increasing the out-of-pocket costs for the
26        covered drug;

 

 

10300HB5395ham001- 43 -LRB103 37071 RPS 70534 a

1            (ii) moving the covered drug to a more restrictive
2        tier; or
3            (iii) denying an enrollee coverage of the drug for
4        which the enrollee has been previously approved for
5        coverage by the health care plan.
6        Nothing in this item (3) prevents a health care plan
7    from removing a drug from its formulary or denying an
8    enrollee coverage if the United States Food and Drug
9    Administration has issued a statement about the drug that
10    calls into question the clinical safety of the drug, the
11    drug manufacturer has notified the United States Food and
12    Drug Administration of a manufacturing discontinuance or
13    potential discontinuance of the drug as required by
14    Section 506C of the Federal Food, Drug, and Cosmetic Act,
15    as codified in 21 U.S.C. 356c, or the drug manufacturer
16    has removed the drug from the market.
17        Nothing in this item (3) prohibits a health care plan,
18    by contract, written policy or procedure, or any other
19    agreement or course of conduct, from requiring a
20    pharmacist to effect substitutions of prescription drugs
21    consistent with Section 19.5 of the Pharmacy Practice Act,
22    under which a pharmacist may substitute an interchangeable
23    biologic for a prescribed biologic product, and Section 25
24    of the Pharmacy Practice Act, under which a pharmacist may
25    select a generic drug determined to be therapeutically
26    equivalent by the United States Food and Drug

 

 

10300HB5395ham001- 44 -LRB103 37071 RPS 70534 a

1    Administration and in accordance with the Illinois Food,
2    Drug and Cosmetic Act.
3        This item (3) applies to a policy or contract that is
4    amended, delivered, issued, or renewed on or after January
5    1, 2019. This item (3) does not apply to a health plan as
6    defined in the State Employees Group Insurance Act of 1971
7    or medical assistance under Article V of the Illinois
8    Public Aid Code.
9    (b) A health care plan shall provide for continuity of
10care for new enrollees as follows:
11        (1) If a new enrollee whose physician is not a member
12    of the health care plan's provider network, but is within
13    the health care plan's service area, enrolls in the health
14    care plan, the health care plan shall permit the enrollee
15    to continue an ongoing course of treatment with the
16    enrollee's current physician during a transitional period:
17            (A) of 90 days from the effective date of
18        enrollment if the enrollee has an ongoing course of
19        treatment; or
20            (B) if the enrollee has entered the third
21        trimester of pregnancy at the effective date of
22        enrollment, that includes the provision of post-partum
23        care directly related to the delivery.
24        (2) If an enrollee elects to continue to receive care
25    from such physician pursuant to item (1) of this
26    subsection, such care shall be authorized by the health

 

 

10300HB5395ham001- 45 -LRB103 37071 RPS 70534 a

1    care plan for the transitional period only if the
2    physician agrees:
3            (A) to accept reimbursement from the health care
4        plan at rates established by the health care plan;
5        such rates shall be the level of reimbursement
6        applicable to similar physicians within the health
7        care plan for such services;
8            (B) to adhere to the health care plan's quality
9        assurance requirements and to provide to the health
10        care plan necessary medical information related to
11        such care; and
12            (C) to otherwise adhere to the health care plan's
13        policies and procedures including, but not limited to
14        procedures regarding referrals and obtaining
15        preauthorization for treatment.
16    (c) In no event shall this Section be construed to require
17a health care plan to provide coverage for benefits not
18otherwise covered or to diminish or impair preexisting
19condition limitations contained in the enrollee's contract. In
20no event shall this Section be construed to prohibit the
21addition of prescription drugs to a health care plan's list of
22covered drugs during the coverage year.
23    (d) In this Section, "ongoing course of treatment" has the
24meaning ascribed to that term in Section 5 of the Network
25Adequacy and Transparency Act.
26(Source: P.A. 100-1052, eff. 8-24-18.)
 

 

 

10300HB5395ham001- 46 -LRB103 37071 RPS 70534 a

1
Article 3.

 
2    Section 3-5. The Illinois Insurance Code is amended by
3changing Section 355 as follows:
 
4    (215 ILCS 5/355)  (from Ch. 73, par. 967)
5    Sec. 355. Accident and health policies; provisions.
6    (a) As used in this Section:
7    "Inadequate rate" means a rate:
8        (1) that is insufficient to sustain projected losses
9    and expenses to which the rate applies; and
10        (2) the continued use of which endangers the solvency
11    of an insurer using that rate.
12    "Large employer" has the meaning provided in the Illinois
13Health Insurance Portability and Accountability Act.
14    "Plain language" has the meaning provided in the federal
15Plain Writing Act of 2010 and subsequent guidance documents,
16including the Federal Plain Language Guidelines.
17    "Unreasonable rate increase" means a rate increase that
18the Director determines to be excessive, unjustified, or
19unfairly discriminatory in accordance with 45 CFR 154.205.
20    (b) No policy of insurance against loss or damage from the
21sickness, or from the bodily injury or death of the insured by
22accident shall be issued or delivered to any person in this
23State until a copy of the form thereof and of the

 

 

10300HB5395ham001- 47 -LRB103 37071 RPS 70534 a

1classification of risks and the premium rates pertaining
2thereto have been filed with the Director; nor shall it be so
3issued or delivered until the Director shall have approved
4such policy pursuant to the provisions of Section 143. If the
5Director disapproves the policy form, he or she shall make a
6written decision stating the respects in which such form does
7not comply with the requirements of law and shall deliver a
8copy thereof to the company and it shall be unlawful
9thereafter for any such company to issue any policy in such
10form. On and after January 1, 2025, any form filing submitted
11for large employer group accident and health insurance shall
12be automatically deemed approved within 90 days of the
13submission date unless the Director extends by not more than
14an additional 30 days the period within which the form shall be
15approved or disapproved by giving written notice to the
16insurer of such extension before the expiration of the 90
17days. Any form in receipt of such an extension shall be
18automatically deemed approved within 120 days of the
19submission date. The Director may toll the filing due to a
20conflict in legal interpretation of federal or State law as
21long as the tolling is applied uniformly to all applicable
22forms, written notification is provided to the insurer prior
23to the tolling, the duration of the tolling is provided within
24the notice to the insurer, and justification for the tolling
25is posted to the Department's website. The Director may
26disapprove the filing if the insurer fails to respond to an

 

 

10300HB5395ham001- 48 -LRB103 37071 RPS 70534 a

1objection or request for additional information within the
2timeframe identified for response. As used in this subsection,
3"large employer" has the meaning given in Section 5 of the
4federal Health Insurance Portability and Accountability Act.
5    (c) For plan year 2026 and thereafter, premium rates for
6all individual and small group accident and health insurance
7policies must be filed with the Department for approval.
8Unreasonable rate increases or inadequate rates shall be
9modified or disapproved. For any plan year during which the
10Illinois Health Benefits Exchange operates as a full
11State-based exchange, the Department shall provide insurers at
12least 30 days' notice of the deadline to submit rate filings.
13    (c-5) Unless prohibited under federal law, for plan year
142026 and thereafter, each insurer proposing to offer a
15qualified health plan issued in the individual market through
16the Illinois Health Benefits Exchange must incorporate the
17following approach in its rate filing under this Section:
18        (1) The rate filing must apply a cost-sharing
19    reduction defunding adjustment factor within a range that:
20            (A) is uniform across all insurers;
21            (B) is consistent with the total adjustment
22        expected to be needed to cover actual cost-sharing
23        reduction costs across all silver plans on the
24        Illinois Health Benefits Exchange statewide; and
25            (C) assumes that the only enrollees who will
26        purchase silver plans on the Illinois Health Benefits

 

 

10300HB5395ham001- 49 -LRB103 37071 RPS 70534 a

1        Exchange are those individuals who are eligible for
2        87% and 94% cost-sharing reduction plans.
3        (2) The rate filing must apply an induced demand
4    factor based on the following formula: (Plan Actuarial
5    Value)2 - (Plan Actuarial Value) + 1.24.
6    In the annual notice to insurers described in subsection
7(c), the Department must include the specific numerical range
8calculated for the applicable plan year under paragraph (1) of
9this subsection (c-5) and the formula in paragraph (2) of this
10subsection (c-5).
11    (d) For plan year 2025 and thereafter, the Department
12shall post all insurers' rate filings and summaries on the
13Department's website 5 business days after the rate filing
14deadline set by the Department in annual guidance. The rate
15filings and summaries posted to the Department's website shall
16exclude information that is proprietary or trade secret
17information protected under paragraph (g) of subsection (1) of
18Section 7 of the Freedom of Information Act or confidential or
19privileged under any applicable insurance law or rule. All
20summaries shall include a brief justification of any rate
21increase or decrease requested, including the number of
22individual members, the medical loss ratio, medical trend,
23administrative costs, and any other information required by
24rule. The plain writing summary shall include notification of
25the public comment period established in subsection (e).
26    (e) The Department shall open a 30-day public comment

 

 

10300HB5395ham001- 50 -LRB103 37071 RPS 70534 a

1period on the rate filings beginning on the date that all of
2the rate filings are posted on the Department's website. The
3Department shall post all of the comments received to the
4Department's website within 5 business days after the comment
5period ends.
6    (f) After the close of the public comment period described
7in subsection (e), the Department, beginning for plan year
82026, shall issue a decision to approve, disapprove, or modify
9a rate filing within 60 days. Any rate filing or any rates
10within a filing on which the Director does not issue a decision
11within 60 days shall automatically be deemed approved. The
12Director's decision shall take into account the actuarial
13justifications and public comments. The Department shall
14notify the insurer of the decision, make the decision
15available to the public by posting it on the Department's
16website, and include an explanation of the findings, actuarial
17justifications, and rationale that are the basis for the
18decision. Any company whose rate has been modified or
19disapproved shall be allowed to request a hearing within 10
20days after the action taken. The action of the Director in
21disapproving a rate shall be subject to judicial review under
22the Administrative Review Law.
23    (g) If, following the issuance of a decision but before
24the effective date of the premium rates approved by the
25decision, an event occurs that materially affects the
26Director's decision to approve, deny, or modify the rates, the

 

 

10300HB5395ham001- 51 -LRB103 37071 RPS 70534 a

1Director may consider supplemental facts or data reasonably
2related to the event.
3    (h) The Department shall adopt rules implementing the
4procedures described in subsections (d) through (g) by March
531, 2024.
6    (i) Subsection (a) and subsections (c) through (h) of this
7Section do not apply to grandfathered health plans as defined
8in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C.
9300gg-91; student health insurance coverage as defined in 45
10CFR 147.145; the large group market as defined in Section 5 of
11the Illinois Health Insurance Portability and Accountability
12Act; or short-term, limited-duration health insurance coverage
13as defined in Section 5 of the Short-Term, Limited-Duration
14Health Insurance Coverage Act. For a filing of premium rates
15or classifications of risk for any of these types of coverage,
16the Director's initial review period shall not exceed 60 days
17to issue informal objections to the company that request
18additional clarification, explanation, substantiating
19documentation, or correction of concerns identified in the
20filing before the company implements the premium rates,
21classifications, or related rate-setting methodologies
22described in the filing, except that the Director may extend
23by not more than an additional 30 days the period of initial
24review by giving written notice to the company of such
25extension before the expiration of the initial 60-day period.
26Nothing in this subsection shall confer authority upon the

 

 

10300HB5395ham001- 52 -LRB103 37071 RPS 70534 a

1Director to approve, modify, or disapprove rates where that
2authority is not provided by other law. Nothing in this
3subsection shall prohibit the Director from conducting any
4investigation, examination, hearing, or other formal
5administrative or enforcement proceeding with respect to a
6company's rate filing or implementation thereof under
7applicable law at any time, including after the period of
8initial review.
9(Source: P.A. 103-106, eff. 1-1-24.)
 
10
Article 4.

 
11    Section 4-5. The Illinois Insurance Code is amended by
12changing Section 355 as follows:
 
13    (215 ILCS 5/355)  (from Ch. 73, par. 967)
14    Sec. 355. Accident and health policies; provisions.
15    (a) As used in this Section:
16    "Inadequate rate" means a rate:
17        (1) that is insufficient to sustain projected losses
18    and expenses to which the rate applies; and
19        (2) the continued use of which endangers the solvency
20    of an insurer using that rate.
21    "Large employer" has the meaning provided in the Illinois
22Health Insurance Portability and Accountability Act.
23    "Plain language" has the meaning provided in the federal

 

 

10300HB5395ham001- 53 -LRB103 37071 RPS 70534 a

1Plain Writing Act of 2010 and subsequent guidance documents,
2including the Federal Plain Language Guidelines.
3    "Unreasonable rate increase" means a rate increase that
4the Director determines to be excessive, unjustified, or
5unfairly discriminatory in accordance with 45 CFR 154.205.
6    (b) No policy of insurance against loss or damage from the
7sickness, or from the bodily injury or death of the insured by
8accident shall be issued or delivered to any person in this
9State until a copy of the form thereof and of the
10classification of risks and the premium rates pertaining
11thereto have been filed with the Director; nor shall it be so
12issued or delivered until the Director shall have approved
13such policy pursuant to the provisions of Section 143. If the
14Director disapproves the policy form, he or she shall make a
15written decision stating the respects in which such form does
16not comply with the requirements of law and shall deliver a
17copy thereof to the company and it shall be unlawful
18thereafter for any such company to issue any policy in such
19form. On and after January 1, 2025, any form filing submitted
20for large employer group accident and health insurance shall
21be automatically deemed approved within 90 days of the
22submission date unless the Director extends by not more than
23an additional 30 days the period within which the form shall be
24approved or disapproved by giving written notice to the
25insurer of such extension before the expiration of the 90
26days. Any form in receipt of such an extension shall be

 

 

10300HB5395ham001- 54 -LRB103 37071 RPS 70534 a

1automatically deemed approved within 120 days of the
2submission date. The Director may toll the filing due to a
3conflict in legal interpretation of federal or State law as
4long as the tolling is applied uniformly to all applicable
5forms, written notification is provided to the insurer prior
6to the tolling, the duration of the tolling is provided within
7the notice to the insurer, and justification for the tolling
8is posted to the Department's website. The Director may
9disapprove the filing if the insurer fails to respond to an
10objection or request for additional information within the
11timeframe identified for response. As used in this subsection,
12"large employer" has the meaning given in Section 5 of the
13federal Health Insurance Portability and Accountability Act.
14    (c) For plan year 2026 and thereafter, premium rates for
15all individual and small group accident and health insurance
16policies must be filed with the Department for approval.
17Unreasonable rate increases or inadequate rates shall be
18modified or disapproved. For any plan year during which the
19Illinois Health Benefits Exchange operates as a full
20State-based exchange, the Department shall provide insurers at
21least 30 days' notice of the deadline to submit rate filings.
22    (d) For plan year 2025 and thereafter, the Department
23shall post all insurers' rate filings and summaries on the
24Department's website 5 business days after the rate filing
25deadline set by the Department in annual guidance. The rate
26filings and summaries posted to the Department's website shall

 

 

10300HB5395ham001- 55 -LRB103 37071 RPS 70534 a

1exclude information that is proprietary or trade secret
2information protected under paragraph (g) of subsection (1) of
3Section 7 of the Freedom of Information Act or confidential or
4privileged under any applicable insurance law or rule. All
5summaries shall include a brief justification of any rate
6increase or decrease requested, including the number of
7individual members, the medical loss ratio, medical trend,
8administrative costs, and any other information required by
9rule. The plain writing summary shall include notification of
10the public comment period established in subsection (e).
11    (e) The Department shall open a 30-day public comment
12period on the rate filings beginning on the date that all of
13the rate filings are posted on the Department's website. The
14Department shall post all of the comments received to the
15Department's website within 5 business days after the comment
16period ends.
17    (f) After the close of the public comment period described
18in subsection (e), the Department, beginning for plan year
192026, shall issue a decision to approve, disapprove, or modify
20a rate filing within 60 days. Any rate filing or any rates
21within a filing on which the Director does not issue a decision
22within 60 days shall automatically be deemed approved. The
23Director's decision shall take into account the actuarial
24justifications and public comments. The Department shall
25notify the insurer of the decision, make the decision
26available to the public by posting it on the Department's

 

 

10300HB5395ham001- 56 -LRB103 37071 RPS 70534 a

1website, and include an explanation of the findings, actuarial
2justifications, and rationale that are the basis for the
3decision. Any company whose rate has been modified or
4disapproved shall be allowed to request a hearing within 10
5days after the action taken. The action of the Director in
6disapproving a rate shall be subject to judicial review under
7the Administrative Review Law.
8    (g) If, following the issuance of a decision but before
9the effective date of the premium rates approved by the
10decision, an event occurs that materially affects the
11Director's decision to approve, deny, or modify the rates, the
12Director may consider supplemental facts or data reasonably
13related to the event.
14    (h) The Department shall adopt rules implementing the
15procedures described in subsections (d) through (g) by March
1631, 2024.
17    (i) Subsection (a), and subsections (c) through (h), and
18subsection (j) of this Section do not apply to grandfathered
19health plans as defined in 45 CFR 147.140; excepted benefits
20as defined in 42 U.S.C. 300gg-91; student health insurance
21coverage as defined in 45 CFR 147.145; the large group market
22as defined in Section 5 of the Illinois Health Insurance
23Portability and Accountability Act; or short-term,
24limited-duration health insurance coverage as defined in
25Section 5 of the Short-Term, Limited-Duration Health Insurance
26Coverage Act. For a filing of premium rates or classifications

 

 

10300HB5395ham001- 57 -LRB103 37071 RPS 70534 a

1of risk for any of these types of coverage, the Director's
2initial review period shall not exceed 60 days to issue
3informal objections to the company that request additional
4clarification, explanation, substantiating documentation, or
5correction of concerns identified in the filing before the
6company implements the premium rates, classifications, or
7related rate-setting methodologies described in the filing,
8except that the Director may extend by not more than an
9additional 30 days the period of initial review by giving
10written notice to the company of such extension before the
11expiration of the initial 60-day period. Nothing in this
12subsection shall confer authority upon the Director to
13approve, modify, or disapprove rates where that authority is
14not provided by other law. Nothing in this subsection shall
15prohibit the Director from conducting any investigation,
16examination, hearing, or other formal administrative or
17enforcement proceeding with respect to a company's rate filing
18or implementation thereof under applicable law at any time,
19including after the period of initial review.
20    (j) Subsections (c) through (h) do not apply to group
21policies issued to large employers. For large employer group
22policies issued, delivered, amended, or renewed on or after
23January 1, 2026 that are not described in subsection (i), the
24premium rates and risk classifications, including any rate
25manuals and rules used to arrive at the rates, must be filed
26with the Department annually for approval at least 120 days

 

 

10300HB5395ham001- 58 -LRB103 37071 RPS 70534 a

1before the rates are intended to take effect.
2        (1) A rate filing shall be modified or disapproved if
3    rates will be unreasonable in relation to the benefits,
4    unjustified, or unfairly discriminatory, or otherwise in
5    violation of applicable State or federal law.
6        (2) Within 60 days of receipt of the rate filing, the
7    Director shall issue a decision to approve, disapprove, or
8    modify the filing along with the reasons and actuarial
9    justification for the decision. Any rate filing or rates
10    within a filing on which the Director does not issue a
11    decision within 60 days shall be automatically deemed
12    approved.
13        (3) Any company whose rate or rate filing has been
14    modified or disapproved shall be allowed to request a
15    hearing within 10 days after the action taken. The action
16    of the Director in disapproving a rate or rate filing
17    shall be subject to judicial review under the
18    Administrative Review Law.
19        (4) Nothing in this subsection requires a company to
20    file a large employer group policy's final premium rates
21    for prior approval if the company negotiates the final
22    rates or rate adjustments with the large employer in
23    accordance with the rate manual and rules of the currently
24    approved rate filing for the policy.
25(Source: P.A. 103-106, eff. 1-1-24.)
 

 

 

10300HB5395ham001- 59 -LRB103 37071 RPS 70534 a

1    Section 4-10. The Health Maintenance Organization Act is
2amended by changing Section 4-12 as follows:
 
3    (215 ILCS 125/4-12)  (from Ch. 111 1/2, par. 1409.5)
4    Sec. 4-12. Changes in rate methodology and benefits,
5material modifications. A health maintenance organization
6shall file with the Director, prior to use, a notice of any
7change in rate methodology, or benefits and of any material
8modification of any matter or document furnished pursuant to
9Section 2-1, together with such supporting documents as are
10necessary to fully explain the change or modification.
11    (a) Contract modifications described in subsections
12(c)(5), (c)(6) and (c)(7) of Section 2-1 shall include all
13form agreements between the organization and enrollees,
14providers, administrators of services and insurers of health
15maintenance organizations.
16    (b) Material transactions or series of transactions other
17than those described in subsection (a) of this Section, the
18total annual value of which exceeds the greater of $100,000 or
195% of net earned subscription revenue for the most current
2012-month period as determined from filed financial statements.
21    (c) Any agreement between the organization and an insurer
22shall be subject to the provisions of the laws of this State
23regarding reinsurance as provided in Article XI of the
24Illinois Insurance Code. All reinsurance agreements must be
25filed. Approval of the Director is required for all agreements

 

 

10300HB5395ham001- 60 -LRB103 37071 RPS 70534 a

1except the following: individual stop loss, aggregate excess,
2hospitalization benefits or out-of-area of the participating
3providers unless 20% or more of the organization's total risk
4is reinsured, in which case all reinsurance agreements require
5approval.
6    (d) In addition to any applicable provisions of this Act,
7premium rate filings shall be subject to subsections (a) and
8(c) through (j) (i) of Section 355 of the Illinois Insurance
9Code.
10(Source: P.A. 103-106, eff. 1-1-24.)
 
11    Section 4-15. The Limited Health Service Organization Act
12is amended by changing Section 3006 as follows:
 
13    (215 ILCS 130/3006)  (from Ch. 73, par. 1503-6)
14    Sec. 3006. Changes in rate methodology and benefits;
15material modifications; addition of limited health services.
16    (a) A limited health service organization shall file with
17the Director prior to use, a notice of any change in rate
18methodology, charges, or benefits and of any material
19modification of any matter or document furnished pursuant to
20Section 2001, together with such supporting documents as are
21necessary to fully explain the change or modification.
22        (1) Contract modifications described in paragraphs (5)
23    and (6) of subsection (c) of Section 2001 shall include
24    all agreements between the organization and enrollees,

 

 

10300HB5395ham001- 61 -LRB103 37071 RPS 70534 a

1    providers, administrators of services, and insurers of
2    limited health services; also other material transactions
3    or series of transactions, the total annual value of which
4    exceeds the greater of $100,000 or 5% of net earned
5    subscription revenue for the most current 12-month 12
6    month period as determined from filed financial
7    statements.
8        (2) Contract modification for reinsurance. Any
9    agreement between the organization and an insurer shall be
10    subject to the provisions of Article XI of the Illinois
11    Insurance Code, as now or hereafter amended. All
12    reinsurance agreements must be filed with the Director.
13    Approval of the Director in required agreements must be
14    filed. Approval of the director is required for all
15    agreements except individual stop loss, aggregate excess,
16    hospitalization benefits, or out-of-area of the
17    participating providers, unless 20% or more of the
18    organization's total risk is reinsured, in which case all
19    reinsurance agreements shall require approval.
20    (b) If a limited health service organization desires to
21add one or more additional limited health services, it shall
22file a notice with the Director and, at the same time, submit
23the information required by Section 2001 if different from
24that filed with the prepaid limited health service
25organization's application. Issuance of such an amended
26certificate of authority shall be subject to the conditions of

 

 

10300HB5395ham001- 62 -LRB103 37071 RPS 70534 a

1Section 2002 of this Act.
2    (c) In addition to any applicable provisions of this Act,
3premium rate filings shall be subject to subsection (i) and,
4for pharmaceutical policies, subsection (j) of Section 355 of
5the Illinois Insurance Code.
6(Source: P.A. 103-106, eff. 1-1-24; revised 1-2-24.)
 
7
Article 5.

 
8    Section 5-5. The Illinois Insurance Code is amended by
9changing Sections 121-2.05, 356z.18, 367.3, 367a, and 368f and
10by adding Section 352c as follows:
 
11    (215 ILCS 5/121-2.05)  (from Ch. 73, par. 733-2.05)
12    Sec. 121-2.05. Group insurance policies issued and
13delivered in other State-Transactions in this State. With the
14exception of insurance transactions authorized under Sections
15230.2 or 367.3 of this Code or transactions described under
16Section 352c, transactions in this State involving group
17legal, group life and group accident and health or blanket
18accident and health insurance or group annuities where the
19master policy of such groups was lawfully issued and delivered
20in, and under the laws of, a State in which the insurer was
21authorized to do an insurance business, to a group properly
22established pursuant to law or regulation, and where the
23policyholder is domiciled or otherwise has a bona fide situs.

 

 

10300HB5395ham001- 63 -LRB103 37071 RPS 70534 a

1(Source: P.A. 86-753.)
 
2    (215 ILCS 5/352c new)
3    Sec. 352c. Short-term, limited-duration insurance
4prohibited; rules for excepted benefits.
5    (a) Definitions. As used in this Section:
6    "Excepted benefits" has the meaning given to that term in
742 U.S.C. 300gg-91 and implementing regulations. "Excepted
8benefits" includes individual, group, or blanket coverage.
9    "Short-term, limited-duration insurance" means any type of
10accident and health insurance offered or provided within this
11State pursuant to a group or individual policy or individual
12certificate by a company, regardless of the situs state of the
13delivery of the policy, that has an expiration date specified
14in the contract that is fewer than 365 days after the original
15effective date. Regardless of the duration of coverage,
16"short-term, limited-duration insurance" does not include
17excepted benefits or any student health insurance coverage.
18    "Student health insurance coverage" has the meaning given
19to that term in 45 CFR 147.145.
20    (b) On and after January 1, 2025, no company shall issue,
21deliver, amend, or renew short-term, limited-duration
22insurance to any natural or legal person that is a resident or
23domiciled in this State.
24    (c) To prevent the use, design, and combination of
25excepted benefits to circumvent State or federal requirements

 

 

10300HB5395ham001- 64 -LRB103 37071 RPS 70534 a

1for comprehensive forms of health insurance coverage, to
2prevent confusion or misinformation of insureds about
3duplicate or distinct types of coverage, and to ensure a
4measure of consistency within product lines across the
5individual, group, and blanket markets, the Department may
6adopt rules as deemed necessary that prescribe specific
7standards for or restrictions on policy provisions, benefit
8design, disclosures, and sales and marketing practices for
9excepted benefits. For purposes of these rules, the Director's
10authority under subsections (3) and (4) of Section 355a is
11extended to group and blanket excepted benefits. To ensure
12compliance with these rules, the Director may require policy
13forms and rates to be filed as provided in Sections 143 and 355
14and rules thereunder with respect to excepted benefits
15coverage intended to be issued to residents of this State
16under a master contract issued to a group domiciled or
17otherwise with bona fide situs outside of this State. This
18subsection does not apply to limited-scope dental,
19limited-scope vision, long-term care, Medicare supplement,
20credit life, credit health, or any excepted benefits that are
21filed under subsections (b) through (l) of Class 2 or under
22Class 3 of Section 4. Nothing in this subsection shall be
23construed to limit the Director's authority under other
24statutes.
 
25    (215 ILCS 5/356z.18)

 

 

10300HB5395ham001- 65 -LRB103 37071 RPS 70534 a

1    (Text of Section before amendment by P.A. 103-512)
2    Sec. 356z.18. Prosthetic and customized orthotic devices.
3    (a) For the purposes of this Section:
4    "Customized orthotic device" means a supportive device for
5the body or a part of the body, the head, neck, or extremities,
6and includes the replacement or repair of the device based on
7the patient's physical condition as medically necessary,
8excluding foot orthotics defined as an in-shoe device designed
9to support the structural components of the foot during
10weight-bearing activities.
11    "Licensed provider" means a prosthetist, orthotist, or
12pedorthist licensed to practice in this State.
13    "Prosthetic device" means an artificial device to replace,
14in whole or in part, an arm or leg and includes accessories
15essential to the effective use of the device and the
16replacement or repair of the device based on the patient's
17physical condition as medically necessary.
18    (b) This amendatory Act of the 96th General Assembly shall
19provide benefits to any person covered thereunder for expenses
20incurred in obtaining a prosthetic or custom orthotic device
21from any Illinois licensed prosthetist, licensed orthotist, or
22licensed pedorthist as required under the Orthotics,
23Prosthetics, and Pedorthics Practice Act.
24    (c) A group or individual major medical policy of accident
25or health insurance or managed care plan or medical, health,
26or hospital service corporation contract that provides

 

 

10300HB5395ham001- 66 -LRB103 37071 RPS 70534 a

1coverage for prosthetic or custom orthotic care and is
2amended, delivered, issued, or renewed 6 months after the
3effective date of this amendatory Act of the 96th General
4Assembly must provide coverage for prosthetic and orthotic
5devices in accordance with this subsection (c). The coverage
6required under this Section shall be subject to the other
7general exclusions, limitations, and financial requirements of
8the policy, including coordination of benefits, participating
9provider requirements, utilization review of health care
10services, including review of medical necessity, case
11management, and experimental and investigational treatments,
12and other managed care provisions under terms and conditions
13that are no less favorable than the terms and conditions that
14apply to substantially all medical and surgical benefits
15provided under the plan or coverage.
16    (d) The policy or plan or contract may require prior
17authorization for the prosthetic or orthotic devices in the
18same manner that prior authorization is required for any other
19covered benefit.
20    (e) Repairs and replacements of prosthetic and orthotic
21devices are also covered, subject to the co-payments and
22deductibles, unless necessitated by misuse or loss.
23    (f) A policy or plan or contract may require that, if
24coverage is provided through a managed care plan, the benefits
25mandated pursuant to this Section shall be covered benefits
26only if the prosthetic or orthotic devices are provided by a

 

 

10300HB5395ham001- 67 -LRB103 37071 RPS 70534 a

1licensed provider employed by a provider service who contracts
2with or is designated by the carrier, to the extent that the
3carrier provides in-network and out-of-network service, the
4coverage for the prosthetic or orthotic device shall be
5offered no less extensively.
6    (g) The policy or plan or contract shall also meet
7adequacy requirements as established by the Health Care
8Reimbursement Reform Act of 1985 of the Illinois Insurance
9Code.
10    (h) This Section shall not apply to accident only,
11specified disease, short-term travel hospital or medical,
12hospital confinement indemnity, credit, dental, vision,
13Medicare supplement, long-term care, basic hospital and
14medical-surgical expense coverage, disability income insurance
15coverage, coverage issued as a supplement to liability
16insurance, workers' compensation insurance, or automobile
17medical payment insurance.
18(Source: P.A. 96-833, eff. 6-1-10.)
 
19    (Text of Section after amendment by P.A. 103-512)
20    Sec. 356z.18. Prosthetic and customized orthotic devices.
21    (a) For the purposes of this Section:
22    "Customized orthotic device" means a supportive device for
23the body or a part of the body, the head, neck, or extremities,
24and includes the replacement or repair of the device based on
25the patient's physical condition as medically necessary,

 

 

10300HB5395ham001- 68 -LRB103 37071 RPS 70534 a

1excluding foot orthotics defined as an in-shoe device designed
2to support the structural components of the foot during
3weight-bearing activities.
4    "Licensed provider" means a prosthetist, orthotist, or
5pedorthist licensed to practice in this State.
6    "Prosthetic device" means an artificial device to replace,
7in whole or in part, an arm or leg and includes accessories
8essential to the effective use of the device and the
9replacement or repair of the device based on the patient's
10physical condition as medically necessary.
11    (b) This amendatory Act of the 96th General Assembly shall
12provide benefits to any person covered thereunder for expenses
13incurred in obtaining a prosthetic or custom orthotic device
14from any Illinois licensed prosthetist, licensed orthotist, or
15licensed pedorthist as required under the Orthotics,
16Prosthetics, and Pedorthics Practice Act.
17    (c) A group or individual major medical policy of accident
18or health insurance or managed care plan or medical, health,
19or hospital service corporation contract that provides
20coverage for prosthetic or custom orthotic care and is
21amended, delivered, issued, or renewed 6 months after the
22effective date of this amendatory Act of the 96th General
23Assembly must provide coverage for prosthetic and orthotic
24devices in accordance with this subsection (c). The coverage
25required under this Section shall be subject to the other
26general exclusions, limitations, and financial requirements of

 

 

10300HB5395ham001- 69 -LRB103 37071 RPS 70534 a

1the policy, including coordination of benefits, participating
2provider requirements, utilization review of health care
3services, including review of medical necessity, case
4management, and experimental and investigational treatments,
5and other managed care provisions under terms and conditions
6that are no less favorable than the terms and conditions that
7apply to substantially all medical and surgical benefits
8provided under the plan or coverage.
9    (d) With respect to an enrollee at any age, in addition to
10coverage of a prosthetic or custom orthotic device required by
11this Section, benefits shall be provided for a prosthetic or
12custom orthotic device determined by the enrollee's provider
13to be the most appropriate model that is medically necessary
14for the enrollee to perform physical activities, as
15applicable, such as running, biking, swimming, and lifting
16weights, and to maximize the enrollee's whole body health and
17strengthen the lower and upper limb function.
18    (e) The requirements of this Section do not constitute an
19addition to this State's essential health benefits that
20requires defrayal of costs by this State pursuant to 42 U.S.C.
2118031(d)(3)(B).
22    (f) The policy or plan or contract may require prior
23authorization for the prosthetic or orthotic devices in the
24same manner that prior authorization is required for any other
25covered benefit.
26    (g) Repairs and replacements of prosthetic and orthotic

 

 

10300HB5395ham001- 70 -LRB103 37071 RPS 70534 a

1devices are also covered, subject to the co-payments and
2deductibles, unless necessitated by misuse or loss.
3    (h) A policy or plan or contract may require that, if
4coverage is provided through a managed care plan, the benefits
5mandated pursuant to this Section shall be covered benefits
6only if the prosthetic or orthotic devices are provided by a
7licensed provider employed by a provider service who contracts
8with or is designated by the carrier, to the extent that the
9carrier provides in-network and out-of-network service, the
10coverage for the prosthetic or orthotic device shall be
11offered no less extensively.
12    (i) The policy or plan or contract shall also meet
13adequacy requirements as established by the Health Care
14Reimbursement Reform Act of 1985 of the Illinois Insurance
15Code.
16    (j) This Section shall not apply to accident only,
17specified disease, short-term travel hospital or medical,
18hospital confinement indemnity, credit, dental, vision,
19Medicare supplement, long-term care, basic hospital and
20medical-surgical expense coverage, disability income insurance
21coverage, coverage issued as a supplement to liability
22insurance, workers' compensation insurance, or automobile
23medical payment insurance.
24(Source: P.A. 103-512, eff. 1-1-25.)
 
25    (215 ILCS 5/367.3)  (from Ch. 73, par. 979.3)

 

 

10300HB5395ham001- 71 -LRB103 37071 RPS 70534 a

1    Sec. 367.3. Group accident and health insurance;
2discretionary groups.
3    (a) No group health insurance offered to a resident of
4this State under a policy issued to a group, other than one
5specifically described in Section 367(1), shall be delivered
6or issued for delivery in this State unless the Director
7determines that:
8        (1) the issuance of the policy is not contrary to the
9    public interest;
10        (2) the issuance of the policy will result in
11    economies of acquisition and administration; and
12        (3) the benefits under the policy are reasonable in
13    relation to the premium charged.
14    (b) No such group health insurance may be offered in this
15State under a policy issued in another state unless this State
16or the state in which the group policy is issued has made a
17determination that the requirements of subsection (a) have
18been met.
19    Where insurance is to be offered in this State under a
20policy described in this subsection, the insurer shall file
21for informational review purposes:
22        (1) a copy of the group master contract;
23        (2) a copy of the statute authorizing the issuance of
24    the group policy in the state of situs, which statute has
25    the same or similar requirements as this State, or in the
26    absence of such statute, a certification by an officer of

 

 

10300HB5395ham001- 72 -LRB103 37071 RPS 70534 a

1    the company that the policy meets the Illinois minimum
2    standards required for individual accident and health
3    policies under authority of Section 401 of this Code, as
4    now or hereafter amended, as promulgated by rule at 50
5    Illinois Administrative Code, Ch. I, Sec. 2007, et seq.,
6    as now or hereafter amended, or by a successor rule;
7        (3) evidence of approval by the state of situs of the
8    group master policy; and
9        (4) copies of all supportive material furnished to the
10    state of situs to satisfy the criteria for approval.
11    (c) The Director may, at any time after receipt of the
12information required under subsection (b) and after finding
13that the standards of subsection (a) have not been met, order
14the insurer to cease the issuance or marketing of that
15coverage in this State.
16    (d) Notwithstanding subsections (a) and (b), group Group
17accident and health insurance subject to the provisions of
18this Section is also subject to the provisions of Sections
19352c and Section 367i of this Code and rules thereunder.
20(Source: P.A. 90-655, eff. 7-30-98.)
 
21    (215 ILCS 5/367a)  (from Ch. 73, par. 979a)
22    Sec. 367a. Blanket accident and health insurance.
23    (1) Blanket accident and health insurance is the that form
24of accident and health insurance providing excepted benefits,
25as defined in Section 352c, that covers covering special

 

 

10300HB5395ham001- 73 -LRB103 37071 RPS 70534 a

1groups of persons as enumerated in one of the following
2paragraphs (a) to (g), inclusive:
3    (a) Under a policy or contract issued to any carrier for
4hire, which shall be deemed the policyholder, covering a group
5defined as all persons who may become passengers on such
6carrier.
7    (b) Under a policy or contract issued to an employer, who
8shall be deemed the policyholder, covering all employees or
9any group of employees defined by reference to exceptional
10hazards incident to such employment.
11    (c) Under a policy or contract issued to a college,
12school, or other institution of learning or to the head or
13principal thereof, who or which shall be deemed the
14policyholder, covering students or teachers. However, except
15where inconsistent with 45 CFR 147.145, student health
16insurance coverage other than excepted benefits that is
17provided pursuant to a written agreement with an institution
18of higher education for the benefit of its enrolled students
19and their dependents shall remain subject to the standards and
20requirements for individual coverage.
21    (d) Under a policy or contract issued in the name of any
22volunteer fire department, first aid, or other such volunteer
23group, which shall be deemed the policyholder, covering all of
24the members of such department or group.
25    (e) Under a policy or contract issued to a creditor, who
26shall be deemed the policyholder, to insure debtors of the

 

 

10300HB5395ham001- 74 -LRB103 37071 RPS 70534 a

1creditors; Provided, however, that in the case of a loan which
2is subject to the Small Loans Act, no insurance premium or
3other cost shall be directly or indirectly charged or assessed
4against, or collected or received from the borrower.
5    (f) Under a policy or contract issued to a sports team or
6to a camp, which team or camp sponsor shall be deemed the
7policyholder, covering members or campers.
8    (g) Under a policy or contract issued to any other
9substantially similar group which, in the discretion of the
10Director, may be subject to the issuance of a blanket accident
11and health policy or contract.
12    (2) Any insurance company authorized to write accident and
13health insurance in this state shall have the power to issue
14blanket accident and health insurance. No such blanket policy
15may be issued or delivered in this State unless a copy of the
16form thereof shall have been filed in accordance with Section
17355, and it contains in substance such of those provisions
18contained in Sections 357.1 through 357.30 as may be
19applicable to blanket accident and health insurance and the
20following provisions:
21    (a) A provision that the policy and the application shall
22constitute the entire contract between the parties, and that
23all statements made by the policyholder shall, in absence of
24fraud, be deemed representations and not warranties, and that
25no such statements shall be used in defense to a claim under
26the policy, unless it is contained in a written application.

 

 

10300HB5395ham001- 75 -LRB103 37071 RPS 70534 a

1    (b) A provision that to the group or class thereof
2originally insured shall be added from time to time all new
3persons or individuals eligible for coverage.
4    (3) An individual application shall not be required from a
5person covered under a blanket accident or health policy or
6contract, nor shall it be necessary for the insurer to furnish
7each person a certificate.
8    (4) All benefits under any blanket accident and health
9policy shall be payable to the person insured, or to his
10designated beneficiary or beneficiaries, or to his or her
11estate, except that if the person insured be a minor or person
12under legal disability, such benefits may be made payable to
13his or her parent, guardian, or other person actually
14supporting him or her. Provided further, however, that the
15policy may provide that all or any portion of any indemnities
16provided by any such policy on account of hospital, nursing,
17medical or surgical services may, at the insurer's option, be
18paid directly to the hospital or person rendering such
19services; but the policy may not require that the service be
20rendered by a particular hospital or person. Payment so made
21shall discharge the insurer's obligation with respect to the
22amount of insurance so paid.
23    (5) Nothing contained in this section shall be deemed to
24affect the legal liability of policyholders for the death of
25or injury to, any such member of such group.
26(Source: P.A. 83-1362.)
 

 

 

10300HB5395ham001- 76 -LRB103 37071 RPS 70534 a

1    (215 ILCS 5/368f)
2    Sec. 368f. Military service member insurance
3reinstatement.
4    (a) No Illinois resident activated for military service
5and no spouse or dependent of the resident who becomes
6eligible for a federal government-sponsored health insurance
7program, including the TriCare program providing coverage for
8civilian dependents of military personnel, as a result of the
9activation shall be denied reinstatement into the same
10individual health insurance coverage with the health insurer
11that the resident lapsed as a result of activation or becoming
12covered by the federal government-sponsored health insurance
13program. The resident shall have the right to reinstatement in
14the same individual health insurance coverage without medical
15underwriting, subject to payment of the current premium
16charged to other persons of the same age and gender that are
17covered under the same individual health coverage. Except in
18the case of birth or adoption that occurs during the period of
19activation, reinstatement must be into the same coverage type
20as the resident held prior to lapsing the individual health
21insurance coverage and at the same or, at the option of the
22resident, higher deductible level. The reinstatement rights
23provided under this subsection (a) are not available to a
24resident or dependents if the activated person is discharged
25from the military under other than honorable conditions.

 

 

10300HB5395ham001- 77 -LRB103 37071 RPS 70534 a

1    (b) The health insurer with which the reinstatement is
2being requested must receive a request for reinstatement no
3later than 63 days following the later of (i) deactivation or
4(ii) loss of coverage under the federal government-sponsored
5health insurance program. The health insurer may request proof
6of loss of coverage and the timing of the loss of coverage of
7the government-sponsored coverage in order to determine
8eligibility for reinstatement into the individual coverage.
9The effective date of the reinstatement of individual health
10coverage shall be the first of the month following receipt of
11the notice requesting reinstatement.
12    (c) All insurers must provide written notice to the
13policyholder of individual health coverage of the rights
14described in subsection (a) of this Section. In lieu of the
15inclusion of the notice in the individual health insurance
16policy, an insurance company may satisfy the notification
17requirement by providing a single written notice:
18        (1) in conjunction with the enrollment process for a
19    policyholder initially enrolling in the individual
20    coverage on or after the effective date of this amendatory
21    Act of the 94th General Assembly; or
22        (2) by mailing written notice to policyholders whose
23    coverage was effective prior to the effective date of this
24    amendatory Act of the 94th General Assembly no later than
25    90 days following the effective date of this amendatory
26    Act of the 94th General Assembly.

 

 

10300HB5395ham001- 78 -LRB103 37071 RPS 70534 a

1    (d) The provisions of subsection (a) of this Section do
2not apply to any policy or certificate providing coverage for
3any specified disease, specified accident or accident-only
4coverage, credit, dental, disability income, hospital
5indemnity, long-term care, Medicare supplement, vision care,
6or short-term travel nonrenewable health policy or other
7limited-benefit supplemental insurance, or any coverage issued
8as a supplement to any liability insurance, workers'
9compensation or similar insurance, or any insurance under
10which benefits are payable with or without regard to fault,
11whether written on a group, blanket, or individual basis.
12    (e) Nothing in this Section shall require an insurer to
13reinstate the resident if the insurer requires residency in an
14enrollment area and those residency requirements are not met
15after deactivation or loss of coverage under the
16government-sponsored health insurance program.
17    (f) All terms, conditions, and limitations of the
18individual coverage into which reinstatement is made apply
19equally to all insureds enrolled in the coverage.
20    (g) The Secretary may adopt rules as may be necessary to
21carry out the provisions of this Section.
22(Source: P.A. 94-1037, eff. 7-20-06.)
 
23    Section 5-10. The Health Maintenance Organization Act is
24amended by changing Section 5-3 as follows:
 

 

 

10300HB5395ham001- 79 -LRB103 37071 RPS 70534 a

1    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
2    Sec. 5-3. Insurance Code provisions.
3    (a) Health Maintenance Organizations shall be subject to
4the provisions of Sections 133, 134, 136, 137, 139, 140,
5141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
6154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
7352c, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q,
8356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
9356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
10356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
11356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,
12356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
13356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
14356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,
15356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
16356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
17356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
18368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
19408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
20subsection (2) of Section 367, and Articles IIA, VIII 1/2,
21XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
22Illinois Insurance Code.
23    (b) For purposes of the Illinois Insurance Code, except
24for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
25Health Maintenance Organizations in the following categories
26are deemed to be "domestic companies":

 

 

10300HB5395ham001- 80 -LRB103 37071 RPS 70534 a

1        (1) a corporation authorized under the Dental Service
2    Plan Act or the Voluntary Health Services Plans Act;
3        (2) a corporation organized under the laws of this
4    State; or
5        (3) a corporation organized under the laws of another
6    state, 30% or more of the enrollees of which are residents
7    of this State, except a corporation subject to
8    substantially the same requirements in its state of
9    organization as is a "domestic company" under Article VIII
10    1/2 of the Illinois Insurance Code.
11    (c) In considering the merger, consolidation, or other
12acquisition of control of a Health Maintenance Organization
13pursuant to Article VIII 1/2 of the Illinois Insurance Code,
14        (1) the Director shall give primary consideration to
15    the continuation of benefits to enrollees and the
16    financial conditions of the acquired Health Maintenance
17    Organization after the merger, consolidation, or other
18    acquisition of control takes effect;
19        (2)(i) the criteria specified in subsection (1)(b) of
20    Section 131.8 of the Illinois Insurance Code shall not
21    apply and (ii) the Director, in making his determination
22    with respect to the merger, consolidation, or other
23    acquisition of control, need not take into account the
24    effect on competition of the merger, consolidation, or
25    other acquisition of control;
26        (3) the Director shall have the power to require the

 

 

10300HB5395ham001- 81 -LRB103 37071 RPS 70534 a

1    following information:
2            (A) certification by an independent actuary of the
3        adequacy of the reserves of the Health Maintenance
4        Organization sought to be acquired;
5            (B) pro forma financial statements reflecting the
6        combined balance sheets of the acquiring company and
7        the Health Maintenance Organization sought to be
8        acquired as of the end of the preceding year and as of
9        a date 90 days prior to the acquisition, as well as pro
10        forma financial statements reflecting projected
11        combined operation for a period of 2 years;
12            (C) a pro forma business plan detailing an
13        acquiring party's plans with respect to the operation
14        of the Health Maintenance Organization sought to be
15        acquired for a period of not less than 3 years; and
16            (D) such other information as the Director shall
17        require.
18    (d) The provisions of Article VIII 1/2 of the Illinois
19Insurance Code and this Section 5-3 shall apply to the sale by
20any health maintenance organization of greater than 10% of its
21enrollee population (including, without limitation, the health
22maintenance organization's right, title, and interest in and
23to its health care certificates).
24    (e) In considering any management contract or service
25agreement subject to Section 141.1 of the Illinois Insurance
26Code, the Director (i) shall, in addition to the criteria

 

 

10300HB5395ham001- 82 -LRB103 37071 RPS 70534 a

1specified in Section 141.2 of the Illinois Insurance Code,
2take into account the effect of the management contract or
3service agreement on the continuation of benefits to enrollees
4and the financial condition of the health maintenance
5organization to be managed or serviced, and (ii) need not take
6into account the effect of the management contract or service
7agreement on competition.
8    (f) Except for small employer groups as defined in the
9Small Employer Rating, Renewability and Portability Health
10Insurance Act and except for medicare supplement policies as
11defined in Section 363 of the Illinois Insurance Code, a
12Health Maintenance Organization may by contract agree with a
13group or other enrollment unit to effect refunds or charge
14additional premiums under the following terms and conditions:
15        (i) the amount of, and other terms and conditions with
16    respect to, the refund or additional premium are set forth
17    in the group or enrollment unit contract agreed in advance
18    of the period for which a refund is to be paid or
19    additional premium is to be charged (which period shall
20    not be less than one year); and
21        (ii) the amount of the refund or additional premium
22    shall not exceed 20% of the Health Maintenance
23    Organization's profitable or unprofitable experience with
24    respect to the group or other enrollment unit for the
25    period (and, for purposes of a refund or additional
26    premium, the profitable or unprofitable experience shall

 

 

10300HB5395ham001- 83 -LRB103 37071 RPS 70534 a

1    be calculated taking into account a pro rata share of the
2    Health Maintenance Organization's administrative and
3    marketing expenses, but shall not include any refund to be
4    made or additional premium to be paid pursuant to this
5    subsection (f)). The Health Maintenance Organization and
6    the group or enrollment unit may agree that the profitable
7    or unprofitable experience may be calculated taking into
8    account the refund period and the immediately preceding 2
9    plan years.
10    The Health Maintenance Organization shall include a
11statement in the evidence of coverage issued to each enrollee
12describing the possibility of a refund or additional premium,
13and upon request of any group or enrollment unit, provide to
14the group or enrollment unit a description of the method used
15to calculate (1) the Health Maintenance Organization's
16profitable experience with respect to the group or enrollment
17unit and the resulting refund to the group or enrollment unit
18or (2) the Health Maintenance Organization's unprofitable
19experience with respect to the group or enrollment unit and
20the resulting additional premium to be paid by the group or
21enrollment unit.
22    In no event shall the Illinois Health Maintenance
23Organization Guaranty Association be liable to pay any
24contractual obligation of an insolvent organization to pay any
25refund authorized under this Section.
26    (g) Rulemaking authority to implement Public Act 95-1045,

 

 

10300HB5395ham001- 84 -LRB103 37071 RPS 70534 a

1if any, is conditioned on the rules being adopted in
2accordance with all provisions of the Illinois Administrative
3Procedure Act and all rules and procedures of the Joint
4Committee on Administrative Rules; any purported rule not so
5adopted, for whatever reason, is unauthorized.
6(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
7102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
81-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
9eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
10102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
111-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
12eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
13103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
146-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
15eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
16    Section 5-15. The Limited Health Service Organization Act
17is amended by changing Section 4003 as follows:
 
18    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
19    Sec. 4003. Illinois Insurance Code provisions. Limited
20health service organizations shall be subject to the
21provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
22141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
23154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c,
24355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10,

 

 

10300HB5395ham001- 85 -LRB103 37071 RPS 70534 a

1356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
2356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
3356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
4364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
5444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
6XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
7Nothing in this Section shall require a limited health care
8plan to cover any service that is not a limited health service.
9For purposes of the Illinois Insurance Code, except for
10Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
11health service organizations in the following categories are
12deemed to be domestic companies:
13        (1) a corporation under the laws of this State; or
14        (2) a corporation organized under the laws of another
15    state, 30% or more of the enrollees of which are residents
16    of this State, except a corporation subject to
17    substantially the same requirements in its state of
18    organization as is a domestic company under Article VIII
19    1/2 of the Illinois Insurance Code.
20(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
21102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
221-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
23eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
24102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
251-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
26eff. 1-1-24; revised 8-29-23.)
 

 

 

10300HB5395ham001- 86 -LRB103 37071 RPS 70534 a

1    (215 ILCS 190/Act rep.)
2    Section 5-20. The Short-Term, Limited-Duration Health
3Insurance Coverage Act is repealed.
 
4
Article 6.

 
5    Section 6-5. The Illinois Insurance Code is amended by
6changing Sections 155.36, 155.37, 356z.40, and 370c as
7follows:
 
8    (215 ILCS 5/155.36)
9    Sec. 155.36. Managed Care Reform and Patient Rights Act.
10Insurance companies that transact the kinds of insurance
11authorized under Class 1(b) or Class 2(a) of Section 4 of this
12Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65,
1370, and 85, and 87, subsection (d) of Section 30, and the
14definitions definition of the term "emergency medical
15condition" and any other term in Section 10 of the Managed Care
16Reform and Patient Rights Act that is used in the other
17Sections listed in this Section.
18(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
19    (215 ILCS 5/155.37)
20    Sec. 155.37. Drug formulary; notice.
21    (a) Insurance companies that transact the kinds of

 

 

10300HB5395ham001- 87 -LRB103 37071 RPS 70534 a

1insurance authorized under Class 1(b) or Class 2(a) of Section
24 of this Code and provide coverage for prescription drugs
3through the use of a drug formulary must notify insureds of any
4change in the formulary. A company may comply with this
5Section by posting changes in the formulary on its website.
6    (b) No later than July 1, 2025, insurance companies that
7use a drug formulary shall post the formulary on their
8websites in a manner that is searchable and accessible to the
9general public without requiring an individual to create any
10account. This formulary shall adhere to a template developed
11by the Department, which shall take into consideration
12existing requirements for reporting of information established
13by the federal Centers for Medicare and Medicaid Services as
14well as display of cost-sharing information. This template and
15all formularies also shall do all the following:
16        (1) include information on cost-sharing tiers and
17    utilization controls, such as prior authorization, for
18    each covered drug;
19        (2) indicate any drugs on the formulary that are
20    preferred over other drugs on the formulary;
21        (3) include information to educate insureds about the
22    differences between drugs administered or provided under a
23    policy's medical benefit and drugs covered under a drug
24    benefit and how to obtain coverage information about drugs
25    that are not covered under the drug benefit;
26        (4) include information to educate insureds that

 

 

10300HB5395ham001- 88 -LRB103 37071 RPS 70534 a

1    policies that provide drug benefits are required to have a
2    method for enrollees to obtain drugs not listed in the
3    formulary if they are deemed medically necessary by a
4    clinician under Section 45.1 of the Managed Care Reform
5    and Patient Rights Act;
6        (5) include information on which medications are
7    covered, including both generic and brand name; and
8        (6) include information on what tier of the plan's
9    drug formulary each medication is in.
10    (c) No formulary may establish a step therapy requirement
11for any formulary drug or any drug covered as a result of a
12medical exceptions procedure.
13(Source: P.A. 92-440, eff. 8-17-01; 92-651, eff. 7-11-02.)
 
14    (215 ILCS 5/356z.40)
15    Sec. 356z.40. Pregnancy and postpartum coverage.
16    (a) An individual or group policy of accident and health
17insurance or managed care plan amended, delivered, issued, or
18renewed on or after the effective date of this amendatory Act
19of the 102nd General Assembly shall provide coverage for
20pregnancy and newborn care in accordance with 42 U.S.C.
2118022(b) regarding essential health benefits.
22    (b) Benefits under this Section shall be as follows:
23        (1) An individual who has been identified as
24    experiencing a high-risk pregnancy by the individual's
25    treating provider shall have access to clinically

 

 

10300HB5395ham001- 89 -LRB103 37071 RPS 70534 a

1    appropriate case management programs. As used in this
2    subsection, "case management" means a mechanism to
3    coordinate and assure continuity of services, including,
4    but not limited to, health services, social services, and
5    educational services necessary for the individual. "Case
6    management" involves individualized assessment of needs,
7    planning of services, referral, monitoring, and advocacy
8    to assist an individual in gaining access to appropriate
9    services and closure when services are no longer required.
10    "Case management" is an active and collaborative process
11    involving a single qualified case manager, the individual,
12    the individual's family, the providers, and the community.
13    This includes close coordination and involvement with all
14    service providers in the management plan for that
15    individual or family, including assuring that the
16    individual receives the services. As used in this
17    subsection, "high-risk pregnancy" means a pregnancy in
18    which the pregnant or postpartum individual or baby is at
19    an increased risk for poor health or complications during
20    pregnancy or childbirth, including, but not limited to,
21    hypertension disorders, gestational diabetes, and
22    hemorrhage.
23        (2) An individual shall have access to medically
24    necessary treatment of a mental, emotional, nervous, or
25    substance use disorder or condition consistent with the
26    requirements set forth in this Section and in Sections

 

 

10300HB5395ham001- 90 -LRB103 37071 RPS 70534 a

1    370c and 370c.1 of this Code.
2        (3) The benefits provided for inpatient and outpatient
3    services for the treatment of a mental, emotional,
4    nervous, or substance use disorder or condition related to
5    pregnancy or postpartum complications shall be provided if
6    determined to be medically necessary, consistent with the
7    requirements of Sections 370c and 370c.1 of this Code. The
8    facility or provider shall notify the insurer of both the
9    admission and the initial treatment plan within 48 hours
10    after admission or initiation of treatment. Subject to the
11    requirements of Sections 370c and 370c.1 of this Code,
12    nothing Nothing in this paragraph shall prevent an insurer
13    from applying concurrent and post-service utilization
14    review of health care services, including review of
15    medical necessity, case management, experimental and
16    investigational treatments, managed care provisions, and
17    other terms and conditions of the insurance policy.
18        (4) The benefits for the first 48 hours of initiation
19    of services for an inpatient admission, detoxification or
20    withdrawal management program, or partial hospitalization
21    admission for the treatment of a mental, emotional,
22    nervous, or substance use disorder or condition related to
23    pregnancy or postpartum complications shall be provided
24    without post-service or concurrent review of medical
25    necessity, as the medical necessity for the first 48 hours
26    of such services shall be determined solely by the covered

 

 

10300HB5395ham001- 91 -LRB103 37071 RPS 70534 a

1    pregnant or postpartum individual's provider. Subject to
2    Section 370c and 370c.1 of this Code, nothing Nothing in
3    this paragraph shall prevent an insurer from applying
4    concurrent and post-service utilization review, including
5    the review of medical necessity, case management,
6    experimental and investigational treatments, managed care
7    provisions, and other terms and conditions of the
8    insurance policy, of any inpatient admission,
9    detoxification or withdrawal management program admission,
10    or partial hospitalization admission services for the
11    treatment of a mental, emotional, nervous, or substance
12    use disorder or condition related to pregnancy or
13    postpartum complications received 48 hours after the
14    initiation of such services. If an insurer determines that
15    the services are no longer medically necessary, then the
16    covered person shall have the right to external review
17    pursuant to the requirements of the Health Carrier
18    External Review Act.
19        (5) If an insurer determines that continued inpatient
20    care, detoxification or withdrawal management, partial
21    hospitalization, intensive outpatient treatment, or
22    outpatient treatment in a facility is no longer medically
23    necessary, the insurer shall, within 24 hours, provide
24    written notice to the covered pregnant or postpartum
25    individual and the covered pregnant or postpartum
26    individual's provider of its decision and the right to

 

 

10300HB5395ham001- 92 -LRB103 37071 RPS 70534 a

1    file an expedited internal appeal of the determination.
2    The insurer shall review and make a determination with
3    respect to the internal appeal within 24 hours and
4    communicate such determination to the covered pregnant or
5    postpartum individual and the covered pregnant or
6    postpartum individual's provider. If the determination is
7    to uphold the denial, the covered pregnant or postpartum
8    individual and the covered pregnant or postpartum
9    individual's provider have the right to file an expedited
10    external appeal. An independent utilization review
11    organization shall make a determination within 72 hours.
12    If the insurer's determination is upheld and it is
13    determined that continued inpatient care, detoxification
14    or withdrawal management, partial hospitalization,
15    intensive outpatient treatment, or outpatient treatment is
16    not medically necessary, the insurer shall remain
17    responsible for providing benefits for the inpatient care,
18    detoxification or withdrawal management, partial
19    hospitalization, intensive outpatient treatment, or
20    outpatient treatment through the day following the date
21    the determination is made, and the covered pregnant or
22    postpartum individual shall only be responsible for any
23    applicable copayment, deductible, and coinsurance for the
24    stay through that date as applicable under the policy. The
25    covered pregnant or postpartum individual shall not be
26    discharged or released from the inpatient facility,

 

 

10300HB5395ham001- 93 -LRB103 37071 RPS 70534 a

1    detoxification or withdrawal management, partial
2    hospitalization, intensive outpatient treatment, or
3    outpatient treatment until all internal appeals and
4    independent utilization review organization appeals are
5    exhausted. A decision to reverse an adverse determination
6    shall comply with the Health Carrier External Review Act.
7        (6) Except as otherwise stated in this subsection (b),
8    the benefits and cost-sharing shall be provided to the
9    same extent as for any other medical condition covered
10    under the policy.
11        (7) The benefits required by paragraphs (2) and (6) of
12    this subsection (b) are to be provided to all covered
13    pregnant or postpartum individuals with a diagnosis of a
14    mental, emotional, nervous, or substance use disorder or
15    condition. The presence of additional related or unrelated
16    diagnoses shall not be a basis to reduce or deny the
17    benefits required by this subsection (b).
18(Source: P.A. 102-665, eff. 10-8-21.)
 
19    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
20    Sec. 370c. Mental and emotional disorders.
21    (a)(1) On and after January 1, 2022 (the effective date of
22Public Act 102-579), every insurer that amends, delivers,
23issues, or renews group accident and health policies providing
24coverage for hospital or medical treatment or services for
25illness on an expense-incurred basis shall provide coverage

 

 

10300HB5395ham001- 94 -LRB103 37071 RPS 70534 a

1for the medically necessary treatment of mental, emotional,
2nervous, or substance use disorders or conditions consistent
3with the parity requirements of Section 370c.1 of this Code.
4    (2) Each insured that is covered for mental, emotional,
5nervous, or substance use disorders or conditions shall be
6free to select the physician licensed to practice medicine in
7all its branches, licensed clinical psychologist, licensed
8clinical social worker, licensed clinical professional
9counselor, licensed marriage and family therapist, licensed
10speech-language pathologist, or other licensed or certified
11professional at a program licensed pursuant to the Substance
12Use Disorder Act of his or her choice to treat such disorders,
13and the insurer shall pay the covered charges of such
14physician licensed to practice medicine in all its branches,
15licensed clinical psychologist, licensed clinical social
16worker, licensed clinical professional counselor, licensed
17marriage and family therapist, licensed speech-language
18pathologist, or other licensed or certified professional at a
19program licensed pursuant to the Substance Use Disorder Act up
20to the limits of coverage, provided (i) the disorder or
21condition treated is covered by the policy, and (ii) the
22physician, licensed psychologist, licensed clinical social
23worker, licensed clinical professional counselor, licensed
24marriage and family therapist, licensed speech-language
25pathologist, or other licensed or certified professional at a
26program licensed pursuant to the Substance Use Disorder Act is

 

 

10300HB5395ham001- 95 -LRB103 37071 RPS 70534 a

1authorized to provide said services under the statutes of this
2State and in accordance with accepted principles of his or her
3profession.
4    (3) Insofar as this Section applies solely to licensed
5clinical social workers, licensed clinical professional
6counselors, licensed marriage and family therapists, licensed
7speech-language pathologists, and other licensed or certified
8professionals at programs licensed pursuant to the Substance
9Use Disorder Act, those persons who may provide services to
10individuals shall do so after the licensed clinical social
11worker, licensed clinical professional counselor, licensed
12marriage and family therapist, licensed speech-language
13pathologist, or other licensed or certified professional at a
14program licensed pursuant to the Substance Use Disorder Act
15has informed the patient of the desirability of the patient
16conferring with the patient's primary care physician.
17    (4) "Mental, emotional, nervous, or substance use disorder
18or condition" means a condition or disorder that involves a
19mental health condition or substance use disorder that falls
20under any of the diagnostic categories listed in the mental
21and behavioral disorders chapter of the current edition of the
22World Health Organization's International Classification of
23Disease or that is listed in the most recent version of the
24American Psychiatric Association's Diagnostic and Statistical
25Manual of Mental Disorders. "Mental, emotional, nervous, or
26substance use disorder or condition" includes any mental

 

 

10300HB5395ham001- 96 -LRB103 37071 RPS 70534 a

1health condition that occurs during pregnancy or during the
2postpartum period and includes, but is not limited to,
3postpartum depression.
4    (5) Medically necessary treatment and medical necessity
5determinations shall be interpreted and made in a manner that
6is consistent with and pursuant to subsections (h) through
7(t).
8    (b)(1) (Blank).
9    (2) (Blank).
10    (2.5) (Blank).
11    (3) Unless otherwise prohibited by federal law and
12consistent with the parity requirements of Section 370c.1 of
13this Code, the reimbursing insurer that amends, delivers,
14issues, or renews a group or individual policy of accident and
15health insurance, a qualified health plan offered through the
16health insurance marketplace, or a provider of treatment of
17mental, emotional, nervous, or substance use disorders or
18conditions shall furnish medical records or other necessary
19data that substantiate that initial or continued treatment is
20at all times medically necessary. An insurer shall provide a
21mechanism for the timely review by a provider holding the same
22license and practicing in the same specialty as the patient's
23provider, who is unaffiliated with the insurer, jointly
24selected by the patient (or the patient's next of kin or legal
25representative if the patient is unable to act for himself or
26herself), the patient's provider, and the insurer in the event

 

 

10300HB5395ham001- 97 -LRB103 37071 RPS 70534 a

1of a dispute between the insurer and patient's provider
2regarding the medical necessity of a treatment proposed by a
3patient's provider. If the reviewing provider determines the
4treatment to be medically necessary, the insurer shall provide
5reimbursement for the treatment. Future contractual or
6employment actions by the insurer regarding the patient's
7provider may not be based on the provider's participation in
8this procedure. Nothing prevents the insured from agreeing in
9writing to continue treatment at his or her expense. When
10making a determination of the medical necessity for a
11treatment modality for mental, emotional, nervous, or
12substance use disorders or conditions, an insurer must make
13the determination in a manner that is consistent with the
14manner used to make that determination with respect to other
15diseases or illnesses covered under the policy, including an
16appeals process. Medical necessity determinations for
17substance use disorders shall be made in accordance with
18appropriate patient placement criteria established by the
19American Society of Addiction Medicine. No additional criteria
20may be used to make medical necessity determinations for
21substance use disorders.
22    (4) A group health benefit plan amended, delivered,
23issued, or renewed on or after January 1, 2019 (the effective
24date of Public Act 100-1024) or an individual policy of
25accident and health insurance or a qualified health plan
26offered through the health insurance marketplace amended,

 

 

10300HB5395ham001- 98 -LRB103 37071 RPS 70534 a

1delivered, issued, or renewed on or after January 1, 2019 (the
2effective date of Public Act 100-1024):
3        (A) shall provide coverage based upon medical
4    necessity for the treatment of a mental, emotional,
5    nervous, or substance use disorder or condition consistent
6    with the parity requirements of Section 370c.1 of this
7    Code; provided, however, that in each calendar year
8    coverage shall not be less than the following:
9            (i) 45 days of inpatient treatment; and
10            (ii) beginning on June 26, 2006 (the effective
11        date of Public Act 94-921), 60 visits for outpatient
12        treatment including group and individual outpatient
13        treatment; and
14            (iii) for plans or policies delivered, issued for
15        delivery, renewed, or modified after January 1, 2007
16        (the effective date of Public Act 94-906), 20
17        additional outpatient visits for speech therapy for
18        treatment of pervasive developmental disorders that
19        will be in addition to speech therapy provided
20        pursuant to item (ii) of this subparagraph (A); and
21        (B) may not include a lifetime limit on the number of
22    days of inpatient treatment or the number of outpatient
23    visits covered under the plan.
24        (C) (Blank).
25    (5) An issuer of a group health benefit plan or an
26individual policy of accident and health insurance or a

 

 

10300HB5395ham001- 99 -LRB103 37071 RPS 70534 a

1qualified health plan offered through the health insurance
2marketplace may not count toward the number of outpatient
3visits required to be covered under this Section an outpatient
4visit for the purpose of medication management and shall cover
5the outpatient visits under the same terms and conditions as
6it covers outpatient visits for the treatment of physical
7illness.
8    (5.5) An individual or group health benefit plan amended,
9delivered, issued, or renewed on or after September 9, 2015
10(the effective date of Public Act 99-480) shall offer coverage
11for medically necessary acute treatment services and medically
12necessary clinical stabilization services. The treating
13provider shall base all treatment recommendations and the
14health benefit plan shall base all medical necessity
15determinations for substance use disorders in accordance with
16the most current edition of the Treatment Criteria for
17Addictive, Substance-Related, and Co-Occurring Conditions
18established by the American Society of Addiction Medicine. The
19treating provider shall base all treatment recommendations and
20the health benefit plan shall base all medical necessity
21determinations for medication-assisted treatment in accordance
22with the most current Treatment Criteria for Addictive,
23Substance-Related, and Co-Occurring Conditions established by
24the American Society of Addiction Medicine.
25    As used in this subsection:
26    "Acute treatment services" means 24-hour medically

 

 

10300HB5395ham001- 100 -LRB103 37071 RPS 70534 a

1supervised addiction treatment that provides evaluation and
2withdrawal management and may include biopsychosocial
3assessment, individual and group counseling, psychoeducational
4groups, and discharge planning.
5    "Clinical stabilization services" means 24-hour treatment,
6usually following acute treatment services for substance
7abuse, which may include intensive education and counseling
8regarding the nature of addiction and its consequences,
9relapse prevention, outreach to families and significant
10others, and aftercare planning for individuals beginning to
11engage in recovery from addiction.
12    (6) An issuer of a group health benefit plan may provide or
13offer coverage required under this Section through a managed
14care plan.
15    (6.5) An individual or group health benefit plan amended,
16delivered, issued, or renewed on or after January 1, 2019 (the
17effective date of Public Act 100-1024):
18        (A) shall not impose prior authorization requirements,
19    other than those established under the Treatment Criteria
20    for Addictive, Substance-Related, and Co-Occurring
21    Conditions established by the American Society of
22    Addiction Medicine, on a prescription medication approved
23    by the United States Food and Drug Administration that is
24    prescribed or administered for the treatment of substance
25    use disorders;
26        (B) shall not impose any step therapy requirements,

 

 

10300HB5395ham001- 101 -LRB103 37071 RPS 70534 a

1    except that this prohibition applies to the Department of
2    Healthcare and Family Services only with respect to step
3    therapy requirements that have not been , other than those
4    established under the Treatment Criteria for Addictive,
5    Substance-Related, and Co-Occurring Conditions
6    established by the American Society of Addiction Medicine,
7    before authorizing coverage for a prescription medication
8    approved by the United States Food and Drug Administration
9    that is prescribed or administered for the treatment of
10    substance use disorders;
11        (C) shall place all prescription medications approved
12    by the United States Food and Drug Administration
13    prescribed or administered for the treatment of substance
14    use disorders on, for brand medications, the lowest tier
15    of the drug formulary developed and maintained by the
16    individual or group health benefit plan that covers brand
17    medications and, for generic medications, the lowest tier
18    of the drug formulary developed and maintained by the
19    individual or group health benefit plan that covers
20    generic medications; and
21        (D) shall not exclude coverage for a prescription
22    medication approved by the United States Food and Drug
23    Administration for the treatment of substance use
24    disorders and any associated counseling or wraparound
25    services on the grounds that such medications and services
26    were court ordered.

 

 

10300HB5395ham001- 102 -LRB103 37071 RPS 70534 a

1    (7) (Blank).
2    (8) (Blank).
3    (9) With respect to all mental, emotional, nervous, or
4substance use disorders or conditions, coverage for inpatient
5treatment shall include coverage for treatment in a
6residential treatment center certified or licensed by the
7Department of Public Health or the Department of Human
8Services.
9    (c) This Section shall not be interpreted to require
10coverage for speech therapy or other habilitative services for
11those individuals covered under Section 356z.15 of this Code.
12    (d) With respect to a group or individual policy of
13accident and health insurance or a qualified health plan
14offered through the health insurance marketplace, the
15Department and, with respect to medical assistance, the
16Department of Healthcare and Family Services shall each
17enforce the requirements of this Section and Sections 356z.23
18and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
19Mental Health Parity and Addiction Equity Act of 2008, 42
20U.S.C. 18031(j), and any amendments to, and federal guidance
21or regulations issued under, those Acts, including, but not
22limited to, final regulations issued under the Paul Wellstone
23and Pete Domenici Mental Health Parity and Addiction Equity
24Act of 2008 and final regulations applying the Paul Wellstone
25and Pete Domenici Mental Health Parity and Addiction Equity
26Act of 2008 to Medicaid managed care organizations, the

 

 

10300HB5395ham001- 103 -LRB103 37071 RPS 70534 a

1Children's Health Insurance Program, and alternative benefit
2plans. Specifically, the Department and the Department of
3Healthcare and Family Services shall take action:
4        (1) proactively ensuring compliance by individual and
5    group policies, including by requiring that insurers
6    submit comparative analyses, as set forth in paragraph (6)
7    of subsection (k) of Section 370c.1, demonstrating how
8    they design and apply nonquantitative treatment
9    limitations, both as written and in operation, for mental,
10    emotional, nervous, or substance use disorder or condition
11    benefits as compared to how they design and apply
12    nonquantitative treatment limitations, as written and in
13    operation, for medical and surgical benefits;
14        (2) evaluating all consumer or provider complaints
15    regarding mental, emotional, nervous, or substance use
16    disorder or condition coverage for possible parity
17    violations;
18        (3) performing parity compliance market conduct
19    examinations or, in the case of the Department of
20    Healthcare and Family Services, parity compliance audits
21    of individual and group plans and policies, including, but
22    not limited to, reviews of:
23            (A) nonquantitative treatment limitations,
24        including, but not limited to, prior authorization
25        requirements, concurrent review, retrospective review,
26        step therapy, network admission standards,

 

 

10300HB5395ham001- 104 -LRB103 37071 RPS 70534 a

1        reimbursement rates, and geographic restrictions;
2            (B) denials of authorization, payment, and
3        coverage; and
4            (C) other specific criteria as may be determined
5        by the Department.
6    The findings and the conclusions of the parity compliance
7market conduct examinations and audits shall be made public.
8    The Director may adopt rules to effectuate any provisions
9of the Paul Wellstone and Pete Domenici Mental Health Parity
10and Addiction Equity Act of 2008 that relate to the business of
11insurance.
12    (e) Availability of plan information.
13        (1) The criteria for medical necessity determinations
14    made under a group health plan, an individual policy of
15    accident and health insurance, or a qualified health plan
16    offered through the health insurance marketplace with
17    respect to mental health or substance use disorder
18    benefits (or health insurance coverage offered in
19    connection with the plan with respect to such benefits)
20    must be made available by the plan administrator (or the
21    health insurance issuer offering such coverage) to any
22    current or potential participant, beneficiary, or
23    contracting provider upon request.
24        (2) The reason for any denial under a group health
25    benefit plan, an individual policy of accident and health
26    insurance, or a qualified health plan offered through the

 

 

10300HB5395ham001- 105 -LRB103 37071 RPS 70534 a

1    health insurance marketplace (or health insurance coverage
2    offered in connection with such plan or policy) of
3    reimbursement or payment for services with respect to
4    mental, emotional, nervous, or substance use disorders or
5    conditions benefits in the case of any participant or
6    beneficiary must be made available within a reasonable
7    time and in a reasonable manner and in readily
8    understandable language by the plan administrator (or the
9    health insurance issuer offering such coverage) to the
10    participant or beneficiary upon request.
11    (f) As used in this Section, "group policy of accident and
12health insurance" and "group health benefit plan" includes (1)
13State-regulated employer-sponsored group health insurance
14plans written in Illinois or which purport to provide coverage
15for a resident of this State; and (2) State employee health
16plans.
17    (g) (1) As used in this subsection:
18    "Benefits", with respect to insurers, means the benefits
19provided for treatment services for inpatient and outpatient
20treatment of substance use disorders or conditions at American
21Society of Addiction Medicine levels of treatment 2.1
22(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
23(Clinically Managed Low-Intensity Residential), 3.3
24(Clinically Managed Population-Specific High-Intensity
25Residential), 3.5 (Clinically Managed High-Intensity
26Residential), and 3.7 (Medically Monitored Intensive

 

 

10300HB5395ham001- 106 -LRB103 37071 RPS 70534 a

1Inpatient) and OMT (Opioid Maintenance Therapy) services.
2    "Benefits", with respect to managed care organizations,
3means the benefits provided for treatment services for
4inpatient and outpatient treatment of substance use disorders
5or conditions at American Society of Addiction Medicine levels
6of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
7Hospitalization), 3.5 (Clinically Managed High-Intensity
8Residential), and 3.7 (Medically Monitored Intensive
9Inpatient) and OMT (Opioid Maintenance Therapy) services.
10    "Substance use disorder treatment provider or facility"
11means a licensed physician, licensed psychologist, licensed
12psychiatrist, licensed advanced practice registered nurse, or
13licensed, certified, or otherwise State-approved facility or
14provider of substance use disorder treatment.
15    (2) A group health insurance policy, an individual health
16benefit plan, or qualified health plan that is offered through
17the health insurance marketplace, small employer group health
18plan, and large employer group health plan that is amended,
19delivered, issued, executed, or renewed in this State, or
20approved for issuance or renewal in this State, on or after
21January 1, 2019 (the effective date of Public Act 100-1023)
22shall comply with the requirements of this Section and Section
23370c.1. The services for the treatment and the ongoing
24assessment of the patient's progress in treatment shall follow
25the requirements of 77 Ill. Adm. Code 2060.
26    (3) Prior authorization shall not be utilized for the

 

 

10300HB5395ham001- 107 -LRB103 37071 RPS 70534 a

1benefits under this subsection. The substance use disorder
2treatment provider or facility shall notify the insurer of the
3initiation of treatment. For an insurer that is not a managed
4care organization, the substance use disorder treatment
5provider or facility notification shall occur for the
6initiation of treatment of the covered person within 2
7business days. For managed care organizations, the substance
8use disorder treatment provider or facility notification shall
9occur in accordance with the protocol set forth in the
10provider agreement for initiation of treatment within 24
11hours. If the managed care organization is not capable of
12accepting the notification in accordance with the contractual
13protocol during the 24-hour period following admission, the
14substance use disorder treatment provider or facility shall
15have one additional business day to provide the notification
16to the appropriate managed care organization. Treatment plans
17shall be developed in accordance with the requirements and
18timeframes established in 77 Ill. Adm. Code 2060. If the
19substance use disorder treatment provider or facility fails to
20notify the insurer of the initiation of treatment in
21accordance with these provisions, the insurer may follow its
22normal prior authorization processes.
23    (4) For an insurer that is not a managed care
24organization, if an insurer determines that benefits are no
25longer medically necessary, the insurer shall notify the
26covered person, the covered person's authorized

 

 

10300HB5395ham001- 108 -LRB103 37071 RPS 70534 a

1representative, if any, and the covered person's health care
2provider in writing of the covered person's right to request
3an external review pursuant to the Health Carrier External
4Review Act. The notification shall occur within 24 hours
5following the adverse determination.
6    Pursuant to the requirements of the Health Carrier
7External Review Act, the covered person or the covered
8person's authorized representative may request an expedited
9external review. An expedited external review may not occur if
10the substance use disorder treatment provider or facility
11determines that continued treatment is no longer medically
12necessary.
13    If an expedited external review request meets the criteria
14of the Health Carrier External Review Act, an independent
15review organization shall make a final determination of
16medical necessity within 72 hours. If an independent review
17organization upholds an adverse determination, an insurer
18shall remain responsible to provide coverage of benefits
19through the day following the determination of the independent
20review organization. A decision to reverse an adverse
21determination shall comply with the Health Carrier External
22Review Act.
23    (5) The substance use disorder treatment provider or
24facility shall provide the insurer with 7 business days'
25advance notice of the planned discharge of the patient from
26the substance use disorder treatment provider or facility and

 

 

10300HB5395ham001- 109 -LRB103 37071 RPS 70534 a

1notice on the day that the patient is discharged from the
2substance use disorder treatment provider or facility.
3    (6) The benefits required by this subsection shall be
4provided to all covered persons with a diagnosis of substance
5use disorder or conditions. The presence of additional related
6or unrelated diagnoses shall not be a basis to reduce or deny
7the benefits required by this subsection.
8    (7) Nothing in this subsection shall be construed to
9require an insurer to provide coverage for any of the benefits
10in this subsection.
11    (h) As used in this Section:
12    "Generally accepted standards of mental, emotional,
13nervous, or substance use disorder or condition care" means
14standards of care and clinical practice that are generally
15recognized by health care providers practicing in relevant
16clinical specialties such as psychiatry, psychology, clinical
17sociology, social work, addiction medicine and counseling, and
18behavioral health treatment. Valid, evidence-based sources
19reflecting generally accepted standards of mental, emotional,
20nervous, or substance use disorder or condition care include
21peer-reviewed scientific studies and medical literature,
22recommendations of nonprofit health care provider professional
23associations and specialty societies, including, but not
24limited to, patient placement criteria and clinical practice
25guidelines, recommendations of federal government agencies,
26and drug labeling approved by the United States Food and Drug

 

 

10300HB5395ham001- 110 -LRB103 37071 RPS 70534 a

1Administration.
2    "Medically necessary treatment of mental, emotional,
3nervous, or substance use disorders or conditions" means a
4service or product addressing the specific needs of that
5patient, for the purpose of screening, preventing, diagnosing,
6managing, or treating an illness, injury, or condition or its
7symptoms and comorbidities, including minimizing the
8progression of an illness, injury, or condition or its
9symptoms and comorbidities in a manner that is all of the
10following:
11        (1) in accordance with the generally accepted
12    standards of mental, emotional, nervous, or substance use
13    disorder or condition care;
14        (2) clinically appropriate in terms of type,
15    frequency, extent, site, and duration; and
16        (3) not primarily for the economic benefit of the
17    insurer, purchaser, or for the convenience of the patient,
18    treating physician, or other health care provider.
19    "Utilization review" means either of the following:
20        (1) prospectively, retrospectively, or concurrently
21    reviewing and approving, modifying, delaying, or denying,
22    based in whole or in part on medical necessity, requests
23    by health care providers, insureds, or their authorized
24    representatives for coverage of health care services
25    before, retrospectively, or concurrently with the
26    provision of health care services to insureds.

 

 

10300HB5395ham001- 111 -LRB103 37071 RPS 70534 a

1        (2) evaluating the medical necessity, appropriateness,
2    level of care, service intensity, efficacy, or efficiency
3    of health care services, benefits, procedures, or
4    settings, under any circumstances, to determine whether a
5    health care service or benefit subject to a medical
6    necessity coverage requirement in an insurance policy is
7    covered as medically necessary for an insured.
8    "Utilization review criteria" means patient placement
9criteria or any criteria, standards, protocols, or guidelines
10used by an insurer to conduct utilization review.
11    (i)(1) Every insurer that amends, delivers, issues, or
12renews a group or individual policy of accident and health
13insurance or a qualified health plan offered through the
14health insurance marketplace in this State and Medicaid
15managed care organizations providing coverage for hospital or
16medical treatment on or after January 1, 2023 shall, pursuant
17to subsections (h) through (s), provide coverage for medically
18necessary treatment of mental, emotional, nervous, or
19substance use disorders or conditions.
20    (2) An insurer shall not set a specific limit on the
21duration of benefits or coverage of medically necessary
22treatment of mental, emotional, nervous, or substance use
23disorders or conditions or limit coverage only to alleviation
24of the insured's current symptoms.
25    (3) All medical necessity determinations made by the
26insurer concerning service intensity, level of care placement,

 

 

10300HB5395ham001- 112 -LRB103 37071 RPS 70534 a

1continued stay, and transfer or discharge of insureds
2diagnosed with mental, emotional, nervous, or substance use
3disorders or conditions shall be conducted in accordance with
4the requirements of subsections (k) through (u).
5    (4) An insurer that authorizes a specific type of
6treatment by a provider pursuant to this Section shall not
7rescind or modify the authorization after that provider
8renders the health care service in good faith and pursuant to
9this authorization for any reason, including, but not limited
10to, the insurer's subsequent cancellation or modification of
11the insured's or policyholder's contract, or the insured's or
12policyholder's eligibility. Nothing in this Section shall
13require the insurer to cover a treatment when the
14authorization was granted based on a material
15misrepresentation by the insured, the policyholder, or the
16provider. Nothing in this Section shall require Medicaid
17managed care organizations to pay for services if the
18individual was not eligible for Medicaid at the time the
19service was rendered. Nothing in this Section shall require an
20insurer to pay for services if the individual was not the
21insurer's enrollee at the time services were rendered. As used
22in this paragraph, "material" means a fact or situation that
23is not merely technical in nature and results in or could
24result in a substantial change in the situation.
25    (j) An insurer shall not limit benefits or coverage for
26medically necessary services on the basis that those services

 

 

10300HB5395ham001- 113 -LRB103 37071 RPS 70534 a

1should be or could be covered by a public entitlement program,
2including, but not limited to, special education or an
3individualized education program, Medicaid, Medicare,
4Supplemental Security Income, or Social Security Disability
5Insurance, and shall not include or enforce a contract term
6that excludes otherwise covered benefits on the basis that
7those services should be or could be covered by a public
8entitlement program. Nothing in this subsection shall be
9construed to require an insurer to cover benefits that have
10been authorized and provided for a covered person by a public
11entitlement program. Medicaid managed care organizations are
12not subject to this subsection.
13    (k) An insurer shall base any medical necessity
14determination or the utilization review criteria that the
15insurer, and any entity acting on the insurer's behalf,
16applies to determine the medical necessity of health care
17services and benefits for the diagnosis, prevention, and
18treatment of mental, emotional, nervous, or substance use
19disorders or conditions on current generally accepted
20standards of mental, emotional, nervous, or substance use
21disorder or condition care. All denials and appeals shall be
22reviewed by a professional with experience or expertise
23comparable to the provider requesting the authorization.
24    (l) For medical necessity determinations relating to level
25of care placement, continued stay, and transfer or discharge
26of insureds diagnosed with mental, emotional, and nervous

 

 

10300HB5395ham001- 114 -LRB103 37071 RPS 70534 a

1disorders or conditions, an insurer shall apply the patient
2placement criteria set forth in the most recent version of the
3treatment criteria developed by an unaffiliated nonprofit
4professional association for the relevant clinical specialty
5or, for Medicaid managed care organizations, patient placement
6criteria determined by the Department of Healthcare and Family
7Services that are consistent with generally accepted standards
8of mental, emotional, nervous or substance use disorder or
9condition care. Pursuant to subsection (b), in conducting
10utilization review of all covered services and benefits for
11the diagnosis, prevention, and treatment of substance use
12disorders an insurer shall use the most recent edition of the
13patient placement criteria established by the American Society
14of Addiction Medicine.
15    (m) For medical necessity determinations relating to level
16of care placement, continued stay, and transfer or discharge
17that are within the scope of the sources specified in
18subsection (l), an insurer shall not apply different,
19additional, conflicting, or more restrictive utilization
20review criteria than the criteria set forth in those sources.
21For all level of care placement decisions, the insurer shall
22authorize placement at the level of care consistent with the
23assessment of the insured using the relevant patient placement
24criteria as specified in subsection (l). If that level of
25placement is not available, the insurer shall authorize the
26next higher level of care. In the event of disagreement, the

 

 

10300HB5395ham001- 115 -LRB103 37071 RPS 70534 a

1insurer shall provide full detail of its assessment using the
2relevant criteria as specified in subsection (l) to the
3provider of the service and the patient.
4    Nothing in this subsection or subsection (l) prohibits an
5insurer from applying utilization review criteria that were
6developed in accordance with subsection (k) to health care
7services and benefits for mental, emotional, and nervous
8disorders or conditions that are not related to medical
9necessity determinations for level of care placement,
10continued stay, and transfer or discharge. If an insurer
11purchases or licenses utilization review criteria pursuant to
12this subsection, the insurer shall verify and document before
13use that the criteria were developed in accordance with
14subsection (k).
15    (n) In conducting utilization review that is outside the
16scope of the criteria as specified in subsection (l) or
17relates to the advancements in technology or in the types or
18levels of care that are not addressed in the most recent
19versions of the sources specified in subsection (l), an
20insurer shall conduct utilization review in accordance with
21subsection (k).
22    (o) This Section does not in any way limit the rights of a
23patient under the Medical Patient Rights Act.
24    (p) This Section does not in any way limit early and
25periodic screening, diagnostic, and treatment benefits as
26defined under 42 U.S.C. 1396d(r).

 

 

10300HB5395ham001- 116 -LRB103 37071 RPS 70534 a

1    (q) To ensure the proper use of the criteria described in
2subsection (l), every insurer shall do all of the following:
3        (1) Educate the insurer's staff, including any third
4    parties contracted with the insurer to review claims,
5    conduct utilization reviews, or make medical necessity
6    determinations about the utilization review criteria.
7        (2) Make the educational program available to other
8    stakeholders, including the insurer's participating or
9    contracted providers and potential participants,
10    beneficiaries, or covered lives. The education program
11    must be provided at least once a year, in-person or
12    digitally, or recordings of the education program must be
13    made available to the aforementioned stakeholders.
14        (3) Provide, at no cost, the utilization review
15    criteria and any training material or resources to
16    providers and insured patients upon request. For
17    utilization review criteria not concerning level of care
18    placement, continued stay, and transfer or discharge used
19    by the insurer pursuant to subsection (m), the insurer may
20    place the criteria on a secure, password-protected website
21    so long as the access requirements of the website do not
22    unreasonably restrict access to insureds or their
23    providers. No restrictions shall be placed upon the
24    insured's or treating provider's access right to
25    utilization review criteria obtained under this paragraph
26    at any point in time, including before an initial request

 

 

10300HB5395ham001- 117 -LRB103 37071 RPS 70534 a

1    for authorization.
2        (4) Track, identify, and analyze how the utilization
3    review criteria are used to certify care, deny care, and
4    support the appeals process.
5        (5) Conduct interrater reliability testing to ensure
6    consistency in utilization review decision making that
7    covers how medical necessity decisions are made; this
8    assessment shall cover all aspects of utilization review
9    as defined in subsection (h).
10        (6) Run interrater reliability reports about how the
11    clinical guidelines are used in conjunction with the
12    utilization review process and parity compliance
13    activities.
14        (7) Achieve interrater reliability pass rates of at
15    least 90% and, if this threshold is not met, immediately
16    provide for the remediation of poor interrater reliability
17    and interrater reliability testing for all new staff
18    before they can conduct utilization review without
19    supervision.
20        (8) Maintain documentation of interrater reliability
21    testing and the remediation actions taken for those with
22    pass rates lower than 90% and submit to the Department of
23    Insurance or, in the case of Medicaid managed care
24    organizations, the Department of Healthcare and Family
25    Services the testing results and a summary of remedial
26    actions as part of parity compliance reporting set forth

 

 

10300HB5395ham001- 118 -LRB103 37071 RPS 70534 a

1    in subsection (k) of Section 370c.1.
2    (r) This Section applies to all health care services and
3benefits for the diagnosis, prevention, and treatment of
4mental, emotional, nervous, or substance use disorders or
5conditions covered by an insurance policy, including
6prescription drugs.
7    (s) This Section applies to an insurer that amends,
8delivers, issues, or renews a group or individual policy of
9accident and health insurance or a qualified health plan
10offered through the health insurance marketplace in this State
11providing coverage for hospital or medical treatment and
12conducts utilization review as defined in this Section,
13including Medicaid managed care organizations, and any entity
14or contracting provider that performs utilization review or
15utilization management functions on an insurer's behalf.
16    (t) If the Director determines that an insurer has
17violated this Section, the Director may, after appropriate
18notice and opportunity for hearing, by order, assess a civil
19penalty between $1,000 and $5,000 for each violation. Moneys
20collected from penalties shall be deposited into the Parity
21Advancement Fund established in subsection (i) of Section
22370c.1.
23    (u) An insurer shall not adopt, impose, or enforce terms
24in its policies or provider agreements, in writing or in
25operation, that undermine, alter, or conflict with the
26requirements of this Section.

 

 

10300HB5395ham001- 119 -LRB103 37071 RPS 70534 a

1    (v) The provisions of this Section are severable. If any
2provision of this Section or its application is held invalid,
3that invalidity shall not affect other provisions or
4applications that can be given effect without the invalid
5provision or application.
6    (w) Beginning January 1, 2026, coverage for inpatient
7mental health treatment at participating hospitals shall
8comply with the following requirements:
9        (1) Subject to paragraphs (2) and (3) of this
10    subsection, no policy shall require prior authorization
11    for admission for such treatment at any participating
12    hospital.
13        (2) Coverage provided under this subsection shall also
14    not be subject to concurrent review unless a discharge
15    plan is fully developed and continuity services are
16    prepared to meet the patient's needs and the patient's
17    community placement preference upon release. Nothing in
18    this paragraph supersedes a health maintenance
19    organization's referral requirement for services from
20    nonparticipating providers upon a patient's discharge from
21    a hospital.
22        (3) Treatment provided under this subsection may be
23    reviewed retrospectively.
24    (x) Notwithstanding any provision of this Section, nothing
25shall require the medical assistance program under Article V
26of the Illinois Public Aid Code to violate any applicable

 

 

10300HB5395ham001- 120 -LRB103 37071 RPS 70534 a

1federal laws, regulations, or grant requirements or any State
2or federal consent decrees. Nothing in subsection (w) shall
3prevent the Department of Healthcare and Family Services from
4requiring a health care provider to use specified level of
5care, admission, continued stay, or discharge criteria,
6including, but not limited to, those under Section 5-5.23 of
7the Illinois Public Aid Code, as long as the Department of
8Healthcare and Family Services does not require a health care
9provider to seek prior authorization or concurrent review from
10the Department of Healthcare and Family Services, a Medicaid
11managed care organization, or a utilization review
12organization under the circumstances expressly prohibited by
13subsection (w).
14    (y) Children's Mental Health. Nothing in this Section
15shall suspend the screening and assessment requirements for
16mental health services for children participating in the
17State's medical assistance program as required in Section
185-5.23 of the Illinois Public Aid Code.
19(Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22;
20102-813, eff. 5-13-22; 103-426, eff. 8-4-23.)
 
21    Section 6-10. The Managed Care Reform and Patient Rights
22Act is amended by changing Sections 10, 45.1, and 85 and by
23adding Section 87 as follows:
 
24    (215 ILCS 134/10)

 

 

10300HB5395ham001- 121 -LRB103 37071 RPS 70534 a

1    Sec. 10. Definitions. In this Act:
2    "Adverse determination" means a determination by a health
3care plan under Section 45 or by a utilization review program
4under Section 85 that a health care service is not medically
5necessary.
6    "Clinical peer" means a health care professional who is in
7the same profession and the same or similar specialty as the
8health care provider who typically manages the medical
9condition, procedures, or treatment under review.
10    "Department" means the Department of Insurance.
11    "Emergency medical condition" means a medical condition
12manifesting itself by acute symptoms of sufficient severity,
13regardless of the final diagnosis given, such that a prudent
14layperson, who possesses an average knowledge of health and
15medicine, could reasonably expect the absence of immediate
16medical attention to result in:
17        (1) placing the health of the individual (or, with
18    respect to a pregnant woman, the health of the woman or her
19    unborn child) in serious jeopardy;
20        (2) serious impairment to bodily functions;
21        (3) serious dysfunction of any bodily organ or part;
22        (4) inadequately controlled pain; or
23        (5) with respect to a pregnant woman who is having
24    contractions:
25            (A) inadequate time to complete a safe transfer to
26        another hospital before delivery; or

 

 

10300HB5395ham001- 122 -LRB103 37071 RPS 70534 a

1            (B) a transfer to another hospital may pose a
2        threat to the health or safety of the woman or unborn
3        child.
4    "Emergency medical screening examination" means a medical
5screening examination and evaluation by a physician licensed
6to practice medicine in all its branches, or to the extent
7permitted by applicable laws, by other appropriately licensed
8personnel under the supervision of or in collaboration with a
9physician licensed to practice medicine in all its branches to
10determine whether the need for emergency services exists.
11    "Emergency services" means, with respect to an enrollee of
12a health care plan, transportation services, including but not
13limited to ambulance services, and covered inpatient and
14outpatient hospital services furnished by a provider qualified
15to furnish those services that are needed to evaluate or
16stabilize an emergency medical condition. "Emergency services"
17does not refer to post-stabilization medical services.
18    "Enrollee" means any person and his or her dependents
19enrolled in or covered by a health care plan.
20    "Generally accepted standards of care" means standards of
21care and clinical practice that are generally recognized by
22health care providers practicing in relevant clinical
23specialties for the illness, injury, or condition or its
24symptoms and comorbidities. Valid, evidence-based sources
25reflecting generally accepted standards of care include
26peer-reviewed scientific studies and medical literature,

 

 

10300HB5395ham001- 123 -LRB103 37071 RPS 70534 a

1recommendations of nonprofit health care provider professional
2associations and specialty societies, including, but not
3limited to, patient placement criteria and clinical practice
4guidelines, recommendations of federal government agencies,
5and drug labeling approved by the United States Food and Drug
6Administration.
7    "Health care plan" means a plan, including, but not
8limited to, a health maintenance organization, a managed care
9community network as defined in the Illinois Public Aid Code,
10or an accountable care entity as defined in the Illinois
11Public Aid Code that receives capitated payments to cover
12medical services from the Department of Healthcare and Family
13Services, that establishes, operates, or maintains a network
14of health care providers that has entered into an agreement
15with the plan to provide health care services to enrollees to
16whom the plan has the ultimate obligation to arrange for the
17provision of or payment for services through organizational
18arrangements for ongoing quality assurance, utilization review
19programs, or dispute resolution. Nothing in this definition
20shall be construed to mean that an independent practice
21association or a physician hospital organization that
22subcontracts with a health care plan is, for purposes of that
23subcontract, a health care plan.
24    For purposes of this definition, "health care plan" shall
25not include the following:
26        (1) indemnity health insurance policies including

 

 

10300HB5395ham001- 124 -LRB103 37071 RPS 70534 a

1    those using a contracted provider network;
2        (2) health care plans that offer only dental or only
3    vision coverage;
4        (3) preferred provider administrators, as defined in
5    Section 370g(g) of the Illinois Insurance Code;
6        (4) employee or employer self-insured health benefit
7    plans under the federal Employee Retirement Income
8    Security Act of 1974;
9        (5) health care provided pursuant to the Workers'
10    Compensation Act or the Workers' Occupational Diseases
11    Act; and
12        (6) except with respect to subsections (a) and (b) of
13    Section 65 and subsection (a-5) of Section 70,
14    not-for-profit voluntary health services plans with health
15    maintenance organization authority in existence as of
16    January 1, 1999 that are affiliated with a union and that
17    only extend coverage to union members and their
18    dependents.
19    "Health care professional" means a physician, a registered
20professional nurse, or other individual appropriately licensed
21or registered to provide health care services.
22    "Health care provider" means any physician, hospital
23facility, facility licensed under the Nursing Home Care Act,
24long-term care facility as defined in Section 1-113 of the
25Nursing Home Care Act, or other person that is licensed or
26otherwise authorized to deliver health care services. Nothing

 

 

10300HB5395ham001- 125 -LRB103 37071 RPS 70534 a

1in this Act shall be construed to define Independent Practice
2Associations or Physician-Hospital Organizations as health
3care providers.
4    "Health care services" means any services included in the
5furnishing to any individual of medical care, or the
6hospitalization incident to the furnishing of such care, as
7well as the furnishing to any person of any and all other
8services for the purpose of preventing, alleviating, curing,
9or healing human illness or injury including behavioral
10health, mental health, home health, and pharmaceutical
11services and products.
12    "Medical director" means a physician licensed in any state
13to practice medicine in all its branches appointed by a health
14care plan.
15    "Medically necessary" means that a service or product
16addresses the specific needs of a patient for the purpose of
17screening, preventing, diagnosing, managing, or treating an
18illness, injury, or condition or its symptoms and
19comorbidities, including minimizing the progression of an
20illness, injury, or condition or its symptoms and
21comorbidities, in a manner that is all of the following:
22        (1) in accordance with generally accepted standards of
23    care;
24        (2) clinically appropriate in terms of type,
25    frequency, extent, site, and duration; and
26        (3) not primarily for the economic benefit of the

 

 

10300HB5395ham001- 126 -LRB103 37071 RPS 70534 a

1    health care plan, purchaser, or utilization review
2    organization, or for the convenience of the patient,
3    treating physician, or other health care provider.
4    "Person" means a corporation, association, partnership,
5limited liability company, sole proprietorship, or any other
6legal entity.
7    "Physician" means a person licensed under the Medical
8Practice Act of 1987.
9    "Post-stabilization medical services" means health care
10services provided to an enrollee that are furnished in a
11licensed hospital by a provider that is qualified to furnish
12such services, and determined to be medically necessary and
13directly related to the emergency medical condition following
14stabilization.
15    "Stabilization" means, with respect to an emergency
16medical condition, to provide such medical treatment of the
17condition as may be necessary to assure, within reasonable
18medical probability, that no material deterioration of the
19condition is likely to result.
20    "Step therapy requirement" means a fail-first utilization
21review or formulary requirement that specifies, as a condition
22of coverage under a health care plan, the order in which
23certain health care services must be used to treat or manage an
24enrollee's health condition.
25    "Utilization review" means the evaluation of the medical
26necessity, appropriateness, and efficiency of the use of

 

 

10300HB5395ham001- 127 -LRB103 37071 RPS 70534 a

1health care services, procedures, and facilities.
2    "Utilization review" includes either of the following:
3        (1) prospectively, retrospectively, or concurrently
4    reviewing and approving, modifying, delaying, or denying,
5    based, in whole or in part, on medical necessity, requests
6    by health care providers, enrollees, or their authorized
7    representatives for coverage of health care services
8    before, retrospectively, or concurrently with the
9    provision of health care services to enrollees; or
10        (2) evaluating the medical necessity, appropriateness,
11    level of care, service intensity, efficacy, or efficiency
12    of health care services, benefits, procedures, or
13    settings, under any circumstances, to determine whether a
14    health care service or benefit subject to a medical
15    necessity coverage requirement in a health care plan is
16    covered as medically necessary for an enrollee.
17    "Utilization review criteria" means patient placement
18criteria or any criteria, standards, protocols, or guidelines
19used by a utilization review program to conduct utilization
20review.
21    "Utilization review program" means a program established
22by a person to perform utilization review.
23(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
24    (215 ILCS 134/45.1)
25    Sec. 45.1. Medical exceptions procedures required.

 

 

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1    (a) Notwithstanding any other provision of law, on or
2after January 1, 2018 (the effective date of Public Act
399-761), every insurer licensed in this State to sell a policy
4of group or individual accident and health insurance or a
5health benefits plan shall establish and maintain a medical
6exceptions process that allows covered persons or their
7authorized representatives to request any clinically
8appropriate prescription drug when (1) the drug is not covered
9based on the health benefit plan's formulary; (2) the health
10benefit plan is discontinuing coverage of the drug on the
11plan's formulary for reasons other than safety or other than
12because the prescription drug has been withdrawn from the
13market by the drug's manufacturer; (3) (blank) the
14prescription drug alternatives required to be used in
15accordance with a step therapy requirement (A) has been
16ineffective in the treatment of the enrollee's disease or
17medical condition or, based on both sound clinical evidence
18and medical and scientific evidence, the known relevant
19physical or mental characteristics of the enrollee, and the
20known characteristics of the drug regimen, is likely to be
21ineffective or adversely affect the drug's effectiveness or
22patient compliance or (B) has caused or, based on sound
23medical evidence, is likely to cause an adverse reaction or
24harm to the enrollee; or (4) the number of doses available
25under a dose restriction for the prescription drug (A) has
26been ineffective in the treatment of the enrollee's disease or

 

 

10300HB5395ham001- 129 -LRB103 37071 RPS 70534 a

1medical condition or (B) based on both sound clinical evidence
2and medical and scientific evidence, the known relevant
3physical and mental characteristics of the enrollee, and known
4characteristics of the drug regimen, is likely to be
5ineffective or adversely affect the drug's effective or
6patient compliance.
7    (b) The health carrier's established medical exceptions
8procedures must require, at a minimum, the following:
9        (1) Any request for approval of coverage made verbally
10    or in writing (regardless of whether made using a paper or
11    electronic form or some other writing) at any time shall
12    be reviewed by appropriate health care professionals.
13        (2) The health carrier must, within 72 hours after
14    receipt of a request made under subsection (a) of this
15    Section, either approve or deny the request. In the case
16    of a denial, the health carrier shall provide the covered
17    person or the covered person's authorized representative
18    and the covered person's prescribing provider with the
19    reason for the denial, an alternative covered medication,
20    if applicable, and information regarding the procedure for
21    submitting an appeal to the denial. A health carrier,
22    except for a Medicaid managed care plan under contract
23    with the Department of Healthcare and Family Services,
24    shall not use the authorization of alternative covered
25    medications under this Section in a manner that
26    effectively creates a step therapy requirement.

 

 

10300HB5395ham001- 130 -LRB103 37071 RPS 70534 a

1        (3) In the case of an expedited coverage
2    determination, the health carrier must either approve or
3    deny the request within 24 hours after receipt of the
4    request. In the case of a denial, the health carrier shall
5    provide the covered person or the covered person's
6    authorized representative and the covered person's
7    prescribing provider with the reason for the denial, an
8    alternative covered medication, if applicable, and
9    information regarding the procedure for submitting an
10    appeal to the denial.
11    (c) (Blank). A step therapy requirement exception request
12shall be approved if:
13        (1) the required prescription drug is contraindicated;
14        (2) the patient has tried the required prescription
15    drug while under the patient's current or previous health
16    insurance or health benefit plan and the prescribing
17    provider submits evidence of failure or intolerance; or
18        (3) the patient is stable on a prescription drug
19    selected by his or her health care provider for the
20    medical condition under consideration while on a current
21    or previous health insurance or health benefit plan.
22    (d) Upon the granting of an exception request, the
23insurer, health plan, utilization review organization, or
24other entity shall authorize the coverage for the drug
25prescribed by the enrollee's treating health care provider, to
26the extent the prescribed drug is a covered drug under the

 

 

10300HB5395ham001- 131 -LRB103 37071 RPS 70534 a

1policy or contract up to the quantity covered.
2    (e) Any approval of a medical exception request made
3pursuant to this Section shall be honored for 12 months
4following the date of the approval or until renewal of the
5plan.
6    (f) Notwithstanding any other provision of this Section,
7nothing in this Section shall be interpreted or implemented in
8a manner not consistent with the federal Patient Protection
9and Affordable Care Act (Public Law 111-148), as amended by
10the federal Health Care and Education Reconciliation Act of
112010 (Public Law 111-152), and any amendments thereto, or
12regulations or guidance issued under those Acts.
13    (g) Nothing in this Section shall require or authorize the
14State agency responsible for the administration of the medical
15assistance program established under the Illinois Public Aid
16Code to approve, supply, or cover prescription drugs pursuant
17to the procedure established in this Section.
18(Source: P.A. 103-154, eff. 6-30-23.)
 
19    (215 ILCS 134/85)
20    Sec. 85. Utilization review program registration.
21    (a) No person may conduct a utilization review program in
22this State unless once every 2 years the person registers the
23utilization review program with the Department and certifies
24compliance with the Health Utilization Management Standards of
25the American Accreditation Healthcare Commission (URAC)

 

 

10300HB5395ham001- 132 -LRB103 37071 RPS 70534 a

1sufficient to achieve American Accreditation Healthcare
2Commission (URAC) accreditation or submits evidence of
3accreditation by the American Accreditation Healthcare
4Commission (URAC) for its Health Utilization Management
5Standards. Nothing in this Act shall be construed to require a
6health care plan or its subcontractors to become American
7Accreditation Healthcare Commission (URAC) accredited.
8    (b) In addition, the Director of the Department, in
9consultation with the Director of the Department of Public
10Health, may certify alternative utilization review standards
11of national accreditation organizations or entities in order
12for plans to comply with this Section. Any alternative
13utilization review standards shall meet or exceed those
14standards required under subsection (a).
15    (b-5) The Department shall recognize the Accreditation
16Association for Ambulatory Health Care among the list of
17accreditors from which utilization organizations may receive
18accreditation and qualify for reduced registration and renewal
19fees.
20    (c) The provisions of this Section do not apply to:
21        (1) persons providing utilization review program
22    services only to the federal government;
23        (2) self-insured health plans under the federal
24    Employee Retirement Income Security Act of 1974, however,
25    this Section does apply to persons conducting a
26    utilization review program on behalf of these health

 

 

10300HB5395ham001- 133 -LRB103 37071 RPS 70534 a

1    plans;
2        (3) hospitals and medical groups performing
3    utilization review activities for internal purposes unless
4    the utilization review program is conducted for another
5    person.
6    Nothing in this Act prohibits a health care plan or other
7entity from contractually requiring an entity designated in
8item (3) of this subsection to adhere to the utilization
9review program requirements of this Act.
10    (d) This registration shall include submission of all of
11the following information regarding utilization review program
12activities:
13        (1) The name, address, and telephone number of the
14    utilization review programs.
15        (2) The organization and governing structure of the
16    utilization review programs.
17        (3) The number of lives for which utilization review
18    is conducted by each utilization review program.
19        (4) Hours of operation of each utilization review
20    program.
21        (5) Description of the grievance process for each
22    utilization review program.
23        (6) Number of covered lives for which utilization
24    review was conducted for the previous calendar year for
25    each utilization review program.
26        (7) Written policies and procedures for protecting

 

 

10300HB5395ham001- 134 -LRB103 37071 RPS 70534 a

1    confidential information according to applicable State and
2    federal laws for each utilization review program.
3    (e) (1) A utilization review program shall have written
4procedures for assuring that patient-specific information
5obtained during the process of utilization review will be:
6        (A) kept confidential in accordance with applicable
7    State and federal laws; and
8        (B) shared only with the enrollee, the enrollee's
9    designee, the enrollee's health care provider, and those
10    who are authorized by law to receive the information.
11    Summary data shall not be considered confidential if it
12does not provide information to allow identification of
13individual patients or health care providers.
14        (2) Only a health care professional may make
15    determinations regarding the medical necessity of health
16    care services during the course of utilization review.
17    Only a clinical peer may make an adverse determination.
18        (3) When making retrospective reviews, utilization
19    review programs shall base reviews solely on the medical
20    information available to the attending physician or
21    ordering provider at the time the health care services
22    were provided.
23        (4) When making prospective, concurrent, and
24    retrospective determinations, utilization review programs
25    shall collect only information that is necessary to make
26    the determination and shall not routinely require health

 

 

10300HB5395ham001- 135 -LRB103 37071 RPS 70534 a

1    care providers to numerically code diagnoses or procedures
2    to be considered for certification, unless required under
3    State or federal Medicare or Medicaid rules or
4    regulations, but may request such code if available, or
5    routinely request copies of medical records of all
6    enrollees reviewed. During prospective or concurrent
7    review, copies of medical records shall only be required
8    when necessary to verify that the health care services
9    subject to review are medically necessary. In these cases,
10    only the necessary or relevant sections of the medical
11    record shall be required.
12    (f) If the Department finds that a utilization review
13program is not in compliance with this Section, the Department
14shall issue a corrective action plan and allow a reasonable
15amount of time for compliance with the plan. If the
16utilization review program does not come into compliance, the
17Department may issue a cease and desist order. Before issuing
18a cease and desist order under this Section, the Department
19shall provide the utilization review program with a written
20notice of the reasons for the order and allow a reasonable
21amount of time to supply additional information demonstrating
22compliance with requirements of this Section and to request a
23hearing. The hearing notice shall be sent by certified mail,
24return receipt requested, and the hearing shall be conducted
25in accordance with the Illinois Administrative Procedure Act.
26    (g) A utilization review program subject to a corrective

 

 

10300HB5395ham001- 136 -LRB103 37071 RPS 70534 a

1action may continue to conduct business until a final decision
2has been issued by the Department.
3    (h) Any adverse determination made by a health care plan
4or its subcontractors may be appealed in accordance with
5subsection (f) of Section 45.
6    (i) The Director may by rule establish a registration fee
7for each person conducting a utilization review program. All
8fees paid to and collected by the Director under this Section
9shall be deposited into the Insurance Producer Administration
10Fund.
11(Source: P.A. 99-111, eff. 1-1-16.)
 
12    (215 ILCS 134/87 new)
13    Sec. 87. General standards for use of utilization review
14criteria.
15    (a) Except as provided in subsections (g) and (h),
16beginning January 1, 2027, all medical necessity
17determinations made by a utilization review program shall be
18conducted in accordance with the requirements of this Section.
19No policy, contract, certificate, or evidence of coverage
20issued to any enrollee, nor any formulary, may contain terms
21or conditions to the contrary.
22    (b) A utilization review program shall base any medical
23necessity determination or the utilization review criteria
24that the program applies to determine the medical necessity of
25health care services and benefits on current generally

 

 

10300HB5395ham001- 137 -LRB103 37071 RPS 70534 a

1accepted standards of care.
2    (c) A utilization review program shall apply the most
3recent version of the treatment criteria developed by an
4unaffiliated nonprofit professional association for the
5relevant clinical specialty or, for Medicaid managed care
6organizations, treatment criteria determined by the Department
7of Healthcare and Family Services that are not inconsistent
8with generally accepted standards of care. Nothing in this
9Section shall be construed to supersede requirements provided
10under any other State or federal law or federal regulation
11that any coverage subject to this Section be subject to
12specific utilization review criteria for a specific illness,
13level of care placement, injury, or condition or its symptoms
14and comorbidities.
15    (d) For medical necessity determinations that are within
16the scope of the sources specified in subsection (c), a
17utilization review program shall not apply different,
18additional, conflicting, or more restrictive utilization
19review criteria than the criteria set forth in those sources.
20For all level of care placement decisions, the utilization
21review program or health care plan shall authorize placement
22at the level of care consistent with the assessment of the
23enrollee using the relevant patient placement criteria as
24specified in subsection (c). If that level of placement is not
25available, the utilization review program or health care plan
26shall authorize the next highest level of care. In the event of

 

 

10300HB5395ham001- 138 -LRB103 37071 RPS 70534 a

1disagreement, the utilization review program shall provide
2full detail of its assessment using the relevant criteria as
3specified in subsection (c) to the provider of the service and
4the patient.
5    (e) In conducting utilization review that is outside the
6scope of the criteria specified in subsection (c) or that
7relates to the advancements in technology or in the types or
8levels of care that are not addressed in the most recent
9versions of the sources specified in subsection (c), a
10utilization review program shall conduct utilization review in
11accordance with subsection (b). If a utilization review
12program purchases or licenses utilization review criteria
13pursuant to this subsection, the utilization review program
14shall verify and document before use that the criteria were
15developed in accordance with subsection (b).
16    (f) To ensure the proper use of utilization review
17criteria that were not developed by or that diverge from those
18developed by an unaffiliated nonprofit professional
19association for the relevant clinical specialty, every health
20care plan shall do all of the following:
21        (1) Make an educational program available to the
22    health care plan's staff, as well as the staff of any other
23    utilization review program contracted to review claims,
24    conduct utilization reviews, or make medical necessity
25    determinations about the utilization review criteria.
26        (2) Make the educational program available to other

 

 

10300HB5395ham001- 139 -LRB103 37071 RPS 70534 a

1    stakeholders, including the health care plan's
2    participating or contracted providers and potential
3    enrollees. The education program must be provided at least
4    once a year, in person or digitally, or recordings of the
5    education program must be made available to those
6    stakeholders.
7        (3) Provide, at no cost, the utilization review
8    criteria and any training material or resources to
9    providers and enrollees upon request. The health care plan
10    may place the criteria on a secure, password-protected
11    website so long as the access requirements of the website
12    do not unreasonably restrict access to enrollees or their
13    providers. No restrictions shall be placed upon the
14    enrollee's or treating provider's access right to
15    utilization review criteria obtained under this paragraph
16    at any point in time, including before an initial request
17    for authorization.
18        (4) Track, identify, and analyze how the utilization
19    review criteria are used to certify care, deny care, and
20    support the appeals process.
21        (5) Conduct interrater reliability testing to ensure
22    consistency in utilization review decision-making that
23    covers how medical necessity decisions are made. This
24    assessment shall cover all aspects of utilization review
25    as defined in Section 10.
26        (6) Run interrater reliability reports about how the

 

 

10300HB5395ham001- 140 -LRB103 37071 RPS 70534 a

1    clinical guidelines are used in conjunction with the
2    utilization review process and parity compliance
3    activities.
4        (7) Achieve interrater reliability pass rates of at
5    least 90% and, if this threshold is not met, immediately
6    provide for the remediation of poor interrater reliability
7    and interrater reliability testing for all new staff
8    before they can conduct utilization review without
9    supervision.
10        (8) Maintain documentation of interrater reliability
11    testing and the remediation actions taken for those with
12    pass rates lower than 90% and submit to the Department of
13    Insurance or, in the case of Medicaid managed care
14    organizations, the Department of Healthcare and Family
15    Services the testing results and a summary of remedial
16    actions.
17    (g) Beginning January 1, 2025, except for Medicaid managed
18care plans under contract with the Department of Healthcare
19and Family Services, no utilization review program or any
20policy, contract, certificate, evidence of coverage, or
21formulary shall impose step therapy requirements for any
22health care service, including prescription drugs. Nothing in
23this subsection prohibits a health care plan, by contract,
24written policy or procedure, or any other agreement or course
25of conduct, from requiring a pharmacist to effect
26substitutions of prescription drugs consistent with Section

 

 

10300HB5395ham001- 141 -LRB103 37071 RPS 70534 a

119.5 of the Pharmacy Practice Act, under which a pharmacist
2may substitute an interchangeable biologic for a prescribed
3biologic product, and Section 25 of the Pharmacy Practice Act,
4under which a pharmacist may select a generic drug determined
5to be therapeutically equivalent by the United States Food and
6Drug Administration and in accordance with the Illinois Food,
7Drug and Cosmetic Act.
8    (h) Except for subsection (g), this Section does not apply
9to medical necessity determinations concerning service
10intensity, level of care placement, continued stay, or
11transfer or discharge of enrollees diagnosed with mental,
12emotional, nervous, or substance use disorders or conditions,
13which shall be governed by Section 370c of the Illinois
14Insurance Code.
 
15    Section 6-15. The Health Carrier External Review Act is
16amended by changing Section 10 as follows:
 
17    (215 ILCS 180/10)
18    Sec. 10. Definitions. For the purposes of this Act:
19    "Adverse determination" means:
20        (1) a determination by a health carrier or its
21    designee utilization review organization that, based upon
22    the information provided, a request for a benefit under
23    the health carrier's health benefit plan upon application
24    of any utilization review technique does not meet the

 

 

10300HB5395ham001- 142 -LRB103 37071 RPS 70534 a

1    health carrier's requirements for medical necessity,
2    appropriateness, health care setting, level of care, or
3    effectiveness or is determined to be experimental or
4    investigational and the requested benefit is therefore
5    denied, reduced, or terminated or payment is not provided
6    or made, in whole or in part, for the benefit;
7        (2) the denial, reduction, or termination of or
8    failure to provide or make payment, in whole or in part,
9    for a benefit based on a determination by a health carrier
10    or its designee utilization review organization that a
11    preexisting condition was present before the effective
12    date of coverage; or
13        (3) a rescission of coverage determination, which does
14    not include a cancellation or discontinuance of coverage
15    that is attributable to a failure to timely pay required
16    premiums or contributions towards the cost of coverage.
17    "Authorized representative" means:
18        (1) a person to whom a covered person has given
19    express written consent to represent the covered person
20    for purposes of this Law;
21        (2) a person authorized by law to provide substituted
22    consent for a covered person;
23        (3) a family member of the covered person or the
24    covered person's treating health care professional when
25    the covered person is unable to provide consent;
26        (4) a health care provider when the covered person's

 

 

10300HB5395ham001- 143 -LRB103 37071 RPS 70534 a

1    health benefit plan requires that a request for a benefit
2    under the plan be initiated by the health care provider;
3    or
4        (5) in the case of an urgent care request, a health
5    care provider with knowledge of the covered person's
6    medical condition.
7    "Best evidence" means evidence based on:
8        (1) randomized clinical trials;
9        (2) if randomized clinical trials are not available,
10    then cohort studies or case-control studies;
11        (3) if items (1) and (2) are not available, then
12    case-series; or
13        (4) if items (1), (2), and (3) are not available, then
14    expert opinion.
15    "Case-series" means an evaluation of a series of patients
16with a particular outcome, without the use of a control group.
17    "Clinical review criteria" means the written screening
18procedures, decision abstracts, clinical protocols, and
19practice guidelines used by a health carrier to determine the
20necessity and appropriateness of health care services.
21"Clinical review criteria" includes all utilization review
22criteria as defined in Section 10 of the Managed Care Reform
23and Patient Rights Act.
24    "Cohort study" means a prospective evaluation of 2 groups
25of patients with only one group of patients receiving specific
26intervention.

 

 

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1    "Concurrent review" means a review conducted during a
2patient's stay or course of treatment in a facility, the
3office of a health care professional, or other inpatient or
4outpatient health care setting.
5    "Covered benefits" or "benefits" means those health care
6services to which a covered person is entitled under the terms
7of a health benefit plan.
8    "Covered person" means a policyholder, subscriber,
9enrollee, or other individual participating in a health
10benefit plan.
11    "Director" means the Director of the Department of
12Insurance.
13    "Emergency medical condition" means a medical condition
14manifesting itself by acute symptoms of sufficient severity,
15including, but not limited to, severe pain, such that a
16prudent layperson who possesses an average knowledge of health
17and medicine could reasonably expect the absence of immediate
18medical attention to result in:
19        (1) placing the health of the individual or, with
20    respect to a pregnant woman, the health of the woman or her
21    unborn child, in serious jeopardy;
22        (2) serious impairment to bodily functions; or
23        (3) serious dysfunction of any bodily organ or part.
24    "Emergency services" means health care items and services
25furnished or required to evaluate and treat an emergency
26medical condition.

 

 

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1    "Evidence-based standard" means the conscientious,
2explicit, and judicious use of the current best evidence based
3on an overall systematic review of the research in making
4decisions about the care of individual patients.
5    "Expert opinion" means a belief or an interpretation by
6specialists with experience in a specific area about the
7scientific evidence pertaining to a particular service,
8intervention, or therapy.
9    "Facility" means an institution providing health care
10services or a health care setting.
11    "Final adverse determination" means an adverse
12determination involving a covered benefit that has been upheld
13by a health carrier, or its designee utilization review
14organization, at the completion of the health carrier's
15internal grievance process procedures as set forth by the
16Managed Care Reform and Patient Rights Act.
17    "Health benefit plan" means a policy, contract,
18certificate, plan, or agreement offered or issued by a health
19carrier to provide, deliver, arrange for, pay for, or
20reimburse any of the costs of health care services.
21    "Health care provider" or "provider" means a physician,
22hospital facility, or other health care practitioner licensed,
23accredited, or certified to perform specified health care
24services consistent with State law, responsible for
25recommending health care services on behalf of a covered
26person.

 

 

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1    "Health care services" means services for the diagnosis,
2prevention, treatment, cure, or relief of a health condition,
3illness, injury, or disease.
4    "Health carrier" means an entity subject to the insurance
5laws and regulations of this State, or subject to the
6jurisdiction of the Director, that contracts or offers to
7contract to provide, deliver, arrange for, pay for, or
8reimburse any of the costs of health care services, including
9a sickness and accident insurance company, a health
10maintenance organization, or any other entity providing a plan
11of health insurance, health benefits, or health care services.
12"Health carrier" also means Limited Health Service
13Organizations (LHSO) and Voluntary Health Service Plans.
14    "Health information" means information or data, whether
15oral or recorded in any form or medium, and personal facts or
16information about events or relationships that relate to:
17        (1) the past, present, or future physical, mental, or
18    behavioral health or condition of an individual or a
19    member of the individual's family;
20        (2) the provision of health care services to an
21    individual; or
22        (3) payment for the provision of health care services
23    to an individual.
24    "Independent review organization" means an entity that
25conducts independent external reviews of adverse
26determinations and final adverse determinations.

 

 

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1    "Medical or scientific evidence" means evidence found in
2the following sources:
3        (1) peer-reviewed scientific studies published in or
4    accepted for publication by medical journals that meet
5    nationally recognized requirements for scientific
6    manuscripts and that submit most of their published
7    articles for review by experts who are not part of the
8    editorial staff;
9        (2) peer-reviewed medical literature, including
10    literature relating to therapies reviewed and approved by
11    a qualified institutional review board, biomedical
12    compendia, and other medical literature that meet the
13    criteria of the National Institutes of Health's Library of
14    Medicine for indexing in Index Medicus (Medline) and
15    Elsevier Science Ltd. for indexing in Excerpta Medicus
16    (EMBASE);
17        (3) medical journals recognized by the Secretary of
18    Health and Human Services under Section 1861(t)(2) of the
19    federal Social Security Act;
20        (4) the following standard reference compendia:
21            (a) The American Hospital Formulary Service-Drug
22        Information;
23            (b) Drug Facts and Comparisons;
24            (c) The American Dental Association Accepted
25        Dental Therapeutics; and
26            (d) The United States Pharmacopoeia-Drug

 

 

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1        Information;
2        (5) findings, studies, or research conducted by or
3    under the auspices of federal government agencies and
4    nationally recognized federal research institutes,
5    including:
6            (a) the federal Agency for Healthcare Research and
7        Quality;
8            (b) the National Institutes of Health;
9            (c) the National Cancer Institute;
10            (d) the National Academy of Sciences;
11            (e) the Centers for Medicare & Medicaid Services;
12            (f) the federal Food and Drug Administration; and
13            (g) any national board recognized by the National
14        Institutes of Health for the purpose of evaluating the
15        medical value of health care services; or
16        (6) any other medical or scientific evidence that is
17    comparable to the sources listed in items (1) through (5).
18    "Person" means an individual, a corporation, a
19partnership, an association, a joint venture, a joint stock
20company, a trust, an unincorporated organization, any similar
21entity, or any combination of the foregoing.
22    "Prospective review" means a review conducted prior to an
23admission or the provision of a health care service or a course
24of treatment in accordance with a health carrier's requirement
25that the health care service or course of treatment, in whole
26or in part, be approved prior to its provision.

 

 

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1    "Protected health information" means health information
2(i) that identifies an individual who is the subject of the
3information; or (ii) with respect to which there is a
4reasonable basis to believe that the information could be used
5to identify an individual.
6    "Randomized clinical trial" means a controlled prospective
7study of patients that have been randomized into an
8experimental group and a control group at the beginning of the
9study with only the experimental group of patients receiving a
10specific intervention, which includes study of the groups for
11variables and anticipated outcomes over time.
12    "Retrospective review" means any review of a request for a
13benefit that is not a concurrent or prospective review
14request. "Retrospective review" does not include the review of
15a claim that is limited to veracity of documentation or
16accuracy of coding.
17    "Utilization review" has the meaning provided by the
18Managed Care Reform and Patient Rights Act.
19    "Utilization review organization" means a utilization
20review program as defined in the Managed Care Reform and
21Patient Rights Act.
22(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12;
2398-756, eff. 7-16-14.)
 
24    Section 6-20. The Prior Authorization Reform Act is
25amended by changing Section 20 as follows:
 

 

 

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1    (215 ILCS 200/20)
2    Sec. 20. Disclosure and review of prior authorization
3requirements.
4    (a) A health insurance issuer shall maintain a complete
5list of services for which prior authorization is required,
6including for all services where prior authorization is
7performed by an entity under contract with the health
8insurance issuer. The health insurance issuer shall publish
9this list on its public website without requiring a member of
10the general public to create any account or enter any
11credentials to access it. The list described in this
12subsection is not required to contain the clinical review
13criteria applicable to these services.
14    (b) A health insurance issuer shall make any current prior
15authorization requirements and restrictions, including the
16written clinical review criteria, readily accessible and
17conspicuously posted on its website to enrollees, health care
18professionals, and health care providers. Content published by
19a third party and licensed for use by a health insurance issuer
20or its contracted utilization review organization may be made
21available through the health insurance issuer's or its
22contracted utilization review organization's secure,
23password-protected website so long as the access requirements
24of the website do not unreasonably restrict access.
25Requirements shall be described in detail, written in easily

 

 

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1understandable language, and readily available to the health
2care professional and health care provider at the point of
3care. The website shall indicate for each service subject to
4prior authorization:
5        (1) when prior authorization became required for
6    policies issued or delivered in Illinois, including the
7    effective date or dates and the termination date or dates,
8    if applicable, in Illinois;
9        (2) the date the Illinois-specific requirement was
10    listed on the health insurance issuer's or its contracted
11    utilization review organization's website;
12        (3) where applicable, the date that prior
13    authorization was removed for Illinois; and
14        (4) where applicable, access to a standardized
15    electronic prior authorization request transaction
16    process.
17    (c) The clinical review criteria must:
18        (1) be based on nationally recognized, generally
19    accepted standards except where State law provides its own
20    standard;
21        (2) be developed in accordance with the current
22    standards of a national medical accreditation entity;
23        (3) ensure quality of care and access to needed health
24    care services;
25        (4) be evidence-based;
26        (5) be sufficiently flexible to allow deviations from

 

 

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1    norms when justified on a case-by-case basis; and
2        (6) be evaluated and updated, if necessary, at least
3    annually.
4    (d) A health insurance issuer shall not deny a claim for
5failure to obtain prior authorization if the prior
6authorization requirement was not in effect on the date of
7service on the claim.
8    (e) A health insurance issuer or its contracted
9utilization review organization shall not deem as incidental
10or deny supplies or health care services that are routinely
11used as part of a health care service when:
12        (1) an associated health care service has received
13    prior authorization; or
14        (2) prior authorization for the health care service is
15    not required.
16    (f) If a health insurance issuer intends either to
17implement a new prior authorization requirement or restriction
18or amend an existing requirement or restriction, the health
19insurance issuer shall provide contracted health care
20professionals and contracted health care providers of
21enrollees written notice of the new or amended requirement or
22amendment no less than 60 days before the requirement or
23restriction is implemented. The written notice may be provided
24in an electronic format, including email or facsimile, if the
25health care professional or health care provider has agreed in
26advance to receive notices electronically. The health

 

 

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1insurance issuer shall ensure that the new or amended
2requirement is not implemented unless the health insurance
3issuer's or its contracted utilization review organization's
4website has been updated to reflect the new or amended
5requirement or restriction.
6    (g) Entities using prior authorization shall make
7statistics available regarding prior authorization approvals
8and denials on their website in a readily accessible format.
9The statistics must be updated annually and include all of the
10following information:
11        (1) a list of all health care services, including
12    medications, that are subject to prior authorization;
13        (2) the total number of prior authorization requests
14    received;
15        (3) the number of prior authorization requests denied
16    during the previous plan year by the health insurance
17    issuer or its contracted utilization review organization
18    with respect to each service described in paragraph (1)
19    and the top 5 reasons for denial;
20        (4) the number of requests described in paragraph (3)
21    that were appealed, the number of the appealed requests
22    that upheld the adverse determination, and the number of
23    appealed requests that reversed the adverse determination;
24        (5) the average time between submission and response;
25    and
26        (6) any other information as the Director determines

 

 

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1    appropriate.
2(Source: P.A. 102-409, eff. 1-1-22.)
 
3
Article 99.

 
4    Section 99-95. No acceleration or delay. Where this Act
5makes changes in a statute that is represented in this Act by
6text that is not yet or no longer in effect (for example, a
7Section represented by multiple versions), the use of that
8text does not accelerate or delay the taking effect of (i) the
9changes made by this Act or (ii) provisions derived from any
10other Public Act.
 
11    Section 99-99. Effective date. This Act takes effect
12January 1, 2025.".