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1 | | emergency rules implementing federal standards for provider |
2 | | ratios, travel time and distance, and appointment wait times |
3 | | if such standards apply to health insurance coverage regulated |
4 | | by the Department of Insurance and are more stringent than the |
5 | | State standards extant at the time the final federal standards |
6 | | are published may be adopted in accordance with Section 5-45 |
7 | | by the Department of Insurance. The adoption of emergency |
8 | | rules authorized by Section 5-45 and this Section is deemed to |
9 | | be necessary for the public interest, safety, and welfare. |
10 | | Section 2-10. The Network Adequacy and Transparency Act is |
11 | | amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and |
12 | | by adding Sections 35, 40, and 50 as follows: |
13 | | (215 ILCS 124/3) |
14 | | Sec. 3. Applicability of Act. This Act applies to an |
15 | | individual or group policy of accident and health insurance |
16 | | coverage with a network plan amended, delivered, issued, or |
17 | | renewed in this State on or after January 1, 2019. This Act |
18 | | does not apply to an individual or group policy for excepted |
19 | | benefits or short-term, limited-duration health insurance |
20 | | coverage dental or vision insurance or a limited health |
21 | | service organization with a network plan amended, delivered, |
22 | | issued, or renewed in this State on or after January 1, 2019 , |
23 | | except to the extent that federal law establishes network |
24 | | adequacy and transparency standards for stand-alone dental |
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1 | | plans, 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 |
6 | | beneficiary has given express written consent to represent the |
7 | | beneficiary; a person authorized by law to provide substituted |
8 | | consent for a beneficiary; or the beneficiary's treating |
9 | | provider only when the beneficiary or his or her family member |
10 | | is unable to provide consent. |
11 | | "Beneficiary" means an individual, an enrollee, an |
12 | | insured, a participant, or any other person entitled to |
13 | | reimbursement for covered expenses of or the discounting of |
14 | | provider fees for health care services under a program in |
15 | | which the beneficiary has an incentive to utilize the services |
16 | | of a provider that has entered into an agreement or |
17 | | arrangement with an issuer insurer . |
18 | | "Department" means the Department of Insurance. |
19 | | "Essential community provider" has the meaning ascribed to |
20 | | that term in 45 CFR 156.235. |
21 | | "Excepted benefits" has the meaning ascribed to that term |
22 | | in 42 U.S.C. 300gg-91(c). |
23 | | "Exchange" has the meaning ascribed to that term in 45 CFR |
24 | | 155.20. |
25 | | "Director" means the Director of Insurance. |
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1 | | "Family caregiver" means a relative, partner, friend, or |
2 | | neighbor who has a significant relationship with the patient |
3 | | and administers or assists the patient with activities of |
4 | | daily living, instrumental activities of daily living, or |
5 | | other medical or nursing tasks for the quality and welfare of |
6 | | that patient. |
7 | | "Group health plan" has the meaning ascribed to that term |
8 | | in Section 5 of the Illinois Health Insurance Portability and |
9 | | Accountability Act. |
10 | | "Health insurance coverage" has the meaning ascribed to |
11 | | that term in Section 5 of the Illinois Health Insurance |
12 | | Portability and Accountability Act. "Health insurance |
13 | | coverage" does not include any coverage or benefits under |
14 | | Medicare or under the medical assistance program established |
15 | | under Article V of the Illinois Public Aid Code. |
16 | | "Issuer" means a "health insurance issuer" as defined in |
17 | | Section 5 of the Illinois Health Insurance Portability and |
18 | | Accountability Act. |
19 | | "Insurer" means any entity that offers individual or group |
20 | | accident and health insurance, including, but not limited to, |
21 | | health maintenance organizations, preferred provider |
22 | | organizations, exclusive provider organizations, and other |
23 | | plan structures requiring network participation, excluding the |
24 | | medical assistance program under the Illinois Public Aid Code, |
25 | | the State employees group health insurance program, workers |
26 | | compensation insurance, and pharmacy benefit managers. |
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1 | | "Material change" means a significant reduction in the |
2 | | number of providers available in a network plan, including, |
3 | | but not limited to, a reduction of 10% or more in a specific |
4 | | type of providers within any county , the removal of a major |
5 | | health system that causes a network to be significantly |
6 | | different within any county from the network when the |
7 | | beneficiary purchased the network plan, or any change that |
8 | | would cause the network to no longer satisfy the requirements |
9 | | of this Act or the Department's rules for network adequacy and |
10 | | transparency. |
11 | | "Network" means the group or groups of preferred providers |
12 | | providing services to a network plan. |
13 | | "Network plan" means an individual or group policy of |
14 | | accident and health insurance coverage that either requires a |
15 | | covered person to use or creates incentives, including |
16 | | financial incentives, for a covered person to use providers |
17 | | managed, owned, under contract with, or employed by the issuer |
18 | | or by a third party contracted to arrange, contract for, or |
19 | | administer such provider-related incentives for the issuer |
20 | | insurer . |
21 | | "Ongoing course of treatment" means (1) treatment for a |
22 | | life-threatening condition, which is a disease or condition |
23 | | for which likelihood of death is probable unless the course of |
24 | | the disease or condition is interrupted; (2) treatment for a |
25 | | serious acute condition, defined as a disease or condition |
26 | | requiring complex ongoing care that the covered person is |
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1 | | currently receiving, such as chemotherapy, radiation therapy, |
2 | | or post-operative visits , or a serious and complex condition |
3 | | as defined under 42 U.S.C. 300gg-113(b)(2) ; (3) a course of |
4 | | treatment for a health condition that a treating provider |
5 | | attests that discontinuing care by that provider would worsen |
6 | | the condition or interfere with anticipated outcomes; or (4) |
7 | | the third trimester of pregnancy through the post-partum |
8 | | period ; (5) undergoing a course of institutional or inpatient |
9 | | care from the provider within the meaning of 42 U.S.C. |
10 | | 300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective |
11 | | surgery from the provider, including receipt of preoperative |
12 | | or postoperative care from such provider with respect to such |
13 | | a surgery; (7) being determined to be terminally ill, as |
14 | | determined under 42 U.S.C. 1395x(dd)(3)(A), and receiving |
15 | | treatment for such illness from such provider; or (8) any |
16 | | other treatment of a condition or disease that requires |
17 | | repeated health care services pursuant to a plan of treatment |
18 | | by a provider because of the potential for changes in the |
19 | | therapeutic regimen or because of the potential for a |
20 | | recurrence of symptoms . |
21 | | "Preferred provider" means any provider who has entered, |
22 | | either directly or indirectly, into an agreement with an |
23 | | employer or risk-bearing entity relating to health care |
24 | | services that may be rendered to beneficiaries under a network |
25 | | plan. |
26 | | "Providers" means physicians licensed to practice medicine |
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1 | | in all its branches, other health care professionals, |
2 | | hospitals, or other health care institutions or facilities |
3 | | that provide health care services. |
4 | | "Short-term, limited-duration insurance" means any type of |
5 | | accident and health insurance offered or provided within this |
6 | | State pursuant to a group or individual policy or individual |
7 | | certificate by a company, regardless of the situs state of the |
8 | | delivery of the policy, that has an expiration date specified |
9 | | in the contract that is fewer than 365 days after the original |
10 | | effective date. Regardless of the duration of coverage, |
11 | | "short-term, limited-duration insurance" does not include |
12 | | excepted benefits or any student health insurance coverage. |
13 | | "Stand-alone dental plan" has the meaning ascribed to that |
14 | | term in 45 CFR 156.400. |
15 | | "Telehealth" has the meaning given to that term in Section |
16 | | 356z.22 of the Illinois Insurance Code. |
17 | | "Telemedicine" has the meaning given to that term in |
18 | | Section 49.5 of the Medical Practice Act of 1987. |
19 | | "Tiered network" means a network that identifies and |
20 | | groups some or all types of provider and facilities into |
21 | | specific groups to which different provider reimbursement, |
22 | | covered person cost-sharing or provider access requirements, |
23 | | or any combination thereof, apply for the same services. |
24 | | "Woman's principal health care provider" means a physician |
25 | | licensed to practice medicine in all of its branches |
26 | | specializing 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 |
5 | | plan, an issuer An insurer providing a network plan shall file |
6 | | a 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 |
19 | | from discussing any specific or all treatment options with |
20 | | beneficiaries irrespective of the insurer's position on those |
21 | | treatment options or from advocating on behalf of |
22 | | beneficiaries within the utilization review, grievance, or |
23 | | appeals processes established by the issuer insurer in |
24 | | accordance with any rights or remedies available under |
25 | | applicable State or federal law. |
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1 | | (b) Before issuing, delivering, or renewing a network |
2 | | plan, an issuer Insurers must file for review a description of |
3 | | the services to be offered through a network plan. The |
4 | | description 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 |
13 | | Director a minimum ratio of providers to plan beneficiaries as |
14 | | required 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 | | (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 |
24 | | maximum travel and distance standards and appointment wait |
25 | | time standards for plan beneficiaries, which shall be |
26 | | established annually by the Department in consultation with |
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1 | | the Department of Public Health based upon the guidance from |
2 | | the federal Centers for Medicare and Medicaid Services. These |
3 | | standards shall consist of the maximum minutes or miles to be |
4 | | traveled by a plan beneficiary for each county type, such as |
5 | | large counties, metro counties, or rural counties as defined |
6 | | by Department rule. |
7 | | The maximum travel time and distance standards must |
8 | | include standards for each physician and other provider |
9 | | category listed for which ratios have been established. |
10 | | The Director shall establish a process for the review of |
11 | | the adequacy of these standards along with an assessment of |
12 | | additional specialties to be included in the list under this |
13 | | subsection (d). |
14 | | Notwithstanding any other law or Department rule, the |
15 | | maximum travel time and distance standards and appointment |
16 | | wait time standards shall be no greater than any such |
17 | | standards established for qualified health plans in |
18 | | Federally-Facilitated Exchanges by federal law or by the |
19 | | federal Centers for Medicare and Medicaid Services, even if |
20 | | the network plan is issued in the large group market or is |
21 | | otherwise not issued through an exchange. Federal standards |
22 | | for stand-alone dental plans shall only apply to such network |
23 | | plans. In the absence of an applicable Department rule, the |
24 | | federal standards shall apply for the time period specified in |
25 | | the federal law, regulation, or guidance. If the Centers for |
26 | | Medicare and Medicaid Services establish standards that are |
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1 | | more stringent than the standards in effect under any |
2 | | Department rule, the Department may amend its rules to conform |
3 | | to the more stringent federal standards. |
4 | | If the federal area designations for the maximum time or |
5 | | distance or appointment wait time standards required are |
6 | | changed by the most recent Letter to Issuers in the |
7 | | Federally-facilitated Marketplaces, the Department shall post |
8 | | on its website notice of such changes and may amend its rules |
9 | | to conform to those designations if the Director deems |
10 | | appropriate. |
11 | | (d-5)(1) Every issuer insurer shall ensure that |
12 | | beneficiaries have timely and proximate access to treatment |
13 | | for mental, emotional, nervous, or substance use disorders or |
14 | | conditions in accordance with the provisions of paragraph (4) |
15 | | of subsection (a) of Section 370c of the Illinois Insurance |
16 | | Code. Issuers Insurers shall use a comparable process, |
17 | | strategy, evidentiary standard, and other factors in the |
18 | | development and application of the network adequacy standards |
19 | | for timely and proximate access to treatment for mental, |
20 | | emotional, nervous, or substance use disorders or conditions |
21 | | and those for the access to treatment for medical and surgical |
22 | | conditions. As such, the network adequacy standards for timely |
23 | | and proximate access shall equally be applied to treatment |
24 | | facilities and providers for mental, emotional, nervous, or |
25 | | substance use disorders or conditions and specialists |
26 | | providing medical or surgical benefits pursuant to the parity |
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1 | | requirements of Section 370c.1 of the Illinois Insurance Code |
2 | | and the federal Paul Wellstone and Pete Domenici Mental Health |
3 | | Parity and Addiction Equity Act of 2008. Notwithstanding the |
4 | | foregoing, the network adequacy standards for timely and |
5 | | proximate access to treatment for mental, emotional, nervous, |
6 | | or substance use disorders or conditions shall, at a minimum, |
7 | | satisfy 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, |
26 | | network adequacy standards for timely and proximate access to |
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1 | | treatment for mental, emotional, nervous, or substance use |
2 | | disorders or conditions means a beneficiary shall not have to |
3 | | travel longer than 60 minutes or 60 miles from the |
4 | | beneficiary's residence to receive inpatient or residential |
5 | | treatment for mental, emotional, nervous, or substance use |
6 | | disorders or conditions. |
7 | | (3) If there is no in-network facility or provider |
8 | | available for a beneficiary to receive timely and proximate |
9 | | access to treatment for mental, emotional, nervous, or |
10 | | substance use disorders or conditions in accordance with the |
11 | | network adequacy standards outlined in this subsection, the |
12 | | issuer insurer shall provide necessary exceptions to its |
13 | | network to ensure admission and treatment with a provider or |
14 | | at a treatment facility in accordance with the network |
15 | | adequacy standards in this subsection. |
16 | | (4) If the federal Centers for Medicare and Medicaid |
17 | | Services establishes or law requires more stringent standards |
18 | | for qualified health plans in the Federally-Facilitated |
19 | | Exchanges, the federal standards shall control for all network |
20 | | plans for the time period specified in the federal law, |
21 | | regulation, or guidance, even if the network plan is issued in |
22 | | the large group market, is issued through a different type of |
23 | | Exchange, or is otherwise not issued through an Exchange. |
24 | | (e) Except for network plans solely offered as a group |
25 | | health plan, these ratio and time and distance standards apply |
26 | | to 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 |
2 | | service delivery options, such as telemedicine or telehealth, |
3 | | mobile clinics, and centers of excellence, or other ways of |
4 | | delivering care to partially meet the requirements set under |
5 | | this Section. |
6 | | (g) Except for the requirements set forth in subsection |
7 | | (d-5), issuers insurers who are not able to comply with the |
8 | | provider ratios and time and distance or appointment wait time |
9 | | standards established under this Act or federal law by the |
10 | | Department may request an exception to these requirements from |
11 | | the Department. The Department may grant an exception in the |
12 | | following 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 |
7 | | Director any material change to an approved network plan |
8 | | within 15 days after the change occurs and any change that |
9 | | would result in failure to meet the requirements of this Act. |
10 | | The issuer shall submit a revised version of the portions of |
11 | | the network adequacy filing affected by the material change, |
12 | | as determined by the Director by rule, and the issuer shall |
13 | | attach versions with the changes indicated for each document |
14 | | that was revised from the previous version of the filing. Upon |
15 | | notice from the issuer insurer , the Director shall reevaluate |
16 | | the network plan's compliance with the network adequacy and |
17 | | transparency standards of this Act. For every day past 15 days |
18 | | that the issuer fails to submit a revised network adequacy |
19 | | filing to the Director, the Director may order a fine of $5,000 |
20 | | per day. |
21 | | (i) If a network plan is inadequate under this Act with |
22 | | respect to a provider type in a county, and if the network plan |
23 | | does not have an approved exception for that provider type in |
24 | | that county pursuant to subsection (g), an issuer shall |
25 | | process out-of-network claims for covered health care services |
26 | | received from that provider type within that county at the |
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1 | | in-network benefit level and shall retroactively adjudicate |
2 | | and reimburse beneficiaries to achieve that objective if their |
3 | | claims were processed at the out-of-network level contrary to |
4 | | this subsection. |
5 | | (j) If the Director determines that a network is |
6 | | inadequate in any county and no exception has been granted |
7 | | under subsection (g) and the issuer does not have a process in |
8 | | place to comply with subsection (d-5), the Director may |
9 | | prohibit the network plan from being issued or renewed within |
10 | | that county until the Director determines that the network is |
11 | | adequate apart from processes and exceptions described in |
12 | | subsections (d-5) and (g). Nothing in this subsection shall be |
13 | | construed to terminate any beneficiary's health insurance |
14 | | coverage under a network plan before the expiration of the |
15 | | beneficiary's policy period if the Director makes a |
16 | | determination under this subsection after the issuance or |
17 | | renewal of the beneficiary's policy or certificate because of |
18 | | a material change. Policies or certificates issued or renewed |
19 | | in violation of this subsection may subject the issuer to a |
20 | | civil penalty of $5,000 per policy. |
21 | | (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; |
22 | | 102-1117, 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 |
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1 | | nonrenewal or termination of a provider to the provider and to |
2 | | the beneficiaries served by the provider. The notice shall |
3 | | include a name and address to which a beneficiary or provider |
4 | | may direct comments and concerns regarding the nonrenewal or |
5 | | termination and the telephone number maintained by the |
6 | | Department for consumer complaints. Immediate written notice |
7 | | may be provided without 60 days' notice when a provider's |
8 | | license has been disciplined by a State licensing board or |
9 | | when the network plan reasonably believes direct imminent |
10 | | physical harm to patients under the provider's providers care |
11 | | may occur. The notice to the beneficiary shall provide the |
12 | | individual with an opportunity to notify the issuer of the |
13 | | individual's need for transitional care. |
14 | | (b) Primary care providers must notify active affected |
15 | | patients of nonrenewal or termination of the provider from the |
16 | | network 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 |
21 | | for 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 |
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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 |
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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 |
20 | | for 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 |
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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 |
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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 |
7 | | a network plan to provide coverage for benefits not otherwise |
8 | | covered or to diminish or impair preexisting condition |
9 | | limitations contained in the beneficiary's contract. |
10 | | (d) A provider shall comply with the requirements of 42 |
11 | | U.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 |
16 | | up-to-date, accurate, and complete provider directory for each |
17 | | of its network plans, with the information and search |
18 | | functions, 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 |
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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 |
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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 |
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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 |
23 | | available through an electronic provider directory the |
24 | | following information in a searchable format: |
25 | | (1) for health care professionals: |
26 | | (A) name; |
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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 |
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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 |
15 | | network plan, a network plan shall make available all of the |
16 | | following information in addition to the searchable |
17 | | information 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 |
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1 | | (3) for facilities other than hospitals, telephone |
2 | | number. |
3 | | (d) The issuer insurer or network plan shall make |
4 | | available in print, upon request, the following provider |
5 | | directory 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 |
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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 |
21 | | print format provider directory that the information included |
22 | | in the directory is accurate as of the date of printing and |
23 | | that beneficiaries or prospective beneficiaries should consult |
24 | | the issuer's insurer's electronic provider directory on its |
25 | | website and contact the provider. The network plan shall also |
26 | | include a telephone number in the print format provider |
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1 | | directory for a customer service representative where the |
2 | | beneficiary can obtain current provider directory information. |
3 | | (f) The Director may conduct periodic audits of the |
4 | | accuracy of provider directories. A network plan shall not be |
5 | | subject to any fines or penalties for information required in |
6 | | this Section that a provider submits that is inaccurate or |
7 | | incomplete. |
8 | | (g) To the extent not otherwise provided in this Act, an |
9 | | issuer shall comply with the requirements of 42 U.S.C. |
10 | | 300gg-115, except that "provider directory information" shall |
11 | | include all information required to be included in a provider |
12 | | directory pursuant to this Section. |
13 | | (h) This Section applies to network plans not otherwise |
14 | | exempt 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 |
19 | | continuing obligation to comply with the requirements of this |
20 | | Act. Other than the duties specifically created in this Act, |
21 | | nothing in this Act is intended to preclude, prevent, or |
22 | | require the adoption, modification, or termination of any |
23 | | utilization management, quality management, or claims |
24 | | processing methodologies of an issuer insurer . |
25 | | (b) Nothing in this Act precludes, prevents, or requires |
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1 | | the adoption, modification, or termination of any network plan |
2 | | term, benefit, coverage or eligibility provision, or payment |
3 | | methodology. |
4 | | (c) The Director shall enforce the provisions of this Act |
5 | | pursuant to the enforcement powers granted to it by law. |
6 | | (d) The Department shall adopt rules to enforce compliance |
7 | | with this Act to the extent necessary. |
8 | | (e) In accordance with Section 5-45 of the Illinois |
9 | | Administrative Procedure Act, the Department may adopt |
10 | | emergency rules to implement federal standards for provider |
11 | | ratios, travel time and distance, and appointment wait times |
12 | | if such standards apply to health insurance coverage regulated |
13 | | by the Department and are more stringent than the State |
14 | | standards extant at the time the final federal standards are |
15 | | published. |
16 | | (Source: P.A. 100-502, eff. 9-15-17.) |
17 | | (215 ILCS 124/35 new) |
18 | | Sec. 35. Provider requirements. Providers shall comply |
19 | | with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations |
20 | | promulgated 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 |
23 | | required to be included in a provider directory pursuant to |
24 | | Section 25 of this Act. |
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1 | | (215 ILCS 124/40 new) |
2 | | Sec. 40. Confidentiality. |
3 | | (a) All records in the custody or possession of the |
4 | | Department are presumed to be open to public inspection or |
5 | | copying unless exempt from disclosure by Section 7 or 7.5 of |
6 | | the Freedom of Information Act. Except as otherwise provided |
7 | | in this Section or other applicable law, the filings required |
8 | | under this Act shall be open to public inspection or copying. |
9 | | (b) The following information shall not be deemed |
10 | | confidential: |
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 |
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1 | | self-audit of its provider directories shall remain |
2 | | confidential unless expressly waived by the insurer or unless |
3 | | deemed public information under federal law. |
4 | | (d) The filings required under Section 10 of this Act |
5 | | shall be confidential while they remain under the Department's |
6 | | review but shall become open to public inspection and copying |
7 | | upon completion of the review, except as provided in this |
8 | | Section or under other applicable law. |
9 | | (e) Nothing in this Section shall supersede the statutory |
10 | | requirement that work papers obtained during a market conduct |
11 | | examination be deemed confidential. |
12 | | (215 ILCS 124/50 new) |
13 | | Sec. 50. Funds for enforcement. Moneys from fines and |
14 | | penalties collected from issuers for violations of this Act |
15 | | shall be deposited into the Insurance Producer Administration |
16 | | Fund for appropriation by the General Assembly to the |
17 | | Department to be used for providing financial support of the |
18 | | Department's enforcement of this Act. |
19 | | Section 2-15. The Managed Care Reform and Patient Rights |
20 | | Act 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 |
23 | | care plan must give at least 60 days notice of nonrenewal or |
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1 | | termination of a health care provider to the health care |
2 | | provider and to the enrollees served by the health care |
3 | | provider. The notice shall include a name and address to which |
4 | | an enrollee or health care provider may direct comments and |
5 | | concerns regarding the nonrenewal or termination. Immediate |
6 | | written notice may be provided without 60 days notice when a |
7 | | health care provider's license has been disciplined by a State |
8 | | licensing board. The notice to the enrollee shall provide the |
9 | | individual with an opportunity to notify the health care plan |
10 | | of 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 |
15 | | care 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 |
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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; |
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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 |
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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; |
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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 |
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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 |
10 | | care 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 |
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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 |
17 | | a health care plan to provide coverage for benefits not |
18 | | otherwise covered or to diminish or impair preexisting |
19 | | condition limitations contained in the enrollee's contract. In |
20 | | no event shall this Section be construed to prohibit the |
21 | | addition of prescription drugs to a health care plan's list of |
22 | | covered drugs during the coverage year. |
23 | | (d) In this Section, "ongoing course of treatment" has the |
24 | | meaning ascribed to that term in Section 5 of the Network |
25 | | Adequacy and Transparency Act. |
26 | | (Source: P.A. 100-1052, eff. 8-24-18.) |
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1 | | Article 3. |
2 | | Section 3-5. The Illinois Insurance Code is amended by |
3 | | changing 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 |
13 | | Health Insurance Portability and Accountability Act. |
14 | | "Plain language" has the meaning provided in the federal |
15 | | Plain Writing Act of 2010 and subsequent guidance documents, |
16 | | including the Federal Plain Language Guidelines. |
17 | | "Unreasonable rate increase" means a rate increase that |
18 | | the Director determines to be excessive, unjustified, or |
19 | | unfairly discriminatory in accordance with 45 CFR 154.205. |
20 | | (b) No policy of insurance against loss or damage from the |
21 | | sickness, or from the bodily injury or death of the insured by |
22 | | accident shall be issued or delivered to any person in this |
23 | | State until a copy of the form thereof and of the |
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1 | | classification of risks and the premium rates pertaining |
2 | | thereto have been filed with the Director; nor shall it be so |
3 | | issued or delivered until the Director shall have approved |
4 | | such policy pursuant to the provisions of Section 143. If the |
5 | | Director disapproves the policy form, he or she shall make a |
6 | | written decision stating the respects in which such form does |
7 | | not comply with the requirements of law and shall deliver a |
8 | | copy thereof to the company and it shall be unlawful |
9 | | thereafter for any such company to issue any policy in such |
10 | | form. On and after January 1, 2025, any form filing submitted |
11 | | for large employer group accident and health insurance shall |
12 | | be automatically deemed approved within 90 days of the |
13 | | submission date unless the Director extends by not more than |
14 | | an additional 30 days the period within which the form shall be |
15 | | approved or disapproved by giving written notice to the |
16 | | insurer of such extension before the expiration of the 90 |
17 | | days. Any form in receipt of such an extension shall be |
18 | | automatically deemed approved within 120 days of the |
19 | | submission date. The Director may toll the filing due to a |
20 | | conflict in legal interpretation of federal or State law as |
21 | | long as the tolling is applied uniformly to all applicable |
22 | | forms, written notification is provided to the insurer prior |
23 | | to the tolling, the duration of the tolling is provided within |
24 | | the notice to the insurer, and justification for the tolling |
25 | | is posted to the Department's website. The Director may |
26 | | disapprove the filing if the insurer fails to respond to an |
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1 | | objection or request for additional information within the |
2 | | timeframe identified for response. As used in this subsection, |
3 | | "large employer" has the meaning given in Section 5 of the |
4 | | federal Health Insurance Portability and Accountability Act. |
5 | | (c) For plan year 2026 and thereafter, premium rates for |
6 | | all individual and small group accident and health insurance |
7 | | policies must be filed with the Department for approval. |
8 | | Unreasonable rate increases or inadequate rates shall be |
9 | | modified or disapproved. For any plan year during which the |
10 | | Illinois Health Benefits Exchange operates as a full |
11 | | State-based exchange, the Department shall provide insurers at |
12 | | least 30 days' notice of the deadline to submit rate filings. |
13 | | (c-5) Unless prohibited under federal law, for plan year |
14 | | 2026 and thereafter, each insurer proposing to offer a |
15 | | qualified health plan issued in the individual market through |
16 | | the Illinois Health Benefits Exchange must incorporate the |
17 | | following 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 |
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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 |
8 | | calculated for the applicable plan year under paragraph (1) of |
9 | | this subsection (c-5) and the formula in paragraph (2) of this |
10 | | subsection (c-5). |
11 | | (d) For plan year 2025 and thereafter, the Department |
12 | | shall post all insurers' rate filings and summaries on the |
13 | | Department's website 5 business days after the rate filing |
14 | | deadline set by the Department in annual guidance. The rate |
15 | | filings and summaries posted to the Department's website shall |
16 | | exclude information that is proprietary or trade secret |
17 | | information protected under paragraph (g) of subsection (1) of |
18 | | Section 7 of the Freedom of Information Act or confidential or |
19 | | privileged under any applicable insurance law or rule. All |
20 | | summaries shall include a brief justification of any rate |
21 | | increase or decrease requested, including the number of |
22 | | individual members, the medical loss ratio, medical trend, |
23 | | administrative costs, and any other information required by |
24 | | rule. The plain writing summary shall include notification of |
25 | | the public comment period established in subsection (e). |
26 | | (e) The Department shall open a 30-day public comment |
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1 | | period on the rate filings beginning on the date that all of |
2 | | the rate filings are posted on the Department's website. The |
3 | | Department shall post all of the comments received to the |
4 | | Department's website within 5 business days after the comment |
5 | | period ends. |
6 | | (f) After the close of the public comment period described |
7 | | in subsection (e), the Department, beginning for plan year |
8 | | 2026, shall issue a decision to approve, disapprove, or modify |
9 | | a rate filing within 60 days. Any rate filing or any rates |
10 | | within a filing on which the Director does not issue a decision |
11 | | within 60 days shall automatically be deemed approved. The |
12 | | Director's decision shall take into account the actuarial |
13 | | justifications and public comments. The Department shall |
14 | | notify the insurer of the decision, make the decision |
15 | | available to the public by posting it on the Department's |
16 | | website, and include an explanation of the findings, actuarial |
17 | | justifications, and rationale that are the basis for the |
18 | | decision. Any company whose rate has been modified or |
19 | | disapproved shall be allowed to request a hearing within 10 |
20 | | days after the action taken. The action of the Director in |
21 | | disapproving a rate shall be subject to judicial review under |
22 | | the Administrative Review Law. |
23 | | (g) If, following the issuance of a decision but before |
24 | | the effective date of the premium rates approved by the |
25 | | decision, an event occurs that materially affects the |
26 | | Director's decision to approve, deny, or modify the rates, the |
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1 | | Director may consider supplemental facts or data reasonably |
2 | | related to the event. |
3 | | (h) The Department shall adopt rules implementing the |
4 | | procedures described in subsections (d) through (g) by March |
5 | | 31, 2024. |
6 | | (i) Subsection (a) and subsections (c) through (h) of this |
7 | | Section do not apply to grandfathered health plans as defined |
8 | | in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C. |
9 | | 300gg-91; student health insurance coverage as defined in 45 |
10 | | CFR 147.145; the large group market as defined in Section 5 of |
11 | | the Illinois Health Insurance Portability and Accountability |
12 | | Act; or short-term, limited-duration health insurance coverage |
13 | | as defined in Section 5 of the Short-Term, Limited-Duration |
14 | | Health Insurance Coverage Act. For a filing of premium rates |
15 | | or classifications of risk for any of these types of coverage, |
16 | | the Director's initial review period shall not exceed 60 days |
17 | | to issue informal objections to the company that request |
18 | | additional clarification, explanation, substantiating |
19 | | documentation, or correction of concerns identified in the |
20 | | filing before the company implements the premium rates, |
21 | | classifications, or related rate-setting methodologies |
22 | | described in the filing, except that the Director may extend |
23 | | by not more than an additional 30 days the period of initial |
24 | | review by giving written notice to the company of such |
25 | | extension before the expiration of the initial 60-day period. |
26 | | Nothing in this subsection shall confer authority upon the |
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1 | | Director to approve, modify, or disapprove rates where that |
2 | | authority is not provided by other law. Nothing in this |
3 | | subsection shall prohibit the Director from conducting any |
4 | | investigation, examination, hearing, or other formal |
5 | | administrative or enforcement proceeding with respect to a |
6 | | company's rate filing or implementation thereof under |
7 | | applicable law at any time, including after the period of |
8 | | initial 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 |
12 | | changing 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 |
22 | | Health Insurance Portability and Accountability Act. |
23 | | "Plain language" has the meaning provided in the federal |
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1 | | Plain Writing Act of 2010 and subsequent guidance documents, |
2 | | including the Federal Plain Language Guidelines. |
3 | | "Unreasonable rate increase" means a rate increase that |
4 | | the Director determines to be excessive, unjustified, or |
5 | | unfairly discriminatory in accordance with 45 CFR 154.205. |
6 | | (b) No policy of insurance against loss or damage from the |
7 | | sickness, or from the bodily injury or death of the insured by |
8 | | accident shall be issued or delivered to any person in this |
9 | | State until a copy of the form thereof and of the |
10 | | classification of risks and the premium rates pertaining |
11 | | thereto have been filed with the Director; nor shall it be so |
12 | | issued or delivered until the Director shall have approved |
13 | | such policy pursuant to the provisions of Section 143. If the |
14 | | Director disapproves the policy form, he or she shall make a |
15 | | written decision stating the respects in which such form does |
16 | | not comply with the requirements of law and shall deliver a |
17 | | copy thereof to the company and it shall be unlawful |
18 | | thereafter for any such company to issue any policy in such |
19 | | form. On and after January 1, 2025, any form filing submitted |
20 | | for large employer group accident and health insurance shall |
21 | | be automatically deemed approved within 90 days of the |
22 | | submission date unless the Director extends by not more than |
23 | | an additional 30 days the period within which the form shall be |
24 | | approved or disapproved by giving written notice to the |
25 | | insurer of such extension before the expiration of the 90 |
26 | | days. Any form in receipt of such an extension shall be |
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1 | | automatically deemed approved within 120 days of the |
2 | | submission date. The Director may toll the filing due to a |
3 | | conflict in legal interpretation of federal or State law as |
4 | | long as the tolling is applied uniformly to all applicable |
5 | | forms, written notification is provided to the insurer prior |
6 | | to the tolling, the duration of the tolling is provided within |
7 | | the notice to the insurer, and justification for the tolling |
8 | | is posted to the Department's website. The Director may |
9 | | disapprove the filing if the insurer fails to respond to an |
10 | | objection or request for additional information within the |
11 | | timeframe identified for response. As used in this subsection, |
12 | | "large employer" has the meaning given in Section 5 of the |
13 | | federal Health Insurance Portability and Accountability Act. |
14 | | (c) For plan year 2026 and thereafter, premium rates for |
15 | | all individual and small group accident and health insurance |
16 | | policies must be filed with the Department for approval. |
17 | | Unreasonable rate increases or inadequate rates shall be |
18 | | modified or disapproved. For any plan year during which the |
19 | | Illinois Health Benefits Exchange operates as a full |
20 | | State-based exchange, the Department shall provide insurers at |
21 | | least 30 days' notice of the deadline to submit rate filings. |
22 | | (d) For plan year 2025 and thereafter, the Department |
23 | | shall post all insurers' rate filings and summaries on the |
24 | | Department's website 5 business days after the rate filing |
25 | | deadline set by the Department in annual guidance. The rate |
26 | | filings and summaries posted to the Department's website shall |
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1 | | exclude information that is proprietary or trade secret |
2 | | information protected under paragraph (g) of subsection (1) of |
3 | | Section 7 of the Freedom of Information Act or confidential or |
4 | | privileged under any applicable insurance law or rule. All |
5 | | summaries shall include a brief justification of any rate |
6 | | increase or decrease requested, including the number of |
7 | | individual members, the medical loss ratio, medical trend, |
8 | | administrative costs, and any other information required by |
9 | | rule. The plain writing summary shall include notification of |
10 | | the public comment period established in subsection (e). |
11 | | (e) The Department shall open a 30-day public comment |
12 | | period on the rate filings beginning on the date that all of |
13 | | the rate filings are posted on the Department's website. The |
14 | | Department shall post all of the comments received to the |
15 | | Department's website within 5 business days after the comment |
16 | | period ends. |
17 | | (f) After the close of the public comment period described |
18 | | in subsection (e), the Department, beginning for plan year |
19 | | 2026, shall issue a decision to approve, disapprove, or modify |
20 | | a rate filing within 60 days. Any rate filing or any rates |
21 | | within a filing on which the Director does not issue a decision |
22 | | within 60 days shall automatically be deemed approved. The |
23 | | Director's decision shall take into account the actuarial |
24 | | justifications and public comments. The Department shall |
25 | | notify the insurer of the decision, make the decision |
26 | | available to the public by posting it on the Department's |
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1 | | website, and include an explanation of the findings, actuarial |
2 | | justifications, and rationale that are the basis for the |
3 | | decision. Any company whose rate has been modified or |
4 | | disapproved shall be allowed to request a hearing within 10 |
5 | | days after the action taken. The action of the Director in |
6 | | disapproving a rate shall be subject to judicial review under |
7 | | the Administrative Review Law. |
8 | | (g) If, following the issuance of a decision but before |
9 | | the effective date of the premium rates approved by the |
10 | | decision, an event occurs that materially affects the |
11 | | Director's decision to approve, deny, or modify the rates, the |
12 | | Director may consider supplemental facts or data reasonably |
13 | | related to the event. |
14 | | (h) The Department shall adopt rules implementing the |
15 | | procedures described in subsections (d) through (g) by March |
16 | | 31, 2024. |
17 | | (i) Subsection (a) , and subsections (c) through (h) , and |
18 | | subsection (j) of this Section do not apply to grandfathered |
19 | | health plans as defined in 45 CFR 147.140; excepted benefits |
20 | | as defined in 42 U.S.C. 300gg-91; student health insurance |
21 | | coverage as defined in 45 CFR 147.145; the large group market |
22 | | as defined in Section 5 of the Illinois Health Insurance |
23 | | Portability and Accountability Act; or short-term, |
24 | | limited-duration health insurance coverage as defined in |
25 | | Section 5 of the Short-Term, Limited-Duration Health Insurance |
26 | | Coverage Act. For a filing of premium rates or classifications |
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1 | | of risk for any of these types of coverage, the Director's |
2 | | initial review period shall not exceed 60 days to issue |
3 | | informal objections to the company that request additional |
4 | | clarification, explanation, substantiating documentation, or |
5 | | correction of concerns identified in the filing before the |
6 | | company implements the premium rates, classifications, or |
7 | | related rate-setting methodologies described in the filing, |
8 | | except that the Director may extend by not more than an |
9 | | additional 30 days the period of initial review by giving |
10 | | written notice to the company of such extension before the |
11 | | expiration of the initial 60-day period. Nothing in this |
12 | | subsection shall confer authority upon the Director to |
13 | | approve, modify, or disapprove rates where that authority is |
14 | | not provided by other law. Nothing in this subsection shall |
15 | | prohibit the Director from conducting any investigation, |
16 | | examination, hearing, or other formal administrative or |
17 | | enforcement proceeding with respect to a company's rate filing |
18 | | or implementation thereof under applicable law at any time, |
19 | | including after the period of initial review. |
20 | | (j) Subsections (c) through (h) do not apply to group |
21 | | policies issued to large employers. For large employer group |
22 | | policies issued, delivered, amended, or renewed on or after |
23 | | January 1, 2026 that are not described in subsection (i), the |
24 | | premium rates and risk classifications, including any rate |
25 | | manuals and rules used to arrive at the rates, must be filed |
26 | | with the Department annually for approval at least 120 days |
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1 | | before 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 .) |
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1 | | Section 4-10. The Health Maintenance Organization Act is |
2 | | amended 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, |
5 | | material modifications. A health maintenance organization |
6 | | shall file with the Director, prior to use, a notice of any |
7 | | change in rate methodology, or benefits and of any material |
8 | | modification of any matter or document furnished pursuant to |
9 | | Section 2-1, together with such supporting documents as are |
10 | | necessary 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 |
13 | | form agreements between the organization and enrollees, |
14 | | providers, administrators of services and insurers of health |
15 | | maintenance organizations. |
16 | | (b) Material transactions or series of transactions other |
17 | | than those described in subsection (a) of this Section, the |
18 | | total annual value of which exceeds the greater of $100,000 or |
19 | | 5% of net earned subscription revenue for the most current |
20 | | 12-month period as determined from filed financial statements. |
21 | | (c) Any agreement between the organization and an insurer |
22 | | shall be subject to the provisions of the laws of this State |
23 | | regarding reinsurance as provided in Article XI of the |
24 | | Illinois Insurance Code. All reinsurance agreements must be |
25 | | filed. Approval of the Director is required for all agreements |
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1 | | except the following: individual stop loss, aggregate excess, |
2 | | hospitalization benefits or out-of-area of the participating |
3 | | providers unless 20% or more of the organization's total risk |
4 | | is reinsured, in which case all reinsurance agreements require |
5 | | approval. |
6 | | (d) In addition to any applicable provisions of this Act, |
7 | | premium rate filings shall be subject to subsections (a) and |
8 | | (c) through (j) (i) of Section 355 of the Illinois Insurance |
9 | | Code. |
10 | | (Source: P.A. 103-106, eff. 1-1-24 .) |
11 | | Section 4-15. The Limited Health Service Organization Act |
12 | | is 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; |
15 | | material modifications; addition of limited health services. |
16 | | (a) A limited health service organization shall file with |
17 | | the Director prior to use, a notice of any change in rate |
18 | | methodology, charges , or benefits and of any material |
19 | | modification of any matter or document furnished pursuant to |
20 | | Section 2001, together with such supporting documents as are |
21 | | necessary 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, |
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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 |
21 | | add one or more additional limited health services, it shall |
22 | | file a notice with the Director and, at the same time, submit |
23 | | the information required by Section 2001 if different from |
24 | | that filed with the prepaid limited health service |
25 | | organization's application. Issuance of such an amended |
26 | | certificate of authority shall be subject to the conditions of |
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1 | | Section 2002 of this Act. |
2 | | (c) In addition to any applicable provisions of this Act, |
3 | | premium rate filings shall be subject to subsection (i) and, |
4 | | for pharmaceutical policies, subsection (j) of Section 355 of |
5 | | the 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 |
9 | | changing Sections 121-2.05, 356z.18, 367.3, 367a, and 368f and |
10 | | by 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 |
13 | | delivered in other State-Transactions in this State. With the |
14 | | exception of insurance transactions authorized under Sections |
15 | | 230.2 or 367.3 of this Code or transactions described under |
16 | | Section 352c , transactions in this State involving group |
17 | | legal, group life and group accident and health or blanket |
18 | | accident and health insurance or group annuities where the |
19 | | master policy of such groups was lawfully issued and delivered |
20 | | in, and under the laws of, a State in which the insurer was |
21 | | authorized to do an insurance business, to a group properly |
22 | | established pursuant to law or regulation, and where the |
23 | | policyholder is domiciled or otherwise has a bona fide situs. |
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1 | | (Source: P.A. 86-753.) |
2 | | (215 ILCS 5/352c new) |
3 | | Sec. 352c. Short-term, limited-duration insurance |
4 | | prohibited; rules for excepted benefits. |
5 | | (a) Definitions. As used in this Section: |
6 | | "Excepted benefits" has the meaning given to that term in |
7 | | 42 U.S.C. 300gg-91 and implementing regulations. "Excepted |
8 | | benefits" includes individual, group, or blanket coverage. |
9 | | "Short-term, limited-duration insurance" means any type of |
10 | | accident and health insurance offered or provided within this |
11 | | State pursuant to a group or individual policy or individual |
12 | | certificate by a company, regardless of the situs state of the |
13 | | delivery of the policy, that has an expiration date specified |
14 | | in the contract that is fewer than 365 days after the original |
15 | | effective date. Regardless of the duration of coverage, |
16 | | "short-term, limited-duration insurance" does not include |
17 | | excepted benefits or any student health insurance coverage. |
18 | | "Student health insurance coverage" has the meaning given |
19 | | to that term in 45 CFR 147.145. |
20 | | (b) On and after January 1, 2025, no company shall issue, |
21 | | deliver, amend, or renew short-term, limited-duration |
22 | | insurance to any natural or legal person that is a resident or |
23 | | domiciled in this State. |
24 | | (c) To prevent the use, design, and combination of |
25 | | excepted benefits to circumvent State or federal requirements |
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1 | | for comprehensive forms of health insurance coverage, to |
2 | | prevent confusion or misinformation of insureds about |
3 | | duplicate or distinct types of coverage, and to ensure a |
4 | | measure of consistency within product lines across the |
5 | | individual, group, and blanket markets, the Department may |
6 | | adopt rules as deemed necessary that prescribe specific |
7 | | standards for or restrictions on policy provisions, benefit |
8 | | design, disclosures, and sales and marketing practices for |
9 | | excepted benefits. For purposes of these rules, the Director's |
10 | | authority under subsections (3) and (4) of Section 355a is |
11 | | extended to group and blanket excepted benefits. To ensure |
12 | | compliance with these rules, the Director may require policy |
13 | | forms and rates to be filed as provided in Sections 143 and 355 |
14 | | and rules thereunder with respect to excepted benefits |
15 | | coverage intended to be issued to residents of this State |
16 | | under a master contract issued to a group domiciled or |
17 | | otherwise with bona fide situs outside of this State. This |
18 | | subsection does not apply to limited-scope dental, |
19 | | limited-scope vision, long-term care, Medicare supplement, |
20 | | credit life, credit health, or any excepted benefits that are |
21 | | filed under subsections (b) through (l) of Class 2 or under |
22 | | Class 3 of Section 4. Nothing in this subsection shall be |
23 | | construed to limit the Director's authority under other |
24 | | statutes. |
25 | | (215 ILCS 5/356z.18) |
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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 |
5 | | the body or a part of the body, the head, neck, or extremities, |
6 | | and includes the replacement or repair of the device based on |
7 | | the patient's physical condition as medically necessary, |
8 | | excluding foot orthotics defined as an in-shoe device designed |
9 | | to support the structural components of the foot during |
10 | | weight-bearing activities. |
11 | | "Licensed provider" means a prosthetist, orthotist, or |
12 | | pedorthist licensed to practice in this State. |
13 | | "Prosthetic device" means an artificial device to replace, |
14 | | in whole or in part, an arm or leg and includes accessories |
15 | | essential to the effective use of the device and the |
16 | | replacement or repair of the device based on the patient's |
17 | | physical condition as medically necessary. |
18 | | (b) This amendatory Act of the 96th General Assembly shall |
19 | | provide benefits to any person covered thereunder for expenses |
20 | | incurred in obtaining a prosthetic or custom orthotic device |
21 | | from any Illinois licensed prosthetist, licensed orthotist, or |
22 | | licensed pedorthist as required under the Orthotics, |
23 | | Prosthetics, and Pedorthics Practice Act. |
24 | | (c) A group or individual major medical policy of accident |
25 | | or health insurance or managed care plan or medical, health, |
26 | | or hospital service corporation contract that provides |
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1 | | coverage for prosthetic or custom orthotic care and is |
2 | | amended, delivered, issued, or renewed 6 months after the |
3 | | effective date of this amendatory Act of the 96th General |
4 | | Assembly must provide coverage for prosthetic and orthotic |
5 | | devices in accordance with this subsection (c). The coverage |
6 | | required under this Section shall be subject to the other |
7 | | general exclusions, limitations, and financial requirements of |
8 | | the policy, including coordination of benefits, participating |
9 | | provider requirements, utilization review of health care |
10 | | services, including review of medical necessity, case |
11 | | management, and experimental and investigational treatments, |
12 | | and other managed care provisions under terms and conditions |
13 | | that are no less favorable than the terms and conditions that |
14 | | apply to substantially all medical and surgical benefits |
15 | | provided under the plan or coverage. |
16 | | (d) The policy or plan or contract may require prior |
17 | | authorization for the prosthetic or orthotic devices in the |
18 | | same manner that prior authorization is required for any other |
19 | | covered benefit. |
20 | | (e) Repairs and replacements of prosthetic and orthotic |
21 | | devices are also covered, subject to the co-payments and |
22 | | deductibles, unless necessitated by misuse or loss. |
23 | | (f) A policy or plan or contract may require that, if |
24 | | coverage is provided through a managed care plan, the benefits |
25 | | mandated pursuant to this Section shall be covered benefits |
26 | | only if the prosthetic or orthotic devices are provided by a |
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1 | | licensed provider employed by a provider service who contracts |
2 | | with or is designated by the carrier, to the extent that the |
3 | | carrier provides in-network and out-of-network service, the |
4 | | coverage for the prosthetic or orthotic device shall be |
5 | | offered no less extensively. |
6 | | (g) The policy or plan or contract shall also meet |
7 | | adequacy requirements as established by the Health Care |
8 | | Reimbursement Reform Act of 1985 of the Illinois Insurance |
9 | | Code. |
10 | | (h) This Section shall not apply to accident only, |
11 | | specified disease, short-term travel hospital or medical , |
12 | | hospital confinement indemnity, credit, dental, vision, |
13 | | Medicare supplement, long-term care, basic hospital and |
14 | | medical-surgical expense coverage, disability income insurance |
15 | | coverage, coverage issued as a supplement to liability |
16 | | insurance, workers' compensation insurance, or automobile |
17 | | medical 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 |
23 | | the body or a part of the body, the head, neck, or extremities, |
24 | | and includes the replacement or repair of the device based on |
25 | | the patient's physical condition as medically necessary, |
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1 | | excluding foot orthotics defined as an in-shoe device designed |
2 | | to support the structural components of the foot during |
3 | | weight-bearing activities. |
4 | | "Licensed provider" means a prosthetist, orthotist, or |
5 | | pedorthist licensed to practice in this State. |
6 | | "Prosthetic device" means an artificial device to replace, |
7 | | in whole or in part, an arm or leg and includes accessories |
8 | | essential to the effective use of the device and the |
9 | | replacement or repair of the device based on the patient's |
10 | | physical condition as medically necessary. |
11 | | (b) This amendatory Act of the 96th General Assembly shall |
12 | | provide benefits to any person covered thereunder for expenses |
13 | | incurred in obtaining a prosthetic or custom orthotic device |
14 | | from any Illinois licensed prosthetist, licensed orthotist, or |
15 | | licensed pedorthist as required under the Orthotics, |
16 | | Prosthetics, and Pedorthics Practice Act. |
17 | | (c) A group or individual major medical policy of accident |
18 | | or health insurance or managed care plan or medical, health, |
19 | | or hospital service corporation contract that provides |
20 | | coverage for prosthetic or custom orthotic care and is |
21 | | amended, delivered, issued, or renewed 6 months after the |
22 | | effective date of this amendatory Act of the 96th General |
23 | | Assembly must provide coverage for prosthetic and orthotic |
24 | | devices in accordance with this subsection (c). The coverage |
25 | | required under this Section shall be subject to the other |
26 | | general exclusions, limitations, and financial requirements of |
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1 | | the policy, including coordination of benefits, participating |
2 | | provider requirements, utilization review of health care |
3 | | services, including review of medical necessity, case |
4 | | management, and experimental and investigational treatments, |
5 | | and other managed care provisions under terms and conditions |
6 | | that are no less favorable than the terms and conditions that |
7 | | apply to substantially all medical and surgical benefits |
8 | | provided under the plan or coverage. |
9 | | (d) With respect to an enrollee at any age, in addition to |
10 | | coverage of a prosthetic or custom orthotic device required by |
11 | | this Section, benefits shall be provided for a prosthetic or |
12 | | custom orthotic device determined by the enrollee's provider |
13 | | to be the most appropriate model that is medically necessary |
14 | | for the enrollee to perform physical activities, as |
15 | | applicable, such as running, biking, swimming, and lifting |
16 | | weights, and to maximize the enrollee's whole body health and |
17 | | strengthen the lower and upper limb function. |
18 | | (e) The requirements of this Section do not constitute an |
19 | | addition to this State's essential health benefits that |
20 | | requires defrayal of costs by this State pursuant to 42 U.S.C. |
21 | | 18031(d)(3)(B). |
22 | | (f) The policy or plan or contract may require prior |
23 | | authorization for the prosthetic or orthotic devices in the |
24 | | same manner that prior authorization is required for any other |
25 | | covered benefit. |
26 | | (g) Repairs and replacements of prosthetic and orthotic |
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1 | | devices are also covered, subject to the co-payments and |
2 | | deductibles, unless necessitated by misuse or loss. |
3 | | (h) A policy or plan or contract may require that, if |
4 | | coverage is provided through a managed care plan, the benefits |
5 | | mandated pursuant to this Section shall be covered benefits |
6 | | only if the prosthetic or orthotic devices are provided by a |
7 | | licensed provider employed by a provider service who contracts |
8 | | with or is designated by the carrier, to the extent that the |
9 | | carrier provides in-network and out-of-network service, the |
10 | | coverage for the prosthetic or orthotic device shall be |
11 | | offered no less extensively. |
12 | | (i) The policy or plan or contract shall also meet |
13 | | adequacy requirements as established by the Health Care |
14 | | Reimbursement Reform Act of 1985 of the Illinois Insurance |
15 | | Code. |
16 | | (j) This Section shall not apply to accident only, |
17 | | specified disease, short-term travel hospital or medical , |
18 | | hospital confinement indemnity, credit, dental, vision, |
19 | | Medicare supplement, long-term care, basic hospital and |
20 | | medical-surgical expense coverage, disability income insurance |
21 | | coverage, coverage issued as a supplement to liability |
22 | | insurance, workers' compensation insurance, or automobile |
23 | | medical payment insurance. |
24 | | (Source: P.A. 103-512, eff. 1-1-25.) |
25 | | (215 ILCS 5/367.3) (from Ch. 73, par. 979.3) |
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1 | | Sec. 367.3. Group accident and health insurance; |
2 | | discretionary groups. |
3 | | (a) No group health insurance offered to a resident of |
4 | | this State under a policy issued to a group, other than one |
5 | | specifically described in Section 367(1), shall be delivered |
6 | | or issued for delivery in this State unless the Director |
7 | | determines 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 |
15 | | State under a policy issued in another state unless this State |
16 | | or the state in which the group policy is issued has made a |
17 | | determination that the requirements of subsection (a) have |
18 | | been met. |
19 | | Where insurance is to be offered in this State under a |
20 | | policy described in this subsection, the insurer shall file |
21 | | for 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 |
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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 |
12 | | information required under subsection (b) and after finding |
13 | | that the standards of subsection (a) have not been met, order |
14 | | the insurer to cease the issuance or marketing of that |
15 | | coverage in this State. |
16 | | (d) Notwithstanding subsections (a) and (b), group Group |
17 | | accident and health insurance subject to the provisions of |
18 | | this Section is also subject to the provisions of Sections |
19 | | 352c 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 |
24 | | of accident and health insurance providing excepted benefits, |
25 | | as defined in Section 352c, that covers covering special |
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1 | | groups of persons as enumerated in one of the following |
2 | | paragraphs (a) to (g), inclusive: |
3 | | (a) Under a policy or contract issued to any carrier for |
4 | | hire, which shall be deemed the policyholder, covering a group |
5 | | defined as all persons who may become passengers on such |
6 | | carrier. |
7 | | (b) Under a policy or contract issued to an employer, who |
8 | | shall be deemed the policyholder, covering all employees or |
9 | | any group of employees defined by reference to exceptional |
10 | | hazards incident to such employment. |
11 | | (c) Under a policy or contract issued to a college, |
12 | | school, or other institution of learning or to the head or |
13 | | principal thereof, who or which shall be deemed the |
14 | | policyholder, covering students or teachers. However, except |
15 | | where inconsistent with 45 CFR 147.145, student health |
16 | | insurance coverage other than excepted benefits that is |
17 | | provided pursuant to a written agreement with an institution |
18 | | of higher education for the benefit of its enrolled students |
19 | | and their dependents shall remain subject to the standards and |
20 | | requirements for individual coverage. |
21 | | (d) Under a policy or contract issued in the name of any |
22 | | volunteer fire department, first aid, or other such volunteer |
23 | | group, which shall be deemed the policyholder, covering all of |
24 | | the members of such department or group. |
25 | | (e) Under a policy or contract issued to a creditor, who |
26 | | shall be deemed the policyholder, to insure debtors of the |
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1 | | creditors; Provided, however, that in the case of a loan which |
2 | | is subject to the Small Loans Act, no insurance premium or |
3 | | other cost shall be directly or indirectly charged or assessed |
4 | | against, or collected or received from the borrower. |
5 | | (f) Under a policy or contract issued to a sports team or |
6 | | to a camp, which team or camp sponsor shall be deemed the |
7 | | policyholder, covering members or campers. |
8 | | (g) Under a policy or contract issued to any other |
9 | | substantially similar group which, in the discretion of the |
10 | | Director, may be subject to the issuance of a blanket accident |
11 | | and health policy or contract. |
12 | | (2) Any insurance company authorized to write accident and |
13 | | health insurance in this state shall have the power to issue |
14 | | blanket accident and health insurance. No such blanket policy |
15 | | may be issued or delivered in this State unless a copy of the |
16 | | form thereof shall have been filed in accordance with Section |
17 | | 355, and it contains in substance such of those provisions |
18 | | contained in Sections 357.1 through 357.30 as may be |
19 | | applicable to blanket accident and health insurance and the |
20 | | following provisions: |
21 | | (a) A provision that the policy and the application shall |
22 | | constitute the entire contract between the parties, and that |
23 | | all statements made by the policyholder shall, in absence of |
24 | | fraud, be deemed representations and not warranties, and that |
25 | | no such statements shall be used in defense to a claim under |
26 | | the policy, unless it is contained in a written application. |
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1 | | (b) A provision that to the group or class thereof |
2 | | originally insured shall be added from time to time all new |
3 | | persons or individuals eligible for coverage. |
4 | | (3) An individual application shall not be required from a |
5 | | person covered under a blanket accident or health policy or |
6 | | contract, nor shall it be necessary for the insurer to furnish |
7 | | each person a certificate. |
8 | | (4) All benefits under any blanket accident and health |
9 | | policy shall be payable to the person insured, or to his |
10 | | designated beneficiary or beneficiaries, or to his or her |
11 | | estate, except that if the person insured be a minor or person |
12 | | under legal disability, such benefits may be made payable to |
13 | | his or her parent, guardian, or other person actually |
14 | | supporting him or her. Provided further, however, that the |
15 | | policy may provide that all or any portion of any indemnities |
16 | | provided by any such policy on account of hospital, nursing, |
17 | | medical or surgical services may, at the insurer's option, be |
18 | | paid directly to the hospital or person rendering such |
19 | | services; but the policy may not require that the service be |
20 | | rendered by a particular hospital or person. Payment so made |
21 | | shall discharge the insurer's obligation with respect to the |
22 | | amount of insurance so paid. |
23 | | (5) Nothing contained in this section shall be deemed to |
24 | | affect the legal liability of policyholders for the death of |
25 | | or injury to, any such member of such group. |
26 | | (Source: P.A. 83-1362.) |
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1 | | (215 ILCS 5/368f) |
2 | | Sec. 368f. Military service member insurance |
3 | | reinstatement. |
4 | | (a) No Illinois resident activated for military service |
5 | | and no spouse or dependent of the resident who becomes |
6 | | eligible for a federal government-sponsored health insurance |
7 | | program, including the TriCare program providing coverage for |
8 | | civilian dependents of military personnel, as a result of the |
9 | | activation shall be denied reinstatement into the same |
10 | | individual health insurance coverage with the health insurer |
11 | | that the resident lapsed as a result of activation or becoming |
12 | | covered by the federal government-sponsored health insurance |
13 | | program. The resident shall have the right to reinstatement in |
14 | | the same individual health insurance coverage without medical |
15 | | underwriting, subject to payment of the current premium |
16 | | charged to other persons of the same age and gender that are |
17 | | covered under the same individual health coverage. Except in |
18 | | the case of birth or adoption that occurs during the period of |
19 | | activation, reinstatement must be into the same coverage type |
20 | | as the resident held prior to lapsing the individual health |
21 | | insurance coverage and at the same or, at the option of the |
22 | | resident, higher deductible level. The reinstatement rights |
23 | | provided under this subsection (a) are not available to a |
24 | | resident or dependents if the activated person is discharged |
25 | | from the military under other than honorable conditions. |
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1 | | (b) The health insurer with which the reinstatement is |
2 | | being requested must receive a request for reinstatement no |
3 | | later than 63 days following the later of (i) deactivation or |
4 | | (ii) loss of coverage under the federal government-sponsored |
5 | | health insurance program. The health insurer may request proof |
6 | | of loss of coverage and the timing of the loss of coverage of |
7 | | the government-sponsored coverage in order to determine |
8 | | eligibility for reinstatement into the individual coverage. |
9 | | The effective date of the reinstatement of individual health |
10 | | coverage shall be the first of the month following receipt of |
11 | | the notice requesting reinstatement. |
12 | | (c) All insurers must provide written notice to the |
13 | | policyholder of individual health coverage of the rights |
14 | | described in subsection (a) of this Section. In lieu of the |
15 | | inclusion of the notice in the individual health insurance |
16 | | policy, an insurance company may satisfy the notification |
17 | | requirement 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. |
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1 | | (d) The provisions of subsection (a) of this Section do |
2 | | not apply to any policy or certificate providing coverage for |
3 | | any specified disease, specified accident or accident-only |
4 | | coverage, credit, dental, disability income, hospital |
5 | | indemnity, long-term care, Medicare supplement, vision care, |
6 | | or short-term travel nonrenewable health policy or other |
7 | | limited-benefit supplemental insurance, or any coverage issued |
8 | | as a supplement to any liability insurance, workers' |
9 | | compensation or similar insurance, or any insurance under |
10 | | which benefits are payable with or without regard to fault, |
11 | | whether written on a group, blanket, or individual basis. |
12 | | (e) Nothing in this Section shall require an insurer to |
13 | | reinstate the resident if the insurer requires residency in an |
14 | | enrollment area and those residency requirements are not met |
15 | | after deactivation or loss of coverage under the |
16 | | government-sponsored health insurance program. |
17 | | (f) All terms, conditions, and limitations of the |
18 | | individual coverage into which reinstatement is made apply |
19 | | equally to all insureds enrolled in the coverage. |
20 | | (g) The Secretary may adopt rules as may be necessary to |
21 | | carry 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 |
24 | | amended by changing Section 5-3 as follows: |
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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 |
4 | | the provisions of Sections 133, 134, 136, 137, 139, 140, |
5 | | 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, |
6 | | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, |
7 | | 352c, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, |
8 | | 356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, |
9 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
10 | | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, |
11 | | 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, |
12 | | 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, |
13 | | 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, |
14 | | 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, |
15 | | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, |
16 | | 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, |
17 | | 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, |
18 | | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, |
19 | | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of |
20 | | subsection (2) of Section 367, and Articles IIA, VIII 1/2, |
21 | | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the |
22 | | Illinois Insurance Code. |
23 | | (b) For purposes of the Illinois Insurance Code, except |
24 | | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, |
25 | | Health Maintenance Organizations in the following categories |
26 | | are deemed to be "domestic companies": |
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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 |
12 | | acquisition of control of a Health Maintenance Organization |
13 | | pursuant 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 |
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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 |
19 | | Insurance Code and this Section 5-3 shall apply to the sale by |
20 | | any health maintenance organization of greater than 10% of its |
21 | | enrollee population (including , without limitation , the health |
22 | | maintenance organization's right, title, and interest in and |
23 | | to its health care certificates). |
24 | | (e) In considering any management contract or service |
25 | | agreement subject to Section 141.1 of the Illinois Insurance |
26 | | Code, the Director (i) shall, in addition to the criteria |
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1 | | specified in Section 141.2 of the Illinois Insurance Code, |
2 | | take into account the effect of the management contract or |
3 | | service agreement on the continuation of benefits to enrollees |
4 | | and the financial condition of the health maintenance |
5 | | organization to be managed or serviced, and (ii) need not take |
6 | | into account the effect of the management contract or service |
7 | | agreement on competition. |
8 | | (f) Except for small employer groups as defined in the |
9 | | Small Employer Rating, Renewability and Portability Health |
10 | | Insurance Act and except for medicare supplement policies as |
11 | | defined in Section 363 of the Illinois Insurance Code, a |
12 | | Health Maintenance Organization may by contract agree with a |
13 | | group or other enrollment unit to effect refunds or charge |
14 | | additional 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 |
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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 |
11 | | statement in the evidence of coverage issued to each enrollee |
12 | | describing the possibility of a refund or additional premium, |
13 | | and upon request of any group or enrollment unit, provide to |
14 | | the group or enrollment unit a description of the method used |
15 | | to calculate (1) the Health Maintenance Organization's |
16 | | profitable experience with respect to the group or enrollment |
17 | | unit and the resulting refund to the group or enrollment unit |
18 | | or (2) the Health Maintenance Organization's unprofitable |
19 | | experience with respect to the group or enrollment unit and |
20 | | the resulting additional premium to be paid by the group or |
21 | | enrollment unit. |
22 | | In no event shall the Illinois Health Maintenance |
23 | | Organization Guaranty Association be liable to pay any |
24 | | contractual obligation of an insolvent organization to pay any |
25 | | refund authorized under this Section. |
26 | | (g) Rulemaking authority to implement Public Act 95-1045, |
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1 | | if any, is conditioned on the rules being adopted in |
2 | | accordance with all provisions of the Illinois Administrative |
3 | | Procedure Act and all rules and procedures of the Joint |
4 | | Committee on Administrative Rules; any purported rule not so |
5 | | adopted, for whatever reason, is unauthorized. |
6 | | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; |
7 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. |
8 | | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, |
9 | | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; |
10 | | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. |
11 | | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, |
12 | | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; |
13 | | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. |
14 | | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, |
15 | | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) |
16 | | Section 5-15. The Limited Health Service Organization Act |
17 | | is 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 |
20 | | health service organizations shall be subject to the |
21 | | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, |
22 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, |
23 | | 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c, |
24 | | 355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, |
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1 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, |
2 | | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, |
3 | | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, |
4 | | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, |
5 | | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, |
6 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. |
7 | | Nothing in this Section shall require a limited health care |
8 | | plan to cover any service that is not a limited health service. |
9 | | For purposes of the Illinois Insurance Code, except for |
10 | | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited |
11 | | health service organizations in the following categories are |
12 | | deemed 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; |
21 | | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. |
22 | | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, |
23 | | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; |
24 | | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. |
25 | | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, |
26 | | eff. 1-1-24; revised 8-29-23.) |
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1 | | (215 ILCS 190/Act rep.) |
2 | | Section 5-20. The Short-Term, Limited-Duration Health |
3 | | Insurance Coverage Act is repealed. |
4 | | Article 6. |
5 | | Section 6-5. The Illinois Insurance Code is amended by |
6 | | changing Sections 155.36, 155.37, 356z.40, and 370c as |
7 | | follows: |
8 | | (215 ILCS 5/155.36) |
9 | | Sec. 155.36. Managed Care Reform and Patient Rights Act. |
10 | | Insurance companies that transact the kinds of insurance |
11 | | authorized under Class 1(b) or Class 2(a) of Section 4 of this |
12 | | Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65, |
13 | | 70, and 85, and 87, subsection (d) of Section 30, and the |
14 | | definitions definition of the term "emergency medical |
15 | | condition" and any other term in Section 10 of the Managed Care |
16 | | Reform and Patient Rights Act that is used in the other |
17 | | Sections 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 |
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1 | | insurance authorized under Class 1(b) or Class 2(a) of Section |
2 | | 4 of this Code and provide coverage for prescription drugs |
3 | | through the use of a drug formulary must notify insureds of any |
4 | | change in the formulary. A company may comply with this |
5 | | Section by posting changes in the formulary on its website. |
6 | | (b) No later than July 1, 2025, insurance companies that |
7 | | use a drug formulary shall post the formulary on their |
8 | | websites in a manner that is searchable and accessible to the |
9 | | general public without requiring an individual to create any |
10 | | account. This formulary shall adhere to a template developed |
11 | | by the Department, which shall take into consideration |
12 | | existing requirements for reporting of information established |
13 | | by the federal Centers for Medicare and Medicaid Services as |
14 | | well as display of cost-sharing information. This template and |
15 | | all 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 |
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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 |
11 | | for any formulary drug or any drug covered as a result of a |
12 | | medical 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 |
17 | | insurance or managed care plan amended, delivered, issued, or |
18 | | renewed on or after the effective date of this amendatory Act |
19 | | of the 102nd General Assembly shall provide coverage for |
20 | | pregnancy and newborn care in accordance with 42 U.S.C. |
21 | | 18022(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 |
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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 |
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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 |
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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 |
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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, |
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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 |
22 | | Public Act 102-579), every insurer that amends, delivers, |
23 | | issues, or renews group accident and health policies providing |
24 | | coverage for hospital or medical treatment or services for |
25 | | illness on an expense-incurred basis shall provide coverage |
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1 | | for the medically necessary treatment of mental, emotional, |
2 | | nervous, or substance use disorders or conditions consistent |
3 | | with the parity requirements of Section 370c.1 of this Code. |
4 | | (2) Each insured that is covered for mental, emotional, |
5 | | nervous, or substance use disorders or conditions shall be |
6 | | free to select the physician licensed to practice medicine in |
7 | | all its branches, licensed clinical psychologist, licensed |
8 | | clinical social worker, licensed clinical professional |
9 | | counselor, licensed marriage and family therapist, licensed |
10 | | speech-language pathologist, or other licensed or certified |
11 | | professional at a program licensed pursuant to the Substance |
12 | | Use Disorder Act of his or her choice to treat such disorders, |
13 | | and the insurer shall pay the covered charges of such |
14 | | physician licensed to practice medicine in all its branches, |
15 | | licensed clinical psychologist, licensed clinical social |
16 | | worker, licensed clinical professional counselor, licensed |
17 | | marriage and family therapist, licensed speech-language |
18 | | pathologist, or other licensed or certified professional at a |
19 | | program licensed pursuant to the Substance Use Disorder Act up |
20 | | to the limits of coverage, provided (i) the disorder or |
21 | | condition treated is covered by the policy, and (ii) the |
22 | | physician, licensed psychologist, licensed clinical social |
23 | | worker, licensed clinical professional counselor, licensed |
24 | | marriage and family therapist, licensed speech-language |
25 | | pathologist, or other licensed or certified professional at a |
26 | | program licensed pursuant to the Substance Use Disorder Act is |
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1 | | authorized to provide said services under the statutes of this |
2 | | State and in accordance with accepted principles of his or her |
3 | | profession. |
4 | | (3) Insofar as this Section applies solely to licensed |
5 | | clinical social workers, licensed clinical professional |
6 | | counselors, licensed marriage and family therapists, licensed |
7 | | speech-language pathologists, and other licensed or certified |
8 | | professionals at programs licensed pursuant to the Substance |
9 | | Use Disorder Act, those persons who may provide services to |
10 | | individuals shall do so after the licensed clinical social |
11 | | worker, licensed clinical professional counselor, licensed |
12 | | marriage and family therapist, licensed speech-language |
13 | | pathologist, or other licensed or certified professional at a |
14 | | program licensed pursuant to the Substance Use Disorder Act |
15 | | has informed the patient of the desirability of the patient |
16 | | conferring with the patient's primary care physician. |
17 | | (4) "Mental, emotional, nervous, or substance use disorder |
18 | | or condition" means a condition or disorder that involves a |
19 | | mental health condition or substance use disorder that falls |
20 | | under any of the diagnostic categories listed in the mental |
21 | | and behavioral disorders chapter of the current edition of the |
22 | | World Health Organization's International Classification of |
23 | | Disease or that is listed in the most recent version of the |
24 | | American Psychiatric Association's Diagnostic and Statistical |
25 | | Manual of Mental Disorders. "Mental, emotional, nervous, or |
26 | | substance use disorder or condition" includes any mental |
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1 | | health condition that occurs during pregnancy or during the |
2 | | postpartum period and includes, but is not limited to, |
3 | | postpartum depression. |
4 | | (5) Medically necessary treatment and medical necessity |
5 | | determinations shall be interpreted and made in a manner that |
6 | | is 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 |
12 | | consistent with the parity requirements of Section 370c.1 of |
13 | | this Code, the reimbursing insurer that amends, delivers, |
14 | | issues, or renews a group or individual policy of accident and |
15 | | health insurance, a qualified health plan offered through the |
16 | | health insurance marketplace, or a provider of treatment of |
17 | | mental, emotional, nervous, or substance use disorders or |
18 | | conditions shall furnish medical records or other necessary |
19 | | data that substantiate that initial or continued treatment is |
20 | | at all times medically necessary. An insurer shall provide a |
21 | | mechanism for the timely review by a provider holding the same |
22 | | license and practicing in the same specialty as the patient's |
23 | | provider, who is unaffiliated with the insurer, jointly |
24 | | selected by the patient (or the patient's next of kin or legal |
25 | | representative if the patient is unable to act for himself or |
26 | | herself), the patient's provider, and the insurer in the event |
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1 | | of a dispute between the insurer and patient's provider |
2 | | regarding the medical necessity of a treatment proposed by a |
3 | | patient's provider. If the reviewing provider determines the |
4 | | treatment to be medically necessary, the insurer shall provide |
5 | | reimbursement for the treatment. Future contractual or |
6 | | employment actions by the insurer regarding the patient's |
7 | | provider may not be based on the provider's participation in |
8 | | this procedure. Nothing prevents the insured from agreeing in |
9 | | writing to continue treatment at his or her expense. When |
10 | | making a determination of the medical necessity for a |
11 | | treatment modality for mental, emotional, nervous, or |
12 | | substance use disorders or conditions, an insurer must make |
13 | | the determination in a manner that is consistent with the |
14 | | manner used to make that determination with respect to other |
15 | | diseases or illnesses covered under the policy, including an |
16 | | appeals process. Medical necessity determinations for |
17 | | substance use disorders shall be made in accordance with |
18 | | appropriate patient placement criteria established by the |
19 | | American Society of Addiction Medicine. No additional criteria |
20 | | may be used to make medical necessity determinations for |
21 | | substance use disorders. |
22 | | (4) A group health benefit plan amended, delivered, |
23 | | issued, or renewed on or after January 1, 2019 (the effective |
24 | | date of Public Act 100-1024) or an individual policy of |
25 | | accident and health insurance or a qualified health plan |
26 | | offered through the health insurance marketplace amended, |
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1 | | delivered, issued, or renewed on or after January 1, 2019 (the |
2 | | effective 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 |
26 | | individual policy of accident and health insurance or a |
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1 | | qualified health plan offered through the health insurance |
2 | | marketplace may not count toward the number of outpatient |
3 | | visits required to be covered under this Section an outpatient |
4 | | visit for the purpose of medication management and shall cover |
5 | | the outpatient visits under the same terms and conditions as |
6 | | it covers outpatient visits for the treatment of physical |
7 | | illness. |
8 | | (5.5) An individual or group health benefit plan amended, |
9 | | delivered, issued, or renewed on or after September 9, 2015 |
10 | | (the effective date of Public Act 99-480) shall offer coverage |
11 | | for medically necessary acute treatment services and medically |
12 | | necessary clinical stabilization services. The treating |
13 | | provider shall base all treatment recommendations and the |
14 | | health benefit plan shall base all medical necessity |
15 | | determinations for substance use disorders in accordance with |
16 | | the most current edition of the Treatment Criteria for |
17 | | Addictive, Substance-Related, and Co-Occurring Conditions |
18 | | established by the American Society of Addiction Medicine. The |
19 | | treating provider shall base all treatment recommendations and |
20 | | the health benefit plan shall base all medical necessity |
21 | | determinations for medication-assisted treatment in accordance |
22 | | with the most current Treatment Criteria for Addictive, |
23 | | Substance-Related, and Co-Occurring Conditions established by |
24 | | the American Society of Addiction Medicine. |
25 | | As used in this subsection: |
26 | | "Acute treatment services" means 24-hour medically |
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1 | | supervised addiction treatment that provides evaluation and |
2 | | withdrawal management and may include biopsychosocial |
3 | | assessment, individual and group counseling, psychoeducational |
4 | | groups, and discharge planning. |
5 | | "Clinical stabilization services" means 24-hour treatment, |
6 | | usually following acute treatment services for substance |
7 | | abuse, which may include intensive education and counseling |
8 | | regarding the nature of addiction and its consequences, |
9 | | relapse prevention, outreach to families and significant |
10 | | others, and aftercare planning for individuals beginning to |
11 | | engage in recovery from addiction. |
12 | | (6) An issuer of a group health benefit plan may provide or |
13 | | offer coverage required under this Section through a managed |
14 | | care plan. |
15 | | (6.5) An individual or group health benefit plan amended, |
16 | | delivered, issued, or renewed on or after January 1, 2019 (the |
17 | | effective 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 , |
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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. |
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1 | | (7) (Blank). |
2 | | (8) (Blank). |
3 | | (9) With respect to all mental, emotional, nervous, or |
4 | | substance use disorders or conditions, coverage for inpatient |
5 | | treatment shall include coverage for treatment in a |
6 | | residential treatment center certified or licensed by the |
7 | | Department of Public Health or the Department of Human |
8 | | Services. |
9 | | (c) This Section shall not be interpreted to require |
10 | | coverage for speech therapy or other habilitative services for |
11 | | those individuals covered under Section 356z.15 of this Code. |
12 | | (d) With respect to a group or individual policy of |
13 | | accident and health insurance or a qualified health plan |
14 | | offered through the health insurance marketplace, the |
15 | | Department and, with respect to medical assistance, the |
16 | | Department of Healthcare and Family Services shall each |
17 | | enforce the requirements of this Section and Sections 356z.23 |
18 | | and 370c.1 of this Code, the Paul Wellstone and Pete Domenici |
19 | | Mental Health Parity and Addiction Equity Act of 2008, 42 |
20 | | U.S.C. 18031(j), and any amendments to, and federal guidance |
21 | | or regulations issued under, those Acts, including, but not |
22 | | limited to, final regulations issued under the Paul Wellstone |
23 | | and Pete Domenici Mental Health Parity and Addiction Equity |
24 | | Act of 2008 and final regulations applying the Paul Wellstone |
25 | | and Pete Domenici Mental Health Parity and Addiction Equity |
26 | | Act of 2008 to Medicaid managed care organizations, the |
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1 | | Children's Health Insurance Program, and alternative benefit |
2 | | plans. Specifically, the Department and the Department of |
3 | | Healthcare 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, |
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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 |
7 | | market conduct examinations and audits shall be made public. |
8 | | The Director may adopt rules to effectuate any provisions |
9 | | of the Paul Wellstone and Pete Domenici Mental Health Parity |
10 | | and Addiction Equity Act of 2008 that relate to the business of |
11 | | insurance. |
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 |
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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 |
12 | | health insurance" and "group health benefit plan" includes (1) |
13 | | State-regulated employer-sponsored group health insurance |
14 | | plans written in Illinois or which purport to provide coverage |
15 | | for a resident of this State; and (2) State employee health |
16 | | plans. |
17 | | (g) (1) As used in this subsection: |
18 | | "Benefits", with respect to insurers, means the benefits |
19 | | provided for treatment services for inpatient and outpatient |
20 | | treatment of substance use disorders or conditions at American |
21 | | Society 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 |
25 | | Residential), 3.5 (Clinically Managed High-Intensity |
26 | | Residential), and 3.7 (Medically Monitored Intensive |
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1 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. |
2 | | "Benefits", with respect to managed care organizations, |
3 | | means the benefits provided for treatment services for |
4 | | inpatient and outpatient treatment of substance use disorders |
5 | | or conditions at American Society of Addiction Medicine levels |
6 | | of treatment 2.1 (Intensive Outpatient), 2.5 (Partial |
7 | | Hospitalization), 3.5 (Clinically Managed High-Intensity |
8 | | Residential), and 3.7 (Medically Monitored Intensive |
9 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. |
10 | | "Substance use disorder treatment provider or facility" |
11 | | means a licensed physician, licensed psychologist, licensed |
12 | | psychiatrist, licensed advanced practice registered nurse, or |
13 | | licensed, certified, or otherwise State-approved facility or |
14 | | provider of substance use disorder treatment. |
15 | | (2) A group health insurance policy, an individual health |
16 | | benefit plan, or qualified health plan that is offered through |
17 | | the health insurance marketplace, small employer group health |
18 | | plan, and large employer group health plan that is amended, |
19 | | delivered, issued, executed, or renewed in this State, or |
20 | | approved for issuance or renewal in this State, on or after |
21 | | January 1, 2019 (the effective date of Public Act 100-1023) |
22 | | shall comply with the requirements of this Section and Section |
23 | | 370c.1. The services for the treatment and the ongoing |
24 | | assessment of the patient's progress in treatment shall follow |
25 | | the requirements of 77 Ill. Adm. Code 2060. |
26 | | (3) Prior authorization shall not be utilized for the |
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1 | | benefits under this subsection. The substance use disorder |
2 | | treatment provider or facility shall notify the insurer of the |
3 | | initiation of treatment. For an insurer that is not a managed |
4 | | care organization, the substance use disorder treatment |
5 | | provider or facility notification shall occur for the |
6 | | initiation of treatment of the covered person within 2 |
7 | | business days. For managed care organizations, the substance |
8 | | use disorder treatment provider or facility notification shall |
9 | | occur in accordance with the protocol set forth in the |
10 | | provider agreement for initiation of treatment within 24 |
11 | | hours. If the managed care organization is not capable of |
12 | | accepting the notification in accordance with the contractual |
13 | | protocol during the 24-hour period following admission, the |
14 | | substance use disorder treatment provider or facility shall |
15 | | have one additional business day to provide the notification |
16 | | to the appropriate managed care organization. Treatment plans |
17 | | shall be developed in accordance with the requirements and |
18 | | timeframes established in 77 Ill. Adm. Code 2060. If the |
19 | | substance use disorder treatment provider or facility fails to |
20 | | notify the insurer of the initiation of treatment in |
21 | | accordance with these provisions, the insurer may follow its |
22 | | normal prior authorization processes. |
23 | | (4) For an insurer that is not a managed care |
24 | | organization, if an insurer determines that benefits are no |
25 | | longer medically necessary, the insurer shall notify the |
26 | | covered person, the covered person's authorized |
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1 | | representative, if any, and the covered person's health care |
2 | | provider in writing of the covered person's right to request |
3 | | an external review pursuant to the Health Carrier External |
4 | | Review Act. The notification shall occur within 24 hours |
5 | | following the adverse determination. |
6 | | Pursuant to the requirements of the Health Carrier |
7 | | External Review Act, the covered person or the covered |
8 | | person's authorized representative may request an expedited |
9 | | external review. An expedited external review may not occur if |
10 | | the substance use disorder treatment provider or facility |
11 | | determines that continued treatment is no longer medically |
12 | | necessary. |
13 | | If an expedited external review request meets the criteria |
14 | | of the Health Carrier External Review Act, an independent |
15 | | review organization shall make a final determination of |
16 | | medical necessity within 72 hours. If an independent review |
17 | | organization upholds an adverse determination, an insurer |
18 | | shall remain responsible to provide coverage of benefits |
19 | | through the day following the determination of the independent |
20 | | review organization. A decision to reverse an adverse |
21 | | determination shall comply with the Health Carrier External |
22 | | Review Act. |
23 | | (5) The substance use disorder treatment provider or |
24 | | facility shall provide the insurer with 7 business days' |
25 | | advance notice of the planned discharge of the patient from |
26 | | the substance use disorder treatment provider or facility and |
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1 | | notice on the day that the patient is discharged from the |
2 | | substance use disorder treatment provider or facility. |
3 | | (6) The benefits required by this subsection shall be |
4 | | provided to all covered persons with a diagnosis of substance |
5 | | use disorder or conditions. The presence of additional related |
6 | | or unrelated diagnoses shall not be a basis to reduce or deny |
7 | | the benefits required by this subsection. |
8 | | (7) Nothing in this subsection shall be construed to |
9 | | require an insurer to provide coverage for any of the benefits |
10 | | in this subsection. |
11 | | (h) As used in this Section: |
12 | | "Generally accepted standards of mental, emotional, |
13 | | nervous, or substance use disorder or condition care" means |
14 | | standards of care and clinical practice that are generally |
15 | | recognized by health care providers practicing in relevant |
16 | | clinical specialties such as psychiatry, psychology, clinical |
17 | | sociology, social work, addiction medicine and counseling, and |
18 | | behavioral health treatment. Valid, evidence-based sources |
19 | | reflecting generally accepted standards of mental, emotional, |
20 | | nervous, or substance use disorder or condition care include |
21 | | peer-reviewed scientific studies and medical literature, |
22 | | recommendations of nonprofit health care provider professional |
23 | | associations and specialty societies, including, but not |
24 | | limited to, patient placement criteria and clinical practice |
25 | | guidelines, recommendations of federal government agencies, |
26 | | and drug labeling approved by the United States Food and Drug |
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1 | | Administration. |
2 | | "Medically necessary treatment of mental, emotional, |
3 | | nervous, or substance use disorders or conditions" means a |
4 | | service or product addressing the specific needs of that |
5 | | patient, for the purpose of screening, preventing, diagnosing, |
6 | | managing, or treating an illness, injury, or condition or its |
7 | | symptoms and comorbidities, including minimizing the |
8 | | progression of an illness, injury, or condition or its |
9 | | symptoms and comorbidities in a manner that is all of the |
10 | | following: |
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. |
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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 |
9 | | criteria or any criteria, standards, protocols, or guidelines |
10 | | used by an insurer to conduct utilization review. |
11 | | (i)(1) Every insurer that amends, delivers, issues, or |
12 | | renews a group or individual policy of accident and health |
13 | | insurance or a qualified health plan offered through the |
14 | | health insurance marketplace in this State and Medicaid |
15 | | managed care organizations providing coverage for hospital or |
16 | | medical treatment on or after January 1, 2023 shall, pursuant |
17 | | to subsections (h) through (s), provide coverage for medically |
18 | | necessary treatment of mental, emotional, nervous, or |
19 | | substance use disorders or conditions. |
20 | | (2) An insurer shall not set a specific limit on the |
21 | | duration of benefits or coverage of medically necessary |
22 | | treatment of mental, emotional, nervous, or substance use |
23 | | disorders or conditions or limit coverage only to alleviation |
24 | | of the insured's current symptoms. |
25 | | (3) All medical necessity determinations made by the |
26 | | insurer concerning service intensity, level of care placement, |
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1 | | continued stay, and transfer or discharge of insureds |
2 | | diagnosed with mental, emotional, nervous, or substance use |
3 | | disorders or conditions shall be conducted in accordance with |
4 | | the requirements of subsections (k) through (u). |
5 | | (4) An insurer that authorizes a specific type of |
6 | | treatment by a provider pursuant to this Section shall not |
7 | | rescind or modify the authorization after that provider |
8 | | renders the health care service in good faith and pursuant to |
9 | | this authorization for any reason, including, but not limited |
10 | | to, the insurer's subsequent cancellation or modification of |
11 | | the insured's or policyholder's contract, or the insured's or |
12 | | policyholder's eligibility. Nothing in this Section shall |
13 | | require the insurer to cover a treatment when the |
14 | | authorization was granted based on a material |
15 | | misrepresentation by the insured, the policyholder, or the |
16 | | provider. Nothing in this Section shall require Medicaid |
17 | | managed care organizations to pay for services if the |
18 | | individual was not eligible for Medicaid at the time the |
19 | | service was rendered. Nothing in this Section shall require an |
20 | | insurer to pay for services if the individual was not the |
21 | | insurer's enrollee at the time services were rendered. As used |
22 | | in this paragraph, "material" means a fact or situation that |
23 | | is not merely technical in nature and results in or could |
24 | | result in a substantial change in the situation. |
25 | | (j) An insurer shall not limit benefits or coverage for |
26 | | medically necessary services on the basis that those services |
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1 | | should be or could be covered by a public entitlement program, |
2 | | including, but not limited to, special education or an |
3 | | individualized education program, Medicaid, Medicare, |
4 | | Supplemental Security Income, or Social Security Disability |
5 | | Insurance, and shall not include or enforce a contract term |
6 | | that excludes otherwise covered benefits on the basis that |
7 | | those services should be or could be covered by a public |
8 | | entitlement program. Nothing in this subsection shall be |
9 | | construed to require an insurer to cover benefits that have |
10 | | been authorized and provided for a covered person by a public |
11 | | entitlement program. Medicaid managed care organizations are |
12 | | not subject to this subsection. |
13 | | (k) An insurer shall base any medical necessity |
14 | | determination or the utilization review criteria that the |
15 | | insurer, and any entity acting on the insurer's behalf, |
16 | | applies to determine the medical necessity of health care |
17 | | services and benefits for the diagnosis, prevention, and |
18 | | treatment of mental, emotional, nervous, or substance use |
19 | | disorders or conditions on current generally accepted |
20 | | standards of mental, emotional, nervous, or substance use |
21 | | disorder or condition care. All denials and appeals shall be |
22 | | reviewed by a professional with experience or expertise |
23 | | comparable to the provider requesting the authorization. |
24 | | (l) For medical necessity determinations relating to level |
25 | | of care placement, continued stay, and transfer or discharge |
26 | | of insureds diagnosed with mental, emotional, and nervous |
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1 | | disorders or conditions, an insurer shall apply the patient |
2 | | placement criteria set forth in the most recent version of the |
3 | | treatment criteria developed by an unaffiliated nonprofit |
4 | | professional association for the relevant clinical specialty |
5 | | or, for Medicaid managed care organizations, patient placement |
6 | | criteria determined by the Department of Healthcare and Family |
7 | | Services that are consistent with generally accepted standards |
8 | | of mental, emotional, nervous or substance use disorder or |
9 | | condition care. Pursuant to subsection (b), in conducting |
10 | | utilization review of all covered services and benefits for |
11 | | the diagnosis, prevention, and treatment of substance use |
12 | | disorders an insurer shall use the most recent edition of the |
13 | | patient placement criteria established by the American Society |
14 | | of Addiction Medicine. |
15 | | (m) For medical necessity determinations relating to level |
16 | | of care placement, continued stay, and transfer or discharge |
17 | | that are within the scope of the sources specified in |
18 | | subsection (l), an insurer shall not apply different, |
19 | | additional, conflicting, or more restrictive utilization |
20 | | review criteria than the criteria set forth in those sources. |
21 | | For all level of care placement decisions, the insurer shall |
22 | | authorize placement at the level of care consistent with the |
23 | | assessment of the insured using the relevant patient placement |
24 | | criteria as specified in subsection (l). If that level of |
25 | | placement is not available, the insurer shall authorize the |
26 | | next higher level of care. In the event of disagreement, the |
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1 | | insurer shall provide full detail of its assessment using the |
2 | | relevant criteria as specified in subsection (l) to the |
3 | | provider of the service and the patient. |
4 | | Nothing in this subsection or subsection (l) prohibits an |
5 | | insurer from applying utilization review criteria that were |
6 | | developed in accordance with subsection (k) to health care |
7 | | services and benefits for mental, emotional, and nervous |
8 | | disorders or conditions that are not related to medical |
9 | | necessity determinations for level of care placement, |
10 | | continued stay, and transfer or discharge. If an insurer |
11 | | purchases or licenses utilization review criteria pursuant to |
12 | | this subsection, the insurer shall verify and document before |
13 | | use that the criteria were developed in accordance with |
14 | | subsection (k). |
15 | | (n) In conducting utilization review that is outside the |
16 | | scope of the criteria as specified in subsection (l) or |
17 | | relates to the advancements in technology or in the types or |
18 | | levels of care that are not addressed in the most recent |
19 | | versions of the sources specified in subsection (l), an |
20 | | insurer shall conduct utilization review in accordance with |
21 | | subsection (k). |
22 | | (o) This Section does not in any way limit the rights of a |
23 | | patient under the Medical Patient Rights Act. |
24 | | (p) This Section does not in any way limit early and |
25 | | periodic screening, diagnostic, and treatment benefits as |
26 | | defined under 42 U.S.C. 1396d(r). |
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1 | | (q) To ensure the proper use of the criteria described in |
2 | | subsection (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 |
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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 |
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1 | | in subsection (k) of Section 370c.1. |
2 | | (r) This Section applies to all health care services and |
3 | | benefits for the diagnosis, prevention, and treatment of |
4 | | mental, emotional, nervous, or substance use disorders or |
5 | | conditions covered by an insurance policy, including |
6 | | prescription drugs. |
7 | | (s) This Section applies to an insurer that amends, |
8 | | delivers, issues, or renews a group or individual policy of |
9 | | accident and health insurance or a qualified health plan |
10 | | offered through the health insurance marketplace in this State |
11 | | providing coverage for hospital or medical treatment and |
12 | | conducts utilization review as defined in this Section, |
13 | | including Medicaid managed care organizations, and any entity |
14 | | or contracting provider that performs utilization review or |
15 | | utilization management functions on an insurer's behalf. |
16 | | (t) If the Director determines that an insurer has |
17 | | violated this Section, the Director may, after appropriate |
18 | | notice and opportunity for hearing, by order, assess a civil |
19 | | penalty between $1,000 and $5,000 for each violation. Moneys |
20 | | collected from penalties shall be deposited into the Parity |
21 | | Advancement Fund established in subsection (i) of Section |
22 | | 370c.1. |
23 | | (u) An insurer shall not adopt, impose, or enforce terms |
24 | | in its policies or provider agreements, in writing or in |
25 | | operation, that undermine, alter, or conflict with the |
26 | | requirements of this Section. |
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1 | | (v) The provisions of this Section are severable. If any |
2 | | provision of this Section or its application is held invalid, |
3 | | that invalidity shall not affect other provisions or |
4 | | applications that can be given effect without the invalid |
5 | | provision or application. |
6 | | (w) Beginning January 1, 2026, coverage for inpatient |
7 | | mental health treatment at participating hospitals shall |
8 | | comply 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 |
25 | | shall require the medical assistance program under Article V |
26 | | of the Illinois Public Aid Code to violate any applicable |
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1 | | federal laws, regulations, or grant requirements or any State |
2 | | or federal consent decrees. Nothing in subsection (w) shall |
3 | | prevent the Department of Healthcare and Family Services from |
4 | | requiring a health care provider to use specified level of |
5 | | care, admission, continued stay, or discharge criteria, |
6 | | including, but not limited to, those under Section 5-5.23 of |
7 | | the Illinois Public Aid Code, as long as the Department of |
8 | | Healthcare and Family Services does not require a health care |
9 | | provider to seek prior authorization or concurrent review from |
10 | | the Department of Healthcare and Family Services, a Medicaid |
11 | | managed care organization, or a utilization review |
12 | | organization under the circumstances expressly prohibited by |
13 | | subsection (w). |
14 | | (y) Children's Mental Health. Nothing in this Section |
15 | | shall suspend the screening and assessment requirements for |
16 | | mental health services for children participating in the |
17 | | State's medical assistance program as required in Section |
18 | | 5-5.23 of the Illinois Public Aid Code. |
19 | | (Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22; |
20 | | 102-813, eff. 5-13-22; 103-426, eff. 8-4-23.) |
21 | | Section 6-10. The Managed Care Reform and Patient Rights |
22 | | Act is amended by changing Sections 10, 45.1, and 85 and by |
23 | | adding Section 87 as follows: |
24 | | (215 ILCS 134/10) |
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1 | | Sec. 10. Definitions. In this Act: |
2 | | "Adverse determination" means a determination by a health |
3 | | care plan under Section 45 or by a utilization review program |
4 | | under Section 85 that a health care service is not medically |
5 | | necessary. |
6 | | "Clinical peer" means a health care professional who is in |
7 | | the same profession and the same or similar specialty as the |
8 | | health care provider who typically manages the medical |
9 | | condition, procedures, or treatment under review. |
10 | | "Department" means the Department of Insurance. |
11 | | "Emergency medical condition" means a medical condition |
12 | | manifesting itself by acute symptoms of sufficient severity, |
13 | | regardless of the final diagnosis given, such that a prudent |
14 | | layperson, who possesses an average knowledge of health and |
15 | | medicine, could reasonably expect the absence of immediate |
16 | | medical 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 |
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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 |
5 | | screening examination and evaluation by a physician licensed |
6 | | to practice medicine in all its branches, or to the extent |
7 | | permitted by applicable laws, by other appropriately licensed |
8 | | personnel under the supervision of or in collaboration with a |
9 | | physician licensed to practice medicine in all its branches to |
10 | | determine whether the need for emergency services exists. |
11 | | "Emergency services" means, with respect to an enrollee of |
12 | | a health care plan, transportation services, including but not |
13 | | limited to ambulance services, and covered inpatient and |
14 | | outpatient hospital services furnished by a provider qualified |
15 | | to furnish those services that are needed to evaluate or |
16 | | stabilize an emergency medical condition. "Emergency services" |
17 | | does not refer to post-stabilization medical services. |
18 | | "Enrollee" means any person and his or her dependents |
19 | | enrolled in or covered by a health care plan. |
20 | | "Generally accepted standards of care" means standards of |
21 | | care and clinical practice that are generally recognized by |
22 | | health care providers practicing in relevant clinical |
23 | | specialties for the illness, injury, or condition or its |
24 | | symptoms and comorbidities. Valid, evidence-based sources |
25 | | reflecting generally accepted standards of care include |
26 | | peer-reviewed scientific studies and medical literature, |
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1 | | recommendations of nonprofit health care provider professional |
2 | | associations and specialty societies, including, but not |
3 | | limited to, patient placement criteria and clinical practice |
4 | | guidelines, recommendations of federal government agencies, |
5 | | and drug labeling approved by the United States Food and Drug |
6 | | Administration. |
7 | | "Health care plan" means a plan, including, but not |
8 | | limited to, a health maintenance organization, a managed care |
9 | | community network as defined in the Illinois Public Aid Code, |
10 | | or an accountable care entity as defined in the Illinois |
11 | | Public Aid Code that receives capitated payments to cover |
12 | | medical services from the Department of Healthcare and Family |
13 | | Services, that establishes, operates, or maintains a network |
14 | | of health care providers that has entered into an agreement |
15 | | with the plan to provide health care services to enrollees to |
16 | | whom the plan has the ultimate obligation to arrange for the |
17 | | provision of or payment for services through organizational |
18 | | arrangements for ongoing quality assurance, utilization review |
19 | | programs, or dispute resolution. Nothing in this definition |
20 | | shall be construed to mean that an independent practice |
21 | | association or a physician hospital organization that |
22 | | subcontracts with a health care plan is, for purposes of that |
23 | | subcontract, a health care plan. |
24 | | For purposes of this definition, "health care plan" shall |
25 | | not include the following: |
26 | | (1) indemnity health insurance policies including |
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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 |
20 | | professional nurse, or other individual appropriately licensed |
21 | | or registered to provide health care services. |
22 | | "Health care provider" means any physician, hospital |
23 | | facility, facility licensed under the Nursing Home Care Act, |
24 | | long-term care facility as defined in Section 1-113 of the |
25 | | Nursing Home Care Act, or other person that is licensed or |
26 | | otherwise authorized to deliver health care services. Nothing |
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1 | | in this Act shall be construed to define Independent Practice |
2 | | Associations or Physician-Hospital Organizations as health |
3 | | care providers. |
4 | | "Health care services" means any services included in the |
5 | | furnishing to any individual of medical care, or the |
6 | | hospitalization incident to the furnishing of such care, as |
7 | | well as the furnishing to any person of any and all other |
8 | | services for the purpose of preventing, alleviating, curing, |
9 | | or healing human illness or injury including behavioral |
10 | | health, mental health, home health, and pharmaceutical |
11 | | services and products. |
12 | | "Medical director" means a physician licensed in any state |
13 | | to practice medicine in all its branches appointed by a health |
14 | | care plan. |
15 | | "Medically necessary" means that a service or product |
16 | | addresses the specific needs of a patient for the purpose of |
17 | | screening, preventing, diagnosing, managing, or treating an |
18 | | illness, injury, or condition or its symptoms and |
19 | | comorbidities, including minimizing the progression of an |
20 | | illness, injury, or condition or its symptoms and |
21 | | comorbidities, 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 |
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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, |
5 | | limited liability company, sole proprietorship, or any other |
6 | | legal entity. |
7 | | "Physician" means a person licensed under the Medical |
8 | | Practice Act of 1987. |
9 | | "Post-stabilization medical services" means health care |
10 | | services provided to an enrollee that are furnished in a |
11 | | licensed hospital by a provider that is qualified to furnish |
12 | | such services, and determined to be medically necessary and |
13 | | directly related to the emergency medical condition following |
14 | | stabilization. |
15 | | "Stabilization" means, with respect to an emergency |
16 | | medical condition, to provide such medical treatment of the |
17 | | condition as may be necessary to assure, within reasonable |
18 | | medical probability, that no material deterioration of the |
19 | | condition is likely to result. |
20 | | "Step therapy requirement" means a fail-first utilization |
21 | | review or formulary requirement that specifies, as a condition |
22 | | of coverage under a health care plan, the order in which |
23 | | certain health care services must be used to treat or manage an |
24 | | enrollee's health condition. |
25 | | "Utilization review" means the evaluation of the medical |
26 | | necessity, appropriateness, and efficiency of the use of |
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1 | | health 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 |
18 | | criteria or any criteria, standards, protocols, or guidelines |
19 | | used by a utilization review program to conduct utilization |
20 | | review . |
21 | | "Utilization review program" means a program established |
22 | | by 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 |
2 | | after January 1, 2018 (the effective date of Public Act |
3 | | 99-761), every insurer licensed in this State to sell a policy |
4 | | of group or individual accident and health insurance or a |
5 | | health benefits plan shall establish and maintain a medical |
6 | | exceptions process that allows covered persons or their |
7 | | authorized representatives to request any clinically |
8 | | appropriate prescription drug when (1) the drug is not covered |
9 | | based on the health benefit plan's formulary; (2) the health |
10 | | benefit plan is discontinuing coverage of the drug on the |
11 | | plan's formulary for reasons other than safety or other than |
12 | | because the prescription drug has been withdrawn from the |
13 | | market by the drug's manufacturer; (3) (blank) the |
14 | | prescription drug alternatives required to be used in |
15 | | accordance with a step therapy requirement (A) has been |
16 | | ineffective in the treatment of the enrollee's disease or |
17 | | medical condition or, based on both sound clinical evidence |
18 | | and medical and scientific evidence, the known relevant |
19 | | physical or mental characteristics of the enrollee, and the |
20 | | known characteristics of the drug regimen, is likely to be |
21 | | ineffective or adversely affect the drug's effectiveness or |
22 | | patient compliance or (B) has caused or, based on sound |
23 | | medical evidence, is likely to cause an adverse reaction or |
24 | | harm to the enrollee ; or (4) the number of doses available |
25 | | under a dose restriction for the prescription drug (A) has |
26 | | been ineffective in the treatment of the enrollee's disease or |
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1 | | medical condition or (B) based on both sound clinical evidence |
2 | | and medical and scientific evidence, the known relevant |
3 | | physical and mental characteristics of the enrollee, and known |
4 | | characteristics of the drug regimen, is likely to be |
5 | | ineffective or adversely affect the drug's effective or |
6 | | patient compliance. |
7 | | (b) The health carrier's established medical exceptions |
8 | | procedures 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. |
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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 |
12 | | shall 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 |
23 | | insurer, health plan, utilization review organization, or |
24 | | other entity shall authorize the coverage for the drug |
25 | | prescribed by the enrollee's treating health care provider, to |
26 | | the extent the prescribed drug is a covered drug under the |
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1 | | policy or contract up to the quantity covered. |
2 | | (e) Any approval of a medical exception request made |
3 | | pursuant to this Section shall be honored for 12 months |
4 | | following the date of the approval or until renewal of the |
5 | | plan. |
6 | | (f) Notwithstanding any other provision of this Section, |
7 | | nothing in this Section shall be interpreted or implemented in |
8 | | a manner not consistent with the federal Patient Protection |
9 | | and Affordable Care Act (Public Law 111-148), as amended by |
10 | | the federal Health Care and Education Reconciliation Act of |
11 | | 2010 (Public Law 111-152), and any amendments thereto, or |
12 | | regulations or guidance issued under those Acts. |
13 | | (g) Nothing in this Section shall require or authorize the |
14 | | State agency responsible for the administration of the medical |
15 | | assistance program established under the Illinois Public Aid |
16 | | Code to approve, supply, or cover prescription drugs pursuant |
17 | | to 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 |
22 | | this State unless once every 2 years the person registers the |
23 | | utilization review program with the Department and certifies |
24 | | compliance with the Health Utilization Management Standards of |
25 | | the American Accreditation Healthcare Commission (URAC) |
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1 | | sufficient to achieve American Accreditation Healthcare |
2 | | Commission (URAC) accreditation or submits evidence of |
3 | | accreditation by the American Accreditation Healthcare |
4 | | Commission (URAC) for its Health Utilization Management |
5 | | Standards. Nothing in this Act shall be construed to require a |
6 | | health care plan or its subcontractors to become American |
7 | | Accreditation Healthcare Commission (URAC) accredited. |
8 | | (b) In addition, the Director of the Department, in |
9 | | consultation with the Director of the Department of Public |
10 | | Health, may certify alternative utilization review standards |
11 | | of national accreditation organizations or entities in order |
12 | | for plans to comply with this Section. Any alternative |
13 | | utilization review standards shall meet or exceed those |
14 | | standards required under subsection (a). |
15 | | (b-5) The Department shall recognize the Accreditation |
16 | | Association for Ambulatory Health Care among the list of |
17 | | accreditors from which utilization organizations may receive |
18 | | accreditation and qualify for reduced registration and renewal |
19 | | fees. |
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 |
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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 |
7 | | entity from contractually requiring an entity designated in |
8 | | item (3) of this subsection to adhere to the utilization |
9 | | review program requirements of this Act. |
10 | | (d) This registration shall include submission of all of |
11 | | the following information regarding utilization review program |
12 | | activities: |
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 |
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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 |
4 | | procedures for assuring that patient-specific information |
5 | | obtained 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 |
12 | | does not provide information to allow identification of |
13 | | individual 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 |
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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 |
13 | | program is not in compliance with this Section, the Department |
14 | | shall issue a corrective action plan and allow a reasonable |
15 | | amount of time for compliance with the plan. If the |
16 | | utilization review program does not come into compliance, the |
17 | | Department may issue a cease and desist order. Before issuing |
18 | | a cease and desist order under this Section, the Department |
19 | | shall provide the utilization review program with a written |
20 | | notice of the reasons for the order and allow a reasonable |
21 | | amount of time to supply additional information demonstrating |
22 | | compliance with requirements of this Section and to request a |
23 | | hearing. The hearing notice shall be sent by certified mail, |
24 | | return receipt requested, and the hearing shall be conducted |
25 | | in accordance with the Illinois Administrative Procedure Act. |
26 | | (g) A utilization review program subject to a corrective |
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1 | | action may continue to conduct business until a final decision |
2 | | has been issued by the Department. |
3 | | (h) Any adverse determination made by a health care plan |
4 | | or its subcontractors may be appealed in accordance with |
5 | | subsection (f) of Section 45. |
6 | | (i) The Director may by rule establish a registration fee |
7 | | for each person conducting a utilization review program. All |
8 | | fees paid to and collected by the Director under this Section |
9 | | shall be deposited into the Insurance Producer Administration |
10 | | Fund. |
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 |
14 | | criteria. |
15 | | (a) Except as provided in subsections (g) and (h), |
16 | | beginning January 1, 2027, all medical necessity |
17 | | determinations made by a utilization review program shall be |
18 | | conducted in accordance with the requirements of this Section. |
19 | | No policy, contract, certificate, or evidence of coverage |
20 | | issued to any enrollee, nor any formulary, may contain terms |
21 | | or conditions to the contrary. |
22 | | (b) A utilization review program shall base any medical |
23 | | necessity determination or the utilization review criteria |
24 | | that the program applies to determine the medical necessity of |
25 | | health care services and benefits on current generally |
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1 | | accepted standards of care. |
2 | | (c) A utilization review program shall apply the most |
3 | | recent version of the treatment criteria developed by an |
4 | | unaffiliated nonprofit professional association for the |
5 | | relevant clinical specialty or, for Medicaid managed care |
6 | | organizations, treatment criteria determined by the Department |
7 | | of Healthcare and Family Services that are not inconsistent |
8 | | with generally accepted standards of care. Nothing in this |
9 | | Section shall be construed to supersede requirements provided |
10 | | under any other State or federal law or federal regulation |
11 | | that any coverage subject to this Section be subject to |
12 | | specific utilization review criteria for a specific illness, |
13 | | level of care placement, injury, or condition or its symptoms |
14 | | and comorbidities. |
15 | | (d) For medical necessity determinations that are within |
16 | | the scope of the sources specified in subsection (c), a |
17 | | utilization review program shall not apply different, |
18 | | additional, conflicting, or more restrictive utilization |
19 | | review criteria than the criteria set forth in those sources. |
20 | | For all level of care placement decisions, the utilization |
21 | | review program or health care plan shall authorize placement |
22 | | at the level of care consistent with the assessment of the |
23 | | enrollee using the relevant patient placement criteria as |
24 | | specified in subsection (c). If that level of placement is not |
25 | | available, the utilization review program or health care plan |
26 | | shall authorize the next highest level of care. In the event of |
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1 | | disagreement, the utilization review program shall provide |
2 | | full detail of its assessment using the relevant criteria as |
3 | | specified in subsection (c) to the provider of the service and |
4 | | the patient. |
5 | | (e) In conducting utilization review that is outside the |
6 | | scope of the criteria specified in subsection (c) or that |
7 | | relates to the advancements in technology or in the types or |
8 | | levels of care that are not addressed in the most recent |
9 | | versions of the sources specified in subsection (c), a |
10 | | utilization review program shall conduct utilization review in |
11 | | accordance with subsection (b). If a utilization review |
12 | | program purchases or licenses utilization review criteria |
13 | | pursuant to this subsection, the utilization review program |
14 | | shall verify and document before use that the criteria were |
15 | | developed in accordance with subsection (b). |
16 | | (f) To ensure the proper use of utilization review |
17 | | criteria that were not developed by or that diverge from those |
18 | | developed by an unaffiliated nonprofit professional |
19 | | association for the relevant clinical specialty, every health |
20 | | care 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 |
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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 |
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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 |
18 | | care plans under contract with the Department of Healthcare |
19 | | and Family Services, no utilization review program or any |
20 | | policy, contract, certificate, evidence of coverage, or |
21 | | formulary shall impose step therapy requirements for any |
22 | | health care service, including prescription drugs. Nothing in |
23 | | this subsection prohibits a health care plan, by contract, |
24 | | written policy or procedure, or any other agreement or course |
25 | | of conduct, from requiring a pharmacist to effect |
26 | | substitutions of prescription drugs consistent with Section |
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1 | | 19.5 of the Pharmacy Practice Act, under which a pharmacist |
2 | | may substitute an interchangeable biologic for a prescribed |
3 | | biologic product, and Section 25 of the Pharmacy Practice Act, |
4 | | under which a pharmacist may select a generic drug determined |
5 | | to be therapeutically equivalent by the United States Food and |
6 | | Drug Administration and in accordance with the Illinois Food, |
7 | | Drug and Cosmetic Act. |
8 | | (h) Except for subsection (g), this Section does not apply |
9 | | to medical necessity determinations concerning service |
10 | | intensity, level of care placement, continued stay, or |
11 | | transfer or discharge of enrollees diagnosed with mental, |
12 | | emotional, nervous, or substance use disorders or conditions, |
13 | | which shall be governed by Section 370c of the Illinois |
14 | | Insurance Code. |
15 | | Section 6-15. The Health Carrier External Review Act is |
16 | | amended 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 |
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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 |
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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 |
16 | | with a particular outcome, without the use of a control group. |
17 | | "Clinical review criteria" means the written screening |
18 | | procedures, decision abstracts, clinical protocols, and |
19 | | practice guidelines used by a health carrier to determine the |
20 | | necessity and appropriateness of health care services. |
21 | | "Clinical review criteria" includes all utilization review |
22 | | criteria as defined in Section 10 of the Managed Care Reform |
23 | | and Patient Rights Act. |
24 | | "Cohort study" means a prospective evaluation of 2 groups |
25 | | of patients with only one group of patients receiving specific |
26 | | intervention. |
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1 | | "Concurrent review" means a review conducted during a |
2 | | patient's stay or course of treatment in a facility, the |
3 | | office of a health care professional, or other inpatient or |
4 | | outpatient health care setting. |
5 | | "Covered benefits" or "benefits" means those health care |
6 | | services to which a covered person is entitled under the terms |
7 | | of a health benefit plan. |
8 | | "Covered person" means a policyholder, subscriber, |
9 | | enrollee, or other individual participating in a health |
10 | | benefit plan. |
11 | | "Director" means the Director of the Department of |
12 | | Insurance. |
13 | | "Emergency medical condition" means a medical condition |
14 | | manifesting itself by acute symptoms of sufficient severity, |
15 | | including, but not limited to, severe pain, such that a |
16 | | prudent layperson who possesses an average knowledge of health |
17 | | and medicine could reasonably expect the absence of immediate |
18 | | medical 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 |
25 | | furnished or required to evaluate and treat an emergency |
26 | | medical condition. |
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1 | | "Evidence-based standard" means the conscientious, |
2 | | explicit, and judicious use of the current best evidence based |
3 | | on an overall systematic review of the research in making |
4 | | decisions about the care of individual patients. |
5 | | "Expert opinion" means a belief or an interpretation by |
6 | | specialists with experience in a specific area about the |
7 | | scientific evidence pertaining to a particular service, |
8 | | intervention, or therapy. |
9 | | "Facility" means an institution providing health care |
10 | | services or a health care setting. |
11 | | "Final adverse determination" means an adverse |
12 | | determination involving a covered benefit that has been upheld |
13 | | by a health carrier, or its designee utilization review |
14 | | organization, at the completion of the health carrier's |
15 | | internal grievance process procedures as set forth by the |
16 | | Managed Care Reform and Patient Rights Act. |
17 | | "Health benefit plan" means a policy, contract, |
18 | | certificate, plan, or agreement offered or issued by a health |
19 | | carrier to provide, deliver, arrange for, pay for, or |
20 | | reimburse any of the costs of health care services. |
21 | | "Health care provider" or "provider" means a physician, |
22 | | hospital facility, or other health care practitioner licensed, |
23 | | accredited, or certified to perform specified health care |
24 | | services consistent with State law, responsible for |
25 | | recommending health care services on behalf of a covered |
26 | | person. |
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1 | | "Health care services" means services for the diagnosis, |
2 | | prevention, treatment, cure, or relief of a health condition, |
3 | | illness, injury, or disease. |
4 | | "Health carrier" means an entity subject to the insurance |
5 | | laws and regulations of this State, or subject to the |
6 | | jurisdiction of the Director, that contracts or offers to |
7 | | contract to provide, deliver, arrange for, pay for, or |
8 | | reimburse any of the costs of health care services, including |
9 | | a sickness and accident insurance company, a health |
10 | | maintenance organization, or any other entity providing a plan |
11 | | of health insurance, health benefits, or health care services. |
12 | | "Health carrier" also means Limited Health Service |
13 | | Organizations (LHSO) and Voluntary Health Service Plans. |
14 | | "Health information" means information or data, whether |
15 | | oral or recorded in any form or medium, and personal facts or |
16 | | information 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 |
25 | | conducts independent external reviews of adverse |
26 | | determinations and final adverse determinations. |
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1 | | "Medical or scientific evidence" means evidence found in |
2 | | the 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 |
19 | | partnership, an association, a joint venture, a joint stock |
20 | | company, a trust, an unincorporated organization, any similar |
21 | | entity, or any combination of the foregoing. |
22 | | "Prospective review" means a review conducted prior to an |
23 | | admission or the provision of a health care service or a course |
24 | | of treatment in accordance with a health carrier's requirement |
25 | | that the health care service or course of treatment, in whole |
26 | | or 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 |
3 | | information; or (ii) with respect to which there is a |
4 | | reasonable basis to believe that the information could be used |
5 | | to identify an individual. |
6 | | "Randomized clinical trial" means a controlled prospective |
7 | | study of patients that have been randomized into an |
8 | | experimental group and a control group at the beginning of the |
9 | | study with only the experimental group of patients receiving a |
10 | | specific intervention, which includes study of the groups for |
11 | | variables and anticipated outcomes over time. |
12 | | "Retrospective review" means any review of a request for a |
13 | | benefit that is not a concurrent or prospective review |
14 | | request. "Retrospective review" does not include the review of |
15 | | a claim that is limited to veracity of documentation or |
16 | | accuracy of coding. |
17 | | "Utilization review" has the meaning provided by the |
18 | | Managed Care Reform and Patient Rights Act. |
19 | | "Utilization review organization" means a utilization |
20 | | review program as defined in the Managed Care Reform and |
21 | | Patient Rights Act. |
22 | | (Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12; |
23 | | 98-756, eff. 7-16-14.) |
24 | | Section 6-20. The Prior Authorization Reform Act is |
25 | | amended by changing Section 20 as follows: |
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1 | | (215 ILCS 200/20) |
2 | | Sec. 20. Disclosure and review of prior authorization |
3 | | requirements. |
4 | | (a) A health insurance issuer shall maintain a complete |
5 | | list of services for which prior authorization is required, |
6 | | including for all services where prior authorization is |
7 | | performed by an entity under contract with the health |
8 | | insurance issuer. The health insurance issuer shall publish |
9 | | this list on its public website without requiring a member of |
10 | | the general public to create any account or enter any |
11 | | credentials to access it. The list described in this |
12 | | subsection is not required to contain the clinical review |
13 | | criteria applicable to these services. |
14 | | (b) A health insurance issuer shall make any current prior |
15 | | authorization requirements and restrictions, including the |
16 | | written clinical review criteria, readily accessible and |
17 | | conspicuously posted on its website to enrollees, health care |
18 | | professionals, and health care providers. Content published by |
19 | | a third party and licensed for use by a health insurance issuer |
20 | | or its contracted utilization review organization may be made |
21 | | available through the health insurance issuer's or its |
22 | | contracted utilization review organization's secure, |
23 | | password-protected website so long as the access requirements |
24 | | of the website do not unreasonably restrict access. |
25 | | Requirements shall be described in detail, written in easily |
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1 | | understandable language, and readily available to the health |
2 | | care professional and health care provider at the point of |
3 | | care. The website shall indicate for each service subject to |
4 | | prior 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 |
5 | | failure to obtain prior authorization if the prior |
6 | | authorization requirement was not in effect on the date of |
7 | | service on the claim. |
8 | | (e) A health insurance issuer or its contracted |
9 | | utilization review organization shall not deem as incidental |
10 | | or deny supplies or health care services that are routinely |
11 | | used 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 |
17 | | implement a new prior authorization requirement or restriction |
18 | | or amend an existing requirement or restriction, the health |
19 | | insurance issuer shall provide contracted health care |
20 | | professionals and contracted health care providers of |
21 | | enrollees written notice of the new or amended requirement or |
22 | | amendment no less than 60 days before the requirement or |
23 | | restriction is implemented. The written notice may be provided |
24 | | in an electronic format, including email or facsimile, if the |
25 | | health care professional or health care provider has agreed in |
26 | | advance to receive notices electronically. The health |
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1 | | insurance issuer shall ensure that the new or amended |
2 | | requirement is not implemented unless the health insurance |
3 | | issuer's or its contracted utilization review organization's |
4 | | website has been updated to reflect the new or amended |
5 | | requirement or restriction. |
6 | | (g) Entities using prior authorization shall make |
7 | | statistics available regarding prior authorization approvals |
8 | | and denials on their website in a readily accessible format. |
9 | | The statistics must be updated annually and include all of the |
10 | | following 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 |