Sen. Robert Peters

Filed: 5/20/2024

 

 


 

 


 
10300HB5395sam002LRB103 37071 RPS 73717 a

1
AMENDMENT TO HOUSE BILL 5395

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

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

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

 

 

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1emergency rules implementing federal standards for provider
2ratios, travel time and distance, and appointment wait times
3if such standards apply to health insurance coverage regulated
4by the Department of Insurance and are more stringent than the
5State standards extant at the time the final federal standards
6are published may be adopted in accordance with Section 5-45
7by the Department of Insurance. The adoption of emergency
8rules authorized by Section 5-45 and this Section is deemed to
9be necessary for the public interest, safety, and welfare.
 
10    Section 2-10. The Network Adequacy and Transparency Act is
11amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and
12by adding Sections 35, 36, 40, 50, and 55 as follows:
 
13    (215 ILCS 124/3)
14    Sec. 3. Applicability of Act. This Act applies to an
15individual or group policy of accident and health insurance
16coverage with a network plan amended, delivered, issued, or
17renewed in this State on or after January 1, 2019. This Act
18does not apply to an individual or group policy for excepted
19benefits or short-term, limited-duration health insurance
20coverage dental or vision insurance or a limited health
21service organization with a network plan amended, delivered,
22issued, or renewed in this State on or after January 1, 2019,
23except to the extent that federal law establishes network
24adequacy and transparency standards for stand-alone dental

 

 

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1plans, which the Department shall enforce for plans amended,
2delivered, issued, or renewed on or after January 1, 2025.
3(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
 
4    (215 ILCS 124/5)
5    Sec. 5. Definitions. In this Act:
6    "Authorized representative" means a person to whom a
7beneficiary has given express written consent to represent the
8beneficiary; a person authorized by law to provide substituted
9consent for a beneficiary; or the beneficiary's treating
10provider only when the beneficiary or his or her family member
11is unable to provide consent.
12    "Beneficiary" means an individual, an enrollee, an
13insured, a participant, or any other person entitled to
14reimbursement for covered expenses of or the discounting of
15provider fees for health care services under a program in
16which the beneficiary has an incentive to utilize the services
17of a provider that has entered into an agreement or
18arrangement with an issuer insurer.
19    "Department" means the Department of Insurance.
20    "Essential community provider" has the meaning ascribed to
21that term in 45 CFR 156.235.
22    "Excepted benefits" has the meaning ascribed to that term
23in 42 U.S.C. 300gg-91(c) and implementing regulations.
24"Excepted benefits" includes individual, group, or blanket
25coverage.

 

 

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1    "Exchange" has the meaning ascribed to that term in 45 CFR
2155.20.
3    "Director" means the Director of Insurance.
4    "Family caregiver" means a relative, partner, friend, or
5neighbor who has a significant relationship with the patient
6and administers or assists the patient with activities of
7daily living, instrumental activities of daily living, or
8other medical or nursing tasks for the quality and welfare of
9that patient.
10    "Group health plan" has the meaning ascribed to that term
11in Section 5 of the Illinois Health Insurance Portability and
12Accountability Act.
13    "Health insurance coverage" has the meaning ascribed to
14that term in Section 5 of the Illinois Health Insurance
15Portability and Accountability Act. "Health insurance
16coverage" does not include any coverage or benefits under
17Medicare or under the medical assistance program established
18under Article V of the Illinois Public Aid Code.
19    "Issuer" means a "health insurance issuer" as defined in
20Section 5 of the Illinois Health Insurance Portability and
21Accountability Act.
22    "Insurer" means any entity that offers individual or group
23accident and health insurance, including, but not limited to,
24health maintenance organizations, preferred provider
25organizations, exclusive provider organizations, and other
26plan structures requiring network participation, excluding the

 

 

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

 

 

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1the disease or condition is interrupted; (2) treatment for a
2serious acute condition, defined as a disease or condition
3requiring complex ongoing care that the covered person is
4currently receiving, such as chemotherapy, radiation therapy,
5or post-operative visits, or a serious and complex condition
6as defined under 42 U.S.C. 300gg-113(b)(2); (3) a course of
7treatment for a health condition that a treating provider
8attests that discontinuing care by that provider would worsen
9the condition or interfere with anticipated outcomes; or (4)
10the third trimester of pregnancy through the post-partum
11period; (5) undergoing a course of institutional or inpatient
12care from the provider within the meaning of 42 U.S.C.
13300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective
14surgery from the provider, including receipt of preoperative
15or postoperative care from such provider with respect to such
16a surgery; (7) being determined to be terminally ill, as
17determined under 42 U.S.C. 1395x(dd)(3)(A), and receiving
18treatment for such illness from such provider; or (8) any
19other treatment of a condition or disease that requires
20repeated health care services pursuant to a plan of treatment
21by a provider because of the potential for changes in the
22therapeutic regimen or because of the potential for a
23recurrence of symptoms.
24    "Preferred provider" means any provider who has entered,
25either directly or indirectly, into an agreement with an
26employer or risk-bearing entity relating to health care

 

 

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1services that may be rendered to beneficiaries under a network
2plan.
3    "Providers" means physicians licensed to practice medicine
4in all its branches, other health care professionals,
5hospitals, or other health care institutions or facilities
6that provide health care services.
7    "Short-term, limited-duration insurance" means any type of
8accident and health insurance offered or provided within this
9State pursuant to a group or individual policy or individual
10certificate by a company, regardless of the situs state of the
11delivery of the policy, that has an expiration date specified
12in the contract that is fewer than 365 days after the original
13effective date. Regardless of the duration of coverage,
14"short-term, limited-duration insurance" does not include
15excepted benefits or any student health insurance coverage.
16    "Stand-alone dental plan" has the meaning ascribed to that
17term in 45 CFR 156.400.
18    "Telehealth" has the meaning given to that term in Section
19356z.22 of the Illinois Insurance Code.
20    "Telemedicine" has the meaning given to that term in
21Section 49.5 of the Medical Practice Act of 1987.
22    "Tiered network" means a network that identifies and
23groups some or all types of provider and facilities into
24specific groups to which different provider reimbursement,
25covered person cost-sharing or provider access requirements,
26or any combination thereof, apply for the same services.

 

 

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

 

 

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

 

 

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1        provided by the network plan;
2            (B) the ratio of physicians and other providers to
3        beneficiaries, by specialty and including primary care
4        physicians and facility-based physicians when
5        applicable under the contract, necessary to meet the
6        health care needs and service demands of the currently
7        enrolled population;
8            (C) the travel and distance standards for plan
9        beneficiaries in county service areas; and
10            (D) a description of how the use of telemedicine,
11        telehealth, or mobile care services may be used to
12        partially meet the network adequacy standards, if
13        applicable.
14        (6) A provision ensuring that whenever a beneficiary
15    has made a good faith effort, as evidenced by accessing
16    the provider directory, calling the network plan, and
17    calling the provider, to utilize preferred providers for a
18    covered service and it is determined the insurer does not
19    have the appropriate preferred providers due to
20    insufficient number, type, unreasonable travel distance or
21    delay, or preferred providers refusing to provide a
22    covered service because it is contrary to the conscience
23    of the preferred providers, as protected by the Health
24    Care Right of Conscience Act, the issuer insurer shall
25    ensure, directly or indirectly, by terms contained in the
26    payer contract, that the beneficiary will be provided the

 

 

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

 

 

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1    preferred provider. This provision shall be consistent
2    with Section 356z.3a of the Illinois Insurance Code.
3        (8) A limitation that, if the plan provides that the
4    beneficiary will incur a penalty for failing to
5    pre-certify inpatient hospital treatment, the penalty may
6    not exceed $1,000 per occurrence in addition to the plan
7    cost sharing provisions.
8        (9) For a network plan to be offered through the
9    Exchange in the individual or small group market, as well
10    as any off-Exchange mirror of such a network plan,
11    evidence that the network plan includes essential
12    community providers in accordance with rules established
13    by the Exchange that will operate in this State for the
14    applicable plan year.
15    (c) The issuer network plan shall demonstrate to the
16Director a minimum ratio of providers to plan beneficiaries as
17required by the Department for each network plan.
18        (1) The minimum ratio of physicians or other providers
19    to plan beneficiaries shall be established annually by the
20    Department in consultation with the Department of Public
21    Health based upon the guidance from the federal Centers
22    for Medicare and Medicaid Services. The Department shall
23    not establish ratios for vision or dental providers who
24    provide services under dental-specific or vision-specific
25    benefits, except to the extent provided under federal law
26    for stand-alone dental plans. The Department shall

 

 

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1    consider establishing ratios for the following physicians
2    or other providers:
3            (A) Primary Care;
4            (B) Pediatrics;
5            (C) Cardiology;
6            (D) Gastroenterology;
7            (E) General Surgery;
8            (F) Neurology;
9            (G) OB/GYN;
10            (H) Oncology/Radiation;
11            (I) Ophthalmology;
12            (J) Urology;
13            (K) Behavioral Health;
14            (L) Allergy/Immunology;
15            (M) Chiropractic;
16            (N) Dermatology;
17            (O) Endocrinology;
18            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
19            (Q) Infectious Disease;
20            (R) Nephrology;
21            (S) Neurosurgery;
22            (T) Orthopedic Surgery;
23            (U) Physiatry/Rehabilitative;
24            (V) Plastic Surgery;
25            (W) Pulmonary;
26            (X) Rheumatology;

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

10300HB5395sam002- 22 -LRB103 37071 RPS 73717 a

1that county pursuant to subsection (g), an issuer shall cover
2out-of-network claims for covered health care services
3received from that provider type within that county at the
4in-network benefit level and shall retroactively adjudicate
5and reimburse beneficiaries to achieve that objective if their
6claims were processed at the out-of-network level contrary to
7this subsection. Nothing in this subsection shall be construed
8to supersede Section 356z.3a of the Illinois Insurance Code.
9    (j) If the Director determines that a network is
10inadequate in any county and no exception has been granted
11under subsection (g) and the issuer does not have a process in
12place to comply with subsection (d-5), the Director may
13prohibit the network plan from being issued or renewed within
14that county until the Director determines that the network is
15adequate apart from processes and exceptions described in
16subsections (d-5) and (g). Nothing in this subsection shall be
17construed to terminate any beneficiary's health insurance
18coverage under a network plan before the expiration of the
19beneficiary's policy period if the Director makes a
20determination under this subsection after the issuance or
21renewal of the beneficiary's policy or certificate because of
22a material change. Policies or certificates issued or renewed
23in violation of this subsection may subject the issuer to a
24civil penalty of $5,000 per policy.
25    (k) For the Department to enforce any new or modified
26federal standard before the Department adopts the standard by

 

 

10300HB5395sam002- 23 -LRB103 37071 RPS 73717 a

1rule, the Department must, no later than May 15 before the
2start of the plan year, give public notice to the affected
3health insurance issuers through a bulletin.
4(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
5102-1117, eff. 1-13-23.)
 
6    (215 ILCS 124/15)
7    Sec. 15. Notice of nonrenewal or termination.
8    (a) A network plan must give at least 60 days' notice of
9nonrenewal or termination of a provider to the provider and to
10the beneficiaries served by the provider. The notice shall
11include a name and address to which a beneficiary or provider
12may direct comments and concerns regarding the nonrenewal or
13termination and the telephone number maintained by the
14Department for consumer complaints. Immediate written notice
15may be provided without 60 days' notice when a provider's
16license has been disciplined by a State licensing board or
17when the network plan reasonably believes direct imminent
18physical harm to patients under the provider's providers care
19may occur. The notice to the beneficiary shall provide the
20individual with an opportunity to notify the issuer of the
21individual's need for transitional care.
22    (b) Primary care providers must notify active affected
23patients of nonrenewal or termination of the provider from the
24network plan, except in the case of incapacitation.
25(Source: P.A. 100-502, eff. 9-15-17.)
 

 

 

10300HB5395sam002- 24 -LRB103 37071 RPS 73717 a

1    (215 ILCS 124/20)
2    Sec. 20. Transition of services.
3    (a) A network plan shall provide for continuity of care
4for its beneficiaries as follows:
5        (1) If a beneficiary's physician or hospital provider
6    leaves the network plan's network of providers for reasons
7    other than termination of a contract in situations
8    involving imminent harm to a patient or a final
9    disciplinary action by a State licensing board and the
10    provider remains within the network plan's service area,
11    if benefits provided under such network plan with respect
12    to such provider or facility are terminated because of a
13    change in the terms of the participation of such provider
14    or facility in such plan, or if a contract between a group
15    health plan and a health insurance issuer offering a
16    network plan in connection with the group health plan is
17    terminated and results in a loss of benefits provided
18    under such plan with respect to such provider, then the
19    network plan shall permit the beneficiary to continue an
20    ongoing course of treatment with that provider during a
21    transitional period for the following duration:
22            (A) 90 days from the date of the notice to the
23        beneficiary of the provider's disaffiliation from the
24        network plan if the beneficiary has an ongoing course
25        of treatment; or

 

 

10300HB5395sam002- 25 -LRB103 37071 RPS 73717 a

1            (B) if the beneficiary has entered the third
2        trimester of pregnancy at the time of the provider's
3        disaffiliation, a period that includes the provision
4        of post-partum care directly related to the delivery.
5        (2) Notwithstanding the provisions of paragraph (1) of
6    this subsection (a), such care shall be authorized by the
7    network plan during the transitional period in accordance
8    with the following:
9            (A) the provider receives continued reimbursement
10        from the network plan at the rates and terms and
11        conditions applicable under the terminated contract
12        prior to the start of the transitional period;
13            (B) the provider adheres to the network plan's
14        quality assurance requirements, including provision to
15        the network plan of necessary medical information
16        related to such care; and
17            (C) the provider otherwise adheres to the network
18        plan's policies and procedures, including, but not
19        limited to, procedures regarding referrals and
20        obtaining preauthorizations for treatment.
21        (3) The provisions of this Section governing health
22    care provided during the transition period do not apply if
23    the beneficiary has successfully transitioned to another
24    provider participating in the network plan, if the
25    beneficiary has already met or exceeded the benefit
26    limitations of the plan, or if the care provided is not

 

 

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1    medically necessary.
2    (b) A network plan shall provide for continuity of care
3for new beneficiaries as follows:
4        (1) If a new beneficiary whose provider is not a
5    member of the network plan's provider network, but is
6    within the network plan's service area, enrolls in the
7    network plan, the network plan shall permit the
8    beneficiary to continue an ongoing course of treatment
9    with the beneficiary's current physician during a
10    transitional period:
11            (A) of 90 days from the effective date of
12        enrollment if the beneficiary has an ongoing course of
13        treatment; or
14            (B) if the beneficiary has entered the third
15        trimester of pregnancy at the effective date of
16        enrollment, that includes the provision of post-partum
17        care directly related to the delivery.
18        (2) If a beneficiary, or a beneficiary's authorized
19    representative, elects in writing to continue to receive
20    care from such provider pursuant to paragraph (1) of this
21    subsection (b), such care shall be authorized by the
22    network plan for the transitional period in accordance
23    with the following:
24            (A) the provider receives reimbursement from the
25        network plan at rates established by the network plan;
26            (B) the provider adheres to the network plan's

 

 

10300HB5395sam002- 27 -LRB103 37071 RPS 73717 a

1        quality assurance requirements, including provision to
2        the network plan of necessary medical information
3        related to such care; and
4            (C) the provider otherwise adheres to the network
5        plan's policies and procedures, including, but not
6        limited to, procedures regarding referrals and
7        obtaining preauthorization for treatment.
8        (3) The provisions of this Section governing health
9    care provided during the transition period do not apply if
10    the beneficiary has successfully transitioned to another
11    provider participating in the network plan, if the
12    beneficiary has already met or exceeded the benefit
13    limitations of the plan, or if the care provided is not
14    medically necessary.
15    (c) In no event shall this Section be construed to require
16a network plan to provide coverage for benefits not otherwise
17covered or to diminish or impair preexisting condition
18limitations contained in the beneficiary's contract.
19    (d) A provider shall comply with the requirements of 42
20U.S.C. 300gg-138.
21(Source: P.A. 100-502, eff. 9-15-17.)
 
22    (215 ILCS 124/25)
23    Sec. 25. Network transparency.
24    (a) A network plan shall post electronically an
25up-to-date, accurate, and complete provider directory for each

 

 

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1of its network plans, with the information and search
2functions, as described in this Section.
3        (1) In making the directory available electronically,
4    the network plans shall ensure that the general public is
5    able to view all of the current providers for a plan
6    through a clearly identifiable link or tab and without
7    creating or accessing an account or entering a policy or
8    contract number.
9        (2) An issuer's failure to update a network plan's
10    directory shall subject the issuer to a civil penalty of
11    $5,000 per month. The network plan shall update the online
12    provider directory at least monthly. Providers shall
13    notify the network plan electronically or in writing
14    within 10 business days of any changes to their
15    information as listed in the provider directory, including
16    the information required in subsections (b), (c), and (d)
17    subparagraph (K) of paragraph (1) of subsection (b). With
18    regard to subparagraph (I) of paragraph (1) of subsection
19    (b), the provider must give notice to the issuer within 20
20    business days of deciding to cease accepting new patients
21    covered by the plan if the new patient limitation is
22    expected to last 40 business days or longer. The network
23    plan shall update its online provider directory in a
24    manner consistent with the information provided by the
25    provider within 2 10 business days after being notified of
26    the change by the provider. Nothing in this paragraph (2)

 

 

10300HB5395sam002- 29 -LRB103 37071 RPS 73717 a

1    shall void any contractual relationship between the
2    provider and the plan.
3        (3) At least once every 90 days, the issuer shall
4    self-audit each network plan's The network plan shall
5    audit periodically at least 25% of its provider
6    directories for accuracy, make any corrections necessary,
7    and retain documentation of the audit. The issuer shall
8    submit the self-audit and a summary to the Department, and
9    the Department shall make the summary of each self-audit
10    publicly available. The Department shall specify the
11    requirements of the summary, which shall be statistical in
12    nature except for a high-level narrative evaluating the
13    impact of internal and external factors on the accuracy of
14    the directory and the timeliness of updates. The network
15    plan shall submit the audit to the Director upon request.
16    As part of these self-audits audits, the network plan
17    shall contact any provider in its network that has not
18    submitted a claim to the plan or otherwise communicated
19    his or her intent to continue participation in the plan's
20    network. The self-audits shall comply with 42 U.S.C.
21    300gg-115(a)(2), except that "provider directory
22    information" shall include all information required to be
23    included in a provider directory pursuant to this Act.
24        (4) A network plan shall provide a print copy of a
25    current provider directory or a print copy of the
26    requested directory information upon request of a

 

 

10300HB5395sam002- 30 -LRB103 37071 RPS 73717 a

1    beneficiary or a prospective beneficiary. Except when an
2    issuer's print copies use the same provider information as
3    the electronic provider directory on each print copy's
4    date of printing, print Print copies must be updated at
5    least every 90 days quarterly and an errata that reflects
6    changes in the provider network must be included in each
7    update updated quarterly.
8        (5) For each network plan, a network plan shall
9    include, in plain language in both the electronic and
10    print directory, the following general information:
11            (A) in plain language, a description of the
12        criteria the plan has used to build its provider
13        network;
14            (B) if applicable, in plain language, a
15        description of the criteria the issuer insurer or
16        network plan has used to create tiered networks;
17            (C) if applicable, in plain language, how the
18        network plan designates the different provider tiers
19        or levels in the network and identifies for each
20        specific provider, hospital, or other type of facility
21        in the network which tier each is placed, for example,
22        by name, symbols, or grouping, in order for a
23        beneficiary-covered person or a prospective
24        beneficiary-covered person to be able to identify the
25        provider tier; and
26            (D) if applicable, a notation that authorization

 

 

10300HB5395sam002- 31 -LRB103 37071 RPS 73717 a

1        or referral may be required to access some providers; .
2            (E) a telephone number and email address for a
3        customer service representative to whom directory
4        inaccuracies may be reported; and
5            (F) a detailed description of the process to
6        dispute charges for out-of-network providers,
7        hospitals, or facilities that were incorrectly listed
8        as in-network prior to the provision of care and a
9        telephone number and email address to dispute such
10        charges.
11        (6) A network plan shall make it clear for both its
12    electronic and print directories what provider directory
13    applies to which network plan, such as including the
14    specific name of the network plan as marketed and issued
15    in this State. The network plan shall include in both its
16    electronic and print directories a customer service email
17    address and telephone number or electronic link that
18    beneficiaries or the general public may use to notify the
19    network plan of inaccurate provider directory information
20    and contact information for the Department's Office of
21    Consumer Health Insurance.
22        (7) A provider directory, whether in electronic or
23    print format, shall accommodate the communication needs of
24    individuals with disabilities, and include a link to or
25    information regarding available assistance for persons
26    with limited English proficiency.

 

 

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1    (b) For each network plan, a network plan shall make
2available through an electronic provider directory the
3following information in a searchable format:
4        (1) for health care professionals:
5            (A) name;
6            (B) gender;
7            (C) participating office locations;
8            (D) patient population served (such as pediatric,
9        adult, elderly, or women) and specialty or
10        subspecialty, if applicable;
11            (E) medical group affiliations, if applicable;
12            (F) facility affiliations, if applicable;
13            (G) participating facility affiliations, if
14        applicable;
15            (H) languages spoken other than English, if
16        applicable;
17            (I) whether accepting new patients;
18            (J) board certifications, if applicable; and
19            (K) use of telehealth or telemedicine, including,
20        but not limited to:
21                (i) whether the provider offers the use of
22            telehealth or telemedicine to deliver services to
23            patients for whom it would be clinically
24            appropriate;
25                (ii) what modalities are used and what types
26            of services may be provided via telehealth or

 

 

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1            telemedicine; and
2                (iii) whether the provider has the ability and
3            willingness to include in a telehealth or
4            telemedicine encounter a family caregiver who is
5            in a separate location than the patient if the
6            patient wishes and provides his or her consent;
7            (L) whether the health care professional accepts
8        appointment requests from patients; and
9            (M) the anticipated date the provider will leave
10        the network, if applicable, which shall be included no
11        more than 10 days after the issuer confirms that the
12        provider is scheduled to leave the network;
13        (2) for hospitals:
14            (A) hospital name;
15            (B) hospital type (such as acute, rehabilitation,
16        children's, or cancer);
17            (C) participating hospital location; and
18            (D) hospital accreditation status; and
19            (E) the anticipated date the hospital will leave
20        the network, if applicable, which shall be included no
21        more than 10 days after the issuer confirms the
22        hospital is scheduled to leave the network; and
23        (3) for facilities, other than hospitals, by type:
24            (A) facility name;
25            (B) facility type;
26            (C) types of services performed; and

 

 

10300HB5395sam002- 34 -LRB103 37071 RPS 73717 a

1            (D) participating facility location or locations;
2        and .
3            (E) the anticipated date the facility will leave
4        the network, if applicable, which shall be included no
5        more than 10 days after the issuer confirms the
6        facility is scheduled to leave the network.
7    (c) For the electronic provider directories, for each
8network plan, a network plan shall make available all of the
9following information in addition to the searchable
10information required in this Section:
11        (1) for health care professionals:
12            (A) contact information, including both a
13        telephone number and digital contact information if
14        the provider has supplied digital contact information;
15        and
16            (B) languages spoken other than English by
17        clinical staff, if applicable;
18        (2) for hospitals, telephone number and digital
19    contact information; and
20        (3) for facilities other than hospitals, telephone
21    number.
22    (d) The issuer insurer or network plan shall make
23available in print, upon request, the following provider
24directory information for the applicable network plan:
25        (1) for health care professionals:
26            (A) name;

 

 

10300HB5395sam002- 35 -LRB103 37071 RPS 73717 a

1            (B) contact information, including a telephone
2        number and digital contact information if the provider
3        has supplied digital contact information;
4            (C) participating office location or locations;
5            (D) patient population (such as pediatric, adult,
6        elderly, or women) and specialty or subspecialty, if
7        applicable;
8            (E) languages spoken other than English, if
9        applicable;
10            (F) whether accepting new patients; and
11            (G) use of telehealth or telemedicine, including,
12        but not limited to:
13                (i) whether the provider offers the use of
14            telehealth or telemedicine to deliver services to
15            patients for whom it would be clinically
16            appropriate;
17                (ii) what modalities are used and what types
18            of services may be provided via telehealth or
19            telemedicine; and
20                (iii) whether the provider has the ability and
21            willingness to include in a telehealth or
22            telemedicine encounter a family caregiver who is
23            in a separate location than the patient if the
24            patient wishes and provides his or her consent;
25            and
26            (H) whether the health care professional accepts

 

 

10300HB5395sam002- 36 -LRB103 37071 RPS 73717 a

1        appointment requests from patients.
2        (2) for hospitals:
3            (A) hospital name;
4            (B) hospital type (such as acute, rehabilitation,
5        children's, or cancer); and
6            (C) participating hospital location, and telephone
7        number, and digital contact information; and
8        (3) for facilities, other than hospitals, by type:
9            (A) facility name;
10            (B) facility type;
11            (C) patient population (such as pediatric, adult,
12        elderly, or women) served, if applicable, and types of
13        services performed; and
14            (D) participating facility location or locations,
15        and telephone numbers, and digital contact information
16        for each location.
17    (e) The network plan shall include a disclosure in the
18print format provider directory that the information included
19in the directory is accurate as of the date of printing and
20that beneficiaries or prospective beneficiaries should consult
21the issuer's insurer's electronic provider directory on its
22website and contact the provider. The network plan shall also
23include a telephone number and email address in the print
24format provider directory for a customer service
25representative where the beneficiary can obtain current
26provider directory information or report provider directory

 

 

10300HB5395sam002- 37 -LRB103 37071 RPS 73717 a

1inaccuracies. The printed provider directory shall include a
2detailed description of the process to dispute charges for
3out-of-network providers, hospitals, or facilities that were
4incorrectly listed as in-network prior to the provision of
5care and a telephone number and email address to dispute those
6charges.
7    (f) The Director may conduct periodic audits of the
8accuracy of provider directories. A network plan shall not be
9subject to any fines or penalties for information required in
10this Section that a provider submits that is inaccurate or
11incomplete.
12    (g) To the extent not otherwise provided in this Act, an
13issuer shall comply with the requirements of 42 U.S.C.
14300gg-115, except that "provider directory information" shall
15include all information required to be included in a provider
16directory pursuant to this Section.
17    (h) If the issuer or the Department identifies a provider
18incorrectly listed in the provider directory, the issuer shall
19check each of the issuer's network plan provider directories
20for the provider within 2 business days to ascertain whether
21the provider is a preferred provider in that network plan and,
22if the provider is incorrectly listed in the provider
23directory, remove the provider from the provider directory
24without delay.
25    (i) If the Director determines that an issuer violated
26this Section, the Director may assess a fine up to $5,000 per

 

 

10300HB5395sam002- 38 -LRB103 37071 RPS 73717 a

1violation, except for inaccurate information given by a
2provider to the issuer. If an issuer, or any entity or person
3acting on the issuer's behalf, knew or reasonably should have
4known that a provider was incorrectly included in a provider
5directory, the Director may assess a fine of up to $25,000 per
6violation against the issuer.
7    (j) This Section applies to network plans not otherwise
8exempt under Section 3, including stand-alone dental plans.
9(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
 
10    (215 ILCS 124/30)
11    Sec. 30. Administration and enforcement.
12    (a) Issuers Insurers, as defined in this Act, have a
13continuing obligation to comply with the requirements of this
14Act. Other than the duties specifically created in this Act,
15nothing in this Act is intended to preclude, prevent, or
16require the adoption, modification, or termination of any
17utilization management, quality management, or claims
18processing methodologies of an issuer insurer.
19    (b) Nothing in this Act precludes, prevents, or requires
20the adoption, modification, or termination of any network plan
21term, benefit, coverage or eligibility provision, or payment
22methodology.
23    (c) The Director shall enforce the provisions of this Act
24pursuant to the enforcement powers granted to it by law.
25    (d) The Department shall adopt rules to enforce compliance

 

 

10300HB5395sam002- 39 -LRB103 37071 RPS 73717 a

1with this Act to the extent necessary.
2    (e) In accordance with Section 5-45 of the Illinois
3Administrative Procedure Act, the Department may adopt
4emergency rules to implement federal standards for provider
5ratios, travel time and distance, and appointment wait times
6if such standards apply to health insurance coverage regulated
7by the Department and are more stringent than the State
8standards extant at the time the final federal standards are
9published.
10(Source: P.A. 100-502, eff. 9-15-17.)
 
11    (215 ILCS 124/35 new)
12    Sec. 35. Provider requirements. Providers shall comply
13with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations
14promulgated thereunder, as well as Section 20, paragraph (2)
15of subsection (a) of Section 25, subsections (h) and (j) of
16Section 25, and Section 36 of this Act, except that "provider
17directory information" includes all information required to be
18included in a provider directory pursuant to Section 25 of
19this Act.
 
20    (215 ILCS 124/36 new)
21    Sec. 36. Complaint of incorrect charges.
22    (a) A beneficiary who, taking into account the
23reimbursement, if any, by the issuer, incurs a cost in excess
24of the in-network cost-sharing for a covered service from a

 

 

10300HB5395sam002- 40 -LRB103 37071 RPS 73717 a

1provider, facility, or hospital that was listed as in-network
2in the plan's provider directory prior to or at the time of the
3provision of services may file a complaint with the
4Department. The Department shall investigate the complaint and
5determine if the provider was incorrectly included in the
6plan's provider directory when the beneficiary made the
7appointment or received the service.
8    (b) Upon the Department's confirmation of the allegations
9in the complaint that the beneficiary incurred a cost in
10excess of the in-network cost-sharing for covered services
11provided by an incorrectly included provider when the
12appointment was made or service was provided, the issuer shall
13reimburse the beneficiary for all costs incurred in excess of
14the in-network cost-sharing. However, if the issuer has paid
15the claim to the provider directly, the issuer shall notify
16the beneficiary and the provider of the beneficiary's right to
17reimbursement from the provider for any payments in excess of
18the in-network cost-sharing amount pursuant to 42 U.S.C.
19300gg-139(b), and the issuer's notice shall specify the
20in-network cost-sharing amount for the covered services. The
21amounts paid by the beneficiary within the in-network
22cost-sharing amount shall apply towards the in-network
23deductible and out-of-pocket maximum, if any.
 
24    (215 ILCS 124/40 new)
25    Sec. 40. Confidentiality.

 

 

10300HB5395sam002- 41 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 42 -LRB103 37071 RPS 73717 a

1self-audit of its provider directories, including any
2communications between the issuer and the Department, shall
3remain confidential unless expressly waived by the issuer or
4unless deemed public information under federal law.
5    (d) The filings required under Section 10 of this Act
6shall be confidential while they remain under the Department's
7review but shall become open to public inspection and copying
8upon completion of the review, except as provided in this
9Section or under other applicable law.
10    (e) Nothing in this Section shall supersede the statutory
11requirement that work papers obtained during a market conduct
12examination be deemed confidential.
 
13    (215 ILCS 124/50 new)
14    Sec. 50. Funds for enforcement. Moneys from fines and
15penalties collected from issuers for violations of this Act
16shall be deposited into the Insurance Producer Administration
17Fund for appropriation by the General Assembly to the
18Department to be used for providing financial support of the
19Department's enforcement of this Act.
 
20    (215 ILCS 124/55 new)
21    Sec. 55. Uniform electronic provider directory information
22notification forms.
23    (a) On or before January 1, 2026, the Department shall
24develop and publish a uniform electronic provider directory

 

 

10300HB5395sam002- 43 -LRB103 37071 RPS 73717 a

1information form that issuers shall make available to
2onboarding, current, and former preferred providers to notify
3the issuer of the provider's currently accurate provider
4directory information under Section 25 of this Act and 42
5U.S.C. 300gg-139. The form shall address information needed
6from newly onboarding preferred providers, updates to
7previously supplied provider directory information, reporting
8an inaccurate directory entry of previously supplied
9information, contract terminations, and differences in
10information for specific network plans offered by an issuer,
11such as whether the provider is a preferred provider for the
12network plan or is accepting new patients under that plan. The
13Department shall allow issuers to implement this form through
14either a PDF or a web portal that requests the same
15information.
16    (b) Notwithstanding any other provision of law to the
17contrary, beginning 6 months after the Department publishes
18the uniform electronic provider directory information form and
19no later than July 1, 2026, every provider must use the uniform
20electronic provider directory information form to notify
21issuers of their provider directory information as required
22under Section 25 of this Act and 42 U.S.C. 300gg-139. Issuers
23shall accept this form as sufficient to update their provider
24directories. Issuers shall not accept paper or fax submissions
25of provider directory information from providers.
26    (c) The Uniform Electronic Provider Directory Information

 

 

10300HB5395sam002- 44 -LRB103 37071 RPS 73717 a

1Form Task Force is created. The purpose of this task force is
2to provide input and advice to the Department of Insurance in
3the development of a uniform electronic provider directory
4information form. The task force shall include at least the
5following individuals:
6        (1) the Director of Insurance or a designee, as chair;
7        (2) the Marketplace Director or a designee;
8        (3) the Director of the Division of Professional
9    Regulation or a designee;
10        (4) the Director of Public Health or a designee;
11        (5) the Secretary of Innovation and Technology or a
12    designee;
13        (6) the Director of Healthcare and Family Services or
14    a designee;
15        (7) the following individuals appointed by the
16    Director:
17            (A) one representative of a statewide association
18        representing physicians;
19            (B) one representative of a statewide association
20        representing nurses;
21            (C) one representative of a statewide organization
22        representing a majority of Illinois hospitals;
23            (D) one representative of a statewide organization
24        representing Illinois pharmacies;
25            (E) one representative of a statewide organization
26        representing mental health care providers;

 

 

10300HB5395sam002- 45 -LRB103 37071 RPS 73717 a

1            (F) one representative of a statewide organization
2        representing substance use disorder health care
3        providers;
4            (G) 2 representatives of health insurance issuers
5        doing business in this State or issuer trade
6        associations, at least one of which represents a
7        State-domiciled mutual health insurance company, with
8        a demonstrated expertise in the business of health
9        insurance or health benefits administration; and
10            (H) 2 representatives of a health insurance
11        consumer advocacy group.
12    (d) The Department shall convene the task force described
13in this Section no later than April 1, 2025.
14    (e) The Department, in development of the uniform
15electronic provider directory information form, and the task
16force, in offering input, shall take into consideration the
17following:
18        (1) readability and user experience;
19        (2) interoperability;
20        (3) existing regulations established by the federal
21    Centers for Medicare and Medicaid Services, the Department
22    of Insurance, the Department of Healthcare and Family
23    Service, the Department of Financial and Professional
24    Regulation, and the Department of Public Health;
25        (4) potential opportunities to avoid duplication of
26    data collection efforts, including, but not limited to,

 

 

10300HB5395sam002- 46 -LRB103 37071 RPS 73717 a

1    opportunities related to:
2            (A) integrating any provider reporting required
3        under Section 25 of this Act and 42 U.S.C. 300gg-139
4        with the provider reporting required under the Health
5        Care Professional Credentials Data Collection Act;
6            (B) furnishing information to any national
7        provider directory established by the federal Centers
8        for Medicare and Medicaid Services or another federal
9        agency with jurisdiction over health care providers;
10        and
11            (C) furnishing information in compliance with the
12        Patients' Right to Know Act;
13        (5) compatibility with the Illinois Health Benefits
14    Exchange;
15        (6) provider licensing requirements and forms; and
16        (7) information needed to classify a provider under
17    any specialty type for which a network adequacy standard
18    may be established under this Act when a specialty board
19    certification or State license does not currently exist.
 
20    Section 2-15. The Managed Care Reform and Patient Rights
21Act is amended by changing Sections 20 and 25 as follows:
 
22    (215 ILCS 134/20)
23    Sec. 20. Notice of nonrenewal or termination. A health
24care plan must give at least 60 days notice of nonrenewal or

 

 

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

 

 

10300HB5395sam002- 48 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 49 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 50 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 51 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 52 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 53 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 54 -LRB103 37071 RPS 73717 a

1(Source: P.A. 100-1052, eff. 8-24-18.)
 
2
Article 3.

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

 

 

10300HB5395sam002- 55 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 56 -LRB103 37071 RPS 73717 a

1disapprove the filing if the insurer fails to respond to an
2objection or request for additional information within the
3timeframe identified for response. As used in this subsection,
4"large employer" has the meaning given in Section 5 of the
5federal Health Insurance Portability and Accountability Act.
6    (c) For plan year 2026 and thereafter, premium rates for
7all individual and small group accident and health insurance
8policies must be filed with the Department for approval.
9Unreasonable rate increases or inadequate rates shall be
10modified or disapproved. For any plan year during which the
11Illinois Health Benefits Exchange operates as a full
12State-based exchange, the Department shall provide insurers at
13least 30 days' notice of the deadline to submit rate filings.
14    (c-5) Unless prohibited under federal law, for plan year
152026 and thereafter, each insurer proposing to offer a
16qualified health plan issued in the individual market through
17the Illinois Health Benefits Exchange must incorporate the
18following approach in its rate filing under this Section:
19        (1) The rate filing must apply a cost-sharing
20    reduction defunding adjustment factor within a range that:
21            (A) is uniform across all insurers;
22            (B) is consistent with the total adjustment
23        expected to be needed to cover actual cost-sharing
24        reduction costs across all silver plans on the
25        Illinois Health Benefits Exchange statewide, provided
26        that such costs are calculated assuming utilization by

 

 

10300HB5395sam002- 57 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 58 -LRB103 37071 RPS 73717 a

1the public comment period established in subsection (e).
2    (e) The Department shall open a 30-day public comment
3period on the rate filings beginning on the date that all of
4the rate filings are posted on the Department's website. The
5Department shall post all of the comments received to the
6Department's website within 5 business days after the comment
7period ends.
8    (f) After the close of the public comment period described
9in subsection (e), the Department, beginning for plan year
102026, shall issue a decision to approve, disapprove, or modify
11a rate filing within 60 days. Any rate filing or any rates
12within a filing on which the Director does not issue a decision
13within 60 days shall automatically be deemed approved. The
14Director's decision shall take into account the actuarial
15justifications and public comments. The Department shall
16notify the insurer of the decision, make the decision
17available to the public by posting it on the Department's
18website, and include an explanation of the findings, actuarial
19justifications, and rationale that are the basis for the
20decision. Any company whose rate has been modified or
21disapproved shall be allowed to request a hearing within 10
22days after the action taken. The action of the Director in
23disapproving a rate shall be subject to judicial review under
24the Administrative Review Law.
25    (g) If, following the issuance of a decision but before
26the effective date of the premium rates approved by the

 

 

10300HB5395sam002- 59 -LRB103 37071 RPS 73717 a

1decision, an event occurs that materially affects the
2Director's decision to approve, deny, or modify the rates, the
3Director may consider supplemental facts or data reasonably
4related to the event.
5    (h) The Department shall adopt rules implementing the
6procedures described in subsections (d) through (g) by March
731, 2024.
8    (i) Subsection (a) and subsections (c) through (h) of this
9Section do not apply to grandfathered health plans as defined
10in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C.
11300gg-91; student health insurance coverage as defined in 45
12CFR 147.145; the large group market as defined in Section 5 of
13the Illinois Health Insurance Portability and Accountability
14Act; or short-term, limited-duration health insurance coverage
15as defined in Section 5 of the Short-Term, Limited-Duration
16Health Insurance Coverage Act. For a filing of premium rates
17or classifications of risk for any of these types of coverage,
18the Director's initial review period shall not exceed 60 days
19to issue informal objections to the company that request
20additional clarification, explanation, substantiating
21documentation, or correction of concerns identified in the
22filing before the company implements the premium rates,
23classifications, or related rate-setting methodologies
24described in the filing, except that the Director may extend
25by not more than an additional 30 days the period of initial
26review by giving written notice to the company of such

 

 

10300HB5395sam002- 60 -LRB103 37071 RPS 73717 a

1extension before the expiration of the initial 60-day period.
2Nothing in this subsection shall confer authority upon the
3Director to approve, modify, or disapprove rates where that
4authority is not provided by other law. Nothing in this
5subsection shall prohibit the Director from conducting any
6investigation, examination, hearing, or other formal
7administrative or enforcement proceeding with respect to a
8company's rate filing or implementation thereof under
9applicable law at any time, including after the period of
10initial review.
11(Source: P.A. 103-106, eff. 1-1-24.)
 
12    Section 3-10. The Illinois Health Benefits Exchange Law is
13amended by changing Section 5-5 as follows:
 
14    (215 ILCS 122/5-5)
15    Sec. 5-5. State health benefits exchange. It is declared
16that this State, beginning October 1, 2013, in accordance with
17Section 1311 of the federal Patient Protection and Affordable
18Care Act, shall establish a State health benefits exchange to
19be known as the Illinois Health Benefits Exchange in order to
20help individuals and small employers with no more than 50
21employees shop for, select, and enroll in qualified,
22affordable private health plans that fit their needs at
23competitive prices. The Exchange shall separate coverage pools
24for individuals and small employers and shall supplement and

 

 

10300HB5395sam002- 61 -LRB103 37071 RPS 73717 a

1not supplant any existing private health insurance market for
2individuals and small employers. The Department of Insurance
3shall operate the Illinois Health Benefits Exchange as a
4State-based exchange using the federal platform by plan year
52025 and as a State-based exchange by plan year 2026. The
6Director of Insurance may require that all plans in the
7individual and small group markets, other than grandfathered
8health plans, be made available for comparison on the Illinois
9Health Benefits Exchange, but may not require that all plans
10in the individual and small group markets be purchased
11exclusively on the Illinois Health Benefits Exchange. Through
12the adoption of rules, the Director of Insurance may require
13that plans offered on the exchange conform with standardized
14plan designs that provide for standardized cost sharing for
15covered health services. Except when it is inconsistent with
16State law, the Department of Insurance shall enforce the
17coverage requirements under the federal Patient Protection and
18Affordable Care Act, including the coverage of all United
19States Preventive Services Task Force Grade A and B preventive
20services without cost sharing notwithstanding any federal
21overturning or repeal of 42 U.S.C. 300gg-13(a)(1), that apply
22to the individual and small group markets. Beginning for plan
23year 2026, if a health insurance issuer offers a product as
24defined under 45 CFR 144.103 at the gold or silver level
25through the Illinois Health Benefits Exchange, the issuer must
26offer that product at both the gold and silver levels. The

 

 

10300HB5395sam002- 62 -LRB103 37071 RPS 73717 a

1Director of Insurance may elect to add a small business health
2options program to the Illinois Health Benefits Exchange to
3help small employers enroll their employees in qualified
4health plans in the small group market. The General Assembly
5shall appropriate funds to establish the Illinois Health
6Benefits Exchange.
7(Source: P.A. 103-103, eff. 6-27-23.)
 
8
Article 4.

 
9    Section 4-5. The Illinois Insurance Code is amended by
10changing Section 355 as follows:
 
11    (215 ILCS 5/355)  (from Ch. 73, par. 967)
12    Sec. 355. Accident and health policies; provisions.
13    (a) As used in this Section:
14    "Inadequate rate" means a rate:
15        (1) that is insufficient to sustain projected losses
16    and expenses to which the rate applies; and
17        (2) the continued use of which endangers the solvency
18    of an insurer using that rate.
19    "Large employer" has the meaning provided in the Illinois
20Health Insurance Portability and Accountability Act.
21    "Plain language" has the meaning provided in the federal
22Plain Writing Act of 2010 and subsequent guidance documents,
23including the Federal Plain Language Guidelines.

 

 

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1    "Unreasonable rate increase" means a rate increase that
2the Director determines to be excessive, unjustified, or
3unfairly discriminatory in accordance with 45 CFR 154.205.
4    (b) No policy of insurance against loss or damage from the
5sickness, or from the bodily injury or death of the insured by
6accident shall be issued or delivered to any person in this
7State until a copy of the form thereof and of the
8classification of risks and the premium rates pertaining
9thereto have been filed with the Director; nor shall it be so
10issued or delivered until the Director shall have approved
11such policy pursuant to the provisions of Section 143. If the
12Director disapproves the policy form, he or she shall make a
13written decision stating the respects in which such form does
14not comply with the requirements of law and shall deliver a
15copy thereof to the company and it shall be unlawful
16thereafter for any such company to issue any policy in such
17form. On and after January 1, 2025, any form filing submitted
18for large employer group accident and health insurance shall
19be automatically deemed approved within 90 days of the
20submission date unless the Director extends by not more than
21an additional 30 days the period within which the form shall be
22approved or disapproved by giving written notice to the
23insurer of such extension before the expiration of the 90
24days. Any form in receipt of such an extension shall be
25automatically deemed approved within 120 days of the
26submission date. The Director may toll the filing due to a

 

 

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

 

 

10300HB5395sam002- 65 -LRB103 37071 RPS 73717 a

1Section 7 of the Freedom of Information Act or confidential or
2privileged under any applicable insurance law or rule. All
3summaries shall include a brief justification of any rate
4increase or decrease requested, including the number of
5individual members, the medical loss ratio, medical trend,
6administrative costs, and any other information required by
7rule. The plain writing summary shall include notification of
8the public comment period established in subsection (e).
9    (e) The Department shall open a 30-day public comment
10period on the rate filings beginning on the date that all of
11the rate filings are posted on the Department's website. The
12Department shall post all of the comments received to the
13Department's website within 5 business days after the comment
14period ends.
15    (f) After the close of the public comment period described
16in subsection (e), the Department, beginning for plan year
172026, shall issue a decision to approve, disapprove, or modify
18a rate filing within 60 days. Any rate filing or any rates
19within a filing on which the Director does not issue a decision
20within 60 days shall automatically be deemed approved. The
21Director's decision shall take into account the actuarial
22justifications and public comments. The Department shall
23notify the insurer of the decision, make the decision
24available to the public by posting it on the Department's
25website, and include an explanation of the findings, actuarial
26justifications, and rationale that are the basis for the

 

 

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1decision. Any company whose rate has been modified or
2disapproved shall be allowed to request a hearing within 10
3days after the action taken. The action of the Director in
4disapproving a rate shall be subject to judicial review under
5the Administrative Review Law.
6    (g) If, following the issuance of a decision but before
7the effective date of the premium rates approved by the
8decision, an event occurs that materially affects the
9Director's decision to approve, deny, or modify the rates, the
10Director may consider supplemental facts or data reasonably
11related to the event.
12    (h) The Department shall adopt rules implementing the
13procedures described in subsections (d) through (g) by March
1431, 2024.
15    (i) Subsection (a), and subsections (c) through (h), and
16subsection (j) of this Section do not apply to grandfathered
17health plans as defined in 45 CFR 147.140; excepted benefits
18as defined in 42 U.S.C. 300gg-91; or student health insurance
19coverage as defined in 45 CFR 147.145; the large group market
20as defined in Section 5 of the Illinois Health Insurance
21Portability and Accountability Act; or short-term,
22limited-duration health insurance coverage as defined in
23Section 5 of the Short-Term, Limited-Duration Health Insurance
24Coverage Act. For a filing of premium rates or classifications
25of risk for any of these types of coverage, the Director's
26initial review period shall not exceed 60 days to issue

 

 

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

 

 

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1    the premiums are unreasonable in relation to the benefits
2    because the rates were not calculated in accordance with
3    sound actuarial principles.
4        (2) Within 60 days of receipt of the rate filing, the
5    Director shall issue a decision to approve, disapprove, or
6    modify the filing along with the reasons and actuarial
7    justification for the decision. Any rate filing or rates
8    within a filing on which the Director does not issue a
9    decision within 60 days shall be automatically deemed
10    approved.
11        (3) Any company whose rate or rate filing has been
12    modified or disapproved shall be allowed to request a
13    hearing within 10 days after the action taken. The action
14    of the Director in disapproving a rate or rate filing
15    shall be subject to judicial review under the
16    Administrative Review Law.
17        (4) Nothing in this subsection requires a company to
18    file a large employer group policy's final premium rates
19    for prior approval if the company negotiates the final
20    rates or rate adjustments with the large employer in
21    accordance with the rate manual and rules of the currently
22    approved rate filing for the policy.
23(Source: P.A. 103-106, eff. 1-1-24.)
 
24    Section 4-10. The Health Maintenance Organization Act is
25amended by changing Section 4-12 as follows:
 

 

 

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1    (215 ILCS 125/4-12)  (from Ch. 111 1/2, par. 1409.5)
2    Sec. 4-12. Changes in rate methodology and benefits,
3material modifications. A health maintenance organization
4shall file with the Director, prior to use, a notice of any
5change in rate methodology, or benefits and of any material
6modification of any matter or document furnished pursuant to
7Section 2-1, together with such supporting documents as are
8necessary to fully explain the change or modification.
9    (a) Contract modifications described in subsections
10(c)(5), (c)(6) and (c)(7) of Section 2-1 shall include all
11form agreements between the organization and enrollees,
12providers, administrators of services and insurers of health
13maintenance organizations.
14    (b) Material transactions or series of transactions other
15than those described in subsection (a) of this Section, the
16total annual value of which exceeds the greater of $100,000 or
175% of net earned subscription revenue for the most current
1812-month period as determined from filed financial statements.
19    (c) Any agreement between the organization and an insurer
20shall be subject to the provisions of the laws of this State
21regarding reinsurance as provided in Article XI of the
22Illinois Insurance Code. All reinsurance agreements must be
23filed. Approval of the Director is required for all agreements
24except the following: individual stop loss, aggregate excess,
25hospitalization benefits or out-of-area of the participating

 

 

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

 

 

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1    or series of transactions, the total annual value of which
2    exceeds the greater of $100,000 or 5% of net earned
3    subscription revenue for the most current 12-month 12
4    month period as determined from filed financial
5    statements.
6        (2) Contract modification for reinsurance. Any
7    agreement between the organization and an insurer shall be
8    subject to the provisions of Article XI of the Illinois
9    Insurance Code, as now or hereafter amended. All
10    reinsurance agreements must be filed with the Director.
11    Approval of the Director in required agreements must be
12    filed. Approval of the director is required for all
13    agreements except individual stop loss, aggregate excess,
14    hospitalization benefits, or out-of-area of the
15    participating providers, unless 20% or more of the
16    organization's total risk is reinsured, in which case all
17    reinsurance agreements shall require approval.
18    (b) If a limited health service organization desires to
19add one or more additional limited health services, it shall
20file a notice with the Director and, at the same time, submit
21the information required by Section 2001 if different from
22that filed with the prepaid limited health service
23organization's application. Issuance of such an amended
24certificate of authority shall be subject to the conditions of
25Section 2002 of this Act.
26    (c) In addition to any applicable provisions of this Act,

 

 

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

 
6    Section 6-5. The Illinois Insurance Code is amended by
7changing Sections 155.36, 155.37, 356z.40, and 370c as
8follows:
 
9    (215 ILCS 5/155.36)
10    Sec. 155.36. Managed Care Reform and Patient Rights Act.
11Insurance companies that transact the kinds of insurance
12authorized under Class 1(b) or Class 2(a) of Section 4 of this
13Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65,
1470, and 85, and 87, subsection (d) of Section 30, and the
15definitions definition of the term "emergency medical
16condition" and any other term in Section 10 of the Managed Care
17Reform and Patient Rights Act that is used in the other
18Sections listed in this Section.
19(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
20    (215 ILCS 5/155.37)
21    Sec. 155.37. Drug formulary; notice.
22    (a) Insurance companies that transact the kinds of

 

 

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1insurance authorized under Class 1(b) or Class 2(a) of Section
24 of this Code and provide coverage for prescription drugs
3through the use of a drug formulary must notify insureds of any
4change in the formulary. A company may comply with this
5Section by posting changes in the formulary on its website.
6    (b) No later than October 1, 2025, insurance companies
7that use a drug formulary shall post the formulary on their
8websites in a manner that is searchable and accessible to the
9general public without requiring an individual to create any
10account. This formulary shall adhere to a template developed
11by the Department by March 31, 2025, which shall take into
12consideration existing requirements for reporting of
13information established by the federal Centers for Medicare
14and Medicaid Services as well as display of cost-sharing
15information. This template and all formularies also shall do
16all the following:
17        (1) include information on cost-sharing tiers and
18    utilization controls, such as prior authorization, for
19    each covered drug;
20        (2) indicate any drugs on the formulary that are
21    preferred over other drugs on the formulary;
22        (3) include information to educate insureds about the
23    differences between drugs administered or provided under a
24    policy's medical benefit and drugs covered under a drug
25    benefit and how to obtain coverage information about drugs
26    that are not covered under the drug benefit;

 

 

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1        (4) include information to educate insureds that
2    policies that provide drug benefits are required to have a
3    method for enrollees to obtain drugs not listed in the
4    formulary if they are deemed medically necessary by a
5    clinician under Section 45.1 of the Managed Care Reform
6    and Patient Rights Act;
7        (5) include information on which medications are
8    covered, including both generic and brand name; and
9        (6) include information on what tier of the plan's
10    drug formulary each medication is in.
11    (c) No formulary may establish a step therapy requirement
12as prohibited by Section 87 of the Managed Care Reform and
13Patient Rights Act.
14(Source: P.A. 92-440, eff. 8-17-01; 92-651, eff. 7-11-02.)
 
15    (215 ILCS 5/356z.40)
16    Sec. 356z.40. Pregnancy and postpartum coverage.
17    (a) An individual or group policy of accident and health
18insurance or managed care plan amended, delivered, issued, or
19renewed on or after the effective date of this amendatory Act
20of the 102nd General Assembly shall provide coverage for
21pregnancy and newborn care in accordance with 42 U.S.C.
2218022(b) regarding essential health benefits.
23    (b) Benefits under this Section shall be as follows:
24        (1) An individual who has been identified as
25    experiencing a high-risk pregnancy by the individual's

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

10300HB5395sam002- 91 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 92 -LRB103 37071 RPS 73717 a

1means the benefits provided for treatment services for
2inpatient and outpatient treatment of substance use disorders
3or conditions at American Society of Addiction Medicine levels
4of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
5Hospitalization), 3.5 (Clinically Managed High-Intensity
6Residential), and 3.7 (Medically Monitored Intensive
7Inpatient) and OMT (Opioid Maintenance Therapy) services.
8    "Substance use disorder treatment provider or facility"
9means a licensed physician, licensed psychologist, licensed
10psychiatrist, licensed advanced practice registered nurse, or
11licensed, certified, or otherwise State-approved facility or
12provider of substance use disorder treatment.
13    (2) A group health insurance policy, an individual health
14benefit plan, or qualified health plan that is offered through
15the health insurance marketplace, small employer group health
16plan, and large employer group health plan that is amended,
17delivered, issued, executed, or renewed in this State, or
18approved for issuance or renewal in this State, on or after
19January 1, 2019 (the effective date of Public Act 100-1023)
20shall comply with the requirements of this Section and Section
21370c.1. The services for the treatment and the ongoing
22assessment of the patient's progress in treatment shall follow
23the requirements of 77 Ill. Adm. Code 2060.
24    (3) Prior authorization shall not be utilized for the
25benefits under this subsection. The substance use disorder
26treatment provider or facility shall notify the insurer of the

 

 

10300HB5395sam002- 93 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 94 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 95 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 96 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 97 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 98 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 99 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 100 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 101 -LRB103 37071 RPS 73717 a

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

 

 

10300HB5395sam002- 102 -LRB103 37071 RPS 73717 a

1    (p) This Section does not in any way limit early and
2periodic screening, diagnostic, and treatment benefits as
3defined under 42 U.S.C. 1396d(r).
4    (q) To ensure the proper use of the criteria described in
5subsection (l), every insurer shall do all of the following:
6        (1) Educate the insurer's staff, including any third
7    parties contracted with the insurer to review claims,
8    conduct utilization reviews, or make medical necessity
9    determinations about the utilization review criteria.
10        (2) Make the educational program available to other
11    stakeholders, including the insurer's participating or
12    contracted providers and potential participants,
13    beneficiaries, or covered lives. The education program
14    must be provided at least once a year, in-person or
15    digitally, or recordings of the education program must be
16    made available to the aforementioned stakeholders.
17        (3) Provide, at no cost, the utilization review
18    criteria and any training material or resources to
19    providers and insured patients upon request. For
20    utilization review criteria not concerning level of care
21    placement, continued stay, and transfer, or discharge, or
22    other patient care decisions used by the insurer pursuant
23    to subsection (m), the insurer may place the criteria on a
24    secure, password-protected website so long as the access
25    requirements of the website do not unreasonably restrict
26    access to insureds or their providers. No restrictions

 

 

10300HB5395sam002- 103 -LRB103 37071 RPS 73717 a

1    shall be placed upon the insured's or treating provider's
2    access right to utilization review criteria obtained under
3    this paragraph at any point in time, including before an
4    initial request for authorization.
5        (4) Track, identify, and analyze how the utilization
6    review criteria are used to certify care, deny care, and
7    support the appeals process.
8        (5) Conduct interrater reliability testing to ensure
9    consistency in utilization review decision making that
10    covers how medical necessity decisions are made; this
11    assessment shall cover all aspects of utilization review
12    as defined in subsection (h).
13        (6) Run interrater reliability reports about how the
14    clinical guidelines are used in conjunction with the
15    utilization review process and parity compliance
16    activities.
17        (7) Achieve interrater reliability pass rates of at
18    least 90% and, if this threshold is not met, immediately
19    provide for the remediation of poor interrater reliability
20    and interrater reliability testing for all new staff
21    before they can conduct utilization review without
22    supervision.
23        (8) Maintain documentation of interrater reliability
24    testing and the remediation actions taken for those with
25    pass rates lower than 90% and submit to the Department of
26    Insurance or, in the case of Medicaid managed care

 

 

10300HB5395sam002- 104 -LRB103 37071 RPS 73717 a

1    organizations, the Department of Healthcare and Family
2    Services the testing results and a summary of remedial
3    actions as part of parity compliance reporting set forth
4    in subsection (k) of Section 370c.1.
5    (r) This Section applies to all health care services and
6benefits for the diagnosis, prevention, and treatment of
7mental, emotional, nervous, or substance use disorders or
8conditions covered by an insurance policy, including
9prescription drugs.
10    (s) This Section applies to an insurer that amends,
11delivers, issues, or renews a group or individual policy of
12accident and health insurance or a qualified health plan
13offered through the health insurance marketplace in this State
14providing coverage for hospital or medical treatment and
15conducts utilization review as defined in this Section,
16including Medicaid managed care organizations, and any entity
17or contracting provider that performs utilization review or
18utilization management functions on an insurer's behalf.
19    (t) If the Director determines that an insurer has
20violated this Section, the Director may, after appropriate
21notice and opportunity for hearing, by order, assess a civil
22penalty between $1,000 and $5,000 for each violation. Moneys
23collected from penalties shall be deposited into the Parity
24Advancement Fund established in subsection (i) of Section
25370c.1.
26    (u) An insurer shall not adopt, impose, or enforce terms

 

 

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1in its policies or provider agreements, in writing or in
2operation, that undermine, alter, or conflict with the
3requirements of this Section.
4    (v) The provisions of this Section are severable. If any
5provision of this Section or its application is held invalid,
6that invalidity shall not affect other provisions or
7applications that can be given effect without the invalid
8provision or application.
9    (w) Beginning January 1, 2026, coverage for inpatient
10mental health treatment at participating hospitals shall
11comply with the following requirements:
12        (1) Subject to paragraphs (2) and (3) of this
13    subsection, no policy shall require prior authorization
14    for admission for such treatment at any participating
15    hospital.
16        (2) Coverage provided under this subsection also shall
17    not be subject to concurrent review for the first 72
18    hours, provided that the hospital must notify the insurer
19    of both the admission and the initial treatment plan
20    within 48 hours of admission. A discharge plan must be
21    fully developed and continuity services prepared to meet
22    the patient's needs and the patient's community preference
23    upon release. Nothing in this paragraph supersedes a
24    health maintenance organization's referral requirement for
25    services from nonparticipating providers upon a patient's
26    discharge from a hospital.

 

 

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1        (3) Treatment provided under this subsection may be
2    reviewed retrospectively. If coverage is denied
3    retrospectively, neither the insurer nor the participating
4    hospital shall bill, and the insured shall not be liable,
5    for any treatment under this subsection through the date
6    the adverse determination is issued, other than any
7    copayment, coinsurance, or deductible for the stay through
8    that date as applicable under the policy. Coverage shall
9    not be retrospectively denied for the first 72 hours of
10    treatment at a participating hospital except:
11            (A) upon reasonable determination that the
12        inpatient mental health treatment was not provided;
13            (B) upon determination that the patient receiving
14        the treatment was not an insured, enrollee, or
15        beneficiary under the policy;
16            (C) upon material misrepresentation by the patient
17        or health care provider. In this item (C), "material"
18        means a fact or situation that is not merely technical
19        in nature and results or could result in a substantial
20        change in the situation; or
21            (D) upon determination that a service was excluded
22        under the terms of coverage. In that case, the
23        limitation to billing for a copayment, coinsurance, or
24        deductible shall not apply.
25        (4) Nothing in this subsection shall be construed to
26    require a policy to cover any health care service excluded

 

 

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1    under the terms of coverage.
2    (x) Notwithstanding any provision of this Section, nothing
3shall require the medical assistance program under Article V
4of the Illinois Public Aid Code to violate any applicable
5federal laws, regulations, or grant requirements or any State
6or federal consent decrees. Nothing in subsection (w) shall
7prevent the Department of Healthcare and Family Services from
8requiring a health care provider to use specified level of
9care, admission, continued stay, or discharge criteria,
10including, but not limited to, those under Section 5-5.23 of
11the Illinois Public Aid Code, as long as the Department of
12Healthcare and Family Services does not require a health care
13provider to seek prior authorization or concurrent review from
14the Department of Healthcare and Family Services, a Medicaid
15managed care organization, or a utilization review
16organization under the circumstances expressly prohibited by
17subsection (w). Nothing in this Section prohibits a health
18plan, including a Medicaid managed care organization, from
19conducting reviews for fraud, waste, or abuse and reporting
20suspected fraud, waste, or abuse according to State and
21federal requirements.
22    (y) Children's Mental Health. Nothing in this Section
23shall suspend the screening and assessment requirements for
24mental health services for children participating in the
25State's medical assistance program as required in Section
265-5.23 of the Illinois Public Aid Code.

 

 

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1(Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22;
2102-813, eff. 5-13-22; 103-426, eff. 8-4-23.)
 
3    Section 6-10. The Managed Care Reform and Patient Rights
4Act is amended by changing Sections 10, 45.1, and 85 and by
5adding Section 87 as follows:
 
6    (215 ILCS 134/10)
7    Sec. 10. Definitions. In this Act:
8    "Adverse determination" means a determination by a health
9care plan under Section 45 or by a utilization review program
10under Section 85 that a health care service is not medically
11necessary.
12    "Clinical peer" means a health care professional who is in
13the same profession and the same or similar specialty as the
14health care provider who typically manages the medical
15condition, procedures, or treatment under review.
16    "Department" means the Department of Insurance.
17    "Emergency medical condition" means a medical condition
18manifesting itself by acute symptoms of sufficient severity,
19regardless of the final diagnosis given, such that a prudent
20layperson, who possesses an average knowledge of health and
21medicine, could reasonably expect the absence of immediate
22medical attention to result in:
23        (1) placing the health of the individual (or, with
24    respect to a pregnant woman, the health of the woman or her

 

 

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1    unborn child) in serious jeopardy;
2        (2) serious impairment to bodily functions;
3        (3) serious dysfunction of any bodily organ or part;
4        (4) inadequately controlled pain; or
5        (5) with respect to a pregnant woman who is having
6    contractions:
7            (A) inadequate time to complete a safe transfer to
8        another hospital before delivery; or
9            (B) a transfer to another hospital may pose a
10        threat to the health or safety of the woman or unborn
11        child.
12    "Emergency medical screening examination" means a medical
13screening examination and evaluation by a physician licensed
14to practice medicine in all its branches, or to the extent
15permitted by applicable laws, by other appropriately licensed
16personnel under the supervision of or in collaboration with a
17physician licensed to practice medicine in all its branches to
18determine whether the need for emergency services exists.
19    "Emergency services" means, with respect to an enrollee of
20a health care plan, transportation services, including but not
21limited to ambulance services, and covered inpatient and
22outpatient hospital services furnished by a provider qualified
23to furnish those services that are needed to evaluate or
24stabilize an emergency medical condition. "Emergency services"
25does not refer to post-stabilization medical services.
26    "Enrollee" means any person and his or her dependents

 

 

10300HB5395sam002- 110 -LRB103 37071 RPS 73717 a

1enrolled in or covered by a health care plan.
2    "Generally accepted standards of care" means standards of
3care and clinical practice that are generally recognized by
4health care providers practicing in relevant clinical
5specialties for the illness, injury, or condition or its
6symptoms and comorbidities. Valid, evidence-based sources
7reflecting generally accepted standards of care include
8peer-reviewed scientific studies and medical literature,
9recommendations of nonprofit health care provider professional
10associations and specialty societies, including, but not
11limited to, patient placement criteria and clinical practice
12guidelines, recommendations of federal government agencies,
13and drug labeling approved by the United States Food and Drug
14Administration.
15    "Health care plan" means a plan, including, but not
16limited to, a health maintenance organization, a managed care
17community network as defined in the Illinois Public Aid Code,
18or an accountable care entity as defined in the Illinois
19Public Aid Code that receives capitated payments to cover
20medical services from the Department of Healthcare and Family
21Services, that establishes, operates, or maintains a network
22of health care providers that has entered into an agreement
23with the plan to provide health care services to enrollees to
24whom the plan has the ultimate obligation to arrange for the
25provision of or payment for services through organizational
26arrangements for ongoing quality assurance, utilization review

 

 

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1programs, or dispute resolution. Nothing in this definition
2shall be construed to mean that an independent practice
3association or a physician hospital organization that
4subcontracts with a health care plan is, for purposes of that
5subcontract, a health care plan.
6    For purposes of this definition, "health care plan" shall
7not include the following:
8        (1) indemnity health insurance policies including
9    those using a contracted provider network;
10        (2) health care plans that offer only dental or only
11    vision coverage;
12        (3) preferred provider administrators, as defined in
13    Section 370g(g) of the Illinois Insurance Code;
14        (4) employee or employer self-insured health benefit
15    plans under the federal Employee Retirement Income
16    Security Act of 1974;
17        (5) health care provided pursuant to the Workers'
18    Compensation Act or the Workers' Occupational Diseases
19    Act; and
20        (6) except with respect to subsections (a) and (b) of
21    Section 65 and subsection (a-5) of Section 70,
22    not-for-profit voluntary health services plans with health
23    maintenance organization authority in existence as of
24    January 1, 1999 that are affiliated with a union and that
25    only extend coverage to union members and their
26    dependents.

 

 

10300HB5395sam002- 112 -LRB103 37071 RPS 73717 a

1    "Health care professional" means a physician, a registered
2professional nurse, or other individual appropriately licensed
3or registered to provide health care services.
4    "Health care provider" means any physician, hospital
5facility, facility licensed under the Nursing Home Care Act,
6long-term care facility as defined in Section 1-113 of the
7Nursing Home Care Act, or other person that is licensed or
8otherwise authorized to deliver health care services. Nothing
9in this Act shall be construed to define Independent Practice
10Associations or Physician-Hospital Organizations as health
11care providers.
12    "Health care services" means any services included in the
13furnishing to any individual of medical care, or the
14hospitalization incident to the furnishing of such care, as
15well as the furnishing to any person of any and all other
16services for the purpose of preventing, alleviating, curing,
17or healing human illness or injury including behavioral
18health, mental health, home health, and pharmaceutical
19services and products.
20    "Medical director" means a physician licensed in any state
21to practice medicine in all its branches appointed by a health
22care plan.
23    "Medically necessary" means that a service or product
24addresses the specific needs of a patient for the purpose of
25screening, preventing, diagnosing, managing, or treating an
26illness, injury, or condition or its symptoms and

 

 

10300HB5395sam002- 113 -LRB103 37071 RPS 73717 a

1comorbidities, including minimizing the progression of an
2illness, injury, or condition or its symptoms and
3comorbidities, in a manner that is all of the following:
4        (1) in accordance with generally accepted standards of
5    care;
6        (2) clinically appropriate in terms of type,
7    frequency, extent, site, and duration; and
8        (3) not primarily for the economic benefit of the
9    health care plan, purchaser, or utilization review
10    organization, or for the convenience of the patient,
11    treating physician, or other health care provider.
12    "Person" means a corporation, association, partnership,
13limited liability company, sole proprietorship, or any other
14legal entity.
15    "Physician" means a person licensed under the Medical
16Practice Act of 1987.
17    "Post-stabilization medical services" means health care
18services provided to an enrollee that are furnished in a
19licensed hospital by a provider that is qualified to furnish
20such services, and determined to be medically necessary and
21directly related to the emergency medical condition following
22stabilization.
23    "Stabilization" means, with respect to an emergency
24medical condition, to provide such medical treatment of the
25condition as may be necessary to assure, within reasonable
26medical probability, that no material deterioration of the

 

 

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1condition is likely to result.
2    "Step therapy requirement" means a utilization review or
3formulary requirement that specifies, as a condition of
4coverage under a health care plan, the order in which certain
5health care services must be used to treat or manage an
6enrollee's health condition.
7    "Step therapy requirement" does not include:
8        (1) utilization review to identify when a treatment or
9    health care service is contraindicated or clinically
10    appropriate or to limit quantity or dosage for an enrollee
11    based on utilization review criteria consistent with
12    generally accepted standards of care developed in
13    accordance with Section 87 of this Act;
14        (2) the removal of a drug from a formulary or changing
15    the drug's preferred or cost-sharing tier to higher cost
16    sharing;
17        (3) use of the medical exceptions process under
18    Section 45.1 of this Act; any decision during a medical
19    exceptions process based on cost is step therapy and
20    prohibited;
21        (4) a requirement to obtain prior authorization for
22    the requested treatment; or
23        (5) for health care plans operated or overseen by the
24    Department of Healthcare and Family Services, including
25    Medicaid managed care plans, any utilization controls
26    mandated by 42 CFR 456.703 or a preferred drug list as

 

 

10300HB5395sam002- 115 -LRB103 37071 RPS 73717 a

1    described in Section 5-30.14 of the Illinois Public Aid
2    Code.
3    "Utilization review" means the evaluation of the medical
4necessity, appropriateness, and efficiency of the use of
5health care services, procedures, and facilities.
6    "Utilization review" includes either of the following:
7        (1) prospectively, retrospectively, or concurrently
8    reviewing and approving, modifying, delaying, or denying,
9    based, in whole or in part, on medical necessity, requests
10    by health care providers, enrollees, or their authorized
11    representatives for coverage of health care services
12    before, retrospectively, or concurrently with the
13    provision of health care services to enrollees; or
14        (2) evaluating the medical necessity, appropriateness,
15    level of care, service intensity, efficacy, or efficiency
16    of health care services, benefits, procedures, or
17    settings, under any circumstances, to determine whether a
18    health care service or benefit subject to a medical
19    necessity coverage requirement in a health care plan is
20    covered as medically necessary for an enrollee.
21    "Utilization review criteria" means criteria, standards,
22protocols, or guidelines used by a utilization review program
23to conduct utilization review to ensure that a patient's care
24is aligned with generally accepted standards of care and
25consistent with State law.
26    "Utilization review program" means a program established

 

 

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1by a person to perform utilization review.
2(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
3    (215 ILCS 134/45.1)
4    Sec. 45.1. Medical exceptions procedures required.
5    (a) Notwithstanding any other provision of law, on or
6after January 1, 2018 (the effective date of Public Act
799-761), every insurer licensed in this State to sell a policy
8of group or individual accident and health insurance or a
9health benefits plan shall establish and maintain a medical
10exceptions process that allows covered persons or their
11authorized representatives to request any clinically
12appropriate prescription drug when (1) the drug is not covered
13based on the health benefit plan's formulary; (2) the health
14benefit plan is discontinuing coverage of the drug on the
15plan's formulary for reasons other than safety or other than
16because the prescription drug has been withdrawn from the
17market by the drug's manufacturer; (3) (blank) the
18prescription drug alternatives required to be used in
19accordance with a step therapy requirement (A) has been
20ineffective in the treatment of the enrollee's disease or
21medical condition or, based on both sound clinical evidence
22and medical and scientific evidence, the known relevant
23physical or mental characteristics of the enrollee, and the
24known characteristics of the drug regimen, is likely to be
25ineffective or adversely affect the drug's effectiveness or

 

 

10300HB5395sam002- 117 -LRB103 37071 RPS 73717 a

1patient compliance or (B) has caused or, based on sound
2medical evidence, is likely to cause an adverse reaction or
3harm to the enrollee; or (4) the number of doses available
4under a dose restriction for the prescription drug (A) has
5been ineffective in the treatment of the enrollee's disease or
6medical condition or (B) based on both sound clinical evidence
7and medical and scientific evidence, the known relevant
8physical and mental characteristics of the enrollee, and known
9characteristics of the drug regimen, is likely to be
10ineffective or adversely affect the drug's effective or
11patient compliance.
12    (b) The health carrier's established medical exceptions
13procedures must require, at a minimum, the following:
14        (1) Any request for approval of coverage made verbally
15    or in writing (regardless of whether made using a paper or
16    electronic form or some other writing) at any time shall
17    be reviewed by appropriate health care professionals.
18        (2) The health carrier must, within 72 hours after
19    receipt of a request made under subsection (a) of this
20    Section, either approve or deny the request. In the case
21    of a denial, the health carrier shall provide the covered
22    person or the covered person's authorized representative
23    and the covered person's prescribing provider with the
24    reason for the denial, an alternative covered medication,
25    if applicable, and information regarding the procedure for
26    submitting an appeal to the denial. A health carrier shall

 

 

10300HB5395sam002- 118 -LRB103 37071 RPS 73717 a

1    not use the authorization of alternative covered
2    medications under this Section in a manner that
3    effectively creates a step therapy requirement.
4        (3) In the case of an expedited coverage
5    determination, the health carrier must either approve or
6    deny the request within 24 hours after receipt of the
7    request. In the case of a denial, the health carrier shall
8    provide the covered person or the covered person's
9    authorized representative and the covered person's
10    prescribing provider with the reason for the denial, an
11    alternative covered medication, if applicable, and
12    information regarding the procedure for submitting an
13    appeal to the denial.
14    (c) An off-formulary A step therapy requirement exception
15request shall not be denied be approved if:
16        (1) the formulary required prescription drug is
17    contraindicated;
18        (2) the patient has tried the formulary required
19    prescription drug while under the patient's current or
20    previous health insurance or health benefit plan and the
21    prescribing provider submits evidence of failure or
22    intolerance; or
23        (3) the patient is stable on a prescription drug
24    selected by his or her health care provider for the
25    medical condition under consideration while on a current
26    or previous health insurance or health benefit plan.

 

 

10300HB5395sam002- 119 -LRB103 37071 RPS 73717 a

1    (d) Upon the granting of an exception request, the
2insurer, health plan, utilization review organization, or
3other entity shall authorize the coverage for the drug
4prescribed by the enrollee's treating health care provider, to
5the extent the prescribed drug is a covered drug under the
6policy or contract up to the quantity covered.
7    (e) Any approval of a medical exception request made
8pursuant to this Section shall be honored for 12 months
9following the date of the approval or until renewal of the
10plan.
11    (f) Notwithstanding any other provision of this Section,
12nothing in this Section shall be interpreted or implemented in
13a manner not consistent with the federal Patient Protection
14and Affordable Care Act (Public Law 111-148), as amended by
15the federal Health Care and Education Reconciliation Act of
162010 (Public Law 111-152), and any amendments thereto, or
17regulations or guidance issued under those Acts.
18    (g) Nothing in this Section shall require or authorize the
19State agency responsible for the administration of the medical
20assistance program established under the Illinois Public Aid
21Code to approve, supply, or cover prescription drugs pursuant
22to the procedure established in this Section.
23(Source: P.A. 103-154, eff. 6-30-23.)
 
24    (215 ILCS 134/85)
25    Sec. 85. Utilization review program registration.

 

 

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1    (a) No person may conduct a utilization review program in
2this State unless once every 2 years the person registers the
3utilization review program with the Department and certifies
4compliance with the Health Utilization Management Standards of
5the American Accreditation Healthcare Commission (URAC)
6sufficient to achieve American Accreditation Healthcare
7Commission (URAC) accreditation or submits evidence of
8accreditation by the American Accreditation Healthcare
9Commission (URAC) for its Health Utilization Management
10Standards. Nothing in this Act shall be construed to require a
11health care plan or its subcontractors to become American
12Accreditation Healthcare Commission (URAC) accredited.
13    (b) In addition, the Director of the Department, in
14consultation with the Director of the Department of Public
15Health, may certify alternative utilization review standards
16of national accreditation organizations or entities in order
17for plans to comply with this Section. Any alternative
18utilization review standards shall meet or exceed those
19standards required under subsection (a).
20    (b-5) The Department shall recognize the Accreditation
21Association for Ambulatory Health Care among the list of
22accreditors from which utilization organizations may receive
23accreditation and qualify for reduced registration and renewal
24fees.
25    (c) The provisions of this Section do not apply to:
26        (1) persons providing utilization review program

 

 

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1    services only to the federal government;
2        (2) self-insured health plans under the federal
3    Employee Retirement Income Security Act of 1974, however,
4    this Section does apply to persons conducting a
5    utilization review program on behalf of these health
6    plans;
7        (3) hospitals and medical groups performing
8    utilization review activities for internal purposes unless
9    the utilization review program is conducted for another
10    person.
11    Nothing in this Act prohibits a health care plan or other
12entity from contractually requiring an entity designated in
13item (3) of this subsection to adhere to the utilization
14review program requirements of this Act.
15    (d) This registration shall include submission of all of
16the following information regarding utilization review program
17activities:
18        (1) The name, address, and telephone number of the
19    utilization review programs.
20        (2) The organization and governing structure of the
21    utilization review programs.
22        (3) The number of lives for which utilization review
23    is conducted by each utilization review program.
24        (4) Hours of operation of each utilization review
25    program.
26        (5) Description of the grievance process for each

 

 

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1    utilization review program.
2        (6) Number of covered lives for which utilization
3    review was conducted for the previous calendar year for
4    each utilization review program.
5        (7) Written policies and procedures for protecting
6    confidential information according to applicable State and
7    federal laws for each utilization review program.
8    (e) (1) A utilization review program shall have written
9procedures for assuring that patient-specific information
10obtained during the process of utilization review will be:
11        (A) kept confidential in accordance with applicable
12    State and federal laws; and
13        (B) shared only with the enrollee, the enrollee's
14    designee, the enrollee's health care provider, and those
15    who are authorized by law to receive the information.
16    Summary data shall not be considered confidential if it
17does not provide information to allow identification of
18individual patients or health care providers.
19        (2) Only a clinical peer health care professional may
20    make adverse determinations regarding the medical
21    necessity of health care services during the course of
22    utilization review. Either a health care professional or
23    an accredited algorithmic automated process, or both in
24    combination, may certify the medical necessity of a health
25    care service in accordance with accreditation standards.
26    Nothing in this subsection prohibits an accredited

 

 

10300HB5395sam002- 123 -LRB103 37071 RPS 73717 a

1    algorithmic automated process from being used to refer a
2    case to a clinical peer for a potential adverse
3    determination.
4        (3) When making retrospective reviews, utilization
5    review programs shall base reviews solely on the medical
6    information available to the attending physician or
7    ordering provider at the time the health care services
8    were provided.
9        (4) When making prospective, concurrent, and
10    retrospective determinations, utilization review programs
11    shall collect only information that is necessary to make
12    the determination and shall not routinely require health
13    care providers to numerically code diagnoses or procedures
14    to be considered for certification, unless required under
15    State or federal Medicare or Medicaid rules or
16    regulations, but may request such code if available, or
17    routinely request copies of medical records of all
18    enrollees reviewed. During prospective or concurrent
19    review, copies of medical records shall only be required
20    when necessary to verify that the health care services
21    subject to review are medically necessary. In these cases,
22    only the necessary or relevant sections of the medical
23    record shall be required.
24    (f) If the Department finds that a utilization review
25program is not in compliance with this Section, the Department
26shall issue a corrective action plan and allow a reasonable

 

 

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1amount of time for compliance with the plan. If the
2utilization review program does not come into compliance, the
3Department may issue a cease and desist order. Before issuing
4a cease and desist order under this Section, the Department
5shall provide the utilization review program with a written
6notice of the reasons for the order and allow a reasonable
7amount of time to supply additional information demonstrating
8compliance with requirements of this Section and to request a
9hearing. The hearing notice shall be sent by certified mail,
10return receipt requested, and the hearing shall be conducted
11in accordance with the Illinois Administrative Procedure Act.
12    (g) A utilization review program subject to a corrective
13action may continue to conduct business until a final decision
14has been issued by the Department.
15    (h) Any adverse determination made by a health care plan
16or its subcontractors may be appealed in accordance with
17subsection (f) of Section 45.
18    (i) The Director may by rule establish a registration fee
19for each person conducting a utilization review program. All
20fees paid to and collected by the Director under this Section
21shall be deposited into the Insurance Producer Administration
22Fund.
23(Source: P.A. 99-111, eff. 1-1-16.)
 
24    (215 ILCS 134/87 new)
25    Sec. 87. General standards for use of utilization review

 

 

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1criteria.
2    (a) Beginning January 1, 2026, all utilization review
3programs shall make medical necessity determinations in
4accordance with the requirements of this Section. No policy,
5contract, certificate, formulary, or evidence of coverage
6issued to any enrollee may contain terms or conditions to the
7contrary.
8    (b) All utilization review programs shall determine
9medical necessity by using the most recent treatment criteria
10developed by:
11        (1) an unaffiliated, nonprofit professional
12    association for the relevant clinical specialty;
13        (2) a third-party entity that develops treatment
14    criteria that: (i) are updated annually; (ii) are not paid
15    for clinical care decision outcomes; (iii) do not offer
16    different treatment criteria for the same health care
17    service unless otherwise required by State or federal law;
18    and (iv) are consistent with current generally accepted
19    standards of care; or
20        (3) the Department of Healthcare and Family Services
21    if the criteria are consistent with current generally
22    accepted standards of care.
23    (c) For all level of care placement decisions, the
24utilization review program shall authorize placement at the
25level of care at or above the level ordered by the provider
26using the relevant treatment criteria as specified in

 

 

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1subsection (b). If there is a disagreement between the health
2care plan and the provider or patient, the health care plan or
3utilization review program shall provide its complete
4assessment to the provider and the patient.
5    (d) If a utilization review program purchases or licenses
6utilization review criteria pursuant to this Section, the
7utilization review program shall, before using the criteria,
8verify and document that the criteria were developed in
9accordance with subsection (b).
10    (e) All health care plans and utilization review programs
11must:
12        (1) make an educational program on the chosen
13    treatment criteria available to all staff and contracted
14    entities performing utilization review;
15        (2) provide, at no cost, the treatment criteria and
16    any related training material to providers and enrollees
17    upon request; enrollees and treating providers shall be
18    able to access treatment criteria at any point in time,
19    including before an initial request for authorization;
20        (3) track, identify, and analyze how the treatment
21    criteria are used to certify care, deny care, and support
22    the appeals process;
23        (4) conduct interrater reliability testing to ensure
24    consistency in utilization review decision-making; this
25    testing shall cover all aspects of utilization review
26    criteria as defined in Section 10;

 

 

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1        (5) achieve interrater reliability pass rates of at
2    least 90% and, if this threshold is not met, initiate
3    remediation of poor interrater reliability within 3
4    business days after the finding and conduct interrater
5    reliability testing for all new staff before they can
6    conduct utilization review supervision; and
7        (6) maintain documentation of interrater reliability
8    testing and any remediation and submit to the Department
9    of Insurance, or, in the case of Medicaid managed care
10    organizations, the Department of Healthcare and Family
11    Services, the testing results de-identified of patient or
12    employee personal information and a summary of remedial
13    actions.
14    (f) Beginning January 1, 2026, no utilization review
15program or any policy, contract, certificate, evidence of
16coverage, or formulary shall impose step therapy requirements.
17Nothing in this subsection prohibits a health care plan, by
18contract, written policy, procedure, or any other agreement or
19course of conduct, from requiring a pharmacist to effect
20substitutions of prescription drugs consistent with Section
2119.5 of the Pharmacy Practice Act, under which a pharmacist
22may substitute an interchangeable biologic for a prescribed
23biologic product, and Section 25 of the Pharmacy Practice Act,
24under which a pharmacist may select a generic drug determined
25to be therapeutically equivalent by the United States Food and
26Drug Administration and in accordance with the Illinois Food,

 

 

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1Drug and Cosmetic Act. For health care plans operated or
2overseen by the Department of Healthcare and Family Services,
3including Medicaid managed care plans, the prohibition in this
4subsection does not apply to step therapy requirements for
5drugs that do not appear on the most recent Preferred Drug List
6published by the Department of Healthcare and Family Services.
7    (g) Except for subsection (f), this Section does not apply
8to utilization review concerning diagnosis, prevention, and
9treatment of mental, emotional, nervous, or substance use
10disorders or conditions, which shall be governed by Section
11370c of the Illinois Insurance Code.
12    (h) Nothing in this Section supersedes or waives
13requirements provided under any other State or federal law or
14federal regulation that any coverage subject to this Section
15comply with specific utilization review criteria for a
16specific illness, level of care placement, injury, or
17condition or its symptoms and comorbidities.
 
18    Section 6-15. The Health Carrier External Review Act is
19amended by changing Section 10 as follows:
 
20    (215 ILCS 180/10)
21    Sec. 10. Definitions. For the purposes of this Act:
22    "Adverse determination" means:
23        (1) a determination by a health carrier or its
24    designee utilization review organization that, based upon

 

 

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

 

 

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

 

 

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

 

 

10300HB5395sam002- 132 -LRB103 37071 RPS 73717 a

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

 

 

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

 

 

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

 

 

10300HB5395sam002- 135 -LRB103 37071 RPS 73717 a

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

 

 

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1of treatment in accordance with a health carrier's requirement
2that the health care service or course of treatment, in whole
3or in part, be approved prior to its provision.
4    "Protected health information" means health information
5(i) that identifies an individual who is the subject of the
6information; or (ii) with respect to which there is a
7reasonable basis to believe that the information could be used
8to identify an individual.
9    "Randomized clinical trial" means a controlled prospective
10study of patients that have been randomized into an
11experimental group and a control group at the beginning of the
12study with only the experimental group of patients receiving a
13specific intervention, which includes study of the groups for
14variables and anticipated outcomes over time.
15    "Retrospective review" means any review of a request for a
16benefit that is not a concurrent or prospective review
17request. "Retrospective review" does not include the review of
18a claim that is limited to veracity of documentation or
19accuracy of coding.
20    "Utilization review" has the meaning provided by the
21Managed Care Reform and Patient Rights Act.
22    "Utilization review organization" means a utilization
23review program as defined in the Managed Care Reform and
24Patient Rights Act.
25(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12;
2698-756, eff. 7-16-14.)
 

 

 

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1    Section 6-20. The Prior Authorization Reform Act is
2amended by changing Sections 15 and 20 as follows:
 
3    (215 ILCS 200/15)
4    Sec. 15. Definitions. As used in this Act:
5    "Adverse determination" has the meaning given to that term
6in Section 10 of the Health Carrier External Review Act.
7    "Appeal" means a formal request, either orally or in
8writing, to reconsider an adverse determination.
9    "Approval" means a determination by a health insurance
10issuer or its contracted utilization review organization that
11a health care service has been reviewed and, based on the
12information provided, satisfies the health insurance issuer's
13or its contracted utilization review organization's
14requirements for medical necessity and appropriateness.
15    "Clinical review criteria" has the meaning given to that
16term in Section 10 of the Health Carrier External Review Act.
17    "Department" means the Department of Insurance.
18    "Emergency medical condition" has the meaning given to
19that term in Section 10 of the Managed Care Reform and Patient
20Rights Act.
21    "Emergency services" has the meaning given to that term in
22federal health insurance reform requirements for the group and
23individual health insurance markets, 45 CFR 147.138.
24    "Enrollee" has the meaning given to that term in Section

 

 

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110 of the Managed Care Reform and Patient Rights Act.
2    "Health care professional" has the meaning given to that
3term in Section 10 of the Managed Care Reform and Patient
4Rights Act.
5    "Health care provider" has the meaning given to that term
6in Section 10 of the Managed Care Reform and Patient Rights
7Act, except that facilities licensed under the Nursing Home
8Care Act and long-term care facilities as defined in Section
91-113 of the Nursing Home Care Act are excluded from this Act.
10    "Health care service" means any services or level of
11services included in the furnishing to an individual of
12medical care or the hospitalization incident to the furnishing
13of such care, as well as the furnishing to any person of any
14other services for the purpose of preventing, alleviating,
15curing, or healing human illness or injury, including
16behavioral health, mental health, home health, and
17pharmaceutical services and products.
18    "Health insurance issuer" has the meaning given to that
19term in Section 5 of the Illinois Health Insurance Portability
20and Accountability Act.
21    "Medically necessary" has the meaning given to that term
22in Section 10 of the Managed Care Reform and Patient Rights
23Act. means a health care professional exercising prudent
24clinical judgment would provide care to a patient for the
25purpose of preventing, diagnosing, or treating an illness,
26injury, disease, or its symptoms and that are: (i) in

 

 

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1accordance with generally accepted standards of medical
2practice; (ii) clinically appropriate in terms of type,
3frequency, extent, site, and duration and are considered
4effective for the patient's illness, injury, or disease; and
5(iii) not primarily for the convenience of the patient,
6treating physician, other health care professional, caregiver,
7family member, or other interested party, but focused on what
8is best for the patient's health outcome.
9    "Physician" means a person licensed under the Medical
10Practice Act of 1987 or licensed under the laws of another
11state to practice medicine in all its branches.
12    "Prior authorization" means the process by which health
13insurance issuers or their contracted utilization review
14organizations determine the medical necessity and medical
15appropriateness of otherwise covered health care services
16before the rendering of such health care services. "Prior
17authorization" includes any health insurance issuer's or its
18contracted utilization review organization's requirement that
19an enrollee, health care professional, or health care provider
20notify the health insurance issuer or its contracted
21utilization review organization before, at the time of, or
22concurrent to providing a health care service.
23    "Urgent health care service" means a health care service
24with respect to which the application of the time periods for
25making a non-expedited prior authorization that in the opinion
26of a health care professional with knowledge of the enrollee's

 

 

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1medical condition:
2        (1) could seriously jeopardize the life or health of
3    the enrollee or the ability of the enrollee to regain
4    maximum function; or
5        (2) could subject the enrollee to severe pain that
6    cannot be adequately managed without the care or treatment
7    that is the subject of the utilization review.
8    "Urgent health care service" does not include emergency
9services.
10    "Utilization review organization" has the meaning given to
11that term in 50 Ill. Adm. Code 4520.30.
12(Source: P.A. 102-409, eff. 1-1-22.)
 
13    (215 ILCS 200/20)
14    Sec. 20. Disclosure and review of prior authorization
15requirements.
16    (a) A health insurance issuer shall maintain a complete
17list of services for which prior authorization is required,
18including for all services where prior authorization is
19performed by an entity under contract with the health
20insurance issuer. The health insurance issuer shall publish
21this list on its public website without requiring a member of
22the general public to create any account or enter any
23credentials to access it. The list described in this
24subsection is not required to contain the clinical review
25criteria applicable to these services.

 

 

10300HB5395sam002- 141 -LRB103 37071 RPS 73717 a

1    (b) A health insurance issuer shall make any current prior
2authorization requirements and restrictions, including the
3written clinical review criteria, readily accessible and
4conspicuously posted on its website to enrollees, health care
5professionals, and health care providers. Content published by
6a third party and licensed for use by a health insurance issuer
7or its contracted utilization review organization may be made
8available through the health insurance issuer's or its
9contracted utilization review organization's secure,
10password-protected website so long as the access requirements
11of the website do not unreasonably restrict access.
12Requirements shall be described in detail, written in easily
13understandable language, and readily available to the health
14care professional and health care provider at the point of
15care. The website shall indicate for each service subject to
16prior authorization:
17        (1) when prior authorization became required for
18    policies issued or delivered in Illinois, including the
19    effective date or dates and the termination date or dates,
20    if applicable, in Illinois;
21        (2) the date the Illinois-specific requirement was
22    listed on the health insurance issuer's or its contracted
23    utilization review organization's website;
24        (3) where applicable, the date that prior
25    authorization was removed for Illinois; and
26        (4) where applicable, access to a standardized

 

 

10300HB5395sam002- 142 -LRB103 37071 RPS 73717 a

1    electronic prior authorization request transaction
2    process.
3    (c) The clinical review criteria must:
4        (1) be based on nationally recognized, generally
5    accepted standards except where State law provides its own
6    standard;
7        (2) be developed in accordance with the current
8    standards of a national medical accreditation entity;
9        (3) ensure quality of care and access to needed health
10    care services;
11        (4) be evidence-based;
12        (5) be sufficiently flexible to allow deviations from
13    norms when justified on a case-by-case basis; and
14        (6) be evaluated and updated, if necessary, at least
15    annually.
16    (d) A health insurance issuer shall not deny a claim for
17failure to obtain prior authorization if the prior
18authorization requirement was not in effect on the date of
19service on the claim.
20    (e) A health insurance issuer or its contracted
21utilization review organization shall not deem as incidental
22or deny supplies or health care services that are routinely
23used as part of a health care service when:
24        (1) an associated health care service has received
25    prior authorization; or
26        (2) prior authorization for the health care service is

 

 

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1    not required.
2    (f) If a health insurance issuer intends either to
3implement a new prior authorization requirement or restriction
4or amend an existing requirement or restriction, the health
5insurance issuer shall provide contracted health care
6professionals and contracted health care providers of
7enrollees written notice of the new or amended requirement or
8amendment no less than 60 days before the requirement or
9restriction is implemented. The written notice may be provided
10in an electronic format, including email or facsimile, if the
11health care professional or health care provider has agreed in
12advance to receive notices electronically. The health
13insurance issuer shall ensure that the new or amended
14requirement is not implemented unless the health insurance
15issuer's or its contracted utilization review organization's
16website has been updated to reflect the new or amended
17requirement or restriction.
18    (g) Entities using prior authorization shall make
19statistics available regarding prior authorization approvals
20and denials on their website in a readily accessible format.
21The statistics must be updated annually and include all of the
22following information:
23        (1) a list of all health care services, including
24    medications, that are subject to prior authorization;
25        (2) the total number of prior authorization requests
26    received;

 

 

10300HB5395sam002- 144 -LRB103 37071 RPS 73717 a

1        (3) the number of prior authorization requests denied
2    during the previous plan year by the health insurance
3    issuer or its contracted utilization review organization
4    with respect to each service described in paragraph (1)
5    and the top 5 reasons for denial;
6        (4) the number of requests described in paragraph (3)
7    that were appealed, the number of the appealed requests
8    that upheld the adverse determination, and the number of
9    appealed requests that reversed the adverse determination;
10        (5) the average time between submission and response;
11    and
12        (6) any other information as the Director determines
13    appropriate.
14(Source: P.A. 102-409, eff. 1-1-22.)
 
15    Section 6-25. The Illinois Public Aid Code is amended by
16changing Section 5-16.12 as follows:
 
17    (305 ILCS 5/5-16.12)
18    Sec. 5-16.12. Managed Care Reform and Patient Rights Act.
19The medical assistance program and other programs administered
20by the Department are subject to the provisions of the Managed
21Care Reform and Patient Rights Act. The Department may adopt
22rules to implement those provisions. These rules shall require
23compliance with that Act in the medical assistance managed
24care programs and other programs administered by the

 

 

10300HB5395sam002- 145 -LRB103 37071 RPS 73717 a

1Department. The medical assistance fee-for-service program is
2not subject to the provisions of the Managed Care Reform and
3Patient Rights Act, except for Sections 85 and 87 of the
4Managed Care Reform and Patient Rights Act and for any
5definition in Section 10 of the Managed Care Reform and
6Patient Rights Act that applies to Sections 85 and 87 of the
7Managed Care Reform and Patient Rights Act.
8    Nothing in the Managed Care Reform and Patient Rights Act
9shall be construed to mean that the Department is a health care
10plan as defined in that Act simply because the Department
11enters into contractual relationships with health care plans;
12provided that this clause shall not defeat the applicability
13of Sections 10, 85, and 87 of the Managed Care Reform and
14Patient Rights Act to the fee-for-service program.
15(Source: P.A. 91-617, eff. 1-1-00.)
 
16
Article 99.

 
17    Section 99-95. No acceleration or delay. Where this Act
18makes changes in a statute that is represented in this Act by
19text that is not yet or no longer in effect (for example, a
20Section represented by multiple versions), the use of that
21text does not accelerate or delay the taking effect of (i) the
22changes made by this Act or (ii) provisions derived from any
23other Public Act.
 

 

 

10300HB5395sam002- 146 -LRB103 37071 RPS 73717 a

1    Section 99-99. Effective date. This Act takes effect
2January 1, 2025, except that the changes to Section 45.1 of the
3Managed Care Reform and Patient Rights Act take effect January
41, 2026.".