Full Text of HB0465 101st General Assembly
HB0465ham001 101ST GENERAL ASSEMBLY | Rep. Gregory Harris Filed: 3/11/2019
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| 1 | | AMENDMENT TO HOUSE BILL 465
| 2 | | AMENDMENT NO. ______. Amend House Bill 465 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. The Freedom of Information Act is amended by | 5 | | changing Section 7.5 as follows: | 6 | | (5 ILCS 140/7.5) | 7 | | Sec. 7.5. Statutory exemptions. To the extent provided for | 8 | | by the statutes referenced below, the following shall be exempt | 9 | | from inspection and copying: | 10 | | (a) All information determined to be confidential | 11 | | under Section 4002 of the Technology Advancement and | 12 | | Development Act. | 13 | | (b) Library circulation and order records identifying | 14 | | library users with specific materials under the Library | 15 | | Records Confidentiality Act. | 16 | | (c) Applications, related documents, and medical |
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| 1 | | records received by the Experimental Organ Transplantation | 2 | | Procedures Board and any and all documents or other records | 3 | | prepared by the Experimental Organ Transplantation | 4 | | Procedures Board or its staff relating to applications it | 5 | | has received. | 6 | | (d) Information and records held by the Department of | 7 | | Public Health and its authorized representatives relating | 8 | | to known or suspected cases of sexually transmissible | 9 | | disease or any information the disclosure of which is | 10 | | restricted under the Illinois Sexually Transmissible | 11 | | Disease Control Act. | 12 | | (e) Information the disclosure of which is exempted | 13 | | under Section 30 of the Radon Industry Licensing Act. | 14 | | (f) Firm performance evaluations under Section 55 of | 15 | | the Architectural, Engineering, and Land Surveying | 16 | | Qualifications Based Selection Act. | 17 | | (g) Information the disclosure of which is restricted | 18 | | and exempted under Section 50 of the Illinois Prepaid | 19 | | Tuition Act. | 20 | | (h) Information the disclosure of which is exempted | 21 | | under the State Officials and Employees Ethics Act, and | 22 | | records of any lawfully created State or local inspector | 23 | | general's office that would be exempt if created or | 24 | | obtained by an Executive Inspector General's office under | 25 | | that Act. | 26 | | (i) Information contained in a local emergency energy |
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| 1 | | plan submitted to a municipality in accordance with a local | 2 | | emergency energy plan ordinance that is adopted under | 3 | | Section 11-21.5-5 of the Illinois Municipal Code. | 4 | | (j) Information and data concerning the distribution | 5 | | of surcharge moneys collected and remitted by carriers | 6 | | under the Emergency Telephone System Act. | 7 | | (k) Law enforcement officer identification information | 8 | | or driver identification information compiled by a law | 9 | | enforcement agency or the Department of Transportation | 10 | | under Section 11-212 of the Illinois Vehicle Code. | 11 | | (l) Records and information provided to a residential | 12 | | health care facility resident sexual assault and death | 13 | | review team or the Executive Council under the Abuse | 14 | | Prevention Review Team Act. | 15 | | (m) Information provided to the predatory lending | 16 | | database created pursuant to Article 3 of the Residential | 17 | | Real Property Disclosure Act, except to the extent | 18 | | authorized under that Article. | 19 | | (n) Defense budgets and petitions for certification of | 20 | | compensation and expenses for court appointed trial | 21 | | counsel as provided under Sections 10 and 15 of the Capital | 22 | | Crimes Litigation Act. This subsection (n) shall apply | 23 | | until the conclusion of the trial of the case, even if the | 24 | | prosecution chooses not to pursue the death penalty prior | 25 | | to trial or sentencing. | 26 | | (o) Information that is prohibited from being |
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| 1 | | disclosed under Section 4 of the Illinois Health and | 2 | | Hazardous Substances Registry Act. | 3 | | (p) Security portions of system safety program plans, | 4 | | investigation reports, surveys, schedules, lists, data, or | 5 | | information compiled, collected, or prepared by or for the | 6 | | Regional Transportation Authority under Section 2.11 of | 7 | | the Regional Transportation Authority Act or the St. Clair | 8 | | County Transit District under the Bi-State Transit Safety | 9 | | Act. | 10 | | (q) Information prohibited from being disclosed by the | 11 | | Personnel Record Records Review Act. | 12 | | (r) Information prohibited from being disclosed by the | 13 | | Illinois School Student Records Act. | 14 | | (s) Information the disclosure of which is restricted | 15 | | under Section 5-108 of the Public Utilities Act.
| 16 | | (t) All identified or deidentified health information | 17 | | in the form of health data or medical records contained in, | 18 | | stored in, submitted to, transferred by, or released from | 19 | | the Illinois Health Information Exchange, and identified | 20 | | or deidentified health information in the form of health | 21 | | data and medical records of the Illinois Health Information | 22 | | Exchange in the possession of the Illinois Health | 23 | | Information Exchange Authority due to its administration | 24 | | of the Illinois Health Information Exchange. The terms | 25 | | "identified" and "deidentified" shall be given the same | 26 | | meaning as in the Health Insurance Portability and |
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| 1 | | Accountability Act of 1996, Public Law 104-191, or any | 2 | | subsequent amendments thereto, and any regulations | 3 | | promulgated thereunder. | 4 | | (u) Records and information provided to an independent | 5 | | team of experts under the Developmental Disability and | 6 | | Mental Health Safety Act (also known as Brian's Law ) . | 7 | | (v) Names and information of people who have applied | 8 | | for or received Firearm Owner's Identification Cards under | 9 | | the Firearm Owners Identification Card Act or applied for | 10 | | or received a concealed carry license under the Firearm | 11 | | Concealed Carry Act, unless otherwise authorized by the | 12 | | Firearm Concealed Carry Act; and databases under the | 13 | | Firearm Concealed Carry Act, records of the Concealed Carry | 14 | | Licensing Review Board under the Firearm Concealed Carry | 15 | | Act, and law enforcement agency objections under the | 16 | | Firearm Concealed Carry Act. | 17 | | (w) Personally identifiable information which is | 18 | | exempted from disclosure under subsection (g) of Section | 19 | | 19.1 of the Toll Highway Act. | 20 | | (x) Information which is exempted from disclosure | 21 | | under Section 5-1014.3 of the Counties Code or Section | 22 | | 8-11-21 of the Illinois Municipal Code. | 23 | | (y) Confidential information under the Adult | 24 | | Protective Services Act and its predecessor enabling | 25 | | statute, the Elder Abuse and Neglect Act, including | 26 | | information about the identity and administrative finding |
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| 1 | | against any caregiver of a verified and substantiated | 2 | | decision of abuse, neglect, or financial exploitation of an | 3 | | eligible adult maintained in the Registry established | 4 | | under Section 7.5 of the Adult Protective Services Act. | 5 | | (z) Records and information provided to a fatality | 6 | | review team or the Illinois Fatality Review Team Advisory | 7 | | Council under Section 15 of the Adult Protective Services | 8 | | Act. | 9 | | (aa) Information which is exempted from disclosure | 10 | | under Section 2.37 of the Wildlife Code. | 11 | | (bb) Information which is or was prohibited from | 12 | | disclosure by the Juvenile Court Act of 1987. | 13 | | (cc) Recordings made under the Law Enforcement | 14 | | Officer-Worn Body Camera Act, except to the extent | 15 | | authorized under that Act. | 16 | | (dd) Information that is prohibited from being | 17 | | disclosed under Section 45 of the Condominium and Common | 18 | | Interest Community Ombudsperson Act. | 19 | | (ee) Information that is exempted from disclosure | 20 | | under Section 30.1 of the Pharmacy Practice Act. | 21 | | (ff) Information that is exempted from disclosure | 22 | | under the Revised Uniform Unclaimed Property Act. | 23 | | (gg) Information that is prohibited from being | 24 | | disclosed under Section 7-603.5 of the Illinois Vehicle | 25 | | Code. | 26 | | (hh) Records that are exempt from disclosure under |
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| 1 | | Section 1A-16.7 of the Election Code. | 2 | | (ii) Information which is exempted from disclosure | 3 | | under Section 2505-800 of the Department of Revenue Law of | 4 | | the Civil Administrative Code of Illinois. | 5 | | (jj) Information and reports that are required to be | 6 | | submitted to the Department of Labor by registering day and | 7 | | temporary labor service agencies but are exempt from | 8 | | disclosure under subsection (a-1) of Section 45 of the Day | 9 | | and Temporary Labor Services Act. | 10 | | (kk) Information prohibited from disclosure under the | 11 | | Seizure and Forfeiture Reporting Act. | 12 | | (ll) Information the disclosure of which is restricted | 13 | | and exempted under Section 5-30.8 of the Illinois Public | 14 | | Aid Code. | 15 | | (mm) (ll) Records that are exempt from disclosure under | 16 | | Section 4.2 of the Crime Victims Compensation Act. | 17 | | (nn) (ll) Information that is exempt from disclosure | 18 | | under Section 70 of the Higher Education Student Assistance | 19 | | Act. | 20 | | (oo) Information that is exempt from disclosure under | 21 | | subsection (j) of Section 5-36 of the Illinois Public Aid | 22 | | Code. | 23 | | (Source: P.A. 99-78, eff. 7-20-15; 99-298, eff. 8-6-15; 99-352, | 24 | | eff. 1-1-16; 99-642, eff. 7-28-16; 99-776, eff. 8-12-16; | 25 | | 99-863, eff. 8-19-16; 100-20, eff. 7-1-17; 100-22, eff. 1-1-18; | 26 | | 100-201, eff. 8-18-17; 100-373, eff. 1-1-18; 100-464, eff. |
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| 1 | | 8-28-17; 100-465, eff. 8-31-17; 100-512, eff. 7-1-18; 100-517, | 2 | | eff. 6-1-18; 100-646, eff. 7-27-18; 100-690, eff. 1-1-19; | 3 | | 100-863, eff. 8-14-18; 100-887, eff. 8-14-18; revised | 4 | | 10-12-18.) | 5 | | Section 5. The State Employees Group Insurance Act of 1971 | 6 | | is amended by changing Section 6.11 as follows:
| 7 | | (5 ILCS 375/6.11)
| 8 | | Sec. 6.11. Required health benefits; Illinois Insurance | 9 | | Code
requirements. The program of health
benefits shall provide | 10 | | the post-mastectomy care benefits required to be covered
by a | 11 | | policy of accident and health insurance under Section 356t of | 12 | | the Illinois
Insurance Code. The program of health benefits | 13 | | shall provide the coverage
required under Sections 356g, | 14 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 15 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 16 | | 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, and 356z.26, and | 17 | | 356z.29 , and 356z.32 of the
Illinois Insurance Code.
The | 18 | | program of health benefits must comply with Sections 155.22a, | 19 | | 155.37, 355b, 356z.19, 370c, and 370c.1 , and Article XXXIIB of | 20 | | the
Illinois Insurance Code. The Department of Insurance shall | 21 | | enforce the requirements of this Section.
| 22 | | Rulemaking authority to implement Public Act 95-1045, if | 23 | | any, is conditioned on the rules being adopted in accordance | 24 | | with all provisions of the Illinois Administrative Procedure |
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| 1 | | Act and all rules and procedures of the Joint Committee on | 2 | | Administrative Rules; any purported rule not so adopted, for | 3 | | whatever reason, is unauthorized. | 4 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 5 | | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff. | 6 | | 1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | 7 | | 10-3-18.) | 8 | | Section 10. The Illinois Insurance Code is amended by | 9 | | adding Article XXXIIB as follows: | 10 | | (215 ILCS 5/Art. XXXIIB heading new) | 11 | | ARTICLE XXXIIB. PHARMACY BENEFIT MANAGERS | 12 | | (215 ILCS 5/513b1 new) | 13 | | Sec. 513b1. Pharmacy benefit manager contracts. | 14 | | (a) As used in this Section: | 15 | | "Maximum allowable cost" means the per-unit amount that a | 16 | | pharmacy benefit manager reimburses a pharmacist for a | 17 | | prescription drug, excluding dispensing fees, prior to the | 18 | | application of copayments, coinsurance, and other cost-sharing | 19 | | charges, if any. | 20 | | "Pharmacy benefit manager" means a person, business, or | 21 | | entity, including a wholly or partially owned or controlled | 22 | | subsidiary of a pharmacy benefit manager, that provides claims | 23 | | processing services or other prescription drug or device |
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| 1 | | services, or both, for health benefit plans. | 2 | | (b) A contract between a health insurer and a pharmacy | 3 | | benefit manager must require that the pharmacy benefit manager: | 4 | | (1) Update maximum allowable cost pricing information | 5 | | at least every 7 calendar days. | 6 | | (2) Maintain a process that will, in a timely manner, | 7 | | eliminate drugs from maximum allowable cost lists or modify | 8 | | drug prices to remain consistent with changes in pricing | 9 | | data used in formulating maximum allowable cost prices and | 10 | | product availability. | 11 | | (c) In order to place a particular prescription drug on a | 12 | | maximum allowable cost list, the pharmacy benefit manager must, | 13 | | at a minimum, ensure that: | 14 | | (1) The drug must have at least 3 or more nationally | 15 | | available, therapeutically equivalent, multiple source | 16 | | generic drugs with a significant cost difference. | 17 | | (2) The products must be listed as therapeutically and | 18 | | pharmaceutically equivalent or "A" or "AB" rated in the | 19 | | Food and Drug Administration's most recent version of the | 20 | | "Orange Book." | 21 | | (3) The product must be available for purchase without | 22 | | limitations by all pharmacies in the State from national or | 23 | | regional wholesalers and not obsolete or temporarily | 24 | | unavailable. | 25 | | (d) A contract between a health insurer and a pharmacy | 26 | | benefit manager must prohibit the pharmacy benefit manager from |
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| 1 | | limiting a pharmacist's ability to disclose whether the | 2 | | cost-sharing obligation exceeds the retail price for a covered | 3 | | prescription drug, and the availability of a more affordable | 4 | | alternative drug, in accordance with Section 42 of the Pharmacy | 5 | | Practice Act. | 6 | | (e) A contract between a health insurer and a pharmacy | 7 | | benefit manager must prohibit the pharmacy benefit manager from | 8 | | requiring an insured to make a payment for a prescription drug | 9 | | at the point of sale in an amount that exceeds the lesser of: | 10 | | (1) the applicable cost-sharing amount; or | 11 | | (2) the retail price of the drug in the absence of | 12 | | prescription drug coverage. | 13 | | (f) This Section applies to contracts entered into or | 14 | | renewed on or after July 1, 2020. | 15 | | (g) This Section applies to any group or individual policy | 16 | | of accident and health insurance or managed care plan that | 17 | | provides coverage for prescription drugs and that is amended, | 18 | | delivered, issued, or renewed on or after July 1, 2020. | 19 | | (215 ILCS 5/513b2 new) | 20 | | Sec. 513b2. Licensure requirements. | 21 | | (a) Beginning on July 1, 2020, to conduct business in this | 22 | | State, a pharmacy benefit manager must register with the | 23 | | Director. To initially register or renew a registration, a | 24 | | pharmacy benefit manager shall submit: | 25 | | (1) A nonrefundable fee not to exceed $500. |
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| 1 | | (2) A copy of the registrant's corporate charter, | 2 | | articles of incorporation, or other charter document. | 3 | | (3) A completed registration form adopted by the | 4 | | Director containing: | 5 | | (A) The name and address of the registrant. | 6 | | (B) The name, address, and official position of | 7 | | each officer and director of the registrant. | 8 | | (b) The registrant shall report any change in information | 9 | | required under this Section to the Director in writing within | 10 | | 60 days after the change occurs. | 11 | | (c) Upon receipt of a completed registration form, the | 12 | | required documents, and the registration fee, the Director | 13 | | shall issue a registration certificate. The certificate may be | 14 | | in paper or electronic form, and shall clearly indicate the | 15 | | expiration date of the registration. Registration certificates | 16 | | are nontransferable. | 17 | | (d) A registration certificate is valid for 2 years after | 18 | | its date of issue. The Director shall adopt by rule an initial | 19 | | registration fee not to exceed $500 and a registration renewal | 20 | | fee not to exceed $500, both of which shall be nonrefundable. | 21 | | Total fees may not exceed the cost of administering this | 22 | | Section. | 23 | | (e) The Department shall adopt any rules necessary to | 24 | | implement this Section. | 25 | | (215 ILCS 5/513b3 new) |
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| 1 | | Sec. 513b3. Examination. | 2 | | (a) The Director, or his or her designee, may examine a | 3 | | registered pharmacy benefit manager. | 4 | | (b) Any pharmacy benefit manager being examined shall | 5 | | provide to the Director, or his or her designee, convenient and | 6 | | free access to all books, records, documents, and other papers | 7 | | relating to such pharmacy benefit manager's business affairs at | 8 | | all reasonable hours at its offices. | 9 | | (c) The Director, or his or her designee, may administer | 10 | | oaths and thereafter examine any individual about the business | 11 | | of the pharmacy benefit manager. | 12 | | (d) The examiners designated by the Director under this | 13 | | Section may make reports to the Director. Any report alleging | 14 | | substantive violations of this Article, any applicable | 15 | | provisions of this Code, or any applicable Part of Title 50 of | 16 | | the Illinois Administrative Code shall be in writing and be | 17 | | based upon facts obtained by the examiners. The report shall be | 18 | | verified by the examiners. | 19 | | (e) If a report is made, the Director shall either deliver | 20 | | a duplicate report to the pharmacy benefit manager being | 21 | | examined or send such duplicate by certified or registered mail | 22 | | to the pharmacy benefit manager's address specified in the | 23 | | records of the Department. The Director shall afford the | 24 | | pharmacy benefit manager an opportunity to request a hearing to | 25 | | object to the report. The pharmacy benefit manager may request | 26 | | a hearing within 30 days after receipt of the duplicate report |
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| 1 | | by giving the Director written notice of such request together | 2 | | with written objections to the report. Any hearing shall be | 3 | | conducted in accordance with Sections 402 and 403 of this Code. | 4 | | The right to a hearing is waived if the delivery of the report | 5 | | is refused or the report is otherwise undeliverable or the | 6 | | pharmacy benefit manager does not timely request a hearing. | 7 | | After the hearing or upon expiration of the time period during | 8 | | which a pharmacy benefit manager may request a hearing, if the | 9 | | examination reveals that the pharmacy benefit manager is | 10 | | operating in violation of any applicable provision of this | 11 | | Code, any applicable Part of Title 50 of the Illinois | 12 | | Administrative Code, a provision of this Article, or prior | 13 | | order, the Director, in the written order, may require the | 14 | | pharmacy benefit manager to take any action the Director | 15 | | considers necessary or appropriate in accordance with the | 16 | | report or examination hearing. If the Director issues an order, | 17 | | it shall be issued within 90 days after the report is filed, or | 18 | | if there is a hearing, within 90 days after the conclusion of | 19 | | the hearing. The order is subject to review under the | 20 | | Administrative Review Law. | 21 | | (215 ILCS 5/513b4 new) | 22 | | Sec. 513b4. Administrative fine. | 23 | | (a) If the Director finds that one or more grounds exist | 24 | | for the revocation or suspension of a registration issued under | 25 | | this Article, the Director may, in lieu of or in addition to |
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| 1 | | such suspension or revocation, impose a fine upon the pharmacy | 2 | | benefit manager as provided under subsection (b). | 3 | | (b) With respect to any knowing and willful violation of a | 4 | | lawful order of the Director, any applicable portion of this | 5 | | Code, Part of Title 50 of the Illinois Administrative Code, or | 6 | | provision of this Article, the Director may impose a fine upon | 7 | | the pharmacy benefit manager in an amount not to exceed $50,000 | 8 | | for each violation. | 9 | | (215 ILCS 5/513b5 new) | 10 | | Sec. 513b5. Failure to register. Any pharmacy benefit | 11 | | manager that operates without a registration or fails to | 12 | | register with the Director and pay the fee prescribed by this | 13 | | Article is an unauthorized insurer as defined in Article VII of | 14 | | this Code and shall be subject to all penalties provided for | 15 | | therein. | 16 | | (215 ILCS 5/513b6 new) | 17 | | Sec. 513b6. Insurance Producer Administration Fund. All | 18 | | fees and fines paid to and collected by the Director under this | 19 | | Article shall be paid promptly after receipt thereof, together | 20 | | with a detailed statement of such fees, into the Insurance | 21 | | Producer Administration Fund. The moneys deposited into the | 22 | | Insurance Producer Administration Fund may be transferred to | 23 | | the Professions Indirect Cost Fund, as authorized under Section | 24 | | 2105-300 of the Department of Professional Regulation Law of |
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| 1 | | the Civil Administrative Code of Illinois. | 2 | | Section 15. The Health Maintenance Organization Act is | 3 | | amended by changing Section 5-3 as follows:
| 4 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 5 | | Sec. 5-3. Insurance Code provisions.
| 6 | | (a) Health Maintenance Organizations
shall be subject to | 7 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 8 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 9 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 10 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 11 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 12 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | 13 | | 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 364, | 14 | | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, | 15 | | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | 16 | | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | 17 | | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | 18 | | and XXVI , and XXXIIB of the Illinois Insurance Code.
| 19 | | (b) For purposes of the Illinois Insurance Code, except for | 20 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 21 | | Maintenance Organizations in
the following categories are | 22 | | deemed to be "domestic companies":
| 23 | | (1) a corporation authorized under the
Dental Service | 24 | | Plan Act or the Voluntary Health Services Plans Act;
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| 1 | | (2) a corporation organized under the laws of this | 2 | | State; or
| 3 | | (3) a corporation organized under the laws of another | 4 | | state, 30% or more
of the enrollees of which are residents | 5 | | of this State, except a
corporation subject to | 6 | | substantially the same requirements in its state of
| 7 | | organization as is a "domestic company" under Article VIII | 8 | | 1/2 of the
Illinois Insurance Code.
| 9 | | (c) In considering the merger, consolidation, or other | 10 | | acquisition of
control of a Health Maintenance Organization | 11 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 12 | | (1) the Director shall give primary consideration to | 13 | | the continuation of
benefits to enrollees and the financial | 14 | | conditions of the acquired Health
Maintenance Organization | 15 | | after the merger, consolidation, or other
acquisition of | 16 | | control takes effect;
| 17 | | (2)(i) the criteria specified in subsection (1)(b) of | 18 | | Section 131.8 of
the Illinois Insurance Code shall not | 19 | | apply and (ii) the Director, in making
his determination | 20 | | with respect to the merger, consolidation, or other
| 21 | | acquisition of control, need not take into account the | 22 | | effect on
competition of the merger, consolidation, or | 23 | | other acquisition of control;
| 24 | | (3) the Director shall have the power to require the | 25 | | following
information:
| 26 | | (A) certification by an independent actuary of the |
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| 1 | | adequacy
of the reserves of the Health Maintenance | 2 | | Organization sought to be acquired;
| 3 | | (B) pro forma financial statements reflecting the | 4 | | combined balance
sheets of the acquiring company and | 5 | | the Health Maintenance Organization sought
to be | 6 | | acquired as of the end of the preceding year and as of | 7 | | a date 90 days
prior to the acquisition, as well as pro | 8 | | forma financial statements
reflecting projected | 9 | | combined operation for a period of 2 years;
| 10 | | (C) a pro forma business plan detailing an | 11 | | acquiring party's plans with
respect to the operation | 12 | | of the Health Maintenance Organization sought to
be | 13 | | acquired for a period of not less than 3 years; and
| 14 | | (D) such other information as the Director shall | 15 | | require.
| 16 | | (d) The provisions of Article VIII 1/2 of the Illinois | 17 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 18 | | any health maintenance
organization of greater than 10% of its
| 19 | | enrollee population (including without limitation the health | 20 | | maintenance
organization's right, title, and interest in and to | 21 | | its health care
certificates).
| 22 | | (e) In considering any management contract or service | 23 | | agreement subject
to Section 141.1 of the Illinois Insurance | 24 | | Code, the Director (i) shall, in
addition to the criteria | 25 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 26 | | into account the effect of the management contract or
service |
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| 1 | | agreement on the continuation of benefits to enrollees and the
| 2 | | financial condition of the health maintenance organization to | 3 | | be managed or
serviced, and (ii) need not take into account the | 4 | | effect of the management
contract or service agreement on | 5 | | competition.
| 6 | | (f) Except for small employer groups as defined in the | 7 | | Small Employer
Rating, Renewability and Portability Health | 8 | | Insurance Act and except for
medicare supplement policies as | 9 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 10 | | Maintenance Organization may by contract agree with a
group or | 11 | | other enrollment unit to effect refunds or charge additional | 12 | | premiums
under the following terms and conditions:
| 13 | | (i) the amount of, and other terms and conditions with | 14 | | respect to, the
refund or additional premium are set forth | 15 | | in the group or enrollment unit
contract agreed in advance | 16 | | of the period for which a refund is to be paid or
| 17 | | additional premium is to be charged (which period shall not | 18 | | be less than one
year); and
| 19 | | (ii) the amount of the refund or additional premium | 20 | | shall not exceed 20%
of the Health Maintenance | 21 | | Organization's profitable or unprofitable experience
with | 22 | | respect to the group or other enrollment unit for the | 23 | | period (and, for
purposes of a refund or additional | 24 | | premium, the profitable or unprofitable
experience shall | 25 | | be calculated taking into account a pro rata share of the
| 26 | | Health Maintenance Organization's administrative and |
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| 1 | | marketing expenses, but
shall not include any refund to be | 2 | | made or additional premium to be paid
pursuant to this | 3 | | subsection (f)). The Health Maintenance Organization and | 4 | | the
group or enrollment unit may agree that the profitable | 5 | | or unprofitable
experience may be calculated taking into | 6 | | account the refund period and the
immediately preceding 2 | 7 | | plan years.
| 8 | | The Health Maintenance Organization shall include a | 9 | | statement in the
evidence of coverage issued to each enrollee | 10 | | describing the possibility of a
refund or additional premium, | 11 | | and upon request of any group or enrollment unit,
provide to | 12 | | the group or enrollment unit a description of the method used | 13 | | to
calculate (1) the Health Maintenance Organization's | 14 | | profitable experience with
respect to the group or enrollment | 15 | | unit and the resulting refund to the group
or enrollment unit | 16 | | or (2) the Health Maintenance Organization's unprofitable
| 17 | | experience with respect to the group or enrollment unit and the | 18 | | resulting
additional premium to be paid by the group or | 19 | | enrollment unit.
| 20 | | In no event shall the Illinois Health Maintenance | 21 | | Organization
Guaranty Association be liable to pay any | 22 | | contractual obligation of an
insolvent organization to pay any | 23 | | refund authorized under this Section.
| 24 | | (g) Rulemaking authority to implement Public Act 95-1045, | 25 | | if any, is conditioned on the rules being adopted in accordance | 26 | | with all provisions of the Illinois Administrative Procedure |
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| 1 | | Act and all rules and procedures of the Joint Committee on | 2 | | Administrative Rules; any purported rule not so adopted, for | 3 | | whatever reason, is unauthorized. | 4 | | (Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17; | 5 | | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff. | 6 | | 8-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | 7 | | 10-4-18.) | 8 | | Section 20. The Managed Care Reform and Patient Rights Act | 9 | | is amended by changing Sections 30 and 65 as follows:
| 10 | | (215 ILCS 134/30)
| 11 | | Sec. 30. Prohibitions.
| 12 | | (a) No health care plan or its subcontractors may prohibit | 13 | | or discourage
health care providers
by contract or policy from
| 14 | | discussing any health care services and health care providers, | 15 | | utilization
review and quality assurance policies, terms and | 16 | | conditions of plans and plan
policy with enrollees, prospective | 17 | | enrollees, providers, or the public.
| 18 | | (b) No health care plan by contract, written policy, or | 19 | | procedure may
permit or allow an individual or entity to | 20 | | dispense a different
drug in place of the drug or brand of drug | 21 | | ordered or prescribed without the
express permission of the | 22 | | person ordering or prescribing the drug, except as
provided | 23 | | under Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
| 24 | | (c) No health care plan or its subcontractors may by |
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| 1 | | contract, written
policy, procedure, or otherwise mandate or | 2 | | require an enrollee
to substitute his or her participating | 3 | | primary care physician
under the plan during inpatient | 4 | | hospitalization, such as with a hospitalist physician licensed | 5 | | to practice medicine in all its branches,
without the agreement | 6 | | of that enrollee's
participating primary care physician. | 7 | | "Participating primary care
physician" for health care plans | 8 | | and subcontractors that do not require
coordination of care by | 9 | | a primary care physician means the participating
physician | 10 | | treating the patient. All health care plans shall inform | 11 | | enrollees
of any policies, recommendations, or guidelines | 12 | | concerning the
substitution of the enrollee's primary care | 13 | | physician when hospitalization is
necessary in the manner set | 14 | | forth in subsections (d) and (e) of Section 15.
| 15 | | (d) A health care plan shall apply any third-party | 16 | | payments, financial assistance, discount, product vouchers, or | 17 | | any other reduction in out-of-pocket expenses made by or on | 18 | | behalf of such insured for prescription drugs toward a covered | 19 | | individual's deductible, copay, or cost-sharing | 20 | | responsibility, or out-of-pocket maximum associated with the | 21 | | individual's health insurance. | 22 | | (e) (d) Any violation of this Section shall be subject to | 23 | | the
penalties under this Act.
| 24 | | (Source: P.A. 94-866, eff. 6-16-06.)
| 25 | | (215 ILCS 134/65)
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| 1 | | Sec. 65. Emergency services prior to stabilization.
| 2 | | (a) A health care plan
that provides or that is required by | 3 | | law to provide coverage for emergency
services shall provide | 4 | | coverage such that payment under this coverage is not
dependent | 5 | | upon whether the services are performed by a plan or non-plan | 6 | | health
care provider and without regard to prior authorization. | 7 | | This coverage shall be
at the same benefit level as if the | 8 | | services or treatment had been rendered by
the health care plan | 9 | | physician licensed to practice medicine in all
its branches or | 10 | | health care provider.
| 11 | | (b) Prior authorization or approval by the plan shall not | 12 | | be required for
emergency services.
| 13 | | (c) Coverage and payment shall only be retrospectively | 14 | | denied under the
following circumstances:
| 15 | | (1) upon reasonable determination that the emergency | 16 | | services claimed were
never performed;
| 17 | | (2) upon timely determination that the emergency | 18 | | evaluation and treatment
were
rendered to an enrollee who | 19 | | sought emergency services and whose circumstance
did not | 20 | | meet the definition of emergency medical condition; any | 21 | | denial under this paragraph (2) shall be based on the | 22 | | prudent layperson standard at the time the enrollee first | 23 | | sought emergency evaluation and treatment for his or her | 24 | | symptoms; insurers are prohibited from denying claims | 25 | | under this paragraph (2) based on the use of diagnosis or | 26 | | procedure codes;
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| 1 | | (3) upon determination that the patient receiving such | 2 | | services was not an
enrollee of the health care plan; or
| 3 | | (4) upon material misrepresentation by the enrollee or | 4 | | health care
provider; "material" means a fact or situation | 5 | | that is not merely technical in
nature and results or could | 6 | | result in a substantial change in the situation.
| 7 | | (d) When an enrollee presents to a hospital seeking | 8 | | emergency services,
the determination as to whether the need | 9 | | for those
services exists shall be made for purposes of | 10 | | treatment by a
physician licensed to practice medicine in all | 11 | | its branches or, to the extent
permitted by applicable law, by | 12 | | other appropriately licensed
personnel under the supervision | 13 | | of
or in collaboration with a physician licensed to practice | 14 | | medicine in all its
branches.
The physician or other
| 15 | | appropriate personnel shall indicate in the patient's chart the | 16 | | results of the
emergency medical screening examination.
| 17 | | (e) The appropriate use of the 911 emergency telephone | 18 | | system or its local
equivalent shall not be discouraged or | 19 | | penalized by the health care plan when
an emergency medical | 20 | | condition exists.
This provision shall not imply that the use | 21 | | of 911 or its local equivalent is a
factor in determining the | 22 | | existence of an emergency medical condition.
| 23 | | (f) The medical director's or his or her designee's
| 24 | | determination of whether the enrollee meets the standard of an | 25 | | emergency
medical condition shall be based solely upon the | 26 | | presenting symptoms documented
in the medical record at the |
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| 1 | | time care was
sought.
Only a clinical peer may make an adverse | 2 | | determination.
| 3 | | (g) Nothing in this Section shall prohibit the imposition | 4 | | of deductibles,
copayments, and co-insurance.
Nothing in this | 5 | | Section alters the prohibition on billing enrollees contained
| 6 | | in the Health Maintenance Organization Act.
| 7 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 8 | | Section 25. The Pharmacy Practice Act is amended by adding | 9 | | Section 42 as follows: | 10 | | (225 ILCS 85/42 new) | 11 | | Sec. 42. Information disclosure. A pharmacist or her or his | 12 | | authorized employee must inform customers of a less expensive, | 13 | | generically equivalent drug product for her or his prescription | 14 | | and whether the cost-sharing obligation to the customer exceeds | 15 | | the retail price of the prescription in the absence of | 16 | | prescription drug coverage. | 17 | | Section 30. The Illinois Public Aid Code is amended by | 18 | | adding Section 5-36 as follows: | 19 | | (305 ILCS 5/5-36 new) | 20 | | Sec. 5-36. Pharmacy benefits. | 21 | | (a)(1) The Department may enter into a contract with any | 22 | | third party on a fee-for-service reimbursement model for the |
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| 1 | | purpose of administering pharmacy benefits as provided in this | 2 | | Section; however, these services shall be approved by the | 3 | | Department. The Department shall ensure coordination of care | 4 | | between the third-party administrator and managed care | 5 | | organizations as a consideration in any contracts established | 6 | | in accordance with this Section. Any managed care techniques, | 7 | | principles, or administration of benefits utilized in | 8 | | accordance with this subsection shall comply with State law. | 9 | | (2) The following shall apply to contracts between entities | 10 | | contracting relating to third-party administrators and | 11 | | pharmacies: | 12 | | (A) the Department shall approve any contract between a | 13 | | third-party administrator and a pharmacy; | 14 | | (B) a third-party administrator shall not change the | 15 | | terms of a contract between a third-party administrator and | 16 | | a pharmacy without written approval by the Department; and | 17 | | (C) a third-party administrator shall not create, | 18 | | modify, implement, or indirectly establish any fee on a | 19 | | pharmacy, pharmacist, or a recipient of medical assistance | 20 | | without written approval by the Department. | 21 | | (b) The provisions of this Section shall not apply to | 22 | | outpatient pharmacy services provided by a health care facility | 23 | | registered as a covered entity pursuant to 42 U.S.C. 256b or | 24 | | any pharmacy owned by or contracted with the covered entity. A | 25 | | Medicaid managed care organization shall, either directly or | 26 | | through a pharmacy benefit manager, administer and reimburse |
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| 1 | | outpatient pharmacy claims submitted by a health care facility | 2 | | registered as a covered entity pursuant to 42 U.S.C. 256b, its | 3 | | owned pharmacies, and contracted pharmacies in accordance with | 4 | | the contractual agreements the Medicaid managed care | 5 | | organization or its pharmacy benefit manager has with such | 6 | | facilities and pharmacies. A Medicaid managed care | 7 | | organization or its pharmacy benefit manager shall not exclude | 8 | | any health care facility registered as a covered entity | 9 | | pursuant to 42 U.S.C. 256b from its pharmacy network. Any | 10 | | pharmacy benefit manager that contracts with a Medicaid managed | 11 | | care organization to administer and reimburse outpatient | 12 | | pharmacy claims as provided in this Section must be registered | 13 | | with the Director of Insurance in accordance with Section 513b2 | 14 | | of the Illinois Insurance Code. | 15 | | (c) On at least an annual basis, the Director of the | 16 | | Department of Healthcare and Family Services shall submit a | 17 | | report beginning no later than one year after the effective | 18 | | date of this amendatory Act of the 101st General Assembly to | 19 | | the House and Senate Human Services Committees and the House | 20 | | and Senate Financial Institutions Committees that provides an | 21 | | update on any contract, contract issues, formulary, dispensing | 22 | | fees, and maximum allowable cost concerns regarding a | 23 | | third-party administrator and managed care. | 24 | | (d) A pharmacy benefit manager shall notify the Department | 25 | | in writing of any activity, policy, or practice of the pharmacy | 26 | | benefit manager that directly or indirectly presents a conflict |
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| 1 | | of interest that interferes with the discharge of the pharmacy | 2 | | benefit manager's duty to a managed care organization to | 3 | | exercise its contractual duties. | 4 | | (e) A pharmacy benefit manager shall, upon request, | 5 | | disclose to the Department the following information: | 6 | | (1) whether the pharmacy benefit manager has a | 7 | | contract, agreement, or other arrangement with a | 8 | | pharmaceutical manufacturer to exclusively dispense or | 9 | | provide a drug to a managed care organization's enrollees, | 10 | | and the application of all consideration or economic | 11 | | benefits collected or received pursuant to that | 12 | | arrangement; | 13 | | (2) the percentage of claims payments made by the | 14 | | pharmacy benefit manager to pharmacies owned, managed, or | 15 | | controlled by the pharmacy benefit manager or any of the | 16 | | pharmacy benefit manager's management companies, parent | 17 | | companies, subsidiary companies, jointly held companies, | 18 | | or companies otherwise affiliated by a common owner, | 19 | | manager, or holding company for the previous year; | 20 | | (3) the aggregate amount of the fees or assessments | 21 | | imposed on, or collected from, pharmacy providers; and | 22 | | (4) the average annualized percentage of revenue | 23 | | collected by the pharmacy benefit manager as a result of | 24 | | each contract it has executed with a managed care | 25 | | organization contracted by the Department to provide | 26 | | medical assistance benefits which is not paid by the |
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| 1 | | pharmacy benefit manager to pharmacy providers and | 2 | | pharmaceutical manufacturers or labelers or in order to | 3 | | perform administrative functions pursuant to its contracts | 4 | | with managed care organizations. | 5 | | (f) The information disclosed under subsection (e) shall | 6 | | include all retail, mail order, specialty, and compounded | 7 | | prescription products. All information made
available to the | 8 | | Department under subsection (e) is confidential and not subject | 9 | | to disclosure under the Freedom of Information Act. | 10 | | (g) A pharmacy benefit manager shall disclose directly in | 11 | | writing to a pharmacy provider contracting with the pharmacy | 12 | | benefit manager of any material change to a contract provision | 13 | | that affects the terms of the reimbursement, the process for | 14 | | verifying benefits and eligibility, dispute resolution, | 15 | | procedures for verifying drugs included on the formulary, and | 16 | | contract termination at least 30 days prior to the date of the | 17 | | change to the provision. | 18 | | (h) A pharmacy benefit manager shall not include the | 19 | | following in a contract with a pharmacy provider: | 20 | | (1) a provision prohibiting the provider from | 21 | | informing a patient of a less costly alternative to a | 22 | | prescribed medication; or | 23 | | (2) a provision that prohibits the provider from | 24 | | dispensing a particular amount of a prescribed medication, | 25 | | if the pharmacy benefit manager allows that amount to be | 26 | | dispensed through a pharmacy owned or controlled by the |
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| 1 | | pharmacy benefit manager, unless the prescription drug is | 2 | | subject to restricted distribution by the United States | 3 | | Food and Drug Administration or requires special handling, | 4 | | provider coordination, or patient education that cannot be | 5 | | provided by a retail pharmacy. | 6 | | (i) Nothing in this Section shall be construed to prohibit | 7 | | a pharmacy benefit manager from requiring the same | 8 | | reimbursement and terms and conditions for a pharmacy provider | 9 | | as for a pharmacy owned, controlled, or otherwise associated | 10 | | with the pharmacy benefit manager. | 11 | | (j) A pharmacy benefit manager shall establish and | 12 | | implement a process for the resolution of disputes arising out | 13 | | of this Section, which shall be approved by the Department. | 14 | | (k) The Department shall adopt rules establishing | 15 | | reasonable dispensing fees in accordance with guidance or | 16 | | guidelines from the federal Centers for Medicare and Medicaid | 17 | | Services.
| 18 | | Section 97. Severability. If any provision of this Act or | 19 | | the application of this Act to any person or circumstance is | 20 | | held invalid, the invalidity shall not affect other provisions | 21 | | or applications of this Act which can be given effect without | 22 | | the invalid provision or application, and to this end, the | 23 | | provisions of this Act are declared severable.".
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