Illinois General Assembly - Full Text of HB0711
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Full Text of HB0711  102nd General Assembly

HB0711eng 102ND GENERAL ASSEMBLY

  
  
  

 


 
HB0711 EngrossedLRB102 10190 BMS 20259 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be cited as the Prior
5Authorization Reform Act.
 
6    Section 5. Purpose. The General Assembly hereby finds and
7declares that:
8        (1) the health care professional-patient relationship
9    is paramount and should not be subject to third-party
10    intrusion;
11        (2) prior authorization programs shall be subject to
12    member coverage agreements and medical policies but shall
13    not hinder the independent medical judgment of a physician
14    or health care provider; and
15        (3) prior authorization programs must be transparent
16    to ensure a fair and consistent process for health care
17    providers and patients.
 
18    Section 10. Applicability; scope. This Act applies to
19health insurance coverage as defined in the Illinois Health
20Insurance Portability and Accountability Act, and policies
21issued or delivered in this State to the Department of
22Healthcare and Family Services and providing coverage to

 

 

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1persons who are enrolled under Article V of the Illinois
2Public Aid Code or under the Children's Health Insurance
3Program Act, amended, delivered, issued, or renewed on or
4after the effective date of this Act, with the exception of
5employee or employer self-insured health benefit plans under
6the federal Employee Retirement Income Security Act of 1974,
7health care provided pursuant to the Workers' Compensation Act
8or the Workers' Occupational Diseases Act, and State,
9employee, unit of local government, or school district health
10plans. This Act does not diminish a health care plan's duties
11and responsibilities under other federal or State law or rules
12promulgated thereunder. This Act is not intended to alter or
13impede the provisions of any consent decree or judicial order
14to which the State or any of its agencies is a party.
 
15    Section 15. Definitions. As used in this Act:
16    "Adverse determination" has the meaning given to that term
17in Section 10 of the Health Carrier External Review Act.
18    "Appeal" means a formal request, either orally or in
19writing, to reconsider an adverse determination.
20    "Approval" means a determination by a health insurance
21issuer or its contracted utilization review organization that
22a health care service has been reviewed and, based on the
23information provided, satisfies the health insurance issuer's
24or its contracted utilization review organization's
25requirements for medical necessity and appropriateness.

 

 

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1    "Clinical review criteria" has the meaning given to that
2term in Section 10 of the Health Carrier External Review Act.
3    "Department" means the Department of Insurance.
4    "Emergency medical condition" has the meaning given to
5that term in Section 10 of the Managed Care Reform and Patient
6Rights Act.
7    "Emergency services" has the meaning given to that term in
8federal health insurance reform requirements for the group and
9individual health insurance markets, 45 CFR 147.138.
10    "Enrollee" has the meaning given to that term in Section
1110 of the Managed Care Reform and Patient Rights Act.
12    "Health care professional" has the meaning given to that
13term in Section 10 of the Managed Care Reform and Patient
14Rights Act.
15    "Health care provider" has the meaning given to that term
16in Section 10 of the Managed Care Reform and Patient Rights
17Act, except that facilities licensed under the Nursing Home
18Care Act and long-term care facilities as defined in Section
191-113 of the Nursing Home Care Act are excluded from this Act.
20    "Health care service" means any services or level of
21services included in the furnishing to an individual of
22medical care or the hospitalization incident to the furnishing
23of such care, as well as the furnishing to any person of any
24other services for the purpose of preventing, alleviating,
25curing, or healing human illness or injury, including
26behavioral health, mental health, home health, and

 

 

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1pharmaceutical services and products.
2    "Health insurance issuer" has the meaning given to that
3term in Section 5 of the Illinois Health Insurance Portability
4and Accountability Act.
5    "Medically necessary" means a health care professional
6exercising prudent clinical judgment would provide care to a
7patient for the purpose of preventing, diagnosing, or treating
8an illness, injury, disease, or its symptoms and that are: (i)
9in accordance with generally accepted standards of medical
10practice; (ii) clinically appropriate in terms of type,
11frequency, extent, site, and duration and are considered
12effective for the patient's illness, injury, or disease; and
13(iii) not primarily for the convenience of the patient,
14treating physician, other health care professional, caregiver,
15family member, or other interested party, but focused on what
16is best for the patient's health outcome.
17    "Physician" means a person licensed under the Medical
18Practice Act of 1987 or licensed under the laws of another
19state to practice medicine in all its branches.
20    "Prior authorization" means the process by which health
21insurance issuers or their contracted utilization review
22organizations determine the medical necessity and medical
23appropriateness of otherwise covered health care services
24before the rendering of such health care services. "Prior
25authorization" includes any health insurance issuer's or its
26contracted utilization review organization's requirement that

 

 

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1an enrollee, health care professional, or health care provider
2notify the health insurance issuer or its contracted
3utilization review organization before, at the time of, or
4concurrent to providing a health care service.
5    "Urgent health care service" means a health care service
6with respect to which the application of the time periods for
7making a non-expedited prior authorization that in the opinion
8of a health care professional with knowledge of the enrollee's
9medical condition:
10        (1) could seriously jeopardize the life or health of
11    the enrollee or the ability of the enrollee to regain
12    maximum function; or
13        (2) could subject the enrollee to severe pain that
14    cannot be adequately managed without the care or treatment
15    that is the subject of the utilization review.
16    "Urgent health care service" does not include emergency
17services.
18    "Utilization review organization" has the meaning given to
19that term in 50 Ill. Adm. Code 4520.30.
 
20    Section 20. Disclosure and review of prior authorization
21requirements.
22    (a) A health insurance issuer shall maintain a complete
23list of services for which prior authorization is required,
24including for all services where prior authorization is
25performed by an entity under contract with the health

 

 

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

 

 

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

 

 

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

 

 

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1    received;
2        (3) the number of prior authorization requests denied
3    during the previous plan year by the health insurance
4    issuer or its contracted utilization review organization
5    with respect to each service described in paragraph (1)
6    and the top 5 reasons for denial;
7        (4) the number of requests described in paragraph (3)
8    that were appealed, the number of the appealed requests
9    that upheld the adverse determination, and the number of
10    appealed requests that reversed the adverse determination;
11        (5) the average time between submission and response;
12    and
13        (6) any other information as the Director determines
14    appropriate.
 
15    Section 25. Health insurance issuer's and its contracted
16utilization review organization's obligations with respect to
17prior authorizations in nonurgent circumstances.
18Notwithstanding any other provision of law, if a health
19insurance issuer requires prior authorization of a health care
20service, the health insurance issuer or its contracted
21utilization review organization must make an approval or
22adverse determination and notify the enrollee, the enrollee's
23health care professional, and the enrollee's health care
24provider of the approval or adverse determination as required
25by applicable law, but no later than 5 calendar days after

 

 

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1obtaining all necessary information to make the approval or
2adverse determination. As used in this Section, "necessary
3information" includes the results of any face-to-face clinical
4evaluation, second opinion, or other clinical information that
5is directly applicable to the requested service that may be
6required.
 
7    Section 30. Health insurance issuer's and its contracted
8utilization review organization's obligations with respect to
9prior authorizations concerning urgent health care services.
10    (a) Notwithstanding any other provision of law, a health
11insurance issuer or its contracted utilization review
12organization must render an approval or adverse determination
13concerning urgent care services and notify the enrollee, the
14enrollee's health care professional, and the enrollee's health
15care provider of that approval or adverse determination as
16required by law, but not later than 48 hours after receiving
17all information needed to complete the review of the requested
18health care services.
19    (b) To facilitate the rendering of a prior authorization
20determination in conformance with this Section, a health
21insurance issuer or its contracted utilization review
22organization must establish a mechanism to ensure health care
23professionals have access to appropriately trained and
24licensed clinical personnel who have access to physicians for
25consultation, designated by the plan to make such

 

 

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1determinations for prior authorization concerning urgent care
2services.
 
3    Section 35. Personnel qualified to make adverse
4determinations of a prior authorization request. A health
5insurance issuer or its contracted utilization review
6organization must ensure that all adverse determinations are
7made by a physician when the request is by a physician or a
8representative of a physician. The physician must:
9        (1) possess a current and valid nonrestricted license
10    in any United States jurisdiction; and
11        (2) have experience treating and managing patients
12    with the medical condition or disease for which the health
13    care service is being requested.
14    Notwithstanding the foregoing, a licensed health care
15professional who satisfies the requirements of this Section
16may make an adverse determination of a prior authorization
17request submitted by a health care professional licensed in
18the same profession.
 
19    Section 40. Requirements for adverse determination. If a
20health insurance issuer or its contracted utilization review
21organization makes an adverse determination, the health
22insurance issuer or its contracted utilization review
23organization shall include the following in the notification
24to the enrollee, the enrollee's health care professional, and

 

 

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1the enrollee's health care provider:
2        (1) the reasons for the adverse determination and
3    related evidence-based criteria, including a description
4    of any missing or insufficient documentation;
5        (2) the right to appeal the adverse determination;
6        (3) instructions on how to file the appeal; and
7        (4) additional documentation necessary to support the
8    appeal.
 
9    Section 45. Requirements applicable to the personnel who
10can review appeals. A health insurance issuer or its
11contracted utilization review organization must ensure that
12all appeals are reviewed by a physician when the request is by
13a physician or a representative of a physician. The physician
14must:
15        (1) possess a current and valid nonrestricted license
16    to practice medicine in any United States jurisdiction;
17        (2) be in the same or similar specialty as a physician
18    who typically manages the medical condition or disease;
19        (3) be knowledgeable of, and have experience
20    providing, the health care services under appeal;
21        (4) not have been directly involved in making the
22    adverse determination; and
23        (5) consider all known clinical aspects of the health
24    care service under review, including, but not limited to,
25    a review of all pertinent medical records provided to the

 

 

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1    health insurance issuer or its contracted utilization
2    review organization by the enrollee's health care
3    professional or health care provider and any medical
4    literature provided to the health insurance issuer or its
5    contracted utilization review organization by the health
6    care professional or health care provider.
7    Notwithstanding the foregoing, a licensed health care
8professional who satisfies the requirements in this Section
9may review appeal requests submitted by a health care
10professional licensed in the same profession.
 
11    Section 50. Review of prior authorization requirements. A
12health insurance issuer shall periodically review its prior
13authorization requirements and consider removal of prior
14authorization requirements:
15        (1) where a medication or procedure prescribed is
16    customary and properly indicated or is a treatment for the
17    clinical indication as supported by peer-reviewed medical
18    publications; or
19        (2) for patients currently managed with an established
20    treatment regimen.
 
21    Section 55. Denial.
22    (a) The health insurance issuer or its contracted
23utilization review organization may not revoke or further
24limit, condition, or restrict a previously issued prior

 

 

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1authorization approval while it remains valid under this Act.
2    (b) Notwithstanding any other provision of law, if a claim
3is properly coded and submitted timely to a health insurance
4issuer, the health insurance issuer shall make payment
5according to the terms of coverage on claims for health care
6services for which prior authorization was required and
7approval received before the rendering of health care
8services, unless one of the following occurs:
9        (1) it is timely determined that the enrollee's health
10    care professional or health care provider knowingly
11    provided health care services that required prior
12    authorization from the health insurance issuer or its
13    contracted utilization review organization without first
14    obtaining prior authorization for those health care
15    services;
16        (2) it is timely determined that the health care
17    services claimed were not performed;
18        (3) it is timely determined that the health care
19    services rendered were contrary to the instructions of the
20    health insurance issuer or its contracted utilization
21    review organization or delegated reviewer if contact was
22    made between those parties before the service being
23    rendered;
24        (4) it is timely determined that the enrollee
25    receiving such health care services was not an enrollee of
26    the health care plan; or

 

 

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1        (5) the approval was based upon a material
2    misrepresentation by the enrollee, health care
3    professional, or health care provider; as used in this
4    paragraph (5), "material" means a fact or situation that
5    is not merely technical in nature and results or could
6    result in a substantial change in the situation.
7    (c) Nothing in this Section shall preclude a utilization
8review organization or a health insurance issuer from
9performing post-service reviews of health care claims for
10purposes of payment integrity or for the prevention of fraud,
11waste, or abuse.
 
12    Section 60. Length of prior authorization approval. A
13prior authorization approval shall be valid for the lesser of
146 months after the date the health care professional or health
15care provider receives the prior authorization approval or the
16length of treatment as determined by the patient's health care
17professional or the renewal of the plan, and the approval
18period shall be effective regardless of any changes, including
19any changes in dosage for a prescription drug prescribed by
20the health care professional. All dosage increases must be
21based on established evidentiary standards and nothing in this
22Section shall prohibit a health insurance issuer from having
23safety edits in place. This Section shall not apply to the
24prescription of benzodiazepines or Schedule II narcotic drugs,
25such as opioids. Except to the extent required by medical

 

 

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1exceptions processes for prescription drugs set forth in
2Section 45.1 of the Managed Care Reform and Patient Rights
3Act, nothing in this Section shall require a policy to cover
4any care, treatment, or services for any health condition that
5the terms of coverage otherwise completely exclude from the
6policy's covered benefits without regard for whether the care,
7treatment, or services are medically necessary.
 
8    Section 65. Length of prior authorization approval for
9treatment for chronic or long-term conditions. If a health
10insurance issuer requires a prior authorization for a
11recurring health care service or maintenance medication for
12the treatment of a chronic or long-term condition, the
13approval shall remain valid for the lesser of 12 months from
14the date the health care professional or health care provider
15receives the prior authorization approval or the length of the
16treatment as determined by the patient's health care
17professional. This Section shall not apply to the prescription
18of benzodiazepines or Schedule II narcotic drugs, such as
19opioids. Except to the extent required by medical exceptions
20processes for prescription drugs set forth in Section 45.1 of
21the Managed Care Reform and Patient Rights Act, nothing in
22this Section shall require a policy to cover any care,
23treatment, or services for any health condition that the terms
24of coverage otherwise completely exclude from the policy's
25covered benefits without regard for whether the care,

 

 

HB0711 Engrossed- 17 -LRB102 10190 BMS 20259 b

1treatment, or services are medically necessary.
 
2    Section 70. Continuity of care for enrollees.
3    (a) On receipt of information documenting a prior
4authorization approval from the enrollee or from the
5enrollee's health care professional or health care provider, a
6health insurance issuer shall honor a prior authorization
7granted to an enrollee from a previous health insurance issuer
8or its contracted utilization review organization for at least
9the initial 90 days of an enrollee's coverage under a new
10health plan, subject to the terms of the member's coverage
11agreement.
12    (b) During the time period described in subsection (a), a
13health insurance issuer or its contracted utilization review
14organization may perform its own review to grant a prior
15authorization approval subject to the terms of the member's
16coverage agreement.
17    (c) If there is a change in coverage of or approval
18criteria for a previously authorized health care service, the
19change in coverage or approval criteria does not affect an
20enrollee who received prior authorization approval before the
21effective date of the change for the remainder of the
22enrollee's plan year.
23    (d) Except to the extent required by medical exceptions
24processes for prescription drugs, nothing in this Section
25shall require a policy to cover any care, treatment, or

 

 

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1services for any health condition that the terms of coverage
2otherwise completely exclude from the policy's covered
3benefits without regard for whether the care, treatment, or
4services are medically necessary.
 
5    Section 75. Health care services deemed authorized if a
6health insurance issuer or its contracted utilization review
7organization fails to comply with the requirements of this
8Act. A failure by a health insurance issuer or its contracted
9utilization review organization to comply with the deadlines
10and other requirements specified in this Act shall result in
11any health care services subject to review to be automatically
12deemed authorized by the health insurance issuer or its
13contracted utilization review organization.
 
14    Section 80. Severability. If any provision of this Act or
15its application to any person or circumstance is held invalid,
16the invalidity does not affect other provisions or
17applications of this Act that can be given effect without the
18invalid provision or application, and to this end the
19provisions of this Act are declared to be severable.
 
20    Section 85. Administration and enforcement.
21    (a) The Department shall enforce the provisions of this
22Act pursuant to the enforcement powers granted to it by law. To
23enforce the provisions of this Act, the Director is hereby

 

 

HB0711 Engrossed- 19 -LRB102 10190 BMS 20259 b

1granted specific authority to issue a cease and desist order
2or require a utilization review organization or health
3insurance issuer to submit a plan of correction for violations
4of this Act, or both, in accordance with the requirements and
5authority set forth in Section 85 of the Managed Care Reform
6and Patient Rights Act. Subject to the provisions of the
7Illinois Administrative Procedure Act, the Director may,
8pursuant to Section 403A of the Illinois Insurance Code,
9impose upon a utilization review organization or health
10insurance issuer an administrative fine not to exceed $250,000
11for failure to submit a requested plan of correction, failure
12to comply with its plan of correction, or repeated violations
13of this Act.
14    (b) Any person who believes that his or her utilization
15review organization or health insurance issuer is in violation
16of the provisions of this Act may file a complaint with the
17Department. The Department shall review all complaints
18received and investigate all complaints that it deems to state
19a potential violation. The Department shall fairly,
20efficiently, and timely review and investigate complaints.
21Health insurance issuers and utilization review organizations
22found to be in violation of this Act shall be penalized in
23accordance with this Section.
24    (c) The Department of Healthcare and Family Services shall
25enforce the provisions of this Act as it applies to persons
26enrolled under Article V of the Illinois Public Aid Code or

 

 

HB0711 Engrossed- 20 -LRB102 10190 BMS 20259 b

1under the Children's Health Insurance Program Act.
 
2    Section 900. The Illinois Insurance Code is amended by
3changing Sections 155.36 and 370g as follows:
 
4    (215 ILCS 5/155.36)
5    Sec. 155.36. Managed Care Reform and Patient Rights Act.
6Insurance companies that transact the kinds of insurance
7authorized under Class 1(b) or Class 2(a) of Section 4 of this
8Code shall comply with Sections 45, 45.1, 45.2, 65, 70, and 85,
9subsection (d) of Section 30, and the definition of the term
10"emergency medical condition" in Section 10 of the Managed
11Care Reform and Patient Rights Act.
12(Source: P.A. 101-608, eff. 1-1-20.)
 
13    (215 ILCS 5/370g)  (from Ch. 73, par. 982g)
14    Sec. 370g. Definitions. As used in this Article, the
15following definitions apply:
16    (a) "Health care services" means health care services or
17products rendered or sold by a provider within the scope of the
18provider's license or legal authorization. The term includes,
19but is not limited to, hospital, medical, surgical, dental,
20vision and pharmaceutical services or products.
21    (b) "Insurer" means an insurance company or a health
22service corporation authorized in this State to issue policies
23or subscriber contracts which reimburse for expenses of health

 

 

HB0711 Engrossed- 21 -LRB102 10190 BMS 20259 b

1care services.
2    (c) "Insured" means an individual entitled to
3reimbursement for expenses of health care services under a
4policy or subscriber contract issued or administered by an
5insurer.
6    (d) "Provider" means an individual or entity duly licensed
7or legally authorized to provide health care services.
8    (e) "Noninstitutional provider" means any person licensed
9under the Medical Practice Act of 1987, as now or hereafter
10amended.
11    (f) "Beneficiary" means an individual entitled to
12reimbursement for expenses of or the discount of provider fees
13for health care services under a program where the beneficiary
14has an incentive to utilize the services of a provider which
15has entered into an agreement or arrangement with an
16administrator.
17    (g) "Administrator" means any person, partnership or
18corporation, other than an insurer or health maintenance
19organization holding a certificate of authority under the
20"Health Maintenance Organization Act", as now or hereafter
21amended, that arranges, contracts with, or administers
22contracts with a provider whereby beneficiaries are provided
23an incentive to use the services of such provider.
24    (h) "Emergency medical condition" has the meaning given to
25that term in Section 10 of the Managed Care Reform and Patient
26Rights Act. means a medical condition manifesting itself by

 

 

HB0711 Engrossed- 22 -LRB102 10190 BMS 20259 b

1acute symptoms of sufficient severity (including severe pain)
2such that a prudent layperson, who possesses an average
3knowledge of health and medicine, could reasonably expect the
4absence of immediate medical attention to result in:
5        (1) placing the health of the individual (or, with
6    respect to a pregnant woman, the health of the woman or her
7    unborn child) in serious jeopardy;
8        (2) serious impairment to bodily functions; or
9        (3) serious dysfunction of any bodily organ or part.
10(Source: P.A. 91-617, eff. 1-1-00.)
 
11    Section 905. The Managed Care Reform and Patient Rights
12Act is amended by changing Section 10 as follows:
 
13    (215 ILCS 134/10)
14    Sec. 10. Definitions.
15    "Adverse determination" means a determination by a health
16care plan under Section 45 or by a utilization review program
17under Section 85 that a health care service is not medically
18necessary.
19    "Clinical peer" means a health care professional who is in
20the same profession and the same or similar specialty as the
21health care provider who typically manages the medical
22condition, procedures, or treatment under review.
23    "Department" means the Department of Insurance.
24    "Emergency medical condition" means a medical condition

 

 

HB0711 Engrossed- 23 -LRB102 10190 BMS 20259 b

1manifesting itself by acute symptoms of sufficient severity,
2regardless of the final diagnosis given, such that a prudent
3layperson, who possesses an average knowledge of health and
4medicine, could reasonably expect the absence of immediate
5medical attention to result in:
6        (1) placing the health of the individual (or, with
7    respect to a pregnant woman, the health of the woman or her
8    unborn child) in serious jeopardy;
9        (2) serious impairment to bodily functions;
10        (3) serious dysfunction of any bodily organ or part;
11        (4) inadequately controlled pain; or
12        (5) with respect to a pregnant woman who is having
13    contractions:
14            (A) inadequate time to complete a safe transfer to
15        another hospital before delivery; or
16            (B) a transfer to another hospital may pose a
17        threat to the health or safety of the woman or unborn
18        child.
19    "Emergency medical screening examination" means a medical
20screening examination and evaluation by a physician licensed
21to practice medicine in all its branches, or to the extent
22permitted by applicable laws, by other appropriately licensed
23personnel under the supervision of or in collaboration with a
24physician licensed to practice medicine in all its branches to
25determine whether the need for emergency services exists.
26    "Emergency services" means, with respect to an enrollee of

 

 

HB0711 Engrossed- 24 -LRB102 10190 BMS 20259 b

1a health care plan, transportation services, including but not
2limited to ambulance services, and covered inpatient and
3outpatient hospital services furnished by a provider qualified
4to furnish those services that are needed to evaluate or
5stabilize an emergency medical condition. "Emergency services"
6does not refer to post-stabilization medical services.
7    "Enrollee" means any person and his or her dependents
8enrolled in or covered by a health care plan.
9    "Health care plan" means a plan, including, but not
10limited to, a health maintenance organization, a managed care
11community network as defined in the Illinois Public Aid Code,
12or an accountable care entity as defined in the Illinois
13Public Aid Code that receives capitated payments to cover
14medical services from the Department of Healthcare and Family
15Services, that establishes, operates, or maintains a network
16of health care providers that has entered into an agreement
17with the plan to provide health care services to enrollees to
18whom the plan has the ultimate obligation to arrange for the
19provision of or payment for services through organizational
20arrangements for ongoing quality assurance, utilization review
21programs, or dispute resolution. Nothing in this definition
22shall be construed to mean that an independent practice
23association or a physician hospital organization that
24subcontracts with a health care plan is, for purposes of that
25subcontract, a health care plan.
26    For purposes of this definition, "health care plan" shall

 

 

HB0711 Engrossed- 25 -LRB102 10190 BMS 20259 b

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

 

 

HB0711 Engrossed- 26 -LRB102 10190 BMS 20259 b

1in this Act shall be construed to define Independent Practice
2Associations or Physician-Hospital Organizations as health
3care providers.
4    "Health care services" means any services included in the
5furnishing to any individual of medical care, or the
6hospitalization incident to the furnishing of such care, as
7well as the furnishing to any person of any and all other
8services for the purpose of preventing, alleviating, curing,
9or healing human illness or injury including behavioral
10health, mental health, home health, and pharmaceutical
11services and products.
12    "Medical director" means a physician licensed in any state
13to practice medicine in all its branches appointed by a health
14care plan.
15    "Person" means a corporation, association, partnership,
16limited liability company, sole proprietorship, or any other
17legal entity.
18    "Physician" means a person licensed under the Medical
19Practice Act of 1987.
20    "Post-stabilization medical services" means health care
21services provided to an enrollee that are furnished in a
22licensed hospital by a provider that is qualified to furnish
23such services, and determined to be medically necessary and
24directly related to the emergency medical condition following
25stabilization.
26    "Stabilization" means, with respect to an emergency

 

 

HB0711 Engrossed- 27 -LRB102 10190 BMS 20259 b

1medical condition, to provide such medical treatment of the
2condition as may be necessary to assure, within reasonable
3medical probability, that no material deterioration of the
4condition is likely to result.
5    "Utilization review" means the evaluation of the medical
6necessity, appropriateness, and efficiency of the use of
7health care services, procedures, and facilities.
8    "Utilization review program" means a program established
9by a person to perform utilization review.
10(Source: P.A. 101-452, eff. 1-1-20.)
 
11    Section 910. The Illinois Public Aid Code is amended by
12adding Section 5-5.12d as follows:
 
13    (305 ILCS 5/5-5.12d new)
14    Sec. 5-5.12d. Managed care organization prior
15authorization of health care services.
16    (a) As used in this Section, "health care service" has the
17meaning given to that term in the Prior Authorization Reform
18Act.
19    (b) Notwithstanding any other provision of law to the
20contrary, all managed care organizations shall comply with the
21requirements of the Prior Authorization Reform Act.
 
22    Section 999. Effective date. This Act takes effect January
231, 2022.