Full Text of HB3549 99th General Assembly
HB3549enr 99TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Health Maintenance Organization Act is | 5 | | amended by changing Section 5-3 as follows:
| 6 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 7 | | Sec. 5-3. Insurance Code provisions.
| 8 | | (a) Health Maintenance Organizations
shall be subject to | 9 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 10 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 11 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 12 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 13 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 14 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | 15 | | 356z.22, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | 16 | | 368d, 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, | 17 | | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | 18 | | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | 19 | | XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| 20 | | (b) For purposes of the Illinois Insurance Code, except for | 21 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 22 | | Maintenance Organizations in
the following categories are | 23 | | deemed to be "domestic companies":
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| 1 | | (1) a corporation authorized under the
Dental Service | 2 | | Plan Act or the Voluntary Health Services Plans Act;
| 3 | | (2) a corporation organized under the laws of this | 4 | | State; or
| 5 | | (3) a corporation organized under the laws of another | 6 | | state, 30% or more
of the enrollees of which are residents | 7 | | of this State, except a
corporation subject to | 8 | | substantially the same requirements in its state of
| 9 | | organization as is a "domestic company" under Article VIII | 10 | | 1/2 of the
Illinois Insurance Code.
| 11 | | (c) In considering the merger, consolidation, or other | 12 | | acquisition of
control of a Health Maintenance Organization | 13 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 14 | | (1) the Director shall give primary consideration to | 15 | | the continuation of
benefits to enrollees and the financial | 16 | | conditions of the acquired Health
Maintenance Organization | 17 | | after the merger, consolidation, or other
acquisition of | 18 | | control takes effect;
| 19 | | (2)(i) the criteria specified in subsection (1)(b) of | 20 | | Section 131.8 of
the Illinois Insurance Code shall not | 21 | | apply and (ii) the Director, in making
his determination | 22 | | with respect to the merger, consolidation, or other
| 23 | | acquisition of control, need not take into account the | 24 | | effect on
competition of the merger, consolidation, or | 25 | | other acquisition of control;
| 26 | | (3) the Director shall have the power to require the |
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| 1 | | following
information:
| 2 | | (A) certification by an independent actuary of the | 3 | | adequacy
of the reserves of the Health Maintenance | 4 | | Organization sought to be acquired;
| 5 | | (B) pro forma financial statements reflecting the | 6 | | combined balance
sheets of the acquiring company and | 7 | | the Health Maintenance Organization sought
to be | 8 | | acquired as of the end of the preceding year and as of | 9 | | a date 90 days
prior to the acquisition, as well as pro | 10 | | forma financial statements
reflecting projected | 11 | | combined operation for a period of 2 years;
| 12 | | (C) a pro forma business plan detailing an | 13 | | acquiring party's plans with
respect to the operation | 14 | | of the Health Maintenance Organization sought to
be | 15 | | acquired for a period of not less than 3 years; and
| 16 | | (D) such other information as the Director shall | 17 | | require.
| 18 | | (d) The provisions of Article VIII 1/2 of the Illinois | 19 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 20 | | any health maintenance
organization of greater than 10% of its
| 21 | | enrollee population (including without limitation the health | 22 | | maintenance
organization's right, title, and interest in and to | 23 | | its health care
certificates).
| 24 | | (e) In considering any management contract or service | 25 | | agreement subject
to Section 141.1 of the Illinois Insurance | 26 | | Code, the Director (i) shall, in
addition to the criteria |
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| 1 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 2 | | into account the effect of the management contract or
service | 3 | | agreement on the continuation of benefits to enrollees and the
| 4 | | financial condition of the health maintenance organization to | 5 | | be managed or
serviced, and (ii) need not take into account the | 6 | | effect of the management
contract or service agreement on | 7 | | competition.
| 8 | | (f) Except for small employer groups as defined in the | 9 | | Small Employer
Rating, Renewability and Portability Health | 10 | | Insurance Act and except for
medicare supplement policies as | 11 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 12 | | Maintenance Organization may by contract agree with a
group or | 13 | | other enrollment unit to effect refunds or charge additional | 14 | | premiums
under the following terms and conditions:
| 15 | | (i) the amount of, and other terms and conditions with | 16 | | respect to, the
refund or additional premium are set forth | 17 | | in the group or enrollment unit
contract agreed in advance | 18 | | of the period for which a refund is to be paid or
| 19 | | additional premium is to be charged (which period shall not | 20 | | be less than one
year); and
| 21 | | (ii) the amount of the refund or additional premium | 22 | | shall not exceed 20%
of the Health Maintenance | 23 | | Organization's profitable or unprofitable experience
with | 24 | | respect to the group or other enrollment unit for the | 25 | | period (and, for
purposes of a refund or additional | 26 | | premium, the profitable or unprofitable
experience shall |
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| 1 | | be calculated taking into account a pro rata share of the
| 2 | | Health Maintenance Organization's administrative and | 3 | | marketing expenses, but
shall not include any refund to be | 4 | | made or additional premium to be paid
pursuant to this | 5 | | subsection (f)). The Health Maintenance Organization and | 6 | | the
group or enrollment unit may agree that the profitable | 7 | | or unprofitable
experience may be calculated taking into | 8 | | account the refund period and the
immediately preceding 2 | 9 | | plan years.
| 10 | | The Health Maintenance Organization shall include a | 11 | | statement in the
evidence of coverage issued to each enrollee | 12 | | describing the possibility of a
refund or additional premium, | 13 | | and upon request of any group or enrollment unit,
provide to | 14 | | the group or enrollment unit a description of the method used | 15 | | to
calculate (1) the Health Maintenance Organization's | 16 | | profitable experience with
respect to the group or enrollment | 17 | | unit and the resulting refund to the group
or enrollment unit | 18 | | or (2) the Health Maintenance Organization's unprofitable
| 19 | | experience with respect to the group or enrollment unit and the | 20 | | resulting
additional premium to be paid by the group or | 21 | | enrollment unit.
| 22 | | In no event shall the Illinois Health Maintenance | 23 | | Organization
Guaranty Association be liable to pay any | 24 | | contractual obligation of an
insolvent organization to pay any | 25 | | refund authorized under this Section.
| 26 | | (g) Rulemaking authority to implement Public Act 95-1045, |
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| 1 | | if any, is conditioned on the rules being adopted in accordance | 2 | | with all provisions of the Illinois Administrative Procedure | 3 | | Act and all rules and procedures of the Joint Committee on | 4 | | Administrative Rules; any purported rule not so adopted, for | 5 | | whatever reason, is unauthorized. | 6 | | (Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437, | 7 | | eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, | 8 | | eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14; | 9 | | 98-1091, eff. 1-1-15 .) | 10 | | Section 10. The Managed Care Reform and Patient Rights Act | 11 | | is amended by changing Section 45.1 as follows: | 12 | | (215 ILCS 134/45.1) | 13 | | Sec. 45.1. Medical exceptions procedures required. | 14 | | (a) Notwithstanding any other provision of law, on or after
| 15 | | the effective date of this amendatory Act of the 99th General
| 16 | | Assembly, every insurer licensed in this State to sell a policy
| 17 | | of group or individual accident and health insurance or a
| 18 | | health benefits plan shall Every health carrier that offers a | 19 | | qualified health plan, as defined in the federal Patient | 20 | | Protection and Affordable Care Act of 2010 (Public Law | 21 | | 111-148), as amended by the federal Health Care and Education | 22 | | Reconciliation Act of 2010 (Public Law 111-152), and any | 23 | | amendments thereto, or regulations or guidance issued under | 24 | | those Acts (collectively, "the Federal Act"), directly to |
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| 1 | | consumers in this State shall establish and maintain a medical | 2 | | exceptions process that allows covered persons or their | 3 | | authorized representatives to request any clinically | 4 | | appropriate prescription drug when (1) the drug is not covered | 5 | | based on the health benefit plan's formulary; (2) the health | 6 | | benefit plan is discontinuing coverage of the drug on the | 7 | | plan's formulary for reasons other than safety or other than | 8 | | because the prescription drug has been withdrawn from the | 9 | | market by the drug's manufacturer; (3) the prescription drug | 10 | | alternatives required to be used in accordance with a step | 11 | | therapy requirement (A) has been ineffective in the treatment | 12 | | of the enrollee's disease or medical condition or, based on | 13 | | both sound clinical evidence and medical and scientific | 14 | | evidence, the known relevant physical or mental | 15 | | characteristics of the enrollee, and the known characteristics | 16 | | of the drug regimen, is likely to be ineffective or adversely | 17 | | affect the drug's effectiveness or patient compliance or (B) | 18 | | has caused or, based on sound medical evidence, is likely to | 19 | | cause an adverse reaction or harm to the enrollee; or (4) the | 20 | | number of doses available under a dose restriction for the | 21 | | prescription drug (A) has been ineffective in the treatment of | 22 | | the enrollee's disease or medical condition or (B) based on | 23 | | both sound clinical evidence and medical and scientific | 24 | | evidence, the known relevant physical and mental | 25 | | characteristics of the enrollee, and known characteristics of | 26 | | the drug regimen, is likely to be ineffective or adversely |
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| 1 | | affect the drug's effective or patient compliance. | 2 | | (b) The health carrier's established medical exceptions | 3 | | procedures must require, at a minimum, the following: | 4 | | (1) Any request for approval of coverage made verbally | 5 | | or in writing (regardless of whether made using a paper or | 6 | | electronic form or some other writing) at any time shall be | 7 | | reviewed by appropriate health care professionals. | 8 | | (2) The health carrier must, within 72 hours after | 9 | | receipt of a request made under subsection (a) of this | 10 | | Section, either approve or deny the request. In the case of | 11 | | a denial, the health carrier shall provide the covered | 12 | | person or the covered person's authorized representative | 13 | | and the covered person's prescribing provider with the | 14 | | reason for the denial, an alternative covered medication, | 15 | | if applicable, and information regarding the procedure for | 16 | | submitting an appeal to the denial. | 17 | | (3) In the case of an expedited coverage determination, | 18 | | the health carrier must either approve or deny the request | 19 | | within 24 hours after receipt of the request. In the case | 20 | | of a denial, the health carrier shall provide the covered | 21 | | person or the covered person's authorized representative | 22 | | and the covered person's prescribing provider with the | 23 | | reason for the denial, an alternative covered medication, | 24 | | if applicable, and information regarding the procedure for | 25 | | submitting an appeal to the denial. | 26 | | (c) A step therapy requirement exception request shall be
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| 1 | | approved if: | 2 | | (1) the required prescription drug is contraindicated; | 3 | | (2) the patient has tried the required prescription
| 4 | | drug while under the patient's current or previous health
| 5 | | insurance or health benefit plan and the prescribing
| 6 | | provider submits evidence of failure or intolerance; or | 7 | | (3) the patient is stable on a prescription
drug | 8 | | selected by his or her health care provider for the
medical | 9 | | condition under consideration while on a
current or | 10 | | previous health insurance or health benefit plan. | 11 | | (d) Upon the granting of an exception request, the insurer,
| 12 | | health plan, utilization review organization, or other entity
| 13 | | shall authorize the coverage for the drug
prescribed by the | 14 | | enrollee's treating health care provider,
to the extent the | 15 | | prescribed drug is a covered drug under the policy or contract | 16 | | up to the quantity covered. | 17 | | (e) Any approval of a medical exception request made | 18 | | pursuant to this Section shall be honored for 12 months | 19 | | following the date of the approval or until renewal of the | 20 | | plan. | 21 | | (f) (c) Notwithstanding any other provision of this | 22 | | Section, nothing in this Section shall be interpreted or | 23 | | implemented in a manner not consistent with the federal Patient | 24 | | Protection and Affordable Care Act of 2010 (Public Law | 25 | | 111-148), as amended by the federal Health Care and Education | 26 | | Reconciliation Act of 2010 (Public Law 111-152), and any |
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| 1 | | amendments thereto, or regulations or guidance issued under | 2 | | those Acts Federal Act .
| 3 | | (g) Nothing in this Section shall require or authorize the | 4 | | State agency responsible for the administration of the medical | 5 | | assistance program established under the Illinois Public Aid | 6 | | Code to approve, supply, or cover prescription drugs pursuant | 7 | | to the procedure established in this Section. | 8 | | (Source: P.A. 98-1035, eff. 8-25-14.)
| 9 | | Section 99. Effective date. This Act takes effect January | 10 | | 1, 2018.
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